This information is intended for use by health professionals

 This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. See section 4.8 for how to report adverse reactions.

1. Name of the medicinal product

Tecentriq 1,200 mg concentrate for solution for infusion.

2. Qualitative and quantitative composition

One 20 mL vial of concentrate contains 1,200 mg atezolizumab*.

After dilution (see section 6.6), one mL of solution contains approximately 4.4 mg of atezolizumab.

*Atezolizumab is an Fc-engineered, humanised IgG1 anti-programmed death-ligand 1 (PD-L1) monoclonal antibody produced in Chinese hamster ovary cells by recombinant DNA technology.

For the full list of excipients, see section 6.1.

3. Pharmaceutical form

Concentrate for solution for infusion.

Clear, colourless to slightly yellowish liquid.

4. Clinical particulars
4.1 Therapeutic indications

Urothelial carcinoma

Tecentriq as monotherapy is indicated for the treatment of adult patients with locally advanced or metastatic urothelial carcinoma (UC):

• after prior platinum-containing chemotherapy, or

• who are considered cisplatin ineligible, and whose tumours have a PD-L1 expression ≥ 5% (see section 5.1).

Non-small cell lung cancer

Tecentriq, in combination with bevacizumab, paclitaxel and carboplatin, is indicated for the first-line treatment of adult patients with metastatic non-squamous non-small cell lung cancer (NSCLC). In patients with EGFR mutant or ALK-positive NSCLC, Tecentriq, in combination with bevacizumab, paclitaxel and carboplatin, is indicated only after failure of appropriate targeted therapies (see section 5.1).

Tecentriq as monotherapy is indicated for the treatment of adult patients with locally advanced or metastatic NSCLC after prior chemotherapy. Patients with EGFR mutant or ALK-positive NSCLC should also have received targeted therapies before receiving Tecentriq (see section 5.1).

Tecentriq, in combination with nab-paclitaxel and carboplatin, is indicated for the first-line treatment of adult patients with metastatic non-squamous NSCLC who do not have EGFR mutant or ALK-positive NSCLC (see section 5.1).

Small cell lung cancer

Tecentriq, in combination with carboplatin and etoposide, is indicated for the first-line treatment of adult patients with extensive-stage small cell lung cancer (ES-SCLC) (see section 5.1).

4.2 Posology and method of administration

Tecentriq must be initiated and supervised by physicians experienced in the treatment of cancer.

PD-L1 testing for patients with UC

Patients with previously untreated UC should be selected for treatment based on the tumour expression of PD-L1 confirmed by a validated test (see section 5.1).

Posology

Tecentriq monotherapy

The recommended dose of Tecentriq is 1,200 mg administered intravenously every three weeks.

Tecentriq in combination therapy

Please also refer to the full prescribing information for the combination products (see also section 5.1).

1L non-squamous NSCLC

Tecentriq in combination with bevacizumab, paclitaxel, and carboplatin

During the induction phase, the recommended dose of Tecentriq is 1,200 mg administered by intravenous infusion, followed by bevacizumab, paclitaxel, and then carboplatin every three weeks for four or six cycles.

The induction phase is followed by a maintenance phase without chemotherapy in which 1,200 mg Tecentriq followed by bevacizumab, is administered by intravenous infusion every three weeks.

Tecentriq in combination with nab-paclitaxel and carboplatin

During the induction phase, the recommended dose of Tecentriq is 1,200 mg administered by intravenous infusion, followed by nab-paclitaxel and carboplatin every three weeks for four or six cycles. For each 21-day cycle, Tecentriq, nab-paclitaxel, and carboplatin are administered on day 1. In addition, nab-paclitaxel is administered on days 8 and 15.

The induction phase is followed by a maintenance phase without chemotherapy in which 1,200 mg Tecentriq is administered by intravenous infusion every three weeks.

1L ES-SCLC

Tecentriq in combination with carboplatin and etoposide

During the induction phase, the recommended dose of Tecentriq is 1,200 mg administered by intravenous infusion followed by carboplatin, and then etoposide administered by intravenous infusion on day 1. Etoposide is also administered by intravenous infusion on days 2 and 3. This regimen is administered every three weeks for four cycles.

The induction phase is followed by a maintenance phase without chemotherapy in which 1,200 mg Tecentriq is administered by intravenous infusion every three weeks.

Duration of treatment

It is recommended that patients are treated with Tecentriq until loss of clinical benefit (see section 5.1) or unmanageable toxicity.

For ES-SCLC and for first-line NSCLC, in patients given Tecentriq in combination with carboplatin and nab-paclitaxel, it is recommended that patients are treated with Tecentriq until disease progression or unmanageable toxicity. Treatment beyond disease progression may be considered at the discretion of the physician (see section 5.1).

Delayed or missed doses

If a planned dose of Tecentriq is missed, it should be administered as soon as possible. The schedule of administration must be adjusted to maintain a 3-week interval between doses.

Dose modifications during treatment

Dose reductions of Tecentriq are not recommended.

Dose delay or discontinuation (see also sections 4.4 and 4.8)

Table 1: Dose modification advice for Tecentriq

Immune related adverse reaction

Severity

Treatment modification

Pneumonitis

Grade 2

Withhold Tecentriq

Treatment may be resumed when the event improves to Grade 0 or Grade 1 within 12 weeks, and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day

Grade 3 or 4

Permanently discontinue Tecentriq

Hepatitis

Grade 2:

(ALT or AST > 3 to 5 x upper limit of normal [ULN]

or

blood bilirubin > 1.5 to 3 x ULN)

Withhold Tecentriq

Treatment may be resumed when the event improves to Grade 0 or Grade 1 within 12 weeks and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day

Grade 3 or 4:

(ALT or AST > 5 x ULN

or

blood bilirubin > 3 x ULN)

Permanently discontinue Tecentriq

Colitis

Grade 2 or 3 Diarrhoea (increase of ≥ 4 stools/day over baseline)

or

Symptomatic Colitis

Withhold Tecentriq

Treatment may be resumed when the event improves to Grade 0 or Grade 1 within 12 weeks and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day

Grade 4 Diarrhoea or Colitis (life threatening; urgent intervention indicated)

Permanently discontinue Tecentriq

Hypothyroidism or hyperthyroidism

Symptomatic

Withhold Tecentriq

Hypothyroidism:

Treatment may be resumed when symptoms are controlled by thyroid replacement therapy and TSH levels are decreasing

Hyperthyroidism:

Treatment may be resumed when symptoms are controlled by anti-thyroid medicinal product and thyroid function is improving

Adrenal insufficiency

Symptomatic

Withhold Tecentriq

Treatment may be resumed when the symptoms improve to Grade 0 or Grade 1 within 12 weeks and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day and patient is stable on replacement therapy

Hypophysitis

Grade 2 or 3

Withhold Tecentriq

Treatment may be resumed when the symptoms improve to Grade 0 or Grade 1 within 12 weeks and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day and patient is stable on replacement therapy

Grade 4

Permanently discontinue Tecentriq

Type 1 diabetes mellitus

Grade 3 or 4 hyperglycaemia (fasting glucose > 250 mg/dL or 13.9 mmol/L)

Withhold Tecentriq

Treatment may be resumed when metabolic control is achieved on insulin replacement therapy

Infusion-related reactions

Grade 1 or 2

Reduce infusion rate or interrupt. Treatment may be resumed when the event is resolved

Grade 3 or 4

Permanently discontinue Tecentriq

Rash

Grade 3

Withhold Tecentriq

Treatment may be resumed when rash is resolved and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day

Grade 4

Permanently discontinue Tecentriq

Myasthenic syndrome/myasthenia gravis, Guillain-Barré syndrome and Meningoencephalitis

All Grades

Permanently discontinue Tecentriq

Pancreatitis

Grade 3 or 4 serum amylase or lipase levels increased (> 2 x ULN)

or Grade 2 or 3 pancreatitis

Withhold Tecentriq

Treatment may be resumed when serum amylase and lipase levels improve to Grade 0 or Grade 1 within 12 weeks, or symptoms of pancreatitis have resolved, and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day

Grade 4 or any grade of recurrent pancreatitis

Permanently discontinue Tecentriq

Myocarditis

Grade 2

Withhold Tecentriq

Treatment may be resumed when the symptoms improve to Grade 0 or Grade 1 within 12 weeks and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day

Grade 3 and 4

Permanently discontinue Tecentriq

Nephritis

Grade 2:

(creatinine level > 1.5 to 3.0 x baseline or > 1.5 to 3.0 x ULN)

Withhold Tecentriq

Treatment may be resumed when the event improves to Grade 0 or Grade 1 within 12 weeks and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day

Grade 3 or 4:

(creatinine level > 3.0 x baseline or > 3.0 x ULN)

Permanently discontinue Tecentriq

Myositis

Grade 2 or 3

Withhold Tecentriq

Grade 4 or grade 3 recurrent myositis

Permanently discontinue Tecentriq

Other immune-related adverse reactions

Grade 2 or Grade 3

Withhold until adverse reactions recovers to Grade 0-1 within 12 weeks, and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day.

Grade 4 or recurrent Grade 3

Permanently discontinue Tecentriq (except endocrinopathies controlled with replacement hormones)

Note: Toxicity grades are in accordance with National Cancer Institute Common Terminology Criteria for Adverse Event Version 4.0 (NCI-CTCAE v.4.).

Special populations

Paediatric population

The safety and efficacy of Tecentriq in children and adolescents aged below 18 years have not been established. No data are available.

Elderly

Based on a population pharmacokinetic analysis, no dose adjustment of Tecentriq is required in patients ≥ 65 years of age (see sections 4.8 and 5.1).

Asian patients

Due to increased haematologic toxicities observed in Asian patients in IMpower150, it is recommended that the starting dose of paclitaxel should be 175 mg/m2 every three weeks.

Renal impairment

Based on a population pharmacokinetic analysis, no dose adjustment is required in patients with mild or moderate renal impairment (see section 5.2). Data from patients with severe renal impairment are too limited to draw conclusions on this population.

Hepatic impairment

Based on a population pharmacokinetic analysis, no dose adjustment is required for patients with mild hepatic impairment. Tecentriq has not been studied in patients with moderate or severe hepatic impairment (see section 5.2).

Eastern Cooperative Oncology Group (ECOG) performance status ≥ 2

Patients with ECOG performance status ≥ 2 were excluded from the clinical trials in NSCLC, ES-SCLC and 2nd line UC (see sections 4.4 and 5.1).

Method of administration

Tecentriq is for intravenous use. The infusions must not be administered as an intravenous push or bolus.

The initial dose of Tecentriq must be administered over 60 minutes. If the first infusion is well tolerated, all subsequent infusions may be administered over 30 minutes.

For instructions on dilution and handling of the medicinal product before administration, see section 6.6.

4.3 Contraindications

Hypersensitivity to atezolizumab or to any of the excipients listed in section 6.1.

4.4 Special warnings and precautions for use

Traceability

In order to improve the traceability of biological medicinal products, the trade name and the batch number of the administered product should be clearly recorded in the patient file.

Immune-related adverse reactions

Most immune-related adverse reactions occurring during treatment with atezolizumab were reversible with interruptions of atezolizumab and initiation of corticosteroids and/or supportive care. Immune-related adverse reactions affecting more than one body system have been observed. Immune-related adverse reactions with atezolizumab may occur after the last dose of atezolizumab.

For suspected immune-related adverse reactions, thorough evaluation to confirm aetiology or exclude other causes should be performed. Based on the severity of the adverse reaction, atezolizumab should be withheld and corticosteroids administered. Upon improvement to Grade ≤ 1, corticosteroid should be tapered over ≥ 1 month. Based on limited data from clinical studies in patients whose immune-related adverse reactions could not be controlled with systemic corticosteroid use, administration of other systemic immunosuppressants may be considered.

Atezolizumab must be permanently discontinued for any Grade 3 immune-related adverse reaction that recurs and for any Grade 4 immune-related adverse reactions, except for endocrinopathies that are controlled with replacement hormones (see sections 4.2 and 4.8).

Immune-related pneumonitis

Cases of pneumonitis, including fatal cases, have been observed in clinical trials with atezolizumab (see section 4.8). Patients should be monitored for signs and symptoms of pneumonitis.

Treatment with atezolizumab should be withheld for Grade 2 pneumonitis, and 1 to 2 mg/kg/day prednisone or equivalent should be started. If symptoms improve to ≤ Grade 1, corticosteroids should be tapered over ≥ 1 month. Treatment with atezolizumab may be resumed if the event improves to ≤ Grade 1 within 12 weeks, and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day. Treatment with atezolizumab must be permanently discontinued for Grade 3 or 4 pneumonitis.

Immune-related hepatitis

Cases of hepatitis, some leading to fatal outcomes have been observed in clinical trials with atezolizumab (see section 4.8). Patients should be monitored for signs and symptoms of hepatitis.

Aspartate aminotransferase (AST), alanine aminotransferase (ALT) and bilirubin should be monitored prior to initiation of treatment, periodically during treatment with atezolizumab and as indicated based on clinical evaluation.

Treatment with atezolizumab should be withheld if Grade 2 event (ALT or AST > 3 to 5 x ULN or blood bilirubin > 1.5 to 3 x ULN) persists for more than 5 to 7 days, and 1 to 2 mg/kg/day of prednisone or equivalent should be started. If the event improves to ≤ Grade 1, corticosteroids should be tapered over ≥ 1 month.

Treatment with atezolizumab may be resumed if the event improves to ≤ Grade 1 within 12 weeks and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day. Treatment with atezolizumab must be permanently discontinued for Grade 3 or Grade 4 events (ALT or AST > 5.0 x ULN or blood bilirubin > 3 x ULN).

Immune-related colitis

Cases of diarrhoea or colitis have been observed in clinical trials with atezolizumab (see section 4.8). Patients should be monitored for signs and symptoms of colitis.

Treatment with atezolizumab should be withheld for Grade 2 or 3 diarrhoea (increase of ≥ 4 stools/day over baseline) or colitis (symptomatic). For Grade 2 diarrhoea or colitis, if symptoms persist > 5 days or recur, treatment with 1 to 2 mg/kg/day prednisone or equivalent should be started. For Grade 3 diarrhoea or colitis, treatment with intravenous corticosteroids (1 to 2 mg/kg/day methylprednisolone or equivalent) should be started. Once symptoms improve, treatment with 1 to 2 mg/kg/day of prednisone or equivalent should be started. If symptoms improve to ≤ Grade 1, corticosteroids should be tapered over ≥ 1 month. Treatment with atezolizumab may be resumed if the event improves to ≤ Grade 1 within 12 weeks and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day. Treatment with atezolizumab must be permanently discontinued for Grade 4 (life threatening; urgent intervention indicated) diarrhoea or colitis.

Immune-related endocrinopathies

Hypothyroidism, hyperthyroidism, adrenal insufficiency, hypophysitis and type 1 diabetes mellitus, including diabetic ketoacidosis have been observed in clinical trials with atezolizumab (see section 4.8).

Patients should be monitored for clinical signs and symptoms of endocrinopathies. Thyroid function should be monitored prior to and periodically during treatment with atezolizumab. Appropriate management of patients with abnormal thyroid function tests at baseline should be considered.

Asymptomatic patients with abnormal thyroid function tests can receive atezolizumab. For symptomatic hypothyroidism, atezolizumab should be withheld and thyroid hormone replacement should be initiated as needed. Isolated hypothyroidism may be managed with replacement therapy and without corticosteroids. For symptomatic hyperthyroidism, atezolizumab should be withheld and an anti-thyroid medicinal product should be initiated as needed. Treatment with atezolizumab may be resumed when symptoms are controlled and thyroid function is improving.

For symptomatic adrenal insufficiency, atezolizumab should be withheld and treatment with intravenous corticosteroids (1 to 2 mg/kg/day methylprednisolone or equivalent) should be started. Once symptoms improve, treatment with 1 to 2 mg/kg/day of prednisone or equivalent should follow. If symptoms improve to ≤ Grade 1, corticosteroids should be tapered over ≥ 1 month. Treatment may be resumed if the event improves to ≤ Grade 1 within 12 weeks and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day and the patient is stable on replacement therapy (if required).

For Grade 2 or Grade 3 hypophysitis, atezolizumab should be withheld and treatment with intravenous corticosteroids (1 to 2 mg/kg/day methylprednisolone or equivalent) should be started, and hormone replacement should be initiated as needed. Once symptoms improve, treatment with 1 to 2 mg/kg/day of prednisone or equivalent should follow. If symptoms improve to ≤ Grade 1, corticosteroids should be tapered over ≥ 1 month. Treatment may be resumed if the event improves to ≤ Grade 1 within 12 weeks and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day and the patient is stable on replacement therapy (if required). Treatment with atezolizumab should be permanently discontinued for Grade 4 hypophysitis.

Treatment with insulin should be initiated for type 1 diabetes mellitus. For ≥ Grade 3 hyperglycaemia (fasting glucose > 250 mg/dL or 13.9 mmol/L), atezolizumab should be withheld. Treatment with atezolizumab may be resumed if metabolic control is achieved on insulin replacement therapy.

Immune-related meningoencephalitis

Meningoencephalitis has been observed in clinical trials with atezolizumab (see section 4.8). Patients should be monitored for clinical signs and symptoms of meningitis or encephalitis.

Treatment with atezolizumab must be permanently discontinued for any grade of meningitis or encephalitis. Treatment with intravenous corticosteroids (1 to 2 mg/kg/day methylprednisolone or equivalent) should be started. Once symptoms improve, treatment with 1 to 2 mg/kg/day of prednisone or equivalent should follow.

Immune-related neuropathies

Myasthenic syndrome/myasthenia gravis or Guillain-Barré syndrome, which may be life threatening, were observed in patients receiving atezolizumab. Patients should be monitored for symptoms of motor and sensory neuropathy.

Treatment with atezolizumab must be permanently discontinued for any grade of myasthenic syndrome / myasthenia gravis or Guillain-Barré syndrome. Initiation of systemic corticosteroids (at a dose of 1 to 2 mg/kg/day of prednisone or equivalent) should be considered.

Immune-related pancreatitis

Pancreatitis, including increases in serum amylase and lipase levels, has been observed in clinical trials with atezolizumab (see section 4.8). Patients should be closely monitored for signs and symptoms that are suggestive of acute pancreatitis.

Treatment with atezolizumab should be withheld for ≥ Grade 3 serum amylase or lipase levels increased (> 2 x ULN), or Grade 2 or 3 pancreatitis, and treatment with intravenous corticosteroids

(1 to 2 mg/kg/day methylprednisolone or equivalent) should be started. Once symptoms improve, treatment with 1 to 2 mg/kg/day of prednisone or equivalent should follow. Treatment with atezolizumab may be resumed when serum amylase and lipase levels improve to ≤ Grade 1 within 12 weeks, or symptoms of pancreatitis have resolved, and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day. Treatment with atezolizumab should be permanently discontinued for Grade 4, or any grade of recurrent pancreatitis.

Immune-related myocarditis

Myocarditis has been observed in clinical trials with atezolizumab (see section 4.8). Patients should be monitored for signs and symptoms of myocarditis.

Treatment with atezolizumab should be withheld for Grade 2 myocarditis, and treatment with systemic corticosteroids at a dose of 1 to 2mg/kg/day of prednisone or equivalent should be started. Treatment with atezolizumab may be resumed if the event improves to ≤ Grade 1 within 12 weeks, and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day. Treatment with atezolizumab must be permanently discontinued for Grade 3 or 4 myocarditis.

Immune-related nephritis

Nephritis has been observed in clinical trials with atezolizumab (see section 4.8). Patients should be monitored for changes in renal function.

Treatment with atezolizumab should be withheld for Grade 2 nephritis, and treatment with systemic corticosteroids at a dose of 1 to 2mg/kg/day of prednisone or equivalent should be started. Treatment with atezolizumab may be resumed if the event improves to ≤ Grade 1 within 12 weeks, and corticosteroids have been reduced to ≤ 10 mg prednisone or equivalent per day. Treatment with atezolizumab must be permanently discontinued for Grade 3 or 4 nephritis.

Immune-related myositis

Cases of myositis, including fatal cases, have been observed in clinical trials with atezolizumab (see section 4.8). Patients should be monitored for signs and symptoms of myositis.

Treatment with atezolizumab should be withheld for Grade 2 or 3 myositis and corticosteroid therapy (1-2 mg/kg/day prednisone or equivalent) should be initiated. If symptoms improve to ≤ Grade 1, taper corticosteroids as clinically indicated. Treatment with atezolizumab may be resumed if the event improves to ≤ Grade 1 within 12 weeks, and corticosteroids have been reduced to ≤ 10 mg oral prednisone or equivalent per day. Treatment with atezolizumab should be permanently discontinued for Grade 4 or grade 3 recurrent myositis, or when unable to reduce the corticosteroid dose to the equivalent of ≤ 10 mg prednisone per day within 12 weeks after onset.

Infusion-related reactions

Infusion-related reactions have been observed with atezolizumab (see section 4.8).

The rate of infusion should be reduced or treatment should be interrupted in patients with Grade 1 or 2 infusion-related reactions. Atezolizumab should be permanently discontinued in patients with Grade 3 or 4 infusion-related reactions. Patients with Grade 1 or 2 infusion-related reactions may continue to receive atezolizumab with close monitoring; premedication with antipyretic and antihistamines may be considered.

Disease-specific precautions

Use of atezolizumab in combination with bevacizumab, paclitaxel and carboplatin in metastatic non-squamous non-small cell lung cancer

Physicians should carefully consider the combined risks of the four-drug regimen of atezolizumab bevacizumab, paclitaxel, and carboplatin before initiating treatment (see section 4.8).

Use of atezolizumab in combination with nab-paclitaxel in metastatic triple negative breast cancer

Neutropenia and peripheral neuropathies occurring during treatment with atezolizumab and nab-paclitaxel may be reversible with interruptions of atezolizumab and/or nab-paclitaxel. Physicians should consult the nab-paclitaxel summary of product characteristics (SmPC) for specific precautions and contraindications of this medicine.

Patients excluded from clinical trials

Patients with the following conditions were excluded from clinical trials: a history of autoimmune disease, history of pneumonitis, active brain metastasis, HIV, hepatitis B or hepatitis C infection, significant cardiovascular disease and patients with inadequate hematologic and end-organ function. Patients who were administered a live, attenuated vaccine within 28 days prior to enrolment; systemic immunostimulatory agents within 4 weeks or systemic immunosuppressive medicinal products within 2 weeks prior to study entry were excluded from clinical trials.

Use of atezolizumab in urothelial carcinoma for previously untreated patients who are considered cisplatin ineligible

The baseline and prognostic disease characteristics of the IMvigor210 Cohort 1 study population were overall comparable to patients in the clinic who would be considered cisplatin ineligible but would be eligible for a carboplatin-based combination chemotherapy. There are insufficient data for the subgroup of patients that would be unfit for any chemotherapy; therefore atezolizumab should be used with caution in these patients, after careful consideration of the potential balance of risks and benefits on an individual basis.

Use of atezolizumab in combination with bevacizumab, paclitaxel and carboplatin

Patients with NSCLC that had clear tumour infiltration into the thoracic great vessels or clear cavitation of pulmonary lesions, as seen on imaging, were excluded from the pivotal clinical study IMpower150 after several cases of fatal pulmonary haemorrhage were observed, which is a known risk factor of treatment with bevacizumab.

In the absence of data, atezolizumab should be used with caution in these populations after careful evaluation of the balance of benefits and risks for the patient.

Use of atezolizumab in combination with bevacizumab, paclitaxel and carboplatin in EGFR+ patients with NSCLC who have progressed on erlotinib+bevacizumab

In study IMpower150, there are no data on the efficacy of atezolizumab in combination with bevacizumab, paclitaxel and carboplatin in EGFR+ patients who have progressed previously on erlotinib+bevacizumab.

Patient alert card

All prescribers of Tecentriq must be familiar with the Physician Information and Management Guidelines. The prescriber must discuss the risks of Tecentriq therapy with the patient. The patient will be provided with the patient alert card and instructed to carry the card at all times.

