US FDA approves Merck’s Keytruda in combo with chemotherapy, with or without bevacizumab to treat patients with persistent, recurrent or metastatic cervical cancer whose tumors express PD-L1
Merck, known as MSD outside the United States and Canada, announced that the US Food and Drug Administration (FDA) has approved Keytruda, Merck’s anti-PD-1 therapy, in combination with chemotherapy, with or without bevacizumab, for the treatment of patients with persistent, recurrent or metastatic cervical cancer whose tumors express PD-L1 (Combined Positive Score [CPS] =1)as determined by an FDA-approved test. The approval is based on the phase 3 KEYNOTE-826 trial evaluating Keytruda plus chemotherapy (paclitaxel plus cisplatin or paclitaxel plus carboplatin), with or without bevacizumab, compared to the same chemotherapy regimens, with or without bevacizumab.
In this patient population, Keytruda plus chemotherapy, with or without bevacizumab, demonstrated superior overall survival (OS; HR=0.64 [95% CI, 0.50-0.81]; p=0.0001) and progression-free survival (PFS; HR=0.62 [95% CI, 0.50-0.77]; p<0.0001) compared to chemotherapy, with or without bevacizumab, in patients whose tumors express PD-L1 (CPS =1). Additionally, more patients responded to Keytruda plus chemotherapy, with or without bevacizumab, than to chemotherapy, with or without bevacizumab, with an objective response rate (ORR) of 68% (95% CI, 62-74) versus 50% (95% CI, 44-56), respectively. Among patients who responded, the median duration of response (DOR) was 18.0 months (range, 1.3+ to 24.2+) for Keytruda plus chemotherapy, with or without bevacizumab, and 10.4 months (range, 1.5+ to 22.0+) for chemotherapy, with or without bevacizumab.
Immune-mediated adverse reactions, which may be severe or fatal, can occur in any organ system or tissue and can affect more than one body system simultaneously. Immune-mediated adverse reactions can occur at any time during or after treatment with Keytruda, including pneumonitis, colitis, hepatitis, endocrinopathies, nephritis, dermatologic reactions, solid organ transplant rejection, and complications of allogeneic hematopoietic stem cell transplantation. Important immune-mediated adverse reactions listed here may not include all possible severe and fatal immune-mediated adverse reactions. Early identification and management of immune-mediated adverse reactions are essential to ensure safe use of Keytruda. Based on the severity of the adverse reaction, Keytruda should be withheld or permanently discontinued and corticosteroids administered if appropriate. Keytruda can also cause severe or life-threatening infusion-related reactions. Based on its mechanism of action, Keytruda can cause fetal harm when administered to a pregnant woman. For more information, see “Selected Important Safety Information” below.
“Cervical cancer more commonly affects younger women and certain women of color in the US, and unfortunately, women diagnosed with persistent, recurrent or metastatic cervical cancer often have a low survival rate,” said Dr. Bradley Monk, oncologist with Arizona Oncology, medical director of US Oncology Research Gynecology Program and professor of obstetrics and gynecology at University of Arizona’s College of Medicine and Creighton University School of Medicine. “There have been no first-line approvals for women with persistent, recurrent or metastatic cervical cancer in the past seven years. I am excited for today’s approval of a new combination with Keytruda, which offers a new treatment option for appropriate patients.”
“Today’s news is a meaningful step forward, as it offers a new therapeutic option for these patients and reinforces the role of Keytruda in treating certain types of cervical cancers, with a second indication for the disease,” said Dr. Roy Baynes, senior vice president and head of global clinical development, chief medical officer, Merck Research Laboratories. “The data showing a 36% reduction in the risk of death are compelling, and this approval brings an important new first-line treatment option to women with persistent, recurrent or metastatic cervical cancer whose tumors express PD-L1 (CPS =1).”
Additionally, the FDA converted the accelerated approval of Keytruda as a single agent for the treatment of patients with recurrent or metastatic cervical cancer with disease progression on or after chemotherapy whose tumors express PD-L1 (CPS =1), as determined by an FDA-approved test, to a regular approval based on confirmatory data from KEYNOTE-826. This approval was originally granted in June 2018 based on results from the KEYNOTE-158 trial.
Merck is committed to delivering meaningful advances in women’s cancers. The company is rapidly expanding its extensive clinical development program for Keytruda and several other investigational and approved medicines across gynecologic cancers, including researching Keytruda for the treatment of other types of cervical cancer.
The approval was based on data from KEYNOTE-826 (ClinicalTrials.gov, NCT03635567), a multicenter, randomized, double-blind, placebo-controlled Phase 3 trial that enrolled 617 patients with persistent, recurrent or first-line metastatic cervical cancer who had not been treated with chemotherapy except when used concurrently as a radio-sensitizing agent. Patients were enrolled regardless of tumor PD-L1 expression status. Patients with autoimmune disease that required systemic therapy within two years of treatment or a medical condition that required immunosuppression were ineligible. Randomization was stratified by metastatic status at initial diagnosis, investigator decision to use bevacizumab and PD-L1 status (CPS <1 vs. CPS 1 to <10 vs. CPS =10). Patients were randomized (1:1) to one of the two treatment groups.
Patients in the Keytruda arm received Keytruda 200 mg intravenously every three weeks (Q3W) plus investigator’s choice of paclitaxel plus cisplatin or paclitaxel plus carboplatin Q3W, with or without bevacizumab Q3W. Patients in the placebo arm received placebo plus investigator’s choice of paclitaxel plus cisplatin or paclitaxel plus carboplatin Q3W, with or without bevacizumab Q3W. All study treatments were administered on Day 1 of each 3-week treatment cycle. Cisplatin could be administered on Day 2 of each three-week treatment cycle. Treatment with Keytruda continued until RECIST v1.1-defined progression of disease, unacceptable toxicity or a maximum of 24 months. Administration of Keytruda was permitted beyond RECIST-defined disease progression if the patient was clinically stable and considered to be deriving clinical benefit by the investigator. Assessment of tumor status was performed every nine weeks for the first year, followed by every twelve weeks thereafter. The main efficacy outcome measures were OS and PFS as assessed by investigator review according to RECIST v1.1, modified to follow a maximum of 10 target lesions and a maximum of five target lesions per organ. Additional efficacy outcome measures were ORR and DOR, according to RECIST v1.1, as assessed by investigator review.
Of the 617 enrolled patients, 548 patients (89%) had tumors expressing PD-L1 with a CPS =1. Among these 548 enrolled patients with tumors expressing PD-L1, 273 patients were randomized to Keytruda in combination with chemotherapy, with or without bevacizumab, and 275 patients were randomized to placebo in combination with chemotherapy, with or without bevacizumab. Sixty-three percent of the 548 patients received bevacizumab as part of study treatment. At study entry, 21% of patients had metastatic disease only, and 79% had persistent or recurrent disease, with or without distant metastases, of whom 39% had received prior chemoradiation only, and 17% had received prior chemoradiation plus surgery.
Keytruda is an anti-programmed death receptor-1 (PD-1) therapy that works by increasing the ability of the body’s immune system to help detect and fight tumor cells. Keytruda is a humanized monoclonal antibody that blocks the interaction between PD-1 and its ligands, PD-L1 and PD-L2, thereby activating T lymphocytes which may affect both tumor cells and healthy cells.
Merck has the industry’s largest immuno-oncology clinical research program. There are currently more than 1,600 trials studying Keytruda across a wide variety of cancers and treatment settings. The Keytruda clinical program seeks to understand the role of Keytruda across cancers and the factors that may predict a patient's likelihood of benefitting from treatment with Keytruda, including exploring several different biomarkers.
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