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Effect of TTFields (150 kHz) in Non-small Cell Lung Cancer (NSCLC) Patients With 1-10 Brain Metastases Following Radiosurgery (METIS)

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ClinicalTrials.gov Identifier: NCT02831959
Recruitment Status : Recruiting
First Posted : July 13, 2016
Last Update Posted : January 27, 2020
Sponsor:
Information provided by (Responsible Party):
NovoCure Ltd.

Tracking Information
First Submitted Date  ICMJE July 8, 2016
First Posted Date  ICMJE July 13, 2016
Last Update Posted Date January 27, 2020
Study Start Date  ICMJE July 2016
Estimated Primary Completion Date December 2020   (Final data collection date for primary outcome measure)
Current Primary Outcome Measures  ICMJE
 (submitted: October 29, 2017)
Time to intracranial progression [ Time Frame: 3 years ]
Original Primary Outcome Measures  ICMJE
 (submitted: July 11, 2016)
Time to first cerebral progression [ Time Frame: 3 years ]
Change History
Current Secondary Outcome Measures  ICMJE
 (submitted: October 29, 2017)
  • Time to neurocognitive failure [ Time Frame: 3 years ]
    Measured by cognitive decline on a battery of tests: Hopkins Verbal Learning Test (HVLT-R) free recall, delayed recall, and delayed recognition; Controlled Oral Word Association Test (COWAT); and Trail Making Tests (TMT) Parts A and B
  • Overall survival [ Time Frame: 3 years ]
  • Radiological response in the brain [ Time Frame: 3 years ]
  • Time to second intracranial progression [ Time Frame: 3 years ]
  • Time to first and second intracranial progression evaluated in two cohorts, 1-4 brain metastases and 5-10 brain metastases. [ Time Frame: 3 years ]
  • Rate of intracranial progression at 2, 4, 6, 8, 10, 12 months [ Time Frame: 3 years ]
  • Time to distant progression [ Time Frame: 3 years ]
  • Rate of decline in cognitive function at 2, 4, 6, 8, 10, 12 months [ Time Frame: 3 years ]
    Measured by HVLT-R free recall, delayed recall, and delayed recognition; COWAT; and TMT Parts A and B
  • Neurocognitive failure-free survival [ Time Frame: 3 years ]
    Defined from the date of first SRS treatment to neurocognitive failure (as measured by HVLT-R free recall, delayed recall, and delayed recognition; COWAT; and TMT Parts A and B) or death (whichever occurs first), censored at the last neurocognitive assessment on which the patient was reported alive without neurocognitive failure
  • Quality of Life using the EORTC QLQ C30 with BN20 addendum [ Time Frame: 3 years ]
  • Toxicity during NovoTTF-100M treatment based on incidence and severity of treatment emergent adverse events as evaluated using the CTCAE version 4.0 [ Time Frame: 3 years ]
Original Secondary Outcome Measures  ICMJE
 (submitted: July 11, 2016)
  • Time to neurocognitive failure [ Time Frame: 3 years ]
    Measured by cognitive decline on a battery of tests: Hopkins Verbal Learning Test (HVLT-R) free recall, delayed recall, and delayed recognition; Controlled Oral Word Association Test (COWAT); and Trail Making Tests (TMT) Parts A and B
  • Overall survival [ Time Frame: 3 years ]
  • Radiological response in the brain [ Time Frame: 3 years ]
  • Time to second cerebral progression [ Time Frame: 3 years ]
  • Time to first and second cerebral progression evaluated in two cohorts, 1-4 brain metastases and 5-10 brain metastases. [ Time Frame: 3 years ]
  • Rate of cerebral progression at 2, 4, 6, 8, 10, 12 months [ Time Frame: 3 years ]
  • Intracranial progression free survival [ Time Frame: 3 years ]
  • Time to distant progression in the supratentorial region [ Time Frame: 3 years ]
  • Rate of decline in cognitive function at 2, 4, 6, 8, 10, 12 months [ Time Frame: 3 years ]
    Measured by HVLT-R free recall, delayed recall, and delayed recognition; COWAT; and TMT Parts A and B
  • Neurocognitive failure-free survival [ Time Frame: 3 years ]
    Defined from the date of first SRS treatment to neurocognitive failure (as measured by HVLT-R free recall, delayed recall, and delayed recognition; COWAT; and TMT Parts A and B) or death (whichever occurs first), censored at the last neurocognitive assessment on which the patient was reported alive without neurocognitive failure
  • Quality of Life using the EORTC QLQ C30 with BN20 addendum [ Time Frame: 3 years ]
  • Toxicity during NovoTTF-100M treatment based on incidence and severity of treatment emergent adverse events as evaluated using the CTCAE version 4.0 [ Time Frame: 3 years ]
Current Other Pre-specified Outcome Measures Not Provided
Original Other Pre-specified Outcome Measures Not Provided
 
