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Chung BH, Huang J, Uemura H, Choi YD, Ye ZQ, Suzuki H, Kang TW, He DL, Joung JY, Brookman-May SD, McCarthy S, Bhaumik A, Singh A, Mundle S, Chowdhury S, Agarwal N, Ye DW, Chi KN, Uemura H. Apalutamide for metastatic castration-sensitive prostate cancer: final analysis of the Asian subpopulation in the TITAN trial. Asian J Androl 2023; 25:653-661. [PMID: 37322621 DOI: 10.4103/aja202320] [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: 10/27/2022] [Accepted: 04/17/2023] [Indexed: 06/17/2023] Open
Abstract
The final analysis of the phase 3 Targeted Investigational Treatment Analysis of Novel Anti-androgen (TITAN) trial showed improvement in overall survival (OS) and other efficacy endpoints with apalutamide plus androgen deprivation therapy (ADT) versus ADT alone in patients with metastatic castration-sensitive prostate cancer (mCSPC). As ethnicity and regional differences may affect treatment outcomes in advanced prostate cancer, a post hoc final analysis was conducted to assess the efficacy and safety of apalutamide in the Asian subpopulation. Event-driven endpoints were OS, and time from randomization to initiation of castration resistance, prostate-specific antigen (PSA) progression, and second progression-free survival (PFS2) on first subsequent therapy or death. Efficacy endpoints were assessed using the Kaplan-Meier method and Cox proportional-hazards models without formal statistical testing and adjustment for multiplicity. Participating Asian patients received once-daily apalutamide 240 mg ( n = 111) or placebo ( n = 110) plus ADT. After a median follow-up of 42.5 months and despite crossover of 47 placebo recipients to open-label apalutamide, apalutamide reduced the risk of death by 32% (hazard ratio [HR]: 0.68; 95% confidence interval [CI]: 0.42-1.13), risk of castration resistance by 69% (HR: 0.31; 95% CI: 0.21-0.46), PSA progression by 79% (HR: 0.21; 95% CI: 0.13-0.35) and PFS2 by 24% (HR: 0.76; 95% CI: 0.44-1.29) relative to placebo. The outcomes were comparable between subgroups with low- and high-volume disease at baseline. No new safety issues were identified. Apalutamide provides valuable clinical benefits to Asian patients with mCSPC, with an efficacy and safety profile consistent with that in the overall patient population.
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Affiliation(s)
- Byung Ha Chung
- Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, South Korea
| | - Jian Huang
- Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510123, China
| | - Hiroji Uemura
- Yokohama City University Medical Center, Minami-ku, Yokohama, Kanagwa 232-0024, Japan
| | - Young Deuk Choi
- Severance Hospital, Yonsei University College of Medicine, Seoul 03722, South Korea
| | - Zhang-Qun Ye
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | | | - Taek Won Kang
- Chonnam National University Hospital and Medical School, Gwangju 61469, South Korea
| | - Da-Lin He
- Department of Urology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Jae Young Joung
- Prostate Cancer Center, National Cancer Center, Goyang 10408, South Korea
| | - Sabine D Brookman-May
- Janssen Research and Development, Spring House, PA 19002, USA
- Ludwig Maximilians University, Munich 80539, Germany
| | | | | | - Anildeep Singh
- Janssen Medical Affairs, Asia Pacific, Singapore 118222, Singapore
| | - Suneel Mundle
- Janssen Research and Development, Raritan, NJ 08869, USA
| | - Simon Chowdhury
- Guy's and St Thomas' NHS Foundation Trust, London SE1 4YB, UK
| | - Neeraj Agarwal
- University of Utah Huntsman Cancer Institute, Salt Lake City, UT 84112, USA
| | - Ding-Wei Ye
- Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Kim N Chi
- Vancouver Prostate Centre, University of British Columbia, Vancouver, British Columbia V6H 3Z6, Canada
| | - Hirotsugu Uemura
- Kindai University, Faculty of Medicine, Osaka-Sayama 589-8511, Japan
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Honma Y, Monden N, Yamazaki K, Kano S, Satake H, Kadowaki S, Nagao T, Nakatogawa T, Fujii K, Koroki Y, Aoyama J, Ouchi S, Ogawa T, McCarthy S, Brookman-May SD, Mundle S, Li J, Tada Y. Yatagarasu: A single-arm, open-label, phase 2 study of apalutamide (APA) plus goserelin (GOS) for patients (pts) with far locally advanced or recurrent/metastatic (fLA/RM) and androgen receptor (AR)-expressing salivary gland carcinoma (SGC). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.6079] [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
6079 Background: Overexpression of AR is identified as a potential molecular target of SGC treatment. Combined androgen blockade (CAB) with bicalutamide has been evaluated previously, but the clinical usefulness of CAB with a next generation AR inhibitor has been unclear in SGC. We prospectively assessed the efficacy and safety of APA+GOS for pts with AR-expressing SGC. Methods: Eligible pts had fLA/RM SGC, and AR expression with at least 1% of cell nuclei immunohistochemistry staining positive. Pts were treated with APA 240 mg orally once daily and GOS 3.6 mg subcutaneously once 28 days. Primary endpoint was overall response rate (ORR) by central review according to RECIST v1.1, and a response (complete response [CR] or partial response [PR]) was confirmed by repeat assessments at least 4 weeks after the initial evaluation showing a response. Primary analysis was performed based on first 24 response evaluable (RE) pts who had been observed at least 24 weeks (Primary RE pts). The ORR was tested using exact test based on the binominal distribution, the null hypothesis for ORR of 14% was rejected when at least 8 of the 24 Primary RE pts were responders, and the efficacy was to be declared. Key secondary endpoints included clinical benefit rate (CBR), disease control rate (DCR), duration of response (DOR), and time to response (TTR) in the Primary RE pts, and overall survival (OS), progression free survival (PFS), and safety in the treated pts. Results: Twenty-six of the 31 pts treated with APA+GOS were regarded as RE by central review. For the 24 Primary RE pts, ORR was 25.0% (6/24), while 37.5% (9/24) including unconfirmed PR. Clinical benefit rate and DCR in the Primary RE pts were 50.0% and 70.8%, respectively. At the data cut-off (Apr 28, 2021), 5 of 6 pts with confirmed response were still on protocol treatment. Median PFS and OS in the treated pts were 7.43 months (mos) and not reached, respectively, with the median follow-up period of 8.57 mos. Grade 3 or higher treatment-related adverse events were reported in 4/31 (12.9%) pts, and the events were rash maculo-papular (n=2), anemia (n=1), and leukopenia (n=1). Conclusions: This is the first prospective trial evaluating CAB with APA for AR-expressing SGC. Although this study did not meet the predefined criteria of efficacy, clinically meaningful activity with well-tolerated safety profile of APA+GOS was shown. Clinical trial information: NCT04325828. [Table: see text]
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Affiliation(s)
- Yoshitaka Honma
- Department of Head and Neck, Esophageal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Nobuya Monden
- Department of Head and Neck Surgery, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | - Keisuke Yamazaki
- Department of Otolaryngology Head and Neck Surgery, Niigata University, Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Satoshi Kano
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hironaga Satake
- Cancer Treatment Center, Kansai Medical University Hospital, Hirakata, Japan
| | - Shigenori Kadowaki
- Department of Clinical Oncology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Toshitaka Nagao
- Department of Anatomic Pathology, Tokyo Medical University, Tokyo, Japan
| | | | - Koji Fujii
- Janssen Pharmaceutical K.K., Tokyo, Japan
| | - Yosuke Koroki
- Department of Medical Affairs, Janssen Pharmaceutical K.K., Tokyo, Japan
| | | | | | | | | | | | | | - Jinhui Li
- Janssen Research & Development, San Diego, CA
| | - Yuichiro Tada
- Department of Head and Neck Oncology and Surgery, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
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Sandler HM, Freedland SJ, Shore ND, Smith MR, Rosales RS, Brookman-May SD, Dearnaley DP, Dicker AP, McKenzie MR, Bossi A, Widmark A, Wiegel T, Martin JL, Miladinovic B, Whalen JA, Ciprotti M, McCarthy S, Mundle S, Tombal BF, Feng FY. Patient (pt) population and radiation therapy (RT) type in the long-term phase 3 double-blind, placebo (PBO)-controlled ATLAS study of apalutamide (APA) added to androgen deprivation therapy (ADT) in high-risk localized or locally advanced prostate cancer (HRLPC). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.5084] [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
5084 Background: Current management of HRLPC includes long-term ADT with primary RT. Despite definitive primary treatment, these pts have a high risk of metastasis and death. The phase 3 ATLAS study (NCT02531516) is investigating whether treatment intensification with the addition of APA to neoadjuvant and adjuvant treatment with gonadotropin-releasing hormone agonist (GnRHa) and external beam radiation therapy (EBRT) will improve metastasis-free survival (MFS) in high-risk pts. Here we describe (1) the distribution of baseline characteristics in this high-risk pt population and (2) the application of different RT regimens reflecting recent international guidelines and clinical practice changes for pts with HRLPC. Methods: Eligible HRLPC pts (Gleason score [GS] ≥ 8 or 7 and prostate-specific antigen [PSA] ≥ 20 ng/mL and stage ≥ cT2c), with ECOG PS 0/1 and Charlson Comorbidity Index (CCI) ≤ 3 are stratified by GS, pelvic nodal status, use of brachytherapy boost, and region; pts are randomized 1:1 to APA or PBO plus GnRHa for 30 (28-d) treatment cycles. Study treatment is applied neoadjuvant/concurrent to RT with APA 240 mg/d vs bicalutamide 50 mg/d for 4 cycles; another 26 cycles are completed adjuvantly after RT with APA 240 mg/d vs PBO. Primary end point is MFS (time from randomization to first distant metastasis on CT/MRI/bone scan by independent central review blinded to treatment or death from any cause). Imaging is conducted at baseline and q6m from biochemical failure until MFS. The protocol has been amended to include PET imaging (PSMA, fluciclovine, or choline). Results: Pts (N = 1503) were randomized at 266 sites in 24 countries in North America, Latin America, Europe, and Asia. The study is fully enrolled, but ongoing. Baseline characteristics for the total population: median age, 67 yrs; ECOG PS 0/1; 89%/11%; tumor classification at study entry: high-risk, 66%/very high–risk, 34%; median PSA, 6.3 ng/mL; cT2, 44%/cT3, 50%; cN1, 13%. In 90% of ATLAS pts, RT used was standard EBRT to prostate/pelvis over 6-8 weeks (cumulative 78-81 Gy); in 10%, recent hypofractionation schedules (per CHHiP or NRG/RTOG 0415) were applied (20x3 Gy/d or 28x2.5 Gy/d). 5.6% of pts had EBRT combined with brachytherapy (per ASCENDE-RT). Conclusions: Baseline characteristics of the ATLAS study population are reflective of pts with high- and very high–risk features and pelvic nodal involvement undergoing primary RT in clinical practice. The RT schedules applied reflect recent evidence and guideline changes for the use of hypofractionation in this pt population. ATLAS is an example of how RT can be included in phase 3 trials of HRLPC, in combination with next-generation androgen receptor inhibitors (eg, APA). Clinical trial information: NCT02531516.
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Affiliation(s)
| | - Stephen J. Freedland
- Division of Urology, Department of Surgery, Cedars-Sinai Medical Center and Department of Surgery, Durham Veterans Affairs Health Care System, Durham, NC
| | | | | | | | - Sabine D. Brookman-May
- Janssen Research & Development, Los Angeles, CA and Ludwig-Maximilians-University, Munich, Germany
| | - David P. Dearnaley
- The Royal Marsden Hospital and The Institute of Cancer Research, London, United Kingdom
| | - Adam P. Dicker
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | | | | | | | | | - Jason L. Martin
- Janssen Research & Development, High Wycombe, United Kingdom
| | | | | | | | | | | | - Bertrand F. Tombal
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Felix Y Feng
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
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Agarwal N, Lucas J, Aguilar-Bonavides C, Thomas S, Gormley M, Chowdhury S, Merseburger AS, Bjartell A, Uemura H, Özgüroğlu M, McCarthy S, Brookman-May SD, Lefresne F, Mundle S, Chi KN. Genomic aberrations associated with overall survival (OS) in metastatic castration-sensitive prostate cancer (mCSPC) treated with apalutamide (APA) or placebo (PBO) plus androgen deprivation therapy (ADT) in TITAN. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.5066] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5066 Background: TITAN, a phase 3 PBO-controlled study in patients (pts) with mCSPC, showed APA + ADT improved radiographic progression-free survival and OS vs PBO + ADT. In this exploratory analysis, we report the relationships between biomarkers and OS in TITAN. Methods: Circulating tumor (ct)DNA and genomic aberrations in 17 PC-related genes, including androgen receptor (AR), were assessed at baseline (BL; 114 pts) and end of study treatment (EOST; 129 pts) using next-generation sequencing. ctDNA was assessed qualitatively; genomic aberrations were assessed within ctDNA-positive samples as inactivation (heterozygous/homozygous deletion or single nucleotide variant [SNV]) or activation (amplification or SNV). Associations of detected ctDNA/aberrations at BL or EOST with OS, and biomarkers at EOST with OS on subsequent therapies, were evaluated using univariate or multivariate analyses and Cox proportional hazards model; results were stratified by treatment arm. Results: Among pts from both treatment groups, 36% had detectable ctDNA, of which 27% had any genomic AR aberration and 24% had AR gene amplification at BL; prevalence of these biomarkers increased significantly from BL to EOST (Table). The most prevalent non-AR aberrations at BL ( TP53, homologous recombination repair [HRR] pathway, PTEN, RB1, and PIK3CA genes) increased at EOST but not significantly (Table). Among assessed aberrations, presence of ctDNA or any AR genomic aberrations at BL (HR, 1.9 or 6.7; all p < 0.05) and any AR genomic aberrations or PI3K pathway activation at EOST (1.7, p < 0.05 or 2.2, p < 0.001) was significantly associated with poor OS in multivariate analyses from both treatment groups. In univariate analyses of pts who received subsequent therapy (chemotherapy: 106; hormonal therapy: 161), worse OS was associated only with PIK3CA activation, PI3K pathway activation, or TP53 inactivation at EOST (3.7, p < 0.05; 2.4, p < 0.05; 3.0, p < 0.01, respectively) in chemo-treated pts. A small sample size in some biomarker subgroups limits interpretation. Conclusions: These hypothesis-generating data from TITAN show that presence of ctDNA or select AR and non-AR biomarkers at BL or EOST were associated with poor OS. The predictive value of these biomarkers for survival in mCSPC needs further confirmation. Clinical trial information: NCT02489318. [Table: see text]
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Affiliation(s)
- Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Justin Lucas
- Janssen Research & Development, Spring House, PA
| | | | - Shibu Thomas
- Janssen Research & Development, Spring House, PA
| | | | - Simon Chowdhury
- Guy's, King's, and St. Thomas' Hospitals, and Sarah Cannon Research Institute, London, United Kingdom
| | | | | | | | - Mustafa Özgüroğlu
- Istanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, Istanbul, Turkey
| | | | - Sabine D. Brookman-May
- Janssen Research & Development, Los Angeles, CA and Ludwig-Maximilians-University, Munich, Germany
| | | | | | - Kim N. Chi
- BC Cancer; Vancouver Prostate Centre, Vancouver, BC, Canada
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5
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Uemura H, Arai G, Uemura H, Suzuki H, Aoyama J, Hatayama T, Ito M, Lefresne F, McCarthy S, Mundle S, He J, Chi KN. Safety and efficacy of apalutamide in Japanese patients with metastatic castration-sensitive prostate cancer receiving androgen deprivation therapy: Final report for the Japanese subpopulation analysis of the randomized, placebo-controlled, phase III TITAN study. Int J Urol 2022; 29:533-540. [PMID: 35293030 PMCID: PMC9310605 DOI: 10.1111/iju.14843] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 02/06/2022] [Indexed: 12/19/2022]
Abstract
Objectives The TITAN study is a randomized, double‐blind, placebo‐controlled, multinational trial that evaluated apalutamide with androgen deprivation therapy in patients with metastatic castration‐sensitive prostate cancer. At the first interim analysis in the Japanese subpopulation (median follow‐up 25.7 months), there was an improvement in overall survival and radiological progression‐free survival with apalutamide versus placebo. Here, we report the final analysis results for the Japanese subpopulation. Methods Patients were randomized 1:1 to receive apalutamide 240 mg or placebo. After the first interim analysis, protocol treatment was unblinded, and crossover was allowed. Efficacy and safety were evaluated in the preplanned, event‐driven final analysis. Results Fifty‐one patients were Japanese (apalutamide n = 28; placebo n = 23). After a median follow‐up of 46.0 months, the median overall survival was not reached neither in the apalutamide nor the placebo group; the hazard ratio was 0.45, favoring apalutamide, which was consistent with the overall population. Hazard ratios for time to cytotoxic chemotherapy (0.39), time to pain progression (0.87), and time to chronic opioid use (0.82) also favored apalutamide and were comparable with those of the overall population. Time to prostate‐specific antigen progression and progression‐free survival 2, respectively, was favored in the apalutamide group (0.21 and 0.44). Apalutamide was associated with higher incidences of rash and fracture in the Japanese subpopulation compared with the overall population. Conclusions The efficacy of apalutamide with androgen deprivation therapy in Japanese patients was consistent with efficacy demonstrated in the overall population. No new safety concerns emerged with long‐term follow‐up.
