This study is for people who have anal cancer and have not yet had treatment. The regular treatment for people who have anal cancer is chemoradiation therapy (CRT). CRT is when chemotherapy and radiation therapy are given at the same time. Studies show that CRT works well to treat anal cancer and prevents many people from needing surgery which may require a colostomy bag. Doctors know that CRT is an effective way to treat anal cancer. But, they are doing studies to find out how much dose of radiation and chemotherapy should be given during the CRT. Higher doses of chemotherapy and radiation could increase the risk of side effects, but lowering the dose of chemoradiation has the risk of not being as effective to treat the cancer. One way to predict whether participants need higher or lower doses of radiation therapy is to do a blood test called ctDNA (circulating tumor DNA) to test for the presence of human papillomavirus (HPV). This test is done at certain times while participants are getting CRT. This has been shown to be a marker for the presence of anal cancer. In this study, doctors will tailor lower versus higher doses of CRT based on the tumor response that is measured by ctDNA. The purpose of this study is to see if customizing the dose of chemoradiation based on the amount of ctDNA will increase survival in participants with anal cancer and/or decrease the risk of side effects. Some participants in this study whose cancer does not respond as well to the CRT may have the opportunity to receive a drug called Retifanlimab that stimulates the body's immune system. Retifanlimab is approved by the Federal Drug Administration (FDA) for treating anal cancer that is recurrent or metastatic since there is proven benefit in these situations.
For people with advanced-stage squamous cell carcinoma of the anus (SCCA), there is a great need to adjust the amount of chemoradiation therapy (CRT) they receive based on how well they are responding to the treatment. This allows doctors to increase the dose for people whose cancer is not getting better or to decrease the dose for people whose cancer is getting better from the treatment. Decreasing the dose for people who don't need it is important so that they might have a lower risk of negative side effects of CRT. Doctors may be able to use HPV ctDNA as a biomarker to figure out how people's cancer is responding to CRT in order to make these changes to dosage. For this study, investigators will change the dosage of CRT that participants receive based on HPV ctDNA response at various points throughout treatment. People who have a favorable response will have their CRT dosage decreased. Participants who have an intermediate response will have their CRT dosage unchanged. Participants who have an unfavorable response will have their CRT dosage increased and receive Retifanlimab after CRT.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
TREATMENT
Masking
NONE
Enrollment
33
Total radiation doses per response group: * Favorable response: 5040 cGy in 28 fractions * Intermediate response: 5400 cGy in 30 fractions * Unfavorable response: 6120 cGy in 34 fractions
1. Mitomycin-C(MMC) 12 mg/m2 on day 1 AND one of the following: 2. Capecitabine 825 mg/m2 twice daily on all days of radiotherapy for all response groups OR 5-Fluorouracil: 1000 mg/m²/day as a continuous infusion for 96 hours on days 1-4 and 29-32
Only participants who have an unfavorable response to treatment (measured on blood tests at Weeks 4 and 5) will be eligible to receive Retifanlimab. Retifanlimab is a 500 mg infusion administered intravenously (by IV) over 30 minutes and begins two weeks after participants finish chemoradiation therapy (at Weeks 7-9). Retifanlimab will be administered on Day 1 of each cycle (each cycle is 4 weeks) as tolerated for up to 1 year.
University Hospitals Cleveland Medical Center, Seidman Cancer Center, Cleveland Clinic Taussig Cancer Center, Case Comprehensive Cancer Center
Cleveland, Ohio, United States
Case Comprehensive Cancer Center, Cleveland Clinic Taussig Cancer Center
Cleveland, Ohio, United States
1-year Disease-free survival (DFS) by response subgroup
DFS is defined the occurrence of progression of local disease, distant metastases, second primary or death. 1-year DFS, will be analyzed using the Kaplan-Meier method and be compared using a 0.05-level one-sided two-proportion test. DFS will be compared among the three subgroups: favorable response subgroup, intermediate response subgroup, unfavorable response subgroup.
Time frame: 1 year
2-year disease free survival by response subgroup
DFS is defined the occurrence of progression of local disease, distant metastases, second primary or death. 2-year DFS, will be analyzed using the Kaplan-Meier method and be compared using a 0.05-level one-sided two-proportion test. DFS will be compared among the three subgroups: favorable response subgroup, intermediate response subgroup, unfavorable response subgroup.
Time frame: 2 years
1-year disease control by response subgroup
Disease control is defined as a composite endpoint that includes failure to achieve a clinical response or subsequent disease recurrence. Achieving a clinical response includes the proportion of participants who achieve complete response (CR), partial response (PR), or stable disease (SD) according to Response Evaluation Criteria in Solid Tumors version 1.1. CR is defined as the absence of tumor on re-staging scans and explant or mucosal biopsies (if applicable). PR is defined as a 30% decrease in the sum of diameters of target lesions. SD is defined as neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for progressive disease (PD). PD is defined as a 20% increase in the sum of diameters of target lesions with an absolute increase of at least 5 millimeters (mm) or the appearance of one or more new lesions. Disease control will be analyzed using the Kaplan-Meier method and be compared using a 0.05-level one-sided two-proportion test.
Time frame: 1 year
2-year disease control by response subgroup
Disease control is defined as a composite endpoint that includes failure to achieve a clinical response or subsequent disease recurrence. Achieving a clinical response includes the proportion of participants who achieve complete response (CR), partial response (PR), or stable disease (SD) according to Response Evaluation Criteria in Solid Tumors version 1.1. CR is defined as the absence of tumor on re-staging scans and explant or mucosal biopsies (if applicable). PR is defined as a 30% decrease in the sum of diameters of target lesions. SD is defined as neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for progressive disease (PD). PD is defined as a 20% increase in the sum of diameters of target lesions with an absolute increase of at least 5 millimeters (mm) or the appearance of one or more new lesions. Disease control will be analyzed using the Kaplan-Meier method and be compared using a 0.05-level one-sided two-proportion test.
Time frame: 2 years
Toxicity Index as assessed by the number of CTCAE events
Events will be graded per National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 5.
Time frame: 3 months post-treatment (up to 2 years)
Change in patient-reported outcomes (PRO) as assessed by FISI (Fecal Incontinence Severity Index)
FISI measures fecal incontinence by four types of leakage: gas, mucus, liquid, solid. Participants answer a total of 5 questions ranking the frequency and severity of symptoms on 5-point Likert scale from 0 ("No symptoms" or "Not bothersome") to 5 ("Extremely severe" or "Always") for each type of leakage. Higher scores indicate higher incontinence severity. Changes in PRO will be summarized, visualized for each response subgroup. A generalized linear mixed model will be fitted to compare the clinically meaningful changes between groups.
Time frame: Baseline (Day 1), Year 2
Change in patient-reported outcomes (PRO) as assessed by FIQoL (Fecal Incontinence quality of life scale)
FIQoL has a total of four questions to assess quality of life related to fecal incontinence. One questions asks participants to rank their general health on a 5-point Likert scale from 1 ("Excellent") to 5 ("Poor"). One question with a total of 13 sub-questions asks participants to rank their symptom frequency on a 4-point Likert scale from 4 ("Most of the time") to 0 ("None of the time"). One question asks participants to rank their feelings around symptoms according to how much they agree with 14 statements on a Likert scale from 4 ("Strongly agree") to 0 ("Strongly disagree"). One question asks participants to rank negative feelings of well-being on a 6-point Likert scale from 1 ("Extremely so") to 6 ("Not at all"). Higher scores indicate high quality of life. Changes in PRO will be summarized, visualized for each response subgroup. A generalized linear mixed model will be fitted to compare the clinically meaningful changes between groups.
Time frame: Baseline (Day 1), Year 2
Change in participant-reported outcomes (PRO) as assessed by PROMIS Sexual Function and Satisfaction (SexFS) questionnaire
SexFS has a total of nine questions that assess for sexual function and satisfaction. Three questions ask participants to rank frequency of sexual interest on a 4-point Likert scale from 1 ("Not at all) to 4 ("Very much"). Two questions ask participants to rank satisfaction on a 7-point Likert scale from 1 ("Very dissatisfied") to 7 ("Very satisfied"). Two additional questions assess sexual desire on a 5-point Likert scale from 0 ("Never") to 4 ("Always"). Two final questions ask participants if they have recently had sexual activity (Yes/No) and, if "No," to list reasons why they have not. Higher scores indicate greater sexual function and satisfaction. Changes in PRO will be summarized, visualized for each response subgroup. A generalized linear mixed model will be fitted to compare the clinically meaningful changes between groups.
Time frame: Baseline (Day 1), Year 2
Change in participant-reported outcomes (PRO) as assessed by Sexual Function-Vaginal Changes Questionnaire (SVQ)
SVQ is a 27-item questionnaire where participants answer questions about their sexual function and vaginal changes before and after cancer. Twenty questions about current sexual function are answered on a 4-point Likert scale from 1 ("Not at all") to 4 ("Very much"). Seven additional questions ask about changes that have occurred since having cancer and are answered on a 3-point Likert scale from 1 ("Less now than before") to 3 ("More now than before"). Higher scores indicate greater sexual function. Changes in PRO will be summarized, visualized for each response subgroup. A generalized linear mixed model will be fitted to compare the clinically meaningful changes between groups.
Time frame: Baseline (Day 1), Year 2
Change in participant-reported outcomes (PRO) as assessed by International Index of Erectile Function (IIEF)
IIEF is a 15-item questionnaire that assesses effects of erectile problems on sexual functioning and well-being. All 15 questions are a 6-point Likert scale from 0 ("No/None" or "Very dissatisfied") to 5 ("Almost always or always" or "Very satisfied"). Higher scores indicate greater erectile function. Changes in PRO will be summarized, visualized for each response subgroup. A generalized linear mixed model will be fitted to compare the clinically meaningful changes between groups.
Time frame: Baseline (Day 1), Year 2
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