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Joharatnam-Hogan N, Hatem D, Cafferty FH, Petrucci G, Cameron DA, Ring A, Kynaston HG, Gilbert DC, Wilson RH, Hubner RA, Swinson DEB, Cleary S, Robbins A, MacKenzie M, Scott-Brown MWG, Sothi S, Dawson LK, Capaldi LM, Churn M, Cunningham D, Khoo V, Armstrong AC, Ainsworth NL, Horan G, Wheatley DA, Mullen R, Lofts FJ, Walther A, Herbertson RA, Eaton JD, O'Callaghan A, Eichholz A, Kagzi MM, Patterson DM, Narahari K, Bradbury J, Stokes Z, Rizvi AJ, Walker GA, Kunene VL, Srihari N, Gentry-Maharaj A, Meade A, Patrono C, Rocca B, Langley RE. Thromboxane biosynthesis in cancer patients and its inhibition by aspirin: a sub-study of the Add-Aspirin trial. Br J Cancer 2023; 129:706-720. [PMID: 37420000 PMCID: PMC10421951 DOI: 10.1038/s41416-023-02310-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 05/09/2023] [Accepted: 06/05/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Pre-clinical models demonstrate that platelet activation is involved in the spread of malignancy. Ongoing clinical trials are assessing whether aspirin, which inhibits platelet activation, can prevent or delay metastases. METHODS Urinary 11-dehydro-thromboxane B2 (U-TXM), a biomarker of in vivo platelet activation, was measured after radical cancer therapy and correlated with patient demographics, tumour type, recent treatment, and aspirin use (100 mg, 300 mg or placebo daily) using multivariable linear regression models with log-transformed values. RESULTS In total, 716 patients (breast 260, colorectal 192, gastro-oesophageal 53, prostate 211) median age 61 years, 50% male were studied. Baseline median U-TXM were breast 782; colorectal 1060; gastro-oesophageal 1675 and prostate 826 pg/mg creatinine; higher than healthy individuals (~500 pg/mg creatinine). Higher levels were associated with raised body mass index, inflammatory markers, and in the colorectal and gastro-oesophageal participants compared to breast participants (P < 0.001) independent of other baseline characteristics. Aspirin 100 mg daily decreased U-TXM similarly across all tumour types (median reductions: 77-82%). Aspirin 300 mg daily provided no additional suppression of U-TXM compared with 100 mg. CONCLUSIONS Persistently increased thromboxane biosynthesis was detected after radical cancer therapy, particularly in colorectal and gastro-oesophageal patients. Thromboxane biosynthesis should be explored further as a biomarker of active malignancy and may identify patients likely to benefit from aspirin.
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Affiliation(s)
| | - Duaa Hatem
- Department of Safety and Bioethics, Division of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Fay H Cafferty
- MRC Clinical Trials Unit, UCL, London, UK
- The Institute of Cancer Research, London, UK
| | - Giovanna Petrucci
- Department of Safety and Bioethics, Division of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - David A Cameron
- Cancer Research UK Edinburgh Centre, Institute of Genetics and Cancer, The University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Alistair Ring
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Howard G Kynaston
- Department of Urology, Cardiff University School of Medicine, Cardiff, UK
| | - Duncan C Gilbert
- MRC Clinical Trials Unit, UCL, London, UK
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Richard H Wilson
- School of Cancer Sciences, University of Glasgow, Glasgow, UK
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Richard A Hubner
- The Christie NHS Foundation Trust, Department of Medical Oncology, Manchester, UK
- University of Manchester, Division of Cancer Sciences, Manchester, UK
| | | | | | | | | | | | - Sharmila Sothi
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Lesley K Dawson
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | | | - Mark Churn
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | | | - Vincent Khoo
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Anne C Armstrong
- The Christie NHS Foundation Trust, Department of Medical Oncology, Manchester, UK
| | - Nicola L Ainsworth
- The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
| | - Gail Horan
- The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
| | | | - Russell Mullen
- The Highland Breast Centre, Raigmore Hospital, Inverness, UK
| | - Fiona J Lofts
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Axel Walther
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - John D Eaton
- University Hospitals of Morecambe Bay NHS Foundation Trust, Kendal, UK
| | | | | | | | | | - Krishna Narahari
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
- Division of Cancer and Genetics, Cardiff University, Cardiff, UK
| | | | - Zuzana Stokes
- United Lincolnshire Hospitals NHS Trust, Lincoln City, UK
| | - Azhar J Rizvi
- Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | | | - Victoria L Kunene
- Walsall Manor Hospital and University Hospitals, Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | | | - Carlo Patrono
- Department of Safety and Bioethics, Division of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Bianca Rocca
- Department of Safety and Bioethics, Division of Pharmacology, Catholic University School of Medicine, Rome, Italy
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Attard G, Murphy L, Clarke NW, Sachdeva A, Jones C, Hoyle A, Cross W, Jones RJ, Parker CC, Gillessen S, Cook A, Brawley C, Gilson C, Rush H, Abdel-Aty H, Amos CL, Murphy C, Chowdhury S, Malik Z, Russell JM, Parkar N, Pugh C, Diaz-Montana C, Pezaro C, Grant W, Saxby H, Pedley I, O'Sullivan JM, Birtle A, Gale J, Srihari N, Thomas C, Tanguay J, Wagstaff J, Das P, Gray E, Alzouebi M, Parikh O, Robinson A, Montazeri AH, Wylie J, Zarkar A, Cathomas R, Brown MD, Jain Y, Dearnaley DP, Mason MD, Gilbert D, Langley RE, Millman R, Matheson D, Sydes MR, Brown LC, Parmar MKB, James ND. Abiraterone acetate plus prednisolone with or without enzalutamide for patients with metastatic prostate cancer starting androgen deprivation therapy: final results from two randomised phase 3 trials of the STAMPEDE platform protocol. Lancet Oncol 2023; 24:443-456. [PMID: 37142371 DOI: 10.1016/s1470-2045(23)00148-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/17/2023] [Accepted: 03/23/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Abiraterone acetate plus prednisolone (herein referred to as abiraterone) or enzalutamide added at the start of androgen deprivation therapy improves outcomes for patients with metastatic prostate cancer. Here, we aimed to evaluate long-term outcomes and test whether combining enzalutamide with abiraterone and androgen deprivation therapy improves survival. METHODS We analysed two open-label, randomised, controlled, phase 3 trials of the STAMPEDE platform protocol, with no overlapping controls, conducted at 117 sites in the UK and Switzerland. Eligible patients (no age restriction) had metastatic, histologically-confirmed prostate adenocarcinoma; a WHO performance status of 0-2; and adequate haematological, renal, and liver function. Patients were randomly assigned (1:1) using a computerised algorithm and a minimisation technique to either standard of care (androgen deprivation therapy; docetaxel 75 mg/m2 intravenously for six cycles with prednisolone 10 mg orally once per day allowed from Dec 17, 2015) or standard of care plus abiraterone acetate 1000 mg and prednisolone 5 mg (in the abiraterone trial) orally or abiraterone acetate and prednisolone plus enzalutamide 160 mg orally once a day (in the abiraterone and enzalutamide trial). Patients were stratified by centre, age, WHO performance status, type of androgen deprivation therapy, use of aspirin or non-steroidal anti-inflammatory drugs, pelvic nodal status, planned radiotherapy, and planned docetaxel use. The primary outcome was overall survival assessed in the intention-to-treat population. Safety was assessed in all patients who started treatment. A fixed-effects meta-analysis of individual patient data was used to compare differences in survival between the two trials. STAMPEDE is registered with ClinicalTrials.gov (NCT00268476) and ISRCTN (ISRCTN78818544). FINDINGS Between Nov 15, 2011, and Jan 17, 2014, 1003 patients were randomly assigned to standard of care (n=502) or standard of care plus abiraterone (n=501) in the abiraterone trial. Between July 29, 2014, and March 31, 2016, 916 patients were randomly assigned to standard of care (n=454) or standard of care plus abiraterone and enzalutamide (n=462) in the abiraterone and enzalutamide trial. Median follow-up was 96 months (IQR 86-107) in the abiraterone trial and 72 months (61-74) in the abiraterone and enzalutamide trial. In the abiraterone trial, median overall survival was 76·6 months (95% CI 67·8-86·9) in the abiraterone group versus 45·7 months (41·6-52·0) in the standard of care group (hazard ratio [HR] 0·62 [95% CI 0·53-0·73]; p<0·0001). In the abiraterone and enzalutamide trial, median overall survival was 73·1 months (61·9-81·3) in the abiraterone and enzalutamide group versus 51·8 months (45·3-59·0) in the standard of care group (HR 0·65 [0·55-0·77]; p<0·0001). We found no difference in the treatment effect between these two trials (interaction HR 1·05 [0·83-1·32]; pinteraction=0·71) or between-trial heterogeneity (I2 p=0·70). In the first 5 years of treatment, grade 3-5 toxic effects were higher when abiraterone was added to standard of care (271 [54%] of 498 vs 192 [38%] of 502 with standard of care) and the highest toxic effects were seen when abiraterone and enzalutamide were added to standard of care (302 [68%] of 445 vs 204 [45%] of 454 with standard of care). Cardiac causes were the most common cause of death due to adverse events (five [1%] with standard of care plus abiraterone and enzalutamide [two attributed to treatment] and one (<1%) with standard of care in the abiraterone trial). INTERPRETATION Enzalutamide and abiraterone should not be combined for patients with prostate cancer starting long-term androgen deprivation therapy. Clinically important improvements in survival from addition of abiraterone to androgen deprivation therapy are maintained for longer than 7 years. FUNDING Cancer Research UK, UK Medical Research Council, Swiss Group for Clinical Cancer Research, Janssen, and Astellas.
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Affiliation(s)
- Gerhardt Attard
- Cancer Institute, University College London, London, UK; University College London Hospitals, London, UK.
| | - Laura Murphy
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Noel W Clarke
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Ashwin Sachdeva
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Craig Jones
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Alex Hoyle
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | | | - Robert J Jones
- Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow, UK
| | | | - Silke Gillessen
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; CH and Universita della Svizzera Italiana, Lugano, Switzerland
| | - Adrian Cook
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Chris Brawley
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Clare Gilson
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Hannah Rush
- Medical Research Council Clinical Trials Unit, University College London, London, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Hoda Abdel-Aty
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - Claire L Amos
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Claire Murphy
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | - Zafar Malik
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | - J Martin Russell
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Nazia Parkar
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Cheryl Pugh
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Carlos Diaz-Montana
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | | | - Helen Saxby
- Torbay and South Devon NHS Foundation Trust, Torbay, UK
| | - Ian Pedley
- Northern Centre for Cancer Care, Newcastle upon Tyne, UK
| | | | - Alison Birtle
- Rosemere Cancer Centre, Royal Preston Hospital, Preston, UK
| | | | | | | | | | | | | | - Emma Gray
- Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | | | - Omi Parikh
- East Lancashire Hospitals NHS Trust, Preston, UK
| | | | | | - James Wylie
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Anjali Zarkar
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard Cathomas
- Division of Oncology and Hematology, Cantonal Hospital Graubünden, Chur, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | - Michael D Brown
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Yatin Jain
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - David P Dearnaley
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | | | - Duncan Gilbert
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Ruth E Langley
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Robin Millman
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - David Matheson
- Faculty of Education Health and Wellbeing, University of Wolverhampton, Walsall, UK
| | - Matthew R Sydes
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Louise C Brown
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Mahesh K B Parmar
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Nicholas D James
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
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Dearnaley D, Hinder V, Hijab A, Horan G, Srihari N, Rich P, Houston G, Henry A, Gibbs S, Venkitaraman R, Cruickshank C, Hassan S, Mason M, Pedley I, Payne H, Brock S, Wade R, Robinson A, Din O, Lees K, Murray J, Parker C, Griffin C, Sohaib A, Hall E. OC-0105 PROMPTS RCT of screening MRI for spinal cord compression in prostate cancer (ISRCTN74112318). Radiother Oncol 2022. [DOI: 10.1016/s0167-8140(22)02481-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Dearnaley D, Hinder V, Hijab A, Horan G, Srihari N, Rich P, Houston JG, Henry AM, Gibbs S, Venkitaraman R, Cruickshank C, Hassan S, Miners A, Mason M, Pedley I, Payne H, Brock S, Wade R, Robinson A, Din O, Lees K, Graham J, Worlding J, Murray J, Parker C, Griffin C, Sohaib A, Hall E. Observation versus screening spinal MRI and pre-emptive treatment for spinal cord compression in patients with castration-resistant prostate cancer and spinal metastases in the UK (PROMPTS): an open-label, randomised, controlled, phase 3 trial. Lancet Oncol 2022; 23:501-513. [PMID: 35279270 PMCID: PMC8960282 DOI: 10.1016/s1470-2045(22)00092-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/10/2022] [Accepted: 02/10/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Early diagnosis of malignant spinal cord compression (SCC) is crucial because pretreatment neurological status is the major determinant of outcome. In metastatic castration-resistant prostate cancer, SCC is a clinically significant cause of disease-related morbidity and mortality. We investigated whether screening for SCC with spinal MRI, and pre-emptive treatment if radiological SCC (rSCC) was detected, reduced the incidence of clinical SCC (cSCC) in asymptomatic patients with metastatic castration-resistant prostate cancer and spinal metastasis. METHODS We did a parallel-group, open-label, randomised, controlled, phase 3, superiority trial. Patients with metastatic castration-resistant prostate cancer were recruited from 45 National Health Service hospitals in the UK. Eligible patients were aged at least 18 years, with an Eastern Co-operative Oncology Group performance status of 0-2, asymptomatic spinal metastasis, no previous SCC, and no spinal MRI in the past 12 months. Participants were randomly assigned (1:1), using a minimisation algorithm with a random element (balancing factors were treatment centre, alkaline phosphatase [normal vs raised, with the upper limit of normal being defined at each participating laboratory], number of previous systemic treatments [first-line vs second-line or later], previous spinal treatment, and imaging of thorax and abdomen), to no MRI (control group) or screening spinal MRI (intervention group). Serious adverse events were monitored in the 24 h after screening MRI in the intervention group. Participants with screen-detected rSCC were offered pre-emptive treatment (radiotherapy or surgical decompression was recommended per treating physician's recommendation) and 6-monthly spinal MRI. All patients were followed up every 3 months, and then at month 30 and 36. The primary endpoint was time to and incidence of confirmed cSCC in the intention-to-treat population (defined as all patients randomly assigned), with the primary timepoint of interest being 1 year after randomisation. The study is registered with ISRCTN, ISRCTN74112318, and is now complete. FINDINGS Between Feb 26, 2013, and April 25, 2017, 420 patients were randomly assigned to the control (n=210) or screening MRI (n=210) groups. Median age was 74 years (IQR 68 to 79), 222 (53%) of 420 patients had normal alkaline phosphatase, and median prostate-specific antigen concentration was 48 ng/mL (IQR 17 to 162). Screening MRI detected rSCC in 61 (31%) of 200 patients with assessable scans in the intervention group. As of data cutoff (April 23, 2020), at a median follow-up of 22 months (IQR 13 to 31), time to cSCC was not significantly improved with screening (hazard ratio 0·64 [95% CI 0·37 to 1·11]; Gray's test p=0·12). 1-year cSCC rates were 6·7% (95% CI 3·8-10·6; 14 of 210 patients) for the control group and 4·3% (2·1-7·7; nine of 210 patients) for the intervention group (difference -2·4% [95% CI -4·2 to 0·1]). Median time to cSCC was not reached in either group. No serious adverse events were reported within 24 h of screening. INTERPRETATION Despite the substantial incidence of rSCC detected in the intervention group, the rate of cSCC in both groups was low at a median of 22 months of follow-up. Routine use of screening MRI and pre-emptive treatment to prevent cSCC is not warranted in patients with asymptomatic castration-resistant prostate cancer with spinal metastasis. FUNDING Cancer Research UK.
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Affiliation(s)
- David Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Urology Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Victoria Hinder
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Adham Hijab
- Urology Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Gail Horan
- Clinical Oncology, The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
| | - Narayanan Srihari
- Clinical Oncology, The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Philip Rich
- Radiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - J Graeme Houston
- Imaging Science and Technology, University of Dundee, Dundee, UK
| | - Ann M Henry
- Clinical Oncology, University of Leeds, Leeds, UK
| | - Stephanie Gibbs
- Clinical Oncology, Barking, Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Ram Venkitaraman
- Clinical Oncology, East Suffolk and North Essex NHS Foundation Trust, Ipswich, UK
| | - Clare Cruickshank
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Shama Hassan
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Alec Miners
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Ian Pedley
- Clinical Oncology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Heather Payne
- Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Susannah Brock
- Clinical Oncology, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Robert Wade
- Clinical Oncology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Angus Robinson
- Clinical Oncology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Omar Din
- Clinical Oncology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Kathryn Lees
- Clinical Oncology, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - John Graham
- Clinical Oncology, Somerset NHS Foundation Trust, Taunton, UK
| | - Jane Worlding
- Oncology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Julia Murray
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Urology Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Chris Parker
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK; Urology Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Clare Griffin
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Aslam Sohaib
- Urology Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK.
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Attard G, Murphy L, Clarke NW, Cross W, Jones RJ, Parker CC, Gillessen S, Cook A, Brawley C, Amos CL, Atako N, Pugh C, Buckner M, Chowdhury S, Malik Z, Russell JM, Gilson C, Rush H, Bowen J, Lydon A, Pedley I, O'Sullivan JM, Birtle A, Gale J, Srihari N, Thomas C, Tanguay J, Wagstaff J, Das P, Gray E, Alzoueb M, Parikh O, Robinson A, Syndikus I, Wylie J, Zarkar A, Thalmann G, de Bono JS, Dearnaley DP, Mason MD, Gilbert D, Langley RE, Millman R, Matheson D, Sydes MR, Brown LC, Parmar MKB, James ND. Abiraterone acetate and prednisolone with or without enzalutamide for high-risk non-metastatic prostate cancer: a meta-analysis of primary results from two randomised controlled phase 3 trials of the STAMPEDE platform protocol. Lancet 2022; 399:447-460. [PMID: 34953525 PMCID: PMC8811484 DOI: 10.1016/s0140-6736(21)02437-5] [Citation(s) in RCA: 157] [Impact Index Per Article: 78.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Men with high-risk non-metastatic prostate cancer are treated with androgen-deprivation therapy (ADT) for 3 years, often combined with radiotherapy. We analysed new data from two randomised controlled phase 3 trials done in a multiarm, multistage platform protocol to assess the efficacy of adding abiraterone and prednisolone alone or with enzalutamide to ADT in this patient population. METHODS These open-label, phase 3 trials were done at 113 sites in the UK and Switzerland. Eligible patients (no age restrictions) had high-risk (defined as node positive or, if node negative, having at least two of the following: tumour stage T3 or T4, Gleason sum score of 8-10, and prostate-specific antigen [PSA] concentration ≥40 ng/mL) or relapsing with high-risk features (≤12 months of total ADT with an interval of ≥12 months without treatment and PSA concentration ≥4 ng/mL with a doubling time of <6 months, or a PSA concentration ≥20 ng/mL, or nodal relapse) non-metastatic prostate cancer, and a WHO performance status of 0-2. Local radiotherapy (as per local guidelines, 74 Gy in 37 fractions to the prostate and seminal vesicles or the equivalent using hypofractionated schedules) was mandated for node negative and encouraged for node positive disease. In both trials, patients were randomly assigned (1:1), by use of a computerised algorithm, to ADT alone (control group), which could include surgery and luteinising-hormone-releasing hormone agonists and antagonists, or with oral abiraterone acetate (1000 mg daily) and oral prednisolone (5 mg daily; combination-therapy group). In the second trial with no overlapping controls, the combination-therapy group also received enzalutamide (160 mg daily orally). ADT was given for 3 years and combination therapy for 2 years, except if local radiotherapy was omitted when treatment could be delivered until progression. In this primary analysis, we used meta-analysis methods to pool events from both trials. The primary endpoint of this meta-analysis was metastasis-free survival. Secondary endpoints were overall survival, prostate cancer-specific survival, biochemical failure-free survival, progression-free survival, and toxicity and adverse events. For 90% power and a one-sided type 1 error rate set to 1·25% to detect a target hazard ratio for improvement in metastasis-free survival of 0·75, approximately 315 metastasis-free survival events in the control groups was required. Efficacy was assessed in the intention-to-treat population and safety according to the treatment started within randomised allocation. STAMPEDE is registered with ClinicalTrials.gov, NCT00268476, and with the ISRCTN registry, ISRCTN78818544. FINDINGS Between Nov 15, 2011, and March 31, 2016, 1974 patients were randomly assigned to treatment. The first trial allocated 455 to the control group and 459 to combination therapy, and the second trial, which included enzalutamide, allocated 533 to the control group and 527 to combination therapy. Median age across all groups was 68 years (IQR 63-73) and median PSA 34 ng/ml (14·7-47); 774 (39%) of 1974 patients were node positive, and 1684 (85%) were planned to receive radiotherapy. With median follow-up of 72 months (60-84), there were 180 metastasis-free survival events in the combination-therapy groups and 306 in the control groups. Metastasis-free survival was significantly longer in the combination-therapy groups (median not reached, IQR not evaluable [NE]-NE) than in the control groups (not reached, 97-NE; hazard ratio [HR] 0·53, 95% CI 0·44-0·64, p<0·0001). 6-year metastasis-free survival was 82% (95% CI 79-85) in the combination-therapy group and 69% (66-72) in the control group. There was no evidence of a difference in metatasis-free survival when enzalutamide and abiraterone acetate were administered concurrently compared with abiraterone acetate alone (interaction HR 1·02, 0·70-1·50, p=0·91) and no evidence of between-trial heterogeneity (I2 p=0·90). Overall survival (median not reached [IQR NE-NE] in the combination-therapy groups vs not reached [103-NE] in the control groups; HR 0·60, 95% CI 0·48-0·73, p<0·0001), prostate cancer-specific survival (not reached [NE-NE] vs not reached [NE-NE]; 0·49, 0·37-0·65, p<0·0001), biochemical failure-free-survival (not reached [NE-NE] vs 86 months [83-NE]; 0·39, 0·33-0·47, p<0·0001), and progression-free-survival (not reached [NE-NE] vs not reached [103-NE]; 0·44, 0·36-0·54, p<0·0001) were also significantly longer in the combination-therapy groups than in the control groups. Adverse events grade 3 or higher during the first 24 months were, respectively, reported in 169 (37%) of 451 patients and 130 (29%) of 455 patients in the combination-therapy and control groups of the abiraterone trial, respectively, and 298 (58%) of 513 patients and 172 (32%) of 533 patients of the combination-therapy and control groups of the abiraterone and enzalutamide trial, respectively. The two most common events more frequent in the combination-therapy groups were hypertension (abiraterone trial: 23 (5%) in the combination-therapy group and six (1%) in control group; abiraterone and enzalutamide trial: 73 (14%) and eight (2%), respectively) and alanine transaminitis (abiraterone trial: 25 (6%) in the combination-therapy group and one (<1%) in control group; abiraterone and enzalutamide trial: 69 (13%) and four (1%), respectively). Seven grade 5 adverse events were reported: none in the control groups, three in the abiraterone acetate and prednisolone group (one event each of rectal adenocarcinoma, pulmonary haemorrhage, and a respiratory disorder), and four in the abiraterone acetate and prednisolone with enzalutamide group (two events each of septic shock and sudden death). INTERPRETATION Among men with high-risk non-metastatic prostate cancer, combination therapy is associated with significantly higher rates of metastasis-free survival compared with ADT alone. Abiraterone acetate with prednisolone should be considered a new standard treatment for this population. FUNDING Cancer Research UK, UK Medical Research Council, Swiss Group for Clinical Cancer Research, Janssen, and Astellas.
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Affiliation(s)
- Gerhardt Attard
- Cancer Institute, University College London, London, UK; University College London Hospitals, London, UK.
| | - Laura Murphy
- MRC Clinical Trials Unit at University College London, London, UK
| | - Noel W Clarke
- The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | | | | | | | - Silke Gillessen
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Universita della Svizzera Italiana, Lugano, Switzerland
| | - Adrian Cook
- MRC Clinical Trials Unit at University College London, London, UK
| | - Chris Brawley
- MRC Clinical Trials Unit at University College London, London, UK
| | - Claire L Amos
- MRC Clinical Trials Unit at University College London, London, UK
| | - Nafisah Atako
- MRC Clinical Trials Unit at University College London, London, UK
| | - Cheryl Pugh
- MRC Clinical Trials Unit at University College London, London, UK
| | - Michelle Buckner
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Zafar Malik
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | | | - Clare Gilson
- MRC Clinical Trials Unit at University College London, London, UK
| | - Hannah Rush
- MRC Clinical Trials Unit at University College London, London, UK
| | - Jo Bowen
- Cheltenham General Hospital, Cheltenham, UK
| | - Anna Lydon
- Torbay and South Devon NHS Foundation Trust, Torbay, UK
| | - Ian Pedley
- Northern Centre for Cancer Care, Newcastle upon Tyne, UK
| | | | | | | | | | | | | | | | | | - Emma Gray
- Yeovil District Hospital NHS Foundation Trust, Yeovil, UK; Musgrove Park Hospital, Taunton, UK
| | | | - Omi Parikh
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | | | - Isabel Syndikus
- Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | - James Wylie
- The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Anjali Zarkar
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Johann S de Bono
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - David P Dearnaley
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | | | - Duncan Gilbert
- MRC Clinical Trials Unit at University College London, London, UK
| | - Ruth E Langley
- MRC Clinical Trials Unit at University College London, London, UK
| | - Robin Millman
- MRC Clinical Trials Unit at University College London, London, UK
| | - David Matheson
- Faculty of Education Health and Wellbeing, University of Wolverhampton, Walsall, UK
| | - Matthew R Sydes
- MRC Clinical Trials Unit at University College London, London, UK
| | - Louise C Brown
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Nicholas D James
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
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Best J, Starkey T, Chatterjee A, Fackrell D, Pettit L, Srihari N, Tween H, Olsson-Brown A, Cheng V, Hughes DJ, Lee AJX, Purshouse K, Arnold R, Uk Coronavirus Cancer Monitoring Project Team, Sivakumar S, Cazier JB, Lee LYW. Coronavirus Disease 2019: the Pivotal Role of UK Clinical Oncology and the UK Coronavirus Cancer Monitoring Project. Clin Oncol (R Coll Radiol) 2021; 33:e50-e53. [PMID: 32593552 PMCID: PMC7274595 DOI: 10.1016/j.clon.2020.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/20/2020] [Accepted: 05/28/2020] [Indexed: 01/08/2023]
Affiliation(s)
- J Best
- Shrewsbury and Telford Hospital NHS Trust, Royal Shrewsbury Hospital, Shrewsbury, UK
| | - T Starkey
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - A Chatterjee
- Shrewsbury and Telford Hospital NHS Trust, Royal Shrewsbury Hospital, Shrewsbury, UK
| | - D Fackrell
- Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - L Pettit
- Shrewsbury and Telford Hospital NHS Trust, Royal Shrewsbury Hospital, Shrewsbury, UK
| | - N Srihari
- Shrewsbury and Telford Hospital NHS Trust, Royal Shrewsbury Hospital, Shrewsbury, UK
| | - H Tween
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | | | - V Cheng
- Leeds Cancer Centre, Bexley Wing, St James's University Hospital, Leeds, UK
| | - D J Hughes
- Department of Cancer Imaging, Division of Cancer Studies, Guy's Campus, King's College London, London, UK
| | - A J X Lee
- University College London, UCL Cancer Institute, London, UK
| | - K Purshouse
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - R Arnold
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | | | - S Sivakumar
- Department of Oncology, University of Oxford, Oxford, UK
| | - J-B Cazier
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK; Centre for Computational Biology, University of Birmingham, Birmingham, UK
| | - L Y W Lee
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK.
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Procopio G, Bamias A, Schmidinger M, Hawkins R, Sánchez AR, Estevez SV, Srihari N, Kalofonos H, Bono P, Pisal CB, Hirschberg Y, Dezzani L, Ahmad Q, Rodriguez CS, Jonasch E. Real-world Effectiveness and Safety of Pazopanib in Patients With Intermediate Prognostic Risk Advanced Renal Cell Carcinoma. Clin Genitourin Cancer 2020; 17:e526-e533. [PMID: 31196680 DOI: 10.1016/j.clgc.2019.01.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/18/2019] [Accepted: 01/29/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The objective of this study was to determine the effectiveness and safety of pazopanib in patients with intermediate-risk advanced/metastatic renal cell carcinoma in the PRINCIPAL study (NCT01649778). PATIENTS AND METHODS Patients had clear-cell advanced/metastatic renal cell carcinoma and met intermediate-risk International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) and Memorial Sloan Kettering Cancer Center (MSKCC) criteria. Assessments included progression-free survival, overall survival, objective response rate, and safety. We also evaluated effectiveness based on number of risk factors, age, and performance status (PS), as well as safety in older and younger patients. RESULTS Three hundred sixty three and 343 intermediate-risk MSKCC and IMDC patients were included, respectively. The median progression-free survival was 13.8 months (95% confidence interval [CI], 10.7-18.1 months) and 7.4 months (95% CI, 6.2-10.3 months) for patients with 1 and 2 MSKCC risk factors, respectively, and 13.1 months (95% CI, 10.7-18.1 months) and 8.1 months (95% CI, 6.4-10.7 months) for patients with 1 and 2 IMDC risk factors, respectively. The median overall survival was not reached and was 15.2 months (95% CI, 12.3-26.5 months) for patients with 1 and 2 MSKCC risk factors, respectively, and 33.9 months (95% CI, 33.9 months to not estimable) and 19.4 months (95% CI, 14.3 months to not estimable) with 1 and 2 IMDC risk factors, respectively. A lower overall response rate was observed with Eastern Cooperative Oncology Group PS ≥ 2 (vs. PS < 2). All-grade treatment-related adverse events occurred in approximately 63% of patients, and the safety profile among older and younger patients was similar. CONCLUSIONS Outcomes with pazopanib in intermediate-risk patients suggest that patients can be further stratified by number of risk factors (1 vs. 2) and Eastern Cooperative Oncology Group PS (< 2 vs. ≥ 2) to more accurately predict outcomes.
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Affiliation(s)
- Giuseppe Procopio
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Aristotelis Bamias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Alexandra Hospital, Athens, Greece
| | | | - Robert Hawkins
- The Christie NHS Foundation Trust, Christie CRC Research Centre, Manchester, UK
| | | | | | - Narayanan Srihari
- Department of Oncology, Shrewsbury & Telford Hospitals NHS Trust, Shrewsbury, UK
| | - Haralabos Kalofonos
- Division of Oncology, Department of Medicine, University of Patras, Panepistimioupoli Patron, Patra, Greece
| | - Petri Bono
- Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland
| | - Chaitali Babanrao Pisal
- Novartis Healthcare Private Limited, Salarpuria-Sattva Knowledge City, Raidurg, Hyderabad, India
| | | | - Luca Dezzani
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - Qasim Ahmad
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - Cristina Suárez Rodriguez
- Department of Oncology, Vall d'Hebron University Hospital and Institute of Oncology, Universitat Autònoma de Barcelona, Centro Cellex, Barcelona, Spain
| | - Eric Jonasch
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Schmidinger M, Bamias A, Procopio G, Hawkins R, Sanchez AR, Vázquez S, Srihari N, Kalofonos H, Bono P, Pisal CB, Hirschberg Y, Dezzani L, Ahmad Q, Jonasch E. Prospective Observational Study of Pazopanib in Patients with Advanced Renal Cell Carcinoma (PRINCIPAL Study). Oncologist 2019; 24:491-497. [PMID: 30867244 DOI: 10.1634/theoncologist.2018-0787] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 02/04/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Real-world data are essential to accurately assessing efficacy and toxicity of approved agents in everyday practice. PRINCIPAL, a prospective, observational study, was designed to confirm the real-world safety and efficacy of pazopanib in patients with advanced renal cell carcinoma (RCC). SUBJECTS, MATERIALS, AND METHODS Patients with clear cell advanced/metastatic RCC and a clinical decision to initiate pazopanib treatment within 30 days of enrollment were eligible. Primary objectives included progression-free survival (PFS), overall survival (OS), objective response rate (ORR), relative dose intensity (RDI) and its effect on treatment outcomes, change in health-related quality of life (HRQoL), and safety. We also compared characteristics and outcomes of clinical-trial-eligible (CTE) patients, defined using COMPARZ trial eligibility criteria, with those of non-clinical-trial-eligible (NCTE) patients. Secondary study objectives were to evaluate clinical efficacy, safety, and RDI in patient subgroups. RESULTS Six hundred fifty-seven patients were enrolled and received ≥1 dose of pazopanib. Median PFS and OS were 10.3 months (95% confidence interval [CI], 9.2-12.0) and 29.9 months (95% CI, 24.7 to not reached), respectively, and the ORR was 30.3%. HRQoL showed no or little deterioration over time. Treatment-related serious adverse events (AEs) and AEs of special interest occurred in 64 (9.7%), and 399 (60.7%) patients, respectively. More patients were classified NCTE than CTE (85.2% vs. 14.8%). Efficacy of pazopanib was similar between the two groups. CONCLUSION PRINCIPAL confirms the efficacy and safety of pazopanib in patients with advanced/metastatic RCC in a real-world clinical setting. IMPLICATIONS FOR PRACTICE PRINCIPAL is the largest (n = 657) prospective, observational study of pazopanib in patients with advanced/metastatic renal cell carcinoma, to the authors' knowledge. Consistent with clinical trial results that often contain specific patient types, the PRINCIPAL study demonstrated that the effectiveness and safety of pazopanib is similarly safe and effective in patients with advanced kidney cancer in a real-world clinical setting. The PRINCIPAL study showed that patients with advanced kidney cancer who are treated with first-line pazopanib generally do not show disease progression for approximately 10 months and generally survive for nearly 30 months.
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Affiliation(s)
| | - Aristotelis Bamias
- National and Kapodistrian University of Athens Alexandra Hospital, Athens, Greece
| | | | - Robert Hawkins
- The Christie Hospital and University of Manchester, Manchester, United Kingdom
| | | | | | - Narayanan Srihari
- Shrewsbury & Telford Hospitals NHS Trust, Shrewsbury, United Kingdom
| | | | - Petri Bono
- Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Yulia Hirschberg
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Luca Dezzani
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Qasim Ahmad
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Eric Jonasch
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Procopio G, Bamias A, Schmidinger M, Hawkins R, Rodriguez Sanchez A, Vazquez S, Srihari N, Kalofonos H, Bono P, Pisal C, Hirschberg Y, Dezzani L, Ahmad Q, Suarez Rodriguez C, Jonasch E. Real-world effectiveness of pazopanib in patients with intermediate prognostic risk advanced renal cell carcinoma (PRINCIPAL study). Ann Oncol 2018. [DOI: 10.1093/annonc/mdy283.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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10
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Jonasch E, Procopio G, Hawkins RE, Rodriguez Sanchez A, Vazquez S, Srihari N, Kalofonos H, Bamias A, Bono P, Babanrao Pisal C, Hirschberg Y, Dezzani L, Ahmad QI, Schmidinger M. Comparison of clinical outcomes with first-line pazopanib in clinical trial eligible and non-clinical trial eligible patients with renal cell carcinoma. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.4561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Eric Jonasch
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Robert E. Hawkins
- The Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
| | | | | | | | | | | | - Petri Bono
- Comprehensive Cancer Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland., Helsinki, Finland
| | | | | | - Luca Dezzani
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
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Schmidinger M, Procopio G, Hawkins RE, Rodriguez Sanchez A, Vazquez S, Srihari N, Kalofonos H, Bamias A, Bono P, Babanrao Pisal C, Hirschberg Y, Dezzani L, Ahmad QI, Jonasch E. Prospective, multinational, observational study of real-world treatment outcomes with pazopanib in patients with advanced or metastatic renal cell carcinoma (PRINCIPAL study). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.4574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Robert E. Hawkins
- The Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
| | | | | | | | | | | | - Petri Bono
- Comprehensive Cancer Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland., Helsinki, Finland
| | | | | | - Luca Dezzani
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | | | - Eric Jonasch
- The University of Texas MD Anderson Cancer Center, Houston, TX
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12
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Sydes MR, Spears MR, Mason MD, Clarke NW, Dearnaley DP, de Bono JS, Attard G, Chowdhury S, Cross W, Gillessen S, Malik ZI, Jones R, Parker CC, Ritchie AWS, Russell JM, Millman R, Matheson D, Amos C, Gilson C, Birtle A, Brock S, Capaldi L, Chakraborti P, Choudhury A, Evans L, Ford D, Gale J, Gibbs S, Gilbert DC, Hughes R, McLaren D, Lester JF, Nikapota A, O'Sullivan J, Parikh O, Peedell C, Protheroe A, Rudman SM, Shaffer R, Sheehan D, Simms M, Srihari N, Strebel R, Sundar S, Tolan S, Tsang D, Varughese M, Wagstaff J, Parmar MKB, James ND. Adding abiraterone or docetaxel to long-term hormone therapy for prostate cancer: directly randomised data from the STAMPEDE multi-arm, multi-stage platform protocol. Ann Oncol 2018; 29:1235-1248. [PMID: 29529169 PMCID: PMC5961425 DOI: 10.1093/annonc/mdy072] [Citation(s) in RCA: 175] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Adding abiraterone acetate with prednisolone (AAP) or docetaxel with prednisolone (DocP) to standard-of-care (SOC) each improved survival in systemic therapy for advanced or metastatic prostate cancer: evaluation of drug efficacy: a multi-arm multi-stage platform randomised controlled protocol recruiting patients with high-risk locally advanced or metastatic PCa starting long-term androgen deprivation therapy (ADT). The protocol provides the only direct, randomised comparative data of SOC + AAP versus SOC + DocP. Method Recruitment to SOC + DocP and SOC + AAP overlapped November 2011 to March 2013. SOC was long-term ADT or, for most non-metastatic cases, ADT for ≥2 years and RT to the primary tumour. Stratified randomisation allocated pts 2 : 1 : 2 to SOC; SOC + docetaxel 75 mg/m2 3-weekly×6 + prednisolone 10 mg daily; or SOC + abiraterone acetate 1000 mg + prednisolone 5 mg daily. AAP duration depended on stage and intent to give radical RT. The primary outcome measure was death from any cause. Analyses used Cox proportional hazards and flexible parametric models, adjusted for stratification factors. This was not a formally powered comparison. A hazard ratio (HR) <1 favours SOC + AAP, and HR > 1 favours SOC + DocP. Results A total of 566 consenting patients were contemporaneously randomised: 189 SOC + DocP and 377 SOC + AAP. The patients, balanced by allocated treatment were: 342 (60%) M1; 429 (76%) Gleason 8-10; 449 (79%) WHO performance status 0; median age 66 years and median PSA 56 ng/ml. With median follow-up 4 years, 149 deaths were reported. For overall survival, HR = 1.16 (95% CI 0.82-1.65); failure-free survival HR = 0.51 (95% CI 0.39-0.67); progression-free survival HR = 0.65 (95% CI 0.48-0.88); metastasis-free survival HR = 0.77 (95% CI 0.57-1.03); prostate cancer-specific survival HR = 1.02 (0.70-1.49); and symptomatic skeletal events HR = 0.83 (95% CI 0.55-1.25). In the safety population, the proportion reporting ≥1 grade 3, 4 or 5 adverse events ever was 36%, 13% and 1% SOC + DocP, and 40%, 7% and 1% SOC + AAP; prevalence 11% at 1 and 2 years on both arms. Relapse treatment patterns varied by arm. Conclusions This direct, randomised comparative analysis of two new treatment standards for hormone-naïve prostate cancer showed no evidence of a difference in overall or prostate cancer-specific survival, nor in other important outcomes such as symptomatic skeletal events. Worst toxicity grade over entire time on trial was similar but comprised different toxicities in line with the known properties of the drugs. Trial registration Clinicaltrials.gov: NCT00268476.
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Affiliation(s)
- M R Sydes
- MRC Clinical Trials Unit at UCL, London.
| | | | | | - N W Clarke
- Christie and Royal Salford Hospital, Manchester
| | | | | | - G Attard
- UCL Cancer Institute, University College London, London
| | - S Chowdhury
- Guy's & St Thomas NHS, Foundation Trust, London
| | - W Cross
- St James University Hospital, Leeds, UK
| | - S Gillessen
- Division of Oncology and Hematology, Kantonsspital St. Gallen, St. Gallen; University of Bern, Bern; Swiss Group for Cancer Clinical Research (SAKK), Bern, Switzerland
| | - Z I Malik
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - R Jones
- Institute of Cancer Sciences, University of Glasgow, Glasgow; Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow
| | - C C Parker
- Institute of Cancer Research, Sutton; Royal Marsden Hospital, Sutton
| | | | - J M Russell
- Institute of Cancer Sciences, University of Glasgow, Glasgow; Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow
| | - R Millman
- MRC Clinical Trials Unit at UCL, London
| | - D Matheson
- Faculty of Education, Health and Wellbeing, University of Wolverhampton, Wolverhampton
| | - C Amos
- MRC Clinical Trials Unit at UCL, London
| | - C Gilson
- MRC Clinical Trials Unit at UCL, London
| | - A Birtle
- Rosemere Cancer Centre, Royal Preston Hospital, Preston
| | - S Brock
- Dorset Cancer Centre, Poole Hospital, Poole
| | - L Capaldi
- Worcestershire Acute Hospitals NHS Trust, Worcester
| | | | - A Choudhury
- Division of Cancer Sciences, University of Manchester, Manchester; Manchester Academic Health Science Centre, Manchester; Christie Hospital NHS Foundation Trust, Manchester
| | - L Evans
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - D Ford
- City Hospital, Cancer Centre at Queen Elizabeth Hospital, Birmingham
| | - J Gale
- Portsmouth Oncology Centre, Queen Alexandra Hospital, Portsmouth
| | | | - D C Gilbert
- Sussex Cancer Centre, Royal Sussex County Hospital, Brighton
| | - R Hughes
- Mount Vernon Group, Mount Vernon Hospital, Middlesex
| | | | | | | | - J O'Sullivan
- Centre for Cancer Research and Cell Biology, Queens University Belfast, Belfast; Belfast City Hospital, Belfast
| | - O Parikh
- Lancashire Teaching Hospitals NHS Trust, Preston
| | - C Peedell
- Department of Oncology & Radiotherapy, South Tees NHS Trust, Middlesbrough
| | - A Protheroe
- Oxford University Hospitals NHS Foundation Trust
| | - S M Rudman
- Guy's & St Thomas NHS, Foundation Trust, London
| | - R Shaffer
- Department of Oncology, Royal Surrey County Hospital, Guildford
| | - D Sheehan
- Royal Devon and Exeter Hospital, Exeter
| | - M Simms
- Hull & East Yorkshire Hospitals NHS Trust, Hull
| | - N Srihari
- Shrewsbury and Telford Hospitals NHS Trust, Shrewsbury, UK
| | - R Strebel
- Kantonsspital Graubünden, Chur; Swiss Group for Cancer Clinical Research (SAKK), Bern, Switzerland
| | - S Sundar
- Department of Oncology, Nottingham, University Hospitals NHS Trust, Nottingham
| | - S Tolan
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool
| | - D Tsang
- Southend Hospital, Southend-on-Sea
| | - M Varughese
- Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust
| | - J Wagstaff
- Swansea University College of Medicine, Swansea
| | | | - N D James
- Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, UK
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James ND, Sydes MR, Clarke NW, Mason MD, Dearnaley DP, Spears MR, Ritchie AWS, Parker CC, Russell JM, Attard G, de Bono J, Cross W, Jones RJ, Thalmann G, Amos C, Matheson D, Millman R, Alzouebi M, Beesley S, Birtle AJ, Brock S, Cathomas R, Chakraborti P, Chowdhury S, Cook A, Elliott T, Gale J, Gibbs S, Graham JD, Hetherington J, Hughes R, Laing R, McKinna F, McLaren DB, O'Sullivan JM, Parikh O, Peedell C, Protheroe A, Robinson AJ, Srihari N, Srinivasan R, Staffurth J, Sundar S, Tolan S, Tsang D, Wagstaff J, Parmar MKB. Addition of docetaxel, zoledronic acid, or both to first-line long-term hormone therapy in prostate cancer (STAMPEDE): survival results from an adaptive, multiarm, multistage, platform randomised controlled trial. Lancet 2016; 387:1163-77. [PMID: 26719232 PMCID: PMC4800035 DOI: 10.1016/s0140-6736(15)01037-5] [Citation(s) in RCA: 1426] [Impact Index Per Article: 178.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Long-term hormone therapy has been the standard of care for advanced prostate cancer since the 1940s. STAMPEDE is a randomised controlled trial using a multiarm, multistage platform design. It recruits men with high-risk, locally advanced, metastatic or recurrent prostate cancer who are starting first-line long-term hormone therapy. We report primary survival results for three research comparisons testing the addition of zoledronic acid, docetaxel, or their combination to standard of care versus standard of care alone. METHODS Standard of care was hormone therapy for at least 2 years; radiotherapy was encouraged for men with N0M0 disease to November, 2011, then mandated; radiotherapy was optional for men with node-positive non-metastatic (N+M0) disease. Stratified randomisation (via minimisation) allocated men 2:1:1:1 to standard of care only (SOC-only; control), standard of care plus zoledronic acid (SOC + ZA), standard of care plus docetaxel (SOC + Doc), or standard of care with both zoledronic acid and docetaxel (SOC + ZA + Doc). Zoledronic acid (4 mg) was given for six 3-weekly cycles, then 4-weekly until 2 years, and docetaxel (75 mg/m(2)) for six 3-weekly cycles with prednisolone 10 mg daily. There was no blinding to treatment allocation. The primary outcome measure was overall survival. Pairwise comparisons of research versus control had 90% power at 2·5% one-sided α for hazard ratio (HR) 0·75, requiring roughly 400 control arm deaths. Statistical analyses were undertaken with standard log-rank-type methods for time-to-event data, with hazard ratios (HRs) and 95% CIs derived from adjusted Cox models. This trial is registered at ClinicalTrials.gov (NCT00268476) and ControlledTrials.com (ISRCTN78818544). FINDINGS 2962 men were randomly assigned to four groups between Oct 5, 2005, and March 31, 2013. Median age was 65 years (IQR 60-71). 1817 (61%) men had M+ disease, 448 (15%) had N+/X M0, and 697 (24%) had N0M0. 165 (6%) men were previously treated with local therapy, and median prostate-specific antigen was 65 ng/mL (IQR 23-184). Median follow-up was 43 months (IQR 30-60). There were 415 deaths in the control group (347 [84%] prostate cancer). Median overall survival was 71 months (IQR 32 to not reached) for SOC-only, not reached (32 to not reached) for SOC + ZA (HR 0·94, 95% CI 0·79-1·11; p=0·450), 81 months (41 to not reached) for SOC + Doc (0·78, 0·66-0·93; p=0·006), and 76 months (39 to not reached) for SOC + ZA + Doc (0·82, 0·69-0·97; p=0·022). There was no evidence of heterogeneity in treatment effect (for any of the treatments) across prespecified subsets. Grade 3-5 adverse events were reported for 399 (32%) patients receiving SOC, 197 (32%) receiving SOC + ZA, 288 (52%) receiving SOC + Doc, and 269 (52%) receiving SOC + ZA + Doc. INTERPRETATION Zoledronic acid showed no evidence of survival improvement and should not be part of standard of care for this population. Docetaxel chemotherapy, given at the time of long-term hormone therapy initiation, showed evidence of improved survival accompanied by an increase in adverse events. Docetaxel treatment should become part of standard of care for adequately fit men commencing long-term hormone therapy. FUNDING Cancer Research UK, Medical Research Council, Novartis, Sanofi-Aventis, Pfizer, Janssen, Astellas, NIHR Clinical Research Network, Swiss Group for Clinical Cancer Research.
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Affiliation(s)
- Nicholas D James
- Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, The Medical School, University of Birmingham, Birmingham, UK
| | | | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Malcolm D Mason
- Cardiff University School of Medicine, Velindre Hospital, Cardiff, UK
| | - David P Dearnaley
- The Institute of Cancer Research & Royal Marsden NHS Foundation Trust, London, UK
| | | | | | - Christopher C Parker
- The Institute of Cancer Research & Royal Marsden NHS Foundation Trust, London, UK
| | - J Martin Russell
- Institute of Cancer Sciences, University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Gerhardt Attard
- The Institute of Cancer Research & Royal Marsden NHS Foundation Trust, London, UK
| | - Johann de Bono
- The Institute of Cancer Research & Royal Marsden NHS Foundation Trust, London, UK
| | - William Cross
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds
| | - Rob J Jones
- Institute of Cancer Sciences, University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - George Thalmann
- Department of Urology, University Hospital, Bern, Switzerland
| | | | - David Matheson
- Patient rep, MRC Clinical Trials Unit at UCL, London, UK
| | - Robin Millman
- Patient rep, MRC Clinical Trials Unit at UCL, London, UK
| | - Mymoona Alzouebi
- Department of Oncology, Weston Park Hospital, Sheffield & Doncaster, UK
| | | | - Alison J Birtle
- Department of Oncology, Rosemere Cancer Centre, Royal Preston Hospital, Preston, UK
| | - Susannah Brock
- Department of Oncology, Poole Hospital NHS Foundation Trust and Royal Bournemouth Hospital NHS Foundation Trust, Chur, Switzerland
| | | | - Prabir Chakraborti
- Department of Oncology, Derby Hospitals NHS Foundation Trust, Royal Derby Hospital, Derby, UK
| | | | - Audrey Cook
- Department of Oncology, Cheltenham General Hospital & Hereford County Hospital, UK
| | - Tony Elliott
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Joanna Gale
- Oncology and Haematology Clinical Trials Unit, Queen Alexandra Hospital, Portsmouth, UK
| | | | | | - John Hetherington
- Department of Urology, Hull & East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Robert Hughes
- Mount Vernon Group, Mount Vernon Hospital, Middlesex, UK
| | - Robert Laing
- Department of Oncology, Royal Surrey County Hospital, Guildford, UK
| | - Fiona McKinna
- Department of Oncology, East Sussex Hospitals Trust, East Sussex, UK
| | | | - Joe M O'Sullivan
- Centre for Cancer Research and Cell Biology, Queens University Belfast/Belfast City Hospital, Belfast, UK
| | - Omi Parikh
- Department of Oncology, East Lancashire Hospitals NHS Trust, East Lancashire, UK
| | - Clive Peedell
- Department of Oncology & Radiotherapy, South Tees NHS Trust, Middlesbrough, UK
| | | | | | - Narayanan Srihari
- Department of Oncology, Shrewsbury & Telford Hospitals NHS Trust, Shrewsbury, UK
| | - Rajaguru Srinivasan
- Department of Oncology, Royal Devon & Exeter Hospital, Exeter, UK/Torbay Hospital, Torquay, UK
| | - John Staffurth
- Cardiff University School of Medicine, Velindre Hospital, Cardiff, UK
| | - Santhanam Sundar
- Department of Oncology, Nottingham University Hospitals NHS trust, Nottingham, UK
| | - Shaun Tolan
- Department of Oncology & Radiotherapy, Clatterbridge Cancer Centre, Wirral, UK
| | - David Tsang
- Department of Oncology, Southend & Basildon Hospitals, Essex, UK
| | - John Wagstaff
- The South West Wales Cancer Institute and Swansea University College of Medicine, Swansea, UK
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James ND, Spears MR, Clarke NW, Dearnaley DP, Mason MD, Parker CC, Ritchie AWS, Russell JM, Schiavone F, Attard G, de Bono JS, Birtle A, Engeler DS, Elliott T, Matheson D, O'Sullivan J, Pudney D, Srihari N, Wallace J, Barber J, Syndikus I, Parmar MKB, Sydes MR. Failure-Free Survival and Radiotherapy in Patients With Newly Diagnosed Nonmetastatic Prostate Cancer: Data From Patients in the Control Arm of the STAMPEDE Trial. JAMA Oncol 2016; 2:348-57. [PMID: 26606329 PMCID: PMC4789485 DOI: 10.1001/jamaoncol.2015.4350] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The natural history of patients with newly diagnosed high-risk nonmetastatic (M0) prostate cancer receiving hormone therapy (HT) either alone or with standard-of-care radiotherapy (RT) is not well documented. Furthermore, no clinical trial has assessed the role of RT in patients with node-positive (N+) M0 disease. The STAMPEDE Trial includes such individuals, allowing an exploratory multivariate analysis of the impact of radical RT. OBJECTIVE To describe survival and the impact on failure-free survival of RT by nodal involvement in these patients. DESIGN, SETTING, AND PARTICIPANTS Cohort study using data collected for patients allocated to the control arm (standard-of-care only) of the STAMPEDE Trial between October 5, 2005, and May 1, 2014. Outcomes are presented as hazard ratios (HRs) with 95% CIs derived from adjusted Cox models; survival estimates are reported at 2 and 5 years. Participants were high-risk, hormone-naive patients with newly diagnosed M0 prostate cancer starting long-term HT for the first time. Radiotherapy is encouraged in this group, but mandated for patients with node-negative (N0) M0 disease only since November 2011. EXPOSURES Long-term HT either alone or with RT, as per local standard. Planned RT use was recorded at entry. MAIN OUTCOMES AND MEASURES Failure-free survival (FFS) and overall survival. RESULTS A total of 721 men with newly diagnosed M0 disease were included: median age at entry, 66 (interquartile range [IQR], 61-72) years, median (IQR) prostate-specific antigen level of 43 (18-88) ng/mL. There were 40 deaths (31 owing to prostate cancer) with 17 months' median follow-up. Two-year survival was 96% (95% CI, 93%-97%) and 2-year FFS, 77% (95% CI, 73%-81%). Median (IQR) FFS was 63 (26 to not reached) months. Time to FFS was worse in patients with N+ disease (HR, 2.02 [95% CI, 1.46-2.81]) than in those with N0 disease. Failure-free survival outcomes favored planned use of RT for patients with both N0M0 (HR, 0.33 [95% CI, 0.18-0.61]) and N+M0 disease (HR, 0.48 [95% CI, 0.29-0.79]). CONCLUSIONS AND RELEVANCE Survival for men entering the cohort with high-risk M0 disease was higher than anticipated at study inception. These nonrandomized data were consistent with previous trials that support routine use of RT with HT in patients with N0M0 disease. Additionally, the data suggest that the benefits of RT extend to men with N+M0 disease. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00268476; ISRCTN78818544.
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Affiliation(s)
- Nicholas D James
- Warwick Medical School, University of Warwick, Coventry, United Kingdom2University Hospitals Birmingham NHS Foundation Trust, The Medical School, University of Birmingham, Birmingham, United Kingdom
| | - Melissa R Spears
- Medical Research Council Clinical Trials Unit, University College, London, United Kingdom
| | - Noel W Clarke
- Department of Urology, Christie NHS Foundation Trust, Manchester, United Kingdom
| | - David P Dearnaley
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | - Christopher C Parker
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alastair W S Ritchie
- Medical Research Council Clinical Trials Unit, University College, London, United Kingdom
| | - J Martin Russell
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Francesca Schiavone
- Medical Research Council Clinical Trials Unit, University College, London, United Kingdom
| | - Gerhardt Attard
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Johann S de Bono
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | | | | | - Tony Elliott
- Greater Manchester Group, Manchester, United Kingdom
| | | | | | | | | | - Jan Wallace
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Jim Barber
- Velindre Hospital, Cardiff, United Kingdom
| | | | - Mahesh K B Parmar
- Medical Research Council Clinical Trials Unit, University College, London, United Kingdom
| | - Matthew R Sydes
- Medical Research Council Clinical Trials Unit, University College, London, United Kingdom
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Bamias A, Bono P, Procopio G, Herrmann E, Vazquez-Estevez S, Rodriguez Sanchez A, Srihari N, Schrijvers DL, Hawkins RE, Vogelzang NJ, Sapunar FJ, Kothari D, Khan S, Mehmud F, Jonasch E, Schmidinger M. Principal: A prospective observational study of real-world treatment patterns and treatment outcomes in patients with advanced or metastatic renal cell carcinoma (mRCC) receiving pazopanib. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.tps4600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Petri Bono
- Helsinki University Hospital, Helsinki, Finland
| | - Giuseppe Procopio
- Oncology Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | | | | | | | | | - Robert E. Hawkins
- School of Cancer and Imaging Sciences, Faculty of Medical & Human Sciences, University of Manchester, Manchester, United Kingdom
| | | | | | | | - Sadya Khan
- GlaxoSmithKline, Uxbridge, United Kingdom
| | | | - Eric Jonasch
- The University of Texas MD Anderson Cancer Center, Houston, TX
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James ND, Sydes MR, Mason MD, Clarke NW, Anderson J, Dearnaley DP, Dwyer J, Jovic G, Ritchie AWS, Russell JM, Sanders K, Thalmann GN, Bertelli G, Birtle AJ, O'Sullivan JM, Protheroe A, Sheehan D, Srihari N, Parmar MKB. Celecoxib plus hormone therapy versus hormone therapy alone for hormone-sensitive prostate cancer: first results from the STAMPEDE multiarm, multistage, randomised controlled trial. Lancet Oncol 2012; 13:549-58. [PMID: 22452894 PMCID: PMC3398767 DOI: 10.1016/s1470-2045(12)70088-8] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background Long-term hormone therapy alone is standard care for metastatic or high-risk, non-metastatic prostate cancer. STAMPEDE—an international, open-label, randomised controlled trial—uses a novel multiarm, multistage design to assess whether the early additional use of one or two drugs (docetaxel, zoledronic acid, celecoxib, zoledronic acid and docetaxel, or zoledronic acid and celecoxib) improves survival in men starting first-line, long-term hormone therapy. Here, we report the preplanned, second intermediate analysis comparing hormone therapy plus celecoxib (arm D) with hormone therapy alone (control arm A). Methods Eligible patients were men with newly diagnosed or rapidly relapsing prostate cancer who were starting long-term hormone therapy for the first time. Hormone therapy was given as standard care in all trial arms, with local radiotherapy encouraged for newly diagnosed patients without distant metastasis. Randomisation was done using minimisation with a random element across seven stratification factors. Patients randomly allocated to arm D received celecoxib 400 mg twice daily, given orally, until 1 year or disease progression (including prostate-specific antigen [PSA] failure). The intermediate outcome was failure-free survival (FFS) in three activity stages; the primary outcome was overall survival in a subsequent efficacy stage. Research arms were compared pairwise against the control arm on an intention-to-treat basis. Accrual of further patients was discontinued in any research arm showing safety concerns or insufficient evidence of activity (lack of benefit) compared with the control arm. The minimum targeted activity at the second intermediate activity stage was a hazard ratio (HR) of 0·92. This trial is registered with ClinicalTrials.gov, number NCT00268476, and with Current Controlled Trials, number ISRCTN78818544. Findings 2043 patients were enrolled in the trial from Oct 17, 2005, to Jan 31, 2011, of whom 584 were randomly allocated to receive hormone therapy alone (control group; arm A) and 291 to receive hormone therapy plus celecoxib (arm D). At the preplanned analysis of the second intermediate activity stage, with 305 FFS events (209 in arm A, 96 in arm D), there was no evidence of an advantage for hormone therapy plus celecoxib over hormone therapy alone: HR 0·98 (95% CI 0·90–1·06). 2-year FFS was 51% (95% CI 46–56) in arm A and 51% (95% CI 43–58) in arm D. There was no evidence of differences in the incidence of adverse events between groups (events of grade 3 or higher were noted at any time in 123 [23%, 95% CI 20–27] patients in arm A and 64 [25%, 19–30] in arm D). The most common grade 3–5 events adverse effects in both groups were endocrine disorders (55 [11%] of patients in arm A vs 19 [7%] in arm D) and musculoskeletal disorders (30 [6%] of patients in arm A vs 15 [6%] in arm D). The independent data monitoring committee recommended stopping accrual to both celecoxib-containing arms on grounds of lack of benefit and discontinuing celecoxib for patients currently on treatment, which was endorsed by the trial steering committee. Interpretation Celecoxib 400 mg twice daily for up to 1 year is insufficiently active in patients starting hormone therapy for high-risk prostate cancer, and we do not recommend its use in this setting. Accrual continues seamlessly to the other research arms and follow-up of all arms will continue to assess effects on overall survival. Funding Cancer Research UK, Pfizer, Novartis, Sanofi-Aventis, Medical Research Council (London, UK).
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Affiliation(s)
- Nicholas D James
- School of Cancer Sciences, University of Birmingham, Birmingham, UK
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James ND, Sydes MR, Mason MD, Clarke NW, Anderson J, Dearnaley DP, Dwyer J, Jovic G, Ritchie ASW, Russell JM, Sanders K, Thalmann G, Bertelli G, Birtle AJ, O'Sullivan JM, Protheroe A, Sheehan D, Srihari N, Parmar M. Celecoxib plus hormone therapy versus hormone therapy alone for hormone-sensitive prostate cancer: First results from STAMPEDE (MRC PR08, CRUK/06/019), a randomized controlled trial. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.5_suppl.26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
26 Background: Long-term hormone therapy (HT) alone is standard of care for men with metastatic or high-risk non-metastatic prostate cancer (PCa). STAMPEDE investigates whether early use of additional therapies improves overall survival. It is an international randomised controlled trial ( NCT00268476 ) using novel multi-arm, multi-stage methods to assess adding 1 or 2 of three agents (docetaxel, zoledronic acid (ZA), celecoxib) in 5 research arms in men with PCa starting long-term HT for the first time. Methods: HT was given as per standard care. Celecoxib was planned as 400mg bid until the sooner of 1 year or disease (including PSA) progression. The trial has 3 intermediate activity stages (I-III) where the outcome measure (OM) is failure-free survival (FFS) and 1 final efficacy stage (IV) with overall survival as primary OM. At the end of each stage, research arms are compared pairwise to the control arm. Accrual of further patients is discontinued early for any research arm either showing (a) safety concerns or (b) insufficient evidence of activity (lack-of-benefit) where the treatment effect on FFS is compared against a pre-defined stopping guideline. The interim activity “hurdle” becomes increasingly stringent stage-by-stage. Results: From Oct-2008 to Feb-2011, 2114 patients were consented and randomised, including 875 in this comparison. With 205 control FFS events, there was evidence of insufficient activity for HT+celecoxib over HT-alone: HR 0.98 (95%CI 0.90-1.06). The Independent Data Monitoring Committee recommended stopping accrual to this arm; stopping celecoxib was also recommended for patients currently on treatment. (Accrual was also stopped to HT+celecoxib+ZA but data are not disclosed.) There was no evidence of differences in toxicity: 25% and 23% of patients reporting grade ≥3 toxicities or adverse events with or without celecoxib. Control arm FFS was 51% at 2 years, in line with expectations. Conclusions: Celecoxib shows no evidence of activity in this setting. Accrual continues seamlessly to the other research arms. Follow-up of all arms is ongoing. Support: MRC, Cancer Research UK, Novartis, Sanofi-Aventis, Pfizer.
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Affiliation(s)
- Nicholas David James
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - Matthew Robert Sydes
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - Malcolm David Mason
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - Noel W Clarke
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - John Anderson
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - David Paul Dearnaley
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - John Dwyer
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - Gordana Jovic
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - Alastair SW Ritchie
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - J. Martin Russell
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - Karen Sanders
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - George Thalmann
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - Gianfilippo Bertelli
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - Alison J Birtle
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - Joe M. O'Sullivan
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - Andrew Protheroe
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - Denise Sheehan
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - Narayanan Srihari
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
| | - Mahesh Parmar
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom; MRC Clinical Trials Unit, London, United Kingdom; Cardiff University, Cardiff, United Kingdom; Department of Urology, The Christie NHS Foundation Trust, Manchester, United Kingdom; The Royal Hallamshire Hospital, Sheffield, United Kingdom; Institute of Cancer Research/Royal Marsden Hospital, Sutton, United Kingdom; Prostate Cancer Support Federation, Stockport, United Kingdom; Beatson West of Scotland Cancer Centre, Glasgow,
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Hartley A, Giridharan S, Srihari N, McConkey C, Geh JI. Impaired postoperative neutrophil leucocytosis and acute complications following short course preoperative radiotherapy for operable rectal cancer. Eur J Surg Oncol 2003; 29:155-7. [PMID: 12633558 DOI: 10.1053/ejso.2002.1364] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM Postoperative mortality following total mesorectal excision is increased if this is performed more than 3 days after the completion of short course preoperative radiotherapy. Suppression of neutrophil leucocytosis which is normally seen following surgery has been a suggested reason. This study was to determine the relationship between postoperative complications and perioperative neutrophil counts. METHOD A database of 176 patients treated at a single radiotherapy centre in 1998 and 1999 was used. A two-sample Wilcoxon test was used to compare preoperative neutrophil counts, postoperative neutrophil counts and their ratio in patients with and without complications. RESULTS There was no association between acute complications and preoperative (P = 0.25) or postoperative (P = 0.45) neutrophil count. The post/preoperative ratio was significantly higher in patients without complications (median 1.61 vs 1.16, P = 0.02). CONCLUSIONS There appears to be an inverse relationship between the magnitude of postoperative neutrophil leucocytosis and the risk of acute complications following short course preoperative radiotherapy.
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Affiliation(s)
- A Hartley
- Cancer Centre, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK. agjhartley.fsnet.co.uk
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