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Affiliation(s)
- Hirotsugu Uemura
- Department of Urology, Kindai University Hospital, Osakasayama, Osaka, Japan
| | - Gaku Arai
- Department of Urology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Hiroji Uemura
- Department of Urology and Renal Transplantation, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Hiroyoshi Suzuki
- Department of Urology, Toho University Sakura Medical Center, Sakura, Chiba, Japan
| | | | | | - Miku Ito
- Janssen Pharmaceutical K.K., Tokyo, Japan
| | | | - Sharon McCarthy
- Janssen Research and Development US, Raritan, New Jersey, USA
| | - Suneel Mundle
- Janssen Research and Development US, Raritan, New Jersey, USA
| | - Jin He
- Janssen Asia Pacific, Medical Affairs, Singapore
| | - Kim N Chi
- BC Cancer and Vancouver Prostate Centre, Vancouver, British Columbia, Canada
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Chi KN, Merseburger AS, Ozguroglu M, Chowdhury S, Bjartell A, Chung B, Pereira de Santana Gomes AJ, Given R, Juárez Á, Uemura H, Ye D, Karsh LI, Gartrell BA, Brookman-May SD, Mundle S, McCarthy SA, Lefresne F, Rooney OB, Bhaumik A, Agarwal N. The effect of prior docetaxel (DOC) treatment on efficacy and safety of apalutamide (APA) plus androgen deprivation therapy (ADT) in patients (pts) with metastatic castration-sensitive prostate cancer (mCSPC) from TITAN. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.6_suppl.089] [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
89 Background: Addition of androgen receptor signaling inhibitors to ADT + DOC has been shown to improve clinical outcomes in pts with mCSPC. TITAN, a placebo-controlled phase 3 study, showed that APA + ADT improved overall survival (OS) and other clinical outcomes in mCSPC (Chi, J Clin Oncol 2021). This post hoc analysis of TITAN evaluated outcomes in pts who had received DOC prior to treatment with APA + ADT versus those who did not. Methods: In TITAN, 1052 pts were randomized 1:1 to APA (240 mg QD) or placebo added to ongoing ADT. We assessed radiographic progression-free survival (rPFS), OS, and time to prostate-specific antigen (PSA) progression in pts receiving DOC and ADT prior to adding APA vs those receiving only ADT plus APA. Outcomes by prior DOC were also assessed in pts with high- or low-volume disease at randomization (baseline [BL]) per adapted CHAARTED criteria, or those with matched BL characteristics. A Cox proportional hazards model was used to derive hazard ratios (HRs) and p values. rPFS was assessed using the first interim analysis cutoff (23 mo median follow-up); OS and time to PSA progression were assessed using the final analysis cutoff (44 mo median follow-up). Results: A total of 58/525 (11%) pts from the APA + ADT group had received DOC prior to randomization: 76% (n = 44) had high-volume disease, 62% (n = 36) had bone-only metastases, 16% (n = 9) had visceral metastases, and 59% (n = 34) had > 10 bone lesions. In the overall APA-treated population and in the subset of pts with high-volume disease, OS, rPFS, and time to PSA progression were similar in those who received prior DOC and those who did not (Table). Pts with low-volume disease also had similar results, although the number of pts was small. Clinical outcomes in pts with matched BL characteristics (including PSA and time from initial diagnosis to randomization, among others) were similar regardless of prior use of DOC (Table). The safety profile of APA was not substantially different between pts with or without prior DOC. Limitations of this analysis include lack of data on tumor volume and other disease characteristics at the initiation of prior DOC treatment; interpretation was based on small number of pts with prior DOC (only 11% of TITAN pts), most notably in the rPFS analysis. Conclusions: Prior use of DOC in pts with mCSPC did not further improve clinical benefits of APA + ADT in TITAN. Clinical trial information: NCT02489318. [Table: see text]
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Affiliation(s)
- Kim N. Chi
- BC Cancer and Vancouver Prostate Centre, Vancouver, BC, Canada
| | | | - Mustafa Ozguroglu
- Istanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, Istanbul, Turkey
| | - Simon Chowdhury
- Guy's, King's, and St. Thomas' Hospitals, and Sarah Cannon Research Institute, London, United Kingdom
| | | | - Byung Chung
- Yonsei University College of Medicine and Gangnam Severance Hospital, Seoul, South Korea
| | | | - Robert Given
- Urology of Virginia, Eastern Virginia Medical School, Norfolk, VA
| | - Álvaro Juárez
- Hospital Universitario de Jerez de la Frontera, Cadiz, Spain
| | | | - Dingwei Ye
- Fudan University Shanghai Cancer Center, Shanghai, China
| | | | | | - Sabine D. Brookman-May
- Ludwig-Maximilians-University (LMU), Munich, Germany, Janssen Research & Development, Los Angeles, CA
| | | | | | | | | | | | - Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
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Small EJ, Chi KN, Chowdhury S, Bevans KB, Bhaumik A, Saad F, Chung B, Karsh LI, Oudard S, De Porre P, Brookman-May SD, McCarthy SA, Mundle S, Uemura H, Smith MR, Agarwal N. Association between patient-reported outcomes (PROs) and changes in prostate-specific antigen (PSA) in patients (pts) with advanced prostate cancer treated with apalutamide (APA) in the SPARTAN and TITAN studies. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.6_suppl.073] [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
73 Background: In phase 3 placebo (PBO)-controlled studies, addition of APA to androgen deprivation therapy (ADT) improved overall survival, resulted in rapid and deep PSA declines, and reduced risk of disease progression while preserving health-related quality of life (HRQoL) in nonmetastatic castration-resistant prostate cancer (nmCRPC; SPARTAN) and metastatic castration-sensitive prostate cancer (mCSPC; TITAN). This post hoc analysis evaluated the association of a deep PSA decline with PROs in these studies. Methods: Pts on ADT were randomized to APA (240 mg QD) or PBO: SPARTAN 2:1 (N = 1,207; APA n = 806), TITAN 1:1 (N = 1,052; APA n = 525). Each cycle was 28 d. PROs were assessed using Functional Assessment of Cancer Therapy-Prostate (FACT-P), Brief Pain Inventory-Short Form (BPI-SF; TITAN only), and Brief Fatigue Inventory (BFI; TITAN only) at baseline, specific cycles during study treatment, and post progression up to 1 yr. A landmark analysis at Month 3 evaluated association between deep PSA decline (≤ 0.2 ng/mL) and time to subsequent deterioration in PROs (defined as decrease ≥ 10 points FACT-P total, ≥ 3 points Physical Wellbeing, ≥ 30% baseline for BPI-SF worst pain, or ≥ 2 points for BFI worst fatigue). At time of the landmark analysis, only pts continuing treatment were included; all deep PSA responses after, and all PRO deterioration events before, were ignored. Time-to-event end points were analyzed by Kaplan-Meier method and Cox proportional hazards model. Results: Median treatment durations were 32.9 mo (SPARTAN) and 39.3 mo (TITAN). Per assessment, > 90% (SPARTAN, cycles 1-81) and > 50% (TITAN, cycles 1-33) of eligible pts completed FACT-P; BPI-SF and BFI, both > 62% (TITAN, cycles 1-33). Pts in either study who achieved PSA ≤ 0.2 ng/mL at Month 3 had a lower risk of deterioration in FACT-P total or Physical Wellbeing (Table). Pts in TITAN with PSA ≤ 0.2 ng/mL at Month 3 had a lower risk of BPI-SF worst pain intensity or BFI worst fatigue intensity progression (Table). Conclusions: Deep and rapid PSA responses with APA were associated with prolonged time to deterioration in HRQoL, FACT-P Physical Wellbeing, BPI-SF worst pain intensity, and BFI worst fatigue intensity in pts with advanced PC. Clinical trial information: NCT02489318 (TITAN); NCT01946204 (SPARTAN). [Table: see text]
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Affiliation(s)
- Eric Jay Small
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
| | - Kim N. Chi
- BC Cancer and Vancouver Prostate Centre, Vancouver, BC, Canada
| | - Simon Chowdhury
- Guy's, King's, and St. Thomas' Hospitals, and Sarah Cannon Research Institute, London, United Kingdom
| | | | | | - Fred Saad
- Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Byung Chung
- Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | | | - Stephane Oudard
- Georges Pompidou Hospital, Université Paris Descartes, Paris, France
| | | | - Sabine D. Brookman-May
- Janssen Research & Development, Los Angeles, CA, Ludwig-Maximilians-University, Munich, Germany
| | | | | | | | | | - Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
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Baciarello G, Özgüroğlu M, Mundle S, Leitz G, Richarz U, Hu P, Feyerabend S, Matsubara N, Chi KN, Fizazi K. Impact of abiraterone acetate plus prednisone in patients with castration-sensitive prostate cancer and visceral metastases over four years of follow-up: A post-hoc exploratory analysis of the LATITUDE study. Eur J Cancer 2021; 162:56-64. [PMID: 34953443 DOI: 10.1016/j.ejca.2021.11.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 09/13/2021] [Accepted: 11/03/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND A post-hoc analysis of the phase-3 LATITUDE study assessed the impact of abiraterone acetate plus prednisone (AA+P) on overall survival (OS) and radiographic progression-free survival (rPFS) in men with metastatic castration-sensitive prostate cancer (mCSPC) and visceral metastases (VM). METHODS Newly diagnosed mCSPC patients were randomized (1:1) to AA+P and androgen deprivation therapy (ADT) or placebo+ADT. Patients with VM in liver or lungs with or without other soft tissue and bone metastases (based on CT/MRI) at baseline were analyzed, after 51.8 months' median follow-up. Co-primary endpoints, OS and rPFS, were analyzed. RESULTS Among 1199 patients enrolled, 228 (19%) had VM at baseline (114 each in AA+P and placebo groups), of which 53 (23.2%; AA+P = 29, Placebo = 24) had liver metastases and 117 (51.3%; AA+P = 60, Placebo = 57) had lung metastases. In patients with VM, treatment with AA+P versus placebo showed an improvement in OS (median 55.4 vs 33.0 months; HR = 0.582; 95%CI = 0.406-0.835;P = 0.0029) and rPFS (median 30.7 vs 18.3 months; HR = 0.527; 95%CI = 0.366-0.759;P = 0.0005), comparable to that of patients without VM. AA+P versus placebo in lung metastases patients was associated with greater improvement in OS (HR = 0.60; 95%CI = 0.35-1.04;P = 0.0678) than in liver metastases patients (HR = 0.82; 95%CI = 0.41-1.66;P = 0.5814). AA+P versus placebo showed improvement in rPFS in lung metastases patients (HR = 0.50; 95%CI = 0.29-0.89;P = 0.0157), but not in liver metastases patients (HR = 1.05; 95%CI = 0.53-2.09; P = 0.8970). CONCLUSION AA+P treatment improved both rPFS and OS in men with mCSPC and visceral disease, especially those with lung metastases. Men with liver metastases had a poorer prognosis and their optimal treatment remains to be defined. REGISTRATION ClinicalTrials.gov, number NCT01715285.
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Affiliation(s)
- Giulia Baciarello
- Gustave Roussy, University of Paris-Saclay, Villejuif, France; Medical Oncology Department, Fondazione IRCCS Istituto Dei Tumori, Milan, Italy
| | - Mustafa Özgüroğlu
- Cerrahpaşa Medical Faculty, Istanbul University Cerrahpaşa, Istanbul, Turkey
| | | | | | - Ute Richarz
- Janssen Global Services LLC, Titusville, NJ, USA
| | - Peter Hu
- Janssen Research & Development, Raritan, NJ, USA
| | | | | | - Kim N Chi
- BC Cancer Agency - Vancouver Centre, Vancouver, BC, Canada
| | - Karim Fizazi
- Gustave Roussy, University of Paris-Saclay, Villejuif, France.
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Chung BH, Huang J, Ye ZQ, He DL, Uemura H, Arai G, Kim CS, Zhang YY, Koroki Y, Jeong S, Mundle S, Triantos S, McCarthy S, Chi KN, Ye DW. Apalutamide for patients with metastatic castrationsensitive prostate cancer in East Asia: a subgroup analysis of the TITAN trial. Asian J Androl 2021; 24:161-166. [PMID: 34259202 PMCID: PMC8887099 DOI: 10.4103/aja.aja_64_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Ethnicity might be associated with treatment outcomes in advanced prostate cancer. This study aimed to evaluate the efficacy and safety of androgen deprivation therapy (ADT) combined with apalutamide in East Asians with metastatic castration-sensitive prostate cancer (mCSPC). The original phase 3 Targeted Investigational Treatment Analysis of Novel Anti-androgen (TITAN) trial was conducted at 260 sites in 23 countries. This subgroup analysis included patients enrolled in 62 participating centers in China, Japan, and Korea. Radiographic progression-free survival (PFS), time to prostate-specific antigen (PSA) progression, and PSA changes from baseline were compared between groups in the East Asian population. The intent-to-treat East Asian population included 111 and 110 participants in the apalutamide and placebo groups, respectively. The 24-month radiographic PFS rates were 76.1% and 52.3% in the apalutamide and placebo groups, respectively (apalutamide vs placebo: hazard ratio [HR] = 0.506; 95% confidence interval [CI], 0.302–0.849; P = 0.009). Median time to PSA progression was more favorable with apalutamide than placebo (HR = 0.210; 95% CI, 0.124–0.357; P < 0.001). Median maximum percentages of PSA decline from baseline were 99.0% and 73.9% in the apalutamide and placebo groups, respectively. The most common adverse event (AE) was rash in the apalutamide group, with a higher rate than that in the placebo group (37.3% vs 9.1%). The most common grade 3 or 4 AEs were rash (12 [10.9%]) and hypertension (12 [10.9%]) for apalutamide. The efficacy and safety of apalutamide in the East Asian subgroup of the TITAN trial are consistent with the global results.
