Safety Testing of Adding Nivolumab to Chemotherapy in Patients With Intermediate and High-Risk Local-Regionally Advanced Head and Neck Cancer

Study Overview
=================
Brief Summary
-----------------
This study will evaluate the safety of adding nivolumab to several chemotherapy platforms with weekly cisplatin, high-dose cisplatin, cetuximab or radiation therapy alone.

Official Title
-----------------
Safety Evaluations of Nivolumab (Anti-PD-1) Added To Chemotherapy (CRT) Platforms In Patients With Intermediate And High-Risk Local-Regionally Advanced Head and Neck Squamous Cell Carcinoma

Conditions
-----------------
Head and Neck Squamous Cell Carcinoma (HNSCC)

Intervention / Treatment
-----------------
* Drug: Nivolumab
* Drug: Cisplatin
* Drug: Cetuximab
* Radiation: IMRT


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Histologically or cytologically-confirmed diagnosis of HNSCC of the oral cavity, oropharynx, larynx, or hypopharynx. Intermediate-risk group: Oropharynx cancer that is p16-positive by immunohistochemistry with smoking status > 10 Pack-years, stage T1-2N2b-N3 OR ≤ 10 pack-years, stage T4N0-N3 or T1-3N3. High-risk group: Oral cavity, larynx, hypopharynx, or p16-negative oropharynx cancer, stage T1-2N2a-N3 or T3-4-N0-3 based on the following diagnostic workup: Mandatory submission of H&E and p16 stained slides for central review of p16 staining is required for oropharyngeal patients and H&E stained slide block (or punch biopsy of paraffin block) for PD-L1 expression analysis for all patients History/physical examination within 28 days prior to registration Examination by Radiation Oncologist, Medical Oncologist, and Ear, Nose, Throat (ENT) or Head & Neck Surgeon within 28 days prior to registration Fiberoptic exam with laryngopharyngoscopy within 28 days prior to registration Diagnostic quality, cross sectional imaging of the thorax within 28 days prior to registration; 18-F-FDG-PET/CT or conventional CT are acceptable. Diagnostic quality CT or MRI of neck, with contrast, within 28 days prior to registration; a 18-F-FDG-PET/CT of the neck only is acceptable as a substitute if the CT is of diagnostic quality and with IV contrast. Age ≥ 18 years The trial is open to both genders Exclusion Criteria: Definitive clinical or radiologic evidence of distant (beyond cervical lymph node and neck tissue) metastatic disease. Patients with oral cavity cancer are excluded from participation if resection of the primary tumor is considered technically feasible by an oral or head and neck cancers surgical subspecialist. Carcinoma of the neck of unknown primary site origin (even if p16-positive). Absence of RECIST, v. 1.1 defined measurable disease. Gross total excision of both primary and nodal disease; this includes tonsillectomy, local excision of primary site, and nodal excision that removes all clinically and radiographically evident disease. Patients with RECIST, v. 1.1 evaluable remaining cancer either in the neck or primary site remain eligible. Simultaneous primary cancers or separate bilateral primary tumor sites. Prior invasive malignancy (except non-melanomatous skin cancer) unless disease free for a minimum of 3 years; (for example, carcinoma in situ of the breast, oral cavity, or cervix are all permissible). Prior systemic chemotherapy for the study cancer. Prior radiotherapy to the region of the study cancer that would result in overlap of radiation therapy fields. Patients with active autoimmune disease, with exceptions of vitiligo, type I diabetes mellitus, hypothyroidism and psoriasis. Use of systemic corticosteroids (> 10 mg daily prednisone or equivalent) or other immunosuppressive medications within 14 days of study drug administration, with exception of inhaled or topical steroids. Known immunosuppressive disease, for example HIV infection or history of bone marrow transplant or chronic lymphocytic leukemia (CLL).

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Non-Randomized
Intervention Model: Sequential Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Arm 1 (Nivolumab + Cisplatin)<br>Patients will receive Nivolumab via IV administration every 14 days for 10 doses starting 14 days prior to IMRT. Cisplatin will be given weekly. IMRT will be given at 5 fractions per week for 7 weeks for a dose of 70 Gy. Adjuvant nivolumab every 28 days for 7 doses will be administered starting 3 months after end of chemoradiation. Adjuvant administration of nivolumab may be discontinued if more than 4 of first 8 patients receive less than 7 doses. | Drug: Nivolumab<br>* Anti-PD-1 targeted immunotherapy<br>* Other names: Opdivo;Drug: Cisplatin<br>* Anti-cancer alkylating agent<br>* Other names: Platinol;Radiation: IMRT<br>* High-precision radiotherapy<br>* Other names: Intensity Modulated Radiation Therapy;|
| Experimental: Arm 2 (Nivolumab + High-dose Cisplatin)<br>Patients will receive Nivolumab via IV administration starting 14 days prior to IMRT, then Day 1 of IMRT and then every 21 days for 6 doses. Cisplatin will be given every 21 days for 3 doses. IMRT will be given at 5 fractions per week for 7 weeks for a dose of 70 Gy. Adjuvant nivolumab every 28 days for 7 doses will be administered starting 3 months after end of chemoradiation. Adjuvant administration of nivolumab may be discontinued if more than 4 of first 8 patients receive less than 7 doses. | Drug: Nivolumab<br>* Anti-PD-1 targeted immunotherapy<br>* Other names: Opdivo;Drug: Cisplatin<br>* Anti-cancer alkylating agent<br>* Other names: Platinol;Radiation: IMRT<br>* High-precision radiotherapy<br>* Other names: Intensity Modulated Radiation Therapy;|
| Experimental: Arm 3 (Nivolumab + Cetuximab)<br>Patients will receive Nivolumab via IV administration every 14 days for 10 doses starting 14 days prior to IMRT. Cetuximab will be given for 7 doses. IMRT will be given at 5 fractions per week for 7 weeks for a dose of 70 Gy. Adjuvant nivolumab every 28 days for 7 doses will be administered starting 3 months after end of chemoradiation. Adjuvant administration of nivolumab may be discontinued if more than 4 of first 8 patients receive less than 7 doses. | Drug: Nivolumab<br>* Anti-PD-1 targeted immunotherapy<br>* Other names: Opdivo;Drug: Cetuximab<br>* Epidermal Growth Factor Receptor (EGFR) antagonist<br>* Other names: Erbitux;Radiation: IMRT<br>* High-precision radiotherapy<br>* Other names: Intensity Modulated Radiation Therapy;|
| Experimental: Arm 4 (Nivolumab + IMRT)<br>Patients will receive Nivolumab via IV administration every 14 days for 10 doses starting 14 days prior to IMRT. IMRT will be given at 5 fractions per week for 7 weeks for a dose of 70 Gy. Adjuvant nivolumab every 28 days for 7 doses will be administered starting 3 months after end of chemoradiation. Adjuvant administration of nivolumab may be discontinued if more than 4 of first 8 patients receive less than 7 doses. | Drug: Nivolumab<br>* Anti-PD-1 targeted immunotherapy<br>* Other names: Opdivo;Radiation: IMRT<br>* High-precision radiotherapy<br>* Other names: Intensity Modulated Radiation Therapy;|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Dose Limiting Toxicity (DLT) | A nivolumab attributable, dose-limiting toxicity (DLT) will be defined as follows: 1) Any ≥ grade 3 adverse event (CTCAE, v. 4) that is related to nivolumab that does not resolve to grade 1 or less within 28 days; 2) A delay in radiotherapy of > 2 weeks due to toxicity related to nivolumab; 3) Inability to complete radiotherapy due to toxicity related to nivolumab; 4) Inability to receive an adequate dose (≥ 70%) of cisplatin (Arm 1 and 2) or cetuximab (Arm 3) due to toxicity definitely related to nivolumab. | From the first dose of nivolumab to 28 days after the completion of radiation therapy. | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
Head and Neck Squamous Cell Carcinoma, HNSCC, Nivolumab