Radiographic Progression-Free Survival and Clinical Progression-Free Survival as Potential Surrogates for Overall Survival in Men With Metastatic Hormone-Sensitive Prostate Cancer

PURPOSE

Despite major increases in the longevity of men with metastatic hormone-sensitive prostate cancer (mHSPC), most men still die of prostate cancer. Phase III trials assessing new therapies in mHSPC with overall survival (OS) as the primary end point will take approximately a decade to complete. We investigated whether radiographic progression-free survival (rPFS) and clinical PFS (cPFS) are valid surrogates for OS in men with mHSPC and could potentially be used to expedite future phase III clinical trials.

METHODS

We obtained individual patient data (IPD) from 9 eligible randomized trials comparing treatment regimens (different androgen deprivation therapy [ADT] strategies or ADT plus docetaxel in the control or research arms) in mHSPC. rPFS was defined as the time from random assignment to radiographic progression or death from any cause whichever occurred first; cPFS was defined as the time from random assignment to the date of radiographic progression, symptoms, initiation of new treatment, or death, whichever occurred first. We implemented a two-stage meta-analytic validation model where conditions of patient-level and trial-level surrogacy had to be met. We then computed the surrogate threshold effect (STE).

RESULTS

IPD from 6,390 patients randomly assigned from 1994 to 2012 from 13 units were pooled for a stratified analysis. The median OS, rPFS, and cPFS were 4.3 (95% CI, 4.2 to 4.5), 2.4 (95% CI, 2.3 to 2.5), and 2.3 years (95% CI, 2.2 to 2.4), respectively. The STEs were 0.80 and 0.81 for rPFS and cPFS end points, respectively.

CONCLUSION

Both rPFS and cPFS appear to be promising surrogate end points for OS. The STE of 0.80 or higher makes it viable for either rPFS or cPFS to be used as the primary end point that is surrogate for OS in phase III mHSPC trials with testosterone suppression alone as the backbone therapy and would expedite trial conduct.

Long term pregnancy outcomes of women with cancer following fertility preservation: A systematic review and meta-analysis

OBJECTIVE

As cancer survivorship increases, there is higher uptake of fertility preservation treatments among affected women. However, there is limited evidence on the subsequent use of preserved material and pregnancy outcomes in women who underwent fertility preservation (FP) before cancer treatments. We aimed to systematically review the long-term reproductive and pregnancy outcomes in this cohort of women.

PATIENTS

Women who underwent any type of the following FP treatments: embryo cryopreservation (EC), oocyte cryopreservation (OC) and ovarian tissue cryopreservation (OTC)) before any planned cancer treatment.

EVIDENCE REVIEW

We searched electronic databases (MEDLINE, Embase, Cochrane CENTRAL, and HTA) from inception until May 2021 for all observational studies that met our inclusion criteria. We extracted data on reproductive and pregnancy outcomes in duplicate and assessed the risk of bias in included studies using the ROBINS-I tool. We pooled data using a random-effects model and reported using odds ratios (OR) with 95% confidence intervals (CI).

MAIN OUTCOME MEASURES

Our primary outcome was live birth rate and other important reproductive and pregnancy outcomes.

RESULTS

Of 5405 citations, we screened 103 and included 26 observational studies (n = 7061 women). Hematologic malignancy was the commonest cause for seeking FP treatments, followed by breast and gynecology cancers. Twelve studies reported on OTC (12/26, 46 %), eight included EC (8/26, 30 %), and twelve reported on OC (12/26, 46 %). The cumulative live birth rate following any FP treatment was 0.046 (95 %CI 0.029-0.066). Only 8 % of women returned to use their frozen reproductive material (558/7037, 8.0 %), resulting in 210 live births in total, including assisted conceptions following EC/OC/OTC and natural conceptions following OTC. The odds for live birth was OR 0.38 (95 %CI 0.29-0.48 I² 83.7 %). The odds for live birth was the highest among women who had EC (OR 0.45, 95 %CI 0.14-0.76, I² 95.1 %), followed by the OTC group (OR 0.37, 95 %CI 0.22-0.53, I² 88.7 %) and OC group (OR 0.31, 95 %CI 0.15-0.47, I² 78.2 %).

