Two studies reported at the European Society for Medical Oncology (ESMO) Congress 2019—ClarIDHy and FIGHT-202—demonstrated clinical benefits with novel molecularly targeted agents in the treatment of advanced cholangiocarcinoma.
Currently, first-line treatment for locally advanced or metastatic cholangiocarcinoma consists of chemotherapy with gemcitabine and cisplatin. There is no standard second-line treatment, and all regimens have shown limited efficacy. The novel agents evaluated in the ClarIDHy and FIGHT-202 studies greatly improve upon these historical outcomes.
In the phase III ClarIDHy trial, the risk of disease progression or death was reduced by 63% with ivosidenib, an inhibitor of the isocitrate dehydrogenase 1 (IDH1) mutation.1 The results were reported at a Presidential Symposium during the ESMO Congress by Ghassan K. Abou-Alfa, MD, of Memorial Sloan Kettering Cancer Center, New York.
A significant improvement in progression-free survival … and a favorable overall survival trend and tolerable safety profile all support the clinical benefit of ivosidenib in patients with IDH1-mutated advanced cholangiocarcinoma.— Ghassan K. Abou-Alfa, MD
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“A significant improvement in progression-free survival, by central review, and a favorable overall survival trend and tolerable safety profile all support the clinical benefit of ivosidenib in patients with IDH1-mutated advanced cholangiocarcinoma,” Dr. Abou-Alfa said. “This pivotal trial also represents a practice-changing result, where genomic testing would become a standard of care and would open the possibility for more target-specific trials in a tumor where little progress has been made in recent years.”
Ivosidenib is a first-in-class, oral, small-molecule inhibitor of the mutant IDH1 protein, which occurs in up to 20% of patients with cholangiocarcinoma. It is approved for patients with acute myeloid leukemia (AML) and IDH1 mutations who have relapsed or refractory disease or are newly diagnosed but not eligible for intensive chemotherapy.
In ClarIDHy, ivosidenib was evaluated in 185 patients with advanced, unresectable IDH1-mutated cholangiocarcinoma who had received one or two prior lines of therapy. Patients were randomly assigned 2:1 to receive ivosidenib at 500 mg once daily or placebo.
The primary endpoint was progression-free survival by central review. Crossover from placebo to ivosidenib was permitted upon disease progression, and the crossover-adjusted overall survival was derived using rank-preserving structural failure time analysis.
Key Findings of ClarIDHy
Ivosidenib improved progression-free survival from 1.4 months with placebo to 2.7 months (hazard ratio [HR] = 0.37; P < .001). At 6 months and 12 months, 32% and 22% of ivosidenib-treated patients, respectively, were progression-free. In contrast, all patients on the placebo arm had disease progression at data cutoff, Dr. Abou-Alfa reported.
Although the objective response rate was low (2.4%), stable disease was achieved by 50.8% of patients. No responses were observed with placebo, and 27.9% of this arm had stable disease. “Ivosidenib efficacy was consistent across all subgroups,” he said, citing line of therapy, extent of disease at screening, cancer type at initial diagnosis, region of treatment, and other factors.
According to the intention-to-treat analysis, median overall survival was 10.8 months with ivosidenib vs 9.7 months with placebo (HR = 0.69; one-sided P = .06), which included the 57% of patients who crossed over from placebo. “Using the [rank-preserving structural failure time] method to reconstruct the survival curve as if the placebo subjects had never crossed over to ivosidenib, the median overall survival with placebo was corrected to 6 months (HR = 0.46; P < .001),” he further reported. Beside looking at the absolute median survival times achieved, Dr. Abou-Alfa said it is key to “focus on the continued separation of the Kaplan-Meier curve and the continued spread that carries on to 22% survival at 12 months.”
Overall, I think these data [from FIGHT-202] indicate that FGFR inhibition is a meaningful treatment for this genetically defined subgroup of patients with cholangiocarcinoma.— Arndt Vogel, MD, PhD
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The most common treatment-related adverse events among all patients who received ivosidenib (including after crossover) included nausea (32.1%), diarrhea (28.8%), fatigue (23.7%), cough (19.2%), abdominal pain (18.6%), ascites (18.6%), decreased appetite (17.3%), anemia (16.0%), and vomiting (16.0%). Grade 3 adverse events were reported in 46% of patients treated with ivosidenib compared with 36% of patients treated with placebo.
“These pivotal data demonstrate the clinical relevance and benefit of ivosidenib in patients with IDH1-mutated cholangiocarcinoma and establish the role for genomic testing in this rare cancer with a high unmet need,” Dr. Abou-Alfa said. All patients with cholangiocarcinoma should be tested for the IDH1 mutation, he maintained.
“In many cholangiocarcinomas, you can detect genetic alterations, which allow for targeted therapies,” he said. “Among them are many patients with FGFR2 fusions or rearrangements. They exclusively occur in intrahepatic cholangiocarcinoma and are detectable in about 15% of patients, indicating that this might be an interesting patient population to be treated by an FGFR inhibitor,” said Arndt Vogel, MD, PhD, of Hannover Medical School in Germany, who reported the results of FIGHT-202 at the ESMO Congress.2
FIGHT-202 was a global, open-label, single-arm phase II trial of pemigatinib, a selective, potent oral inhibitor of fibroblast growth factor receptor (FGFR) 1, 2, and 3 in patients previously treated with at least one line of therapy and with centrally confirmed FGF/FGFR status. All patients received oral pemigatinib at 13.5 mg/d on a 2 weeks on/1 week off schedule.
Of 1,206 patients screened, 146 were enrolled, including 107 with FGFR2 fusions or rearrangements (cohort A), 20 with other FGF/FGFR genetic alterations (cohort B), and 18 with no FGF/FGFR genetic alterations. The primary endpoint was objective response rate in cohort A by independent central review.
In cohort A, the investigators identified 92 fusions and 15 rearrangements of the gene. Analysis revealed 56 different partner genes, 42 of which were unique to single patients. The most common partner gene was BICC1 (29%); no fusion partner was identified in 5%.
Key Findings of FIGHT-202
The study met its primary endpoint, showing responses in 35.5% of patients with FGFR2 fusions/rearrangements and a median duration of response of 7.5 months. Response was independent of the prior line of treatment or fusion partner. In contrast, there were no responses in cohort B or cohort C. Disease control rates were 82%, 40%, and 22% for the respective cohorts.
“Most patients in cohort A had some degree of tumor regression. In only a few patients did we see lesions increase in size,” Dr. Vogel observed. This higher response rate translated into a median progression-free survival in cohort A of 6.9 months. In contrast, the other cohorts had rapid disease progression, he said, with median progression-free survivals of 2.1 months for cohort B and 1.7 months for cohort C.
Overall survival data were not mature, but with a median follow-up time of 15.4 months, the median overall survival was 21.1 months in the cohort with FGFR2 fusions or rearrangements, dropping to 6.7 months for patients with other FGF/FGFR alterations and to 4.0 months for patients lacking FGF/FGFR alterations.
Adverse events were manageable and consistent with the known mechanism of action of pemigatinib, the most common being hyperphosphatemia (60% all grades; 0% grade ≥ 3), with dose reductions or interruptions required in three patients. Hypophosphatemia was also common (23% all grades; 12% grade ≥ 3), but no cases were clinically significant, and none led to treatment discontinuation or dose reduction.
DISCLOSURE: ClarIDHy was funded by Agios Pharmaceuticals. Dr. Abou-Alfa has advised or consulted for Agios and disclosed financial relationships with numerous other pharmaceutical corporations. FIGHT-202 was sponsored by Incyte Corporation. Dr. Vogel has received honoraria from Incyte, as well as from numerous other pharmaceutical corporations.
1. Abou-Alfa GK, Macarulla Mercade T, Javle M, et al: ClarIDHy: A global, phase III, randomized, double-blind study of ivosidenib vs placebo in patients with advanced cholangiocarcinoma with an isocitrate dehydrogenase 1 (IDH1) mutation. ESMO Congress 2019. Abstract LBA10_PR. Presented September 30, 2019.
2. Vogel A, Sahai V, Hollebecque A, et al: FIGHT-202: A phase 2 study of pemigatinib in patients with previously treated locally advanced or metastatic cholangiocarcinoma. ESMO Congress 2019. Abstract LBA40. Presented September 27, 2019.
Angela Lamarca, MD, PhD
Angela Lamarca, MD, PhD, of the Christie NHS Foundation Trust, Manchester, United Kingdom, served as European Society for Medical Oncology (ESMO) commentator for the ClarIDHy trial in a press briefing held during the ESMO Congress 2019. Dr. Lamarca acknowledged, “The...