CV301 Combined With PD-1/L1 Blockade in Patients With Locally Advanced or Metastatic Urothelial Bladder Cancer

Study Overview
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Brief Summary
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This is a Phase 2, single-arm, multi-institutional clinical trial designed to study the combination of CV301 with atezolizumab in the first-line treatment of UC not eligible for cisplatin-containing chemotherapy (Cohort 1) and in the second-line treatment of UC previously treated with standard first-line cisplatin-based chemotherapy (Cohort 2).

Detailed Description
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This is a Phase 2, single-arm, multi-institutional clinical trial designed to study the combination of CV301 with atezolizumab in the first-line treatment of UC not eligible for cisplatin-containing chemotherapy (Cohort 1) and in the second-line treatment of UC previously treated with standard first-line cisplatin-based chemotherapy (Cohort 2). The trial will be performed using an optimal two-stage design within each cohort. Stage 1, Cohort 1: Enroll 14 subjects. If objective response is not achieved in at least four patients, the cohort will be stopped for futility. If objective response is achieved in at least four subjects, the cohort will proceed to stage 2. If any patient is not evaluable for the primary endpoint, the patient may be replaced. Stage 1, Cohort 2: Enroll 13 subjects. If objective response is not achieved in at least three patients, the cohort will be stopped for futility. If objective response is achieved in at least three subjects, the cohort will proceed to stage 2. If any patient is not evaluable for the primary endpoint, the patient may be replaced. Stage 2, Cohort 1: Enroll an additional 19 subjects. If any patient is not evaluable for the primary endpoint, the patient may be replaced until a total of 33 patients are evaluable for the primary endpoint. Stage 2, Cohort 2: Enroll an additional 22 subjects. If any patient is not evaluable for the primary endpoint, the patient may be replaced until a total of 35 patients are evaluable for the primary endpoint.

Official Title
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A Phase 2, Multicenter, Single-Arm Trial of CV301 in Combination With PD-1/L1 Blockade in Patients With Locally Advanced or Metastatic Urothelial Bladder Cancer

Conditions
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Bladder Cancer

Intervention / Treatment
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* Biological: CV301
* Biological: Atezolizumab


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age ≥ 18 years at date of ICF signature having the ability to comply with protocol. Histologically or cytologically documented locally advanced (T4b, any N; or any T, N 2-3) or metastatic (M1, Stage IV; or metastatic recurrence after locoregional treatment) UC (including renal pelvis, ureters, urinary bladder, urethra) Patients with mixed histologies were required to have a dominant transitional cell pattern. Locally advanced bladder cancer that was inoperable on the basis of involvement of the pelvic sidewall or adjacent viscera (clinical stage T4b) or bulky nodal metastasis (N2-N3). Life expectancy ≥ 12 weeks. Measurable disease, as defined by RECIST v1.1. Previously irradiated lesions cannot be counted as target lesions unless there has been demonstrated progression in the lesion since radiotherapy and no other lesions are available for selection as target lesions. Demonstrate adequate organ function. For female patients of childbearing potential and male patients with partners of childbearing potential, agreement (by patient and/or partner) to use a highly effective form(s) of contraception (i.e., one that results in a low failure rate [< 1% per year] when used consistently and correctly) and to continue its use for 5 months after the last dose of atezolizumab. Representative formalin-fixed paraffin-embedded (FFPE) tumor specimens in paraffin blocks (blocks preferred) or 10-15 unstained slides, with an associated pathology report. For Cohort 1: Untreated with chemotherapy Have at least one of the following: ECOG (Eastern Cooperative Oncology Group) performance status of 2. Glomerular filtration rate calculated as creatinine clearance (Cockroft-Gault formula) of ≥20 mL/min and less than 60 mL/min Hearing loss or neuropathy of any cause Common Terminology Criteria for Adverse Events (CTCAE) Grade ≥2 For Cohort 2: Disease progression during or following treatment with at least one platinum-containing regimen (e.g., GC, MVAC, CarboGem, carboplatin-paclitaxel) for inoperable locally advanced or metastatic urothelial carcinoma or disease recurrence, as defined by: Regimen is defined as patients receiving at least one cycle of a platinum-containing regimen with response assessment. Patients who received one cycle of a platinum-containing regimen but discontinued due to toxicity are also eligible. Patients who received prior adjuvant/neoadjuvant chemotherapy and progressed within 12 months of treatment with a platinum-containing adjuvant/neoadjuvant regimen are considered as second-line patients. ECOG (Eastern Cooperative Oncology Group) performance status of < 2 Calculated creatinine clearance (Cockroft-Gault formula) of ≥20 mL/min Exclusion Criteria: Any approved anti-cancer therapy, including chemotherapy, within 3 weeks prior to initiation of trial treatment; the following exceptions are allowed: Palliative radiotherapy for bone metastases or non-target soft tissue lesions completed >7 days prior to baseline imaging. Hormone-replacement therapy or oral contraceptives. Treatment with any other investigational agent or participation in another clinical trial with therapeutic intent within 28 days prior to screening given that all AEs related to prior treatment have resolved to baseline or Grade 1. Active central nervous system (CNS) metastases as determined by computed tomography (CT) or magnetic resonance imaging (MRI) evaluation during screening and prior radiographic assessments or Leptomeningeal disease. Uncontrolled tumor-related pain: Patients requiring pain medication must be on a stable regimen at trial entry. Symptomatic lesions amenable to palliative radiotherapy (e.g., bone metastases or metastases causing nerve impingement) should be treated prior to trial entry. Asymptomatic metastatic lesions whose further growth would likely cause functional deficits or intractable pain (e.g., epidural metastasis that is not currently associated with spinal cord compression) could be considered for loco-regional therapy if appropriate prior to enrollment. Uncontrolled pleural effusion, pericardial effusion, or ascites requiring recurrent drainage procedures (once monthly or more frequently) a. Patients with indwelling catheters (e.g., PleurX) are allowed. Uncontrolled hypercalcemia (>1.5 mmol/L ionized calcium or Ca >12 mg/dL or corrected serum calcium >ULN) or symptomatic hypercalcemia requiring continued use of bisphosphonate therapy or denosumab: Patients who are receiving bisphosphonate therapy or denosumab specifically to prevent skeletal events and who did not have a history of clinically significant hypercalcemia are eligible. Patients who are receiving denosumab prior to enrollment have to be willing and eligible to receive a bisphosphonate instead while in the trial. Malignancies other than urothelial carcinoma within 3 years prior to Day 1, with the exception of those with a negligible risk of metastasis or death treated with expected curative outcome (such as adequately treated carcinoma in situ of the cervix, basal or squamous cell skin cancer, or ductal carcinoma in situ treated surgically with curative intent) or localized prostate cancer treated with curative intent and no intent for further treatment or incidental prostate cancer (T1/T2b, Gleason score ≤7 undergoing active surveillance and treatment naive). Pregnant and lactating women. History of severe allergic, anaphylactic, or other hypersensitivity reactions to chimeric or humanized antibodies or fusion proteins, or aminoglycoside antibiotics or egg products, poxvirus-based vaccinations, or beef or bovine meat. Known hypersensitivity or allergy to biopharmaceuticals produced in Chinese hamster ovary cells or any component of the atezolizumab formulation. History of autoimmune disease, including but not limited to myasthenia gravis, myositis, autoimmune hepatitis, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, vascular thrombosis associated with anti-phospholipid syndrome, granulomatosis with polyangiitis, Sjogren's syndrome, Guillain-Barre syndrome, multiple sclerosis, vasculitis, or glomerulonephritis. Patients with a history of autoimmune-related hypothyroidism on a stable dose of thyroid replacement hormone are eligible for this trial. Patients with controlled Type I diabetes mellitus on a stable