4.5 Interaction with other medicinal products and other forms of interaction

No formal pharmacokinetic drug interaction studies have been conducted with atezolizumab. Since atezolizumab is cleared from the circulation through catabolism, no metabolic drug-drug interactions are expected.

The use of systemic corticosteroids or immunosuppressants before starting atezolizumab should be avoided because of their potential interference with the pharmacodynamic activity and efficacy of atezolizumab. However, systemic corticosteroids or other immunosuppressants can be used to treat immune-related adverse reactions after starting atezolizumab (see section 4.4).

4.6 Fertility, pregnancy and lactation

Women of childbearing potential

Women of childbearing potential have to use effective contraception during and for 5 months after treatment with atezolizumab.

Pregnancy

There are no data from the use of atezolizumab in pregnant women. No developmental and reproductive studies were conducted with atezolizumab. Animal studies have demonstrated that inhibition of the PD-L1/PD-1 pathway in murine pregnancy models can lead to immune-related rejection of the developing foetus resulting in foetal death (see section 5.3). These results indicate a potential risk, based on its mechanism of action, that administration of atezolizumab during pregnancy could cause foetal harm, including increased rates of abortion or stillbirth.

Human immunoglobulins G1 (IgG1) are known to cross the placental barrier and atezolizumab is an IgG1; therefore, atezolizumab has the potential to be transmitted from the mother to the developing foetus.

Atezolizumab should not be used during pregnancy unless the clinical condition of the woman requires treatment with atezolizumab.

Breast-feeding

It is unknown whether atezolizumab is excreted in human milk. Atezolizumab is a monoclonal antibody and is expected to be present in the first milk and at low levels afterwards. A risk to the newborns/infants cannot be excluded. A decision must be made whether to discontinue breast-feeding or to discontinue Tecentriq therapy taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman.

Fertility

No clinical data are available on the possible effects of atezolizumab on fertility. No reproductive and development toxicity studies have been conducted with atezolizumab; however, based on the 26-week repeat dose toxicity study, atezolizumab had an effect on menstrual cycles at an estimated AUC approximately 6 times the AUC in patients receiving the recommended dose and was reversible (see section 5.3). There were no effects on the male reproductive organs.

4.7 Effects on ability to drive and use machines

Tecentriq has minor influence on the ability to drive and use machines. Patients experiencing fatigue should be advised not to drive and use machines until symptoms abate (see section 4.8).

4.8 Undesirable effects

Summary of the safety profile

The safety of atezolizumab as monotherapy is based on pooled data in 3,178 patients across multiple tumour types. The most common adverse reactions (> 10%) were fatigue (35.9%), decreased appetite (25.5%), nausea (23.5%), cough (20.8%), dyspnoea (20.5%), pyrexia (20.1%), diarrhoea (19.7%), rash (19.5%), back pain (15.3%), vomiting (15.0%), asthenia (14.5%), arthralgia (13.9%), musculoskeletal pain (13.0%), pruritus (12.6%) and urinary tract infection (11.6%).

The safety of atezolizumab given in combination with other medicinal products, has been evaluated in 2,759 patients across multiple tumour types. The most common adverse reactions (≥ 20%) were nausea (37.4%), fatigue (36.4%), neutropenia (33.7%), anaemia (33.2%), diarrhoea (29.5%), rash (28.5%), constipation (27.0%), peripheral neuropathy (26.8%), decreased appetite (24.6%), thrombocytopenia (21.2%) and cough (20.1%).

Further details on serious adverse reactions are provided in Section 4.4 Warnings & Precautions.

Tabulated list of adverse reactions

The Adverse Drug Reactions (ADRs) are listed by MedDRA system organ class (SOC) and categories of frequency in Table 2 for atezolizumab given as monotherapy or as combination therapy. Adverse reactions known to occur with atezolizumab or chemotherapies given alone may occur during treatment with these medicinal products in combination, even if these reactions were not reported in clinical trials with combination therapy. The following categories of frequency have been used: very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100), rare (≥ 1/10,000 to < 1/1,000), very rare (< 1/10,000). Within each frequency grouping, adverse reactions are presented in the order of decreasing seriousness.

Table 2: Summary of adverse reactions occurring in patients treated with atezolizumab

Atezolizumab monotherapy

Atezolizumab in combination therapy

Infections and infestations

Very common

urinary tract infectiona

lung infectionb

Blood and lymphatic system disorders

Very common

anaemia, thrombocytopeniac, neutropeniad, leukopeniae

Common

thrombocytopeniac

lymphocyte count decreased

Immune system disorders

Common

infusion-related reactionf

Endocrine disorders

Very common

hypothyroidismg

Common

hypothyroidismg

Uncommon

hyperthyroidismh, diabetes mellitusi, adrenal insufficiencyj

Rare

hypophysitisk

Metabolism and nutrition disorders

Very common

decreased appetite

decreased appetite

Common

hypokalaemia, hyponatraemia, hyperglycaemia

hypokalaemia, hyponatraemia, hypomagnesaemia

Nervous system disorders

Very Common

peripheral neuropathyl , dizziness, headache

Common

syncope

Uncommon

Guillain-Barré syndromem, meningoencephalitisn

Rare

myasthenic syndromeo

Cardiac disorders

Rare

myocarditisp

Vascular disorders

Common

hypotension

Respiratory, thoracic, and mediastinal disorders

Very common

cough, dyspnoea

dyspnoea, cough

Common

pneumonitisq, hypoxia, nasal congestion, nasopharyngitis

dysphonia

Gastrointestinal disorders

Very common

nausea, vomiting, diarrhoear

nausea, diarrhoear, constipation, vomiting

Common

abdominal pain, colitiss, dysphagia, oropharyngeal paint

stomatitis, dysgeusia

Uncommon

pancreatitisu

Hepatobiliary disorders

Common

AST increased, ALT increased, hepatitisv

AST increased, ALT increased

Skin and subcutaneous tissue disorders

Very Common

rashw, pruritus

rashw, pruritus

Musculoskeletal and connective tissue disorders

Very common

arthralgia, back pain, musculoskeletal painx

arthralgia, musculoskeletal painx, back pain

Uncommon

myositisy

Renal and urinary disorders

Common

proteinuriaz

Rare

nephritisaa

General disorders and administration site conditions

Very Common

pyrexia, fatigue, asthenia

pyrexia, fatigue, asthenia

Common

influenza like illness, chills

a Includes reports of urinary tract infection, cystitis, pyelonephritis, escherichia urinary tract infection, urinary tract infection bacterial, kidney infection, pyelonephritis acute, urinary tract infection fungal, urinary tract infection pseudomonal.

b Includes reports of pneumonia, bronchitis, lung infection, lower respiratory tract infection, infective exacerbation of COPD, infectious pleural effusion, tracheobronchitis, atypical pneumonia, lung abscess, pyopneumothorax.

c Includes reports of thrombocytopenia and platelet count decreased.

d Includes reports of neutropenia, neutrophil count decreased, febrile neutropenia, neutropenic sepsis, granulocytopenia.

e Includes reports of white blood cell count decreased and leukopenia.

f Includes reports of cytokine release syndrome, hypersensitivity, anaphylaxis.

g Includes reports of autoimmune hypothyroidism, autoimmune thyroiditis, blood thyroid stimulating hormone abnormal, blood thyroid stimulating hormone decreased, blood thyroid stimulating hormone increased, euthyroid sick syndrome, goitre, hypothyroidism, myxoedema, thyroid disorder, thyroid function test abnormal, thyroiditis, thyroiditis acute, thyroxine decreased, thyroxine free decreased, thyroxine free increased, thyroxine increased, tri-iodothyronine decreased, tri-iodothyronine free abnormal, tri-iodothyronine free decreased, tri-iodothyronine free increased.

h Includes reports of hyperthyroidism, Basedow's disease, endocrine ophthalmopathy, exophthalmos.

i Includes reports of diabetes mellitus, type 1 diabetes mellitus, diabetic ketoacidosis, ketoacidosis.

j Includes reports of adrenal insufficiency and primary adrenal insufficiency.

k Incudes reports of hypophysitis and temperature regulation disorder.

l Includes reports of neuropathy peripheral, autoimmune neuropathy, peripheral sensory neuropathy, polyneuropathy, herpes zoster, peripheral motor neuropathy, neuralgic amyotrophy, peripheral sensorimotor neuropathy, toxic neuropathy, axonal neuropathy, lumbosacral plexopathy, neuropathic arthropathy, peripheral nerve infection.

m Includes reports of Guillain-Barré syndrome and demyelinating polyneuropathy.

n Includes reports of encephalitis, meningitis, photophobia.

o Incudes reports of myasthenia gravis.

p Reported in studies outside the pooled dataset. The frequency is based on the program wide exposure.

q Includes reports of pneumonitis, lung infiltration, bronchiolitis, interstitial lung disease, radiation pneumonitis.

r Includes reports of diarrhoea, defaecation urgency, frequent bowel movements, gastrointestinal hypermotility.

s Includes reports of colitis, autoimmune colitis, colitis ischaemic, colitis microscopic, colitis ulcerative.

t Includes reports of oropharyngeal pain, oropharyngeal discomfort, throat irritation.

u Includes reports of autoimmune pancreatitis, pancreatitis, pancreatitis acute, lipase increased, amylase increased.

v Includes reports of ascites, autoimmune hepatitis, hepatocellular injury, hepatitis, hepatitis acute, hepatotoxicity, liver disorder, drug-induced liver injury, hepatic failure, hepatic steatosis, hepatic lesion, oesophageal varices haemorrhage, varices oesophageal.

w Includes reports of acne, acne pustular, dermatitis, dermatitis acneiform, dermatitis allergic, dermatitis bullous, dermatitis exfoliative generalised, drug eruption, eczema, eczema infected, erythema, erythema multiforme, erythema of eyelid, exfoliative rash, eyelid rash, fixed eruption, folliculitis, furuncle, generalised erythema, palmar-plantar erythrodysaesthesia syndrome, rash , rash erythematous, rash generalised, rash macular, rash maculo-papular, rash papular, rash papulosquamous, rash pruritic, rash pustular, rash vesicular, seborrhoeic dermatitis, skin exfoliation, skin toxicity, skin ulcer, toxic epidermal necrolysis, toxic skin eruption.

x Includes reports of musculoskeletal pain and myalgia.

y Includes reports of myositis, rhabdomyolysis, polymyalgia rheumatica, dermatomyositis, muscle abscess, myoglobin urine present.

z Includes reports of proteinuria, protein urine present, haemoglobinurea, nephrotic syndrome.

aa Includes report of nephritis, Henoch-Schonlein Purpura nephritis.

Description of selected adverse reactions

The data below reflect information for significant adverse reactions for atezolizumab as monotherapy in clinical studies (see section 5.1). Details for the significant adverse reactions for atezolizumab when given in combination are presented if clinically relevant differences were noted in comparison to atezolizumab monotherapy. The management guidelines for these adverse reactions are described in sections 4.2 and 4.4.

Immune-related pneumonitis

Pneumonitis occurred in 2.7% (87/3,178) of patients who received atezolizumab monotherapy. Of the 87 patients, one experienced a fatal event. The median time to onset was 3.4 months (range 3 days to 24.8 months). The median duration was 1.4 months (range 0 day to 21.2+ months; + denotes a censored value). Pneumonitis led to discontinuation of atezolizumab in 12 (0.4%) patients. Pneumonitis requiring the use of corticosteroids occurred in 1.6% (51/3,178) of patients receiving atezolizumab monotherapy.

Immune-related hepatitis

Hepatitis occurred in 2.0% (62/3,178) of patients who received atezolizumab monotherapy. Of the 62 patients, two experienced a fatal event. The median time to onset was 1.5 months (range 6 days to 18.8 months). The median duration was 2.1 months (range 0 day to 22.0+ months; + denotes a censored value). Hepatitis led to discontinuation of atezolizumab in 6 (< 0.2%) patients. Hepatitis requiring the use of corticosteroids occurred in 0.6% (18/3,178) of patients receiving atezolizumab monotherapy.

