FDA Approves Avelumab for Merkel Cell Carcinoma

Richard Pazdur, MD

The FDA has granted an accelerated approval to the PD-L1 inhibitor avelumab (Bavencio) for the treatment of adults and pediatric patients 12 years and older with metastatic Merkel cell carcinoma, including those who have not received prior chemotherapy.

The approval is based on data from the phase II JAVELIN Merkel 200 study. In the open-label trial, the objective response rate (ORR) with avelumab was 33% (95% CI, 23.3-43.8), which included an 11.4% (95% CI, 6.6-19.9) complete response rate and a 21.6% (95% CI, 13.5-31.7) partial response rate. The duration of response (DOR) was at least 6 months in 86% of patients, with 45% of patients having a DOR of 12 months or more.

“While skin cancer is one of the most common cancers, patients with a rare form called Merkel cell cancer have not had an approved treatment option until now,” Richard Pazdur, MD, acting director of the Office of Hematology and Oncology Products in the FDA’s Center for Drug Evaluation and Research and director of the FDA’s Oncology Center of Excellence, said in a statement. “The scientific community continues to make advances targeting the body’s immune system mechanisms for the treatment of various types of cancer. These advancements are leading to new therapies—even in rare forms of cancer where treatment options are limited or non-existent.”

Results from the JAVELIN Merkel 200 study, which enrolled 88 previously treated patients with metastatic Merkel cell carcinoma, were previously presented at the 2016 ASCO Annual Meeting and published in the Lancet Oncology.^1,2 The median age of patients in the study was 72.5 years, and each received avelumab at 10 mg/kg every 2 weeks. Patients had received at least 1 prior therapy (59.1%), with 11.4% having ≥3 prior system treatments. Most patients in the study were male (73.9%) and the ECOG performance status was 0 (55.7%) and 1 (44.3%).

The most common site of primary tumor was the skin (76.1%) and all patients had metastatic involvement at the time of study entry. Visceral disease was present for 53.4% of patients. Overall, 65.9% of patients were PD-L1-positive and 52.3% were positive for the Merkel cell polyomavirus (MCPyV). Eight percent of patients were negative for both PD-L1 and MCPyV and 40.9% were positive for both markers.

Median progression-free survival (PFS) with avelumab was 2.7 months (95% CI, 1.4-6.9). The 6-month PFS rate was 40%. The median overall survival (OS) was 11.3 months (95% CI, 7.5-14.0) and the 6-month OS rate was 69%.

The ORR was 34.5% in the PD-L1-positive arm and 18.8% in the PD-L1-negative group. The response rate in those who were not evaluable for PD-L1 status was 35.7%. The ORRs were 26.1% and 35.5% in the MCPyV-positive and -negative arms, respectively. In those not evaluable for the virus the ORR was 45.5%. Patients who were positive for both markers had an ORR of 30.6% and those negative for both markers had an ORR of 28.6%.

Treatment-related adverse events (AEs) of any grade were experienced by 70.5% of patients in the study. The most common AEs, which were mostly grade 1/2, were fatigue (23.9%), infusion-related reaction (17%), diarrhea (9.1%), nausea (9.1%), asthenia (8%), rash (6.8%), decreased appetite (5.7%), and maculopapular rash (5.7%).

Grade 3 AEs were experienced by 4.5% of patients and were mostly laboratory abnormalities, such as lymphopenia, blood CPK increase, transaminase increase, and blood cholesterol increase. There were no grade 4 AEs or deaths related to avelumab. Two patients discontinued treatment due to AEs.

Avelumab is the first treatment approved by the FDA for metastatic Merkel cell carcinoma. The accelerated approval of avelumab in this setting is contingent upon the results of confirmatory trials.

This is the first FDA approval for avelumab. The FDA has also granted a priority review to the PD-L1 inhibitor for the treatment of patients with locally advanced or metastatic urothelial carcinoma whose disease has progressed after platinum-based therapy. The agency is scheduled to make its final approval on this indication on or before August 27, 2017.

References:

1. Kaufman H, Russell JS, Hamid O, et al. Avelumab (MSB0010718C; anti-PD-L1) in patients with metastatic Merkel cell carcinoma previously treated with chemotherapy: Results of the phase 2 JAVELIN Merkel 200 trial. J Clin Oncol. 2016;34 (suppl; abstr 9508).
2. Kaufman H, Russell JS, Hamid O, et al. Avelumab in patients with chemotherapy-refractory metastatic Merkel cell carcinoma: a multicentre, single-group, open-label, phase 2 trial. Lancet Oncol. 2016;17(10):1374-1385.