CONCLUSIONS

Fertility preservation treatments offered good long-term reproductive outcomes for women with cancer with a high chance to achieve a live birth. Further research is needed to evaluate the long-term pregnancy and offspring outcomes in this cohort.

Assessing intermediate clinical endpoints (ICE) as potential surrogates for overall survival (OS) in men with metastatic hormone-sensitive prostate cancer (mHSPC)

5006

Background: We hypothesized that radiographic progression free survival (rPFS) and clinical PFS (cPFS) are valid surrogates for OS in men with mHSPC and could potentially be used to expedite phase 3 clinical trials. This hypothesis was investigated by the STOPCAP M1 Collaboration. Methods: We obtained individual patient data (IPD) from 13/26 eligible randomized trials comparing treatment regimens (androgen deprivation therapy (ADT) or ADT + docetaxel in the control or research arms) in mHSPC. We evaluated the surrogacy of rPFS and cPFS as potential ICEs. rPFS was defined as time from randomization to radiographic progression (defined per protocol) or death from any cause whichever occurred first; cPFS was defined as time from randomization to date of radiographic progression, symptoms, initiation of new treatment, or death, whichever occurred first. OS was defined as time from randomization to death from any cause, if patients had not died they were censored at the date of last follow-up. We implemented a two-stage meta-analytic validation model where conditions of trial level and patient level surrogacy had to be met. We computed the surrogate threshold effect (STE), which is the minimum ICE treatment effect necessary to estimate a non-zero effect on OS. Results: IPD from 8592 patients randomized from 1994-2012 from 13 trials were pooled for a stratified analysis. There were 5377 deaths, of which 3971 (74%) were due to prostate cancer. The median follow-up for surviving patients was 75.6 months. In addition, there were 6227 rPFS and 6314 cPFS events. The median OS, rPFS and cPFS were 49.4, 26.8 and 25.2 months, respectively. The STE was 0.82 for rPFS and 0.84 for cPFS. Conclusions: Both rPFS and cPFS appear to be valid surrogate endpoints for OS. A surrogate threshold effect of 0.82 or higher makes it viable for either rPFS or cPFS to be used as the primary endpoint as a surrogate for OS in phase 3 mHSPC trials and would expedite trial conduct. Validation of these ICEs in trials with drugs having other mechanisms of action is planned. Clinical trial information: Several. [Table: see text]

Postoperative radiotherapy for non-small cell lung cancer

BACKGROUND

The role of postoperative radiotherapy (PORT) in the treatment of patients with completely resected non-small cell lung cancer (NSCLC) was not clear. A systematic review and individual participant data meta-analysis was undertaken to evaluate available evidence from randomised controlled trials (RCTs). These results were first published in Lung Cancer in 2013.

OBJECTIVES

To evaluate the effects of PORT on survival and recurrence in patients with completely resected NSCLC. To investigate whether predefined patient subgroups benefit more or less from PORT.

SEARCH METHODS

We supplemented MEDLINE and CANCERLIT searches (1965 to 8 July 2016) with information from trial registers, handsearching of relevant meeting proceedings and discussion with trialists and organisations.

SELECTION CRITERIA

We included trials of surgery versus surgery plus radiotherapy, provided they randomised participants with NSCLC using a method that precluded prior knowledge of treatment assignment.

DATA COLLECTION AND ANALYSIS

We carried out a quantitative meta-analysis using updated information from individual participants from all randomised trials. We sought data on all participants from those responsible for the trial. We obtained updated individual participant data (IPD) on survival and date of last follow-up, as well as details on treatment allocation, date of randomisation, age, sex, histological cell type, stage, nodal status and performance status. To avoid potential bias, we requested information on all randomised participants, including those excluded from investigators' original analyses. We conducted all analyses on intention-to-treat on the endpoint of survival.

MAIN RESULTS

We identified 14 trials evaluating surgery versus surgery plus radiotherapy. Individual participant data were available for 11 of these trials, and our analyses are based on 2343 participants (1511 deaths). Results show a significant adverse effect of PORT on survival, with a hazard ratio of 1.18, or an 18% relative increase in risk of death. This is equivalent to an absolute detriment of 5% at two years (95% confidence interval (CI) 2% to 9%), reducing overall survival from 58% to 53%. Subgroup analyses showed no differences in effects of PORT by any participant subgroup covariate.We did not undertake analysis of the effects of PORT on quality of life and adverse events. Investigators did not routinely collect quality of life information during these trials, and it was unlikely that any benefit of PORT would offset the observed survival disadvantage. We considered risk of bias in the included trials to be low.

AUTHORS' CONCLUSIONS

Results from 11 trials and 2343 participants show that PORT is detrimental to those with completely resected non-small cell lung cancer and should not be used in the routine treatment of such patients. Results of ongoing RCTs will clarify the effects of modern radiotherapy in patients with N2 tumours.

Postoperative radiotherapy for non-small cell lung cancer

BACKGROUND

The role of postoperative radiotherapy (PORT) in the treatment of patients with completely resected non-small cell lung cancer (NSCLC) was not clear. A systematic review and individual participant data meta-analysis was undertaken to evaluate available evidence from randomised controlled trials (RCTs). These results were first published in Lung Cancer in 2013.

OBJECTIVES

To evaluate the effects of PORT on survival and recurrence in patients with completely resected NSCLC. To investigate whether predefined patient subgroups benefit more or less from PORT.

SEARCH METHODS

We supplemented MEDLINE and CANCERLIT searches (1965 to 8 July 2016) with information from trial registers, handsearching of relevant meeting proceedings and discussion with trialists and organisations.

SELECTION CRITERIA

We included trials of surgery versus surgery plus radiotherapy, provided they randomised participants with NSCLC using a method that precluded prior knowledge of treatment assignment.

DATA COLLECTION AND ANALYSIS

We carried out a quantitative meta-analysis using updated information from individual participants from all randomised trials. We sought data on all participants from those responsible for the trial. We obtained updated individual participant data (IPD) on survival and date of last follow-up, as well as details on treatment allocation, date of randomisation, age, sex, histological cell type, stage, nodal status and performance status. To avoid potential bias, we requested information on all randomised participants, including those excluded from investigators' original analyses. We conducted all analyses on intention-to-treat on the endpoint of survival.

MAIN RESULTS

We identified 14 trials evaluating surgery versus surgery plus radiotherapy. Individual participant data were available for 11 of these trials, and our analyses are based on 2343 participants (1511 deaths). Results show a significant adverse effect of PORT on survival, with a hazard ratio of 1.18, or an 18% relative increase in risk of death. This is equivalent to an absolute detriment of 5% at two years (95% confidence interval (CI) 2% to 9%), reducing overall survival from 58% to 53%. Subgroup analyses showed no differences in effects of PORT by any participant subgroup covariate.We did not undertake analysis of the effects of PORT on quality of life and adverse events. Investigators did not routinely collect quality of life information during these trials, and it was unlikely that any benefit of PORT would offset the observed survival disadvantage. We considered risk of bias in the included trials to be low.

AUTHORS' CONCLUSIONS

Results from 11 trials and 2343 participants show that PORT is detrimental to those with completely resected non-small cell lung cancer and should not be used in the routine treatment of such patients. Results of ongoing RCTs will clarify the effects of modern radiotherapy in patients with N2 tumours.

Neoadjuvant chemotherapy plus surgery versus surgery for cervical cancer

BACKGROUND

A previous systematic review found that giving neoadjuvant chemotherapy before surgery improved survival compared with radiotherapy. However, the role of neoadjuvant chemotherapy followed by surgery versus surgery alone is still unclear.

OBJECTIVES

To assess the role of neoadjuvant chemotherapy in women with early or locally-advanced cervical cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) (to Issue 8, 2012), MEDLINE (OVID) (to Aug 2012), LILACS (to Aug 2012), Physician's Data Query (PDQ) (to Aug 2012). We sought both published and unpublished trials and undertook systematic searches of a number of trial sources with no restrictions.

SELECTION CRITERIA

Randomised trials comparing neoadjuvant chemotherapy with surgery in women with early or locally-advanced cervical cancer who had not undergone any prior treatment likely to interfere with the treatment comparison. Trials giving radical radiotherapy for inoperable tumours and/or post-operative radiotherapy were also eligible. The primary outcome was overall survival (OS). Secondary outcomes were progression-free survival (PFS), local and distant recurrence, rates of resection and surgical morbidity.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted and checked data from trial reports, Depending on the type of outcome, trial hazard ratios (HRs) and odds ratios (ORs) were obtained or estimated from trial reports, or sought from trial investigators.