Immune-related colitis

Colitis occurred in 1.1% (34/3,178) of patients who received atezolizumab monotherapy. The median time to onset was 4.7 months (range 15 days to 17.2 months). The median duration was 1.2 months (range 3 days to 17.8+ months; + denotes a censored value). Colitis led to discontinuation of atezolizumab in 8 (0.3%) patients. Colitis requiring the use of corticosteroids occurred in 0.6% (19/3,178) of patients receiving atezolizumab monotherapy.

Immune-related endocrinopathies

Thyroid disorders

Hypothyroidism occurred in 5.2% (164/3,178) of patients who received atezolizumab monotherapy. The median time to onset was 4.9 months (range: 0 day to 31.3 months). Hyperthyroidism occurred in 0.9% (30/3,178) of patients who received atezolizumab monotherapy. The median time to onset was 2.1 months (range 21 days to 15.7 months).

Adrenal insufficiency

Adrenal insufficiency occurred in 0.4% (12/3,178) of patients who received atezolizumab monotherapy. The median time to onset was 5.5 months (range: 3 days to 19 months). The median duration was 16.8 months (range: 0 day to 16.8 months). Adrenal insufficiency led to discontinuation of atezolizumab in 1 (<0.1%) patient. Adrenal insufficiency requiring the use of corticosteroids occurred in 0.3% (9/3,178) of patients receiving atezolizumab monotherapy.

Hypophysitis

Hypophysitis occurred in < 0.1% (2/3,178) of patients who received atezolizumab monotherapy. The median time to onset 7.2 months (range: 24 days to 13.7 months). One patient required the use of corticosteroids and treatment with atezolizumab was discontinued.

Hypophysitis occurred in 0.8% (3/393) of patients who received atezolizumab with bevacizumab, paclitaxel, and carboplatin. The median time to onset was 7.7 months (range: 5.0 to 8.8 months). Two patients required the use of corticosteroids.

Hypophysitis occurred in 0.4% (2/473) of patients who received atezolizumab in combination with nab-paclitaxel and carboplatin. The median time to onset was 5.2 months (range: 5.1 to 5.3 months). Both patients required the use of corticosteroids.

Diabetes mellitus

Diabetes mellitus occurred in 0.3% (11/3,178) of patients who received atezolizumab monotherapy. The median time to onset was 3.6 months (range 3 days to 9.9 months). Diabetes mellitus led to the discontinuation of atezolizumab in < 0.1% (3/3,178) patients.

Immune-related meningoencephalitis

Meningoencephalitis occurred in 0.4% (13/3,178) of patients who received atezolizumab monotherapy. The median time to onset was 15 days (range: 0 day to 12.5 months). The median duration was 26 days (range 6 days to 14.5+ months; + denotes a censored value).

Meningoencephalitis requiring the use of corticosteroids occurred in 0.2% (6/3,178) of patients receiving atezolizumab and four patients discontinued atezolizumab.

Immune-related neuropathies

Guillain-Barré syndrome and demyelinating polyneuropathy occurred in 0.2% (5/3,178) of patients who received atezolizumab monotherapy. The median time to onset was 7 months (range: 18 days to 8.1 months). The median duration was 8.0 months (range 18 days to 8.3+ months; + denotes a censored value). Guillain-Barré syndrome led to discontinuation of atezolizumab in 1 patient (< 0.1%). Guillain-Barré syndrome requiring the use of corticosteroids occurred in < 0.1% (2/3,178) of patients receiving atezolizumab monotherapy.

Myasthenic syndrome

Myasthenia gravis occurred in < 0.1% (1/3,178) of patients who received atezolizumab monotherapy. The time to onset was 1.2 months.

Immune-related pancreatitis

Pancreatitis, including amylase increased and lipase increased, occurred in 0.6% (18/3,178) of patients who received atezolizumab monotherapy. The median time to onset was 5.0 months (range: 9 days to 16.9 months). The median duration was 24 days (range 3 days to 12.0+ months; + denotes a censored value). Pancreatitis led to the discontinuation of atezolizumab in 3 (< 0.1%) patients. Pancreatitis requiring the use of corticosteroids occurred in 0.1% (4/3,178) of patients receiving atezolizumab monotherapy.

Immune-related myocarditis

Myocarditis occurred in < 0.1% (2/8,000) of patients across all atezolizumab clinical trials in multiple tumour types and treatment combinations. The time to onset was 18 and 33 days. Both patients required corticosteroids and discontinued atezolizumab.

Immune-related nephritis

Nephritis occurred in < 0.1% (3/3,178) of patients who received atezolizumab. The median time to onset was 13.1 months (range: 9.0 to 17.5 months). The median duration was 2.8 months (range 15 days to 9.5+ months; + denotes a censored value). Nephritis led to discontinuation of atezolizumab in 2 (<0.1%) patients. One patient required corticosteroids and discontinued atezolizumab.

Immune-related myositis

Myositis occurred in 0.4% (12/3178) of patients who received atezolizumab monotherapy. The median time to onset was 5.4 months (range: 0.7 to 11.0 months). The median duration was 3.5 months (range 0.1 to 22.6+ months; + denotes a censored value). Myositis led to discontinuation of atezolizumab in 1 (<0.1%) patient. Seven (0.2%) patients required the use of corticosteroids.

Use of atezolizumab in combination with bevacizumab, paclitaxel and carboplatin

In the first-line NSCLC study (IMpower150), an overall higher frequency of adverse events was observed in the four-drug regimen of atezolizumab, bevacizumab, paclitaxel, and carboplatin compared to atezolizumab, paclitaxel and carboplatin, including Grade 3 and 4 events (63.6% compared to 57.5%), Grade 5 events (6.1% compared to 2.5%), adverse events of special interest to atezolizumab (52.4% compared to 48.0%), as well as adverse events leading to withdrawal of any study treatment (33.8% compared to 13.3%). Nausea, diarrhoea, stomatitis, fatigue, pyrexia, mucosal inflammation, decreased appetite, weight decreased, hypertension and proteinuria were reported higher (≥5% difference) in patients receiving atezolizumab in combination with bevacizumab, paclitaxel and carboplatin. Other clinically significant adverse events which were observed more frequently in the atezolizumab, bevacizumab, paclitaxel, and carboplatin arm were epistaxis, haemoptysis, cerebrovascular accident, including fatal events.

Immunogenicity

Across multiple phase III studies, 13.1 % to 36.4% of patients developed treatment-emergent anti-drug antibodies (ADAs). Overall, ADA status appeared to have no clinically relevant impact on safety.

No data are available to allow conclusions to be drawn on possible effects of neutralising antibodies.

Elderly patients

No overall differences in safety were observed between patients ≥ 65 years of age and younger patients receiving atezolizumab monotherapy. In study IMpower150, age ≥ 65 was associated with an increased risk of developing adverse events in patients receiving atezolizumab in combination with bevacizumab, carboplatin and paclitaxel.

In studies IMpower150 and IMpower133, data for patients ≥75 years of age are too limited to draw conclusions on this population.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions (see details below).

United Kingdom

Yellow Card Scheme

Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store

4.9 Overdose

There is no information on overdose with atezolizumab.

In case of overdose, patients should be closely monitored for signs or symptoms of adverse reactions, and appropriate symptomatic treatment instituted.

5. Pharmacological properties
5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antineoplastic agents, monoclonal antibodies. ATC code: L01XC32

Mechanism of action

Programmed death-ligand 1 (PD-L1) may be expressed on tumour cells and/or tumour-infiltrating immune cells, and can contribute to the inhibition of the antitumour immune response in the tumour microenvironment. Binding of PD-L1 to the PD-1 and B7.1 receptors found on T-cells and antigen presenting cells suppresses cytotoxic T-cell activity, T-cell proliferation and cytokine production.

Atezolizumab is an Fc-engineered, humanised immunoglobulin G1 (IgG1) monoclonal antibody that directly binds to PD-L1 and provides a dual blockade of the PD-1 and B7.1 receptors, releasing PD-L1/PD-1 mediated inhibition of the immune response, including reactivating the antitumour immune response without inducing antibody-dependent cellular cytotoxicity. Atezolizumab spares the PD-L2/PD-1 interaction allowing PD-L2/PD-1 mediated inhibitory signals to persist.

Clinical efficacy and safety

Duration of treatment

Treatment with atezolizumab until loss of clinical benefit was permitted as defined by the following criteria:

• Absence of symptoms and signs (including worsening of laboratory values [e.g., new or worsening hypercalcaemia]) indicating unequivocal progression of disease

• No decline in ECOG performance status

• Absence of tumour progression at critical anatomical sites (e.g., leptomeningeal disease) that cannot be readily managed and stabilised by protocol-allowed medical interventions prior to repeat dosing

• Evidence of clinical benefit as assessed by the investigator

Patients with ES-SCLC were treated with atezolizumab until disease progression. Treatment beyond disease progression was permitted at the discretion of the physician.

Patients with locally advanced or metastatic UC who are ineligible for cisplatin therapy were treated with atezolizumab until disease progression.

Urothelial carcinoma

IMvigor211 (GO29294): Randomised trial in locally advanced or metastatic UC patients previously treated with chemotherapy

A phase III, open-label, multi-center, international, randomised study, (IMvigor211), was conducted to evaluate the efficacy and safety of atezolizumab compared with chemotherapy (investigator's choice of vinflunine, docetaxel, or paclitaxel) in patients with locally advanced or metastatic UC who progressed during or following a platinum-containing regimen. This study excluded patients who had a history of autoimmune disease; active or corticosteroid-dependent brain metastases; administration of a live, attenuated vaccine within 28 days prior to enrolment; and administration of systemic immunostimulatory agents within 4 weeks or systemic immunosuppressive medicinal product within 2 weeks prior to enrolment. Tumour assessments were conducted every 9 weeks for the first 54 weeks, and every 12 weeks thereafter. Tumour specimens were evaluated prospectively for PD-L1 expression on tumour-infiltrating immune cells (IC) and the results were used to define the PD-L1 expression subgroups for the analyses described below.

A total of 931 patients were enrolled. Patients were randomised (1:1) to receive either atezolizumab or chemotherapy. Randomisation was stratified by chemotherapy (vinflunine vs. taxane), PD-L1 expression status on IC (< 5% vs. ≥ 5%), number of prognostic risk factors (0 vs. 1-3), and liver metastases (yes vs. no). Prognostic risk factors included time from prior chemotherapy of < 3 months, ECOG performance status > 0 and haemoglobin < 10 g/dL.

Atezolizumab was administered as a fixed dose of 1,200 mg by intravenous infusion every 3 weeks. No dose reduction of atezolizumab was allowed. Patients were treated until loss of clinical benefit as assessed by the investigator or unacceptable toxicity. Vinflunine was administered 320 mg/m2 by intravenous infusion on day 1 of each 3-week cycle until disease progression or unacceptable toxicity. Paclitaxel was administered 175 mg/m2 by intravenous infusion over 3 hours on day 1 of each 3-week cycle until disease progression or unacceptable toxicity. Docetaxel was administered 75 mg/m2 by intravenous infusion on day 1 of each 3-week cycle until disease progression or unacceptable toxicity. For all treated patients, the median duration of treatment was 2.8 months for the atezolizumab arm, 2.1 months for the vinflunine and paclitaxel arms and 1.6 months for the docetaxel arm.

The demographic and baseline disease characteristics of the primary analysis population were well balanced between the treatment arms. The median age was 67 years (range: 31 to 88), and 77.1% of patients were male. The majority of patients were white (72.1%), 53.9% of patients within the chemotherapy arm received vinflunine, 71.4% of patients had at least one poor prognostic risk factor and 28.8% had liver metastases at baseline. Baseline ECOG performance status was 0 (45.6%) or 1 (54.4%). Bladder was the primary tumour site for 71.1% of patients and 25.4% of patients had upper tract urothelial carcinoma. There were 24.2% of patients who received only prior platinum-containing adjuvant or neoadjuvant therapy and progressed within 12 months.

The primary efficacy endpoint for IMvigor211 is overall survival (OS). Secondary efficacy endpoints evaluated per investigator-assessed Response Evaluation Criteria in Solid Tumours (RECIST) v1.1 are objective response rate (ORR), progression-free survival (PFS), and duration of response (DOR). Comparisons with respect to OS between the treatment arm and control arm within the IC2/3, IC1/2/3, and ITT (Intention-to-treat, i.e. all comers) populations were tested using a hierarchical fixed-sequence procedure based on a stratified log-rank test at two-sided level of 5% as follows: step 1) IC2/3 population; step 2) IC1/2/3 population; step 3) all comers population. OS results for each of steps 2 and 3 could be formally tested for statistical significance only if the result in the preceding step was statistically significant.

The median survival follow-up is 17 months. The primary analysis of study IMvigor211 did not meet its primary endpoint of OS. Atezolizumab did not demonstrate a statistically significant survival benefit compared to chemotherapy in patients with previously treated, locally advanced or metastatic urothelial carcinoma. Per the pre-specified hierarchical testing order, the IC2/3 population was tested first, with an OS HR of 0.87 (95% CI: 0.63, 1.21; median OS of 11.1 vs. 10.6 months for atezolizumab and chemotherapy respectively). The stratified log-rank p-value was 0.41 and therefore the results are considered not statistically significant in this population. As a consequence, no formal tests of statistical significance could be performed for OS in the IC1/2/3 or all comer populations, and results of those analyses would be considered exploratory. The key results in the all comer population are summarised in Table 3. The Kaplan-Meier curve for OS in the all comer population is presented in Figure 1.

Table 3: Summary of efficacy in all comers (IMvigor211)

Efficacy endpoint

Atezolizumab

(n = 467)

Chemotherapy

(n = 464)

Primary efficacy endpoint

OS*

No. of deaths (%)

324 (69.4%)

350 (75.4%)

Median time to events (months)

8.6

8.0

95% CI

7.8, 9.6

7.2, 8.6

Stratifiedǂ hazard ratio (95% CI)

0.85 (0.73, 0.99)

12-month OS (%)**

39.2%

32.4%

Secondary and exploratory endpoints

Investigator-assessed PFS (RECIST v1.1)

No. of events (%)

407 (87.2%)

410 (88.4%)

Median duration of PFS (months)

2.1

4.0

95% CI

2.1, 2.2

3.4, 4.2

Stratified hazard ratio (95% CI)

1.10 (0.95, 1.26)

Investigator-assessed ORR (RECIST v1.1)

n = 462

n = 461

No. of confirmed responders (%)

62 (13.4%)

62 (13.4%)

95% CI

10.45, 16.87

10.47, 16.91

No. of complete response (%)

16 (3.5%)

16 (3.5%)

No. of partial response (%)

46 (10.0%)

46 (10.0%)

No. of stable disease (%)

92 (19.9%)

162 (35.1%)

Investigator-assessed DOR (RECIST v1.1)

n = 62

n = 62

Median in months ***

21.7

7.4

95% CI

13.0, 21.7

6.1, 10.3

CI = confidence interval; DOR = duration of response; ORR = objective response rate; OS = overall survival; PFS = progression-free survival; RECIST = Response Evaluation Criteria in Solid Tumours v1.1.

* An analysis of OS in the all comer population was performed based on the stratified log-rank test and the result is provided for descriptive purposes only (p = 0.0378); according to the pre-specified analysis hierarchy, the p-value for the OS analysis in the all comer population cannot be considered statistically significant.

ǂ Stratified by chemotherapy (vinflunine vs. taxane), status on IC (< 5% vs. ≥ 5%), number of prognostic risk factors (0 vs. 1-3), and liver metastases (yes vs. no).

** Based on Kaplan-Meier estimate

*** Responses were ongoing in 63% of responders in the atezolizumab arm and in 21% of responders in the chemotherapy arm.

Figure 1 : Kaplan-Meier curve for overall survival (IMvigor211)

IMvigor210 (GO29293): Single-arm trial in previously untreated urothelial carcinoma patients who are ineligible for cisplatin therapy and in urothelial carcinoma patients previously treated with chemotherapy

A phase II, multi-centre, international, two-cohort, single-arm clinical trial, IMvigor210, was conducted in patients with locally advanced or metastatic UC (also known as urothelial bladder cancer).

The study enrolled a total of 438 patients and had two patient cohorts. Cohort 1 included previously untreated patients with locally advanced or metastatic UC who were ineligible or unfit for cisplatin-based chemotherapy or had disease progression at least 12 months after treatment with a platinum-containing neoadjuvant or adjuvant chemotherapy regimen. Cohort 2 included patients who received at least one platinum-based chemotherapy regimen for locally advanced or metastatic UC or had disease progression within 12 months of treatment with a platinum-containing neoadjuvant or adjuvant chemotherapy regimen.

In Cohort 1, 119 patients were treated with atezolizumab 1,200 mg by intravenous infusion every 3 weeks until disease progression. The median age was 73 years. Most patients were male (81%), and the majority of patients were White (91%).

Cohort 1 included 45 patients (38%) with ECOG performance status of 0, 50 patients (42%) with ECOG performance status of 1 and 24 patients (20%) with ECOG performance status of 2, 35 patients (29%) with no Bajorin risk factors (ECOG performance status ≥ 2 and visceral metastasis), 66 patients (56%) with one Bajorin risk factor and 18 patients (15 %) with two Bajorin risk factors, 84 patients (71%) with impaired renal function (glomerular filtration rate [GFR] < 60 mL/min), and 25 patients (21%) with liver metastasis.

The primary efficacy endpoint for Cohort 1 was confirmed objective response rate (ORR) as assessed by an independent review facility (IRF) using RECIST v1.1.

The primary analysis was performed when all patients had at least 24 weeks of follow-up. Median duration of treatment was 15.0 weeks and median duration of survival follow-up was 8.5 months in all comers. Clinically relevant IRF-assessed ORRs per RECIST v1.1 were shown; however, when compared to a pre-specified historical control response rate of 10%, statistical significance was not reached for the primary endpoint. The confirmed ORRs per IRF-RECIST v1.1 were 21.9% (95% CI: 9.3, 40.0) in patients with PD-L1 expression ≥ 5%, 18.8% (95% CI: 10.9, 29.0) in patients with PD-L1 expression ≥ 1%, and 19.3% (95% CI: 12.7, 27.6) in all comers. The median duration of response (DOR) was not reached in any PD-L1 expression subgroup or in all comers. OS was not mature with an event patient ratio of approximately 40%. Median OS for all patient subgroups (PD-L1 expression ≥ 5 % and ≥ 1 %) and in all comers was 10.6 months.

An updated analysis was performed with a median duration of survival follow-up of 17.2 months for Cohort 1 and is summarised in Table 4. The median DOR was not reached in any PD-L1 expression subgroup or in all comers.

Table 4: Summary of updated efficacy (IMvigor210 Cohort 1)

Efficacy endpoint

PD-L1 expression of

≥ 5% in IC

PD-L1 expression of

≥ 1% in IC

All Comers

ORR (IRF-assessed; RECIST v1.1)

n = 32

n = 80

n = 119

No. of Responders (%)

9 (28.1%)

19 (23.8%)

27 (22.7%)

95% CI

13.8, 46.8

15.0, 34.6

15.5, 31.3

No. of complete response (%)

95% CI

4 (12.5%)

(3.5, 29.0)

8 (10.0%)

(4.4, 18.8)

11 (9.2%)

(4.7, 15.9)

No. of partial response (%)

95% CI

5 (15.6%)

(5.3, 32.8)

11 (13.8%)

(7.1, 23.3)

16 (13.4%)

(7.9, 20.9)

DOR (IRF-assessed; RECIST v1.1)

n = 9

n = 19

n = 27

Patients with event (%)

3 (33.3%)

5 (26.3%)

8 (29.6%)

Median (months) (95% CI)

NE (11.1, NE)

NE (NE)

NE (14.1, NE)

PFS (IRF-assessed; RECIST v1.1)

n = 32

n = 80

n = 119

Patients with event (%)

24 (75.0%)

59 (73.8%)

88 (73.9%)

Median (months) (95% CI)

4.1 (2.3, 11.8)

2.9 (2.1, 5.4)

2.7 (2.1, 4.2)

OS

n = 32

n = 80

n = 119

Patients with event (%)

18 (56.3%)

42 (52.5%)

59 (49.6%)

Median (months) (95% CI)

12.3 (6.0, NE)

14.1 (9.2, NE)

15.9 (10.4, NE)

1-year OS rate (%)

52.4%

54.8%

57.2%

CI = confidence interval; DOR=duration of response; IC = tumour-infiltrating immune cells; IRF = independent review facility; NE = not estimable; ORR = objective response rate; OS = overall survival; PFS = progression-free survival; RECIST = Response Evaluation Criteria in Solid Tumours v1.1.

In Cohort 2, the co-primary efficacy endpoints were confirmed ORR as assessed by an IRF using RECIST v1.1 and investigator-assessed ORR according to Modified RECIST (mRECIST) criteria. There were 310 patients treated with atezolizumab 1,200 mg by intravenous infusion every 3 weeks until loss of clinical benefit. The primary analysis of Cohort 2 was performed when all patients had at least 24 weeks of follow-up. The study met its co-primary endpoints in Cohort 2, demonstrating statistically significant ORRs per IRF-assessed RECIST v1.1 and investigator-assessed mRECIST compared to a pre-specified historical control response rate of 10%.

An analysis was also performed with a median duration of survival follow-up of 21.1 months for Cohort 2. The confirmed ORRs per IRF-RECIST v1.1 were 28.0% (95% CI: 19.5, 37.9) in patients with PD-L1 expression ≥ 5%, 19.3% (95% CI: 14.2, 25.4) in patients with PD-L1 expression ≥ 1%, and 15.8% (95% CI: 11.9, 20.4) in all comers. The confirmed ORR per investigator-assessed mRECIST was 29.0% (95% CI: 20.4, 38.9) in patients with PD-L1 expression ≥ 5%, 23.7% (95% CI: 18.1, 30.1) in patients with PD-L1 expression ≥ 1%, and 19.7% (95% CI: 15.4, 24.6) in all comers. The rate of complete response per IRF-RECIST v1.1 in the all comer population was 6.1% (95% CI: 3.7, 9.4). For Cohort 2, median DOR was not reached in any PD-L1 expression subgroup or in all comers, however was reached in patients with PD-L1 expression < 1% (13.3 months; 95% CI 4.2, NE). The OS rate at 12 month was 37% in all comers.

IMvigor130 (WO30070): Phase III multi-center, randomized, placebo-controlled study of atezolizumab as monotherapy and in combination with platinum-based chemotherapy in patients with untreated locally advanced or metastatic urothelial carcinoma

Based on an independent Data Monitoring Committee (iDMC) recommendation following an early review of survival data, accrual of patients on the atezolizumab monotherapy treatment arm whose tumours have a low PD-L1 expression (less than 5% of immune cells staining positive for PD-L1 by immunohistochemistry) was stopped after observing decreased overall survival for this subgroup. The iDMC did not recommend any change of therapy for patients who had already been randomized to and were receiving treatment in the monotherapy arm. No other changes were recommended.

Non-small cell lung cancer

First-line treatment of non-small cell lung cancer

IMpower150 (GO29436): Randomised phase III trial in chemotherapy-naïve patients with metastatic non-squamous NSCLC, in combination with paclitaxel and carboplatin with or without bevacizumab

A phase III, open-label, multicenter, international, randomised study, IMpower150, was conducted to evaluate the efficacy and safety of atezolizumab in combination with paclitaxel and carboplatin, with or without bevacizumab, in chemotherapy-naïve patients with metastatic non-squamous NSCLC.

Patients were excluded if they had history of autoimmune disease, administration of a live, attenuated vaccine within 28 days prior to randomisation, administration of systemic immunostimulatory agents within 4 weeks or systemic immunosuppressive medicinal product within 2 weeks prior to randomisation, active or untreated CNS metastases, clear tumour infiltration into the thoracic great vessels or clear cavitation of pulmonary lesions, as seen on imaging. Tumour assessments were conducted every 6 weeks for the first 48 weeks following Cycle 1, Day 1 and then every 9 weeks thereafter. Tumour specimens were evaluated for PD-L1 expression on tumour cells (TC) and tumour-infiltrating immune cells (IC) and the results were used to define the PD-L1 expression subgroups for the analyses described below.

