Diversity of US participants in AstraZeneca-sponsored clinical trials

BACKGROUND

To develop medicines that are safe and efficacious to all patients, clinical trials must enroll appropriate target populations, but imbalances related to race, ethnicity and sex have been reported. A comprehensive analysis and improvement in understanding representativeness of patient enrollment in industry-sponsored trials are key public health needs.

METHODS

We assessed race/ethnicity and sex representation in AstraZeneca (AZ)-sponsored clinical trials in the United States (US) from 2010 to 2022, compared with the 2019 US Census.

RESULTS

In total, 246 trials representing 95,372 patients with complete race/ethnicity and sex records were analyzed. The proportions of different race/ethnicity subgroups in AZ-sponsored clinical trials and the US Census were similar (White: 69.5% vs 60.1%, Black or African American: 13.3% vs 12.5%, Asian: 1.8% vs 5.8%, Hispanic: 14.4% vs 18.5%). We also observed parity in the proportions of males and females between AZ clinical trials and US Census (males: 52.4% vs 49.2%, females: 47.6% vs 50.8%). Comparisons of four distinct therapy areas within AZ (Respiratory and Immunology [R&I]; Cardiovascular, Renal, and Metabolism [CVRM]; Solid Tumors; and Hematological Malignancies), including by trial phases, revealed greater variability, with proportions observed above and below US Census levels.

CONCLUSION

This analysis provides the first detailed insights into the representativeness of AZ trials. Overall, the proportions of different race/ethnicity and sex subgroups in AZ-sponsored clinical trials were broadly aligned with the US Census. We outline some of AZ's planned health equity initiatives that are intended to continue to improve equitable patient enrollment.

IGNYTE-ESO: A master protocol to assess safety and activity of letetresgene autoleucel (lete-cel; GSK3377794) in HLA-A*02+ patients with synovial sarcoma or myxoid/round cell liposarcoma (Substudies 1 and 2)

TPS11582

Background: Letetresgene autoleucel (lete-cel; GSK3377794) is an autologous T-cell product using a genetically modified T-cell receptor to target cancer cells expressing the cancer testis antigen New-York esophageal squamous cell carcinoma 1 (NY-ESO-1). Lete-cel is currently being investigated alone and in combination in multiple tumor types [1,2]. NY-ESO-1 is expressed in 70‒80% of synovial sarcoma (SS) and 80‒90% of myxoid/round cell liposarcoma (MRCLS) tumors [3,4], suggesting these tumors may be prime lete-cel targets. This master protocol design (IGNYTE-ESO; NCT03967223) enables evaluation of multiple cell therapies in multiple tumor types and treatment stages in separate substudies, beginning with lete-cel in Substudies 1 and 2 for SS and MRCLS. Methods: Substudy 1 is a single-arm study assessing lete-cel in treatment-naïve patients (pts; ie, anthracycline therapy-naïve for metastatic disease) with advanced (metastatic/unresectable) NY-ESO-1+ SS or MRCLS as a first line of therapy (n=10 planned). Substudy 2 is a pivotal, single-arm study assessing lete-cel in pts with NY-ESO-1+ SS or MRCLS who progressed after anthracycline therapy (n=70 planned). Key eligibility criteria are age ≥10 y and NY-ESO-1 and HLA-A*02 positivity. Exclusion criteria include prior NY-ESO-1–specific/gene therapy, allogeneic stem cell transplant, and central nervous system metastases. Screened pts undergo leukapheresis for lete-cel manufacture, lymphodepletion, lete-cel infusion, and follow-up (FU). Long-term FU (15 y) may be done under a separate protocol. The Substudy 2 primary endpoint is overall response rate (ORR) per RECIST v1.1 assessed by central independent review. Substudy 1 is not testing any formal hypotheses; statistical analysis will be descriptive. Substudy 2 is comparing ORR with the historical control assuming at least 90% power with 0.025 one-sided type I error. Secondary endpoints include efficacy (time to/duration of response, disease control rate, progression-free survival), safety (adverse event [AE] frequency/severity, serious AEs, AEs of special interest), and pharmacokinetic (maximum transgene expansion [Cmax], time to Cmax, area under the time curve from zero to time t as data permit). Enrollment began in December 2019. References: 1. Reckamp KL, et al. Ann Oncol 2019;30(Suppl_5):v602–v660. 2. Rapoport A, et al. J Clin Oncol 2020 38:15_suppl, TPS8555. 3. D’Angelo SP, et al. Cancer Discov 2018;8(8):944–957. 4. D’Angelo SP, et al. J Clin Oncol 2018 36:15_suppl, 3005. Funding: GSK. Editorial support was provided by Eithne Maguire, PhD, of Fishawack Indicia, part of Fishawack Health, and funded by GSK. Previously presented at BSG 2021 (P914542). Clinical trial information: NCT03967223.

Safety and activity of autologous T cells with enhanced NY-ESO-1–specific T-cell receptor (GSK3377794) in HLA-a*02+ previously-treated and -untreated patients with advanced metastatic/unresectable synovial sarcoma: A master protocol study design (IGNYTE-ESO)

TPS11571

Background: T cells modified to target NY-ESO-1 have shown encouraging activity in HLA-A*02+ patients with NY-ESO-1–positive synovial sarcoma. NY-ESO-1 is a cancer/testis antigen that is expressed across multiple tumor types and highly expressed in synovial sarcoma. NY-ESO-1 TCR T (GSK3377794) are autologous polyclonal T cells transduced by a self-inactivating lentiviral vector to express an affinity-enhanced TCR able to recognize NY-ESO-1 epitope in complex with HLA-A*02. Ongoing trials are evaluating GSK3377794 in multiple solid tumors and multiple myeloma. Methods: This study (NCT03967223) uses a Master Protocol design that allows investigation of GSK3377794 in multiple tumor types under the same protocol in separate substudies. The first two are single-arm substudies in patients with advanced metastatic or unresectable synovial sarcoma: treatment-naïve (1st line [1L], substudy 1; n = 10 planned) and progressing after anthracycline-based chemotherapy (2L+, substudy 2; n = 55 planned). Patients must be aged ≥10 years, have adequate organ function, ECOG performance status 0–1, measurable disease, and no central nervous system metastases. Excluded prior treatments include gene therapy with an integrating vector or NY-ESO-1–specific T cells, vaccine or targeting antibody, or allogeneic stem cell transplant. Patients will undergo leukapheresis and manufacture of GSK3377794; lymphodepletion then GSK3377794 infusion, followed by safety and disease assessments; and long-term follow-up for 15 years (under a separate protocol). The primary objective of substudy 2 is overall response rate per RECIST v1.1 by central independent review. Secondary objectives include time to response, duration of response, disease control rate, progression-free survival, overall survival, plus safety and tolerability. Exploratory objectives include assessment of the correlation of T-cell persistence with safety, clinical responses, and infused T-cell phenotype. Evaluation of quality of life and daily functioning of patients will also be assessed. Enrollment began in December 2019. These data are presented on behalf of the original authors with their permission. A similar presentation (P453) was presented at the SITC Annual Meeting, National Harbor, MD, USA, Nov 6–10, 2019. Funding: GlaxoSmithKline (208467) Clinical trial information: NCT03967223 .

Phase I/Ib study of olaparib and carboplatin in heavily pretreated recurrent high-grade serous ovarian cancer at low genetic risk

Purpose: To investigate maximum tolerated dose (MTD), activity and predictive biomarkers of olaparib with carboplatin in BRCA wild-type (BRCAwt) high grade serous ovarian carcinoma (HGSOC) patients. Methods: A 3+3 dose escalation study examined olaparib capsules (400 mg twice daily [BID], days 1-7) with carboplatin (AUC3-5 on day 1) every 21 days for 8 cycles, followed by olaparib 400 mg BID maintenance. Blood and tumor biopsy samples were collected pre- and on-treatment in the expansion cohort for PAR levels and proteomic endpoints. Results: 30 patients (median 7 prior regimens [2-12], 63% (19/30) platinum-resistant) were enrolled. Dose-limiting toxicity was thrombocytopenia/neutropenia, and infection with carboplatin AUC5 (2/6 patients). MTD was olaparib 400 mg BID + carboplatin AUC4. Grade 3/4 adverse events (>10%) included neutropenia (23%), thrombocytopenia (20%), and anemia (13%). Five of 25 (20%) evaluable patients had partial response (PR; median 4.5 months [3.3-9.5]). Clinical benefit rate (PR + stable disease ≥4 months) was 64% (16/25). A greater decrease in tissue PAR levels was seen in the clinical benefit group versus no benefit (median normalized linear change -1.84 [-3.39- -0.28] vs 0.51 [-0.27- 1.29], p = 0.001) and a DNA repair score by proteomics did not correlate with response. Conclusions: The olaparib and carboplatin combination is tolerable and has clinical benefit in subsets of heavily pretreated BRCAwt HGSOC, independent of platinum sensitivity.

Abstract CT126: A phase I first time in human study to evaluate the safety, pharmacokinetics, and immunogenicity of MEDI5083 alone and in combination with durvalumab in selected advanced solid tumors

Background

CD40 is a member of the TNFR superfamily that is broadly expressed by immune, vascular, epithelial, and tumor cells. Interaction between CD40 and its ligand CD40L plays an important role in innate and adaptive immunity. APCs such as dendritic cells can be primed by CD4+ T cells by interaction between CD40 and CD40L. Several studies have confirmed that CD40 is broadly expressed on multiple solid tumor types. Thus, further evaluation of investigational agents and combination immunotherapies targeting the CD40 pathway is warranted across multiple cancer indications.

MEDI5083 is a homodimeric fusion protein consisting of 3 scCD40L domains and an IgG4P Fc domain. MEDI5083 agonizes CD40 on APCs and bridges the innate and adaptive immune systems by promoting potent antitumor T cell mediated immune responses. Durvalumab is a selective, high-affinity, engineered human IgG1 mAb that blocks PD-L1 binding to PD-1 and CD80, allowing T cells to recognize and kill tumor cells. In clinical studies durvalumab has shown a manageable and consistent tolerability profile across multiple tumor types. The combination of MEDI5083 and durvalumab has the potential to activate the adaptive immune system through potentially complementary mechanisms, leading to enhanced targeting of tumor cells.

Methods

This Phase 1 first in human study evaluates the safety, pharmacokinetics, and immunogenicity of MEDI5083 alone and in combination with durvalumab in select advanced solid tumors. The primary objective is to evaluate the safety and tolerability, describe dose-limiting toxicity, and determine the maximum tolerated dose or the highest protocol-defined dose for MEDI5083 when administered as monotherapy and when administered concurrently in combination with durvalumab. Key secondary objectives include describing PK, systemic pharmacodynamics, immunogenicity and preliminary clinical activity of MEDI5083 administered alone or concurrently with durvalumab. This is a 3-part study; Part 1 is dose escalation of MEDI5083 monotherapy followed by either durvalumab monotherapy or potential reinduction with MEDI5083. Part 2 is dose escalation of MEDI5083 with concurrent durvalumab therapy, followed by durvalumab monotherapy restricted to selected tumor types. Part 3 is MEDI5083 with concurrent durvalumab, followed by durvalumab monotherapy in tumor specific expansion cohorts. Recruitment is ongoing (NCT03089645).

Citation Format: Ben Tran, Johanna Bendell, Martin Gutierrez, Jie Yang, Natasha Angra, Victoria L. Chiou, Mark Voskoboynik. A phase I first time in human study to evaluate the safety, pharmacokinetics, and immunogenicity of MEDI5083 alone and in combination with durvalumab in selected advanced solid tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT126.

