Sequential Two-agent Assessment in Renal Cell Carcinoma Therapy: The START Trial

The Study Drugs:

Everolimus is designed to block the growth of cancer cells, which may cause cancer cells to
die.

Bevacizumab is designed to block the growth of blood vessels that supply nutrients necessary
for tumor growth. This may prevent or slow down the growth of cancer cells.

Pazopanib is designed to block a protein that may cause uncontrolled tumor growth. Blocking
this protein may prevent cancer from growing and spreading.

Study Drug Administration:

If you are found to be eligible to take part in this study, you will be randomly assigned (as
in the roll of dice) to 1 of 6 groups. There is an equal chance of being assigned to each
group.

- Group 1 will receive pazopanib, possibly followed by bevacizumab.

- Group 2 will receive pazopanib, possibly followed by everolimus.

- Group 3 will receive everolimus, possibly followed by bevacizumab.

- Group 4 will receive everolimus, possibly followed by pazopanib.

- Group 5 will receive bevacizumab, possibly followed by pazopanib.

- Group 6 will receive bevacizumab, possibly followed by everolimus.

If the disease gets worse while you receive your first assigned drug, you will stop taking
the drug. Then if you are not having side effects, you will start taking your second assigned
drug 2-4 weeks later.

Everolimus is taken by mouth 1 time per day (at about the same time each day).

Bevacizumab is given by vein over 30-90 minutes, 1 time every 2 weeks.

Pazopanib is taken by mouth 1 time per day (at about the same time each day on an empty
stomach).

You may be able to receive the bevacizumab doses at your local doctor's office. Ask your
study doctor about this.

Study Visits:

Every week during Weeks 1-4, your blood pressure will be checked (either at home, at the
clinic, or by your local doctor) if you are taking pazopanib or bevacizumab. If you are
checking your own blood pressure at home, you should keep a log to write down your blood
pressure. Bring the log to your next clinic visit.

Every 2 weeks, urine will be collected for routine tests if you are receiving bevacizumab.

Every 4 weeks:

- You will have a physical exam, including measurement of your weight and vital signs.

- Your performance status will be recorded.

- You will be asked about any drugs you may be taking.

- You will be asked about any side effects you may have had.

- Blood (about 3 tablespoons) will be drawn for routine tests. If you are receiving
everolimus, you will fast (have nothing to eat or drink except water) starting the night
before these tests. The doctor will discuss this with you.

- Urine will be collected for routine tests if you are receiving everolimus or pazopanib.

Every 8 weeks, the following tests and procedures will be performed. If you are receiving the
study treatment at your local doctor's office, you must return to MD Anderson for these tests
and procedures.

- Blood (about 3 teaspoons) will be drawn for routine tests. If you are receiving
pazopanib, this blood will also be used to check your thyroid function.

- You will have CT scans of the chest and abdomen to check the status of the disease.

- You will fill out 5 questionnaires about the quality of your life and about how you are
feeling. This should take about 30 minutes.

Every year, you will have an MRI of the brain to check the status of the disease.

Every year, you will have an ECHO or MUGA scan to check the health of your heart.

Anytime the doctor decides it is needed, you will have scans such as a CT scan of the pelvis,
an MRI scan of the abdomen or brain, ECHO or MUGA scan, and/or a bone scan.

After 1 year, if the disease has not gotten worse, you may have less clinic visits and tests.

Length of Participation:

You may continue taking a study drug for as long as the doctor thinks it is in your best
interest. You will no longer be able to take a study drug if intolerable side effects occur,
or if the disease gets worse after you take your second assigned study drug.

End-of-Treatment Visit:

When you are finished taking the study drug(s):

- You will have a physical exam, including measurement of your weight and vital signs.

- You will be asked about any drugs you may be taking.

- You will be asked about any side effects you may have had.

Long-Term Follow-Up:

After your End-of-Treatment visit, the study staff will contact you by phone, e-mail, or you
will come in for a clinic visit. You will be asked about how you are feeling and any side
effects you may have had. Each follow-up will take about 5 minutes. Follow-up will take place
every 3 months for the first 2 years, every 6 months for the third year, and 1 time a year
after that. The last follow-up will be about 5 years after the last patient is enrolled.

This is an investigational study. Everolimus, bevacizumab, and pazopanib are all FDA approved
and commercially available for kidney cancer. The investigational part of this study is to
find out which order these drugs should be given in.

Up to 240 patients will be enrolled in this study. All will be enrolled at MD Anderson.

Inclusion Criteria:

1. Confirmed metastatic RCC with a clear cell component.

2. Prior radical or partial nephrectomy required. Patients whose primary tumor was
treated with cryoablation or radiofrequency ablation would also be eligible.

3. Measurable disease

4. Age >/= 18 years. Because no dosing or adverse event data are currently available on
the use of these targeted agents in patients < 18 years of age, children are excluded
from this study

5. ECOG performance status 0 or 1

6. Adequate organ and marrow function within 14 days as defined below: a) Absolute
neutrophil count /=> 1,500/microL; b) Platelets >/= 100,000/microL; c) Hgb >/= 9.0
g/dL (transfusion allowed); d) Total bilirubin < 1.5 mg/dl; e) Albumin > 2.5 g/dL; f)
AST and ALT ULN for subjects with liver metastases; h) Serum creatinine /= 50
cc/min; i) Fasting serum cholesterol triglycerides exceeded, the patient can only be included after initiation of appropriate lipid
lowering medication.