dose of insulin regimen are eligible for this trial. Patients with history of vitiligo and controlled psoriasis are eligible for the trial. History of idiopathic pulmonary fibrosis, organizing pneumonia (e.g., bronchiolitis obliterans), drug-induced pneumonitis, idiopathic pneumonitis, or evidence of active pneumonitis on screening chest CT scan a. History of radiation pneumonitis in the radiation field (fibrosis) is permitted. Positive test for Human Immunodeficiency Virus (HIV). Patients with active hepatitis B virus (HBV; chronic or acute, defined as having a positive hepatitis B surface antigen [HBsAg] test at screening) or hepatitis C virus (HCV) Patients with past HBV infection or resolved HBV infection (defined as the presence of hepatitis B core antibody [HBcAb] and absence of HbsAg, negative polymerase chain reaction (PCR) for HBV) are eligible. HBV Deoxyribonucleic Acid (DNA) PCR must be obtained in these patients prior to Day 1. Patients positive for HCV antibody are eligible only if polymerase chain reaction is negative for HCV Ribonucleic Acid (RNA) prior to enrollment. Active tuberculosis. Signs or symptoms clinically significant of infection within 2 weeks prior to Day 1. Received therapeutic oral or intravenous (IV) antibiotics within 1 week prior to Day 1 a. Patients receiving prophylactic antibiotics (e.g., for prevention of a urinary tract infection or to prevent chronic obstructive pulmonary disease exacerbation) are eligible. Significant cardiovascular disease, which includes but is not limited to New York Heart Association (NYHA) Heart Failure Class II or greater, myocardial infarction within the previous 3 months, unstable arrhythmias, unstable angina. a. Patients with known coronary artery disease, congestive heart failure not meeting the above criteria, or left ventricular ejection fraction < 50% on a stable medical regimen that was optimized in the opinion of the treating physician, in consultation with a cardiologist if appropriate, are eligible. Major surgical procedure other than for diagnosis within 28 days prior to Day 1 or anticipation of need for a major surgical procedure during the course of the trial. Prior allogeneic stem cell or solid organ transplant. Administration of a live, attenuated vaccine within 4 weeks before Day 1 or anticipation that such a live attenuated vaccine would be required during the trial a. Influenza vaccination may be given during influenza season only (approximately October to March). Patients cannot receive live, attenuated influenza vaccine (e.g., FluMist®) within 4 weeks prior to Day 1 or at any time during the trial. Any other diseases, metabolic dysfunction, physical examination finding, or clinical laboratory finding giving reasonable suspicion of a disease or condition that contraindicated the use of an investigational drug or that could affect the interpretation of the results or render the patient at high risk from treatment complications. Prior treatment with CD137 agonists or immune checkpoint blockade therapies, including anti-CTLA-4, anti-PD-1, and anti-PD-L1 therapeutic antibodies Treatment with systemic immunostimulatory agents (including but not limited to IFNs, interleukin [IL]-2) within 6 weeks or five half-lives of the drug, whichever was shorter, prior to Day 1. Treatment with systemic corticosteroids or other systemic immunosuppressive medications (including but not limited to prednisone, dexamethasone, cyclophosphamide, azathioprine, methotrexate, and anti-tumor necrosis factor [anti-TNF] agents) within 2 weeks prior to Day 1, or anticipated requirement for systemic immunosuppressive medications during the trial a. Patients who receive acute, low-dose, systemic corticosteroid medications (e.g., a one-time dose of dexamethasone for nausea) or for prevention of hypersensitivity reactions to contrast agents may be enrolled in the trial. The use of inhaled, nasal, ophthalmic, intra-articular, auricular or topical corticosteroids, physiologic replacement doses of glucocorticoids (i.e., for adrenal insufficiency), and mineralocorticoids (e.g. Fludrocortisone for adrenal insufficiency) is allowed.