Acalabrutinib in Combination With Venetoclax or Obinutuzumab for the Treatment of Treatment-naive Chronic Lymphocytic Leukemia

Inclusion Criteria:

Men and women >= 18 years of age
Diagnosis of CLL/small lymphocytic lymphoma (SLL) meeting criteria established in the 2018 International Workshop (iw)CLL guidelines
Must be treatment-naive: Received no prior chemotherapy, immunotherapy, or targeted therapy for the treatment of CLL, with the exceptions of palliative loco-regional radiotherapy, rituximab for autoimmune conditions, or corticosteroids for symptoms control

Patients must meet criteria for treatment as defined by 2018 iwCLL guidelines which includes at least one of the following criteria:

Evidence of marrow failure as manifested by the development or worsening of anemia or thrombocytopenia (not attributable to autoimmune hemolytic anemia or thrombocytopenia)
Massive (>= 6 cm below the costal margin), progressive or symptomatic splenomegaly
Massive nodes (>= 10 cm) or progressive or symptomatic lymphadenopathy
Progressive lymphocytosis with a lymphocyte doubling time < 6 months or an increase of >= 50% over a 2 month period
Autoimmune anemia and/or thrombocytopenia that is poorly responsive to standard therapy
Symptomatic or functional extranodal involvement (e.g. skin, kidney, lung, spine)

Constitutional symptoms, which include any of the following:

Unintentional weight loss of 10% or more within 6 months
Significant fatigue
Fevers > 100.5 degrees Fahrenheit (F) for 2 weeks or more without evidence of infection
Night sweats >= 1 month without evidence of infection
Eastern Cooperative Oncology Group (ECOG) performance status of =< 2
Adequate bone marrow independent of growth factor support or infusion support at screening unless evidence shows that the cytopenia(s) is due to marrow involvement by CLL/SLL and/or disease-related immune thrombocytopenia, or anemia. If cytopenias are due to disease in the bone marrow any degree of cytopenias are allowed. Patients with active uncontrolled autoimmune cytopenias are excluded
Absolute neutrophil count (ANC) >= 1000/mm^3
Platelets >= 30,000/mm^3
Hemoglobin >= 7 g/dL
Total bilirubin =< 2.0 x upper limit of normal (ULN) (excepting Gilbert's syndrome)
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) =< 2.5 x ULN

Creatinine clearance >= 30 mL/min/1.73m^2

Using 24-hour creatinine clearance or modified Cockcroft-Gault equation
Woman of childbearing potential (WOCBP) who are sexually active must use highly effective methods of contraception during treatment and for at least 2 days after last acalabrutinib dose, 30 days after last venetoclax dose, and 6 months after last obinutuzumab dose
Willing and able to participate in all required evaluations and procedures in this study protocol
Ability to understand the purpose and risks of the study and provide signed and dated informed consent and authorization to use protected health information

Exclusion Criteria:

Patients with high-risk disease as defined by:

Presence of deletion 17p13 on cytogenetic analysis by fluorescent in situ hybridization (FISH)
Presence of TP53 mutation on next generation sequencing

Presence of complex karyotype on cytogenetic evaluation

Defined as >= 3 karyotypic abnormalities
Treatment with a moderate or strong CYP3A inhibitor or inducer within 7 days prior to first dose of acalabrutinib or venetoclax or need for treatment with a strong CYP3A inhibitor or inducer during the period or the study. Patients who have a need for treatment with a moderate CYP3A inhibitor or inducer during acalabrutinib or venetoclax dose escalation will also be excluded
Known active involvement of the central nervous system by lymphoma or leukemia
Subject with other malignancies that are associated with a life expectancy of < 2 years or that would confound assessment of toxicity in this study
Clinically significant cardiovascular disease such as symptomatic arrhythmias, congestive heart failure, or myocardial infarction within 6 months of screening, or any Class 3 or 4 cardiac disease as defined by the New York Heart Association Functional Classification. Note: Subjects with controlled atrial fibrillation can enroll on study
Is unable to swallow oral medication, or has significant gastrointestinal disease that would limit absorption of oral medication
Known history of infection with human immunodeficiency virus (HIV)
Subjects with active infections requiring intravenous (IV) antibiotic/antiviral therapy are not eligible for entry onto the study until resolution of the infection. Subjects on prophylactic antibiotics or antivirals are acceptable
Known history of hypersensitivity or anaphylaxis to study drug(s) including active product or excipient components
Active bleeding or history of bleeding diathesis (e.g., hemophilia or von Willebrand disease)
Uncontrolled autoimmune hemolytic anemia (AIHA) or idiopathic thrombocytopenic purpura (ITP) unrelated to underlying CLL
Patients with uncontrolled autoimmune disease requiring > 20 mg of daily prednisone or equivalent
Presence of a gastrointestinal ulcer diagnosed by endoscopy within 3 months before screening
Requires or receiving anticoagulation with warfarin or equivalent vitamin K antagonists
Prothrombin time (PT)/international normalized ratio (INR) or activated partial thromboplastin time (aPTT) (in the absence of lupus anticoagulant) > 2 x ULN
History of significant cerebrovascular disease/event, including stroke or intracranial hemorrhage, within 6 months before the first dose of study drug
Major surgical procedure within 28 days of first dose of study drug. Note: If a subject had major surgery, they must have recovered adequately from any toxicity and/or complications from the intervention before the first dose of study drug

Hepatitis B or C serologic status:

Subjects who are hepatitis B core antibody (anti-HBc) positive and who are hepatitis B surface antigen (HBsAg) negative will need to have a negative polymerase chain reaction (PCR) and must be willing to undergo deoxyribonucleic acid (DNA) PCR testing during the study to be eligible. Those who are HBsAg positive or hepatitis B PCR positive will be excluded
Subjects who are hepatitis C antibody positive will need to have a negative PCR result to be eligible. Those who are hepatitis C PCR positive will be excluded
Breastfeeding or pregnant
Vaccination with live vaccines 28 days prior to registration for study screening
Concurrent participation in another therapeutic clinical trial