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Sathianathen NJ, Oestreich MC, Brown SJ, Gupta S, Konety BR, Dahm P, Kunath F. Abiraterone acetate in combination with androgen deprivation therapy compared to androgen deprivation therapy only for metastatic hormone-sensitive prostate cancer. Cochrane Database Syst Rev 2020; 12:CD013245. [PMID: 33314020 PMCID: PMC8092456 DOI: 10.1002/14651858.cd013245.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Systemic androgen deprivation therapy (ADT), also referred to as hormone therapy,ÃÂ has long been the primary treatment for metastatic prostate cancer. Additional agents have been reserved for the castrate-resistant disease stage when ADT start becoming less effective. Abiraterone is an agent with an established role in that disease stage, which has only recently been evaluated in the hormone-sensitive setting. OBJECTIVES To assess the effects of early abiraterone acetate, in combination with systemic ADT, for newly diagnosed metastatic hormone-sensitive prostate cancer. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, six other databases, two trials registries, grey literature, and conference proceedings, up to 15 May 2020. We applied no restrictions on publication language or status. SELECTION CRITERIA We included randomized trials, in which men diagnosed with hormone-sensitive prostate cancer were administered abiraterone acetate and prednisolone with ADT or ADTÃÂ alone. DATA COLLECTION AND ANALYSIS Two review authors independently classified studies and abstracted data from the included studies. We performed statistical analyses using a random-effects model. We rated the quality of evidence according to the GRADE approach. MAIN RESULTS The search identified two randomized controlled trials (RCT), with 2201 men, who were assigned to receive either abiraterone acetate 1000 mg once daily and low dose prednisone (5mg) in addition to ADT, or ADT alone. In the LATITUDE trial, the median age and range of men in the intervention group was 68 (38 to 89) years, and 67 (33 to 92) years in the control group. Nearly all of the men in thisÃÂ study (97.6%) had prostate cancer with a Gleason score of at least 8 (ISUP grade group 4). Primary outcomes The addition of abiraterone acetate to ADT reduces the probability of death from any cause compared to ADT alone (hazard ratio [HR] 0.64, 95% confidence interval [CI] 0.56 to 0.73; 2 RCTs, 2201 men; high certainty of evidence); this corresponds to 163 fewer deaths per 1000 men with hormone-sensitive metastaticÃÂ prostate cancerÃÂ (210 fewer to 115 fewer) at five years. Abiraterone acetate in addition to ADT probably results in little to no differenceÃÂ in quality of life compared to ADT alone, measured with the Functional Assessment of Cancer Therapy-prostate total score (FACT-P; range 0 to 156; higher values indicates better quality of life),ÃÂ at 12 months (mean difference [MD] 2.90 points, 95% CI 0.11 to 5.60; 1 RCT, 838 men; moderate certainty of evidence). Secondary outcomes Abiraterone plus ADT increases the risk of grades III to V adverse events compared to ADT alone (risk ratio [RR] 1.34, 95% CI 1.22 to 1.47; 1 RCT, 1199 men; high certainty of evidence); this corresponds to 162 more grade III to VÃÂ events per 1000 men with hormone-sensitive metastaticÃÂ prostate cancerÃÂ (105 more to 224 more) at a median follow-up of 30ÃÂ months. Abiraterone acetate in addition to ADT probably reduces the probability of death due to prostate cancer compared to ADT alone (HR 0.58, 95% CI 0.50 to 0.68; 2 RCTs, 2201 men; moderate certainty of evidence). This corresponds to 120 fewer death from prostate cancer per 1000 men with hormone-sensitive metastaticÃÂ prostate cancerÃÂ (95% CI 145 fewer to 90 fewer) afterÃÂ a median follow-up of 30 months. The addition of abiraterone acetate to ADT probably decreases the probability of disease progression compared to ADT alone (HR 0.35, 95%CI 0.26 to 0.49; 2 RCTs, 2097 men; moderate certainty of evidence). This corresponds to 369 fewer incidences of disease progression per 1000 men with hormone-sensitive metastaticÃÂ prostate cancerÃÂ (456 fewer to 256 fewer)ÃÂ after a median follow-up of 30 months. The addition of abiraterone acetate to ADT probably increases the risk of discontinuing treatment due to adverse events compared to ADT alone (RR 1.50, 95% CI 1.17 to 1.92; 1 RCT, 1199 men; moderate certainty of evidence). This corresponds to 51 more men (95% CI 17 more to 93 more) discontinuing treatment because of adverse events per 1000 men treated with abiraterone acetate and ADT compared to ADT alone afterÃÂ a median follow-up of 30 months. AUTHORS' CONCLUSIONS The addition of abiraterone acetate to androgen deprivation therapy improves overall survival but probably not quality of life. ItÃÂ probably also extends disease-specific survival, and delays disease progression compared to androgen deprivation therapy alone. However, the risk of grades III to V adverse events is increased, and probably, so is the risk of discontinuing treatment due to adverse events.
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Affiliation(s)
| | - Makinna C Oestreich
- University of Minnesota Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sarah Jane Brown
- Health Sciences Libraries, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shilpa Gupta
- Department of Medicine, Division of Hematology, Oncology and Transplatation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Badrinath R Konety
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Frank Kunath
- Department of Urology, University Hospital Erlangen, Erlangen, Germany
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Park JJH, Siden E, Zoratti MJ, Dron L, Harari O, Singer J, Lester RT, Thorlund K, Mills EJ. Systematic review of basket trials, umbrella trials, and platform trials: a landscape analysis of master protocols. Trials 2019; 20:572. [PMID: 31533793 PMCID: PMC6751792 DOI: 10.1186/s13063-019-3664-1] [Citation(s) in RCA: 183] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/19/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Master protocols, classified as basket trials, umbrella trials, and platform trials, are novel designs that investigate multiple hypotheses through concurrent sub-studies (e.g., multiple treatments or populations or that allow adding/removing arms during the trial), offering enhanced efficiency and a more ethical approach to trial evaluation. Despite the many advantages of these designs, they are infrequently used. METHODS We conducted a landscape analysis of master protocols using a systematic literature search to determine what trials have been conducted and proposed for an overall goal of improving the literacy in this emerging concept. On July 8, 2019, English-language studies were identified from MEDLINE, EMBASE, and CENTRAL databases and hand searches of published reviews and registries. RESULTS We identified 83 master protocols (49 basket, 18 umbrella, and 16 platform trials). The number of master protocols has increased rapidly over the last five years. Most have been conducted in the US (n = 44/83) and investigated experimental drugs (n = 82/83) in the field of oncology (n = 76/83). The majority of basket trials were exploratory (i.e., phase I/II; n = 47/49) and not randomized (n = 44/49), and more than half (n = 28/48) investigated only a single intervention. The median sample size of basket trials was 205 participants (interquartile range, Q3-Q1 [IQR]: 500-90 = 410), and the median study duration was 22.3 (IQR: 74.1-42.9 = 31.1) months. Similar to basket trials, most umbrella trials were exploratory (n = 16/18), but the use of randomization was more common (n = 8/18). The median sample size of umbrella trials was 346 participants (IQR: 565-252 = 313), and the median study duration was 60.9 (IQR: 81.3-46.9 = 34.4) months. The median number of interventions investigated in umbrella trials was 5 (IQR: 6-4 = 2). The majority of platform trials were randomized (n = 15/16), and phase III investigation (n = 7/15; one did not report information on phase) was more common in platform trials with four of them using seamless II/III design. The median sample size was 892 (IQR: 1835-255 = 1580), and the median study duration was 58.9 (IQR: 101.3-36.9 = 64.4) months. CONCLUSIONS We anticipate that the number of master protocols will continue to increase at a rapid pace over the upcoming decades. More efforts to improve awareness and training are needed to apply these innovative trial design methods to fields outside of oncology.
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Affiliation(s)
- Jay J. H Park
- Experimental Medicine, Department of Medicine, 10th Floor, 2775 Laurel Street, Vancouver, BC V5Z 1M9 Canada
- MTEK Sciences, 802-777 West Broadway, Vancouver, BC V5Z 1J5 Canada
| | - Ellie Siden
- MTEK Sciences, 802-777 West Broadway, Vancouver, BC V5Z 1J5 Canada
| | - Michael J. Zoratti
- Department of Health Research Methods, Evidence, and Impact, McMaster University Medical Centre, 1280 Main Street West, 2C Area, Hamilton, ON L8S 4K1 Canada
| | - Louis Dron
- MTEK Sciences, 802-777 West Broadway, Vancouver, BC V5Z 1J5 Canada
| | - Ofir Harari
- MTEK Sciences, 802-777 West Broadway, Vancouver, BC V5Z 1J5 Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC V6T 1Z3 Canada
- Data and Methodology Program, CIHR Canadian HIV Trials Network, 588 – 1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Richard T. Lester
- Experimental Medicine, Department of Medicine, 10th Floor, 2775 Laurel Street, Vancouver, BC V5Z 1M9 Canada
| | - Kristian Thorlund
- MTEK Sciences, 802-777 West Broadway, Vancouver, BC V5Z 1J5 Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University Medical Centre, 1280 Main Street West, 2C Area, Hamilton, ON L8S 4K1 Canada
- Knowledge Integration, Bill and Melinda Gates Foundation, 500 5th Ave N, Seattle, WA 98109 USA
| | - Edward J. Mills
- MTEK Sciences, 802-777 West Broadway, Vancouver, BC V5Z 1J5 Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University Medical Centre, 1280 Main Street West, 2C Area, Hamilton, ON L8S 4K1 Canada
