Tafasitamab, Acalabrutinib, and Obinutuzumab for the Treatment of Previously Untreated Chronic Lymphocytic Leukemia

Inclusion Criteria:

Written informed consent. Participant or legally authorized representative (LAR) must provide written informed consent prior to any study-specific procedures or interventions
Age >= 18 years. All genders, races, and ethnic groups will be included
Ability to swallow and retain oral medication
Documented previously untreated CLL. Diagnosis must be confirmed by peripheral flow cytometry and made in accordance with international workshop (iw)CLL diagnostic criteria
Baseline detectable immunoglobulin heavy (IGH) gene signature determined as part of clonoSEQ for minimal residual disease (MRD) testing

Must meet at least 1 criterion for treatment based on iwCLL guidelines

Evidence of progressive marrow failure as manifested by the onset or worsening of anemia and/or thrombocytopenia, or
Massive (i.e., lower edge of spleen >= 6 cm below the left costal margin), progressive, or symptomatic splenomegaly, or
Massive (i.e., >= 10 cm in the longest diameter), progressive, or symptomatic lymphadenopathy, or
Progressive lymphocytosis in the absence of infection, with an increase in blood absolute lymphocyte count (ALC) > 50% over a 2 month period, or lymphocyte doubling time of < 6 months (as long as initial ALC was >= 30,000/uL), or
Autoimmune anemia and / or thrombocytopenia that is poorly responsive to corticosteroids or other standard therapy, or

Constitutional symptoms, defined as any one or more of the following disease related symptoms or signs occurring in the absence of evidence of infection:

Unintentional weight loss of >= 10% within the previous 6 months, or
Significant fatigue (grade >= 2), or
Fevers > 100.5°F or 38.0°C for >= 2 weeks, or
Night sweats for > 1 month
Presence of measurable lymphadenopathy, defined as the presence of > 1 nodal lesion that measures > 2.0 cm in the longest diameter (LD) and > 1.0 cm in the longest perpendicular diameter (LPD) as assessed by computed tomography (CT) or magnetic resonance imaging (MRI)
Eastern Cooperative Oncology Group (ECOG) performance status =< 2
Life expectancy of greater than 12 months, as estimated by the treating physician or investigator
Absolute neutrophil count (ANC) > 1,000/mm^3 (uL)
Platelet count > 50,000/mm^3 (uL).
Serum creatinine =< 2 x upper limit of normal (ULN) or creatinine clearance (CrCl) >= 40 mL/min by Cockcroft-Gault
Aspartate aminotransferase (AST) =< 3 x ULN
Alanine aminotransferase (ALT) =< 3 x ULN
Alkaline phosphatase (ALP) =< 3 x ULN
Total bilirubin =< 2.5 x ULN unless documented history of Gilbert's syndrome

Negative for hepatitis C infection and chronic hepatitis B infection

Participants with positive serology for hepatitis C virus (HCV) must have been tested for HCV ribonucleic acid (RNA) and are eligible only in the case of negative HCV RNA by polymerase chain reaction (PCR) testing
Participants must be hepatitis B virus (HBV) negative by serology. Participants with occult or prior HBV infection (defined as negative hepatitis B [HB] surface antigen [sAg] and positive serology testing for anti-HBV core antigen [cAb]) may be included if HBV deoxyribonucleic acid (DNA) was undetectable by PCR, provided that they are willing to undergo monthly ongoing DNA testing. Antiviral prophylaxis may be administered as per institutional guidelines
Participants who have protective HBV titers of HB surface antibody (sAb) (HBsAb positive, HBcAb negative, and HBsAg negative) after vaccination or previously cured hepatitis B are eligible
Individuals with childbearing potential must have documented negative pregnancy test at least 7 days prior to start of any treatment drug and must commit to the use of study approved methods of contraception during study treatment and for 6 months after the last dose of obinutuzumab
Individuals that can contribute sperm for the conception of a child must commit to the use of study approved methods of contraception during the trial period and for 6 months after the last dose of obinutuzumab. Such individuals must also refrain from donation of sperm during study treatment and for 6 months after the last dose of obinutuzumab
Individuals of reproductive and lactating potential must agree to stop breastfeeding and refrain from donation of ova from the start of study treatment (cycle [C]1 day [D]1) and for 6 months after the last dose of obinutuzumab

Exclusion Criteria:

Previous or concurrent diagnosis of any other hematologic malignancy
Any previous CLL-directed treatment. Prior corticosteroids (or ongoing prednisone =< 20 mg daily, or equivalent) for symptom control are permitted. Enrollment will be considered for those individuals that can taper ongoing use of a corticosteroid at > 20 mg daily to 0 mg within 14 days of C1D1

Known history of hypersensitivity to

Humanized or murine monoclonal antibodies or products
A CD19 or CD20 antibody
Tafasitamab
Acalabrutinib
Receipt of live vaccine within 14 days of trial enrollment
Prior history of any solid malignancy, unless disease-free for over 2 years, exclusive of any prior history of squamous cell carcinoma of the skin or cervix, basal cell carcinoma of the skin, transitional cell urothelial carcinoma, prostate cancer, or early-stage melanoma. Exceptions will be considered, at the discretion of the investigator, if the prior treatment (i.e., within 2 years) is not expected to confound the results of this study
Patients with history of confirmed progressive multifocal leukoencephalopathy (PML)
Active autoimmune disease requiring treatment with > 20 mg of prednisone (or prednisone equivalent daily), apart from autoimmune hemolytic anemia or immune thrombocytopenic purpura (ITP).
Evidence of ongoing systemic bacterial, fungal, or viral infection, except localized fungal infections of skin or nails. NOTE: Participants may be receiving prophylactic antiviral or antibacterial therapies at the discretion of the investigator
Seropositivity for, or history of active viral infection with, human immunodeficiency virus (HIV)
Known histological transformation from CLL to an aggressive lymphoma (i.e., Richter's transformation)
Known bleeding disorders
Use of warfarin, marcumar, or phenprocoumon unless drug can be discontinued with normalization of international normalized ratio (INR) (e.g., INR < 2, or baseline) within 7 days of C1D1
Any participant having received agents known to be strong and moderate cytochrome P450 3A inhibitors or inducers within 7 days prior to screening / baseline may require special approval and / or a wash-out period before day 1, at the discretion of the investigator
Ongoing use of proton pump inhibitors (PPI). PPI must be discontinued 48 hours prior to C1D1

Any severe and / or uncontrolled medical conditions or other conditions that could affect their participation in the study such as:

Symptomatic, or history of documented congestive heart failure (New York [NY] Heart Association functional classification III-IV)
Left ventricular ejection fraction (LVEF) < 50%
Poorly controlled atrial fibrillation
A history of ventricular arrhythmias
Uncontrolled hypertension (HTN): Defined as hypertension despite the use of > 2 anti-HTN agents at optimal doses
Myocardial infarction within 6 months of enrollment
Angina not well-controlled by medication
Poorly controlled or clinically significant atherosclerotic vascular disease including cerebrovascular accident (CVA), transient ischemic attack (TIA), angioplasty, cardiac / vascular stenting within 6 months of enrollment
Any other significant medical illness, abnormality, or condition that would, in the investigator's judgement, make the participant inappropriate for study participation or would put the participant at risk