A Study of Vemurafenib and Obinutuzumab Compared to Cladribine and Rituximab in People with Hairy Cell Leukemia (HCL)

Inclusion Criteria:

• Patients must be ≥ 18 years of age

• Histologically confirmed classical HCL by the enrolling institution

• Presence of BRAF V600E mutation as confirmed by PCR, NGS or immunohistochemistry. Ifpatient is known to have negative BRAF mutation, repeat testing is advisable as wellas discussion with the main study principal investigator.

• Has not received any prior therapy for the disease

• Patients who meet the standard treatment initiation criteria, as defined by ANC ≤1.0, Hgb ≤ 10.0 or PLT ≤100K

• ECOG performance status of 0 - 2

• Acceptable pre-study organ function during screening as defined as:

• Total bilirubin ≤ 1.5 times the upper limit of normal (ULN);

• Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤ 2.5x ULN;and

• Serum creatinine ≤ 1.5x ULN

• Electrocardiogram (ECG) without evidence of clinically significant ventriculararrhythmias or ischemia as determined by the investigator and a rate-corrected QTinterval (QTc, Bazett's formula) of < 480 msec

• For women of childbearing potential, agreement to the use of two acceptable methodsof contraception, including one barrier method, during the study and for 6 monthsafter discontinuation of vemurafenib and cladribine, and 18 months afterdiscontinuation of rituximab and obinutuzumab

• For men with female partners of childbearing potential, agreement to use a latexcondom and to advise their female partner to use an additional method ofcontraception during the study and for 6 months after discontinuation of vemurafenib

• Negative serum pregnancy test within 7 days of commencement of treatment in women ofchildbearing potential

Exclusion Criteria:

• Have had previous treatment for HCL, including purine analogs, vemurafenib,rituximab, obinutuzumab, and other investigational agents. Previous treatment withtransfusions and other supportive care such as G-CSF and erythropoietin are allowed.

• Known hypersensitivity to any of the study drugs.

• Patients with known long QT syndrome or uncorrectable electrolyte abnormalities

• Clinically significant history of liver disease, including viral or other hepatitis,current alcohol abuse, or cirrhosis.

• Presence of positive test results for hepatitis B virus (HBV), hepatitis B surfaceantigen (HBsAg) or hepatitis C (HCV) antibody

° Patients with occult or prior HBV infection (defined as positive total hepatitis Bcore antibody [HBcAb] and negative HBsAg) may be included if HBV DNA isundetectable. These patients must be willing to undergo monthly DNA testing and takeHBV viral prophylaxis such as entecavir.

• Known infection with HIV or human T-cell leukemia virus 1 (HTLV-1)

• Active uncontrolled infection, e.g. persistent bacteremia, supplemental oxygen orpressor supports, etc.

• Live vaccination within 28 days of randomization

• Patients with concurrent active malignancies as defined by malignancies requiringany therapy other than expectant observation or hormonal therapy, with the exceptionof squamous and basal cell carcinoma of the skin, in situ cervical cancer,adequately treated stage I/II cancer from which the patient is current in completeremission, or any other cancer from which the patient has been disease free for fiveyears

• Malabsorption syndrome or other condition that precludes enteral route ofadministration

• Patients with HCL variant (as defined by absence of expression of CD25)

• Pregnant or lactating, or intending to become pregnant during the study