A Study to Evaluate Enfortumab Vedotin Versus (vs) Chemotherapy in Subjects With Previously Treated Locally Advanced or Metastatic Urothelial Cancer (EV-301)
Condition: Ureteral Cancer; Urothelial Cancer; Bladder Cancer
MeSH terms: Ureteral Neoplasms
Intervention: Enfortumab Vedotin; Docetaxel; Vinflunine; Paclitaxel
Intervention description: Intravenous infusion; Intravenous infusion; Intravenous infusion; Intravenous infusion
Intervention MeSH terms: Paclitaxel; Docetaxel
Phase: Phase 3
Study type: Interventional
Primary purpose: Treatment
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Enrollment: 608.0
Sex: All
Minimum age: 18 Years
Healthy volunteers: No
Keywords: antibody drug conjugate; enfortumab vedotin (EV); ASG-22ME; ASG-22CE; urothelial cancer

Summary:

      The purpose of this study was to compare the overall survival (OS) of participants with
      locally advanced or metastatic urothelial cancer treated with enfortumab vedotin (EV) to the
      OS of participants treated with chemotherapy.

      This study compared progression-free survival on study therapy (PFS1); the overall response
      rate (ORR) and the disease control rate (DCR) per Response Evaluation Criteria in Solid
      Tumors (RECIST) V1.1 of participants treated with EV to participants treated with
      chemotherapy.

      In addition, this study evaluated the duration of response (DOR) per RECIST V1.1 of EV and
      chemotherapy and assessed the safety and tolerability of EV, as well as, the quality of life
      (QOL) and Patient Reported Outcomes (PRO) parameters.
    

Eligibility criteria:

        Inclusion Criteria:

          -  Subject is legally an adult according to local regulation at the time of signing
             informed consent.

          -  Subject has histologically or cytologically confirmed urothelial carcinoma (i.e.,
             cancer of the bladder, renal pelvis, ureter, or urethra). Subjects with urothelial
             carcinoma (transitional cell) with squamous differentiation or mixed cell types are
             eligible.

          -  Subject must have experienced radiographic progression or relapse during or after a
             checkpoint inhibitor (CPI) (anti-programmed cell death protein 1 (PD1) or
             anti-programmed death-ligand 1 (PD-L1)) for locally advanced or metastatic disease.
             Subjects who discontinued CPI treatment due to toxicity are eligible provided that the
             subjects have evidence of disease progression following discontinuation. The CPI need
             not be the most recent therapy. Subjects for whom the most recent therapy has been a
             non-CPI based regimen are eligible if the subjects have progressed/relapsed during or
             after the subjects most recent therapy. Locally advanced disease must not be amenable
             to resection with curative intent per the treating physician.

          -  Subject must have received a platinum containing regimen (cisplatin or carboplatin) in
             the metastatic/locally advanced, neoadjuvant or adjuvant setting. If platinum was
             administered in the adjuvant/neoadjuvant setting subject must have progressed within
             12 months of completion.

          -  Subject has radiologically documented metastatic or locally advanced disease at
             baseline.

          -  An archival tumor tissue sample should be available for submission to central
             laboratory prior to study treatment. If an archival tumor tissue sample is not
             available, a fresh tissue sample should be provided. If a fresh tissue sample cannot
             be provided due to safety concerns, enrollment into the study must be discussed with
             the medical monitor.

          -  Subject has ECOG PS of 0 or 1

          -  The subject has the following baseline laboratory data:

               -  absolute neutrophil count (ANC) ≥ 1500/mm3

               -  platelet count ≥ 100 × 10^9/L

               -  hemoglobin ≥ 9 g/dL

               -  serum total bilirubin ≤ 1.5 × upper limit of normal (ULN) or ≤ 3 × ULN for
                  subjects with Gilbert's disease

               -  creatinine clearance (CrCl) ≥ 30 mL/min as estimated per institutional standards
                  or as measured by 24 hour urine collection (glomerular filtration rate [GFR] can
                  also be used instead of CrCl)

               -  alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤ 2.5 × ULN
                  or ≤ 3 x ULN for subjects with liver metastases

          -  Female subject must either:

               -  Be of nonchildbearing potential: Postmenopausal (defined as at least 1 year
                  without any menses for which there is no other obvious pathological or
                  physiological cause) prior to screening, or documented surgically sterile (e.g.,
                  hysterectomy, bilateral salpingectomy, bilateral oophorectomy).

