Source: European Medicines Agency (EU) Revision Year: 2020 Publisher: Ipsen Pharma, 65 quai Georges Gorse, 92100, Boulogne-Billancourt, France
Pharmacotherapeutic group: antineoplastic agent, protein kinase inhibitor
ATC code: L01XE26
Cabozantinib is a small molecule that inhibits multiple receptor tyrosine kinases (RTKs) implicated in tumour growth and angiogenesis, pathologic bone remodeling, drug resistance, and metastatic progression of cancer. Cabozantinib was evaluated for its inhibitory activity against a variety of kinases and was identified as an inhibitor of MET (hepatocyte growth factor receptor protein) and VEGF (vascular endothelial growth factor) receptors. In addition, cabozantinib inhibits other tyrosine kinases including the GAS6 receptor (AXL), RET, ROS1, TYRO3, MER, the stem cell factor receptor (KIT), TRKB, Fms-like tyrosine kinase-3 (FLT3), and TIE-2.
Cabozantinib exhibited dose-related tumour growth inhibition, tumour regression, and/or inhibited metastasis in a broad range of preclinical tumour models.
An increase from baseline in corrected QT interval by Fridericia (QTcF) of 10–15 ms on Day 29 (but not on Day 1) following initiation of cabozantinib treatment (at a dose of 140 mg qd) was observed in a controlled clinical study in medullary thyroid cancer patients. This effect was not associated with a change in cardiac wave form morphology or new rhythms. No cabozantinib-treated subjects in this study had a confirmed QTcF >500 ms, nor did any cabozantinib-treated subjects in the RCC or HCC studies (at a dose of 60 mg).
The safety and efficacy of CABOMETYX for the treatment of renal cell carcinoma following prior vascular endothelial growth factor (VEGF)targeted therapy were evaluated in a randomized, open label, multicenter Phase 3 study (METEOR). Patients (N=658) with advanced RCC with a clear cell component who had previously received at least 1 prior VEGF receptor tyrosine kinase inhibitor (VEGFR TKI) were randomized (1:1) to receive CABOMETYX (N=330) or everolimus (N=328). Patients could have received other prior therapies, including cytokines, and antibodies targeting VEGF, the programmed death 1 (PD-1) receptor, or its ligands. Patients with treated brain metastases were allowed. Progression-free survival (PFS) was assessed by a blinded independent radiology review committee, and the primary analysis was conducted among the first 375 subjects randomized. Secondary efficacy endpoints were objective response rate (ORR) and overall survival (OS). Tumor assessments were conducted every 8 weeks for the first 12 months, then every 12 weeks thereafter.
The baseline demographic and disease characteristics were similar between the CABOMETYX and everolimus arms. The majority of the patients were male (75%), with a median age of 62 years. Seventy-one percent (71%) received only one prior VEGFR TKI; 41% of patients received sunitinib as their only prior VEGFR TKI. According to the Memorial Sloan Kettering Cancer Center criteria for prognostic risk category, 46% were favorable (0 risk factors), 42% were intermediate (1 risk factor), and 13% were poor (2 or 3 risk factors). Fifty-four percent (54%) of patients had 3 or more organs with metastatic disease, including lung (63%), lymph nodes (62%), liver (29%), and bone (22%). The median duration of treatment was 7.6 months (range 0.3 – 20.5) for patients receiving CABOMETYX and 4.4 months (range 0.21 – 18.9) for patients receiving everolimus.
A statistically significant improvement in PFS was demonstrated for CABOMETYX compared to everolimus (Figure 1 and Table 3). A planned interim analysis of OS was conducted at the time of the PFS analysis and did not reach the interim boundary for statistical significance (202 events, HR=0.68 [0.51, 0.90], p=0.006). In a subsequent unplanned interim analysis of OS, a statistically significant improvement was demonstrated for patients randomized to CABOMETYX as compared with everolimus (320 events, median of 21.4 months vs. 16.5 months; HR=0.66 [0.53, 0.83], p=0.0003; Figure 2). Comparable results for OS were observed with a follow-up analysis (descriptive) at 430 events.
Exploratory analyses of PFS and OS in the ITT population have also shown consistent results in favour of CABOMETYX compared to everolimus across different subgroups according to age (<65 vs. ≥65, sex, MSKCC risk group (favourable, intermediate, poor), ECOG status (0 vs. 1), time from diagnosis to randomisation (<1 year vs. ≥1 year), tumour MET status (high vs. low vs. unknown), bone metastases (absence vs. presence), visceral metastases (absence vs. presence), visceral and bone metastases (absence vs. presence), number of prior VEGFR-TKIs (1 vs. ≥2), duration of first VEGFR-TKI (≤6 months vs. >6 months).
