Adenocarcinoma
Conditions
Keywords
Avastin, Metastatic Adenocarcinoma, AVAGAST
Brief summary
This study will compare treatment with bevacizumab in combination with capecitabine and cisplatin versus placebo in combination with capecitabine and cisplatin, as first-line therapy in patients with locally advanced or metastatic gastric cancer who had not received prior chemotherapy for advanced or metastatic disease.
Detailed description
This is a 2 arm, randomized, double-blind, multicenter phase III study. Patients will be randomized (1:1) to capecitabine/cisplatin plus bevacizumab or capecitabine/cisplatin plus placebo. This is an event-driven trial with the primary analysis planned after approximately 517 deaths had been observed. After the primary analysis, the study will remain open and patients can continue with study treatment until progressive disease or earlier at the investigator's discretion. After discontinuation of the last patient, the study will end globally.
Interventions
DRUGBevacizumab
Intravenous bevacizumab 7.5 mg/kg once every 3 weeks, given until disease progression or unmanageable toxicity.
DRUGCapecitabine
Oral capecitabine 1,000 mg/m˄2 twice daily for 14 days every 3 weeks, given until disease progression or unmanageable toxicity.
DRUGCisplatin
Cisplatin 80 mg/m˄2 as a 2 hr intravenous infusion with hyper-hydration and pre-medication (steroids and anti-emetics), given every 3 weeks for a maximum of 6 cycles or until disease progression or unmanageable toxicity.
DRUGPlacebo
Intravenous placebo every 3 weeks, given until disease progression or unmanageable toxicity.
DRUG5-fluorouracil
For participants with difficulty swallowing, malabsorption, or other conditions that could affect intake of oral capecitabine medication, 5-fluorouracil was administered instead, at a dose of 800 mg/m˄2/day as a continuous intravenous infusion over 5 days (days 1 to 5 of each cycle), every 3 weeks.
Sponsors
Hoffmann-La Roche
Chugai Pharmaceutical
Genentech, Inc.
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Investigator)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Written informed consent obtained prior to any study specific procedures. * Age ≥ 18 years. * Eastern Cooperative Oncology Group (ECOG) performance status of 0, 1, or 2. * Life expectancy of at least 3 months. * Able to comply with the protocol. * Histologically confirmed adenocarcinoma of the stomach or gastro-oesophageal junction with inoperable, locally advanced, or metastatic disease, not amenable to curative therapy. * Measurable disease or non-measurable but evaluable disease, according to the Response Evaluation Criteria in Solid Tumours (RECIST). * Patient not receiving anticoagulant medication must have an International normalized ratio (INR) ≤ 1.5 and activated partial thromboplastin time (aPTT) ≤ 1.5 x Upper Limit of Normal (ULN) within 7 days prior to randomisation.
Exclusion criteria
* Previous chemotherapy for locally advanced or metastatic gastric cancer. Patients may have received prior neoadjuvant or adjuvant chemotherapy as long as it was completed at least 6 months prior to randomisation. * Previous platinum or anti-angiogenic therapy (ie, anti-vascular endothelial growth factor \[VEGF\] or VEGF receptor tyrosine kinase inhibitor, etc.). * Patients with locally advanced disease who are candidates for curative therapy (including operation and/or chemotherapy and/or radiotherapy). * Radiotherapy within 28 days of randomisation. * Major surgical procedure, open biopsy or significant traumatic injury within 28 days prior to randomisation, or anticipation of the need for major surgery during the course of the study treatment (planned elective surgery). * Minor surgical procedures within 2 days prior to randomisation. * Evidence of central nervous system (CNS) metastasis at baseline. * History or evidence upon physical/neurological examination of CNS disease unrelated to cancer unless adequately treated with standard medical therapy, eg, uncontrolled seizures. * History of another malignancy which could affect compliance with the protocol or interpretation of results. * Inadequate bone marrow function. * Inadequate liver function. * Inadequate renal function. * Uncontrolled hypertension or clinically significant (ie, active) cardiovascular disease. * Active infection requiring intravenous antibiotics at randomisation. * History or evidence of inherited bleeding diathesis or coagulopathy with the risk of bleeding. * Serious or non-healing wound, peptic ulcer, or (incompletely healed) bone fracture. * Active gastrointestinal bleeding. * History of abdominal fistula, gastrointestinal perforation, or intra-abdominal abscess within 6 months of randomisation. * Neuropathy (eg, impairment of hearing and balance) ≥ grade II according to Common Terminology Criteria for Adverse Events (CTCAE) v3.0. * Chronic daily treatment with aspirin or clopidogrel. * Chronic daily treatment with oral corticosteroids; inhaled steroids and short courses of oral steroids for anti-emesis or as an appetite stimulant are allowed. * Known hypersensitivity to any of the study drugs or excipients or to Chinese hamster ovary cell products or to other recombinant human or humanised antibodies. * Known dihydropyrimidine dehydrogenase (DPD) deficiency. * Evidence of any other disease, metabolic or psychological dysfunction, physical examination finding, or clinical laboratory finding giving reasonable suspicion of a disease or condition that contraindicates use of an investigational drug, or that may affect patient compliance with the study, or place the patient at high risk from treatment complications. * Known acute or chronic-active infection with hepatitis B virus (HBV) or hepatitis C virus (HCV). * Pregnant or lactating females. * Women of childbearing potential not using effective nonhormonal (intrauterine contraceptive device, barrier method of contraception in conjunction with spermicidal jelly, or surgically sterile) means of contraception. * Sexually active men unwilling to practice contraception during the study. * Current or recent (within the 28 days prior to randomisation) treatment with another investigational drug or participation in another investigational study.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Overall Survival | From randomization until death, up to 26 months | The primary efficacy endpoint for this study was overall survival (time to death), defined as the time between randomization and the date of death irrespective of the cause of death. Patients for whom no death was captured on the clinical database were censored at the most recent date they were known to be alive. Median survival was estimated by the Kaplan-Meier method. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Progression-free Survival During First-line Therapy | From randomization until 28-days after the last study treatment was administered, up to 26 months. | Progression-free survival (PFS) during first-line therapy is defined as the time between randomization and the date of first documented disease progression or death, whichever occurs first and only if it occurs no later than 28 days after last confirmed intake of any study medication and only if it occurs before the start of non-study antineoplastic treatment. Participants who did not progress or die in this interval or were lost to follow-up were censored at the date of the last tumor assessment within this time window. Median PFS was estimated using the Kaplan-Meier method. |
| Time to Disease Progression | From randomization until disease progression; assessed every 6 weeks for the first year and every 12 weeks thereafter, up to 26 months. | Time to progression is defined as the time from randomization to the first occurrence of progressive disease (PD). PD was assessed according to the Response Evaluation Criteria in Solid Tumors (RECIST) criteria and defined as at least a 20% increase in the sum of the longest diameter of target lesions, or appearance of ≥1 new lesions and/or unequivocal progression of existing non-target lesions. Patients with no PD at study completion (including those who died before PD) were censored at the date of the last tumor assessment. Median time to PD was estimated using the Kaplan-Meier method. |
| Participants With a Best Overall Response of Complete or Partial Response | From randomization until the end of study, up to 26 months. | Best overall response during first-line therapy is defined as the occurrence of either a confirmed complete (CR) or a partial (PR) best overall response, as determined by the RECIST criteria. CR is defined as the disappearance of all target and non-target lesions and PR is defined as at least a 30% decrease in the sum of the longest diameter of target lesions and no new or progression of non-target lesions, or the disappearance of all target lesions and persistence of one or more non-target lesion(s). |
| Progression-free Survival | From randomization until disease progression or death, up to 26 months. | Progression-free survival (PFS) is defined as the time between randomization and the date of first documented disease progression or death, whichever occurs first. Patients who neither progressed nor died at the time of study completion or who were lost to follow-up were censored at the date of the last tumor assessment or last follow up for progression of disease. Median PFS was estimated using the Kaplan-Meier method. |
| Participants With Disease Control | From randomization until the end of study, up to 26 months. | Disease control for participants with measurable disease was defined as a complete response (CR), partial response (PR) or stable disease (SD) for 6 weeks or longer, as determined by the RECIST criteria. For participants without measurable disease, disease control was defined as no disease progression for ≥ 6 weeks. |
| Participants With Adverse Events | From randomization until 3 months after last dose (up to 26 months) | The intensity of Adverse Events (AEs) was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE), Version 3.0 on a five-point scale from Grade 1 (Mild) to Grade 5 (Death). A serious AE (SAE) was defined as any event that is fatal, life-threatening, requires in-patient hospitalization or prolongation of existing hospitalization, results in persistent or significant disability/incapacity, is a congenital anomaly/birth defect, is medically significant or requires intervention to prevent one or other of the outcomes listed above. |
| Duration of Response | From randomization to the end of study, up to 26 months | Duration of response during first line therapy is defined as the time from when response (CR or PR) was first documented to first documented disease progression or death (whichever occurs first) during first line therapy. This was only be calculated for participants who achieved a best overall response of CR or PR. Participants who did not progress or die after they had a confirmed response were censored at the date of their last tumor measurement or last follow up for progression of disease during first line therapy. Median duration of response was estimated using the Kaplan-Meier method. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Bevacizumab Participants received intravenous (IV) bevacizumab 7.5 mg/kg every 3 weeks, oral capecitabine 1,000 mg/m˄2 twice daily for 14 days every 3 weeks, or 5-fluorouracil (5-FU) at a dose of 800 mg/m˄2/day as a continuous IV infusion over the first 5 days of every 3 week cycle, and cisplatin 80 mg/m˄2 as an IV infusion every 3 weeks for a maximum of 6 cycles. Bevacizumab and capecitabine/5-FU were administered until disease progression or unacceptable toxicity. | 387 |
| Placebo Participants received intravenous (IV) placebo infusion every 3 weeks, oral capecitabine 1,000 mg/m˄2 twice daily for 14 days every 3 weeks, or 5-fluorouracil (5-FU) at a dose of 800 mg/m˄2/day as a continuous IV infusion over the first 5 days of every 3 week cycle, and cisplatin 80 mg/m˄2 as an IV infusion every 3 weeks for a maximum of 6 cycles. The placebo and capecitabine/5-FU were administered until disease progression or unacceptable toxicity. | 387 |
| Total | 774 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Overall Study | Death | 345 | 348 |
| Overall Study | Lost to Follow-up | 17 | 18 |
Baseline characteristics
| Characteristic | Bevacizumab | Placebo | Total |
|---|---|---|---|
| Age, Customized <40 | 36 participants | 29 participants | 65 participants |
| Age, Customized 40-65 | 241 participants | 249 participants | 490 participants |
| Age, Customized ≥65 | 110 participants | 109 participants | 219 participants |
| Sex: Female, Male Female | 130 Participants | 129 Participants | 259 Participants |
| Sex: Female, Male Male | 257 Participants | 258 Participants | 515 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 378 / 386 | 373 / 381 |
| serious Total, serious adverse events | 134 / 386 | 137 / 381 |
Outcome results
Primary
Overall Survival
The primary efficacy endpoint for this study was overall survival (time to death), defined as the time between randomization and the date of death irrespective of the cause of death. Patients for whom no death was captured on the clinical database were censored at the most recent date they were known to be alive. Median survival was estimated by the Kaplan-Meier method.
Time frame: From randomization until death, up to 26 months
Population: The Intent-to-Treat population, including all randomized participants.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Bevacizumab | Overall Survival | 12.1 months |
| Placebo | Overall Survival | 10.1 months |
Secondary
Duration of Response
Duration of response during first line therapy is defined as the time from when response (CR or PR) was first documented to first documented disease progression or death (whichever occurs first) during first line therapy. This was only be calculated for participants who achieved a best overall response of CR or PR. Participants who did not progress or die after they had a confirmed response were censored at the date of their last tumor measurement or last follow up for progression of disease during first line therapy. Median duration of response was estimated using the Kaplan-Meier method.
Time frame: From randomization to the end of study, up to 26 months
Population: Participants with measurable disease at baseline who had a best overall response of complete response or partial response, and for whom duration of response data was available.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Bevacizumab | Duration of Response | 7.1 months |
| Placebo | Duration of Response | 5.8 months |
Secondary
Participants With a Best Overall Response of Complete or Partial Response
Best overall response during first-line therapy is defined as the occurrence of either a confirmed complete (CR) or a partial (PR) best overall response, as determined by the RECIST criteria. CR is defined as the disappearance of all target and non-target lesions and PR is defined as at least a 30% decrease in the sum of the longest diameter of target lesions and no new or progression of non-target lesions, or the disappearance of all target lesions and persistence of one or more non-target lesion(s).
Time frame: From randomization until the end of study, up to 26 months.
