Nivolumab, Cabozantinib S-Malate, and Ipilimumab in Treating Patients With Recurrent Stage IV Non-small Cell Lung Cancer

PRIMARY OBJECTIVES:

I. To demonstrate whether combination therapy of nivolumab and cabozantinib s-malate
(cabozantinib), or of nivolumab and cabozantinib, and ipilimumab as compared to nivolumab
alone, extends progression-free survival (PFS) for this patient population with non-squamous
non-small cell lung cancer (NSCLC).

SECONDARY OBJECTIVES:

I. To estimate the overall survival for each arm of the trial. II. To estimate the best
overall response rate for each arm of the trial. III. To estimate the progression free
survival of the targeted therapy arm of the trial.

IV. To describe the toxicity profile of monotherapy with nivolumab, and the combination of
nivolumab and cabozantinib, and the combination of nivolumab and cabozantinib and ipilimumab,
in this patient population with non-squamous NSCLC.

CORRELATIVE OBJECTIVES:

I. To adjust progression free survival for each arm based on PD-L1 tumor status.

IMAGING OBJECTIVES:

I. To describe time point tumor response assessment, overall best response and
progression-free survival using the conventional Response Evaluation Criteria in Solid Tumors
(RECIST) 1.1 criteria and the exploratory uni-dimensional immune response criteria (iRRC) and
the imaging (i)RECIST criteria with all measurements performed by the central review.

I I. To compare RECIST 1.1 imaging response assessment measurements (time point response
assessment and overall best response) assess by site study personnel to those performed by
central review.

EXPLORATORY TOBACCO USE OBJECTIVES:

I. To determine the effects of tobacco, operationalized as combustible tobacco (1a), other
forms of tobacco (1b), and environmental tobacco exposure (ETS) (1c) on provider-reported
cancer-treatment toxicity (adverse events (both clinical and hematologic) and dose
modifications).

II. To determine the effects of tobacco on patient-reported physical symptoms and
psychological symptoms.

III. To examine quitting behaviors and behavioral counseling/support and cessation medication
utilization.

IV. To explore the effect of tobacco use and exposure on treatment duration, relative dose
intensity, and therapeutic benefit.

OUTLINE: Patients are randomized to 1 of 3 arms. Patients with ROS1 gene rearrangement, MET
exon 14 splice mutations, MET high amplification, or RET gene rearrangement are assigned to
Arm T.

ARM A: Patients receive nivolumab intravenously (IV) over 60 minutes on day 1. Courses repeat
every 28 days in the absence of disease progression or unacceptable toxicity.

ARM B: Patients receive nivolumab IV over 60 minutes on day 1 and cabozantinib s-malate
orally (PO) daily on days 1-28. Courses repeat every 28 days in the absence of disease
progression or unacceptable toxicity.

ARM C: Patients receive nivolumab IV over 60 minutes on day 1, cabozantinib s-malate PO daily
on days 1-28, and ipilimumab IV over 90 minutes every 8 weeks. Courses for nivolumab and
cabozantinib s-malate repeat every 28 days in the absence of disease progression or
unacceptable toxicity.

ARM T: Patients with ROS1 gene rearrangement, MET exon 14 splice mutations, MET high
amplification, or RET gene rearrangement receive nivolumab IV over 60 minutes on day 1 and
cabozantinib s-malate PO daily on days 1-28. Courses repeat every 28 days in the absence of
disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up every 3 months for up to 3
years.

Inclusion Criteria:

- ELIGIBILITY CRITERIA FOR STEP 0

- Patients with tumors with the following molecular alterations must submit testing
results via Medidata Rave to determine eligibility to Arm T; the study chair,
co-chair, biology co-chair, or a delegate must review the molecular testing and agree
that the testing meets eligibility outlined below:

- ROS1 gene rearrangement by fluorescence in situ hybridization (FISH) or
deoxyribonucleic acid (DNA) analysis (may have progressed on prior crizotinib
therapy)

- MET exon 14 splice mutations on DNA analysis (may have progressed on prior
crizotinib therapy)

- MET high amplification by FISH or DNA analysis or other MET mutations predicted
to be sensitive to MET inhibitor (no prior targeted therapy allowed)

- RET gene rearrangement by FISH or DNA analysis (no prior targeted therapy
allowed)

- Institutions will be notified of the patient's eligibility status for Arm T
within two (2) business days of submission of the molecular testing reports

- If patients do not have tumors with the above molecular alterations noted
proceed directly to step 1

- ELIGIBILITY CRITERIA FOR STEP 1

- For patients with known molecular alterations, institution has been notified that
patient is deemed eligible for Arm T per review of molecular testing reports

- Pathologically confirmed non-squamous non-small cell lung carcinoma (NSCLC)

- Stage IV disease (includes M1a, M1b, or recurrent disease), according to the 7th
edition of the lung cancer tumor, node, and metastasis (TNM) classification system

- Predominant non-squamous histology (patients with NSCLC not otherwise specified [NOS]
are eligible); mixed tumors will be categorized by the predominant cell type; if small
cell elements are present the patient is ineligible

- Tumors must be tested and known negative for EGFR tyrosine kinase inhibitor (TKI)
sensitizing mutations (EGFR exon 19 deletions, L858R, L861Q, G719X) and ALK gene
rearrangements by routine Clinical Laboratory Improvement Act (CLIA)-certified
clinical testing methods; negative circulating tumor DNA results alone are not
acceptable; prior testing for tumor PD-L1 status is not required

- Patients must have progressed radiographically following first line platinum-based
chemotherapy, no additional lines of therapy are permitted

- NOTE: Prior adjuvant chemotherapy for early stage disease does not count as one
line of therapy if 12 months or greater elapsed between completion of adjuvant
therapy and initiation of first-line systemic therapy; if less than 12 months
elapsed, adjuvant chemotherapy counts as one line of therapy

- Exception for targeted therapy sub-study (Arm T): At least one line of prior
chemotherapy or targeted therapy is required, but there is no limit on number of
prior treatments

- Patients must have measurable disease as defined by RECIST v. 1.1 criteria; baseline
measurements and evaluation of ALL sites of disease must be obtained within 4 weeks
prior to registration

- No prior anti-MET therapy such as crizotinib or cabozantinib, or PD-1/PD-L1 immune
checkpoint inhibitor therapy (such as nivolumab, pembrolizumab, atezolizumab) or CTLA4
inhibitor therapy (such as ipilimumab); no prior allergic reaction to small molecule
tyrosine kinase inhibitors or monoclonal antibodies

- Exception for targeted therapy sub-study (Arm T): Prior crizotinib may be allowed
depending on the gene alteration

- Any prior chemotherapy (based on administration schedule) must have been completed in
greater than or equal to the following times prior to registration:

- Chemotherapy/ targeted oral therapy administered in a daily or weekly schedule
must be completed >= 1 week prior to registration;

- Any chemotherapy administered in an every 2 week or greater schedule must be
completed >= 2 weeks prior to registration

- Additionally, patients should be recovered to equal to or less than grade 1
Common Terminology Criteria for Adverse Events (CTCAE) v5.0 from toxicities
related to any prior treatment, unless adverse event (AE)(s) are clinically
nonsignificant and/or stable on supportive therapy

- No prior radiation therapy for bone metastasis within 2 weeks, any other radiation
therapy within 4 weeks prior to registration

- Patients with no known brain metastasis must have baseline brain imaging within 12
weeks prior to study registration not demonstrating brain metastases OR

- Patients with known brain metastases must have baseline brain imaging within 4 weeks
prior to study registration and meet all of the following criteria:

- Have completed treatment to all symptomatic brain metastases (with whole brain
radiation or radiosurgery) >= 4 weeks prior to registration, or have undergone
complete neurosurgical resection >= 3 months prior to registration

- Be clinically stable from brain metastases at time of screening, if no treatment
was administered

- Known leptomeningeal disease is not allowed

- Patients must have Eastern Cooperative Oncology Group (ECOG) performance status 0-1

- NOTE: Participants with impaired decision-making capacity (IDMC) should not be
allowed to participate in this study due to its complexity

- Patients must have anticipated life expectancy greater than 3 months

- Within 2 weeks prior to registration: Absolute neutrophil count >= 1,500/mm^3

- Within 2 weeks prior to registration: Platelets >= 100,000/mm^3

- Within 2 weeks prior to registration: Hemoglobin >= 9 g/dL

- Within 2 weeks prior to registration: Subject has prothrombin time (PT)/international
normalized ratio (INR) and partial thromboplastin time (PTT) test =< 1.3 x the
laboratory upper limit of normal (ULN)

- Within 2 weeks prior to registration: Total bilirubin =< 1.5 x ULN

- Within 2 weeks prior to registration: Aspartate aminotransferase (AST) (serum glutamic
oxaloacetic transaminase [SGOT]) and alanine aminotransferase (ALT) (serum glutamic
pyruvic transaminase [SGPT]) =< 3 x ULN

- Within 2 weeks prior to registration: Serum albumin >= 2.8 g/dL

- Within 2 weeks prior to registration: Serum calcium (absolute or albumin corrected),
magnesium and potassium >= lower limit of normal (LLN)

- NOTE: serum calcium, magnesium and potassium can be replaced if values are below
LLN

- Within 2 weeks prior to registration: Creatinine =< 1.5 x ULN or calculated
(Cockcroft-Gault formula) or measured creatinine clearance >= 50 mL/min/1.73 m^2
(normalized to body surface area [BSA]) for patients with creatinine levels greater
than 1.5 times the institutional normal

- Within 2 weeks prior to registration: Screening urine dipstick must equal 0 or
"trace"; if urine dipstick results are >= 1+, or if dipstick was not performed,
calculation of urine protein creatinine (UPC) is required and patients must have a UPC
ratio =< 1 to participate in the study

- No history of the following:

- Clinically-significant gastrointestinal bleeding within 6 months prior to
registration

- Hemoptysis of >= 0.5 teaspoon (2.5 mL) of red blood within 3 months prior to
registration

- Drug induced pneumonitis within 3 months prior to registration

- Signs indicative of pulmonary hemorrhage within 3 months before the first dose of
study treatment

- Radiographic evidence of cavitating pulmonary lesion(s)

- Tumor invading any major blood vessels

- Evidence of tumor invading the GI tract (esophagus, stomach, small or large
bowel, rectum or anus), or any evidence of endotracheal or mainstem endobronchial
tumor within 28 days before the first dose of cabozantinib

- No concomitant treatment, in therapeutic doses, with anticoagulants such as warfarin
or warfarin-related agents, heparin, low molecular weight heparin (LMWH), thrombin or
factor Xa inhibitors, or antiplatelet agents (e.g., clopidogrel); (low dose aspirin
[=< 81 mg/day] and prophylactic LMWH are permitted)

- No concomitant anticoagulation with oral anticoagulants (e.g., warfarin, direct
thrombin and Factor Xa inhibitors) or platelet inhibitors (e.g., clopidogrel); allowed
anticoagulants are the following:

- Low-dose aspirin for cardioprotection (per local applicable guidelines) is
permitted

- Low molecular weight heparins (LMWH) or unfractionated heparin is permitted

- Anticoagulation with therapeutic doses of LMWH is allowed in subjects without
known brain metastases who are on a stable dose of LMWH for at least 6 weeks
before first dose of study treatment, and who have had no clinically significant
hemorrhagic complications from the anticoagulation regimen or the tumor

- No concomitant treatment of strong CYP3A4 inducers (e.g., dexamethasone, phenytoin,
carbamazepine, rifampin, rifabutin, rifapentine, phenobarbital, and St. John's wort)

- No cardiovascular disorders including:

- Congestive heart failure (CHF): New York Heart Association (NYHA) class III
(moderate) or class IV (severe) at the time of screening

- Concurrent uncontrolled hypertension defined as sustained blood pressure (BP) >
150 mm Hg systolic, or > 100 mm Hg diastolic despite optimal antihypertensive
treatment within 7 days prior to registration

- Any of the following within 6 months prior to registration:

- Unstable angina pectoris

- Clinically-significant cardiac arrhythmias

- Stroke (including transient ischemic attack [TIA], or other ischemic event)

- Myocardial infarction

- No gastrointestinal disorders associated with a high risk of perforation or fistula
formation within 3 months prior to registration:

- Active peptic ulcer disease

- Inflammatory bowel disease (including ulcerative colitis and Crohn's disease),
diverticulitis, cholecystitis, symptomatic cholangitis or appendicitis

- Known malabsorption syndrome

- Bowel obstruction or gastric outlet obstruction

- Percutaneous endoscopic gastrostomy (PEG) tube placement

- No gastrointestinal disorders associated with a high risk of perforation or fistula
formation within 6 months prior to registration:

- Abdominal fistula

- Gastrointestinal perforation

- Intra-abdominal abscess; Note: Complete resolution of an intra-abdominal abscess
must be confirmed prior to initiating treatment with cabozantinib even if the
abscess occurred more than 6 months prior to registration

- None of the following conditions:

- Grade 3 or greater infection, or infection requiring intravenous systemic
treatment within 28 days prior to registration; patients should be off
antibiotics at the time of registration.

- Serious non-healing wound/ulcer/bone fracture within 28 days prior to
registration

- History of organ transplant

- Concurrent uncompensated hypothyroidism or thyroid dysfunction within 7 days
prior to registration

- History of surgery as follows:

- Major surgery (as an example, surgery requiring anesthesia and a > 24 hour
hospital stay) within 3 months prior to registration, with wound healing at
least 28 days prior to registration

- Minor surgery within 28 days prior to registration with complete wound
healing at least 10 days prior to registration

- Minor procedures within 7 days prior to registration such as thoracentesis,
paracentesis, or 18 g or smaller needle biopsy of tumor

- Patients with clinically relevant ongoing complications from prior surgery
are not eligible

- Patients must have corrected QT interval calculated by the Fridericia formula (QTcF)
=< 500 ms within 28 days before registration

- Patients must be able to swallow tablets

- No currently active other malignancies which require systemic treatment

- No patients that have a condition requiring systemic treatment with either
corticosteroids (> 10 mg daily prednisone equivalents) or other immunosuppressive
medications within 14 days of study drug administration; inhaled or topical steroids
and adrenal replacement doses =< 10 mg daily prednisone equivalents are permitted in
the absence of active autoimmune disease; patients are permitted to use topical,
ocular, intra-articular, intranasal, and inhalational corticosteroids (with minimal
systemic absorption); physiologic replacement doses of systemic corticosteroids are
permitted, even if < 10 mg/day prednisone equivalents; a brief course of
corticosteroids for prophylaxis (e.g., contrast dye allergy) or for treatment of
non-autoimmune conditions (e.g., delayed-type hypersensitivity reaction caused by
contact allergen) is permitted

- No patients with known active autoimmune disease or known history of autoimmune
disease for which recurrence may affect vital organ function or require immune
suppressive treatment including systemic corticosteroids; these include but are not
limited to patients with a history of immune related neurologic disease, multiple
sclerosis, autoimmune (demyelinating) neuropathy, Guillain-Barre syndrome, myasthenia
gravis; systemic autoimmune disease such as systemic lupus erythematosus (SLE),
connective tissue diseases, scleroderma, inflammatory bowel disease (IBD), Crohn's,
ulcerative colitis, autoimmune hepatitis; patients with a history of toxic epidermal
necrolysis (TEN), Stevens-Johnson syndrome, or phospholipid syndrome should be
excluded because of the risk of recurrence or exacerbation of disease; patients with
vitiligo, endocrine deficiencies including type I diabetes mellitus or thyroiditis
managed with replacement hormones including physiologic corticosteroids are eligible;
patients with rheumatoid arthritis and other arthropathies, Sjogren's syndrome and
psoriasis controlled with topical medication and patients with positive serology, such
as antinuclear antibodies (ANA), anti-thyroid antibodies should be evaluated for the
presence of target organ involvement and potential need for systemic treatment but
should otherwise be eligible

- No ongoing major illness or psychosocial issues that would limit compliance with the
protocol

- Women must not be pregnant or breast-feeding

- All females of childbearing potential must have a blood test or urine study
within 2 weeks prior to registration to rule out pregnancy

- A female of childbearing potential is any woman, regardless of sexual orientation
or whether they have undergone tubal ligation, who meets the following criteria:
1) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been
naturally postmenopausal for at least 24 consecutive months (i.e., has had menses
at any time in the preceding 24 consecutive months)

- Women of childbearing potential (WOCBP) and males who are sexually active with WOCBP
must use an accepted and effective method of contraception or abstain from sexual
intercourse for at least one week prior to the start of treatment, and continue for 5
months after the last dose of protocol treatment for women of childbearing potential
and 7 months after the last dose of protocol treatment for males who are sexually
active with WOCBP

- Patients with known human immunodeficiency virus (HIV) disease taking antiret