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: CV301 + Atezolizumab<br>Subject receiving combination treatment with CV301 + Atezolizumab | Biological: CV301<br>* Prime with MVA-BN-CV301 (nominal titer 1.6 x 10^9 Inf.U) given subcutaneously (SC) on Day 1 and Day 22. One dose = four 0.5 mL injections. One injection = nominal titer 4 x 10^8 Inf.U in 0.5 mL. Boost with FPV-CV301 (nominal titer of 1 × 10^9 Inf.U in 0.5 mL, given SC every 21 days for 4 doses (on days 43, 64, 85, and 106), followed by boosts every 6 weeks until 6 months on trial (i.e., days 148 and 190), then every 12 weeks until completion of 2 years. One dose = one 0.5 mL injection.<br>Biological: Atezolizumab<br>* Atezolizumab fixed dose of 1200 mg intravenous on Day 1 of each 21-day cycle<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Objective Response Rate (ORR) | ORR is the proportion of subjects in the analysis population with a Complete Response (CR) or Partial Response (PR) based on best overall RECIST v1.1 evaluations as performed by the investigator. According to RECIST v1.1, the sum of the longest diameters of non-nodal target lesions and short axis of nodal target lesions are used to evaluate tumor response. Maximum of 2 target lesions per organ and 5 target lesions are used for the measurement. CR means disappearance of all known disease, confirmed at 4 week, lymph nodes must be < 10 mm short axis. PR means >=30% decrease from baseline measurement, confirmed at 4 week. | up to 24 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Progression Free Survival (PFS) | The time interval from first treatment to objective tumor progression or death of any cause. Subjects without death or progression are censored at the date when the last assessment determined a lack of progression. The time interval from first vaccination to death of any cause, up to 4 years for each subject or discontinuation of the study by sponsor. | The time from day of first treatment to the start of disease progression or death, whichever occurs first, or the last assessment date if there is a lack of progression, up to 24 months for each subject or discontinuation of the study by sponsor. | 
| Overall Survival (OS) | Time interval from first treatment to death of any cause. Subjects are censored at their date of last contact if they did not meet the survival endpoint by the outcome measure time frame. | The time interval from first vaccination to death of any cause, up to 24 months for each subject or discontinuation of the study by sponsor. | 
| Duration of Response | The time from objective response (CR or PR, whichever comes first) to investigator assessed progression using RECIST v1.1 or death | up to 24 months | 
| Treatment-Emergent Adverse Events | An Overall Summary of Subjects with any Treatment-Emergent Adverse Events (TEAEs) and TEAEs Categories. TEAEs Categories include Related Adverse Events, >=Grade 3 Adverse Events, Related >= Grade 3 Adverse Events, Serious Adverse Events, Related Serious Adverse Events, Adverse Events of Special Interest and Related Adverse Events of Special Interest. TEAEs are considered as related when the investigator-assessed relationship of the corresponding trial treatment is possible, probable, definite or missing. Per CTCAE v5, Grade 1=Mild; asymptomatic or mild symptoms. Grade 2=Moderate; minimal, local or noninvasive intervention indicated. Grade 3=Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated. Grade 4=Life-threatening consequences; urgent intervention indicated. Grade 5=Death related to AE. Immune Mediated Adverse Events (IMAE) and Cardiac events are considered AESIs. | up to 24 months | 
| Toxicity Grade Shift From Baseline in Laboratory Results | Toxicity grades are based on CTCAE v5 scales for hematology and chemistry laboratory parameters. Grade 0=Normal, Grade 1=Mild, Grade 2=Moderate, Grade 3=Severe, Grade 5=Life-threatening, and Grade 5=Death. Toxicity grade shift is defined to evaluate categorical changes from baseline results to post-treatment results with respect to dichotomized CTCAE v5 grading value (<= Grade 2, >= Grade 3). | Overall Study up to 24 months | 
| Vital Signs Results - Pulse Rate | Vital signs results assessed throughout the study. | Overall study up to 24 months | 
| Vital Signs Results - System Blood Pressure | Vital signs results assessed throughout the study. | Overall study up to 24 months | 
| Vital Signs Results - Diastolic Blood Pressure | Vital signs results assessed throughout the study. | Overall study up to 24 months | 
| Vital Signs Results - Temperature | Vital signs results assessed throughout the study. | Overall study up to 24 months | 
| Vital Signs Results - Respiratory Rate | Vital signs results assessed throughout the study. | Overall study up to 24 months |