A Phase 2 Study of Acalabrutinib, Venetoclax, and Obinutuzumab (AVO) for Initial Therapy of Chronic Lymphocytic Leukemia

This research study is evaluating the combination of three drugs - acalabrutinib,
venetoclax, and obinutuzumab -- as a possible treatment for chronic lymphocytic leukemia
(CLL).

The drugs involved in this study are:

- Acalabrutinib

- Venetoclax

- Obinutuzmab

Inclusion Criteria:

- Subjects must have CLL or SLL

- In cohort 2, subjects must have TP53-aberrant disease defined as:

- Del(17p) detected on karyotype and/or FISH; OR

- TP53 mutation

- Participants must have measurable disease (lymphocytosis > 5,000 / µl, or palpable
or CT measurable lymphadenopathy ≥ 1.5 cm, or bone marrow involvement ≥30%).

- Subjects must not have received any prior systemic therapy for CLL or SLL due to
meeting IWCLL 2018 guidelines and must currently have an indication for treatment as
defined by the IWCLL 2018 guidelines:

- Massive or progressive or symptomatic splenomegaly; OR

- Massive lymph nodes, nodal clusters, or progressive lymphadenopathy; OR

- Significant fatigue (i.e. ECOG PS 2 or worse; cannot work or unable to perform
usual activities); OR

- Fever ≥ 100.5°F for 2 or more weeks without evidence of infection; OR

- Night sweats for ≥ 1 months without evidence of infection; OR

- Presence of weight loss ≥ 10% over the preceding 6 months; OR

- Progressive lymphocytosis with an increase of ≥ 50% over a 2-month period or
lymphocyte doubling time of less than 6 months; OR

- Evidence of progressive marrow failure as manifested by the development of or
worsening of anemia and/or thrombocytopenia; OR

- Autoimmune anemia and/or thrombocytopenia that is poorly responsive to
corticosteroids and another standard therapy such as rituximab; OR

- Symptomatic or functional extranodal involvement

- Age greater than or equal to 18 years.

- ECOG performance status ≤2

- Participants must have adequate organ and marrow function as defined below:

- total bilirubin ≤1.5 times upper limit of normal, unless there is disease
involvement of the liver, hemolysis, or a known history of Gilbert's disease,
in which case direct bilirubin must be ≤3 times the upper limit of normal

- AST and ALT ≤ 2.5 times the upper limit of normal. If there is hemolysis or
documented disease involvement of the liver, then patients with any AST or ALT
abnormalities remain eligible.

- creatinine clearance (CrCl) ≥ 50 mL/min using 24-hour urine collection for
creatinine clearance or calculated CrCl

- PT/INR ≤2 times the upper limit of normal and PTT ≤2 times the upper limit of
normal

- Absolute neutrophil count ≥750 cells/mm3 or ≥500 cells/mm3 in subjects with
documented bone marrow involvement

- Platelet count without transfusional support must be ≥50,000 cells/mm3 or ≥
30,000 cells/mm3 in subjects with documented bone marrow involvement

- Pregnant or lactating

Exclusion Criteria:

- Participants who have a history of other malignancies except:

- Malignancy treated with curative intent and with no known active disease
present and felt to be at low risk for recurrence by treating physician.
Current adjuvant hormonal therapy for disease treated with curative intent is
permissible.

- Adequately treated non-melanoma skin cancer or lentigo maligna without evidence
of disease.

- Adequately treated carcinoma in situ without evidence of disease.

- Low-risk prostate cancer on active surveillance

- Participants who are receiving any other investigational agents.

- History of severe allergic reactions attributed to compounds of similar chemical or
biologic composition to obinutuzumab, venetoclax, or acalabrutinib. Patients with
reactions to other CD20 monoclonal antibodies (e.g. rituximab, ofatumumab) are not
excluded.

- Unable to receive prophylactic treatment for pneumocystis, herpes simplex virus
(HSV), and herpes zoster (VZV) at start of treatment

- Known or suspected Richter's transformation or known CNS involvement

- Concurrent systemic immunosuppressant therapy (e.g., cyclosporine A, tacrolimus,
etc., within 28 days of the first dose of study drug or chronic administration of
>20 mg/day of prednisone within 7 days of the first dose)

- Vaccinated with live, attenuated vaccines within 4 weeks of first dose of study
drug.

- Ongoing or recent infection requiring intravenous antimicrobials at time of
screening.

- Known bleeding disorders (e.g. von Willebrand's disease) or hemophilia.

- Presence of a gastrointestinal ulcer diagnosed by endoscopy within 3 months before
screening.

- History of stroke or intracranial hemorrhage within 6 months prior to enrollment.

- Major surgery within 4 weeks of first dose of study drug. If a subject had major
surgery greater than 4 weeks prior to the first dose, they must have recovered
adequately from any toxicity and/or complications from the intervention before the
first dose of study drug.

- Currently active, clinically significant cardiovascular disease, such as
uncontrolled arrhythmia or Class 3 or 4 congestive heart failure as defined by the
New York Heart Association Functional Classification; or a history of myocardial
infarction, unstable angina, or acute coronary syndrome within 6 months prior to
randomization.

- Baseline QTcF >480 ms. NOTE: This criterion does not apply to patients with a left
bundle branch block.

- Patients who require warfarin or other vitamin K antagonists for anticoagulation
(other anticoagulants are allowed).

- Patients who require treatment with proton pump inhibitors (see Appendix F).
Subjects receiving proton pump inhibitors who switch to H2-receptor antagonists or
antacids are eligible for enrollment on this study.

- Patients who require concurrent treatment with strong CYP3A inhibitors or strong
CYP3A inducers are excluded from the study. If patients are receiving strong CYP3A
inhibitors/inducers at time of screening but do not require continuous
administration of these agents, these patients are eligible if there is a 3-day
washout period between discontinuation of the strong CYP3A inhibitor/inducer and
initiation of the first study drug, acalabrutinib.

- Patients who require concurrent treatment with P-gp inhibitors or narrow therapeutic
index P-gp substrates are excluded from the study. If patients are receiving P-gp
inhibitors or narrow therapeutic index P-gp substrates at time of screening but do
not require continuous administration of these agents, these patients are eligible
if there is a 3-day washout period between discontinuation of the P-gp inhibitor and
initiation of acalabrutinib.

- Unable to swallow capsules or malabsorption syndrome, disease significantly
affecting gastrointestinal function, or resection of the stomach or small bowel if
thought by the investigator to compromise systemic absorption, active, symptomatic
inflammatory bowel disease or ulcerative colitis, or partial or complete bowel
obstruction.

- Patients with human immunodeficiency virus (HIV) or active hepatitis C virus (HCV)
or hepatitis B virus (HBV) infection.

- Significant co-morbid condition or disease which in the judgment of the Principal
Investigator would place the patient at undue risk or interfere with the study

- Uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, or psychiatric illness/social situations that would limit compliance
with study requirements, compromise the subject's safety, or put the study outcomes
at undue risk.