Nirogacestat, a γ-Secretase Inhibitor for Desmoid Tumors.

Gounder, Mrinal Ratan, Ravin Alcindor, Thierry Schöffski, Patrick van der Graaf, Winette T Wilky, Breelyn A Riedel, Richard F Lim, Allison Smith, L Mary Moody, Stephanie Attia, Steven Chawla, Sant D'Amato, Gina Federman, Noah Merriam, Priscilla Van Tine, Brian A Vincenzi, Bruno Benson, Charlotte Bui, Nam Quoc Chugh, Rashmi Tinoco, Gabriel Charlson, John Dileo, Palma Hartner, Lee Lapeire, Lore Mazzeo, Filomena [UCL] Palmerini, Emanuela Reichardt, Peter Stacchiotti, Silvia Bailey, Howard H Burgess, Melissa A Cote, Gregory M Davis, Lara E Deshpande, Hari Gelderblom, Hans Grignani, Giovanni Loggers, Elizabeth Philip, Tony Pressey, Joseph G Kummar, Shivaani Kasper, Bernd et al.[show all]

BACKGROUND: Desmoid tumors are rare, locally aggressive, highly recurrent soft-tissue tumors without approved treatments. METHODS: We conducted a phase 3, international, double-blind, randomized, placebo-controlled trial of nirogacestat in adults with progressing desmoid tumors according to the Response Evaluation Criteria in Solid Tumors, version 1.1. Patients were assigned in a 1:1 ratio to receive the oral γ-secretase inhibitor nirogacestat (150 mg) or placebo twice daily. The primary end point was progression-free survival. RESULTS: From May 2019 through August 2020, a total of 70 patients were assigned to receive nirogacestat and 72 to receive placebo. Nirogacestat had a significant progression-free survival benefit over placebo (hazard ratio for disease progression or death, 0.29; 95% confidence interval, 0.15 to 0.55; P<0.001); the likelihood of being event-free at 2 years was 76% with nirogacestat and 44% with placebo. Between-group differences in progression-free survival were consistent across prespecified subgroups. The percentage of patients who had an objective response was significantly higher with nirogacestat than with placebo (41% vs. 8%; P<0.001), with a median time to response of 5.6 months and 11.1 months, respectively; the percentage of patients with a complete response was 7% and 0%, respectively. Significant between-group differences in secondary patient-reported outcomes, including pain, symptom burden, physical or role functioning, and health-related quality of life, were observed (P≤0.01). Frequent adverse events with nirogacestat included diarrhea (in 84% of the patients), nausea (in 54%), fatigue (in 51%), hypophosphatemia (in 42%), and maculopapular rash (in 32%); 95% of adverse events were of grade 1 or 2. Among women of childbearing potential receiving nirogacestat, 27 of 36 (75%) had adverse events consistent with ovarian dysfunction, which resolved in 20 women (74%). CONCLUSIONS: Nirogacestat was associated with significant benefits with respect to progression-free survival, objective response, pain, symptom burden, physical functioning, role functioning, and health-related quality of life in adults with progressing desmoid tumors. Adverse events with nirogacestat were frequent but mostly low grade. (Funded by SpringWorks Therapeutics; DeFi ClinicalTrials.gov number, NCT03785964.).