Tumor Treating Fields for Locally Advanced NSCLC

Inclusion criteria

Step 1: Pre-Chemoradiation Inclusion Criteria

• Histologically or cytologically confirmed diagnosis of non-small cell lung cancer (NSCLC).
• Clinical AJCC (AJCC, 8th ed.) stage IIIA or IIIB, or IIIC NSCLC with unresectable disease. Staging FDG-PET/CT and MRI brain (preferred) or CT head with contrast scan must have been completed within 60 days prior to initiation of concurrent CRT. Unresectable disease must be determined by a multi-disciplinary team unless, in the opinion of the treating investigator, the subject's disease is clearly unresectable. Subjects who refuse surgery will be considered to have unresectable disease.
• Able to operate the NovoTTF-200T System independently or with the help of a caregiver.
• Eligible to receive standard of care chemoradiation per institutional standards.
• Subject must have measurable disease by RECIST 1.1 criteria by CT.
• ECOG Performance Status ≤ 1.
• Adequate organ function as defined as:
• Hematologic:

• Absolute neutrophil count (ANC) ≥ 1500/mm3
• Platelet count ≥ 100,000/mm3
• Hemoglobin ≥ 10 g/dL (transfusions are allowed for Device Duration Level 2 only if anemia is due to prior therapy.)
• Hepatic:

• Total Bilirubin ≤ 1.5x institutional upper limit of normal (ULN) or direct bilirubin ≤ULN for participants with total bilirubin levels >1.5 × ULN.
• AST(SGOT)/ALT(SGPT) ≤ 3 × institutional ULN
• Subjects with liver metastases will be allowed to enroll with AST and ALT levels ≤ 5 x ULN.
• Renal:

• Estimated creatinine clearance ≥ 50 mL/min by Cockcroft-Gault formula:
• Males:

• ((140-age)×weight[kg])/(serum creatinine [mg/dL]×72)
• Females:

• (((140-age)×weight[kg])/(serum creatinine [mg/dL]×72))×0.85
• For subjects of childbearing potential:

• Negative pregnancy test or evidence of post-menopausal status. The post-menopausal status will be defined as having been amenorrheic for 12 months without an alternative medical cause. The following age-specific requirements apply:
• Subjects < 50 years of age:

• Amenorrheic for ≥ 12 months following cessation of exogenous hormonal treatments; and
• Luteinizing hormone and follicle-stimulating hormone levels in the post-menopausal range for the institution; or
• Underwent surgical sterilization (bilateral oophorectomy or hysterectomy).
• Subjects ≥ 50 years of age:

• Amenorrheic for 12 months or more following cessation of all exogenous hormonal treatments; or
• Had radiation-induced menopause with last menses >1 year ago; or
• Had chemotherapy-induced menopause with last menses >1 year ago; or
• Underwent surgical sterilization (bilateral oophorectomy, bilateral salpingectomy, or hysterectomy).
• Subjects of childbearing potential and subjects with a sexual partner of childbearing potential must agree to use a highly effective method of contraception as described in Section 4.6.
• Able to provide informed consent and willing to sign an approved consent form that conforms to federal and institutional guidelines.

Step 2: Pre-Consolidative Immunotherapy Phase Inclusion Criteria

• The subject must have previously completed and been eligible for Step 1 registration.
• Completion of post-chemoradiation CT scan and RECIST 1.1 assessment.
• Eligible to receive consolidation immunotherapy per institutional standards and Investigator judgement.
• Able to operate the NovoTTF-200T System independently or with the help of a caregiver.
• ECOG Performance Status ≤ 1.
• Adequate organ function as defined as:
• Hematologic:

• Absolute neutrophil count (ANC) ≥ 1500/mm3
• Platelet count ≥ 100,000/mm3
• Hemoglobin ≥ 10 g/dL (transfusions are allowed for Device Duration Level 2 only if anemia is due to prior therapy with concurrent chemoradiation.)
• Hepatic:

• Total Bilirubin ≤ 1.5x institutional upper limit of normal (ULN) or direct bilirubin ≤ULN for participants with total bilirubin levels >1.5 × ULN.
• AST(SGOT)/ALT(SGPT) ≤ 3 × institutional ULN
• Subjects with liver metastases will be allowed to enroll with AST and ALT levels ≤ 5 x ULN.
• Renal:

• Estimated creatinine clearance ≥ 50 mL/min by Cockcroft-Gault formula:
• Males:

• ((140-age)×weight[kg])/(serum creatinine [mg/dL]×72)
• Females:

• (((140-age)×weight[kg])/(serum creatinine [mg/dL]×72))×0.85
• Recovery to baseline or ≤ Grade 1 CTCAE v5.0 from toxicities related to any prior cancer therapy (except for alopecia or fatigue) unless considered clinically not significant and/or stable by the treating investigator.
• Resolution of any pneumonitis from prior radiation therapy to < grade 1 per the treating investigator.

Exclusion criteria

Step 1: Pre-Chemoradiation Phase Exclusion Criteria

• Prior thoracic radiation, including breatbreast radiation.
• Prior exposure to TTFields.
• Prior systemic immunotherapy or radiotherapy for NSCLC.
• nown underlying skin hypersensitivity or known allergy to skin adhesives or hydrogel.
• Known hypersensitivity to radiation due to genetic susceptibility, connective tissue disease, or any other cause.
• Receiving other investigational agents.
• Major surgery (per treating investigator) within 4 weeks prior to starting study drug or who have not fully recovered from major surgery. Note: Biopsies without significant complications will not be considered major surgery.
• The diagnosis of another malignancy within ≤ 2 years before study enrollment, except for those considered to be adequately treated with no evidence of disease or symptoms and/or will not require therapy during the study duration (i.e., basal cell or squamous cell skin cancer, carcinoma in situ of the breast, bladder or of the cervix, or low-grade prostate cancer with Gleason Score ≤ 6).
• Current evidence of uncontrolled, significant intercurrent illness including, but not limited to, the following conditions:
• Cardiovascular disorders:

• Congestive heart failure New York Heart Association Class III or IV, unstable angina pectoris, serious or clinically significant cardiac arrhythmias.
• Stroke (including transient ischemic attack [TIA]), myocardial infarction (MI), or other ischemic events, or thromboembolic event (eg, deep venous thrombosis, pulmonary embolism) within 3 months before the first dose.
• QTc prolongation defined as a QTcF > 500 ms.
• Known congenital long QT.
• Left ventricular ejection fraction < 50%.
• Uncontrolled hypertension defined as persistent blood pressure of ≥ 160/90 as assessed from the mean of three consecutive blood pressure measurements taken over 10 minutes.
• Implanted pacemaker, defibrillator or other electrical medical devices;
• Any other condition that would, in the Investigator's judgment, contraindicate the subject's participation in the clinical study due to safety concerns or compliance with clinical study procedures (e.g., infection/inflammation, intestinal obstruction, unable to swallow medication, [subjects may not receive the drug through a feeding tube], social/ psychological issues, etc.)
• Known HIV infection with a detectable viral load within 6 months of the anticipated start of treatment. Note: Subjects on effective antiretroviral therapy with an undetectable viral load within 6 months of the anticipated start of treatment are eligible for this trial.
• Active known infection including tuberculosis (clinical evaluation that includes clinical history, physical examination, radiographic findings, and TB testing in line with local practice), hepatitis B (known positive HBV surface antigen (HBsAg) result), or hepatitis C. Note: Subjects with a past or resolved HBV infection (defined as the presence of hepatitis B core antibody [anti-HBc] and absence of HBsAg) are eligible. Subjects positive for hepatitis C (HCV) antibody are eligible only if polymerase chain reaction is negative for HCV RNA.
• Medical, psychiatric, cognitive, or other conditions that may compromise the subject's ability to understand the subject information, give informed consent, comply with the study protocol or complete the study.
• History of allogenic stem cell or solid organ transplantation
• Active or prior documented autoimmune or inflammatory disorders (including inflammatory bowel disease [e.g., colitis or Crohn's disease], systemic lupus erythematosus, Sarcoidosis syndrome, or Wegener syndrome [granulomatosis with polyangiitis, Graves' disease, rheumatoid arthritis, uveitis, etc.]). The following are exceptions to this criterion:

• Patients with vitiligo or alopecia
• Patients with endocrine disorders with controlled disease on hormone replacement therapy (e.g. adrenal, thyroid, or pituitary replacement therapy)
• Any chronic skin condition that does not require systemic therapy
• Patients without active disease in the last 5 years may be included but only after consultation with the principal investigator.
• Patients with celiac disease controlled by diet alone
• Current or prior use of immunosuppressive medication within 14 days of cycle one day one, EXCEPT for the following permitted steroids:

• Intranasal, inhaled, topical steroids, eye drops, or local steroid injection (e.g., intra-articular injection);
• Systemic corticosteroids at physiologic doses ≤ 10mg/day of prednisone or equivalent;
• Steroids as premedication for hypersensitivity reactions (e.g., computed tomography (CT) scan premedication).
• Subjects taking prohibited medications as described in Section 5.11. A washout period of prohibited medications for a period of at least five half-lives or as clinically indicated should occur before the start of treatment.
• History of exudative pleural effusions, regardless of cytology.
• Peripheral neuropathy > grade 1 for patients receiving concurrent carboplatin and paclitaxel with radiation.

Step 2 Pre-Consolidative Immunotherapy Phase Exclusion Criteria

• Subjects who in the investigators opinion had disease progression following concurrent chemoradiation.
• Known underlying skin hypersensitivity or known allergy to skin adhesives or hydrogel.
• Major surgery (per treating investigator) 4 weeks prior to starting study drug or who have not fully recovered from major surgery.
• Current evidence of uncontrolled, significant intercurrent illness including, but not limited to, the following conditions:
• Cardiovascular disorders:

• Congestive heart failure New York Heart Association Class III or IV, unstable angina pectoris, serious or clinically significant cardiac arrhythmias.
• Stroke (including transient ischemic attack [TIA]), myocardial infarction (MI), or other ischemic events, or thromboembolic event (eg, deep venous thrombosis, pulmonary embolism) within 3 months before the first dose.
• QTc prolongation defined as a QTcF > 500 ms.
• Known congenital long QT.
• Left ventricular ejection fraction < 50%.
• Uncontrolled hypertension defined as persistent blood pressure of ≥ 160/90 as assessed from the mean of three consecutive blood pressure measurements taken over 10 minutes.
• Implanted pacemaker, defibrillator or other electrical medical devices;
• Any other condition that would, in the Investigator's judgment, contraindicate the subject's participation in the clinical study due to safety concerns or compliance with clinical study procedures (e.g., infection/inflammation, intestinal obstruction, unable to swallow medication, [subjects may not receive the drug through a feeding tube], social/ psychological issues, etc.)
• Medical, psychiatric, cognitive, or other conditions that may compromise the subject's ability to understand the subject information, give informed consent, comply with the study protocol or complete the study.
• History of allogenic stem cell or solid organ transplantation
• Active or prior documented autoimmune or inflammatory disorders (including inflammatory bowel disease [e.g., colitis or Crohn's disease], systemic lupus erythematosus, Sarcoidosis syndrome, or Wegener syndrome [granulomatosis with polyangiitis, Graves' disease, rheumatoid arthritis, uveitis, etc.]).
• The following are exceptions to this criterion:

• Patients with vitiligo or alopecia
• Patients with endocrine disorders with controlled disease on hormone replacement therapy (e.g. adrenal, thyroid, or pituitary replacement therapy)
• Any chronic skin condition that does not require systemic therapy
• Patients without active disease in the last 5 years may be included but only after consultation with the principal investigator
• Patients with celiac disease controlled by diet alone.
• Current or prior use of immunosuppressive medication within 14 days of cycle one day one, EXCEPT for the following permitted steroids:

• Intranasal, inhaled, topical steroids, eye drops, or local steroid injection (e.g., intra-articular injection)
• Systemic corticosteroids at physiologic doses ≤ 10mg/day of prednisone or equivalent
• History of exudative pleural effusions, regardless of cytology.