A total of 1,202 patients were enrolled and were randomised (1:1:1) to receive one of the treatment regimens described in Table 5. Randomization was stratified by sex, presence of liver metastases and PD-L1 tumour expression on TC and IC.

Table 5: Intravenous treatment regimens (IMpower150)

Treatment regimen

Induction

(Four or Six 21-day cycles)

Maintenance

(21-day cycles)

A

Atezolizumaba (1,200 mg) + paclitaxel (200 mg/m2)b,c + carboplatinc (AUC 6)

Atezolizumaba (1,200 mg)

B

Atezolizumaba (1,200 mg) + bevacizumabd (15 mg/kg) + paclitaxel (200 mg/m2)b,c + carboplatinc (AUC 6)

Atezolizumaba (1,200 mg) + bevacizumabd (15 mg/kg)

C

Bevacizumabd (15 mg/kg) + paclitaxel (200 mg/m2)b,c + carboplatinc (AUC 6)

Bevacizumabd (15 mg/kg)

a Atezolizumab is administered until loss of clinical benefit as assessed by the investigator

b The paclitaxel starting dose for patients of Asian race/ethnicity was 175 mg/m2 due to higher overall level of haematologic toxicities in patients from Asian countries compared with those from non-Asian countries

c Paclitaxel and carboplatin are administered until completion of 4 or 6 cycles, or progressive disease, or unacceptable toxicity whichever occurs first

d. Bevacizumab is administered until progressive disease or unacceptable toxicity

The demographics and baseline disease characteristics of the study population were well balanced between the treatment arms. The median age was 63 years (range: 31 to 90), and 60% of patients were male. The majority of patients were white (82%). Approximately 10% of patients had known EGFR mutation, 4% had known ALK rearrangements, 14% had liver metastasis at baseline, and most patients were current or previous smokers (80%). Baseline ECOG performance status was 0 (43%) or 1 (57%). 51% of patients' tumours had PD-L1 expression of ≥ 1% TC or ≥ 1% IC and 49% of patients' tumours had PD-L1 expression of < 1% TC and < 1% IC.

At the time of the final analysis for PFS, patients had a median follow up time of 15.3 months. The ITT population, including patients with EGFR mutations or ALK rearrangements who should have been previously treated with tyrosine kinase inhibitors, demonstrated clinically meaningful PFS improvement in Arm B as compared to Arm C (HR of 0.61, 95% CI: 0.52, 0.72; median PFS 8.3 vs. 6.8 months).

At the time of the interim OS analysis, patients had a median follow-up of 19.7 months. The key results from this analysis as well as from the updated PFS analysis in the ITT population are summarised in Tables 6 and 7. The Kaplan-Meier curve for OS in the ITT population is presented in Figure 2. Figure 3 summarises the results of OS in the ITT and PD-L1 subgroups. Updated PFS results are also presented in Figures 4 and 5.

Table 6: Summary of updated efficacy in the ITT population (IMpower150)

Efficacy endpoint

Arm A

(Atezolizumab + Paclitaxel + Carboplatin)

Arm B

(Atezolizumab + Bevacizumab + Paclitaxel + Carboplatin)

Arm C

(Bevacizumab + Paclitaxel + Carboplatin)

Secondary Endpoints#

Investigator-assessed PFS (RECIST v1.1)*

n = 402

n = 400

n = 400

No. of events (%)

330 (82.1%)

291 (72.8%)

355 (88.8%)

Median duration of PFS (months)

6.7

8.4

6.8

95% CI

(5.7, 6.9)

(8.0, 9.9)

(6.0, 7.0)

Stratified hazard ratio‡^ (95% CI)

p-value1,2

0.91 (0.78, 1.06)

0.2194

0.59 (0.50, 0.69)

< 0.0001

---

12-month PFS (%)

24

38

20

OS interim analysis*

n = 402

n = 400

n = 400

No. of deaths (%)

Median time to events (months)

95% CI

206 (51.2%)

19.5

(16.3, 21.3)

192 (48.0%)

19.8

(17.4, 24.2)

230 (57.5%)

14.9

(13.4, 17.1)

Stratified hazard ratio‡^ (95% CI)

p-value1,2

0.85 (0.71, 1.03)

0.0983

0.76 (0.63, 0.93)

0.006

---

6-month OS (%)

84

85

81

12-month OS (%)

66

68

61

Investigator-assessed Overall Best Response3* (RECIST 1.1)

n = 401

n = 397

n = 393

No. of responders (%)

163 (40.6%)

224 (56.4%)

158 (40.2%)

95% CI

(35.8, 45.6)

(51.4, 61.4)

(35.3, 45.2)

No. of complete response (%)

8 (2.0%)

11 (2.8%)

3 (0.8%)

No. of partial response (%)

155 (38.7%)

213 (53.7%)

155 (39.4%)

Investigator-assessed DOR* (RECIST v1.1)

n = 163

n = 224

n = 158

Median in months

8.3

11.5

6.0

95% CI

(7.1, 11.8)

(8.9, 15.7)

(5.5, 6.9)

# Primary efficacy endpoints were PFS and OS and they were analysed in the ITT-wild-type (WT) population, i.e. excluding patients with EGFR mutations or ALK rearrangements.

1 Based on the stratified log-rank test

2 For informational purposes; in the ITT population, comparisons between Arm B and Arm C as well as between Arm A and Arm C were not formally tested yet as per the pre-specified analysis hierarchy

3 Overall best response for complete response and partial response

Stratified by sex, presence of liver metastases and PD-L1 tumour expression on TC and IC

^ The Arm C is the comparison group for all hazard ratios

* Updated PFS analysis and interim OS analysis at clinical cut-off 22 January 2018

PFS = progression-free survival; RECIST = Response Evaluation Criteria in Solid Tumours v1.1.

CI = confidence interval; DOR = duration of response; OS = overall survival.

Table 7: Summary of updated efficacy for Arm A vs. Arm B in the ITT population (IMpower150)

Efficacy endpoint

Arm A

(Atezolizumab + Paclitaxel + Carboplatin)

Arm B

(Atezolizumab + Bevacizumab + Paclitaxel + Carboplatin)

Investigator-assessed PFS (RECIST v1.1)*

n = 402

n = 400

No. of events (%)

330 (82.1%)

291 (72.8%)

Median duration of PFS (months)

6.7

8.4

95% CI

(5.7, 6.9)

(8.0, 9.9)

Stratified hazard ratio^ (95% CI)

p-value1,2

0.67 (0.57, 0.79)

< 0.0001

OS interim analysis*

n = 402

n = 400

No. of deaths (%)

Median time to events (months)

95% CI

206 (51.2%)

19.5

(16.3, 21.3)

192 (48.0%)

19.8

(17.4, 24.2)

Stratified hazard ratio^ (95% CI)

p-value1,2

0.90 (0.74, 1.10)

0.3000

1 Based on the stratified log-rank test

2 For informational purposes; in the ITT population, comparisons between Arm A and Arm B were not included in the pre-specified analysis hierarchy

Stratified by sex, presence of liver metastases and PD-L1 expression on TC and IC

* Updated PFS analysis and interim OS analysis at clinical cut-off 22 January 2018

^ The Arm A is the comparison group for all hazard ratios

Figure 2: Kaplan-Meier curve for overall survival in the ITT population (IMpower150)

Figure 3: Forest plot of overall survival by PD-L1 expression in the ITT population, Arm B vs. C (IMpower150)

Figure 4: Kaplan-Meier curve for PFS in the ITT population (IMpower150)

Figure 5: Forest plot of progression free survival by PD-L1 expression in the ITT population, Arm B vs. C (IMpower150)

In Arm B as compared to Arm C, pre-specified subgroup analyses from the interim OS analysis showed an OS improvement for patients with EGFR mutations or ALK rearrangements (hazard ratio [HR] of 0.54, 95% CI: 0.29, 1.03; median OS not reached vs. 17.5 months), and liver metastases (HR of 0.52, 95% CI: 0.33, 0.82; median OS 13.3 vs. 9.4 months). PFS improvements were also shown in patients with EGFR mutations or ALK rearrangements (HR of 0.55, 95% CI: 0.35, 0.87; median PFS 10.0 vs. 6.1 months) and liver metastases (HR of 0.41, 95% CI: 0.26, 0.62; median PFS 8.2 vs. 5.4 months). OS results were similar for patients aged < 65 and ≥ 65 subgroups, respectively. Data for patients ≥ 75 years of age are too limited to draw conclusions on this population. For all subgroup analyses, formal statistical testing was not planned.

IMpower130 (GO29537): Randomised phase III trial in chemotherapy-naïve patients with metastatic non-squamous NSCLC, in combination with nab-paclitaxel and carboplatin

A phase III, open-label, randomised study, GO29537 (IMpower130), was conducted to evaluate the efficacy and safety of atezolizumab in combination with nab-paclitaxel and carboplatin, in chemotherapy-naïve patients with metastatic non-squamous NSCLC. Patients with EGFR mutations or ALK rearrangements should have been previously treated with tyrosine kinase inhibitors.

Patients were staged according to the American Joint Committee on Cancer (AJCC) 7th edition. Patients were excluded if they had a history of autoimmune disease, administration of live, attenuated vaccine within 28 days prior to randomisation, administration of immunostimulatory agents within 4 weeks or systemic immunosuppressive medications within 2 weeks prior to randomisation, and active or untreated CNS metastases. Patients who had prior treatment with CD137 agonists or immune checkpoint blockade therapies (anti-PD-1, and anti-PD-L1 therapeutic antibodies) were not eligible. However, patients who had prior anti-CTLA-4 treatment could be enrolled, as long as the last dose was received at least 6 weeks prior to randomization, and there was no history of severe immune-related adverse effects from anti-CTLA-4 (NCI CTCAE Grades 3 and 4). Tumour assessments were conducted every 6 weeks for the first 48 weeks following Cycle 1, then every 9 weeks thereafter. Tumour specimens were evaluated for PD-L1 expression on tumour cells (TC) and tumour infiltrating immune cells (IC) and the results were used to define the PD-L1 expression subgroups for the analyses described below.

Patients, including those with EGFR mutations or ALK rearrangements, were enrolled and were randomised in a 2:1 ratio to receive one of the treatment regimens described in Table 8. Randomisation was stratified by sex, presence of liver metastases and PD-L1 expression on TC and IC. Patients receiving treatment regimen B were able to crossover and receive atezolizumab monotherapy following disease progression.

Table 8: Intravenous treatment regimens (IMpower130)

Treatment

Regimen

Induction

(Four or six 21-day cycles)

Maintenance

(21-day cycles)

A

Atezolizumab (1,200 mg)a + nab-paclitaxel (100 mg/m2)b,c + carboplatin (AUC 6)c

Atezolizumab (1,200 mg)a

B

Nab-paclitaxel (100 mg/m2)b,c + carboplatin (AUC 6)c

Best supportive care or pemetrexed

a Atezolizumab is administered until loss of clinical benefit as assessed by investigator

b Nab-paclitaxel is administered on days 1, 8, and 15 of each cycle

c Nab-paclitaxel and carboplatin are administered until completion of 4-6 cycles, or progressive disease or unacceptable toxicity whichever occurs first

The demographics and baseline disease characteristics of the study population defined as ITT-WT (n=679) were well balanced between the treatment arms. The median age was 64 years (range 18 to 86 years). The majority of the patients were male (59%) and white (90%). Fourteen point seven percent of patients had liver metastases at baseline, and most patients were current or previous smokers (90%). The majority of patients had a baseline ECOG performance status of 1 (59%) and PD-L1 expression <1% (approximately 52%). Among 107 Arm B patients who had a response status of stable disease, partial response, or complete response after induction therapy, 40 received pemetrexed switch maintenance therapy.

