Clinical trial NCT03289299: Aggressive Smoldering Curative Approach Evaluating Novel Therapies and Transplant
Official title: Aggressive Smoldering Curative Approach Evaluating Novel Therapies (ASCENT): A Phase 2 Trial of Induction, Consolidation, and Maintenance in Subjects With High Risk Smoldering Multiple Myeloma (SMM)
Study type: INTERVENTIONAL
Overall status: ACTIVE_NOT_RECRUITING
Phase: PHASE2
Conditions: Smoldering Multiple Myeloma
Keywords: myeloma
MRD
smoldering
Lead sponsor: International Myeloma Foundation
Sponsor class: OTHER
Collaborators: name: Amgen
name: Janssen Scientific Affairs, LLC
name: Celgene
name: Trevie, Inc.
First posted: 2017-09-20
Enrollment: 87
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NA
Intervention model: SINGLE_GROUP
Intervention model description: Subjects will receive treatment in 3 phases - induction (6 cycles), consolidation (6 cycles), and maintenance (12 cycles).
Primary purpose: TREATMENT

Brief summary: This study evaluates the use of carfilzomib, lenalidomide, daratumumab, and dexamethasone in subjects with high-risk smoldering multiple myeloma (SMM). Subjects will receive treatment in 3 phases - induction (6 cycles), consolidation (6 cycles), and maintenance (12 cycles). Each cycle is 28 days.

Detailed description: This study is a multi-center phase 2 study of carfilzomib, lenalidomide, daratumumab, and dexamethasone in subjects with high-risk smoldering multiple myeloma (SMM). Myeloma remains incurable with the current approaches. The typical natural history of myeloma is one of repeated relapses, accompanied by genetic evolution and development of new abnormalities, which are often responsible for drug resistance. The presence of a precursor phase of smoldering myeloma, and the ability to identify those at the highest risk of progression, sets the stage to examine the possibility that we can cure the disease through early intervention. In order to potentially achieve this, we need to develop a highly effective combination that includes the most active drugs from different classes. Carfilzomib in combination with lenalidomide and dexamethasone results in high response rates and deep responses in subjects with newly diagnosed myeloma. Daratumumab in combination with lenalidomide results in high response rates in relapsed refractory disease. All these drugs are well tolerated and subjects are able to stay on them long term as a maintenance treatment. The combination of the carfilzomib, lenalidomide, daratumumab and dexamethasone presents the potential to enhance the effectiveness of the regimens. We hypothesize that this combination will lead to deep response including a higher proportion of minimal residual disease (MRD) negative disease among those with high risk smoldering myeloma and may translate into cure or long term disease quiescence.

Eligibility criteria: Inclusion Criteria:

* Age 18 years and ≤ 80 years
* High risk smoldering myeloma, which is untreated, as defined by either of the two following criteria:

  1. Presence of any two of the following: Serum M spike \> 2 gm/dL OR an involved to uninvolved free light chain (FLC) ratio \> 20 OR bone marrow PC% \> 20%
  2. Total score of 9 or above using the following scoring system:

FLC Ratio \>10-25 = 2 \>25-40 = 3 \> 40 = 5

Serum M Protein (g/dL) \>1.5-3 = 3 \>3 = 4

BMPC% \>15-20 = 2 \>20-30 = 3 \>30-40 = 5 \>40 = 6

FISH abnormality (t(4,14), t(14,16), 1q gain, or del13q = 2

* The following laboratory values obtained 14 days prior to registration.
* Calculated creatinine clearance (using Cockcroft-Gault equation below)\* ≥ 30 mL/min
* Absolute neutrophil count (ANC) ≥ 1000/mm3 (without the use of growth factors)
* Platelet count ≥ 75000/mm3
* Hemoglobin ≥8.0 g/dL
* Total bilirubin ≤ 1.5 x upper limit of normal (ULN)
* alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤ 3 x ULN
* left ventricular ejection fraction (LVEF) ≥ 40%
* LVEF ≥ 40%
* Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0 or 1 (Appendix VII)
* Previously untreated.
* Provide informed written consent.
* Negative pregnancy test done ≤14 days prior to cycle 1 day 1, for women of childbearing potential only.
* All study participants must be registered into the mandatory Revlimid Risk Evaluation and Mitigation Strategy (REMS®) program and be willing and able to comply with the requirements of the REMS® program.
* Females of reproductive potential must adhere to the scheduled pregnancy testing as required in the Revlimid REMS® program.
* Willing to follow strict birth control measures as outlined in the protocol.

Female subjects: If they are of childbearing potential, agree to one of the following:

* Practice 2 effective methods of contraception, at the same time, from the time of signing the informed consent form through 90 days after the last dose of trial drug, AND must also adhere to the guidelines of any treatment-specific pregnancy prevention program, if applicable, OR
* Agree to practice true abstinence when this is in line with the preferred and usual lifestyle of the subject. (Periodic abstinence \[e.g., calendar, ovulation, symptothermal, post-ovulation methods\] and withdrawal are not acceptable methods of contraception.)

Male subjects: even if surgically sterilized (i.e., status post-vasectomy), must agree to one of the following:

* Agree to practice effective barrier contraception during the entire trial treatment period and through 90 days after the last dose of trial drug, OR
* Must also adhere to the guidelines of any treatment-specific pregnancy prevention program, if applicable, OR
* Agree to practice true abstinence when this is in line with the preferred and usual lifestyle of the subject. (Periodic abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation methods\] and withdrawal are not acceptable methods of contraception).

  * Willing to return to enrolling institution for follow-up during the Active Treatment Phase of the trial.
  * Male subjects must agree not to donate sperm for at least 90 days after the last dose of study treatment.
  * Willing to provide samples for planned research
  * Life expectancy \> 6 months
  * Able to take aspirin (325 mg) daily as prophylactic anticoagulation. Subjects intolerant to aspirin may use warfarin or low dose molecular weight heparin, novel oral anticoagulants, or low dose molecular weight heparin

Exclusion Criteria:

* monoclonal gammopathy of undetermined significance (MGUS), standard risk smoldering myeloma, active myeloma by current IMWG definition, light chain amyloidosis with organ involvement or patients with extramedullary disease.
* Diagnosed or treated for another malignancy ≤ 2 years before trial enrollment or previously diagnosed with another malignancy and have any evidence of residual disease. NOTE: Subjects with nonmelanoma skin cancer or carcinoma in situ of any type are not excluded if they have undergone complete resection.
* If any of the following exist at screening, subject will not be eligible for trial because this trial involves an investigational agent whose genotoxic, mutagenic and teratogenic effects on the developing fetus and newborn are unknown:

  * Pregnant women
  * Nursing women
  * Men or women of childbearing potential who are unwilling to employ adequate contraception (per protocol)
* Other co-morbidity which would interfere with subject's ability to participate in trial, e.g. uncontrolled infection, uncompensated heart or lung disease.
* Other concurrent chemotherapy, or any ancillary therapy considered investigational. NOTE: Bisphosphonates are considered to be supportive care rather than therapy, and are thus allowed while on protocol treatment.
* Peripheral neuropathy ≥ Grade 3 on clinical examination or grade 2 with pain within 30 days prior to C1D1.
* Major surgery ≤14 days prior to C1D1.
* Evidence of current uncontrolled cardiovascular conditions, including hypertension, cardiac arrhythmias, congestive heart failure, unstable angina, or myocardial infarction within the past 6 months. Note: Prior to trial entry, any ECG abnormality at screening must be documented by the investigator as not medically relevant.
* New York Heart Association (NYHA) II, III, IV heart failure
* Known human immunodeficiency virus (HIV) positive.
* Seropositive for hepatitis B (defined by a positive test for hepatitis B surface antigen \[HBsAg\]). Subjects with resolved infection (ie., subjects who are HBsAg negative but positive for antibodies to hepatitis B core antigen \[anti-HBc\] and/or antibodies to hepatitis B surface antigen \[anti-HBs\]) must be screened using real-time polymerase chain reaction (PCR) measurement of hepatitis B virus (HBV) DNA levels. Those who are PCR positive will be excluded. EXCEPTION: subjects with serologic findings suggestive of HBV vaccination (anti-HBs positivity as the only serologic marker) AND a known history of prior HBV vaccination, do not need to be tested for HBV DNA by PCR.
* Known or suspected active hepatitis C infection.
* Any medical or psychiatric illness that could, in the investigator's opinion, potentially interfere with the completion of treatment according to this protocol.
* Prior radiation therapy for bony lesions or plasmacytomas
* Known allergies, hypersensitivity, or intolerance to corticosteroids, monoclonal antibodies or human proteins, or their excipients (refer to respective package inserts or Investigator's Brochure), or known sensitivity to mammalian-derived products. Known allergies, hypersensitivity, or intolerance to trial drugs.
* Inability to comply with protocol/procedures.

Primary outcomes:
measure: Stringent complete response rate
timeFrame: During treatment
Secondary outcomes:
measure: MRD negativity after each treatment phase
timeFrame: 6 months, 12 months, and 2 years
measure: MRD negativity at 1 year post treatment
timeFrame: 1 year post treatment
measure: Overall Survival
timeFrame: up to 10 years post registration
measure: Progression-free survival
timeFrame: up to 10 years post registration
measure: Adverse events
timeFrame: 2 years
Other outcomes:
Locations:
city: Tampa
country: United States
facility: Moffitt Cancer Center
state: Florida
city: Chicago
country: United States
facility: University of Chicago Medical Center
state: Illinois
city: Indianapolis
country: United States
facility: Indiana University Simon Cancer Center
state: Indiana
city: Westwood
country: United States
facility: University of Kansas Cancer Center
state: Kansas
city: Baltimore
country: United States
facility: University of Maryland Medical Center
state: Maryland
city: Rochester
country: United States
facility: Mayo Clinic
state: Minnesota
city: New York
country: United States
facility: Weill Cornell Medicine
state: New York
city: Charlotte
country: United States
facility: Levine Cancer Institute
state: North Carolina
city: Seattle
country: United States
facility: Swedish Cancer Institute
state: Washington
city: Milwaukee
country: United States
facility: Medical College of Wisconsin
state: Wisconsin
Study officials:
affiliation: Mayo Clinic
name: Shaji Kumar, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: International Myeloma Foundation
name: Brian Durie, MD
role: PRINCIPAL_INVESTIGATOR
References: