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Kieran R, Hennessy M, Coakley K, O'Sullivan H, Cronin T, Lynch D, Mulroe E, Cooke K, Collins D, O'Reilly S. Optimising oncology drug expenditure in Ireland. Ir J Med Sci 2024; 193:1735-1747. [PMID: 38568369 PMCID: PMC11294381 DOI: 10.1007/s11845-024-03672-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/15/2024] [Indexed: 08/02/2024]
Abstract
A combination of improvements in patient survival, increasing treatment duration, and the development of more expensive agents has led to a doubling of per-capita spending on cancer medicines in Ireland (2008-2018). Despite this, access to new drugs is poor in comparison to other EU countries. We examine methods to optimise oncology drug spending to facilitate access to newer anticancer agents. Key targets for spending optimisation (biosimilar use, clinical trials and expanded access programs, waste reduction, avoidance of futile treatment, and altered drug scheduling) were identified through an exploratory analysis. A structured literature search was performed, with a focus on articles relevant to the Irish Healthcare system, supplemented by reports from statutory bodies. At the present time, EMA-approved agents are available once approved by the NCPE. Optimising drug costs occurs through guideline-based practice and biosimilar integration, the latter provides €80 million in cost savings annually. Access to novel therapies can occur via over 50 clinical trials and 28 currently available expanded access programmes. Additional strategies include reversion to weight-based immunotherapy dosing, potentially saving €400,000 per year in our centre alone, vial sharing, and optimisation of treatment schedules. A variety of techniques are being employed by oncologists to optimise costs and increase access to innovation for patients. Use of biosimilars, drug wastage, and prescribing at end of life should be audited as key performance indicators, which may lead to reflective practice on treatment planning. Such measures could further optimise oncology drug expenditure nationally facilitating approval of new agents.
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Affiliation(s)
- Ruth Kieran
- Department of Medical Oncology, Cork University Hospital, Cork, Ireland.
- Cancer Research@UCC, College of Medicine & Health, University College Cork, Cork, Ireland.
| | - Maeve Hennessy
- Department of Medical Oncology, Cork University Hospital, Cork, Ireland
- Cancer Research@UCC, College of Medicine & Health, University College Cork, Cork, Ireland
| | - Kate Coakley
- Department of Medical Oncology, Cork University Hospital, Cork, Ireland
| | - Hazel O'Sullivan
- Department of Medical Oncology, Cork University Hospital, Cork, Ireland
| | - Tim Cronin
- College of Medicine & Health, University College Cork, Cork, Ireland
| | - Daire Lynch
- Cancer Trials Ireland, RCSI House, 121 St Stephen's , Dublin 2, Green, Ireland
| | - Eibhlin Mulroe
- Cancer Trials Ireland, RCSI House, 121 St Stephen's , Dublin 2, Green, Ireland
| | - Katie Cooke
- Department of Pharmacy, Cork University Hospital, Cork, Ireland
| | - Dearbhaile Collins
- Department of Medical Oncology, Cork University Hospital, Cork, Ireland
- Cancer Research@UCC, College of Medicine & Health, University College Cork, Cork, Ireland
| | - Seamus O'Reilly
- Department of Medical Oncology, Cork University Hospital, Cork, Ireland
- Cancer Research@UCC, College of Medicine & Health, University College Cork, Cork, Ireland
- Cancer Trials Ireland, RCSI House, 121 St Stephen's , Dublin 2, Green, Ireland
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2
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Ree AH, Šaltytė Benth J, Hamre HM, Kersten C, Hofsli E, Guren MG, Sorbye H, Johansen C, Negård A, Bjørnetrø T, Nilsen HL, Berg JP, Flatmark K, Meltzer S. First-line oxaliplatin-based chemotherapy and nivolumab for metastatic microsatellite-stable colorectal cancer-the randomised METIMMOX trial. Br J Cancer 2024; 130:1921-1928. [PMID: 38664577 PMCID: PMC11183214 DOI: 10.1038/s41416-024-02696-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 06/19/2024] Open
Abstract
BACKGROUND We evaluated first-line treatment of metastatic microsatellite-stable colorectal cancer with short-course oxaliplatin-based chemotherapy alternating with immune checkpoint blockade. METHODS Patients were randomly assigned to chemotherapy (the FLOX regimen; control group) or alternating two cycles each of FLOX and nivolumab (experimental group). Radiographic response assessment was done every eight weeks with progression-free survival (PFS) as the primary endpoint. Cox proportional-hazards regression models estimated associations between PFS and relevant variables. A post hoc analysis explored C-reactive protein as signal of responsiveness to immune checkpoint blockade. RESULTS Eighty patients were randomised and 38 in each group received treatment. PFS was comparable-control group: median 9.2 months (95% confidence interval (CI), 6.3-12.7); experimental group: median 9.2 months (95% CI, 4.5-15.0). The adjusted Cox model revealed that experimental-group subjects aged ≥60 had significantly lowered progression risk (p = 0.021) with hazard ratio 0.17 (95% CI, 0.04-0.76). Experimental-group patients with C-reactive protein <5.0 mg/L when starting nivolumab (n = 17) reached median PFS 15.8 months (95% CI, 7.8-23.7). One-sixth of experimental-group cases (all KRAS/BRAF-mutant) achieved complete response. CONCLUSIONS The investigational regimen did not improve the primary outcome for the intention-to-treat population but might benefit small subgroups of patients with previously untreated, metastatic microsatellite-stable colorectal cancer. TRIAL REGISTRATION ClinicalTrials.gov number, NCT03388190 (02/01/2018).
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Affiliation(s)
- Anne Hansen Ree
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Hanne M Hamre
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
| | - Christian Kersten
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
- Department of Research, Sørlandet Hospital, Kristiansand, Norway
| | - Eva Hofsli
- Department of Oncology, St Olav's Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Marianne G Guren
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Halfdan Sorbye
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Christin Johansen
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
| | - Anne Negård
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Radiology, Akershus University Hospital, Lørenskog, Norway
| | - Tonje Bjørnetrø
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
| | - Hilde L Nilsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Clinical Molecular Biology, Akershus University Hospital, Lørenskog, Norway
| | - Jens P Berg
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Kjersti Flatmark
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Gastroenterological Surgery, Oslo University Hospital, Oslo, Norway
- Department of Tumour Biology, Oslo University Hospital, Oslo, Norway
| | - Sebastian Meltzer
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway
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Petrelli F, Cherri S, Ghidini M, Tomasello G, Ghidini A, Zaniboni A. Efficacy of different maintenance strategies for RAS wild-type colorectal cancer: A network meta-analysis. Dig Liver Dis 2024; 56:242-247. [PMID: 37369616 DOI: 10.1016/j.dld.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023]
Abstract
INTRODUCTION In metastatic RAS wild-type colorectal cancer (CRC), induction combination chemotherapy doublets (CT) with an anti-EGFR agent are considered the primary treatment. We performed a network meta-analysis (NMA) to compare the relative efficacy of different maintenance treatments for advanced RAS wild-type CRC. MATERIALS AND METHODS PubMed, EMBASE and Cochrane, from database inception until December 2021 were used. Randomized clinical trials enrolling adults with advanced RAS wild-type CRC and providing overall survival (OS) and/or progression-free survival (PFS) data PRISMA guidelines for NMA were followed. Between-group comparisons were estimated using hazard ratios (HRs) with 95% credible intervals (95% CrIs). Agents were ranked using surface under the cumulative ranking (SUCRA) probabilities. RESULTS A total of 7 randomized phase 2 trials were included (for a total of 1286 patients). Compared to depotentiation treatments, continuous CT + anti-EGFR was not significantly superior to other maintenance regimens for OS and was ranked as the best option for NMA (SUCRA p-score=0.69). Conversely, in the PFS analysis, single-agent fluoropyrimidines + anti-EGFR was ranked as the best treatment (SUCRA p-score=0.60). CONCLUSIONS Maintaining chemotherapy doublet + anti-EGFR until progression appears to be the best first-line strategy in terms of OS for advanced unresectable RAS wild-type mCRC treatment. However, fluoropyrimidines single-agent + cetuximab or panitumumab represent a reasonable choice regarding PFS.
