Colon Cancer
Conditions
Keywords
Colon Cancer, Irinotecan, FOLFIRI, Genotyping, UGT1A1
Brief summary
This study involves standard combination chemotherapy treatment for colon cancer, 5-Fluorouracil (5FU), leucovorin and irinotecan (known as FOLFIRI), plus bevacizumab (Avastin). The study is designed to test the FOLFIRI regimen based on certain characteristics of a person's genetic makeup or genes. Genes are made of DNA and determine not only inherited traits or appearance (hair and eye color, height, body type, etc.) but also play an important role in health and how the body responds to illness and treatments for those illnesses. In this study, the investigators will examine the relationship between a patient's genes (DNA), or genotype, and how the patient's body breaks down and removes or metabolizes the anti-cancer drug irinotecan. Circulating blood level of irinotecan plays an important role in how well this drug works against a patient's cancer as well as the adverse side effects the patient may experience. The current standard dose of irinotecan was determined in clinical trials without knowing individual genotypes and thus does not take into account a patient's ability to metabolize irinotecan. This means that based on one genotype the current standard dose of irinotecan may be correct or based on other genotypes the standard dose could result in lower and possibly less effective blood levels and result in significant under-dosing of irinotecan. Based on genotype the patient will be assigned to one of the following doses of irinotecan: * 180 mg/m2 (standard dose) * 260 mg/m2 * 310 mg/m2 The purpose of this research study is to determine if dosing irinotecan based on genotype is effective and safe for patients with colon cancer. Patient genotype will be determined from a small sample of blood and a laboratory test or assay performed at University of North Carolina Laboratories. For the purpose of this study, this assay is new and considered to be investigational. This means that the genotype assay used in this study has not yet been approved by the FDA for determining irinotecan dose levels in patients with colon cancer.
Detailed description
This phase II multicenter clinical trial will use a genotype-guided dosing strategy for irinotecan to prospectively analyze efficacy in 100 metastatic colorectal cancer patients (mCRC) receiving FOLFIRI (5-fluorouracil (5-FU), leucovorin, irinotecan) plus bevacizumab. Irinotecan is detoxified and excreted primarily by glucuronidation in the liver via the isoenzyme uridine diphosphate glucuronosyl transferase (UGT1A1). Common variants in UGT1A1 alter the rate of glucuronidation and thus alter exposure to irinotecan. The UGT1A1 \*28 allele results in slower irinotecan glucuronidation, and thus greater exposure to its active metabolite SN-38. At the standard irinotecan dose used in FOLFIRI (180 mg/m2; established prior to our understanding of the importance of genotype in the rate of this drug's metabolism), there is a small increased risk of neutropenia in \*28 homozygotes. However, the risk of clinically important consequences of neutropenia, such as febrile neutropenia and infection, are not significantly increased. Patients with other genotypes have a quite low risk of adverse effects suggesting patients with these low risk genotypes may tolerate higher doses of irinotecan in FOLFIRI. This finding was demonstrated in a phase I study in which \*1/\*28 and \*1/\*1 genotypes were able to tolerate escalating doses of irinotecan up to 260 mg/m2 and 310 mg/m2, respectively. The central hypothesis of this trial is that increasing the irinotecan dose in \*1/\*28 and \*1/\*1 genotypes will increase the overall benefit of FOLFIRI for patients with mCRC as these two groups are likely under-dosed with the current dosing regimen. Eligible patients will be genotyped for UGT1A1 and assigned into 1 of 3 different dosing groups, based on their relative rate of metabolism. The primary objective of this trial is to estimate progression-free survival (PFS), and secondary objectives include characterization of toxicity and objective response rate (OR; complete response (CR) + partial response (PR)).
Interventions
DRUG5-Fluorouracil
400 mg/m2 IV bolus followed by 2400 mg/m2 IV over 46 hours, Day 1 and Day 15 .
DRUGLeucovorin
200-400 mg/m2 IV over 2 hours, Day 1 and Day 15
DRUGIrinotecan
IV infusion over 90 minutes, dosed at 180, 260 or 310 mg/m2 based on genotype.
DRUGBevacizumab
Bevacizumab (5 mg/kg IV infused as per institutional policy, IV, Day 1, 15)
Sponsors
University Cancer Research Fund
UNC Lineberger Comprehensive Cancer Center
Study design
Allocation
NON_RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Subjects must meet all of the inclusion criteria to participate in this study: 1. An Institutional Review Board-approved informed consent obtained and signed 2. Age ≥ 18 years 3. Histological or cytological documentation of adenocarcinoma of the colon or rectum 4. Measurable or non-measurable (but evaluable) disease as defined via RECIST 1.1 5. Metastatic disease not amenable to surgical resection with curative intent 6. No prior chemotherapy for metastatic disease 7. Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2 (see section 11.1, Appendix A) 8. Adequate bone marrow, renal and hepatic function, as evidenced by the following: * absolute neutrophil count (ANC) ≥1,500/mm3 * platelets ≥100,000/mm3 * hemoglobin ≥9.0 g/dL * serum creatinine ≤1.5 x upper limit of normal (ULN) * Aspartate aminotransferase (AST) and Alanine transaminase (ALT) ≤3x ULN ( ≤5.0 × ULN for patients with liver involvement of their cancer * Bilirubin ≤1.5 X ULN * Alkaline phosphatase ≤3 x ULN (≤5 x ULN with liver involvement of their cancer) 9. Willing to undergo UGT1A1 genotyping 10. Negative pregnancy test (urine or serum), within 7 day prior to Day 1 of FOLFIRI in women of childbearing potential 11. Women of childbearing potential and male subjects must agree to use adequate contraception for the duration of study participation. Adequate contraception is defined as any medically recommended method (or combination of methods) as per standard of care.
Exclusion criteria
1. UGT1A1 genotype other than \*1/\*1, \*1/\*28, or \*28/\*28 2. Known dihydropyrimidine dehydrogenase (DPD) deficiency 3. Prior treatment with irinotecan and/or bevacizumab 4. Unable or unwilling to discontinue (and substitute if necessary) use of prohibited drugs for at least 14 days (fruits and juices for at least 7 days) prior to Day 1 of FOLFIRI + bevacizumab initiation (see section 11.2, Appendix B, for list of prohibited drugs) 5. Inadequately controlled hypertension (defined as systolic blood pressure \> 140 mmHg and/or diastolic blood pressure \> 90 mmHg) 6. Prior history of hypertensive encephalopathy 7. Active cardiac disease including any of the following: * New York Heart Association (NYHA) Grade II or greater congestive heart failure (see section 11.3, Appendix C) * History of myocardial infarction or unstable angina within 6 months prior to Day 1 * History of stroke or transient ischemic attack within 6 months prior to Day 1 of FOLFIRI + bevacizumab initiation 8. Significant vascular disease (e.g., aortic aneurysm, requiring surgical repair or recent peripheral arterial thrombosis) within 6 months prior to Day 1 of FOLFIRI + bevacizumab initiation 9. History of hemoptysis (≥ 1/2 teaspoon of bright red blood per episode) within 1 month prior to Day 1 of FOLFIRI + bevacizumab initiation 10. Evidence of bleeding diathesis or significant coagulopathy (in the absence of therapeutic anticoagulation) 11. Major surgical procedure, open biopsy, or significant traumatic injury within 28 days prior to Day 1 of FOLFIRI + bevacizumab initiation or anticipation of need for major surgical procedure during the course of the study 12. Core biopsy or other minor surgical procedure, excluding placement of a vascular access device, within 7 days prior to Day 1 of FOLFIRI + bevacizumab initiation 13. History of abdominal fistula or gastrointestinal perforation within 6 months prior to Day 1 of FOLFIRI + bevacizumab initiation 14. Serious, non-healing wound, active ulcer, or untreated bone fracture 15. Proteinuria as demonstrated by: Urine protein: creatinine (UPC) ratio ≥ 1.0 at screening OR Urine dipstick for proteinuria ≥ 2+ (patients discovered to have ≥2+ proteinuria on dipstick urinalysis at baseline should undergo a 24 hour urine collection and must demonstrate ≤ 1g of protein in 24 hours to be eligible) 16. Any serious uncontrolled medical disorder that would impair the ability of the subject to receive protocol-driven therapy 17. Other anti-cancer or investigational therapy while patients are on study therapy
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Progression Free Survival | From date of registration until date of first documented progression up to 8 years. | Progression-free Free Survival is defined as the time from day 1 (D1) of treatment to progression based on Response Evaluation Criteria In Solid Tumors Criteria (RECIST)1.1 or death from any cause. Radiographic response will be measured by RECIST, indicating if subject experienced a Complete Response (CR), disappearance of all target lesions; Partial Response (PR), \>=30% decrease in the sum of the longest diameter of target lesions; Stable Disease (SD), no response or less response than Partial or Progressive; or Progressive Disease (PD), as a 20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Number of Participants With Grade 3 or Higher Adverse Events | From date of registration up to 8 years. | The toxicity profile when irinotecan is dosed according to isoenzyme uridine diphosphate glucuronosyl transferase (UGT1A1) Genotypes was evaluated and Grade 3 or higher adverse events were reported. Toxicity will be classified and graded according to the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE, version 4.03). |
| Overall Response | 5 years | Overall Response (OR =Complete Response +Partial Response) will be defined per Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1). Radiographic response will be measured by RECIST, Response Evaluation Criteria In Solid Tumors Criteria, indicating if subject experienced a Complete Response (CR), disappearance of all target lesions; Partial Response (PR), \>=30% decrease in the sum of the longest diameter of target lesions; Stable Disease (SD), no response or less response than Partial or Progressive; or Progressive Disease (PD), as a 20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions. |
| Overall Survival Rate | 8 years | The Overall Survival rate (OS) is defined as the percentage of participants alive after time from D1 of treatment to death from any cause. |
Countries
United States
Participant flow
Pre-assignment details
Participants were enrolled in the study between 5/6/2014 and 08/29/20192 at eight cancer centers in the United States.
Participants by arm
| Arm | Count |
|---|---|
| *1/*1 Genotype FOLFIRI (5-fluorouracil (5-FU), leucovorin, irinotecan) Irinotecan dose 310 mg/m2,(IV, Day 1, 15); Bevacizumab (IV, Day 1, 15), repeat treatment cycle every 28 days.
5-Fluorouracil: 400 mg/m2 IV bolus followed by 2400 mg/m2 IV over 46 hours, Day 1 and Day 15 .
Leucovorin: 200-400 mg/m2 IV over 2 hours, Day 1 and Day 15
Irinotecan: IV infusion over 90 minutes, dosed at 180, 260 or 310 mg/m2 based on genotype.
Bevacizumab: Bevacizumab (5 mg/kg IV infused as per institutional policy, IV, Day 1, 15) | 47 |
| *1/*28 Genotype FOLFIRI (5-fluorouracil (5-FU), leucovorin, irinotecan) Irinotecan dose 260 mg/m2, FOLFIRI (IV, Day 1, 15); Bevacizumab (IV, Day 1, 15), repeat treatment cycle every 28 days.
5-Fluorouracil: 400 mg/m2 IV bolus followed by 2400 mg/m2 IV over 46 hours, Day 1 and Day 15 .
Leucovorin: 200-400 mg/m2 IV over 2 hours, Day 1 and Day 15
Irinotecan: IV infusion over 90 minutes, dosed at 180, 260 or 310 mg/m2 based on genotype.
Bevacizumab: Bevacizumab (5 mg/kg IV infused as per institutional policy, IV, Day 1, 15) | 43 |
| *28/*28 FOLFIRI (5-fluorouracil (5-FU), leucovorin, irinotecan) Irinotecan dose 180 mg/m2, FOLFIRI (IV, Day 1, 15); Bevacizumab (IV, Day 1, 15), repeat treatment cycle every 28 days.
5-Fluorouracil: 400 mg/m2 IV bolus followed by 2400 mg/m2 IV over 46 hours, Day 1 and Day 15 .
Leucovorin: 200-400 mg/m2 IV over 2 hours, Day 1 and Day 15
Irinotecan: IV infusion over 90 minutes, dosed at 180, 260 or 310 mg/m2 based on genotype.
Bevacizumab: Bevacizumab (5 mg/kg IV infused as per institutional policy, IV, Day 1, 15) | 10 |
| Total | 100 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 | FG002 |
|---|---|---|---|---|
| Overall Study | Adverse Event | 8 | 5 | 2 |
| Overall Study | Death | 1 | 2 | 2 |
| Overall Study | Disease Progression | 20 | 13 | 4 |
| Overall Study | financial reason | 0 | 1 | 0 |
| Overall Study | other complicating disease | 0 | 2 | 0 |
| Overall Study | other therapy | 3 | 4 | 0 |
| Overall Study | Physician Decision | 7 | 6 | 0 |
| Overall Study | Protocol Violation | 1 | 0 | 0 |
| Overall Study | Withdrawal by Subject | 7 | 10 | 2 |
Baseline characteristics
| Characteristic | *1/*1 Genotype | Total | *28/*28 | *1/*28 Genotype |
|---|---|---|---|---|
| Age, Continuous | 59 years | 59 years | 62 years | 59 years |
| Ethnicity (NIH/OMB) Hispanic or Latino | 3 Participants | 3 Participants | 0 Participants | 0 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 41 Participants | 94 Participants | 10 Participants | 43 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 3 Participants | 3 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 1 Participants | 2 Participants | 0 Participants | 1 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 3 Participants | 12 Participants | 2 Participants | 7 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 3 Participants | 3 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) White | 40 Participants | 83 Participants | 8 Participants | 35 Participants |
| Region of Enrollment United States | 47 participants | 100 participants | 10 participants | 43 participants |
| Sex: Female, Male Female | 22 Participants | 48 Participants | 8 Participants | 18 Participants |
| Sex: Female, Male Male | 25 Participants | 52 Participants | 2 Participants | 25 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk |
|---|---|---|---|
| deaths Total, all-cause mortality | 38 / 47 | 34 / 43 | 9 / 10 |
| other Total, other adverse events | 47 / 47 | 43 / 43 | 9 / 10 |
| serious Total, serious adverse events | 14 / 47 | 13 / 43 | 4 / 10 |
Outcome results
Primary
Progression Free Survival
Progression-free Free Survival is defined as the time from day 1 (D1) of treatment to progression based on Response Evaluation Criteria In Solid Tumors Criteria (RECIST)1.1 or death from any cause. Radiographic response will be measured by RECIST, indicating if subject experienced a Complete Response (CR), disappearance of all target lesions; Partial Response (PR), \>=30% decrease in the sum of the longest diameter of target lesions; Stable Disease (SD), no response or less response than Partial or Progressive; or Progressive Disease (PD), as a 20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions.
Time frame: From date of registration until date of first documented progression up to 8 years.
Population: Participants started the study and response assessments were completed.
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| *1/*1 Genotype | Progression Free Survival | Disease Progression | 3 Participants |
| *1/*1 Genotype | Progression Free Survival | The response was achieved, or the disease remained stable | 38 Participants |
| *1/*28 Genotype | Progression Free Survival | The response was achieved, or the disease remained stable | 34 Participants |
| *1/*28 Genotype | Progression Free Survival | Disease Progression | 2 Participants |
| *28/*28 | Progression Free Survival | The response was achieved, or the disease remained stable | 6 Participants |
| *28/*28 | Progression Free Survival | Disease Progression | 0 Participants |
Secondary
Number of Participants With Grade 3 or Higher Adverse Events
The toxicity profile when irinotecan is dosed according to isoenzyme uridine diphosphate glucuronosyl transferase (UGT1A1) Genotypes was evaluated and Grade 3 or higher adverse events were reported. Toxicity will be classified and graded according to the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE, version 4.03).
Time frame: From date of registration up to 8 years.
Population: Participants started the study and adverse event assessments were completed.
