BiCaZO: A Study Combining Two Immunotherapies (Cabozantinib and Nivolumab) to Treat Patients With Advanced Melanoma or Squamous Cell Head and Neck Cancer, an immunoMATCH Pilot Study

Study Overview
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Brief Summary
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This phase II trial studies the good and bad effects of the combination of drugs called cabozantinib and nivolumab in treating patients with melanoma or squamous cell head and neck cancer that may have spread from where it first started to nearby tissue, lymph nodes, or distant parts of the body (advanced). Cabozantinib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Immunotherapy with monoclonal antibodies, such as nivolumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. This trial may help doctors determine how quickly patients can be divided into groups based on biomarkers in their tumors. A biomarker is a biological molecule found in the blood, other body fluids, or in tissues that is a sign of a normal or abnormal process or a sign of a condition or disease. A biomarker may be used to see how well the body responds to a treatment for a disease or condition. The two biomarkers that this trial is studying are tumor mutational burden and tumor inflammation signature. Another purpose of this trial is to help doctors learn if cabozantinib and nivolumab shrink or stabilize the cancer, and whether patients respond differently to the combination depending on the status of the biomarkers.

Detailed Description
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PRIMARY OBJECTIVES: I. To evaluate the feasibility of molecular characterization based on tumor mutation burden (TMB) for participant stratification, as assessed by the proportion of participants with less than or equal to a 21-day turnaround time for biopsy results in Stage I of the study. II. To evaluate the feasibility of molecular characterization based on TMB and gene expression profiling (GEP) (for Tumor Inflammation Score [TIS]) for stratification in the overall study (Stage I and Stage II). III. To evaluate the efficacy by overall response rate (ORR - defined as confirmed and unconfirmed partial responses plus complete responses) of cabozantinib S-malate (cabozantinib) plus nivolumab in each disease cohort, both across and within tumor biomarker subgroups. SECONDARY OBJECTIVES: I. To assess the difference in ORR in each disease cohort between tumor marker subgroups separately for each disease cohort. II. To assess safety and tolerability of this treatment in these populations. III. To estimate disease control rate (DCR) in participants receiving cabozantinib plus nivolumab in each disease cohort, stratified by tumor biomarkers. IV. To estimate progression-free survival (PFS) in participants receiving cabozantinib plus nivolumab in each disease cohort, stratified by tumor biomarkers. V. To estimate overall survival (OS) in participants receiving cabozantinib plus nivolumab in each disease cohort, stratified by tumor biomarkers. VI. To assess the proportion of patients with assay failure, and the time from the date of tissue collection to molecular group determination at the end of Stage I. VII. To assess turnaround time for TIS for at least 30 patients in stage I to ensure that at least 75% have a turnaround time of < 21 days. If TIS is not ready for real-time testing when 30 slots remain for Stage I, accrual will be paused until assay validation is complete. ADDITIONAL OBJECTIVE: I. To identify candidate biomarkers predictive of response and toxicity to the cabozantinib and nivolumab combination. BANKING OBJECTIVE: I. To bank specimens for future correlative studies. OUTLINE: Patients receive nivolumab intravenously (IV) over 30 minutes on day 1 of each cycle and cabozantinib orally (PO) daily. Cycles repeat every 28 days for 2 years in the absence of disease progression or unacceptable toxicity. Patients also undergo computed tomography (CT) or magnetic resonance imaging (MRI) scans and collection of blood samples throughout the trial. Patients undergo a tumor biopsy during screening and optionally during follow-up. After completion of the study treatment, patients are followed for up to 3 years.

Official Title
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Biomarker Stratified CaboZantinib (NSC#761968) and NivOlumab (NSC#748726) (BiCaZO) - A Phase II Study of Combining Cabozantinib and Nivolumab in Participants With Advanced Solid Tumors (IO Refractory Melanoma or HNSCC) Stratified by Tumor Biomarkers - an immunoMATCH Pilot Study

Conditions
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Clinical Stage III Cutaneous Melanoma AJCC v8, Clinical Stage III HPV-Mediated (p16-Positive) Oropharyngeal Carcinoma AJCC v8, Clinical Stage IV Cutaneous Melanoma AJCC v8, Clinical Stage IV HPV-Mediated (p16-Positive) Oropharyngeal Carcinoma AJCC v8, Head and Neck Squamous Cell Carcinoma, Hypopharyngeal Squamous Cell Carcinoma, Laryngeal Squamous Cell Carcinoma, Lip and Oral Cavity Squamous Cell Carcinoma, Melanoma, Oropharyngeal Squamous Cell Carcinoma, Stage III Hypopharyngeal Carcinoma AJCC v8, Stage III Laryngeal Cancer AJCC v8, Stage III Lip and Oral Cavity Cancer AJCC v8, Stage III Oropharyngeal (p16-Negative) Carcinoma AJCC v8, Stage IV Hypopharyngeal Carcinoma AJCC v8, Stage IV Laryngeal Cancer AJCC v8, Stage IV Lip and Oral Cavity Cancer AJCC v8, Stage IV Oropharyngeal (p16-Negative) Carcinoma AJCC v8

Intervention / Treatment
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* Procedure: Biopsy
* Procedure: Biospecimen Collection
* Drug: Cabozantinib S-malate
* Procedure: Computed Tomography
* Procedure: Magnetic Resonance Imaging
* Biological: Nivolumab


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: STEP 1 - SPECIMEN SUBMISSION Participants must have histologically confirmed melanoma that is stage III or IV, unresectable, recurrent, or metastatic non-uveal melanoma OR Participants must have histologically confirmed squamous cell carcinoma of the head and neck (HNSCC) that is either locally recurrent and non-amendable to curative therapy (e.g., radiation, surgery) or metastatic. The primary tumor location must be the oropharynx, oral cavity, hypopharynx, or larynx. Primary tumor site of nasopharynx (any histology) or unknown primary tumor are not eligible Note: For participants with primary oropharyngeal cancer, human papillomavirus (HPV) or p16 status must be known prior to step 1 registration Participants must have disease presentation consistent with measurable disease. Note: Current disease measurements will not be required until step 2 registration Participants must have had documented progression within 12 weeks after the last dose of PD-1 checkpoint inhibition-based therapy. Participants must have been receiving checkpoint inhibition for a minimum of 6 weeks prior to progression. Participants who recur during adjuvant anti-PD1 treatment or within 12 weeks of completion of adjuvant anti-PD1 treatment are eligible if they have measurable disease and considered unresectable Participants with known human immunodeficiency virus (HIV)-infection must be receiving anti-retroviral therapy and have an undetectable viral load test within 6 months prior to step 1 registration Participants with evidence of chronic hepatitis B virus (HBV) infection must have undetectable HBV viral load within 28 days prior to step 1 registration Participants with a history of hepatitis C virus (HCV) infection must have no detectable viral load within 28 days prior to step 1 registration Participants must not have an active infection requiring systemic therapy (except HBV, HCV or HIV as mentioned above) Participants must not have known history of congenital long QT syndrome and must not have experienced unstable angina pectoris, clinically significant cardiac arrhythmias, or stroke (transient ischemic attack [TIA] or other ischemic event) within 90 days prior to Step 1 registration Participants must not have experienced myocardial infarction or thromboembolic event requiring anticoagulation within 90 days prior to step 1 registration, unless clinically stable with ongoing medical management Participants must have recovered to baseline or =< grade 1 Common Terminology Criteria for Adverse Events (CTCAE) version (v) 5 toxicities related to any prior treatments, unless adverse events are deemed clinically nonsignificant by the treating investigator or stable on supportive therapy Participants must not have received surgery, chemotherapy, radiation therapy, biologic agents, or steroids within 14 days prior to step 1 registration Participants must not have received more than one prior primary radiotherapy regimen, curative or adjuvant, to the head and neck, with the additional following criteria: If the primary radiation is combined with chemotherapy, a minimum of 16 weeks will be required to have elapsed between the end of radiotherapy and step 1 registration. If the radiation is given alone, a minimum of 8 weeks will be required to