Testing Cabozantinib in Patients With Advanced Pancreatic Neuroendocrine and Carcinoid Tumors

Purpose

This phase III trial studies cabozantinib to see how well it works compared with placebo in treating patients with neuroendocrine or carcinoid tumors that may have spread from where it first started to nearby tissue, lymph nodes, or distant parts of the body (advanced). Cabozantinib is a chemotherapy drug known as a tyrosine kinase inhibitor, and it targets specific tyrosine kinase receptors, that when blocked, may slow tumor growth.

Conditions

  • Carcinoid Tumor
  • Functioning Pancreatic Neuroendocrine Tumor
  • Intermediate Grade Lung Neuroendocrine Neoplasm
  • Locally Advanced Digestive System Neuroendocrine Neoplasm
  • Locally Advanced Digestive System Neuroendocrine Tumor G1
  • Locally Advanced Lung Neuroendocrine Neoplasm
  • Locally Advanced Pancreatic Neuroendocrine Tumor
  • Locally Advanced Unresectable Digestive System Neuroendocrine Neoplasm
  • Low Grade Lung Neuroendocrine Neoplasm
  • Lung Neuroendocrine Tumor
  • Lung Neuroendocrine Tumor G2
  • Metastatic Digestive System Neuroendocrine Neoplasm
  • Metastatic Digestive System Neuroendocrine Tumor G1
  • Metastatic Lung Neuroendocrine Neoplasm
  • Metastatic Lung Neuroendocrine Tumor
  • Metastatic Pancreatic Neuroendocrine Neoplasm
  • Metastatic Pancreatic Neuroendocrine Tumor
  • Metastatic Thymic Neuroendocrine Neoplasm
  • Neuroendocrine Neoplasm
  • Neuroendocrine Tumor G2
  • Non-Functioning Pancreatic Neuroendocrine Tumor
  • Pancreatic Serotonin-Producing Neuroendocrine Tumor
  • Thymic Neuroendocrine Tumor
  • Unresectable Digestive System Neuroendocrine Neoplasm
  • Unresectable Digestive System Neuroendocrine Tumor G1
  • Unresectable Lung Neuroendocrine Neoplasm
  • Unresectable Pancreatic Neuroendocrine Neoplasm
  • Unresectable Thymic Neuroendocrine Neoplasm

Eligibility

Eligible Ages
Over 18 Years
Eligible Genders
All
Accepts Healthy Volunteers
No

Criteria


Inclusion Criteria:

- Documentation of Disease:

- Histologic Documentation: Well- or moderately-differentiated neuroendocrine
tumors of pancreatic and non-pancreatic (i.e. carcinoid) origin by local
pathology

- The pathology report must state ONE of the following: 1) well- or
moderately-differentiated neuroendocrine tumor, 2) low- or
intermediate-grade neuroendocrine tumor, or 3) carcinoid tumor or atypical
carcinoid tumor; documentation of histology from a primary or metastatic
site is allowed

- Patients with poorly differentiated neuroendocrine carcinoma, high-grade
neuroendocrine carcinoma without specification of differentiation status,
adenocarcinoid tumor, or goblet cell carcinoid tumor are not eligible.
Patients with well-differentiated grade 3 neuroendocrine tumor are eligible

- Stage: Locally advanced/unresectable or metastatic disease

- Tumor Site: Histological documentation of neuroendocrine tumor of pancreatic,
gastrointestinal (GI), lung, thymus, other, or unknown primary site; GI, lung,
thymus, other, and unknown primary NETs will enroll in the carcinoid tumor cohort
of the study

- Functional (i.e., associated with symptoms or clinical syndrome related to
hormone secretion by tumor) or nonfunctional tumors are allowed

- Radiologic Evaluation: Target lesions must have shown evidence of disease
progression by Response Evaluation Criteria in Solid Tumors (RECIST) version
(v)1.1 criteria in the 12 months prior to registration; the radiologic images,
imaging reports, and clinic notes indicating growth of existing lesions,
development of new lesions, or treatment changes must be submitted

- Measurable Disease

- Patients must have measurable disease per RECIST 1.1 by computer tomography (CT)
scan or magnetic resonance imaging (MRI)

- Lesions must be accurately measured in at least one dimension (longest diameter
to be recorded) as >= 1 cm with CT or MRI (or >= 1.5 cm for lymph nodes);
non-measurable disease includes disease smaller than these dimensions or lesions
considered truly non-measurable including: leptomeningeal disease, ascites,
pleural or pericardial effusion, lymphangitic involvement of skin or lung

- Prior Treatment

- Patient must have experienced disease progression after receiving or intolerance
leading to treatment discontinuation of at least one Food and Drug Administration
(FDA)-approved line of therapy (except somatostatin analogs); prior lines of
therapy must include one of the following: everolimus, sunitinib, or lutetium Lu
177 dotatate in patients with pancreatic NET; everolimus in patients with lung
NET; everolimus or lutetium Lu 177 dotatate in patients with gastrointestinal NET

- Prior treatment (except somatostatin analogs) with biologic therapy,
immunotherapy, chemotherapy, investigational agent for malignancy, and/or
radiation must be completed at least 28 days prior to registration

- Prior treatment with somatostatin analogs is allowed, and continuation of
treatment with somatostatin analogs while on cabozantinib/placebo is allowed
provided that the patient has been on a stable dose for at least two months

- Prior systemic treatment with radionuclide therapy must be completed at least 6
weeks prior to registration

- Prior treatment with hepatic artery embolization (including bland embolization,
chemoembolization, and selective internal radiation therapy) or ablative
therapies is allowed if measurable disease remains outside of the treated area or
if there is documented disease progression in a treated site; prior
liver-directed or other ablative treatment must be completed at least 28 days
prior to registration

- Prior treatment with cabozantinib is not allowed

- Patients should have resolution of any toxic effects of prior therapy (except
alopecia and fatigue) to National Cancer Institute (NCI) CTCAE, version 5.0,
grade 1 or less

- Patients must have completed any major surgery at least 12 weeks prior to
registration and any minor surgery (including uncomplicated tooth extractions) at
least 28 days prior to registration; complete wound healing from major surgery
must have occurred at least 28 days prior to registration, and complete wound
healing from minor surgery must have occurred at least 10 days prior to
registration

- Patient History

- No class III or IV congestive heart failure (CHF) within 6 months of registration

- No clinically significant cardiac arrhythmia within 6 months of registration

- No unstable angina or myocardial infarction (MI) within 6 months of registration

- No thromboembolic events within 6 months of registration (including [incl.]
stroke, transient ischemic attack [TIA], deep vein thrombosis [DVT], & pulmonary
embolism [PE])

- No known history of congenital long QT syndrome

- No uncontrolled hypertension within 14 days of registration (defined as systolic
blood pressure [SBP] >= 150 mmHg and/or diastolic blood pressure [DBP] >= 90 mmHg
despite optimal medical management)

- No clinically significant GI bleeding within 6 months of registration

- No clinically significant gastrointestinal abnormalities that may increase the
risk for gastrointestinal bleeding within 6 months of registration including, but
not limited to: active peptic ulcer, known endoluminal metastatic lesion(s) with
history of bleeding, inflammatory bowel disease, or other gastrointestinal
conditions with increased risk of perforation

- No GI perforation within 6 months of registration

- No known tumor with invasion into the GI tract from the outside causing increased
risk of perforation or bleeding within 28 days of registration

- No radiologic or clinical evidence of pancreatitis

- No known cavitary lung lesions

- No known endobronchial lesions involving the main or lobar bronchi and/or lesions
infiltrating major pulmonary vessels that increase the risk of pulmonary
hemorrhage; (CT with contrast is recommended to evaluate such lesions)

- No hemoptysis greater than 1/2 teaspoon (2.5 mL) or any other signs of pulmonary
hemorrhage within the 3 months prior to registration

- No known tumor invading or encasing any major blood vessels

- No history of non-healing wounds or ulcers within 28 days of registration

- No history of fracture within 28 days of registration

- No brain metastases or cranial epidural disease unless adequately treated,
stable, and off steroid support for at least 4 weeks prior to registration

- No known medical condition causing an inability to swallow oral formulations of
agents

- No history of allergic reaction attributed to compounds of similar chemical or
biological composition to cabozantinib/placebo

- No "currently active" second malignancy other than non-melanoma skin cancers or
cervical carcinoma in situ; patients are not considered to have a "currently
active" malignancy if they have completed therapy and are free of disease for >=
3 years

- Concomitant Medications

- Other planned concurrent investigational agents or other tumor directed therapies
(chemotherapy, radiation) are not allowed while on this study

- Concurrent use of somatostatin analogs while on cabozantinib/placebo is allowed
provided that the patient has been on a stable dose for at least two months

- Full dose oral anticoagulation/antiplatelet therapy is not permitted; low dose
aspirin =< 81 mg/day is allowed; anticoagulation with therapeutic doses of low
molecular weight heparin (LMWH) is allowed in patients who are on a stable dose
of LMWH for at least 6 weeks prior to registration; treatment with warfarin is
not allowed; anticoagulation in patients with brain metastases is not permitted

- Chronic concomitant treatment with strong inhibitors of CYP3A4 is not allowed;
patients must discontinue the drug at least 14 days prior to registration on the
study

- Chronic concomitant treatment with strong CYP3A4 inducers is not allowed;
patients must discontinue the drug at least 14 days prior to registration on the
study

- Not pregnant and not nursing

- Women of childbearing potential must have a negative pregnancy test done =< 14
days prior to registration

- A female of childbearing potential is a sexually mature female who: 1) has not
undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally
postmenopausal for at least 12 consecutive months (i.e. has had menses at any
time in the preceding 12 consecutive months)

- Age >= 18 years

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

- Absolute neutrophil count (ANC) >= 1,500/mm^3

- Hemoglobin >= 9 g/dL

- Platelet count >= 100,000/mm^3

- Prothrombin time (PT)/ international normalized ratio (INR), partial thromboplastin
time (PTT) < 1.3 x upper limit of normal (ULN)

- Aspartate aminotransferase (AST)/ alanine aminotransferase (ALT) =< 3 x ULN

- Total bilirubin =< 1.5 x ULN

- Except in the case of Gilbert disease, in which case total bilirubin must be =< 3
x ULN

- Creatinine =< 1.5 mg/dL OR creatinine clearance >= 45 mL/min

- Albumin >= 2.8 g/dL

- Potassium within normal limits (WNL)

- Supplementation is acceptable to achieve a value WNL; in patients with low
albumin levels, a corrected calcium value WNL is acceptable; in patients with
abnormal thyroid stimulating hormone (TSH), if free T4 is normal and patient is
clinically euthyroid, patient is eligible

- Phosphorus WNL

- Supplementation is acceptable to achieve a value WNL; in patients with low
albumin levels, a corrected calcium value WNL is acceptable; in patients with
abnormal TSH, if free T4 is normal and patient is clinically euthyroid, patient
is eligible

- Calcium WNL

- Supplementation is acceptable to achieve a value WNL; in patients with low
albumin levels, a corrected calcium value WNL is acceptable; in patients with
abnormal TSH, if free T4 is normal and patient is clinically euthyroid, patient
is eligible

- Magnesium WNL

- Supplementation is acceptable to achieve a value WNL; in patients with low
albumin levels, a corrected calcium value WNL is acceptable; in patients with
abnormal TSH, if free T4 is normal and patient is clinically euthyroid, patient
is eligible

- Urine protein to creatinine (UPC) ratio =< 1

- QT interval corrected for heart rate using Fridericia's formula (QTcF) =< 500 msec

- TSH WNL

- Supplementation is acceptable to achieve a value WNL; in patients with low
albumin levels, a corrected calcium value WNL is acceptable; in patients with
abnormal TSH, if free T4 is normal and patient is clinically euthyroid, patient
is eligible

Study Design

Phase
Phase 3
Study Type
Interventional
Allocation
Randomized
Intervention Model
Parallel Assignment
Primary Purpose
Treatment
Masking
Double (Participant, Investigator)

Arm Groups

ArmDescriptionAssigned Intervention
Experimental
Arm I (cabozantinib S-malate)
Patients receive cabozantinib S-malate PO QD on days 1-28 of each cycle. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. Patients also undergo CT, MRI, and/or x-ray imaging during screening and on study.
  • Drug: Cabozantinib S-malate
    Given PO
    Other names:
    • BMS-907351
    • Cabometyx
    • Cometriq
    • XL-184
    • XL184
  • Procedure: Computed Tomography
    Undergo CT
    Other names:
    • CAT
    • CAT Scan
    • Computed Axial Tomography
    • Computerized Axial Tomography
    • Computerized axial tomography (procedure)
    • Computerized Tomography
    • Computerized Tomography (CT) scan
    • CT
    • CT Scan
    • tomography
  • Procedure: Magnetic Resonance Imaging
    Undergo MRI
    Other names:
    • Magnetic Resonance
    • Magnetic Resonance Imaging (MRI)
    • Magnetic resonance imaging (procedure)
    • Magnetic Resonance Imaging Scan
    • Medical Imaging, Magnetic Resonance / Nuclear Magnetic Resonance
    • MR
    • MR Imaging
    • MRI
    • MRI Scan
    • MRIs
    • NMR Imaging
    • NMRI
    • Nuclear Magnetic Resonance Imaging
    • sMRI
    • Structural MRI
  • Other: Quality-of-Life Assessment
    Ancillary studies
    Other names:
    • Quality of Life Assessment
  • Procedure: X-Ray Imaging
    Undergo x-ray
    Other names:
    • Conventional X-Ray
    • Diagnostic Radiology
    • Medical Imaging, X-Ray
    • Plain film radiographs
    • Radiographic Imaging
    • Radiographic imaging procedure (procedure)
    • Radiography
    • RG
    • Static X-Ray
    • X-Ray
Placebo Comparator
Arm II (placebo)
Patients receive placebo PO QD on days 1-28 of each cycle. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. Patients also undergo CT, MRI, and/or x-ray imaging during screening and on study. Patients may crossover to receive cabozantinib S-malate at the time of disease progression.
  • Procedure: Computed Tomography
    Undergo CT
    Other names:
    • CAT
    • CAT Scan
    • Computed Axial Tomography
    • Computerized Axial Tomography
    • Computerized axial tomography (procedure)
    • Computerized Tomography
    • Computerized Tomography (CT) scan
    • CT
    • CT Scan
    • tomography
  • Procedure: Magnetic Resonance Imaging
    Undergo MRI
    Other names:
    • Magnetic Resonance
    • Magnetic Resonance Imaging (MRI)
    • Magnetic resonance imaging (procedure)
    • Magnetic Resonance Imaging Scan
    • Medical Imaging, Magnetic Resonance / Nuclear Magnetic Resonance
    • MR
    • MR Imaging
    • MRI
    • MRI Scan
    • MRIs
    • NMR Imaging
    • NMRI
    • Nuclear Magnetic Resonance Imaging
    • sMRI
    • Structural MRI
  • Other: Placebo Administration
    Given PO
  • Other: Quality-of-Life Assessment
    Ancillary studies
    Other names:
    • Quality of Life Assessment
  • Procedure: X-Ray Imaging
    Undergo x-ray
    Other names:
    • Conventional X-Ray
    • Diagnostic Radiology
    • Medical Imaging, X-Ray
    • Plain film radiographs
    • Radiographic Imaging
    • Radiographic imaging procedure (procedure)
    • Radiography
    • RG
    • Static X-Ray
    • X-Ray

More Details

Status
Active, not recruiting
Sponsor
National Cancer Institute (NCI)

Study Contact

Detailed Description

PRIMARY OBJECTIVES: I. To determine whether cabozantinib S-malate (cabozantinib) can significantly improve progression-free survival (PFS) compared to placebo in patients with advanced pancreatic neuroendocrine tumors (NET) whose disease has progressed after prior therapy. II. To determine whether cabozantinib can significantly improve progression-free survival (PFS) compared to placebo in patients with advanced carcinoid tumors whose disease has progressed after prior therapy. SECONDARY OBJECTIVES: I. To determine whether cabozantinib can significantly improve overall survival (OS) compared to placebo in patients with advanced pancreatic NET whose disease has progressed after prior therapy. II. To determine whether cabozantinib can significantly improve overall survival (OS) compared to placebo in patients with advanced carcinoid tumors whose disease has progressed after prior therapy. III. To evaluate safety and tolerability of cabozantinib versus placebo in patients with advanced pancreatic NET using Common Terminology Criteria for Adverse Events (CTCAE) and Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). IV. To evaluate safety and tolerability of cabozantinib versus placebo in patients with advanced carcinoid tumors using CTCAE and PRO-CTCAE. V. To evaluate the overall radiographic response rate of cabozantinib versus placebo in patients with advanced pancreatic NET whose disease has progressed after prior therapy. VI. To evaluate the overall radiographic response rate of cabozantinib versus placebo in patients with advanced carcinoid tumors whose disease has progressed after prior therapy. OTHER OBJECTIVE: I. Results of the primary analysis will be examined for consistency, while taking into account the stratification factors and/or covariates of baseline quality of life (QOL) and fatigue. QUALITY OF LIFE SUBSTUDY OBJECTIVE: I. To compare overall quality of life, disease-related symptoms, and other domains between the two treatment groups (cabozantinib versus [vs.] placebo) within each cohort of patients (pancreatic NET vs. carcinoid tumor). (Quality of Life Substudy Objective - A021602-HO1) POPULATION PHARMACOKINETICS SUBSTUDY OBJECTIVE: I. To describe the population pharmacokinetic and exposure-response relationships of cabozantinib in patients with advanced neuroendocrine tumors. (Population Pharmacokinetics Substudy Objective - A021602-PP1) OUTLINE: Patients are randomized to 1 of 2 arms. ARM I: Patients receive cabozantinib S-malate orally (PO) once daily (QD) on days 1-28 of each cycle. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. Patients also undergo computed tomography (CT), magnetic resonance imaging (MRI), and/or x-ray imaging during screening and on study. ARM II: Patients receive placebo PO QD on days 1-28 of each cycle. Cycles repeat every 28 days in the absence of disease progression or unacceptable toxicity. Patients also undergo CT, MRI, and/or x-ray imaging during screening and on study. Patients may crossover to receive cabozantinib S-malate at the time of disease progression. After completion of study treatment, patients are followed up every 12 weeks until disease progression or start of new anticancer therapy, and then every 6 months until 8 years after registration.