Phase II double-blind placebo-controlled randomized study of armodafinil for brain radiation-induced fatigue

BACKGROUND

Common acute-term side effects of brain radiotherapy (RT) include fatigue, drowsiness, decreased physical functioning, and decreased quality of life (QOL). We hypothesized that armodafinil (a wakefulness-promoting drug known to reduce fatigue and increase cognitive function in breast cancer patients receiving chemotherapy) would result in reduced fatigue and sleepiness for patients receiving brain RT.

METHODS

A phase II, multi-institutional, placebo-controlled randomized trial assessed feasibility of armodafinil 150 mg/day in participants receiving brain RT, from whom we obtained estimates of variability for fatigue, sleepiness, QOL, cognitive function, and treatment effect.

RESULTS

From September 20, 2010, to October 20, 2012, 54 participants enrolled with 80% retention and 94% self-reported compliance. There were no grade 4-5 toxicities, and the incidence of grade 2-3 toxicities was similar between treatment arms, the most common of which were anxiety and nausea (15%), headaches (19%), and insomnia (20%). There were no statistically significant differences in end-RT or 4 week post-RT outcomes between armodafinil and placebo in any outcomes (Functional Assessment of Chronic Illness Therapy [FACIT]-Fatigue, Brief Fatigue Inventory, Epworth Sleepiness Scale, FACT-Brain, and FACIT-cognitive function). However, in participants with more baseline fatigue, those treated with armodafinil did better than those who received the placebo on the end-RT assessments for several outcomes.

CONCLUSION

Armodafinil 150 mg/day was well tolerated in primary brain tumor patients undergoing RT with good compliance. While there was no overall significant effect on fatigue, those with greater baseline fatigue experienced improved QOL and reduced fatigue when using armodafinil. These data suggest that a prospective, phase III randomized trial is warranted for patients with greater baseline fatigue.

Phase II double-blind placebo-controlled study of armodafinil for brain radiation induced fatigue

9505

Background: Armodafinil (ARM), the R-enantiomer of modafinil, is FDA approved for narcolepsy, shift work disorder, and treated sleep-apnea, and has also been shown to reduce fatigue/improve cognitive function in cancer patients. This phase II study estimated the efficacy and toxicity of ARM in primary brain tumor (PBT) patients receiving brain radiation therapy (RT) to determine whether a larger phase III study would be warranted. Methods: Eligibility criteria – adult, PBT, total RT dose >45Gy, KPS>60, no severe headaches, and concurrent chemotherapy allowed. Patients were assessed at baseline, end of RT, then 4 weeks after end RT with the Brief Fatigue Inventory (BFI), Epworth Sleep Scale (ESS), FACT, and FACT brain and FACIT fatigue subscales. Patients were randomized to receive ARM 150mg/day during RT and for 4 weeks after RT or placebo (PLAC). Results: 54 patients enrolled between 9/10-12/12; 26 to ARM, 28 to placebo PLAC. Median age 59; 59% female; 95% White; 41% KPS 90-100, 59% KPS 60-80; 74% malignant glioma, 26% low-grade glioma/benign histology. 83% patients had concurrent chemotherapy. For all randomized patients, there were no statistically significant differences in outcome between ARM and PLAC groups at end-RT vs. baseline or 4 weeks post RT vs. baseline. For patients who had more baseline fatigue (fatigue subscale score <median), ARM-treated patients had significantly/suggestively better outcomes at end-RT vs. baseline compared to PLAC-treated patients: less fatigue (BFI p=0.056, fatigue subscale p=0.0295), less sleepiness (ESS p=0.1034), and better QOL (FACT p=0.0001). Incidence of grade 2/3 toxicities was the same between the two treatment groups: 7% anxiety, 7% nausea, 18% headaches, and 20% insomnia. There were no grade 4 or 5 toxicities. Conclusions: In irradiated PBT patients, fatigue, sleepiness, and reduced QOL occurring at the end of brain RT was less with ARM in those patients who were more fatigued at baseline. Toxicity was minimal. These data support conducting a larger phase III study. Analysis of cognitive function data is ongoing. Support - NIH/NCI grant 2U10 CA 81851 and Teva Pharmaceuticals. Clinical trial information: 95709.

Phase II trial of neoadjuvant chemotherapy for HPV-associated squamous cell carcinoma of the oropharynx followed by reduced-dose radiotherapy/chemoradiotherapy for responders or standard dose chemoradiotherapy for nonresponders

TPS5601

Background: Recent studies have established an improved outcome for HPV associated oropharyngeal squamous cell cancers with 3 year OS rates approaching 90%. Given that current aggressive treatment modalities for HNC include IMRT and chemotherapy (CT), they adversely affect the long term QOL of these patients who are considered highly curable. The primary objective of our study is to confirm the activity (CR + PR at 3 months post completion RT/CRT) of induction TPF followed by dose reduced IMRT +/- concurrent CT, in nonsmokers with HPV associated, locally advanced SCC of H&N. Secondary objectives include: to define objective tumor RR to induction chemotherapy and to subsequent RT based treatment, per RECIST version 1.1 criteria, assess PFS and OS at 2 years,assess locoregional disease and distant disease control at 2 years, and monitoring of QOL instruments for HNC. Methods: Institutional IRB approval has been obtained for this study. Eligibility criteria include p16 expressing or ISH + SCC of the oropharynx, T1-3, N1-2, age > 17 years, adequate marrow and organ function and adequate PS. Exclusion criteria include T4 or N3 disease, significant smoking history > 10 pack year lifetime exposure. Patients would be treated with standard TPF induction for 3 cycles followed by risk assessment. Pts. achieving locoregional CR or CR/PR at primary site would receive dose reduced RT (66 Gy) +/- CT, while those with SD/PD would receive standard CRT with full dose XRT. Post therapy assessments include serial evaluation of functional quality-of-life, including M. D. Anderson Dysphagia Inventory (MDADI) and Oropharyngeal swallowing efficiency (OPSE) measures of swallowing function, treatment related symptoms, dietary status assessments and formal sialometric measurement of parotid function. Interim analysis would include RR assessment at 3 months post treatment in the first 12 patients who received dose reduced RT and compared with historical controls. Early stopping rules are built into the protocol. This study is currently open and patient accrual is ongoing.