Study to Assess the Effect of Treatment With Bendamustine in Combination With Rituximab on QT Interval in Patients With Advanced Indolent Non-Hodgkin's Lymphoma (NHL) or Mantle Cell Lymphoma (MCL)

A Study to Assess the Effect of Treatment With Bendamustine in Combination With Rituximab on QT Interval in Patients With Advanced Indolent Non-Hodgkin's Lymphoma (NHL) or Mantle Cell Lymphoma (MCL)

The primary objective of this study is to assess the effect of treatment with bendamustine on cardiac repolarization as reflected by the rate-corrected QT interval by the Fridericia method (QTcF).

Study Overview

• Status: Completed
• Conditions: Non-Hodgkin's Lymphoma; Mantle Cell Lymphoma
• Intervention / Treatment: Drug: Bendamustine; Drug: Rituximab

Detailed Description

This study was originally conducted as a substudy in a subset of patients enrolled in the phase 3 study C18083/3064/NL/MN (NCT00877006) who were randomly assigned to treatment with bendamustine in combination with rituximab (BR) and who satisfied additional eligibility criteria related to cardiac function. The objective of the substudy was to obtain results to assess the effect of bendamustine treatment on cardiac polarization and any potential changes in the QT interval (corrected by the Fridericia method [QTcF]). After a period of time, the substudy was amended to be a separate stand-alone study to ensure that an adequate number of patients were included. Patients were treated for 6, and up to 8, cycles in the stand-alone study, and efficacy and safety were also assessed. In addition, a requirement to assess the pharmacokinetics of bendamustine and rituximab when used as combination therapy was added to the objectives, to determine the potential for drug interaction between bendamustine and rituximab.

• Study Type: Interventional
• Enrollment (Actual): 54
• Phase: Phase 3

Contacts and Locations

Study Locations

• Australia
  • Australian Capital Territory
    • Garran, Australian Capital Territory, Australia
      • The Canberra Hospital
  • South Australia
    • Adelaide, South Australia, Australia
      • Royal Adelaide Hospital
    • Woodville, South Australia, Australia
      • The Queen Elizabeth Hospital
  • Tasmania
    • Hobart, Tasmania, Australia
      • Royal Hobart Hospital
  • Victoria
    • Melbourne, Victoria, Australia
      • The Alfred Hospital
• Canada
  • Nova Scotia
    • Halifax, Nova Scotia, Canada
      • Queen Elizabeth II Health Sciences Centre
  • Ontario
    • Ottawa, Ontario, Canada
      • Ottawa Hospital - General Campus
• United States
  • Arizona
    • Tucson, Arizona, United States
      • Hematology Oncology Physicans Extenders Group
  • Arkansas
    • Little Rock, Arkansas, United States
      • University of Arkansas for Medical Sciences
  • California
    • Fullerton, California, United States
      • St. Jude Heritage Medical Group
    • Palm Springs, California, United States
      • Comprehensive Cancer Center
  • Colorado
    • Aurora, Colorado, United States
      • University of Colorado Cancer Center
    • Denver, Colorado, United States
      • Rocky Mountain Cancer Center
  • Connecticut
    • New Britain, Connecticut, United States
      • The Hospital of Central Connecticut
    • Southington, Connecticut, United States
      • Cancer Center of Central Connecticut
  • Florida
    • Hollywood, Florida, United States
      • Memorial Cancer Institute
    • Orlando, Florida, United States
      • Cancer Centers of Florida
    • Orlando, Florida, United States
      • MD Anderson Cancer Cnt Orlando
  • Georgia
    • Columbus, Georgia, United States
      • John B Amos Cancer Center
  • Indiana
    • Beech Grove, Indiana, United States
      • St Francis Cancer Research Foundation
  • Iowa
    • Waterloo, Iowa, United States
      • Cedar Valley Medical Specialists
  • Kansas
    • Wichita, Kansas, United States
      • Cancer Center of Kansas
  • Kentucky
    • Lexington, Kentucky, United States
      • University of Kentucky
  • Louisiana
    • Shreveport, Louisiana, United States
      • LSU Health Sciences Center - Shreveport
  • Maine
    • Augusta, Maine, United States
      • MaineGeneral Medical Center
  • Missouri
    • Columbia, Missouri, United States
      • Missouri Cancer Associates
    • Kansas City, Missouri, United States
      • Kansas City Cancer Center
  • New Mexico
    • Albuquerque, New Mexico, United States
      • UNM Cancer Center/New Mexico Cancer Care Alliance
  • New York
    • Rochester, New York, United States
      • Interlakes Foundation, Inc
    • Syracuse, New York, United States
      • SUNY Upstate / Upstate Medical University
  • Oregon
    • Springfield, Oregon, United States
      • Willamette Valley Cancer Center
  • Pennsylvania
    • Danville, Pennsylvania, United States
      • Geisinger Medical Center
    • Philadelphia, Pennsylvania, United States
      • Pennsylvania Oncology Hematology Associates, Inc.
  • South Carolina
    • Charleston, South Carolina, United States
      • Charleston Hematology Oncology, PA
  • Tennessee
    • Nashville, Tennessee, United States
      • Sarah Cannon Cancer Center
  • Texas
    • Fort Worth, Texas, United States
      • Texas Oncology, P.A.
    • San Antonio, Texas, United States
      • Cancer Care Center of South Texas
    • Tyler, Texas, United States
      • Texas Oncology
  • Virginia
    • Norfolk, Virginia, United States
      • Virginia Oncology Associates
    • Richlands, Virginia, United States
      • Cancer Outreach Asscociates, PC
  • Washington
    • Spokane, Washington, United States
      • Cancer Care Northwest-South
    • Vancouver, Washington, United States
      • Northwest Cancer Specialists, PC
  • West Virginia
    • Morgantown, West Virginia, United States
      • West Virginia University School of Medicine

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Key Inclusion Criteria:

• Histopathologic confirmation of one of the following CD20+ B-cell non-Hodgkin's lymphomas. Tissue diagnostic procedures must be performed within 6 months of study entry and with biopsy material available for review:

  • follicular lymphoma (grade 1 or 2)
  • immunoplasmacytoma/immunocytoma (Waldenstrom's macroglobulinemia)
  • splenic marginal zone B-cell lymphoma
  • extra-nodal marginal zone lymphoma of mucosa associated lymphoid tumor (MALT) type
  • nodal marginal zone B-cell lymphoma
  • mantle cell lymphoma

• Meets one of the following need-for-treatment criteria (with the exception of mantle cell lymphoma for which treatment is indicated):

  • presence of at least one of the following B-symptoms:

    1. fever (>38ºC) of unclear etiology
    2. night sweats
    3. weight loss of greater than 10% within the prior 6 months
  • large tumor mass (bulky disease)
  • presence of lymphoma-related complications, including narrowing of ureters or bile ducts, tumor-related compression of a vital organ, lymphoma induced pain, cytopenias related to lymphoma/leukemia, splenomegaly, pleural effusions, or ascites
  • hyperviscosity syndrome due to monoclonal gammopathy
• CD20-positive B cells in lymph node biopsy or other lymphoma pathology specimen
• No prior treatment. Patients on "watch and wait" may enter the study if a recent biopsy (obtained within the last 6 months) is available.

• Adequate hematologic function (unless abnormalities related to lymphoma infiltration of the bone marrow or hypersplenism due to lymphoma) as follows:

  • hemoglobin of >= 10.0 g/dL
  • absolute neutrophil count (ANC) >=1.5*10^9/L
  • platelet count >=100*10^9/L
• Bidimensionally measurable disease (field not previously radiated)
• Able to provide written informed consent
• Eastern Cooperative Oncology Group (ECOG) performance status <=2
• Estimated life expectancy >=6 months
• Serum creatinine of <=2.0 mg/dL or creatinine clearance >=50 mL/min
• Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤2.5* upper limit of normal (ULN), and alkaline phosphatase and total bilirubin within normal limits
• Left ventricular ejection fraction (LVEF) >=50% by multiple gated acquisition scan (MUGA) or cardiac echocardiogram (ECHO), prior for any patient to be treated with rituximab/cyclophosphamide/doxorubicin/vincristine/prednisolone (R-CHOP)
• A medically accepted method of contraception to be used by women of childbearing potential (not surgically sterile or at least 12 months naturally postmenopausal)
• Men capable of producing offspring and not surgically sterile must practice abstinence or use a barrier method of birth control

