ESGO-ESMO-ESP consensus conference recommendations on ovarian cancer: pathology and molecular biology and early, advanced and recurrent disease

The European Society of Gynaecological Oncology, the European Society for Medical Oncology (ESMO) and the European Society of Pathology held a consensus conference (CC) on ovarian cancer on 15-16 June 2022 in Valencia, Spain. The CC panel included 44 experts in the management of ovarian cancer and pathology, an ESMO scientific advisor and a methodologist. The aim was to discuss new or contentious topics and develop recommendations to improve and harmonise the management of patients with ovarian cancer. Eighteen questions were identified for discussion under four main topics: (i) pathology and molecular biology, (ii) early-stage disease and pelvic mass in pregnancy, (iii) advanced stage (including older/frail patients) and (iv) recurrent disease. The panel was divided into four working groups (WGs) to each address questions relating to one of the four topics outlined above, based on their expertise. Relevant scientific literature was reviewed in advance. Recommendations were developed by the WGs and then presented to the entire panel for further discussion and amendment before voting. This manuscript focuses on the recommendation statements that reached a consensus, their voting results and a summary of evidence supporting each recommendation.

Perspectives of Healthcare Professionals on the Management and Treatment of Advanced Ovarian Cancer in the UK: Results From the KNOW-OC Survey

AIMS

New treatment options for advanced ovarian cancer have the potential to significantly change the treatment pathway in the UK. Understanding the structures and responsibilities of multidisciplinary teams/tumour boards (MDT) and regional variations will enable services to adapt more effectively to these changes.

MATERIALS AND METHODS

The KNOW-OC survey was conducted in 2020 to understand the views of a selected group of 66 healthcare professionals (HCPs) involved in advanced ovarian cancer care in UK hospitals.

RESULTS

The results showed that MDT involvement in the management of advanced ovarian cancer varied depending on pathway stage and line of relapse, with 98.5% of HCPs responding that the MDT was involved in decisions at initial presentation, but only 40.9% for patients with multiple relapses. The MDT was mostly responsible for determining whether the patients would undergo primary or interval cytoreductive surgery according to 75.8% of respondents, and most HCPs (80.3%) stated that tumour dissemination patterns were the most important factor influencing this decision. The most commonly assessed biomarkers at the time of the survey were CA125, gBRCA and tBRCA. Homologous recombination deficiency was viewed as the second most important factor for determining prognosis, but few centres had access to testing at the time of survey completion. The use of active surveillance was expected to decrease in favour of first-line targeted therapies. Nearly all (98.5%) HCPs agreed there is a role for secondary cytoreductive surgery for the treatment of recurrence (for carefully selected patients).

CONCLUSIONS

The results highlighted UK-specific geographical variation in the views of HCPs on MDT involvement and specific practices, such as molecular biomarker testing, and the overall treatment approach. Together, these findings improve the understanding of reported clinical practice across the UK for ovarian cancer and provide insight into decision-making associated with updates to recommendations for best practice (e.g. European Society for Medical Oncology/European Society of Gynaecological Oncology consensus statements) and the introduction of new treatment options.

Absence of Spontaneous Magnetic Fields due to Time-Reversal Symmetry Breaking in Bulk Superconducting UTe_{2}

We have investigated the low-temperature local magnetic properties in the bulk of molten salt-flux (MSF)-grown single crystals of the candidate odd-parity superconductor UTe_{2} by zero-field muon spin relaxation (μSR). In contrast to previous μSR studies of UTe_{2} single crystals grown by a chemical vapor transport method, we find no evidence of magnetic clusters or electronic moments fluctuating slow enough to cause a discernible relaxation of the zero-field μSR asymmetry spectrum. Consequently, our measurements on MSF-grown single crystals rule out the generation of spontaneous magnetic fields in the bulk that would occur near impurities or lattice defects if the superconducting state of UTe_{2} breaks time-reversal symmetry. This result suggests that UTe_{2} is characterized by a single-component superconducting order parameter.

An automated system of intrusion detection by IoT-aided MQTT using improved heuristic-aided autoencoder and LSTM-based Deep Belief Network

The IoT offered an enormous number of services with the help of multiple applications so it faces various security-related problems and also heavy malicious attacks. Initially, the IoT data are gathered from the standard dataset as Message Queuing Telemetry Transport (MQTT) set. Further, the collected data are undergone the pre-processing stage, which is accomplished by using data cleaning and data transformation. The resultant processed data is given into two models named (i) Autoencoder with Deep Belief Network (DBN), in which the optimal features are selected from Autoencoder with the aid of Modified Archimedes Optimization Algorithm (MAOA). Further, the optimal features are subjected to the AL-DBN model, where the first classified outcomes are obtained with the parameter optimization of MAOA. Similarly, (ii) Long Short-Term Memory (LSTM) with DBN, in this model, the optimal features are chosen from LSTM with the aid of MAOA. Consequently, the optimal features are subjected into the AL-DBN model, where the second classified outcomes are acquired. Finally, the average score is estimated by two outcomes to provide the final classified result. Thus, the findings reveal that the suggested system achieves outstanding results to detect the attack significantly.

A Novel Technique to Mitigate the Data Redundancy and to Improvise Network Lifetime Using Fuzzy Criminal Search Ebola Optimization for WMSN

Wireless Multimedia Sensor Network (WMSN) is a powerful technology that is widely used to gather data and monitor the actual environment for analysis. Furthermore, multimedia applications' needs and the features, such as constrained latency and high bandwidth consumption, complicate the design of WMSN routing protocols. Despite several methods, the trouble of designing WMSNs routing protocol remains a hurdle. The miniaturization and enhancement of hardware facilitate an extensive range of applications in the military and public sectors. On the contrary, the streaming of multimedia content is captured and generated due to some event-triggered surveillance for a long duration of time. Hence, it is necessary for wireless multimedia sensor network (WMSN) to provide a strong hardware foundation, thereby satisfying Quality of Service (QoS) requirements. Initially, the network is clustered into several clusters and the nodes with rich resources are chosen as cluster heads. The significant intention of this paper is to eliminate data redundancy and to select optimal cluster heads, thereby minimizing the energy consumption. Therefore, this paper proposes a novel Fuzzy Criminal Search Ebola Optimization (FCSEO) algorithm for optimal selection of cluster heads. In addition to this, the data redundancy present in the proposed algorithm is mitigated and thus the network lifetime is enhanced. Finally, extensive experimentation is carried out for various performance measures to determine the efficiency of the proposed approach.

A Randomized, Double-Blind, Biomarker-Selected, Phase II Clinical Trial of Maintenance Poly ADP-Ribose Polymerase Inhibition With Rucaparib Following Chemotherapy for Metastatic Urothelial Carcinoma

PURPOSE

A DNA repair deficiency (DRD) phenotype exists within a subset of metastatic urothelial carcinomas (mUC) predicting benefit from platinum-based chemotherapy. We tested switch maintenance therapy with the poly ADP-ribose polymerase inhibitor rucaparib, following chemotherapy, for DRD biomarker-positive mUC.

METHODS

DRD biomarker-positive mUC patients, within 10 weeks of chemotherapy, and without cancer progression, were randomly assigned (1:1) to maintenance rucaparib 600 mg twice a day orally, or placebo, until disease progression. The primary end point was progression-free survival (PFS). Statistical analysis targeted a hazard ratio of 0.5 with a 20% one-sided α for this signal-seeking trial. PFS (RECIST 1.1) was compared between trial arms, by intention to treat, within a Cox model.

RESULTS

Out of 248 patients, 74 (29.8%) were DRD biomarker-positive and 40 were randomly assigned. A total of 12 (60%) and 20 (100%) PFS events occurred in the rucaparib and placebo arms, respectively (median follow-up was 94.6 weeks in those still alive). Median PFS was 35.3 weeks (80% CI, 11.7 to 35.6) with rucaparib and 15.1 weeks (80% CI, 11.9 to 22.6) with placebo (hazard ratio, 0.53; 80% CI, 0.30 to 0.92; one-sided P = .07). In the safety population (n = 39) treatment-related adverse events were mostly low grade. Patients received a median duration of 10 rucaparib or six placebo cycles on treatment. Treatment-related adverse events (all grades) of fatigue (63.2% v 30.0%), nausea (36.8% v 5.0%), rash (21.1% v 0%), and raised alanine aminotransferase (57.9% v 10%) were more common with rucaparib.

CONCLUSION

Maintenance rucaparib, following platinum-based chemotherapy, extended PFS in DRD biomarker-selected patients with mUC and was tolerable. Further investigation of poly ADP-ribose polymerase inhibition in selected patients with mUC is warranted.

Modelling and simulation of fluid flow through stenosis and aneurysm blood vessel: a computational hemodynamic analysis

In this article, the hemodynamics of nanofluid flow through the modelled stenosis-aneurysm models in the presence of the catheter has been studied. The eight stenosis-aneurysm models are developed to mimic biological observations and thus make the model more realistic. The mathematical understanding helps in treating the stenosis in the blood vessel by targeting the unhealthy region to the drug, which is coated on nanoparticles. The catheter achieves the active drug release to the aimed organs by coating on the catheter surface, which adds additional benefits. In the present hemodynamic study, the blood is modeled as a couple stress fluid; as a result, the highly non-linear momentum, temperature, and concentration equations were obtained. The fluid flow equations' complexity is further increased by incorporating the variable viscosity effects that arose due to the suspension of nanoparticles. The resultant mathematical model is solved by using the homotopy perturbation method. The convergence of the perturbed solutions is studied and depicted the degree of deformation in the case of temperature and concentration. The effects of the porous nature of the stenosis, no-slip at the catheter surface, and the free slip at the blood vessel boundary in the non-stenotic region are also considered in the model. The essential physiological property like surface shear stress is computed, and various parameters' influence on shear stress is analyzed. The present analysis can be helpful in understanding the enhancement in mass dispersion and heat transfer in unhealthy blood vessels, which could be used for drug delivery in the treatment of stenotic conditions.

Docetaxel for Nonmetastatic Prostate Cancer: Long-Term Survival Outcomes in the STAMPEDE Randomized Controlled Trial

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.

A randomized, double blind, biomarker selected, phase II clinical trial of maintenance PARP inhibition following chemotherapy for metastatic urothelial carcinoma (mUC): Final analysis of the ATLANTIS rucaparib arm

436

Background: A subset of mUC exhibits a DNA repair deficiency (DRD) phenotype predicting benefit from platinum based chemotherapy (PBC). We hypothesised that switch maintenance therapy with the PARP inhibitor rucaparib, in patients who have derived clinical benefit from PBC, would improve outcomes for patients with mUC harbouring a DRD biomarker. Methods: ATLANTIS is an adaptive, multi-comparison, phase II trial platform. It tests multiple biomarker selected maintenance therapies for mUC after 4 to 8 PBC cycles without disease progression. Biomarker allocation to the rucaparib comparison was based on ≥10% genomic loss of heterozygosity (%LOH) and/or somatic alteration in defined DRD associated genes ( ATM, BARD1, BRCA1, BRCA2, BRIP1, CDK12, CHEK2, FANCA, NBN, PALB2, RAD51, RAD51B, RAD51C, RAD51D, RAD54L) and/or germline BRCA1 or BRCA2 alteration. Biomarker positive patients were randomised (1:1) to maintenance rucaparib 600 mg BID PO, or matched placebo, within 10 weeks of completing PBC, until disease progression. The primary endpoint was progression free survival (PFS). Statistical analysis (data cut 17/Nov/2021) was pre-planned to target a hazard ratio of 0.5. We selected a 20% 1-sided alpha for this signal seeking phase II trial with 85.4% power (requiring 30 PFS events in 40 patients). PFS (RECIST 1.1) was compared between trial arms, by intention to treat, within a Cox model incorporating baseline minimisation factors. Adverse events (AE) were assessed by CTCAE v4.03. Results: 74 of 279 (26.5%) screened patients were biomarker positive. 40 were randomised within the rucaparib comparison (Dec 2017-Dec 2020). Biomarker positive status was by high %LOH in 22 (55%), DRD gene alteration in 11 (27.5%) and both in 7 (17.5%). Patient characteristics (median age 70.5; 82.5% male; 87.5% bladder primary; 52.5% ECOG PS 0; 62.5% prior cisplatin; 45% visceral metastases) were balanced by treatment arm. 12 (60%) and 20 (100%) PFS events have occurred in the rucaparib and placebo arms respectively (median duration follow up 94.6 weeks in those still alive). Median PFS was 35.3 weeks (80% confidence interval (CI) 11.7-35.6) with rucaparib and 15.1 weeks (80% CI 11.9-22.6) with placebo (hazard ratio 0.53, 80% CI 0.30-0.92, 1 sided p = 0.07). In the safety population (n = 39) treatment related adverse events were mostly low grade. Rucaparib was tolerable with a median duration of 10 rucaparib or 6 placebo cycles on treatment. The most frequent treatment related AEs (all grades) of fatigue (63.2% vs 30.0%, p = 0.03), nausea (36.9% vs 5.0%, p = 0.03) and rash (21.1% vs 0%, p = 0.04) were more common with rucaparib respectively. Conclusions: Maintenance rucaparib, following PBC, extended PFS in DRD biomarker selected patients with mUC and is tolerable. Further investigation of PARP inhibition for mUC is warranted. Clinical trial information: 25859465.

Quality of life from cytoreductive surgery in advanced Ovarian cancer: investigating association with disease burden and surgical complexity in the international, prospective, SOCQER2 cohort study

OBJECTIVE

To investigate quality of life (QoL) and association with surgical complexity and disease burden after surgical resection for advanced ovarian cancer in centres with variation in surgical approach DESIGN: Prospective multicentre observational study SETTING: United Kingdom, Kolkata, India, and Melbourne, Australia gynaecological cancer surgery centres.

PARTICIPANTS

Patients undergoing surgical resection for late stage ovarian cancer. Exposure Low, intermediate or high Surgical Complexity Score (SCS) surgery MAIN OUTCOMES AND MEASURES: Primary: EORTC-QLQ-C30 Global score change. Secondary: EORTC OV28, progression free survival.

RESULTS

Patients' pre-operative disease burden and SCS varied between centres, confirming differences in surgical ethos. QoL response rates were 90% up to 18 months. Mean change from the pre-surgical baseline in the EORTC QLQ-C30 was 3.4 (SD 1.8, n=88) in the low, 4.0 (SD 2.1, n=55) in the intermediate and 4.3 (SD 2.1, n=52) in the high SCS group after 6 weeks (p=0.048) and 4.3 (SD 2.1, n=51), 5.1 (SD 2.2, n=41) and 5.1 (SD 2.2, n=35) respectively after 12 months (p=0.133). In a repeated measures model, there were no clinically or statistically meaningful differences in EORTC QLQ-C30 global scores between the three SCS groups, p= 0.840 but there was a small statistically significant improvement in all groups over time (p<0.001). The high SCS group experienced small to moderate decreases in physical (p=0.004), role (p=0.016) and emotional (p=0.001) function at 6 weeks post-surgery which resolved by 6-12 months.

CONCLUSIONS AND RELEVANCE

Global QoL of patients undergoing low, intermediate, and high SCS surgery improved at 12 months post operation and was no worse in patients undergoing extensive surgery.

1232 Trust-Wide Assessment of Delirium in Post-Operative Elective Surgery

Aim

Delirium is an acute change in cognition and associated with adverse patient outcomes. The incidence of post-operative delirium after elective non-cardiac surgery is unknown. We aimed to assess the incidence of post-operative delirium in this group and the effect on patient outcomes.

Method

Patients aged 65 and over who underwent elective non-cardiac surgery were identified on post-operative day three. Delirium screening was performed in real time using the validated 4-AT assessment tool. A retrospective review of the patients’ preoperative and perioperative record was conducted to collect demographics and identify risk factors for delirium. Outcome data was collected at 30 days. Patients with a positive delirium score (&gt;4) underwent a more in-depth assessment and managing teams given a delirium management pack.

Results

75 (39 male) consecutive patients were screened over a period of 4 months. Median age 77 years and 18% had frailty assessed as “vulnerable”. The majority of patients (37.3%) underwent thoracic surgery, followed by hepatobiliary (17.3%), gynaecological (17.3%), colorectal (12%), maxillofacial (9.3%) and ENT (4%). 5.3% (4) of patients had a positive 4-AT screen. No patients had a formal delirium screen or diagnosis in the initial 48 hours. The median length of stay for patients with a positive screen was 8.5 days (IQR 7.5-12) compared to 8 days (IQR 5-13) for patients with a negative screen.

Conclusions

Reassuringly, rate of post-operative delirium following elective operations in our Trust are low (5%). Larger numbers of patients are required to assess the impact this has on patient outcomes and identify correlation with risk factors.

Short Androgen Suppression and Radiation Dose Escalation in Prostate Cancer: 12-Year Results of EORTC Trial 22991 in Patients With Localized Intermediate-Risk Disease

PURPOSE

The European Organisation for Research and Treatment of Cancer (EORTC) trial 22991 (NCT00021450) showed that 6 months of concomitant and adjuvant androgen suppression (AS) improves event- (EFS, Phoenix) and clinical disease-free survival (DFS) of intermediate- and high-risk localized prostatic carcinoma, treated by external-beam radiotherapy (EBRT) at 70-78 Gy. We report the long-term results in intermediate-risk patients treated with 74 or 78 Gy EBRT, as per current guidelines.

PATIENT AND METHODS

Of 819 patients randomly assigned between EBRT or EBRT plus AS started on day 1 of EBRT, 481 entered with intermediate risk (International Union Against Cancer TNM 1997 cT1b-c or T2a with prostate-specific antigen (PSA) ≥ 10 ng/mL or Gleason ≤ 7 and PSA ≤ 20 ng/mL, N0M0) and had EBRT planned at 74 (342 patients, 71.1%) or 78 Gy (139 patients, 28.9%). We report the trial primary end point EFS, DFS, distant metastasis-free survival (DMFS), and overall survival (OS) by intention-to-treat stratified by EBRT dose at two-sided α = 5%.

RESULTS

At a median follow-up of 12.2 years, 92 of 245 patients and 132 of 236 had EFS events in the EBRT plus AS and EBRT arm, respectively, mostly PSA relapse (48.7%) or death (45.1%). EBRT plus AS improved EFS and DFS (hazard ratio [HR] = 0.53; CI, 0.41 to 0.70; P < .001 and HR = 0.67; CI, 0.49 to 0.90; P = .008). At 10 years, DMFS was 79.3% (CI, 73.4 to 84.0) with EBRT plus AS and 72.7% (CI, 66.2 to 78.2) with EBRT (HR = 0.74; CI, 0.53 to 1.02; P = .065). With 140 deaths (EBRT plus AS: 64; EBRT: 76), 10-year OS was 80.0% (CI, 74.1 to 84.7) with EBRT plus AS and 74.3% (CI, 67.8 to 79.7) with EBRT, but not statistically significantly different (HR = 0.74; CI, 0.53 to 1.04; P = .082).

CONCLUSION

Six months of concomitant and adjuvant AS statistically significantly improves EFS and DFS in intermediate-risk prostatic carcinoma, treated by irradiation at 74 or 78 Gy. The effects on OS and DMFS did not reach statistical significance.

Folic acid supplementation in postmenopausal women with hot flushes: phase III randomised double-blind placebo-controlled trial

OBJECTIVE

To assess whether folic acid supplementation ameliorates hot flushes.

DESIGN

Double-blind, placebo-controlled randomised trial.

SETTING

Nine hospitals in England.

POPULATION

Postmenopausal women experiencing ≥50 hot flushes weekly.

METHODS

Women (n = 164) were randomly assigned in a 1:1 ratio to receive folic acid 5 mg tablet or placebo daily for 12 weeks. Participants recorded frequency and severity of hot flushes in a Sloan Diary daily and completed Greene Climacteric and Utian Quality of Life (UQoL) Scales at 4-week intervals.

MAIN OUTCOME MEASURES

The change in daily Hot Flush Score at week 12 from randomisation based on Sloan Diary Composite Score B calculation.

RESULTS

Data of 143 (87%) women were available for the primary outcome. The mean change (SD) in Hot Flush Score at week 12 was -6.98 (10.30) and -4.57 (9.46) for folic acid and placebo group, respectively. The difference between groups in the mean change was -2.41 (95% CI -5.68 to 0.87) (P = 0.149) and in the adjusted mean change -2.61 (95% CI -5.72 to 0.49) (P = 0.098). Analysis of secondary outcomes indicated an increased benefit in the folic acid group regarding changes in total and emotional UQoL scores at week 8 when compared with placebo. The difference in the mean change from baseline was 5.22 (95% CI 1.16-9.28) and 1.88 (95% CI 0.23-3.52) for total and emotional score, respectively.

CONCLUSIONS

The study was not able to demonstrate that folic acid had a statistically significant greater benefit in reducing Hot Flush Score over 12 weeks in postmenopausal women when compared with placebo.

TWEETABLE ABSTRACT

Folic acid may ameliorate hot flushes in postmenopausal women but confirmation is required from a larger study.

Pan-AKT Inhibitor Capivasertib With Docetaxel and Prednisolone in Metastatic Castration-Resistant Prostate Cancer: A Randomized, Placebo-Controlled Phase II Trial (ProCAID)

PURPOSE

Capivasertib is a pan-AKT inhibitor. Preclinical data indicate activity in metastatic castration-resistant prostate cancer (mCRPC) and synergism with docetaxel.

PATIENTS AND METHODS

ProCAID was a placebo controlled randomized phase II trial in mCRPC. Patients received up to ten 21-day cycles of docetaxel (75 mg/m2 intravenous, day 1) and prednisolone (5 mg twice daily, oral, day 1-21) and were randomly assigned (1:1) to oral capivasertib (320 mg twice daily, 4 days on/3 days off, from day 2 each cycle), or placebo, until disease progression. Treatment allocation used minimization factors: bone metastases; visceral metastases; investigational site; and prior abiraterone or enzalutamide. The primary objective, by intention to treat, determined if the addition of capivasertib prolonged a composite progression-free survival (cPFS) end point that included prostate-specific antigen progression events. cPFS and overall survival (OS) were also assessed by composite biomarker subgroup for PI3K/AKT/PTEN pathway activation status.

RESULTS

One hundred and fifty patients were enrolled. Median cPFS was 7.03 (95% CI, 6.28 to 8.25) and 6.70 months (95% CI, 5.52 to 7.36) with capivasertib and placebo respectively (hazard ratio [HR], 0.92; 80% CI, 0.73 to 1.16; one-sided P = .32). Median OS was 31.15 (95% CI, 20.07 to not reached) and 20.27 months (95% CI, 17.51 to 24.18), respectively (HR, 0.54; 95% CI, 0.34 to 0.88; two-sided P = .01). cPFS and OS results were consistent irrespective of PI3K/AKT/PTEN pathway activation status. Grade III-IV adverse events were equivalent between arms (62.2%). The most common adverse events of any grade deemed related to capivasertib were diarrhea, fatigue, nausea, and rash.

CONCLUSION

The addition of capivasertib to chemotherapy did not extend cPFS in mCRPC irrespective of PI3K/AKT/PTEN pathway activation status. The observed OS result (a secondary end point) will require prospective validation in future studies to address potential for bias.

Final Analysis of the Ipilimumab Versus Placebo Following Radiotherapy Phase III Trial in Postdocetaxel Metastatic Castration-resistant Prostate Cancer Identifies an Excess of Long-term Survivors

BACKGROUND

The phase 3 trial CA184-043 evaluated radiotherapy to bone metastases followed by Ipilimumab or placebo in men with metastatic castrate-resistant prostate cancer (mCRPC) who had received docetaxel previously. In a prior analysis, the trial's primary endpoint (overall survival [OS]) was not improved significantly.

OBJECTIVE

To report the final analysis of OS.

DESIGN, SETTING, AND PARTICIPANTS

A total of 799 patients were randomized to receive a single dose of radiotherapy to one or more bone metastases followed by either Ipilimumab (n = 399) or placebo (n = 400).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

OS was analyzed in the intention-to-treat population. Prespecified and exploratory subset analyses based on Kaplan-Meier/Cox methodology were performed.

RESULTS AND LIMITATIONS

During an additional follow-up of approximately 2.4 yr since the primary analysis, 721/799 patients have died. Survival analysis showed crossing of the curves at 7-8 mo, followed by persistent separation of the curves beyond that point, favoring the ipilimumab arm. Given the lack of proportional hazards, a piecewise hazard model showed that the hazard ratio (HR) changed over time: the HR was 1.49 (95% confidence interval 1.12, 1.99) for 0-5 mo, 0.66 (0.51, 0.86) for 5-12 mo, and 0.66 (0.52, 0.84) beyond 12 mo. OS rates were higher in the ipilimumab versus placebo arms at 2 yr (25.2% vs 16.6%), 3 yr (15.3% vs 7.9%), 4 yr (10.1% vs 3.3%), and 5 yr (7.9% vs. 2.7%). Disease progression was the most frequent cause of death in both arms. In seven patients (1.8%) in the ipilimumab arm and one (0.3%) in the placebo arm, the primary cause of death was reported as study drug toxicity. No long-term safety signals were identified.

CONCLUSIONS

In this preplanned long-term analysis, OS favored ipilimumab plus radiotherapy versus placebo plus radiotherapy for patients with postdocetaxel mCRPC. OS rates at 3, 4, and 5 yr were approximately two to three times higher in the ipilimumab arm.

PATIENT SUMMARY

After longer follow-up, survival favored the group of men who received ipilimumab, with overall survival rates being two to three times higher at 3 yr and beyond.

ProCAID: A randomized double-blind phase II clinical trial of capivasertib (C) in combination with docetaxel and prednisolone chemotherapy (DP) in metastatic castration-resistant prostate cancer (mCRPC)

5520

Background: DP extends survival in mCRPC, but clinical benefit is modest. PI3K/AKT/PTEN pathway activation is common in mCRPC contributing to disease progression and DP resistance. C is a pan-AKT inhibitor. Pre-clinical data indicate activity in prostate cancer and synergism with DP. This phase II trial combined C with DP in mCRPC. Methods: Key eligibility criteria: histologically or cytologically proven measurable or evaluable mCRPC, suitable for treatment with DP for PSA and/or radiographic disease progression, ECOG performance status 0-1, no prior chemotherapy for mCRPC, not requiring insulin or > 2 oral hypoglycaemic drugs for diabetes mellitus. Treatment: up to 10 cycles of DP (D: 75 mg/m2 IV, day 1; P: 5 mg bd oral, day 1 – 21) and random assignment (1:1, double blind) to oral C (320 mg twice daily, 4 days on/3 days off, from cycle 1, day 2) or matched placebo to disease progression. Primary endpoint: progression free survival (PFS; comprising PSA, radiographic or clinical progression, new cancer therapy or death; PCWG2 criteria) in the intent to treat (ITT) population. Secondary endpoints included overall survival (OS) and safety. PFS and OS were also assessed by composite biomarker (B) subgroup for PI3K/AKT/PTEN pathway activation status (NGS/IHC on archival tumour, contemporaneous ctDNA). Statistics: designed to detect a 50% increase in median PFS (6 to 9 months (mo)) between the placebo and C arms (90% power, 20% 1-sided alpha) by Cox proportional hazards model. Registration: ISRCTN 69139368. Results: 150 patients were randomised to 01/2019. Median follow up 16.77 months (IQR 12.0-26.5). PFS and OS by ITT and B status, are shown in the table (NR, not reached; CI confidence interval). Grade 3–4 adverse events (AE) were equally common between arms (62.2%). The most common AEs were diarrhoea, fatigue and nausea. Conclusions: Adding C to DP did not extend PFS. The OS secondary endpoint was significantly increased. PFS and OS results were consistent irrespective of PI3K/AKT/PTEN pathway activation status. Clinical trial information: 69139368 . [Table: see text]