Nivolumab in Treating Patients With Localized Kidney Cancer Undergoing Nephrectomy

• Sponsor: National Cancer Institute (NCI)
• Collaborator: Canadian Cancer Trials Group
• Information provided by (Responsible Party): National Cancer Institute (NCI)

Study Description

Brief Summary:

This phase III trial compares nephrectomy (surgery to remove a kidney or part of a kidney) with or without nivolumab in treating patients with kidney cancer that is limited to a certain part of the body (localized). Immunotherapy with monoclonal antibodies, such as nivolumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Giving nivolumab before nephrectomy may make the tumor smaller and reduce the amount of normal tissue that needs to be removed, and after nephrectomy to increase survival. It is not yet known whether nivolumab and nephrectomy is more effective than nephrectomy alone in treating patients with kidney cancer.

Condition or disease	Intervention/treatment	Phase
Metastatic Malignant Neoplasm in Lymph Node; Metastatic Malignant Neoplasm in the Adrenal Gland; Metastatic Malignant Neoplasm in the Lung; Metastatic Malignant Neoplasm in the Pancreas; Metastatic Malignant Neoplasm in the Skin; Metastatic Malignant Neoplasm in the Soft Tissues; Metastatic Renal Cell Carcinoma; Oligometastasis; Sarcomatoid Renal Cell Carcinoma; Stage II Renal Cell Cancer AJCC v7; Stage III Renal Cell Cancer AJCC v7; Unclassified Renal Cell Carcinoma	Procedure: Conventional Surgery; Biological: Nivolumab; Other: Patient Observation; Other: Quality-of-Life Assessment; Other: Questionnaire Administration	Phase 3

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Study Design

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Study Type :	Interventional (Clinical Trial)
Estimated Enrollment :	805 participants
Allocation:	Randomized
Intervention Model:	Parallel Assignment
Masking:	Single (Outcomes Assessor)
Primary Purpose:	Treatment
Official Title:	A Phase 3 Randomized Study Comparing Perioperative Nivolumab vs. Observation in Patients With Renal Cell Carcinoma Undergoing Nephrectomy (PROSPER RCC)
Actual Study Start Date :	February 2, 2017
Estimated Primary Completion Date :	November 30, 2023
Estimated Study Completion Date :	November 30, 2023

Arms and Interventions

Arm	Intervention/treatment
Experimental: Arm I (nivolumab, nephrectomy); Patients receive nivolumab IV over 30-60 minutes on day 1. Treatment repeats every 14 days for 2 cycles. Patients then undergo partial or radical nephrectomy 7-28 days later. Patient then receive nivolumab over 30-60 IV on day 1. Treatment repeats every 14 days for 6 cycles, and then every 28 days for 6 cycles in the absence of disease progression or unacceptable toxicity. Patients enrolled after Amendment 4 receive nivolumab IV over 30-60 minutes on day 1. Patients then undergo partial or radical nephrectomy 7-28 days later. Patient then receive nivolumab IV over 30-60 minutes on day 1. Treatment repeats every 4 weeks for 9 cycles in the absence of disease progression or unacceptable toxicity.	Procedure: Conventional Surgery; Undergo nephrectomy; Biological: Nivolumab; Given IV; Other Names: BMS-936558; MDX-1106; NIVO; ONO-4538; Opdivo; Other: Quality-of-Life Assessment; Ancillary studies; Other Name: Quality of Life Assessment; Other: Questionnaire Administration; Ancillary studies
Active Comparator: Arm II (nephrectomy); ARM II: Patients undergo partial or radical nephrectomy within 8 weeks after registration followed by observation.	Procedure: Conventional Surgery; Undergo nephrectomy; Other: Patient Observation; Undergo observation; Other Names: Active Surveillance; deferred therapy; expectant management; observation; Watchful Waiting; Other: Quality-of-Life Assessment; Ancillary studies; Other Name: Quality of Life Assessment; Other: Questionnaire Administration; Ancillary studies

Outcome Measures

Primary Outcome Measures :

1. Recurrence-free survival (RFS) [ Time Frame: Time from randomization to disease recurrence or death from any cause, assessed up to 10 years ]
   Will be assessed among all randomized patients using a stratified log rank test, with nominal one-sided type I error of 2.5%. The type I error will be adjusted for interim analyses.

