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Last Updated: 07/30/2018

NCI-sponsored trials in precision medicine

What is “Precision Medicine?”

Precision medicine uses information about the genes, proteins, and other features of a person's cancer to diagnose or treat their particular disease. 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.

NCI-supported scientists are pursuing new technologies and collaborations, and conducting new kinds of clinical trials, to help fulfill precision medicine's promise.

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:

NCI-MATCH

Goals of the NCI-MATCH ("Molecular Analysis for Therapy Choice") Trial:

  • Examine the molecular features of tumors in patients with solid tumors, myeloma, or lymphoma who have progressed on standard therapy
  • Match at least 1,000 of those patients to 30+ treatment arms with a targeted drug or drug combination

Initial Screening Phase (Completed)

  • NCI-designated MATCH laboratories screened tumor biopsies from over 6,000 patients for abnormalities in up to 143 genes known to be involved in cancer and/or to predict response to a drug or drug combination.

Second ‘Outside Assay’ Enrollment Phase — (Ongoing)

  • Even with over 6,000 screened patients, some of the trial arms addressing rare variants had not accrued the required 35 patients.
  • To complete accrual to these and other arms, certain CLIA-certified laboratories that already test the same variants as NCI-MATCH are now providing screening results in a new phase of the trial through a collaborative agreement. The CLIA-certified/accredited laboratories involved in this effort are listed on ECOG-ACRIN's website. External Link
  • Based on sequencing results from one of these laboratories, patients can enter arms and begin treatment, and the result will be confirmed by the NCI-MATCH assay that was used previously to screen the first 6,000 patients. If the NCI-MATCH assay does not agree with the results from the outside laboratory, the patient can continue treatment, but their data will not be included in the NCI-MATCH trial primary data analysis.
  • Many more patients are obtaining tumor sequencing through commercial vendors, which gives patients broader access to clinical trials information; therefore, thousands of patients who would not otherwise be able to access NCI-MATCH, are being screened for possible referral and enrollment.

Additional Trial Details

  • The NCI-MATCH study is available through the National Clinical Trials Network (NCTN) and is co-led by NCI and EGOG-ACRIN. External Link
  • Because any one molecular abnormality may be present in only 5-10% of patients with solid tumors, myelomas, or lymphomas, NCI-MATCH has more than 30 arms, each with a drug for a molecular abnormality or group of molecular abnormalities.
  • Each targeted therapy is being 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 is not tolerated). At this point, and only if a patient was among the first 6,000 who entered the initial screening portion of the study, patients will have the opportunity to undergo another biopsy to evaluate additional molecular features that could match them to a new targeted drug. Under certain circumstances (e.g., non-response with progression within 6 months), patients who entered the initial biopsy screening portion of the study and have more than one "actionable" genetic abnormality will be able to match to a treatment addressing the second molecular abnormality without a repeat biopsy.
  • Patients who enter the study with screening results from outside laboratories will only be eligible for a single NCI-MATCH treatment.
  • NCI-MATCH will compare pre-treatment biopsies to post-treatment biopsies to study why some tumors develop resistance to cancer treatment.
  • NCI-MATCH will collect blood for potential circulating tumor mutation studies.
  • Molecular tests on tumors in the initial screening study included 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 were sent to a central laboratory at MD Anderson Cancer Center in Houston, TX. Four CLIA-certified laboratories performed the tests — Frederick National Laboratory for Cancer Research, MD Anderson Cancer Center, Yale Cancer Center, and Massachusetts General Hospital. These laboratories also perform the same NCI-MATCH sequencing assay on specimens from patients who enter NCI-MATCH in the ‘outside assay’ phase.

Timeline

  • August 2015 — Trial activation
  • November 2015 — Accrual pause and review
    The protocol design incorporated a pause for review after enrollment of 500 patients for screening. The trial reached the 500-patient enrollment mark in late October 2015, which was five times the number of patients expected to enroll in the trial's first 3 months. The review allowed the investigators to examine how the trial was performing and guided them on how to improve tumor and drug match rates, among other factors.
  • April 2016 — Interim Analysis results released at AACR 2016
    An Executive Summary of the Interim Analysis results is available.
  • Late May 2016 — Trial re-opened for patient enrollment to the screening phase.
  • June 2017 — Completed the planned 6,000 screening biopsies 2 years early; trial began second phase involving outside laboratory testing.

ALCHEMIST

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.)

Lung-MAP

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.

NCI-MPACT

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

NCI-COG Pediatric MATCH

NCI-COG Pediatric MATCH (Molecular Analysis for Therapy Choice) is a phase 2 clinical trial that will enroll children and adolescents with advanced solid tumors-including non-Hodgkin lymphomas, brain tumors, and histiocytoses-that have not responded to treatment or have progressed on standard therapy. The study was developed and will be led jointly by NCI and the Children's Oncology Group (COG) External Link , part of the NCI-sponsored National Clinical Trials Network (NCTN). The trial is taking place at around 200 participating children's hospitals, university medical centers, and cancer centers across the U.S. that are part of COG.