MAIN RESULTS

Six trials (1078 women) were identified for inclusion in this updated review. All six trials provided data on OS (1071 women) and PFS (1027 women). Data on resection rates and pathological response were only available for five trials (908 to 940 women) and data on recurrence were only available for four trials (737 women). Both OS (HR 0.77, 95% confidence interval (CI) 0.62 to 0.96, P = 0.02) and PFS (HR 0.75, 95% CI 0.61 to 0.93, P = 0.008) were significantly improved with neoadjuvant chemotherapy. The estimate for local recurrence was in favour of neoadjuvant chemotherapy (OR 0.67, 95% CI 0.45 to 0.99, P = 0.04), although heterogeneity was observed. The result was no longer significant when the random-effects model was used (OR 0.60, 95% CI 0.32 to 1.12, P = 0.11). Whilst not significant, estimates for distant recurrence (OR 0.72, 95% CI 0.45 to 1.14, P = 0.16) and rates of resection (OR 1.55, 95% CI 0.96 to 2.50, P = 0.07) tended to favour neoadjuvant chemotherapy, although heterogeneity was observed. Exploratory analyses of pathological response showed a significant decrease in adverse pathological findings with neoadjuvant chemotherapy (OR 0.54, 95% CI 0.40 to 0.73, P = < 0.0001 for lymph node status; OR 0.58, 95% CI 0.41 to 0.82, P = 0.002 for parametrial infiltration) which, despite substantial heterogeneity, was still significant when the random-effects model was used. There were also no differences in the effect of neoadjuvant chemotherapy on survival according to total cisplatin dose, chemotherapy cycle length or by cervical cancer stage.

AUTHORS' CONCLUSIONS

Both OS and PFS were improved with neoadjuvant chemotherapy. Although the effects were less clear on all other pre-specified outcomes, they all tended to be in favour of neoadjuvant chemotherapy. Whilst these results appear to indicate that neoadjuvant chemotherapy may offer a benefit over surgery alone for women with early-stage or locally-advanced cervical cancer, the evidence is based on only a small number of trials, and further research may be warranted.

Neoadjuvant chemotherapy plus surgery versus surgery for cervical cancer

BACKGROUND

A prior systematic review found that giving neoadjuvant chemotherapy before surgery improved survival compared with radiotherapy. However, the role of neoadjuvant chemotherapy followed by surgery versus surgery alone is still unclear.

OBJECTIVES

To assess the role of neoadjuvant chemotherapy in women with early or locally advanced cervical cancer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), (Issue 2, 2009), MEDLINE (to March 2009), LILACS (to March 2009), Physician's Data Query (PDQ) (to March 2009). Both published and unpublished trials were sought and systematic searches of a number of trial sources were undertaken with no restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing neoadjuvant chemotherapy with surgery in women with early or locally advanced cervical cancer who had not undergone any prior treatment likely to interfere with the treatment comparison. Trials giving radical radiotherapy for inoperable tumours and/or post-operative radiotherapy were also eligible. The primary outcome was overall survival (OS). Secondary outcomes were progression-free survival (PFS), local and distant recurrence, rates of resection and surgical morbidity.

DATA COLLECTION AND ANALYSIS

Data were extracted from trial reports and independently checked by two review authors. Depending on the type of outcome, trial hazard ratios (HRs) and odds ratios (ORs) were obtained or estimated from trial reports or sought from trial investigators.

MAIN RESULTS

Six trials (1072 women) were identified for inclusion in the review. Although data on PFS was available for all six trials (1036 women), data on overall survival, resection rates and pathological response were only available for five trials (909 to 938 women) and data on recurrence were only available for three trials (604 women). Whilst PFS was significantly improved with neoadjuvant chemotherapy (HR = 0.76, 95% CI = 0.62 to 0.94, p = 0.01), no OS benefit was observed (HR = 0.85, 95% CI = 0.67 to 1.07, p = 0.17). Furthermore, estimates for both local (OR = 0.76, 95% CI = 0.49 to 1.17, p = 0.21) and distant (OR = 0.68, 95% CI = 0.41 to 1.13, p = 0.13) recurrence and rates of resection (OR = 1.55, 95% CI = 0.96 to 2.50, p = 0.07) only tended to be in favour of neoadjuvant chemotherapy, and heterogeneity was observed. Exploratory analyses of pathological response showed a significant decrease in adverse pathological findings with neoadjuvant chemotherapy (OR = 0.54, 95% CI = 0.39 to 0.73, p = < 0.0001 for lymph node status; OR = 0.58, 95% CI = 0.41 to 0.82, p = 0.002 for parametrial infiltration) which despite a high level of heterogeneity was still significant when the random effects model was used. There was also no difference in the effect of neoadjuvant chemotherapy according to total cisplatin dose, chemotherapy cycle length or by cervical cancer stage.

AUTHORS' CONCLUSIONS

Despite outcomes tending to be in favour of neoadjuvant chemotherapy few, including overall survival, were significant. Therefore, it remains unclear whether neoadjuvant chemotherapy consistently offers a benefit over surgery alone for women with early-stage or locally advanced cervical cancer.

Chemotherapy and surgery versus surgery alone in non-small cell lung cancer

BACKGROUND

The role of pre-operative chemotherapy in the treatment of patients with non-small cell lung cancer (NSCLC) was not clear. A systematic review and quantitative meta-analysis were therefore undertaken to evaluate the available evidence from randomised trials.

OBJECTIVES

To evaluate the effect of pre-operative chemotherapy on survival in patients with non-small cell lung cancer. If adequate data are available, to investigate whether or not pre-defined patient subgroups benefit more or less from pre-operative chemotherapy.

SEARCH STRATEGY

MEDLINE and CANCERLIT searches for randomised controlled trials (RCTs) were supplemented by information from trial registers and by handsearching relevant meeting proceedings and by discussion with relevant trialists and organisations.

SELECTION CRITERIA

RCTs were eligible for inclusion provided the patients had been randomised between chemotherapy followed by surgery versus surgery alone and that the method of randomisation precluded prior knowledge of the treatment to be assigned.

DATA COLLECTION AND ANALYSIS

A systematic review and meta-analysis based on aggregate data extracted from trial publications was carried out to assess the effectiveness of pre-operative chemotherapy in NSCLC. This involved identifying eligible RCTs and extracting aggregate data from the abstracts or reports of these RCTs. Hazard ratios were calculated from published summary statistics and then combined to give pooled estimates of treatment efficacy.

MAIN RESULTS

Twelve eligible RCTs were identified. Data were available from seven RCTs including 988 patients (75% of eligible patients). Pre-operative chemotherapy increased survival with a hazard ratio of 0.82 (95%CI 0.69-0.97) P = 0.022. This is equivalent to an absolute benefit of 6%, increasing overall survival across all stages of disease from 14% to 20% at 5 years. There was no evidence of statistical heterogeneity (P = 0.980, I(2 )= 0).

AUTHORS' CONCLUSIONS

This analysis shows a significant increase in survival attributable to pre-operative chemotherapy. This is currently the best estimate of the effectiveness of this therapy, but is based on a small number of trials and patients. This analysis was unable to address important questions such as whether particular types of patients may benefit more or less from pre-operative chemotherapy or whether the early stopping of a number of included RCTs impacted on the results. These issues may be addressed by an ongoing individual patient data (IPD) meta-analysis.

A systematic review and meta-analysis of the literature: chemotherapy and surgery versus surgery alone in non-small cell lung cancer

BACKGROUND

The effectiveness of preoperative chemotherapy in the treatment of non-small cell lung cancer has remained unclear despite the conduct of several randomized controlled trials (RCTs).

METHODS

A systematic review and meta-analysis was carried out to assess the effectiveness of preoperative chemotherapy in non-small cell lung cancer. This involved identifying eligible RCTs and extracting aggregate data from the abstracts or reports of these RCTs. Hazard ratios were calculated from these published summary statistics and then combined to give pooled estimates of treatment efficacy.