Objective response rate findings are summarized in Table 4.
Figure 1. Kaplan Meier curve for progression-free survival by independent radiology review committee, in RCC subjects following prior vascular endothelial growth factor (VEGF)-targeted therapy (first 375 subjects randomized) (METEOR):
Table 3. Summary of PFS findings by independent radiology review committee in RCC subjects following prior vascular endothelial growth factor (VEGF)-targeted therapy (METEOR):
| Primary PFS analysis Population | Intent-To-Treat Population | |||
|---|---|---|---|---|
| Endpoint | CABOMETYX Ν=187 | Everolimus Ν=188 | CABOMETYX Ν=330 | Everolimus Ν=328 |
| Median PFS (95% CI), months | 7,4 (5,6, 9,1) | 3,8 (3,7, 5,4) | 7,4 (6,6, 9,1) | 3,9 (3,7, 5,1) |
| HR (95% CI), p-value1 | 0,58 (0,45, 0,74), p<0,0001 | 0,51 (0,41, 0,62), p<0,0001 | ||
1 stratified log-rank test
Figure 2. Kaplan-Meier curve of overall survival in RCC subjects following prior vascular endothelial growth factor (VEGF)-targeted therapy (METEOR):
Table 4. Summary of ORR findings per independent radiology committee review (IRC) and investigator review, in RCC subjects following prior vascular endothelial growth factor (VEGF)-targeted therapy:
| Primary Analysis ORR Intent-To-Treat Population (IRC) | ORR per Investigator Review Intent-To-Treat Population | |||
|---|---|---|---|---|
| Endpoint | CABOMETYX | Everolimus | CABOMETYX | Everolimus |
| N=330 | N=328 | N=330 | N=328 | |
| ORR (partial responses only) (95% CI) | 17% (13%, 22%) | 3% (2%, 6%) | 24% (19%, 29%) | 4% (2%, 7%) |
| p-value1 | p<0,0001 | p< 0,0001 | ||
| Partial Response | 17% | 3% | 24% | 4% |
| Median time to First Response, months (95% CI) | 1,91 (1,6, 11,0) | 2,14 (1,9, 9,2) | 1,91 (1,3, 9,8) | 3,50 (1,8, 5,6) |
| Stable Disease as Best Response | 65% | 62% | 63% | 63% |
| Progressive Disease as Best Response | 12% | 27% | 9% | 27% |
1 chi-squared test
The safety and efficacy of CABOMETYX for the treatment of treatment-naïve renal cell carcinoma were evaluated in a randomized, open-label, multicenter study (CABOSUN). Patients (N=157) with previously untreated, locally advanced or metastatic RCC with a clear cell component were randomized (1:1) to receive CABOMETYX (N=79) or sunitinib (N=78). Patients had to have intermediate or poor risk disease as defined by the International Metastatic RCC Database Consortium (IMDC) risk group categories. Patients were stratified by IMDC risk group and presence of bone metastases (yes/no). Approximately 75% of patients had a nephrectomy prior to onset of treatment. For intermediate risk disease, one or two of the following risk factors were met, while for poor risk, three or more factors were met: time from diagnosis of RCC to systemic treatment <1 year, Hgb < LLN, Corrected calcium > ULN, KPS <80%, Neutrophil count > ULN and Platelet count > ULN.
The primary endpoint was PFS. Secondary efficacy endpoints were objective response rate (ORR) and overall survival (OS). Tumor assessments were conducted every 12 weeks.
The baseline demographic and disease characteristics were similar between the CABOMETYX and sunitinib arms. The majority of the patients were male (78%) with a median age of 62 years. Patient distribution by IMDC risk groups was 81% intermediate (1-2 risk factors) and 19% poor (≥3 risk factors). Most patients (87%) had ECOG performance status of 0 or 1; 13% had an ECOG performance status of 2. Thirty-six percent (36%) of patients had bone metastases.
A statistically significant improvement in PFS as retrospectively assessed by a blinded Independent Radiology Committee (IRC) was demonstrated for CABOMETYX compared to sunitinib (Figure 3 and Table 5). The results from the Investigator determined analysis and IRC-determined analysis of PFS were consistent.
Patients with both positive and negative MET status showed a favourable effect with CABOMETYX compared to sunitinib, with greater activity in patients with a positive MET status compared to patients with a negative MET status (HR=0.32 (0.16, 0.63) vs 0.67 (0.37, 1.23)) respectively.
CABOMETYX treatment was associated with a trend for longer survival compared to sunitinib (Table 5). The study was not powered for the OS analysis and the data are immature.
Objective response rate (ORR) findings are summarized in Table 5.
Figure 3. Kaplan Meier curve for progression-free survival by IRC in treatment-naïve RCC subjects:
Table 5. Efficacy results in treatment-naïve RCC subjects (ITT population, CABOSUN):
| CABOMETYX (N=79) | Sunitinib (N=78) | |
|---|---|---|
| Progression-free survival (PFS) by IRCa | ||
| Median PFS in months (95% CI) | 8.6 (6.2, 14.0) | 5.3 (3.0, 8.2) |
| HR (95% CI): stratifiedb,c | 0.48 (0.32, 0.73) | |
| Two-sided log-rank p-value: stratifiedb | p=0.0005 | |
| Progression-free survival (PFS) by Investigator | ||
| Median PFS in months (95% CI) | 8.3 (6.5, 12.4) | 5.4 (3.4, 8.2) |
| HR (95% CI): stratifiedb,c | 0.56 (0.37, 0.83) | |
| Two-sided log-rank p-value: stratifiedb | p=0.0042 | |
| Overall Survival | ||
| Median OS in months (95% CI) | 30.3 (14.6, NE) | 21.0 (16.3, 27.0) |
| HR (95% CI): stratifiedb,c | 0.74 (0.47, 1.14) | |
| Objective Response Rate n (%) by IRC | ||
| Complete responses | 0 | 0 |
| Partial responses | 16 (20) | 7 (9) |
| ORR (partial responses only) | 16 (20) | 7 (9) |
| Stable disease | 43 (54) | 30 (38) |
| Progressive Disease | 14 (18) | 23 (29) |
| Objective Response Rate n (%) by Investigator | ||
| Complete responses | 1 (1) | 0 |
| Partial responses | 25 (32) | 9 (12) |
| ORR (partial responses only) | 26 (33) | 9 (12) |
| Stable disease | 34 (43) | 29 (37) |
| Progressive Disease | 14 (18) | 19 (24) |
a in accord with EU censoring
b Stratification factors per IxRS comprise IMDC risk categories (intermediate risk, poor risk and bone metastasis (yes, no)
c Estimated using the Cox proportional hazard model adjusted for stratification factors per IxRS. Hazard ratio <1 indicates progression-free survival in favor of cabozantinib
The safety and efficacy of CABOMETYX were evaluated in a randomized, double-blind, placebo-controlled Phase 3 study (CELESTIAL). Patients (N=707) with HCC not amenable to curative treatment and who had previously received sorafenib for advanced disease were randomized (2:1) to receive CABOMETYX (N=470) or placebo (N=237). Patients could have received one other prior systemic therapy for advanced disease in addition to sorafenib. Randomization was stratified by aetiology of disease (HBV [with or without HCV], HCV [without HBV], or other), geographic region (Asia, other regions) and by presence of extrahepatic spread of disease and/or macrovascular invasions (Yes, No).
The primary efficacy endpoint was overall survival (OS). Secondary efficacy endpoints were progression-free survival (PFS) and objective response rate (ORR), as assessed by the Investigator using Response Evaluation Criteria in Solid Tumours (RECIST) 1.1. Tumour assessments were conducted every 8 weeks. Subjects continued blinded study treatment after radiological disease progression whilst they experienced clinical benefit or until the need for subsequent systemic or liver-directed local anticancer therapy. Crossover from placebo to cabozantinib was not allowed during the blinded treatment phase.
The baseline demographic and disease characteristics were similar between the CABOMETYX and placebo arms and are shown below for all 707 randomised patients:
Male: 82%
Median age: 64 years.
Caucasian: 56%, Asian: 34%
ECOG performance status (PS) 0: 53% or ECOG PS 1: 47%.
Child Pugh A: 99%, Child Pugh B: 1%
Aetiology for HCC included 38% hepatitis B virus (HBV), 21% hepatitis C virus (HCV), 40% other (neither HBV nor HCV).
Presence of macroscopic vascular invasion and/or extra-hepatic tumour spread:78%,
Alfa-fetoprotein (AFP) levels ≥400 μg/L: 41%.
Loco-regional transarterial embolisation or chemoinfusion procedures: 44%
Radiotherapy prior to cabozantinib treatment: 37%
Median duration of sorafenib treatment: 5.32 months
Seventy-two percent (72%) of patients had received one and 28% had received 2 prior systemic therapy regimens for advanced disease.
A statistically significant improvement in OS was demonstrated for CABOMETYX compared to placebo (Table 6 and Figure 4).
PFS and ORR findings are summarized in Table 6.
Table 6. Efficacy results in HCC (ITT population, CELESTIAL):
| CABOMETYX (N=470) | Placebo (N=237) | |
|---|---|---|
| Overall Survival | ||
| Median OS (95% CI), months | 10.2 (9.1, 12.0) | 8.0 (6.8, 9.4) |
| HR (95% CI)1,2 | 0.76 (0.63, 0.92) | |
| p-value1 | p=0.0049 | |
| Progression-free survival (PFS)3 | ||
| Median PFS in months (95% CI) | 5.2 (4.0, 5.5) | 1.9 (1.9, 1.9) |
| HR (95% CI)1 | 0.44 (0.36, 0.52) | |
| p-value1 | p<0.0001 | |
| Kaplan-Meier landmark estimates of percent of subjects event-free at 3 months | ||
| % (95% CI) | 67.0% (62.2%, 71.3%) | 33.3% (27.1%, 39.7%) |
| Objective Response Rate n (%)3 | ||
| Complete responses(CR) | 0 | 0 |
| Partial responses (PR) | 18 (4) | 1 (0.4) |
| ORR (CR+PR) | 18 (4) | 1 (0.4) |
| p-value1,4 | p=0.0086 | |
| Stable disease | 282 (60) | 78 (33) |
| Progressive Disease | 98 (21) | 131 (55) |
1 2-sided stratified log-rank test with etiology of disease (HBV [with or without HCV], HCV [without HBV], or Other), geographic region (Asia, Other Regions), and presence of extrahepatic spread of disease and/or macrovascular invasion (Yes, No) as stratification factors (per IVRS data)
2 estimated using the Cox proportional-hazard model
3 as assessed by investigator per RECIST 1.1
4 stratified Cochran-Mantel-Haenszel (CMH) test
Figure 4. Kaplan-Meier curve of overall survival (CELESTIAL):
Figure 5. Kaplan Meier curve for progression-free survival (CELESTIAL):
The incidence of systemic non-radiation and local liver-directed systemic non-protocol anticancer therapy (NPACT) was 26% in the cabozantinib arm and 33% in the placebo arm. Subjects receiving these therapies had to discontinue study treatment. An exploratory OS analysis censoring for the use of NPACT supported the primary analysis: the HR, adjusted for stratification factors (per IxRS), was 0.66 (95% CI: 0.52, 0.84; stratified logrank p-value=0.0005). The Kaplan-Meier estimates for median duration of OS were 11.1 months in the cabozantinib arm versus 6.9 months in the placebo arm, an estimated 4.2-month difference in the medians.
Non-disease specific quality of life (QoL) was assessed using the EuroQoL EQ-5D-5L. A negative effect of Cabometyx versus placebo on the EQ-5D utility index score was observed during the first weeks of treatment. Only limited QoL data are available after this period.
The European Medicines Agency has waived the obligation to submit the results of studies with CABOMETYX in all subsets of the paediatric population in treatment of hepatocellular carcinoma, and kidney and renal pelvis carcinoma (excluding nephroblastoma, nephroblastomatosis, clear cell sarcoma, mesoblastic nephroma, renal medullary carcinoma and rhabdoid tumour of the kidney) (see section 4.2 for information on paediatric use).
Following oral administration of cabozantinib, peak cabozantinib plasma concentrations are reached at 3 to 4 hours post-dose. Plasma-concentration time profiles show a second absorption peak approximately 24 hours after administration, which suggests that cabozantinib may undergo enterohepatic recirculation.
Repeat daily dosing of cabozantinib at 140 mg for 19 days resulted in an approximately a 4- to 5-fold mean cabozantinib accumulation (based on AUC) compared to a single dose administration; steady state is achieved by approximately Day 15.
A high-fat meal moderately increased Cmax and AUC values (41% and 57%, respectively) relative to fasted conditions in healthy volunteers administered a single 140 mg oral cabozantinib dose. There is no information on the precise food-effect when taken 1 hour after administration of cabozantinib.
Bioequivalence could not be demonstrated between the cabozantinib capsule and tablet formulations following a single 140 mg dose in healthy subjects. A 19% increase in the Cmax of the tablet formulation (CABOMETYX) compared to the capsule formulation (COMETRIQ) was observed. A less than 10% difference in the AUC was observed between cabozantinib tablet (CABOMETYX) and capsule (COMETRIQ) formulations.
Cabozantinib is highly protein bound in vitro in human plasma (≥99.7%). Based on the population-pharmacokinetic (PK) model, the volume of distribution of the central compartment (Vc/F) was estimated to be 212 L. Protein binding was not altered in subjects with mild or moderately impaired renal or hepatic function.
Cabozantinib was metabolized in vivo. Four metabolites were present in plasma at exposures (AUC) greater than 10% of parent: XL184-N-oxide, XL184 amide cleavage product, XL184 monohydroxy sulfate, and 6-desmethyl amide cleavage product sulfate. Two non-conjugated metabolites (XL184-N-oxide and XL184 amide cleavage product), which possess <1% of the on-target kinase inhibition potency of parent cabozantinib, each represent <10% of total drug-related plasma exposure.
Cabozantinib is a substrate for CYP3A4 metabolism in vitro, as a neutralizing antibody to CYP3A4 inhibited formation of metabolite XL184 N-oxide by >80% in a NADPH-catalyzed human liver microsomal (HLM) incubation; in contrast, neutralizing antibodies to CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C19, CYP2D6 and CYP2E1 had no effect on cabozantinib metabolite formation. A neutralizing antibody to CYP2C9 showed a minimal effect on cabozantinib metabolite formation (ie, a <20% reduction).
In a population PK analysis of cabozantinib using data collected from 1883 patients and 140 healthy volunteers following oral administration of a range of doses from 20 to 140 mg, the plasma terminal half-life of cabozantinib is approximately 110 hours. Mean clearance (CL/F) at steady-state was estimated to be 2.48 L/hr. Within a 48-day collection period after a single dose of 14C-cabozantinib in healthy volunteers, approximately 81% of the total administered radioactivity was recovered with 54% in faeces and 27% in urine.
Based on an integrated population pharmacokinetic analysis of cabozantinib in healthy subjects and cancer patients (including HCC), no clinically significant difference in the mean cabozantinib plasma exposure was observed amongst subjects with normal liver function (n=1425) and mild hepatic impairment (n=558). There is limited data in patients with moderate hepatic impairment (n=15) as per NCI-ODWG (National Cancer Institute – Organ Dysfunction working Group) criteria. The pharmacokinetics of cabozantinib was not evaluated in patients with severe hepatic impairment.
A population PK analysis did not identify clinically relevant differences in PK of cabozantinib based on race.
Adverse reactions not observed in clinical studies, but seen in animals at exposure levels similar to clinical exposure levels and with possible relevance to clinical use were as follows:
In rat and dog repeat-dose toxicity studies up to 6 months duration, target organs for toxicity were GI tract, bone marrow, lymphoid tissues, kidney, adrenal and reproductive tract tissues. The no observed adverse effect level (NOAEL) for these findings were below human clinical exposure levels at intended therapeutic dose.
Cabozantinib has shown no mutagenic or clastogenic potential in a standard battery of genotoxicity assays. The carcinogenic potential of cabozantinib has been evaluated in two species: rasH2 transgenic mice and Sprague-Dawley rats. In the 2-year rat carcinogenicity study, cabozantinib-related neoplastic findings consisted of an increased incidence of benign pheochromocytoma, alone or in combination with malignant pheochromocytoma/complex malignant pheochromocytoma of the adrenal medulla in both sexes at exposures well below the intended exposure in humans. The clinical relevance of the observed neoplastic lesions in rats is uncertain, but likely to be low.
Cabozantinib was not carcinogenic in the rasH2 mouse model at a slightly higher exposure than the intended human therapeutic exposure.
Fertility studies in rats have shown reduced male and female fertility. Further, hypospermatogenesis was observed in male dogs at exposure levels below human clinical exposure levels at intended therapeutic dose.
Embryo-foetal development studies were performed in rats and rabbits. In rats, cabozantinib caused postimplantation loss, foetal oedema, cleft palate/lip, dermal aplasia and kinked or rudimentary tail. In rabbits, cabozantinib produced foetal soft tissue changes (reduced spleen size, small or missing intermediate lung lobe) and increased foetal incidence of total malformations. NOAEL for embryo-foetal toxicity and teratogenic findings were below human clinical exposure levels at intended therapeutic dose.
Juvenile rats (comparable to a >2 year-old paediatric population) administered cabozantinib showed increased WBC parameters, decreased haematopoiesis, pubescent/immature female reproductive system (without delayed vaginal opening), tooth abnormalities, reduced bone mineral content and density, liver pigmentation and lymph node lymphoid hyperplasia. Findings in uterus/ovaries and decreased haematopoiesis appeared to be transient, while effects on bone parameters and liver pigmentation were sustained. Juvenile rats (correlating to a <2-year paediatric population) showed similar treatment-related findings but appeared to be more sensitive to cabozantinib-related toxicity at comparable dose levels.
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