7. Female patients of childbearing potential must have a negative pregnancy test
(serum/plasma or urine) within 7 days prior to beginning treatment on the study due to
the possible teratogenic effect

8. Patients of child fathering or childbearing potential must agree to practice a form of
medically acceptable birth control while on study

9. Patients must give written informed consent prior to initiation of study-related
procedures. Patients with a history of major psychiatric illness must be judged able
to fully understand the investigational nature of the study and the risks associated
with the therapy

10. Patients must be able to swallow pills

11. Both men and women and members of all races and ethnic groups are eligible for this
trial

Exclusion Criteria:

1. No patient with any concurrent active malignancy, i.e. a patient requiring or
receiving systemic therapy for another malignancy at the same time of treatment for
RCC

2. Patients must not have received any prior targeted therapy (anti-VEGF agents or mTOR
inhibitors), including adjuvant therapy, and must not have received any prior
chemotherapy for mRCC. However, patients who had received prior immunotherapy, such as
cytokines or vaccines, are permitted to enroll.

3. Patients must not be scheduled to receive another experimental drug while on this
study. Patients are permitted to receive concomitant bisphosphonates.

4. Patients must not have multiple brain metastases or leptomeningeal disease. Patients
with controlled solitary brain metastasis are eligible.

5. Patients must not have had a stroke or transient ischemic attack within 6 months.

6. Patients must not have uncontrolled infections.

7. Patients must not have clinically significant cardiovascular disease, defined as
myocardial infarction (or unstable angina) within 6 months, New York Heart Association
(NYHA) Grade II or greater congestive heart failure, serious cardiac dysrhythmia
refractory to medical management

8. Patients must not have uncontrolled hypertension, defined as > 140/90 or prior history
of hypertensive crisis or hypertensive encephalopathy. Treatment of hypertension with
medications is permitted.

9. History of hemoptysis (>/= 1/2 teaspoon of bright red blood per episode) within 1
month prior to Day 1

10. Significant vascular disease (e.g., aortic aneurysm, aortic dissection)

11. Symptomatic peripheral vascular disease

12. Pregnant women are excluded from this study because of the potential for teratogenic
or abortifacient effects. Because there is an unknown but potential risk for adverse
events in nursing infants secondary to treatment of the mother with these agents,
breast-feeding should be discontinued if the mother is enrolled on this trial.

13. Patients with immune deficiency are at increased risk of lethal infections when
treated with marrow-suppressive therapy. Therefore, HIV-positive patients receiving
combination anti-retroviral therapy are excluded from the study because of possible
pharmacokinetic interactions with some of these agents.

14. Patients must not have a clinical history of coagulopathy or bleeding diathesis.
Patients may be on therapeutic anticoagulation preferably a low-molecular weight
heparin. If the patients are on warfarin, the INR should be maintained within a
therapeutic level and must be checked weekly for the first four weeks, then every 2
weeks for 4 additional weeks. Thereafter, they may be followed at the discretion of
the treating provider. Antiplatelet agents are allowed.

15. Concomitant treatment with rifampin, St. John's wort, or the cytochrome p450
enzyme-inducing antiepileptic drugs (phenytoin, carbamazepine or Phenobarbital) is not
allowed on this study.

16. Patients with significant baseline proteinuria defined as 300 or greater by screening
U/A will be excluded if they have > 1,000 mg proteins in a 24-hour urine collection or
if they have a random urine protein over creatinine (UPC) ratio >1.

17. Major surgical procedure, open biopsy, or significant traumatic injury within 28 days
prior to study enrollment or anticipation of need for major surgical procedure during
the course of the study

18. History of abdominal fistula, gastrointestinal perforation, or intra-abdominal abscess
within 6 months prior to study enrollment

19. Serious, non-healing wound, ulcer, or bone fracture

20. Uncontrolled diabetes as defined by fasting serum glucose >1.5 x ULN

21. Known hypersensitivity to any component of bevacizumab, pazopanib or everolimus.

22. Patients should not receive immunization with attenuated live vaccines within one week
of study entry or during study period. Close contact with those who have received
attenuated live vaccines should be avoided during treatment with everolimus. Examples
of live vaccines include intranasal influenza, measles, mumps, rubella, oral polio,
BCG, yellow fever, varicella and TY21a typhoid vaccines.

23. Patients with severely impaired lung function as defined as spirometry and DLCO that
is 50% of the normal predicted value and/or 02 saturation that is 88% or less at rest
on room air

24. Liver disease such as cirrhosis or severe hepatic impairment (Child-Pugh class C).
Note: A detailed assessment of Hepatitis B/C medical history and risk factors must be
done at screening for all patients. HBV DNA and HCV RNA PCR testing are required at
screening for all patients with a positive medical history based on risk factors
and/or confirmation of prior HBV/HCV infection.

25. Patients receiving chronic, systemic treatment with steroids in pharmacological doses
or immunosuppressive agents are excluded. Patients who receive steroids for
physiological replacement, e.g., after adrenalectomy are not excluded. Topical or
inhaled corticosteroids are also allowed.