Abraxane Plus Bevacizumab Versus Ipilimumab as 1st Line Therapy for BRAFwt Metastatic Melanoma

PRIMARY OBJECTIVES:

I. To assess whether the combination nab-paclitaxel (paclitaxel albumin-stabilized
nanoparticle formulation) and bevacizumab (AB) prolongs progression-free status relative to
ipilimumab as a 1st line treatment in patients with unresectable stage IV melanoma.

SECONDARY OBJECTIVES:

I. To estimate the hazard of death among those randomized to AB then ipilimumab relative to
those randomized to ipilimumab then AB as first line treatment in patients with unresectable
stage IV melanoma.

II. To assess whether tumor response rate (as determined by Response Evaluation Criteria in
Solid Tumors [RECIST] criteria 1.1) differs with respect to 1st treatment course.

III. To estimate whether the tumor response rate differs with respect to 2nd treatment
course for those who progressed during their first treatment course.

IV. To further examine the safety profile of each of these regimens.

TERTIARY OBJECTIVES:

I. To examine the pharmacokinetics of nab-paclitaxel when combined with bevacizumab therapy.

II. To examine pharmacodynamic changes of blood-derived parameters (biomarkers) of
angiogenesis and immunity as a function of therapy.

III. To examine whether changes in serum biomarkers are also seen in the tumor.

OUTLINE: Patients are randomized to 1 of 2 treatment arms.

ARM A: Patients receive bevacizumab intravenously (IV) over 30-90 minutes on days 1 and 15
and paclitaxel albumin-stabilized nanoparticle formulation IV over 30 minutes on days 1, 8,
and 15. Courses repeat every 28 days in the absence of disease progression or unacceptable
toxicity. Patients experiencing progressive disease may cross-over to Arm B within 2-4
weeks.

ARM B: Patients receive ipilimumab IV over 90 minutes on day 1. Treatment repeats every 21
days for up to 4 courses in the absence of disease progression or unacceptable toxicity.
Patients experiencing progressive disease may cross-over to Arm A within 2-4 weeks.

After completion of study treatment, patients are followed up for up to 5 years.

Inclusion Criteria:

- Histologic or cytologic proof of surgically unresectable stage IV malignant melanoma
(biopsy can be of locoregional disease in setting of clinically evident stage IV
disease, but primary tumor alone will not qualify)

- No prior systemic therapy for metastatic melanoma

- No evidence of v-raf murine sarcoma viral oncogene homolog B1 (BRAF) V600 mutation in
the metastatic tumor

- Measurable disease; note: disease that is measurable by physical examination only is
not eligible

- Life expectancy of >= 4 months

- Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0 or 1

- Absolute neutrophil count >=1500/mL

- Platelet count >= 100,000 x 10^9/L

- Hemoglobin >= 9 g/dL (patients may be transfused to meet this requirement)

- Creatinine =< 1.5 x upper limit of normal (ULN); institutional norms are acceptable

- Total bilirubin =< 1.5 mg/dL (exception: patients with documented Gilbert's syndrome
are allowed to participate despite elevated bilirubin)

- Serum glutamic oxaloacetic transaminase (SGOT) (aspartate aminotransferase [AST]) =<
2.5 x ULN and serum glutamate pyruvate transaminase (SGPT) (alanine aminotransferase
[ALT]) =< 2.5 x ULN

- Alkaline phosphatase =< 2.5 x ULN; if bone metastasis is present in the absence of
liver metastasis then =< 5 x ULN

- Urine dipstick for proteinuria < 2+ (patients discovered to have >= 2+ proteinuria on
dipstick urinalysis at baseline should undergo a 24 hour urine collection and must
demonstrate =< 1g of protein in 24 hours to be eligible)

- Negative serum pregnancy test done =< 7 days prior to registration/randomization, for
women of childbearing potential only; note:

- Females: adequate contraception must be used by both patient and partner while
receiving study drug and for 12 weeks after the last dose of study drug

- Males: adequate contraception must be used by both patient and partner while
receiving study drug; men who have a partner of childbearing age should also
avoid fathering a child for 6 months after the last dose of study drug

- Ability to understand and the willingness to sign a written informed consent document

- Willingness to provide mandatory blood samples for research purposes

Exclusion Criteria:

- Brain metastases per magnetic resonance imaging (MRI) or computed tomography (CT);
note: patients must have brain imaging done =< 21 days prior to
registration/randomization; note: patients who have had therapy for brain metastasis
(i.e., surgical resection, whole brain radiation, or stereotactic radiosurgery [SRS]
even if stable) are not eligible

- Other investigational agents =< 4 weeks prior to registration/ randomization

- Any anti-cancer therapy (including immunotherapy) =< 4 weeks prior to
registration/randomization

- Prior treatment in the adjuvant setting with any of the following:

- Agents disrupting vascular endothelial growth factor (VEGF) activity or
targeting vascular endothelial growth factor receptor (VEGFR);

- Ipilimumab;

- Or taxane based chemotherapy regimens (including paclitaxel, docetaxel,
cabazitaxel or nab-paclitaxel)

- Major surgical procedure, open biopsy, or significant traumatic injury =< 4 weeks
prior to registration/randomization; (port-a-cath placement does not count as a major
surgical procedure and patients can be enrolled at any time after placement)

- Fine needle aspirations or core biopsies =< 7 days prior to registration/
randomization

- Planned/or anticipated major surgical procedure during the course of the study

- Other medical conditions including but not limited to:

- History of liver disease such as cirrhosis, chronic active hepatitis, chronic
persistent hepatitis or hepatitis B or C

- Active infection requiring parenteral antibiotics

- Poorly controlled high blood pressure (>= 150 mmHg systolic and/or 100 mmHg
diastolic) despite treatment

- New York Heart Association class II-IV congestive heart failure

- Serious cardiac arrhythmia requiring medication

- Myocardial infarction or unstable angina =< 6 months prior to
registration/randomization

- Clinically significant peripheral vascular disease

- Deep venous thrombosis or pulmonary embolus =< 1 year of
registration/randomization

- Ongoing need for full-dose oral or parenteral anticoagulation

- Ongoing anti-platelet treatment other than low-dose aspirin (i.e., aspirin 81 mg
by mouth daily)

- Active bleeding or pathological conditions that carry high risk of bleeding
(e.g., known esophageal varices, etc.)

- Serious, non-healing wound (including wounds healing by secondary intention),
ulcer or bone fracture

- History of abdominal fistula, gastrointestinal perforation or intra-abdominal
abscess =< 6 months prior to registration/randomization

- History of central nervous system (CNS) disease (e.g., vascular abnormalities,
etc.), clinically significant stroke or transient ischemic attack (TIA) =< 6
months prior to registration/randomization, seizures not controlled with
standard medical therapy

- Radiographically documented tumor invading major blood vessels

- History of hypertensive crisis or hypertensive encephalopathy

- Any of the following as this regimen may be harmful to a developing fetus or nursing
child:

- Pregnant women

- Nursing women

- Men and women of reproductive potential who are not using effective birth
control methods Note: women of childbearing potential must have a negative serum
pregnancy test =< 7 days prior to registration/randomization; adequate
contraception must be used while receiving study drug and for 12 weeks after the
last dose of study drug, by both women and men and by both patient and partner;
men who have a partner of childbearing potential should also avoid fathering a
child for 6 months after the last dose of study drug

- Existence of peripheral sensory neuropathy >= grade 2 (from any cause)

- History of other malignancy =< 5 years with the exception of basal cell or squamous
cell carcinoma of the skin, treated with local resection only, or carcinoma in situ
(e.g. of the cervix, breast, prostate, etc.)

- Radiation therapy (other than palliative) =< 2 weeks prior to randomization; note:
patients who have had >25% of their functional bone marrow irradiated are not
eligible for this trial

- Active or recent history of hemoptysis (>= 1/2 teaspoon of bright red blood per
episode) =< 30 days prior to registration/randomization

- Known hypersensitivity to any of the components of ipilimumab, bevacizumab, or
nab-paclitaxel

- History of inflammatory bowel disease (e.g., Crohn's, ulcerative colitis); note
patients with irritable bowel syndrome are eligible

- Diagnosis of autoimmune disease (i.e., rheumatoid arthritis, scleroderma, systemic
lupus erythematosus [SLE], autoimmune vasculitis, Guillain-Barre syndrome, etc.),
regardless if patient is currently receiving treatment at time of
registration/randomization

- Systemic corticosteroids use =< 2 weeks, regardless of indication; note: patients who
are on inhaled corticosteroids are eligible