Pancreatic Acinar Cell Carcinoma, Pancreatic Ductal Adenocarcinoma, Recurrent Pancreatic Carcinoma, Stage IV Pancreatic Cancer
Conditions
Brief summary
This phase II trial studies how well carboplatin and paclitaxel with or without viral therapy works in treating patients with pancreatic cancer that has come back or has spread to other places in the body. Drugs used in chemotherapy, such as carboplatin and 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. Viral therapy may be able to kill tumor cells without damaging normal cells. It is not yet known whether carboplatin and paclitaxel are more effective with or without viral therapy in treating pancreatic cancer.
Detailed description
PRIMARY OBJECTIVES: I. To assess the improvement in progression-free survival with Reolysin (wild-type reovirus), carboplatin, and paclitaxel relative to carboplatin and paclitaxel alone in patients with recurrent or metastatic pancreatic cancer. SECONDARY OBJECTIVES: I. To evaluate the safety and tolerability of Reolysin in combination with carboplatin and paclitaxel versus without Reolysin in patients with recurrent or metastatic pancreas cancer. II. To compare the treatment groups for other efficacy endpoints such as overall response rate and overall survival. III. To define how the combination of Reolysin and carboplatin and paclitaxel (CP) modulate factors regulating immunity to reovirus and its persistence in the system circulation of patients with pancreatic cancer. IV. To prospectively establish and validate the relationship between Ras mutations in tumor samples and response to Reolysin. OUTLINE: Patients are randomized to 1 of 2 treatment arms. ARM I: Patients receive paclitaxel intravenously (IV) over 3 hours and carboplatin IV over 30 minutes on day 1 and wild-type reovirus IV over 60 minutes on days 1-5. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity. ARM II: Patients receive paclitaxel and carboplatin as in Arm I. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity. Patients with disease progression may crossover to Arm I. After completion of study treatment, patients are followed up at 1 month and then every 2 months thereafter.
Interventions
DRUGCarboplatin
Given IV
OTHERLaboratory Biomarker Analysis
Correlative studies
DRUGPaclitaxel
Given IV
BIOLOGICALWild-type Reovirus
Given IV
Sponsors
National Cancer Institute (NCI)
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Histologically confirmed adenocarcinoma of the pancreas that is recurrent or metastatic; cytological confirmation is not allowed on this study; paraffin embedded tissue from tumor blocks will be required from patients before enrolling on this study; diagnosis of pancreas cancer with histologic confirmation of adenocarcinoma would suffice * Patients must have measurable disease, defined as one lesion that can be accurately measured in at least one dimension per Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 (longest diameter to be recorded) as \>= 10 mm by spiral computed tomography (CT) scan (CT scan slice thickness no greater than 5 mm); malignant lymph nodes will be considered measurable if they are \>= 15 mm in short axis; for patients previously irradiated, the measurable lesion must be outside the radiated field * Patients must not have received any prior chemotherapy in metastatic setting; patients who have received prior chemotherapy in the adjuvant setting will not be eligible for our study; patients should not have received prior Reolysin; prior palliative radiation therapy or major surgery must have occurred at least 28 days prior to study enrollment; prior minor surgeries (such as laparoscopies) must have occurred at least 14 days prior to study enrollment; prior minor procedures such as biopsies and mediport placement must have occurred at least 48 hours prior to study enrollment * Eastern Cooperative Oncology Group (ECOG) status =\< 1 (Karnofsky \>= 70%) * Absolute neutrophil count (ANC) \>= 1.5 x 10\^9/L International System of Units (SI) units * Platelet count \>= 100 x10\^9/L SI units * Hemoglobin \>= 8.5 g/dL SI units * Serum creatinine =\< 1.5 mg/dL OR creatinine clearance \>= 60 mL/min * Bilirubin =\< upper limit of normal (ULN) (=\< 2 x ULN if it is non-rising for a period of 10 days prior to initiation of therapy) * Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) =\< 3 X ULN * Troponin I \< ULN * All patients must have signed an informed consent indicating that they are aware of the neoplastic nature of their disease and have been informed of the procedures of the protocol, the experimental nature of the therapy, alternatives, potential benefits, side effects, risks, and discomforts * Women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation; should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately; patients must be able to avoid direct contact with pregnant or nursing women, infants and immunocompromised individuals while on study and for \>= 3 weeks following the last dose of Reolysin administration * All patients must be willing and able to comply with scheduled visits, the treatment plan, and laboratory tests
Exclusion criteria
