EACH: Evaluating Avelumab in Combination With Cetuximab in Head and Neck Cancer

This is a randomised phase II study comparing the efficacy of avelumab alone with avelumab + cetuximab combination in patients with platinum-resistant advanced or metastatic head & neck cancer. The randomised phase II part of the trial will be preceded by a safety run-in.The objective of the safety run in is to make sure the combination of cetuximab and avelumab at the doses selected for the study are safe and tolerable.

In phase II, the main question the investigator wants to answer is whether or not giving avelumab and cetuximab together is better than giving avelumab alone to treat patients with head and neck cancer that have had previous treatment with cisplatin and whose cancer has come back or spread to other parts of the body. The investigator will compare the number of patients in each group whose cancer has not gotten any worse 6 months after joining the study.

The phase II part of the trial will recruit patients with head & neck squamous cell carcinoma only. However, during the safety run-in, patients with other types of squamous cell carcinomas will also be eligible.

Target accrual:

Safety run-in: up to 16 patients with squamous cell carcinomas; Phase II: 114 patients with head & neck squamous cell cancer

The safety run-in will recruit patients in cohorts of 3 at a time and all patients will be treated with the combination. The safety run in is a dose de-escalation design. That is, patients will be given the dose that is planed for use in phase II and if this proves not tolerable, the dose of cetuximab will be de-escalated and another cohort of patients will be recruited. The investigator will conclude the combination is safe and tolerable if less than 33% of patients who are treated experience side effects that lead to a dose reduction. The purpose is to ensure the safety of the combination prior to starting phase II, as these drugs have not been given together before. However, there is evidence from previous studies that these types of drugs can be combined safely. The trial aims to complete the safety run-in within 5 months and the phase II study within 24 months. The entire duration of recruitment is expected to be 29 months.

Inclusion criteria

• Safety run in: Histologically or cytologically confirmed recurrent or metastatic squamous cell carcinoma that is considered incurable by local therapies

Phase II: Histologically/cytologically confirmed recurrent/metastatic squamous cell carcinoma of the head and neck that is considered incurable by local therapies.

• Prior treatment with a platinum agent (either for recurrent/metastatic disease; or as part of radical intent multimodality treatment if disease has recurred within 6 months). (NB: This criterion is not applicable for the safety run-in).
• No previous treatment with cetuximab for metastatic/recurrent disease
• Age ≥18 years
• WHO Performance Status 0 or 1
• Measurable disease according to RECIST v1.1
• Adequate bone marrow function
• Adequate liver function
• Adequate renal function
• Adequate venous access for administration of treatment and collection blood samples for exploratory biological samples
• Willing to have a new biopsy (NB: This criterion is not applicable for the safety run-in).
• Life expectancy of >3 months
• Women of child-bearing potential and male patients with partners of child-bearing potential must agree to use adequate contraception methods from date of informed consent, which must be continued for 120 days after completion of trial treatment.
• Able to give informed consent, indicating that the patient has been informed of and understands the experimental nature of the study, possible risks and benefits, trial procedures, and alternative options
• Willing and able to comply with the protocol for the duration of the study, including the treatment plan, investigations required and follow up visits.

Exclusion criteria

• Patients with undifferentiated nasopharyngeal or sino-nasal cancers.
• Disease suitable for treatment with curative intent.
• Prior therapy with an anti-PD-1, anti-PD-L1 or anti-PD-L2 agent.
• Treatment with any investigational agent within 4 weeks prior to the first dose of trial treatment.
• Anti-cancer monoclonal antibody therapy within 4 weeks prior to randomisation
• Chemotherapy, targeted small molecule therapy, or radiotherapy within 2 weeks prior to randomisation.
• Persisting grade ≥2 toxicity related to prior therapy
• Patients with concurrent or previous malignancy that could compromise assessment of the primary or secondary endpoints of the trial.
• Women who are pregnant or breast feeding.
• Grade 3 or 4 peripheral neuropathy.
• Any serious and/or unstable pre-existing medical, psychiatric or other condition, or laboratory abnormalities that may increase the risk associated with study participation or study treatment administration or may interfere with the interpretation of study results and, in the judgment of the investigator, would make the patient inappropriate for entry into this study.
• Patients who are not able to give informed consent for any reason.
• Active central nervous system (CNS) metastases and/or carcinomatous meningitis
• Hepatitis infection at screening
• Known history of testing positive for HIV or known acquired immunodeficiency syndrome.
• Prior organ transplantation including allogenic stem-cell transplantation
• Has a history of (non-infectious) pneumonitis that required steroids, or current pneumonitis
• Active infection requiring systemic therapy
• Has received a live vaccine within 28 days prior to first dose of trial treatment
• Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any other form of immunosuppressive therapy within 7 days prior to the first dose of trial treatment (n.b. the use of physiologic doses of corticosteroids may be approved after consultation with UCL CTC)
• Active autoimmune disease that might deteriorate when receiving an immune-stimulatory agent.
• Current use of immunosuppressive medication
• History of idiopathic pulmonary fibrosis (including pneumonitis), drug-induced pneumonitis, organising pneumonia (i.e. bronchiolitis obliterans, cryptogenic organising pneumonia), or evidence of active pneumonitis on screening chest CT scan. (History of radiation pneumonitis in the radiation field is permitted).
• Significant cardiovascular disease
• Known prior severe hypersensitivity to either investigational product or any component in their formulations, including known severe hypersensitivity reactions to monoclonal antibodies
• Other severe acute or chronic medical conditions including immune colitis, inflammatory bowel disease, immune pneumonitis, pulmonary fibrosis.
• Patients with a history of keratitis, ulcerative keratitis or severe dry eye.