Secondary Outcome Measures :

1. Overall survival [ Time Frame: Time from randomization to death from any cause, assessed up to 10 years ]
2. RFS among patients with clear cell cancer [ Time Frame: Up to 10 years ]
   The stratified logrank test will be used.
3. Incidence of toxicity [ Time Frame: Up to 10 years ]
   Graded per Common Criteria for Adverse Events (CTCAE) version (v)4.0. (Starting April 1, 2018, Cancer Therapy Evaluation Program Adverse Event Reporting System [CTEP-AERS] reporting will use CTCAE v5). Adverse events will be described separately for patients treated on each arm to evaluate safety and tolerability.

Other Outcome Measures:

1. Primary tumor's expression of PD-L1 [ Time Frame: Baseline to up to 10 years ]
   The percentage of cells exhibiting cell-surface staining for PD-L1 will be scored. PD-L1 positivity will be defined per specimen by a 5% expression threshold. Additional analyses will assess the 1% and 10% threshold levels. Information with respect to the relative abundance and location (peritumoral/intratumoral) of immune cell (macrophage and lymphocyte) PD-L1 staining will be captured. The expression-by-treatment interaction will be tested using a proportional hazards model. McNemar's Test will be used to explore categorical changes within each treatment group.
2. Expression of PD-L1 on tumor tissue at recurrence [ Time Frame: Up to 10 years ]
3. Pharmacokinetic analysis of nivolumab [ Time Frame: On day 1 of courses 1-3, 5, 7 and the first 2 follow-up visits ]
   Serum concentration analyses for nivolumab will be performed by validated bio-analytical methods for nivolumab.
4. Change in patient-reported symptoms and toxicities [ Time Frame: Baseline to up to 10 years ]
   Using the National Comprehensive Cancer Network/Functional Assessment of Cancer Therapy (NCCN/FACT) Kidney Symptom Index-19 (NFKSI-19) and items from the PRO-CTCAE pool of items measuring patient-reported toxicity. We will describe the severity, interference, and (as appropriate) frequency rates, along with response rates at each time point. Change in symptoms will be tested using a two-sided Wilcoxon rank sum test with Type I error of 3%. Change in physical function will be tested using a two-sided Wilcoxon rank sum test with Type I error of 1%. Changes in NFKSI-19 and PROMIS Physical Function scores from baseline to pre-nephrectomy among patients randomized to nivolumab and will be explored using a Wilcoxon signed rank test. Differences in scores post-nephrectomy between the arms will be described and tested using a Wilcoxon rank-sum test. Differences in the pattern of change over time in NFKSI-19 and PROMIS Physical Function scores will be examined using mixed effects models.
5. Absolute T cell clonotype abundance [ Time Frame: Up to 10 years ]
   Will be determined by assessing the number of unique clonotypes identified. The data will be summarized descriptively and graphically.
6. Change in T cell repertoire [ Time Frame: From diagnosis to on therapy or to time of recurrence, assessed up to 10 years ]
   Morisita's distance will be used as utilized by Cha and colleagues. Morisita's distance ranges from 0-1. Zero indicates minimal change in T cell repertoire (TCR) repertoire size (number of unique clonotypes) and 1 indicates maximal change after treatment.
7. T cell receptor (TCR) diversity using change in repertoire size per patient [ Time Frame: Baseline to up to 10 years ]
   The top 25% of unique clonotypes will be identified by sorting for clone frequency. Fold change after recurrence will be measured and plotted on a logarithmic scale.
8. Change in cytokine levels in patients randomized to the nivolumab arm [ Time Frame: Baseline to up to 10 years ]
   Differences in RFS between patients with and without robust CD8 infiltration will be explored. A Cox proportional hazards model will be used to test the interaction between treatment and cytokine changes.

Eligibility Criteria

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Ages Eligible for Study:	18 Years and older (Adult, Older Adult)
Sexes Eligible for Study:	All
Accepts Healthy Volunteers:	No

Criteria

Inclusion Criteria:

• ELIGIBILITY CRITERIA FOR PREREGISTRATION (STEP 0):
• Patients with a renal mass consistent with a clinical stage >= T2Nx renal cell carcinoma (RCC) or TanyN+ RCC for which radical or partial nephrectomy is planned

• Patients must have no clinical or radiological evidence of distant metastases (M0) unless the presumed M1 disease can be resected/definitively treated (e.g., thermal ablation, stereotactic radiation) at the same time or within a 12 week window from the date of the initial procedure such that the patient is considered "no evidence of disease" (M1 NED)

