A Study of Abemaciclib and Cabozantinib in People With Clear Cell Renal Cell Carcinoma (ccRCC)

Inclusion Criteria:

• Age ≥ 18 years at the time of informed consent

• Patient must be able to provide informed consent, or a legal authorizedrepresentative (LAR) must be identified to provide consent in cases where thepatient cannot

• Signed and dated IRB-approved Informed Consent Form

• Patient must have a histologically confirmed diagnosis of metastatic stage IV clearcell renal cell carcinoma.

• Patient should have availability of archival tissue that enables definitivediagnosis of ccRCC, per review at participating site, accompanied by an associatedpathology report. Specimens can be collected by surgical resection or biopsy of theprimary tumor or biopsy or resection of a metastatic lesion. NOTE: If archivaltissue is unavailable, a patient can still enroll onto the study with documentedconfirmation from the study PI.

• Patients must have at least one extra-skeletal, extracranial measurable lesion asdefined by RECIST v1.1 7. Patients must have Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2

• Patients must have progressed on at least 2 prior lines of systemic therapy and amaximum of 3 prior lines of systemic therapy in the metastatic setting

• Patient must have progressed on 1 prior PD-1 or PD-L1 targeted treatment and priorVEGFR directed TKI therapy

• Patients must have recovered to baseline or < Grade 1 CTCAE v5.0 from toxicitiesrelated to any prior treatments, unless adverse events (AEs) are clinicallynon-significant and/or stable on supportive therapy (See Appendix 2)

• Patients who received radiotherapy must have completed and fully recovered from theacute effects of radiotherapy. A washout period of at least 14 days is requiredbetween end of radiotherapy and registration.

• The patient can swallow oral medications.

• Adequate hematologic and end organ function, defined by the following laboratoryresults obtained within 14 days prior to the first study treatment:

• ANC ≥ 1500 cells/μL (without granulocyte colony stimulating factor support within 2weeks prior to Cycle 1, Day 1)

• WBC counts ≥ 2500/μL and ≤ 15,000/μL without G-CSF

• Absolute Lymphocyte count <0.5K/mcL

• Platelet count ≥100,000/μL (without transfusion within 2 weeks prior to Cycle 1, Day

• Hemoglobin ≥9.0 g/dL (without transfusion within 2 weeks prior to Cycle 1, Day 1)

• Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkalinephosphatase (ALP) ≤ 3 X upper limit of normal (ULN). ALP ≤ 5 x ULN if patient hasdocumented bone metastases.

• Serum bilirubin ≤ 1.5 x ULN. Patients with known Gilbert disease who have serumbilirubin level ≤ 2 x ULN may be enrolled.

• Serum albumin ≥ 2.8 g/dl

• (PT)/INR or partial thromboplastin time (PTT) test < 1.3x the laboratory ULN

• Estimated Glomerular Filtration Rate (eGFR) ≥ 30mL/min using the CKD-EPI formula.

• Urine protein/creatinine ratio (UPCR) ≤ 1.8 mg/mg

• Women of childbearing potential must not be pregnant or lactating at screening.

• Women of childbearing potential who are sexually active with a non-sterilized malepartner must use two methods of effective contraception from screening and mustagree to continue using such precautions for 4 months after the final dose ofinvestigational product; cessation of birth control after this point should bediscussed with a responsible physician. Periodic abstinence, the rhythm method, andthe withdrawal method are not acceptable methods of birth control.

• Sexually active participants must agree to use medically accepted methods ofcontraception (i.e. barrier methods including condoms, female condom, or diaphragmwith spermicidal gel) during the study and for 4 months after the last dose of thestudy treatment. Male patients must agree not to donate sperm during the studytreatment period and for 4 months after the last dose Female patients must agree notto donate eggs during the study period and for 4 months after the last dose.

Exclusion Criteria:

• Prior treatment with abemaciclib or cabozantinib.

• Receipt of any type of anti-cancer antibody, cytotoxic anticancer therapy, or anyother investigational agents within 2 weeks of treatment start or 5 half-lives,whichever is shorter. For immune checkpoint inhibitors, patients must havediscontinued treatment 28 days prior to trial enrollment.

• Symptomatic brain metastasis or leptomeningeal disease requiring steroid use.Patients are eligible if they are neurologically stable for 4 weeks, have completedradiation therapy or surgery, and recovered from side effects. Patients must havediscontinued steroid therapy for at least 2 weeks prior to first dose of studytreatment.

• Diagnosis of another malignancy within 2 years before first dose of study treatment,except for superficial skin cancers, or early stage cancers previously treated withcurative intent.

• Patients requiring moderate or strong CYP3A4 inducers or inhibitors (https://druginteractions.medicine.iu.edu/MainTable.aspx).

• Patients with a history of HIV infection who are not on a stable HAART regimenand/or are requiring antimicrobials for prevention of opportunistic infectionsand/or have CD4 count below 250 or a detectable HIV viral load

• Patients with active hepatitis B or hepatitis C infection with detectable viral loadby PCR

• Active systemic bacterial infection (requiring systemic antibiotics at time ofinitiating study treatment) or fungal infection.

• History of significant cardiovascular events or active cardiovascular disease;including myocardial infarction within the previous 6 months, unstable arrhythmias,unstable angina, prior sudden cardiac arrest, LVEF < 50% by echocardiogram (ECHO).

• Uncontrolled hypertension defined as sustained blood pressure (BP) > 150 mm Hgsystolic or > 90 mm Hg diastolic despite optimal antihypertensive treatment.

• Significant arterial disease (e.g., stroke, transient ischemic attack, aorticaneurysm requiring surgical repair or recent peripheral arterial thrombosis) within 6 months prior to Cycle 1, Day 1.

• Corrected QT interval calculated by the Fridericia formula (QTcF) > 470 ms perelectrocardiogram (ECG) within 28 days before first dose of study treatment.

Note: If a single ECG shows a QTcF with an absolute value > 470 ms, two additional ECGs at intervals of approximately 3 min must be performed within 30 min after the initial ECG, and the average of these three consecutive results for QTcF will be used to determine eligibility

• Concomitant anticoagulation with coumadin agents (e.g., warfarin), direct thrombininhibitors (e.g., dabigatran), direct factor Xa inhibitor betrixaban, or plateletinhibitors (e.g., clopidogrel). Allowed anticoagulants are the following:

• Prophylactic use of low-dose aspirin for cardio-protection (per localapplicable guidelines) and low-dose low molecular weight heparins (LMWH).

• Therapeutic doses of LMWH or anticoagulation with direct factor Xa inhibitorsrivaroxaban, edoxaban, or apixaban in subjects without known brain metastaseswho are on a stable dose of the anticoagulant for at least 1 week before firstdose of study treatment without clinically significant hemorrhagiccomplications from the anticoagulation regimen or the tumor.

• Clinically significant hematuria, hematemesis, or hemoptysis of > 0.5 teaspoon (2.5ml) of red blood, or other history of significant bleeding (eg, pulmonaryhemorrhage) within 12 weeks before first dose. Evidence of bleeding diathesis orsignificant coagulopathy (in the absence of therapeutic anticoagulation).

• Cavitating pulmonary lesion(s) or known endotracheal or endobronchial diseasemanifestation.

• Uncontrolled pleural effusion, pericardial effusion, or ascites requiring recurrentdrainage procedures (once monthly or more frequently)

• Major surgery (eg, GI surgery, removal or biopsy of brain metastasis) within 6 weeksbefore first dose of study treatment. Completeness of wound healing from any surgerymust be ascertained. There must be a minimum of two weeks from completion of woundhealing to start of study.

• Evidence of tumor invading the gastrointestinal tract, active peptic ulcer disease,active inflammatory bowel disease, active diverticulitis, active cholecystitis,symptomatic/active cholangitis or appendicitis, acute pancreatitis, acuteobstruction of pancreatic duct or common bile duct, or active gastric outletobstruction.

• Clinical signs or symptoms of gastrointestinal obstruction or requirement forroutine parenteral hydration, parenteral nutrition, or tube feeding.

• Patients with a history of abdominal fistula, gastrointestinal perforation, orintraabdominal abscess within 6 months prior to study enrollment.

• The patient has tumor invading or encasing any major blood vessels, with exceptionof renal vessels ipsilateral to the primary renal tumor.

• The patient has evidence of tumor invading the GI tract (esophagus, stomach, smallor large bowel, rectum or anus) at time of study screening.

• Patients with malabsorption syndrome.

• Patients with a serious non-healing wound/ulcer/bone fracture.

• Patients with active COVID-19 unless the subject has clinically recovered from thedisease at least 30 days prior to first dose of study treatment.

• Previously identified allergy or hypersensitivity to components of the studytreatment formulations.

• Radiation therapy for bone metastasis within 2 weeks before first dose of studytreatment. Systemic treatment with radionuclides within 6 weeks before first dose ofstudy treatment. Subjects with clinically relevant ongoing complications from priorradiation therapy are not eligible.

• The patient has serious and/or uncontrolled preexisting medical condition(s) that,in the judgment of the investigator, would preclude participation in this study (forexample, interstitial lung disease, severe dyspnea at rest or requiring oxygentherapy, history of major surgical resection involving the stomach or small bowel,or preexisting Crohn's disease or ulcerative colitis or a preexisting chroniccondition resulting in baseline Grade 2 or higher diarrhea).