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Affiliation(s)
| | - Sara Cherri
- Oncology Unit, Fondazione Poliambulanza, Brescia, Italy
| | - Michele Ghidini
- Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Gianluca Tomasello
- Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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Early radiologic signal of responsiveness to immune checkpoint blockade in microsatellite-stable/mismatch repair-proficient metastatic colorectal cancer. Br J Cancer 2022; 127:2227-2233. [PMID: 36229579 PMCID: PMC9726864 DOI: 10.1038/s41416-022-02004-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 09/21/2022] [Accepted: 09/27/2022] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Immune checkpoint blockade (ICB) results in radiologic tumour response dynamics that differ from chemotherapy efficacy measures and require an early signal of clinical utility. METHODS Previously untreated, unresectable microsatellite-stable (MSS)/mismatch repair-proficient (pMMR) colorectal cancer (CRC) patients were randomly assigned to the oxaliplatin-based Nordic FLOX regimen (control arm) or repeat sequential two FLOX cycles and two ICB cycles (experimental arm). The radiologic response was assessed every 8 weeks. In this post hoc analysis, we explored early target lesion (TL) dynamics as indicator of ICB responsiveness. Progression-free survival (PFS) was the primary endpoint. RESULTS Using a landmark analysis approach, we categorised experimental-arm patients into ≥10% (N = 19) or <10% (N = 16) TL reduction at the first post-baseline response assessment. Median PFS for the groups was 16.0 (95% confidence interval (CI), 12.3-19.7) and 3.9 months (95% CI, 2.3-5.5), respectively, superior and inferior (both P < 0.01) to the median PFS of 9.8 months (95% CI, 4.9-14.7) for control arm patients (N = 31). CONCLUSIONS Radiologic TL reduction of ≥10% at the first post-baseline response assessment identified patients with ICB-responsive metastatic MSS/pMMR-CRC. This pragmatic measure may be used to monitor patients in investigational ICB schedules, enabling early treatment adaptation for unresponsive cases. TRIAL REGISTRATION ClinicalTrials.gov number, NCT03388190 (02/01/2018).
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Henderson RH, French D, McFerran E, Adams R, Wasan H, Glynne-Jones R, Fisher D, Richman S, Dunne PD, Wilde L, Maughan TS, Sullivan R, Lawler M. Spend less to achieve more: Economic analysis of intermittent versus continuous cetuximab in KRAS wild-type patients with metastatic colorectal cancer. J Cancer Policy 2022; 33:100342. [PMID: 35718327 DOI: 10.1016/j.jcpo.2022.100342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/02/2022] [Accepted: 06/13/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND In 2014, the COIN-B clinical trial demonstrated that intermittent cetuximab (IC) was a safe alternative to continuous cetuximab (CC), with less cytotoxic chemotherapy, in first-line treatment for KRAS wild-type metastatic colorectal cancer (mCRC). Cetuximab has been available for this indication in England since 2015, but treatment breaks beyond 6 weeks were prohibited, despite real-world evidence that therapy de-escalation maintains equivalent disease control, but with superior Quality-of-Life (QoL). We performed health economic analyses of IC versus CC and used this evidence to help underpin policy change and guide clinical practice through reduction in unnecessary treatment for mCRC patients. METHODS Employing cost-minimization analysis, we conducted partitioned survival modelling (PSM) and Markov Chain Monte-Carlo (MCMC) simulation to determine costs and quality-adjusted-life-years for IC versus CC. RESULTS IC reduced costs by £ 35,763 (PSM; p < 0.001) or £ 30,189 (MCMC) per patient annually, while preserving treatment efficacy and enhancing QoL. Extrapolating to all mCRC patients eligible for cetuximab therapy would have generated cost savings of ~£ 1.2 billion over this cohort's lifetime. These data helped underpin a request to NHS England to remove treatment break restrictions in first-line mCRC therapy, which has been adopted as an interim treatment option policy in colorectal cancer during the Covid-19 pandemic. CONCLUSIONS Our results highlight substantial cost savings achievable by treatment de-escalation, while also reinforcing the importance of therapy breaks to potentially increase tumour responsiveness and reduce treatment toxicity. Our study also highlights how health economic evidence can influence health policy, championing reduced treatment intensity approaches without compromising patient outcomes, which is of particular relevance when addressing the reduced capacity and treatment backlogs experienced during the pandemic.
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Affiliation(s)
- Raymond H Henderson
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, UK; Queen's Management School, Queen's University Belfast, UK; Salutem Insights Ltd, Garryduff, Clough, Portlaoise R32 V653, Ireland.
| | - Declan French
- Queen's Management School, Queen's University Belfast, UK
| | - Ethna McFerran
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, UK
| | | | - Harpreet Wasan
- Oncology Hammersmith Hospital, Imperial College Healthcare Trust & Imperial College, London, UK
| | | | - David Fisher
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, Aviation House, 125 Kingsway, London WC2B 6NH, UK
| | - Susan Richman
- Department of Pathology and Data Analytics, Leeds Institute of Medical Research, St James' University Hospital, Leeds LS9 7TF, UK
| | - Philip D Dunne
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, UK
| | - Lisa Wilde
- Bowel Cancer UK, Edinburgh House, 170 Kennington Lane, London, UK
| | - Timothy S Maughan
- Cancer Research UK and Medical Research Council Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford OX3 7DQ, UK
| | - Richard Sullivan
- Institute of Cancer Policy, School of Cancer Sciences, King's College London, UK
| | - Mark Lawler
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, UK
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Adams R, Wilson R, Brown L, Maughan T. Reply to A. Kurreck et al and M.S. Copur et al. J Clin Oncol 2022; 40:1263-1264. [PMID: 35192371 DOI: 10.1200/jco.21.02806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Richard Adams
- Richard Adams, MD, Centre for Trials Research Cardiff University and Velindre NHS Trust, Cardiff, Wales; Richard Wilson, PhD, Beatson Hospital, Glasgow, Scotland; Louise Brown, PhD, MRC Clinical Trials Unit at UCL, London, United Kingdom; and Timothy Maughan, MD, MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Richard Wilson
- Richard Adams, MD, Centre for Trials Research Cardiff University and Velindre NHS Trust, Cardiff, Wales; Richard Wilson, PhD, Beatson Hospital, Glasgow, Scotland; Louise Brown, PhD, MRC Clinical Trials Unit at UCL, London, United Kingdom; and Timothy Maughan, MD, MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Louise Brown
- Richard Adams, MD, Centre for Trials Research Cardiff University and Velindre NHS Trust, Cardiff, Wales; Richard Wilson, PhD, Beatson Hospital, Glasgow, Scotland; Louise Brown, PhD, MRC Clinical Trials Unit at UCL, London, United Kingdom; and Timothy Maughan, MD, MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Timothy Maughan
- Richard Adams, MD, Centre for Trials Research Cardiff University and Velindre NHS Trust, Cardiff, Wales; Richard Wilson, PhD, Beatson Hospital, Glasgow, Scotland; Louise Brown, PhD, MRC Clinical Trials Unit at UCL, London, United Kingdom; and Timothy Maughan, MD, MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
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7
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Modest DP, Karthaus M, Fruehauf S, Graeven U, Müller L, König AO, Fischer von Weikersthal L, Caca K, Kretzschmar A, Goekkurt E, Haas S, Kurreck A, Stahler A, Held S, Jarosch A, Horst D, Reinacher-Schick A, Kasper S, Heinemann V, Stintzing S, Trarbach T. Panitumumab Plus Fluorouracil and Folinic Acid Versus Fluorouracil and Folinic Acid Alone as Maintenance Therapy in RAS Wild-Type Metastatic Colorectal Cancer: The Randomized PANAMA Trial (AIO KRK 0212). J Clin Oncol 2022; 40:72-82. [PMID: 34533973 PMCID: PMC8683209 DOI: 10.1200/jco.21.01332] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE The randomized PANAMA trial investigated the efficacy of panitumumab (Pmab) when added to maintenance therapy with fluorouracil and folinic acid (FU/FA) in patients with RAS wild-type metastatic colorectal cancer. METHODS Following first-line induction therapy with six cycles of FU/FA and oxaliplatin plus Pmab, responding patients (stable disease or partial or complete remission) were randomly assigned (1:1, open-label) to maintenance treatment with either FU/FA plus Pmab or FU/FA alone. The primary objective was to demonstrate superiority of progression-free survival (PFS, time from random assignment until progression or death) in favor of FU/FA plus Pmab with a hazard ratio (HR) of 0.75, a power of 80%, and a significance level of 10%. Secondary end points included overall survival, objective response rate of maintenance therapy, and toxicity. Survival end points were analyzed by the Kaplan-Meier method and compared by log-rank test and Cox regressions. Dichotomous variables were compared by Fisher's exact test; odds ratios were indicated when appropriate. The trial is registered with ClinicalTrials.gov (NCT01991873). RESULTS Overall, 248 patients were randomly assigned and received maintenance therapy with either FU/FA plus Pmab (125 patients) or FU/FA alone (123 patients). At data cutoff, with 218 events (of 218 needed), PFS of maintenance therapy was significantly improved with FU/FA plus Pmab (8.8 months v 5.7 months; HR, 0.72; 80% CI, 0.60 to 0.85; P = .014). Overall survival (event rate 54%) numerically favored the FU/FA plus Pmab arm (28.7 months v 25.7 months; HR, 0.84; 95% CI, 0.60 to 1.18; P = .32). Objective response rates were 40.8% in patients receiving FU/FA plus Pmab versus 26.0% in patients receiving FU/FA alone (odds ratio, 1.96; 95% CI, 1.14 to 3.36; P = .02). The most frequent Common Terminology Criteria for Adverse Event grade ≥ 3 event during maintenance therapy was skin rash (7.2%). CONCLUSION In RAS wild-type metastatic colorectal cancer, maintenance therapy with FU/FA plus Pmab induced a significantly superior PFS compared with FU/FA alone. If active maintenance therapy is aspired following induction therapy with FU/FA and oxaliplatin plus Pmab, FU/FA plus Pmab appears to be the most favorable option.
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Affiliation(s)
- Dominik Paul Modest
- Department of Hematology, Oncology and Tumorimmunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany,Dominik Paul Modest, Department of Hematology, Oncology, and Tumorimmunology (CVK), Charité-Universitätsmedizin Berlin, Augustenburgerplatz 1, 13353 Berlin, Germany; e-mail:
| | - Meinolf Karthaus
- Department of Hematology and Oncology, Munich Hospital Neuperlach, Munich, Germany
| | | | | | | | - Alexander Otto König
- Department of Gastroenterology, University Medicine Göttingen, Göttingen, Germany
| | | | - Karel Caca
- Department of Gastroenterology, Hematology and Oncology, Hospital Ludwigsburg, Ludwigsburg, Germany
| | | | - Eray Goekkurt
- Practice of Hematology and Oncology (HOPE), Hamburg, Germany,University Cancer Center Hamburg (UCCH), Hamburg, Germany
| | - Siegfried Haas
- Department of Hematology and Oncology, Friedrich-Ebert-Hospital, Neumünster, Germany
| | - Annika Kurreck
- Department of Hematology, Oncology and Tumorimmunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Arndt Stahler
- Department of Hematology, Oncology and Tumorimmunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Swantje Held
- Charité Universitätsmedizin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Pathology, Berlin, Germany
| | - Armin Jarosch
- Charité Universitätsmedizin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Pathology, Berlin, Germany
| | - David Horst
- German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany,Charité Universitätsmedizin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Pathology, Berlin, Germany
| | | | - Stefan Kasper
- German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany,Department of Medical Oncology, West German Cancer Center, Westdeutsches Tumorzentrum, University Hospital of Essen, Essen, Germany
| | - Volker Heinemann
- German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany,Department of Medicine III and Comprehensive Cancer Center, University Hospital (LMU), Munich, Germany
| | - Sebastian Stintzing
- Department of Hematology, Oncology and Tumorimmunology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany,German Cancer Consortium (DKTK), German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - Tanja Trarbach
- Zentrum für Tumorbiologie und Integrative Medizin, Klinikum Wilhelmshaven, Wilhelmshaven, Germany
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Seligmann JF, Fisher DJ, Brown LC, Adams RA, Graham J, Quirke P, Richman SD, Butler R, Domingo E, Blake A, Yates E, Braun M, Collinson F, Jones R, Brown E, de Winton E, Humphrey TC, Parmar M, Kaplan R, Wilson RH, Seymour M, Maughan TS. Inhibition of WEE1 Is Effective in TP53- and RAS-Mutant Metastatic Colorectal Cancer: A Randomized Trial (FOCUS4-C) Comparing Adavosertib (AZD1775) With Active Monitoring. J Clin Oncol 2021; 39:3705-3715. [PMID: 34538072 PMCID: PMC8601321 DOI: 10.1200/jco.21.01435] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/27/2021] [Accepted: 08/16/2021] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Outcomes in RAS-mutant metastatic colorectal cancer (mCRC) remain poor and patients have limited therapeutic options. Adavosertib is the first small-molecule inhibitor of WEE1 kinase. We hypothesized that aberrations in DNA replication seen in mCRC with both RAS and TP53 mutations would sensitize tumors to WEE1 inhibition. METHODS Patients with newly diagnosed mCRC were registered into FOCUS4 and tested for TP53 and RAS mutations. Those with both mutations who were stable or responding after 16 weeks of chemotherapy were randomly assigned 2:1 between adavosertib and active monitoring (AM). Adavosertib (250 mg or 300 mg) was taken orally once on days 1-5 and days 8-12 of a 3-week cycle. The primary outcome was progression-free survival (PFS), with a target hazard ratio (HR) of 0.5 and 80% power with a one-sided 0.025 significance level. RESULTS FOCUS4-C was conducted between April 2017 and Mar 2020 during which time 718 patients were registered; 247 (34%) were RAS/TP53-mutant. Sixty-nine patients were randomly assigned from 25 UK hospitals (adavosertib = 44; AM = 25). Adavosertib was associated with a PFS improvement over AM (median 3.61 v 1.87 months; HR = 0.35; 95% CI, 0.18 to 0.68; P = .0022). Overall survival (OS) was not improved with adavosertib versus AM (median 14.0 v 12.8 months; HR = 0.92; 95% CI, 0.44 to 1.94; P = .93). In prespecified subgroup analysis, adavosertib activity was greater in left-sided tumors (HR = 0.24; 95% CI, 0.11 to 0.51), versus right-sided (HR = 1.02; 95% CI, 0.41 to 2.56; interaction P = .043). Adavosertib was well-tolerated; grade 3 toxicities were diarrhea (9%), nausea (5%), and neutropenia (7%). CONCLUSION In this phase II randomized trial, adavosertib improved PFS compared with AM and demonstrates potential as a well-tolerated therapy for RAS/TP53-mutant mCRC. Further testing is required in this sizable population of unmet need.
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Affiliation(s)
- Jenny F. Seligmann
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | | | | | - Richard A. Adams
- Centre for Trials Research University and Velindre NHS Trust, Cardiff, United Kingdom
| | | | - Philip Quirke
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Susan D. Richman
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Rachel Butler
- Bristol Genetics Laboratory, Bristol, United Kingdom
| | - Enric Domingo
- MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Andrew Blake
- MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Emma Yates
- MRC Clinical Trials Unit at UCL, London, United Kingdom
| | | | - Fiona Collinson
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Rob Jones
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Ewan Brown
- Western General Hospital, Edinburgh, United Kingdom
| | | | - Timothy C. Humphrey
- MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Mahesh Parmar
- MRC Clinical Trials Unit at UCL, London, United Kingdom
| | | | | | - Matthew Seymour
- Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Timothy S. Maughan
- MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
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