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Efficacy data in 2L DTC CABOMETYX® (cabozantinib) monotherapy

In patients who are RAI-R or ineligible and progressed on a prior VEGFR-targeted therapy1

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Meaningful results led to early unblinding in the COSMIC-311 trial2

    COSMIC-311: STUDY DESIGN

    COSMIC-311 was a phase 3, multicenter, randomized, double-blind, placebo-controlled trial.1,3

    2:1 randomization
    (N=187)
    RAI-R DTC progressed after prior VEGFR-targeting TKI
    Cabozantinib 60-mg QD + BSC*
    (n=125)    		Placebo + BSC*
    (n=62)
    Treatment until disease progression
    Eligible placebo patients were allowed to cross over to receive open-label cabozantinib after BIRC-confirmed PD per RECIST 1.1†
    UNBLINDED TRIAL‡Cabozantinib 60-mg
    Post-treatment follow-up§

    The multiple primary efficacy outcome measures assessed ORR in the first 100 patients (OITT) after 6 months of enrollment and PFS in all patients randomly assigned (ITT). Median follow-up was 6.2 months (IQR: 3.4–9.2) for the ITT population and 8.9 months (IQR: 7.1–10.5) for the OITT population. Median duration of treatment exposure in the safety population was 4.4 months (IQR: 2.1-7.3) for the CABOMETYX patients and 2.3 months (IQR: 1.6-5.6) for the placebo group. An updated analysis, with median follow-up of 10.1 months, evaluated a total of 258 randomized patients.1,3,4​​​​​​​

    *

    BSC included dose modification and dose interruption. After unblinding, BSC included potentially receiving open-label cabozantinib.1,3

    †

    Tumor response and progression were assessed by MRI or CT. Tumor assessments were performed every 8 weeks after randomization for 12 months, then every 12 weeks thereafter.3

    ‡

    An IDMC for COSMIC-311 recommended ending enrollment and unblinding sites and patients based on cabozantinib reducing the risk of disease progression or death by 78% (HR=0.22; 95% CI: 0.14-0.35; P<0.0001).2

    Multiple primary efficacy outcome measures1

    • PFS

    • ORR
    Stratification factors1

    • Age ≤65 years

    • Prior lenvatinib

    Baseline Characteristics in ITT Population1,3

      Total Population
    Median age, years (range)

    ECOG 0

    ECOG 1    		 65 (31-85)

    46%

    54%
      CABOMETYX Placebo
    One previous VEGFR TKI

    Two previous VEGFR TKIs    		 73% (91/125)

    27% (34/125)    		 77% (48/62)

    23% (14/62)
    73% of patients received CABOMETYX after one previous systemic therapy3§
    §

    Updated analysis (N=258).1

    CABOMETYX delivered a significant benefit in the primary PFS analysis1

    Median PFS was not reached in the primary analysis (n=125, 95% CI: 5.7-NE) vs PFS of 1.9 months with placebo (n=62, 95% CI: 1.8-3.6); HR=0.22 (95% CI: 0.14-0.35); P<0.0001.
     

    Early and sustained separation demonstrated at updated analysis -- with a median PFS of 11 months1

    Updated analysis

    Kaplan-Meier curve shows significant benefit in the primary PFS analysis from COSMIC-311

    No formal statistical testing was conducted at the time of the updated analysis.

    78% reduction in risk of progression or death in both primary and updated analyses

     

    Tumor response observed at the OITT analysis3

    In the COSMIC-311 trial, the overall response rate (ORR) did not reach a prespecified endpoint for statistical significance (critical P value=0.01). Data below cover tumor response information collected, inclusive of ORR.1,3

      CABOMETYX Placebo
    ORR, % (95% CI)‖

    Stable disease, % (n/N)

    Disease control rate, % (n/N)**    		 15 (7-26)

    69 (46/67)

    84 (56/67)    		 0 (0-11)

    42 (14/33)

    42 (14/33)
    ‖

    P=0.0281; all responses confirmed were partial responses.3

    Stable disease is defined as neither sufficient shrinkage to qualify for partial response nor sufficient increase to qualify for PD.5
    Stable disease may reflect the natural history of disease rather than any effect of the drug.

    **

    Disease control rate was defined as the percentage of patients with a complete response, partial response, or stable disease, as measured by RECIST 1.1.3

    76% of patients experienced tumor shrinkage with CABOMETYX at the OITT analysis3††

    Bar graph shows 76% of patients experienced tumor shrinkage COSMIC-311 OITT analysis

    Each vertical line represents 1 patient. The plot represents the best percentage change in tumor size from baseline in the evaluable patient population, as determined by the investigators, per RECIST 1.1.3††

    • Among patients with baseline and postbaseline target lesion assessment, 44 (76%) of 58 patients with ≥1 postbaseline target lesion assessment in the CABOMETYX arm had some level of reduction in target lesions compared with 9 (29%) of 31 patients in the placebo arm3
    ††

    Data from OITT analysis of evaluable patients.3

    ‡‡

    Confirmed partial response.3

    National Comprehensive Cancer Network® (NCCN®)

    Cabozantinib (CABOMETYX) has a Category 1 recommendation for patients with RAI-R papillary thyroid cancer that has progressed following VEGFR-targeted therapy§§

    NCCN makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way.
    NCCN Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.

    §§

    If progression after lenvatinib and/or sorafenib.

    See Monotherapy Safety Data
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    BIRC=blinded independent radiology committee; BSC=best supportive care; CI=confidence interval; CT=computed tomography; ECOG=Eastern Cooperative Oncology Group performance status; HR=hazard ratio; IDMC=independent data-monitoring committee; IQR=interquartile range; ITT=intent to treat; MRI=magnetic resonance imaging; NE=not estimable; OITT=ORR intent to treat; ORR=overall response rate; PD=progressive disease; PFS=progression-free survival; QD=every day; RAI-R=radioactive iodine-refractory; RECIST=Response Evaluation Criteria in Solid Tumors; SoD=sum of diameter; TKI=tyrosine kinase inhibitor; VEGFR=vascular endothelial growth factor receptor.

    References:

    1. CABOMETYX® (cabozantinib) Prescribing Information. Exelixis, Inc.
    2. Exelixis press release. December 21, 2020. https://ir.exelixis.com/news-releases/news-release-details/exelixis-announces-cabozantinib-significantly-improved.
    3. Brose MS, Robinson B, Sherman SI, et al. Cabozantinib for radioiodine-refractory differentiated thyroid cancer (COSMIS-311): a randomized, double-blind, placebo-controlled, phase 3 trial. Lancet Oncol. 2021;22(8):1126-1138. doi:10.1016/S1470-2045(21)00332-6.
    4. European Medicines Agency: Committee for Medicinal Products for Human Use (CHMP). Assessment report: CABOMETYX. September 2018. Accessed September 15, 2022.
    5. Eisenhauer EA, Therasse P, Bogaerts J, et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009;45(2):228-247.
    6. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Thyroid Cancer V.3.2022.  © National Comprehensive Cancer Network, Inc. 2022. All rights reserved. Accessed November 1, 2022. To view the most recent and complete version of the guideline, go online to NCCN.org.

    IMPORTANT SAFETY INFORMATION 

    WARNINGS AND PRECAUTIONS 

    Hemorrhage: Severe and fatal hemorrhages occurred with CABOMETYX. The incidence of Grade 3 to 5 hemorrhagic events was 5% in CABOMETYX patients in RCC, HCC, and DTC studies. Discontinue CABOMETYX for Grade 3 or 4 hemorrhage and prior to surgery as recommended. Do not administer CABOMETYX to patients who have a recent history of hemorrhage, including hemoptysis, hematemesis, or melena. 

    Perforations and Fistulas: Fistulas, including fatal cases, occurred in 1% of CABOMETYX patients. Gastrointestinal (GI) perforations, including fatal cases, occurred in 1% of CABOMETYX patients. Monitor patients for signs and symptoms of fistulas and perforations, including abscess and sepsis. Discontinue CABOMETYX in patients who experience a Grade 4 fistula or a GI perforation. 

    Thrombotic Events: CABOMETYX increased the risk of thrombotic events. Venous thromboembolism occurred in 7% (including 4% pulmonary embolism) and arterial thromboembolism in 2% of CABOMETYX patients. Fatal thrombotic events occurred in CABOMETYX patients. Discontinue CABOMETYX in patients who develop an acute myocardial infarction or serious arterial or venous thromboembolic events that require medical intervention. 

    Hypertension and Hypertensive Crisis: CABOMETYX can cause hypertension, including hypertensive crisis. Hypertension was reported in 37% (16% Grade 3 and <1% Grade 4) of CABOMETYX patients. Do not initiate CABOMETYX in patients with uncontrolled hypertension. Monitor blood pressure regularly during CABOMETYX treatment. Withhold CABOMETYX for hypertension that is not adequately controlled with medical management; when controlled, resume at a reduced dose. Permanently discontinue CABOMETYX for severe hypertension that cannot be controlled with anti-hypertensive therapy or for hypertensive crisis. 

    Diarrhea: Diarrhea occurred in 62% of CABOMETYX patients. Grade 3 diarrhea occurred in 10% of CABOMETYX patients. Monitor and manage patients using antidiarrheals as indicated. Withhold CABOMETYX until improvement to ≤ Grade 1, resume at a reduced dose.

    Palmar-Plantar Erythrodysesthesia (PPE): PPE occurred in 45% of CABOMETYX patients. Grade 3 PPE occurred in 13% of CABOMETYX patients. Withhold CABOMETYX until improvement to Grade 1 and resume at a reduced dose for intolerable Grade 2 PPE or Grade 3 PPE. 

