Dabrafenib and Trametinib Followed by Ipilimumab and Nivolumab or Ipilimumab and Nivolumab Followed by Dabrafenib and Trametinib in Treating Patients With Stage III-IV BRAFV600 Melanoma

• ClinicalTrials.gov Identifier: NCT02224781
• Recruitment Status: Active, not recruiting
• First Posted: August 25, 2014
• Last Update Posted: May 20, 2024
• Sponsor: National Cancer Institute (NCI)
• Information provided by (Responsible Party): National Cancer Institute (NCI)

Tracking Information

• First Submitted Date: August 22, 2014
• First Posted Date: August 25, 2014
• Last Update Posted Date: May 20, 2024
• Actual Study Start Date: September 8, 2015
• Estimated Primary Completion Date: December 31, 2024 (Final data collection date for primary outcome measure)

Current Primary Outcome Measures (submitted: June 5, 2019)

Overall survival (OS) rate [ Time Frame: The time from randomization to death from any cause, assessed for up to 2 years ]

Defined as the proportion of patients alive after 2 years of follow-up time. Will be estimated and compared between the two arms using the Mantel-Haenszel test based (stratified by Eastern Cooperative Oncology Group [ECOG] performance status [PS] and lactate dehydrogenase [LDH]) based on two-sided overall type I error rate of 0.05 adjusting for two-interim analysis. Mantel-Haenszel test will compare the 2-year OS rates while controlling for the stratification factors. The difference in 2-year OS rates in arms A and B will be estimated and presented with 95% repeated confidence interval of Jennison-Turnbull. In addition, OS distribution will be estimated using the Kaplan-Meier method. The distribution of OS will be compared using the stratified log rank test. Hazard of OS will be estimated as a function of time in arm A and in arm B (as randomized in step 1 to arm A versus B) and presented graphically.

Original Primary Outcome Measures (submitted: August 22, 2014)

OS rate, defined as the proportion of patients alive after 2 years of follow-up time [ Time Frame: 2 years ]

Will be estimated and compared between the two arms using the Fisher's exact test based on two-sided overall type I error rate of 0.05 adjusting for two-interim analysis. Distribution will be estimated using the Kaplan-Meier method.

Current Secondary Outcome Measures (submitted: June 5, 2019)

• Progression-free survival (PFS) [ Time Frame: The time from randomization to disease progression or death (whichever occurs first), assessed up to 5 years ]
  Evaluated based on Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. Distribution will be estimated using the Kaplan-Meier method. PFS will be compared using the log-rank test.
• Response rate [ Time Frame: Up to 5 years ]
  According to RECIST 1.1. Response rates will be compared using the Mantel-Haenszel test (stratified by ECOG PS and LDH) test in arms A vs. B. Response rate for patients who are treated with ipilimumab/nivolumab before crossover (arm A) vs. for patients who were initially treated with dabrafenib/trametinib and crossed over to ipilimumab/nivolumab will be compared (arm D). Response rates will be compared using the Fisher's exact test.
• Toxicity rate for individual adverse events (AEs) [ Time Frame: Up to 5 years ]
  Will be assessed using Common Terminology Criteria for Adverse Events (CTCAE) version (v) 4.0. Compared using the chi-square of Fisher's exact test. Two-sided p-values will be reported for these comparisons.
• Toxicity rate for categorized AEs [ Time Frame: Up to 5 years ]
  Will be assessed using CTCAE v 4.0. Compared using the chi-square of Fisher's exact test. Two-sided p-values will be reported for these comparisons.
• Toxicity rate for worst degree AEs [ Time Frame: Up to 5 years ]
  Will be assessed using CTCAE v 4.0. Compared using the chi-square of Fisher's exact test. Two-sided p-values will be reported for these comparisons.

Original Secondary Outcome Measures (submitted: August 22, 2014)

• PFS, evaluated based on RECIST version 1.1 [ Time Frame: The time from randomization to disease progression or death (whichever occurs first), assessed up to 5 years ]
  Distribution will be estimated using the Kaplan-Meier method. The distribution will be compared using the stratified log rank test with two overall type I error rate of 0.100 (adjusting for the one interim analysis).
• Response rate according to RECIST version 1.1 [ Time Frame: Up to 5 years ]
  Response rates for patients who are treated with ipilimumab/nivolumab before cross-over vs. for patients who were initially treated with dabrafenib/trametinib will be compared using the Fisher's exact test.
• Toxicity rate for individual adverse events (AEs) [ Time Frame: Up to 5 years ]
  Compared using the chi-square of Fisher's exact test. Two-sided p-values will be reported for these comparisons.
• Toxicity rate for categorized AEs [ Time Frame: Up to 5 years ]
  Compared using the chi-square of Fisher's exact test. Two-sided p-values will be reported for these comparisons.
• Toxicity rate for worst degree AEs [ Time Frame: Up to 5 years ]
  Compared using the chi-square of Fisher's exact test. Two-sided p-values will be reported for these comparisons.

Current Other Pre-specified Outcome Measures (submitted: April 11, 2019)

• Genetic characteristics [ Time Frame: Baseline ]
  Genetic associations with immune-related adverse events (irAE) status will be assessed using Fisher's exact test, one-degree-of-freedom genotypic trend test or the two-degrees-of-freedom chi-squared test of independence at each individual SNP marker. Tests of association will be adjusted for age, sex, center or clinical protocol, and dose as well as American Joint Committee on Cancer stage, ulceration, performance status, LDH level, number of involved sites, BRAF mutation status (when available) and number of prior therapies using logistic regression modeling assuming an additive genetic model.
• Immune-related adverse events (irAE) status [ Time Frame: Up to 2 years ]
  Genetic associations with irAE status will be assessed using Fisher's exact test, one-degree-of-freedom genotypic trend test or the two-degrees-of-freedom chi-squared test of independence at each individual SNP marker. Tests of association will be adjusted for age, sex, center or clinical protocol, and dose as well as American Joint Committee on Cancer stage, ulceration, performance status, LDH level, number of involved sites, BRAF mutation status (when available) and number of prior therapies using logistic regression modeling assuming an additive genetic model.
• Quality-adjusted time without symptoms of disease progression or toxicity of treatment (Q-TWIST) [ Time Frame: Up to 2 years ]
  The restricted mean amount of time for each health state will be estimated using the Kaplan-Meier method, with time limit set at 2 years for computation of all restricted means. The mean amount of time for each health state and the average group utility scores will be summarized by initial treatment (i.e., arm A: ipilimumab + nivolumab [with subsequent dabrafenib + trametinib] vs. arm B: dabrafenib + trametinib [with subsequent ipilimumab + nivolumab]). The Q-TWiST subscore and the overall Q-TWiST score will then be reported by initial treatment. Differences between treatment groups in the mean Q-TWiST score (including the overall score and the subscore) will be calculated. For each score, a 95% confidence interval and two-sided P-value for testing the null hypothesis of no difference between treatment groups will be conducted using a Z-test (with normal approximation), with standard errors calculated by the bootstrap method.
• Overall function [ Time Frame: Up to 24 months from study entry ]
  Assessed using Patient-Reported Outcomes Measurement Information System (PROMIS) PROFILE-29. A log-normal survival model for analyzing longitudinal data which incorporates the non-ignorable censoring mechanism will be fitted for each short form T-score and pain intensity, separately, to assess initial treatment effect (i.e., arm A: ipilimumab + nivolumab [with subsequent dabrafenib + trametinib] vs. arm B: dabrafenib + trametinib [with subsequent ipilimumab + nivolumab]) on each function. To evaluate the effect of treatment sequence on patient function, each of the PROMIS short form T-score and pain intensity (with longitudinal data collected at baseline, 6-, 12-weeks, and 6-months after the initiation of treatment in each step) will be compared by treatment sequence for ipilimumab + nivolumab (arm A vs. D) and for dabrafenib + trametinib (arm B vs. C), using a log-normal survival model as described above.
• Change in patient-reported symptoms [ Time Frame: Baseline to up to 6 months after the initiation of treatment in each step ]
  Assessed using the Patient Reported Outcomes Common Terminology Criteria for Adverse Events. To evaluate the effect of treatment sequence on symptoms, summary statistics (frequency [N] and percentage [%]) will be reported with respect to presence, frequency and severity (if applicable) for each symptom by treatment sequence for ipilimumab + nivolumab (arm A vs. D), and for dabrafenib + trametinib (arm B vs. C) at baseline, 6-, 12-weeks, and 6-months after the initiation of the first treatment and the secondary treatment.

Original Other Pre-specified Outcome Measures (submitted: August 22, 2014)

• Genetic characteristics [ Time Frame: Baseline ]
  Genetic associations with irAE status will be assessed using Fisher's exact test, one-degree-of-freedom genotypic trend test or the two-degrees-of-freedom chi-squared test of independence at each individual SNP marker. Tests of association will be adjusted for age, sex, center or clinical protocol, and dose as well as American Joint Committee on Cancer (AJCC) stage, ulceration, performance status, LDH level, number of involved sites, BRAF mutation status (when available) and number of prior therapies using logistic regression modeling assuming an additive genetic model.
• irAE status [ Time Frame: Up to 5 years ]
  Genetic associations with irAE status will be assessed using Fisher's exact test, one-degree-of-freedom genotypic trend test or the two-degrees-of-freedom chi-squared test of independence at each individual SNP marker. Tests of association will be adjusted for age, sex, center or clinical protocol, and dose as well as American Joint Committee on Cancer stage, ulceration, performance status, LDH level, number of involved sites, BRAF mutation status (when available) and number of prior therapies using logistic regression modeling assuming an additive genetic model.
• HRQL, measured by Trial Outcome Index based on Functional Assessment of Cancer Therapy-General [ Time Frame: Week 12 ]
  Assessed between the two treatment groups using an independent-sample t-test.
• Symptom burden [ Time Frame: Week 12 ]
  Ten symptoms (new skin changes, headache, fever, abdominal cramps, bone pain, blood in stool, chills, sweating, joint pain, and skin rash/itching) will be analyzed individually to measure the impact of treatment on a specific symptom.
• Change in HRQL [ Time Frame: Baseline to week 12 ]
  Computed and compared between the two treatment groups. Mixed effect models will be constructed as another exploratory analysis to estimate the time profile in the two treatment groups and to evaluate treatment-by-time interactions. Time will be included as a continuous variable if there is a linear trend over time or a set of dummy variables if non-linear trend exists. Adjusted covariates included in the mixed effect models will include patient demographic and disease characteristics, such as sex, age, ECOG performance status, and disease stage.
• Change in HRQL [ Time Frame: Week 12 to week 104 ]
  Computed and compared between the two treatment groups. Mixed effect models will be constructed as another exploratory analysis to estimate the time profile in the two treatment groups and to evaluate treatment-by-time interactions. Time will be included as a continuous variable if there is a linear trend over time or a set of dummy variables if non-linear trend exists. Adjusted covariates included in the mixed effect models will include patient demographic and disease characteristics, such as sex, age, ECOG performance status, and disease stage.
• Change in symptom burden [ Time Frame: Baseline to week 12 ]
  Computed and compared between the two treatment groups. Mixed effect models will be constructed as another exploratory analysis to estimate the time profile in the two treatment groups and to evaluate treatment-by-time interactions. Time will be included as a continuous variable if there is a linear trend over time or a set of dummy variables if non-linear trend exists. Adjusted covariates included in the mixed effect models will include patient demographic and disease characteristics, such as sex, age, ECOG performance status, and disease stage.
• Change in symptom burden [ Time Frame: Week 12 to week 104 ]
  Computed and compared between the two treatment groups. Mixed effect models will be constructed as another exploratory analysis to estimate the time profile in the two treatment groups and to evaluate treatment-by-time interactions. Time will be included as a continuous variable if there is a linear trend over time or a set of dummy variables if non-linear trend exists. Adjusted covariates included in the mixed effect models will include patient demographic and disease characteristics, such as sex, age, ECOG performance status, and disease stage.

Descriptive Information

• Brief Title: Dabrafenib and Trametinib Followed by Ipilimumab and Nivolumab or Ipilimumab and Nivolumab Followed by Dabrafenib and Trametinib in Treating Patients With Stage III-IV BRAFV600 Melanoma
• Official Title: DREAMseq (Doublet, Randomized Evaluation in Advanced Melanoma Sequencing) a Phase III Trial
• Brief Summary: This phase III trial studies how well initial treatment with ipilimumab and nivolumab followed by dabrafenib and trametinib works and compares it to initial treatment with dabrafenib and trametinib followed by ipilimumab and nivolumab in treating patients with stage III-IV melanoma that contains a mutation known as BRAFV600 and cannot be removed by surgery (unresectable). Immunotherapy with monoclonal antibodies, such as ipilimumab and nivolumab, may help the body's immune system attack the cancer, and may interfere with the ability of tumor cells to grow and spread. Dabrafenib and trametinib may block tumor growth by targeting the BRAFV600 gene. It is not yet known whether treating patients with ipilimumab and nivolumab followed by dabrafenib and trametinib is more effective than treatment with dabrafenib and trametinib followed by ipilimumab and nivolumab.

Detailed Description

PRIMARY OBJECTIVE:

I. To determine whether initial treatment with either combination ipilimumab + nivolumab (with subsequent dabrafenib mesylate [dabrafenib] in combination with trametinib dimethyl sulfoxide [trametinib]) or dabrafenib in combination with trametinib (with subsequent ipilimumab + nivolumab) significantly improves 2 year overall survival (OS) in patients with unresectable stage III or stage IV BRAFV600 mutant melanoma.

SECONDARY CLINICAL OBJECTIVES:

I. To evaluate the impact of initial treatment on median OS and hazard ratio for death.

II. To determine whether initial treatment choice significantly improves 3 year OS.

III. To evaluate the anti-tumor activities (Response Evaluation Criteria in Solid Tumors [RECIST]-defined response rate, median progression-free survival [PFS]) and safety profiles of ipilimumab + nivolumab and dabrafenib-trametinib in a Cooperative Group trial of patients with V600 mutant melanoma.

IV. To evaluate the activity (RECIST-defined response rate, median PFS) and safety of dabrafenib + trametinib in patients who have had disease progression on ipilimumab + nivolumab and in comparison to its activity and safety in ipilimumab + nivolumab naive patients.

V. To evaluate the activity of ipilimumab + nivolumab (RECIST-defined response rate, median PFS) and safety in patients who have had disease progression on dabrafenib + trametinib and in comparison to its activity and safety in dabrafenib + trametinib naive patients.

VI. To assess the feasibility of crossover to the alternative treatment strategy (percentage of patients who are able to crossover from one arm to the other and complete at least an initial course [12 weeks] of treatment after cross-over without intervening symptomatic disease progression or treatment limiting toxicity).

SECONDARY LABORATORY OBJECTIVES:

I. Association of inherited variation with immune mediated adverse events and response to ipilimumab + nivolumab.

Ia. To determine the association of inherited genetic variation and immune-associated adverse events in patients with metastatic melanoma treated with ipilimumab containing regimens by completing candidate-based gene and pathway analyses of genes involved in lymphocyte activation, cytokines, cytokine receptors and within the major histocompatibility complex (MHC) region and an agnostic genome-wide single nucleotide polymorphism (SNP)-based approach; Ib. To investigate the association between inherited genetics and survival in patients with metastatic melanoma treated with ipilimumab containing regimens by completing candidate-based gene and pathway analyses of genes involved in lymphocyte activation, cytokines profile, cytokine receptors and within the MHC region and an agnostic genome-wide SNP-based approach; Ic. To replicate genomic markers identified in the above aims in an independent sample set of patients treated with ipilimumab containing regimens and preliminarily characterize their potential functional role by completing replication of variation as associated with immune-related adverse events (irAEs) and survival and bio-informatic assessment of genomic markers.

II. To determine the utility of circulating BRAF levels in determining the response and resistance to either BRAF/MEK directed and/or combination immunotherapy in patients with BRAF mutant melanoma.

IIa. To determine if changes in blood BRAF levels utilizing peripheral blood BRAFV600 mutational testing in patients with stage IV BRAF mutant melanoma correlate with response and resistance to combination BRAF/MEK directed therapy; IIb. To determine if changes in blood BRAF levels utilizing peripheral blood BRAFV600 mutational testing in patients with stage IV BRAF mutant melanoma correlate with response and resistance to combination immunotherapy; IIc. To compare the kinetics of peripheral blood BRAFV600 levels during response and resistance in groups of patients receiving BRAF targeted therapy or combination immunotherapy as initial therapy; IId. To compare the kinetics of peripheral blood BRAFV600 levels during response and resistance to combination BRAF targeted therapy or combination immunotherapy in individual patients (initial treatment versus [vs] crossover treatment).

SECONDARY PATIENT REPORTED OUTCOMES OBJECTIVES:

I. To evaluate differences in overall health between initial treatment arms (dabrafenib + trametinib vs. ipilimumab + nivolumab immunotherapy) at 2 years, accounting for toxicities and overall survival. (Primary) II. To assess differences in overall function over 2 years between initial treatment with dabrafenib + trametinib vs. ipilimumab + nivolumab. (Secondary) III. To document the effects of treatment crossover and treatment administration sequence on symptom burden and overall function. (Secondary) IIIa. To compare differences in function and symptoms by treatment sequence for ipilimumab + nivolumab (arm A vs. D), and dabrafenib + trametinib, (arm B vs. C) at baseline, 6 weeks, 12 weeks, and 6 months after the initiation of each treatment; IIIb. To describe the frequency and severity of treatment toxicities at baseline, 6 weeks, 12 weeks, and 6 months after initiation of each treatment.

EXPLORATORY TOBACCO USE OBJECTIVES:

I. To determine the effects of tobacco, operationalized as combustible tobacco (1a), other forms of tobacco (1b), and environmental tobacco exposure (ETS) (1c) on provider-reported cancer-treatment toxicity (adverse events [both clinical and hematologic] and dose modifications).

II. To determine the effects of tobacco on patient-reported physical symptoms and psychological symptoms.

III. To examine quitting behaviors and behavioral counseling/support and cessation medication utilization.

IV. To explore the effect of tobacco use and exposure on treatment duration, relative dose intensity, and therapeutic benefit.

EXPLORATORY CORRELATIVE OBJECTIVES:

I. To assess serum based biomarkers of efficacy and adverse events due to treatment with immune checkpoint inhibitors.

II. To monitor tumor response by comparing changes in circulating cell-free mutant tumor deoxyribonucleic acid (DNA) (ctDNA) as a readout of tumor burden (a) at week 12 relative to baseline before treatment in responders and non-responders; (b) before and during immunosuppressive treatment to control irAEs.

III. To monitor organ-specific adverse events (irAEs) using circulating cell-free, tissue-specific methylated DNA (cmeDNA) as a readout of tissue-specific toxicity (a) at the time of grade 3-4 irAE relative to baseline and control patients without irAEs; (b) during immunosuppressive treatment for irAEs.

OUTLINE: Patients are randomized to 1 of 2 treatment arms (Arm A or Arm B).

ARM A:

IMMUNOTHERAPY INDUCTION (CYCLES 1-2): Patients receive nivolumab intravenously (IV) over 30-60 minutes and ipilimumab IV over 30-90 minutes on days 1 and 22. Treatment repeats every 6 weeks for 2 cycles in the absence of disease progression or unacceptable toxicity.

IMMUNOTHERAPY MAINTENANCE (CYCLES 3-14): Patients receive nivolumab IV over 30-60 minutes on days 1, 15, and 29. Treatment repeats every 6 weeks for up to 12 cycles in the absence of disease progression or unacceptable toxicity. Upon disease progression (or before), patients re-register and cross over to Arm C.

ARM C: Patients receive dabrafenib mesylate orally (PO) twice daily (BID) and trametinib dimethyl sulfoxide PO daily on days 1-42. Cycles repeat every 6 weeks in the absence of disease progression or unacceptable toxicity.

ARM B: Patients receive dabrafenib mesylate PO BID and trametinib dimethyl sulfoxide PO daily on days 1-42. Cycles repeat every 6 weeks in the absence of disease progression or unacceptable toxicity. Upon disease progression (or before), patients re-register and cross over to Arm D.

ARM D:

IMMUNOTHERAPY INDUCTION (CYCLES 1-2): Patients receive nivolumab IV over 30-60 minutes and ipilimumab IV over 30-90 minutes on days 1 and 22. Treatment repeats every 6 weeks for 2 cycles in the absence of disease progression or unacceptable toxicity.

IMMUNOTHERAPY MAINTENANCE (CYCLES 3-14): Patients receive nivolumab IV over 30-60 minutes on days 1, 15, and 29. Treatment repeats every 6 weeks for up to 12 cycles in the absence of disease progression or unacceptable toxicity.

All patients also undergo computed tomography (CT), echocardiography (ECHO) or multigated acquisition scan (MUGA), and collection of blood samples throughout the trial.

After completion of study treatment, patients are followed up every 3 months for 2 years and then every 6 months for 3 years.

• Study Type: Interventional
• Study Phase: Phase 3
• Study Design: Allocation: Randomized; Intervention Model: Crossover Assignment; Masking: None (Open Label); Primary Purpose: Treatment

Condition

• Clinical Stage III Cutaneous Melanoma AJCC v8
• Clinical Stage IV Cutaneous Melanoma AJCC v8
• Metastatic Melanoma
• Recurrent Melanoma
• Unresectable Melanoma

Intervention

• Procedure: Biospecimen Collection
  Undergo collection of blood samples
  Other Names:

  • Biological Sample Collection
  • Biospecimen Collected
  • Specimen Collection
• Procedure: Computed Tomography
  Undergo CT
  Other Names:

  • CAT
  • CAT Scan
  • Computed Axial Tomography
  • Computerized Axial Tomography
  • Computerized axial tomography (procedure)
  • Computerized Tomography
  • Computerized Tomography (CT) scan
  • CT
  • CT Scan
  • tomography
• Drug: Dabrafenib Mesylate
  Given PO
  Other Names:

  • Dabrafenib Methanesulfonate
  • GSK2118436 Methane Sulfonate Salt
  • GSK2118436B
  • Tafinlar
• Procedure: Echocardiography
  Undergo ECHO
  Other Name: EC
• Biological: Ipilimumab
  Given IV
  Other Names:

  • Anti-Cytotoxic T-Lymphocyte-Associated Antigen-4 Monoclonal Antibody
  • BMS-734016
  • Ipilimumab Biosimilar CS1002
  • MDX-010
  • MDX-CTLA4
  • Yervoy
• Procedure: Multigated Acquisition Scan
  Undergo MUGA scan
  Other Names:

  • Blood Pool Scan
  • Equilibrium Radionuclide Angiography
  • Gated Blood Pool Imaging
  • MUGA
  • Radionuclide Ventriculography
  • RNVG
  • SYMA Scanning
  • Synchronized Multigated Acquisition Scanning
• Biological: Nivolumab
  Given IV
  Other Names:

  • ABP 206
  • BCD-263
  • BMS-936558
  • CMAB819
  • MDX-1106
  • NIVO
  • Nivolumab Biosimilar ABP 206
  • Nivolumab Biosimilar BCD-263
  • Nivolumab Biosimilar CMAB819
  • ONO-4538
  • Opdivo
• Other: Quality-of-Life Assessment
  Ancillary studies
  Other Name: Quality of Life Assessment
• Drug: Trametinib Dimethyl Sulfoxide
  Given PO
  Other Names:

  • Mekinist
  • Meqsel

Study Arms

• Experimental: Arm A (immunotherapy)

  IMMUNOTHERAPY INDUCTION (CYCLES 1-2): Patients receive nivolumab IV over 30-60 minutes and ipilimumab IV over 30-90 minutes on days 1 and 22. Treatment repeats every 6 weeks for 2 cycles in the absence of disease progression or unacceptable toxicity.

  IMMUNOTHERAPY MAINTENANCE (CYCLES 3-14): Patients receive nivolumab IV over 30-60 minutes on days 1, 15, and 29. Treatment repeats every 6 weeks for up to 12 cycles in the absence of disease progression or unacceptable toxicity. Upon disease progression (or before), patients re-register and cross over to Arm C.

  Patients also undergo CT, ECHO or MUGA, and collection of blood samples throughout the trial.

  Interventions:

  • Procedure: Biospecimen Collection
  • Procedure: Computed Tomography
  • Procedure: Echocardiography
  • Biological: Ipilimumab
  • Procedure: Multigated Acquisition Scan
  • Biological: Nivolumab
  • Other: Quality-of-Life Assessment
• Experimental: Arm B (BRAF inhibitor therapy)

  Patients receive dabrafenib mesylate PO BID and trametinib dimethyl sulfoxide PO daily on days 1-42. Cycles repeat every 6 weeks in the absence of disease progression or unacceptable toxicity. Upon disease progression (or before), patients re-register and cross over to Arm D.

  Patients also undergo CT, ECHO or MUGA, and collection of blood samples throughout the trial.

  Interventions:

  • Procedure: Biospecimen Collection
  • Procedure: Computed Tomography
  • Drug: Dabrafenib Mesylate
  • Procedure: Echocardiography
  • Procedure: Multigated Acquisition Scan
  • Other: Quality-of-Life Assessment
  • Drug: Trametinib Dimethyl Sulfoxide
• Experimental: Arm C (BRAF inhibitor therapy)

  Patients receive dabrafenib mesylate PO BID and trametinib dimethyl sulfoxide PO daily on days 1-42. Cycles repeat every 6 weeks in the absence of disease progression or unacceptable toxicity.

  Patients also undergo CT, ECHO or MUGA, and collection of blood samples throughout the trial.

  Interventions:

  • Procedure: Biospecimen Collection
  • Procedure: Computed Tomography
  • Drug: Dabrafenib Mesylate
  • Procedure: Echocardiography
  • Procedure: Multigated Acquisition Scan
  • Other: Quality-of-Life Assessment
  • Drug: Trametinib Dimethyl Sulfoxide
• Experimental: Arm D (immunotherapy)

  IMMUNOTHERAPY INDUCTION (CYCLES 1-2): Patients receive nivolumab IV over 30-60 minutes and ipilimumab IV over 30-90 minutes on days 1 and 22. Treatment repeats every 6 weeks for 2 cycles in the absence of disease progression or unacceptable toxicity.

  IMMUNOTHERAPY MAINTENANCE (CYCLES 3-14): Patients receive nivolumab IV over 30-60 minutes on days 1, 15, and 29. Treatment repeats every 6 weeks for up to 12 cycles in the absence of disease progression or unacceptable toxicity.

  Patients also undergo CT, ECHO or MUGA, and collection of blood samples throughout the trial.

  Interventions:

  • Procedure: Biospecimen Collection
  • Procedure: Computed Tomography
  • Procedure: Echocardiography
  • Biological: Ipilimumab
  • Procedure: Multigated Acquisition Scan
  • Biological: Nivolumab
  • Other: Quality-of-Life Assessment

Publications *

• Atkins MB, Lee SJ, Chmielowski B, Tarhini AA, Cohen GI, Truong TG, Moon HH, Davar D, O'Rourke M, Stephenson JJ, Curti BD, Urba WJ, Brell JM, Funchain P, Kendra KL, Ikeguchi AP, Jaslowski A, Bane CL, Taylor MA, Bajaj M, Conry RM, Ellis RJ, Logan TF, Laudi N, Sosman JA, Crockett DG, Pecora AL, Okazaki IJ, Reganti S, Chandra S, Guild S, Chen HX, Streicher HZ, Wolchok JD, Ribas A, Kirkwood JM. Combination Dabrafenib and Trametinib Versus Combination Nivolumab and Ipilimumab for Patients With Advanced BRAF-Mutant Melanoma: The DREAMseq Trial-ECOG-ACRIN EA6134. J Clin Oncol. 2023 Jan 10;41(2):186-197. doi: 10.1200/JCO.22.01763. Epub 2022 Sep 27.
• Barker CA, Salama AK. New NCCN Guidelines for Uveal Melanoma and Treatment of Recurrent or Progressive Distant Metastatic Melanoma. J Natl Compr Canc Netw. 2018 May;16(5S):646-650. doi: 10.6004/jnccn.2018.0042.

Recruitment Information

• Recruitment Status: Active, not recruiting
• Estimated Enrollment (submitted: August 22, 2014): 300
• Original Estimated Enrollment: Same as current
• Estimated Study Completion Date: December 31, 2024
• Estimated Primary Completion Date: December 31, 2024 (Final data collection date for primary outcome measure)

Eligibility Criteria

Inclusion Criteria:

• STEP 1
• Age >= 18 years. Because no dosing or adverse event data are currently available on the use of dabrafenib or dabrafenib + trametinib or nivolumab or nivolumab + ipilimumab therapy in patients < 18 years of age, children are excluded from this study, but will be eligible for future pediatric trials
• Eastern Cooperative Oncology Group (ECOG) performance status: 0 or 1
• The effects of dabrafenib and trametinib or ipilimumab and nivolumab on the developing human fetus are unknown; furthermore, dabrafenib has been reported to interfere with the effect of hormone based oral contraceptives; for this reason and because other therapeutic agents used in this trial are known to be teratogenic, women of child-bearing potential and sexually active males must agree to use at least two other accepted and effective methods of contraception and/or to abstain from sexual intercourse for the duration of their participation in the study, and for at least 4 weeks after treatment with dabrafenib or for 4 months after dabrafenib in combination with trametinib; women of child-bearing potential must use at least two other accepted and effective methods of contraception and/or to abstain from sexual intercourse for at least 5 months after the last dose of nivolumab and/or ipilimumab and sexually active males must use at least two other accepted and effective methods of contraception and/or abstain from sexual intercourse for at least 7 months after the last dose of nivolumab and/or ipilimumab; should a woman become pregnant or suspect she is pregnant while she is participating in this study, she should inform her treating physician immediately
• Patients must have unresectable stage III or stage IV disease
• Patients must have measurable disease; all sites of disease must be evaluated within 4 weeks prior to randomization

• Patients must have histological or cytological confirmation of melanoma that is metastatic or unresectable and clearly progressive

  • NOTE: Any patient with BRAF V600 mutant melanoma (whether cutaneous, acral or mucosal primary) who meets the eligibility criteria is eligible for participation in this trial; patients with uveal melanoma are not eligible for this trial
• Patients must have BRAF V600 mutation, identified by a Food and Drug Administration (FDA)-approved test at a Clinical Laboratory Improvement Act (CLIA)-certified lab; if test at CLIA-certified lab used a non-FDA approved method, information about the assay must be provided (FDA approved tests for BRAF V600 mutations in melanoma include: THxID BRAF Detection Kit and Cobas 4800 BRAF V600 Mutation Test, Foundation Medicine); prompt information on tumor BRAF mutation status can also be obtained via Novartis "knowNow" Program
• Patients may have had prior systemic therapy in the adjuvant setting; however this adjuvant treatment must not have included a CTLA4 or PD1 pathway blocking antibody or a BRAF/MEK inhibitor. Also, patients may not have had any prior systemic treatment for advanced (measurable metastatic) disease
• Patients must have discontinued chemotherapy, immunotherapy or other investigational agents used in the adjuvant setting >= 4 weeks prior to entering the study and recovered from adverse events due to those agents; mitomycin and nitrosoureas must have been discontinued at least 6 weeks prior to entering the study; patients must have discontinued radiation therapy >= 1 week prior to entering the study and recovered from any adverse events associated with treatment; prior surgery must be >= 2 weeks from registration and patients must be fully recovered from post-surgical complications
• Patients must not receive any other investigational agents while on study or within four weeks prior to registration
• Patients are ineligible if they have any currently known active and definitive central nervous system (CNS) metastases; patients who have treated brain metastases (with either surgical resection or stereotactic radiosurgery [SRS]) could be eligible; patients must not have taken any steroids =< 10 days prior to randomization for the purpose of managing their brain metastases; repeat imaging after SRS or surgical resection is not required so long as baseline magnetic resonance imaging (MRI) is within 4 weeks of registration; patients with multiple brain metastases treated with SRS (with [w] or without [w/o] whole-brain radiotherapy [WBRT]), are not an exclusion; patients with definitive CNS metastases treated with only WBRT are ineligible; patients with potential CNS metastases that are too small for treatment with either SRS or surgery (e.g. 1-2 mm) and/or are of uncertain etiology are potentially eligible, but need to be discussed with and approved by the study principal investigator (PI)
• Patients must not have other current malignancies, other than basal cell skin cancer, squamous cell skin cancer, in situ cervical cancer, ductal or lobular carcinoma in situ of the breast; patients with other malignancies are eligible if they have been continuously disease-free for > 2 years prior to the time of registration
• White blood count >= 3,000/uL (obtained within 4 weeks prior to randomization)
• Absolute neutrophil count (ANC) >= 1,500/uL (obtained within 4 weeks prior to randomization)
• Platelet count >= 100,000/uL (obtained within 4 weeks prior to randomization)
• Hemoglobin > 8 g/dL (obtained within 4 weeks prior to randomization)
• Serum creatinine =< 1.5 x upper limit of normal (ULN) or serum creatinine clearance (CrCl) >= 40 ml/min (obtained within 4 weeks prior to randomization)
• Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 3 x ULN (=< 5 x ULN for patients with documented liver metastases) (obtained within 4 weeks prior to randomization)
• Alkaline phosphatase =< 2 x ULN (=< 5 x ULN for patients with known liver involvement and =< 7 x ULN for patients with known bone involvement) (obtained within 4 weeks prior to randomization)
• Total bilirubin =< 1.5 x ULN except subjects with normal direct bilirubin or those with known Gilbert's syndrome (obtained within 4 weeks prior to randomization)
• Patients must not have any serious or unstable pre-existing medical conditions (aside from malignancy exceptions specified above), including but not limited to, ongoing or active infection requiring parenteral antibiotics on day 1, or psychiatric illness/social situations that would limit compliance with study requirements, interfere with subject's safety, or obtaining informed consent; therapeutic level dosing of warfarin can be used with close monitoring of prothrombin time (PT)/international normalized ratio (INR) by the site; exposure may be decreased due to enzyme induction when on treatment, thus warfarin dosing may need to be adjusted based upon PT/INR; consequently, when discontinuing dabrafenib, warfarin exposure may be increased and thus close monitoring via PT/INR and warfarin dose adjustments must be made as clinically appropriate; prophylactic low dose warfarin may be given to maintain central catheter patency

• Patients must not have a history of or evidence of cardiovascular risks including any of the following:

  • QT interval corrected for heart rate using the Bazett's formula (QTcB) >= 480 msec. at baseline
  • History of acute coronary syndromes (including myocardial infarction or unstable angina), coronary angioplasty, or stenting within the past 24 weeks prior to registration
  • History prior to registration or evidence of current >= class II congestive heart failure as defined by the New York Heart Association (NYHA) functional classification system
  • Left ventricular ejection fraction (LVEF) =< 45% on cardiac echocardiogram (echo) or multi gated acquisition scan (MUGA)
  • Intra-cardiac defibrillator
• Individuals who are known to be human immunodeficiency virus (HIV) infected are ineligible (note: HIV testing is not required for entry into the study)
• Patients with active autoimmune disease or history of autoimmune disease that might recur, which may affect vital organ function or require immune suppressive treatment including systemic corticosteroids, should be excluded; these include but are not limited to patients with a history of immune related neurologic disease, multiple sclerosis, autoimmune (demyelinating) neuropathy, Guillain-Barre syndrome, myasthenia gravis; systemic autoimmune disease such as systemic lupus erythematosus (SLE), connective tissue diseases, scleroderma, inflammatory bowel disease (IBD), Crohn's, ulcerative colitis, hepatitis; and patients with a history of toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome, or phospholipid syndrome should be excluded because of the risk of recurrence or exacerbation of disease; patients with vitiligo, endocrine deficiencies including thyroiditis managed with replacement hormones including physiologic corticosteroids are eligible; patients with rheumatoid arthritis and other arthropathies, Sjogren's syndrome and psoriasis controlled with topical medication and patients with positive serology, such as antinuclear antibodies (ANA), should be evaluated for the presence of target organ involvement and potential need for systemic treatment; if no systemic immune suppression is deemed necessary they can be eligible

• The following medications or non-drug therapies are also prohibited while on treatment in this study:

  • Other anti-cancer therapies
  • Other investigational drugs
  • Patients taking any medications or substances that are strong inhibitors or inducers of CYP3A or CYP2C8 are ineligible
• Patients must not have history of retinal vein occlusion (RVO)
• Patients must not have evidence of interstitial lung disease or pneumonitis
• Patients must not have malabsorption, swallowing difficulty, or other conditions that would interfere with the ingestion or absorption of dabrafenib or trametinib

• STEP 2 (CROSSOVER ARMS): The patient must have met all eligibility criteria (except as detailed below) at the time of crossover

  • RECIST defined measurable disease is not required
  • Only prior systemic therapy as part of step 1 is allowed; patients who received allowed systemic therapy in the adjuvant setting prior to Step 1 and were eligible for Step 1 are not excluded from proceeding to Step 2 if they meet other eligibility criteria
  • Malabsorption, swallowing difficulty, or other conditions that would interfere with the ingestion or absorption of dabrafenib or trametinib, or history of retinal vein occlusion are acceptable for patients crossing over to Arm D (ipilimumab + nivolumab) treatment
  • History of autoimmune disease, excluding interstitial lung disease or pneumonitis, is allowed in patients crossing over to Arm C (dabrafenib/trametinib) therapy
  • Patients crossing over from Arm A (nivolumab/ipilimumab) to Arm C (dabrafenib/trametinib) who underwent surgery or SRS to CNS metastases need not be off of steroids to start treatment
  • There is no restriction on serum lactate dehydrogenase (LDH) at crossover
  • Patients with a history of cardiovascular risks that developed during step 1 of therapy should be discussed with study principal investigator (PI) at time of crossover

• STEP 2 (CROSSOVER ARMS): Patients randomized to Arm A on Step 1 must have melanoma that is metastatic and clearly progressive on Step 1 therapy prior to crossing over to Arm C

  • NOTE: Patients should (if possible) be at least 1 week from documented PD on Step 1 of current study. All sites of disease must be evaluated within 4 weeks prior to registration

• STEP 2 (CROSSOVER ARMS): Patients randomized to Arm B on Step 1 may cross over to Arm D at or prior to disease progression

  • NOTE: If possible, patients should wait to cross over until after the cycle with the next protocol-required imaging assessment is completed; all sites of disease must be evaluated within 4 weeks prior to Step 2 registration
  • NOTE: Patients should start Arm D treatment at least 1 week after stopping dabrafenib and trametinib, unless otherwise clinically indicated
  • NOTE: Baseline labs and QOL assessments should be completed, and patients should follow the Arm D schedule
• STEP 2 (CROSSOVER ARMS): Patients must have recovered from adverse events (toxicities resolved to grade 1 or less) of prior therapy; patients with immune related toxicities from ipilimumab + nivolumab may continue onto Step 2 even if still on steroids to control side effects, so long as toxicity has resolved to grade 1 or less
• STEP 2 (CROSSOVER ARMS): Patients must have discontinued radiation therapy prior to registering to Step 2 of the study and recovered from any adverse events associated with treatment; prior surgery must be >= 2 weeks from registration to Step 2 and patients must be fully recovered from post-surgical complications
• STEP 2 (CROSSOVER ARMS): Patients are ineligible if they have any currently active and definitive CNS metastases; patients who have treated brain metastases (with either surgical resection or stereotactic radiosurgery [SRS]) could be eligible to proceed; patients crossing over from Arm B (dabrafenib/trametinib) to Arm D (nivolumab [nivo]/ipilimumab [ipi]) must not have taken any steroids =< 10 days prior to Step 2 registration for the purpose of managing their brain metastases; patients with only whole brain irradiation for treatment of CNS metastases are ineligible; patients with definitive CNS metastases treated with only WBRT are ineligible; patients with potential CNS metastases that are too small for treatment with either SRS or surgery (e.g. 1-2 mm) and/or are of uncertain etiology are potentially eligible, but need to be discussed with and approved by the study PI
• STEP 2 (CROSSOVER ARMS): Patients must not have other current malignancies
• STEP 2 (CROSSOVER ARMS): Women must not be pregnant or breast-feeding, as the effects of ipilimumab + nivolumab or dabrafenib + trametinib on the developing human fetus are unknown; all females of childbearing potential must have a blood test or urine study within 2 weeks prior to registration to Step 2 crossover to rule out pregnancy; a female of childbearing potential is any woman, regardless of sexual orientation or whether they have undergone tubal ligation, who meets the following criteria: 1) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months
• STEP 2 (CROSSOVER ARMS): The effects of dabrafenib and trametinib or ipilimumab and nivolumab on the developing human fetus are unknown; furthermore, dabrafenib has been reported to interfere with the effect of hormone based oral contraceptives; for this reason and because other therapeutic agents used in this trial are known to be teratogenic, women of child-bearing potential and sexually active males must agree to continue to use the same contraception requirements as on Step 1 of this study (i.e.: use at least two other accepted and effective methods of contraception and/or to abstain from sexual intercourse for the duration of their participation in the study, and for at least 4 weeks after treatment with dabrafenib or for 4 months after dabrafenib in combination with trametinib; women of child-bearing potential must use at least two other accepted and effective methods of contraception and/or to abstain from sexual intercourse for at least 5 months after the last dose of nivolumab and/or ipilimumab and sexually active males must use at least two other accepted and effective methods of contraception and/or to abstain from sexual intercourse for at least 7 months after the last dose of nivolumab and/or ipilimumab); should a woman become pregnant or suspect she is pregnant while she is participating in this study, she should inform her treating physician immediately

Exclusion Criteria:

• Women must not be pregnant or breast-feeding, as the effects of ipilimumab + nivolumab or dabrafenib + trametinib on the developing human fetus are unknown

  • All females of childbearing potential must have a blood test or urine study within 2 weeks prior to registration to rule out pregnancy
  • A female of childbearing potential is any woman, regardless of sexual orientation or whether they have undergone tubal ligation, who meets the following criteria: 1) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally postmenopausal for at least 24 consecutive months (i.e., has had menses at any time in the preceding 24 consecutive months)

Sex/Gender

• Sexes Eligible for Study: All

• Ages: 18 Years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Contacts: Contact information is only displayed when the study is recruiting subjects
• Listed Location Countries: United States

Administrative Information

• NCT Number: NCT02224781
• Other Study ID Numbers: NCI-2014-01747; NCI-2014-01747 ( Registry Identifier: CTRP (Clinical Trial Reporting Program) ); EA6134 ( Other Identifier: ECOG-ACRIN Cancer Research Group ); EA6134 ( Other Identifier: CTEP ); U10CA180820 ( U.S. NIH Grant/Contract )
• Has Data Monitoring Committee: No
• U.S. FDA-regulated Product: Not Provided
• IPD Sharing Statement: Not Provided
• Current Responsible Party: National Cancer Institute (NCI)
• Original Responsible Party: Same as current
• Current Study Sponsor: National Cancer Institute (NCI)
• Original Study Sponsor: Same as current
• Collaborators: Not Provided

Investigators

• Principal Investigator: Michael B Atkins; ECOG-ACRIN Cancer Research Group

• PRS Account: National Cancer Institute (NCI)
• Verification Date: April 2024