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["project_title"]=>
string(140) "IPD meta-analyses of the effects of ADT, docetaxel and androgen receptor pathway inhibitors for hormone-sensitive metastatic prostate cancer"
["project_narrative_summary"]=>
string(652) "Results of trials have shown that adding docetaxel or androgen-receptor pathway inhibitors (ARPIs) to standard hormone therapy) helps men to live longer. But it is not clear if adding an ARPI helps all men. And we want to know if having all three treatments - ARPI, docetaxel and hormone therapy is better than having two of them. No clinical trials are comparing the treatments like this. The most reliable way to work out how the different treatments and treatment combinations work in different groups of men is to collect data on individual participants from all the important clinical trials and combine these using a method called meta-analysis."
["project_learn_source"]=>
string(9) "colleague"
["principal_investigator"]=>
array(7) {
["first_name"]=>
string(5) "Jayne"
["last_name"]=>
string(7) "Tierney"
["degree"]=>
string(3) "PhD"
["primary_affiliation"]=>
string(31) "MRC Clinical Trials Unit at UCL"
["email"]=>
string(23) "jayne.tierney@ucl.ac.uk"
["state_or_province"]=>
string(2) "UK"
["country"]=>
string(14) "United Kingdom"
}
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["p_pers_f_name"]=>
string(6) "Larysa"
["p_pers_l_name"]=>
string(9) "Rydzewska"
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string(3) "BSc"
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string(31) "MRC Clinical Trials Unit at UCL"
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string(6) "Fisher"
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string(31) "MRC Clinical Trials Unit at UCL"
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string(6) "Claire"
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string(4) "Vale"
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string(3) "PhD"
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string(31) "MRC Clinical Trials Unit at UCL"
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string(10) "7005266088"
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string(5) "Sarah"
["p_pers_l_name"]=>
string(7) "Burdett"
["p_pers_degree"]=>
string(3) "MSc"
["p_pers_pr_affil"]=>
string(31) "MRC Clinical Trials Unit at UCL"
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string(10) "6601959922"
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string(3) "yes"
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["project_ext_grants"]=>
array(2) {
["value"]=>
string(3) "yes"
["label"]=>
string(65) "External grants or funds are being used to support this research."
}
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string(18) "full_crs_supp_docs"
["property_scientific_abstract"]=>
string(1734) "Background
Trial results have shown that adding androgen receptor pathway inhibitors (ARPIs) to standard care improves survival. It is unclear if these effects vary across different subgroups of men, or by docetaxel use.
Objective
To assess if the effects of ARPIs vary by patient characteristics and/or docetaxel use, and which treatments are better and for whom.
Study design
Using pairwise IPD meta-analysis to assess, reliably and precisely, if effects of ARPIs vary by participant characteristics or by docetaxel use. We will combine these data with IPD from docetaxel trials in an IPD network meta-analysis (NMA) to determine if “triplet” (ADT+docetaxel+ARPI) or “doublet” (ADT+docetaxel/ARPI) therapy is better, and for whom.
Participants
Men with hormone-sensitive, metastatic prostate cancer.
Primary and secondary outcome measures
Primary: overall survival
Secondary: progression-free survival, failure-free survival
Supplemental: radiological progression-free survival, prostate-cancer specific survival, time to PSA failure and to castration-resistance
Statistical analysis
Intention-to-treat, 2-stage, fixed-effect, meta-analysis of hazard ratios (adjusted for core covariates) to assess main effects of ARPIs on overall survival and subgroup effects based on progression-free survival. 1-stage flexible parametric modelling and standardisation to analyse multiple subgroup interactions and generate subgroup-specific survival curves. 2-stage NMA to compare doublets, then effects of triplet therapy, and if any results vary by patient characteristics (www.stopcapm1.org/protocol/)."
["project_brief_bg"]=>
string(3303) "Results of trials adding new androgen receptor pathway inhibitors (ARPIs) (1-8) to standard care have shown improved overall survival in men with hormone-sensitive metastatic prostate cancer (mHSPC). However, it is less clear whether or how the effects of these agents vary across different groups of men, or because of prior or concurrent docetaxel therapy. Furthermore, there is a need to determine which treatment or treatment combination, i.e. “triplet” therapy (standard ADT plus both docetaxel plus ARPI); or “doublet” therapy (standard ADT plus either ARPI or docetaxel), is preferable and for whom.
Results from the PEACE-1 (3), ENZAMET (4) and ARASENS (8) trials indicate that an upfront “triplet” of ADT plus docetaxel and an ARPI may further prolong survival compared to “doublet” ADT plus docetaxel therapy. However, it remains unclear whether these results can be extrapolated to patients with metachronous disease.
Furthermore, the lack of trials designed to directly compare “doublet” and “triplet” therapies has implications for appropriate selection and sequencing of treatment and the additional toxicity of a more intensive treatment regimen, and how the triplet compares with a doublet of ARPI plus ADT.
The best way to address these questions thoroughly and reliably is through rigorous pairwise and network re-analyses of up-to-date individual participant data (IPD) from all the relevant trials. A meta-analysis based on IPD can improve the quantity and quality of available data (9, 10), thus providing greater power than any one trial, and can circumvent the biases and other limitations associated with the traditional aggregate data approach (11). Collecting IPD also allows more flexible and detailed analyses, including the ability to adjust for baseline characteristics, account for missing data and investigate non-proportional hazards (12). Importantly, it also allows a more thorough and appropriate investigation of potential treatment effect modifiers (9, 10). For example, results of a recent STOPCAP IPD meta-analysis (13), has defined more precisely the effects of docetaxel. It appears to be best suited to men with poorer prognosis, based on a high volume of disease and potentially the bulkiness of their primary tumour; whilst those with metachronous, low volume disease gain no meaningful benefit from docetaxel and should be managed differently (13).
Therefore, the STOPCAP collaboration is currently seeking IPD from the relevant ARPI trials. Through pairwise meta-analysis we will ascertain, more reliably and precisely, if and how the effects of ARPIs vary by participant characteristics and/or the use of docetaxel. The subsequent network meta-analysis will combine these data with IPD from previous trials of docetaxel, to help determine which treatment or treatment combination, i.e., “triplet” or “doublet” therapy” is preferable and for whom.
Both the LATITUDE and TITAN trials will play a key role in helping us to address these important clinical questions to determine more precisely how ARPIs should be used for men with mHSPC. Notably, TITAN is the only eligible trial which can tell us about the effects of apalutamide in this context."
["project_specific_aims"]=>
string(1150) "1. To provide up-to-date estimates of the overall effects of adding an ARPI to standard of care, which may include docetaxel and/or radiotherapy as well as standard androgen deprivation therapy (ADT):
• ARPI + ADT (± docetaxel ± RT) versus ADT (± docetaxel ± RT)
2. To assess whether the effect of these agents varies according to any or all of the following:
• The class of ARPI used
• The characteristics of the included men and/or their disease
• Whether or not docetaxel was used as part of standard care
3. To assess which of the available ‘doublet’ or ‘triplet’ combinations of treatments is most effective for mHSPC. The treatments under consideration are:
• ADT alone, the standard of care (or a part thereof) in all trials under consideration
• ADT + docetaxel
• ADT + any androgen receptor pathway inhibitor (ARPI):
i. Androgen biosynthesis inhibitors (abiraterone or orteronel)
ii. Androgen receptor inhibitors (enzalutamide, apalutamide or darolutamide)
• ADT + any ARPI (above) + docetaxel
"
["project_study_design"]=>
array(2) {
["value"]=>
string(7) "meta_an"
["label"]=>
string(52) "Meta-analysis (analysis of multiple trials together)"
}
["project_purposes"]=>
array(5) {
[0]=>
array(2) {
["value"]=>
string(56) "new_research_question_to_examine_treatment_effectiveness"
["label"]=>
string(114) "New research question to examine treatment effectiveness on secondary endpoints and/or within subgroup populations"
}
[1]=>
array(2) {
["value"]=>
string(76) "confirm_or_validate previously_conducted_research_on_treatment_effectiveness"
["label"]=>
string(76) "Confirm or validate previously conducted research on treatment effectiveness"
}
[2]=>
array(2) {
["value"]=>
string(22) "participant_level_data"
["label"]=>
string(36) "Participant-level data meta-analysis"
}
[3]=>
array(2) {
["value"]=>
string(56) "participant_level_data_meta_analysis_from_yoda_and_other"
["label"]=>
string(69) "Meta-analysis using data from the YODA Project and other data sources"
}
[4]=>
array(2) {
["value"]=>
string(37) "develop_or_refine_statistical_methods"
["label"]=>
string(37) "Develop or refine statistical methods"
}
}
["project_research_methods"]=>
string(1330) "Eligibility
- Randomized trials; comparing a) an ARPI + ADT (± docetaxel; ± radiotherapy) with ADT (±docetaxel; ±radiotherapy) or b) docetaxel + ADT (±radiotherapy) with ADT (±radiotherapy)
-Supportive treatments (e.g., prednisone/prednisolone) allowed (research arm only)
- Randomisation between ARPI/non-steroidal anti-androgen (e.g. enzalutamide/bicalutamide as in the ENZAMET trial) allowed, with impact assessed in planned sensitivity analysis
- Men with mHSPC starting/responding to first-line hormone therapy (prior local treatments allowed)
Other trials included in this project (further details in Appendix 1)
Non-repository sources:
ENZAMET
GETUG-15
NCI-2014-00212
PEACE-1
STAMPEDE (A vs C, G, J)
SWOG-1216
Via repository:
ARASENS: Vivli
ARCHES: CSDR
CHAARTED: NCTN
As per Statistical Analysis Plan (below) and direct access request (attached), ideally TITAN and LATITUDE IPD will be downloadable to allow combination into a single dataset with other trial IPD and so full evaluation of planned outcomes. If not downloadable, we will conduct analyses in YODA, generate summary results and export these to the same secure location as other trial IPD."
["project_main_outcome_measure"]=>
string(1177) "Primary outcome
• Overall survival – defined as time from randomisation until death from any cause. Patients remaining alive and those lost to follow-up will be censored on the date of last follow-up. This is the primary outcome for analyses of main treatment effects.
Secondary outcomes
• Progression-free survival – defined as time from randomisation until first clinical or radiological progression or death (from any cause), whichever happened first. Those patients alive without progression will be censored on the date of last follow-up. This is the primary outcome for analyses of interaction between treatment effect and patient covariates.
• Failure-free survival – defined as the time from randomisation until the first biochemical, clinical, or radiological progression or death. Patients alive without biochemical, clinical or radiological progression will be censored on the date of last follow-up.
Supplementary outcomes
• Radiological progression-free survival
• Prostate cancer specific survival
• Time to PSA failure
• Time to castrate-resistant disease"
["project_main_predictor_indep"]=>
string(1224) "For analyses by patient level characteristics, we will aim to categorise the variables listed below as follows:
• Age [years] (continuous)
• Age category (75)
• WHO Performance Status (0 / 1 / 2+)
• Clinical T stage (1-2 / 3 / 4)
• Nodal involvement (N0 / N+)
• Gleason Score (=8)
• Baseline Alkaline phosphatase (continuous)
• Timing of entry into trials (Synchronous (de novo M1 disease/ metachronous (progressed to M1 disease after prior diagnosis with M0 disease)
• Lymph node disease only (Yes / No)
• Location of metastases (bone only, visceral only, bone and visceral)
• Number of bone metastases (0/1-3/4-9/>9; also continuous)
• BMI [kg/m2] (continuous)
• Volume [CHAARTED definition*] (High / Low)
• Risk [LATITIUDE definition**] (High / Low)
• Use of docetaxel (Yes / No)
* Modified CHAARTED definition: High volume defined as: any visceral metastasis and / or at least 4 bone metastases
** LATITUDE definition: High risk as defined in the LATITUDE trial: any 2 of: Gleason score >=8; at least 3 bone lesions; measurable visceral metastasis
"
["project_other_variables_interest"]=>
string(1454) "Baseline characteristics at randomisation (in addition to main predictor variables)
• Patient identifier (anonymised)
• Prostate-specific antigen (PSA)
Treatment characteristics
• Treatment allocation
• Date of randomisation
• Details of allocated control/standard treatment(s) (all patients randomised)
• Details of allocated research arm treatment(s) (if not randomized to control group)
• Details of radiotherapy to the prostate (where part of allocated trial treatments)
• Date trial treatment started
• Duration of trial treatments
• Doses and dosing schedules of trial treatment
• Details of treatment initiated based on disease progression
Data used to derive outcomes
• Overall survival (death) status
• Date of death
• Cause of death
• Clinical progression status
• Date of clinical progression
• PSA progression status
• Date of PSA progression
• Radiological progression status
• Date of radiological progression
• Date of new bone metastases
• Date of new non-lymph soft-tissue metastases
• Date of last follow-up
• Date of last radiological follow-up (CT/MRI/PET bone scan)
• Date of last PSA assessment
Other
• Whether excluded from original trial analysis
• Reason excluded"
["project_stat_analysis_plan"]=>
string(4004) "We request that LATITUDE and TITAN IPD are downloadable, to combine them with other trial IPD in the same secure space. This permits the most flexible, unbiased and informative analysis needed to appropriately evaluate potential effect modifiers, account for docetaxel use, examine any drug class effects and compare doublet versus triplet therapy. With access confined to the YODA platform, we can only combine summary results from LATITUDE/TITAN with IPD, thus compromising their contribution to key analyses, principally those relating to estimation of effects on the “absolute” survival scale, which provides more clinically-useful answers, but requires more computationally-intensive analysis techniques. In our recent STOPCAP IPD analysis of docetaxel trials, we generated predicted survival curves by key patient subgroups (e.g. volume), demonstrating differing levels of efficacy by baseline prognosis and over time. Additional complexities arising from concomitant docetaxel use and ARPI class (biosynthesis inhibitors vs receptor blockers), and the need to disentangle doublet and triplet therapies, such analyses will have even greater clinical importance. Downloadable access to the IPD increases power and reliability to answer key questions, ensuring representation of all ARPI agents, and generalisability of findings to the mHSPC population.
TITAN/LATITUDE IPD will be combined with IPD obtained from other trials with all data management undertaken using Stata v18 or later. We have obtained IPD from 8 ARPI and docetaxel trials for which all data were supplied directly by trialists or downloaded from a data repository. Requests are in process for a further 3. Data are transferred securely, without any direct identifiers. Data are stored at UCL on a secure drive, with access confined to the STOPCAP Core Research Team, all fully trained in information governance and data security. To maximize interpretability and clinical utility of our analyses, we aim to harmonise IPD across trials, irrespective of whether it resides at UCL or within a repository. Thus, we request that the IPD are prepared according to the STOPCAP Data Dictionary developed to facilitate this process. Otherwise, we request clear meta-data to allow mapping of the trial IPD to the Data Dictionary, with input from trial teams as needed. All IPD are checked for validity, range and consistency, to ensure trials are represented accurately; with additional checks to inform Risk of Bias assessments. Any queries are resolved with trial teams. Final versions of directly-supplied IPD are stored in the same secure location.
Each analysis will be based on updated IPD with all randomised participants included in the analyses, which will be performed on an intention-to-treat basis. All p-values will be two-sided. Full details of all the analysis methods are described in separate statistical analysis plans (http://www.stopcapm1.org/protocol/) and summarized briefly below. IPD collated from ARPI trials will be combined with existing IPD from docetaxel trials. Main outcomes are overall survival and progression-free survival. For the ARPI trials, we will use intention-to-treat, 2-stage, fixed-effect, pairwise meta-analysis of hazard ratios, adjusted for a core set of covariates, with missing values imputed. Main effects will be based on overall survival. Subgroup analyses will be based on progression-free survival to increase events/maximise power, then overall survival whenever interactions are found for progression-free survival. Analyses of multiple subgroup interactions and estimation of subgroup-specific survival curves will use 1-stage flexible parametric modelling and standardisation. Doublets will be compared using 2-stage contrast-based network meta-analysis (NMA) excluding concurrent docetaxel. Then, triplet therapy will be included, accounting for non-randomised docetaxel use. We will assess if NMA results are modified by patient characteristics."
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["label"]=>
string(5) "STATA"
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["project_timeline"]=>
string(1346) "June 2023 to Jan 2024
- Finalise and register protocol (v3.0)
- Develop and finalise SAP (v3.0)
Jan 2024 to Mar 2024
- Finalise collection, harmonisation and checking of IPD from abiraterone and orteronel trials
- For trials supplying data via repositories, help to align IPD to STOPCAP data dictionary
- Conduct pairwise meta-analyses of trials of abiraterone
April 2024 to Nov 2024
- Submit abstract to ASCO GU (by 15/10/2024) on preliminary pairwise and network meta-analyses
- Continue data collection, harmonisation and checking of IPD from other ARPI trials
- Finalise collection, harmonisation and checking of IPD from available ARPI trials
Dec 2024 to Jan 2025
- Finalise collection, harmonisation and checking of IPD from available ARPI trials
- Conduct pairwise meta-analyses of all ARPI trials
- Conduct network meta-analysis of ARPI/Doc trials
- Present results to Advisory Group
- Submit abstract(s) of updated results or late-breaker placeholder to ASCO (by 28/01/2025)
Feb 2025 to Sep 2025
- Present results to collaborators
- Present results at ASCO GU & ASCO
- Draft and circulate manuscript to collaborators
- Finalise and submit manuscript"
["project_dissemination_plan"]=>
string(1298) "We aim to present results of the IPD meta-analysis at relevant international conferences and publish them in a peer-reviewed open-access journal, irrespective of the findings. Results will be published under the auspices of “The STOPCAP Collaboration”, comprising the Core Research Team, International Advisory Group, trial representatives and Patient Research Partners. If there are too many authors to be listed individually, publication will be in the name of the Collaborative Group for this project. The Core Research Team will draft abstract(s) and manuscript(s) relating to the results and circulate them to all Collaboration members for comment and final pre-submission approval (detailed IPD results may first be circulated or presented at a closed Collaboration meeting prior to manuscript preparation). Presentations and publications will be accompanied by press releases, social media threads, and mainline news media articles. Engagement with UCL and Prostate Cancer UK communications and press teams will ensure appropriate wording and broad reach and our Patient Research Partners will help us shape the interpretation and reporting of results. Results will also be shared via our website (www.stopcapm1.org/), at Prostate Cancer UK clinical forum meetings and Movember webinars."
["project_bibliography"]=>
string(3105) "
- James ND, et al. Abiraterone for prostate cancer not previously treated with hormone therapy. N Engl J Med. 2017;377(4):338-51.
- Fizazi K, et al. Abiraterone acetate plus prednisone in patients with newly diagnosed high-risk metastatic castration-sensitive prostate cancer (LATITUDE): final overall survival analysis of a randomised, double-blind, phase 3 trial. The lancet oncology. 2019;20(5):686-700.
- Fizazi K, et al. Abiraterone plus prednisone added to androgen deprivation therapy and docetaxel in de novo metastatic castrationsensitive prostate cancer (PEACE-1): a multicentre, openlabel, randomised, phase 3 study with a 2 × 2 factorial design. Lancet. 2022;399(10336):1695-707.
- Davis ID, et al. Updated overall survival outcomes in ENZAMET (ANZUP 1304), an international, cooperative group trial of enzalutamide in metastatic hormone-sensitive prostate cancer (mHSPC). J Clin Oncol. 2022;40(17_suppl):LBA5004-LBA.
- Armstrong AJ, et al. Improved Survival With Enzalutamide in Patients With Metastatic Hormone-Sensitive Prostate Cancer. J Clin Oncol. 2022;40(15):1616-22.
- Attard G, et al. Abiraterone acetate plus prednisolone with or without enzalutamide for patients with metastatic prostate cancer starting androgen deprivation therapy: final results from two randomised phase 3 trials of the STAMPEDE platform protocol. The lancet oncology. 2023;24(5):443-56.
- Chi KN, et al. Apalutamide in Patients With Metastatic Castration-Sensitive Prostate Cancer: Final Survival Analysis of the Randomized, Double-Blind, Phase III TITAN Study. J Clin Oncol. 2021;39(20):2294-303.
- Smith MR, et al. Darolutamide and Survival in Metastatic, Hormone-Sensitive Prostate Cancer. N Engl J Med. 2022;386(12):1132-42.
- Agarwal N, et al. Orteronel for Metastatic Hormone-Sensitive Prostate Cancer: A Multicenter, Randomized, Open-Label Phase III Trial (SWOG-1216). J Clin Oncol. 2022;40(28):3301-9.
- Tierney JF, et al. Rationale for embarking on an IPD meta-analysis project. In: Riley RD, Tierney JF, Stewart LA, editors. Individual participant data meta-analysis: A handbook for healthcare research: Wiley; 2021. p. 9-19.
- Stewart LA, Tierney JF. To IPD or Not to IPD? Advantages and disadvantages of systematic reviews using individual patient data. Eval Health Prof. 2002;25(1):76-97.
- Stewart L, et al. Do systematic reviews based on individual patient data offer a means of circumventing biases associated with trial publications? In: Rothstein H, Sutton A, Borenstein M, editors. Publication Bias in Meta-Analysis: Prevention, Assessment and Adjustments. First ed. Chichester: John Wiley & Sons; 2005. p. 261-86.
- Royston P, Lambert PC. Flexible parametric survival analysis in Stata: Beyond the Cox model. : Stata Press; 2011. 347 p.
- Vale CL, et al. Which patients with metastatic hormone-sensitive prostate cancer benefit from docetaxel: a systematic review and meta-analysis of individual participant data from randomised trials. The lancet oncology. 2023;24(7):783-97.
"
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Research Proposal
Project Title:
IPD meta-analyses of the effects of ADT, docetaxel and androgen receptor pathway inhibitors for hormone-sensitive metastatic prostate cancer
Scientific Abstract:
Background
Trial results have shown that adding androgen receptor pathway inhibitors (ARPIs) to standard care improves survival. It is unclear if these effects vary across different subgroups of men, or by docetaxel use.
Objective
To assess if the effects of ARPIs vary by patient characteristics and/or docetaxel use, and which treatments are better and for whom.
Study design
Using pairwise IPD meta-analysis to assess, reliably and precisely, if effects of ARPIs vary by participant characteristics or by docetaxel use. We will combine these data with IPD from docetaxel trials in an IPD network meta-analysis (NMA) to determine if "triplet" (ADT+docetaxel+ARPI) or "doublet" (ADT+docetaxel/ARPI) therapy is better, and for whom.
Participants
Men with hormone-sensitive, metastatic prostate cancer.
Primary and secondary outcome measures
Primary: overall survival
Secondary: progression-free survival, failure-free survival
Supplemental: radiological progression-free survival, prostate-cancer specific survival, time to PSA failure and to castration-resistance
Statistical analysis
Intention-to-treat, 2-stage, fixed-effect, meta-analysis of hazard ratios (adjusted for core covariates) to assess main effects of ARPIs on overall survival and subgroup effects based on progression-free survival. 1-stage flexible parametric modelling and standardisation to analyse multiple subgroup interactions and generate subgroup-specific survival curves. 2-stage NMA to compare doublets, then effects of triplet therapy, and if any results vary by patient characteristics (www.stopcapm1.org/protocol/).
Brief Project Background and Statement of Project Significance:
Results of trials adding new androgen receptor pathway inhibitors (ARPIs) (1-8) to standard care have shown improved overall survival in men with hormone-sensitive metastatic prostate cancer (mHSPC). However, it is less clear whether or how the effects of these agents vary across different groups of men, or because of prior or concurrent docetaxel therapy. Furthermore, there is a need to determine which treatment or treatment combination, i.e. "triplet" therapy (standard ADT plus both docetaxel plus ARPI); or "doublet" therapy (standard ADT plus either ARPI or docetaxel), is preferable and for whom.
Results from the PEACE-1 (3), ENZAMET (4) and ARASENS (8) trials indicate that an upfront "triplet" of ADT plus docetaxel and an ARPI may further prolong survival compared to "doublet" ADT plus docetaxel therapy. However, it remains unclear whether these results can be extrapolated to patients with metachronous disease.
Furthermore, the lack of trials designed to directly compare "doublet" and "triplet" therapies has implications for appropriate selection and sequencing of treatment and the additional toxicity of a more intensive treatment regimen, and how the triplet compares with a doublet of ARPI plus ADT.
The best way to address these questions thoroughly and reliably is through rigorous pairwise and network re-analyses of up-to-date individual participant data (IPD) from all the relevant trials. A meta-analysis based on IPD can improve the quantity and quality of available data (9, 10), thus providing greater power than any one trial, and can circumvent the biases and other limitations associated with the traditional aggregate data approach (11). Collecting IPD also allows more flexible and detailed analyses, including the ability to adjust for baseline characteristics, account for missing data and investigate non-proportional hazards (12). Importantly, it also allows a more thorough and appropriate investigation of potential treatment effect modifiers (9, 10). For example, results of a recent STOPCAP IPD meta-analysis (13), has defined more precisely the effects of docetaxel. It appears to be best suited to men with poorer prognosis, based on a high volume of disease and potentially the bulkiness of their primary tumour; whilst those with metachronous, low volume disease gain no meaningful benefit from docetaxel and should be managed differently (13).
Therefore, the STOPCAP collaboration is currently seeking IPD from the relevant ARPI trials. Through pairwise meta-analysis we will ascertain, more reliably and precisely, if and how the effects of ARPIs vary by participant characteristics and/or the use of docetaxel. The subsequent network meta-analysis will combine these data with IPD from previous trials of docetaxel, to help determine which treatment or treatment combination, i.e., "triplet" or "doublet" therapy" is preferable and for whom.
Both the LATITUDE and TITAN trials will play a key role in helping us to address these important clinical questions to determine more precisely how ARPIs should be used for men with mHSPC. Notably, TITAN is the only eligible trial which can tell us about the effects of apalutamide in this context.
Specific Aims of the Project:
1. To provide up-to-date estimates of the overall effects of adding an ARPI to standard of care, which may include docetaxel and/or radiotherapy as well as standard androgen deprivation therapy (ADT):
- ARPI + ADT (+/- docetaxel +/- RT) versus ADT (+/- docetaxel +/- RT)
2. To assess whether the effect of these agents varies according to any or all of the following:
- The class of ARPI used
- The characteristics of the included men and/or their disease
- Whether or not docetaxel was used as part of standard care
3. To assess which of the available 'doublet' or 'triplet' combinations of treatments is most effective for mHSPC. The treatments under consideration are:
- ADT alone, the standard of care (or a part thereof) in all trials under consideration
- ADT + docetaxel
- ADT + any androgen receptor pathway inhibitor (ARPI):
i. Androgen biosynthesis inhibitors (abiraterone or orteronel)
ii. Androgen receptor inhibitors (enzalutamide, apalutamide or darolutamide)
- ADT + any ARPI (above) + docetaxel
Study Design:
Meta-analysis (analysis of multiple trials together)
What is the purpose of the analysis being proposed? Please select all that apply.:
New research question to examine treatment effectiveness on secondary endpoints and/or within subgroup populations
Confirm or validate previously conducted research on treatment effectiveness
Participant-level data meta-analysis
Meta-analysis using data from the YODA Project and other data sources
Develop or refine statistical methods
Software Used:
STATA
Data Source and Inclusion/Exclusion Criteria to be used to define the patient sample for your study:
Eligibility
- Randomized trials; comparing a) an ARPI + ADT (+/- docetaxel; +/- radiotherapy) with ADT (+/-docetaxel; +/-radiotherapy) or b) docetaxel + ADT (+/-radiotherapy) with ADT (+/-radiotherapy)
-Supportive treatments (e.g., prednisone/prednisolone) allowed (research arm only)
- Randomisation between ARPI/non-steroidal anti-androgen (e.g. enzalutamide/bicalutamide as in the ENZAMET trial) allowed, with impact assessed in planned sensitivity analysis
- Men with mHSPC starting/responding to first-line hormone therapy (prior local treatments allowed)
Other trials included in this project (further details in Appendix 1)
Non-repository sources:
ENZAMET
GETUG-15
NCI-2014-00212
PEACE-1
STAMPEDE (A vs C, G, J)
SWOG-1216
Via repository:
ARASENS: Vivli
ARCHES: CSDR
CHAARTED: NCTN
As per Statistical Analysis Plan (below) and direct access request (attached), ideally TITAN and LATITUDE IPD will be downloadable to allow combination into a single dataset with other trial IPD and so full evaluation of planned outcomes. If not downloadable, we will conduct analyses in YODA, generate summary results and export these to the same secure location as other trial IPD.
Primary and Secondary Outcome Measure(s) and how they will be categorized/defined for your study:
Primary outcome
- Overall survival -- defined as time from randomisation until death from any cause. Patients remaining alive and those lost to follow-up will be censored on the date of last follow-up. This is the primary outcome for analyses of main treatment effects.
Secondary outcomes
- Progression-free survival -- defined as time from randomisation until first clinical or radiological progression or death (from any cause), whichever happened first. Those patients alive without progression will be censored on the date of last follow-up. This is the primary outcome for analyses of interaction between treatment effect and patient covariates.
- Failure-free survival -- defined as the time from randomisation until the first biochemical, clinical, or radiological progression or death. Patients alive without biochemical, clinical or radiological progression will be censored on the date of last follow-up.
Supplementary outcomes
- Radiological progression-free survival
- Prostate cancer specific survival
- Time to PSA failure
- Time to castrate-resistant disease
Main Predictor/Independent Variable and how it will be categorized/defined for your study:
For analyses by patient level characteristics, we will aim to categorise the variables listed below as follows:
- Age [years] (continuous)
- Age category (75)
- WHO Performance Status (0 / 1 / 2+)
- Clinical T stage (1-2 / 3 / 4)
- Nodal involvement (N0 / N+)
- Gleason Score (=8)
- Baseline Alkaline phosphatase (continuous)
- Timing of entry into trials (Synchronous (de novo M1 disease/ metachronous (progressed to M1 disease after prior diagnosis with M0 disease)
- Lymph node disease only (Yes / No)
- Location of metastases (bone only, visceral only, bone and visceral)
- Number of bone metastases (0/1-3/4-9/>9; also continuous)
- BMI [kg/m2] (continuous)
- Volume [CHAARTED definition*] (High / Low)
- Risk [LATITIUDE definition**] (High / Low)
- Use of docetaxel (Yes / No)
* Modified CHAARTED definition: High volume defined as: any visceral metastasis and / or at least 4 bone metastases
** LATITUDE definition: High risk as defined in the LATITUDE trial: any 2 of: Gleason score >=8; at least 3 bone lesions; measurable visceral metastasis
Other Variables of Interest that will be used in your analysis and how they will be categorized/defined for your study:
Baseline characteristics at randomisation (in addition to main predictor variables)
- Patient identifier (anonymised)
- Prostate-specific antigen (PSA)
Treatment characteristics
- Treatment allocation
- Date of randomisation
- Details of allocated control/standard treatment(s) (all patients randomised)
- Details of allocated research arm treatment(s) (if not randomized to control group)
- Details of radiotherapy to the prostate (where part of allocated trial treatments)
- Date trial treatment started
- Duration of trial treatments
- Doses and dosing schedules of trial treatment
- Details of treatment initiated based on disease progression
Data used to derive outcomes
- Overall survival (death) status
- Date of death
- Cause of death
- Clinical progression status
- Date of clinical progression
- PSA progression status
- Date of PSA progression
- Radiological progression status
- Date of radiological progression
- Date of new bone metastases
- Date of new non-lymph soft-tissue metastases
- Date of last follow-up
- Date of last radiological follow-up (CT/MRI/PET bone scan)
- Date of last PSA assessment
Other
- Whether excluded from original trial analysis
- Reason excluded
Statistical Analysis Plan:
We request that LATITUDE and TITAN IPD are downloadable, to combine them with other trial IPD in the same secure space. This permits the most flexible, unbiased and informative analysis needed to appropriately evaluate potential effect modifiers, account for docetaxel use, examine any drug class effects and compare doublet versus triplet therapy. With access confined to the YODA platform, we can only combine summary results from LATITUDE/TITAN with IPD, thus compromising their contribution to key analyses, principally those relating to estimation of effects on the "absolute" survival scale, which provides more clinically-useful answers, but requires more computationally-intensive analysis techniques. In our recent STOPCAP IPD analysis of docetaxel trials, we generated predicted survival curves by key patient subgroups (e.g. volume), demonstrating differing levels of efficacy by baseline prognosis and over time. Additional complexities arising from concomitant docetaxel use and ARPI class (biosynthesis inhibitors vs receptor blockers), and the need to disentangle doublet and triplet therapies, such analyses will have even greater clinical importance. Downloadable access to the IPD increases power and reliability to answer key questions, ensuring representation of all ARPI agents, and generalisability of findings to the mHSPC population.
TITAN/LATITUDE IPD will be combined with IPD obtained from other trials with all data management undertaken using Stata v18 or later. We have obtained IPD from 8 ARPI and docetaxel trials for which all data were supplied directly by trialists or downloaded from a data repository. Requests are in process for a further 3. Data are transferred securely, without any direct identifiers. Data are stored at UCL on a secure drive, with access confined to the STOPCAP Core Research Team, all fully trained in information governance and data security. To maximize interpretability and clinical utility of our analyses, we aim to harmonise IPD across trials, irrespective of whether it resides at UCL or within a repository. Thus, we request that the IPD are prepared according to the STOPCAP Data Dictionary developed to facilitate this process. Otherwise, we request clear meta-data to allow mapping of the trial IPD to the Data Dictionary, with input from trial teams as needed. All IPD are checked for validity, range and consistency, to ensure trials are represented accurately; with additional checks to inform Risk of Bias assessments. Any queries are resolved with trial teams. Final versions of directly-supplied IPD are stored in the same secure location.
Each analysis will be based on updated IPD with all randomised participants included in the analyses, which will be performed on an intention-to-treat basis. All p-values will be two-sided. Full details of all the analysis methods are described in separate statistical analysis plans (http://www.stopcapm1.org/protocol/) and summarized briefly below. IPD collated from ARPI trials will be combined with existing IPD from docetaxel trials. Main outcomes are overall survival and progression-free survival. For the ARPI trials, we will use intention-to-treat, 2-stage, fixed-effect, pairwise meta-analysis of hazard ratios, adjusted for a core set of covariates, with missing values imputed. Main effects will be based on overall survival. Subgroup analyses will be based on progression-free survival to increase events/maximise power, then overall survival whenever interactions are found for progression-free survival. Analyses of multiple subgroup interactions and estimation of subgroup-specific survival curves will use 1-stage flexible parametric modelling and standardisation. Doublets will be compared using 2-stage contrast-based network meta-analysis (NMA) excluding concurrent docetaxel. Then, triplet therapy will be included, accounting for non-randomised docetaxel use. We will assess if NMA results are modified by patient characteristics.
Narrative Summary:
Results of trials have shown that adding docetaxel or androgen-receptor pathway inhibitors (ARPIs) to standard hormone therapy) helps men to live longer. But it is not clear if adding an ARPI helps all men. And we want to know if having all three treatments - ARPI, docetaxel and hormone therapy is better than having two of them. No clinical trials are comparing the treatments like this. The most reliable way to work out how the different treatments and treatment combinations work in different groups of men is to collect data on individual participants from all the important clinical trials and combine these using a method called meta-analysis.
Project Timeline:
June 2023 to Jan 2024
- Finalise and register protocol (v3.0)
- Develop and finalise SAP (v3.0)
Jan 2024 to Mar 2024
- Finalise collection, harmonisation and checking of IPD from abiraterone and orteronel trials
- For trials supplying data via repositories, help to align IPD to STOPCAP data dictionary
- Conduct pairwise meta-analyses of trials of abiraterone
April 2024 to Nov 2024
- Submit abstract to ASCO GU (by 15/10/2024) on preliminary pairwise and network meta-analyses
- Continue data collection, harmonisation and checking of IPD from other ARPI trials
- Finalise collection, harmonisation and checking of IPD from available ARPI trials
Dec 2024 to Jan 2025
- Finalise collection, harmonisation and checking of IPD from available ARPI trials
- Conduct pairwise meta-analyses of all ARPI trials
- Conduct network meta-analysis of ARPI/Doc trials
- Present results to Advisory Group
- Submit abstract(s) of updated results or late-breaker placeholder to ASCO (by 28/01/2025)
Feb 2025 to Sep 2025
- Present results to collaborators
- Present results at ASCO GU & ASCO
- Draft and circulate manuscript to collaborators
- Finalise and submit manuscript
Dissemination Plan:
We aim to present results of the IPD meta-analysis at relevant international conferences and publish them in a peer-reviewed open-access journal, irrespective of the findings. Results will be published under the auspices of "The STOPCAP Collaboration", comprising the Core Research Team, International Advisory Group, trial representatives and Patient Research Partners. If there are too many authors to be listed individually, publication will be in the name of the Collaborative Group for this project. The Core Research Team will draft abstract(s) and manuscript(s) relating to the results and circulate them to all Collaboration members for comment and final pre-submission approval (detailed IPD results may first be circulated or presented at a closed Collaboration meeting prior to manuscript preparation). Presentations and publications will be accompanied by press releases, social media threads, and mainline news media articles. Engagement with UCL and Prostate Cancer UK communications and press teams will ensure appropriate wording and broad reach and our Patient Research Partners will help us shape the interpretation and reporting of results. Results will also be shared via our website (www.stopcapm1.org/), at Prostate Cancer UK clinical forum meetings and Movember webinars.
Bibliography:
- James ND, et al. Abiraterone for prostate cancer not previously treated with hormone therapy. N Engl J Med. 2017;377(4):338-51.
- Fizazi K, et al. Abiraterone acetate plus prednisone in patients with newly diagnosed high-risk metastatic castration-sensitive prostate cancer (LATITUDE): final overall survival analysis of a randomised, double-blind, phase 3 trial. The lancet oncology. 2019;20(5):686-700.
- Fizazi K, et al. Abiraterone plus prednisone added to androgen deprivation therapy and docetaxel in de novo metastatic castrationsensitive prostate cancer (PEACE-1): a multicentre, openlabel, randomised, phase 3 study with a 2 x 2 factorial design. Lancet. 2022;399(10336):1695-707.
- Davis ID, et al. Updated overall survival outcomes in ENZAMET (ANZUP 1304), an international, cooperative group trial of enzalutamide in metastatic hormone-sensitive prostate cancer (mHSPC). J Clin Oncol. 2022;40(17_suppl):LBA5004-LBA.
- Armstrong AJ, et al. Improved Survival With Enzalutamide in Patients With Metastatic Hormone-Sensitive Prostate Cancer. J Clin Oncol. 2022;40(15):1616-22.
- Attard G, et al. Abiraterone acetate plus prednisolone with or without enzalutamide for patients with metastatic prostate cancer starting androgen deprivation therapy: final results from two randomised phase 3 trials of the STAMPEDE platform protocol. The lancet oncology. 2023;24(5):443-56.
- Chi KN, et al. Apalutamide in Patients With Metastatic Castration-Sensitive Prostate Cancer: Final Survival Analysis of the Randomized, Double-Blind, Phase III TITAN Study. J Clin Oncol. 2021;39(20):2294-303.
- Smith MR, et al. Darolutamide and Survival in Metastatic, Hormone-Sensitive Prostate Cancer. N Engl J Med. 2022;386(12):1132-42.
- Agarwal N, et al. Orteronel for Metastatic Hormone-Sensitive Prostate Cancer: A Multicenter, Randomized, Open-Label Phase III Trial (SWOG-1216). J Clin Oncol. 2022;40(28):3301-9.
- Tierney JF, et al. Rationale for embarking on an IPD meta-analysis project. In: Riley RD, Tierney JF, Stewart LA, editors. Individual participant data meta-analysis: A handbook for healthcare research: Wiley; 2021. p. 9-19.
- Stewart LA, Tierney JF. To IPD or Not to IPD? Advantages and disadvantages of systematic reviews using individual patient data. Eval Health Prof. 2002;25(1):76-97.
- Stewart L, et al. Do systematic reviews based on individual patient data offer a means of circumventing biases associated with trial publications? In: Rothstein H, Sutton A, Borenstein M, editors. Publication Bias in Meta-Analysis: Prevention, Assessment and Adjustments. First ed. Chichester: John Wiley & Sons; 2005. p. 261-86.
- Royston P, Lambert PC. Flexible parametric survival analysis in Stata: Beyond the Cox model. : Stata Press; 2011. 347 p.
- Vale CL, et al. Which patients with metastatic hormone-sensitive prostate cancer benefit from docetaxel: a systematic review and meta-analysis of individual participant data from randomised trials. The lancet oncology. 2023;24(7):783-97.
Supplementary Material:
STOPCAP-M1_DataDictionary_TransferGuide_v5.0_Sep2022_FINAL-1.pdf
STOPCAP-M1_ARPI_Protocol_v4.0-01Feb2024-1.pdf
STOPCAP_IPDNMA_Protocol_v1.0_01Feb2024-1.pdf
YODA-2024-0652_Appendix1_Studies-from-other-sources_15Oct24.pdf
YODA-2024-0652_Direct-Access-Request_TITAN-LATITUDE_FINAL_15Oct24.pdf