Key Exclusion Criteria:

• Chronic lymphocytic leukemia, small lymphocytic lymphoma (SLL), or grade 3 follicular lymphoma
• Transformed disease. Bone marrow blasts are permitted, however, transformed disease indicating leukemic involvement is not permitted
• Central nervous system (CNS) lymphomatous involvement or leptomeningeal lymphoma
• Prior radiation for non-Hodgkin's lymphoma (NHL), except for a single course of locally delimited radiation therapy with a radiation field not exceeding 2 adjacent lymph node regions
• Active malignancy, other than NHL, within the past 3 years except for localized prostate cancer treated with hormone therapy, cervical carcinoma in situ, breast cancer in situ, or non-melanoma skin cancer following definitive treatment
• New York Heart Association (NYHA) Class III or IV heart failure, arrhythmias or unstable angina, electrocardiographic evidence of active ischemia or active conduction system abnormalities, or myocardial infarction within the last 6 months. (Prior to study entry, ECG abnormalities at screening must be documented by the investigator as not medically relevant)
• Known human immunodeficiency virus (HIV) positivity
• Active hepatitis B or hepatitis C infection (Hepatitis B surface antigen testing required)
• Women who are pregnant or lactating
• Corticosteroids for treatment of lymphoma within 28 days of study entry. Chronically administered low-dose corticosteroids (e.g., prednisone ≤20 mg/day) for indications other than lymphoma or lymphoma-related complications are permitted
• Any serious uncontrolled, medical or psychological disorder that would impair the ability of the patient to receive therapy
• Any condition which places the patient at unacceptable risk or confounds the ability of the investigators to interpret study data
• Any other investigational agent within 28 days of study entry
• Known hypersensitivity to bendamustine, mannitol, or other study-related drugs
• The patient has Ann Arbor stage I disease
• The patient has a history of congenital long QT syndrome
• The patient has a history of cardiac disease with significant potential for QT prolongation
• The patient has screening electrocardiography (ECG) on Day 1 of Cycle 1 with QTcF interval >450 ms that is confirmed by a second ECG. If the QTcF interval is >450 ms on both ECGs, the ECGs will be sent to eResearch Technology, Inc. (ERT), the Central ECG Reader vendor, for an overread (with 24-hour turn around time) and ERT will make a final decision on enrollment
• The patient has serum potassium or magnesium less than the lower limit of normal

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Bendamustine with Rituximab; Participants were administered bendamustine intravenous (IV) infusion at 90 mg/m^2 on Days 1 and 2 of each 28-day cycle, and rituximab IV infusion at 375 mg/m^2 on Day 1 of each 28-day cycle.	Drug: Bendamustine; Bendamustine at 90 mg/m^2 IV on Days 1 and 2 of a 28-day cycle.; Other Names: Treanda; SDX-105; Levact; Ribomustin; Treakisym; Drug: Rituximab; Rituximab at 375 mg/m^2 IV on Day 1 of a 28-day cycle.; Other Names: Rituxan; MabThera; IDEC-C2B8

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mean Change From Baseline in QT Interval as Corrected by the Fridericia Method (QTcF) at End of Infusion	On Day 2 of Cycle 1, three electrocardiograms (ECGs) were collected 15 minutes prior to any study drug administration. The baseline ECG interval value was obtained by averaging these 3 ECGs, and was compared to the average of the 3 ECGs taken on treatment with bendamustine at the end of the infusion.	Baseline ECGs (Day 2 of Cycle 1): 15 minutes prior to bendamustine infusion. Postinfusion ECGs (Day 2 of Cycle 1): at the end of the 30-minute infusion.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mean Change From Baseline in QTcF at 1 Hour Postinfusion	On Day 2 of Cycle 1, three ECGs were collected 15 minutes prior to any study drug administration. The baseline ECG interval value was obtained by averaging these 3 ECGs, and was compared to the average of the 3 ECGs taken on treatment with bendamustine 1 hour postinfusion.	Baseline ECGs (Day 2 of Cycle 1): 15 minutes prior to bendamustine infusion. Postinfusion ECGs (Day 2 of Cycle 1): 1 hour postinfusion.
Number of Participants With QTcF New Outlier Events at End of Infusion and 1 Hour Postinfusion	Participants were considered to have an outlier ECG value based on the most extreme value across each of the time points. "New" means not present at baseline and becomes present on at least 1 on-treatment ECG time point. A participant had a new outlier event (500) if the maximum QTcF was >500 ms while their baseline was <=500 ms, or had an outlier event (480) if the maximum QTcF was >480 ms while their baseline was <= 480 ms. QTcF in the 30-60 ms or >60 ms categories were also considered outliers.	Baseline ECGs (Day 2 of Cycle 1): 15 minutes prior to bendamustine infusion. Postinfusion ECGs (Day 2 of Cycle 1): at the end of the 30-minute infusion and 1 hour postinfusion.
Number of Participants With New Onset ECG Waveform Morphological Changes	The core ECG laboratory cardiologist assessed all leads in the ECGs and defined morphological changes. Changes from baseline (looking at each of the 3 ECGs at Day 2 Cycle 1 individually and the ECGs at all on-treatment time points individually) were noted for the following events: atrial fibrillation or flutter; second degree heart block; third degree heart block; complete right bundle branch block; complete left bundle branch block; ST segment depression; T wave abnormalities (negative T waves only); myocardial infarction pattern; any new abnormal U waves.	Baseline ECGs (Day 2 of Cycle 1): 15 minutes prior to bendamustine infusion. Postinfusion ECGs (Day 2 of Cycle 1): at the end of the 30-minute infusion and 1 hour postinfusion.
Number of Participants With Treatment-Emergent Cardiac Disorders	Number of participants with cardiac disorders overall, with severity from grades 1 (mild) to grade 4 (severe), according to the Common Terminology Criteria for Adverse Events (CTCAE) version 3.0 (grade 1=mild, grade 2=moderate, grade 3=severe, grade 4=life-threatening, grade 5= death). Participants may have reported more than 1 event.	Adverse events were collected throughout the study and up to 30 days after the last dose of study drug. The median number of 28-day cycles was 6.0. The median duration of the treatment period was 143 days.
Change From Baseline in QTcF at Maximum Concentration (Cmax) of Bendamustine and Its Metabolites (M3 and M4)	Results from a pharmacokinetic-pharmacodynamic model to show the relationship of the overall predicted change from Baseline in QTcF at the average Cmax of bendamustine and its metabolites M3 and M4.	Baseline ECGs (Day 2 of Cycle 1): 15 minutes prior to bendamustine infusion. Postinfusion ECGs (Day 2 of Cycle 1): at the end of the 30-minute infusion and 1 hour postinfusion.
Model-predicted Bayesian Bendamustine Clearance in the Presence of Rituximab	Boxplots of model-predicted Bayesian bendamustine clearance (CL) values in the presence of rituximab were generated based on the administered bendamustine doses, rate of infusion, and sample times.	Day 1 of Cycle 1: prior to start of bendamustine infusion, immediately postinfusion, 15 minutes and 30 minutes postinfusion. Day 2 of Cycle 1: 15 minutes prior to start of bendamustine infusion, 15 minutes, 30 minutes, 1, 3, and 5 hours postinfusion.
Rituximab Concentrations at 0.5 Hours, 24 Hours, and 7 Days Postinfusion		Day 1 of Cycle 1: prior to start of rituximab infusion, immediately postinfusion. Day 2 of Cycle 1: 15 minutes prior to the start of the bendamustine infusion. Day 7 and Day 14: anytime. Day 1 of Cycle 2: prior to start of rituximab infusion.
Percentage of Participants With Complete Response (CR)	Complete response, as defined by the International Working Group (IWG) Revised Response Criteria For Malignant Lymphoma. Results are presented for participants with non-Hodgkin lymphoma and mantle cell lymphoma as well as all participants.	The median number of 28-day cycles was 6.0. The median duration of the treatment period was 143 days.
Percentage of Participants With Overall Response	Overall Response was comprised of those participants who had Complete Response (CR) plus those who had Partial Response (PR), as defined by the International Working Group (IWG) Revised Response Criteria For Malignant Lymphoma. Results are presented for participants with non-Hodgkin lymphoma and mantle cell lymphoma as well as all participants.	The median number of 28-day cycles was 6.0. The median duration of the treatment period was 143 days.
Overview of Adverse Events	Adverse event (AE)=any untoward medical occurrence in a patient administered study drug that develops or worsens in severity during the conduct of a clinical study of a pharmaceutical product and does not necessarily have a causal relationship to the study drug. Treatment-related AEs=those that began or worsened after treatment with study drug. AE severity was graded according to the National Cancer Institute's Common Terminology Criteria for AEs (grade 1=mild, grade 2=moderate, grade 3=severe, grade 4=life-threatening, grade 5= death). Relationship of an AE to study drug was categorized as definite, probable, possible, unlikely, or not related. Serious AE (SAE)=one that occurred at any dose that resulted in any of the following outcomes or actions: death; a life-threatening adverse event; inpatient hospitalization or prolongation of existing hospitalization; a persistent or significant disability/incapacity; a congenital anomaly/birth defect; or an otherwise important medical event.	Adverse events were collected throughout the study and up to 30 days after the last dose of study drug. The median number of 28-day cycles was 6.0. The median duration of the treatment period was 143 days.
Eastern Cooperative Oncology Group (ECOG) Performance Status at Endpoint	The investigator assessed each patient's ECOG performance status according to the ECOG scale at screening, on Day 1 of each treatment cycle, and at the end-of-treatment visit. Scale scores were: 0=fully active, able to carry on all pre-disease performance without restriction; 1=restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature; 2=ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours; 3=capable of only limited self-care, confined to bed or chair more than 50% of waking hours; 4=completely disabled. Cannot carry on any self-care. Totally confined to bed or chair; 5=dead. Any change in score to a higher value signifies worsening, and any change to a lower value signifies improvement.	End of study. The median number of 28-day cycles was 6.0. The median duration of the treatment period was 143 days.
Worst Common Terminology Criteria for Adverse Events (CTCAE) Version 3.0 Grades for Hematology Laboratory Tests Results Overall	Grade 1=Mild, 2=Moderate, 3=Severe/medically significant, 4=Life-threatening. Overall is defined as the worst postbaseline grade value for each patient and laboratory test across all cycles. Only postbaseline grades are summarized. If absolute neutrophil count (ANC) and neutrophils absolute (ABS) were both measured, the worse grade value from the two was summarized. Otherwise the worst ANC grade value or the worst neutrophils ABS grade value was summarized. WBC=white blood cell; LLN=lower limit of normal	Adverse events were collected throughout the study and up to 30 days after the last dose of study drug. The median number of 28-day cycles was 6.0. The median duration of the treatment period was 143 days.

Collaborators and Investigators

• Sponsor: Cephalon

Study record dates

Study Major Dates

• Study Start: February 1, 2010
• Primary Completion (Actual): June 1, 2012
• Study Completion (Actual): June 1, 2012

Study Registration Dates

• First Submitted: February 19, 2010
• First Submitted That Met QC Criteria: February 19, 2010
• First Posted (Estimate): February 23, 2010

Study Record Updates

• Last Update Posted (Estimate): April 24, 2014
• Last Update Submitted That Met QC Criteria: April 7, 2014
• Last Verified: April 1, 2014

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Immune System Diseases; Neoplasms by Histologic Type; Neoplasms; Lymphoproliferative Disorders; Lymphatic Diseases; Immunoproliferative Disorders; Lymphoma; Lymphoma, Non-Hodgkin; Lymphoma, Mantle-Cell; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Antirheumatic Agents; Antineoplastic Agents; Immunologic Factors; Antineoplastic Agents, Alkylating; Alkylating Agents; Antineoplastic Agents, Immunological; Bendamustine Hydrochloride; Rituximab
• Other Study ID Numbers: C18083/3070