Trial Outcomes & Findings for Pembrolizumab, Combination Chemotherapy, and Radiation Therapy Before Surgery in Treating Adult Patients With Locally Advanced Gastroesophageal Junction or Gastric Cardia Cancer That Can Be Removed by Surgery (NCT NCT02730546)

NCT ID: NCT02730546

Last Updated: 2025-06-22

Results Overview

Defined as number of patients with pathologic complete responses (pCR) divided by total evaluable patients. pCR is defined as no recognized cancer and margins free of tumor as found by the pathologist following resection of the esophageal specimen and accompanying lymph nodes.

Recruitment status

COMPLETED

Study phase

PHASE1/PHASE2

Target enrollment

31 participants

Primary outcome timeframe

Up to 3 years

Results posted on

2025-06-22

Participant Flow

Participant milestones

Participant milestones
Measure
Treatment (Pembrolizumab, Chemotherapy, Radiation, Surgery)
See Detailed Description\> \> Carboplatin: Given IV\> \> Computed Tomography: Undergo CT scan\> \> Fluorouracil: Given IV\> \> Laboratory Biomarker Analysis: Correlative studies\> \> Leucovorin Calcium: Given IV\> \> Oxaliplatin: Given IV\> \> Paclitaxel: Given IV\> \> Pembrolizumab: Given IV\> \> Positron Emission Tomography: Undergo PET scan\> \> Radiation Therapy: Undergo radiation therapy\> \> Therapeutic Conventional Surgery: Undergo curative-intent surgery
Overall Study
STARTED
31
Overall Study
COMPLETED
31
Overall Study
NOT COMPLETED
0

Reasons for withdrawal

Withdrawal data not reported

Baseline Characteristics

Pembrolizumab, Combination Chemotherapy, and Radiation Therapy Before Surgery in Treating Adult Patients With Locally Advanced Gastroesophageal Junction or Gastric Cardia Cancer That Can Be Removed by Surgery

Baseline characteristics by cohort

Baseline characteristics by cohort
Measure
Treatment (Pembrolizumab, Chemotherapy, Radiation, Surgery)
n=31 Participants
See Detailed Description\> \> Carboplatin: Given IV\> \> Computed Tomography: Undergo CT scan\> \> Fluorouracil: Given IV\> \> Laboratory Biomarker Analysis: Correlative studies\> \> Leucovorin Calcium: Given IV\> \> Oxaliplatin: Given IV\> \> Paclitaxel: Given IV\> \> Pembrolizumab: Given IV\> \> Positron Emission Tomography: Undergo PET scan\> \> Radiation Therapy: Undergo radiation therapy\> \> Therapeutic Conventional Surgery: Undergo curative-intent surgery
Age, Continuous
62 years
n=93 Participants
Sex: Female, Male
Female
1 Participants
n=93 Participants
Sex: Female, Male
Male
30 Participants
n=93 Participants
Ethnicity (NIH/OMB)
Hispanic or Latino
0 Participants
n=93 Participants
Ethnicity (NIH/OMB)
Not Hispanic or Latino
31 Participants
n=93 Participants
Ethnicity (NIH/OMB)
Unknown or Not Reported
0 Participants
n=93 Participants
Race (NIH/OMB)
American Indian or Alaska Native
0 Participants
n=93 Participants
Race (NIH/OMB)
Asian
0 Participants
n=93 Participants
Race (NIH/OMB)
Native Hawaiian or Other Pacific Islander
0 Participants
n=93 Participants
Race (NIH/OMB)
Black or African American
0 Participants
n=93 Participants
Race (NIH/OMB)
White
31 Participants
n=93 Participants
Race (NIH/OMB)
More than one race
0 Participants
n=93 Participants
Race (NIH/OMB)
Unknown or Not Reported
0 Participants
n=93 Participants
Region of Enrollment
United States
31 participants
n=93 Participants
Tumor Location
Gastroesophageal junction
29 Participants
n=93 Participants
Tumor Location
Gastric cardia
2 Participants
n=93 Participants
Histologic Grade (differentiation)
G2 (moderately differentiated)
18 Participants
n=93 Participants
Histologic Grade (differentiation)
G3 (poorly differentiated)
12 Participants
n=93 Participants
Histologic Grade (differentiation)
GX (grade cannot be assessed)
1 Participants
n=93 Participants
Clinical Tumor Stage
T2
2 Participants
n=93 Participants
Clinical Tumor Stage
T3
29 Participants
n=93 Participants
Clinical Nodal Stage
N0
4 Participants
n=93 Participants
Clinical Nodal Stage
N1
13 Participants
n=93 Participants
Clinical Nodal Stage
N2
12 Participants
n=93 Participants
Clinical Nodal Stage
N3
2 Participants
n=93 Participants
Signet Ring Cell Histology
Yes
6 Participants
n=93 Participants
Signet Ring Cell Histology
No
25 Participants
n=93 Participants
PD-L1 Combined Positive Score (CPS)
<1
11 Participants
n=93 Participants
PD-L1 Combined Positive Score (CPS)
1-9
11 Participants
n=93 Participants
PD-L1 Combined Positive Score (CPS)
≥10
8 Participants
n=93 Participants
PD-L1 Combined Positive Score (CPS)
Unknown
1 Participants
n=93 Participants