* Patients may not be receiving any other investigational agents or concurrent therapy with other anti-cancer agents while on study * Patients with untreated brain metastases will be excluded from this clinical trial; however, patients with resected oligometastasis are eligible if postresection magnetic resonance imaging (MRI) demonstrates resolution; gamma-knife treated patients are also eligible if there are no more than two treated metastases confined to the same area of the brain and a post treatment MRI shows a decrease in the metastases * History of allergic reactions attributed to compounds of similar chemical or biologic composition to Reolysin or other agents used in the study * Patients may not have received any viral-based therapy within the past 6 months * Patients must have NO continuing acute toxic effects (except alopecia) of any prior radiotherapy, chemotherapy, or surgical procedures; all such effects must have resolved to Common Terminology Criteria for Adverse Events (CTCAE, version \[v.\] 4 ) grade =\< 1 prior to study enrollment * Patients must not have grade 2 or higher baseline peripheral neuropathy according to CTCAE v. 4 * Patients with uncontrolled cardiac dysfunction or arrhythmia, including a myocardial infarction in the preceding 6 months, known cardiac ejection fraction \< 40%, symptomatic congestive heart failure, or unstable angina pectoris * Patients must not be receiving concurrent systemic immunosuppressive therapy * Patients must not have known human immunodeficiency virus (HIV) infection or active hepatitis B or C * Patients must not have uncontrolled intercurrent illness including, but not limited to, ongoing or active infection or known psychiatric illness/social situations that would limit compliance with study requirements * Patients must not have dementia or altered mental status that would prohibit informed consent * Patients must not have other known severe, acute, or chronic medical or psychiatric condition or laboratory abnormality that may increase the risk associated with study participation, study drug administration, or may interfere with the interpretation of study results that, in the judgment of the Principal Investigator, would make the patient inappropriate for this study * Pregnant women are excluded from this study; breastfeeding should be discontinued while the mother is being treated with the agents in this clinical trial
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Progression-free Survival Using RECIST v. 1.1 | From study entry to the date of documented progression and/or death, assessed up to 4 years | The progression-free survival distributions between the two arms will be compared using log-rank tests. Progression-free survival curves will be constructed using the Kaplan-Meier product limit method, and additional analyses will be done using the Cox proportional hazards model. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Up to 4 years | Toxicities will be described for each treatment arm, but will also be compared between the arms. Fisher's exact tests will be used to quantitatively compare the incidence of severe as well as specific toxicities of interest between the treatment arms and we will graphically assess differences in maximum grades observed for toxicities between the arms. |
| Overall Response Rate (Partial or Complete Response) Evaluated Using the Standard RECIST v. 1.1 | Up to 4 years | 95% confidence intervals will be calculated. Differences in objective response rates between the treatment arms will be assessed using Fisher's exact test. |
| Overall Survival | From study entry to the time of death due to any cause, assessed up to 4 years | Evaluated and compared between the two treatment groups using log-rank statistics and graphically using the methods of Kaplan and Meier. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Immunologic Correlative Markers | Up to day 1 of course 12 | The inflammatory cytokine profile, immune effector cell phenotype and function, and NARA titers will be assessed and compared. Patterns of change in the longitudinal data on these markers will be evaluated for each of the correlative outcomes of interest. |
| Percentage of Patients With Ras Pathway Activation | Baseline | The 95% confidence interval will be assessed. Cochran-Mantel-Haenszel test will be used to assess differences in the relationships between response and Ras pathway activation and the association of treatment groups on these relationships. |
Countries
United States
Participant flow
Recruitment details
Patients were randomized between February 2011 and April 2014
Participants by arm
| Arm | Count |
|---|---|
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) Patients receive paclitaxel IV over 3 hours and carboplatin IV over 30 minutes on day 1 and wild-type reovirus IV over 60 minutes on days 1-5. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity.
Carboplatin: Given IV
Laboratory Biomarker Analysis: Correlative studies
Paclitaxel: Given IV
Wild-type Reovirus: Given IV | 36 |
| Arm B (Carboplatin, Paclitaxel) Patients receive paclitaxel and carboplatin as in Arm I. Courses repeat every 21 days in the absence of disease progression or unacceptable toxicity. Patients with disease progression may crossover to Arm I.
Carboplatin: Given IV
Laboratory Biomarker Analysis: Correlative studies
Paclitaxel: Given IV | 37 |
| Total | 73 |
Baseline characteristics
| Characteristic | Arm B (Carboplatin, Paclitaxel) | Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Total |
|---|---|---|---|
| Age, Continuous | 66 years | 61.5 years | 64 years |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 1 Participants | 1 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 0 Participants | 2 Participants | 2 Participants |
| Race (NIH/OMB) More than one race | 1 Participants | 0 Participants | 1 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 1 Participants | 1 Participants | 2 Participants |
| Race (NIH/OMB) White | 35 Participants | 32 Participants | 67 Participants |
| Region of Enrollment United States | 37 Participants | 36 Participants | 73 Participants |
| Sex: Female, Male Female | 18 Participants | 14 Participants | 32 Participants |
| Sex: Female, Male Male | 19 Participants | 22 Participants | 41 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 36 / 36 | 37 / 37 |
| serious Total, serious adverse events | 36 / 36 | 37 / 37 |
Outcome results
Primary
Progression-free Survival Using RECIST v. 1.1
The progression-free survival distributions between the two arms will be compared using log-rank tests. Progression-free survival curves will be constructed using the Kaplan-Meier product limit method, and additional analyses will be done using the Cox proportional hazards model.
Time frame: From study entry to the date of documented progression and/or death, assessed up to 4 years
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Progression-free Survival Using RECIST v. 1.1 | 4.9 months |
| Arm B (Carboplatin, Paclitaxel) | Progression-free Survival Using RECIST v. 1.1 | 5.2 months |
Secondary
Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0
Toxicities will be described for each treatment arm, but will also be compared between the arms. Fisher's exact tests will be used to quantitatively compare the incidence of severe as well as specific toxicities of interest between the treatment arms and we will graphically assess differences in maximum grades observed for toxicities between the arms.
Time frame: Up to 4 years
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Leukopenia | 33 percentage of patients |
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Fatigue | 11 percentage of patients |
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Anemia | 25 percentage of patients |
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Infection | 11 percentage of patients |
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Thrombocytopenia | 28 percentage of patients |
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Dose Delay | 37 percentage of patients |
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Febrile Neutropenia | 8 percentage of patients |
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Dose reduction | 36 percentage of patients |
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Neutropenia | 56 percentage of patients |
| Arm B (Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Dose reduction | 43 percentage of patients |
| Arm B (Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Neutropenia | 59 percentage of patients |
| Arm B (Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Leukopenia | 46 percentage of patients |
| Arm B (Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Thrombocytopenia | 24 percentage of patients |
| Arm B (Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Anemia | 30 percentage of patients |
| Arm B (Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Febrile Neutropenia | 11 percentage of patients |
| Arm B (Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Fatigue | 8 percentage of patients |
| Arm B (Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Infection | 5 percentage of patients |
| Arm B (Carboplatin, Paclitaxel) | Incidence of Severe (Grade 3+) Adverse Events That Are Classified as Either Possibly, Probably, or Definitely Related to Study Treatment, as Assessed by NCI CTCAE Version 4.0 | Dose Delay | 54 percentage of patients |
Secondary
Overall Response Rate (Partial or Complete Response) Evaluated Using the Standard RECIST v. 1.1
95% confidence intervals will be calculated. Differences in objective response rates between the treatment arms will be assessed using Fisher's exact test.
Time frame: Up to 4 years
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Overall Response Rate (Partial or Complete Response) Evaluated Using the Standard RECIST v. 1.1 | Partial Response | 7 Participants |
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Overall Response Rate (Partial or Complete Response) Evaluated Using the Standard RECIST v. 1.1 | Complete Response | 0 Participants |
| Arm B (Carboplatin, Paclitaxel) | Overall Response Rate (Partial or Complete Response) Evaluated Using the Standard RECIST v. 1.1 | Partial Response | 7 Participants |
| Arm B (Carboplatin, Paclitaxel) | Overall Response Rate (Partial or Complete Response) Evaluated Using the Standard RECIST v. 1.1 | Complete Response | 0 Participants |
Secondary
Overall Survival
Evaluated and compared between the two treatment groups using log-rank statistics and graphically using the methods of Kaplan and Meier.
Time frame: From study entry to the time of death due to any cause, assessed up to 4 years
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Overall Survival | 7.3 months |
| Arm B (Carboplatin, Paclitaxel) | Overall Survival | 8.8 months |
Other Pre-specified
Immunologic Correlative Markers
The inflammatory cytokine profile, immune effector cell phenotype and function, and NARA titers will be assessed and compared. Patterns of change in the longitudinal data on these markers will be evaluated for each of the correlative outcomes of interest.
Time frame: Up to day 1 of course 12
Population: data was not collected
Other Pre-specified
Percentage of Patients With Ras Pathway Activation
The 95% confidence interval will be assessed. Cochran-Mantel-Haenszel test will be used to assess differences in the relationships between response and Ras pathway activation and the association of treatment groups on these relationships.
Time frame: Baseline
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Arm A (Wild-type Reovirus, Carboplatin, Paclitaxel) | Percentage of Patients With Ras Pathway Activation | 71 percentage of patients |
| Arm B (Carboplatin, Paclitaxel) | Percentage of Patients With Ras Pathway Activation | 75 percentage of patients |