RESULTS

Twelve eligible RCTs were identified, from which data from seven RCTs, including 988 patients (75% of eligible patients), could be combined in a systematic review and meta-analysis. Preoperative chemotherapy improved survival with a hazard ratio of 0.82 (95% confidence interval, 0.69-0.97; p = 0.02). This is equivalent to an absolute benefit of 6%, increasing overall survival across all stages of disease from 14% to 20% at 5 years. There was no evidence of statistical heterogeneity.

CONCLUSIONS

This analysis shows a significant benefit of preoperative chemotherapy and is currently the best estimate of the effectiveness of this therapy, but this is based on a small number of trials and patients. This current analysis was unable to address important questions such as whether particular types of patients may benefit more or less from preoperative chemotherapy or whether the early stopping of a number of included RCTs impacted on the results. To assess this, an individual patient data meta-analysis is required.

Neoadjuvant chemotherapy for locally advanced cervix cancer

BACKGROUND

Despite the enrollment of more than 3000 women in randomised trials, the benefits and risks of neoadjuvant chemotherapy in the treatment of locally advanced cervical cancer remained uncertain.

OBJECTIVES

This systematic review and individual patient data (IPD) meta-analysis aimed to assess the effect of neoadjuvant chemotherapy in two comparisons: (1) neoadjuvant chemotherapy followed by radical radiotherapy compared to the same radiotherapy alone; and (2) neoadjuvant chemotherapy followed by surgery compared to radical radiotherapy alone.

SEARCH STRATEGY

Medline and CancerLit searches were supplemented with information from trial registers and by hand searching relevant meeting proceedings and by discussion with relevant trialists and organisations. These searches have been updated regularly until December 2002.

SELECTION CRITERIA

To be included, trials had to be properly randomised and had to include patients with locally advanced cervical cancer who had received neoadjuvant cytotoxic chemotherapy before radiotherapy or surgery or both treatments. Concurrent chemoradiotherapy trials were not included. The comparisons had to be unconfounded by use of additional agents or interventions. Patient enrollment should have started after 1 January 1975 and be completed by September 2000.

DATA COLLECTION AND ANALYSIS

We collected, validated and re-analysed updated trial data on all randomised patients from all relevant trials. Any queries were resolved and the final database entries verified by the responsible trial investigator, data manager or statistician. Two separate sets of analyses (by intention-to-treat) were carried out according to the treatment comparisons (1 and 2) already described. For all outcomes, we obtained overall pooled hazard ratios using the fixed effect model. To explore the potential impact of trial design, we pre-planned analyses that grouped trials by important aspects of their design that might influence the treatment effect. To investigate the effects of neoadjuvant chemotherapy within pre-specified subgroups of patients stratified logrank analyses were done on the primary endpoint of survival.

MAIN RESULTS

In the first comparison, we obtained data from 18 trials and 2074 patients. When all trials were considered together, a high level of statistical heterogeneity suggested that the results could not be combined indiscriminately. A substantial amount of heterogeneity was explained by separate analyses of groups of trials. Trials using chemotherapy cycle lengths shorter than 14 days (HR = 0.83, 95% CI = 0.69 to 1.00, p = 0.046) or cisplatin dose intensities greater than 25 mg/m2 per week (HR = 0.91, 95% CI = 0.78 to 1.05, p = 0.20) tended to show an advantage for neoadjuvant chemotherapy on survival. In contrast, trials using cycle lengths longer than 14 days (HR = 1.25, 95% CI = 1.07 to 1.46, p = 0.005) or cisplatin dose intensities lower than 25 mg/m2 per week (HR = 1.35, 95% CI = 1.11 to 1.14, p = 0.002) tended to show a detrimental effect of neoadjuvant chemotherapy on survival. In the second comparison, data from 5 trials and 872 patients were obtained. The combined results from all trials (HR = 0.65, 95% CI = 0.53 to 0.80, p = 0.0004) indicated a highly significant reduction in the risk of death with neoadjuvant chemotherapy, but there were some differences between trials in their design and results.

REVIEWERS' CONCLUSIONS

Despite some unexplained heterogeneity, the timing and dose intensity of cisplatin-based neoadjuvant chemotherapy appears to have an important impact on whether or not it benefits women with locally advanced cervical cancer and warrants further exploration.