PRIMARY outcome

Timeframe: Up to 3 years

Defined as number of patients with pathologic complete responses (pCR) divided by total evaluable patients. pCR is defined as no recognized cancer and margins free of tumor as found by the pathologist following resection of the esophageal specimen and accompanying lymph nodes.

Outcome measures

Outcome measures
Measure
Treatment (Pembrolizumab, Chemotherapy, Radiation, Surgery)
n=31 Participants
See Detailed Description \> \> Carboplatin: Given IV \> \> Computed Tomography: Undergo CT scan \> \> Fluorouracil: Given IV \> \> Laboratory Biomarker Analysis: Correlative studies \> \> Leucovorin Calcium: Given IV \> \> Oxaliplatin: Given IV \> \> Paclitaxel: Given IV \> \> Pembrolizumab: Given IV \> \> Positron Emission Tomography: Undergo PET scan \> \> Radiation Therapy: Undergo radiation therapy \> \> Therapeutic Conventional Surgery: Undergo curative-intent surgery
Pathological Complete Response (PathCR) Rate
22.6 percentage of patients
Interval 11.4 to 39.8

SECONDARY outcome

Timeframe: Up to 3 years

Defined as the number of patients who achieve R0 resection divided by total number of evaluable patients.

Outcome measures

Outcome measures
Measure
Treatment (Pembrolizumab, Chemotherapy, Radiation, Surgery)
n=31 Participants
See Detailed Description \> \> Carboplatin: Given IV \> \> Computed Tomography: Undergo CT scan \> \> Fluorouracil: Given IV \> \> Laboratory Biomarker Analysis: Correlative studies \> \> Leucovorin Calcium: Given IV \> \> Oxaliplatin: Given IV \> \> Paclitaxel: Given IV \> \> Pembrolizumab: Given IV \> \> Positron Emission Tomography: Undergo PET scan \> \> Radiation Therapy: Undergo radiation therapy \> \> Therapeutic Conventional Surgery: Undergo curative-intent surgery
Complete Resection With no Tumor Within 1 mm of the Resection Margins (R0) Rate
28 Participants

SECONDARY outcome

Timeframe: Up to 3 years

Population: All patients that achieved an R0

Defined as the time from the date of study registration to the date of death due to any cause

Outcome measures

Outcome measures
Measure
Treatment (Pembrolizumab, Chemotherapy, Radiation, Surgery)
n=27 Participants
See Detailed Description \> \> Carboplatin: Given IV \> \> Computed Tomography: Undergo CT scan \> \> Fluorouracil: Given IV \> \> Laboratory Biomarker Analysis: Correlative studies \> \> Leucovorin Calcium: Given IV \> \> Oxaliplatin: Given IV \> \> Paclitaxel: Given IV \> \> Pembrolizumab: Given IV \> \> Positron Emission Tomography: Undergo PET scan \> \> Radiation Therapy: Undergo radiation therapy \> \> Therapeutic Conventional Surgery: Undergo curative-intent surgery
Disease-free Survival (DFS)
8.87 months
Interval 7.46 to
Upper limit on 95% confidence interval is not estimable (NE), due to an insufficient number of participants with events.

SECONDARY outcome

Timeframe: Up to 3 years

Population: All patients that achieved an R0

Defined as the time from the date of study registration to the date of 1st documented relapse/recurrence among patients who achieve R0 resection

Outcome measures

Outcome measures
Measure
Treatment (Pembrolizumab, Chemotherapy, Radiation, Surgery)
n=27 Participants
See Detailed Description \> \> Carboplatin: Given IV \> \> Computed Tomography: Undergo CT scan \> \> Fluorouracil: Given IV \> \> Laboratory Biomarker Analysis: Correlative studies \> \> Leucovorin Calcium: Given IV \> \> Oxaliplatin: Given IV \> \> Paclitaxel: Given IV \> \> Pembrolizumab: Given IV \> \> Positron Emission Tomography: Undergo PET scan \> \> Radiation Therapy: Undergo radiation therapy \> \> Therapeutic Conventional Surgery: Undergo curative-intent surgery
Time to Relapse (TTR)
8.87 months
Interval 7.46 to
Upper limit on 95% confidence interval is not estimable (NE), due to an insufficient number of participants with events.

SECONDARY outcome

Timeframe: 2 years

The distribution of OS will be estimated using the method of Kaplan-Meier. Two-year OS rate and confidence interval will be estimated based on Kaplan-Meier curve.

Outcome measures

Outcome measures
Measure
Treatment (Pembrolizumab, Chemotherapy, Radiation, Surgery)
n=31 Participants
See Detailed Description \> \> Carboplatin: Given IV \> \> Computed Tomography: Undergo CT scan \> \> Fluorouracil: Given IV \> \> Laboratory Biomarker Analysis: Correlative studies \> \> Leucovorin Calcium: Given IV \> \> Oxaliplatin: Given IV \> \> Paclitaxel: Given IV \> \> Pembrolizumab: Given IV \> \> Positron Emission Tomography: Undergo PET scan \> \> Radiation Therapy: Undergo radiation therapy \> \> Therapeutic Conventional Surgery: Undergo curative-intent surgery
Overall Survival (OS) at Two Years
63.3 percentage of participants
Interval 47.4 to 84.4

SECONDARY outcome

Timeframe: 2 years

The distribution of PFS will be estimated using the method of Kaplan-Meier. Two-year PFS rate and confidence interval will be estimated based on Kaplan-Meier curve.

Outcome measures

Outcome measures
Measure
Treatment (Pembrolizumab, Chemotherapy, Radiation, Surgery)
n=31 Participants
See Detailed Description \> \> Carboplatin: Given IV \> \> Computed Tomography: Undergo CT scan \> \> Fluorouracil: Given IV \> \> Laboratory Biomarker Analysis: Correlative studies \> \> Leucovorin Calcium: Given IV \> \> Oxaliplatin: Given IV \> \> Paclitaxel: Given IV \> \> Pembrolizumab: Given IV \> \> Positron Emission Tomography: Undergo PET scan \> \> Radiation Therapy: Undergo radiation therapy \> \> Therapeutic Conventional Surgery: Undergo curative-intent surgery
Progression-free Survival (PFS) Rate at Two Years
16.7 percentage of participants
Interval 6.0 to 46.5

SECONDARY outcome

Timeframe: Up to 3 years

Population: The 16 eligible patients enrolled in the phase 1b portion of the study were assessed for DLTs.

Assessed by Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. The maximum grade for each type of adverse events that are possibly, probably or definitely related to study treatments will be recorded for each patient.

Outcome measures

Outcome measures
Measure
Treatment (Pembrolizumab, Chemotherapy, Radiation, Surgery)
n=16 Participants
See Detailed Description \> \> Carboplatin: Given IV \> \> Computed Tomography: Undergo CT scan \> \> Fluorouracil: Given IV \> \> Laboratory Biomarker Analysis: Correlative studies \> \> Leucovorin Calcium: Given IV \> \> Oxaliplatin: Given IV \> \> Paclitaxel: Given IV \> \> Pembrolizumab: Given IV \> \> Positron Emission Tomography: Undergo PET scan \> \> Radiation Therapy: Undergo radiation therapy \> \> Therapeutic Conventional Surgery: Undergo curative-intent surgery
Number of Patients Experiencing Dose-limiting Toxicities (DLTs)
2 Participants

Adverse Events

Treatment (Pembrolizumab, Chemotherapy, Radiation, Surgery)

Serious events: 13 serious events
Other events: 31 other events
Deaths: 11 deaths

Serious adverse events

Serious adverse events
Measure
Treatment (Pembrolizumab, Chemotherapy, Radiation, Surgery)
n=31 participants at risk
Therapeutic Conventional Surgery: Undergo curative-intent surgery
Investigations
Lymphocyte count decreased
6.5%
2/31 • Number of events 2 • 3 years, 6 months
Investigations
Platelet count decreased
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Investigations
White blood cell decreased
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Metabolism and nutrition disorders
Dehydration
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Metabolism and nutrition disorders
Hypernatremia
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Nervous system disorders
Syncope
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Renal and urinary disorders
Acute kidney injury
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Respiratory, thoracic and mediastinal disorders
Aspiration
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Respiratory, thoracic and mediastinal disorders
Pleural effusion
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Respiratory, thoracic and mediastinal disorders
Resp, thoracic, mediastinal - Oth spec
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Vascular disorders
Hypertension
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Vascular disorders
Hypotension
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Investigations
Alanine aminotransferase increased
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Investigations
Investigations - Other, specify
6.5%
2/31 • Number of events 2 • 3 years, 6 months
Gastrointestinal disorders
Colitis
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Gastrointestinal disorders
Diarrhea
3.2%
1/31 • Number of events 2 • 3 years, 6 months
Gastrointestinal disorders
Dysphagia
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Gastrointestinal disorders
Enterocolitis
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Gastrointestinal disorders
Gastric hemorrhage
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Gastrointestinal disorders
Gastric perforation
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Gastrointestinal disorders
Ileus
3.2%
1/31 • Number of events 1 • 3 years, 6 months
General disorders
Fatigue
3.2%
1/31 • Number of events 1 • 3 years, 6 months
General disorders
Fever
3.2%
1/31 • Number of events 1 • 3 years, 6 months
General disorders
Non-cardiac chest pain
3.2%
1/31 • Number of events 2 • 3 years, 6 months
Infections and infestations
Enterocolitis infectious
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Infections and infestations
Infections and infestations - Oth spec
6.5%
2/31 • Number of events 2 • 3 years, 6 months
Infections and infestations
Sepsis
9.7%
3/31 • Number of events 4 • 3 years, 6 months
Injury, poisoning and procedural complications
Esophageal anastomotic leak
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Injury, poisoning and procedural complications
Postoperative hemorrhage
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Blood and lymphatic system disorders
Febrile neutropenia
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Blood and lymphatic system disorders
Hemolysis
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Cardiac disorders
Atrial fibrillation
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Cardiac disorders
Pericardial effusion
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Cardiac disorders
Pericarditis
3.2%
1/31 • Number of events 2 • 3 years, 6 months
Cardiac disorders
Sinus tachycardia
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Endocrine disorders
Endocrine disorders - Other, specify
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Eye disorders
Eye disorders - Other, specify
3.2%
1/31 • Number of events 2 • 3 years, 6 months
Gastrointestinal disorders
Abdominal pain
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Gastrointestinal disorders
Ascites
3.2%
1/31 • Number of events 1 • 3 years, 6 months

Other adverse events

Other adverse events
Measure
Treatment (Pembrolizumab, Chemotherapy, Radiation, Surgery)
n=31 participants at risk
Therapeutic Conventional Surgery: Undergo curative-intent surgery
Blood and lymphatic system disorders
Anemia
25.8%
8/31 • Number of events 11 • 3 years, 6 months
Blood and lymphatic system disorders
Febrile neutropenia
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Blood and lymphatic system disorders
Leukocytosis
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Cardiac disorders
Atrial fibrillation
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Cardiac disorders
Myocarditis
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Cardiac disorders
Palpitations
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Cardiac disorders
Pericardial effusion
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Cardiac disorders
Sinus bradycardia
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Cardiac disorders
Sinus tachycardia
6.5%
2/31 • Number of events 2 • 3 years, 6 months
Endocrine disorders
Hyperthyroidism
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Endocrine disorders
Hypothyroidism
3.2%
1/31 • Number of events 2 • 3 years, 6 months
Gastrointestinal disorders
Constipation
64.5%
20/31 • Number of events 28 • 3 years, 6 months
Gastrointestinal disorders
Diarrhea
58.1%
18/31 • Number of events 52 • 3 years, 6 months
Gastrointestinal disorders
Dysphagia
19.4%
6/31 • Number of events 7 • 3 years, 6 months
Gastrointestinal disorders
Gastric fistula
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Gastrointestinal disorders
Gastrointestinal disorders - Oth spec
12.9%
4/31 • Number of events 7 • 3 years, 6 months
Gastrointestinal disorders
Ileus
6.5%
2/31 • Number of events 2 • 3 years, 6 months
Gastrointestinal disorders
Mucositis oral
9.7%
3/31 • Number of events 3 • 3 years, 6 months
Gastrointestinal disorders
Nausea
83.9%
26/31 • Number of events 53 • 3 years, 6 months
Gastrointestinal disorders
Obstruction gastric
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Gastrointestinal disorders
Vomiting
45.2%
14/31 • Number of events 30 • 3 years, 6 months
General disorders
Fatigue
93.5%
29/31 • Number of events 166 • 3 years, 6 months
General disorders
Gen disord and admin site conds-Oth spec
3.2%
1/31 • Number of events 1 • 3 years, 6 months
General disorders
Pain
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Hepatobiliary disorders
Cholecystitis
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Immune system disorders
Allergic reaction
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Infections and infestations
Abdominal infection
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Infections and infestations
Pelvic infection
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Infections and infestations
Sepsis
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Injury, poisoning and procedural complications
Esophageal anastomotic leak
6.5%
2/31 • Number of events 2 • 3 years, 6 months
Injury, poisoning and procedural complications
Inj, pois and proced complic - Oth spec
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Investigations
Alanine aminotransferase increased
12.9%
4/31 • Number of events 5 • 3 years, 6 months
Investigations
Alkaline phosphatase increased
16.1%
5/31 • Number of events 6 • 3 years, 6 months
Investigations
Aspartate aminotransferase increased
12.9%
4/31 • Number of events 6 • 3 years, 6 months
Investigations
Cardiac troponin I increased
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Investigations
Cardiac troponin T increased
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Investigations
Creatinine increased
19.4%
6/31 • Number of events 8 • 3 years, 6 months
Investigations
Investigations - Other, specify
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Investigations
Lymphocyte count decreased
80.6%
25/31 • Number of events 67 • 3 years, 6 months
Investigations
Neutrophil count decreased
51.6%
16/31 • Number of events 17 • 3 years, 6 months
Investigations
Platelet count decreased
51.6%
16/31 • Number of events 24 • 3 years, 6 months
Investigations
Weight loss
9.7%
3/31 • Number of events 7 • 3 years, 6 months
Investigations
White blood cell decreased
48.4%
15/31 • Number of events 18 • 3 years, 6 months
Metabolism and nutrition disorders
Anorexia
19.4%
6/31 • Number of events 7 • 3 years, 6 months
Metabolism and nutrition disorders
Hyperglycemia
6.5%
2/31 • Number of events 2 • 3 years, 6 months
Metabolism and nutrition disorders
Hypoalbuminemia
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Metabolism and nutrition disorders
Hypokalemia
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Musculoskeletal and connective tissue disorders
Back pain
6.5%
2/31 • Number of events 3 • 3 years, 6 months
Musculoskeletal and connective tissue disorders
Flank pain
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Musculoskeletal and connective tissue disorders
Pain in extremity
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Neoplasms benign, mal, uncpec - Oth spec
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Nervous system disorders
Peripheral motor neuropathy
3.2%
1/31 • Number of events 2 • 3 years, 6 months
Nervous system disorders
Peripheral sensory neuropathy
35.5%
11/31 • Number of events 36 • 3 years, 6 months
Respiratory, thoracic and mediastinal disorders
Aspiration
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Respiratory, thoracic and mediastinal disorders
Cough
3.2%
1/31 • Number of events 3 • 3 years, 6 months
Respiratory, thoracic and mediastinal disorders
Dyspnea
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Respiratory, thoracic and mediastinal disorders
Hypoxia
3.2%
1/31 • Number of events 1 • 3 years, 6 months
Skin and subcutaneous tissue disorders
Alopecia
6.5%
2/31 • Number of events 2 • 3 years, 6 months
Skin and subcutaneous tissue disorders
Rash maculo-papular
35.5%
11/31 • Number of events 25 • 3 years, 6 months
Vascular disorders
Hypertension
19.4%
6/31 • Number of events 11 • 3 years, 6 months
Vascular disorders
Hypotension
6.5%
2/31 • Number of events 2 • 3 years, 6 months
Vascular disorders
Thromboembolic event
3.2%
1/31 • Number of events 1 • 3 years, 6 months

Additional Information

Harry H Yoon MD MHS

Mayo Clinic

Phone: 507-284-2511

Results disclosure agreements

  • Principal investigator is a sponsor employee
  • Publication restrictions are in place