On October 22, 2018 Celgene Corporation (NASDAQ:CELG) reported the first results from the IMpassion130 study evaluating ABRAXANE (paclitaxel protein-bound particles for injectable suspension) (albumin-bound) in combination with atezolizumab (Tecentriq) in patients with first-line locally advanced triple negative breast cancer (TNBC) and the IMpower130 study evaluating ABRAXANE/carboplatin in combination with atezolizumab in first-line advanced non-squamous non-small cell lung cancer (Press release, Celgene, OCT 22, 2018, View Source [SID1234530032]). These findings were presented at the European Society for Medical Oncology (ESMO) (Free ESMO Whitepaper) 2018 Congress, taking place from October 19-23 in Munich, Germany. Both studies were sponsored by Roche.
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IMpassion130 Demonstrated a PFS Benefit of ABRAXANE plus Atezolizumab Combination as Initial Treatment in Locally Advanced or Metastatic TNBC
Results from the Phase 3 Impassion study showed that the investigational combination of ABRAXANE plus atezolizumab significantly reduced the risk of disease worsening or death (PFS) in first-line metastatic or unresectable locally advanced TNBC patients compared to ABRAXANE alone (7.2 months vs. 5.5 months [p=0.0025; HR=0.80 (95% CI: 0.69,0.92)]) in all randomized patients and in the PD-L1 positive subgroup population (median PFS=7.5 months vs. 5.0 months; HR=0.62(95% CI: 0.49-0.78, p<0.0001).
At this first interim analysis, statistical significance was not met for overall survival (OS) in the ITT population (median OS=21.3 months in the ABRAXANE plus atezolizumab arm vs. 17.6 months in the ABRAXANE monotherapy arm; HR=0.84, 95% CI 0.69-1.02, p=0.0840). In the PD-L1-positive population (which was not tested due to hierarchal design), the ABRAXANE plus atezolizumab arm demonstrated a 9.5-month OS improvement (median OS=25.0 vs. 15.5 months; HR=0.62, 95% CI 0.45-0.86). Follow-up will continue until the next planned analysis. The safety findings were consistent with the known profiles of the individual regimens investigated.
IMpassion130 is the first phase III study to demonstrate a statistically significant PFS improvement in first-line metastatic or unresectable locally advanced TNBC.
"The findings of the IMpassion130 trial illustrate that the ABRAXANE plus atezolizumab regimen has activity in an aggressive type of breast cancer with few viable treatments," said Jay Backstrom, M.D., Chief Medical Officer and Head of Global Regulatory Affairs for Celgene. "We are particularly excited about these findings because triple negative breast cancer is such a difficult disease to treat and patients are in need of additional treatment options."
The most common Grade 3/4 treatment-emergent adverse events (TEAE) were neutropenia (8% in both treatment arms), decreased neutrophil count (ABRAXANE plus atezolizumab: 5%; ABRAXANE plus placebo: 3%), peripheral neuropathy (ABRAXANE plus atezolizumab: 6%; ABRAXANE plus placebo: 3%), fatigue (ABRAXANE plus atezolizumab: 4%; ABRAXANE plus placebo: 3%) and anemia (3% in both treatment groups). A higher proportion of patients in the ABRAXANE plus atezolizumab arm reported serious AEs (23% vs. 18%).
IMpower130 Demonstrated Significant OS and PFS Benefit of ABRAXANE/Carboplatin plus Atezolizumab in Advanced Non-Squamous NSCLC
Results from the Phase III IMpower130 study showed that first-line treatment with the investigational combination of ABRAXANE/carboplatin plus atezolizumab significantly improved overall survival of patients with previously untreated metastatic non-squamous NSCLC compared to ABRAXANE/carboplatin alone (median OS= 18.6 versus 13.9 months; HR= 0.79; 95 percent CI: 0.64–0.98; p=0.033) in the intention-to-treat wild-type (ITT-WT) population. The ABRAXANE/carboplatin plus atezolizumab combination also significantly reduced the risk of disease worsening or death (PFS) compared to ABRAXANE/carboplatin alone (median PFS=7.0 versus 5.5 months; HR=0.64; 95 percent CI: 0.54–0.77; p<0.0001) in the ITT-WT population.
