A Phase 1 Study of BET Bromodomain Inhibitor ZEN003694 in Combination with the CDK4/6 Inhibitor Abemaciclib in Patients with NUT Carcinoma, Breast Cancer and Other Solid Tumors

This phase I trial tests the safety, side effects, and best dose of a ZEN003694 when
given together with abemaciclib in treating patients with NUT carcinoma, breast cancer or
other solid tumors that have spread from where it first started (primary site) to other
places in the body (metastatic) or cannot be removed by surgery (unresectable). ZEN003694
is an inhibitor of a family of proteins called the bromodomain and extra-terminal (BET).
It may prevent the growth of tumor cells that overproduce BET protein. Abemaciclib may
stop the growth of tumor cells by blocking some of the enzymes needed for cell growth.
Giving ZEN003694 and abemaciclib may help shrink or stabilize cancer in patients with NUT
carcinoma, breast cancer or other solid tumors.

Inclusion Criteria:

- Participants must have histologically confirmed malignancy that is metastatic or
unresectable and for which standard curative or palliative measures do not exist or
are no longer effective

- Dose Escalation Cohort Only: Participants must have evaluable disease or measurable
disease per RECIST 1.1 criteria

- Dose Expansion Cohort Only:

- Participants must have a diagnosis of NUT carcinoma (NC) based on standard
criteria for the disease, with diagnostic testing performed in a Clinical
Laboratory Improvement Act (CLIA) certified laboratory:

- Ectopic expression of NUT protein per World Health Organization (WHO)
criteria as determined by immunohistochemistry (IHC) testing, OR

- Detection of the NUT gene translocation as determined by fluorescence in
situ hybridization (FISH) testing

- Detection of the NUT gene translocation as determined by either
deoxyribonucleic acid (DNA) next-generation sequencing (NGS) or
ribonucleic acid (RNA) sequencing.

- Participants must have measurable disease per RECIST 1.1 criteria

- Any number of prior lines of therapy in the metastatic setting are allowed,
including prior BET inhibitor therapy and prior CDK4/6 inhibitor therapy

- Patients who received chemotherapy must have recovered (Common Terminology Criteria
for Adverse Events [CTCAE] grade =< 1) from the acute effects of chemotherapy except
for residual alopecia or grade 2 peripheral neuropathy

- Patients who received radiotherapy must have completed and fully recovered from the
acute effects of radiotherapy. A washout period of at least 14 days is required
between end of radiotherapy

- Participants may have previously undergone surgical resection

- Age >= 12 years. Patients 12-17 years of age must be > 40 kg at enrollment. Patients
12-17 years of age will not participate in the mandatory tumor biopsies. Since there
is no data on patients less than 18 years of age, this population may require lower
doses and additional safety precautions and should be closely monitored. Because no
dosing or adverse event data are currently available on the use of ZEN003694 in
combination with abemaciclib in patients <12 years of age, younger children are
excluded from this study

- Eastern Cooperative Oncology Group (ECOG) performance status =< 2 for participants
>= 16 years of age, Lansky >= 50% if < 16 years of age

- Hemoglobin >= 8 g/dL; Patients may receive erythrocyte transfusions to achieve this
hemoglobin level at the discretion of the investigator. Initial treatment must not
begin earlier than the day after the erythrocyte transfusion

- Absolute neutrophil count >= 1.5 x 10^9/L

- Platelets >= 1 x 10^11/L

- Total bilirubin =< 1.5 x institutional upper limit of normal (ULN) for age. Patients
with Gilbert's syndrome with a total bilirubin =< 2.0 times ULN and direct bilirubin
within normal limits are permitted

- Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase
[SGOT])/alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase
[SGPT]) =< 2.5 x institutional ULN for age

- Serum or plasma creatinine =< 1.5 x institutional ULN OR calculated creatinine
clearance >= 50 mL/min (via the chronic kidney disease epidemiology (CKD-EPI)
glomerular filtration rate estimation for participants >= 18 years old, or 60
mL/min/1.73m^2 for patients 12-17 years as calculated based on bedside Schwartz
formula)

- Human immunodeficiency virus (HIV)-infected patients on effective anti-retroviral
therapy with undetectable viral load within 6 months are eligible for this trial

- For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV
viral load must be undetectable on suppressive therapy, if indicated

- Patients with a history of hepatitis C virus (HCV) infection must have been treated
and cured. For patients with HCV infection who are currently on treatment, they are
eligible if they have an undetectable HCV viral load. Hepatitis C (HepC antibody)
testing is required. Hepatitis C RNA is optional; however, a confirmatory negative
Hepatitis C RNA test must be obtained to be able to enroll participants with
positive Hepatitis C antibody due to prior resolved disease

- Patients with treated brain metastases are eligible if follow-up brain imaging after
central nervous system (CNS)-directed therapy shows no evidence of progression and
has been clinically stable for at least 1 month. Patients must meet the following
criteria:

- Disease outside the CNS is present

- Recovery from acute toxicity associated with the treatment to =< CTCAE grade 1
or baseline (with the exception of alopecia), with no requirement for
escalating doses of corticosteroids over the past 7 days

- Patients with a prior or concurrent malignancy whose natural history or treatment
does not have the potential to interfere with the safety or efficacy assessment of
the investigational regimen are eligible for this trial

- Patients should be New York Heart Association Functional Classification of class 2B
or better

- Ability to swallow and retain oral medications

- The effects of ZEN00364 and abemaciclib on the developing human fetus are unknown.
For this reason and because BETi and CDKi-inhibiting agents are known to be
teratogenic, women of child-bearing potential and men must agree to use adequate
contraception (hormonal or barrier method of birth control; abstinence) prior to
study entry and for the duration of study participation. Women of child-bearing
potential must have a negative pregnancy test prior to study entry. Should a woman
become pregnant or suspect she is pregnant while she or her partner is participating
in this study, she should inform her treating physician immediately. Men and women
treated or enrolled on this protocol must also agree to use adequate contraception
prior to the study, for the duration of study participation, and 3 weeks after
completion of ZEN003694 and abemaciclib administration

- For female subjects of child-bearing potentially receiving ZEN003694, hormonal
means of birth control alone, such as oral, injectable, dermal, subdermal or
topical contraceptives are NOT acceptable forms of birth control given that
their efficacy has not been evaluated when given in combination with the
investigational drugs. "Adequate contraception" is defined as the following:

- Contraceptive methods with a failure rate of =< 1% used in combination
with the barrier method. The following contraceptive methods are
acceptable to use in combination with the barrier method: intrauterine
device (IUD), intrauterine system (IUS), or oral contraceptive pills
(OCPs) that meet the < 1% failure rate as stated in the product label.
Note: Hormonal IUDs/OCPs may only be used if the following criteria are
met: male condoms are required AND subjects are informed of the potential
for reduced systemic hormone levels from the IUD/OCP when taking
ZEN003694. Alternatively, male partner sterilization (vasectomy with
documentation of azoospermia) prior to the female subject's entry into the
study, and this male is the sole partner for that subject. For this
definition, "documented" refers to the outcome of the
investigator's/designee's medical examination of the subject or review of
the subject's medical history for study eligibility, as obtained via a
verbal interview with the subject or from the subject's medical records

- Male subjects with female partners of child-bearing potential must use one of
the following contraceptive methods:

- Vasectomy with documentation of azoospermia OR

- Condom use PLUS partner use of a highly effective contraceptive (=< 1%
rate of failure per year) such as intrauterine device or system, or
hormonal birth control such as contraceptive subdermal implant, combined
estrogen and progestogen oral contraceptive, injectable progestogen,
contraceptive vaginal ring, or percutaneous contraceptive patches

- Male subjects should not donate sperm while on study and for 12 weeks after the
last dose of study medication. Male subjects whose partners are or become
pregnant must continue to use condoms for 12 weeks after the last dose of study
medication

- Women of childbearing potential must have a negative pregnancy test within 7 days of
starting treatment

- Ability to understand and the willingness to sign a written informed consent
document. Participants with impaired decision-making capacity who have a
legally-authorized representative (LAR) and/or family member available may be
eligible after discussion with the Principal Investigator of this study. There will
be a separate assent process for minors

Exclusion Criteria:

- Participants who have had cytotoxic chemotherapy, immunotherapy, or other
investigational therapy within 2 weeks prior to entering the study. There is a two
week required washout period for previous BET inhibitor therapy