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| *1/*1 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Mucositis | 4 Participants |
| *1/*1 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Nausea | 1 Participants |
| *1/*1 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Lymphopenia | 0 Participants |
| *1/*1 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Neutropenia | 24 Participants |
| *1/*1 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Thrombocytopenia | 2 Participants |
| *1/*1 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Anemia | 1 Participants |
| *1/*1 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | General Fatigue | 2 Participants |
| *1/*1 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Febrile neutropenia | 1 Participants |
| *1/*1 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Diarrhea | 6 Participants |
| *1/*1 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Sepsis | 1 Participants |
| *1/*1 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Hypertension | 5 Participants |
| *1/*1 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Vomiting | 2 Participants |
| *1/*1 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Leukopenia | 2 Participants |
| *1/*28 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Anemia | 3 Participants |
| *1/*28 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | General Fatigue | 5 Participants |
| *1/*28 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Febrile neutropenia | 0 Participants |
| *1/*28 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Neutropenia | 20 Participants |
| *1/*28 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Sepsis | 0 Participants |
| *1/*28 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Leukopenia | 3 Participants |
| *1/*28 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Lymphopenia | 5 Participants |
| *1/*28 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Thrombocytopenia | 2 Participants |
| *1/*28 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Nausea | 2 Participants |
| *1/*28 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Vomiting | 3 Participants |
| *1/*28 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Diarrhea | 5 Participants |
| *1/*28 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Mucositis | 3 Participants |
| *1/*28 Genotype | Number of Participants With Grade 3 or Higher Adverse Events | Hypertension | 4 Participants |
| *28/*28 | Number of Participants With Grade 3 or Higher Adverse Events | Nausea | 1 Participants |
| *28/*28 | Number of Participants With Grade 3 or Higher Adverse Events | Sepsis | 1 Participants |
| *28/*28 | Number of Participants With Grade 3 or Higher Adverse Events | Mucositis | 2 Participants |
| *28/*28 | Number of Participants With Grade 3 or Higher Adverse Events | Vomiting | 1 Participants |
| *28/*28 | Number of Participants With Grade 3 or Higher Adverse Events | Neutropenia | 5 Participants |
| *28/*28 | Number of Participants With Grade 3 or Higher Adverse Events | General Fatigue | 1 Participants |
| *28/*28 | Number of Participants With Grade 3 or Higher Adverse Events | Diarrhea | 1 Participants |
| *28/*28 | Number of Participants With Grade 3 or Higher Adverse Events | Anemia | 3 Participants |
| *28/*28 | Number of Participants With Grade 3 or Higher Adverse Events | Lymphopenia | 1 Participants |
| *28/*28 | Number of Participants With Grade 3 or Higher Adverse Events | Febrile neutropenia | 1 Participants |
| *28/*28 | Number of Participants With Grade 3 or Higher Adverse Events | Thrombocytopenia | 3 Participants |
| *28/*28 | Number of Participants With Grade 3 or Higher Adverse Events | Leukopenia | 3 Participants |
| *28/*28 | Number of Participants With Grade 3 or Higher Adverse Events | Hypertension | 1 Participants |
Secondary
Overall Response
Overall Response (OR =Complete Response +Partial Response) will be defined per Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST 1.1). Radiographic response will be measured by RECIST, Response Evaluation Criteria In Solid Tumors Criteria, indicating if subject experienced a Complete Response (CR), disappearance of all target lesions; Partial Response (PR), \>=30% decrease in the sum of the longest diameter of target lesions; Stable Disease (SD), no response or less response than Partial or Progressive; or Progressive Disease (PD), as a 20% increase in the sum of the longest diameter of target lesions, or a measurable increase in a non-target lesion, or the appearance of new lesions.
Time frame: 5 years
Population: Participants started the study and response assessments were completed.
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| *1/*1 Genotype | Overall Response | Complete Response or Partial Response was achieved | 28 Participants |
| *1/*1 Genotype | Overall Response | Stable disease or progression | 13 Participants |
| *1/*28 Genotype | Overall Response | Complete Response or Partial Response was achieved | 20 Participants |
| *1/*28 Genotype | Overall Response | Stable disease or progression | 16 Participants |
| *28/*28 | Overall Response | Complete Response or Partial Response was achieved | 3 Participants |
| *28/*28 | Overall Response | Stable disease or progression | 3 Participants |
Secondary
Overall Survival Rate
The Overall Survival rate (OS) is defined as the percentage of participants alive after time from D1 of treatment to death from any cause.
Time frame: 8 years
Population: Participants started the study.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| *1/*1 Genotype | Overall Survival Rate | 26.5 months |
| *1/*28 Genotype | Overall Survival Rate | 25.9 months |
| *28/*28 | Overall Survival Rate | 13.4 months |