BACKGROUND

Zanidatamab, a dual human epidermal growth factor receptor 2 (HER2)-targeted bispecific antibody, previously demonstrated encouraging antitumour activity and a manageable safety profile in patients with treatment-refractory HER2-expressing gastro-oesophageal adenocarcinoma. Here, we evaluated the antitumour activity and safety of zanidatamab plus chemotherapy in first-line HER2-positive advanced gastro-oesophageal adenocarcinoma.

METHODS

This phase 2 trial enrolled patients in Canada, South Korea, and the USA who were aged 18 years and older with untreated, metastatic, or advanced HER2-positive gastro-oesophageal adenocarcinoma (HER2 IHC 3+ or 2+ by local or central assessment [part 1]; HER2 IHC 3+ or 2+ with FISH+ by central assessment [part 2]). Eligible patients, with an Eastern Cooperative Oncology Group performance status of 0 or 1 received zanidatamab intravenously plus standard chemotherapy (CAPOX [capecitabine plus oxaliplatin], FP [5-fluorouracil [5-FU] plus cisplatin], or modified FOLFOX6 [mFOLFOX6; leucovorin, 5-FU, and oxaliplatin]). In our study, part 1 aimed to characterise the safety and tolerability of zanidatamab and find the recommended dose when administered with combination chemotherapy and part 2 aimed to evaluate the antitumour activity of zanidatamab administered with combination chemotherapy in patients receiving first-line treatment for HER2-expressing advanced gastro-oesophageal adenocarcinoma. Two dosing schemes for zanidatamab were used in this study: a weight-based regimen and a two-tiered flat dosing regimen. In the CAPOX and FP groups, patients received either 30 mg/kg zanidatamab or 1800 mg or 2400 mg (patients weighing <70 kg and ≥70 kg, respectively) every 3 weeks. In the CAPOX group, patients also received 1000 mg/m capecitabine orally twice daily on days 1-14 every 3 weeks, plus 130 mg/m oxaliplatin intravenously every 3 weeks. In the FP cohort, patients also received 80 mg/m cisplatin intravenously every 3 weeks, plus 800 mg/m 5-FU per day continuous intravenous infusion on days 1-5 every 3 weeks. In the mFOLFOX6 group, patients received either 20 mg/kg zanidatamab or 1200 mg or 1600 mg for patients weighing under 70 kg or 70 kg and above, respectively, every 2 weeks, plus 400 mg/m intravenous leucovorin every 2 weeks, 85 mg/m intravenous oxaliplatin every 2 weeks, and 1200 mg/m 5-FU per day as a continuous intravenous infusion for 48 h every 2 weeks. mFOLFOX6-1 included the administration of a 400 mg/m 5-FU intravenous bolus on days 1 and 15; mFOLFOX6-2 omitted this 5-FU bolus. The primary endpoints of part 1 were safety and tolerability, which included frequencies of dose-limiting toxicities and dose reductions of zanidatamab and chemotherapy. The primary antitumour activity endpoint of part 2 was confirmed objective response rate assessed in the response-evaluable analysis set. Secondary endpoints included objective response rate, duration of response, disease control rate, clinical benefit rate, progression-free survival, and overall survival. Safety outcomes were assessed in all treated patients. We report the results from an interim analysis. This trial is registered at ClinicalTrials.gov (NCT03929666) and is complete for enrolment.

FINDINGS

Between Aug 29, 2019, and Feb 18, 2022, 46 patients were enrolled (39 [85%] were male; seven [15%] were female; 28 [61%] were white, 17 [37%] were Asian, and 43 [93%] were not Hispanic or Latino). Median follow-up was 47·9 months (IQR 39·2-53·7); eight (17%) patients were on treatment and 19 (41%) were in survival follow-up. The confirmed objective response rate was 76·2% (95% CI 60·5-87·9) with a median duration of response of 18·7 months (95% CI 10·4-44·1). The median progression-free survival was 12·5 months (95% CI 8·2-21·8) and median overall survival was 36·5 months (23·6-not estimable). The disease control rate was 88·1% (95% CI 74·4-96·0) and clinical benefit rate was 78·6% (95% CI 63·2-89·7). In part 1, there were no dose-limiting toxicities in six patients treated with zanidatamab plus CAPOX. One (50%) of two patients treated with zanidatamab plus FP had dose-limiting toxicities of diarrhoea and acute kidney injury (both grade 3). Two dose-limiting toxicities of diarrhoea (both grade 3) occurred in 2 (15%) of 13 patients receiving 5-FU 400 mg/m bolus on day 1 and 15 as part of the zanidatamab plus mFOLFOX6-1 regimen. 30 (65%) patients had treatment-related grade 3 or 4 adverse events. The most common treatment-related grade 3 or 4 adverse events were diarrhoea (18 [39%]; five [24%] in the 21 patients after implementing mandatory antidiarrhoeal prophylaxis) and hypokalaemia (ten [22%]). Six (13%) patients discontinued zanidatamab due to adverse events. No treatment-related deaths occurred.

INTERPRETATION

Zanidatamab plus chemotherapy as first-line treatment of HER2-positive advanced gastro-oesophageal adenocarcinoma demonstrated clinically meaningful and durable antitumour activity, with a manageable safety profile.

FUNDING

Jazz Pharmaceuticals, Zymeworks.