- Participants who have had radiotherapy within at least 2 weeks prior to entering the
study. Stereotactic radiosurgery (SRS) within 1 week prior to entering the study
will be allowed

- Participants who have had major surgery within 3 weeks prior to entering the study

- Participants who have received tyrosine kinase inhibitors (TKIs) or small molecules
within 5 half-lives or 1 week (whichever is shorter) of study entry

- Patients who are receiving any other investigational agents

- History of allergic reactions attributed to compounds of similar chemical or
biologic composition to ZEN003694 or abemaciclib

- Patients requiring medications or substances that are strong inhibitors or strong
inducers of CYP3A4 or CYP3A enzymes are ineligible. Strong inhibitors or inducers of
CYP3A4 must be discontinued at least 7 days prior to the first dose of ZEN003694 and
abemaciclib. Because the lists of these agents are constantly changing, it is
important to regularly consult a frequently-updated list such as
http://medicine.iupui.edu/clinpharm/ddis/table.aspx; medical reference texts such as
the Physicians' Desk Reference may also provide this information. As part of the
enrollment/informed consent procedures, the patient will be counseled on the risk of
interactions with other agents, and what to do if new medications need to be
prescribed or if the patient is considering a new over-the-counter medicine or
herbal product

- Patients with uncontrolled intercurrent illness, including but not limited to:
ongoing or active infection requiring systemic therapy, symptomatic congestive heart
failure, unstable angina pectoris, cardiac arrhythmia, interstitial lung disease,
severe dyspnea at rest or requiring oxygen therapy, severe renal impairment (e.g.
estimated creatinine clearance < 30ml/min), history of major surgical resection
involving the stomach or small bowel, or preexisting Crohn's disease or ulcerative
colitis or a preexisting chronic condition resulting in baseline grade 2 or higher
diarrhea that, in the judgment of the investigator, would preclude participation in
this study

- Patients receiving any medications or substances that are strong inhibitors or
inducers of CYP3A4 or substrates of CYP1A2 with narrow therapeutic windows are
ineligible. Strong inhibitors or inducers of CYP3A4 must be discontinued at least 7
days prior to the first dose of ZEN003694. As proton pump inhibitors (PPIs), H2
receptor antagonists, and antacids may alter the pharmacokinetics of ZEN003694 by
reducing ZEN003694 exposure, patients receiving proton pump inhibitors are
ineligible. If H2 blockers or other acid reducing agents are used concomitantly with
ZEN003694, a staggered dosing schedule should be used. Because the lists of these
agents are constantly changing, it is important to regularly consult a
frequently-updated medical reference. As part of the enrollment/informed consent
procedures, the patient will be counseled on the risk of interactions with other
agents, and what to do if new medications need to be prescribed or if the patient is
considering a new over-the-counter medicine or herbal product

- Pregnant women are excluded from this study because ZEN003694 is a BETi agent with
the potential for teratogenic or abortifacient effects. Because there is an unknown
but potential risk for adverse events in nursing infants secondary to treatment of
the mother with ZEN003694, breastfeeding should be discontinued if the mother is
treated with ZEN003694. These potential risks may also apply to other agents used in
this study

- Fridericia's correction formula (QTcF) >= 450 msec on screening electrocardiogram
(ECG) (machine or manual read allowed). Patients should avoid medications which
prolong the QT

- Patients receiving any medications or substances that are Factor Xa inhibitors
(i.e., rivaroxaban, apixaban, betrixaban, edoxaban otamixaban, letaxaban,
eribaxaban) or Factor IIa inhibitors (i.e., dabigatran). Low molecular weight
heparin is allowed

- Patients with radiation to > 25% of the bone marrow

- Patients who have had a bone-targeted radionuclide within 6 weeks of the first dose
of ZEN003694

- Myocardial infarction or unstable angina within 6 months prior to the first dose of
ZEN003694

- Impairment of gastrointestinal function that may significantly alter the absorption
of ZEN003694 and/or abemaciclib

- The patient has a personal history of any of the following conditions: syncope of
cardiovascular etiology, ventricular arrhythmia of pathological origin (including,
but not limited to, ventricular tachycardia and ventricular fibrillation), or sudden
cardiac arrest