Safety for the ABRAXANE/carboplatin plus atezolizumab combination appeared consistent with the known safety profile of the individual medicines. Grade 3/4 TEAEs were reported in 73.2 percent of people receiving ABRAXANE/carboplatin plus atezolizumab compared to 60.3 percent of people receiving ABRAXANE/carboplatin alone. The most common Grade 3/4 AEs in people receiving ABRAXANE/carboplatin plus atezolizumab were: an abnormal low count of a certain type of white blood cell (neutropenia, 32.1 percent), a decrease in red blood cells (anemia, 29.2 percent) and a decreased neutrophil count (12.1 percent).
"Data from these studies continue to shape our understanding of the current and future treatment landscapes in areas where historically there have been limited treatment options available to patients," said Nadim Ahmed, President, Hematology and Oncology for Celgene. "We are very encouraged by the findings of these studies as they add to the growing body of research evaluating the potential of ABRAXANE as a backbone therapy in combination with immunotherapy."
ABRAXANE alone or in combination with atezolizumab is not approved for the first-line treatment of triple negative breast cancer, and ABRAXANE/carboplatin in combination with atezolizumab is not approved for the treatment of advanced NSCLC.
Tecentriq (atezolizumab) is a registered trademark of Genentech, a member of the Roche Group.
About the IMpassion130 study
IMpassion130is a Phase III multicenter, randomized, double-blind study evaluating the efficacy, safety, and pharmacokinetics of ABRAXANE and atezolizumabcompared with placebo in combination with ABRAXANE alone in patients with locally advanced or metastatic TNBC who have not received prior systemic therapy for metastatic breast cancer (mBC). The study enrolled 902 people who were randomized equally (1:1). The co-primary endpoints were PFS (RECIST 1.1) in all randomized participants, as well as in those who disease expressed PD-L1, and OS in all randomized participants. Secondary endpoints included overall response rate, duration of response and time to deterioration in Global Health Status/Health-Related Quality of Life.
During the treatment duration, people in:
Arm Areceived atezolizumab at a fixed dose of 840 milligrams via intravenous (IV) infusion on Days 1 and 15 of each 28-day cycle and ABRAXANE at a dose of 100 milligrams per square meter via IV infusion on Days 1, 8, and 15 of each 28-day cycle.ABRAXANEwas administered for a target of at least 6 cycles, with no maximum. Participants received both agents until unacceptable toxicity or disease progression.
Arm Breceived ABRAXANE at a dose of 100 milligrams per square meter via IV infusion on Days 1, 8, and 15 of each 28-day cycle. ABRAXANE was administered for a target of at least 6 cycles, with no maximum, and placebo was administered via IV infusion on Days 1 and 15 of each 28-day cycle. Participants assigned to placebo plus ABRAXANE received both agents until unacceptable toxicity or disease progression.
About the IMpower130 study
IMpower130 is a Phase III, multicenter, open-label, randomized study evaluating the efficacy and safety of atezolizumab in combination with carboplatin and ABRAXANE versus chemotherapy (carboplatin and ABRAXANE) alone for chemotherapy-naïve patients with stage IV non-squamous NSCLC. The study enrolled 723 people who were randomized (2:1) to receive:
Atezolizumab (1200 mg via IV every 3 weeks) plus carboplatin (AUC 6 mg/mL/min via IV every 3 weeks) and ABRAXANE (100 mg/m2 via IV every 3 weeks) (Arm A), or
Carboplatin (AUC 6 mg/mL/min via IV every 3 weeks) and ABRAXANE (100 mg/m2 via IV every 3 weeks) (Arm B, control arm)
During the treatment-induction phase, people in Arm A received atezolizumab and carboplatin on day 1 of each 21-day cycle, and ABRAXANE on days 1, 8 and 15 of each 21-day cycle for 4 or 6 cycles or until loss of clinical benefit, whichever occurs first. People received atezolizumab during the maintenance treatment phase until loss of clinical benefit was observed.
During the treatment-induction phase, people in Arm B received carboplatin on day 1 and ABRAXANE on days 1, 8 and 15 of each 21-day cycle for 4 or 6 cycles or until disease progression, whichever occurred first. People received best supportive care during the maintenance treatment phase. Switch maintenance to pemetrexed was also permitted. People who were consented prior to a protocol revision were given the option to crossover to receive atezolizumab as monotherapy until disease progression.
The co-primary endpoints were:
PFS as determined by the investigator using RECIST v1.1 in the ITT-WT population
OS in the ITT-WT population
About ABRAXANE
ABRAXANE is indicated for the treatment of breast cancer after failure of combination chemotherapy for metastatic disease or relapse within 6 months of adjuvant chemotherapy. Prior therapy should have included an anthracycline unless clinically contraindicated.
ABRAXANE is indicated for the first-line treatment of locally advanced or metastatic non–small cell lung cancer, in combination with carboplatin, in patients who are not candidates for curative surgery or radiation therapy.
Important Safety Information
WARNING – NEUTROPENIA
Do not administer ABRAXANE therapy to patients who have baseline neutrophil counts of less than 1500 cells/mm 3 . In order to monitor the occurrence of bone marrow suppression, primarily neutropenia, which may be severe and result in infection, it is recommended that frequent peripheral blood cell counts be performed on all patients receiving ABRAXANE
Note: An albumin form of paclitaxel may substantially affect a drug’s functional properties relative to those of drug in solution. DO NOT SUBSTITUTE FOR OR WITH OTHER PACLITAXEL FORMULATIONS
CONTRAINDICATIONS
Neutrophil Counts
ABRAXANE should not be used in patients who have baseline neutrophil counts of <1500 cells/mm3
Hypersensitivity
Patients who experience a severe hypersensitivity reaction to ABRAXANE should not be rechallenged with the drug
WARNINGS AND PRECAUTIONS
Hematologic Effects
Bone marrow suppression (primarily neutropenia) is dose-dependent and a dose-limiting toxicity of ABRAXANE. In clinical studies, Grade 3-4 neutropenia occurred in 34% of patients with metastatic breast cancer (MBC) and 47% of patients with non–small cell lung cancer (NSCLC)
Monitor for myelotoxicity by performing complete blood cell counts frequently, including prior to dosing on Day 1 (for MBC) and Days 1, 8, and 15 for NSCLC
Do not administer ABRAXANE to patients with baseline absolute neutrophil counts (ANC) of less than 1500 cells/mm3
In the case of severe neutropenia (<500 cells/mm3 for 7 days or more) during a course of ABRAXANE therapy, reduce the dose of ABRAXANE in subsequent courses in patients with either MBC or NSCLC
In patients with MBC, resume treatment with every-3-week cycles of ABRAXANE after ANC recovers to a level >1500 cells/mm3 and platelets recover to a level >100,000 cells/mm3
In patients with NSCLC, resume treatment if recommended at permanently reduced doses for both weekly ABRAXANE and every-3-week carboplatin after ANC recovers to at least 1500 cells/mm3 and platelet count of at least 100,000 cells/mm3 on Day 1 or to an ANC of at least 500 cells/mm3 and platelet count of at least 50,000 cells/mm3 on Days 8 or 15 of the cycle
Nervous System
Sensory neuropathy is dose- and schedule-dependent
The occurrence of Grade 1 or 2 sensory neuropathy does not generally require dose modification
If ≥ Grade 3 sensory neuropathy develops, withhold ABRAXANE treatment until resolution to Grade 1 or 2 for MBC or until resolution to ≤ Grade 1 for NSCLC followed by a dose reduction for all subsequent courses of ABRAXANE
Hypersensitivity
Severe and sometimes fatal hypersensitivity reactions, including anaphylactic reactions, have been reported
Patients who experience a severe hypersensitivity reaction to ABRAXANE should not be rechallenged with this drug
Cross-hypersensitivity between ABRAXANE and other taxane products has been reported and may include severe reactions such as anaphylaxis. Patients with a previous history of hypersensitivity to other taxanes should be closely monitored during initiation of ABRAXANE therapy
Hepatic Impairment
Because the exposure and toxicity of paclitaxel can be increased with hepatic impairment, administration of ABRAXANE in patients with hepatic impairment should be performed with caution
Patients with hepatic impairment may be at an increased risk of toxicity, particularly from myelosuppression, and should be monitored for development of profound myelosuppression
For MBC and NSCLC, the starting dose should be reduced for patients with moderate or severe hepatic impairment
Albumin (Human)
ABRAXANE contains albumin (human), a derivative of human blood
Embryo Fetal Toxicity
Based on mechanism of action and findings in animals, ABRAXANE can cause fetal harm when administered to a pregnant woman
Advise females of reproductive potential of the potential risk to a fetus.
