BLockade of PD-1 Added to Standard Therapy to Target Measurable Residual Disease in Acute Myeloid Leukemia 1 (BLAST MRD AML-1): A Randomized Phase 2 Study of the Anti-PD-1 Antibody Pembrolizumab in Combination With Conventional Intensive Chemotherapy as Frontline Therapy in Patients With Acute Myeloid Leukemia

Primary Outcome Measures  :

1. Percentage of patients with minimal residual disease - complete response (MRD-CR) [ Time Frame: At time of count recovery after first cycle of consolidation therapy with chemotherapy and pembrolizumab ]MRD will be assessed by multicolor flow cytometry as an integral biomarker.
   
2. Rate of MRD-negative CR [ Time Frame: At end of induction therapy ]
   
3. Rate of MRD-negative CR [ Time Frame: At end of consolidation ]
   

Secondary Outcome Measures  :

1. Assess the rate of CR/incomplete count recovery (CRi) [ Time Frame: At time of count recovery after induction therapy with chemotherapy and pembrolizumab ]Will be defined per European LeukemiaNet 2017.
   
2. MRD negativity [ Time Frame: At day 14 ]
   
3. Event-free survival [ Time Frame: From randomization to failure to achieve CR/CRi, relapse or death from any cause, assessed up to 5 years ]
   
4. Relapse-free survival (RFS) [ Time Frame: From first documentation of CR/CRi to either disease relapse or death from any cause, assessed up to 5 years ]Median RFS will be estimated with Kaplan-Meier curves with 95% confidence interval calculated based on the Brookmeyer-Crowley method
   
5. Duration of response (DOR) [ Time Frame: From first CR to the date of the first documented relapse or death, whichever occurs first, assessed up to 5 years ]Median DOR will be estimated with Kaplan-Meier curves with 95% confidence interval calculated based on the Brookmeyer-Crowley method.
   
6. Incidence of adverse events [ Time Frame: Up to 35 days from start of treatment ]Will be assessed per Common Terminology Criteria for Adverse Events version 5.0.

Inclusion Criteria:

