ETCTN 10476: A randomized phase 2 study of combination atezolizumab and varlilumab (CDX-1127) with or without addition of cobimetinib in previously treated unresectable biliary tract cancer.
Authors: Heumann Thatcher Ross , Yarchoan Mark , Murray Judy , Wang Hao , Wright John Joseph , Sharon Elad , Lesinski Gregory B. , Azad Nilofer Saba 
Published: January 2023

TPS639 Background: The combination of the MEK inhibitor, Cobimetinib, with the PD-L1 antagonist, Atezolizumab, significantly improved progression-free survival (PFS) compared to Atezolizumab monotherapy in patients with advanced biliary tract cancer (BTC) following first-line chemotherapy (NCT03201458). Interrogation of biospecimens from this trial and parallel pre-clinical work showed that the addition of MEK inhibition enhanced tumor immunogenicity but simultaneously had detrimental effects on host T-cell activation and priming. The addition of immune co-stimulants rescues T-cell function in the setting of systemic MEK inhibition in vivo. Unlike other immune co-stimulatory markers, CD27 is one of the most positively differentially expressed receptors in the TME post-treatment with combined MEK inhibition and PD-L1 blockade. We hypothesize that addition of CD27 immune agonism to the combination of PD-L1 and MEK inhibition can improve immunotherapy outcomes in patients with BTC. Methods: We are conducting an open-label, randomized ph 2 trial evaluating a PD-L1 inhibitor (atezolizumab) in combination with a CD27 immune agonist (CDX-1127 [Varlilumab]) with or without addition of a MEK inhibitor (Cobimetinib) in patients with unresectable, previously treated, BTC. Key inclusion criteria include: adults with pathologically-confirmed BTC, s/p 1-2 lines of systemic therapy (including any FDA-approved targeted therapies) in the metastatic setting, measurable disease, ECOG performance status ≤1, adequate baseline organ and marrow function. Patients who have received gem-cis-durvalumab, and/or prior FGFR2/IDH1 targeted therapy are eligible for enrollment. The study is planned for 64 evaluable subjects (32 subjects per treatment arm) randomized in a 1:1 ratio, stratified by site of BTC location, to either Atezolizumab + CDX-1127 or Atezolizumab + CDX-1127 + Cobimetinib. During the 28-day treatment cycles, all patients receive Atezolizumab (840mg flat dose) and CDX-1127 (3mg/kg) infusions on D1 and D15. For those randomized to the triplet regimen arm, the additional Cobimetinib will be dosed orally at 60mg daily on days 1-21. Overall response rate and PFS are co-primary endpoints. A clinically meaningful improvement in ORR warranting further study is 20%. The primary correlative outcome is treatment-related changes in CD8+ infiltrating T cells. After an initial safety lead-in, a planned interim efficacy analysis will take place following enrollment of the first 18 patients in each treatment arm. Currently, 14 participants (n=6 [triplet arm], n=8 [doublet arm]), have been enrolled & treated on protocol. This study is sponsored by the NCI Cancer Therapy Evaluation Program and is open nationally at designated NCI Experimental Therapeutics Clinical Trials Network sites. Clinical trial information: NCT04941287 .