A phase 1 study to evaluate the safety, pharmacokinetics, pharmacodynamics, immunogenicity, and antitumor activity of the OX40 agonist MEDI0562 in combination with tremelimumab or durvalumab in adult aubjects with advanced solid tumors

TPS3100

Background: Recent advances in treatment of solid tumors include single or combined use of monoclonal antibodies (mAbs) against the immune checkpoints CTLA-4 or PD-1/PD-L1 that can reactivate antitumor cytotoxic tumor-infiltrating lymphocytes (TILs) and significantly improve OS (Menon S, et al. Cancers (Basel). 2016;8:E106.) (Antonia S, et al. Lancet Oncol. 2016; 17:299-308). Activation of TILs via the costimulatory OX40 (CD134) molecule, may offer an alternative and non-redundant pathway for increasing antitumor immunity. OX40 costimulation promotes effector T cell expansion and longevity, overcomes regulatory T cell suppression and provides survival benefit in animal models of tumor challenge (Linch SN, et al. Front Oncol. 2015;5:34). MEDI0562 is an investigational, humanized IgG1κ anti-OX40 mAb that triggers OX40 signaling. Coadministration of an OX40 agonist and either a CTLA-4 or PD-1/PD-L1 pathway inhibitor may promote synergistic effects against certain solid tumors and may be tolerable administered in combination. Methods: A Phase 1, multicenter, open-label study (NCT02705482) is underway to evaluate safety (primary endpoint), pharmacokinetics, pharmacodynamics, immunogenicity and antitumor activity (secondary endpoints) of MEDI0562 in combination with either anti-PD-L1 mAb durvalumab or anti-CTLA-4 mAb tremelimumab in adult subjects with previously treated advanced solid tumors. Subjects with primary CNS tumors and hematologic malignancies are excluded. The study includes a dose escalation and expansion phase, with 2 treatment arms in each: MEDI0562/durvalumab combination (Arm A) and MEDI0562/tremelimumab combination (Arm B). Safety assessments include AEs, serious AEs, dose-limiting toxicities, abnormal laboratory parameters, vital signs, and electrocardiogram results. Antitumor efficacy will be assessed as OR, disease control, duration of response, PFS, and OS using RECIST Version 1.1. Subjects will remain on treatment until unacceptable toxicity, progressive disease or other reasons for discontinuation. Clinical trial information: NCT02705482.

Phase I/Ib study of olaparib and carboplatin in women with triple negative breast cancer

PURPOSE

To investigate the safety, activity, and potential biomarkers of response to olaparib and carboplatin combination in sporadic triple negative breast cancer (TNBC). EXPERIMENTAL DESIGN: Metastatic or recurrent TNBC patients with no germline BRCA mutation or with BRCAPro scores <10% and a negative family history were eligible. A 3+3 dose escalation tested olaparib capsules (400mg bid, days1-7) with carboplatin AUC3-5 on day1 or 2 every 21 days, ≤ 8 cycles, with olaparib 400mg bid maintenance. Peripheral blood mononuclear cells were collected for polymorphisms and PAR levels, and paired tumor biopsies (pre-/post-cycle 1) for proteomics and apoptosis endpoints.

RESULTS

28 women were treated (median 5 prior regimens [0-12]). Dose-limiting toxicity was thrombocytopenia, and symptomatic hyponatremia with carboplatin AUC5. The maximum tolerated dose was olaparib 400mg bid+carboplatin AUC4. Grade 3 and 4 adverse events included neutropenia (36%), thrombocytopenia (11%), and anemia (11%). Responses included 1 complete response (CR; 69⁺months) and 5/27 partial responses (19%; median 4months [4-7]), for a response rate of 22%. Biomarker findings did not correlate with response. The long-term CR patient with prior negative BRCA testing was found to have deletion of BRCA1 exons1-2.

CONCLUSIONS

The olaparib/carboplatin combination is tolerable and has modest activity in sporadic TNBC patients. Further evaluation of predictive biomarkers to identify those with BRCA wild type who had response is warranted.

Sequence-Specific Pharmacokinetic and Pharmacodynamic Phase I/Ib Study of Olaparib Tablets and Carboplatin in Women's Cancer

Purpose: Our preclinical studies showed that the PARP inhibitor, olaparib, prior to carboplatin attenuated carboplatin cytotoxicity. We evaluated sequence-specific pharmacokinetic and pharmacodynamic effects, safety, and activity of the combination.Experimental Design: Eligible patients had metastatic or recurrent women's cancer. Olaparib tablets were introduced (100 or 200 mg twice daily, days 1-7) in a 3 + 3 dose escalation with carboplatin AUC4 or 5 every 21 days, up to eight cycles, followed by olaparib 300 mg twice daily maintenance. Patients were randomly assigned to starting schedule: cohort A (olaparib days 1-7, carboplatin on day 8) or B (carboplatin on day 1, olaparib days 2-8) during cycle 1. Patients received the reversed scheme in cycle 2. Blood was collected for olaparib pharmacokinetics, platinum-DNA adducts, comet assay, and PAR concentrations. The primary objectives were to examine schedule-dependent effects on olaparib pharmacokinetics and platinum-DNA adducts.Results: A total of 77 (60 ovarian, 14 breast, and 3 uterine cancer) patients were treated. Dose-limiting toxicity was thrombocytopenia and neutropenia, defining olaparib 200 mg twice daily + carboplatin AUC4 as the MTD. Olaparib clearance was increased approximately 50% when carboplatin was given 24 hours before olaparib. In vitro experiments demonstrated carboplatin preexposure increased olaparib clearance due to intracellular olaparib uptake. Quantities of platinum-DNA adducts were not different as a function of the order of drug administration. Responses included 2 CRs and 31 PRs (46%) with a higher RR in BRCA mutation carriers compared with nonmutation carriers (68% vs. 19%).Conclusions: Tablet olaparib with carboplatin is a safe and active combination. Carboplatin preexposure causes intracellular olaparib accumulation reducing bioavailable olaparib, suggesting carboplatin should be administered prior to olaparib. Clin Cancer Res; 23(6); 1397-406. ©2016 AACR.

Abstract CT326: Pharmacokinetic/pharmacodynamic study of sequence specificity of the PARP inhibitor, olaparib and carboplatin in recurrent women's cancers

Background: Olaparib/carboplatin are active in gBRCA1/2m+ or BRCA-like breast and ovarian cancer (Br/OvCa). Our in vitro data suggest that pretreatment with olaparib before carboplatin attenuates C-induced DNA double stranded breaks (DSBs) and cytotoxicity. We hypothesize olaparib/carboplatin sequence may affect DNA DSBs and toxicity in pts.

Methods: Eligible pts had recurrent women's cancers, normal end-organ function, and evaluable disease. Pts were randomized to arm A or B for intra-pt and inter-cohort analysis of PK/PD endpoints. 21 pts were required per arm for 80% power to determine one SD difference between arms. PBMCs were collected prior to and 24hrs after olaparib or carboplatin on cyc 1&2 for comet DNA damage assay and PAR incorporation ELISA. Toxicity was evaluated q3 wks, and response q2 cyc by RECISTv1.1.

Results: 59 women (age 59 [25-74]; 47 OvCa (26 gBRCAm+)/10 triple negative BrCa [TNBC; 4 gBRCAm+]/1 uterine carcinosarcoma/1 endometrial Ca) were treated. All had prior therapy (median 5[2-14]). Intra-pt comparisons of PD endpoints indicated olaparib/carboplatin yields greater DNA DSBs than olaparib or carboplatin alone (median fold change compared to baseline; 1.21+/- 0.30 SD v. 1.13 or 0.97 [arm A], 1.33 +/- 0.67 SD v. 1.02 or 1.04 [arm B], both p&lt;0.05). Intra-pt and inter-cohort comparisons show no significant differences in DNA DSBs, PAR incorporation and frequencies of Gr3/4 AEs as a function of the order of the schedule. Gr3/4 AEs included neutropenia (22%), anemia (12%), thrombocytopenia (10%), and carboplatin hypersensitivity (3%). Responses (54pts) included 1 CR (2%, 23mo; TNBC) and 23 PR (43%, 9[5-15]mo; 20 OvCa/3 TNBC). gBRCAm+ pts had a higher response rate (RR; 1CR/19 PR) compared to BRCAwt/unknown (4 PR; 65% v. 17%, p&lt;0.001).

Conclusions: Combination O/C induced greater DNA damage than single agents, consistent with the higher than expected RR. However, the O/C sequence did not impact DNA damage, PAR incorporation or toxicity. Olaparib tablets 200mg bid x 7d with carboplatin AUC 4 q 21d is active and tolerable in recurrent women's cancers, especially for gBRCAm+ pts. (NCT01237067)

Treatment schedule armsCycle (cyc) 1Cyc 2Cyc 3-8Cyc 9+Arm AO tablet 200mg bid d1-7⇒C AUC4 d8C AUC4 d1⇒O tablet 200mg bid d2-8O tablet 200mg bid d1-7, C AUC4 d1or2maintenance O tablet 300mg bid

Citation Format: Victoria L. Chiou, Christina Annunziata, Stanley Lipkowitz, Lori Minasian, Nicolas Gordon, Minshu Yu, Seth Steinberg, Nicole Houston, Elise Kohn, Jung-min Lee. Pharmacokinetic/pharmacodynamic study of sequence specificity of the PARP inhibitor, olaparib and carboplatin in recurrent women's cancers. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr CT326. doi:10.1158/1538-7445.AM2015-CT326

The MAPK pathway across different malignancies: a new perspective

The mitogen-activated protein kinase/extracellular signal-regulated (MAPK/ERK) pathway is activated by upstream genomic events and/or activation of multiple signaling events in which information coalesces at this important nodal pathway point. This pathway is tightly regulated under normal conditions by phosphatases and bidirectional communication with other pathways, like the protein kinase B/mammalian target of rapamycin (AKT/m-TOR) pathway. Recent evidence indicates that the MAPK/ERK signaling node can function as a tumor suppressor as well as the more common pro-oncogenic signal. The effect that predominates depends on the intensity of the signal and the context or tissue in which the signal is aberrantly activated. Genomic profiling of tumors has revealed common mutations in MAPK/ERK pathway components, such as v-raf murine sarcoma viral oncogene homolog B1 (BRAF). Currently approved for the treatment of melanoma, inhibitors of BRAF kinase are being studied alone and in combination with inhibitors of the MAPK and other pathways to optimize the treatment of many tumor types. Therapies targeted toward MAPK/ERK components have various response rates when used in different solid tumors, such as colorectal cancer and ovarian cancer. Understanding the differential nature of activation of the MAPK/ERK pathway in each tumor type is critical in developing single and combination regimens, because different tumors have unique mechanisms of primary and secondary signaling and subsequent sensitivity to drugs.

Profile of minocycline neuroprotection in bilirubin-induced auditory system dysfunction

Excessive hyperbilirubinemia in human neonates can cause permanent dysfunction of the auditory system, as assessed with brainstem auditory evoked potentials (BAEPs). Jaundiced Gunn rat pups (jjs) exhibit similar BAEP abnormalities as hyperbilirubinemic neonates. Sulfadimethoxine (sulfa) administration to jjs, which displaces bilirubin from serum albumin into tissues including brain, exacerbates acute toxicity. Minocycline administered prior to sulfa in jjs protects against BAEP abnormalities. This study evaluates the neuroprotective capabilities of minocycline HCl (50 mg/kg) administered 30 or 120 min after sulfa (200 mg/kg) in 16 days old jjs. BAEPs are recorded at 6 or 24 h post-sulfa. Abnormal BAEP waves exhibit increased latency and decreased amplitude. The sulfa/saline treated jjs exhibited a significantly increased interwave interval between waves I and II (I-II IWI) and significantly decreased amplitudes of waves II and III compared to the saline/saline jjs. The minocycline 30 min post-sulfa (sulfa/mino+30) group was not significantly different from the saline/saline control group, indicating neuroprotection. The minocycline 120 min post-sulfa (sulfa/mino+120) group had a significantly decreased amplitude of wave III at both 6 and 24h. These studies indicate that minocycline has a graded neuroprotective effect when administered after acute bilirubin neurotoxicity.