• Newly diagnosed and pathologically-confirmed AML, confirmed by a bone marrow aspirate and/or biopsy with >= 20% myeloid blasts. Secondary AML (myelodysplastic syndrome [MDS]/AML, therapy-related [t]-AML) is also allowed. High risk MDS (EB2 with > 10% blasts) is excluded, but AML arising from prior MDS is allowed. AML arising from myeloproliferative neoplasms (MPN), MPN/MDS overlap (including chronic myelomonocytic leukemia [CMML]) or other hematologic malignancy are NOT allowed. Note: Patients must have evidence of bone marrow involvement on aspirate or biopsy. Patients with only extramedullary disease and no bone marrow involvement will be excluded. Every effort should be made to get an aspirate for central flow assessment at screening and all subsequent required time points, but in cases were an aspirate cannot be collected-including dry taps-the patient will not be excluded and assessments will be performed on peripheral blood (PB) which should be collected at every time that bone marrow (BM) is collected.
• Eastern Cooperative Oncology Group (ECOG) performance status =< 1 and/or (Karnofsky >= 70%)
• The patient has to be eligible to receive intensive "7+3" induction chemotherapy as judged by the treating physician
• Prior use of hypomethylating agents (HMA), lenalidomide, erythropoiesis-stimulating agents (ESAs), and growth factors is allowed if used to treat prior MDS. AML must be previously untreated
• Hydroxyurea/leukapheresis allowed for control of hyperleukocytosis but hydroxyurea must be discontinued day prior to start of chemotherapy
• Creatinine =< 1.5 x upper limit of normal (ULN) OR measured or calculated creatinine clearance (CrCl) >= 60 mL/min for patient with creatinine levels > 1.5 x institutional ULN (within 14 days prior to the first day of 7+3)
  • Creatinine clearance (CrCl) should be calculated per institutional standard
  • Glomerular filtration rate (GFR) can also be used in place of creatinine or CrCl
• Total bilirubin =< 1.5 x ULN or direct bilirubin =< ULN for patients with total bilirubin levels > 1.5 x ULN (within 14 days prior to the first day of 7+3)
• Aspartate aminotransferase (AST) (serum glutamic oxaloacetic transaminase [SGOT]) and alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 3 x ULN OR =< 5 x ULN for patients with liver metastases (within 14 days prior to the first day of 7+3)
• International normalized ratio (INR) or prothrombin time (PT) =< 1.5 x ULN unless patient is receiving anticoagulant therapy as long as PT or partial thromboplastin time (PTT) is within therapeutic range of intended use of anticoagulants (within 14 days prior to the first day of 7+3)
• Activated partial thromboplastin time (aPTT) =< 1.5 x ULN unless patient is receiving anticoagulant therapy as long as PT or PTT is within therapeutic range of intended use of anticoagulants (within 14 days prior to the first day of 7+3)
• Patients with a known history of being human immunodeficiency virus (HIV) positive may participate IF they meet the following eligibility requirements:
  • They must be stable on their anti-retroviral regimen, and they must be healthy from an HIV perspective
  • Patients must have an undetectable HIV viral load
• 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. For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral load must be undetectable on suppressive therapy, if indicated
• Patients who have received major surgery must have recovered adequately from the toxicity and/or complications from the intervention prior to starting therapy
• Patients with known history or current symptoms of cardiac disease, or history of treatment with cardiotoxic agents, should have a clinical risk assessment of cardiac function using the New York Heart Association functional classification. To be eligible for this trial, patients should be class 2B or better
• Female patients of childbearing potential must have a negative urine or serum pregnancy test within 72 hours prior to receiving the first dose of 7+3 treatment. If the urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be required. A female of childbearing potential is any woman, regardless of sexual orientation or whether they have undergone tubal ligation, who meets the following criteria: 1) has not undergone a hysterectomy or bilateral oophorectomy; or 2) has not been naturally postmenopausal for at least 12 consecutive months (i.e., has had menses at any time in the preceding 12 consecutive months). Female patients of childbearing potential must be willing to use an adequate method of contraception for the course of the study through 120 days after the last dose of study medication. Male patients with female partners of childbearing potential must agree to use an adequate method of contraception, starting with the first dose of study therapy through 120 days after the last dose of study therapy
  • NOTE: Abstinence is acceptable if this is the usual lifestyle and preferred contraception for the patient
• Ability to understand and the willingness to sign a written informed consent document. Participants with impaired decision-making capacity (IDMC) who have a legally-authorized representative (LAR) and/or family member available will also be eligible
• Treatment with a BCR-ABL tyrosine kinase inhibitor (TKI) for another indication (e.g. a gastrointestinal stromal tumor [GIST]) is allowed in the study

Exclusion Criteria:

• Patients with a known additional malignancy that is progressing or requires active treatment. Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the skin that has undergone potentially curative therapy or in situ cervical cancer. Prior treatment with the following are not allowed:
  • Patient who have received anthracyclines for treatment of a prior, unrelated, curatively-treated malignancy which would limit their ability to receive 7 + 3 chemotherapy treatment on study
  • Anti-PD-1, anti-PD-L1, or anti-PD-L2, for a prior, unrelated, curatively-treated malignancy, within last 3 months of enrollment in the study
  • Anti-cancer monoclonal antibody (mAb) within 4 weeks, for a prior, unrelated, curatively-treated malignancy, prior to study registration or have not recovered (recovery defined as baseline or =< grade 1) from adverse events (AEs) due to agents administered more than 4 weeks earlier
  • Experimental treatment within 4 weeks prior to study registration
• Patients who have had chemotherapy (except hydroxyurea and all trans retinoic acid [ATRA] which are allowed but have to be stopped the day before induction therapy starts), targeted small molecule therapy (aside from imatinib, dasatinib, or nilotinib), or curative-intent radiotherapy within 4 weeks (6 weeks for nitrosoureas or mitomycin C), for a prior curatively treated malignancy, prior to entering the study
• Patients who have received prior anthracyclines not to exceed 150 mg/m^2 of daunorubicin or equivalent for treatment of a prior, unrelated, curatively-treated malignancy which would limit their ability to receive 7 + 3 chemotherapy treatment on study
• Patients with a cardiac ejection fraction less than 50%
• Other active primary malignancy (other than non-melanomatous skin cancer or carcinoma in situ of the cervix) requiring treatment or limiting expected survival to =< 2 years
  • NOTE: If there is a history of prior malignancy, they must not be receiving other specific treatment (other than hormonal therapy for their cancer)
• Patients who have FLT3-mutated AML
• Patients who have not recovered from AEs due to prior anti-cancer therapy (i.e., have not returned to baseline or have residual toxicities > grade 1) with the exception of =< grade 2 neuropathy and alopecia
  • NOTE: Participants must have recovered from all radiation-related toxicities, not require corticosteroids, and not have had radiation pneumonitis. A 1-week washout is permitted for palliative radiation (=< 2 weeks of radiotherapy) to non-central nervous system (CNS) disease
• Patients currently participating and receiving study therapy or have participated in a study of an investigational agent and received study therapy or used an investigational device within 4 weeks of the first dose of treatment are ineligible
• History of hypersensitivity to MK-3475 (pembrolizumab) or any of its excipients, or other agents used in this study
• Current use of corticosteroids
  • EXCEPTION: Low doses of steroids (< 10 mg of prednisone or equivalent dose of other steroid) used for treatment of non-hematologic medical condition (e.g., chronic adrenal insufficiency) is permitted
• Patients who received prior allogenic transplant
• Patients with a known history of hepatitis B (defined as hepatitis B surface antigen [HBsAg] reactive) who are not on appropriate suppressive therapy
• Patient with a history or current evidence of any condition, therapy, or laboratory abnormality that might confound the results of the trial, interfere with the subject's participation for the full duration of the trial, or is not in the best interest of the subject to participate, in the opinion of the treating investigator
• Patient with known active CNS disease and/or carcinomatous meningitis. Assessment of the cerebral spinal fluid (CSF) is not required to enroll in the study unless there is clinical suspicion for CNS involvement. However, if CSF assessment is performed for any reason, there should be no evidence of active leukemia in the CSF. Subjects with previously treated brain metastases may participate provided they are stable (without evidence of progression by imaging for at least four weeks prior to the first dose of protocol treatment and any neurologic symptoms have returned to baseline), have no evidence of new or enlarging brain metastases, and are not using steroids for at least 7 days prior to protocol treatment. This exception does not include carcinomatous meningitis which is excluded regardless of clinical stability
• Patients with active autoimmune disease except for patients with hypothyroidism and vitiligo that has required systemic treatment in the past 2 years (i.e., with use of disease modifying agents, corticosteroids or immunosuppressive drugs). Replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic treatment
• Patients with a known history of non-infectious pneumonitis that required the use of steroids or current pneumonitis
• Patients with active infection requiring systemic therapy
• Patients with a known history of active TB (Bacillus tuberculosis)
• Patients with uncontrolled intercurrent illness
• Patients with psychiatric illness/social situations that would limit compliance with study requirements
• Pregnant women are excluded from this study because MK-3475 (pembrolizumab) is humanized antibody 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 MK-3475 (pembrolizumab), breastfeeding should be discontinued if the mother is treated with MK-3475 (pembrolizumab). These potential risks may also apply to other agents used in this study
• Patient who have received a live vaccine within 30 days of planned start of study therapy
  • NOTE: Seasonal influenza vaccines for injection are generally inactivated flu vaccines and are allowed; however intranasal influenza vaccines (e.g., Flu-Mist) are live attenuated vaccines, and are not allowed
• Active hemolytic anemia requiring immunosuppressive therapy or other pharmacologic treatment. Patients who have a positive Coombs test but no evidence of hemolysis are NOT excluded from participation
• Patients with clinically significant disseminated intravascular coagulation (DIC), as assessed by treating physician, will be excluded from study
• Patients with no bone marrow involvement will be excluded (i.e., those with only extramedullary disease)
• Patients with acute promyelocytic leukemia will be excluded