| E.1 Medical condition or disease under investigation |
| E.1.1 | Medical condition(s) being investigated |
| Gastric, lower esophageal or GE-junction adenocarcinoma |
|
| E.1.1.1 | Medical condition in easily understood language |
| Stomach cancer and cancer of the lower part of the esophageus |
|
| E.1.1.2 | Therapeutic area | Diseases [C] - Cancer [C04] |
| MedDRA Classification |
| E.1.2 Medical condition or disease under investigation |
| E.1.2 | Version | 21.1 |
| E.1.2 | Level | LLT |
| E.1.2 | Classification code | 10066354 |
| E.1.2 | Term | Adenocarcinoma of the gastroesophageal junction |
| E.1.2 | System Organ Class | 10029104 - Neoplasms benign, malignant and unspecified (incl cysts and polyps) |
|
| E.1.2 Medical condition or disease under investigation |
| E.1.2 | Version | 21.1 |
| E.1.2 | Level | LLT |
| E.1.2 | Classification code | 10015323 |
| E.1.2 | Term | Esophageal adenocarcinoma lower third stage unspecified |
| E.1.2 | System Organ Class | 10029104 - Neoplasms benign, malignant and unspecified (incl cysts and polyps) |
|
| E.1.2 Medical condition or disease under investigation |
| E.1.2 | Version | 20.0 |
| E.1.2 | Level | PT |
| E.1.2 | Classification code | 10001150 |
| E.1.2 | Term | Adenocarcinoma gastric |
| E.1.2 | System Organ Class | 10029104 - Neoplasms benign, malignant and unspecified (incl cysts and polyps) |
|
| E.1.2 Medical condition or disease under investigation |
| E.1.2 | Version | 21.0 |
| E.1.2 | Level | PT |
| E.1.2 | Classification code | 10030137 |
| E.1.2 | Term | Oesophageal adenocarcinoma |
| E.1.2 | System Organ Class | 10029104 - Neoplasms benign, malignant and unspecified (incl cysts and polyps) |
|
| E.1.2 Medical condition or disease under investigation |
| E.1.2 | Version | 20.0 |
| E.1.2 | Level | HLGT |
| E.1.2 | Classification code | 10017991 |
| E.1.2 | Term | Gastrointestinal neoplasms malignant and unspecified |
| E.1.2 | System Organ Class | 10029104 - Neoplasms benign, malignant and unspecified (incl cysts and polyps) |
|
| E.1.2 Medical condition or disease under investigation |
| E.1.2 | Version | 20.0 |
| E.1.2 | Level | SOC |
| E.1.2 | Classification code | 10029104 |
| E.1.2 | Term | Neoplasms benign, malignant and unspecified (incl cysts and polyps) |
| E.1.2 | System Organ Class | 10029104 - Neoplasms benign, malignant and unspecified (incl cysts and polyps) |
|
| E.1.3 | Condition being studied is a rare disease | No |
| E.2 Objective of the trial |
| E.2.1 | Main objective of the trial |
| The primary objective of the trial is to investigate if nivolumab plus ipilimumab given as adjuvant treatment improve disease free survival (DFS) in patients with stage Ib-IVa gastric and esophagogastric junction (EGJ) adenocarcinoma and high risk of recurrence (defined by ypN1-3 and/or R1 status) following neoadjuvant chemotherapy and resection. |
|
| E.2.2 | Secondary objectives of the trial |
Other study objectives:
- To investigate the safety and effect of adjuvant immunotherapy on long term oncologic outcomes and quality of life of patients in the study
- To correlate nutritional status assessment on outcomes and quality of life of patients |
|
| E.2.3 | Trial contains a sub-study | No |
| E.3 | Principal inclusion criteria |
- Histologically proven gastric or EGJ and lower esophageal adenocarcinoma
- Subjects must have completed pre-operative chemotherapy with a fluoropyrimidine-platinum containing regimen and macroscopically complete surgery prior to randomization
- Minimal duration of neoadjuvant chemotherapy should be 6 weeks, maximum 12 weeks.
- Total or distal gastrectomy with D2 lymphadenectomy according to ESMO guidelines should have been completed for gastric and junctional Siewert type III cancers. Ivor Lewis or McKeown oesophagectomy with two field lymphadenectomy should have been performed for junctional Siewert type I cancers and lower esophageal adenocarcinomas. For Siewert type II cancers either total gastrectomy with D2-lymphadenectomy or oesophagectomy with two field lymphadenectomy should have been completed. Open, minimal invasive or hybrid surgical approaches are acceptable as long as the requirements above are fulfilled.
- Regardless of the type of surgery a minimum of 15 lymph nodes should have been resected and examined.
- Recovered from surgery and fit for study treatment as assessed by a multidisciplinary team. Surgery should have been performed within 2 to 3 months before randomization.
- ypN1-3 status according to current (8th) version of TNM classification system. In case of an ypN0 status patients must meet the inclusion criterion of R1 resection.