    Proteinuria: Proteinuria was observed in 8% of CABOMETYX patients. Monitor urine protein regularly during CABOMETYX treatment. For Grade 2 or 3 proteinuria, withhold CABOMETYX until improvement to ≤ Grade 1 proteinuria; resume CABOMETYX at a reduced dose. Discontinue CABOMETYX in patients who develop nephrotic syndrome. 

    Osteonecrosis of the Jaw (ONJ): ONJ occurred in <1% of CABOMETYX patients. ONJ can manifest as jaw pain, osteomyelitis, osteitis, bone erosion, tooth or periodontal infection, toothache, gingival ulceration or erosion, persistent jaw pain, or slow healing of the mouth or jaw after dental surgery. Perform an oral examination prior to CABOMETYX initiation and periodically during treatment. Advise patients regarding good oral hygiene practices. Withhold CABOMETYX for at least 3 weeks prior to scheduled dental surgery or invasive dental procedures, if possible. Withhold CABOMETYX for development of ONJ until complete resolution, resume at a reduced dose. 

    Impaired Wound Healing: Wound complications occurred with CABOMETYX. Withhold CABOMETYX for at least 3 weeks prior to elective surgery. Do not administer CABOMETYX for at least 2 weeks after major surgery and until adequate wound healing. The safety of resumption of CABOMETYX after resolution of wound healing complications has not been established. 

    Reversible Posterior Leukoencephalopathy Syndrome (RPLS): RPLS, a syndrome of subcortical vasogenic edema diagnosed by characteristic findings on MRI, can occur with CABOMETYX. Evaluate for RPLS in patients presenting with seizures, headache, visual disturbances, confusion, or altered mental function. Discontinue CABOMETYX in patients who develop RPLS. 

    Thyroid Dysfunction: Thyroid dysfunction, primarily hypothyroidism, has been observed with CABOMETYX. Based on the safety population, thyroid dysfunction occurred in 19% of patients treated with CABOMETYX, including Grade 3 in 0.4% of patients. 

    Patients should be assessed for signs of thyroid dysfunction prior to the initiation of CABOMETYX and monitored for signs and symptoms of thyroid dysfunction during CABOMETYX treatment. Thyroid function testing and management of dysfunction should be performed as clinically indicated. 

    Hypocalcemia: CABOMETYX can cause hypocalcemia. Based on the safety population, hypocalcemia occurred in 13% of patients treated with CABOMETYX, including Grade 3 in 2% and Grade 4 in 1% of patients. Laboratory abnormality data were not collected in CABOSUN. 

    In COSMIC-311, hypocalcemia occurred in 36% of patients treated with CABOMETYX, including Grade 3 in 6% and Grade 4 in 3% of patients. 

    Monitor blood calcium levels and replace calcium as necessary during treatment. Withhold and resume at reduced dose upon recovery or permanently discontinue CABOMETYX depending on severity.

    Embryo-Fetal Toxicity: CABOMETYX can cause fetal harm. Advise pregnant women and females of reproductive potential of the potential risk to a fetus. Verify the pregnancy status of females of reproductive potential prior to initiating CABOMETYX and advise them to use effective contraception during treatment and for 4 months after the last dose. 

    ADVERSE REACTIONS 

    The most common (≥20%) adverse reactions are: 

    CABOMETYX as a single agent: diarrhea, fatigue, PPE, decreased appetite, hypertension, nausea, vomiting, weight decreased, and constipation. 

    DRUG INTERACTIONS 

    Strong CYP3A4 Inhibitors: If coadministration with strong CYP3A4 inhibitors cannot be avoided, reduce the CABOMETYX dosage. Avoid grapefruit or grapefruit juice. 

    Strong CYP3A4 Inducers: If coadministration with strong CYP3A4 inducers cannot be avoided, increase the CABOMETYX dosage. Avoid St. John’s wort. 

    USE IN SPECIFIC POPULATIONS 

    Lactation: Advise women not to breastfeed during CABOMETYX treatment and for 4 months after the final dose. 

    Hepatic Impairment: In patients with moderate hepatic impairment, reduce the CABOMETYX dosage. Avoid CABOMETYX in patients with severe hepatic impairment. 

    Pediatric Use: Physeal widening has been observed in children with open growth plates when treated with CABOMETYX. Physeal and longitudinal growth monitoring is recommended in children (12 years and older with DTC) with open growth plates. Consider interrupting or discontinuing CABOMETYX if abnormalities occur. 

    Please see accompanying full Prescribing Information. 
    You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.FDA.gov/medwatch or call 1-800-FDA-1088.

    Indication

    CABOMETYX is indicated for the treatment of adult and pediatric patients 12 years of age and older with locally advanced or metastatic differentiated thyroid cancer (DTC) that has progressed following prior VEGFR-targeted therapy and who are radioactive iodine-refractory or ineligible.

    CABOMETYX is indicated for the treatment of adult and pediatric patients 12 years of age and older with locally advanced or metastatic differentiated thyroid cancer (DTC) that has progressed following prior VEGFR-targeted therapy and who are radioactive iodine-refractory or ineligible.

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