Ipilimumab or FOLFOX in Combination With Nivolumab and Trastuzumab in HER2 Positive EsophagoGastric Adenocarcinoma (INTEGA)

Ipilimumab or FOLFOX in Combination With Nivolumab and Trastuzumab in Previously Untreated HER2 Positive Locally Advanced or Metastatic EsophagoGastric Adenocarcinoma

The INTEGA study assesses therapy Options for advanced or metastatic esophagogastric Adenocarcinoma in patients overexpressing human epidermal receptor type 2 (HER2 positive patients). Current treatment options in this situation include chemotherapy based palliative treatment in combination withTrastuzumab.

Recent studies have shown that immunotherapy with Nivolumab or Ipilimumab after previous chemotherapy can also improve survival in esophagogastric cancer.

This study assesses the efficacy of two experimental first line treatment strategies: A) Chemo-free immunotherapy with Trastuzumab, Nivolumab and Ipilimumab and B) addition of Nivolumab to the standard regimen (FOLFOX chemotherapy and Trastuzumab).

Study Overview

• Status: Completed
• Conditions: Gastric Cancer; Esophageal Cancer; Adenocarcinoma Gastric; Metastatic Gastric Cancer; GastroEsophageal Cancer; HER2 Positive Gastric Cancer
• Intervention / Treatment: Drug: Nivolumab; Drug: Nivolumab; Drug: Ipilimumab

Detailed Description

Gastric cancer is the fifth most common cancer in the world, and the third leading cause of cancer death in both sexes worldwide.

Surgical resection is currently the only curative treatment option for gastric cancer; however, ~50% of patients have metastatic disease at the time of diagnosis and chemotherapy is the mainstay of palliation in this setting.

Trastuzumab, in combination with chemotherapy, significantly improved survival in patients with overexpression of HER2.

In regard of the very limited therapeutic landscape of HER2 positive EGA, compared to breast cancer, further treatment options to relevantly improve the outcome is warranted. The integration of check-point inhibitors (e.g. Nivolumab, Ipilimumab) into the first line setting either within a chemotherapy-free combination arm or within an intensified standard arm of FOLFOX and trastuzumab with nivolumab may be able to improve the current limited survival of median 14 months.

• Study Type: Interventional
• Enrollment (Actual): 97
• Phase: Phase 2

Contacts and Locations

Study Locations

• Germany
  • Amberg, Germany, 92224
    • Gesundheitszentrum St. Marien Amberg - MVZ
  • Bad Nauheim, Germany, 61231
    • Gesundheitszentrum Wetterau - Facharztzentrum
  • Bad Saarow, Germany, 15526
    • Helios Klinikum Bad Saarow - Hämatologie, Onkologie und Palliativmedizin
  • Berlin, Germany, 13353
    • Charité Universitätsmedizin Campus Virchow Klinikum - Hämatologie / Onkologie
  • Berlin, Germany, 13589
    • Ev. Waldkrankenhaus Spandau - Onkologisches Zentrum
  • Bochum, Germany, 44791
    • St. Josef Hospital Bochum - Hämatologie, Onkologie und Palliativmedizin
  • Bottrop, Germany, 46236
    • Schwerpunktpraxis Hämatologie und Onkologie Bottrop
  • Coburg, Germany, 96450
    • MVZ Klinikum Coburg
  • Dresden, Germany, 01307
    • BAG Onkologische Gemeinschaftspraxis Dresden
  • Essen, Germany, 45136
    • Kliniken Essen-Mitte - Klinik für Internistische Onkologie und Hämatologie
  • Frankfurt a.M., Germany, 60488
    • Krankenhaus Nordwest - Institut für klinische Forschung
  • Frankfurt a.M., Germany, 60590
    • Uniklinikum Frankfurt - Med. I
  • Halle (Saale), Germany, 06120
    • Universitätsklinikum Halle (Saale) - Innere Med. I
  • Hamburg, Germany, 20246
    • Universitätsklinikum Hamburg Eppendorf - II. Med.
  • Hamburg, Germany, 20249
    • HOPE - Hämatologisch-onkologische Praxis Eppendorf
  • Hannover, Germany, 30625
    • Med. Hochschule Hannover - Gastroenterologie, Hepatologie und Endokrinologie
  • Jena, Germany, 07740
    • Universitätsklinikum Jena - Innere Med. Hämatologie und Onkologie
  • Kassel, Germany, 34121
    • DRK Kliniken Nordhessen - Klinik für interdisziplinäre Onkologie
  • Kassel, Germany, 34125
    • Klinikum Kassel - Onkologie und Hämatologie
  • Lahr, Germany, 77933
    • Ortenau-Klinikum Lahr - Sektion Hämatologie und Onkologie
  • Leipzig, Germany, 04103
    • MVZ-Mitte - Onkologische Schwerpunktpraxis Leipzig
  • Leipzig, Germany, 04109
    • Universitätsklinikum Leipzig - Krebszentrum
  • Magdeburg, Germany, 39130
    • Klinikum Magdeburg - Hämatologie und Onkologie
  • Marburg, Germany, 35032
    • Universitätsklinikum Marburg - Hämatologie, Onkologie und Immunologie
  • Mutlangen, Germany, 73557
    • Stauferklinikum Schwäbisch Gmünd - Innere Med.
  • Mönchengladbach, Germany, 41063
    • Kliniken Maria Hilf Mönchengladbach - Hämatologie, Onkologie und Gastroenterologie
  • München, Germany, 81377
    • Klinikum der LMU München - Med. III
  • München, Germany, 81675
    • Klinikum rechts der Isar der TU München - Innere Med. III
  • Oldenburg, Germany, 26133
    • Klinikum Oldenburg - Universitätsklinikum für Innere Med. - Onkologie und Hämatologie
  • Reutlingen, Germany, 72764
    • Ermstalklinik Reutlingen - Med. I
  • Riesa, Germany, 01589
    • Elblandklinikum Riesa - Innere Med.
  • Schweinfurt, Germany, 97422
    • Leopoldina Krankenhaus Schweinfurt - Med. III
  • Ulm, Germany, 89081
    • Universitätsklinikum Ulm - Innere Med. I
  • Wesel, Germany, 46483
    • Marien-Hospital Wesel - Med. II
  • Wolfsburg, Germany, 38440
    • Klinikum Wolfsburg - Med. II

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. All subjects must have inoperable, advanced or metastatic esophagogastric adenocarcinoma
2. Subjects must have HER2-positive disease defined as either IHC 3+ or IHC 2+, the latter in combination with ISH+, as assessed locally on a primary or metastatic tumour (Note: Availability of formalin-fixed paraffin-embedded (FFPE) representative tumor tissue for central confirmation of HER2 is mandatory (Preferably fresh biopsy))
3. Subject must be previously untreated with systemic treatment (including HER 2 inhibitors) given as primary therapy for advanced or metastatic disease.
4. Prior adjuvant or neoadjuvant chemotherapy, radiotherapy and/or chemoradiotherapy are permitted as long as the last administration of the last regimen (whichever was given last) occurred at least 3 months prior to randomization.
5. Subjects must have measurable or evaluable non-measurable disease as assessed by the investigator, according to RECIST v1.1 (Appendix D).
6. ECOG performance status score of 0 or 1 (Appendix B).

7. Screening laboratory values must meet the following criteria (using NCI CTCAE v.4.03 ):

   • WBC ≥ 2000/µL
   • Neutrophils ≥ 1500/uL
   • Platelets ≥ 100x10^3/µL
   • Hemoglobin ≥ 9.0 g/dL
   • eGFR ≥ 30ml/min (e.g. MDRD formula, appendix G)
   • AST ≤ 3.0 x ULN (or ≤ 5.0X ULN if liver metastases are present)
   • ALT ≤ 3.0 x ULN (or ≤ 5.0X ULN if liver metastases are present)
   • Total Bilirubin ≤ 1.5 x ULN (except subjects with Gilbert Syndrome who must have a total bilirubin level of < 3.0 x ULN)
8. Males and Females, ≥ 18 years of age
9. Subjects must have signed and dated an IRB/IEC approved written informed consent form in accordance with regulatory and institutional guidelines. This must be obtained before the performance of any protocol-related procedures that are not part of normal subject care.
10. Subjects must be willing and able to comply with scheduled visits, treatment schedule, laboratory tests and other requirements of the study.
11. Women of childbearing potential (WOCBP) must have a negative serum or urine pregnancy test (minimum sensitivity 25 IU/L or equivalent units of HCG) within 24 hours prior to the start of study drug. Women must not be breastfeeding.
12. WOCBP must use a highly effective method(s) of contraception for a period of 30 days (duration of ovulatory cycle) plus the time required for the investigational drug to undergo 5 half-lives. The terminal half-lives of nivolumab and ipilimumab are approximately 25 days and 15 days, respectively. WOCBP should use an adequate method to avoid pregnancy for approximately 5 months (30 days plus the time required for nivolumab to undergo 5 half-lives) after the last dose of investigational drug.
13. Males who are sexually active with WOCBP must agree to follow instructions for method(s) of contraception for a period of 90 days (duration of sperm turnover) plus the time required for the investigational drug to undergo 5 half-lives. The terminal half-lives of nivolumab and ipilimumab are approximately 25 days and 15 days, respectively. Males who are sexually active with WOCBP must continue contraception for approximately 7 months (90 days plus the time required for nivolumab to undergo 5 half-lives) after the last dose of investigational drug. In addition, male subjects must be willing to refrain from sperm donation during this time.

Exclusion Criteria:

1. Malignancies other than disease under study within 5 years prior to inclusion, with the exception of those with a negligible risk of metastasis or death (e.g., expected 5-year OS > 90%) treated with expected curative outcome (such as adequately treated carcinoma in situ of the cervix, basal or squamous cell skin cancer, localized prostate cancer treated surgically with curative intent, ductal carcinoma in situ treated surgically with curative intent)
2. Subjects with untreated known CNS metastases. Subjects are eligible if CNS metastases are adequately treated and subjects are neurologically returned to baseline (except for residual signs or symptoms related to the CNS treatment) for at least 2 weeks prior to randomization. In addition, subjects must be either off corticosteroids, or on a stable or decreasing dose of < 10 mg daily prednisone (or equivalent) for at least 2 weeks prior to randomization.
3. History of exposure to the following cumulative doses of anthracyclines (epirubicin > 720 mg/m2, doxorubicin or liposomal doxorubicin > 360 mg/m2, mitoxantrone > 120 mg/m2 and idarubicin > 90 mg/m2, other (e.g., liposomal doxorubicin or other anthracycline greater than the equivalent of 360 mg/m2 of doxorubicin). If more than one anthracycline has been used, then the cumulative dose must not exceed the equivalent of 360 mg/m2 of doxorubicin
4. Abnormal baseline LVEF, assessed by echocardiogram [ECHO], multigated acquisition (MUGA) scan, or cardiac magnetic resonance imaging (MRI) scan
5. Subjects with active, known, or suspected autoimmune disease. Subjects with Type I diabetes mellitus, residual hypothyroidism due to autoimmune thyroiditis only requiring hormone replacement, or skin disorders (such as vitiligo, psoriasis, or alopecia) not requiring systemic treatment are permitted to enroll. For any cases of uncertainty, it is recommended that the medical monitor be consulted prior to signing informed consent.
6. Subjects with a condition requiring systemic treatment with either corticosteroids (> 10 mg daily prednisone equivalents) or other immunosuppressive medications within 14 days of study drug administration. Inhaled or topical steroids, and adrenal replacement doses > 10 mg daily prednisone equivalents are permitted in the absence of active autoimmune disease.
7. Prior treatment with an anti-PD-1, anti-PD-L1, anti-PD-L2, anti-CD137, or anti-CTLA-4 antibody, or any other antibody or drug specifically targeting T-cell co-stimulation or checkpoint pathways.
8. Persisting toxicity related to prior therapy (NCI CTCAE v. 4.03 Grade > 1); however, alopecia, sensory neuropathy Grade ≤ 2, or other Grade ≤ 2 not constituting a safety risk based on investigator's judgment are acceptable.
9. Any serious or uncontrolled medical disorder or active infection that, in the opinion of the investigator, may increase the risk associated with study participation, study drug administration, or would impair the ability of the subject to receive study drug.

10. Significant acute or chronic infections including, among others:

    • Any positive test for human immunodeficiency virus (HIV) or known acquired immunodeficiency syndrome (AIDS)
    • Any positive test result for hepatitis B virus or hepatitis C virus indicating acute or chronic infection.
11. History of allergy or hypersensitivity to study drug or any constituent of the products
12. Participation in another clinical study with an investigational product during the last 30 days before inclusion
13. Patient who has been incarcerated or involuntarily institutionalized by court order or by the authorities § 40 Abs. 1 S. 3 Nr. 4 AMG.
14. Patients who are unable to consent because they do not understand the nature, significance and implications of the clinical trial and therefore cannot form a rational intention in the light of the facts [§ 40 Abs. 1 S. 3 Nr. 3a AMG].

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: A: Chemo-free immunotherapy; Week 1-12 Trastuzumab 6mg/kg d1 every 3 weeks (loading dose 8mg/kg) Nivolumab 1mg/kg i.v. d1 every 3 weeks Ipilimumab 3mg/kg i.v. d1 every 3 weeks Week 13 till EOT (max treatment period 12 months) Trastuzumab 4mg/kg d1 every 2 weeks Nivolumab 240mg i.v. d1 every 2 weeks	Drug: Nivolumab; Addition of Nivolumab to Standard therapy (chemotherapy and Trastuzumab); Drug: Nivolumab; Chemo-free immunotherapy with Nivolumab, Ipilimumab, Trastuzumab; Drug: Ipilimumab; Chemo-free immunotherapy with Nivolumab, Ipilimumab, Trastuzumab
Experimental: B: Chemo- / immunotherapy; Trastuzumab 4mg/kg d1 every 2 weeks (loading dose 6mg/kg) Nivolumab 240mg i.v. d1 every 2 weeks mFOLFOX6 every 2 weeks Oxaliplatin at a dose of 85 mg/m2 IV over two hours (day 1) 5-FU 400 mg/m2 IV bolus (day 1) LV at a dose of 400 mg/m2 iv over two hours (day 1) 5-FU at a dose of 2400 mg/m2 IV over 46 hours (day 1-3) Max Treatment period 12 months	Drug: Nivolumab; Addition of Nivolumab to Standard therapy (chemotherapy and Trastuzumab); Drug: Nivolumab; Chemo-free immunotherapy with Nivolumab, Ipilimumab, Trastuzumab

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Overall Survival	Overall survival including milestone rate at 12 months	Milestone at 12 months, max observation period 48 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of Treatment-Emergent Adverse Events [Safety and Tolerability]	according to Common Terminology Criteria for Adverse Events and to the obtained data on vital signs, clinical parameters and feasibility of the regimen	48 months
Progression Free Survival	Response Evaluation Criteria in Solid Tumors (RECIST 1.1.)	48 months
Response Rate	Response Rate (RR) according to RECIST v1.1	15 months
Health related Quality of Life	EORTC QLQ-C30 (European Organisation for Research and Treatment of Cancer - Quality of Life Core Questionnaire (30 items) Version 3.0. The QLQ-C30 is composed of multi-item scales and single-item measures, including five functional scales, three symptom scales, a global health status / QoL scale, and six single items. All of the scales and single-item measures have a score range from 0 to 100. A high score shows a high response level. A high score for a functional scale represents a high / healthy level of functioning, a high score for the global health status / QoL represents a high QoL, but a high score for a symptom scale / item represents a high level of symptomatology / problems	48 months
Health related Quality of Life	EORTC STO-22 (European Organisation for Research and Treatment of Cancer - Quality of Life Questionnaire Gastric Module (STO = stomach) (22 items), comprising five multi-item and four single-item subscales. The multi-item subscales include questions about dysphagia (4 items), dietary restriction (5 items), pain (3 items), upper gastro-esophageal symptoms such as reflux (3 items), and emotional problems such as anxiety (3 items). The single-item subscales include questions related to four gastric cancer-specific symptoms: dry mouth, body image, hair loss, and problems with taste. Items are assessed on a 4-level numerical scale with 1= "not at all", 2= "a little", 3= "quite a bit", and 4= "very much". Scores are linearly converted and summated into a scaled score from 0 to 100, with a higher score representing a worse QOL.	48 months
Translational research tumor block	Tumor-infiltrating lymphocytes (TiL) repertoire determination from tumor	48 months
Translational research blood - immunoprofiling	Liquid biopsy next-generation sequencing (NGS) immunoprofiling (TCRβ & IgH) before treatment initiation and before second cycle to determine response predictive immune signature	Up to 7 weeks
Translational research blood - circulating Tumor cells (CTC)	CTC will be evaluated for changes in HER2 and PD-L1 status	48 months
Translational research blood - circulating Tumor DNA (ctDNA)	ctDNA will be evaluated for HER signaling alterations	48 months
Central Imaging Review - ORR	Retrospective central radiological review of ORR according to modified RECIST	48 months
Central Imaging Review - PFS	Retrospective central radiological review of PFS according to modified RECIST	48 months

Collaborators and Investigators

• Sponsor: AIO-Studien-gGmbH
• Collaborators: Bristol-Myers Squibb
• Investigators: Principal Investigator: Alexander Stein, Dr., HOPE - Hämatologisch-onkologische Praxis Eppendorf

Publications and helpful links

General Publications

• Stein A, Paschold L, Tintelnot J, Goekkurt E, Henkes SS, Simnica D, Schultheiss C, Willscher E, Bauer M, Wickenhauser C, Thuss-Patience P, Lorenzen S, Ettrich T, Riera-Knorrenschild J, Jacobasch L, Kretzschmar A, Kubicka S, Al-Batran SE, Reinacher-Schick A, Pink D, Sinn M, Lindig U, Hiegl W, Hinke A, Hegewisch-Becker S, Binder M. Efficacy of Ipilimumab vs FOLFOX in Combination With Nivolumab and Trastuzumab in Patients With Previously Untreated ERBB2-Positive Esophagogastric Adenocarcinoma: The AIO INTEGA Randomized Clinical Trial. JAMA Oncol. 2022 Aug 1;8(8):1150-1158. doi: 10.1001/jamaoncol.2022.2228.
• Tintelnot J, Goekkurt E, Binder M, Thuss-Patience P, Lorenzen S, Knorrenschild JR, Kretzschmar A, Ettrich T, Lindig U, Jacobasch L, Pink D, Al-Batran SE, Hinke A, Hegewisch-Becker S, Nilsson S, Bokemeyer C, Stein A. Ipilimumab or FOLFOX with Nivolumab and Trastuzumab in previously untreated HER2-positive locally advanced or metastatic EsophagoGastric Adenocarcinoma - the randomized phase 2 INTEGA trial (AIO STO 0217). BMC Cancer. 2020 Jun 1;20(1):503. doi: 10.1186/s12885-020-06958-3.

Helpful Links

• AIO-Studien-gGmbH
• AIO - Working Group for Medical Oncology from the German Cancer Society

Study record dates

Study Major Dates

• Study Start (Actual): March 1, 2018
• Primary Completion (Actual): March 5, 2022
• Study Completion (Actual): March 5, 2022

Study Registration Dates

• First Submitted: January 3, 2018
• First Submitted That Met QC Criteria: January 18, 2018
• First Posted (Actual): January 24, 2018

Study Record Updates

• Last Update Posted (Actual): May 18, 2022
• Last Update Submitted That Met QC Criteria: May 17, 2022
• Last Verified: May 1, 2022

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Digestive System Diseases; Neoplasms by Histologic Type; Neoplasms; Neoplasms by Site; Carcinoma; Neoplasms, Glandular and Epithelial; Gastrointestinal Neoplasms; Digestive System Neoplasms; Gastrointestinal Diseases; Stomach Diseases; Stomach Neoplasms; Adenocarcinoma; Molecular Mechanisms of Pharmacological Action; Antineoplastic Agents; Antineoplastic Agents, Immunological; Immune Checkpoint Inhibitors; Nivolumab; Ipilimumab
• Other Study ID Numbers: AIO-STO-0217; 2017-000624-10 (EudraCT Number); CA209-99R (Other Grant/Funding Number: Bristol-Myers Squibb)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No