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SWOG 1403

A Randomized Phase II/III Trial of Afatinib Plus Cetuximab Versus Afatinib Alone in Treatment-Naive Patients with Advanced, EGFR Mutation Positive Non-Small Cell Lung Cancer

Inclusion Criteria
  • Patients must have histologically or cytologically confirmed Stage IV or recurrent non-small cell lung cancer.

  • Patients must have documented presence of an EGFR exon 19 deletion or exon 21 (L858R) substitution mutation. T790M mutation or other molecular abnormality will be allowed as long as it accompanies one of the mutations listed above. EGFR testing must have been performed using a FDA-approved test or in a CLIA-certified laboratory.

  • Patients must have tissue available and must agree to submission of tissue and blood. One to two paraffin-embedded tissue blocks or 15-20 unstained slides are requested (a minimum of 12 slides is required). Cytology (i.e. fine-needle aspirations, pleural effusion specimens) is acceptable if a cell block or sufficient unstained slides are not available. Tumor material must be reviewed by a local pathologist who must confirm that at least 100 viable tumor cells are present in the sample. Patients must also be willing to submit blood samples for correlative research at baseline, during treatment and at progression.

  • Patients must not have received any prior systemic anticancer therapy for advanced or metastatic disease including chemotherapy or EGFR tyrosine kinase inhibitor therapy (including gefitinib, erlotinib, afatinib, or any experimental EGFR TKI agents). Prior chemotherapy for non-metastatic disease (i.e. adjuvant therapy or concurrent chemo-radiotherapy) is allowed as long as >12 months has passed since completion of therapy. Adjuvant EGFR-directed therapy is not allowed. Local therapy (i.e. palliative radiotherapy) is allowed as long as a period of 7 days has passed since the last dose was received and the patient has recovered from any associated toxicity at the time of registration.

  • Patients may have measurable or non-measurable disease documented by CT or MRI within 42 days prior to registration. The CT from a combined PET/CT may be used only if it is of diagnostic quality. Laboratory parameters are not acceptable as the only evidence of disease. In order to qualify as measurable, progressive disease must be outside previous radiation field.

  • Patients must have a CT or MRI scan of the brain to evaluate for CNS disease within 42 days prior to registration. Patient must not have symptomatic brain metastases or evidence of leptomeningeal carcinomatosis. Patients with asymptomatic brain metastases are eligible if off of steroids for at least 7 days prior to registration without development of symptoms.

  • Patients must not have any known clinically active interstitial lung disease.

  • Patients must have adequate bone marrow function as evidenced by all of the following: ANC ≥ 1,500/mcL; platelets ≥ 75,000/mcL; and hemoglobin ≥ 9 g/dL. These results must be obtained within 28 days prior to registration.

  • Patients must have adequate liver function as evidenced by the following: total bilirubin ≤ 1.5 x institutional upper limit of normal (IULN), and AST and ALT ≤ 2.5 x IULN (or ≤ 5 x IULN for patients with known liver metastases). These results must be obtained within 28 days prior to registration.

  • Patient must have adequate renal function as evidenced by ONE of the following: serum creatinine ≤ 1.5 x IULN OR measured or calculated creatinine clearance ≥ 60 mL/min. This result must have been obtained within 28 days prior to registration.

  • Patients must not have significant gastrointestinal disorders with diarrhea as a major symptom (e.g. Crohn’s disease, malabsorption, etc).

  • Patients must be able to swallow medication by oral route.

  • Patients must not have a history of clinically relevant cardiovascular abnormalities such as uncontrolled hypertension, congestive heart failure NYHA classification of 3, unstable angina or poorly controlled arrhythmia or myocardial infarction within 6 months prior to registration. If clinically indicated, echocardiogram or MUGA must be performed and cardiac ejection fraction must be >50%.

  • Patients must not have had major surgery within 28 days prior to registration or be scheduled for surgery during the projected course of protocol treatment. Tumor biopsy is allowed.

  • Patients must not have a known history of active hepatitis B infection (defined as presence of Hep B sAg and/ or Hep B DNA), active hepatitis C infection (defined as presence of Hep C RNA) and/or known HIV seropositive.

  • Patients must not have any other concomitant serious illness or organ system dysfunction which in the opinion of the investigator would either compromise patient safety or interfere with the evaluation of the safety of the study drug.

  • Patients must not be planning to receive any other investigational agents during the course of protocol treatment.

  • Patients must not have a history of allergic reactions attributed to compounds of similar chemical or biologic composition to afatinib and/or cetuximab.

  • Patients must have Zubrod Performance Status of 0 - 2.

  • No other prior malignancy is allowed except for the following: adequately treated basal cell or squamous cell skin cancer, in situ cervical cancer, adequately treated Stage I or II cancer from which the patient is currently in complete remission, or any other cancer from which the patient has been disease free for three years.

  • Patients must not be pregnant or nursing because of the risk of fetal harm including fetal death. Women/men of reproductive potential must have agreed to use an effective contraceptive method. A woman is considered to be of "reproductive potential" if she has had menses at any time in the preceding 12 consecutive months. In addition to routine contraceptive methods, "effective contraception" also includes heterosexual celibacy and surgery intended to prevent pregnancy (or with a side-effect of pregnancy prevention) defined as a hysterectomy, bilateral oophorectomy or bilateral tubal ligation. However, if at any point a previously celibate patient chooses to become heterosexually active during the time period for use of contraceptive measures outlined in the protocol, he/she is responsible for beginning contraceptive measures.

Treatment Plan

Eligible patients will be ranomized to Arm 1 or Arm 2.

Arm 1: Afatinib 40 mg po daily + Cetuximab 500 mg/m2 IV days 1 and 15 q28days
Arm 2: Afatinib 40 mg po daily  

Treatment will continue until unequivocal progression of disease, symptomatic deterioration, unacceptable toxicity, treatment delay for any reason > 28 days, patient withdrawal from study for any reason, or in the event a women enolled on study becomes pregnant.