  • Permitted sites of oligo-metastases: lung, adrenal, nodes, pancreas, soft tissue or skin; liver or bone metastases are not permitted
  • No more than 3 metastases are permitted and all must be able to be removed or definitively treated within 12 weeks of the primary tumor resection

• If histological confirmation of RCC has not been done within 12 months prior to pre-registration (Step 0), patient must be willing to undergo a core biopsy for this purpose if randomized to Arm H

  • NOTE: This can be a (1) standard of care diagnostic biopsy or (2) a research biopsy following assignment to Arm H or a planned metastasectomy before or after randomization; if the biopsy performed following pre-registration (Step 0) clearly demonstrates a benign condition, oncocytoma or a different type of cancer that is not RCC, the patient is not eligible for registration (Step 1); a non-diagnostic biopsy is considered a good faith effort and does not need to be repeated unless deemed clinically necessary by the treating investigator
  • NOTE: Patients randomized to Arm O (Observation) are permitted to register to Step 1 (Arm B) immediately following pre-registration assignment to Arm O, regardless of whether or not they have had a standard of care diagnostic biopsy

• No prior systemic or local anti-cancer therapy for the current RCC is permitted

  • Partial nephrectomy for prior RCC
  • Metastasectomy for the current RCC diagnosis is not allowed unless performed to render patient NED (in addition to the planned nephrectomy) within 6 months of the current diagnosis
  • Radiation therapyto the bilateral kidney or any distant metastatic sites, is not allowed unless administered to render patient NED within 6 months of the current diagnosis
  • Current or past antineoplastic systemic therapies for RCC are not allowed: i.e., chemotherapy, hormonal therapy, immunotherapy, or standard or investigational agents for treatment of RCC
  • Prior treatment with an anti-PD-1, anti-PD-L1, anti-PD-L2, anti-CD137, or anti-CTLA-4 antibody, or any other antibody or drug specifically targeting T-cell co-stimulation or checkpoint pathways
• Eastern Cooperative Oncology Group (ECOG) performance status: 0 or 1

• Patient must have no prior history of RCC that was resected with curative intent within the past 5 years

  • Patients with a prior RCC that was treated > 5 years before, are eligible if the current tumor is consistent with a new primary in the opinion of the treating investigator

  • Patients with bilateral synchronous RCCs are eligible if they can be resected or definitively treated at the same time or within a 12 week window from time of initial nephrectomy (partial or radical) or procedure and maintain adequate residual renal function; the patient is not eligible if both kidneys are completely removed and subsequent hemodialysis is required

    • Permitted forms of local therapy for second tumor:

      • Partial or radical nephrectomy
      • If tumor is =< 3cm: thermal ablation (e.g., radiofrequency ablation, cryoablation or stereotactic radiosurgery)

• Patients cannot have concurrent malignancies, with the following exceptions:

  • Adequately treated basal cell or squamous cell skin cancer

  • In situ cervical cancer

    • A history of superficial Ta urothelial cancer is permitted (as long as not currently undergoing treatment) whereas T1 or greater disease is excluded if < 3 years from diagnosis; concurrent persistent disease is not permitted
    • Adequately treated stage I or II cancer from which the patient is currently in complete remission
    • Any other cancer and stage from which the patient has been disease-free for at least 3 years prior to the time of pre-registration and as long as they are not receiving any current treatment (e.g. adjuvant or maintenance systemic or local therapy)
    • Concurrent low risk prostate cancer on active surveillance
• No active known or suspected autoimmune disease; the following autoimmune disorders are permitted: patients with vitiligo, type I diabetes mellitus, controlled/stable hypothyroidism due to autoimmune or non-autoimmune conditions (hormone replacement is allowed), psoriasis not requiring systemic treatment, or other conditions not expected to recur

• No ongoing condition requiring systemic treatment with either corticosteroids (> 10 mg daily prednisone equivalent) or other immunosuppressive medications with the exceptions outlined below; no treatment with other immunosuppressive agents within 14 days prior to the first dose of study drug with the following exceptions:

