A Phase II Multi-Center Open-Label Trial of Six Doses of Pembrolizumab Monotherapy Prior to Limited Chemotherapy as Front-Line Therapy for Patients With Classical Hodgkin Lymphoma, Including Elderly Patients.
A Phase II Multi-Center Open-Label Trial of Six Doses of Pembrolizumab Monotherapy Prior to Limited Chemotherapy as Front-Line Therapy for Patients With Classical Hodgkin Lymphoma, Including Elderly Patients.
This phase II trial tests how well giving pembrolizumab followed by chemotherapy with doxorubicin, vinblastine and dacarbazine works to treat patients with classical Hodgkin lymphoma. Pembrolizumab is a type of drug called a "monoclonal antibody (mAb)" that uses the body's immune system to help fight and kill cancer cells. Chemotherapy drugs, such as doxorubicin, vinblastine and dacarbazine, work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing or by stopping them from spreading. Giving pembrolizumab followed by chemotherapy may work to treat patients with classical Hodgkin lymphoma.
PRIMARY OBJECTIVE:
I. To assess the percent of patients that achieve a complete response (CR) after frontline pembrolizumab monotherapy induction, among classic Hodgkin lymphoma (cHL) patients with early unfavorable or advanced stage disease, per Lugano 2014 response criteria at positron emission tomography (PET) #2.
SECONDARY OBJECTIVES:
I. To assess the efficacy of a reduced number of cycles (2-4) of doxorubicin (adriamycin), vinblastine, and dacarbazine (AVD) when used following treatment with frontline pembrolizumab monotherapy in classic Hodgkin lymphoma (cHL), per Lugano 2014 Response Criteria.
II. To assess the safety and tolerability of sequential immunotherapy with upfront pembrolizumab followed by AVD chemotherapy in cHL per National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version (ver.) 5.0.
III. To assess progression-free-survival (PFS) of cHL patients who received sequential immunotherapy with upfront pembrolizumab followed by AVD chemotherapy, assessed by central review, according to Lugano 2014 Response Criteria.
IV. To assess overall survival (OS) of cHL patients who received sequential immunotherapy with upfront pembrolizumab followed by AVD chemotherapy.
V. To assess the CR rate at the end of pembrolizumab (PEM) induction by PET-computed tomography (CT) in all treated patients, regardless of number of cycles of PEM received, per Lugano 2014 Response Criteria.
OUTLINE:
INDUCTION: Patients receive pembrolizumab intravenously (IV) over 30 minutes on day 1 of each cycle. Treatment repeats repeat every 21 days for 3 cycles in the absence of disease progression or unacceptable toxicity. Patients then undergo disease assessment. Patients with a response complete 3 additional cycles of pembrolizumab, undergo disease assessment and proceed to consolidation. Patients without response or with progressive disease proceed to consolidation.
CONSOLIDATION: Patients receive doxorubicin IV, vinblastine IV and dacarbazine IV on days 1 and 15 of each cycle. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity for 2 to 6 cycles dependent upon response and disease type. Patients undergo echocardiography/ multigated acquisition (MUGA) scan, CT scan, PET scan and blood sample collection throughout the study and may undergo tumor biopsy during screening.
After completion of study treatment, patients are followed up at 30 days, every 3 months for 1 year, and every 6 months for 4 years.
Inclusion Criteria:
NCCN Unfavorable Factors include bulky disease defined as:
A mass >10 cm disease in any dimension or
Mediastinal mass ratio greater than one third defined as maximum width of mediastinal ass/intrathoracic diameter at T5-6
B symptoms
Erythrocyte sedimentation rate (ESR) ≥ 50
And >3 sites of disease
Platelet transfusions are acceptable prior to treatment to achieve the above numbers, however growth factors are not allowed within 14 days of registration
No lower limit if cytopenia is related to bone marrow involvement.
Platelet transfusions are acceptable prior to treatment to achieve the above numbers, however growth factors are not allowed within 14 days of registration
No lower limit if cytopenia is related to bone marrow involvement
Platelet transfusions are acceptable prior to treatment to achieve the above numbers, however growth factors are not allowed within 14 days of registration
No lower limit if cytopenia is related to bone marrow involvement
Platelet transfusions are acceptable prior to treatment to achieve the above numbers, however growth factors are not allowed within 14 days of registration
No lower limit if cytopenia is related to bone marrow involvement
Total bilirubin ≤1.5 × institutional upper limit of normal (ULN) OR direct bilirubin ≤ institutional ULN for participants with total bilirubin levels >1.5 × institutional ULN
Aspartate aminotransferase (AST)(serum glutamic oxaloacetic transaminase [SGOT]) ≤ 2.5 x institutional ULN
≤ 5 × institutional ULN for participants with liver metastases
Alanine aminotransferase (ALT) (serum glutamic pyruvic transaminase [SGPT]) ≤ 2.5 x institutional ULN
≤ 5 × institutional ULN for participants with liver metastases
Creatinine OR measured or calculated creatinine clearance (CrCl) (Glomerular filtration rate [GFR] can also be used in place of creatinine or CrCl) ≤ 1.5 x institutional ULN or ≥ 30 mL/min for participant including for participants with creatinine levels > 1.5 × institutional ULN
Creatinine clearance (CrCl) should be calculated per institutional standard
NOTE: A POCBP is any person with an egg-producing reproductive tract (regardless of sexual orientation, having undergone a tubal ligation, or remaining celibate by choice) who meets the following criteria:
Has not undergone a hysterectomy or bilateral oophorectomy
Has had menses at any time in the preceding 12 consecutive months (and therefore has not been naturally postmenopausal for > 12 months)
Exclusion Criteria:
NOTE: If patient received major surgery, they must have recovered adequately from the toxicity and/or complications from the intervention prior to starting therapy. No radiation therapy for Hodgkin lymphoma (cHL) will be allowed prior to and while participation on this clinical trial, including for system control
NOTE: Patients who have entered the follow-up phase of an investigational study will be eligible to participate as long as ≥ 30 days has elapsed since the administration of the last dose of an investigational treatment for a disease/condition other than cHL
Patients who have known active central nervous system (CNS) metastases and/or lymphomatous meningitis are not eligible
Patients who have a history of allergic reactions attributed to compounds of similar chemical or biologic composition to pembrolizumab, and/or any of its excipients
Patients who have any contraindication to the use of any of the chemotherapeutic agents used in this study
Patients who have had an allogenic tissue or solid organ transplant
Patients who are pregnant or nursing NOTE: Pregnant persons are excluded from this study because the chemotherapy regimen (AVD) includes adriamycin (also known as doxorubicin), which is an anthracycline; anthracyclines are known chemotherapy agents with the potential for teratogenic or abortifacient effects. In addition, the investigational agent, pembrolizumab, has the potential for embryo-fetal toxicity. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with adriamycin (doxorubicin) as part of the AVD chemotherapy regimen, and the investigational agent, pembrolizumab, breastfeeding should be discontinued if the mother is treated with AVD and/or pembrolizumab.
Patients who have a diagnosis of immunodeficiency or are receiving systemic steroid therapy or any other form of immunosuppressive therapy within 7 days prior to registration are not eligible. NOTE: Replacement therapy (e.g., thyroxine, insulin, physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency) is not considered a form of systemic treatment and is allowed
Patients who have a known history of active TB (Bacillus Tuberculosis) are not eligible
Patients who have an uncontrolled intercurrent illness including, but not limited to any of the following, are not eligible:
Patients who have any prior malignancy OR a known additional malignancy that is progressing or requires active treatment are not eligible. NOTE: Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the skin that has undergone potentially curative therapy or in situ cervical cancer. Participants with low-risk early-stage prostate cancer (T1-T2a, Gleason score ≤ 6, and PSA < 10 ng/mL) either treated with definitive intent or untreated in active surveillance with stable disease are not excluded
Patients who have active autoimmune disease that has required systemic treatment in the past 2 years are not eligible (i.e. with use of disease modifying agents, corticosteroids or immunosuppressive drugs) NOTE: Replacement therapy (e.g. thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment and is allowed
Patients who have a history of (non-infectious) pneumonitis that required steroids or current pneumonitis are not eligible
Patients who have an active infection requiring systemic therapy are not eligible, except for uncomplicated urinary tract infections
Patients are not eligible who have a history or current evidence of any condition, therapy, or laboratory abnormality that might confound the results of the trial, interfere with the subject's participation for the full duration of the trial, or is not in the best interest of the subject to participate, in the opinion of the treating investigator
Patients who have known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the trial are not eligible
Patients may not be pregnant or breastfeeding or expecting to conceive or father children within the projected duration of the trial, from registration through 120 days after the last dose of trial treatment
Patients who have received prior therapy with an anti-PD-1, anti-PD-L1, anti-PD-L2, anti-CTLA-4, anti-OX-40 or anti-LAG-3 agent are not eligible
Patients who have a known history of Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies) are not eligible NOTE: HIV testing is not required unless mandated by local health authority
Patients who have an active hepatitis B (e.g., hepatitis B surface antigen [HbsAg] reactive) or hepatitis C (e.g. hepatitis C virus [HCV] ribonucleic acid [RNA] [qualitative] is detected) are not eligible. NOTE: Testing for hepatitis B or C is not required unless mandated by local health authority
Patients requiring urgent tumor debulking
Patients who received a live vaccine within 30 days of planned start of study therapy are not eligible. Examples of live vaccines include, but are not limited to, the following: measles, mumps, rubella, some varicella/zoster vaccines, yellow fever, rabies, bacillus calmette-guerin (BCG), and typhoid vaccine.
NOTE: Seasonal influenza vaccines for injection are generally inactivated flu vaccines and are allowed; however intranasal influenza vaccines (e.g., Flu-Mist®) are live attenuated vaccines, and are not allowed. Coronavirus 19 (COVID-19) vaccines for injection are generally messenger RNA vaccines and are also allowed