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Mallardo D, Sparano F, Vitale MG, Trojaniello C, Fordellone M, Cioli E, Esposito A, Festino L, Mallardo M, Vanella V, Facchini BA, De Filippi R, Meinardi P, Ottaviano M, Caracò C, Simeone E, Ascierto PA. Impact of cemiplimab treatment duration on clinical outcomes in advanced cutaneous squamous cell carcinoma. Cancer Immunol Immunother 2024; 73:160. [PMID: 38850335 DOI: 10.1007/s00262-024-03728-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/10/2024] [Indexed: 06/10/2024]
Abstract
Treatment duration with checkpoint inhibitors must be optimized to prevent unjustified toxicity, but evidence for the management of cutaneous squamous cell carcinoma is lacking. A retrospective study was performed to evaluate the survival of patients with cutaneous squamous cell carcinoma (CSCC) who discontinued cemiplimab due to different causes and without progression. Among 95 patients with CSCC who received cemiplimab, 22 (23%) patients discontinued immunotherapy due to causes other than progression, such as comorbidities, toxicity, complete response or lack of compliance (group that discontinued before censoring [DBC]), then 73 patients had standard treatment scheduled (STS). The overall survival was 25.2 months (95% CI: 8.9-29.4) in STS group and 28.3 months (95% CI: 12.7-28.3) in the DBC group; deaths for all causes were 11/22 (50%) in the DBC group and 34/73 (46.6%) in the STS group (p = 0.32). 10/22 (45.4%) subjects died due to CSCC in the DBC after discontinuation and 34/73 (46.6%) in the STS group, and the difference between groups was not significant (p = 0.230). Duration of treatment was significantly lower in subjects with stable disease versus those with complete or partial response (16.9, 30.6 and 34.9 months, respectively; p = 0.004). Among the 22 STS patients, 12 received cemiplimab for less than 12 months (10 [83%] died) and 10 for at least 12 months (1 [10%] died). Our observation, finding no outcome difference between DBC and STS groups, suggests that ICI treatment after one year might expose patients to further treatment related events without efficacy advantages.
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MESH Headings
- Humans
- Male
- Female
- Skin Neoplasms/drug therapy
- Skin Neoplasms/mortality
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Carcinoma, Squamous Cell/drug therapy
- Carcinoma, Squamous Cell/mortality
- Aged
- Retrospective Studies
- Middle Aged
- Aged, 80 and over
- Treatment Outcome
- Antineoplastic Agents, Immunological/therapeutic use
- Antineoplastic Agents, Immunological/administration & dosage
- Antineoplastic Agents, Immunological/adverse effects
- Adult
- Immune Checkpoint Inhibitors/therapeutic use
- Immune Checkpoint Inhibitors/administration & dosage
- Immune Checkpoint Inhibitors/adverse effects
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Affiliation(s)
- Domenico Mallardo
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori - IRCCS - Fondazione 'G. Pascale', Naples, Italy
| | - Francesca Sparano
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori - IRCCS - Fondazione 'G. Pascale', Naples, Italy
| | - Maria Grazia Vitale
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori - IRCCS - Fondazione 'G. Pascale', Naples, Italy
| | - Claudia Trojaniello
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori - IRCCS - Fondazione 'G. Pascale', Naples, Italy
| | - Mario Fordellone
- Universitiy of Campania "Luigi Vanvitelli", 81100, Naples, Italy
| | - Eleonora Cioli
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori - IRCCS - Fondazione 'G. Pascale', Naples, Italy
| | - Assunta Esposito
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori - IRCCS - Fondazione 'G. Pascale', Naples, Italy
| | - Lucia Festino
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori - IRCCS - Fondazione 'G. Pascale', Naples, Italy
| | - Mario Mallardo
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori - IRCCS - Fondazione 'G. Pascale', Naples, Italy
| | - Vito Vanella
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori - IRCCS - Fondazione 'G. Pascale', Naples, Italy
| | - Bianca Arianna Facchini
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori - IRCCS - Fondazione 'G. Pascale', Naples, Italy
| | - Rosaria De Filippi
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Paolo Meinardi
- Division of Surgery of Melanoma and Skin Cancer, Istituto Nazionale Tumori 'Fondazione Pascale' IRCCS, Naples, Italy
| | - Margaret Ottaviano
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori - IRCCS - Fondazione 'G. Pascale', Naples, Italy
| | - Corrado Caracò
- Division of Surgery of Melanoma and Skin Cancer, Istituto Nazionale Tumori 'Fondazione Pascale' IRCCS, Naples, Italy
| | - Ester Simeone
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori - IRCCS - Fondazione 'G. Pascale', Naples, Italy
| | - Paolo Antonio Ascierto
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori - IRCCS - Fondazione 'G. Pascale', Naples, Italy.
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2
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Namikawa K, Nakano E, Ogata D, Yamazaki N. Long-term survival with systemic therapy in the last decade: Can melanoma be cured? J Dermatol 2024; 51:343-352. [PMID: 38358050 DOI: 10.1111/1346-8138.17147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/16/2024]
Abstract
Immune checkpoint inhibitors have been shown to prolong survival of patients with several types of cancer, and the finding was first established in melanoma. Previously, systemic therapy for advanced melanoma aimed only at tumor control and palliation of symptoms. However, in recent years, some patients who received systemic therapy have achieved a complete response and survived without continuous treatment for more than several years. This review discusses the long-term survival rates achieved with currently used systemic therapies and their future perspectives. Long-term survival is currently most likely to be achieved with the use of the standard-dose combination of nivolumab plus ipilimumab, however, this regimen is associated with a high frequency of serious or persistent immune-related adverse events. Several new anti-PD-1-based combination therapies with a better risk-benefit balance are currently under development. Although the acral and mucosal subtypes tend to be less responsive to immune checkpoint inhibitors, anti-PD-1-based combination therapy should continue to be investigated for these subtypes owing to its potential for better long-term survival. With the development of efficacious immunotherapy and targeted therapy, it is important to determine the optimal duration of systemic therapy to avoid unnecessary health and financial burdens as well as to improve efforts to support long-term cancer survivors. As the goal of systemic therapy shifts from tumor control to long-term survival, in future clinical trials, long-term clinical outcomes should be evaluated to assess the benefits of novel agents.
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Affiliation(s)
- Kenjiro Namikawa
- Department of Dermatologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Eiji Nakano
- Department of Dermatologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Dai Ogata
- Department of Dermatologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Naoya Yamazaki
- Department of Dermatologic Oncology, National Cancer Center Hospital, Tokyo, Japan
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Zijlker LP, Levy S, Wolters W, van Thienen JV, van Akkooi ACJ, Tesselaar MET. Avelumab treatment for patients with metastatic Merkel cell carcinoma can be safely stopped after 1 year and a PET/CT-confirmed complete response. Cancer 2024; 130:433-438. [PMID: 37788133 DOI: 10.1002/cncr.35050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Immune checkpoint inhibitor treatment of patients with metastatic Merkel cell carcinoma (mMCC) has shown high response rates, ranging from 33% to 73%. The ideal duration of treatment, however, is currently unknown. The aim of this study was to evaluate if avelumab treatment for mMCC can be safely stopped after 1 year of treatment and a complete response (CR) confirmed by fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) imaging. METHODS Patients who received more than one dose of avelumab treatment for mMCC between November 2017 and February 2022 were included in this study. Treatment was discontinued in case of a FDG-PET/CT confirmed CR after 1 year (26 cycles) of avelumab or a CR and unacceptable toxicity earlier. The primary end point was recurrence-free survival (RFS). RESULTS Sixty-five patients were included: 25 (38%) had a FDG-PET/CT-confirmed CR at discontinuation of avelumab. In those 25 patients, reasons for discontinuation of treatment were completion of 1 year of treatment in 13 (52%), toxicity in five (20%), and patient preference in seven (28%). Median duration of treatment in this group was 11 months (interquartile range, 6.1-11.7). Median follow-up was 27 months (interquartile range, 15.8-33.8). The 12-month RFS was 88% (95% CI, 0.74-1) and median RFS was not reached. Two patients (8%) had a recurrence at 4 and 7 months after discontinuation of treatment. CONCLUSIONS Patients with mMCC who acquire a CR on PET/CT imaging appear to have durable responses after discontinuation of treatment after 1 year.