As in the adult NCI-MATCH trial, molecular tests to be performed on the tumor tissue include genetic sequencing using a panel of 160 genes (on the Ion S5 System from Ion Torrent), as well as other diagnostic assays for specific molecular features. The tumor tissue will be sent to a central laboratory at Nationwide Children's Hospital in Columbus, Ohio. Two CLIA-certified laboratories will perform the tests initially- the Molecular Characterization Laboratory at Frederick National Laboratory for Cancer Research and MD Anderson Cancer Center with Dartmouth joining at a later time. DNA sequencing results will be used to identify children and adolescents whose tumors have a genetic abnormality for which there is a treatment arm testing either an approved or investigational targeted agent. Tissues from previous biopsies can be used if obtained after patients have had treatment. Pediatric patients with brain stem gliomas may be entered if they had a biopsy at the time of diagnosis. Researchers plan to screen the tumors of 200 to 300 children and adolescents each year until 1,000 have been screened. Current research suggests that 1 out of 10 (10%) patients screened for this study will match one of the targeted drugs being tested. The genomic data captured in the trial will serve as an invaluable resource for studying the genetic basis of pediatric cancers.

In contrast to NCI-MATCH, a unique aspect of Pediatric MATCH is that germline testing will be performed on DNA from the patient's peripheral blood, collected at the time of study enrollment. The germline testing results will be used to determine if the genetic variants identified in the tumor were inherited or not. The information gleaned from this portion of the trial can help oncologists counsel families about genetic testing, genetic counseling, and follow-up care for the patient and other family members.

The trial opened to accrual in July 2017 with approximately six treatment arms, expanding to eight or more. At least 20 patients will be enrolled on each treatment arm. Patients who enroll on a treatment arm will continue to receive the experimental treatment as long as their tumors are stable or getting smaller and as long as they do not develop significant toxicity from the treatment. More information is available on the clinical trials information page on NCI's website and in NCI's July 2017 press release.

“Phenotype to Genotype” trial:

The “Exceptional Responders” study

As of November 21, 2017, the Exceptional Responders study accrual goals have been met, and the study is now closed to accrual.

Rarely, a patient has all tumor disappear, or has a long-term response to a drug that does not usually cause such responses to happen. In the Exceptional Responders pilot study, investigators will study the molecular characteristics of archived tumor samples from patients who had an exceptional response to a cancer therapy to determine if a hypothesis can be made about the reasons for the exceptional responses. 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 molecular and clinical information (de-identified) will be placed into a large database 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.

The Exceptional Responders study is led by NCI's Division of Cancer Treatment and Diagnosis and Center for Cancer Genomics, with genetic sequencing performed at Baylor and at Foundation Medicine Inc. The NCI will collect up to 300 samples to successfully analyze 100 cases.

Because the study is closed for accrual, the information below is being provided for informational purposes. Cases are no longer being accepted for consideration for the study. For additional information please contact NCIExceptionalResponders@mail.nih.gov.

Case Submission Overview for the Exceptional Responders Initiative

Definition of “Exceptional Responder”:

In a setting where the patient has:

  1. a complete response to a drug(s) where complete response is seen in < 10% of patients receiving similar treatment
    or
  2. a partial response of at least 6 months duration where such a response is seen in < 10% of patients receiving similar treatment
    or
  3. a complete or partial response that lasts longer than 3 times the median response duration in the literature for the treatment

The response can be to an experimental systemic therapy or to a standard systemic therapy, in a trial setting or in a clinical setting.

Proposed cases by providers or investigators are submitted to NCIExceptionalResponders@mail.nih.gov and include the information below:

  1. A short description of the case, without patient identifiers. The description should include the patient’s disease, length of response, and treatment (treatment associated with the exceptional response and prior treatment). No Personal Health information should be included in the description.
  2. A note on 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.
  3. A note on whether informed consent was given to use tissue for research. (The study has a process to address cases without informed consent.)
  4. A note on the patient’s vital status.
  5. Any additional information.

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 core facility for the tissue transfer, and a contract with the CTSU for reimbursement for the provision of samples and data. To complete these steps, the site must have IRB approval for the study; the study does have approval from an NCI Central IRB (CIRB).

After the full clinical data are provided and reviewed, and if the case is provisionally approved at this stage, the site will be asked to send the tissue to the biospecimen core resource. Once the sequencing has been done, the proposer for the case is welcome to participate in the analysis of the data for their case. Results of the sequencing are being done in a research laboratory, not a clinical laboratory, so they cannot be given back to the provider or the patient.

We have also initiated a study of complementary and alternative medicine use, lifestyle changes and comorbid conditions and their medications in patients who are exceptional responders. These data will assist our analysis of why the patient may have responded exceptionally, as well as assist in understanding the prescribed and unprescribed medications that cancer patients take along with their cancer treatment.

Other links to information about Precision Medicine: