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Parker CC, Petersen PM, Cook AD, Clarke NW, Catton C, Cross WR, Kynaston H, Parulekar WR, Persad RA, Saad F, Bower L, Durkan GC, Logue J, Maniatis C, Noor D, Payne H, Anderson J, Bahl AK, Bashir F, Bottomley DM, Brasso K, Capaldi L, Cooke PW, Chung C, Donohue J, Eddy B, Heath CM, Henderson A, Henry A, Jaganathan R, Jakobsen H, James ND, Joseph J, Lees K, Lester J, Lindberg H, Makar A, Morris SL, Oommen N, Ostler P, Owen L, Patel P, Pope A, Popert R, Raman R, Ramani V, Røder A, Sayers I, Simms M, Srinivasan V, Sundaram S, Tarver KL, Tran A, Wells P, Wilson J, Zarkar AM, Parmar MKM, Sydes MR. Timing of Radiotherapy (RT) After Radical Prostatectomy (RP): Long-term outcomes in the RADICALS-RT trial [NCT00541047]. Ann Oncol 2024:S0923-7534(24)00105-4. [PMID: 38583574 DOI: 10.1016/j.annonc.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND The optimal timing of radiotherapy (RT) after radical prostatectomy for prostate cancer has been uncertain. RADICALS-RT compared efficacy and safety of adjuvant RT versus an observation policy with salvage RT for PSA failure. METHODS RADICALS-RT was a randomised controlled trial enrolling patients with ≥1 risk factor (pT3/4, Gleason 7-10, positive margins, pre-op PSA≥10ng/ml) for recurrence after radical prostatectomy. Patients were randomised 1:1 to adjuvant RT ("Adjuvant-RT") or an observation policy with salvage RT for PSA failure ("Salvage-RT") defined as PSA≥0.1ng/ml or 3 consecutive rises. Stratification factors were Gleason score, margin status, planned RT schedule (52.5Gy/20 fractions or 66Gy/33 fractions) and treatment centre. The primary outcome measure was freedom-from-distant metastasis, designed with 80% power to detect an improvement from 90% with Salvage-RT (control) to 95% at 10yr with Adjuvant-RT. Secondary outcome measures were bPFS, freedom-from-non-protocol hormone therapy, safety and patient-reported outcomes. Standard survival analysis methods were used; HR<1 favours Adjuvant-RT. FINDINGS Between Oct-2007 and Dec-2016, 1396 participants from UK, Denmark, Canada and Ireland were randomised: 699 Salvage-RT, 697 Adjuvant-RT. Allocated groups were balanced with median age 65yr. 93% (649/697) Adjuvant-RT reported RT within 6m after randomisation; 39% (270/699) Salvage-RT reported RT during follow-up. Median follow-up was 7.8 years. With 80 distant metastasis events, 10yr FFDM was 93% for Adjuvant-RT and 90% for Salvage-RT: HR=0.68 (95%CI 0·43-1·07, p=0·095). Of 109 deaths, 17 were due to prostate cancer. Overall survival was not improved (HR=0.980, 95%CI 0.667-1.440, p=0.917). Adjuvant-RT reported worse urinary and faecal incontinence one year after randomisation (p=0.001); faecal incontinence remained significant after ten years (p=0.017). INTERPRETATION Long-term results from RADICALS-RT confirm adjuvant RT after radical prostatectomy increases the risk of urinary and bowel morbidity, but does not meaningfully improve disease control. An observation policy with salvage RT for PSA failure should be the current standard after radical prostatectomy.
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Affiliation(s)
- C C Parker
- Institute of Cancer Research, Royal Marsden NHS Foundation Trust, Sutton, UK
| | - P M Petersen
- Dept of Oncology, Copenhagen Prostate Cancer Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - A D Cook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - N W Clarke
- Dept of Urology, The Christie and Salford Royal Hospitals, Manchester, UK; The University of Manchester, Manchester, UK
| | - C Catton
- Dept of Radiation Oncology, Princess Margaret Hospital, University Health Network, Toronto, ON, Canada
| | - W R Cross
- Dept of Urology, St James's University Hospital, Leeds, UK
| | - H Kynaston
- Division of Cancer and Genetics, Cardiff University, Cardiff, UK
| | - W R Parulekar
- Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - R A Persad
- Dept of Urology, Bristol Urological Institute, Bristol, UK
| | - F Saad
- Dept of Urology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - L Bower
- Guy's and St Thomas' NHS Foundation Trust, London, UK; Institute of Cancer Research, Royal Marsden NHS Foundation Trust, London, UK
| | - G C Durkan
- Dept of Urology, University Hospital Galway, Galway, Ireland
| | - J Logue
- Dept of Oncology, The Christie Hospital NHS FT, Wilmslow Road, Manchester, UK
| | - C Maniatis
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - D Noor
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - H Payne
- The Prostate Centre, London, UK
| | - J Anderson
- St James's Institute of Oncology, Leeds, UK
| | - A K Bahl
- Bristol Haematology and Oncology Centre, University Hospitals Bristol & Weston NHS Trust, Bristol, UK
| | - F Bashir
- Queen's Centre for Oncology, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| | | | - K Brasso
- Dept of Urology, Copenhagen Prostate Cancer Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - L Capaldi
- Worcester Oncology Centre, Worcestershire Acute NHS Hospitals Trust, Worcester, UK
| | - P W Cooke
- Dept of Urology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - C Chung
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - J Donohue
- Dept of Urology, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - B Eddy
- East Kent University Hospitals Foundation Trust, Kent, UK
| | - C M Heath
- Dept of Clinical Oncology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - A Henderson
- Dept of Urology, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - A Henry
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - R Jaganathan
- Dept of Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - H Jakobsen
- Dept of Urology, Herlev University Hospital, Herlev, Denmark
| | - N D James
- Institute of Cancer Research, Royal Marsden NHS Foundation Trust, London, UK
| | - J Joseph
- Leeds Teaching Hospitals, UK; York and Scarborough Teaching Hospitals, UK
| | - K Lees
- Dept of Oncology, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - J Lester
- South West Wales Cancer Centre, Singleton Hospital, Swansea, UK
| | - H Lindberg
- Dept of Oncology, Herlev University Hospital, Herlev, Denmark
| | - A Makar
- Dept of Urology, Worcestershire Acute Hospitals Trust, Worcester, UK
| | - S L Morris
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - N Oommen
- Wrexham Maelor Hospital, Wrexham, UK
| | - P Ostler
- Mount Vernon Cancer Centre, Northwood, UK
| | - L Owen
- Bradford Royal Infirmary, Bradford, UK; Leeds Cancer Centre, Leeds, UK
| | - P Patel
- Dept of Urology, University College London Hospitals, London, UK
| | - A Pope
- Mount Vernon Cancer Centre, Northwood, UK
| | - R Popert
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - R Raman
- Kent Oncology Centre, Kent & Canterbury Hospital, Canterbury, UK
| | - V Ramani
- Dept of Urology, The Christie and Salford Royal Hospitals, Manchester, UK
| | - A Røder
- Dept of Urology, Copenhagen Prostate Cancer Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - I Sayers
- Deanesly Centre, New Cross Hospital, Wolverhampton, UK
| | - M Simms
- Dept of Urology, Hull University Hospitals NHS Trust, UK
| | - V Srinivasan
- Glan Clwyd Hospital, Betsi Cadwaladr University Health Board, Rhyl, UK
| | - S Sundaram
- Dept of Urology, Mid Yorkshire Teaching Hospital, Pontefract, UK
| | - K L Tarver
- Dept of Oncology, Queen's Hospital, Romford, UK
| | - A Tran
- Dept of Oncology, The Christie Hospital NHS FT, Wilmslow Road, Manchester, UK
| | - P Wells
- St Bartholomews Hospital, London UK
| | - J Wilson
- Royal Gwent Hospital, Newport, UK
| | - A M Zarkar
- Dept of Oncology, University Hospitals Birmingham, Birmingham, UK
| | - M K M Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - M R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK.
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Saad F, Armstrong AJ, Oya M, Vianna K, Özgüroğlu M, Gedye C, Buchschacher GL, Lee JY, Emmenegger U, Navratil J, Virizuela JA, Salazar A, Maillet D, Uemura H, Kim J, Oscroft E, Barker L, Degboe A, Clarke NW. Tolerability of Olaparib Combined with Abiraterone in Patients with Metastatic Castration-resistant Prostate Cancer: Further Results from the Phase 3 PROpel Trial. Eur Urol Oncol 2024:S2588-9311(24)00082-8. [PMID: 38582650 DOI: 10.1016/j.euo.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/14/2024] [Accepted: 03/11/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND The PROpel study (NCT03732820) demonstrated a statistically significant progression-free survival benefit with olaparib plus abiraterone versus placebo plus abiraterone in the first-line metastatic castration-resistant prostate cancer (mCRPC) setting, irrespective of homologous recombination repair mutation status. OBJECTIVE We report additional safety analyses from PROpel to increase clinical understanding of the adverse-event (AE) profiles of olaparib plus abiraterone versus placebo plus abiraterone. DESIGN, SETTING, AND PARTICIPANTS A randomised (1:1), double-blind, placebo-controlled trial was conducted at 126 centres in 17 countries (October 2018-January 2020). Patients had mCRPC and no prior systemic mCRPC treatment. INTERVENTION Olaparib (300 mg bid) or placebo with abiraterone (1000 mg od) plus prednisone/prednisolone (5 mg bid). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The data cut-off date was July 30, 2021. Safety was assessed by AE reporting (Common Terminology Criteria for Adverse Events v4.03) and analysed descriptively. RESULTS AND LIMITATIONS The most common AEs (all grades) for olaparib plus abiraterone versus placebo plus abiraterone were anaemia (46.0% vs 16.4%), nausea (28.1% vs 12.6%), and fatigue (27.9% vs 18.9%). Grade ≥3 anaemia occurred in 15.1% versus 3.3% of patients in the olaparib plus abiraterone versus placebo plus abiraterone arm. The incidences of the most common AEs for olaparib plus abiraterone peaked early, within 2 mo, and were managed typically by dose modifications or standard medical practice. Overall, 13.8% versus 7.8% of patients discontinued treatment with olaparib plus abiraterone versus placebo plus abiraterone because of an AE; 3.8% versus 0.8% of patients discontinued because of anaemia. More venous thromboembolism events were observed in the olaparib plus abiraterone arm (any grade, 7.3%; grade ≥3, 6.8%) than in the placebo plus abiraterone arm (any grade, 3.3%; grade ≥3, 2.0%), most commonly pulmonary embolism (6.5% vs 1.8% for olaparib plus abiraterone vs placebo plus abiraterone). CONCLUSIONS Olaparib plus abiraterone has a manageable and predictable safety profile. PATIENT SUMMARY The PROpel trial showed that in patients who had not received any previous treatment for metastatic castration-resistant prostate cancer, olaparib combined with abiraterone was more effective in delaying progression of the disease than abiraterone alone. Most side effects caused by combining olaparib with abiraterone could be managed with supportive care methods, by pausing olaparib administration for a short period of time and/or by reducing the dose of olaparib.
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Affiliation(s)
- Fred Saad
- Centre Hospitalier de l'Université de Montréal/CRCHUM, Université de Montréal, Montreal, QC, Canada.
| | - Andrew J Armstrong
- Duke Cancer Institute Center for Prostate and Urologic Cancer, Duke University, Durham, NC, USA
| | | | - Karina Vianna
- Centro Integrado de Oncologia de Curitiba, Curitiba, Brazil
| | - Mustafa Özgüroğlu
- Istanbul University Cerrahpaşa, Faculty of Medicine, Istanbul, Türkiye
| | - Craig Gedye
- Calvary Mater Newcastle, Waratah, NSW, Australia
| | | | - Ji Youl Lee
- The Catholic University of Korea Seoul St Mary's Hospital, Seoul, South Korea
| | | | - Jiri Navratil
- Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | | | | | - Denis Maillet
- Centre Hospitalier Lyon Sud, Pierre-Bénite, France; Faculté de Médecine Jacques Lisfranc, Saint-Etienne, France
| | - Hiroji Uemura
- Yokohama City University Medical Center, Kanagawa, Japan
| | - Jeri Kim
- Merck & Co., Inc., Rahway, NJ, USA
| | | | | | | | - Noel W Clarke
- The Christie and Salford Royal Hospital NHS Foundation Trusts, and University of Manchester, Manchester, UK
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Parry MG, Sujenthiran A, Nossiter J, Morris M, Berry B, Nathan A, Aggarwal A, Payne H, van der Meulen J, Clarke NW. Reply to: Letter to the editor regarding the article 'Prostate cancer outcomes following whole-gland and focal high-intensity focused ultrasound'. BJU Int 2024. [PMID: 38515403 DOI: 10.1111/bju.16348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, The London School of Hygiene and Tropical Medicine (LSHTM), London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Arunan Sujenthiran
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Flatiron, London, UK
| | - Julie Nossiter
- Department of Health Services Research and Policy, The London School of Hygiene and Tropical Medicine (LSHTM), London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Melanie Morris
- Department of Health Services Research and Policy, The London School of Hygiene and Tropical Medicine (LSHTM), London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Brendan Berry
- Department of Health Services Research and Policy, The London School of Hygiene and Tropical Medicine (LSHTM), London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Arjun Nathan
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- University College London, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, The London School of Hygiene and Tropical Medicine (LSHTM), London, UK
- Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, The London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal Hospitals, Manchester, UK
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Gilbert DC, Nankivell M, Rush H, Clarke NW, Mangar S, Al-Hasso A, Rosen S, Kockelbergh R, Sundaram SK, Dixit S, Laniado M, McPhail N, Shaheen A, Brown S, Gale J, Deighan J, Marshall J, Duong T, Macnair A, Griffiths A, Amos CL, Sydes MR, James ND, Parmar MKB, Langley RE. A Repurposing Programme Evaluating Transdermal Oestradiol Patches for the Treatment of Prostate Cancer Within the PATCH and STAMPEDE Trials: Current Results and Adapting Trial Design. Clin Oncol (R Coll Radiol) 2024; 36:e11-e19. [PMID: 37973477 DOI: 10.1016/j.clon.2023.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 07/03/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
AIMS Androgen deprivation therapy (ADT), usually achieved with luteinising hormone releasing hormone analogues (LHRHa), is central to prostate cancer management. LHRHa reduce both testosterone and oestrogen and are associated with significant long-term toxicity. Previous use of oral oestrogens as ADT was curtailed because of cardiovascular toxicity. Transdermal oestrogen (tE2) patches are a potential alternative ADT, supressing testosterone without the associated oestrogen-depletion toxicities (osteoporosis, hot flushes, metabolic abnormalities) and avoiding cardiovascular toxicity, and we here describe their evaluation in men with prostate cancer. MATERIALS AND METHODS The PATCH (NCT00303784) adaptive trials programme (incorporating recruitment through the STAMPEDE [NCT00268476] platform) is evaluating the safety and efficacy of tE2 patches as ADT for men with prostate cancer. An initial randomised (LHRHa versus tE2) phase II study (n = 251) with cardiovascular toxicity as the primary outcome measure has expanded into a phase III evaluation. Those with locally advanced (M0) or metastatic (M1) prostate cancer are eligible. To reflect changes in both management and prognosis, the PATCH programme is now evaluating these cohorts separately. RESULTS Recruitment is complete, with 1362 and 1128 in the M0 and M1 cohorts, respectively. Rates of androgen suppression with tE2 were equivalent to LHRHa, with improved metabolic parameters, quality of life and bone health indices (mean absolute change in lumbar spine bone mineral density of -3.0% for LHRHa and +7.9% for tE2 with an estimated difference between arms of 9.3% (95% confidence interval 5.3-13.4). Importantly, rates of cardiovascular events were not significantly different between the two arms and the time to first cardiovascular event did not differ between treatment groups (hazard ratio 1.11, 95% confidence interval 0.80-1.53; P = 0.54). Oncological outcomes are awaited. FUTURE Efficacy results for the M0 cohort (primary outcome measure metastases-free survival) are expected in the final quarter of 2023. For M1 patients (primary outcome measure - overall survival), analysis using restricted mean survival time is being explored. Allied translational work on longitudinal samples is underway.
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Affiliation(s)
- D C Gilbert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK; University Hospitals Sussex NHS Foundation Trust, Royal Sussex County Hospital, Brighton, UK.
| | - M Nankivell
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - H Rush
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - N W Clarke
- The Christie and Salford Royal Hospitals, Manchester, UK
| | - S Mangar
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - A Al-Hasso
- Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - S Rosen
- National Heart and Lung Institute, Imperial College, London, UK
| | - R Kockelbergh
- Department of Urology, University Hospitals of Leicester, Leicester, UK
| | - S K Sundaram
- Mid-Yorkshire Teaching NHS Trust, Pinderfields Hospital, Wakefield, UK
| | - S Dixit
- Scunthorpe General Hospital, Scunthorpe, UK
| | | | | | | | - S Brown
- Airedale General Hospital, Keighley, UK
| | - J Gale
- Queen Alexandra Hospital, Portsmouth, UK
| | - J Deighan
- Patient Representative, MRC Clinical Trials Unit at UCL, London, UK
| | - J Marshall
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - T Duong
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - A Macnair
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK; Guys and St Thomas' NHS Foundation Trust, London, UK
| | - A Griffiths
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - C L Amos
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - M R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - N D James
- Institute of Cancer Research, Sutton, UK
| | - M K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - R E Langley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
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Saad F, Del Rosario P, Clarke NW. Reply to Lin Ding, Bin Yang, and Xudong Yao's Letter to the Editor re: Fred Saad, Noel W. Clarke, Mototsugu Oya, et al. Olaparib plus Abiraterone Versus Placebo plus Abiraterone in Metastatic Castration-resistant Prostate Cancer (PROpel): Final Prespecified Overall Survival Results of a Randomised, Double-blind, Phase 3 Trial. Lancet Oncol 2023;24:1094-108. Eur Urol 2023:S0302-2838(23)03274-8. [PMID: 38042647 DOI: 10.1016/j.eururo.2023.11.015] [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] [Received: 11/07/2023] [Accepted: 11/15/2023] [Indexed: 12/04/2023]
Affiliation(s)
- Fred Saad
- Centre Hospitalier de l'Université de Montréal, Montreal, Canada.
| | - Paula Del Rosario
- Global Medicines Development, Oncology R&D, AstraZeneca, Cambridge, UK
| | - Noel W Clarke
- The Christie and Salford Royal Hospital NHS Foundation Trusts and University of Manchester, Manchester, UK
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Parry MG, Sujenthiran A, Nossiter J, Morris M, Berry B, Nathan A, Aggarwal A, Payne H, van der Meulen J, Clarke NW. Prostate cancer outcomes following whole-gland and focal high-intensity focused ultrasound. BJU Int 2023; 132:568-574. [PMID: 37422679 DOI: 10.1111/bju.16122] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
OBJECTIVE To report the 5-year failure-free survival (FFS) following high-intensity focused ultrasound (HIFU). PATIENTS AND METHODS This observational cohort study used linked National Cancer Registry data, radiotherapy data, administrative hospital data and mortality records of 1381 men treated with HIFU for clinically localised prostate cancer in England. The primary outcome, FFS, was defined as freedom from local salvage treatment and cancer-specific mortality. Secondary outcomes were freedom from repeat HIFU, prostate cancer-specific survival (CSS) and overall survival (OS). Cox regression was used to determine whether baseline characteristics, including age, treatment year, T stage and International Society of Urological Pathology (ISUP) Grade Group were associated with FFS. RESULTS The median (interquartile range [IQR]) follow-up was 37 (20-62) months. The median (IQR) age was 65 (59-70) years and 81% had an ISUP Grade Group of 1-2. The FFS was 96.5% (95% confidence interval [CI] 95.4%-97.4%) at 1 year, 86.0% (95% CI 83.7%-87.9%) at 3 years and 77.5% (95% CI 74.4%-80.3%) at 5 years. The 5-year FFS for ISUP Grade Groups 1-5 was 82.9%, 76.6%, 72.2%, 52.3% and 30.8%, respectively (P < 0.001). Freedom from repeat HIFU was 79.1% (95% CI 75.7%-82.1%), CSS was 98.8% (95% CI 97.7%-99.4%) and OS was 95.9% (95% CI 94.2%-97.1%) at 5 years. CONCLUSION Four in five men were free from local salvage treatment at 5 years but treatment failure varied significantly according to ISUP Grade Group. Patients should be appropriately informed with respect to salvage radical treatment following HIFU.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
| | - Arunan Sujenthiran
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
- Flatiron, London, UK
| | - Julie Nossiter
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
| | - Melanie Morris
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
| | - Brendan Berry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
| | - Arjun Nathan
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of UK, London, UK
- University College London, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Noel W Clarke
- Departments of Urology, The Christie and Salford Royal Hospitals, Manchester, UK
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Saad F, Clarke NW, Oya M, Shore N, Procopio G, Guedes JD, Arslan C, Mehra N, Parnis F, Brown E, Schlürmann F, Joung JY, Sugimoto M, Sartor O, Liu YZ, Poehlein C, Barker L, Del Rosario PM, Armstrong AJ. Olaparib plus abiraterone versus placebo plus abiraterone in metastatic castration-resistant prostate cancer (PROpel): final prespecified overall survival results of a randomised, double-blind, phase 3 trial. Lancet Oncol 2023; 24:1094-1108. [PMID: 37714168 DOI: 10.1016/s1470-2045(23)00382-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND PROpel met its primary endpoint showing statistically significant improvement in radiographic progression-free survival with olaparib plus abiraterone versus placebo plus abiraterone in patients with first-line metastatic castration-resistant prostate cancer (mCRPC) unselected by homologous recombination repair mutation (HRRm) status, with benefit observed in all prespecified subgroups. Here we report the final prespecified overall survival analysis. METHODS This was a randomised, double-blind, phase 3 trial done at 126 centres in 17 countries worldwide. Patients with mCRPC aged at least 18 years, Eastern Cooperative Oncology Group performance status 0-1, a life expectancy of at least 6 months, with no previous systemic treatment for mCRPC and unselected by HRRm status were randomly assigned (1:1) centrally by means of an interactive voice response system-interactive web response system to abiraterone acetate (orally, 1000 mg once daily) plus prednisone or prednisolone with either olaparib (orally, 300 mg twice daily) or placebo. The patients, the investigator, and study centre staff were masked to drug allocation. Stratification factors were site of metastases and previous docetaxel at metastatic hormone-sensitive cancer stage. Radiographic progression-free survival was the primary endpoint and overall survival was a key secondary endpoint with alpha-control (alpha-threshold at prespecified final analysis: 0·0377 [two-sided]), evaluated in the intention-to-treat population. Safety was evaluated in all patients who received at least one dose of a study drug. This study is registered with ClinicalTrials.gov, NCT03732820, and is completed and no longer recruiting. FINDINGS Between Oct 31, 2018 and March 11, 2020, 1103 patients were screened, of whom 399 were randomly assigned to olaparib plus abiraterone and 397 to placebo plus abiraterone. Median follow-up for overall survival in patients with censored data was 36·6 months (IQR 34·1-40·3) for olaparib plus abiraterone and 36·5 months (33·8-40·3) for placebo plus abiraterone. Median overall survival was 42·1 months (95% CI 38·4-not reached) with olaparib plus abiraterone and 34·7 months (31·0-39·3) with placebo plus abiraterone (hazard ratio 0·81, 95% CI 0·67-1·00; p=0·054). The most common grade 3-4 adverse event was anaemia reported in 64 (16%) of 398 patients in the olaparib plus abiraterone and 13 (3%) of 396 patients in the placebo plus abiraterone group. Serious adverse events were reported in 161 (40%) in the olaparib plus abiraterone group and 126 (32%) in the placebo plus abiraterone group. One death in the placebo plus abiraterone group, from interstitial lung disease, was considered treatment related. INTERPRETATION Overall survival was not significantly different between treatment groups at this final prespecified analysis. FUNDING Supported by AstraZeneca and Merck Sharp & Dohme.
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Affiliation(s)
- Fred Saad
- Centre Hospitalier de l'Université de Montréal, Montreal, Canada.
| | - Noel W Clarke
- The Christie and Salford Royal Hospital NHS Foundation Trusts and University of Manchester, Manchester, UK.
| | | | - Neal Shore
- Carolina Urologic Research Center, Myrtle Beach, SC, USA
| | - Giuseppe Procopio
- Programma Prostata Fondazione Istituto Nazionale Tumori Milano, Milan, Italy
| | - João Daniel Guedes
- Hospital de Base de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Cagatay Arslan
- Izmir Economy University Medical Point Hospital, Karsiyaka, Izmir, Turkey
| | - Niven Mehra
- Radboud Universitair Medisch Centrum, Nijmegen, Netherlands
| | | | - Emma Brown
- University Hospital Southampton, Southampton, UK
| | | | | | | | | | - Yu-Zhen Liu
- Precision Medicine, Oncology R&D, AstraZeneca, Cambridge, UK
| | | | - Laura Barker
- Global Medicines Development, Oncology R&D, AstraZeneca, Cambridge, UK
| | | | - Andrew J Armstrong
- Duke Cancer Institute Center for Prostate and Urologic Cancer, Duke University, Durham, NC, USA
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Nelson AJ, Lopes RD, Hong H, Hua K, Slovin S, Tan S, Nilsson J, Bhatt DL, Goodman SG, Evans CP, Clarke NW, Shore ND, Margel D, Klotz LH, Tombal B, Leong DP, Alexander JH, Higano CS. Cardiovascular Effects of GnRH Antagonists Compared With Agonists in Prostate Cancer: A Systematic Review. JACC CardioOncol 2023; 5:613-624. [PMID: 37969642 PMCID: PMC10635880 DOI: 10.1016/j.jaccao.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 11/17/2023] Open
Abstract
Background Androgen deprivation therapy is the cornerstone of treatment for patients with advanced prostate cancer. Meta-analysis of small, oncology-focused trials suggest gonadotropin-releasing hormone (GnRH) antagonists may be associated with fewer adverse cardiovascular outcomes compared with GnRH agonists. Objectives This study sought to determine whether GnRH antagonists were associated with fewer major adverse cardiovascular events compared with GnRH agonists. Methods Electronic databases were searched for all prospective, randomized trials comparing GnRH antagonists with agonists. The primary outcome was a major adverse cardiovascular event as defined by the following standardized Medical Dictionary for Regulatory Activities terms: "myocardial infarction," "central nervous system hemorrhages and cerebrovascular conditions," and all-cause mortality. Bayesian meta-analysis models with random effects were fitted. Results A total of 11 eligible studies of a maximum duration of 3 to 36 months (median = 12 months) enrolling 4,248 participants were included. Only 1 trial used a blinded, adjudicated event process, whereas potential bias persisted in all trials given their open-label design. A total of 152 patients with primary outcome events were observed, 76 of 2,655 (2.9%) in GnRH antagonist-treated participants and 76 of 1,593 (4.8%) in agonist-treated individuals. Compared with GnRH agonists, the pooled OR of GnRH antagonists for the primary endpoint was 0.57 (95% credible interval: 0.37-0.86) and 0.58 (95% credible interval: 0.32-1.08) for all-cause death. Conclusions Despite the addition of the largest, dedicated cardiovascular outcome trial, the volume and quality of available data to definitively answer this question remain suboptimal. Notwithstanding these limitations, the available data suggest that GnRH antagonists are associated with fewer cardiovascular events, and possibly mortality, compared with GnRH agonists.
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Affiliation(s)
- Adam J. Nelson
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Monash Heart, Monash Health, Melbourne, Victoria
| | - Renato D. Lopes
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Hwanhee Hong
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Kaiyuan Hua
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Susan Slovin
- Genitourinary Oncology Service, Department of Medicine, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sean Tan
- Monash Heart, Monash Health, Melbourne, Victoria
| | - Jan Nilsson
- Department of Clinical Sciences Malmö, Lund University, Sweden
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, USA
| | - Shaun G. Goodman
- Division of Cardiology, St. Michael’s Hospital, Department of Medicine, University of Toronto, Ontario, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher P. Evans
- Department of Urologic Surgery, University of California, Davis, Davis, California, USA
| | - Noel W. Clarke
- Department of Urology, The Christie and Salford Royal Hospitals, Manchester, United Kingdom
| | - Neal D. Shore
- Carolina Urologic Research Center, Myrtle Beach, South Carolina, USA
| | - David Margel
- Division of Urology, Rabin Medical Center, Petach Tikva, Israel
| | - Laurence H. Klotz
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Bertrand Tombal
- Institut de Recherche Cliniques, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Darryl P. Leong
- Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
- The Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Celestia S. Higano
- Division of Medical Oncology, University of Washington and Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
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9
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Clarke NW, James ND. How to Compose Platform Trials. Eur Urol Focus 2023; 9:715-718. [PMID: 37925327 DOI: 10.1016/j.euf.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023]
Abstract
Platform trials are adaptive randomised controlled trials that address multiple questions using a single protocol, which reduces the time taken to reach a meaningful trial endpoint. This mini review provides a description of how to conceive, design, and carry out a platform trial in urology, using experience gained in the STAMPEDE trial. PATIENT SUMMARY: Clinical trials to test how well a new drug or treatment works can take a long time before meaningful results can be assessed. Trials with a platform design can test multiple treatments using just one protocol and control, which reduces the time taken to reach a trial endpoint.
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Affiliation(s)
- Noel W Clarke
- Department of Urology, The Christie Hospital, Manchester, UK.
| | - Nicholas D James
- Department of Clinical Oncology, Royal Marsden NHS Foundation Trust, London, UK; Institute of Cancer Research, London, UK
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10
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Vale CL, Fisher DJ, Godolphin PJ, Rydzewska LH, Boher JM, Burdett S, Chen YH, Clarke NW, Fizazi K, Gravis G, James ND, Liu G, Matheson D, Murphy L, Oldroyd RE, Parmar MKB, Rogozinska E, Sfumato P, Sweeney CJ, Sydes MR, Tombal B, White IR, Tierney JF. Which patients with metastatic hormone-sensitive prostate cancer benefit from docetaxel: a systematic review and meta-analysis of individual participant data from randomised trials. Lancet Oncol 2023; 24:783-797. [PMID: 37414011 DOI: 10.1016/s1470-2045(23)00230-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/19/2023] [Accepted: 05/10/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Adding docetaxel to androgen deprivation therapy (ADT) improves survival in patients with metastatic, hormone-sensitive prostate cancer, but uncertainty remains about who benefits most. We therefore aimed to obtain up-to-date estimates of the overall effects of docetaxel and to assess whether these effects varied according to prespecified characteristics of the patients or their tumours. METHODS The STOPCAP M1 collaboration conducted a systematic review and meta-analysis of individual participant data. We searched MEDLINE (from database inception to March 31, 2022), Embase (from database inception to March 31, 2022), the Cochrane Central Register of Controlled Trials (from database inception to March 31, 2022), proceedings of relevant conferences (from Jan 1, 1990, to Dec 31, 2022), and ClinicalTrials.gov (from database inception to March 28, 2023) to identify eligible randomised trials that assessed docetaxel plus ADT compared with ADT alone in patients with metastatic, hormone-sensitive prostate cancer. Detailed and updated individual participant data were requested directly from study investigators or through relevant repositories. The primary outcome was overall survival. Secondary outcomes were progression-free survival and failure-free survival. Overall pooled effects were estimated using an adjusted, intention-to-treat, two-stage, fixed-effect meta-analysis, with one-stage and random-effects sensitivity analyses. Missing covariate values were imputed. Differences in effect by participant characteristics were estimated using adjusted two-stage, fixed-effect meta-analysis of within-trial interactions on the basis of progression-free survival to maximise power. Identified effect modifiers were also assessed on the basis of overall survival. To explore multiple subgroup interactions and derive subgroup-specific absolute treatment effects we used one-stage flexible parametric modelling and regression standardisation. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool. This study is registered with PROSPERO, CRD42019140591. FINDINGS We obtained individual participant data from 2261 patients (98% of those randomised) from three eligible trials (GETUG-AFU15, CHAARTED, and STAMPEDE trials), with a median follow-up of 72 months (IQR 55-85). Individual participant data were not obtained from two additional small trials. Based on all included trials and patients, there were clear benefits of docetaxel on overall survival (hazard ratio [HR] 0·79, 95% CI 0·70 to 0·88; p<0·0001), progression-free survival (0·70, 0·63 to 0·77; p<0·0001), and failure-free survival (0·64, 0·58 to 0·71; p<0·0001), representing 5-year absolute improvements of around 9-11%. The overall risk of bias was assessed to be low, and there was no strong evidence of differences in effect between trials for all three main outcomes. The relative effect of docetaxel on progression-free survival appeared to be greater with increasing clinical T stage (pinteraction=0·0019), higher volume of metastases (pinteraction=0·020), and, to a lesser extent, synchronous diagnosis of metastatic disease (pinteraction=0·077). Taking into account the other interactions, the effect of docetaxel was independently modified by volume and clinical T stage, but not timing. There was no strong evidence that docetaxel improved absolute effects at 5 years for patients with low-volume, metachronous disease (-1%, 95% CI -15 to 12, for progression-free survival; 0%, -10 to 12, for overall survival). The largest absolute improvement at 5 years was observed for those with high-volume, clinical T stage 4 disease (27%, 95% CI 17 to 37, for progression-free survival; 35%, 24 to 47, for overall survival). INTERPRETATION The addition of docetaxel to hormone therapy is best suited to patients with poorer prognosis for metastatic, hormone-sensitive prostate cancer based on a high volume of disease and potentially the bulkiness of the primary tumour. There is no evidence of meaningful benefit for patients with metachronous, low-volume disease who should therefore be managed differently. These results will better characterise patients most and, importantly, least likely to gain benefit from docetaxel, potentially changing international practice, guiding clinical decision making, better informing treatment policy, and improving patient outcomes. FUNDING UK Medical Research Council and Prostate Cancer UK.
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Affiliation(s)
- Claire L Vale
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK.
| | - David J Fisher
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Peter J Godolphin
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Larysa H Rydzewska
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | | | - Sarah Burdett
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Yu-Hui Chen
- Department of Biostatistics and Computational Biology ECOG-ACRIN Cancer Research Group, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Noel W Clarke
- Department of Surgery and Department of Urology, The Christie and Salford Royal Hospitals, Manchester, UK
| | - Karim Fizazi
- Department of Cancer Medicine, Institut Gustave Roussy, Paris, France
| | - Gwenaelle Gravis
- Department of Medical Oncology, Institut Paoli-Calmettes, Marseille, France
| | | | - Glenn Liu
- Department of Urology, Department of Medicine, University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David Matheson
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Laura Murphy
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Robert E Oldroyd
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Mahesh K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Ewelina Rogozinska
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Patrick Sfumato
- Biostatistics Unit, Institut Paoli-Calmettes, Marseille, France
| | | | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Bertrand Tombal
- Institut de Recherche Clinique, Université Catholique de Louvain, Louvain-la-Neuve, Belgium
| | - Ian R White
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Jayne F Tierney
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
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11
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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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12
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Sujenthiran A, Parry MG, Dodkins J, Nossiter J, Morris M, Berry B, Nathan A, Cathcart P, Clarke NW, Payne H, van der Meulen J, Aggarwal A. Treatment-related toxicity using prostate bed versus prostate bed and pelvic lymph node radiation therapy following radical prostatectomy: A national population-based study. Clin Transl Radiat Oncol 2023; 40:100622. [PMID: 37152844 PMCID: PMC10159812 DOI: 10.1016/j.ctro.2023.100622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 03/08/2023] [Accepted: 03/25/2023] [Indexed: 05/09/2023] Open
Abstract
Purpose There is debate about the effectiveness and toxicity of pelvic lymph node (PLN) irradiation in addition to prostate bed radiotherapy when used to treat disease recurrence following radical prostatectomy. We compared toxicity from radiation therapy (RT) to the prostate bed and pelvic lymph nodes (PBPLN-RT) with prostatebed only radiation therapy (PBO-RT) following radical prostatectomy. Methods and Materials Patients with prostate cancer who underwent post-prostatectomy RT between 2010 and 2016 were identified by using the National Prostate Cancer Audit (NPCA) database. Follow-up data was available up to December 31, 2018. Validated outcome measures, based on a framework of procedural and diagnostic codes, were used to capture ≥Grade 2 gastrointestinal (GI) and genitourinary (GU) toxicity. An adjusted competing-risks regression analysis estimated subdistribution hazard ratios (sHR). A sHR > 1 indicated a higher incidence of toxicity with PBPLN-RT than with PBO-RT. Results 5-year cumulative incidences in the PBO-RT (n = 5,087) and PBPLNRT (n = 593) groups was 18.2% and 15.9% for GI toxicity, respectively. For GU toxicity it was 19.1% and 20.7%, respectively. There was no evidence of difference in GI or GU toxicity after adjustment between PBO-RT and PBPLN-RT (GI: adjusted sHR, 0.90, 95% CI, 0.67-1.19; P = 0.45); (GU: adjusted sHR, 1.19, 95% CI, 0.99-1.44; P = 0.09). Conclusions This national population-based study found that including PLNs in the radiation field following radical prostatectomy is not associated with a significant increase in rates of ≥Grade 2 GI or GU toxicity at 5 years.
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Affiliation(s)
- Arunan Sujenthiran
- Clinical Effectiveness Unit, Royal College of Surgeons of England, UK
- Flatiron Health, UK
| | - Matthew G. Parry
- Clinical Effectiveness Unit, Royal College of Surgeons of England, UK
- Department of Health Services Research & Policy, LHSTM, UK
| | - Joanna Dodkins
- Clinical Effectiveness Unit, Royal College of Surgeons of England, UK
- Department of Health Services Research & Policy, LHSTM, UK
- Corresponding authors at: Clinical Effectiveness Unit, Royal College of Surgeons of England, 35-43 Lincoln’s Inn Fields, London WC2A 3PE, England, UK.
| | - Julie Nossiter
- Department of Health Services Research & Policy, LHSTM, UK
| | - Melanie Morris
- Clinical Effectiveness Unit, Royal College of Surgeons of England, UK
- Department of Health Services Research & Policy, LHSTM, UK
| | - Brendan Berry
- Clinical Effectiveness Unit, Royal College of Surgeons of England, UK
- Department of Health Services Research & Policy, LHSTM, UK
| | - Arjun Nathan
- Clinical Effectiveness Unit, Royal College of Surgeons of England, UK
| | - Paul Cathcart
- Department of Urology, Guy’s & St Thomas’ NHS Foundation Trust, UK
| | - Noel W. Clarke
- Department of Urology, The Christie & Salford Royal NHS Foundation Trusts, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | | | - Ajay Aggarwal
- Department of Health Services Research & Policy, LHSTM, UK
- Department of Radiotherapy, Guy’s & St Thomas’ NHS Foundation Trust, UK
- Department of Cancer Epidemiology, Population & Global Health, KCL, UK
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13
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Macnair A, Nankivell M, Murray ML, Rosen SD, Appleyard S, Sydes MR, Forcat S, Welland A, Clarke NW, Mangar S, Kynaston H, Kockelbergh R, Al-Hasso A, Deighan J, Marshall J, Parmar M, Langley RE, Gilbert DC. Healthcare systems data in the context of clinical trials - A comparison of cardiovascular data from a clinical trial dataset with routinely collected data. Contemp Clin Trials 2023; 128:107162. [PMID: 36933612 DOI: 10.1016/j.cct.2023.107162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/03/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Routinely-collected healthcare systems data (HSD) are proposed to improve the efficiency of clinical trials. A comparison was undertaken between cardiovascular (CVS) data from a clinical trial database with two HSD resources. METHODS Protocol-defined and clinically reviewed CVS events (heart failure (HF), acute coronary syndrome (ACS), thromboembolic stroke, venous and arterial thromboembolism) were identified within the trial data. Data (using pre-specified codes) was obtained from NHS Hospital Episode Statistics (HES) and National Institute for Cardiovascular Outcomes Research (NICOR) HF and myocardial ischaemia audits for trial participants recruited in England between 2010 and 2018 who had provided consent. The primary comparison was trial data versus HES inpatient (APC) main diagnosis (Box-1). Correlations are presented with descriptive statistics and Venn diagrams. Reasons for non-correlation were explored. RESULTS From 1200 eligible participants, 71 protocol-defined clinically reviewed CVS events were recorded in the trial database. 45 resulted in a hospital admission and therefore could have been recorded by either HES APC/ NICOR. Of these, 27/45 (60%) were recorded by HES inpatient (Box-1) with an additional 30 potential events also identified. HF and ACS were potentially recorded in all 3 datasets; trial data recorded 18, HES APC 29 and NICOR 24 events respectively. 12/18 (67%) of the HF/ACS events in the trial dataset were recorded by NICOR. CONCLUSION Concordance between datasets was lower than anticipated and the HSD used could not straightforwardly replace current trial practices, nor directly identify protocol-defined CVS events. Further work is required to improve the quality of HSD and consider event definitions when designing clinical trials incorporating HSD.
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Affiliation(s)
- Archie Macnair
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, London WC1V 6LJ, UK; Health Data Research, UK; Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Matthew Nankivell
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, London WC1V 6LJ, UK
| | - Macey L Murray
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, London WC1V 6LJ, UK; Health Data Research, UK; NHS DigiTrials, NHS Digital, 7 and 8 Wellington Place, Leeds, West Yorkshire LS1 4AP, UK
| | - Stuart D Rosen
- National Heart and Lung Institute, Imperial College, London, UK
| | - Sally Appleyard
- University Hospitals Sussex NHS Foundation Trust, Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE, UK
| | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, London WC1V 6LJ, UK; Health Data Research, UK; BHF Data Science Centre, Health Data Research UK (Central Office), Gibbs Building, 215 Euston Road, London NW1 2BE, UK
| | - Sylvia Forcat
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, London WC1V 6LJ, UK
| | - Andrew Welland
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, London WC1V 6LJ, UK
| | - Noel W Clarke
- The Christie and Salford Royal Hospitals, Manchester, UK
| | - Stephen Mangar
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Howard Kynaston
- Division of Cancer and Genetics, Cardiff University Medical School, Cardiff, UK
| | - Roger Kockelbergh
- Department of Urology, University Hospitals of Leicester, Leicester, UK
| | | | - John Deighan
- Patient representative, MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, London WC1V 6LJ, UK
| | - John Marshall
- Patient representative, MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, London WC1V 6LJ, UK
| | - Mahesh Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, London WC1V 6LJ, UK
| | - Ruth E Langley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, London WC1V 6LJ, UK
| | - Duncan C Gilbert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, London WC1V 6LJ, UK; University Hospitals Sussex NHS Foundation Trust, Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE, UK.
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14
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Fankhauser CD, Parry MG, Ali A, Cowling TE, Nossiter J, Sujenthiran A, Berry B, Morris M, Aggarwal A, Payne H, van der Meulen J, Clarke NW. A low prostate specific antigen predicts a worse outcome in high but not in low/intermediate-grade prostate cancer. Eur J Cancer 2023; 181:70-78. [PMID: 36641896 DOI: 10.1016/j.ejca.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 09/09/2022] [Revised: 12/14/2022] [Accepted: 12/18/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The relationship between prostate-specific antigen (PSA) and prostate cancer (PCa) grade was traditionally thought to be linear but recent reports suggest this is not true in high-grade cancers. We aimed to compare the association between PSA and PCa-specific mortality (PCSM) in clinically localised low/intermediate and high-grade PCa. SUBJECTS/PATIENTS AND METHODS Retrospective cohort study using the National Prostate Cancer Audit database in England of men treated with external beam radiotherapy (EBRT), EBRT and brachytherapy boost (EBRT + BT), radical prostatectomy or no radical local treatment between 2014 and 2018. Multivariable competing-risk regression was used to examine the association between PSA, Gleason, and PCSM. Multivariable restricted cubic spline regression was used to explore the non-linear associations of PSA and PCSM. RESULTS 102,089 men were included, of whom 71,138 had low/intermediate-grade and 22,425 had high-grade PCa. In high-grade, 4-year PCSM was higher with PSA ≤5 than PSA 5.1-10 for men treated with EBRT (hazard ratio 1.96 (95% confidence interval 1.15-3.34) or no radical local treatment (hazard ratio 1.99 (95% confidence interval 1.33-2.98). Restricted cubic spline regression showed that PSA and PCSM have a non-linear association in high-grade but a linear association in low/intermediate-grade PCa. CONCLUSION The low-PSA/high-grade combination in M0 PCa treated with EBRT has a higher PCSM than those with high-grade and intermediate PSA levels. In high-grade disease, the PSA association was non-linear; by contrast, low/intermediate-grade had a linear relationship. This confirms a more aggressive biology in low PSA secreting high-grade PCa and a worse outcome following treatment.
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Affiliation(s)
- Christian D Fankhauser
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK; National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; University of Zurich, Zurich, Switzerland; Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland.
| | - Matthew G Parry
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Adnan Ali
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK; GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Thomas E Cowling
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Julie Nossiter
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Arun Sujenthiran
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Brendan Berry
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Melanie Morris
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Ajay Aggarwal
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom; Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust
| | - Heather Payne
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Department of Clinical Oncology University College London Hospital NHS Trust, London, United Kingdom
| | - Jan van der Meulen
- National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, GU Cancer/FASTMAN Research Group, Manchester University, Manchester, United Kingdom
| | - Noel W Clarke
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK; National Prostate Cancer Audit, Royal College of Surgeons of England, London, UK; Department of Urology, Salford Royal NHS Foundation Trust, Manchester, UK
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15
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Azhar F, Sachdeva A, Hart CA, Brown MD, Sangar V, Parnham A, Lau M, Oliveria P, Clarke NW. Differential expression of PDL-1 and tumour-associated macrophages in N0 and N+ penile cancer. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023] Open
Abstract
12 Background: Penile squamous cell carcinoma (PSCC) is rare, representing 0.4-0.6% of all male malignancies in the global-north, as compared with 2-10% in the global-south. Overall survival (OS) dramatically decreases with increased lymph node metastases (LNM). Increased prevalence of pro-tumorigenic M2 CD163+ tumour associated macrophages (TAM) is associated with poor PSCC OS, whereas increased prevalence of the generic M1/2 CD68+ TAMs is associated with better PSCC OS. PDL-1 expression has been noted in 40-60% of PSCC primary lesions. However, there is a paucity of evidence on the overall tumour immune microenvironment (TME) within penile LNM disease. This study describes the relationship between PDL-1 expression and TAMs within the TME of the primary tumour and paired LNMs, with the goal of predicting the utility of PD-1 inhibitors in clinical trials in PSCC. Methods: The Ventana Discovery ULTRA platform was used to optimise a 7-marker multiplex immunofluorescence panel on whole FFPE sections of primary and LNM lesions. Multispectral images were captured using a Vectra 3 microscope. Single cell spatial analysis was performed using HALO software, with statistical analysis of data using R 4.2.1. Results: 52 cases with differing LN stages were identified: N0 (N=20); N1/N2 (N=21); N3 (N=11). Increased expression of PDL-1 was noted at the primary lesion invasive margin (IM) of N+, compared with N0 patients. High expression in inguinal LNMs (iLN+) and pelvic LNMs (pLN+) was also observed, with no expression detected in microscopically normal, tumour free LNs (LN-) in the N0 cohort. More CD163+ M2 TAMs were observed at the IM of N+ compared with N0. However, no significant difference was observed between the three LN groups. M1/2 CD68+ TAMs were more prevalent within pLN+ vs iLN+ or LN-. There was no significant difference in M1/2 CD68+ TAMs number at the IM. Conclusions: Our data highlights increased prevalence of M2 CD163+ TAMs within the IM is associated with LNM. Increased presence of CD68+ M1/2 TAMs in pLN+ may represent active inflammation at the leading microscopic edge of metastatic deposits. A significant difference in the expression of PDL-1 between localised and metastatic disease at both primary and LN location is noted. High PDL-1 expression at the IM of the primary lesion is associated with increased LNMs, where PDL-1 expression is significantly higher as compared to LN-. This study supports the rationale for the use of anti-PD-1/PDL-1 therapies in patients with LNM disease.
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Affiliation(s)
- Fowz Azhar
- GenitoUrinary Cancer Research Group, The University of Manchester, The Christie NHS Foundation Trust, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
| | - Ashwin Sachdeva
- GenitoUrinary Cancer Research Group, FASTMAN Movember Centre of Excellence, University of Manchester, Manchester, United Kingdom
| | - Claire Alexandre Hart
- GenitoUrinary Cancer Research Group, FASTMAN Movember Centre of Excellence, University of Manchester, Manchester, United Kingdom
| | - Mick D. Brown
- GenitoUrinary Cancer Research Group, The University of Manchester, Manchester, United Kingdom
| | - Vijay Sangar
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Arie Parnham
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Maurice Lau
- Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
| | - Pedro Oliveria
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Noel W Clarke
- The University of Manchester, The Christie NHS Foundation Trust, Salford Royal NHS Foundation Trust, Manchester, United Kingdom
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16
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Clarke NW, Armstrong AJ, Thiery-Vuillemin A, Oya M, Shore ND, Procopio G, Guedes JDC, Arslan C, Mehra N, Parnis F, Brown E, Schlürmann F, Joung JY, Sugimoto M, Sartor AO, Liu YZ, Poehlein CH, Barker L, del Rosario PM, Saad F. Final overall survival (OS) in PROpel: Abiraterone (abi) and olaparib (ola) versus abiraterone and placebo (pbo) as first-line (1L) therapy for metastatic castration-resistant prostate cancer (mCRPC). J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.lba16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
LBA16 Background: PROpel (NCT03732820) met its primary endpoint showing significant investigator-assessed radiographic progression-free survival (rPFS) benefit for patients with mCRPC treated with abi + ola vs abi + pbo in the 1L setting (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.54–0.81, P< 0.001, data cut-off: 7/30/2021). Sensitivity analysis by blinded independent central review was consistent. A trend toward OS benefit with abi + ola was observed at the time of the primary rPFS analysis (28.6% maturity, HR 0.86, 95% CI 0.66–1.12) and a subsequent interim analysis (40.1% maturity, HR 0.83, 95% CI 0.66–1.03). We report OS and safety from the pre-planned final analysis (data cut-off: 10/12/2022). Methods: PROpel is a randomized, double-blind phase 3 trial of 1L therapy for patients with mCRPC eligible for abiraterone. Patients were prospectively assessed for homologous recombination repair mutation (HRRm) status using tumor tissue (FoundationOne CDx) and/or circulating tumor DNA (ctDNA; FoundationOne Liquid CDx) tests after randomization 1:1 to ola (300 mg twice daily [bid]) or pbo, and abi (1000 mg once daily) plus prednisone/prednisolone (5 mg bid). Treatment continued until radiographic disease progression, unacceptable toxicity or withdrawal of consent. OS was a key secondary endpoint (2-sided boundary for significance 0.0377). Aggregate results from tumor tissue and ctDNA tests were used to assign patients to HRRm/BRCAm subgroups. Results: Patient (n = 796) characteristics (including prior docetaxel, site of metastasis, symptom score and HRRm status) were generally balanced. There was a consistent trend toward OS benefit in the intention-to-treat (ITT) population with abi + ola vs abi + pbo (maturity 47.9%, HR 0.81, 95% CI 0.67–1.00, P= 0.0544), with median OS 42.1 months (m) vs 34.7 m, respectively. OS medians and HRs for HRRm, non-HRRm, BRCAm and non-BRCAm subgroups all favored abi + ola vs abi + pbo. In the abi + ola arm the most common Grade ≥3 adverse event was anemia (16.1%). Conclusions: At the prespecified final analysis in PROpel, abi + ola prolonged OS by > 7 m vs standard-of-care abiraterone (abi + pbo) in the ITT population. The median OS of > 42 m is the longest median reported to date in a phase 3 trial in 1L mCRPC. Consistent with rPFS results, a trend toward OS benefit was observed in HRRm, non-HRRm, BRCAm and non-BRCAm subgroups with greatest benefit in the BRCAm subgroup. No new long-term safety issues were identified. These results support the use of abi + ola in 1L mCRPC. Clinical trial information: NCT03732820 . [Table: see text]
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Affiliation(s)
- Noel W. Clarke
- The Christie and Salford Royal NHS Foundation Trusts, Manchester, United Kingdom
| | - Andrew J. Armstrong
- Duke Cancer Institute Center for Prostate and Urologic Cancer, Duke University, Durham, NC
| | | | | | | | | | | | - Cagatay Arslan
- İzmir Economy University Medical Park Hospital, Karsiyaka, Turkey
| | - Niven Mehra
- Radboud Universitair Medisch Centrum, Nijmegen, Netherlands
| | - Francis Parnis
- Ashford Cancer Centre Research, Kurralta Park, SA, Australia
| | - Emma Brown
- University Hospital Southampton, Southampton, United Kingdom
| | | | | | | | | | - Yu-Zhen Liu
- Precision Medicine, Oncology R&D, AstraZeneca, Cambridge, United Kingdom
| | | | - Laura Barker
- Global Medicines Development, Oncology R&D, AstraZeneca, Cambridge, United Kingdom
| | | | - Fred Saad
- Centre Hospitalier de l’Université de Montréal/CRCHUM, Université de Montreal, Montreal, QC, Canada
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17
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Parry MA, Grist E, Mendes L, Dutey-Magni P, Sachdeva A, Brawley C, Murphy L, Proudfoot J, Lall S, Liu Y, Friedrich S, Ismail M, Hoyle A, Ali A, Haran A, Wingate A, Zakka L, Wetterskog D, Amos CL, Atako NB, Wang V, Rush HL, Jones RJ, Leung H, Cross WR, Gillessen S, Parker CC, Chowdhury S, Lotan T, Marafioti T, Urbanucci A, Schaeffer EM, Spratt DE, Waugh D, Powles T, Berney DM, Sydes MR, Parmar MK, Hamid AA, Feng FY, Sweeney CJ, Davicioni E, Clarke NW, James ND, Brown LC, Attard G. Clinical testing of transcriptome-wide expression profiles in high-risk localized and metastatic prostate cancer starting androgen deprivation therapy: an ancillary study of the STAMPEDE abiraterone Phase 3 trial. Res Sq 2023:rs.3.rs-2488586. [PMID: 36798177 PMCID: PMC9934744 DOI: 10.21203/rs.3.rs-2488586/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Metastatic and high-risk localized prostate cancer respond to hormone therapy but outcomes vary. Following a pre-specified statistical plan, we used Cox models adjusted for clinical variables to test associations with survival of multi-gene expression-based classifiers from 781 patients randomized to androgen deprivation with or without abiraterone in the STAMPEDE trial. Decipher score was strongly prognostic (p<2×10-5) and identified clinically-relevant differences in absolute benefit, especially for localized cancers. In metastatic disease, classifiers of proliferation, PTEN or TP53 loss and treatment-persistent cells were prognostic. In localized disease, androgen receptor activity was protective whilst interferon signaling (that strongly associated with tumor lymphocyte infiltration) was detrimental. Post-Operative Radiation-Therapy Outcomes Score was prognostic in localized but not metastatic disease (interaction p=0.0001) suggesting the impact of tumor biology on clinical outcome is context-dependent on metastatic state. Transcriptome-wide testing has clinical utility for advanced prostate cancer and identified worse outcomes for localized cancers with tumor-promoting inflammation.
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Affiliation(s)
| | - Emily Grist
- Cancer Institute, University College London; London, UK
| | | | - Peter Dutey-Magni
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, University College London; London, UK
| | - Ashwin Sachdeva
- Genito-Urinary Cancer Research Group, Division of Cancer Sciences, Manchester Cancer Research Centre, The University of Manchester; Manchester, UK
| | - Christopher Brawley
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, University College London; London, UK
| | - Laura Murphy
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, University College London; London, UK
| | | | | | | | | | | | - Alex Hoyle
- Genito-Urinary Cancer Research Group, Division of Cancer Sciences, Manchester Cancer Research Centre, The University of Manchester; Manchester, UK
- Department of Surgery, The Christie and Salford Royal Hospitals; Manchester, UK
| | - Adnan Ali
- Genito-Urinary Cancer Research Group, Division of Cancer Sciences, Manchester Cancer Research Centre, The University of Manchester; Manchester, UK
| | - Aine Haran
- Genito-Urinary Cancer Research Group, Division of Cancer Sciences, Manchester Cancer Research Centre, The University of Manchester; Manchester, UK
- Department of Surgery, The Christie and Salford Royal Hospitals; Manchester, UK
| | - Anna Wingate
- Cancer Institute, University College London; London, UK
| | - Leila Zakka
- Cancer Institute, University College London; London, UK
| | | | - Claire L. Amos
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, University College London; London, UK
| | - Nafisah B. Atako
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, University College London; London, UK
| | - Victoria Wang
- Department of Data Science, Dana-Farber Cancer Institute; Boston, USA
| | - Hannah L. Rush
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, University College London; London, UK
| | - Robert J. Jones
- University of Glasgow, Beatson West of Scotland Cancer Centre; Glasgow, UK
| | - Hing Leung
- University of Glasgow, Beatson West of Scotland Cancer Centre; Glasgow, UK
| | | | - Silke Gillessen
- Istituto Oncologico della Svizzera Italiana, EOC; Bellinzona, Switzerland
- Università della Svizzera Italiana; Lugano, Switzerland
| | - Chris C. Parker
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research; London, UK
| | | | | | - Tamara Lotan
- Johns Hopkins University School of Medicine; Baltimore, USA
| | | | - Alfonso Urbanucci
- Department of Tumor Biology, Institute for Cancer Research, Oslo University Hospital; Oslo, Norway
- Prostate Cancer Research Center, Faculty of Medicine and Health Technology, Tampere University and Tays Cancer Center, Tampere University Hospital; Tampere, Finland
| | - Edward M. Schaeffer
- Department of Urology, Northwestern University Feinberg School of Medicine; Chicago, USA
| | - Daniel E. Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center; Cleveland, USA
| | - David Waugh
- Queensland University of Technology; Brisbane, Australia
| | - Thomas Powles
- Barts Experimental Cancer Medicine Centre, Barts Cancer Institute, Queen Mary University of London; London, UK
| | - Daniel M. Berney
- Barts Cancer Institute, Queen Mary University of London; London, UK
| | - Matthew R. Sydes
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, University College London; London, UK
| | - Mahesh K.B. Parmar
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, University College London; London, UK
| | - Anis A. Hamid
- Department of Medical Oncology, Dana-Farber Cancer Institute; Boston, USA
| | - Felix Y. Feng
- University of California San Francisco; San Francisco, USA
| | | | | | - Noel W. Clarke
- Genito-Urinary Cancer Research Group, Division of Cancer Sciences, Manchester Cancer Research Centre, The University of Manchester; Manchester, UK
- Department of Surgery, The Christie and Salford Royal Hospitals; Manchester, UK
| | - Nicholas D. James
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research; London, UK
| | - Louise C. Brown
- MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, University College London; London, UK
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18
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Clarke NW. Following the Narrow Path. Eur Urol 2023; 83:27-28. [PMID: 36270833 DOI: 10.1016/j.eururo.2022.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/27/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Noel W Clarke
- Department of Urology, The Christie and Salford Royal Hospitals, Manchester, UK.
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19
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Coelingh Bennink HJT, Krijgh J, Egberts JFM, Slootweg M, van Melick HHE, Roos EPM, Somford DM, Zimmerman Y, Schultz IJ, Clarke NW, van Moorselaar RJA, Debruyne FMJ. Maintaining bone health by estrogen therapy in patients with advanced prostate cancer: a narrative review. Endocr Connect 2022; 11:e220182. [PMID: 36283120 PMCID: PMC9716371 DOI: 10.1530/ec-22-0182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/25/2022] [Indexed: 11/08/2022]
Abstract
The purpose of androgen deprivation therapy (ADT) in prostate cancer (PCa), using luteinizing hormone-releasing hormone agonists (LHRHa) or gonadotrophin-releasing hormone antagonists, is to suppress the levels of testosterone. Since testosterone is the precursor of estradiol (E2), one of the major undesired effects of ADT is the concomitant loss of E2, causing among others an increased bone turnover and bone loss and an increased risk of osteoporosis and fractures. Therefore, the guidelines for ADT indicate to combine ADT routinely with bone-sparing agents such as bisphosphonates, denosumab or selective estrogen receptor modulators. However, these compounds may have side effects and some require inconvenient parenteral administration. Co-treatment with estrogens is an alternative approach to prevent bone loss and at the same time, to avoid other side effects caused by the loss of estrogens, which is the topic explored in the present narrative review. Estrogens investigated in PCa patients include parenteral or transdermal E2, diethylstilbestrol (DES), and ethinylestradiol (EE) as monotherapy, or high-dose estetrol (HDE4) combined with ADT. Cardiovascular adverse events have been reported with parenteral E2, DES and EE. Encouraging effects on bone parameters have been obtained with transdermal E2 (tE2) and HDE4, in the tE2 development program (PATCH study), and in the LHRHa/HDE4 co-treatment study (PCombi), respectively. Confirmation of the beneficial effects of estrogen therapy with tE2 or HDE4 on bone health in patients with advanced PCa is needed, with special emphasis on bone mass and fracture rate.
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Affiliation(s)
| | - Jan Krijgh
- Pantarhei Oncology, Zeist, The Netherlands
| | | | | | | | - Erik P M Roos
- Department of Urology, Antonius Hospital, Sneek, The Netherlands
| | - Diederik M Somford
- Department of Urology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | | | - Noel W Clarke
- The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
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20
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Nathan A, Morris M, Parry MG, Berry B, Sujenthiran A, Nossiter J, Payne H, Van Der Meulen J, Clarke NW, Green JSA. Interventions for obstructive uropathy in advanced prostate cancer: a population-based study. BJU Int 2022; 130:688-695. [PMID: 35485254 DOI: 10.1111/bju.15766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To develop and validate a coding framework to identify interventions for upper tract obstructive uropathy (UTOU) in men with locally advanced and metastatic prostate cancer (PCa) using administrative hospital data to assess clinical outcomes. There are no population-based studies on the incidence, treatment, and outcomes of this complication. PATIENTS AND METHODS Patients newly diagnosed with PCa between April 2014 and March 2019 were identified in the English cancer registry. A coding framework based on procedure (Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures fourth edition) and diagnostic (International Classification of Diseases, 10th edition) codes was developed and validated. Subsequent clinical outcomes were determined using Hospital Episodes Statistics to determine the utility of the intervention. RESULTS A total of 77 010 patients newly diagnosed with locally advanced, and 30 083 patients with metastatic PCa were identified. Of these, 1951 (1.8%) patients underwent an intervention for UTOU according to our coding framework: 830 (42.5%) had locally advanced disease and 1121 (57.5%) had metastatic disease. In all, 844 (43.3%) had a percutaneous nephrostomy (PCN), 473 (24.2%) had a PCN with antegrade stent, and 634 (32.5%) had a retrograde stent. The mean follow-up was 43.2 months. The cumulative incidence of the use of these interventions at 1, 3, and 5 years was 2.5%, 3.6% and 4.2% in men with metastases compared to 0.5%, 0.9% and 1.4% in men with locally advanced disease. CONCLUSION A new coding framework, developed to identify procedures for UTOU was applied in the largest study to date of UTOU in men with primary locally advanced and metastatic PCa. Results demonstrated that 2% of men with locally advanced PCa and 4% of men with metastatic PCa require an intervention to resolve UTOU within 5 years of their PCa diagnosis.
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Affiliation(s)
- Arjun Nathan
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Melanie Morris
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew G Parry
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Brendan Berry
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Flatiron Health, UK
| | - Julie Nossiter
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Jan Van Der Meulen
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts Manchester, UK
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21
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Grist E, Friedrich S, Brawley C, Mendes L, Parry M, Ali A, Haran A, Hoyle A, Gilson C, Lall S, Zakka L, Bautista C, Landless A, Nowakowska K, Wingate A, Wetterskog D, Hasan AMM, Akato NB, Richmond M, Ishaq S, Matthews N, Hamid AA, Sweeney CJ, Sydes MR, Berney DM, Lise S, Parmar MKB, Clarke NW, James ND, Cremaschi P, Brown LC, Attard G. Accumulation of copy number alterations and clinical progression across advanced prostate cancer. Genome Med 2022; 14:102. [PMID: 36059000 PMCID: PMC9442998 DOI: 10.1186/s13073-022-01080-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Received: 01/13/2022] [Accepted: 06/23/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Genomic copy number alterations commonly occur in prostate cancer and are one measure of genomic instability. The clinical implication of copy number change in advanced prostate cancer, which defines a wide spectrum of disease from high-risk localised to metastatic, is unknown. METHODS We performed copy number profiling on 688 tumour regions from 300 patients, who presented with advanced prostate cancer prior to the start of long-term androgen deprivation therapy (ADT), in the control arm of the prospective randomised STAMPEDE trial. Patients were categorised into metastatic states as follows; high-risk non-metastatic with or without local lymph node involvement, or metastatic low/high volume. We followed up patients for a median of 7 years. Univariable and multivariable Cox survival models were fitted to estimate the association between the burden of copy number alteration as a continuous variable and the hazard of death or disease progression. RESULTS The burden of copy number alterations positively associated with radiologically evident distant metastases at diagnosis (P=0.00006) and showed a non-linear relationship with clinical outcome on univariable and multivariable analysis, characterised by a sharp increase in the relative risk of progression (P=0.003) and death (P=0.045) for each unit increase, stabilising into more modest increases with higher copy number burdens. This association between copy number burden and outcome was similar in each metastatic state. Copy number loss occurred significantly more frequently than gain at the lowest copy number burden quartile (q=4.1 × 10-6). Loss of segments in chromosome 5q21-22 and gains at 8q21-24, respectively including CHD1 and cMYC occurred more frequently in cases with higher copy number alteration (for either region: Kolmogorov-Smirnov distance, 0.5; adjusted P<0.0001). Copy number alterations showed variability across tumour regions in the same prostate. This variance associated with increased risk of distant metastases (Kruskal-Wallis test P=0.037). CONCLUSIONS Copy number alteration in advanced prostate cancer associates with increased risk of metastases at diagnosis. Accumulation of a limited number of copy number alterations associates with most of the increased risk of disease progression and death. The increased likelihood of involvement of specific segments in high copy number alteration burden cancers may suggest an order underlying the accumulation of copy number changes. TRIAL REGISTRATION ClinicalTrials.gov NCT00268476 , registered on December 22, 2005. EudraCT 2004-000193-31 , registered on October 4, 2004.
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Affiliation(s)
- Emily Grist
- Cancer Institute, University College London, London, UK
| | | | | | | | - Marina Parry
- Cancer Institute, University College London, London, UK
| | - Adnan Ali
- GU Cancer Research/FASTMAN Group, Manchester Cancer Institute, Manchester, UK
| | - Aine Haran
- The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Alex Hoyle
- The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Claire Gilson
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Leila Zakka
- Cancer Institute, University College London, London, UK
| | | | - Alex Landless
- Cancer Institute, University College London, London, UK
| | | | - Anna Wingate
- Cancer Institute, University College London, London, UK
| | | | | | - Nafisah B Akato
- MRC Clinical Trials Unit at University College London, London, UK
| | - Malissa Richmond
- MRC Clinical Trials Unit at University College London, London, UK
| | - Sofeya Ishaq
- MRC Clinical Trials Unit at University College London, London, UK
| | - Nik Matthews
- The Institute of Cancer Research, London, UK
- Imperial College, London, UK
| | - Anis A Hamid
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Matthew R Sydes
- MRC Clinical Trials Unit at University College London, London, UK
| | - Daniel M Berney
- Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Stefano Lise
- Cancer Institute, University College London, London, UK
| | | | - Noel W Clarke
- GU Cancer Research/FASTMAN Group, Manchester Cancer Institute, Manchester, UK
| | - Nicholas D James
- The Royal Marsden Hospital NHS Foundation Trust and The Institute of Cancer Research, London, UK
| | | | - Louise C Brown
- MRC Clinical Trials Unit at University College London, London, UK
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22
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Saad F, Thiery-Vuillemin A, Wiechno P, Alekseev B, Sala N, Jones R, Kocak I, Chiuri VE, Jassem J, Fléchon A, Redfern C, Kang J, Burgents J, Gresty C, Degboe A, Clarke NW. Patient-reported outcomes with olaparib plus abiraterone versus placebo plus abiraterone for metastatic castration-resistant prostate cancer: a randomised, double-blind, phase 2 trial. Lancet Oncol 2022; 23:1297-1307. [DOI: 10.1016/s1470-2045(22)00498-3] [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] [Received: 04/12/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 10/14/2022]
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23
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Parker CC, Clarke NW, Catton C, Kynaston H, Cook A, Cross W, Davidson C, Goldstein C, Logue J, Maniatis C, Petersen PM, Neville P, Payne H, Persad R, Pugh C, Stirling A, Saad F, Parulekar WR, Parmar MKB, Sydes MR. RADICALS-HD: Reflections before the Results are Known. Clin Oncol (R Coll Radiol) 2022; 34:593-597. [PMID: 35810050 DOI: 10.1016/j.clon.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/01/2022] [Accepted: 06/15/2022] [Indexed: 11/16/2022]
Affiliation(s)
- C C Parker
- The Institute of Cancer Research, Royal Marsden NHS Foundation Trust, Sutton, UK.
| | - N W Clarke
- Genito-Urinary Cancer Research Group, Department of Surgery, The Christie Hospital, Manchester, UK; Department of Urology, Salford Royal Hospitals, Manchester, UK
| | - C Catton
- Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - H Kynaston
- Cardiff University School of Medicine, Cardiff University, Cardiff, UK
| | - A Cook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - W Cross
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - C Davidson
- Canadian Cancer Trials Group, Queen's University, Kingston, Canada
| | - C Goldstein
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - J Logue
- Oncology, The Christie Hospital, Manchester, UK
| | - C Maniatis
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - P M Petersen
- Department of Oncology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - P Neville
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - H Payne
- Oncology, University College London Hospitals, London, UK
| | - R Persad
- Bristol Urological Institute, North Bristol Hospitals, Bristol, UK
| | - C Pugh
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - A Stirling
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - F Saad
- University of Montreal Hospital Center (CHUM), Montréal, Canada
| | - W R Parulekar
- Canadian Cancer Trials Group, Queen's University, Kingston, Canada
| | - M K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - M R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
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24
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Clarke NW, Armstrong AJ, Thiery-Vuillemin A, Oya M, Shore N, Loredo E, Procopio G, de Menezes J, Girotto G, Arslan C, Mehra N, Parnis F, Brown E, Schlürmann F, Joung JY, Sugimoto M, Virizuela JA, Emmenegger U, Navratil J, Buchschacher GL, Poehlein C, Harrington EA, Desai C, Kang J, Saad F. Abiraterone and Olaparib for Metastatic Castration-Resistant Prostate Cancer. NEJM Evid 2022; 1:EVIDoa2200043. [PMID: 38319800 DOI: 10.1056/evidoa2200043] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Abiraterone and Olaparib for Metastatic Prostate CancerPatients with metastatic castration-resistant prostate cancer, regardless of homologous recombination repair gene mutation status, received either abiraterone and olaparib or abiraterone and placebo in the first-line setting. Imaging-based progression-free survival was 24.8 months for patients treated with abiraterone and olaparib versus 16.6 months for those receiving abiraterone alone.
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Affiliation(s)
- Noel W Clarke
- The Christie and Salford Royal Hospital NHS Foundation Trusts, University of Manchester, Manchester, United Kingdom
| | - Andrew J Armstrong
- Duke Cancer Institute Center for Prostate and Urologic Cancer, Duke University, Durham, NC
| | | | | | - Neal Shore
- Carolina Urologic Research Center, Myrtle Beach, SC
| | - Eugenia Loredo
- Centro de Investigaciones Clinicas Viña del Mar, Valparaíso, Chile
| | | | | | - Gustavo Girotto
- Hospital de Base São José do Rio Preto, São José do Rio Preto, Brazil
| | - Cagatay Arslan
- Izmir Economy University Medical Park Hospital, Karsiyaka, Turkey
| | - Niven Mehra
- Radboud Universitair Medisch Centrum, Nijmegen, Netherlands
| | - Francis Parnis
- Ashford Cancer Centre Research, Adelaide, South Australia
| | - Emma Brown
- University Hospital Southampton, Southampton, United Kingdom
| | | | | | | | | | | | - Jiri Navratil
- Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | | | | | | | - Chintu Desai
- Global Medicines Development, Oncology R&D, AstraZeneca, Cambridge, United Kingdom
| | - Jinyu Kang
- Global Medicines Development, Oncology R&D, AstraZeneca, Gaithersburg, MD
| | - Fred Saad
- Centre Hospitalier de l'Universite de Montreal, Montreal
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25
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James ND, Clarke NW, Cook A, Ali A, Hoyle AP, Attard G, Brawley CD, Chowdhury S, Cross WR, Dearnaley DP, de Bono JS, Diaz‐Montana C, Gilbert D, Gillessen S, Gilson C, Jones RJ, Langley RE, Malik ZI, Matheson DJ, Millman R, Parker CC, Pugh C, Rush H, Russell JM, Berthold DR, Buckner ML, Mason MD, Ritchie AWS, Birtle AJ, Brock SJ, Das P, Ford D, Gale J, Grant W, Gray EK, Hoskin P, Khan MM, Manetta C, McPhail NJ, O'Sullivan JM, Parikh O, Perna C, Pezaro CJ, Protheroe AS, Robinson AJ, Rudman SM, Sheehan DJ, Srihari NN, Syndikus I, Tanguay JS, Thomas CW, Vengalil S, Wagstaff J, Wylie JP, Parmar MKB, Sydes MR. Abiraterone acetate plus prednisolone for metastatic patients starting hormone therapy: 5-year follow-up results from the STAMPEDE randomised trial (NCT00268476). Int J Cancer 2022; 151:422-434. [PMID: 35411939 PMCID: PMC9321995 DOI: 10.1002/ijc.34018] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [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] [Received: 12/10/2021] [Revised: 02/15/2022] [Accepted: 02/22/2022] [Indexed: 11/17/2022]
Abstract
Abiraterone acetate plus prednisolone (AAP) previously demonstrated improved survival in STAMPEDE, a multiarm, multistage platform trial in men starting long-term hormone therapy for prostate cancer. This long-term analysis in metastatic patients was planned for 3 years after the first results. Standard-of-care (SOC) was androgen deprivation therapy. The comparison randomised patients 1:1 to SOC-alone with or without daily abiraterone acetate 1000 mg + prednisolone 5 mg (SOC + AAP), continued until disease progression. The primary outcome measure was overall survival. Metastatic disease risk group was classified retrospectively using baseline CT and bone scans by central radiological review and pathology reports. Analyses used Cox proportional hazards and flexible parametric models, accounting for baseline stratification factors. One thousand and three patients were contemporaneously randomised (November 2011 to January 2014): median age 67 years; 94% newly-diagnosed; metastatic disease risk group: 48% high, 44% low, 8% unassessable; median PSA 97 ng/mL. At 6.1 years median follow-up, 329 SOC-alone deaths (118 low-risk, 178 high-risk) and 244 SOC + AAP deaths (75 low-risk, 145 high-risk) were reported. Adjusted HR = 0.60 (95% CI: 0.50-0.71; P = 0.31 × 10-9 ) favoured SOC + AAP, with 5-years survival improved from 41% SOC-alone to 60% SOC + AAP. This was similar in low-risk (HR = 0.55; 95% CI: 0.41-0.76) and high-risk (HR = 0.54; 95% CI: 0.43-0.69) patients. Median and current maximum time on SOC + AAP was 2.4 and 8.1 years. Toxicity at 4 years postrandomisation was similar, with 16% patients in each group reporting grade 3 or higher toxicity. A sustained and substantial improvement in overall survival of all metastatic prostate cancer patients was achieved with SOC + abiraterone acetate + prednisolone, irrespective of metastatic disease risk group.
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Affiliation(s)
| | - Noel W. Clarke
- The Departments of Surgery & UrologyThe Christie & Salford Royal HospitalsManchesterUK
| | - Adrian Cook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Adnan Ali
- The Christie NHS Foundation TrustManchesterUK
| | | | | | - Christopher D. Brawley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Simon Chowdhury
- Guy's, King's, & St. Thomas' Hospitals, and Sarah Cannon Research InstituteLondonUK
| | | | - David P. Dearnaley
- The Institute of Cancer Research and Royal Marsden NHS Foundation TrustLondonUK
| | | | - Carlos Diaz‐Montana
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Duncan Gilbert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Silke Gillessen
- Istituto Oncologico della Svizzera ItalianaBellinzonaSwitzerland
| | - Clare Gilson
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
- Royal Marsden HospitalLondonUK
| | - Rob J. Jones
- Beatson West of Scotland Cancer Centre, University of GlasgowGlasgowUK
| | - Ruth E. Langley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Zafar I. Malik
- Radiotherapy UnitThe Clatterbridge Cancer Centre NHS Foundation TrustLiverpoolLiverpoolL7 8YAUK
| | - David J. Matheson
- School of Allied Health and Midwifery, Faculty of Education, Health and WellbeingUniversity of WolverhamptonWolverhamptonWS1 3BDUK
| | | | - Chris C. Parker
- Uro‐Oncology UnitRoyal Marsden Hospital and Institute of Cancer ResearchSuttonUK
| | - Cheryl Pugh
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Hannah Rush
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
- Guys and St Thomas' NHS Foundation TrustLondonUK
| | - J. Martin Russell
- Institute of Cancer Sciences, University of GlasgowGlasgowUK
- Beatson West of Scotland Cancer CentreGlasgowUK
| | | | - Michelle L. Buckner
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | | | | | - Alison J. Birtle
- Rosemere Cancer Centre, Lancashire Teaching Hospitals & University of Manchester, University of Central LancashireLancashireUK
| | | | - Prantik Das
- Department of OncologyUniversity Hospitals of Derby and Burton NHS Foundation TrustDerbyUK
| | - Dan Ford
- City Hospital, Cancer Centre at Queen Elizabeth HospitalBirminghamUK
| | - Joanna Gale
- Portsmouth Hospitals University TrustPortsmouthUK
| | - Warren Grant
- Gloucestershire Oncology Centre, Cheltenham General HospitalCheltenhamUK
| | | | | | - Mohammad M. Khan
- Department of Oncology Castle Hill HospitalHullUK
- Scarborough General HospitalScarboroughUK
| | | | | | - Joe M. O'Sullivan
- Patrick G Johnston Centre for Cancer Research, Queen's University BelfastBelfastUK
| | - Omi Parikh
- Rosemere Cancer Centre, Lancashire Teaching Hospitals NHS TrustPrestonUK
| | - Carla Perna
- Royal Surrey NHS Foundation TrustGuildfordUK
| | | | | | | | | | | | | | - Isabel Syndikus
- Radiotherapy UnitThe Clatterbridge Cancer Centre NHS Foundation TrustLiverpoolLiverpoolL7 8YAUK
| | | | | | - Salil Vengalil
- University Hospital North Midlands NHS TrustStaffordshireUK
| | - John Wagstaff
- Swansea University and the South West UK Cancer CentreSwanseaUK
| | | | - Mahesh K. B. Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
| | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, UCLLondonUK
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26
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James ND, Ingleby FC, Clarke NW, Amos CL, Attard G, Brawley CD, Chowdhury S, Cross W, Dearnaley DP, Gilbert DC, Gillessen S, Jones RJ, Langley RE, Macnair A, Malik ZI, Mason MD, Matheson DJ, Millman R, Parker CC, Rush HL, Russell JM, Au C, Ritchie AWS, Mestre RP, Ahmed I, Birtle AJ, Brock SJ, Das P, Ford VA, Gray EK, Hughes RJ, Manetta CB, McLaren DB, Nikapota AD, O'Sullivan JM, Perna C, Peedell C, Protheroe AS, Sundar S, Tanguay JS, Tolan SP, Wagstaff J, Wallace JB, Wylie JP, Zarkar A, Parmar MKB, Sydes MR. Docetaxel for Nonmetastatic Prostate Cancer: Long-Term Survival Outcomes in the STAMPEDE Randomized Controlled Trial. JNCI Cancer Spectr 2022; 6:6649740. [PMID: 35877084 PMCID: PMC9338456 DOI: 10.1093/jncics/pkac043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 10/26/2021] [Revised: 12/02/2021] [Accepted: 02/24/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND STAMPEDE previously reported adding upfront docetaxel improved overall survival for prostate cancer patients starting long-term androgen deprivation therapy. We report long-term results for non-metastatic patients using, as primary outcome, metastatic progression-free survival (mPFS), an externally demonstrated surrogate for overall survival. METHODS Standard of care (SOC) was androgen deprivation therapy with or without radical prostate radiotherapy. A total of 460 SOC and 230 SOC plus docetaxel were randomly assigned 2:1. Standard survival methods and intention to treat were used. Treatment effect estimates were summarized from adjusted Cox regression models, switching to restricted mean survival time if non-proportional hazards. mPFS (new metastases, skeletal-related events, or prostate cancer death) had 70% power (α = 0.05) for a hazard ratio (HR) of 0.70. Secondary outcome measures included overall survival, failure-free survival (FFS), and progression-free survival (PFS: mPFS, locoregional progression). RESULTS Median follow-up was 6.5 years with 142 mPFS events on SOC (3 year and 54% increases over previous report). There was no good evidence of an advantage to SOC plus docetaxel on mPFS (HR = 0.89, 95% confidence interval [CI] = 0.66 to 1.19; P = .43); with 5-year mPFS 82% (95% CI = 78% to 87%) SOC plus docetaxel vs 77% (95% CI = 73% to 81%) SOC. Secondary outcomes showed evidence SOC plus docetaxel improved FFS (HR = 0.70, 95% CI = 0.55 to 0.88; P = .002) and PFS (nonproportional P = .03, restricted mean survival time difference = 5.8 months, 95% CI = 0.5 to 11.2; P = .03) but no good evidence of overall survival benefit (125 SOC deaths; HR = 0.88, 95% CI = 0.64 to 1.21; P = .44). There was no evidence SOC plus docetaxel increased late toxicity: post 1 year, 29% SOC and 30% SOC plus docetaxel grade 3-5 toxicity. CONCLUSIONS There is robust evidence that SOC plus docetaxel improved FFS and PFS (previously shown to increase quality-adjusted life-years), without excess late toxicity, which did not translate into benefit for longer-term outcomes. This may influence patient management in individual cases.
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Affiliation(s)
- Nicholas D James
- Division of Radiotherapy and Imaging, The Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, UK
| | - Fiona C Ingleby
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Noel W Clarke
- The Christie and Salford Royal Hospitals, Manchester, UK
| | - Claire L Amos
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | | | - Christopher D Brawley
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Simon Chowdhury
- Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Sarah Cannon Research Institute, London, UK
| | | | - David P Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, UK
| | - Duncan C Gilbert
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Silke Gillessen
- Istituto Oncologico della Svizzera Italiana, Bellinzona, Switzerland
| | - Robert J Jones
- Institute of Cancer Sciences, University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Ruth E Langley
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Archie Macnair
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK.,Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Zafar I Malik
- The Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, UK
| | | | - David J Matheson
- Faculty of Education, Health and Wellbeing, University of Wolverhampton, Wolverhampton, UK
| | - Robin Millman
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Chris C Parker
- Division of Radiotherapy and Imaging, The Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, UK
| | - Hannah L Rush
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK.,Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - J Martin Russell
- Institute of Cancer Sciences, University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Carly Au
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Alastair W S Ritchie
- Urology Department, Gloucestershire Royal NHS Foundation Trust, Gloucester, UK (retired)
| | - Ricardo Pereira Mestre
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.,Institute of Oncology Research (IOR), Bellinzona, Switzerland
| | | | - Alison J Birtle
- Rosemere Cancer Centre Lancs Teaching Hospitals, Preston, UK.,University of Manchester, Manchester, UK.,University of Central Lancashire (UCLan), Lancaster, UK
| | | | - Prantik Das
- University Hospitals of Derby NHS Foundation Trust, Derby, UK
| | | | | | | | | | - Duncan B McLaren
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - Ashok D Nikapota
- Sussex Cancer Centre, University Hospitals Sussex, Brighton, UK.,Worthing and Southlands Hospital, Worthing, UK
| | - Joe M O'Sullivan
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
| | - Carla Perna
- Royal Surrey NHS Foundation Trust, Guildford, UK
| | | | | | | | | | - Shaun P Tolan
- The Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, UK
| | - John Wagstaff
- Swansea University College of Medicine & The South West Wales Cancer Centre, Swansea, UK
| | | | | | | | - Mahesh K B Parmar
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Matthew R Sydes
- MRC Clinical Trials Unit at University College London (UCL), Institute of Clinical Trials and Methodology, UCL, London, UK
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Armstrong AJ, Clarke NW, Thiery-Vuillemin A, Oya M, Procopio G, Janoski De Menezes J, Girotto GC, Ghatalia P, Nole F, Din O, Spiegelhalder P, Mincik I, van Alphen RJ, Lumen N, Hosius C, Zhou D, Barker L, Dujka ME, Saad F. Olaparib plus abiraterone as first-line therapy in men with metastatic castration-resistant prostate cancer: Pharmacokinetics data from the PROpel trial. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.5050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
5050 Background: PROpel (NCT03732820) is a double-blind, Phase III trial of abiraterone + olaparib vs abiraterone + placebo as first-line treatment in patients with metastatic castration-resistant prostate cancer (mCRPC). Here we report results from the pharmacokinetics (PK) analysis of patients in PROpel. Methods: Patients were randomized 1:1 to receive abiraterone (1000 mg qd) plus prednisone/prednisolone with either olaparib (full monotherapy dose: 300 mg bid) or placebo. Eligible patients were biomarker unselected with confirmed prostate adenocarcinoma and castration-resistant metastatic disease. They had not received prior chemotherapy or next-generation hormonal agents (NHAs) for mCRPC. PK sampling was performed in a subset of patients. Concentrations of olaparib and abiraterone, and its active metabolite Δ4-abiraterone, were measured at steady state predose, at 30 min, 2 h, 3 h, 5 h, and 8 h postdose. The data underwent noncompartmental analysis to evaluate the effect of olaparib on abiraterone PK. The PK of olaparib in the presence of abiraterone was also compared with olaparib PK from other monotherapy studies to evaluate the effect of abiraterone on olaparib PK. Results: The PK analysis included 66 patients from the olaparib + abiraterone arm and 58 patients from the placebo + abiraterone arm. Olaparib absorption was rapid, with median tmax,ss of 2 h. Absorption of abiraterone was rapid in both treatment groups, with median tmax,ss observed between 2.00 and 2.04 h. The steady state exposure of olaparib in the presence of abiraterone, based on AUCss, Cmax,ss and Cmin,ss, was similar to observations for patients receiving olaparib 300 mg bid monotherapy in other Phase III studies, with values of 39.3 μg⋅h/mL, 6.3 μg/mL, and 1.0 μg/mL, respectively. Steady state exposures for abiraterone were similar between the two treatment arms (abiraterone + placebo: AUC(08) = 339.5 ng⋅h/mL, Cmax,ss = 105.4 ng/mL, Cmin,ss = 8.5 ng/mL; abiraterone + olaparib: AUC(08) = 393.7 ng⋅h/mL, Cmax,ss = 112.6 ng/mL, Cmin,ss = 7.7 ng/mL), and PK data for the abiraterone + olaparib arm were similar to those reported in the literature for abiraterone monotherapy. Conclusions: Combination treatment of olaparib ( full monotherapy dose: 300 mg bid) and abiraterone (1000 mg qd) in patients with mCRPC had no clinically significant effect on the PK profiles of either drug. The steady state exposures for abiraterone were similar between the two treatment arms, indicating that co-administration with olaparib 300 mg bid has no effect on the PK of abiraterone. In line with previous Phase II trial data, results from PROpel confirmed that there were no relevant PK based drugdrug-interactions between olaparib and abiraterone. Clinical trial information: NCT03732820.
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Affiliation(s)
| | - Noel W. Clarke
- The Christie and Salford Royal Hospital NHS Foundation Trusts and University of Manchester, Manchester, United Kingdom
| | | | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | | | | | | | | | - Franco Nole
- Medical Oncology Division of Urogenital and Head and Neck Tumors, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Omar Din
- Weston Park Cancer Centre, Sheffield, United Kingdom
| | | | | | - Robbert J. van Alphen
- Department of Internal Medicine, Elisabeth Tweesteden Hospital, Tilburg, Netherlands
| | - Nicolaas Lumen
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | | | | | | | | | - Fred Saad
- Centre Hospitalier de l’Université de Montréal/CRCHUM, Montreal, QC, Canada
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28
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Thiery-Vuillemin A, Saad F, Armstrong AJ, Oya M, Vianna KCM, Özgüroğlu M, Gedye C, Buchschacher GL, Lee JY, Emmenegger U, Navratil J, Virizuela JA, Salazar A, Maillet D, Uemura H, Kim J, Lukacs E, Barker L, Degboe AN, Clarke NW. Tolerability of abiraterone (abi) combined with olaparib (ola) in patients (pts) with metastatic castration-resistant prostate cancer (mCRPC): Further results from the phase III PROpel trial. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.5019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
5019 Background: The Phase III PROpel (NCT03732820) trial demonstrated at interim analysis a statistically significant clinical benefit from combining ola + abi in the first-line (1L) mCRPC setting vs placebo (pbo) + abi. Benefit was seen irrespective of a pt’s homologous recombination repair mutation (HRRm) status; median radiographic progression-free survival (rPFS) 24.8 for ola + abi vs 16.6 months for pbo + abi (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.54–0.81; P<0.0001). The safety profile of ola + abi was shown to be consistent with that for the individual drugs. We report additional interim safety analysis from PROpel. Methods: Eligible pts were ≥18 years with mCRPC, had received no prior chemotherapy or next-generation hormonal agent treatment at mCRPC stage, and were unselected by HRRm status. Pts were randomized 1:1 to abi (1000 mg qd) plus prednisone/prednisolone with either ola (300 mg bid) or pbo. Primary endpoint was investigator-assessed rPFS. Safety was assessed in all pts receiving ≥1 dose of study treatment by adverse event (AE) reporting (CTCAE v4.03). Results: 398 pts received ola + abi and 396 pbo + abi (safety analysis set). At data cut-off (July 30, 2021), median total duration of exposure for ola was 17.5 vs 15.7 months for pbo, and for abi 18.2 months in the ola + abi arm and 15.7 in the pbo + abi arm. Anemia (n=183) was the most common AE in the ola + abi arm, and 34% of these 183 events were managed by dose interruption, 23% by dose reduction, and 8% resulted in treatment discontinuation. Anemia and pulmonary embolism (PE) were the only Grade ≥3 AEs in ≥5% of pts (anemia: ola + abi, 15.1% vs pbo + abi, 3.3%; PE: 6.5% vs 1.8%, respectively). Most PEs were detected incidentally on radiographic imaging (69.2% and 71.4% in the ola + abi and pbo + abi arms, respectively) and no pts discontinued. More pts in the ola + abi arm experienced venous thromboembolism (Table). Arterial thromboembolism and cardiac failure AEs were balanced between the treatment arms. No AE of myelodysplastic syndrome/acute myeloid leukemia was reported in either treatment arm. COVID-19 was reported more frequently with ola + abi (8.3% vs 4.5%). Conclusions: PROpel demonstrated a predictable safety profile for ola + abi given in combination to pts with 1L mCRPC unselected by HRRm status. AEs of cardiac failure and arterial thromboembolism were reported at similar frequency in both treatment arms. The majority of PEs were asymptomatic. The safety profile of abiraterone was not adversely impacted by its combination with olaparib. Clinical trial information: NCT03732820. [Table: see text]
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Affiliation(s)
| | - Fred Saad
- Centre Hospitalier de l’Université de Montréal/CRCHUM, Université de Montreal, Montreal, QC, Canada
| | - Andrew J. Armstrong
- Duke Cancer Institute Center for Prostate and Urologic Cancer, Duke University, Durham, NC
| | | | | | - Mustafa Özgüroğlu
- Istanbul University Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Craig Gedye
- Calvary Mater Newcastle, Waratah, NSW, Australia
| | | | - Ji Youl Lee
- The Catholic University of Korea Seoul St. Mary's Hospital, Seoul, South Korea
| | | | - Jiri Navratil
- Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | | | | | | | - Hiroji Uemura
- Yokohama City University Medical Center, Kanagawa, Japan
| | - Jeri Kim
- Merck & Co., Inc., Kenilworth, NJ
| | | | | | | | - Noel W. Clarke
- The Christie and Salford Royal Hospital NHS Foundation Trusts and University of Manchester, Manchester, United Kingdom
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29
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Sachdeva A, Hart CA, Carey CD, Vincent AE, Greaves LC, Heer R, Oliveira P, Brown MD, Clarke NW, Turnbull DM. Automated quantitative high-throughput multiplex immunofluorescence pipeline to evaluate OXPHOS defects in formalin-fixed human prostate tissue. Sci Rep 2022; 12:6660. [PMID: 35459777 PMCID: PMC9033818 DOI: 10.1038/s41598-022-10588-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 09/30/2021] [Accepted: 04/01/2022] [Indexed: 11/09/2022] Open
Abstract
Advances in multiplex immunofluorescence (mIF) and digital image analysis has enabled simultaneous assessment of protein defects in electron transport chain components. However, current manual methodology is time consuming and labour intensive. Therefore, we developed an automated high-throughput mIF workflow for quantitative single-cell level assessment of formalin fixed paraffin embedded tissue (FFPE), leveraging tyramide signal amplification on a Ventana Ultra platform coupled with automated multispectral imaging on a Vectra 3 platform. Utilising this protocol, we assessed the mitochondrial oxidative phosphorylation (OXPHOS) protein alterations in a cohort of benign and malignant prostate samples. Mitochondrial OXPHOS plays a critical role in cell metabolism, and OXPHOS perturbation is implicated in carcinogenesis. Marked inter-patient, intra-patient and spatial cellular heterogeneity in OXPHOS protein abundance was observed. We noted frequent Complex IV loss in benign prostate tissue and Complex I loss in age matched prostate cancer tissues. Malignant regions within prostate cancer samples more frequently contained cells with low Complex I & IV and high mitochondrial mass in comparison to benign-adjacent regions. This methodology can now be applied more widely to study the frequency and distribution of OXPHOS alterations in formalin-fixed tissues, and their impact on long-term clinical outcomes.
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Affiliation(s)
- Ashwin Sachdeva
- Genito Urinary Cancer Research Group, Division of Cancer Sciences, Oglesby Cancer Research Building, University of Manchester, Manchester, M20 4GJ, UK.
- Belfast-Manchester Movember FASTMAN Prostate Cancer Centre of Excellence, Manchester, UK.
- Department of Surgery, The Christie NHS Foundation Trust, Manchester, M20 4BX, UK.
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle-upon-Tyne, UK.
| | - Claire A Hart
- Genito Urinary Cancer Research Group, Division of Cancer Sciences, Oglesby Cancer Research Building, University of Manchester, Manchester, M20 4GJ, UK
- Belfast-Manchester Movember FASTMAN Prostate Cancer Centre of Excellence, Manchester, UK
| | - Christopher D Carey
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
- NovoPath, Cellular Pathology, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Amy E Vincent
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle-upon-Tyne, UK
| | - Laura C Greaves
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle-upon-Tyne, UK
| | - Rakesh Heer
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Pedro Oliveira
- Department of Pathology, The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
| | - Michael D Brown
- Genito Urinary Cancer Research Group, Division of Cancer Sciences, Oglesby Cancer Research Building, University of Manchester, Manchester, M20 4GJ, UK
- Belfast-Manchester Movember FASTMAN Prostate Cancer Centre of Excellence, Manchester, UK
| | - Noel W Clarke
- Genito Urinary Cancer Research Group, Division of Cancer Sciences, Oglesby Cancer Research Building, University of Manchester, Manchester, M20 4GJ, UK
- Belfast-Manchester Movember FASTMAN Prostate Cancer Centre of Excellence, Manchester, UK
- Department of Surgery, The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
- Department of Urology, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | - Doug M Turnbull
- Wellcome Centre for Mitochondrial Research, Newcastle University, Newcastle-upon-Tyne, UK
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30
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Rush HL, Murphy L, Morgans AK, Clarke NW, Cook AD, Attard G, Macnair A, Dearnaley DP, Parker CC, Russell JM, Gillessen S, Matheson D, Millman R, Brawley CD, Pugh C, Tanguay JS, Jones RJ, Wagstaff J, Rudman S, O'Sullivan JM, Gale J, Birtle A, Protheroe A, Gray E, Perna C, Tolan S, McPhail N, Malik ZI, Vengalil S, Fackrell D, Hoskin P, Sydes MR, Chowdhury S, Gilbert DC, Parmar MKB, James ND, Langley RE. Quality of Life in Men With Prostate Cancer Randomly Allocated to Receive Docetaxel or Abiraterone in the STAMPEDE Trial. J Clin Oncol 2022; 40:825-836. [PMID: 34757812 PMCID: PMC7612717 DOI: 10.1200/jco.21.00728] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [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] [Received: 03/22/2021] [Revised: 08/09/2021] [Accepted: 10/01/2021] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Docetaxel and abiraterone acetate plus prednisone or prednisolone (AAP) both improve survival when commenced alongside standard of care (SOC) androgen deprivation therapy in locally advanced or metastatic hormone-sensitive prostate cancer. Thus, patient-reported quality of life (QOL) data may guide treatment choices. METHODS A group of patients within the STAMPEDE trial were contemporaneously enrolled with the possibility of being randomly allocated to receive either docetaxel + SOC or AAP + SOC. A mixed-model assessed QOL in those who had completed at least one QLQ-C30 + PR25 questionnaire. The primary outcome measure was difference in global-QOL (QLQ-C30 Q29&30) between patients allocated to docetaxel + SOC or AAP + SOC over the 2 years after random assignment, with a predefined criterion for clinically meaningful difference of > 4.0 points. Secondary outcome measures included longitudinal comparison of functional domains, pain, and fatigue, plus global-QOL at defined timepoints. RESULTS Five hundred fifteen patients (173 docetaxel + SOC and 342 AAP + SOC) were included. Baseline characteristics, proportion of missing data, and mean baseline global-QOL scores (docetaxel + SOC 77.8 and AAP + SOC 78.0) were similar. Over the 2 years following random assignment, the mean modeled global-QOL score was +3.9 points (95% CI, +0.5 to +7.2; P = .022) higher in patients allocated to AAP + SOC. Global-QOL was higher for patients allocated to AAP + SOC over the first year (+5.7 points, 95% CI, +3.0 to +8.5; P < .001), particularly at 12 (+7.0 points, 95% CI, +3.0 to +11.0; P = .001) and 24 weeks (+8.3 points, 95% CI, +4.0 to +12.6; P < .001). CONCLUSION Patient-reported QOL was superior for patients allocated to receive AAP + SOC, compared with docetaxel + SOC over a 2-year period, narrowly missing the predefined value for clinical significance. Patients receiving AAP + SOC reported clinically meaningful higher global-QOL scores throughout the first year following random assignment.
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Affiliation(s)
- Hannah L. Rush
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | - Laura Murphy
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | | | - Noel W. Clarke
- The Christie and Salford Royal NHS Foundation Trusts, Manchester, United Kingdom
| | - Adrian D. Cook
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | | | - Archie Macnair
- MRC Clinical Trials Units at University College London, London, United Kingdom
- Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - David P. Dearnaley
- Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - Christopher C. Parker
- Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - J. Martin Russell
- Institute of Cancer Sciences, University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, Scotland
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - David Matheson
- University of Wolverhampton, Wolverhampton, United Kingdom
| | - Robin Millman
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | | | - Cheryl Pugh
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | | | - Robert J. Jones
- Institute of Cancer Sciences, University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, Scotland
| | - John Wagstaff
- Swansea University College of Medicine, Swansea, United Kingdom
| | - Sarah Rudman
- Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Joe M. O'Sullivan
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, United Kingdom
| | - Joanna Gale
- Portsmouth Hospital University Trust, Portsmouth, United Kingdom
| | - Alison Birtle
- Rosemere Cancer Centre, Lancs Teaching Hospitals, Preston, United Kingdom
- University of Manchester, Manchester, United Kingdom
| | - Andrew Protheroe
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Emma Gray
- Musgrove Park Hospital, Taunton, United Kingdom
| | - Carla Perna
- Royal Surrey Hospital Foundation Trust, Guildford, United Kingdom
| | - Shaun Tolan
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | | | - Zaf I. Malik
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Salil Vengalil
- University Hospital North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - David Fackrell
- University Hospital Birmingham, Birmingham, United Kingdom
| | - Peter Hoskin
- University of Manchester, Manchester, United Kingdom
- Mount Vernon Cancer Centre and University of Manchester, Manchester, United Kingdom
| | - Matthew R. Sydes
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | - Simon Chowdhury
- Guys and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Duncan C. Gilbert
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | - Mahesh K. B. Parmar
- MRC Clinical Trials Units at University College London, London, United Kingdom
| | - Nicholas D. James
- Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, United Kingdom
| | - Ruth E. Langley
- MRC Clinical Trials Units at University College London, London, United Kingdom
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31
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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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Nossiter J, Morris M, Parry MG, Sujenthiran A, Cathcart P, van der Meulen J, Aggarwal A, Payne H, Clarke NW. Impact of the Covid-19 pandemic on the diagnosis and treatment of men with prostate cancer. BJU Int 2022; 130:262-270. [PMID: 35080142 DOI: 10.1111/bju.15699] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 01/04/2022] [Accepted: 01/17/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the impact of the Covid-19 pandemic on diagnostic and treatment activity in 2020 across hospital providers of prostate cancer (PCa) care in the English National Health Service. METHODS Diagnostic and treatment activity between March 23rd (start of first national lockdown in England) and December 31st 2020 was compared with same calendar period in 2019. Patients newly diagnosed with PCa were identified in national rapid cancer registration data linked to other electronic healthcare datasets. RESULTS There was a 30.8% reduction (22,419 versus 32,409) in the number of men with newly diagnosed PCa in 2020 after the start of the first lockdown, compared with the corresponding period in 2019. Men diagnosed in 2020 were typically at more advanced stage (21.2% versus 17.4%, stage IV) and slightly older (57.9% versus 55.9% ≥ 70 years, p<0.001). Prostate biopsies in 2020 were more often performed through using transperineal routes (64.0% versus 38.2%). The number of radical prostatectomies in 2020 was reduced by 26.9% (3,896 versus 5,331) and the number treated by external beam radiotherapy (EBRT) by 14.1% (9,719 versus 11,309). Other changes included an increased use of EBRT with hypofractionation and reduced use of docetaxel chemotherapy in men with hormone-sensitive metastatic PCa (413 versus 1,519) with related increase in the use of enzalutamide. CONCLUSION We found substantial deficits in the number of diagnostic and treatment procedures for men with newly diagnosed PCa after the start of the first lockdown in 2020. The number of men diagnosed with PCa decreased by about one third and those diagnosed had more advanced disease. Treatment patterns shifted towards those that limit the risk of Covid-19 exposure including increased use of transperineal biopsy, hypofractionated radiation, and enzalutamide. Urgent concerted action is required to address the Covid-19-related deficits in PCa services to mitigate their impact on long-term outcomes.
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Affiliation(s)
- Julie Nossiter
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine.,Clinical Effectiveness Unit, Royal College of Surgeons of England
| | - Melanie Morris
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine.,Clinical Effectiveness Unit, Royal College of Surgeons of England
| | - Matthew G Parry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine.,Clinical Effectiveness Unit, Royal College of Surgeons of England
| | | | - Paul Cathcart
- Department of Urology, NHS Foundation Trust, Guy's and St Thomas
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine.,Department of Radiotherapy, NHS Foundation Trust, Guy's and St Thomas.,Department of Cancer Epidemiology, Population, and Global Health, King's College London
| | - Heather Payne
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London
| | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts
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33
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Cannistraci A, Hascoet P, Ali A, Mundra P, Clarke NW, Pavet V, Marais R. MiR-378a inhibits glucose metabolism by suppressing GLUT1 in prostate cancer. Oncogene 2022; 41:1445-1455. [PMID: 35039635 PMCID: PMC8897193 DOI: 10.1038/s41388-022-02178-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 11/25/2020] [Revised: 12/07/2021] [Accepted: 01/05/2022] [Indexed: 12/24/2022]
Abstract
Prostate cancer (PCa) is the fifth leading cause of cancer related deaths worldwide, in part due to a lack of molecular stratification tools that can distinguish primary tumours that will remain indolent from those that will metastasise. Amongst potential molecular biomarkers, microRNAs (miRs) have attracted particular interest because of their high stability in body fluids and fixed tissues. These small non-coding RNAs modulate several physiological and pathological processes, including cancer progression. Herein we explore the prognostic potential and the functional role of miRs in localised PCa and their relation to nodal metastasis. We define a 7-miR signature that is associated with poor survival independently of age, Gleason score, pathological T state, N stage and surgical margin status and that is also prognostic for disease-free survival in patients with intermediate-risk localised disease. Within our 7-miR signature, we show that miR-378a-3p (hereafter miR-378a) levels are low in primary tumours compared to benign prostate tissue, and also lower in Gleason score 8-9 compared to Gleason 6-7 PCa. We demonstrate that miR-378a impairs glucose metabolism and reduces proliferation in PCa cells through independent mechanisms, and we identify glucose transporter 1 (GLUT1) messenger RNA as a direct target of miR-378a. We show that GLUT1 inhibition hampers glycolysis, leading to cell death. Our data provides a rational for a new PCa stratification strategy based on miR expression, and it reveals that miR-378a and GLUT1 are potential therapeutic targets in highly aggressive glycolytic PCa.
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Affiliation(s)
- A Cannistraci
- Molecular Oncology Group, Cancer Research UK Manchester Institute, The University of Manchester, Alderley Park, Macclesfield, Cheshire, SK10 4TG, UK
| | - P Hascoet
- Molecular Oncology Group, Cancer Research UK Manchester Institute, The University of Manchester, Alderley Park, Macclesfield, Cheshire, SK10 4TG, UK
| | - A Ali
- Genito-Urinary Cancer Research Group and the FASTMAN Prostate Cancer Centre for Excellence, Division of Cancer Sciences, Manchester Cancer Research Centre, The University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, UK
| | - P Mundra
- Molecular Oncology Group, Cancer Research UK Manchester Institute, The University of Manchester, Alderley Park, Macclesfield, Cheshire, SK10 4TG, UK
| | - N W Clarke
- Genito-Urinary Cancer Research Group and the FASTMAN Prostate Cancer Centre for Excellence, Division of Cancer Sciences, Manchester Cancer Research Centre, The University of Manchester, 555 Wilmslow Road, Manchester, M20 4GJ, UK.,The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, UK
| | - V Pavet
- Molecular Oncology Group, Cancer Research UK Manchester Institute, The University of Manchester, Alderley Park, Macclesfield, Cheshire, SK10 4TG, UK.
| | - R Marais
- Molecular Oncology Group, Cancer Research UK Manchester Institute, The University of Manchester, Alderley Park, Macclesfield, Cheshire, SK10 4TG, UK.
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34
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Parry MG, Nossiter J, Morris M, Sujenthiran A, Skolarus TA, Berry B, Nathan A, Cathcart P, Aggarwal A, van der Meulen J, Trinh QD, Payne H, Clarke NW. Comparison of the treatment of men with prostate cancer between the US and England: an international population-based study. Prostate Cancer Prostatic Dis 2022:10.1038/s41391-021-00482-6. [PMID: 35001083 DOI: 10.1038/s41391-021-00482-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The treatment of prostate cancer varies between the United States (US) and England, however this has not been well characterised using recent data. We therefore investigated the extent of the differences between US and English patients with respect to initial treatment. METHODS We used the Surveillance, Epidemiology, and End Results (SEER) database to identify men diagnosed with prostate cancer in the US and the treatments they received. We also used the National Prostate Cancer Audit (NPCA) database for the same purposes among men diagnosed with prostate cancer in England. Next, we used multivariable regression to estimate the adjusted risk ratio (aRR) of receiving radical local treatment for men with non-metastatic prostate cancer according to the country of diagnosis (US vs. England). The five-tiered Cambridge Prognostic Group (CPG) classification was included as an interaction term. RESULTS We identified 109,697 patients from the SEER database, and 74,393 patients from the NPCA database, who were newly diagnosed with non-metastatic prostate cancer between April 1st 2014 and December 31st 2016 with sufficient information for risk stratification according to the CPG classification. Men in the US were more likely to receive radical local treatment across all prognostic groups compared to men in England (% radical treatment US vs. England, CPG1: 38.1% vs. 14.3% - aRR 2.57, 95% CI 2.47-2.68; CPG2: 68.6% vs. 52.6% - aRR 1.27, 95% CI 1.25-1.29; CPG3: 76.7% vs. 67.1% - aRR 1.12, 95% CI 1.10-1.13; CPG4: 82.6% vs. 72.4% - aRR 1.09, 95% CI 1.08-1.10; CPG5: 78.2% vs. 71.7% - aRR 1.06, 95% CI 1.04-1.07) CONCLUSIONS: Treatment rates were higher in the US compared to England raising potential over-treatment concerns for low-risk disease (CPG1) in the US and under-treatment of clinically significant disease (CPG3-5) in England.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK. .,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.
| | - Julie Nossiter
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Melanie Morris
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,Flatiron, London, UK
| | - Ted A Skolarus
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA.,Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Brendan Berry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Arjun Nathan
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.,University College London, London, UK
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Quoc-Dien Trinh
- Harvard Medical School, Boston, USA.,Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Noel W Clarke
- Department of Urology, The Christie NHS Foundation Trust, Manchester, UK.,Department of Urology, Salford Royal NHS Foundation Trust, Salford, UK
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35
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Clarke CS, Hunter RM, Gabrio A, Brawley CD, Ingleby FC, Dearnaley DP, Matheson D, Attard G, Rush HL, Jones RJ, Cross W, Parker C, Russell JM, Millman R, Gillessen S, Malik Z, Lester JF, Wylie J, Clarke NW, Parmar MKB, Sydes MR, James ND. Cost-utility analysis of adding abiraterone acetate plus prednisone/prednisolone to long-term hormone therapy in newly diagnosed advanced prostate cancer in England: Lifetime decision model based on STAMPEDE trial data. PLoS One 2022; 17:e0269192. [PMID: 35653395 PMCID: PMC9162346 DOI: 10.1371/journal.pone.0269192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/14/2022] [Indexed: 01/27/2023] Open
Abstract
Adding abiraterone acetate (AA) plus prednisolone (P) to standard of care (SOC) improves survival in newly diagnosed advanced prostate cancer (PC) patients starting hormone therapy. Our objective was to determine the value for money to the English National Health Service (NHS) of adding AAP to SOC. We used a decision analytic model to evaluate cost-effectiveness of providing AAP in the English NHS. Between 2011-2014, the STAMPEDE trial recruited 1917 men with high-risk localised, locally advanced, recurrent or metastatic PC starting first-line androgen-deprivation therapy (ADT), and they were randomised to receive SOC plus AAP, or SOC alone. Lifetime costs and quality-adjusted life-years (QALYs) were estimated using STAMPEDE trial data supplemented with literature data where necessary, adjusting for baseline patient and disease characteristics. British National Formulary (BNF) prices (£98/day) were applied for AAP. Costs and outcomes were discounted at 3.5%/year. AAP was not cost-effective. The incremental cost-effectiveness ratio (ICER) was £149,748/QALY gained in the non-metastatic (M0) subgroup, with 2.4% probability of being cost-effective at NICE's £30,000/QALY threshold; and the metastatic (M1) subgroup had an ICER of £47,503/QALY gained, with 12.0% probability of being cost-effective. Scenario analysis suggested AAP could be cost-effective in M1 patients if priced below £62/day, or below £28/day in the M0 subgroup. AAP could dominate SOC in the M0 subgroup with price below £11/day. AAP is effective for non-metastatic and metastatic disease but is not cost-effective when using the BNF price. AAP currently only has UK approval for use in a subset of M1 patients. The actual price currently paid by the English NHS for abiraterone acetate is unknown. Broadening AAP's indication and having a daily cost below the thresholds described above is recommended, given AAP improves survival in both subgroups and its cost-saving potential in M0 subgroup.
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Affiliation(s)
- Caroline S. Clarke
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
- * E-mail:
| | - Rachael M. Hunter
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Andrea Gabrio
- Department of Methodology and Statistics, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Christopher D. Brawley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Fiona C. Ingleby
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David P. Dearnaley
- Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - David Matheson
- Patient Representative, University of Wolverhampton, Wolverhampton, United Kingdom
| | - Gerhardt Attard
- University College London Cancer Institute, London, United Kingdom
| | - Hannah L. Rush
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
- Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Rob J. Jones
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - William Cross
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Chris Parker
- Royal Marsden Hospital and Institute of Cancer Research, Sutton, United Kingdom
| | - J. Martin Russell
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Robin Millman
- Patient Representative, MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Silke Gillessen
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
- Università della Svizzera Italiana, Lugano, Switzerland
| | - Zafar Malik
- Clatterbridge Cancer Centre NHS Foundation Trust, Birkenhead, United Kingdom
| | - Jason F. Lester
- South West Wales Cancer Centre, Singleton Hospital, Swansea, United Kingdom
| | - James Wylie
- Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Noel W. Clarke
- Christie NHS Foundation Trust, Manchester, United Kingdom
- Salford Royal Hospital, Salford, United Kingdom
| | - Mahesh K. B. Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Nicholas D. James
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
- Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, United Kingdom
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36
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Parry MG, Skolarus TA, Nossiter J, Sujenthiran A, Morris M, Cowling TE, Berry B, Aggarwal A, Payne H, Cathcart P, Clarke NW, van der Meulen J. Urinary incontinence and use of incontinence surgery after radical prostatectomy: a national study using patient-reported outcomes. BJU Int 2021; 130:84-91. [PMID: 34846770 DOI: 10.1111/bju.15663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate whether patient-reported urinary incontinence and bother scores after radical prostatectomy result in subsequent intervention with incontinence surgery. METHODS Men diagnosed with prostate cancer in the English National Health Service between April 2014 and January 2016 were identified. Administrative data were used to identify men who had undergone a radical prostatectomy and those who subsequently underwent a urinary incontinence procedure. The National Prostate Cancer Audit database was used to identify men who had also completed a post-treatment survey. These surveys included the Expanded Prostate Cancer Composite Index (EPIC-26). The frequency of subsequent incontinence procedures, within 6 months of the survey, was explored according to EPIC-26 urinary incontinence scores. The relationship between "good" (≥75) or "bad" (≤25) EPIC-26 urinary incontinence scores and perceptions of urinary bother was also explored (responses ranging from 'no problem' to 'big problem' with respect to their urinary function). RESULTS We identified 11,290 men who had undergone a radical prostatectomy. The 3-year cumulative incidence of incontinence surgery was 2.5%. After exclusions, we identified 5,165 men who had also completed a post-treatment survey after a median time of 19 months (response rate 74%). 481 men (9.3%) reported a "bad" urinary incontinence score and 207 men (4.0%) also reported that they had a big problem with their urinary function. 47 men went on to have incontinence surgery within 6 months of survey completion (0.9%), of whom 93.6% had a "bad" urinary incontinence score. Of the 71 men with the worst urinary incontinence score (zero), only 11 men (15.5%) subsequently had incontinence surgery. CONCLUSION In England, there is a significant number of men living with severe, bothersome urinary incontinence following radical prostatectomy, and an unmet clinical need for incontinence surgery. The systematic collection of patient-reported outcomes could be used to identify men who may benefit from incontinence surgery.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research & Policy, LHSTM, USA.,Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | - Ted A Skolarus
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA.,Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Julie Nossiter
- Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, Royal College of Surgeons of England, USA.,Flatiron, UK
| | - Melanie Morris
- Department of Health Services Research & Policy, LHSTM, USA.,Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | | | - Brendan Berry
- Department of Health Services Research & Policy, LHSTM, USA.,Clinical Effectiveness Unit, Royal College of Surgeons of England, USA
| | - Ajay Aggarwal
- Department of Radiotherapy, NHS Foundation Trust, Guy's & St Thomas, UK.,Department of Cancer Epidemiology, KCL, Population & Global Health, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Paul Cathcart
- Department of Urology, NHS Foundation Trust, Guy's & St Thomas, UK
| | - Noel W Clarke
- Department of Urology, Salford Royal NHS Foundation Trusts, The Christie &, UK
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37
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Carr TH, Adelman C, Barnicle A, Kozarewa I, Luke S, Lai Z, Hollis S, Dougherty B, Harrington EA, Kang J, Saad F, Sala N, Thiery-Vuillemin A, Clarke NW, Hodgson D, Barrett JC. Homologous Recombination Repair Gene Mutation Characterization by Liquid Biopsy: A Phase II Trial of Olaparib and Abiraterone in Metastatic Castrate-Resistant Prostate Cancer. Cancers (Basel) 2021; 13:cancers13225830. [PMID: 34830984 PMCID: PMC8616430 DOI: 10.3390/cancers13225830] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary Mutations in homologous recombination repair (HRR) genes are frequent in advanced prostate cancer and tumours harbouring these mutations have known sensitivity to PARP inhibitors, such as olaparib. In the randomized double-blind Phase II study (NCT01972218), olaparib and abiraterone prolonged radiographic progression-free survival (rPFS) versus placebo and abiraterone in patients with metastatic castration-resistant prostate cancer (mCRPC) unselected by HRR status. The study was designed to prioritize tumour samples for a pre-specified analysis of HRR status but was challenged by a low tissue submission rate. Circulating tumour DNA (ctDNA) and germline testing were initiated to supplement the assessment. Here, we present data from further germline and ctDNA analyses which increase the number of patients with confirmed HRR status. Our results support prior findings that patients with mCRPC benefit from olaparib and abiraterone treatment regardless of HRR status and highlight the value of ctDNA testing as a complement to tumour tissue sequencing. Abstract Background: Phase III randomized trial data have confirmed the activity for olaparib in homologous recombination repair (HRR) mutated metastatic castration-resistant prostate cancer (mCRPC) post next-generation hormonal agent (NHA) progression. Preclinical data have suggested the potential for a combined effect between olaparib and NHAs irrespective of whether an HRR gene alteration was present. NCT01972217 was a randomised double-blind Phase II study which evaluated olaparib and abiraterone versus placebo and abiraterone in mCRPC patients who had received prior chemotherapy containing docetaxel. The study showed that radiologic progression was significantly delayed by the combination of olaparib and abiraterone regardless of homologous recombination repair mutation (HRRm) status. The study utilized tumour, blood (germline), and circulating tumour DNA (ctDNA) analysis to profile patient HRRm status, but tumour tissue provision was not mandated, leading to relatively low tissue acquisition and DNA sequencing success rates not representative of real-world testing. Patients and methods: Further analysis of germline and ctDNA samples has been performed for the trial to characterize HRRm status more fully and robustly analyse patient response to treatment. Results: Germline and plasma testing increased the HRRm characterized population from 27% to 68% of 142 randomized patients. Tumour-derived variants were detectable with high confidence in 78% of patients with a baseline plasma sample (71% of randomized patients). There was high concordance across methodologies (plasma vs. tumour; plasma vs. germline). The HR for the exploratory analysis of radiographic progression-free survival was 0.54 (95% CI: 0.32–0.93) in favour of olaparib and abiraterone in the updated HRR wild type (HRRwt) group (n = 73) and 0.62 (95% CI: 0.23–1.65) in the HRRm group (n = 23). Conclusion: Our results confirm the value of plasma testing for HRRm status when there is insufficient high-quality tissue for multi-gene molecular testing. We show that patients with mCRPC benefit from the combination of olaparib and abiraterone treatment regardless of HRRm status. The combination is currently being further investigated in the Phase III PROpel trial.
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Affiliation(s)
- T. Hedley Carr
- AstraZeneca, Cambridge CB4 0WG, UK; (A.B.); (I.K.); (S.L.); (S.H.); (E.A.H.)
- Correspondence: (T.H.C.); (J.C.B.); Tel.: +44-(0)1223-223568 (T.H.C.)
| | - Carrie Adelman
- AstraZeneca, Boston, MA 43183, USA; (C.A.); (Z.L.); (B.D.); (D.H.)
| | - Alan Barnicle
- AstraZeneca, Cambridge CB4 0WG, UK; (A.B.); (I.K.); (S.L.); (S.H.); (E.A.H.)
| | - Iwanka Kozarewa
- AstraZeneca, Cambridge CB4 0WG, UK; (A.B.); (I.K.); (S.L.); (S.H.); (E.A.H.)
| | - Sally Luke
- AstraZeneca, Cambridge CB4 0WG, UK; (A.B.); (I.K.); (S.L.); (S.H.); (E.A.H.)
| | - Zhongwu Lai
- AstraZeneca, Boston, MA 43183, USA; (C.A.); (Z.L.); (B.D.); (D.H.)
| | - Sally Hollis
- AstraZeneca, Cambridge CB4 0WG, UK; (A.B.); (I.K.); (S.L.); (S.H.); (E.A.H.)
| | - Brian Dougherty
- AstraZeneca, Boston, MA 43183, USA; (C.A.); (Z.L.); (B.D.); (D.H.)
| | | | - Jinyu Kang
- AstraZeneca, Gaithersburg, MD 20878, USA;
| | - Fred Saad
- University of Montreal Hospital Research Centre, Montreal, QC H4A 3J1, Canada;
| | - Nuria Sala
- Catalan Institute of Oncology, Hospital Josep Trueta, 17007 Girona, Spain;
| | | | - Noel W. Clarke
- The Christie NHS Foundation Trust, Manchester M20 4BX, UK;
| | - Darren Hodgson
- AstraZeneca, Boston, MA 43183, USA; (C.A.); (Z.L.); (B.D.); (D.H.)
| | - J. Carl Barrett
- AstraZeneca, Boston, MA 43183, USA; (C.A.); (Z.L.); (B.D.); (D.H.)
- Correspondence: (T.H.C.); (J.C.B.); Tel.: +44-(0)1223-223568 (T.H.C.)
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Lopes RD, Higano CS, Slovin SF, Nelson AJ, Bigelow R, Sørensen PS, Melloni C, Goodman SG, Evans CP, Nilsson J, Bhatt DL, Clarke NW, Olesen TK, Doyle-Olsen BT, Kristensen H, Arney L, Roe MT, Alexander JH. Cardiovascular Safety of Degarelix Versus Leuprolide in Patients With Prostate Cancer: The Primary Results of the PRONOUNCE Randomized Trial. Circulation 2021; 144:1295-1307. [PMID: 34459214 DOI: 10.1161/circulationaha.121.056810] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relative cardiovascular safety of gonadotropin-releasing hormone (GnRH) antagonists compared with GnRH agonists in men with prostate cancer and known atherosclerotic cardiovascular disease remains controversial. METHODS In this international, multicenter, prospective, randomized, open-label trial, men with prostate cancer and concomitant atherosclerotic cardiovascular disease were randomly assigned 1:1 to receive the GnRH antagonist degarelix or the GnRH agonist leuprolide for 12 months. The primary outcome was the time to first adjudicated major adverse cardiovascular event (composite of death, myocardial infarction, or stroke) through 12 months. RESULTS Because of slower-than-projected enrollment and fewer-than-projected primary outcome events, enrollment was stopped before the 900 planned participants were accrued. From May 3, 2016, to April 16, 2020, a total of 545 patients from 113 sites across 12 countries were randomly selected. Baseline characteristics were balanced between study groups. The median age was 73 years, 49.8% had localized prostate cancer; 26.3% had locally advanced disease, and 20.4% had metastatic disease. A major adverse cardiovascular event occurred in 15 (5.5%) patients assigned to degarelix and 11 (4.1%) patients assigned to leuprolide (hazard ratio, 1.28 [95% CI, 0.59-2.79]; P=0.53). CONCLUSIONS PRONOUNCE (A Trial Comparing Cardiovascular Safety of Degarelix Versus Leuprolide in Patients With Advanced Prostate Cancer and Cardiovascular Disease) is the first, international, randomized clinical trial to prospectively compare the cardiovascular safety of a GnRH antagonist and a GnRH agonist in patients with prostate cancer. The study was terminated prematurely because of the smaller than planned number of participants and events, and no difference in major adverse cardiovascular events at 1 year between patients assigned to degarelix or leuprolide was observed. The relative cardiovascular safety of GnRH antagonists and agonists remains unresolved. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02663908.
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Affiliation(s)
- Renato D Lopes
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L., A.J.N., C.M., L.A., M.T.R., J.H.A.)
| | - Celestia S Higano
- Division of Medical Oncology, University of Washington and Fred Hutchinson Cancer Research Center, Seattle (C.S.H.)
| | - Susan F Slovin
- Genitourinary Oncology Service, Department of Medicine, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, NY (S.F.S.)
| | - Adam J Nelson
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L., A.J.N., C.M., L.A., M.T.R., J.H.A.)
| | | | - Per S Sørensen
- Ferring Pharmaceuticals A/S, Copenhagen, Denmark (P.S.S., T.K.O., B.T.D.-O., H.K.)
| | - Chiara Melloni
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L., A.J.N., C.M., L.A., M.T.R., J.H.A.)
- IQVIA, Durham, NC (C.M.)
| | - Shaun G Goodman
- Division of Cardiology, St. Michael's Hospital, Department of Medicine, University of Toronto, Ontario, Canada (S.G.G.)
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (S.G.G.)
| | - Christopher P Evans
- Department of Urologic Surgery, University of California, Davis, Sacramento (C.P.E.)
| | - Jan Nilsson
- Department of Clinical Sciences Malmö, Lund University, Sweden (J.N.)
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
| | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal Hospitals Manchester, United Kingdom (N.W.C.)
| | - Tine K Olesen
- Ferring Pharmaceuticals A/S, Copenhagen, Denmark (P.S.S., T.K.O., B.T.D.-O., H.K.)
| | | | - Henriette Kristensen
- Ferring Pharmaceuticals A/S, Copenhagen, Denmark (P.S.S., T.K.O., B.T.D.-O., H.K.)
| | - Lauren Arney
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L., A.J.N., C.M., L.A., M.T.R., J.H.A.)
| | - Matthew T Roe
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L., A.J.N., C.M., L.A., M.T.R., J.H.A.)
- Verana Health, San Francisco, CA (M.T.R.)
| | - John H Alexander
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (R.D.L., A.J.N., C.M., L.A., M.T.R., J.H.A.)
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Attard G, Brown LC, Clarke NW, Parmar MKB, James ND. Should Patients with High-risk Localised or Locally Advanced Prostate Cancer Receive Abiraterone Acetate in Addition to Androgen Deprivation Therapy? Update on a Planned Analysis of the STAMPEDE Trial. Eur Urol 2021; 80:522-523. [PMID: 34274134 DOI: 10.1016/j.eururo.2021.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/29/2021] [Indexed: 11/26/2022]
Affiliation(s)
| | - Louise C Brown
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Noel W Clarke
- FASTMAN Centre of Excellence, Manchester Cancer Research Centre, Manchester, UK; Department of Surgery, Christie NHS Foundation Trust, Manchester, UK; Department of Urology, Salford NHS Foundation Trust, Manchester, UK
| | - Mahesh K B Parmar
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Nicholas D James
- Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, London, UK
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40
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Parry MG, Boyle JM, Nossiter J, Morris M, Sujenthiran A, Berry B, Cathcart P, Aggarwal A, van der Meulen J, Payne H, Clarke NW. Determinants of variation in radical local treatment for men with high-risk localised or locally advanced prostate cancer in England. Prostate Cancer Prostatic Dis 2021:10.1038/s41391-021-00439-9. [PMID: 34493837 DOI: 10.1038/s41391-021-00439-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/27/2021] [Accepted: 08/06/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Many factors are implicated in the potential 'under-treatment' of prostate cancer but little is known about the between-hospital variation. METHODS The National Prostate Cancer Audit (NPCA) database was used to identify high-risk localised or locally advanced prostate cancer patients in England, between January 2014 and December 2017, and the treatments received. Hospital-level variation in radical local treatment was explored visually using funnel plots. The intra-class correlation coefficient (ICC) quantified the between-hospital variation in a random-intercept multivariable logistic regression model. RESULTS 53,888 men, from 128 hospitals, were included and 35,034 (65.0%) received radical local treatment. The likelihood of receiving radical local treatment was increased in men who were younger (the strongest predictor), more affluent, those with fewer comorbidities, and in those with a non-Black ethnic background. There was more between-hospital variation (P < 0.001) for patients aged ≥80 years (ICC: 0.235) compared to patients aged 75-79 years (ICC: 0.070), 70-74 years (ICC: 0.041), and <70 years (ICC: 0.048). Comorbidity and socioeconomic deprivation did not influence the between-hospital variation. CONCLUSIONS Radical local treatment of high-risk localised or locally advanced prostate cancer depended strongly on age and comorbidity, but also on socioeconomic deprivation and ethnicity, with the between-hospital variation being highest in older patients.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK. .,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
| | - Jemma M Boyle
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Julie Nossiter
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Melanie Morris
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Arunan Sujenthiran
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Brendan Berry
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ajay Aggarwal
- Department of Cancer Epidemiology, Population, and Global Health, King's College London, London, UK.,Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
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41
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Parry MG, Nossiter J, Sujenthiran A, Cowling TE, Patel RN, Morris M, Berry B, Cathcart P, Clarke NW, van der Meulen J, Aggarwal A. In Reply to Langley et al. Int J Radiat Oncol Biol Phys 2021; 110:913-914. [PMID: 34089685 DOI: 10.1016/j.ijrobp.2021.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 11/23/2022]
Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, LSHTM, London, England; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England
| | - Julie Nossiter
- Department of Health Services Research and Policy, LSHTM, London, England; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England
| | - Arunan Sujenthiran
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England
| | - Thomas E Cowling
- Department of Health Services Research and Policy, LSHTM, London, England
| | - Rajan N Patel
- Department of Gastroenterology, The Whittington Hospital NHS Trust, London, England
| | - Melanie Morris
- Department of Health Services Research and Policy, LSHTM, London, England; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England
| | - Brendan Berry
- Department of Health Services Research and Policy, LSHTM, London, England; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, England
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, England
| | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester, England; Heather Payne, FRCP FRCR, Department of Oncology, University College London Hospitals, London, England
| | - Jan van der Meulen
- Department of Health Services Research and Policy, LSHTM, London, England
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, LSHTM, London, England; Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, England
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Mendes L, Brawley CD, Grist E, Ali A, Santos Vidal S, Parry M, Lall S, Atako NB, Ishaq S, Richmond M, Haran A, Hoyle A, Zakka L, Sweeney C, Clarke NW, Parmar MKB, James ND, Brown LC, Berney D, Attard G. Proliferation index and survival in men with prostate cancer starting long-term androgen deprivation therapy in the STAMPEDE clinical trial. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.5076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
5076 Background: Treatment intensification with docetaxel or abiraterone improved survival for advanced prostate cancer starting androgen deprivation therapy (ADT) in the Systemic Therapy in Advancing or Metastatic Prostate Cancer: Evaluation of Drug Efficacy (STAMPEDE, NCT00268476) trial. However, survival and time-to-progression is highly variable on ADT, introducing the risk of unnecessary toxicity from additional treatments for some patients. Here we test the prognostic association of proliferation index using Ki67 scores in the control arm of the STAMPEDE population of high-risk localised (M0) and metastatic (M1) prostate cancer. Methods: Pre-ADT diagnostic needle biopsies were obtained from 517 men randomized in STAMPEDE arm A between 2006 and 2015. These were assessed for proliferation using an analytically optimised Ki67 immunohistochemistry assay. Ki67 was tested for associations with baseline clinico-pathological variables (Grade group, pre-ADT serum PSA and imaging metastatic burden) in univariable linear-regression models, and for associations with survival outcomes in multivariable Cox-regression models adjusted for these and additional confounding variables. Primary outcome measure was overall survival, secondary outcomes were prostate cancer-specific, failure-free, progression-free and metastatic progression-free survival. Results: Ki67 was available for 475 patients who received ADT only for at least 2 years ± radiotherapy. Of 202 M0, 74 were node positive. Of 273 M1, 116, 127 and 30 were respectively low, high and unknown radiological M1 volume. Ki67 score associated with higher Gleason (p=7.15x10-11) and presence of extra-pelvic metastases (p=1.41x10-8). Increasing Ki67 scores showed a strong linear association with poorer overall survival, with an estimated 2% increase in the hazard of death per percentage increase in the score (adjusted HR=1.02, 95% CI 1.01-1.02; p=1.04x10-5). There was also strong evidence that Ki67 associated positively with all secondary outcomes, including prostate cancer-specific survival (adjusted p=5.50x10-6) and metastatic progression-free survival (adjusted p=3.50x10-9). Conclusions: Ki67 immuno-score is strongly prognostic in clinically advanced prostate cancer independent of Gleason score and the other clinicopathological variables tested in this study. Ki67 is a clinically scalable assay that could improve selection for treatment intensification and provide a tool for screening patients most likely to benefit from further molecular investigation.
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Affiliation(s)
- Larissa Mendes
- University College London Cancer Institute, London, United Kingdom
| | | | - Emily Grist
- University College London Cancer Institute, London, United Kingdom
| | - Adnan Ali
- University of Manchester, Manchester, United Kingdom
| | | | - Marina Parry
- University College London Cancer Institute, London, United Kingdom
| | - Sharanpreet Lall
- University College London Cancer Institute, London, United Kingdom
| | | | - Sofeya Ishaq
- MRC Clinical Trials Unit UCL, London, United Kingdom
| | | | - Aine Haran
- The Christie and Salford Royal Hospital, Manchester, United Kingdom
| | - Alex Hoyle
- Christie NHS Foundation trust, Manchester, United Kingdom
| | - Leila Zakka
- University College London, London, United Kingdom
| | - Christopher Sweeney
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Noel W. Clarke
- GenitoUrinary Cancer Research Group, The Christie and Salford Royal Hospitals, Manchester, United Kingdom
| | - Mahesh K. B. Parmar
- Medical Research Center Clinical Trials Unit at University College London, London, United Kingdom
| | - Nicholas D. James
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, United Kingdom
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Grist E, Parry M, Friedrich S, Brawley CD, Mendes L, Lall S, Zakka L, Santos Vidal S, Atako NB, Richmond M, Ishaq S, Hoyle A, Ali A, Clarke NW, James ND, Parmar MKB, Berney D, Cremaschi P, Brown LC, Attard G. Copy number profiles of primary tumors for risk stratification of advanced prostate cancer: A biomarker study embedded in the multicenter STAMPEDE trial. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.5021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
5021 Background: Men with advanced hormone-sensitive prostate cancer (HSPC) starting long term androgen deprivation therapy (ADT) follow a highly variable clinical course. Treatment intensification with docetaxel or AR targeted therapies improves outcomes but there is a risk of overtreatment, especially in non-metastatic (M0) or metastatic (M1) low volume disease. We established a framework for biomarker evaluation in the STAMPEDE trial. We aimed to evaluate the feasibility and clinical utility of assessing the burden of copy number (CN) aberrations in newly diagnosed advanced HSPC. We hypothesised that increased percentage genome altered (PGA) would associate with higher disease burden and worse prognosis. Methods: We implemented a scalable strategy using low coverage whole genome sequencing (lpWGS) of formalin fixed paraffin embedded (FFPE) diagnostic core biopsies from STAMPEDE participants randomised to the standard of care ADT arm, between 2005 and 2016. Tissue was retrieved from 136 trial sites. 315 cases were randomly selected, aiming for a biomarker population of 300, anticipating an assay failure rate ̃5%. We defined 40% as the minimum histopathologically determined tumor cellularity (TC) for inclusion. We performed a survival analysis investigating PGA at diagnosis as a continuous measure with fractional polynomial specification in Cox models adjusting for disease burden, Gleason grade, pre-ADT PSA (log-transformed), age at randomisation and TC. We pre-specified that all hypothesis tests required evidence at the 5% significance level to consider rejecting the null hypothesis. Results: We successfully CN profiled 300/315 cases. There were no significantly different baseline clinico-pathological features between the full trial comparison n = 3106 and final biomarker population n = 300, 290/300 cases were de novo presentations. PGA in the core with highest Gleason grade and TC was median 18% (range 0%-75%; n = 300). PGA was significantly higher in M1 (n = 169) compared to M0 (n = 131) cases (median: 21% vs 14%; p = 0.00006). 284/300 were subclassified by disease burden into M0 node negative and node positive, and M1 low and high volume. PGA was significantly associated with increased disease burden (p = 0.00002). Increased PGA was significantly and non-linearly associated with an increased hazard of failure-free survival (p = 0.004), progression-free survival (p = 0.002), metastatic progression-free survival (p = 0.003), overall survival (p = 0.045) and prostate cancer-specific survival (p = 0.011). Conclusions: Evaluation of the burden of CN aberrations in archival, poor quality FFPE diagnostic tissue from men randomised in the STAMPEDE trial is feasible using lpWGS and has potential clinical utility to identify better prognosis advanced HSPC patients, who may not require treatment intensification.
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Affiliation(s)
- Emily Grist
- University College London Cancer Institute, London, United Kingdom
| | - Marina Parry
- University College London Cancer Institute, London, United Kingdom
| | | | | | - Larissa Mendes
- University College London Cancer Institute, London, United Kingdom
| | - Sharanpreet Lall
- University College London Cancer Institute, London, United Kingdom
| | - Leila Zakka
- University College London, London, United Kingdom
| | | | | | | | - Sofeya Ishaq
- MRC Clinical Trials Unit UCL, London, United Kingdom
| | - Alex Hoyle
- Christie NHS Foundation trust, Manchester, United Kingdom
| | - Adnan Ali
- University of Manchester, Manchester, United Kingdom
| | - Noel W. Clarke
- GenitoUrinary Cancer Research Group, The Christie and Salford Royal Hospitals, Manchester, United Kingdom
| | - Nicholas D. James
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Mahesh K. B. Parmar
- Medical Research Center Clinical Trials Unit at University College London, London, United Kingdom
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Ali A, Hoyle A, Haran ÁM, Brawley CD, Cook A, Amos C, Calvert J, Douis H, Mason MD, Dearnaley D, Attard G, Gillessen S, Parmar MKB, Parker CC, Sydes MR, James ND, Clarke NW. Association of Bone Metastatic Burden With Survival Benefit From Prostate Radiotherapy in Patients With Newly Diagnosed Metastatic Prostate Cancer: A Secondary Analysis of a Randomized Clinical Trial. JAMA Oncol 2021; 7:555-563. [PMID: 33599706 PMCID: PMC7893550 DOI: 10.1001/jamaoncol.2020.7857] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/06/2020] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Prostate radiotherapy (RT) improves survival in men with low-burden metastatic prostate cancer. However, owing to the dichotomized nature of metastatic burden criteria, it is not clear how this benefit varies with bone metastasis counts and metastatic site. OBJECTIVE To evaluate the association of bone metastasis count and location with survival benefit from prostate RT. DESIGN, SETTING, AND PARTICIPANTS This exploratory analysis of treatment outcomes based on metastatic site and extent as determined by conventional imaging (computed tomography/magnetic resonance imaging and bone scan) evaluated patients with newly diagnosed metastatic prostate cancer randomized within the STAMPEDE trial's metastasis M1 RT comparison. The association of baseline bone metastasis counts with overall survival (OS) and failure-free survival (FFS) was assessed using a multivariable fractional polynomial interaction procedure. Further analysis was conducted in subgroups. INTERVENTIONS Patients were randomized to receive either standard of care (androgen deprivation therapy with or without docetaxel) or standard of care and prostate RT. MAIN OUTCOMES AND MEASURES The primary outcomes were OS and FFS. RESULTS A total of 1939 of 2061 men were included (median [interquartile range] age, 68 [63-73] years); 1732 (89%) had bone metastases. Bone metastasis counts were associated with OS and FFS benefit from prostate RT. Survival benefit decreased continuously as the number of bone metastases increased, with benefit most pronounced up to 3 bone metastases. A plot of estimated treatment effect indicated that the upper 95% CI crossed the line of equivalence (hazard ratio [HR], 1) above 3 bone metastases without a detectable change point. Further analysis based on subgroups showed that the magnitude of benefit from the addition of prostate RT was greater in patients with low metastatic burden with only nonregional lymph nodes (M1a) or 3 or fewer bone metastases without visceral metastasis (HR for OS, 0.62; 95% CI, 0.46-0.83; HR for FFS, 0.57; 95% CI, 0.47-0.70) than among patients with 4 or more bone metastases or any visceral/other metastasis (HR for OS, 1.08; 95% CI, 0.91-1.28; interaction P = .003; HR for FFS, 0.87; 95% CI, 0.76-0.99; interaction P = .002). CONCLUSIONS AND RELEVANCE In this exploratory analysis of a randomized clinical trial, bone metastasis count and metastasis location based on conventional imaging were associated with OS and FFS benefit from prostate RT in M1 disease. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00268476; ISRCTN.com Identifier: ISRCTN78818544.
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Affiliation(s)
- Adnan Ali
- Genito-Urinary Cancer Research Group, Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
- FASTMAN Centre of Excellence, Manchester Cancer Research Centre, Manchester, United Kingdom
- Department of Surgery, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Alex Hoyle
- Genito-Urinary Cancer Research Group, Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
- FASTMAN Centre of Excellence, Manchester Cancer Research Centre, Manchester, United Kingdom
- Department of Surgery, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Department of Urology, The Salford NHS Foundation Trust, Manchester, United Kingdom
| | - Áine M. Haran
- Genito-Urinary Cancer Research Group, Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
- FASTMAN Centre of Excellence, Manchester Cancer Research Centre, Manchester, United Kingdom
- Department of Surgery, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Department of Urology, The Salford NHS Foundation Trust, Manchester, United Kingdom
| | - Christopher D. Brawley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, United Kingdom
| | - Adrian Cook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, United Kingdom
| | - Claire Amos
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, United Kingdom
| | - Joanna Calvert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, United Kingdom
| | - Hassan Douis
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | - David Dearnaley
- Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom
| | | | - Silke Gillessen
- Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Università della Svizzera Italiana, Lugano, Switzerland
| | - Mahesh K. B. Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, United Kingdom
| | | | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, United Kingdom
| | - Nicholas D. James
- Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom
| | - Noel W. Clarke
- Genito-Urinary Cancer Research Group, Division of Cancer Sciences, The University of Manchester, Manchester, United Kingdom
- FASTMAN Centre of Excellence, Manchester Cancer Research Centre, Manchester, United Kingdom
- Department of Surgery, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Department of Urology, The Salford NHS Foundation Trust, Manchester, United Kingdom
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Aning JJ, Parry MG, van der Meulen J, Fowler S, Payne H, McGrath JS, Challacombe B, Clarke NW. How reliable are surgeon-reported data? A comparison of the British Association of Urological Surgeons radical prostatectomy audit with the National Prostate Cancer Audit Hospital Episode Statistics-linked database. BJU Int 2021; 128:482-489. [PMID: 33752249 DOI: 10.1111/bju.15399] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 03/04/2021] [Accepted: 03/16/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To evaluate the accuracy and completeness of surgeon-reported radical prostatectomy outcome data across a national health system by comparison with a national dataset gathered independently from clinicians directly involved in patient care. PATIENTS AND METHODS Data submitted by surgeons to the British Association of Urological Surgeons (BAUS) radical prostatectomy audit for all men undergoing radical prostatectomy between 2015 and 2016 were assessed by cross linkage to the National Prostate Cancer Audit (NPCA) database. Specific data items collected in both databases were selected for comparison analysis. Data completeness and agreement were assessed by percentages and Cohen's kappa statistic. RESULTS Data from 4707 men in the BAUS and NPCA databases were matched for comparison. Compared with the NPCA, dataset completeness was higher in the BAUS dataset for type of nerve-sparing procedure (92% vs 42%) and postoperative margin status (89% vs 48%) but lower for readmission (87% vs 100%) and Charlson score (80% vs 100%). For all other variables assessed completeness was comparable. Agreement and data reliability were high for most variables. However, despite good agreement, the inter-cohort reliability was poor for readmission, M stage and Charlson score (κ < 0.30). CONCLUSIONS For the first time in urology we show that surgeon-reported data from the BAUS radical prostatectomy audit can reliably be used to benchmark peri-operative radical prostatectomy outcomes. For comorbidity data, to assist with risk analysis, and longer-term outcomes, NPCA routinely collected data provide a more comprehensive source.
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Affiliation(s)
- Jonathan J Aning
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Matthew G Parry
- London School of Hygiene and Tropical Medicine, London, UK.,Royal College of Surgeons of England, London, UK
| | | | - Sarah Fowler
- British Association of Urological Surgeons, London, UK
| | | | - John S McGrath
- Exeter Surgical Health Services Research Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
| | - Ben Challacombe
- Urology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Noel W Clarke
- Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
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Brown MD, Hart CA, Sachdeva A, Faulkner C, Wedge D, Clarke NW. Localized activation of the metastatic phenotype within the perineural region in prostate cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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
253 Background: Perineural Invasion (PNI) is defined as malignant epithelial cell invasion of the perineural space and nerves. Despite widespread acknowledgement of the clinical significance of PNI as a PCa pathological finding associated with recurrence, increased risk of bone metastasis and poor survival, the molecular mechanism underlying this pathology is relatively unknown. The malignant epithelial cells within the PNI potentially provides a spatially defined “snapshot” of disease progression, as the cells switch to a more migrational phenotype associated with metastatic progression. Here we present the initial spatial PNI phenotypic characterisation in PCa. Methods: Archival FFPE blocks, with associated full clinical history, from patients who underwent a radical prostatectomy for prostate cancer were retrieved under research ethics REC#07/H1003/161+5 10_NOCL_02. Biomarkers EphA2, pEphA2s897, pMLC2, E-Cadherin, Vimentin, TOMM20, MTC01, NDUFB8, PTEN were assessed on 4µm serial sections stained using a multiplex TSA protocol, with S100, pan-cytokeratin and DAPI acting as landmarks, on a Ventana Discovery platform prior to scanning on a Versa 3 platform with Halo image analysis. Prostate zones were defined at 500µm intervals either side of the prostate capsule. Univariate and multivariate (hierarchical clustering, UMap clustering) expression analysis and correlation with clinic-pathological features was conducted within R. Results: The PNI epithelial cells within each spatial zone of the prostate are significantly different to each other (Kruskal-Wallis test p < 2.2x10−16 except for MTC01 p = 5.3x10−10). In comparison with the local tumour lesion, PNI epithelial cells localised within 1000µm of the prostate edge and outside the tumour lesion, have undergone a migrational switch, gaining features associated with an activated metastatic phenotype, with increased expression of amoeboid signalling (EphA2, pEphA2s897, pMLC2) and mitochondrial defects (loss of Complex I and IV, gain of mitochondrial mass (TOMM20)). Patients clustering by multivariate expression trends across the prostate regions showed 4 distinct patient groups, with PNI epithelial cells in patient group 1 & 2 displaying a more epithelial to mesenchymal (EMT) phenotype, especially in the first 1000µm inside the prostate organ. Conclusions: Cells within PNI close to the edge of the prostate have features consistent with a switch to migrational/metastatic activation in contrast to the more indolent cell type found deeper within the tumour. Further characterisation of this localised migrational upregulation will help in understanding the transition from a localised to a metastatic phenotype.
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Affiliation(s)
- Mick D. Brown
- GUCR Group, University of Manchester, Manchester, United Kingdom
| | - Claire Alexandre Hart
- GenitoUrinary Cancer Research Group, FASTMAN Movember Centre of Excellence, University of Manchester, Manchester, United Kingdom
| | - Ashwin Sachdeva
- GenitoUrinary Cancer Research Group, FASTMAN Movember Centre of Excellence, University of Manchester, Manchester, United Kingdom
| | | | - David Wedge
- Cancer Genomics and Data Science, Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Noel W. Clarke
- GenitoUrinary Cancer Research Group, The Christie and Salford Royal Hospitals, Manchester, United Kingdom
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Langley RE, Gilbert DC, Duong T, Clarke NW, Nankivell M, Rosen SD, Mangar S, Macnair A, Sundaram SK, Laniado ME, Dixit S, Madaan S, Manetta C, Pope A, Scrase CD, Mckay S, Muazzam IA, Collins GN, Worlding J, Williams ST, Paez E, Robinson A, McFarlane J, Deighan JV, Marshall J, Forcat S, Weiss M, Kockelbergh R, Alhasso A, Kynaston H, Parmar M. Transdermal oestradiol for androgen suppression in prostate cancer: long-term cardiovascular outcomes from the randomised Prostate Adenocarcinoma Transcutaneous Hormone (PATCH) trial programme. Lancet 2021; 397:581-591. [PMID: 33581820 DOI: 10.1016/s0140-6736(21)00100-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Androgen suppression is a central component of prostate cancer management but causes substantial long-term toxicity. Transdermal administration of oestradiol (tE2) circumvents first-pass hepatic metabolism and, therefore, should avoid the cardiovascular toxicity seen with oral oestrogen and the oestrogen-depletion effects seen with luteinising hormone releasing hormone agonists (LHRHa). We present long-term cardiovascular follow-up data from the Prostate Adenocarcinoma Transcutaneous Hormone (PATCH) trial programme. METHODS PATCH is a seamless phase 2/3, randomised, multicentre trial programme at 52 study sites in the UK. Men with locally advanced or metastatic prostate cancer were randomly allocated (1:2 from August, 2007 then 1:1 from February, 2011) to either LHRHa according to local practice or tE2 patches (four 100 μg patches per 24 h, changed twice weekly, reducing to three patches twice weekly if castrate at 4 weeks [defined as testosterone ≤1·7 nmol/L]). Randomisation was done using a computer-based minimisation algorithm and was stratified by several factors, including disease stage, age, smoking status, and family history of cardiac disease. The primary outcome of this analysis was cardiovascular morbidity and mortality. Cardiovascular events, including heart failure, acute coronary syndrome, thromboembolic stroke, and other thromboembolic events, were confirmed using predefined criteria and source data. Sudden or unexpected deaths were attributed to a cardiovascular category if a confirmatory post-mortem report was available and as other relevant events if no post-mortem report was available. PATCH is registered with the ISRCTN registry, ISRCTN70406718; the study is ongoing and adaptive. FINDINGS Between Aug 14, 2007, and July 30, 2019, 1694 men were randomly allocated either LHRHa (n=790) or tE2 patches (n=904). Overall, median follow-up was 3·9 (IQR 2·4-7·0) years. Respective castration rates at 1 month and 3 months were 65% and 93% among patients assigned LHRHa and 83% and 93% among those allocated tE2. 157 events from 145 men met predefined cardiovascular criteria, with a further ten sudden deaths with no post-mortem report (total 167 events in 153 men). 26 (2%) of 1694 patients had fatal cardiovascular events, 15 (2%) of 790 assigned LHRHa and 11 (1%) of 904 allocated tE2. The time to first cardiovascular event did not differ between treatments (hazard ratio 1·11, 95% CI 0·80-1·53; p=0·54 [including sudden deaths without post-mortem report]; 1·20, 0·86-1·68; p=0·29 [confirmed group only]). 30 (34%) of 89 cardiovascular events in patients assigned tE2 occurred more than 3 months after tE2 was stopped or changed to LHRHa. The most frequent adverse events were gynaecomastia (all grades), with 279 (38%) events in 730 patients who received LHRHa versus 690 (86%) in 807 patients who received tE2 (p<0·0001) and hot flushes (all grades) in 628 (86%) of those who received LHRHa versus 280 (35%) who received tE2 (p<0·0001). INTERPRETATION Long-term data comparing tE2 patches with LHRHa show no evidence of a difference between treatments in cardiovascular mortality or morbidity. Oestrogens administered transdermally should be reconsidered for androgen suppression in the management of prostate cancer. FUNDING Cancer Research UK, and Medical Research Council Clinical Trials Unit at University College London.
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Affiliation(s)
- Ruth E Langley
- Medical Research Council (MRC) Clinical Trials Units at University College London (UCL), London, UK.
| | - Duncan C Gilbert
- Medical Research Council (MRC) Clinical Trials Units at University College London (UCL), London, UK
| | - Trinh Duong
- Medical Research Council (MRC) Clinical Trials Units at University College London (UCL), London, UK
| | - Noel W Clarke
- The Christie and Salford Royal Hospitals, Manchester, UK
| | - Matthew Nankivell
- Medical Research Council (MRC) Clinical Trials Units at University College London (UCL), London, UK
| | - Stuart D Rosen
- National Heart and Lung Institute, Imperial College, London, UK
| | - Stephen Mangar
- Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Archie Macnair
- Medical Research Council (MRC) Clinical Trials Units at University College London (UCL), London, UK
| | | | - Marc E Laniado
- Wexham Park Hospital, Frimley Health Foundation Trust, Slough, UK
| | | | - Sanjeev Madaan
- Department of Urology & Nephrology, Dartford and Gravesham NHS Trust, Dartford, UK
| | - Caroline Manetta
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Alvan Pope
- The Hillingdon Hospitals NHS Foundation Trust and Imperial College Healthcare NHS Trust, London, UK
| | | | - Stephen Mckay
- Forth Valley Royal Hospital, Larbert, UK; Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Iqtedar A Muazzam
- Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| | - Gerald N Collins
- Macclesfield District General Hospital, East Cheshire NHS Trust, Macclesfield, UK
| | | | | | - Edgar Paez
- Newcastle Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | | | | | - John V Deighan
- Medical Research Council (MRC) Clinical Trials Units at University College London (UCL), London, UK
| | - John Marshall
- Medical Research Council (MRC) Clinical Trials Units at University College London (UCL), London, UK
| | - Silvia Forcat
- Medical Research Council (MRC) Clinical Trials Units at University College London (UCL), London, UK
| | - Melanie Weiss
- Medical Research Council (MRC) Clinical Trials Units at University College London (UCL), London, UK
| | - Roger Kockelbergh
- Department of Urology, University Hospitals of Leicester, Leicester, UK
| | | | - Howard Kynaston
- Division of Cancer and Genetics, Cardiff University Medical School, Cardiff, UK
| | - Mahesh Parmar
- Medical Research Council (MRC) Clinical Trials Units at University College London (UCL), London, UK
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Parry MG, Nossiter J, Sujenthiran A, Cowling TE, Patel RN, Morris M, Berry B, Cathcart P, Clarke NW, Payne H, van der Meulen J, Aggarwal A. Impact of High-Dose-Rate and Low-Dose-Rate Brachytherapy Boost on Toxicity, Functional and Cancer Outcomes in Patients Receiving External Beam Radiation Therapy for Prostate Cancer: A National Population-Based Study. Int J Radiat Oncol Biol Phys 2020; 109:1219-1229. [PMID: 33279595 DOI: 10.1016/j.ijrobp.2020.11.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/16/2020] [Accepted: 11/09/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE External beam radiation therapy (EBRT) with brachytherapy boost reduces cancer recurrence in patients with prostate cancer compared with EBRT monotherapy. However, randomized controlled trials or large-scale observational studies have not compared brachytherapy boost types directly. METHODS AND MATERIALS This observational cohort study used linked national cancer registry data, radiation therapy data, administrative hospital data, and mortality records of 54,642 patients with intermediate-risk, high-risk, and locally advanced prostate cancer in England. The records of 11,676 patients were also linked to results from a national patient survey collected at least 18 months after diagnosis. Competing risk regression analyses were used to compare gastrointestinal (GI) toxicity, genitourinary (GU) toxicity, skeletal-related events (SRE), and prostate cancer-specific mortality (PCSM) at 5 years with adjustment for patient and tumor characteristics. Linear regression was used to compare Expanded Prostate Cancer Index Composite 26-item version domain scores (scale, 0-100, with higher scores indicating better function). RESULTS Five-year GI toxicity was significantly increased after low-dose-rate brachytherapy boost (LDR-BB) (32.3%) compared with high-dose-rate brachytherapy boost (HDR-BB) (16.7%) or EBRT monotherapy (18.7%). Five-year GU toxicity was significantly increased after both LDR-BB (15.8%) and HDR-BB (16.6%), compared with EBRT monotherapy (10.4%). These toxicity patterns were matched by the mean patient-reported bowel function scores (LDR-BB, 77.3; HDR-BB, 85.8; EBRT monotherapy, 84.4) and the mean patient-reported urinary obstruction/irritation function scores (LDR-BB, 72.2; HDR-BB, 78.9; EBRT monotherapy, 83.8). Five-year incidences of SREs and PCSM were significantly lower after HDR-BB (2.4% and 2.7%, respectively) compared with EBRT monotherapy (2.8% and 3.5%, respectively). CONCLUSIONS Compared with EBRT monotherapy, LDR-BB has worse GI and GU toxicity and HDR-BB has worse GU toxicity. HDR-BB has a lower incidence of SREs and PCSM than EBRT monotherapy.
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Affiliation(s)
- Matthew G Parry
- Department of Health Services Research and Policy, LSHTM, London, UK; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
| | - Julie Nossiter
- Department of Health Services Research and Policy, LSHTM, London, UK; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Arunan Sujenthiran
- The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Thomas E Cowling
- Department of Health Services Research and Policy, LSHTM, London, UK
| | - Rajan N Patel
- Department of Gastroenterology, The Whittington Hospital NHS Trust, London, UK
| | - Melanie Morris
- Department of Health Services Research and Policy, LSHTM, London, UK; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Brendan Berry
- Department of Health Services Research and Policy, LSHTM, London, UK; The National Prostate Cancer Audit, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Paul Cathcart
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Noel W Clarke
- Department of Urology, The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | | | - Ajay Aggarwal
- Department of Health Services Research and Policy, LSHTM, London, UK; Department of Radiotherapy, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Gilson C, Ingleby F, Gilbert DC, Parry MA, Atako NB, Ali A, Hoyle A, Clarke NW, Gannon M, Wanstall C, Brawley C, Mason MD, Malik Z, Simmons A, Loehr A, Parry-Jones A, Eeles R, Kote-Jarai Z, James ND, Amos C, Parmar MKB, Langley RE, Sydes MR, Attard G, Chowdhury S. Genomic Profiles of De Novo High- and Low-Volume Metastatic Prostate Cancer: Results From a 2-Stage Feasibility and Prevalence Study in the STAMPEDE Trial. JCO Precis Oncol 2020; 4:882-897. [PMID: 35050761 DOI: 10.1200/po.19.00388] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2020] [Indexed: 02/11/2024] Open
Abstract
PURPOSE The STAMPEDE trial recruits men with newly diagnosed, high-risk, hormone-sensitive prostate cancer. To ascertain the feasibility of targeted next-generation sequencing (tNGS) and the prevalence of baseline genomic aberrations, we sequenced tumor and germline DNA from patients with metastatic prostate cancer (mPCa) starting long-term androgen-deprivation therapy (ADT). METHODS In a 2-stage approach, archival, formalin-fixed, paraffin-embedded (FFPE) prostate tumor core biopsy samples were retrospectively subjected to 2 tNGS assays. Prospective enrollment enabled validation using tNGS in tumor and germline DNA. RESULTS In stage 1, tNGS data were obtained from 185 tumors from 287 patients (65%); 98% had de novo mPCa. We observed PI3K pathway aberrations in 43%, due to PTEN copy-number loss (34%) and/or activating mutations in PIK3 genes or AKT (18%) and TP53 mutation or loss in 33%. No androgen receptor (AR) aberrations were detected; RB1 loss was observed in < 1%. In stage 2, 93 (92%) of 101 FFPE tumors (biopsy obtained within 8 months) were successfully sequenced prospectively. The prevalence of DNA damage repair (DDR) deficiency was 14% (somatic) and 5% (germline). BRCA2 mutations and mismatch repair gene mutations were exclusive to high-volume disease. Aberrant DDR (22% v 15%), Wnt pathway (16% v 4%), and chromatin remodeling (16% v 8%) were all more common in high-volume compared with low-volume disease, but the small numbers limited statistical comparisons. CONCLUSION Prospective genomic characterization is feasible using residual diagnostic tumor samples and reveals that the genomic landscapes of de novo high-volume mPCa and advanced metastatic prostate cancer have notable similarities (PI3K pathway, DDR, Wnt, chromatin remodeling) and differences (AR, RB1). These results will inform the design and conduct of biomarker-directed trials in men with metastatic hormone-sensitive prostate cancer.
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Affiliation(s)
- Clare Gilson
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Fiona Ingleby
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Duncan C Gilbert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Marina A Parry
- University College London Cancer Institute, London, United Kingdom
| | - Nafisah B Atako
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Adnan Ali
- GU Research and FASTMAN groups, Manchester Cancer Institute, University of Manchester, Manchester, United Kingdom
| | - Alex Hoyle
- GU Research and FASTMAN groups, Manchester Cancer Institute, University of Manchester, Manchester, United Kingdom
- Department of Surgery, The Christie NHS Foundation Trust, Manchester and Salford Royal NHS Foundation Trusts, Manchester, United Kingdom
| | - Noel W Clarke
- GU Research and FASTMAN groups, Manchester Cancer Institute, University of Manchester, Manchester, United Kingdom
- Department of Surgery, The Christie NHS Foundation Trust, Manchester and Salford Royal NHS Foundation Trusts, Manchester, United Kingdom
| | - Melissa Gannon
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Chris Wanstall
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Christopher Brawley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | | | - Zafar Malik
- Clatterbridge Cancer Centre, Liverpool, United Kingdom
| | | | | | | | - Rosalind Eeles
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
- Institute of Cancer Research, London, United Kingdom
| | | | | | - Claire Amos
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Mahesh K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Ruth E Langley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Gerhardt Attard
- University College London Cancer Institute, London, United Kingdom
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50
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Parker CC, Clarke NW, Cook AD, Kynaston HG, Petersen PM, Catton C, Cross W, Logue J, Parulekar W, Payne H, Persad R, Pickering H, Saad F, Anderson J, Bahl A, Bottomley D, Brasso K, Chahal R, Cooke PW, Eddy B, Gibbs S, Goh C, Gujral S, Heath C, Henderson A, Jaganathan R, Jakobsen H, James ND, Kanaga Sundaram S, Lees K, Lester J, Lindberg H, Money-Kyrle J, Morris S, O'Sullivan J, Ostler P, Owen L, Patel P, Pope A, Popert R, Raman R, Røder MA, Sayers I, Simms M, Wilson J, Zarkar A, Parmar MKB, Sydes MR. Timing of radiotherapy after radical prostatectomy (RADICALS-RT): a randomised, controlled phase 3 trial. Lancet 2020; 396:1413-1421. [PMID: 33002429 DOI: 10.1016/s0140-6736(20)31553-1] [Citation(s) in RCA: 194] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/26/2020] [Accepted: 06/12/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND The optimal timing of radiotherapy after radical prostatectomy for prostate cancer is uncertain. We aimed to compare the efficacy and safety of adjuvant radiotherapy versus an observation policy with salvage radiotherapy for prostate-specific antigen (PSA) biochemical progression. METHODS We did a randomised controlled trial enrolling patients with at least one risk factor (pathological T-stage 3 or 4, Gleason score of 7-10, positive margins, or preoperative PSA ≥10 ng/mL) for biochemical progression after radical prostatectomy (RADICALS-RT). The study took place in trial-accredited centres in Canada, Denmark, Ireland, and the UK. Patients were randomly assigned in a 1:1 ratio to adjuvant radiotherapy or an observation policy with salvage radiotherapy for PSA biochemical progression (PSA ≥0·1 ng/mL or three consecutive rises). Masking was not deemed feasible. Stratification factors were Gleason score, margin status, planned radiotherapy schedule (52·5 Gy in 20 fractions or 66 Gy in 33 fractions), and centre. The primary outcome measure was freedom from distant metastases, designed with 80% power to detect an improvement from 90% with salvage radiotherapy (control) to 95% at 10 years with adjuvant radiotherapy. We report on biochemical progression-free survival, freedom from non-protocol hormone therapy, safety, and patient-reported outcomes. Standard survival analysis methods were used. A hazard ratio (HR) of less than 1 favoured adjuvant radiotherapy. This study is registered with ClinicalTrials.gov, NCT00541047. FINDINGS Between Nov 22, 2007, and Dec 30, 2016, 1396 patients were randomly assigned, 699 (50%) to salvage radiotherapy and 697 (50%) to adjuvant radiotherapy. Allocated groups were balanced with a median age of 65 years (IQR 60-68). Median follow-up was 4·9 years (IQR 3·0-6·1). 649 (93%) of 697 participants in the adjuvant radiotherapy group reported radiotherapy within 6 months; 228 (33%) of 699 in the salvage radiotherapy group reported radiotherapy within 8 years after randomisation. With 169 events, 5-year biochemical progression-free survival was 85% for those in the adjuvant radiotherapy group and 88% for those in the salvage radiotherapy group (HR 1·10, 95% CI 0·81-1·49; p=0·56). Freedom from non-protocol hormone therapy at 5 years was 93% for those in the adjuvant radiotherapy group versus 92% for those in the salvage radiotherapy group (HR 0·88, 95% CI 0·58-1·33; p=0·53). Self-reported urinary incontinence was worse at 1 year for those in the adjuvant radiotherapy group (mean score 4·8 vs 4·0; p=0·0023). Grade 3-4 urethral stricture within 2 years was reported in 6% of individuals in the adjuvant radiotherapy group versus 4% in the salvage radiotherapy group (p=0·020). INTERPRETATION These initial results do not support routine administration of adjuvant radiotherapy after radical prostatectomy. Adjuvant radiotherapy increases the risk of urinary morbidity. An observation policy with salvage radiotherapy for PSA biochemical progression should be the current standard after radical prostatectomy. FUNDING Cancer Research UK, MRC Clinical Trials Unit, and Canadian Cancer Society.
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Affiliation(s)
- Christopher C Parker
- Department of Oncology, Royal Marsden NHS Foundation Trust, Sutton, UK; Institute of Cancer Research, Sutton, UK
| | - Noel W Clarke
- Department of Oncology, Genito-Urinary Cancer Research Group, The Christie Hospital, Manchester, UK; Department of Surgery, The Christie Hospital, Manchester, UK; Department of Urology, Salford Royal Hospitals, Manchester, UK
| | - Adrian D Cook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Howard G Kynaston
- Department of Urology, Cardiff University School of Medicine, Cardiff University, Cardiff, UK
| | - Peter Meidahl Petersen
- Department of Oncology, Copenhagen Prostate Cancer Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Charles Catton
- Department of Radiation Oncology, Princess Margaret Hospital, University Health Network, Toronto, ON, Canada
| | - William Cross
- Department Of Urology, St James's University Hospital, Leeds, UK
| | - John Logue
- Department of Oncology, The Christie Hospital, Manchester, UK
| | - Wendy Parulekar
- Department of Oncology, Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Rajendra Persad
- Department of Urology, Bristol Urological Institute, North Bristol Hospitals, Bristol, UK
| | - Holly Pickering
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Fred Saad
- Department of Urology, Centre Hospitalier de l'Université de Montreal, Montreal, QC, Canada
| | - Juliette Anderson
- Department of Oncology, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Amit Bahl
- Department of Oncology, Bristol Cancer Institute, University Hospitals Bristol, Bristol, UK
| | | | - Klaus Brasso
- Department of Urology, Copenhagen Prostate Cancer Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Rohit Chahal
- Department of Urology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Peter W Cooke
- Department of Urology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Ben Eddy
- Department of Urology, East Kent Hospitals University Foundation Trust, Canterbury, UK
| | - Stephanie Gibbs
- Department of Oncology, Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - Chee Goh
- Department of Oncology, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Sandeep Gujral
- Department of Urology, Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - Catherine Heath
- Department of Clinical Oncology, University Hospital Southampton, Southampton, UK
| | - Alastair Henderson
- Department of Urology, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - Ramasamy Jaganathan
- Department of Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Henrik Jakobsen
- Department of Urology, Herlev University Hospital, Herlev, Denmark
| | - Nicholas D James
- Institute of Cancer Research, London, UK; Department of Oncology, Royal Marsden NHS Foundation Trust, London, UK
| | | | - Kathryn Lees
- Kent Oncology Centre, Maidstone Hospital, Kent, UK
| | - Jason Lester
- Department of Oncology, South West Wales Cancer Centre, Swansea, UK
| | | | - Julian Money-Kyrle
- Department of Oncology, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Stephen Morris
- Department of Clinical Oncology, Guys Hospital, London, UK
| | - Joe O'Sullivan
- Department of Clinical Oncology, Belfast Health and Social Care Trust, Belfast, UK
| | | | - Lisa Owen
- Department of Oncology, Leeds Cancer Centre, St James's University Hospital, Leeds, UK
| | - Prashant Patel
- Department of Urology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alvan Pope
- Department of Urology, Hillingdon Hospital, Middlesex, UK; Mount Vernon Hospital, Northwood, UK; Mount Vernon Cancer Centre, Northwood, UK
| | | | - Rakesh Raman
- Department of Clinical Oncology, Kent Oncology Centre, Canterbury, UK
| | - Martin Andreas Røder
- Department of Urology, Copenhagen Prostate Cancer Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ian Sayers
- Department of Oncology, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Matthew Simms
- Department of Urology, Hull University Hospitals NHS Trust, Hull, UK
| | - Jim Wilson
- Department of Urology, Anuerin Bevan University Health Board, Newport, UK
| | - Anjali Zarkar
- Department of Oncology, University Hospital Birmingham, Birmingham, UK
| | - Mahesh K B Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK.
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