UCI 05-46:A Phase II Study of AlbuminBound-Paclitaxel (AbraxaneTM) for Treatment of Recurrent or Metastatic Head and Neck Cancer With the Addition of Cetuximab (Erbitux) (IMC-225) on Disease Progression
Primary Objective: To assess the overall response rate (complete and partial response) to
Abraxane in patients with recurrent or metastatic head and neck cancer with the addition of
Cetuximab on disease progression.
Secondary Objectives: 1. To assess the frequency and severity of toxicities associated with
this treatment. 2. To evaluate overall survival and progression-free survival in patients
with recurrent or metastatic head and neck cancer treated with single agent Abraxane. 3.To
assess whether the addition of Centuximab will re-sensitize head and neck cancer to Abraxane
after progression on single agent Abraxane.
BACKGROUND AND RATIONALE
Approximately 40,000 new cases of head and neck cancer are diagnosed annually in the United
States (Jemal et al, 2003), and over 30% of these patients are expected to die of their
malignancy. Squamous cell carcinoma accounts for more than 90% of head and neck cancer
cases. Although metastatic disease at the time of diagnosis is rather uncommon, and despite
aggressive use of up-front concurrent radiation and cisplatin-based chemotherapy,
approximately 20% of the patients will develop metastases. Patients with recurrent or
metastatic squamous cell carcinoma of the head and neck (SCCHN) have a poor prognosis. Their
median survival is about 6-8 months. Selected patients with locally recurrent disease can be
treated with a curative intent with locoregional therapies, such as salvage surgery or
radiation (De Crevoisier et al, 1998); however the majority of these patients die of their
disease. Despite high response rates, combination chemotherapy has not been shown to produce
a survival benefit compared to single agents in randomized trials in patients with
recurrent/metastatic head and neck cancer (Forastiere et al, 1992; Jacobs et al, 1992;
Clavel et al, 1994). A phase III randomized study conducted by SWOG compared cisplatin-based
combination chemotherapy to single agent methotrexate (Forastiere et al, 1992). The
objective response rates were 32%, 21%, and 10%, for cisplatin/5-Fluorouracil (5-FU),
carboplatin/5-FU, and single methotrexate, respectively, but the median overall survival was
not statistically different between the three arms (ranged between 5 to 6.6 months).
Moreover, toxicity was increased with combination therapy, especially with the
cisplatin-based regimen. Another randomized study conducted in the US demonstrated a
significantly higher response rate of 32% for the combination of cisplatin and 5-FU versus
17% and 13% for single agent cisplatin and 5-FU, respectively (Jacobs et al, 1992). However,
the median survival of all patients was 5.7 months, with no difference between the three
arms. Hematologic toxicity was increased in the combination arm.
A subsequent randomized study conducted by ECOG (E1393) compared high-dose paclitaxel (200
mg/m2) as a 24-hour infusion plus cisplatin 75 mg/m2 with G-CSF support, to low dose
paclitaxel (135 mg/m2) as a 24-hour infusion, plus cisplatin 75 mg/m2 (Forastiere et al,
2001). Patients with newly diagnosed metastatic or recurrent squamous cell carcinoma of the
head and neck, excluding nasopharyngeal primaries were eligible. No prior treatment for
recurrent/metastatic disease was allowed, but patients could have received chemotherapy as a
part of the initial curative therapy that should have been completed 6 months prior to
study. Tow hundred and ten patients were randomized between the 2 arms. No significant
difference in outcome was observed. The response rate was 35% vs 36% and the median survival
was 7.6 vs 6.8 months, in the high-dose vs low-dose paclitaxel arms respectively. Patients
with metastatic disease performed worse in terms of survival. Previously untreated patients
achieved a higher response rate of 58% compared to a response rate of 32% observed in
patients who have failed prior curative therapies. Substantial toxicities were observed in
this trial. Grade 4 neutropenia was seen in 61-71% of patients and febrile neutropenia with
hospitalization occurred in 27-39% of patients. The toxic death rate was 10% (12% vs 9%)
(Forastiere et al, 2001). It was concluded that the 24-hour paclitaxel infusion was
associated with unacceptable toxicity when combined with cisplatin. Instead, a 3-hour
paclitaxel infusion combined with cisplatin was advanced to further testing. A more recent
randomized trial conducted by ECOG (E1395) compared the combination of paclitaxel 175 mg/m2
as a 3-hour infusion and cisplatin 75 mg/m2 to a standard cisplatin and 5-FU regimen. No
statistically significant difference could be demonstrated either in response rates or
survival between the two arms (Murphy et al, 2001). This study, however, indicated that
paclitaxel, a member of the taxane class of anti-tumor agent, is active in head and neck
Recently, another member anti-tumor class of taxane, Docetaxel (Taxotere) has been shown to
be active in advanced head and neck cancer. In a randomized phase III trial of
intensification of induction chemotherapy followed by radiation, the addition of docetaxel
to the induction regimen of cisplatin and 5-fluoruracil when compared to cisplatin and
5-fluoruracil alone resulted in a 3-month improvement in overall survival (Vermorken et al,
2004). Thus both members of the taxane family, paclitaxel and docetaxel, have proven
anti-tumor activity in head and neck cancer.
New agents to treat head and neck cancer need to be investigated. Abraxane, an albumin-bound
formulation of paclitaxel has shown significant single-agent activity in breast cancer and
in head and neck cancer. Recently, Abraxane has approved for use in metastatic breast
cancer. Given previous randomized phase III trials indicated single agent chemotherapy fared
as well as combination chemotherapy regimen in terms of overall survival, this novel
formulation should be actively investigated in head and neck cancer.
Abraxane in solid tumor The clinical database included two single arm studies enrolling a
total of 106 patients and one multi-center randomized trial. The multi-center trial was
conducted in 460 patients with metastatic breast cancer who were randomized to receive
either Abraxane 260 mg/m² administered as a 30-minute infusion or paclitaxel 175 mg/m² given
over 3 hours. Sixty-four percent of patients had impaired performance status (ECOG 1 or 2)
at study entry. Seventy-nine percent had visceral metastases and 76% had > 3 sites of
metastases. Fifty-nine percent of patients had received one or more prior chemotherapy
regimens, and 77% had received an anthracycline-containing regimen. The objective response
rate verified by central review was 21.5% (95% CI: 16.2% to 26.7%) for Abraxane compared to
11.1% (95% CI: 6.9% to 15.1%) for paclitaxel (p=0.003). The conclusion of this phase III
trial is that Abraxane had statistically significant higher target lesion response rate (the
trial primary endpoint) (O'Shaughnessy et al, 2003).
On January 7, 2005 the U. S. Food and Drug Administration approved Abraxane (albumin-bound
paclitaxel) for treatment of breast cancer after failure of combination chemotherapy for
metastatic disease or relapse within 6 months of adjuvant chemotherapy based on the
statistically significant superior response rate from the randomized phase III trial
mentioned above. The recommended dose of Abraxane is 260 mg/m² administered intravenously
over 30 minutes every 3 weeks. No premedication to prevent hypersensitivity reactions is
required prior to Abraxane administration.
Abraxane in Head and Neck Cancer The role of Abraxane in Head and Neck cancer has been
explored in a phase I study (Damascelli et al, 2001). Abraxane was injected intra-arterially
(carotid artery) in 31 patients with advanced Head and Neck cancer. The maximum tolerated
dose in a single administration was determined to be 270 mg/m2 which is very close to the
approved dose of 260 mg/m2. Three patients achieved complete response and 19 patients
achieved partial response for a combined response rate of 76%. Side effects are very
tolerable including three patients with grade 4 neutropenia, and grade 2 non-hematologic
toxicities included: keratitis [1 patient], skin toxicity [5 patients], neurologic
toxicities [4 patients], and flu-like syndrome [7 patients]. However, intra-arterial
administration is technically challenging with potential serious side effects, cumbersome
and not the conventional way of delivering chemotherapy. In another phase 1 study of
Abraxane in advanced solid tumors, 3 out of 5 patients with nasopharyngeal carcinoma had
responses lasting 25, 18 and 13+ weeks (Teng et al, 2005).
Given the hint of anti-tumor activity of Abraxane in advanced Head and Neck cancer from the
above mentioned studies, this current study will seek to determine the efficacy of Abraxane
in recurrent or metastatic head and neck cancer at the dose of 260 mg/m2 given intravenously
every 3 weeks in a systemic manner. Abraxane is not FDA approved in the treatment of this
study disease; however, it is approved for patient use in the treatment of advanced breast
cancer that have failed traditional therapy.
Abraxane is a natural substance and is far more superior to conventional chemistry.
Abraxane is an effective treatment for aggressive cancers because it adversely affects the
process of cell division by preventing this restructuring. Other cells are also affected
adversely, but since cancer cells divide much faster than non-cancerous cells, they are far
more susceptible to Abraxane treatment, thus, the safety of the drug is no more or less then
other chemotherapy regimens.
Human albumin will be used along with the Abraxane.
Description of Cetuximab (IMC-225) (Erbitux) (NSC-714692) Cetuximab, a chimerized antibody
of the IgG1 subclass was originally derived from a mouse myeloma cell line. The
chimerization resulted in an antibody with binding affinity to epidermal growth factor
receptors (EGFR) greater than the natural ligand epidermal growth factor (EGF). Cetuximab
blocks binding EGF and transforming growth factor (TGFa) to EGFR and inhibits ligand-induced
activation of this tyrosine kinase receptor. Cetuximab also stimulates EGFR internalization,
effectively removing the receptor from the cell surface for interaction with ligand.
Safety Precaution Cetuximab therapy should be used with caution in patients with known
hypersensitivity to Cetuximab, murine proteins, or any component of this product.
Administration of Cetuximab: In an effort to prevent a hypersensitivity reaction, all
patients should be premedicated with dexamethasone 20 mg by IV and diphenhydramine
hydrochloride 50 mg by IV given 30-60 minutes prior to the infusion of cetuximab.
The initial/loading dose of cetuximab is 400 mg/m2 IV administered over 120 minutes.
Patients must be continuously observed during the infusion for signs of anaphylaxis and
standard resuscitative meds should be in close proximity. Vital signs should be taken prior
to, during, post and 1-hour post infusion for the initial dose. For subsequent infusions,
vital signs are recommended to be taken to and 1-hour post infusion.
Following the loading dose, patients will receive weekly treatment with cetuximab IV over 60
minutes. The infusion rate of cetuximab should never exceed 5 mL/min. Patients should be
closely monitored for treatment-related adverse events, especially hypersensitivity
reactions, during the infusion and post-infusion.
Cetuximab is used for the treatment of patients with advanced head and neck cancer that has
spread to other parts of the body.
Allocation: Non-Randomized, Intervention Model: Single Group Assignment, Masking: Open Label, Primary Purpose: Treatment
To assess the overall response rate (complete and partial response)
S.-H. Ignatius Ou, MD, PhD
Chao Family Comprehensive Cancer Center
United States: Institutional Review Board
|Chao Family Comprehensive Cancer Center||Orange, California 92868|