               -  Or, if of childbearing potential: Agree not to try to become pregnant during the
                  study and for at least 6 months after the final study drug administration, and
                  have a negative urine or serum pregnancy test within 7 days prior to Day 1
                  (Females with false positive results and documented verification of negative
                  pregnancy status are eligible for participation), and if heterosexually active,
                  agree to consistently use a condom plus 1 form of highly effective birth control
                  per locally accepted standards starting at screening and throughout the study
                  period and for at least 6 months after the final study drug administration.

          -  Female subject must agree not to breastfeed or donate ova starting at screening and
             throughout the study period, and for at least 6 months after the final study drug
             administration.

          -  A sexually active male subject with female partner(s) who is of childbearing potential
             is eligible if:

               -  Agrees to use a male condom starting at screening and continue throughout the
                  study treatment and for at least 6 months after final study drug administration.
                  If the male subject has not had a vasectomy or is not sterile as defined below
                  the subjects female partner(s) is utilizing 1 form of highly effective birth
                  control per locally accepted standards starting at screening and continue
                  throughout study treatment and for at least 6 months after the male subject
                  receives final study drug administration.

          -  Male subject must not donate sperm starting at screening and throughout the study
             period, and for at least 6 months after the final study drug administration.

          -  Male subject with a pregnant or breastfeeding partner(s) must agree to abstinence or
             use a condom for the duration of the pregnancy or time partner is breastfeeding
             throughout the study period and for at least 6 months after the final study drug
             administration.

          -  Subject agrees not to participate in another interventional study while on treatment
             in present study.

        Inclusion Criteria for COE:

          -  Subject is eligible for the COE if they continue to meet all inclusion criteria from
             the main protocol in addition to the following when the patient is evaluated for
             eligibility to participate in the COE portion of the study:

          -  Institutional review board (IRB)/ independent ethics committee (IEC) approved written
             COE informed consent and privacy language as per national regulations (e.g., health
             insurance portability and accountability act [HIPAA] Authorization for US sites) must
             be obtained from the subject prior to any study-related procedures (including
             withdrawal of prohibited medication, if applicable).

          -  Subject was randomized to Arm B and is either currently on study treatment or has
             discontinued study treatment due to intolerance, AE or progression of disease and has
             not started a new systemic anticancer treatment.

        Exclusion Criteria:

          -  Subject has preexisting sensory or motor neuropathy Grade ≥ 2.

          -  Subject has active central nervous system (CNS) metastases. Subjects with treated CNS
             metastases are permitted on study if all the following are true:

               -  CNS metastases have been clinically stable for at least 6 weeks prior to
                  screening

               -  If requiring steroid treatment for CNS metastases, the subject is on a stable
                  dose ≤ 20 mg/day of prednisone or equivalent for at least 2 weeks

               -  Baseline scans show no evidence of new or enlarged brain metastasis

               -  Subject does not have leptomeningeal disease

          -  Subject has ongoing clinically significant toxicity (Grade 2 or higher with the
             exception of alopecia) associated with prior treatment (including systemic therapy,
             radiotherapy or surgery). Subject with ≤ Grade 2 immunotherapy-related hypothyroidism
             or panhypopituitarism may be enrolled when well-maintained/controlled on a stable dose
             of hormone replacement therapy (if indicated). Subjects with ongoing ≥ Grade 3
             immunotherapy-related hypothyroidism or panhypopituitarism are excluded. Subjects with
             ongoing immunotherapy related colitis, uveitis, or pneumonitis or subjects with other
             immunotherapy related AEs requiring high doses of steroids (> 20 mg/day of prednisone
             or equivalent) are excluded.

          -  Subject has prior treatment with EV or other monomethyl auristatin E (MMAE)-based
             Antibody drug conjugates (ADCs).

          -  Subject has received prior chemotherapy for urothelial cancer with all available study
             therapies in the control arm (i.e., both prior paclitaxel and docetaxel in regions
             where vinflunine is not an approved therapy, or prior paclitaxel, docetaxel and
             vinflunine in regions where vinflunine is an approved therapy).

          -  Subject has received more than 1 prior chemotherapy regimen for locally advanced or
             metastatic urothelial cancer, including chemotherapy for adjuvant or neo-adjuvant
             disease if recurrence occurred within 12 months of completing therapy. The
             substitution of carboplatin for cisplatin does not constitute a new regimen provided
             no new chemotherapeutic agents were added to the regimen.

          -  Subject has history of another malignancy within 3 years before the first dose of
             study drug, or any evidence of residual disease from a previously diagnosed
             malignancy. Subjects with nonmelanoma skin cancer, localized prostate cancer treated
             with curative intent with no evidence of progression, low-risk or very low-risk (per
             standard guidelines) localized prostate cancer under active surveillance/watchful
             waiting without intent to treat, or carcinoma in situ of any type (if complete
             resection was performed) are allowed.

          -  Subject is currently receiving systemic antimicrobial treatment for viral, bacterial,
             or fungal infection at the time of first dose of EV. Routine antimicrobial prophylaxis
             is permitted.

          -  Subject has known active Hepatitis B (e.g., hepatitis B surface antigen (HBsAg)
             reactive) or active hepatitis C (e.g., hepatitis C virus (HCV) Ribonucleic Acid (RNA)
             [qualitative] is detected).

          -  Subject has known history of human immunodeficiency virus (HIV) infection (HIV 1 or
             2).

          -  Subject has documented history of a cerebral vascular event (stroke or transient
             ischemic attack), unstable angina, myocardial infarction, or cardiac symptoms
             (including congestive heart failure) consistent with New York Heart Association Class
             III-IV within 6 months prior to the first dose of study drug.

          -  Subject has radiotherapy or major surgery within 4 weeks prior to first dose of study
             drug.

          -  Subject has had chemotherapy, biologics, investigational agents, and/or antitumor
             treatment with immunotherapy that is not completed 2 weeks prior to first dose of
             study drug.

          -  Subject has known hypersensitivity to EV or to any excipient contained in the drug
             formulation of EV; OR subject has known hypersensitivity to biopharmaceuticals
             produced in Chinese hamster ovary (CHO) cells.

          -  Subject has known hypersensitivity to the following: docetaxel or to any of the other
             excipients listed in product label, including polysorbate 80, paclitaxel or to any of
             the other excipients listed in product label, such as macrogolglycerol ricinoleate 35
             (Ph.Eur.); and vinflunine or to any of the other excipients listed in product label
             such as other vinca alkaloids (vinblastine,vincristine, vindesine, vinorelbine).

          -  Subject has known active keratitis or corneal ulcerations.

          -  Subject has other underlying medical condition that would impair the ability of the
             subject to receive or tolerate the planned treatment and follow-up.

          -  History of uncontrolled diabetes mellitus within 3 months of the first dose of study
             drug. Uncontrolled diabetes is defined as hemoglobin A1C (HbA1c) ≥ 8% or HbA1c between
             7 and < 8% with associated diabetes symptoms (polyuria or polydipsia) that are not
             otherwise explained.

        Exclusion Criteria for COE

          -  Subject will be excluded from participation in the COE if they meet any of the
             exclusion criteria listed in the main protocol or if any of the following apply when
             the patient is evaluated for eligibility to participate in the COE portion of the
             study:

          -  Subject has been diagnosed with a new malignancy while on Arm B in the EV-301 study.
             Subjects with nonmelanoma skin cancer, localized prostate cancer treated with curative
             intent with no evidence of progression, low-risk or very low-risk (per standard
             guidelines) localized prostate cancer under active surveillance/watchful waiting
             without intent to treat, or carcinoma in situ of any type (if complete resection was
             performed) are allowed.

          -  Subject has already started commercial EV or arrangements have been made for subject
             to start commercial EV which is reimbursed in their country. Additionally, if EV is
             commercially available with reimbursement in the potential subject's country, the
             subject can consider transitioning to the commercial product unless otherwise
             discussed with sponsor.