- Knowledge Integration, Bill and Melinda Gates Foundation, 500 5th Ave N, Seattle, WA 98109 USA
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Sartor O, Vogelzang NJ, Sweeney C, Fernandez DC, Almeida F, Iagaru A, Brown A, Smith MR, Agrawal M, Dicker AP, Garcia JA, Lutzky J, Wong YN, Petrenciuc O, Gratt J, Shore ND, Morris MJ. Radium-223 Safety, Efficacy, and Concurrent Use with Abiraterone or Enzalutamide: First U.S. Experience from an Expanded Access Program. Oncologist 2017; 23:193-202. [PMID: 29183960 DOI: 10.1634/theoncologist.2017-0413] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 10/10/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In the phase III ALSYMPCA trial, metastatic castration-resistant prostate cancer (mCRPC) patients had few prior life-prolonging therapies. Following ALSYMPCA, which demonstrated radium-223 survival benefit, and before radium-223 U.S. commercial availability, an expanded access program (EAP) providing early-access radium-223 allowed life-prolonging therapies in current use. SUBJECTS, MATERIALS, AND METHODS This phase II, open-label, single-arm, multicenter U.S. EAP (NCT01516762) enrolled patients with symptomatic mCRPC, ≥2 bone metastases, and no lung, liver, or brain metastases. Patients received radium-223 55 kBq/kg intravenously every 4 weeks × 6. Primary outcomes were acute and long-term safety. Additional analyses were done by number of radium-223 injections, and prior or concomitant abiraterone or enzalutamide use. RESULTS Of 252 patients, 184 received radium-223: 165/184 (90%) had Eastern Cooperative Oncology Group (ECOG) performance status 0-1; 183 (99%) had prior systemic anticancer therapy. Treatment-related adverse events occurred in 93/184 (51%) patients during treatment and 11 (6%) during follow-up. Median overall survival was 17 months, with 134/184 (73%) patients censored because of short follow-up due to radium-223 approval. In post hoc analyses, patients with ≥3 prior anticancer medications, baseline ECOG performance status ≥2, and lower baseline hemoglobin were less likely to receive 5-6 radium-223 injections and unlikely to benefit from radium-223. Radium-223 was well tolerated regardless of concurrent or prior abiraterone or enzalutamide. CONCLUSION Radium-223 was well tolerated, with no new safety concerns; safety was maintained with abiraterone or enzalutamide. Patients with more advanced disease were less likely to benefit from radium-223. Clinicians should consider baseline characteristics and therapy sequence for greatest clinical value. IMPLICATIONS FOR PRACTICE In this phase II U.S. expanded access program, radium-223 was well tolerated, with a median overall survival of 17 months in metastatic castration-resistant prostate cancer patients. In post hoc analyses, radium-223 was safe regardless of concurrent abiraterone or enzalutamide, and median overall survival appeared longer when radium-223 was used earlier in patients with less prior treatment. Patients with more advanced disease were less likely to benefit from radium-223. Clinicians should consider baseline clinical characteristics and therapy sequence to provide the greatest clinical value to patients.
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Affiliation(s)
- Oliver Sartor
- Departments of Medicine and Urology, Tulane Cancer Center, New Orleans, Louisiana, USA
| | - Nicholas J Vogelzang
- Division of Hematology/Oncology, Comprehensive Cancer Centers of Nevada, Las Vegas, Nevada, USA
| | - Christopher Sweeney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Daniel C Fernandez
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center, Tampa, Florida, USA
| | - Fabio Almeida
- Department of Radiation Oncology, Phoenix Molecular Imaging, Phoenix, Arizona, USA
| | - Andrei Iagaru
- Division of Nuclear Medicine and Molecular Imaging, Stanford University, Stanford, California, USA
| | - Alan Brown
- Department of Medicine, 21st Century Oncology, Fort Myers, Florida, USA
| | - Matthew R Smith
- Division of Hematology-Oncology, Massachusetts General Hospital Cancer Center, Boston, Massachusetts, USA
| | - Manish Agrawal
- Department of Medical Oncology, Maryland Oncology Hematology, Bethesda, Maryland, USA
| | - Adam P Dicker
- Department of Radiation Oncology, Sidney Kimmel Medical College & Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jorge A Garcia
- Department of Hematology and Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio, USA
| | - Jose Lutzky
- Division of Hematology/Oncology, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Yu-Ning Wong
- Department of Medical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, Pennsylvania, USA
| | - Oana Petrenciuc
- Department of Global Clinical Development, Bayer HealthCare Pharmaceuticals, Whippany, New Jersey, USA
| | - Jeremy Gratt
- Department of Statistical Analysis, Modular Informatics, LLC, Thornwood, New York, USA
| | - Neal D Shore
- Department of Urology, Carolina Urologic Research Center, Myrtle Beach, South Carolina, USA
| | - Michael J Morris
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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