NCI-sponsored trials in precision medicine
- What is “Precision Medicine?”
- NCI trials in precision medicine:
These listings include slide sets for clinicians, press launch materials, as well as other information about the trials.
- Other links
What is “Precision Medicine?”
Genes code for information that allows normal growth and development. In cancer, these processes work abnormally, leading to abnormal growth and spread of cancerous disease. Even cancers that are thought of as similar (e.g. lung cancer) have been found to consist of cancers with different molecular make up, and different rates of progress and response to treatment. Each patient may share a molecular defect with only a few other patients among all patients with the same cancer. Genetic information about a particular person’s cancer can be used to diagnose or treat their particular disease. Understanding the genetic changes in cancer cells can lead to precise treatments that target the specific changes in a person’s tumor. Precision Medicine uses genetic information from a person’s cancer to determine a patient’s treatment with a treatment targeted to that particular genetic abnormality. The NCI is currently testing a new precision medicine strategy that includes both “genotype to phenotype” and “phenotype to genotype” initiatives. “Genotype to Phenotype” refers to clinical trials that screen for molecular features that may predict response to a drug with a given mechanism of action. “Phenotype to Genotype” is the retrospective genomic analysis of a patient’s tumor to determine if molecular factors may explain why a patient responded particularly well to a particular treatment.
“Genotype to Phenotype” trials:
- Slide set describing NCI-MATCH
- NCI-MATCH trial page
- NCI-MATCH infographic
- NCI-MATCH press release, 6/1/15
- ECOG-ACRIN media advisory, 8/17/15
- NCI and the Precision Medicine Initiative
- Precision Medicine and Targeted Therapy
The NCI-MATCH (“Molecular Analysis for Therapy Choice”) trial will examine the molecular features of tumors in approximately 3,000 patients with solid tumors or lymphoma who have progressed on standard therapy, and hopes to match at least 1,000 of those patients to a treatment with a targeted drug or drug combination. Patients will need to have a biopsy, which will be used to screen for abnormalities in up to 143 genes known to be involved in cancer and/or to predict response to a particular drug or drug combination.
Because any one molecular abnormality may be present in only 5-10% of patients with solid tumors or lymphomas, NCI-MATCH will have more than 20 "arms", each with a drug treatment for a particular molecular abnormality or group of molecular abnormalities. Each targeted therapy will be studied in a single-arm phase II trial, with NCI-MATCH functioning as an umbrella protocol for these trials. Patients with a match to a drug treatment will stay on that drug treatment until their disease progresses (or the treatment becomes toxic), at which point they will, if they desire, undergo another biopsy to look for additional molecular features that could match them to a new targeted drug. Under certain circumstances (e.g., non-response with rapid progression), patients who have more than one “actionable” genetic abnormality will be able to match to a treatment addressing the second molecular abnormality without a repeat biopsy. Additionally, NCI-MATCH will compare pre-treatment biopsies to post-treatment biopsies to study why some tumors develop resistance to cancer treatment.
Molecular tests to be performed on the tumors include genetic sequencing using a panel of about 143 genes (on the Ion Torrent PGM™ system), as well as other diagnostic assays for specific molecular features. Biopsies will be sent to a central laboratory at MD Anderson Cancer Center in Houston, TX. Four CLIA-certified laboratories will perform the tests — Frederick National Laboratory for Cancer Research, MD Anderson Cancer Center, Yale Cancer Center, and Massachusetts General Hospital.
NCI-MATCH is available through the National Clinical Trials Network (NCTN) and led by EGOG-ACRIN and NCI. The trial will be available at clinical sites nationwide. The NCI-MATCH study was activated in August 2015. More than ten companies have committed agents to 22-25 separate arms of NCI-MATCH that are open or in development.
NCI-MATCH’s protocol design has a built-in review after 500 patients are enrolled for mutation screening. The trial’s enrollment reached 500 patients in late October 2015. To perform the review required by the protocol, new enrollments must pause until the analysis can be conducted. During this pause, the study team will use the time to thoroughly review data from the first 500 patients, examine the diversity of cancer types among enrolled patients, analyze data of those patients with a mutation that matches, estimate the proportion of patients that may match to additional arms, and review the type and quality of biopsy specimens. The study team will continue to add new treatment arms to the trial as planned, to improve the frequency of matching mutations to drugs, and will expand laboratory capabilities.
