FDA Approves Pemigatinib for FGFR2+ Cholangiocarcinoma

The FDA has approved pemigatinib (Pemazyre) for the treatment of patients with previously treated, locally advanced or metastatic cholangiocarcinoma with FGFR2 fusions or rearrangements, as detected by an FDA-approved test.¹

The approval is based on interim findings from the multicohort, single-arm, phase II FIGHT-202 study, which showed that, at a median follow-up of 15 months, single-agent pemigatinib led to a 36% objective response rate (ORR) and a median duration of response of 7.5 months in a cohort of patients with FGFR2 fusions or rearrangements.² The selective inhibitor of FGFR1, 2, and 3 was also associated with a manageable adverse event (AE) profile, as seen in data that were also published in Lancet Oncology.³

"This approval demonstrates that while we continue to focus our efforts on addressing the COVID-19 pandemic, the FDA remains committed to the important work of reviewing treatments for patients with cancer and other serious conditions," Richard Pazdur, MD, director of the FDA's Oncology Center of Excellence and acting director of the Office of Oncologic Diseases in the FDA's Center for Drug Evaluation and Research, stated in a press release. "With Pemazyre, we considered the observed efficacy results to be clinically meaningful and the overall risk to benefit assessment for patients with tumors harboring FGFR2 gene fusions and other rearrangements to be favorable, particularly when we considered that these patients have no other good options following first line treatment with chemotherapy."

Patients with cholangiocarcinoma are often diagnosed at a late or advanced stage when the prognosis is poor.

While first-line treatment for patients with locally advanced or metastatic cholangiocarcinoma is the chemotherapy combination of gemcitabine and cisplatin, second-line therapies have shown limited efficacy.

The FIGHT-202 trial was conducted in the United States, Europe, Middle East, and Asia. Patients who were eligible for enrollment had locally advanced or metastatic cholangiocarcinoma despite ≥1 line of prior therapy, had their FGF/FGFR status centrally confirmed, and adequate renal function was required.

Patients were stratified into 3 cohorts: those with FGFR2 fusions/rearrangements (cohort A; n = 107), those with other FGF/FGFR genetic alterations (cohort B; n = 20), and no FGF/FGFR alterations (cohort C; n = 18). Patients in each of the 3 cohorts were treated with oral pemigatinib (13.5 mg) using a 2-weeks-on/1-week-off schedule.

The study was not designed to make statistical comparisons between the 3 cohorts. The primary endpoint was the confirmed ORR in cohort A by independent central review.

Median age of the entire 146 patients who were enrolled enrolled was 59 years; however, 77% of patients in cohort A were <65 years, compared with 50% in cohort B, and 39% of patients in cohort C. Overall, 58% of patients were women (61% in cohort A), and 61% of patients were enrolled in North America, 24% in Western Europe, and 15% of patients were enrolled in other geographical areas.

Among the 107 patients in cohort A, 92 fusions and 15 rearrangements identified. A total of 56 unique fusion partners were identified, the most common of which was BICC1, which occurred in 29%. Forty-two partners were unique to a single patient, and no fusion partner was identified in 5% of patients.

Results showed that, in cohort A, the 36% ORR consisted of 3 (2.8%) complete responses, 35 (33%) partial responses, and 50 (46.7%) patients with stable disease, for a disease control rate of 82%. The ORR was consistent across subgroups, including when stratified by the number of prior lines of therapy and by FGFR2 rearrangement partner. Among those who had a response, 24 patients (63%) had a response lasting ≥6 months and 7 patients (18%) had a response lasting ≥12 months.

Additionally, the higher ORR translated into a longer median progression-free survival (PFS) in cohort A. Median PFS was 6.9 months in cohort A compared with 2.1 months in cohort B and 1.7 months in cohort C.

Overall survival (OS) data were not yet mature at the time of the March 22, 2019, data cutoff. However, but with a median duration of follow-up of 15.4 months and a median duration of treatment of 7.2 months, the median OS was 21.1 months in the cohort with FGFR2 fusions/rearrangements. Median OS was only 6.7 months in the cohort with other FGF/FGFR alterations after a median follow-up of 19.9 months, and only 4.0 months in the cohort without an FGF/FGFR alteration after a median follow-up of 24.2 months.

Regarding safety, AEs were found to be manageable and consistent with the mechanism of action of pemigatinib. The most common AE was hyperphosphatemia (60%), but no grade ≥3 cases were encountered. Hyperphosphatemia was managed with a low phosphate diet, phosphate binders, diuretics, and a reduction or interruption in the pemigatinib dose. Three patients required dose reductions/interruptions due to hyperphosphatemia.

Any-grade hypophosphatemia occurred in 23% of patients and was the most common grade ≥3 AE, with a rate of 12%. No case of hypophosphatemia was clinically significant and none led to treatment discontinuation or dose reduction. Serous retinal detachment occurred in 4% of patients and usually resolved spontaneously or after dose interruption.

Nine percent of patients discontinued due to AEs; the most frequent causes were intestinal obstruction and acute kidney injury (2 each). Treatment was discontinued due to progressive disease in all patients in cohorts B and C, and in 57 patients in cohort A. Dose reduction due to AEs was required in 14%, with the most common reasons being stomatitis (n = 11), palmar-plantar erythrodysesthesia syndrome (n = 5), arthralgia (n = 5), asthenia (n = 2), and onychomadesis (n = 2). Approximately 42% of patients required dose interruptions due to AEs.

Based on the data from FIGHT-202, a phase III study of pemigatinib compared with gemcitabine plus cisplatin in the first-line setting in patients with cholangiocarcinoma and FGFR2 fusions/rearrangements is ongoing (NCT03656536).

References

1. FDA Approves First Targeted Treatment for Patients with Cholangiocarcinoma, a Cancer of Bile Ducts [news release]. FDA. Published April 17, 2020. https://prn.to/2xGXrO6. Accessed April 17, 2020.
2. Hollebecque A, Borad M, Sahai V, et al. FIGHT-202: a phase 2 study of pemigatinib in patients (pts) with previously treated locally advanced or metastatic cholangiocarcinoma (CCA). Presented at: 2019 ESMO Congress; September 27-October 1, 2019; Barcelona, Spain. Abstract LBA40.
3. Abou-Alfa GK, Sahai V, Hollebecque A, et al. Pemigatinib for previously treated, locally advanced or metastatic cholangiocarcinoma: a multicentre, open-label, phase 2 study [published online March 20, 2020]. Lancet Oncol. doi: 10.1016/S1470-2045(20)30109-1