- R0 or R1 resection according to current (8th) version of TNM classification system. In case of R0 resection, patients must meet the inclusion criterion of ypN1-3
- Availability of operative and pathology reports for review
- WHO performance status score of 0 or 1
- Age ≥ 18 years
- Adequate organ function assessed within 7 days before randomization:
- White blood cell count (WBC) > 2 x 10E9/L
- Absolute neutrophil count (ANC) > 1.5 x 10E9/L
- Platelets ≥ 100 x 10E9/L
- Hemoglobin ≥ 9 g/dL
- Measured/calculated creatinine clearance ≥ 60 mL/min (according to Cockroft-Gault formula).
- Total bilirubin within normal limits (if the patient has documented Gilbert’s disease ≤ 1.5 * ULN or direct bilirubin ≤ ULN)
- Aspartate transaminase (AST) and alanine transaminase (ALT) ≤ 1.5ULN
- Cardiac assessment by 12 L ECG and if clinically indicated, cardiac function assessment (using either echocardiography or MUGA scan)
- All toxicities (exception alopecia) attributed to prior anti-cancer therapy must have resolved to grade 1 (CTCAE version 5.0) or baseline before administration of study drug.
- Women of childbearing potential (WOCBP) must have a negative serum or urine pregnancy test (minimum sensitivity 25 IU/L or equivalent units of human chorionic gonadotropin (HCG)) within 24 hours prior to randomization.
- Patients of childbearing / reproductive potential should use highly effective method of birth control measures during the study treatment period and for at least 6 months after the last study treatment (both arms). A highly effective method of birth control is defined as those which result in low failure rate (i.e. less than 1% per year) when used consistently and correctly.
- Female subjects who are breast feeding should discontinue nursing prior to the first dose of study treatment and until 6 months after the last study treatment.
- Men who are sexually active with an WOCBP must adhere to contraception (condom) during the study and for a period of 7 months after the last dose of the study treatment in the experimental arm and 6 months in the control arm
- Absence of any psychological, familial, sociological or geographical condition potentially hampering compliance with the study protocol and follow-up schedule; those conditions should be discussed with the patient before registration in the trial
- Before patient registration/randomization, written informed consent must be given according to ICH/GCP, and national/local regulations. |
|
| E.4 | Principal exclusion criteria |
- R2 resection status
- M1 stage according to current (8th) version of TNM classification system
- Patients who have undergone complete resection of metastases
- Impaired renal, hepatic, cardiac, pulmonary or endocrine status that compromises the eligibility of the patient for postoperative chemotherapy or immunotherapy
- Clinically significant (that is, active) cardiovascular disease: cerebral vascular accident/stroke (< 6 months prior to enrollment), myocardial infarction (< 6 months prior to enrollment), unstable angina pectoris, congestive heart failure (New York Heart Association Classification Class ≥ II), or serious cardiac arrhythmia requiring medication
- Subjects with previous malignancies are excluded unless a complete remission was achieved at least 5 years prior to study entry. Adequately treated cervical carcinoma in situ, and localized non-melanoma skin cancer are no exclusion criteria, regardless of timepoint of diagnosis.
- Subjects with active, known, or suspected infectious or autoimmune disease
- Patients who have received antibiotics within the last 14 days before randomization are excluded.
- Subjects with Type I diabetes mellitus, residual hypothyroidism due to autoimmune thyroiditis only requiring hormone replacement, skin disorders (such as vitiligo, psoriasis, or alopecia) not requiring systemic treatment are permitted to enroll
- Subjects with a condition requiring systemic treatment with either corticosteroids (≥ 10 mg daily prednisone or equivalent) or other immunosuppressive medications within 14 days of study drug administration
- Subjects with interstitial lung disease that is symptomatic or may interfere with the detection or management of suspected drug-related pulmonary toxicity
- Subjects with > Grade 1 peripheral neuropathy
- 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 immune checkpoint pathways
- Prior or concomitant treatment with radiotherapy/radiochemotherapy
- Any positive test result for HBV or HCV indicating acute or chronic infection
- Known history of HIV or known AIDS and, if required by local practice or positive HIV testing at screening
- Known uncontrollable hypersensitivity to the components of cisplatin/oxaliplatin, fluorouracil (5-FU) or capecitabine, epirubicine or docetaxel
- Known dihydropyrimidine dehydrogenase (DPD) deficiency
- Ongoing or concomitant use of the antiviral drug sorivudine or its chemically related analogs, such as brivudine. |
|
| E.5 End points |
| E.5.1 | Primary end point(s) |
Primary endpoint: Disease free survival (DFS) defined as the time interval between randomization and the date of disease recurrence or death from any cause, whichever comes first.
|
|
| E.5.1.1 | Timepoint(s) of evaluation of this end point |
52 months after randomization (30 months recruitment + 22 months FU). This has been chosen because of the high proportion of high risk patients who progress within a short timeframe after surgery, assuming an accrual rate at full speed (when all sites are open) of 10 patients per month.Taking into account an overall dropout rate of 5% at 1 year, we plan to randomize 240 patients in a 1:1 ratio between the control arm and the experimental arm in order to observe the required 142 events after an accrual period of 30 months and an additional follow-up of 22 months after closing the trial to patient entry. Total study duration is expected to be 52 months.
|
|
| E.5.2 | Secondary end point(s) |
Secondary endpoints:
- Overall survival (OS)
- Pattern and rate of relapse
- Rate of adverse events according to National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE v5.0)
- Global Health Status and Physical functioning according to EORTC QLQ C30 including nutritional status assessment
Other pre-specified endpoints:
- Quality of life according to EORTC QLQ C30 (and 6 additional items)
- Correlation of patient reported outcomes, quality of life and nutritional status assessment with survival outcomes |
|
| E.5.2.1 | Timepoint(s) of evaluation of this end point |
| 90 months (30 months recruitment + 60 months long term FU). For the analysis of the long term results on the endpoints DFS and OS: when long-term follow-up will be completed i.e. when all patients will have been followed until death or 5 years following randomization. The clinical cut-off date for this second analysis is expected to occur at the latest 5 years after last patient in. |
|
| E.6 and E.7 Scope of the trial |
| E.6 | Scope of the trial |
| E.6.1 | Diagnosis | No |
| E.6.2 | Prophylaxis | No |
| E.6.3 | Therapy | Yes |
| E.6.4 | Safety | Yes |
| E.6.5 | Efficacy | Yes |
| E.6.6 | Pharmacokinetic | No |
| E.6.7 | Pharmacodynamic | No |
| E.6.8 | Bioequivalence | No |
| E.6.9 | Dose response | No |
| E.6.10 | Pharmacogenetic | No |
| E.6.11 | Pharmacogenomic | No |
| E.6.12 | Pharmacoeconomic | No |
| E.6.13 | Others | Yes |
| E.6.13.1 | Other scope of the trial description |
|
| E.7 | Trial type and phase |
| E.7.1 | Human pharmacology (Phase I) | No |
| E.7.1.1 | First administration to humans | No |
| E.7.1.2 | Bioequivalence study | No |
| E.7.1.3 | Other | No |
| E.7.1.3.1 | Other trial type description | |
| E.7.2 | Therapeutic exploratory (Phase II) | Yes |
| E.7.3 | Therapeutic confirmatory (Phase III) | No |
| E.7.4 | Therapeutic use (Phase IV) | No |
| E.8 Design of the trial |
| E.8.1 | Controlled | No |
| E.8.1.1 | Randomised | Yes |
| E.8.1.2 | Open | Yes |
| E.8.1.3 | Single blind | No |
| E.8.1.4 | Double blind | No |
| E.8.1.5 | Parallel group | No |
| E.8.1.6 | Cross over | No |
| E.8.1.7 | Other | No |
| E.8.2 | Comparator of controlled trial |
| E.8.2.1 | Other medicinal product(s) | No |
| E.8.2.2 | Placebo | No |
| E.8.2.3 | Other | No |
| E.8.2.4 | Number of treatment arms in the trial | 2 |
| E.8.3 |
The trial involves single site in the Member State concerned
| No |
| E.8.4 | The trial involves multiple sites in the Member State concerned | Yes |
| E.8.4.1 | Number of sites anticipated in Member State concerned | 4 |
| E.8.5 | The trial involves multiple Member States | Yes |
| E.8.5.1 | Number of sites anticipated in the EEA | 23 |
| E.8.6 Trial involving sites outside the EEA |
| E.8.6.1 | Trial being conducted both within and outside the EEA | Yes |
| E.8.6.2 | Trial being conducted completely outside of the EEA | No |
| E.8.6.3 | If E.8.6.1 or E.8.6.2 are Yes, specify the regions in which trial sites are planned |
| Czech Republic |
| France |
| Germany |
| Israel |
| Italy |
| Norway |
| Poland |
| Spain |
| United Kingdom |
|
| E.8.7 | Trial has a data monitoring committee | Yes |
| E.8.8 |
Definition of the end of the trial and justification where it is not the last
visit of the last subject undergoing the trial
|
End of study occurs when all of the following criteria have been satisfied:
1. Hundred days after all patients have stopped protocol treatment
2. The trial is mature for the analysis of the primary endpoint as defined in the protocol
3. The database has been fully cleaned and frozen for this analysis. |
|
| E.8.9 Initial estimate of the duration of the trial |
| E.8.9.1 | In the Member State concerned years | 7 |
| E.8.9.1 | In the Member State concerned months | 6 |
| E.8.9.1 | In the Member State concerned days | |
| E.8.9.2 | In all countries concerned by the trial years | 7 |
| E.8.9.2 | In all countries concerned by the trial months | 6 |
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