  • Topical, ocular, intra-articular, intranasal, inhaled steroids and adrenal replacement steroid doses > 10 mg daily prednisone or the equivalent are permitted in the absence of active autoimmune disease
  • A brief (less than 3 weeks) course of corticosteroids (any amount) for prophylaxis (for example: contrast dye allergy) or for treatment of non-autoimmune conditions (for example: nausea, delayed-type hypersensitivity reaction caused by a contact allergen) is permitted
• No uncontrolled adrenal insufficiency
• No known chronic active liver disease or evidence of acute or chronic hepatitis B virus (HBV) or hepatitis C virus (HCV)
• No serious intercurrent illness, including ongoing or active infection requiring parenteral antibodies
• No known evidence of human immunodeficiency virus (HIV) infection, since the effects of nivolumab on anti-retroviral therapy have not been studied
• No known medical condition (e.g. a condition associated with uncontrolled diarrhea such as ulcerative colitis or acute diverticulitis) that, in the investigator's opinion, would increase the risk associated with study participation or interfere with the interpretation of safety results
• No major surgery within 28 days prior to randomization
• No patients currently enrolled in other clinical trials testing a therapeutic intervention
• No history of severe hypersensitivity to a monoclonal antibody
• Ability to understand and the willingness to sign a written informed consent document
• ELIGIBILITY CRITERIA FOR RANDOMIZATION (STEP 1):
• Patients must meet all Step 0 eligibility criteria at the time of their registration to Step 1

• In patients randomized to Arm H, core tumor biopsy must demonstrate RCC of any histology, including sarcomatoid, unclassified, or "unknown histology" (if preoperative biopsy was uninformative)

  • NOTE: A non-diagnostic biopsy is considered a good faith effort and does not need to be repeated unless deemed clinically necessary by the treating investigator
• Women must not be pregnant or breast-feeding, as the effects of nivolumab on the developing human fetus or in the nursing infant are unknown; all females of childbearing potential must have a blood test or urine study within 2 weeks prior to registration to rule out pregnancy; a female of childbearing potential is any woman, regardless of sexual orientation or whether they have undergone tubal ligation, who meets the following criteria: 1) has achieved menarche at some point 2) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months)
• Women of childbearing potential (WOCBP) and males who are sexually active with WOCBP must use accepted and effective method(s) of contraception, or to abstain from sexual intercourse for the duration of their participation in the study; women of childbearing potential must use adequate methods to avoid pregnancy for 23 weeks after the last dose of nivolumab; sexually active males must use adequate methods to avoid pregnancy for 31 weeks after the last dose of nivolumab
• White blood cells >= 2000/uL (within 8 weeks of registration)
• Absolute neutrophil count (ANC) >= 1,500/mm^3 (within 8 weeks of registration)
• Platelet count >= 100,000/mm^3 (within 8 weeks of registration)
• Hemoglobin >= 9.0 g/dL (within 8 weeks of registration)
• Serum creatinine =< 1.5 x upper limit of normal (ULN) (except subjects with Gilbert syndrome, who can have total bilirubin < 3.0 x ULN) (within 8 weeks of registration)
• Total bilirubin =< 1.5 x ULN (except subjects with Gilbert syndrome, who can have total bilirubin < 3.0 x ULN) (within 8 weeks of registration)
• Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 2.5 x ULN (within 8 weeks of registration)

Contacts and Locations

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Sponsors and Collaborators

National Cancer Institute (NCI)

Canadian Cancer Trials Group

Investigators

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Principal Investigator:	Lauren C Harshman	ECOG-ACRIN Cancer Research Group

More Information

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Responsible Party:	National Cancer Institute (NCI)
ClinicalTrials.gov Identifier:	NCT03055013 History of Changes
Other Study ID Numbers:	NCI-2016-00326; NCI-2016-00326 ( Registry Identifier: CTRP (Clinical Trial Reporting Program) ); EA8143; EA8143 ( Other Identifier: ECOG-ACRIN Cancer Research Group ); EA8143 ( Other Identifier: CTEP ); U10CA180820 ( U.S. NIH Grant/Contract )
First Posted:	February 16, 2017
Last Update Posted:	June 24, 2019
Last Verified:	May 2019

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Studies a U.S. FDA-regulated Drug Product:		Yes
Studies a U.S. FDA-regulated Device Product:		No

Additional relevant MeSH terms:

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Carcinoma; Neoplasms; Carcinoma, Renal Cell; Neoplasms, Second Primary; Lung Neoplasms; Skin Neoplasms; Neoplasms, Glandular and Epithelial; Neoplasms by Histologic Type; Adenocarcinoma; Kidney Neoplasms; Urologic Neoplasms; Urogenital Neoplasms	Neoplasms by Site; Kidney Diseases; Urologic Diseases; Respiratory Tract Neoplasms; Thoracic Neoplasms; Lung Diseases; Respiratory Tract Diseases; Skin Diseases; Nivolumab; Antineoplastic Agents, Immunological; Antineoplastic Agents