Testing The Addition of a New Anti-cancer Drug Venetoclax to the Usual Treatment (Ibrutinib and Obinutuzumab) in Untreated Older Patients With Chronic Lymphocytic Leukemia

  • STATUS
    Recruiting
  • End date
    Jun 1, 2027
  • participants needed
    454
  • sponsor
    National Cancer Institute (NCI)
Updated on 23 November 2020
platelet count
fever
cancer
corticosteroids
lymphoid leukemia
anemia
chronic lymphocytic leukemia
rituximab
flow cytometry
fatigue
gilbert's syndrome
thrombocytopenia
venetoclax
neutrophil count
immunoglobulin
ibrutinib
lymphadenopathy
night sweats
lymphocytosis
obinutuzumab
constitutional symptoms

Summary

This phase III trial compares adding a new anti-cancer drug (venetoclax) to the usual treatment (ibrutinib plus obinutuzumab) in older patients with chronic lymphocytic leukemia who have not received previous treatment. The addition of venetoclax to the usual treatment might prevent chronic lymphocytic leukemia from returning. This trial also will investigate whether patients who receive ibrutinib plus obinutuzumab plus venetoclax and have no detectable chronic lymphocytic leukemia after 1 year of treatment, can stop taking ibrutinib. Ibrutinib may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth. Immunotherapy with obinutuzumab may induce changes in body's immune system and may interfere with the ability of cancer cells to grow and spread. Drugs used in chemotherapy, such as venetoclax 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 ibrutinib and obinutuzumab with venetoclax may work better at treating chronic lymphocytic leukemia compared to ibrutinib and obinutuzumab.

Description

PRIMARY OBJECTIVE:

I. To compare the progression-free survival (PFS) between control treatment and experimental treatment strategies: ibrutinib/obinutuzumab (IO) with ibrutinib maintenance (IM) versus ibrutinib/venetoclax/obinutuzumab (IVO) regardless of IM or observation.

SECONDARY OBJECTIVES:

I. To compare bone marrow (BM) minimal residual disease (MRD)- complete response (CR) rates, MRD- rates, and depth of response at cycle 15 day 1 between patients treated with IO versus IVO.

II. To compare overall survival (OS) between the control and experimental treatment strategies: IO with IM versus IVO regardless of IM or observation.

III. To compare the 5-year PFS and overall survival (OS) for the control and experimental treatment strategies: IO with IM versus IVO regardless of IM or observation.

IV. To describe the toxicity profile for each of the treatment strategies and by each treatment course.

CORRELATIVES SCIENCE OBJECTIVE:

I. To compare MRD status between blood and bone marrow at the end of induction treatment/cycle 15 day 1 to determine whether blood MRD can be used as a surrogate to bone marrow MRD with these treatment regimens.

OUTLINE: Patients are randomized to 1 of 2 arms.

ARM I: Patients receive ibrutinib orally (PO) once daily (QD) on days 1-28. Patients also receive obinutuzumab intravenously (IV) on days 1, 2, 8, and 15 of cycle 1, and on day 1 of cycles 2-6. Treatment repeats every 28 days for up to 14 cycles in the absence of disease progression or unacceptable toxicity. Beginning cycle 15, patients receive ibrutinib PO QD every 28 days in the absence of disease progression or unacceptable toxicity.

ARM II: Patients receive ibrutinib PO QD on days 1-28. Patients also receive obinutuzumab IV on days 1, 2, 8, and 15 of cycle 1, and on day 1 of cycles 2-6. Beginning cycle 3, patients also receive venetoclax PO QD on days 1-28. Treatment repeats every 28 days for 14 cycles in the absence of disease progression or unacceptable toxicity. All patients will then receive a 15th cycle of ibrutinib. Beginning cycle 16, patients who do not achieve a BM MRD negative CR, receive ibrutinib PO QD every 28 days in the absence of disease progression or unacceptable toxicity. Patients who achieve a BM MRD negative CR undergo observation every 3 cycles for 6 years, then every 6 cycles thereafter.

After completion of study treatment, patients are followed every 6 months until 10 years from registration.

Details
Treatment Ibrutinib, Obinutuzumab, Observation, venetoclax
Clinical Study IdentifierNCT03737981
SponsorNational Cancer Institute (NCI)
Last Modified on23 November 2020

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Eligibility

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Inclusion Criteria

Is your age greater than or equal to 70 yrs?
Gender: Male or Female
Do you have any of these conditions: Chronic Lymphocytic Leukemia or Lymphocytic Leukemia, Chronic?
Do you have any of these conditions: leukemia chronic lymphocytic or chronic lymphocytic leukemia (cll) or Chronic Lymphocytic Leukemia or Lymphocytic Leukemia, Chronic or small lymphocyt...?
Do you have any of these conditions: leukemia chronic lymphocytic or chronic lymphocytic leukemia (cll) or Chronic Lymphocytic Leukemia or Lymphocytic Leukemia, Chronic or small lymphocyt...?
Do you have any of these conditions: chronic lymphocytic leukemia (cll) or Lymphocytic Leukemia, Chronic or small lymphocytic lymphoma or Chronic Lymphocytic Leukemia or leukemia chronic ...?
PRE-REGISTRATION ELIGIBILITY CRITERIA (STEP 0)
Patients must have been diagnosed with chronic lymphocytic leukemia (CLL) and have > 5000 B-cells per uL of peripheral blood at any point during the course of their disease
This blood submission is mandatory prior to registration/randomization to perform fluorescence in situ hybridization (FISH) centrally that will be used for stratification. It should be obtained as soon after pre-registration as possible
REGISTRATION ELIGIBILITY CRITERIA (STEP 1)
Patients must be diagnosed with CLL in accordance with 2018 International Workshop on Chronic Lymphocytic Leukemia (IWCLL) criteria that includes all of the following
>= 5 x10^9 B lymphocytes (5000/uL) in the peripheral blood measured by flow cytometry at any point in the course of the disease
On local morphologic review, the leukemic cells must be small mature lymphocytes, and prolymphocytes must not exceed 55% of the blood lymphocytes
CLL cells on immunophenotype (performed locally) must reveal a clonal B-cell population, which express the B cell surface markers of CD19 and CD20, as well as the T-cell antigen CD5. Patients with bright surface immunoglobulin expression or lack of CD23 expression in > 10% of cells must lack t(11;14) translocation by interphase cytogenetics
Patients must be intermediate or high-risk Rai stage CLL
Intermediate risk (formerly Rai stage I/II) is defined by lymphocytosis plus enlarged lymph nodes at any site, with or without hepatomegaly or splenomegaly
High risk (formerly Rai stage III/IV) is defined by lymphocytosis with or without enlarged nodes and spleen plus disease-related anemia (hemoglobin < 11 g/dL) or thrombocytopenia (platelet count < 100 x 10^9/L) that is not attributable to autoimmune hemolytic anemia or thrombocytopenia
Patients must meet criteria for treatment as defined by 2018 IWCLL guidelines which includes at least one of the following criteria
Evidence of marrow failure as manifested by the development or worsening of anemia or thrombocytopenia (not attributable to autoimmune hemolytic anemia or thrombocytopenia)
Massive (>= 6 cm below the costal margin), progressive or symptomatic splenomegaly
Massive nodes (>= 10 cm) or progressive or symptomatic lymphadenopathy
Progressive lymphocytosis with a lymphocyte doubling time < 6 months or an increase of >= 50% over a 2 month period
Autoimmune anemia and/or thrombocytopenia that is poorly responsive to standard therapy
Symptomatic or functional extranodal involvement (e.g. skin, kidney, lung, spine)
Constitutional symptoms, which include any of the following
Unintentional weight loss of 10% or more within 6 months
Significant fatigue
Fevers > 100.5 degrees Fahrenheit (F) for 2 weeks or more without evidence of infection
Night sweats >= 1 month without evidence of infection