The primary analysis was conducted in all patients, excluding those with EGFR mutations or ALK rearrangements, defined as ITT-WT population (n=679). Patients had a median survival follow up time of 18.6 months and showed improved OS and PFS with atezolizumab, nab-paclitaxel and carboplatin as compared to the control. The key results are summarised in Table 9 and Kaplan-Meier curves for OS and PFS are presented in Figures 6 and 8, respectively. The exploratory results of OS and PFS by PD-L1 expression are summarised in Figures 7 and 9, respectively. Patients with liver metastases did not show improved PFS or OS with atezolizumab, nab-paclitaxel and carboplatin, compared to nab-paclitaxel and carboplatin (HR of 0.93, 95% CI: 0.59, 1.47 for PFS and HR of 1.04, 95% CI: 0.63, 1.72 for OS, respectively).

Fifty-nine percent of patients in the nab-paclitaxel and carboplatin arm received any cancer immunotherapy after disease progression, which includes atezolizumab as crossover treatment (41% of all patients), compared to 7.3% of patients in the atezolizumab, nab paclitaxel and carboplatin arm.

In an exploratory analysis with longer follow up (median: 24.1 months), the median OS for both arms was unchanged relative to the primary analysis, with HR = 0.82 (95% CI: 0.67, 1.01).

Table 9: Summary of efficacy from IMpower130 in the primary analysis (ITT-WT population)

Efficacy endpoints

Arm A

Atezolizumab + nab-paclitaxel + carboplatin

Arm B

Nab-paclitaxel + carboplatin

Co-primary endpoints

OS

n=451

n=228

No. of deaths (%)

226 (50.1%)

131 (57.5%)

Median time to events (months)

18.6

13.9

95% CI

(16.0, 21.2)

(12.0, 18.7)

Stratified hazard ratio (95% CI)

0.79 (0.64, 0.98)

p-value

0.033

12-month OS (%)

63

56

Investigator-assessed PFS (RECIST v1.1 )

n=451

n=228

No. of events (%)

347 (76.9%)

198 (86.8%)

Median duration of PFS (months)

7.0

5.5

95% CI

(6.2, 7.3)

(4.4, 5.9)

Stratified hazard ratio (95% CI)

0.64 (0.54, 0.77)

p-value

< 0.0001

12-month PFS (%)

29%

14%

Other endpoints

Investigator-assessed ORR (RECIST v1.1)^

n=447

n=226

No. of confirmed responders (%)

220 (49.2%)

72 (31.9%)

95% CI

(44.5, 54.0)

(25.8, 38.4)

No. of complete response (%)

11 (2.5%)

3 (1.3%)

No. of partial response (%)

209 (46.8%)

69 (30.5%)

Investigator-assessed confirmed DOR (RECIST 1.1)^

n=220

n=72

Median in months

8.4

6.1

95% CI

(6.9, 11.8)

(5.5, 7.9)

Stratified by sex and PD-L1 expression on TC and IC

^ Confirmed ORR and DoR are exploratory endpoints

PFS=progression-free survival; RECIST=Response Evaluation Criteria in Solid Tumors v1.1.; CI=confidence interval; ORR=objective response rate; DOR=duration of response; OS=overall survival

Figure 6: Kaplan-Meier curves for overall survival (IMpower130)

Figure 7: Forest plot of overall survival by PD-L1 expression (IMpower130)

Figure 8: Kaplan-Meier curves for progression free survival (IMpower130)

Figure 9: Forest plot of progression free survival by PD-L1 expression (IMpower130)

Second-line treatment of non-small cell lung cancer

OAK (GO28915): Randomised phase III trial in locally advanced or metastatic NSCLC patients previously treated with chemotherapy

A phase III, open-label, multi-center, international, randomised study, OAK, was conducted to evaluate the efficacy and safety of atezolizumab compared with docetaxel in patients with locally advanced or metastatic NSCLC who progressed during or following a platinum-containing regimen. This study excluded patients who had a history of autoimmune disease, active or corticosteroid-dependent brain metastases, administration of a live, attenuated vaccine within 28 days prior to enrolment, administration of systemic immunostimulatory agents within 4 weeks or systemic immunosuppressive medicinal product within 2 weeks prior to enrolment. Tumour assessments were conducted every 6 weeks for the first 36 weeks, and every 9 weeks thereafter. Tumour specimens were evaluated prospectively for PD-L1 expression on tumour cells (TC) and tumour-infiltrating immune cells (IC).

A total of 1,225 patients were enrolled and per the analysis plan the first 850 randomised patients were included in the primary efficacy analysis. Randomisation was stratified by PD-L1 expression status on IC, by the number of prior chemotherapy regimens, and by histology. Patients were randomised (1:1) to receive either atezolizumab or docetaxel.

Atezolizumab was administered as a fixed dose of 1,200 mg by intravenous infusion every 3 weeks. No dose reduction was allowed. Patients were treated until loss of clinical benefit as assessed by the investigator. Docetaxel was administered 75 mg/m2 by intravenous infusion on day 1 of each 3-week cycle until disease progression. For all treated patients, the median duration of treatment was 2.1 months for the docetaxel arm and 3.4 months for the atezolizumab arm.

The demographic and baseline disease characteristics of the primary analysis population were well balanced between the treatment arms. The median age was 64 years (range: 33 to 85), and 61% of patients were male. The majority of patients were white (70%). Approximately three-quarters of patients had non-squamous histology (74%), 10% had known EGFR mutation, 0.2% had known ALK rearrangements, 10% had CNS metastases at baseline, and most patients were current or previous smokers (82%). Baseline ECOG performance status was 0 (37%) or 1 (63%). Seventy-five percent of patients received only one prior platinum-based therapeutic regimen.

The primary efficacy endpoint was OS. The key results of this study with a median survival follow-up of 21 months are summarised in Table 10. Kaplan-Meier curves for OS in the ITT population are presented in Figure 10. Figure 11 summarises the results of OS in the ITT and PD-L1 subgroups, demonstrating OS benefit with atezolizumab in all subgroups, including those with PD-L1 expression < 1% in TC and IC.

Table 10: Summary of efficacy in the primary analysis population (all comers)* (OAK)

Efficacy endpoint

Atezolizumab

(n = 425)

Docetaxel

(n = 425)

Primary efficacy endpoint

OS

No. of deaths (%)

271 (64%)

298 (70%)

Median time to events (months)

13.8

9.6

95% CI

(11.8, 15.7)

(8.6, 11.2)

Stratifiedǂ hazard ratio (95% CI)

0.73 (0.62, 0.87)

p-value**

0.0003

12-month OS (%)***

218 (55%)

151 (41%)

18-month OS (%)***

157 (40%)

98 (27%)

Secondary endpoints

Investigator-assessed PFS (RECIST v1.1)

No. of events (%)

380 (89%)

375 (88%)

Median duration of PFS (months)

2.8

4.0

95% CI

(2.6, 3.0)

(3.3, 4.2)

Stratified hazard ratio (95% CI)

0.95 (0.82, 1.10)

Investigator-assessed ORR (RECIST v1.1)

No. of responders (%)

58 (14%)

57 (13%)

95% CI

(10.5, 17.3)

(10.3, 17.0)

Investigator-assessed DOR (RECIST v1.1)

n = 58

n = 57

Median in months

16.3

6.2

95% CI

(10.0, NE)

(4.9, 7.6)

CI = confidence interval; DOR = duration of response; NE = not estimable; ORR = objective response rate; OS = overall survival; PFS = progression-free survival; RECIST = Response Evaluation Criteria in Solid Tumours v1.1.

* The primary analysis population consists of the first 850 randomised patients

ǂStratified by PD-L1 expression in tumour infiltrating immune cells, the number of prior chemotherapy regimens, and histology

** Based on the stratified log-rank test

*** Based on Kaplan-Meier estimates

Figure 10: Kaplan-Meier curve for overall survival in the primary analysis population (all comers) (OAK)

Figure 11: Forest plot of overall survival by PD-L1 expression in the primary analysis population (OAK)

aStratified HR for ITT and TC or IC ≥ 1%. Unstratified HR for other exploratory subgroups.

An improvement in OS was observed with atezolizumab compared to docetaxel in both non-squamous NSCLC patients (hazard ratio [HR] of 0.73, 95% CI: 0.60, 0.89; median OS of 15.6 vs. 11.2 months for atezolizumab and docetaxel, respectively) and squamous NSCLC patients (HR of 0.73, 95% CI: 0.54, 0.98; median OS of 8.9 vs. 7.7 months for atezolizumab and docetaxel, respectively). The observed OS improvement was consistently demonstrated across subgroups of patients including those with brain metastases at baseline (HR of 0.54, 95% CI: 0.31, 0.94; median OS of 20.1 vs. 11.9 months for atezolizumab and docetaxel respectively) and patients who were never smokers (HR of 0.71, 95% CI: 0.47, 1.08; median OS of 16.3 vs. 12.6 months for atezolizumab and docetaxel, respectively). However, patients with EGFR mutations did not show improved OS with atezolizumab compared to docetaxel (HR of 1.24, 95% CI: 0.71, 2.18; median OS of 10.5 vs. 16.2 months for atezolizumab and docetaxel, respectively).

Prolonged time to deterioration of patient-reported pain in chest as measured by the EORTC QLQ-LC13 was observed with atezolizumab compared to docetaxel (HR of 0.71, 95% CI: 0.49, 1.05; median not reached in either arm). The time to deterioration in other lung cancer symptoms (i.e. cough, dyspnoea, and arm/shoulder pain) as measured by the EORTC QLQ-LC13 was similar between atezolizumab and docetaxel. These results should be interpreted with caution due to the open-label design of the study.

POPLAR (GO28753): Randomised phase II trial in locally advanced or metastatic NSCLC patients previously treated with chemotherapy

A phase II, multi-centre, international, randomised, open-label, controlled study, POPLAR, was conducted in patients with locally advanced or metastatic NSCLC who progressed during or following a platinum-containing regimen, regardless of PD-L1 expression. The primary efficacy outcome was overall survival. A total of 287 patients were randomised 1:1 to receive either atezolizumab (1,200 mg by intravenous infusion every 3 weeks until loss of clinical benefit) or docetaxel (75 mg/m2 by intravenous infusion on day 1 of each 3-week cycle until disease progression). Randomisation was stratified by PD-L1 expression status on IC, by the number of prior chemotherapy regimens and by histology. An updated analysis with a total of 200 deaths observed and a median survival follow-up of 22 months showed a median OS of 12.6 months in patients treated with atezolizumab, vs. 9.7 months in patients treated with docetaxel (HR of 0.69, 95% CI: 0.52, 0.92). ORR was 15.3% vs. 14.7% and median DOR was 18.6 months vs. 7.2 months for atezolizumab vs. docetaxel, respectively.

Small cell lung cancer

IMpower133 (GO30081): Randomised phase I/III trial in patients with chemotherapy-naïve extensive-stage SCLC, in combination with carboplatin and etoposide

A Phase I/III, randomised, multicentre, double-blind, placebo-controlled study, IMpower133, was conducted to evaluate the efficacy and safety of atezolizumab in combination with carboplatin and etoposide in patients with chemotherapy-naïve extensive-stage small cell lung cancer (ES-SCLC).

Patients were excluded if they had active or untreated CNS metastases; history of autoimmune disease; administration of live, attenuated vaccine within 4 weeks prior to randomisation; administration of systemic immunosuppressive medications within 1 week prior to randomisation. Tumour assessments were conducted every 6 weeks for the first 48 weeks following Cycle 1, Day 1 and then every 9 weeks thereafter. Patients who met established criteria and who agreed to be treated beyond disease progression had tumour assessments conducted every 6 weeks until treatment discontinuation.

A total of 403 patients were enrolled and randomised (1:1) to receive one of the treatment regimens described in Table 11. Randomisation was stratified by sex, ECOG performance status, and presence of brain metastases.

Table 11: Intravenous treatment regimens (IMpower133)

Treatment regimen

Induction

(Four 21-Day Cycles)

Maintenance

(21-Day Cycles)

A

atezolizumab (1,200 mg)a + carboplatin (AUC 5)b + etoposide (100 mg/m2)b,c

atezolizumab (1,200 mg) a

B

placebo + carboplatin (AUC 5)b + etoposide (100 mg/m2)b,c

placebo

a Atezolizumab was administered until loss of clinical benefit as assessed by investigator

b Carboplatin and etoposide were administered until completion of 4 cycles, or progressive disease or unacceptable toxicity, whichever occurs first

c Etoposide was administered on day 1, 2 and 3 of each cycle

The demographic and baseline disease characteristics of the study population were well balanced between the treatment arms. The median age was 64 years (range: 26 to 90 years) with 10% of patients ≥75 years of age. The majority of patients were male (65%), white (80%), and 9% had brain metastases and most patients were current or previous smokers (97%). Baseline ECOG performance status was 0 (35%) or 1 (65%).

At the time of the primary analysis, patients had a median survival follow up time of 13.9 months. A statistically significant improvement in OS was observed with atezolizumab in combination with carboplatin and etoposide compared to the control arm (HR of 0.70, 95% CI: 0.54, 0.91; median OS of 12.3 months vs. 10.3 months). In the exploratory OS final analysis with longer follow up (median: 22.9 months), the median OS for both arms was unchanged relative to the primary OS interim analysis. The PFS, ORR and DOR results from the primary analysis as well as the exploratory OS final analysis results are summarized in Table 12. Kaplan-Meier curves for OS and PFS are presented in Figures 12 and 13. Data for patients with brain metastases are too limited to draw conclusions on this population.

Table 12: Summary of efficacy (IMpower133)

Key efficacy endpoints

Arm A

(Atezolizumab + carboplatin + etoposide)

Arm B

(Placebo + carboplatin + etoposide)

Co-primary endpoints

OS analysis*

n=201

n=202

No. of deaths (%)

142 (70.6%)

160 (79.2%)

Median time to events (months)

12.3

10.3

95% CI

(10.8, 15.8)

(9.3, 11.3)

Stratified hazard ratio (95% CI)

0.76 (0.60, 0.95)

p-value

0.0154***

12-month OS (%)

51.9

39.0

Investigator-assessed PFS (RECIST v1.1) **

n=201

n=202

No. of events (%)

171 (85.1%)

189 (93.6%)

Median duration of PFS (months)

5.2

4.3

95% CI

(4.4, 5.6)

(4.2, 4.5)

Stratified hazard ratio (95% CI)

0.77 (0.62, 0.96)

p-value

0.0170

6-month PFS (%)

12-month PFS (%)

30.9

12.6

22.4

5.4

Other endpoints

Investigator-assessed ORR (RECIST 1.1)** ^

n=201

n=202

No. of responders (%)

121 (60.2%)

130 (64.4%)

95% CI

(53.1, 67.0)

(57.3, 71.0)

No. of complete response (%)

5 (2.5%)

2 (1.0%)

No. of partial response (%)

116 (57.7%)

128 (63.4%)

Investigator-assessed DOR (RECIST 1.1)** ^

n =121

n = 130

Median in months

4.2

3.9

95% CI

(4.1, 4.5)

(3.1, 4.2)

PFS=progression-free survival; RECIST=Response Evaluation Criteria in Solid Tumours v1.1.; CI=confidence interval; ORR=objective response rate; DOR=duration of response; OS=overall survival

Stratified by sex and ECOG performance status

* Exploratory OS final analysis at clinical cut-off 24 January 2019

** PFS, ORR and DOR analyses at clinical cut-off 24 April 2018

*** For descriptive purposes only

^ Confirmed ORR and DoR are exploratory endpoints

Figure 12: Kaplan-Meier curve for overall survival (IMpower133)

Figure 13: Kaplan-Meier curve for progression-free survival (IMpower133)

Efficacy in elderly patients

No overall differences in efficacy were observed between patients ≥ 65 years of age and younger patients receiving atezolizumab monotherapy. In study IMpower150, age ≥ 65 was associated with a diminished effect of atezolizumab in patients receiving atezolizumab in combination with carboplatin and paclitaxel.

In studies IMpower150 and IMpower133, data for patients ≥75 years of age are too limited to draw conclusions on this population.

Paediatric population

The European Medicines Agency has deferred the obligation to submit the results of studies with atezolizumab in all subsets of the paediatric population in the treatment of malignant neoplasms (except central nervous system tumours, haematopoietic and lymphoid tissue neoplasms) (see section 4.2 for information on paediatric use).

5.2 Pharmacokinetic properties

Exposure to atezolizumab increased dose proportionally over the dose range 1 mg/kg to 20 mg/kg including the fixed dose 1,200 mg administered every 3 weeks. A population analysis that included 472 patients described atezolizumab pharmacokinetics for the dose range: 1 to 20 mg/kg with a linear two-compartment disposition model with first-order elimination. A population pharmacokinetic analysis suggests that steady-state is obtained after 6 to 9 weeks (2 to 3 cycles) of repeated dosing. The systemic accumulation in area under the curve, maximum concentration and trough concentration was 1.91, 1.46 and 2.75-fold, respectively.

Absorption

Atezolizumab is administered as an intravenous infusion. There have been no studies performed with other routes of administration.

Distribution

A population pharmacokinetic analysis indicates that central compartment volume of distribution is 3.28 L and volume at steady-state is 6.91 L in the typical patient.

Biotransformation

The metabolism of atezolizumab has not been directly studied. Antibodies are cleared principally by catabolism.

Elimination

A population pharmacokinetic analysis indicates that the clearance of atezolizumab is 0.200 L/day and the typical terminal elimination half-life is 27 days.

Special populations

Based on population PK and exposure-response analyses age (21-89 years), region, ethnicity, renal impairment, mild hepatic impairment, level of PD-L1 expression, or ECOG performance status have no effect on atezolizumab pharmacokinetics. Body weight, gender, positive ADA status, albumin levels and tumour burden have a statistically significant, but not clinically relevant effect on atezolizumab pharmacokinetics. No dose adjustments are recommended.

Elderly

No dedicated studies of atezolizumab have been conducted in elderly patients. The effect of age on the pharmacokinetics of atezolizumab was assessed in a population pharmacokinetic analysis. Age was not identified as a significant covariate influencing atezolizumab pharmacokinetics based on patients of age range of 21-89 years (n=472), and median of 62 years of age. No clinically important difference was observed in the pharmacokinetics of atezolizumab among patients < 65 years (n=274), patients between 65-75 years (n=152) and patients > 75 years (n=46) (see section 4.2).

Paediatric population

No studies have been conducted to investigate the pharmacokinetics of atezolizumab in children or adolescents.

Renal impairment

No dedicated studies of atezolizumab have been conducted in patients with renal impairment. In the population pharmacokinetic analysis, no clinically important differences in the clearance of atezolizumab were found in patients with mild (estimated glomerular filtration rate [eGFR] 60 to 89 mL/min/1.73 m2; n=208) or, moderate (eGFR 30 to 59 mL/min/1.73 m2; n=116) renal impairment compared to patients with normal (eGFR greater than or equal to 90 mL/min/1.73 m2; n=140) renal function. Only a few patients had severe renal impairment (eGFR 15 to 29 mL/min/1.73 m2; n=8) (see section 4.2). The effect of severe renal impairment on the pharmacokinetics of atezolizumab is unknown.

Hepatic impairment

No dedicated studies of atezolizumab have been conducted in patients with hepatic impairment. In the population pharmacokinetic analysis, there were no clinically important differences in the clearance of atezolizumab between patients with mild hepatic impairment (bilirubin ≤ ULN and AST > ULN or bilirubin > 1.0 × to 1.5 × ULN and any AST, n= 71) and normal hepatic function (bilirubin and AST ≤ ULN, n = 401). No data are available in patients with either moderate or severe hepatic impairment. Hepatic impairment was defined by the National Cancer Institute (NCI) criteria of hepatic dysfunction (see section 4.2). The effect of moderate or severe hepatic impairment (bilirubin > 1.5 × to 3 × ULN and any AST or bilirubin > 3 × ULN and any AST) on the pharmacokinetics of atezolizumab is unknown.

5.3 Preclinical safety data

Carcinogenicity

Carcinogenicity studies have not been performed to establish the carcinogenic potential of atezolizumab.

Mutagenicity

Mutagenicity studies have not been performed to establish the mutagenic potential of atezolizumab. However, monoclonal antibodies are not expected to alter DNA or chromosomes.

Fertility

No fertility studies have been conducted with atezolizumab; however assessment of the cynomolgus monkey male and female reproductive organs was included in the chronic toxicity study. Weekly administration of atezolizumab to female monkeys at an estimated AUC approximately 6 times the AUC in patients receiving the recommended dose caused an irregular menstrual cycle pattern and a lack of newly formed corpora lutea in the ovaries which were reversible. There was no effect on the male reproductive organs.

Teratogenicity

No reproductive or teratogenicity studies in animals have been conducted with atezolizumab. Animal studies have demonstrated that inhibition of the PD-L1/PD-1 pathway can lead to immune-related rejection of the developing foetus resulting in foetal death. Administration of atezolizumab could cause foetal harm, including embryo-foetal lethality.

6. Pharmaceutical particulars
6.1 List of excipients

L-histidine

Glacial acetic acid

Sucrose

Polysorbate 20

Water for injections

6.2 Incompatibilities

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.

6.3 Shelf life

Unopened vial

3 years.

Diluted solution

Chemical and physical in-use stability has been demonstrated for up to 24 hours at ≤ 30 °C and for up to 30 days at 2 C to 8 C from the time of preparation.

From a microbiological point of view, the prepared solution for infusion should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2 °C to 8 °C or 8 hours at ambient temperature (≤ 25 °C) unless dilution has taken place in controlled and validated aseptic conditions.

6.4 Special precautions for storage

Store in a refrigerator (2 °C – 8 °C).

Do not freeze.

Keep the vial in the outer carton in order to protect from light.

For storage conditions after dilution of the medicinal product, see section 6.3.

6.5 Nature and contents of container

Type I glass vial with a butyl rubber stopper and an aluminium seal with a plastic aqua flip-off cap containing 20 mL of concentrate solution for infusion.

Pack of one vial.

6.6 Special precautions for disposal and other handling

Tecentriq does not contain any antimicrobial preservative or bacteriostatic agents and should be prepared by a healthcare professional using aseptic technique to ensure the sterility of prepared solutions.

Aseptic preparation, handling and storage

Aseptic handling must be ensured when preparing the infusion. Preparation should be:

• performed under aseptic conditions by trained personnel in accordance with good practice rules especially with respect to the aseptic preparation of parenteral products.

• prepared in a laminar flow hood or biological safety cabinet using standard precautions for the safe handling of intravenous agents.

• followed by adequate storage of the prepared solution for intravenous infusion to ensure maintenance of the aseptic conditions.

Do not shake.

Instructions for dilution

Twenty mL of Tecentriq concentrate should be withdrawn from the vial and diluted into a 250 mL polyvinyl chloride (PVC), polyolefin (PO), polyethylene (PE) or polypropylene (PP) infusion bag containing sodium chloride 9 mg/mL (0.9%) solution for injection. After dilution, one mL of solution should contain approximately 4.4 mg of Tecentriq (1,200 mg/270 mL). The bag should be gently inverted to mix the solution in order to avoid foaming. Once the infusion is prepared it should be administered immediately (see section 6.3).

Parenteral medicinal products should be inspected visually for particulates and discolouration prior to administration. If particulates or discoloration are observed, the solution should not be used.

No incompatibilities have been observed between Tecentriq and intravenous bags with product-contacting surfaces of polyvinyl chloride (PVC), polyolefin (PO), polyethylene (PE), or polypropylene (PP). In addition, no incompatibilities have been observed with in-line filter membranes composed of polyethersulfone or polysulfone, and infusion sets and other infusion aids composed of PVC, PE, polybutadiene, or polyetherurethane. The use of in-line filter membranes is optional.

Do not co-administer other medicinal products through the same infusion line.

Disposal

The release of Tecentriq in the environment should be minimised. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

7. Marketing authorisation holder

Roche Registration GmbH

Emil-Barell-Strasse 1

79639 Grenzach-Wyhlen

Germany

8. Marketing authorisation number(s)

EU/1/17/1220/001

9. Date of first authorisation/renewal of the authorisation

Date of first authorisation: 21 September 2017

10. Date of revision of the text

03 September 2019

Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu.