A Phase II Study of Bintrafusp Alfa (M7824) in Checkpoint Inhibitor Naive and Refractory Subjects With Urothelial Carcinoma
Condition: Urothelial Cancer
MeSH terms: Carcinoma, Transitional Cell
Intervention: Bintrafusp alfa (M7824)
Intervention description: 1200 mg administered intravenous (IV) every two weeks
Phase: Phase 2
Study type: Interventional
Primary purpose: Treatment
Intervention model: Single Group Assignment
Masking: None (Open Label)
Enrollment: 2.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: No
Keywords: TGF-Beta; Immune Therapy; PD-L1; Immunocytokine

Summary:

      Background:

      Metastatic urothelial carcinoma is lethal and has no cure. Response rates to current
      treatments are modest. Researchers want to find new strategies to treat the disease. In this
      study, they will test a drug called Bintrafusp alfa (M7824). The drug is a new immunotherapy
      that blocks the pathways that cancer cells use to stop the immune system from fighting
      cancer.

      Objective:

      To learn if M7824 can help the immune system's ability to fight urothelial cancer.

      Eligibility:

      People age 18 and older who have urothelial cancer that has spread to other parts of their
      body and they have been previously treated with chemotherapy or immunotherapy

      Design:

      Participants will be screened with a medical history and physical exam. They will have blood
      and urine tests. They will have imaging scans. They will have an electrocardiogram to measure
      heart function. Their ability to perform their normal activities will be evaluated. They may
      have a tumor biopsy. They will take a pregnancy test if needed.

      Participants will repeat some of the screening tests during the study.

      Treatment will be given in a series of 28-day cycles. Participants will get M7824 once every
      2 weeks. It is given through an intravenous infusion. For this, a small plastic tube is put
      into an arm vein. They will get M7824 until their disease gets worse, they have unacceptable
      side effects, or they decide to stop treatment.

      Participants will have a follow-up visit 30 days after treatment ends. Then they will be
      followed every 12 weeks in the clinic or by telephone/email. Follow-up will last
      indefinitely.
    

Eligibility criteria:

        -  INCLUSION CRITERIA:

          -  Ability to understand the purpose of the study, provide signed and dated informed
             consent, and able to comply with all procedures.

          -  Male or female patients aged greater than or equal to 18 years of age at time of
             consent.

          -  Patients with histologically confirmed diagnosis of urothelial carcinoma of the
             urinary tract, including the renal pelvis, ureter, bladder, or urethra.
             Differentiation with variant histologies (e.g. squamous cell differentiated) will be
             permitted. Mixed histologies are required to have a dominant urothelial/transitional
             cell pattern.

          -  Patients must have metastatic disease defined as new or progressive lesions on cross-
             sectional imaging. Radiological evaluation should occur within 21 days prior to
             enrollment.

          -  Patient must have evaluable and measurable disease, per Response Evaluation Criteria
             in Solid Tumors (RECIST) 1.1.

          -  Patients may have been previously treated with prior cytotoxic chemotherapy regimen or
             targeted agent. Patients may have received any number of prior cytotoxic agents.

          -  Patients may have had prior immunomodulating therapy including therapy targeting the
             Programmed death-1 (PD-1)/Programmed Cell Death Ligand 1 (PD-L1 axis (cohort 2A and B)
             but excluding prior treatment with Bintrafusp Alfa (M7824).

          -  Pre-treatment tissue biopsy and/or archival tissue availability for PD-L1 expression
             testing is mandatory for enrollment.

          -  Eastern Cooperative Oncology Group (ECOG) performance status less than or equal to 2

          -  Required laboratory values reflective of organ function are listed below:

               -  Absolute neutrophil count greater than or equal to 1000/microliter

               -  Platelets greater than or equal to 75,000 microliter

               -  Hemoglobin greater than or equal to 9 g/dL (erythrocyte transfusions are allowed
                  to achieve acceptable Hgb)

               -  Aspartate aminotransferase (AST)/Serum glutamic oxaloacetic transaminase
                  (SGOT)/Alanine aminotransferase (ALT)/Serum glutamic-pyruvic transaminase (SGPT)
                  less than or equal to 1.5 institutional upper limit of normal (ULN) with the
                  following exception:

                  ---Patients with liver involvement who have AST and ALT less than or equal to 5
                  ULN may be enrolled.

               -  Total bilirubin within normal limits with the following exceptions:

                    -  Patients with known Gilbert disease who have serum bilirubin level less than
                       or equal to 3 ULN may be enrolled.

                    -  Patients with tumor liver involvement bilirubin with less than or equal to
                       3.0 ULN.

               -  International normalized ratio (INR) and activated partial thromboplastin time
                  (aPTT) less than or equal to 1.5 ULN

                  ---This applies only to patients who are not receiving therapeutic
                  anticoagulation; patients receiving therapeutic anticoagulation (such as
                  low-molecular-weight heparin or warfarin) should be on a stable dose.

               -  Creatinine clearance (CrCl) greater than or equal to 30 mL/min/1.73 m^2
                  (glomerular filtration rate (GFR) may be used in place of CrCl. Creatinine
                  clearance or estimated glomerular filtration rate (eGFR) should be calculated per
                  institutional standard)

          -  The effects of M7824 on the developing human fetus are unknown. For this reason, women
             of child-bearing potential and men must agree to use strict and effective
             contraception (hormonal or barrier method of birth control; abstinence) during
             treatment and for at least 65 days for women and 125 days for men, after the last dose
             of M7824 administration. Should a woman become pregnant or suspect she is pregnant
             while she or her partner is participating in this study, she should inform her
             treating physician immediately.

          -  Human immunodeficiency virus (HIV) positive patients are eligible if on stable dose of
             highly active antiretroviral therapy (HAART), cluster of differentiation 4 (CD4)
             counts are greater than 350 cells/mm3 and viral load is undetectable.

          -  Patients with previously treated brain or central nervous system (CNS) metastases are
             eligible provided that the subjects have recovered from any acute effects of
             radiotherapy and is not requiring steroids, and any whole brain radiation therapy or
             any stereotactic radiosurgery was completed at least 2 weeks prior to M7824
             administration.

          -  Hepatitis B virus (HBV) positive patients are eligible-they must have been treated and
             on a stable dose of antivirals (eg, entecavir, tenofovir, or lamivudine; adefovir or
             interferon are not allowed) at study entry and with planned monitoring and management
             according to appropriate labeling guidance.

          -  Hepatitis C virus (HCV) positive patients are eligible if participants are on active
             HCV therapy at study entry and on a stable dose without documented clinically
             significant impaired liver function test or hematologic abnormalities and with planned
             monitoring and management according to appropriate labeling guidance.

          -  Cohort 1A Cisplatin Ineligible Specific Inclusion Criteria (first-line for metastatic
             cisplatin-ineligible):

               -  No prior chemotherapy for inoperable locally advanced or metastatic or recurrent
                  Urothelial Carcinoma (UC)

                  ---For patients who received prior adjuvant/neoadjuvant chemotherapy or
                  chemoradiation for UC, a treatment-free interval > 12 months between the last
                  treatment administration and the date of recurrence is required in order to be
                  considered treatment naive in the metastatic setting. Prior local intravesical
                  chemotherapy or immunotherapy is allowed if completed at least 4 weeks prior to
                  the initiation of study treatment.

               -  Ineligible ("unfit") for chemotherapy or cisplatin-based chemotherapy as defined
                  by any one of the following criteria:

                    -  Impaired renal function (CrCl > 30 but < 60 mL/min); GFR should be
                       calculated per institutional standard.

                    -  A hearing loss (measured by audiometry) of 25 decibels (dB) at two
                       contiguous frequencies

                    -  Grade greater than or equal to 2 peripheral neuropathy (i.e., sensory
                       alteration or paresthesias including tingling)

                    -  Eastern Cooperative Oncology Group (ECOG) performance score of 2

                    -  Patient declines chemotherapy after informed discussion with the study
                       doctor

          -  Cohort 1B Refractory Post-platinum Therapy Specific Inclusion Criteria (second-line
             for metastatic disease):

             --Disease progression during or following treatment with a platinum-containing regimen
             for inoperable locally advanced or metastatic urothelial carcinoma or disease
             recurrence. Examples of regimens include cisplatin + gemcitabine (GC), methotrexate +
             vinblastine sulfate + doxorubicin + cisplatin (MVAC), and carboplatin + gemcitabine
             (CarboGem).

             ---Patients who received prior adjuvant/neoadjuvant chemotherapy and progressed within
             12 months of treatment with a platinum-containing adjuvant/neoadjuvant regimen will be
             considered as second-line patients.

          -  Cohort 2A Checkpoint Inhibitor Previously Treated Patients that Previously Achieved a
             Complete Response (CR) or Partial Response (PR) Specific Inclusion Criteria:

             --Patients must have been treated with at least one treatment of a PD-1/PD-L1
             checkpoint inhibitor for advance or metastatic UC and achieved a complete response or
             partial response by Response Evaluation Criteria in Solid Tumors (RECIST) 1.1
             criteria.

          -  Cohort 2B Checkpoint inhibitor previously treated patients that previously had stable
             disease (SD) or progressive disease (PD)

          -  Specific Inclusion Criteria:

               -  Patients must have been treated with at least one treatment of a PD-1/PD-L1
                  checkpoint inhibitor for advance or metastatic UC and had stable disease or a
                  progressive disease by RECIST 1.1 criteria.

        EXCLUSION CRITERIA:

          -  History of allergic reactions attributed to compounds of similar chemical or biologic
             composition to M7824 investigational agents used in the study.

          -  Uncontrolled intercurrent illness including, but not limited to, symptomatic
             congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric
             illness/social situations that would limit compliance with study requirements.

          -  Symptomatic central nervous system metastasis.

          -  Subjects unwilling to accept blood products as medically indicated

          -  Pregnant women are excluded from this study because M7824 is an agent with the
             potential for teratogenic or abortifacient effects. Because there is an unknown but
             potential risk for adverse events in nursing infants secondary to treatment of the
             mother with M7824, breastfeeding should be discontinued if the mother is treated with
             these agents.

          -  Patients with any active or recent history of a known or suspected autoimmune disease
             (with the exception of diabetes type I, vitiligo, psoriasis, or hypo- or hyperthyroid
             diseases not requiring immunosuppressive treatment) or recent history of a syndrome
             that required treatment with either systemic corticosteroids (>10 mg daily prednisone
             equivalent) or immunosuppressive medications. Inhaled steroids and adrenal replacement
             steroid doses up to 10 mg daily prednisone equivalents are permitted in the absence of
             active autoimmune disease.

          -  Patients with a currently active second malignancy other than non-melanoma skin
             cancers or cervical carcinoma in situ or incidental organ-confined prostate cancer
             found on cystoprostatectomy (provided that the following criteria are met: Stage
             T2N0M0 or lower; Gleason score <= 3+4, prostate-specific antigen (PSA) undetectable).
             Patients are not considered to have a currently active malignancy if they have
             completed therapy and are free of disease for >= 2 years and currently do not require
             systemic therapy.

          -  Patients who have received or will receive a live vaccine within 30 days prior to the
             first administration of study intervention. Seasonal flu vaccines that do not contain
             a live virus are permitted. Locally approved COVID vaccines are permitted.

          -  Patients having tumor lesion(s) in the liver or chest which are 10 cm or larger.

          -  Patients previously treated with M7824.

          -  Patients previously treated with PD-1/PD-L1 checkpoint inhibitors (for Cohorts 1A and
             1B only)