Advise females of reproductive potential to use effective contraception and avoid becoming pregnant during treatment with ABRAXANE and for at least six months after the last dose of ABRAXANE
Advise male patients with female partners of reproductive potential to use effective contraception and avoid fathering a child during treatment with ABRAXANE and for at least three months after the last dose of ABRAXANE
ADVERSE REACTIONS
Randomized Metastatic Breast Cancer (MBC) Study
The most common adverse reactions (≥20%) with single-agent use of ABRAXANE vs paclitaxel injection in the MBC study are alopecia (90%, 94%), neutropenia (all cases 80%, 82%; severe 9%, 22%), sensory neuropathy (any symptoms 71%, 56%; severe 10%, 2%), abnormal ECG (all patients 60%, 52%; patients with normal baseline 35%, 30%), fatigue/asthenia (any 47%, 39%; severe 8%, 3%), myalgia/arthralgia (any 44%, 49%; severe 8%, 4%), AST elevation (any 39%, 32%), alkaline phosphatase elevation (any 36%, 31%), anemia (any 33%, 25%; severe 1%, <1%), nausea (any 30%, 22%; severe 3%, <1%), diarrhea (any 27%, 15%; severe <1%, 1%) and infections (24%, 20%), respectively
Sensory neuropathy was the cause of ABRAXANE discontinuation in 7/229 (3%) patients
Other adverse reactions of note with the use of ABRAXANE vs paclitaxel injection included vomiting (any 18%, 10%; severe 4%, 1%), fluid retention (any 10%, 8%; severe 0%, <1%), mucositis (any 7%, 6%; severe <1%, 0%), hepatic dysfunction (elevations in bilirubin 7%, 7%), hypersensitivity reactions (any 4%, 12%; severe 0%, 2%), thrombocytopenia (any 2%, 3%; severe <1%, <1%), neutropenic sepsis (<1%, <1%), and injection site reactions (<1%, 1%), respectively. Dehydration and pyrexia were also reported
Renal dysfunction (any 11%, severe 1%) was reported in patients treated with ABRAXANE (n=229)
In all ABRAXANE-treated patients (n=366), ocular/visual disturbances were reported (any 13%; severe 1%)
Severe cardiovascular events possibly related to single-agent ABRAXANE occurred in approximately 3% of patients and included cardiac ischemia/infarction, chest pain, cardiac arrest, supraventricular tachycardia, edema, thrombosis, pulmonary thromboembolism, pulmonary emboli, and hypertension
Cases of cerebrovascular attacks (strokes) and transient ischemic attacks have been reported
Non–Small Cell Lung Cancer (NSCLC) Study
The most common adverse reactions (≥20%) of ABRAXANE in combination with carboplatin are anemia, neutropenia, thrombocytopenia, alopecia, peripheral neuropathy, nausea, and fatigue
The most common serious adverse reactions of ABRAXANE in combination with carboplatin for NSCLC are anemia (4%) and pneumonia (3%)
The most common adverse reactions resulting in permanent discontinuation of ABRAXANE are neutropenia (3%), thrombocytopenia (3%), and peripheral neuropathy (1%)
The most common adverse reactions resulting in dose reduction of ABRAXANE are neutropenia (24%), thrombocytopenia (13%), and anemia (6%)
The most common adverse reactions leading to withholding or delay in ABRAXANE dosing are neutropenia (41%), thrombocytopenia (30%), and anemia (16%)
The following common (≥10% incidence) adverse reactions were observed at a similar incidence in ABRAXANE plus carboplatin–treated and paclitaxel injection plus carboplatin–treated patients: alopecia (56%), nausea (27%), fatigue (25%), decreased appetite (17%), asthenia (16%), constipation (16%), diarrhea (15%), vomiting (12%), dyspnea (12%), and rash (10%); incidence rates are for the ABRAXANE plus carboplatin treatment group
Adverse reactions with a difference of ≥2%, Grade 3 or higher, with combination use of ABRAXANE and carboplatin vs combination use of paclitaxel injection and carboplatin in NSCLC are anemia (28%, 7%), neutropenia (47%, 58%), thrombocytopenia (18%, 9%), and peripheral neuropathy (3%, 12%), respectively
Adverse reactions with a difference of ≥5%, Grades 1-4, with combination use of ABRAXANE and carboplatin vs combination use of paclitaxel injection and carboplatin in NSCLC are anemia (98%, 91%), thrombocytopenia (68%, 55%), peripheral neuropathy (48%, 64%), edema peripheral (10%, 4%), epistaxis (7%, 2%), arthralgia (13%, 25%), and myalgia (10%, 19%), respectively
Neutropenia (all grades) was reported in 85% of patients who received ABRAXANE and carboplatin vs 83% of patients who received paclitaxel injection and carboplatin
Postmarketing Experience With ABRAXANE and Other Paclitaxel Formulations
Severe and sometimes fatal hypersensitivity reactions have been reported with ABRAXANE. The use of ABRAXANE in patients previously exhibiting hypersensitivity to paclitaxel injection or human albumin has not been studied. In postmarketing experience, cross-hypersensitivity between ABRAXANE and other taxanes has been reported
There have been reports of congestive heart failure, left ventricular dysfunction, and atrioventricular block with ABRAXANE, primarily among individuals with underlying cardiac history or prior exposure to cardiotoxic drugs
There have been reports of extravasation of ABRAXANE. Given the possibility of extravasation, it is advisable to monitor closely the ABRAXANE infusion site for possible infiltration during drug administration
DRUG INTERACTIONS
Caution should be exercised when administering ABRAXANE concomitantly with medicines known to inhibit or induce either CYP2C8 or CYP3A4
USE IN SPECIFIC POPULATIONS
Pregnancy
Based on the mechanism of action and findings in animals, ABRAXANE can cause fetal harm when administered to a pregnant woman. Advise females of the potential risk to a fetus and to avoid becoming pregnant while receiving ABRAXANE
Lactation
Paclitaxel and/or its metabolites were excreted into the milk of lactating rats. Nursing must be discontinued when receiving treatment with ABRAXANE and for two weeks after the last dose
Females and Males of Reproductive Potential
Females of reproductive potential should have a pregnancy test prior to starting treatment with ABRAXANE
Advise females of reproductive potential to use effective contraception and avoid becoming pregnant during treatment with and for at least six months after the last dose of ABRAXANE [see Warnings and Precautions]
Advise males with female partners of reproductive potential to use effective contraception and avoid fathering a child during treatment with ABRAXANE and for at least three months after the last dose of ABRAXANE [see Warnings and Precautions]
Based on findings in animals, ABRAXANE may impair fertility in females and males of reproductive potential
Pediatric
The safety and effectiveness of ABRAXANE in pediatric patients have not been evaluated
Geriatric
A higher incidence of epistaxis, diarrhea, dehydration, fatigue, and peripheral edema was found in patients 65 years or older who received ABRAXANE for MBC in a pooled analysis of clinical studies
Myelosuppression, peripheral neuropathy, and arthralgia were more frequent in patients ≥65 years of age treated with ABRAXANE and carboplatin in NSCLC
Renal Impairment
There are insufficient data to permit dosage recommendations in patients with severe renal impairment or end stage renal disease (estimated creatinine clearance <30 mL/min)
DOSAGE AND ADMINISTRATION
Do not administer ABRAXANE to any patient with total bilirubin greater than 5 x ULN or AST greater than 10 x ULN
For MBC and NSCLC, reduce starting dose in patients with moderate to severe hepatic impairment
Dose reductions or discontinuation may be needed based on severe hematologic or neurologic toxicity
Monitor patients closely