have elapsed between the end of radiotherapy and step 1 registration Additional palliative radiotherapy regimens are permitted but cannot have been administered to previously treated tissue (i.e., overlapping fields are excluded) and must be completed at least 4 weeks prior to step 1 registration Treatment areas should be healed with no sequelae from radiation therapy (RT) that would predispose to fistula formation Participants must not have received prior treatment with anti-VEGF therapies for any reason Participants must be >= 18 years of age Participants must have a Zubrod Performance Status 0 or 1 Participants must have adequate cardiac function. Participants with known history or current symptoms of cardiac disease, or history of treatment with cardiotoxic agents, must have a clinical risk assessment of cardiac function using the New York Heart Association Functional Classification and must be class 2B or better to be eligible for this trial Participants must not have any known significant organ disfunction that, in the opinion of the treating investigator, may impact suitability for receiving combination nivolumab/cabozantinib treatment Participants must not have active autoimmune disease requiring systemic steroids (equivalent of > 10mg of prednisone) or other immune suppression. Exceptions: Type 1 diabetes mellitus Hypothyroidism only requiring hormone replacement Skin disorders (e.g., vitiligo, psoriasis, or alopecia) not requiring systemic treatment Conditions not expected to recur in the absence of an external trigger Participants must not have received an organ allograft Participants must not have a history of hemoptysis (defined as >= 1/2 tsp of bright red blood per day) or tumor bleeding within 90 days prior to step 1 registration Participants must not have known central lung lesions involving major blood vessels (arteries or veins) or a tumor encasing major blood vessels (e.g., carotid artery) Participants must not require concomitant anticoagulation with coumarin agents (e.g., warfarin), direct thrombin inhibitors (e.g., dabigatran), direct factor Xa inhibitor betrixaban, or platelet inhibitors (e.g., clopidogrel) Participants must not require anticoagulants except for the following: Prophylactic use of low-dose aspirin for cardio-protection (per local applicable guidelines) and low-dose low molecular weight heparins (LMWH). Therapeutic doses of LMWH or anticoagulation with direct factor Xa inhibitors, rivaroxaban, edoxaban, or apixaban in participants without known brain metastases who are on a stable dose of the anticoagulant for at least 1 week prior to step 1 registration without clinically significant hemorrhagic complications from the anticoagulation regimen or the tumor Participants must not have evidence of preexisting uncontrolled hypertension prior to step 1 registration as documented by 2 baseline blood pressure readings taken at least 30 minutes apart within 28 days prior to step 1 registration. The baseline systolic blood pressure readings must be =< 150 mmHg and the baseline diastolic blood pressure readings must be =< 90 mmHg. Participants on antihypertensive therapies with controlled blood pressure are eligible Participants must not have a prior or concurrent malignancy whose natural history or treatment (in the opinion of the treating physician) has the potential to interfere with the safety or efficacy assessment of the investigational regimen Participants must not be pregnant or nursing due to the known safety profiles of the drugs in this study. Individuals who are of reproductive potential must have agreed to use an effective contraceptive method with details provided as a part of the consent process. A person who has had menses at any time in the preceding 12 consecutive months or who has semen likely to contain sperm is considered to be of reproductive potential. In addition to routine contraceptive methods, effective contraception also includes refraining from sexual activity that might result in pregnancy and surgery intended to prevent pregnancy (or with a side-effect of pregnancy prevention) including hysterectomy, bilateral oophorectomy, bilateral tubal ligation/occlusion and vasectomy with testing showing no sperm in the semen Have adequate tissue specimen from procedure obtained within 6 months prior to step 1 registration and after development of resistance to anti-PD-1/L1 therapy. Archival tissue must consist of tumor block or at least 20 freshly cut serially sectioned and numbered 4-5 micron unstained, positively-uncharged slides OR Be willing to undergo research biopsy AND have tumor accessible for biopsy based on the following criteria: Mediastinal, laparoscopic, gastrointestinal, or bronchial endoscopic biopsies can be obtained incidentally to a clinically necessary procedure and NOT for the sole purpose of the clinical trial Acceptable biopsy procedures are: Percutaneous biopsy with local anesthetic and/or sedation with an expected risk of severe complications < 2% Direct transoral biopsy (with or without local anesthetic and/or sedation) with an expected risk of severe complications < 2% Excisional cutaneous biopsy with local anesthetic and/or sedation with an expected risk of severe complications < 2% Biopsy with removal of additional tumor tissue during a medically necessary mediastinoscopy, laparoscopy, gastrointestinal endoscopy, bronchoscopy or craniotomy. No open surgical, laparoscopic or endoscopic procedure should be performed solely to obtain a biopsy for this protocol Removal of additional tumor tissue during a medically necessary surgical procedure Participants must have been offered the opportunity to participate in specimen banking Note: As a part of the Oncology Patient Enrollment Network (OPEN) registration process the treating institution's identity is provided in order to ensure that the current (within 365 days) date of institutional review board approval for this study has been entered in the system Participants must be informed of the investigational nature of this study and must sign and give informed consent in accordance with institutional and federal guidelines Participants with impaired decision-making capacity are eligible as long as their neurological or psychological condition does not preclude their safe participation in the study (e.g., tracking pill consumption and reporting adverse events to the investigator) STEP 2 TREATMENT REGISTRATION Participants must have been eligible for step 1 registration Participants must have had their tumor tissue submitted via the Southwest Oncology Group (SWOG) Specimen Tracking System prior to step 2 registration Participants registered during stage II of the protocol must have received assignment to an open cohort from the SWOG Statistics and Data Management Center based on their biomarker screening profile (not applicable for patients registered during stage I of the protocol) Participants must have measurable disease. All measurable disease must be assessed within 28 days prior to step 2 registration. All non-measurable disease must be assessed within 42 days prior to step 2 registration. Note: All disease must be assessed and documented on the Baseline Tumor Assessment Form (Response Evaluation Criteria in Solid Tumors [RECIST] 1.1) For melanoma participants, CT chest, abdomen and pelvis must be obtained. For HNSCC participants, CT neck and chest must be obtained. Further imaging (i.e., MR brain, CT abdomen/pelvis or extremities, bone scan) will be performed as deemed appropriate by the treating physician Participants with treated brain metastases must have no evidence of progression on the follow-up brain imaging after central nervous system (CNS)-directed therapy Participants must not have experienced any significant health changes that, in the opinion of the treating investigator, may impact continued suitability for receiving combination nivolumab/cabozantinib treatment Participants with treated brain metastases must have discontinued steroid treatment at least 14 days prior to step 2 registration Participants must not have received more than one prior primary radiotherapy regimen, curative or adjuvant, to the head and neck, with the additional following conditions: If the primary radiation is combined with chemotherapy, a minimum of 16 weeks will be required to have elapsed between the end of radiotherapy and step 2 registration. If the radiation is given alone, a minimum of 8 weeks will be required to have elapsed between the end of radiotherapy and step 2 registration Additional palliative radiotherapy regimens are permitted but cannot have been administered to previously treated tissue (i.e., overlapping fields are excluded) and must be completed at least 4 weeks prior to step 2 registration Treatment areas should be healed with no sequelae from RT that would predispose to fistula formation Participants must not have received investigational agents or monoclonal antibodies (except Food and Drug Administration [FDA] approved supportive care antibodies, such as denosumab) within 28 days prior to step 2 registration Participants must not have received any prior treatment with anti-VEGF based therapies Participants must not have received administration of a live, attenuated vaccine within 30 days prior to step 2 registration. Note: Participants may have received a messenger ribonucleic acid (mRNA) or viral vector-based coronavirus disease 2019 (COVID-19) vaccine within 30 days prior to step 2 registration Participants must not have received administration of any strong CYP3A4 inducers, such as but not limited to rifampin, carbamazepine, enzalutamide, mitotane, phenytoin and St. John's wort, within 14 days prior to step 2 registration Participants must not have received administration of any strong CYP3A4 inhibitors, such as but not limited to clarithromycin, itraconazole, ketoconazole, grapefruit juice, indinavir, nelfinavir, ritonavir, nefazodone, saquinavir, and telithromycin, within 5 times the half-life of the CYP3A inhibitor prior to step 2 registration Participants must have a history and physical examination performed within 28 days prior to step 2 registration Participants must be able to take oral medication without breaking, opening, crushing, dissolving or chewing capsules Leukocytes >= 3,000/uL (within 28 days prior to step 2 registration) Absolute neutrophil count >= 1,500/uL (within 28 days prior to step 2 registration) Platelets >= 100,000/uL (within 28 days prior to step 2 registration) Total bilirubin =< 1.5 x institutional upper limit of normal (ULN) or =< 3 x ULN for participants with Gilbert's disease (within 28 days prior to step 2 registration) Aspartate aminotransferase (AST) =< 3 x institutional ULN (within 28 days prior to step 2 registration) Alanine aminotransferase (ALT) =< 3 x institutional ULN (within 28 days prior to step 2 registration) Urinalysis: For baseline value (no required value for eligibility) Measured (OR calculated) creatinine clearance >= 30 mL/min using the following Cockcroft-Gault Formula. This specimen must have been drawn and processed within 28 days prior to step 2 registration Participants must not have malabsorption syndrome Participants must not have central lung lesions involving major blood vessels (arteries or veins) or a tumor encasing major blood vessels (e.g., carotid artery)

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: Treatment (nivolumab and cabozantinib)<br>Patients receive nivolumab IV over 30 minutes on day 1 of each cycle and cabozantinib PO daily. Cycles repeat every 28 days for 2 years in the absence of disease progression or unacceptable toxicity. Patients also undergo CT or MRI scans and collection of blood samples throughout the trial. Patients undergo a tumor biopsy during screening and optionally during follow-up. | Procedure: Biopsy<br>* Undergo tumor biopsies<br>* Other names: Bx;Procedure: Biospecimen Collection<br>* Undergo collection of blood samples<br>* Other names: Specimen Collection;Drug: Cabozantinib S-malate<br>* Given PO<br>* Other names: XL184;Procedure: Computed Tomography<br>* Undergo CT scans<br>* Other names: tomography;Procedure: Magnetic Resonance Imaging<br>* Undergo MRI scans<br>* Other names: Structural MRI;Biological: Nivolumab<br>* Given IV<br>* Other names: Opdivo;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Biomarker results turnaround time | A biomarker turnaround time estimate of at least 75% within 21 days will be considered successful with respect to feasibility. | Time-period between date of tissue submission by the site to central repository and date the site was sent notification of participant molecular group determination, assessed within 21 days | 
| Objective response rate | Confirmed and unconfirmed complete and partial responses) in molecular subgroups. Assume each biomarker level is associated with an odds-ratio of approximately 3.1 (for example, corresponding to a difference in response rate of 5 percent to 14 percent from Lo/Lo to Lo/Hi or Hi/Lo). A one-sided .10 level test for trend using (0,1,2) coding above with logistic regression has a power of 80 percent. We will also consider biomarker trend analysis adjusting for disease types. We will also conduct disease-by-biomarker interaction tests; however, there will be limited power even to detect relatively large interaction parameters. | At the end of stage I | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate and profile of >= grade 3 treatment-related adverse events | Per Common Terminology Criteria for Adverse Events 5.0. With respect to overall disease group, 60 participants are sufficient to estimate the probability of a particular toxicity to within +/- 13 percent. Any toxicity occurring with at least a 5 percent probability is likely to be seen at least once (95 percent chance). | Up to 2 years | 
| Disease control rate | Will be estimated using the method of Kaplan-Meier. | Up to 2 years | 
| Progression-free survival | Will be estimated using the method of Kaplan-Meier. | From date of registration to date of first documentation of progression or symptomatic deterioration, or death due to any cause, assessed up to 2 years | 
| Overall survival | Will be estimated using the method of Kaplan-Meier. | From date of registration to date of death due to any cause, assessed up to 2 years | 
| Turnaround time for the Tumor Inflammation Score in stage I |  | Assessed within 21 days |