Descriptive Information
Brief Title  ICMJE Effect of TTFields (150 kHz) in Non-small Cell Lung Cancer (NSCLC) Patients With 1-10 Brain Metastases Following Radiosurgery (METIS)
Official Title  ICMJE Pivotal, Open-label, Randomized Study of Radiosurgery With or Without Tumor Treating Fields (TTFields) (150kHz) for 1-10 Brain Metastases From Non-small Cell Lung Cancer (NSCLC)
Brief Summary The study is a prospective, randomized controlled phase III trial, to test the efficacy, safety and neurocognitive outcomes of advanced NSCLC patients, following stereotactic radiosurgery (SRS) for 1-10 brain metastases, treated with NovoTTF-100M compared to supportive treatment alone. The device is an experimental, portable, battery operated device for chronic administration of alternating electric fields (termed TTFields or TTF) to the region of the malignant tumor, by means of surface, insulated electrode arrays.
Detailed Description

PAST PRE-CLINICAL AND CLINICAL EXPERIENCE:

The effect of the electric fields (TTFields, TTF) has demonstrated significant activity in in vitro and in vivo NSCLC pre-clinical models both as a single modality treatment and in combination with chemotherapies. TTFields have also shown to inhibit metastatic spread of malignant melanoma in in vivo experiment.

In a pilot study, 42 patients with advanced NSCLC who had had tumor progression after at least one line of prior chemotherapy, received pemetrexed together with TTFields (150 kHz) applied to the chest and upper abdomen until disease progression (Pless M., et al., Lung Cancer 2011). Efficacy endpoints were remarkably high compared to historical data for pemetrexed alone.

In addition, a phase III trial of Optune® (200 kHz) as monotherapy compared to active chemotherapy in recurrent glioblastoma patients showed TTFields to be equivalent to active chemotherapy in extending survival, associated with minimal toxicity, good quality of life, and activity within the brain (14% response rate) (Stupp R., et al., EJC 2012). Finally, a phase III trial of Optune® combined with maintenance temozolomide compared to maintenance temozolomide alone has shown that combined therapy led to a significant improvement in both progression free survival and overall survival in patients with newly diagnosed glioblastoma without the addition of high grade toxicity and without decline in quality of life (Stupp R., et al., JAMA 2015).

Applying TTFields at 150 kHz to the brain for the treatment of 1-5 brain metastasis from NSCLC using the NovoTTF-100M device has been demonstrated to be safe in a pilot study, where patients were randomize after local therapy of their brain metastasis by neurosurgery and/or stereotactic radiosurgery to receive either NovoTTF-100M treatment or supportive care alone. Eighteen (18) patients have been enrolled in the study. There have been no device-related serious adverse events (SAE) reported to date (Brozova H., et al., Neuro Oncol 2016).

DESCRIPTION OF THE TRIAL:

All patients included in this trial are patients with 1-10 brain metastases from NSCLC which are amenable to stereotactic radiosurgery (SRS). In addition, all patients must meet all eligibility criteria.

Eligible patients will be randomly assigned to one of two groups:

  1. Patients undergo SRS followed by TTFields using the NovoTTF-100M System
  2. Patients undergo SRS alone and receive supportive care.

Patients in both arms of the study may receive systemic therapy for their NSCLC at the discretion of their treating physician.

Patients will be randomized at a 1:1 ratio. Baseline tests will be performed in patients enrolled in both arms. If assigned to the NovoTTF-100M group, the patients will be treated continuously with the device until second intracranial progression.

On both arms, patients who recur anywhere in the brain will be offered one of the following salvage treatments (according to local practice) including, but not limited to:

  • Surgery
  • Repeat SRS
  • Whole brain radiotherapy (WBRT)

Patients on the control arm will be offered to cross over to the NovoTTF-100M arm of the study and receive TTFields after salvage therapy for second intracranial progression if the investigator believes it is in the best interest of the patient and patient agrees.

SCIENTIFIC BACKGROUND:

Electric fields exert forces on electric charges similar to the way a magnet exerts forces on metallic particles within a magnetic field. These forces cause movement and rotation of electrically charged biological building blocks, much like the alignment of metallic particles seen along the lines of force radiating outwards from a magnet.

Electric fields can also cause muscles to twitch and if strong enough may heat tissues. TTFields are alternating electric fields of low intensity. This means that they change their direction repetitively many times a second. Since they change direction very rapidly (150 thousand times a second), they do not cause muscles to twitch, nor do they have any effects on other electrically activated tissues in the body (brain, nerves and heart). Since the intensities of TTFields in the body are very low, they do not cause heating.

The breakthrough finding made by Novocure was that finely tuned alternating fields of very low intensity, now termed TTFields (Tumor Treating Fields), cause a significant slowing in the growth of cancer cells. Due to the unique geometric shape of cancer cells when they are multiplying, TTFields cause electrically-charged cellular components of these cells to change their location within the dividing cell, disrupting their normal function and ultimately leading to cell death.. In addition, cancer cells also contain miniature building blocks which act as tiny motors in moving essential parts of the cells from place to place. TTFields interfere with the normal orientation of these tiny motors related to other cellular components since they are electrically-charged as well. As a result of these two effects, tumor cell division is slowed, results in cellular death or reverses after continuous exposure to TTFields.

Other cells in the body (normal healthy tissues) are affected much less than cancer cells since they multiply at a much slower rate if at all. In addition TTFields can be directed to a certain part of the body, leaving sensitive areas out of their reach. Finally, the frequency of TTFields applied to each type of cancer is specific and may not damage normally dividing cells in healthy tissues.

In conclusion, TTFields hold the promise of serving as a brand new treatment for brain metastases from NSCLC with very few side effects.

Study Type  ICMJE Interventional
Study Phase  ICMJE Phase 3
Study Design  ICMJE Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Condition  ICMJE Brain Metastases From Non-small Cell Lung Cancer (NSCLC)
Intervention  ICMJE
  • Device: NovoTTF-100M device
  • Other: Best Standard of Care
Study Arms  ICMJE
  • Experimental: NovoTTF-100M device
    Patients undergo SRS followed by continuous TTFields treatment using the NovoTTF-100M device. TTFields treatment will consist of wearing four electrically insulated electrode arrays on the head. The treatment enables the patient to maintain regular daily routine.
    Interventions:
    • Device: NovoTTF-100M device
    • Other: Best Standard of Care
  • Active Comparator: Best Standard of Care
    Patients will undergo SRS alone and be treated with the best known standard of care for Non-Small Cell Lung Cancer metastatic to the brain.
    Intervention: Other: Best Standard of Care
Publications *

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruitment Information
Recruitment Status  ICMJE Recruiting
Estimated Enrollment  ICMJE
 (submitted: July 11, 2016)
270
Original Estimated Enrollment  ICMJE Same as current
Estimated Study Completion Date  ICMJE December 2020
Estimated Primary Completion Date December 2020   (Final data collection date for primary outcome measure)
Eligibility Criteria  ICMJE

Inclusion Criteria:

  1. 18 years of age and older
  2. Life expectancy of ≥ 3 months
  3. New diagnosis of brain metastases from a histologically or cytologically confirmed primary or metastatic NSCLC tumor within 5 years of registration on the study. If the original histological proof of malignancy is greater than 5 years, then pathological confirmation is required (i.e.: from extra-cranial or intracranial disease).
  4. Karnofsky performance status (KPS) ≥ 70
  5. 1 inoperable brain metastasis or 2- 10 brain lesions per screening MRI, confirmed by contrast enhanced MRI amenable to SRS according to the following criteria:

    1. largest tumor volume < 10 cc
    2. longest tumor diameter < 3 cm
    3. Cumulative volume of all tumors ≤ 15 cc
  6. At least one measurable lesion per RANO-BM (Response Assessment in Neuro-Oncology Brain Metastases) Criteria for brain metastasis
  7. Patients must be receiving optimal therapy for their extracranial disease according to local practice at each center. Patients may continue on systemic therapy while receiving TTFields.
  8. Able to operate the NovoTTF-100M device independently or with the help of a caregiver
  9. Clinical trials prior to enrollment are allowed, as long as no brain directed therapy was included (current treatment trials are exclusionary)

Exclusion Criteria:

  1. Patients who are known to have somatic tumor mutations in the following genes, for which targeted agents are available that directly affect the treatment of brain metastasis: Anaplastic lymphoma kinase (ALK), epidermal growth factor receptor (EGFR), ROS-1 proto-oncogene, and proto-oncogene B-RAF
  2. Patients who have a single, operable brain metastasis
  3. Patients with significant edema leading to risk of brain herniation
  4. Patients with midline shift > 10mm
  5. Patients with intractable seizures
  6. Leptomeningeal metastases
  7. Recurrent brain metastases
  8. Prior WBRT for newly diagnosed brain metastases
  9. Severe comorbidities:

    1. Clinically-significant inadequate hematological, hepatic and renal function, defined as: Neutrophil count < 1.5 x 10 9/L and platelet count < 100 x 10^9/L; bilirubin > 1.5 x upper limit of normal (ULN); aspartate transaminase (AST) and/or alanine aminotransferase (ALT) > 2.5 x ULN or > 5 x ULN if patient has documented liver metastases; and serum creatinine > 1.5 x ULN
    2. History of significant cardiovascular disease unless the disease is well controlled. Significant cardiac disease includes second/third degree heart block; significant ischemic heart disease; poorly controlled hypertension; congestive heart failure of the New York Heart Association (NYHA) Class II or worse (slight limitation of physical activity; comfortable at rest, but ordinary activity results in fatigue, palpitation or dyspnea).
    3. History of arrhythmia that is symptomatic or requires treatment. Patients with atrial fibrillation or flutter controlled by medication are not excluded from participation in the trial.
    4. History of cerebrovascular accident (CVA) within 6 months prior to randomization or that is not stable
    5. Active infection or serious underlying medical condition that would impair the ability of the patient to received protocol therapy
    6. History of any psychiatric condition that might impair patient's ability to understand or comply with the requirements of the study or to provide consent
  10. Implantable electronic medical devices in the brain
  11. Known allergies to medical adhesives or hydrogel
  12. Currently pregnant or breastfeeding
  13. Concurrent brain directed therapy (beyond SRS and NovoTTF-100M as per protocol)
Sex/Gender  ICMJE
Sexes Eligible for Study: All
Ages  ICMJE 18 Years and older   (Adult, Older Adult)
Accepts Healthy Volunteers  ICMJE No
Contacts  ICMJE
Contact: Antonia Mahnig +41 41 455 36 32 clinicaltrials@novocure.com
Listed Location Countries  ICMJE Austria,   Canada,   France,   Germany,   Israel,   Italy,   Poland,   Spain,   United States
Removed Location Countries  
 
Administrative Information
NCT Number  ICMJE NCT02831959
Other Study ID Numbers  ICMJE EF-25
Has Data Monitoring Committee Yes
U.S. FDA-regulated Product Not Provided
IPD Sharing Statement  ICMJE
Plan to Share IPD: Undecided
Responsible Party NovoCure Ltd.
Study Sponsor  ICMJE NovoCure Ltd.
Collaborators  ICMJE Not Provided
Investigators  ICMJE
Principal Investigator: Minesh Mehta, MD Miami Cancer Institute, Miami FL USA
Principal Investigator: Paul Brown, MD MD Anderson Cancer Center, Houston TX USA
Principal Investigator: Vinai Gondi, MD Northwestern Medicine Cancer Center, Warenville IL USA
Principal Investigator: Manmeet Ahluwalia, MD Cleveland Clinic, Cleveland OH USA
PRS Account NovoCure Ltd.
Verification Date January 2020

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP