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A Phase II Study of Bevacizumab, Irinotecan and Capecitabine in Patients With Previously Untreated Metastatic Colorectal Cancer

Phase 2
18 Years
Not Enrolling
Colorectal Cancer

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Trial Information

A Phase II Study of Bevacizumab, Irinotecan and Capecitabine in Patients With Previously Untreated Metastatic Colorectal Cancer

The FOLFIRI regimen has become the standard 1st line therapy for metastatic colorectal
cancer in Canada. This regimen consists of irinotecan in combination with bolus
5-FU/leucovorin, followed by 46-hour infusional 5-FU every 2 weeks. It requires a central
line and an infusion pump for delivering 5-FU, and necessitates at least 2 visits to the
chemotherapy units every 2 weeks, which not only incurs additional cost and inconvenience to
patients, but also increases the risk of complications such as thrombosis and infection due
to the central line. In addition, due to resources limitations, patients often have to wait
several weeks for central line placement. The XELIRI (irinotecan and capecitabine) regimen
has been in use at the Princess Margaret Hospital (PMH) as the first-line treatment of
patients with metastatic colorectal cancer since May, 2003. The choice of XELIRI over
FOLFIRI was made in efforts to reduce demands on resources, enable patients to start therapy
sooner, increase patient convenience and potentially reduce complications associated with
central venous access. The regimen consists of irinotecan 250 mg/m2 IV on day 1 and
capecitabine 1000 mg/m2 PO BID from days 1-14 every 3 weeks. The dose was reduced to
irinotecan 200 mg/m2 on day 1 and capecitabine 750 mg/m2 in patients > 65 years old or in
patients with renal impairment. So far, 101 patients have been treated on this regimen at
PMH. Among 76 patients evaluable for response, there have been 34 confirmed partial
responses (44.7%) and a further 18 patients with stable disease (23.7%), for a disease
control rate of 68.4%. Furthermore, this regimen was well tolerated with main side
effects being diarrhea and neutropenia. With availability of bevacizumab, 12 patients were
treated with the XELIRI regimen in combination with bevacizumab at PMH as part of the BEAT
(Bevcizumab Expanded Access Trial ) study up to October, 2005. Of 10 patients who were
treated with 3 or more cycles of chemotherapy, there were 7 confirmed partial responses and
2 additional patients with stable disease. One patient with non-measurable but evaluable
disease had marked reduction in infiltration in the sacrum. There were no instances of GI
perforation, febrile neutropenia, or toxic death. The median number of cycles of treatment
was 6, and 9 of 12 patients are still receiving treatment. There were, however, a total of
8 dose reductions of capecitabine in 6 patients, with majority of dose reductions as a
result of hand-foot syndrome. Although these efficacy and toxicity data are extremely
encouraging, the small number of patients limits the potential application of these
data.Because of the encouraging preliminary results, it is necessary to conduct a
prospective clinical study to further evaluate the efficacy and toxicity of irinotecan,
capecitabine and bevacizumab combination (the XELIRI-A regimen) as first-line chemotherapy
for patients with advanced colorectal cancer. Results from this study would provide the
scientific basis for a randomized phase III study to compare the XELIRI-A regimen to the IFL
(FOLFIRI) + bevacizumab regimen. Furthermore, it will have practical implications for our
centre. Compared to infusional or bolus 5-FU based regimens, the XELIRI-A regimen will
reduce workload in the chemotherapy daycare unit and drug costs, reduce demands for
resources such as infusion pumps and interventional radiology time, enable patients to start
therapy sooner, and improve patient convenience.

Inclusion Criteria:

- Patients must have histologically or cytologically confirmed colorectal cancer which
is recurrent or metastatic, and not amendable to surgical resection or radiation.

- Patients must have measurable disease, defined as at least one lesion that can be
accurately measured in at least one dimension (longest diameter to be recorded) as
>20 mm with conventional techniques or as >10 mm with spiral CT scan. See section
11.2 for the evaluation of measurable disease.

- Patients must have had no previous chemotherapy or treatment with an investigational
agent for recurrent or metastatic disease. Prior chemotherapy in the adjuvant
setting for colorectal cancer is acceptable. Prior surgery or radiotherapy for
recurrent or metastatic disease is acceptable, however, patients must be adequately
recovered from the effects of these treatments. At least 6 weeks must have elapsed
from major surgery and 4 weeks must have elapsed from any radiation therapy.

- Age >18 years. Because no dosing or adverse event data are currently available on
the use of bevacizumab in combination with capecitabine and irinotecan in patients
<18 years of age, children are excluded from this study.

- Estimated life expectancy of greater than 3 months.

- ECOG performance status 0, 1, or 2 (or Karnofsky >60%; see Appendix A).

- Patients must have normal organ and marrow function as defined below:

leukocytes >/= 3,000/mcL absolute neutrophil count >/= 1,500/mcL platelets >/= 100,000/mcL
hemoglobin >/= 90 g/L total bilirubin creatinine clearance >/= 50 mL/min/1.73 m2 for patients with creatinine levels above
institutional normal proteinuria < 2+ on dipstick patients with >/= 2+ proteinuria on
urine dipstick at baseline should undergo a 24-hour urine collection, and must have protein / 24 hours

- Appropriate imaging investigations, including chest X-rays and / or CT/MRI of chest /
abdomen / pelvis or other scans as clinically indicated to document all sites of
disease must be performed within 28 days of study entry.

- The effects of bevacizumab on the developing human fetus at the recommended
therapeutic dose are unknown. For this reason and because antiangiogenic agents as
well as other therapeutic agents used in this trial are known to be teratogenic,
women of child-bearing potential and men must agree to use adequate contraception
(hormonal or barrier method of birth control; abstinence) prior to study entry, for
the duration of study and for a period of four weeks after cessation of study
therapy. Should a woman become pregnant or suspect she is pregnant while
participating in this study, she must inform her treating physician immediately.

- Ability to understand and the willingness to sign a written informed consent

Exclusion Criteria:

- History of other malignancies, except: adequately treated non-melanoma skin cancer,
curatively treated in-situ cancer of the cervix, or other solid malignancies
curatively treated with no evidence of disease for ≥ 5 years.

- Patients may not be receiving any other investigational agents.

- Patients with known metastases in the central nervous system.

- Any condition that does not permit compliance with the study protocol

- Previous history of gastrointestinal perforation, uncontrolled gastrointestinal
bleeding, uncontrolled thromboembolism

- Presence of uncontrolled hypertension and / or proteinuria. Patients must have
systolic blood pressure ≤ 150 mmHg and diastolic blood pressure ≤ 100 mmHg, and be on
stable blood pressure medication at the time of study entry. Patients discovered to
have ≥ 1+ proteinuria at baseline, should undergo a 24-hour urine collection and must
have < 500 mg of protein / 24 hours.

- History of allergic reactions, or intolerance, attributed to compounds of similar
chemical or biologic composition to 5-fluorouracil, irinotecan, or bevacizumab.

- Women who are pregnant or breastfeeding are excluded from this study because
bevacizumab is an antiangiogenic agent with the potential for teratogenic or
abortifacient effects. Because there is an unknown but potential risk for adverse
events in nursing infants secondary to treatment of the mother with bevacizumab,
breastfeeding should be discontinued if the mother is treated with bevacizumab.
These potential risks may also apply to other agents used in this study.

- Uncontrolled inter-current illness including, but not limited to, ongoing or active
infection, or psychiatric illness/social situations that would limit compliance with
study requirements.

- HIV-positive patients on combination antiretroviral therapy are ineligible because of
the potential for pharmacokinetic interactions with the agents used in this study.
In addition, these patients are at increased risk of lethal infections when treated
with marrow-suppressive therapy.

- Patients with active cardiovascular disease, i.e., unstable angina, New York Heart
Association grade II or greater congestive heart failure, serious cardiac arrhythmia
requiring medications, or grade II or greater peripheral vascular disease. In
addition, patients with arterial thrombosis, myocardial infarction, and cerebral
vascular accidents (stroke / transient ischemic attach (TIA)) within 6 months prior
to study entry will be excluded.

- Patients who had major surgical procedure, open biopsy or significant traumatic
injury within 28 days prior to the first study treatment, or anticipation of need for
major surgical procedure during the course of the study; minor surgical procedures
within 7 days prior to study treatment start.

- Planned radiotherapy for underlying disease.

- Serious non-healing wound or ulcer.

- Evidence of bleeding diathesis or coagulopathy.

- Current or recent (within 10 days prior to study treatment start) use of full dose
oral or intravenous anticoagulants or thrombolytic agents. Patients on low molecular
weight heparins are allowed to participate in the study. Patients with
anticoagulation for maintenance of patency of permanent indwelling intravenous
catheters will be eligible. However, INR should be monitored closely if patients are
taking low-dose coumadin for this purpose.

- Ongoing treatment with aspirin ( > 325 mg/day) or other medications known to
predispose to gastrointestinal ulceration.

- Patients who have received prior radiation therapy to > 15% of bone marrow (see
Appendix D), or standard pelvic radiation for rectal cancer.

- Patients with predisposing colonic or small bowel disorders in which symptoms are
uncontrolled as indicated by pre-treatment/baseline pattern of > 3 loose stools daily
in patients without a colostomy or ileostomy. Patients with a colostomy or ileostomy
may be entered as the investigator's discretion.

- Patients with partial or complete bowel obstruction, known chronic malabsorption,
total colectomy or other major abdominal surgery that might result in substantial
alteration in absorption of oral medications.

- Patients with known Gilbert's syndrome.

- Patients who were started on phenytoid, phenobarbital, carbamazepine or any other
enzyme-inducing anti-convulsant drug (EIACD) within 7 days prior to the first study
treatment or patients who are unable or unwilling to discontinue EIACD use or switch
to a non-EIACD at least 7 days prior to the first study treatment. Concomitant use
of gabapentin or other non-EIACDs is permitted.

- Patients who are unable or unwilling to discontinue St. John's wort (hypericum
perforatum) at least 14 days prior to the first study treatment; Patients who are
taking fluconazole / ketoconazole at the time of first study treatment.

- Lack of physical integrity of the upper gastrointestinal tract, malabsorption
syndrome, or inability to take oral medication.

- Organ allografts requiring immunosuppressive therapy.

Type of Study:


Study Design:

Endpoint Classification: Safety/Efficacy Study, Intervention Model: Single Group Assignment, Masking: Open Label, Primary Purpose: Treatment

Outcome Measure:

To determine the objective response rate (ie. the rate of partial response plus complete response as defined by RECIST criteria) of irinotecan, capecitabine and bevacizumab (XELIRI-A) in patients with previously untreated metastatic colorectal cancer.

Outcome Time Frame:

Radiological evaluation every 9 weeks, with confirmatory scans 4 weeks after objective response

Safety Issue:


Principal Investigator

Eric Chen

Investigator Role:

Principal Investigator

Investigator Affiliation:

Princess Margaret Hospital, University Health Network


Canada: Ethics Review Committee

Study ID:




Start Date:

December 2006

Completion Date:

July 2011

Related Keywords:

  • Colorectal Cancer
  • Bevacizumab
  • Avastin
  • CPT-11
  • Irinotecan
  • Camptothecin-11
  • Capecitabine
  • Xeloda
  • Metastatic
  • Colorectal
  • Colon
  • Rectal
  • Colorectal Neoplasms