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Affiliation(s)
- Lisanne P Zijlker
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
| | - Sonja Levy
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Wendy Wolters
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Johannes V van Thienen
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Alexander C J van Akkooi
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Margot E T Tesselaar
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Ghorani E, Quartagno M, Blackhall F, Gilbert DC, O'Brien M, Ottensmeier C, Pizzo E, Spicer J, Williams A, Badman P, Parmar MKB, Seckl MJ. REFINE-Lung implements a novel multi-arm randomised trial design to address possible immunotherapy overtreatment. Lancet Oncol 2023; 24:e219-e227. [PMID: 37142383 DOI: 10.1016/s1470-2045(23)00095-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/14/2023] [Accepted: 02/20/2023] [Indexed: 05/06/2023]
Abstract
Increasing evidence suggests that some immunotherapy dosing regimens for patients with advanced cancer could result in overtreatment. Given the high costs of these agents, and important implications for quality of life and toxicity, new approaches are needed to identify and reduce unnecessary treatment. Conventional two-arm non-inferiority designs are inefficient in this context because they require large numbers of patients to explore a single alternative to the standard of care. Here, we discuss the potential problem of overtreatment with anti-PD-1 directed agents in general and introduce REFINE-Lung (NCT05085028), a UK multicentre phase 3 study of reduced frequency pembrolizumab in advanced non-small-cell lung cancer. REFINE-Lung uses a novel multi-arm multi-stage response over continuous interventions (MAMS-ROCI) design to determine the optimal dose frequency of pembrolizumab. Along with a similarly designed basket study of patients with renal cancer and melanoma, REFINE-Lung and the MAMS-ROCI design could contribute to practice-changing advances in patient care and form a template for future immunotherapy optimisation studies across cancer types and indications. This new trial design is applicable to many new or existing agents for which optimisation of dose, frequency, or duration of therapy is desirable.
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Affiliation(s)
- Ehsan Ghorani
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, London, UK
| | - Matteo Quartagno
- Institute for Clinical Trials and Methodology, University College London, London, UK
| | - Fiona Blackhall
- Christie National Health Service Foundation Trust, Manchester, UK
| | - Duncan C Gilbert
- Institute for Clinical Trials and Methodology, University College London, London, UK
| | - Mary O'Brien
- Royal Marsden Hospital, Imperial College London, London, UK
| | - Christian Ottensmeier
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK; Clatterbridge Cancer Center NHS Foundation Trust, Liverpool, UK
| | - Elena Pizzo
- Department of Applied Health Research, University College London, London, UK
| | - James Spicer
- King's College London, Guy's Hospital, London, UK
| | - Alex Williams
- Imperial College Trials Unit-Cancer, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Philip Badman
- Imperial College Trials Unit-Cancer, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Mahesh K B Parmar
- Institute for Clinical Trials and Methodology, University College London, London, UK.
| | - Michael J Seckl
- Department of Medical Oncology, Charing Cross Gestational Trophoblastic Disease Centre, Charing Cross Hospital Campus of Imperial College London, London, UK.
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Malmberg R, Zietse M, Dumoulin DW, Hendrikx JJMA, Aerts JGJV, van der Veldt AAM, Koch BCP, Sleijfer S, van Leeuwen RWF. Alternative dosing strategies for immune checkpoint inhibitors to improve cost-effectiveness: a special focus on nivolumab and pembrolizumab. Lancet Oncol 2022; 23:e552-e561. [DOI: 10.1016/s1470-2045(22)00554-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/30/2022]
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Jiang M, Hu Y, Lin G, Chen C. Dosing Regimens of Immune Checkpoint Inhibitors: Attempts at Lower Dose, Less Frequency, Shorter Course. Front Oncol 2022; 12:906251. [PMID: 35795044 PMCID: PMC9251517 DOI: 10.3389/fonc.2022.906251] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/24/2022] [Indexed: 12/19/2022] Open
Abstract
Immune checkpoint inhibitors (ICIs) are a revolutionary breakthrough in the field of cancer by modulating patient's own immune system to exert anti-tumor effects. The clinical application of ICIs is still in its infancy, and their dosing regimens need to be continuously adjusted. Pharmacokinetic/pharmacodynamic studies showed a significant plateau in the exposure-response curve, with high receptor occupancy and plasma concentrations achieved at low dose levels. Coupled with concerns about drug toxicity and heavy economic costs, there has been an ongoing quest to reevaluate the current ICI dosing regimens while preserving maximum clinical efficacy. Many clinical data showed remarkable anticancer effects with ICIs at the doses far below the approved regimens, indicating the possibility of dose reduction. Our review attempts to summarize the clinical evidence for ICIs regimens with lower-dose, less-frequency, shorter-course, and provide clues for further ICIs regimen optimization.
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Affiliation(s)
| | | | | | - Chao Chen
- Department of Radiotherapy, The First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou, China
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8
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Maio M, Lahn M, Di Giacomo AM, Covre A, Calabrò L, Ibrahim R, Fox B. A vision of immuno-oncology: the Siena think tank of the Italian network for tumor biotherapy (NIBIT) foundation. J Exp Clin Cancer Res 2021; 40:240. [PMID: 34301276 PMCID: PMC8298945 DOI: 10.1186/s13046-021-02023-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/18/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The yearly Think Tank Meeting of the Italian Network for Tumor Biotherapy (NIBIT) Foundation, brings together in Siena, Tuscany (Italy), experts in immuno-oncology to review the learnings from current immunotherapy treatments, and to propose new pre-clinical and clinical investigations in selected research areas. MAIN: While immunotherapies in non-small cell lung cancer and melanoma led to practice changing therapies, the same therapies had only modest benefit for patients with other malignancies, such as mesothelioma and glioblastoma. One way to improve on current immunotherapies is to alter the sequence of each combination agent. Matching the immunotherapy to the host's immune response may thus improve the activity of the current treatments. A second approach is to combine current immunotherapies with novel agents targeting complementary mechanisms. Identifying the appropriate novel agents may require different approaches than the traditional laboratory-based discovery work. For example, artificial intelligence-based research may help focusing the search for innovative and most promising combination partners. CONCLUSION Novel immunotherapies are needed in cancer patients with resistance to or relapse after current immunotherapeutic drugs. Such new treatments may include targeted agents or monoclonal antibodies to overcome the immune-suppressive tumor microenvironment. The mode of combining the novel treatments, including vaccines, needs to be matched to the patient's immune status for achieving the maximum benefit. In this scenario, specific attention should be also paid nowadays to the immune intersection between COVID-19 and cancer.
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Affiliation(s)
- Michele Maio
- Center for Immuno-Oncology, Medical Oncology and Immunotherapy, University Hospital of Siena, Viale Mario Bracci, 16, Siena, Italy.
- Italian Network for Tumor Bio-Immunotherapy Foundation Onlus, Siena, Italy.
| | - Michael Lahn
- iOnctura SA, Avenue Secheron 15, Geneva, Switzerland
| | - Anna Maria Di Giacomo
- Center for Immuno-Oncology, Medical Oncology and Immunotherapy, University Hospital of Siena, Viale Mario Bracci, 16, Siena, Italy
- Italian Network for Tumor Bio-Immunotherapy Foundation Onlus, Siena, Italy
| | - Alessia Covre
- Center for Immuno-Oncology, Medical Oncology and Immunotherapy, University Hospital of Siena, Viale Mario Bracci, 16, Siena, Italy
| | - Luana Calabrò
- Center for Immuno-Oncology, Medical Oncology and Immunotherapy, University Hospital of Siena, Viale Mario Bracci, 16, Siena, Italy
| | - Ramy Ibrahim
- Parker Institute for Cancer Immunotherapy, 1 Letterman Drive, San Francisco, 94012, USA
| | - Bernard Fox
- Earle A. Chiles Research Institute at the Robert W. Franz Cancer Center, 4805 NE Glisan St. Suite 2N35, Portland, OR, 97213, USA
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Coen O, Corrie P, Marshall H, Plummer R, Ottensmeier C, Hook J, Bell S, Sagoo GS, Meads D, Bestall J, Velikova G, Gallagher FA, Smith A, Howard H, Mason E, Katona E, Silva S, Collinson M, Rodwell S, Danson S. The DANTE trial protocol: a randomised phase III trial to evaluate the Duration of ANti-PD-1 monoclonal antibody Treatment in patients with metastatic mElanoma. BMC Cancer 2021; 21:761. [PMID: 34210290 PMCID: PMC8246129 DOI: 10.1186/s12885-021-08509-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 06/14/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Immunotherapy is revolutionising the treatment of patients diagnosed with melanoma and other cancers. The first immune checkpoint inhibitor, ipilimumab (targeting cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4)), showed a survival advantage over standard chemotherapy. Subsequently the anti-programmed cell death protein 1 (PD-1) antibodies, nivolumab and pembrolizumab were shown to be more effective than ipilimumab. Ipilimumab combined with nivolumab gives an incremental gain in overall survival compared with nivolumab alone but increases the risk of severe, potentially life-threatening toxicities. In contrast to ipilimumab monotherapy, anti-PD-1 antibodies are licensed to be continued until disease progression. Follow-up of patients recruited to the first trials evaluating 2 years of pembrolizumab showed that three-quarters of responding patients continue responding after stopping treatment. Suggestive of early response, we hypothesised that continuing anti-PD-1 treatment beyond 1 year in progression-free patients may be unnecessary and so designed the DANTE trial. METHODS DANTE is a multicentre, randomised, phase III, non-inferiority trial to evaluate the duration of anti-PD-1 therapy in patients with metastatic (unresectable stage III and stage IV) melanoma. It uses a two-stage recruitment strategy, registering patients before they complete 1 year of first-line anti-PD-1 +/- CTLA-4 therapy and randomising eligible patients who have received 12 months of treatment and are progression-free at 1 year. At randomisation, 1208 patients are assigned (1:1) to either 1) continue anti-PD-1 treatment until disease progression/ unacceptable toxicity/ for at least 2 years in the absence of disease progression/ unacceptable toxicity or 2) to stop treatment. Randomisation stratifies for baseline prognostic factors. The primary outcome is progression-free survival at 3, 6, 9 and 12 months and then, 6-monthly for up to 4-years. Secondary outcomes collected at all timepoints include overall survival, response-rate and duration and safety, with quality of life and cost-effectiveness outcomes collected 3-monthly for up to 18-months. Sub-studies include a qualitative analysis of patient acceptance of randomisation and sample collection to inform future translational studies into response/ toxicity biomarkers. DISCUSSION DANTE is a unique prospective trial investigating the optimal duration of anti-PD-1 therapy in metastatic melanoma patients. Outcomes will inform future use of these high burden drugs. TRIAL REGISTRATION ISRCTN15837212 , 31 July 2018.
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Affiliation(s)
- Oliver Coen
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Pippa Corrie
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Helen Marshall
- University of Leeds, Leeds, UK
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, Leeds, UK
| | | | | | - Jane Hook
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sue Bell
- University of Leeds, Leeds, UK
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, Leeds, UK
| | | | | | | | - Galina Velikova
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- University of Leeds, Leeds, UK
- Leeds Institute of Medical Research at St James's University Hospital, Leeds, UK
| | - Ferdia A Gallagher
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Alexandra Smith
- University of Leeds, Leeds, UK
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, Leeds, UK
| | - Helen Howard
- University of Leeds, Leeds, UK
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, Leeds, UK
| | - Ellen Mason
- University of Leeds, Leeds, UK
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, Leeds, UK
| | - Eszter Katona
- University of Leeds, Leeds, UK
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, Leeds, UK
| | - Shobha Silva
- Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield, UK
- University of Sheffield, Sheffield, UK
| | - Michelle Collinson
- University of Leeds, Leeds, UK
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, Leeds, UK
| | - Simon Rodwell
- University of Sheffield, Sheffield, UK
- Melanoma Focus, Cambridge, UK
| | - Sarah Danson
- Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield, UK.
- University of Sheffield, Sheffield, UK.
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