Population: Measurable Disease Population, including all randomized participants with measurable disease (per RECIST) for gastric cancer at baseline. Patients were analyzed according to the treatment groups to which they were randomized.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Bevacizumab | Participants With a Best Overall Response of Complete or Partial Response | Responders | 143 participants |
| Bevacizumab | Participants With a Best Overall Response of Complete or Partial Response | Non-responders | 168 participants |
| Placebo | Participants With a Best Overall Response of Complete or Partial Response | Responders | 111 participants |
| Placebo | Participants With a Best Overall Response of Complete or Partial Response | Non-responders | 186 participants |
Secondary
Participants With Adverse Events
The intensity of Adverse Events (AEs) was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE), Version 3.0 on a five-point scale from Grade 1 (Mild) to Grade 5 (Death). A serious AE (SAE) was defined as any event that is fatal, life-threatening, requires in-patient hospitalization or prolongation of existing hospitalization, results in persistent or significant disability/incapacity, is a congenital anomaly/birth defect, is medically significant or requires intervention to prevent one or other of the outcomes listed above.
Time frame: From randomization until 3 months after last dose (up to 26 months)
Population: Safety population, including all patients randomized and exposed to study medication (defined as any one component of the combination). Patients are assigned to treatment groups based on the treatment they actually received.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Bevacizumab | Participants With Adverse Events | Serious AE | 134 participants |
| Bevacizumab | Participants With Adverse Events | Grade 5 AE | 18 participants |
| Bevacizumab | Participants With Adverse Events | Grade 3/4/5 AE | 293 participants |
| Bevacizumab | Participants With Adverse Events | Deaths not due to Progression | 31 participants |
| Bevacizumab | Participants With Adverse Events | Any Adverse event | 380 participants |
| Placebo | Participants With Adverse Events | Deaths not due to Progression | 29 participants |
| Placebo | Participants With Adverse Events | Any Adverse event | 377 participants |
| Placebo | Participants With Adverse Events | Serious AE | 137 participants |
| Placebo | Participants With Adverse Events | Grade 3/4/5 AE | 294 participants |
| Placebo | Participants With Adverse Events | Grade 5 AE | 25 participants |
Secondary
Participants With Disease Control
Disease control for participants with measurable disease was defined as a complete response (CR), partial response (PR) or stable disease (SD) for 6 weeks or longer, as determined by the RECIST criteria. For participants without measurable disease, disease control was defined as no disease progression for ≥ 6 weeks.
Time frame: From randomization until the end of study, up to 26 months.
Population: Intent-to-treat
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Bevacizumab | Participants With Disease Control | Participants with Disease Control | 300 participants |
| Bevacizumab | Participants With Disease Control | Participants without Disease Control | 87 participants |
| Placebo | Participants With Disease Control | Participants with Disease Control | 271 participants |
| Placebo | Participants With Disease Control | Participants without Disease Control | 116 participants |
Secondary
Progression-free Survival
Progression-free survival (PFS) is defined as the time between randomization and the date of first documented disease progression or death, whichever occurs first. Patients who neither progressed nor died at the time of study completion or who were lost to follow-up were censored at the date of the last tumor assessment or last follow up for progression of disease. Median PFS was estimated using the Kaplan-Meier method.
Time frame: From randomization until disease progression or death, up to 26 months.
Population: Intent to treat
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Bevacizumab | Progression-free Survival | 6.7 months |
| Placebo | Progression-free Survival | 5.3 months |
Secondary
Progression-free Survival During First-line Therapy
Progression-free survival (PFS) during first-line therapy is defined as the time between randomization and the date of first documented disease progression or death, whichever occurs first and only if it occurs no later than 28 days after last confirmed intake of any study medication and only if it occurs before the start of non-study antineoplastic treatment. Participants who did not progress or die in this interval or were lost to follow-up were censored at the date of the last tumor assessment within this time window. Median PFS was estimated using the Kaplan-Meier method.
Time frame: From randomization until 28-days after the last study treatment was administered, up to 26 months.
Population: Intent-to treat.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Bevacizumab | Progression-free Survival During First-line Therapy | 6.9 months |
| Placebo | Progression-free Survival During First-line Therapy | 5.4 months |
Secondary
Time to Disease Progression
Time to progression is defined as the time from randomization to the first occurrence of progressive disease (PD). PD was assessed according to the Response Evaluation Criteria in Solid Tumors (RECIST) criteria and defined as at least a 20% increase in the sum of the longest diameter of target lesions, or appearance of ≥1 new lesions and/or unequivocal progression of existing non-target lesions. Patients with no PD at study completion (including those who died before PD) were censored at the date of the last tumor assessment. Median time to PD was estimated using the Kaplan-Meier method.
Time frame: From randomization until disease progression; assessed every 6 weeks for the first year and every 12 weeks thereafter, up to 26 months.
Population: Intent-to-treat
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Bevacizumab | Time to Disease Progression | 7.0 months |
| Placebo | Time to Disease Progression | 5.6 months |