Metformin for Chemoprevention of Lung Cancer in Overweight or Obese Individuals at High Risk for Lung Cancer

Metformin for Chemoprevention of Lung Cancer in High-Risk Overweight or Obese Individuals

This phase II trial determines the effect of metformin extended release on the risk for developing lung cancer in overweight/obese patients that are at high-risk for developing lung cancer. Metformin is widely used to treat type II diabetes and has a long history of safety and minimal side effects. At similar dosage, the drug may have potential anti-cancer activity. Metformin use has been associated with improved survival in patients with non-small cell lung carcinoma, a specific type of lung cancer, and it has also been shown to enhance immune mobilization against tumors. This trial aims to see whether metformin extended release as a preventative treatment may lower the chance of developing lung cancer, and whether it may help patients' immune system learn ("reprogram") to lower a certain type of immune cell (called regulatory T cells) that are linked to tumor development.

Study Overview

• Status: Recruiting
• Conditions: Lung Carcinoma
• Intervention / Treatment: Other: Questionnaire Administration; Procedure: Biospecimen Collection; Procedure: Biopsy; Drug: Extended Release Metformin Hydrochloride; Procedure: Bronchoscopy

Detailed Description

PRIMARY OBJECTIVE:

I. To evaluate the effect of metformin treatment on the expression of programmed cell death protein 1 (PD-1) on airway regulatory T cells (Tregs) in overweight and obese individuals at high risk for lung cancer.

SECONDARY OBJECTIVES:

I. Estimated PD-1 expression of pulmonary Tregs change in Cohort B during the wait period (26 weeks with no treatment).

II. To examine the impact of metformin on circulating immune cell subsets of blood.

EXPLORATORY OBJECTIVES:

I. To examine the impact of metformin on cancer-related transcriptome features of airway lesions.

II. To examine the impact of metformin on immune profile of pulmonary parenchyma represented by bronchoalveolar lavage (BAL).

III To examine the impact of metformin on histologic progression of abnormal airway lesions.

IV. To examine the impact of metformin on serum adipokines and inflammatory cytokines.

OUTLINE: Participants are randomized to 1 of 2 cohorts.

COHORT A: Participants receive metformin extended release (ER) orally (PO) once daily (QD) for 26 weeks in the absence of unacceptable toxicity. Participants undergo bronchoscopy biopsy and blood sample collection at screening, and week 13.

COHORT B: Participants receive no intervention for 26 weeks, then cross-over to cohort A. Participants undergo bronchoscopy biopsy and blood sample collection at screening, at week 26, and at 13 weeks after cross-over to Cohort A.

After completion of study treatment, participants are followed up at weeks 30-32 (Cohort A) and weeks 56-58 (Cohort B).

• Study Type: Interventional
• Enrollment (Estimated): 50
• Phase: Phase 2

Contacts and Locations

Study Locations

• Canada
  • British Columbia
    • Vancouver, British Columbia, Canada, V6T 2B5
      • Not yet recruiting
      • University of British Columbia Hospital
      • Contact: Stephen Lam; Phone Number: 604-675-8090; Email: slam2@bccancer.bc.ca
      • Principal Investigator: Stephen Lam
    • Vancouver, British Columbia, Canada, V5Z 1L3
      • Recruiting
      • BC Cancer Research Centre
      • Contact: Stephen Lam; Phone Number: 604-675-8090; Email: slam2@bccancer.bc.ca
      • Principal Investigator: Stephen Lam
• United States
  • Colorado
    • Aurora, Colorado, United States, 80045
      • Recruiting
      • Rocky Mountain Regional VA Medical Center
      • Contact: Robert L. Keith; Phone Number: 720-857-5120; Email: Robert.keith@cuanschutz.edu
      • Principal Investigator: Robert L. Keith
  • New York
    • Buffalo, New York, United States, 14263
      • Recruiting
      • Roswell Park Cancer Institute
      • Contact: Saikrishna S. Yendamuri; Phone Number: 716-364-4852; Email: sai.yendamuri@roswellpark.org
      • Principal Investigator: Saikrishna S. Yendamuri

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 30 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Former smokers (male and female) with a >= 20 pack year smoking history
• Quit smoking >= 12 months prior to enrollment
• Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCOm2012) Lung Cancer Risk Prediction Score > 1.34%

• Overweight

  • Body mass index (BMI) > 25 and

  • Waist circumference

    • Female > 88 cm (35")
    • Male > 102 cm (40")
• Age greater than 30 years. Participants younger than 30 years are unlikely to accrue enough smoking exposure followed by enough time after quitting (>12 months) to qualify
• Eastern Cooperative Oncology Group (ECOG) performance status =< 2
• Leukocytes >= 3,000/microliter
• Absolute neutrophil count (ANC) >= 1,000/microliter
• Platelets >= 100,000/microliter
• Total bilirubin =< 1.5 x institutional upper limit of normal (IULN)
• Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT])/alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 3.0 x IULN
• Estimated glomerular filtration rate (eGFR) > 45 ml/min/1.73 m^2 (eGFR will be calculated using the equation Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI] creatinine)
• Patients with a history of hepatitis C virus (HCV) infection must have been treated and cured
• Patients on chronic suppressive antiviral therapy for herpes simplex virus (HSV) are eligible
• The effects of metformin ER on the developing human fetus at the recommended therapeutic dose are unknown. For this reason, 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 and for the duration of study participation. Should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her study physician immediately
• Ability to understand and the willingness to sign a written informed consent document

Exclusion Criteria:

• Current or previous diagnosis of diabetes mellitus (type I or type II diabetes)
• Use of metformin within the past 2 years
• Use of GLP-1 agonists within 6 weeks prior to enrollment
• Glycosylated hemoglobin A1C (HbA1c) > 8%
• History of allergic reactions attributed to compounds of similar chemical or biologic composition to metformin ER
• Participants currently using immunosuppressive medication, including systemic steroids (not inhalational) and episodic use of inhaled steroids are excluded from this trial due to the potential impact of these treatments on the primary trial endpoint
• Participants receiving any other investigational agents

• History of chronic alcohol use or abuse defined by any one of the following:

  • Average consumption of 3 or more alcohol containing beverages daily in the past 12 months
  • Consumption of 7 or more alcoholic beverages within a 24 hour period in the past 12 months
• Acute or chronic liver disease, evidence of hepatitis (infectious or autoimmune), cirrhosis or portal hypertension
• History of or current condition predisposing to increased risk for lactic acidosis such as: severe congestive heart failure (New York Heart Association [NYHA] class III or IV), metabolic acidosis, severe liver disease, or renal failure
• Uncontrolled intercurrent illness or psychiatric illness/social situations that would or limit compliance with study requirements
• Pregnant women are excluded from this study. Metformin ER is a class B agent that was not teratogenic in rats and rabbits at doses representing 3 and 6 times the maximum recommended human daily dose of 2000 mg; however, animal reproduction studies are not always predictive of human response. Because there is an unknown but potential risk for adverse events (AEs) in nursing infants secondary to treatment of the mother with metformin ER, breastfeeding should be discontinued if the mother is treated with metformin ER

• Biopsy with invasive carcinoma of the lung or carcinoma in situ

  • Participants with prior stage 1 non-small cell lung cancer (NSCLC) diagnosis are allowed to participate, as long as there has been 12 months since the completion of cancer treatment prior to enrollment with no evidence of recurrence or second primary cancer

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Cohort A (metformin ER); Participants receive metformin ER PO QD for 26 weeks in the absence of unacceptable toxicity. Participants undergo bronchoscopy biopsy and blood sample collection at screening, and week 13.	Other: Questionnaire Administration; Ancillary studies; Procedure: Biospecimen Collection; Undergo blood sample collection; Other Names: Biological Sample Collection; Biospecimen Collected; Specimen Collection; Procedure: Biopsy; Undergo biopsy; Other Names: Bx; BIOPSY_TYPE; Drug: Extended Release Metformin Hydrochloride; Given PO; Other Names: Glucophage XR; Glumetza; ER Metformin Hydrochloride; Extended-release Metformin Hydrochloride; Metformin Hydrochloride Extended Release; Procedure: Bronchoscopy; Undergo bronchoscopy
Active Comparator: Cohort B (metformin ER with waiting period); Participants receive no intervention for 26 weeks, then cross-over to Cohort A. Participants undergo bronchoscopy biopsy and blood sample collection at screening, at week 26, and at 13 weeks after cross-over to Cohort A.	Other: Questionnaire Administration; Ancillary studies; Procedure: Biospecimen Collection; Undergo blood sample collection; Other Names: Biological Sample Collection; Biospecimen Collected; Specimen Collection; Procedure: Biopsy; Undergo biopsy; Other Names: Bx; BIOPSY_TYPE; Drug: Extended Release Metformin Hydrochloride; Given PO; Other Names: Glucophage XR; Glumetza; ER Metformin Hydrochloride; Extended-release Metformin Hydrochloride; Metformin Hydrochloride Extended Release; Procedure: Bronchoscopy; Undergo bronchoscopy

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
PD-1 expression of pulmonary regulatory T cells (Tregs) before and after metformin extended release (ER) treatment	Change from pre- to post-metformin extended release (ER) treatment in cell surface PD-1 expression levels of pulmonary (BAL) Tregs, measured as mean fluorescent intensity (MFI). Changes in MFI due to metformin ER treatment among all n = 40 subjects will be used for the primary analysis.	Pre- to post-treatment

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Estimated PD-1 expression of pulmonary Tregs change in cohort B during the wait period (6 months with no treatment)	This is the estimate of change in MFI following the 6-month wait period among n = 20 subjects randomized to the wait-list arm. This will confirm the stability of the PD-1 expression of pulmonary Tregs over time.	Randomization to week 26
Circulating immune cells	Circulating immune cell composition between blood samples collected pre- and post-metformin ER treatment to assess the effect of metformin ER on circulating immune cells and to identify potential biomarkers of metformin ER response.	Pre- to post-treatment

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Airway gene expression	RNA sequencing of endobronchial biopsies will be performed at visually normal mainstem airway for each participant. The analysis of the RNA seq data will be an unsupervised comparison of differentially expressed genes with and without metformin ER exposure.	Up to study completion
Examination of the immune profile of pulmonary parenchyma represented by bronchoalveolar lavage	This will compare the immune composition of bronchoalveolar lavage samples of participants before and after metformin exposure. Specifically, the prevalence and composition of myeloid derived suppressor cells (MDSCs) as well as monocyte, macrophage and dendritic cells will be assessed.	Pre- to post-treatment
Examination of the effect of metformin on systemic adipokines and inflammatory cytokines	Frozen sera will be analyzed by commercial enzyme-linked immunosorbent assay kits for levels of leptin, adiponectin, resistin, IL6 and TNFalpha. Pre- and post-treatment serum levels will be compared in parametric paired testing.	Pre- to post-treatment
Histologic progression	Bronchoscopic biopsies of at least 6 standard sites will be graded on the World Health Organization (WHO) scale of dysplasia and assigned numerical scores from 1 (normal) to 8 (invasive cancer). Each lesion will be classified as complete response (CR), partial response (PR), stable disease (SD) or progressive disease (PD) and each response rate will be calculated on a per-site and a per-participant basis. Additional measures of dysplasia will include the average dysplastic score and the dysplasia index (% of sites with dysplasia score >= 3 (mild dysplasia)). Changes in maximum dysplasia will be analyzed using a paired t test to determine whether a reduction occurs.	Up to study completion

Collaborators and Investigators

• Sponsor: National Cancer Institute (NCI)
• Investigators: Principal Investigator: Saikrishna S Yendamuri, Roswell Park University

Study record dates

Study Major Dates

• Study Start (Actual): September 9, 2022
• Primary Completion (Estimated): April 1, 2026
• Study Completion (Estimated): November 1, 2026

Study Registration Dates

• First Submitted: June 17, 2021
• First Submitted That Met QC Criteria: June 17, 2021
• First Posted (Actual): June 18, 2021

Study Record Updates

• Last Update Posted (Actual): April 16, 2024
• Last Update Submitted That Met QC Criteria: April 13, 2024
• Last Verified: April 1, 2024

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Overnutrition; Nutrition Disorders; Body Weight; Overweight; Hypoglycemic Agents; Physiological Effects of Drugs; Metformin
• Other Study ID Numbers: NCI-2021-06112 (Registry Identifier: CTRP (Clinical Trial Reporting Program)); P30CA060553 (U.S. NIH Grant/Contract); UG1CA242643 (U.S. NIH Grant/Contract); NCI20-04-01 (Other Identifier: Northwestern University); NWU20-04-01 (Other Identifier: DCP)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: NCI is committed to sharing data in accordance with NIH policy. For more details on how clinical trial data is shared, access the link to the NIH data sharing policy page.

Drug and device information, study documents

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