Treatment with rituximab and/or high dose corticosteroids for autoimmune complications of CLL must be complete at least 4 weeks prior to enrollment. Palliative steroids must be at a dose not higher than 20 mg/day of prednisone or equivalent corticosteroid at the time of registration
Eastern Cooperative Oncology Group (ECOG) performance status 0-2
Absolute neutrophil count (ANC) >= 1,000/mm3 except if due to bone marrow involvement
Platelet count (untransfused) >= 30,000/mm3
Calculated (Calc.) creatinine clearance >= 40 mL/min (by Cockcroft-Gault)
Bilirubin =< 1.5 x upper limit of normal (ULN) except if due to liver involvement, hemolysis, or Gilbert's disease
Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) =< 2.5 x upper limit of normal (ULN) except if due to liver involvement
If evidence of chronic hepatitis B virus (HBV) infection, HBV viral load must be undetectable on suppressive therapy if indicated
Please note: Intravenous immunoglobulin therapy (IVIG) can cause a false positive hepatitis B serology. If patients receiving routine IVIG have core antibody or surface antigen positivity without evidence of active viremia (negative hepatitis B deoxyribonucleic acid [DNA]) they may still participate in the study, must have hepatitis serologies and hepatitis B DNA monitored periodically by the treating physician
If history of hepatitis C virus (HCV) infection, must be treated with undetectable HCV viral load
Human immunodeficiency virus (HIV)-infected patients on effective antiretroviral therapy with undetectable viral load within 6 months are eligible for this trial
Patients must not be receiving active systemic anticoagulation with heparin or warfarin. Patients on warfarin must discontinue the drug for at least 10 days prior to registration on the study
Chronic concomitant treatment with strong inhibitors of CYP3A4/5 is not allowed on this study. Patients on strong CYP3A inhibitors must discontinue the drug for 14 days prior to registration on the study
Chronic concomitant treatment with strong CYP3A4/5 inducers is not allowed. Patients must discontinue the drug 14 days prior to registration on the study
Patients must not require more than 20 mg prednisone or equivalent corticosteroid daily
Patients must not have uncontrolled active systemic infection requiring intravenous antibiotics
Central fluorescent in situ hybridization (FISH) blood results are mandatory prior to registration/randomization for it will be used for stratification
Patients must be able to swallow capsules and not have the following conditions: disease significantly affecting gastrointestinal absorption, resection of the stomach or small bowel, partial or complete bowel obstruction
Patients must not have a known allergy to mannitol
Patients must not have prior significant hypersensitivity to rituximab (not including infusion reactions)
Patients must be able to receive either a xanthine oxidase inhibitor or rasburicase for prophylaxis/treatment of tumor lysis syndrome (TLS)
RE-REGISTRATION ELIGIBILITY CRITERIA (STEP 2)
Completion of treatment through cycle 14 day 28, and remain on ibrutinib therapy
Receipt of central BM MRD results
Response assessment completed with CR determination

Exclusion Criteria

Patients must not have had prior therapy for CLL (except palliative steroids or treatment of autoimmune complications of CLL with rituximab or steroids)
Patients must not have any history of Richter's transformation or prolymphocytic leukemia (prolymphocytes in blood > 55%)
Patients with class III or class IV heart failure by New York Heart Association, those with unstable angina, and those with uncontrolled arrhythmia are not eligible
Patients who have had a myocardial infarction, intracranial bleed, or stroke within the past 6 months are not eligible
Patients may not have had major surgery within 10 days prior to registration, or minor surgery within 7 days prior to registration. Examples of minor surgery include dental surgery, insertion of a venous access device, skin biopsy, or aspiration for a joint. The decision about whether a surgery is major or minor can be made at the discretion of the treating physician
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