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Affiliation(s)
- Byung Ha Chung
- Department of Urology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 135-271, Korea
| | - Jian Huang
- Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China
| | - Zhang-Qun Ye
- Wuhan Tongji Hospital, Tongji Medical College, Wuhan 430030, China
| | - Da-Lin He
- First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 719054, China
| | | | - Gaku Arai
- Dokkyo Medical University Saitama Medical Center, Saitama 2-1-50, Japan
| | - Choung Soo Kim
- Asian Medical Center, University of Ulsan, Seoul 138-040, Korea
| | | | - Yusoke Koroki
- Janssen Medical Affairs Department, Tokyo 101-0065, Japan
| | - SuYeon Jeong
- Janssen Medical Affairs Department, Seoul 140-012, Korea
| | - Suneel Mundle
- Janssen Global Medical Affairs Department, Horsham, PA 08869, USA
| | - Spyros Triantos
- Janssen Research and Development, Spring House, PA 19477, USA
| | | | - Kim N Chi
- BC Cancer and Vancouver Prostate Centre, Vancouver, BC V5Z 1G1, Canada
| | - Ding-Wei Ye
- Fudan University Shanghai Cancer Center, Shanghai 200032, China
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10
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Lucas J, Agarwal N, Feng F, Aguilar-Bonavides C, Thomas S, Gormley M, Mundle S, Brookman-May S, McCarthy SA, Bjartell A, Uemura H, Chowdhury S, Chi KN. Abstract 359: Molecular signatures associated with long-term response to apalutamide (APA) in patients (pts) with metastatic castration-sensitive prostate cancer (mCSPC) in TITAN. Cancer Res 2021. [DOI: 10.1158/1538-7445.am2021-359] [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: 11/16/2022]
Abstract
Abstract
Background: TITAN, a phase 3 placebo (PBO)-controlled study in a broad population of pts with mCSPC (NCT02489318), demonstrated that the addition of APA to androgen deprivation therapy (ADT) significantly improved radiographic progression-free survival (rPFS) (median rPFS in the APA and PBO groups was not reached and was 22.1 months, respectively) and overall survival (OS) compared with PBO + ADT (Chi N Engl J Med 2019). This exploratory analysis investigated molecular signatures of pts with mCSPC who had long-term responses to APA.
Methods: Pts (n = 222) in the biomarker cohort of TITAN were characterized as long-term responders (LTR) or early progressors (EP) by separating rPFS into quartiles. The last quartile with longest rPFS (APA, n = 28; PBO, n = 28) represented LTR. The first quartile, with shortest rPFS (APA, n = 17; PBO, n = 21) represented EP. Gene expression profiles of TITAN pts were generated from archival primary prostate tumors; data were summarized based on 110 predefined gene signatures. Mean signature scores between LTR and EP groups were compared within treatment groups using 2 sample t tests to evaluate whether effects were prognostic or specific to APA treatment. Signatures were also evaluated for association with outcome using Cox proportional hazard models in each treatment group.
Results: At primary analysis, with median 22.7 months follow-up, median rPFS was, respectively, not reached and 32.9 months in APA and PBO pts in the LTR group, and 10.9 and 3.7 months in APA and PBO pts in the EP group. A higher level of expression (above median) of either polycomb repressor complex 2 activation or the Decipher signature was more frequently associated with EP in both groups. LTR in the APA treatment group, but not those in the PBO group, had lower expression of transcriptional signatures describing myeloid-derived suppressor cells (MDSCs) and cell cycle progression. These results suggest that pts with mCSPC who have relatively lower levels of MDSCs in the tumor, indicative of a less immune-suppressed tumor microenvironment, may have long-term benefit from treatment with APA.
Conclusions: Consistent clinical benefit was observed with the addition of APA to ADT in both EP and LTR. Although the data require confirmation in larger studies, these molecular signatures may have utility in selecting pts with mCSPC who may derive the most benefit from APA and other androgen signaling inhibitors.
Citation Format: Justin Lucas, Neeraj Agarwal, Felix Feng, Clemente Aguilar-Bonavides, Shibu Thomas, Michael Gormley, Suneel Mundle, Sabine Brookman-May, Sharon A. McCarthy, Anders Bjartell, Hirotsugu Uemura, Simon Chowdhury, Kim N. Chi. Molecular signatures associated with long-term response to apalutamide (APA) in patients (pts) with metastatic castration-sensitive prostate cancer (mCSPC) in TITAN [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 359.
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Affiliation(s)
- Justin Lucas
- 1Janssen Research & Development, Spring House, PA
| | - Neeraj Agarwal
- 2Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Felix Feng
- 3Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
| | | | - Shibu Thomas
- 1Janssen Research & Development, Spring House, PA
| | | | | | - Sabine Brookman-May
- 5Janssen Research & Development, Los Angeles, CA, and Ludwig Maximilians University, Munich, Germany
| | | | | | | | - Simon Chowdhury
- 8Guy's, King's, and St. Thomas' Hospitals, and Sarah Cannon Research Institute, London, United Kingdom
| | - Kim N. Chi
- 9BC Cancer and Vancouver Prostate Centre, Vancouver, British Columbia, Canada
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11
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Juarez A, Chi KN, Pereira AJ, Chowdhury S, Triantos S, McCarthy S, Bhaumik A, Mundle S, Velasquez E, Rosas S, Fabricio V, Agarwal N. Abstract CT190: Latin American patient subgroup analysis of the phase 3 TITAN study: Apalutamide plus ADT in metastatic Hormone-Sensitive Prostate Cancer (mHSPC). Cancer Res 2021. [DOI: 10.1158/1538-7445.am2021-ct190] [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: 11/16/2022]
Abstract
Abstract
Background: Apalutamide (APA) is an approved treatment in various countries of Latin America to treat patients with metastatic hormone-sensitive prostate cancer (mCSPC) patients based on the TITAN study interim analysis, which demonstrated an improved overall survival (HR 0.48; 95% CI 0.39-0.60) and radiographic progression-free survival (HR 0.67; 95% CI 0.51-0.89) for patients receiving APA + androgen deprivation therapy (ADT) compared to placebo (PBO) + ADT (KN Chi, et al. N Engl J Med 2019; 381:13-24). As there can be geographical differences in disease presentation and management, we undertook a post-hoc analysis of the Latin American (LATAM) patients enrolled to TITAN.
Methods: mCSPC patients were randomly assigned 1:1 to receive APA (240 mg per day) plus ADT or PBO plus ADT. Patients previously treated for localized disease were eligible and treatment with prior docetaxel was permitted. Radiographic progression-free survival (rPFS) and overall survival (OS) were TITAN's dual primary endpoints.
Results: In total, 177 LATAM patients from Argentina, Brazil and Mexico were recruited (16.8% of the study population). Of the 177 patients, 94 were assigned to the APA-ADT arm and 83 randomized to PBO-ADT arm. The LATAM APA and PBO patients were similar with a median age of 69, 64% of the patients had an ECOG Performance Status of 0, and the majority of patients had a high-volume disease, 57% , which was comparable to the TITAN intention to treat (ITT) population. Prior docetaxel was used in 4% of the LATAM population versus 10.7% in the TITAN ITT population. At the first interim analysis of OS with a median follow-up of 22.7 months, the 2 year OS rate was 84% in the APA group versus 79% in the PBO group (HR for death 0.77; 95% CI of 0.38-1.55; p=0.4567). Median rPFS was not reached in the APA group versus 22.0 months for PBO (HR for radiographic progression or death 0.44; 95% CI of 0.26-0.75; p=0.0019). The benefit of APA-ADT for the LATAM patients appeared consistent to the overall ITT population for the primary, secondary and exploratory efficacy endpoints. The frequency of grade 3 or 4 adverse events was 48.9% in the APA group and 42.2% in the placebo group; discontinuation due to adverse events were more frequent in the APA arm than in the placebo group (11.7% vs. 2.4%).
Conclusion: This analysis of the LATAM patients with mCSPC enrolled in the TITAN study confirms the benefit of the addition of APA to ADT with a safety profile that was consistent with the results shown in the ITT population.
Citation Format: Alvaro Juarez, Kim N. Chi, Andrea J. Pereira, Simon Chowdhury, Spyros Triantos, Sharon McCarthy, Amitabha Bhaumik, Suneel Mundle, Esteban Velasquez, Sara Rosas, Vanessa Fabricio, Neeraj Agarwal. Latin American patient subgroup analysis of the phase 3 TITAN study: Apalutamide plus ADT in metastatic Hormone-Sensitive Prostate Cancer (mHSPC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr CT190.
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Affiliation(s)
| | - Kim N. Chi
- 2BC Cancer and Vancouver Prostate Centre, Vancouver, British Columbia, Canada
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12
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Saad F, Efstathiou E, Attard G, Flaig TW, Franke F, Goodman O, Oudard S, Steuber T, Suzuki H, Pieczonka CM, Parnis F, Wu D, Yeruva K, De Porre P, Brookman-May SD, Li S, Li J, Mundle S, McCarthy SA, Rathkopf DE. Analysis of two poor prognosis subgroups in ACIS evaluating apalutamide + abiraterone acetate plus prednisone (APA + AAP) versus placebo (PBO) + AAP in metastatic castration-resistant prostate cancer (mCRPC). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.5037] [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
5037 Background: In the double-blind PBO-controlled ACIS study, investigator-assessed radiographic progression-free survival (rPFS) was significantly improved with APA + AAP vs PBO + AAP in chemo-naive mCRPC, with no significant new safety signals (Rathkopf ASCO GU 2021). Among prespecified subgroups, efficacy and safety were explored in two difficult to treat subgroups: pts with visceral disease (VD; liver, lung, and/or adrenal gland metastasis) or age ≥ 75 y. Methods: Pts with mCRPC with ongoing ADT and no prior life-prolonging treatment were randomized 1:1 to APA (240 mg QD) + AA (1000 mg QD) + P (5 mg BID) or PBO + AAP. Stratified: presence or absence of VD, ECOG PS 0 or 1, geographic region. Primary end point: rPFS (randomization to radiographic progression or death); secondary end points: overall survival (OS), time to initiation of cytotoxic chemotherapy, time to chronic opioid use, time to pain progression, safety. Results: 982 pts enrolled. 14.6% had VD and 35.9% were ≥ 75 y. Median rPFS, OS, and time to pain progression favored APA + AAP vs AAP (HR < 1) in both subgroups (Table). For pts ≥ 75 y, rPFS and OS were ≥ 7 mo longer with APA + AAP. Overall, treatment-emergent adverse events (TEAEs) were similar (all > 94%) in pts with VD, ≥ 75 y, and overall safety population; hypertension was more frequent with APA + AAP vs AAP mainly in pts ≥ 75 y (31.7% vs 17.6%). Grade 3/4 TEAEs (APA + AAP vs AAP): VD, 60.8%, n = 74 vs 48.5%, n = 68; ≥ 75 y, 71.5%, n = 186 vs 68.5%, n = 165; overall, 63.3%, n = 490 vs 56.2%, n = 489. TEAEs leading to discontinuation: VD, 17.6% vs 5.9%; ≥ 75 y, 26.3% vs 20.6%; overall, 16.9% vs 12.5%. TEAEs leading to death: VD, 6.8% vs 5.9%; ≥ 75 y, 5.4% vs 13.9%; overall, 3.5% vs 7.6%. Conclusions: In this analysis of two difficult to treat subgroups, addition of APA to AAP favored rPFS and OS. Safety, while generally consistent with the overall population, showed higher hypertension rate in ≥ 75 y and TEAEs leading to discontinuation in VD. Clinical trial information: NCT02257736. [Table: see text]
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Affiliation(s)
- Fred Saad
- Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | | | | | | | | | - Oscar Goodman
- Comprehensive Cancer Centers of Nevada, Las Vegas, NV
| | - Stephane Oudard
- Georges Pompidou Hospital, University of Paris, Paris, France
| | - Thomas Steuber
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | - Daphne Wu
- Janssen Research & Development, Los Angeles, CA
| | | | | | | | - Susan Li
- Janssen Research & Development, Spring House, PA
| | - Jinhui Li
- Janssen Research & Development, San Diego, CA
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Agarwal N, Chowdhury S, Bjartell A, Chung BH, Pereira de Santana Gomes AJ, Given R, Juárez Á, Merseburger AS, Ozguroglu M, Uemura H, Ye D, Brookman-May SD, Mundle S, McCarthy SA, Lefresne F, Dibaj S, Bevans KB, Chi KN. Health-related quality of life (HRQoL) and patient-reported outcomes at final analysis of the TITAN study of apalutamide (APA) versus placebo (PBO) in patients (pts) with metastatic castration-sensitive prostate cancer (mCSPC) receiving androgen deprivation therapy (ADT). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.5068] [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
5068 Background: The phase 3 TITAN study evaluated APA vs PBO in pts with mCSPC receiving ADT. At primary analysis with 22.7 mo median follow-up, APA significantly improved overall survival (OS) and radiographic progression-free survival vs PBO (Chi NEJM 2019) while preserving HRQoL (Agarwal Lancet Oncol 2019). The study was unblinded; pts on PBO were allowed to cross over to APA. At final analysis with 44 mo median follow-up, APA significantly improved OS vs PBO, reducing risk of death by 35% despite crossover (Chi ASCO GU 2021). We evaluated HRQoL and treatment bother at final analysis. Methods: mCSPC pts (N = 1052) were randomized 1:1 to APA (240 mg QD; n = 525) or PBO (n = 527). All pts received ADT. Patient-reported outcomes were assessed using Brief Pain Inventory-Short Form (BPI-SF) and Functional Assessment of Cancer Therapy-Prostate (FACT-P). BPI was completed for 7d consecutively (Days -6 to 1 of each 28-d cycle [C]) through end of treatment (EOT). FACT-P was completed at baseline (BL), C2-C7, then every other C through EOT. Mean scores were reported by treatment group and over time. Time to deterioration on BPI and FACT-P scores was calculated by Kaplan-Meier methods and compared between groups by fitting proportional hazards regression models. Results: Of eligible pts per C, > 62% completed BPI through C32 and > 50% completed FACT-P through C31. Pts were relatively asymptomatic with good BL HRQoL: on 0-10 worst pain severity scale (BPI), median scores were 1.1 (APA) and 1.0 (PBO); on 0-156 HRQoL scale (FACT-P total; higher score = better HRQoL), median scores were 113.0 (APA) and 113.3 (PBO). Low BL BPI scores remained stable over time in both groups. On average, favorable BL FACT-P scores did not notably worsen over time in APA or PBO groups. There were no significant differences between groups in median time to deterioration in any BPI or FACT-P scores (Table). At each C at least 86% (APA) and 85% (PBO) of pts were either “not at all” or “a little bit” bothered by side effects. At BL, 76% (APA) and 72% (PBO) had favorable energy levels (reporting lack of energy “not at all” or “a little bit”). Energy levels remained stable or improved at each C for > 78% (APA) and > 71% (PBO) of pts. Conclusions: In the final analysis of TITAN, survival benefit with addition of APA to ADT was achieved without significant patient-reported side effect burden or reduced HRQoL compared with PBO in pts with mCSPC. Clinical trial information: NCT02489318. [Table: see text]
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Affiliation(s)
- Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Simon Chowdhury
- Guy's, King's, and St. Thomas' Hospitals, and Sarah Cannon Research Institute, London, United Kingdom
| | | | - Byung Ha Chung
- Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | | | - Robert Given
- Urology of Virginia, Eastern Virginia Medical School, Norfolk, VA
| | - Álvaro Juárez
- Hospital Universitario de Jerez de la Frontera, Cadiz, Spain
| | | | - Mustafa Ozguroglu
- Istanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, Istanbul, Turkey
| | | | - Dingwei Ye
- Fudan University Shanghai Cancer Center, Shanghai, China
| | | | | | | | | | - Shiva Dibaj
- Janssen Research & Development, San Diego, CA
| | | | - Kim N. Chi
- BC Cancer and Vancouver Prostate Centre, Vancouver, BC, Canada
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Feng FY, Aguilar-Bonavides C, Lucas J, Thomas S, Gormley M, McCarthy SA, Brookman-May SD, Triantos S, Mundle S, Smith MR, Small EJ. Molecular determinants associated with long-term response to apalutamide (APA) in nonmetastatic castration-resistant prostate cancer (nmCRPC). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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
8 Background: SPARTAN, a phase 3 placebo (PBO)-controlled study in patients (pts) with nmCRPC, showed that APA plus androgen deprivation therapy (ADT) significantly improves metastasis-free survival compared with PBO + ADT. This exploratory analysis investigated potential biological signatures of pts with long-term responses to APA and PBO. Methods: The biomarker cohort of SPARTAN was characterized as long-term responders (LTR) or early progressors (EP) based on time to metastasis, and separated into quartiles for APA and PBO groups. Pts progressing in the first quartile (APA, 21; PBO, 17), with shortest time to metastatic event, were classified as EP, those progressing in the last quartile (APA, 39; PBO, 20) as LTR. Gene expression profiles were generated from 233 archival primary prostate tumors. Predefined gene signatures indicative of cancer biology were compared between LTR and EP groups within the APA and PBO arms using 2 sample t tests. Signatures associated with LTR and EP were identified using p values of less than 0.05. Results: Median time to metastatic progression was 40.5 months in APA pts and 22 months in PBO pts in the LTR group and 7.3 and 3.6 months in APA and PBO pts, respectively, in the EP group. Signatures categorized into 3 general mechanistic classes (immune regulation, proliferation, and hormone dependence) associated with LTR on APA included increased T cell activity reflected by T cell activation ( p = 0.0045), stimulation ( p = 0.0642), cytokine response ( p = 0.0489), and interferon production (gamma response p = 0.0227 ), and decreased T cell exclusion ( p = 0.0652), low proliferative capacity ( p = 0.0435), and increased hormonal dependence ( p = 0.0485). High risk (DECIPHER p = 0.0406, metastatic potential p = 0.0077), hormone nonresponsive (basal p = 0.0115; androgen receptor activity-low, p = 0.0437), and neuroendocrine-like tumors ( p = 0.0125) were associated with early progression on treatment with PBO. Conclusions: Although the data require confirmation in larger studies, these molecular determinants may have utility in selecting pts with nmCRPC who may derive the most benefit from APA and other androgen signaling inhibitors. Clinical trial information: NCT01946204.
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Affiliation(s)
- Felix Y Feng
- University of California, San Francisco, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | | | - Justin Lucas
- Janssen Research and Development LLC, Bridgewater, NJ
| | - Shibu Thomas
- Janssen Research & Development, Spring House, PA
| | | | | | | | | | | | | | - Eric Jay Small
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
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Rathkopf DE, Efstathiou E, Attard G, Flaig TW, Franke FA, Goodman OB, Oudard S, Steuber T, Suzuki H, Wu D, Yeruva K, De Porre P, Brookman-May SD, Li S, Li J, Mundle S, McCarthy SA, Saad F. Final results from ACIS, a randomized, placebo (PBO)-controlled double-blind phase 3 study of apalutamide (APA) and abiraterone acetate plus prednisone (AAP) versus AAP in patients (pts) with chemo-naive metastatic castration-resistant prostate cancer (mCRPC). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.9] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9 Background: As mCRPC is driven by activated androgen receptors and elevated intratumoral androgens, androgen annihilation may require dual inhibition. APA and AA are approved prostate cancer therapies that have distinct receptor inhibition and ligand suppression actions, respectively. ACIS compared radiographic progression-free survival (rPFS) of APA + AAP vs PBO + AAP in chemo-naive mCRPC. Methods: mCRPC pts with ongoing androgen deprivation therapy (ADT) but no other life-prolonging treatment since diagnosis were randomized 1:1 to APA (240 mg po QD) + AA (1000 mg po QD) + P (5 mg po BID) or PBO + AAP (stratified by presence or absence of visceral metastases, Eastern Cooperative Oncology Group performance status 0 or 1, and geographic region). The primary end point was rPFS (investigator assessed; defined from randomization date to radiographic progression date or death). Secondary/other end points included prostate-specific antigen (PSA) response, overall survival (OS), safety, time to PSA progression, chronic opioid use, initiation of cytotoxic chemotherapy, and pain progression. Results: 982 pts were enrolled (Dec 2014 to Aug 2016). Median rPFS was extended 6 mos with APA + AAP (22.6 mos) vs AAP (16.6 mos) (HR 0.69 [95% CI 0.58-0.83]; p < 0.0001) at the final analysis for rPFS, coinciding with the first interim analysis of OS (median follow-up time 25.7 mo). At final analysis, treatment with APA + AAP vs AAP showed a significantly higher rate of confirmed ≥ 50% PSA decline. Although not statistically significant, treatment with APA + AAP vs AAP showed a longer median OS. Time to PSA progression, chronic opioid use, initiation of cytotoxic chemotherapy, and pain progression did not differ statistically significantly between arms. The safety profile was consistent with prior drug experience, with no new safety concerns. Grade 3/4 treatment-emergent adverse events (TEAEs) were reported in 63.3% (310/490) of APA + AAP–treated pts vs 56.2% (275/489) of AAP-treated pts, with more grade 3 (56.1%, 275/490 vs 45.6%, 223/489) and less grade 4 (7.1%, 35/490 vs 10.6%, 52/489) TEAEs, respectively. Results based on biomarker subpopulations and quality of life will be presented. Conclusions: The ACIS final analysis met the primary end point and demonstrated a 31% reduction in risk of radiographic progression or death in chemo-naive mCRPC pts treated with the combination of APA + AAP with ADT vs AAP with ADT. Funding: Janssen Research & Development. Trial registration: NCT02257736. Clinical trial information: NCT02257736. [Table: see text]
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Affiliation(s)
| | | | | | | | | | | | - Stephane Oudard
- Georges Pompidou Hospital, University of Paris, Paris, France
| | | | | | - Daphne Wu
- Janssen Research & Development, Los Angeles, CA
| | | | | | | | - Susan Li
- Janssen Research & Development, Spring House, PA
| | - Jinhui Li
- Janssen Research & Development, San Diego, CA
| | | | | | - Fred Saad
- Centre Hospitalier de l’Université de Montréal, Montréal, QC, Canada
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Chi KN, Chowdhury S, Bjartell A, Chung BH, Pereira de Santana Gomes AJ, Given R, Juárez Soto Á, Merseburger AS, Ozguroglu M, Uemura H, Ye D, Triantos S, Mundle S, McCarthy SA, Larsen JS, Sun W, Bevans K, Zhang K, Bandyopadhyay N, Agarwal N. Final analysis results from TITAN: A phase III study of apalutamide (APA) versus placebo (PBO) in patients (pts) with metastatic castration-sensitive prostate cancer (mCSPC) receiving androgen deprivation therapy (ADT). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.11] [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
11 Background: TITAN evaluated APA or PBO added to ADT in pts with mCSPC. Pts with high- and low-volume disease, prior docetaxel, prior treatment for localized disease, and prior ADT (≤ 6 mos) were eligible. At the first interim analysis, with 22.7 mos median follow-up, APA significantly improved dual primary end points of overall survival (OS) (hazard ratio [HR] 0.67) and radiographic progression-free survival (rPFS) (HR 0.48) compared with PBO (Chi et al. NEJM. 2019). At that time, OS analysis was first planned interim while rPFS was final. TITAN was unblinded, allowing pts without progression who were still receiving PBO to cross over to APA. Herein, we report the final analysis of efficacy and safety results from TITAN. Methods: 1052 mCSPC pts were randomized 1:1 to receive APA (240 mg QD) or PBO plus ADT. Time-to-event end points were analyzed by Kaplan-Meier method and Cox proportional hazards model. A preplanned sensitivity analysis for OS, accounting for crossover using inverse probability censoring weighted (IPCW) log-rank test, was conducted. No formal statistical retesting was performed; nominal p values were reported without multiplicity adjustment. Change from baseline in Functional Assessment of Cancer Therapy-Prostate (FACT-P) total score was assessed using a mixed-effect repeated-measures model. Results: With 44 mos median follow-up, 405 OS events had occurred. After unblinding, 208 PBO pts (39.5%) crossed over to APA. Median treatment duration was 39.3 mos for the APA group, 20.2 mos for the entire PBO group, and 15.4 mos for the PBO→APA crossover group. OS was superior in the APA group compared with the PBO group despite crossover (Table). 48-mo survival rates were 65% (APA) vs 52% (PBO). Other end points also favored APA vs PBO (Table). Health-related quality of life (HRQoL), per total FACT-P, was maintained in the APA group through the study and was not different from the PBO group. Safety was consistent with previous reports. Conclusions: With close to 4 yrs of follow-up, the final analysis of TITAN demonstrated that in a broad population of pts with mCSPC, APA plus ADT provides an improvement in OS with a 35% reduction in risk of death, which increased to 48% reduction after adjusting for pts who crossed over from PBO to APA. In addition, there was consistent benefit with APA in other end points, including delaying castration resistance, and HRQoL continued to be maintained with an acceptable safety profile. Clinical trial information: NCT02489318. [Table: see text]
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Affiliation(s)
- Kim N. Chi
- BC Cancer and Vancouver Prostate Centre, Vancouver, BC, Canada
| | - Simon Chowdhury
- Guy’s, King's, and St. Thomas' Hospitals, and Sarah Cannon Research Institute, London, United Kingdom
| | | | - Byung Ha Chung
- Yonsei University College of Medicine and Gangnam Severance Hospital, Seoul, South Korea
| | | | - Robert Given
- Urology of Virginia, Eastern Virginia Medical School, Norfolk, VA
| | | | | | - Mustafa Ozguroglu
- Istanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, Istanbul, Turkey
| | | | - Dingwei Ye
- Fudan University Shanghai Cancer Center, Shanghai, China
| | | | | | | | | | - Weili Sun
- Janssen Research & Development, Los Angeles, CA
| | | | - Ke Zhang
- Janssen Research & Development, San Diego, CA
| | | | - Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
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Kemper JI, Li W, Goni S, Flanagan M, Weeks A, Alfirevic Z, Bracken H, Mundle S, Goonewardene M, Ten Eikelder M, Bloemenkamp K, Rengerink KO, Kruit H, Mol BW, Palmer KR. Foley catheter vs oral misoprostol for induction of labor: individual participant data meta-analysis. Ultrasound Obstet Gynecol 2021; 57:215-223. [PMID: 33258514 DOI: 10.1002/uog.23563] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/15/2020] [Accepted: 11/20/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To compare the effectiveness and safety of Foley catheter and oral misoprostol for induction of labor (IOL). METHODS The Cochrane Review on Mechanical Methods for Induction of Labour and Ovid MEDLINE, EMBASE via Ovid, Ovid Emcare, CINAHL Plus, ClinicalTrials.gov and Scopus, from inception to April 2019, were searched for randomized controlled trials (RCTs) comparing Foley catheter to oral misoprostol for IOL in viable singleton gestations. Eligible trials for which raw data were obtained were included and individual participant data meta-analysis was performed. Primary outcomes were vaginal birth, a composite of adverse perinatal outcome (including stillbirth, neonatal death, neonatal seizures, admission to the neonatal intensive care unit, severe respiratory compromise or meconium aspiration syndrome) and a composite of adverse maternal outcome (including admission to the intensive care unit, maternal infection, severe postpartum hemorrhage, maternal death or uterine rupture). The quality of the included RCTs was assessed using the Cochrane Risk of Bias 2 tool and the certainty of evidence was evaluated using the GRADE approach. A two-stage random-effects model was used for meta-analysis according to the intention-to-treat principle and interactions between treatment and baseline characteristics were assessed. RESULTS Of seven eligible trials, four provided individual participant data for a total of 2815 participants undergoing IOL, of whom 1399 were assigned to Foley catheter and 1416 to oral misoprostol. All four trials provided data for each of the primary outcomes in all 2815 women. Compared with those receiving oral misoprostol, Foley catheter recipients had a slightly decreased chance of vaginal birth (risk ratio (RR), 0.95 (95% CI, 0.91-0.99); I2 , 2.0%; moderate-certainty evidence). A trend towards a lower rate of composite adverse perinatal outcome was found in women undergoing IOL using a Foley catheter compared with oral misoprostol (RR, 0.71 (95% CI, 0.48-1.05); I2 , 14.9%; low-certainty evidence). Composite adverse maternal outcome did not differ between the groups (RR, 1.00 (95% CI, 0.97-1.03); I2 , 0%; moderate-certainty evidence). Meta-analyses of effect modifications did not show significant interactions between intervention and parity or gestational age for any of the primary outcomes. CONCLUSIONS For women undergoing IOL, Foley catheter is less effective than oral misoprostol, as it was associated with fewer vaginal births. However, while we found no significant difference in maternal safety, Foley catheter induction may reduce adverse perinatal outcomes. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J I Kemper
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
| | - W Li
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
| | - S Goni
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
| | - M Flanagan
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
| | - A Weeks
- Department of Women's & Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
| | - Z Alfirevic
- Department of Women's & Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
| | - H Bracken
- Gynuity Health Projects, New York, NY, USA
| | - S Mundle
- Department of Obstetrics & Gynaecology, All India Institute of Medical Sciences, Nagpur, India
| | - M Goonewardene
- Department of Obstetrics & Gynaecology, University of Ruhuna, Galle, Sri Lanka
| | - M Ten Eikelder
- Leiden University Medical Center, Leiden, The Netherlands
| | - K Bloemenkamp
- Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - K O Rengerink
- Julius Center for Health Science and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H Kruit
- Department of Obstetrics & Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - B W Mol
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
- Monash Women's, Monash Health, Melbourne, Australia
- Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - K R Palmer
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
- Monash Women's, Monash Health, Melbourne, Australia
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Suzuki H, Shin T, Fukasawa S, Hashine K, Kitani S, Ohtake N, Shibayama K, Tran N, Mundle S, Fizazi K, Matsubara N. Efficacy and safety of abiraterone acetate plus prednisone in Japanese patients with newly diagnosed, metastatic hormone-naive prostate cancer: final subgroup analysis of LATITUDE, a randomized, double-blind, placebo-controlled, phase 3 study. Jpn J Clin Oncol 2020; 50:810-820. [PMID: 32188988 PMCID: PMC7345218 DOI: 10.1093/jjco/hyaa030] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 12/19/2019] [Revised: 02/06/2020] [Accepted: 02/26/2020] [Indexed: 01/30/2023] Open
Abstract
Background LATITUDE was a randomized, double-blind, international and phase 3 study of abiraterone acetate plus prednisone in patients with high-risk metastatic hormone-naïve prostate cancer. In the first interim analysis of LATITUDE (clinical cutoff date: 31 October 2016), significant prolongation in overall survival and radiographic progression-free survival (co-primary endpoints) was observed when compared with placebo. The results of the Japanese subgroup analysis of LATITUDE first interim analysis were consistent with those of the overall population. In this study, overall survival and safety results from the final analysis of the Japanese subgroup of the LATITUDE study are presented (clinical cutoff date: 15 August 2018). Methods Abiraterone acetate (1000 mg/day) and prednisone (5 mg/day) were administered orally in the abiraterone acetate plus prednisone group, and matching placebos in the placebo group. Results Of the 1199 patients included in LATITUDE, 70 constituted the Japanese subgroup (abiraterone acetate plus prednisone: n = 35, placebo: n = 35). Following a median (range) follow-up of 56.6 (2.5, 64.2) months, the median overall survival was not reached in both the treatment arms of the Japanese subgroup (hazard ratio: 0.61; 95% confidence interval: 0.27–1.42; nominal P = 0.2502). A total of 23 deaths (abiraterone acetate plus prednisone: 9 [25.7%], placebo group: 14 [40.0%]) were reported in Japanese subgroup. Grade 3/4 adverse events were reported in 24 (68.6%) and 9 (25.7%) patients in the abiraterone acetate plus prednisone and placebo groups, respectively. Conclusions In this Japanese subgroup analysis, addition of abiraterone acetate plus prednisone to androgen-deprivation therapy demonstrated favorable efficacy and safety outcomes in patients with newly diagnosed, high-risk metastatic hormone-naïve prostate cancer. Survival benefits observed in the Japanese subgroup first interim analysis were sustained long-term and were consistent with the overall population.
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Affiliation(s)
- Hiroyoshi Suzuki
- Department of Urology, Toho University Sakura Medical Center, Chiba, Japan
| | - Toshitaka Shin
- Department of Urology, Oita University Faculty of Medicine, Oita, Japan
| | - Satoshi Fukasawa
- Prostate Center and Division of Urology, Chiba Cancer Center, Chiba, Japan
| | | | | | | | | | | | | | - Karim Fizazi
- Institut Gustave Roussy, Paris-Sud University, Villejuif, France
| | - Nobuaki Matsubara
- Department of Breast and Medical Oncology, National Cancer Center Hospital East, Chiba, Japan
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Chowdhury S, Mainwaring P, Zhang L, Mundle S, Pollozi E, Gray A, Wildgust M. Systematic Review and Meta-Analysis of Correlation of Progression-Free Survival-2 and Overall Survival in Solid Tumors. Front Oncol 2020; 10:1349. [PMID: 32923387 PMCID: PMC7456898 DOI: 10.3389/fonc.2020.01349] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 05/27/2020] [Accepted: 06/26/2020] [Indexed: 12/25/2022] Open
Abstract
Background: Using progression-free survival (PFS)2, time from randomization to 2nd disease progression or death, is proposed as a surrogate for overall survival (OS) in oncology clinical trials. We used published data from solid tumor trials to assess whether PFS2 and OS are correlated. Methods: A literature search identified studies that reported PFS, PFS2, and OS. Two reviewers screened for eligibility, and documented PFS2, PFS or time from 1st to 2nd disease progression or death and OS. Correlation between PFS2 and OS was assessed using: (1) Kendall's Tau + Pearson's correlation coefficient in randomized controlled trials (RCTs); (2) Meta-analysis with the random effects model to compute the pooled correlation of PFS2 and OS. Results: Overall, 133 studies met search criteria, 15 (28 arms) had complete PFS2 and OS data in ovarian, gastric, colorectal, prostate, lung, renal and breast cancers. A positive correlation for PFS2 and OS was found for all 15 studies (Kendall's Tau = 0.7 [95% CIs 0.54, 0.78]); 10 RCTs (Pearson's correlation coefficient = 0.86); and meta-analysis from 7 trials (pooled Spearman's correlation coefficient = 0.84 [p = 0.0001; 95% CIs 0.71, 0.96]). Conclusions: In this retrospective analysis PFS2 strongly correlates with OS supporting the use of PFS2 to measure long-term clinical benefit when OS cannot be assessed.
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Affiliation(s)
- Simon Chowdhury
- Guy's, King's, and St. Thomas' Hospital, London, United Kingdom
| | | | | | - Suneel Mundle
- Janssen Global Services LLC, Raritan, NJ, United States
| | | | | | - Mark Wildgust
- Janssen Global Services LLC, Raritan, NJ, United States
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Agarwal N, Mundle S, Dearden L, Potluri RC, Nair S, Mehra M. Use and outcomes in men with metastatic castration-sensitive prostate cancer (mCSPC) treated with docetaxel in addition to androgen deprivation therapy (ADT): Analysis of real-world data in the United States (US). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e19322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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
e19322 Background: mCSPC patients treated with docetaxel + androgen deprivation therapy (D+ADT) demonstrate increased overall survival (OS)1,2. However, limited real-world outcome data is available for such patients. This study assesses the real-world use and outcomes with D+ADT in mCSPC in the US. Methods: Adult (≥18 years old) men with mCSPC (defined as men with metastasis at index diagnosis of prostate cancer [de novo] or those who progressed to mCSPC after prior diagnosis of localized disease) were retrospectively identified from the Optum (2007–2018) and SEER Medicare (2007–2016) databases. Men diagnosed with mCSPC in or after 2014 with exposure to docetaxel and no brain metastasis were included for analysis. Patients were characterized based on age; baseline prostate specific antigen (PSA) level; administration of ADT; prior radiotherapy (RT); prior radical prostatectomy (RP); presence of visceral disease, bone or bone + visceral metastases; and treatment duration of docetaxel. OS and time to metastatic castration-resistant prostate cancer (mCRPC) were measured. Results: Among 4959 men identified with mCSPC during or after 2014, 192 (3.8%) received D+ADT ± Bicalutamide as first line systemic therapy. Baseline characteristics are presented in the Table below. Mean ± SD duration of docetaxel exposure was 115 ± 84.2 days (median 118 days). Median OS among these men was 30.5 (28.1, 36.7) months and median time to mCRPC was 18.3 (14.5, 24.6) months. Only 9% of men received docetaxel for ≥6 cycles (180 days); median OS in these men was NR (19.1- NR) with 74% surviving at 2 years compared to 65% surviving at 2 years in those with docetaxel duration <6 cycles. Conclusions: Use of docetaxel in the real-world mCSPC patient population in the US is limited. Majority of men received less than the recommended dose of 6 cycles. OS with D+ADT in real-world patients with mCSPC appears to be lower than the OS reported in published trials. References:1) Sweeney CJ, et al. N Engl J Med. 2015;373:737–46. 2) James ND, et al. Lancet. 2016;387:1163–77. Funding: Janssen Research & Development, LLC. [Table: see text]
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Affiliation(s)
- Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
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21
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Chi KN, Saad F, Chowdhury S, Graff JN, Agarwal N, Oudard S, Li G, Lopez-Gitlitz A, Larsen JS, McCarthy SA, Mundle S, Smith MR, Small EJ. Prostate-specific antigen (PSA) kinetics in patients (pts) with advanced prostate cancer treated with apalutamide: Results from the TITAN and SPARTAN studies. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.5541] [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
5541 Background: The phase III TITAN and SPARTAN studies demonstrated improved outcomes with the addition of apalutamide (APA) to androgen deprivation therapy (ADT); outcomes included prolonging overall survival and radiographic progression-free survival (rPFS) in metastatic castration-sensitive prostate cancer (mCSPC) in TITAN, and metastasis-free survival (MFS) in nonmetastatic castration-resistant PC (nmCRPC) in SPARTAN. A post hoc analysis of PSA kinetics in pts from both studies is reported. Methods: Baseline PSA at randomization, time to PSA nadir, and proportion of pts achieving a PSA decline of ≥ 90% (PSA90) and of pts achieving a PSA ≤ 0.2 ng/mL at 3 and 12 months and at any time after treatment in the APA arms of the TITAN and SPARTAN studies were evaluated. Within each study, rPFS/MFS were compared between pts achieving a PSA90 or PSA ≤ 0.2 ng/mL response vs not. Results: 525 TITAN pts and 806 SPARTAN pts treated with APA were included in the analysis. Median baseline PSA, time to PSA nadir, median PSA nadir, and maximum percentage changes from baseline PSA are shown in the table. PSA90 and confirmed PSA ≤ 0.2 ng/mL were evident as early as 3 months in both TITAN and SPARTAN, and percentage of confirmed response continued to increase at 12 months. Pts treated with APA who achieved PSA90 were at lower risk of rPFS events in TITAN and of MFS events in SPARTAN, with a hazard ratio (95% confidence interval) of 0.46 (0.321-0.653) and 0.36 (0.271-0.489) in each respective study (both p < 0.0001), compared with APA pts who did not achieve PSA90. Pts with confirmed PSA ≤ 0.2 ng/mL had similar rPFS and MFS benefits. Conclusions: Pts with advanced PC, whether mCSPC or nmCRPC, treated with APA + ADT demonstrated rapid PSA declines that continued over time. There was a high rate of pts with PSA90 and with PSA ≤ 0.2 ng/mL responses, with a majority of pts reaching PSA90 by 12 months. Pts achieving PSA90 and/or PSA nadir of ≤ 0.2 ng/mL had a prolonged rPFS and MFS in TITAN and SPARTAN, respectively. Clinical trial information: NCT02489318; NCT01946204 . [Table: see text]
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Affiliation(s)
- Kim N. Chi
- BC Cancer and Vancouver Prostate Centre, Vancouver, BC, Canada
| | - Fred Saad
- Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Simon Chowdhury
- Guy’s, King’s and St. Thomas’ Hospitals, and Sarah Cannon Research Institute, London, United Kingdom
| | - Julie N Graff
- VA Portland Health Care System, Portland and Knight Cancer Institute, Oregon Health & Science University, Portland, OR
| | - Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Stephane Oudard
- Georges Pompidou Hospital, University René Descartes, Paris, France
| | - Gang Li
- Janssen Research & Development, Raritan, NJ
| | | | | | | | | | | | - Eric Jay Small
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
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Saad F, Graff JN, Hadaschik BA, Oudard S, Mainwaring PN, Bhaumik A, Gormley M, Londhe A, Thomas S, Lopez-Gitlitz A, Mundle S, Davicioni E, Small EJ, Smith MR, Feng FY. Molecular determinants of prostate specific antigen (PSA) kinetics and clinical response to apalutamide (APA) in patients (pts) with nonmetastatic castration-resistant prostate cancer (nmCRPC) in SPARTAN. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.5521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
5521 Background: In SPARTAN, APA + androgen deprivation therapy (ADT) prolonged metastasis-free survival (MFS) and improved PSA kinetics over placebo (PBO) + ADT in high-risk nmCRPC. All molecular subtypes derived benefit in MFS from APA (Feng FY, et al. ASCO GU 2019; abstract 42). We evaluated the association of PSA decline and efficacy outcomes in SPARTAN pts with different molecular subtypes. Methods: Gene expression from archival primary tumors (biomarker population) was assessed with the DECIPHER platform (Decipher Biosciences, Inc.) and stratified into genomic classifier (GC) high- and low-to-average risk using GC score > 0.6 and ≤ 0.6, respectively, and ADT-resistant or -sensitive basal or luminal A/B (PAM50 classifier) subtypes. PSA nadir and confirmed PSA decline (Table) were assessed in APA pts overall and at 3, 6, and 12 mo. Associations between molecular subtypes and outcomes were assessed. Results: Of 233 available samples, 154 were from APA pts; 49% of APA pts had high GC score and 66% had basal subtype. PSA levels at baseline were similar across all subtypes. Regardless of GC score or basal/luminal subtype, > 50% of patients achieved ≥ 90% reduction in PSA with APA. PSA declined faster and PSA reduction was deeper at 6 mo (Table) in GC low to average vs GC high risk and luminal vs basal subtypes. Overall, only luminal vs basal subtypes had a significantly higher % of pts with ≥ 90% PSA decline (Chi square p = 0.037). In luminal pts, deeper PSA decline with APA was consistent with improved MFS vs basal pts. In GC high pts, MFS benefit with APA was similar to that in GC low to average pts despite lower PSA decline. Although GC low to average and luminal pts had more rapid and deeper PSA responses than GC high or basal pts, respectively, all pts derived MFS benefit. Association of long-term outcomes with PSA decline in these molecular subtypes will be presented. Conclusions: In SPARTAN, all molecular subtypes of pts with nmCRPC treated with APA + ADT had MFS benefit and rapid and sustained PSA decline. PSA responses were deepest and most rapid in GC low to average and luminal subtypes. Clinical trial information: NCT01946204 . [Table: see text]
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Affiliation(s)
- Fred Saad
- Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Julie N Graff
- VA Portland Health Care System, Portland and Knight Cancer Institute, Oregon Health & Science University, Portland, OR
| | - Boris A. Hadaschik
- University of Duisburg-Essen, Essen, and Ruprecht-Karls University Heidelberg, Heidelberg, Germany
| | - Stephane Oudard
- Georges Pompidou Hospital, University René Descartes, Paris, France
| | - Paul N. Mainwaring
- Centre for Personalized Nanomedicine, University of Queensland, Brisbane, Australia
| | | | | | - Anil Londhe
- Janssen Research & Development, Titusville, NJ
| | - Shibu Thomas
- Janssen Research & Development, Spring House, PA
| | | | | | | | - Eric Jay Small
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
| | | | - Felix Y Feng
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
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Agarwal N, Chowdhury S, Bjartell A, Chung BH, Pereira de Santana Gomes AJ, Given RW, Juárez Soto Á, Merseburger AS, Ozguroglu M, Uemura H, Ye D, Londhe A, Lopez-Gitlitz A, McCarthy SA, Mundle S, Chi KN. Time to second progression (PFS2) in patients (pts) from TITAN with metastatic castration-sensitive prostate cancer (mCSPC) by first subsequent therapy (hormonal vs. taxane). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.82] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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
82 Background: TITAN, a phase 3, randomized, double-blind study of apalutamide (APA) vs placebo (PBO) added to androgen deprivation therapy (ADT), demonstrated significant improvement in radiographic progression-free survival and overall survival in a broad pt population with mCSPC who received APA (Chi KN et al. NEJM 2019). This post hoc analysis evaluates whether type of 1st life-prolonging subsequent therapy (hormonal vs taxane) has an effect on PFS2 benefit shown with APA + ADT. Methods: PFS2 (the time from randomization to disease progression on 1st subsequent therapy for prostate cancer or death, whichever occurs first) was evaluated for pts from TITAN based on 1st subsequent life-prolonging therapy (hormonal vs taxane) after study treatment. Analysis censored all other 1st subsequent systemic therapies after start of treatment. Results: 277 pts (APA, 87; PBO, 190) received subsequent systemic therapy for prostate cancer; 86 pts (APA, 24; PBO, 62) received hormonal therapy (abiraterone acetate + prednisone or enzalutamide) and 99 (APA, 30; PBO, 69) received taxane (docetaxel or cabazitaxel) as 1st subsequent therapy. Baseline demographic and disease characteristics were generally similar between groups. The taxane group had a higher proportion of pts with high volume and pts with > 10 bone metastases, and a lower proportion with prior docetaxel exposure when compared with the hormonal group. Median treatment duration with APA and PBO was 11.9 and 11.1 mos in the hormonal group and 11.0 and 11.3 mos in the taxane group. Regardless of subsequent therapy, PFS2 was significantly longer for APA vs PBO (HR 0.66 [95% CI 0.50-0.87], p = 0.0026). Pts in both groups who received APA had a significant reduction in risk of 2nd progression compared with PBO (hormonal: HR 0.68 [0.48-0.97], p = 0.0326; taxane: HR 0.67 [0.48-0.94], p = 0.0189; medians not reached). Safety analyses were not conducted; all pts had discontinued therapy, most due to disease progression. Conclusions: The addition of APA to ADT for treatment of mCSPC results in risk reduction of 2nd progression regardless of choice of hormonal or taxane as the 1st life-prolonging subsequent therapy. Clinical trial information: NCT02489318.
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Affiliation(s)
- Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Simon Chowdhury
- Guy’s, King’s and St. Thomas’ Hospitals, and Sarah Cannon Research Institute, London, United Kingdom
| | | | - Byung Ha Chung
- Yonsei University College of Medicine and Gangnam Severance Hospital, Seoul, South Korea
| | | | - Robert W. Given
- Urology of Virginia, Eastern Virginia Medical School, Norfolk, VA
| | | | | | - Mustafa Ozguroglu
- Cerrahpaşa School of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | | | - Dingwei Ye
- Fudan University Shanghai Cancer Center, Shanghai, China
| | - Anil Londhe
- Janssen Research & Development, Titusville, NJ
| | | | | | | | - Kim N. Chi
- BC Cancer and Vancouver Prostate Centre, Vancouver, BC, Canada
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Matsubara N, Chi KN, Özgüroğlu M, Rodriguez-Antolin A, Feyerabend S, Fein L, Alekseev BY, Sulur G, Protheroe A, Li S, Mundle S, De Porre P, Tran N, Fizazi K. Correlation of Prostate-specific Antigen Kinetics with Overall Survival and Radiological Progression-free Survival in Metastatic Castration-sensitive Prostate Cancer Treated with Abiraterone Acetate plus Prednisone or Placebos Added to Androgen Deprivation Therapy: Post Hoc Analysis of Phase 3 LATITUDE Study. Eur Urol 2019; 77:494-500. [PMID: 31843335 DOI: 10.1016/j.eururo.2019.11.021] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [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: 06/24/2019] [Accepted: 11/26/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND LATITUDE, a randomized, double-blind trial, compared abiraterone acetate and prednisone (AAP) + androgen deprivation therapy (ADT) versus placebo (PBO) + ADT in high-risk metastatic castration-sensitive prostate cancer (mCSPC). OBJECTIVE To assess the correlation of prostate-specific antigen (PSA) kinetics with overall survival (OS) and radiological progression-free survival (rPFS). DESIGN, SETTING, AND PARTICIPANTS A post hoc analysis of data from 597 men receiving AAP + ADT and 602 receiving PBO + ADT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The associations of PSA-related outcomes (rates of confirmed 50% [PSA50] and 90% [PSA90] decline from baseline PSA [Prostate Cancer Working Group 2 criteria], rates of PSA < 0.2 ng/ml, median nadir PSA, time to PSA nadir [TPN], and time to PSA progression [TPP] with long-term outcomes [OS and rPFS]) were evaluated. Hazard ratios (HRs) were estimated using Cox proportional hazard model. Correlations of TPP with coprimary endpoints rPFS and OS were evaluated using Kendall's tau (KT). RESULTS AND LIMITATIONS AAP + ADT significantly delayed median TPP versus PBO + ADT (33.2 vs 7.4 mo; HR: 0.3, p < 0.001). TPP correlated with rPFS (KT = 0.921) and OS (KT = 0.666). In the AAP + ADT group, 91% had PSA50 and 79% had PSA90 responses (relative risk [RR]: 1.36 and 2.30, respectively; p < 0.001 for both comparisons vs PBO + ADT). Compared with nonresponders, PSA50 and PSA90 responders had reduced risk of death (RR: 0.44 and 0.12, respectively). At 6 mo, 40% receiving AAP + ADT and 6.5% receiving PBO + ADT achieved PSA ≤0.1 ng/ml, which was significantly associated with longer rPFS and OS. Median nadir PSA was 0.09 ng/ml with AAP + ADT versus 2.36 ng/ml with PBO + ADT. Median TPN (AAP + ADT, 6.4 mo; PBO + ADT, 3.8 mo) positively correlated with rPFS and OS. CONCLUSIONS Superior PSA response dynamics with AAP + ADT versus ADT + PBO strongly correlated with long-term outcomes of rPFS and OS in high-risk mCSPC. PATIENT SUMMARY We found that low prostate-specific antigen levels (≤0.1 ng/ml) after 6 mo may indicate a good long-term response to treatment. Our results need confirmation.
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Affiliation(s)
| | - Kim N Chi
- BC Cancer Agency, Vancouver, BC, Canada
| | - Mustafa Özgüroğlu
- Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | | | - Luis Fein
- Instituto de Oncologia de Rosário, Rosário, Argentina
| | - Boris Y Alekseev
- P.A. Hertsen Moscow Cancer Research Institute, Moscow, Russian Federation
| | - Giri Sulur
- Janssen Research & Development, Los Angeles, CA, USA
| | | | - Susan Li
- Janssen Research & Development, Spring House, PA, USA
| | | | | | | | - Karim Fizazi
- Institut Gustave Roussy, University of Paris Sud, Villejuif, France
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Pollock YG, Smith MR, Saad F, Chowdhury S, Oudard S, Hadaschik BA, Olmos D, Mainwaring PN, Lee JY, Uemura H, Bhaumik A, Londhe A, Rooney OB, Lopez-Gitlitz A, Mundle S, Cheng S, Small EJ. Predictors of falls and fractures in patients (pts) with nonmetastatic castration-resistant prostate cancer (nmCRPC) treated with apalutamide (APA) plus ongoing androgen deprivation therapy (ADT). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.5025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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
5025 Background: SPARTAN, a phase 3 study of APA vs placebo (PBO) added to ongoing ADT in pts with nmCRPC, demonstrated that APA significantly prolongs metastasis-free survival, time to symptomatic progression, and second progression free survival (Smith et al. NEJM 2018), with no decline in health-related quality of life (Saad et al. Lancet Oncol 2018). SPARTAN pts who received APA, vs PBO, with ongoing ADT had higher rates of falls (15.6% vs 9.0%) and fractures (11.7% vs 6.5%). An analysis was performed to identify clinical characteristics associated with falls and fractures in APA-treated SPARTAN pts. Methods: Of 1207 pts enrolled, 806 were randomized to APA. Univariate Cox proportional hazards model (UVA) assessed the association of 47 baseline clinical characteristics (demographics, comorbidities, and medication use, including bone-sparing agents) with time to fall or time to fracture. Characteristics with p values < 0.10 were included in a multivariate Cox proportional hazards model (MVA) to determine independent factors associated with these outcomes (p < 0.05). Results: Factors associated with time to both fall and fracture on UVA (p < 0.10) included older age, low serum albumin, and poor ECOG performance status (PS). Additional factors associated with time to fall were cerebrovascular accidents/transient ischemic attacks, neuropathy, depression, α-blocker use, and antidepressant use. On MVA, older age, poor ECOG PS, history of neuropathy, and α-blocker use were independently associated with falls; older age and low serum albumin were independently associated with fractures (Table). Conclusions: At initiation of APA added to ongoing ADT, nmCRPC pts with higher risk of falls and fractures can be identified and are candidates for intervention to reduce the risk for these events. Clinical trial information: NCT01946204. [Table: see text]
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Affiliation(s)
- YaoYao Guan Pollock
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
| | | | - Fred Saad
- Centre Hospitalier de l’Université de Montréal/CRCHUM, Montréal, QC, Canada
| | - Simon Chowdhury
- Guy’s, King’s and St. Thomas’ Hospitals, and Sarah Cannon Research Institute, London, United Kingdom
| | | | | | - David Olmos
- Spanish National Cancer Research Centre (CNIO), Madrid and Hospitales Universitarios Virgen de la Victoria y Regional de Málaga, Málaga, Spain
| | | | - Ji Youl Lee
- St. Mary's Hospital of Catholic University, Seoul, South Korea
| | - Hiroji Uemura
- Yokohama City University Medical Center, Yokohama, Japan
| | | | - Anil Londhe
- Janssen Research & Development, Titusville, NJ
| | | | | | | | | | - Eric Jay Small
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
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Fizazi K, Tran N, Fein LE, Matsubara N, Rodríguez Antolín A, Ozguroglu M, Ye D, Feyerabend S, Protheroe A, Sulur G, Luna Y, Li S, Mundle S, Chi KN. Final analysis of phase III LATITUDE study in patients (pts) with newly diagnosed high-risk metastatic castration-naïve prostate cancer (NDx-HR mCNPC) treated with abiraterone acetate + prednisone (AA+P) added to androgen deprivation therapy (ADT). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.7_suppl.141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
141 Background: The first and second interim analyses (IA1 and IA2) of the LATITUDE study in NDx-HR mCNPC pts with addition of AA+P to ADT vs placebo (PBO)+ADT showed significant benefit in the coprimary endpoints of overall survival (OS) and radiographic progression free survival (rPFS), and secondary endpoints. Final OS analysis and updated safety results are presented. Methods: 1,199 pts were randomized (1:1) to AA (1 g QD) + P (5 mg QD) + ADT or PBO + ADT. Primary endpoint of OS and secondary endpoints were assessed (stratified proportional hazards model), and adverse events (AEs) were summarized from final analysis, which was planned for around 852 total death events. Results: Final analysis was conducted after a median follow-up of 51.8 mo (~22 mo from IA1) and 618 deaths were observed (275 [46%] in AA+P and 343 [57%] in PBO). Treatment was ongoing for 157 (26.3%) pts in AA+P; 72 (12.0%) crossed over from PBO to AA+P, of which 59 (81.9%) remained on treatment. AA+P treatment continued to show significant OS benefits vs PBO (HR: 0.7, 95% CI: 0.6-0.8; p<0.0001), along with significant improvements in secondary endpoints (table). Serious AEs were reported in 32.2% pts in AA+P and 25.1% in PBO. Grade 3/4 AEs of special interest (AA+P vs PBO; %) were hypertension (21.9 vs 10.5), hypokalemia (11.7 vs 1.7), hepatotoxicity (8.9 vs 3.5), cardiac disorders (3.9 vs 1) and fluid retention (0.8 vs 1). Conclusions: The final analysis continues to demonstrate a significant OS advantage of combining AA+P to ADT in NDx-HR mCNPC pts. These efficacy findings and AE profiles are consistent with IA1 and IA2 and reinforce AA+P as a standard of care in NDx-HR mCNPC pts. Clinical trial information: NCT01715285. [Table: see text]
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Affiliation(s)
- Karim Fizazi
- Department of Cancer Medicine, Gustave Roussy Cancer Campus, Paris-Sud University, France, Villejuif, France
| | | | | | - Nobuaki Matsubara
- Division of Breast and Medical Oncology, National Cancer Center Hospital East, Chiba, Japan
| | | | | | - Dingwei Ye
- Fudan University Affiliated Cancer Hospital, Shanghai, China
| | | | - Andrew Protheroe
- Oxford University Hospitals Foundation NHS Trust, Oxford, United Kingdom
| | - Giri Sulur
- Janssen Research & Development, Los Angeles, CA
| | | | - Susan Li
- Janssen Research & Development, Spring House, PA
| | | | - Kim N. Chi
- BC Cancer Agency - Vancouver Centre, Vancouver, BC, Canada
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Leigh S, Granby P, Haycox A, Mundle S, Bracken H, Khedikar V, Mulik J, Faragher B, Easterling T, Turner MA, Alfirevic Z, Winikoff B, Weeks AD. Foley catheter vs. oral misoprostol to induce labour among hypertensive women in India: a cost-consequence analysis alongside a clinical trial. BJOG 2018; 125:1734-1742. [PMID: 29782065 PMCID: PMC6282740 DOI: 10.1111/1471-0528.15285] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the effectiveness and economic impact of two methods for induction of labour in hypertensive women, in low-resource settings. DESIGN Cost-consequence analysis of a previously reported multicentre, parallel, open-label randomised trial. SETTING & POPULATION A total of 602 women with a live fetus, aged ≥18 years requiring delivery for pre-eclampsia or hypertension, in two public hospitals in Nagpur, India. METHODS We performed a formal economic evaluation alongside the INFORM clinical trial. Women were randomised to receive transcervical Foley catheterisation or oral misoprostol 25 mcg. Healthcare expenditure was calculated using a provider-side microcosting approach. MAIN OUTCOME MEASURES Rates of vaginal this delivery within 24 hours of induction, healthcare expenditure per completed treatment episode. RESULTS Induction with oral misoprostol resulted in a (mean difference) $20.6USD reduction in healthcare expenditure [95% CI (-) $123.59 (-) $72.49], and improved achievement of vaginal delivery within 24 hours of induction, mean difference 10% [95% CI (-2 to 17.9%), P = 0.016]. Oxytocin administration time was reduced by 135.3 minutes [95% CI (84.4-186.2 minutes), P < 0.01] and caesarean sections by 9.1% [95% CI (1.1-17%), P = 0.025] for those receiving oral misoprostol. Following probabilistic sensitivity analysis, oral misoprostol was cost-saving in 63% of 5,000 bootstrap replications and achieved superior rates of vaginal delivery, delivery within 24 hours of induction and vaginal delivery within 24 hours of induction in 98.7%, 90.7%, and 99.4% of bootstrap simulations. Based on univariate threshold analysis, the unit price of oral misoprostol 25 mcg could feasibly increase 31-fold from $0.24 to $7.50 per 25 mcg tablet and remain cost-saving. CONCLUSION Compared to Foley catheterisation for the induction of high-risk hypertensive women, oral misoprostol improves rates of vaginal delivery within 24 hours of induction and may also reduce costs. Additional research performed in other low-resource settings is required to determine their relative cost-effectiveness. TWEETABLE ABSTRACT Oral misoprostol less costly and more effective than Foley catheter for labour induction in hypertension.
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Affiliation(s)
- S Leigh
- University of Liverpool Management SchoolLiverpoolUK
| | - P Granby
- University of Liverpool Management SchoolLiverpoolUK
| | - A Haycox
- University of Liverpool Management SchoolLiverpoolUK
| | - S Mundle
- Department of Obstetrics & GynaecologyGovernment Medical CollegeNagpurIndia
| | - H Bracken
- Gynuity Health ProjectsNew YorkNYUSA
| | - V Khedikar
- Daga Memorial Women's Government HospitalNagpurIndia
| | - J Mulik
- Department of Obstetrics & GynaecologyGovernment Medical CollegeNagpurIndia
| | - B Faragher
- Medical Statistics UnitDepartment of Clinical SciencesLiverpool School of Tropical MedicineLiverpoolUK
| | - T Easterling
- Department of Obstetrics and GynecologyUniversity of WashingtonSeattleWAUSA
| | - MA Turner
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpool Women's HospitalLiverpoolUK
| | - Z Alfirevic
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpool Women's HospitalLiverpoolUK
| | | | - AD Weeks
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpool Women's HospitalLiverpoolUK
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Chi KN, Tran N, Feyerabend S, Matsubara N, Ozguroglu M, Fein LE, Rodríguez Antolín A, Alekseev BY, Sulur G, Protheroe A, De Porre P, Li S, Park YC, Mundle S, Fizazi K. Subsequent treatment after abiraterone acetate + prednisone (AA + P) in patients (pts) with newly diagnosed high-risk metastatic castration-naïve prostate cancer (NDx-HR mCNPC): Detailed analyses from the phase 3 LATITUDE trial. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.5028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kim N. Chi
- BC Cancer Agency - Vancouver Centre, Vancouver, BC, Canada
| | | | | | | | | | | | | | | | - Giri Sulur
- Janssen Research & Development, Los Angeles, CA
| | - Andrew Protheroe
- Oxford University Hospitals Foundation NHS Trust, Oxford, United Kingdom
| | | | - Susan Li
- Janssen Research & Development, Spring House, PA
| | | | | | - Karim Fizazi
- Gustave Roussy, University of Paris Sud, Villejuif, France
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Fizazi K, Feyerabend S, Matsubara N, Ozguroglu M, Fein LE, Rodríguez Antolín A, Alekseev BY, Sulur G, Protheroe A, De Porre P, Li S, Park YC, Mundle S, Tran N, Chi KN. Longer term preplanned efficacy and safety analysis of abiraterone acetate + prednisone (AA + P) in patients (pts) with newly diagnosed high-risk metastatic castration-naïve prostate cancer (NDx-HR mCNPC) from the phase 3 LATITUDE trial. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.5023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Karim Fizazi
- Gustave Roussy, University of Paris Sud, Villejuif, France
| | | | | | | | | | | | | | - Giri Sulur
- Janssen Research & Development, Los Angeles, CA
| | - Andrew Protheroe
- Oxford University Hospitals Foundation NHS Trust, Oxford, United Kingdom
| | | | - Susan Li
- Janssen Research & Development, Spring House, PA
| | | | | | | | - Kim N. Chi
- BC Cancer Agency - Vancouver Centre, Vancouver, BC, Canada
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Crawford ED, DePalantino JR, Kantoff PW, Shore N, Underwood W, Reddy V, Wang J, Mundle S, Yang Z, McGowan T, Ryan CJ. MP73-12 UNSUSPECTED METASTASES FOUND DURING SCREENING FOR A TRIAL OF PATIENTS WITH NON-METASTATIC CASTRATION RESISTANT PROSTATE CANCER. J Urol 2015. [DOI: 10.1016/j.juro.2015.02.2688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Salinger DH, Mundle S, Regi A, Bracken H, Winikoff B, Vicini P, Easterling T. Magnesium sulphate for prevention of eclampsia: are intramuscular and intravenous regimens equivalent? A population pharmacokinetic study. BJOG 2013; 120:894-900. [PMID: 23530757 DOI: 10.1111/1471-0528.12222] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare magnesium sulphate concentrations achieved by intramuscular and intravenous regimens used for the prevention of eclampsia. SETTING Low-resource obstetric hospitals in Nagpur and Vellore, India. POPULATION Pregnant women at risk for eclampsia due to hypertensive disease. METHODS A pharmacokinetic study was performed as part of a randomised trial that enrolled 300 women comparing intramuscular and intravenous maintenance regimens of magnesium dosing. Data from 258 enrolled women were analysed in the pharmacokinetic study. A single sample was drawn per woman with the expectation of using samples in a pooled data analysis. MAIN OUTCOME MEASURES Pharmacokinetic parameters of magnesium distribution and clearance. RESULTS Magnesium clearance was estimated to be 48.1 dl/hour, volume of distribution to be 156 dl and intramuscular bioavailability to be 86.2%. The intramuscular regimen produced higher initial serum concentrations, consistent with a substantially larger loading dose. At steady state, magnesium concentrations in the intramuscular and intravenous groups were comparable. With either regimen, a substantial number of women would be expected to have serum concentrations lower than those generally held to be therapeutic. CONCLUSIONS Clinical implications were that a larger loading dose for the intravenous regimen should be considered; where feasible, individualised dosing of magnesium sulphate would reduce the variability in serum concentrations and might result in more women with clinically effective magnesium concentrations; and lower dose magnesium sulphate regimens should be considered with caution.
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Affiliation(s)
- D H Salinger
- Department of Bioengineering, University of Washington, Seattle, WA, USA
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Mundle S, Wetzler M. Short communications and case reports—Who cares? Leuk Res Rep 2012; 1:A1. [DOI: 10.1016/j.lrr.2012.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Mundle S, Regi A, Biswas B, Bracken H, Easterling T, Winikoff B. O645 Preeclampsia in low-resource settings: A randomized trial of IV MgSO4 via flow controlled pump. Int J Gynaecol Obstet 2011. [DOI: 10.1016/s0020-7292(09)61018-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mundle S, Lefebvre P, Vekeman F, Duh MS, Rastogi R, Moyo V. An assessment of erythroid response to epoetin α as a single agent versus in combination with granulocyte- or granulocyte-macrophage-colony-stimulating factor in myelodysplastic syndromes using a meta-analysis approach. Cancer 2009; 115:706-15. [DOI: 10.1002/cncr.24090] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Moyo VM, Lefebvre P, Vekeman F, Duh MS, Yektashenas B, Mundle S. Comparison of erythroid response (ER) rates to epoetin alfa (EPO) alone or in combination versus non-erythropoiesis-stimulating agents (non-ESAs) in treatment-naïve anemic MDS patients: A meta-analysis approach. J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.7094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Moyo V, Lefebvre P, Duh MS, Yektashenas B, Mundle S. Erythropoiesis-stimulating agents in the treatment of anemia in myelodysplastic syndromes: a meta-analysis. Ann Hematol 2008; 87:527-36. [DOI: 10.1007/s00277-008-0450-7] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Accepted: 01/23/2008] [Indexed: 11/24/2022]
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Moyo VM, Lefebvre P, Duh M, Yektashenas B, Mundle S. Treating the anemia of MDS with erythropoietin: Impact of higher dose compared to combination with G/GM-CSF. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.7082] [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
7082 Background: Recombinant human erythropoietin (EPO) is extensively used to improve erythropoiesis and reduce transfusions in anemic MDS pts. The addition of G/GM-CSF to EPO alfa or beta has been associated with higher erythroid response (ER) rates vs. EPO alone. Studies suggest higher ER rates could be achieved with EPO monotherapy if higher initiation doses were used. To study this question a meta-analysis was performed on studies of MDS pts treated with EPO alfa or beta + G/GM-CSF. Methods: Data extraction was performed on studies from PubMed, ASCO and ASH proceedings from 1990–2006 in MDS pts treated with EPO (alfa or beta) ± G/GM-CSF. To allow for cross comparisons, only studies including IWG or IWG-like ER criteria were selected for analysis. Pooled estimates of ER rates were calculated using fixed-effect (F-E) meta-analysis methods. Results were stratified by: (i) EPO-alfa at standard doses, (ii) EPO- alfa at high doses, (iii) EPO-alfa + G/GM-CSF, and (iv) EPO-beta + G/GM-CSF. Results: From 39 studies identified, 19 met inclusion criteria. Most pts (>55%) had RA/RARS. Studies using EPO-alfa at standard doses showed comparable ER rates to studies using EPO- alfa + G/GM-CSF (49.0% vs. 50.6%; p=0.731) ( Table ). Among EPO-alfa studies, those using higher EPO doses had higher ER rates vs. studies using standard EPO doses (p<0.001) or EPO + G/GM-CSF combination (p=0.007). Overall ER rates were not available for studies using EPO- beta + G/GM-CSF, however, 52 pts (37.7%) had major ER, similar to that observed in all EPO-alfa monotherapy studies (195/589=33.1%). Conclusions: These findings suggest increasing EPO-alfa dose may have a greater impact on ER than addition of G/GM-CSF. Further validation is warranted. [Table: see text] [Table: see text]
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Affiliation(s)
- V. M. Moyo
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group Inc, Boston, MA
| | - P. Lefebvre
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group Inc, Boston, MA
| | - M. Duh
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group Inc, Boston, MA
| | - B. Yektashenas
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group Inc, Boston, MA
| | - S. Mundle
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group Inc, Boston, MA
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Moyo V, Lefebvre P, Duh MS, Bourezak A, Yektashenas B, Woodman RC, Mundle S. Erythroid response (ER) rates in myelodysplastic syndromes (MDS) patients treated with epoetin alfa (EPO): A meta-analysis using the International Working Group criteria (IWGc) for MDS response. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.6572] [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
6572 Background: Refractory anemia is a clinical hallmark of MDS. The most consistently used therapy for this anemia is EPO. Prior to the introduction of IWGc in 1997, ER rates varied substantially between studies. The present meta-analysis was undertaken to compare ER rates in studies of EPO-treated patients in MDS when defined by either IWGc or non-IWGc. Methods: A systematic review and data extraction of studies published from 1990–2005 in MDS patients treated with EPO was performed and yielded 21 studies evaluating a total of 895 patients. Pooled estimates of ER rates, stratified by IWGc, were calculated using random-effects meta-analysis methods, which incorporated both between- and within-study variations. Univariate meta-regression analyses were conducted to identify study characteristics that were significant determinants of ER rate. Results: Ten studies (604 patients) used the IWGc to define ER (overall, major, minor), while 11 studies (291 patients) used other definitions. Mean age for all patients was 70.6 years; 45% women. Mean baseline (BL) serum erythropoietin level and proportion of patients with refractory anemia or refractory anemia with ringed sideroblasts were comparable between studies; however, the proportion of transfusion-dependent patients at BL was lower in the IWG studies vs the non-IWG studies (36% vs. 84%, respectively, p<.001). The pooled estimate of ER rate was significantly higher for the IWG studies compared to the non-IWG studies (50.5%, 95% CI: 38.6%-62.3% vs. 27.8%, 95% CI: 22.7%-32.8% respectively, p=.002). Among patients in the IWG studies who achieved an ER, 62% (188/305) achieved a major ER. Studies reporting mean BL serum erythropoietin level <400mU/mL, <65% of patients transfusion-dependent at BL and use of subcutaneous EPO were found to be associated with higher ER rates. Conclusions: This meta-analysis of MDS patients treated with EPO demonstrates significantly higher ER rates in studies utilizing IWGc. These findings may be due to more refined definitions of ER and MDS diagnostic criteria as well as improvement in the management of anemia. [Table: see text]
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Affiliation(s)
- V. Moyo
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
| | - P. Lefebvre
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
| | - M. S. Duh
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
| | - A. Bourezak
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
| | - B. Yektashenas
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
| | - R. C. Woodman
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
| | - S. Mundle
- Ortho Biotech Clinical Affairs, LLC, Bridgewater, NJ; Groupe d’Analyse, Montréal, PQ, Canada; Analysis Group, Inc., Boston, MA
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Mundle S, Noskina Y. Cytogenetic testing for therapeutic indication in cancer. Expert Rev Mol Diagn 2005; 5:23-9. [PMID: 15723589 DOI: 10.1586/14737159.5.1.23] [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] [Indexed: 11/08/2022]
Abstract
The association of cytogenetic abnormalities with cancer is well established. However, due to the historic lack of specific insight into the functional role of these anomalies, they have mostly served as diagnostic and/or prognostic indicators. Recent developments in chronic myelogenous leukemia and breast cancer have raised hopes for specific cytogenetic alterations to serve as therapeutic targets. This article reviews the aid provided by molecular diagnostics in these exciting developments in the cancer arena.
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MESH Headings
- Breast Neoplasms/diagnosis
- Breast Neoplasms/genetics
- Breast Neoplasms/therapy
- Chromosome Aberrations
- Cytogenetic Analysis
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
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Affiliation(s)
- Suneel Mundle
- Rush University Medical Center, Department of Biochemistry, Naperville, Chicago, IL 60565, USA.
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Allampallam K, Shetty V, Mundle S, Dutt D, Kravitz H, Reddy PL, Alvi S, Galili N, Saberwal GS, Anthwal S, Shaikh MW, York A, Raza A. Biological significance of proliferation, apoptosis, cytokines, and monocyte/macrophage cells in bone marrow biopsies of 145 patients with myelodysplastic syndrome. Int J Hematol 2002; 75:289-97. [PMID: 11999358 DOI: 10.1007/bf02982044] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Labeling index (LI), apoptosis, levels of 2 pro-apoptotic cytokines tumor necrosis factor-alpha (TNF-alpha) and transforming growth factor-beta(TGF-beta), and the number of monocyte/macrophage cells that are the likely source of the cytokines were simultaneously measured in plastic-embedded bone marrow (BM) biopsy sections of 145 patients with myelodysplastic syndromes (MDS). TNF-alpha was correlated with TGF-beta (P = .001) and with monocyte/macrophage cells (P = .003). Patients with excess blasts in their marrows had a higher TGF-beta level (P = .01) and monocyte/macrophage number (P = .05). In a linear regression model,TGF-beta emerged as the most significant biological difference between patients who have excess of blasts and those who do not (P = .01). We conclude that in addition to TNF-alpha, TGF-beta also plays a significant role in the initiation and pathogenesis of MDS, and that a more precise definition of its role will likely identify better preventive and therapeutic strategies.
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Affiliation(s)
- Krishnan Allampallam
- Rush Cancer Institute, Rush-Presbyterian-St Luke's Medical Center, Chicago, Illinois 60612, USA
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Shetty V, Hussaini S, Alvi S, Joshi L, Shaher A, Dangerfield B, Nascimben F, Mundle S, Allampallam K, Reddy P, Galili N, Raza A. Excessive apoptosis, increased phagocytosis, nuclear inclusion bodies and cylindrical confronting cisternae in bone marrow biopsies of myelodysplastic syndrome patients. Br J Haematol 2002; 116:817-25. [PMID: 11886386 DOI: 10.1046/j.0007-1048.2002.03366.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Transmission electron microscopic (TEM) studies have not been reported in bone marrow (BM) biopsies of patients with myelodysplastic syndromes (MDS) owing to failure to overcome the technical impediment of maintaining ultrastructural detail in decalcified tissue. Using a modified technique to physically separate pieces of bone from marrow tissue under a dissecting microscope, and embedding the material directly for TEM, ultrastructural studies were performed in 15 MDS patients and four normal BM biopsies. Biopsy tissue was also used to initiate long-term in vitro cultures and 12-week plates were sacrificed for TEM analysis. Features noted in freshly obtained decorticated tissue included an excessive apoptosis in both haematopoietic and stromal cells, ringed sideroblasts with iron-laden mitochondria and highly active, enormously increased phagocytosis. In addition, type IV nuclear inclusion body variants (NIB-v) and confronting cylindrical cisternae (CCC) were readily identified in up to 40% of stromal cells in vivo, providing an important footprint of a possible infectious agent in the pathology of MDS. Cultured stromal cells did not show excessive apoptosis and only 2-4% fibroblasts showed the presence of NIB-v or CCC, underscoring the artificial nature of ex vivo systems. We conclude that ultrastructure studies using decorticated tissue can be a powerful tool to investigate the biology and aetiology of a variety of haematopoietic disorders as it enables the direct examination of BM biopsies with their intimate stromal parenchymal cell associations preserved intact.
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Affiliation(s)
- Vilasini Shetty
- MDS Center and Section of Myeloid Diseases, Rush University, Chicago, IL 60612-3515, USA.
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Alvi S, Shaher A, Shetty V, Henderson B, Dangerfield B, Zorat F, Joshi L, Anthwal S, Lisak L, Little L, Gezer S, Mundle S, Reddy PL, Allampallam K, Huang X, Galili N, Borok RZ, Raza A. Successful establishment of long-term bone marrow cultures in 103 patients with myelodysplastic syndromes. Leuk Res 2001; 25:941-54. [PMID: 11597729 DOI: 10.1016/s0145-2126(01)00061-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We used bone marrow biopsies instead of mononuclear cells to maintain long-term cultures from 103 patients belonging to all five sub-categories of myelodysplastic syndromes (MDS), as well as 12 normal controls. By week 4, 30-50% confluency was reached and could be maintained for up to 12 weeks with 100% confluency. The four prominent cells were fibroblasts, macrophages, endothelial cells and adipocytes. Immunohistochemical and electron microscopic studies provided lineage confirmation. Normal hematopoiesis was well supported by MDS stroma. Neither the FAB nor cytogenetics was co-related with the potency of growth. MDS stroma appears to be both morphologically and functionally normal.
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Affiliation(s)
- S Alvi
- MDS Center, Section of Myeloid Diseases, Rush Cancer Institute, Rush University, Suite 108, 2242 West Harrison Street, Chicago, IL 60612-3515, USA
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Mundle S, Allampallam K, Aftab Rashid K, Dangerfield B, Cartlidge J, Zeitler D, Afenya E, Alvi S, Shetty V, Venugopal P, Raza A. Presence of activation-related m-RNA for EBV and CMV in the bone marrow of patients with myelodysplastic syndromes. Cancer Lett 2001; 164:197-205. [PMID: 11179835 DOI: 10.1016/s0304-3835(01)00385-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The bone marrow (BM) in myelodysplastic syndromes (MDS) undergoes pathobiological changes that mimic an inflammatory process, and hence, an infectious etiology was suspected in these disorders. In the present report, we examined the bone marrow mononuclear cells (BMMNC) of 19 MDS patients and seven normal donors for the expression of one latency-related (Latency membrane protein 1 (LMP-1) and immediate early protein (IEP)) and one activation-related (BZLF and DNA-Pol) m-RNA each for two herpes viruses, Epstein-Barr virus (EBV) and cytomegalovirus (CMV), respectively. Reverse transcriptase polymerase chain reaction was used for this purpose. The latency-related transcripts (EBV-LMP-1 and CMV-IEP) were present in all the MDS and normal specimens. Intriguingly, 10/19 MDS specimens ( approximately 53%) and 2/7 normal donors ( approximately 28%) were positive for active EBV-BZLF (P=0.0067), while 2/19 MDS specimens ( approximately 11%) with 1/7 normal ( approximately 14%) showed active CMV-DNA-Pol (P=0.1588). Later, from another set of MDS patients (n=7) and normal donors (n=4), BM stromal cultures were established, which, at a 75% confluency, were overlaid with cord blood mononuclear cells (CBMNC). IEP was detectable in the CBMNC before and after co-incubation with MDS, as well as normal stroma. So, it was also present both in MDS and normal stromal cells. The other three were absent both in MDS and normal stromal layers. In CBMNC though, active EBV-BZLF and CMV-DNA-Pol m-RNA were detectable in one of seven MDS co-cultures each, albeit from different patients. None of the normal co-cultures showed active virus, either in stroma or CBMNC. Thus, the present report demonstrates, for the first time, the presence of active herpes viruses in the BMMNC of MDS patients and reveals the ability of the MDS stroma to support the viral activation.
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Affiliation(s)
- S Mundle
- Rush Cancer Institute, Rush-Presbyterian-St. Luke's Medical Center, 2242 West Harrison Street, Suite 108, Chicago, IL 60612-3515, USA.
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Shetty V, Hussaini S, Broady-Robinson L, Allampallam K, Mundle S, Borok R, Broderick E, Mazzoran L, Zorat F, Raza A. Intramedullary apoptosis of hematopoietic cells in myelodysplastic syndrome patients can be massive: apoptotic cells recovered from high-density fraction of bone marrow aspirates. Blood 2000; 96:1388-92. [PMID: 10942382] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
A higher percentage of apoptotic cells (apoptotic index or AI) is consistently found in bone marrow (BM) biopsies compared to BM aspirates of patients with myelodysplastic syndrome (MDS). Most studies have only investigated the low-density fraction (LDF) mononuclear cells from BM aspirates following density separation for AI determination. In the present study, both LDF and high-density fraction (HDF) cells for AI were examined by electron microscopy (EM) in 10 MDS patients and 4 healthy donors. Matched BM biopsies were subjected to AI detection by in situ end labeling (ISEL) of fragmented DNA. The results indicate that in LDF and HDF cells, AI is consistently higher in MDS patients (8.5% vs 1.5%, respectively; P =.039) compared to healthy donors (27% vs 4%, respectively; P =. 004). The BM biopsy AI was also higher in MDS patients than in healthy donors (3+ vs 0+, respectively; P =.036). In addition, in MDS patients, more apoptotic cells were found in HDF cells than in LDF cells (27% vs 8.5%, respectively;P =.0001). All stages of maturation, ranging from blasts to terminally mature cells belonging to all 3 lineages, were represented in the dying cells in both compartments. Using EM, typical Pelger-Huett-type cells appeared to be apoptotic granulocytes. Both LDF and HDF cells should be examined for an accurate estimation of apoptotic cells because AI would be underestimated if only the LDF cells were studied. Ultrastructural studies consistently show a higher AI in BM biopsies compared to BM aspirates despite the correction factor of HDF cells provided by AI. This may represent the actual extant state, which could conceivably be due to a higher concentration of proapoptotic signals in the biopsies. (Blood. 2000;96:1388-1392)
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Affiliation(s)
- V Shetty
- Rush Cancer Institute, Rush-Presbyterian-St Luke's Medical Center, Chicago, IL 60612-3515, USA.
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Abstract
Apoptosis has been documented in chondrocytes both in the growth plates of young, healthy cartilages and in osteoarthritic cartilages; little, however, is known about apoptosis in chondrocytes of normal adult articular cartilage. For the current study, apoptosis in adult chondrocytes was evaluated by labeling DNA fragments using the ISEL in situ end labeling of 3'-recessed strand breaks) or TUNEL (5'-recessed or blunt-ended strand breaks with terminal deoxynucleotidyl transferase-mediated nick end labeling) techniques in primary cultures of chondrocytes in monolayer. Apoptosis was induced in the chondrocytes by either Tumor Necrosis Factor alpha (TNF alpha), Interleukin 1-beta (IL-1 beta), or anti-Fas antibody but only after 48 hours in culture. At 4 and 24 hours, there was no detectable DNA fragmentation. With TNF alpha, IL1 beta, and anti-Fas antibody, chondrocytes show evidence of at least two types of DNA strand breaks within the same cell (as assessed by simultaneous labeling with ISEL and TUNEL). Therefore, some pathways leading to apoptosis in chondrocytes appear to involve more than one type of endonuclease activity. When the chondrocytes were cultured as explants with the articular matrix intact (ex vivo), neither IL-1 beta, TNF alpha, the anti-Fas antibody, nor fibronectin fragments were able to induce apoptosis in the chondrocytes. In normal human adult cartilage that was untreated and uncultured (in situ), DNA fragmentation was undetectable; however, a significant number of chondrocytes in osteoarthritic cartilage did contain strand breaks. These data suggest that apoptosis occurs in chondrocytes in which the matrix has been disrupted experimentally or destroyed by the osteoarthritic disease process. The results of these studies suggest that the ECM may be an essential survival factor for chondrocytes.
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Affiliation(s)
- B A Fischer
- Department of Biochemistry, Rush Medical College at Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612, USA
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Allampallam K, Dutt D, Nair C, Shetty V, Mundle S, Lisak L, Andrews C, Ahmed B, Mazzone L, Zorat F, Borok R, Muzammil M, Gundroo A, Ansaarie I, Raza A. The clinical and biologic significance of abnormal lipid profiles in patients with myelodysplastic syndromes. J Hematother Stem Cell Res 2000; 9:247-55. [PMID: 10813538 DOI: 10.1089/152581600319469] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Serum lipid profiles were obtained in 108 patients with myelodysplastic syndrome (MDS) and compared to 28 healthy volunteers. Serum cholesterol and low-density and high-density lipoproteins (LDL and HDL) were found to be significantly lower in MDS patients than in normals (p = 0.0001, 0.0038 and 0.037, respectively). This difference was significant for all MDS categories. Serum cholesterol and HDL were negatively related to biopsy cellularity (p = 0.001 and 0.0001, respectively), and serum triglycerides were negatively related to labeling index (p = 0.0003). No differences were noted in the lipid profiles of MDS patients with normal versus abnormal karyotypes. However, low-risk MDS patients with abnormal karyotypes had significantly lower triglyceride levels compared with the high-risk patients (p = 0.027), as did low-risk patients with normal cytogenetics (p = 0.015). Serum HDL levels were significantly higher for the low-risk group with normal cytogenetics as well (p = 0.003). We conclude that serum cholesterol, LDL, and HDL are significantly reduced in MDS patients, probably indicating excessive intracellular lipid biosynthesis in the expanding clone. These relatively simple measurements could serve as important prognostic markers and reliable indicators of disease activity in individual patients. Prospective studies to determine their utility as independent variables that guide the need for active therapeutic intervention are warranted.
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Affiliation(s)
- K Allampallam
- Rush Cancer Institute, Rush-Presbyterian St. Luke's Medical Center, Chicago, IL 60612-3515, USA
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Mundle S, Venugopal P, Shetty V, Ali A, Chopra H, Handa H, Rose S, Mativi BY, Gregory SA, Preisler HD, Raza A. The relative extent and propensity of CD34+ vs. CD34- cells to undergo apoptosis in myelodysplastic marrows. Int J Hematol 1999; 69:152-9. [PMID: 10222652] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
The paradox of peripheral cytopenias despite cellular bone marrow (BM) observed in myelodysplastic syndromes (MDS) has been associated with excessive intramedullary apoptosis of hematopoietic cells. Since MDS is regarded as a stem cell disorder, the present studies were undertaken to examine the relative susceptibility and propensity of early progenitor CD34+ cells to undergo apoptosis as compared to more maturing/matured CD34- cells. Five serial studies were performed on 4 independent groups of 36 newly diagnosed MDS patients. First, in 2 separate groups of 16 and 8 patients each, measurement of the extent of apoptosis in CD34+ and CD34- fractions of the BM aspirate mononuclear cells was carried out using independent biparametric flow cytometry methods, CD34 labeling/terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) (n = 16), and CD34 labeling/reduced uptake of nucleic acid staining dye LDS751 (n = 8). The difference in the median degrees of apoptosis in CD34+ vs. CD34- cells was not statistically significant by either technique (P = 0.583 and P = 0.674 for TUNEL and LDS751, respectively). In the next group of 4 MDS patients, a double-labeling was performed on plastic embedded marrow biopsy sections, to detect CD34 antigen with specific monoclonal antibody and apoptosis by in situ end labeling (ISEL) of fragmented DNA. Despite high overall apoptosis (56.2% +/- 18.4%), only an occasional CD34+ cell was found to be simultaneously labeled with ISEL. Finally, in the last group of 8 MDS patients, CD34+ cells were separated from CD34- cells on affinity column and cultured in serum containing medium for 4 hours. At 0- and 4-hour time points, ISEL was carried out to label apoptotic cells. In addition, a fluorometric assay was employed to estimate the activity of a proapoptotic enzyme, Caspase 3. Both the net increase in % ISEL labeled cells (apoptotic index or AI) and Caspase-3 activity were significantly lower in CD34+ cells as compared to CD34- cells (AI, 0.87% +/- 0.5% vs. 3.97% +/- 1.4%, n = 6, P = 0.028 and Caspase-3 Units/mg protein, 46.9 +/- 25.0 vs. 71.7 +/- 23.03, n = 5, P = 0.042, respectively). We conclude that when estimated in a total population of mononuclear cells, CD34+ cells and CD34- cells show comparable degrees of apoptosis. However, once separated the CD34+ fraction demonstrates lower propensity to undergo apoptosis, thereby suggesting the CD34- fraction as being a possible source for proapoptotic signaling.
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Affiliation(s)
- S Mundle
- Rush Cancer Institute, Rush Presbyterian-St. Luke's Medical Center, Chicago, Illinois 60612, USA.
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Goyal R, Qawi H, Ali I, Dar S, Mundle S, Shetty V, Mativi Y, Allampallam K, Lisak L, Loew J, Venugopal P, Gezer S, Robin E, Rifkin S, Raza A. Biologic characteristics of patients with hypocellular myelodysplastic syndromes. Leuk Res 1999; 23:357-64. [PMID: 10229321 DOI: 10.1016/s0145-2126(98)00187-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Rates of proliferation and apoptosis as well as expression of tumor necrosis factor alpha (TNF-alpha), transforming growth factor beta (TGF-beta) and the number of macrophages were measured in bone marrow (BM) biopsies of 33 patients who presented with hypocellular (cellularity < 30%) myelodysplastic syndromes (MDS). Results showed that 2/3 of the patients had high apoptosis, high cytokine levels and large number of macrophages in their biopsies while 1/3 did not. Apoptosis and TNF-alpha levels were directly related (r = 0.583, P = 0.003, n = 24) as was apoptosis and the degree of anemia (P = 0.033, n = 18). A subgroup of patients with abnormalities of chromosomes 5 or 7 had higher platelets (P = 0.026) and higher apoptosis (P = 0.038) when compared with the rest of the group. Eight patients had no evidence of apoptosis and almost no detectable TNF-alpha in their biopsies. We conclude that within the hypocellular variant of MDS, there may be two distinct sub-groups of patients, one who present with high cytokine-mediated intramedullary apoptosis and the other who may be better characterized as having a stem-cell failure defect since they showed no evidence of apoptosis.
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Affiliation(s)
- R Goyal
- Rush Cancer Institute, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL, USA
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Reza S, Dar S, Andric T, Qawi H, Mundle S, Shetty V, Venugopal P, Ali I, Lisak L, Raza A. Biologic characteristics of 164 patients with myelodysplastic syndromes. Leuk Lymphoma 1999; 33:281-7. [PMID: 10221507 DOI: 10.3109/10428199909058427] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Rates of proliferation, apoptosis and cytokine expression were measured in bone marrow (BM) biopsies of 164 myelodysplastic syndrome (MDS) patients. There were 107 males and 57 females. Median age was 69 years and 101 had refractory anemia (RA), 17 RA with ringed sideroblasts (RARS), 38 with RA and excess blasts (RAEB) and 8 with RAEB in transformation (RAEB-t). Apoptosis measured by in-situ end labeling (ISEL) was directly related to the number of macrophages (p = 0.028, n = 83). Mean tumor necrosis factor alpha (TNF-alpha) and ISEL positivity were higher in RAEB + RAEB-t patients (p = 0.0554 and p = 0.06 respectively) while hemoglobin was higher for RA + RARS group (p = 0.0472). Patients with high apoptosis had lower white blood cell counts (p = 0.0009), lower percentage of blasts (p = 0.0009) and higher number of macrophages (p = 0.0086). We conclude that measurements of apoptosis, proliferation and cytokine expression provide important biological information which helps to distinguish RA + RARS patients from RAEB + RAEB-t patients, and may be of additive prognostic significance.
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Affiliation(s)
- S Reza
- Rush Cancer Institute, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612-3515, USA
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Dar S, Mundle S, Andric T, Qawi H, Shetty V, Reza S, Mativi BY, Allampallam K, Ali A, Venugopal P, Gezer S, Broady-Robinson L, Cartlidge J, Showel M, Hussaini S, Ragasa D, Ali I, Chaudhry A, Waggoner S, Lisak L, Huang RW, Raza A. Biological characteristics of myelodysplastic syndrome patients who demonstrated high versus no intramedullary apoptosis. Eur J Haematol Suppl 1999; 62:90-4. [PMID: 10052711 DOI: 10.1111/j.1600-0609.1999.tb01727.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Spontaneous intramedullary apoptosis was measured in bone marrow (BM) biopsies of 175 patients with myelodysplastic syndromes (MDS) using in situ end-labeling (ISEL) of fragmented DNA. Two groups of high (n=71) versus low (n =43) levels of apoptosis were identified while 61 patients were ISEL-negative. Semiquantitative assessment of 3 cytokines, the number of macrophages and in vivo labeling indices (LI) were also determined from consecutive sections of the biopsy. Patients with high apoptosis levels tended to have a high LI (p=0.013), more macrophages in their BM biopsies (p=0.006) and higher tumor necrosis factor alpha (TNF-alpha) levels (not significant) compared to patients with no apoptosis. In addition, low risk MDS patients had significantly lower rates of apoptosis (p = 0.047) and lower levels of TNF-alpha (p = 0.055) compared to high-risk MDS patients. We conclude that the genesis of cytopenias in MDS is of multifactorial origin and that cytokine-associated apoptosis clearly identifies a distinct biological subgroup of patients who may benefit selectively by use of anti-cytokine therapies.
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Affiliation(s)
- S Dar
- Rush Cancer Institute, Rush-Presbyterian-St Luke's Medical Center, Chicago, IL 60612-3515, USA
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