For physicians who are referring new patients for enrollment, a pause began November 11, 2015, after which time no new patients could enroll. Physicians and patients can discuss other treatment options in the interim but may still be eligible to enroll in Screening Step 0 (the initial biopsy and genetic sequencing portion) of NCI-MATCH when the interim analysis is completed and the enrollment of new patients resumes in May 2016.
- Slide set describing ALCHEMIST
- NCI Press Release for ALCHEMIST (August 18th, 2014)
- NCI Noteworthy Trials — The ALCHEMIST Lung Cancer Trials
- ALCHEMIST Launch Questions and Answers
- ALCHEMIST FAQs: What Sites Need to Know
The ALCHEMIST (“Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trial”) trial will screen several thousand patients with operable, non-squamous, non-small-cell lung cancer to determine if their tumors contain specific molecular alterations that may make them eligible for treatment trial of therapy that targets that alteration:
- Eligible patients with the ALK rearrangement would enroll on a randomized trial studying crizotinib (trial # E4512, led by ECOG-ACRIN).
- Eligible patients with the EGFR mutation would enroll on a randomized trial studying erlotinib (trial #A081105, led by Alliance).
The screening portion will take place via Alliance trial #A151216.
In addition to the two randomized trials, ALCHEMIST will also contain a large discovery component:
- Genomic analysis of primary tumor and blood on all screened patients, no matter if they have the ALK or EGFR alterations or not.
- Genomic analysis of relapse tumor in patients who relapse.
- Collection of plasma for circulating tumor DNA.
- Epidemiological questionnaire.
The genomic analyses will be performed by research labs run by the NCI Center for Cancer Genomics. Genomic information will be linked to clinical and epidemiological information in a public database, enabling researchers to perform further studies on the data. (Data will be de-identified.)
The Lung-MAP (“Lung Cancer Master Protocol”) trial will test the tumors of patients with advanced squamous cell lung cancer whose disease has progressed after one line of chemotherapy to determine if they contain certain genomic features, to match patients to one of the arms studying therapy for that target.
Lung-MAP is a phase II/III trial containing several such arms, each randomized to a control arm of a standard therapy. Patients not testing positive for one of the genomic features will be enrolled in the arm testing immunotherapy. Lung-MAP is a SWOG-led Intergroup trial (trial #S1400) funded through a public-private partnership via the Foundation for the NIH, involving NCI, SWOG, Friends of Cancer Research, Foundation Medicine, and several pharmaceutical companies. The trial will screen up to 1,000 patients per year. The genetic test used will be the Foundation Medicine genetic panel.
- NIH Press Release on NCI-MPACT launch (January 30, 2014)
- ClinicalTrials.gov description of NCI-MPACT
- Slide set describing NCI-MPACT study
NCI’s MPACT (“Molecular Profiling-Based Assignment of Cancer Therapy”) seeks to determine if patients with a mutation in a certain genetic pathway are more likely to benefit from a treatment that targets that pathway, as opposed to another cancer treatment not targeting that pathway.
A multi-center trial led by the NCI, MPACT will analyze tumor biopsies of hundreds of advanced cancer patients to determine if they have mutations in specific genetic pathways that are the target of certain drugs. Eligible patients who have those mutations will be randomized 2:1 to a drug that targets that mutated pathway versus a drug that is not known to target the pathway. Patients on the non-targeted therapy arm whose disease progresses will be allowed to cross over to a drug targeting their mutation(s). It is expected that MPACT will enroll about 180 patients.
Current targeted drugs studied in MPACT include the following (additional arms are expected to be added):
- ABT-888 (PARP inhibitor) with temozolomid: Targets mutations in the DNA repair pathway
- AZD1775 (MK-1775) (Wee1 inhibitor) with carboplatin: Targets mutations in the DNA repair pathway
- Everolimus (mTOR inhibitor): Targets mutations in the PI3K pathway
- Trametinib DMSO (MEK inhibitor): Targets mutations in the RAS/RAF/MEK pathway
The NCI-MATCH (Molecular Analysis for Therapy Choice) trial will have a pediatric counterpart that will enroll children with advanced cancers that have progressed on standard therapy.
As in the adult NCI-MATCH trial, DNA sequencing will be used to identify children whose tumors have a genetic abnormality for which either an approved or investigational targeted therapy exists. NCI is working with numerous pharmaceutical companies to make some of the same drugs available for Pediatric MATCH that will be offered in the adult NCI-MATCH trial.
Pediatric MATCH provides a tremendous opportunity to test molecularly targeted therapies in children with advanced cancers who have few other treatment options. With the genomic data captured in the trial, it will also produce an invaluable resource for studying the genetic basis of pediatric cancers.
Pediatric MATCH, which will be led by the NCI-funded Children's Oncology Group, is still under development and details on a timetable for launch or patient enrollment are not firm. However, the aim is to start the trial in 2016.
“Phenotype to Genotype” trial:
The “Exceptional Responders” study
- Brief description of Exceptional Responders study
- How to inform NCI of a potential “Exceptional Responder” case
- Slide set describing Exceptional Responders study
- Protocol document for Exceptional Responders study
- NCI Press Release – Exceptional Responders
- Exceptional Responders Frequently Asked Questions (FAQs)
- Exceptional Responders on ClinicalTrials.gov
Rarely, a patient has all tumor disappear, or has a long term response to a drug that doesn’t usually cause such responses to happen. In the Exceptional Responders study, investigators will study the molecular characteristics of tumors of patients who had an exceptional response to a cancer therapy. In doing this, they hope to discover molecular features in the tumors that may predict benefit to a particular drug or type of drug. Where possible, non-tumor specimens from the patients will also be examined, as these help in determining which mutations are present only in the tumor, rather than in normal cells/tissue.
The Exceptional Responders Initiative is a pilot study to determine if information can be obtained from archived samples that will enable hypotheses to be made about the reasons for exceptional responses to cancer treatment.
The molecular information will be placed into a large database, along with clinical information, and shared with other approved researchers so that they can help determine why the patient(s) had such an exceptional response, and if this knowledge can be applied to other cancer patients. (Information will be de-identified.)
The Exceptional Responders study will be led by NCI Division of Cancer Treatment and Diagnosis and Center for Cancer Genomics, with genetic sequencing performed at Baylor. The NCI will collect up to 300 samples to successfully analyze 100 cases.
Clinical providers and investigators are invited to send NCI information on patients they believe may be “exceptional responders” by following the instructions below (NCI will provide reimbursement for each accepted case):
How to inform NCI of cases you believe are Exceptional Responders
Definition of “Exceptional Responder”:
In a setting where the overall response rate is typically < 10%, the patient has:
- a complete response
- a partial response of at least 6 months duration
The response can be to an experimental systemic therapy or to a standard systemic therapy, in a trial setting or in a clinical setting.
Providers or investigators who know of a potential “Exceptional Responder” can propose cases by sending an email NCIExceptionalResponders@mail.nih.gov.
In this email, please:
- Provide a short description of the case, without patient identifiers. The description should include the patient’s disease, length of response, and treatment. No Personal Health information should be included in the description.
- Note whether tissue is available from the time before the exceptional response occurred. (This is required.). Additional information on the type of tissue (Fresh frozen or formalin fixed paraffin embedded) is appreciated.
- Note whether informed consent was given to use tissue for research. (The study has a process to address cases without informed consent.)
- Note the patient’s vital status.
- Provide any additional information you wish.
Within 2 weeks, NCI will email you informing you whether the case appears eligible. If the case appears eligible, the site that treated the patient will be asked to provide clinical information, informed consent, tissue samples, and a pathology report. The site will also execute a material transfer agreement (MTA) with the biospecimen facility for the tissue transfer, and a contract with the CTSU for reimbursement for the provision of samples and data.
You may also email NCIExceptionalResponders@mail.nih.gov if you have any questions about the Exceptional Responders study.
Other links to information about Precision Medicine:
- Precision Medicine and Targeted Therapy
- NCI Fact Sheet: Targeted Cancer Therapies
- Improving the Lives of Patients Through Genetically Informed Medicine
- Science article on NCI Director Harold Varmus highlighting unconventional trials
(October 25, 2013)
- “Genome Sequencing Identifies a Basis for Everolimus Sensitivity”