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This phase II trial studies how well onvansertib in combination with gemcitabine and nab-paclitaxel works in treating patients with pancreatic ductal carcinoma (PDAC) that has spread to nearby tissue or lymph nodes (locally advanced), that cannot be removed by surgery (unresectable), or that has spread from where it first started (primary site) to other places in the body (metastatic). Onvansertib is a small chemical molecule that binds and stops the function of of PLK1 in tumor cells. By attacking the PLK1 protein, onvansertib is thought to reduce tumor cells ability to replicate and grow; causing them to die. Chemotherapy drugs, such as gemcitabine and nab-paclitaxel, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving chemotherapy with onvansertib may kill more tumor cells in patients with locally-advanced, unresectable, or metastatic pancreatic ductal carcinoma.

PRIMARY OBJECTIVE:

I. To assess preliminary response to treatment with onvansertib and gemcitabine and nab-paclitaxel (GnP).

SECONDARY OBJECTIVES:

I. To assess the safety of onvansertib in combination with GnP. II. To assess the rate of disease control following treatment with onvansertib and GnP in patients with PDAC.

III. To estimate the duration of response (DOR). IV. To estimate the time to disease progression. V. To estimate the progression-free survival associated with onvansertib and GnP.

VI. To estimate the overall survival associated with onvansertib and GnP.

EXPLORATORY OBJECTIVE:

I. To evaluate therapy induced changes in the tumor and tumor ecosystem.

OUTLINE: This is a safety lead-in study of onvansertib in combination with GnP, followed by a phase II study. Patients are assigned to 1 of 2 groups.

GROUP 1: Patients receive onvansertib orally (PO) once daily (QD) on days 1-5, 8-12, and 15-19 and gemcitabine intravenously (IV) and nab-paclitaxel IV on days 1, 8, and 15. Treatment repeats every 28 days for up to 12 cycles in the absence of disease progression or unacceptable toxicity. Patients undergo electrocardiography at baseline, as well as blood sample collection, tumor biopsy, computed tomography (CT), magnetic resonance imaging (MRI), and/or positron emission tomography (PET) throughout the trial.

GROUP 2: Patients receive onvansertib PO QD on days 1-10. Patients then receive onvansertib, gemcitabine, and nab-paclitaxel as in Group 1. Treatment repeats every 28 days for up to 12 cycles in the absence of disease progression or unacceptable toxicity. Patients undergo electrocardiography at baseline, as well as blood sample collection, tumor biopsy, CT, MRI, and/or PET throughout the trial.

Upon completion of the study treatment, patients are followed up at 30 days and then every 3 months for up to 12 months from date of last dose of study drug.

Inclusion Criteria:

• Must provide written informed consent before any study-specific procedures or interventions are performed

• Must be ≥ 18 years old at the time of informed consent

• Eastern Cooperative Oncology Group (ECOG) performance status of 0-2

• Histologically or cytologically-proven adenocarcinoma of the exocrine pancreas with locally advanced or metastatic disease

• Must not have received prior radiotherapy, surgery, chemotherapy or investigational therapy for the treatment of metastatic disease. Prior palliative radiotherapy of metastases for alleviation of pain is permitted provided that irradiated metastases are not target lesions

• Patient must be eligible to receive GnP regimen for the treatment of their PDAC in accordance with institutional standards

• Must have measurable disease as defined by Response Evaluation Criteria in Solid Tumors (RECIST) version (v)1.1

• Must have at least one disease lesion that is amenable to biopsy procedures performed per institutional standards

  • Group 1 participant must agree to undergo two (2) research biopsies
  • Group 2 participants must agree to undergo three (3) research biopsies

• Hemoglobin ≥ 8.0 g/dL

• Absolute neutrophil count (ANC) ≥ 1.5 x 10^9/L (> 1500 per mm^3)

• Platelet count ≥ 100 x 10^9/L (> 100,000 per mm^3);

• Creatinine ≤ 1.5 x upper limit of normal (ULN), or measured or calculated creatinine clearance > 50 mL/min/1.73 m^2 (per Cockcroft-Gault equation)

• Aspartate aminotransferase (AST)/alanine aminotransferase (ALT): ≤ 3 x ULN, or ≤ 5 x ULN in presence of liver metastases

• Participants of childbearing potential (POCBP) must agree to abstain from sexual intercourse or use effective non-hormonal methods of contraception starting with the first dose of study therapy through 90 days from the last dose of study intervention

• POCBP may participate provided they have a negative serum pregnancy test at screening and a negative serum OR urine pregnancy test within 7 days of starting treatment

• Sperm-producing participants must agree to abstain from sexual intercourse or use effective contraception starting with the first dose through 1 month after last dose of study intervention

Exclusion Criteria:

• Concomitant use of other anti-cancer therapy (chemotherapy, immunotherapy, hormonal therapy (hormone replacement therapy is acceptable), radiotherapy (except for palliative), biological therapy or other novel agent) or live virus and live bacterial vaccines while receiving study medication

• Prior treatment with a PLK1 inhibitor

• Known severe hypersensitivity to onvansertib, gemcitabine, or nab-paclitaxel, or to any excipient of these medicinal products, or history of allergic reactions attributed to compounds of similar chemical or biologic composition

• Major surgery within 6 weeks prior to enrollment

• Uncontrolled intercurrent illness including symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, and myocardial infarction within 3 months of initiating study intervention

• QT interval with Fridericia's correction (QTcF) > 470 milliseconds

  • The QTcF should be calculated based on a mean of triplicate electrocardiogram (ECGs). In the case of potentially correctible causes of QT prolongation (e.g., medications, hypokalemia), the triplicate ECG may be repeated once during Screening and that result may be used to determine eligibility
  • Use of concomitant medications known to increase QTc or risk of Torsades. These drugs should only be used if there are no other alternatives and only with appropriate monitoring (i.e., electrocardiograms)
  • Presence of risk factors for torsade de pointes, including family history of Long QT Syndrome or uncorrected hypokalemia

• Known dysphagia, short-gut syndrome, gastroparesis, or other conditions that limit the ingestion or gastrointestinal absorption of drugs administered orally

• Use of strong CYP3A4 or UGT1A1 inhibitors or strong CYP3A4 inducers. Individuals currently receiving these agents who are able to switch to alternate therapy are still eligible for participation

  • CYP3A4 or UGT1A1 inhibitors should be stopped at least one week prior to the first dose of onvansertib
  • CYP3A4 inducers should be stopped at least two weeks prior to the first dose of onvansertib

• Psychiatric illness/social situations that would limit compliance with study requirements

• Any concurrent severe and/or uncontrolled medical condition (e.g. uncontrolled diabetes, infection, hypertension, etc.)

• Participant is pregnant or breastfeeding, or expecting to conceive or sire children within the projected duration of the trial, starting with the screening visit through 90 days after the last dose of trial treatment

• Judgment by the investigator that the patient should not participate in the study if the patient is unlikely to comply with study procedures, restrictions and requirements