Arthralgia, Breast Cancer, Pain
Conditions
Keywords
estrogen receptor-positive breast cancer, progesterone receptor-positive breast cancer, stage I breast cancer, stage II breast cancer, stage IIIA breast cancer, pain, arthralgia
Brief summary
RATIONALE: An omega-3 fatty acid-enriched nutritional supplement may help improve muscle and bone pain and stiffness caused by hormone therapy in patients with breast cancer. PURPOSE: This randomized phase III trial is studying omega-3 fatty acid supplements in treating muscle and bone pain and stiffness in patients with stage I, stage II, or stage III breast cancer receiving hormone therapy.
Detailed description
OBJECTIVES: Primary * To assess whether omega-3-fatty acid as compared to placebo causes a reduction in worst joint pain and/or stiffness at 12 weeks, as measured by the modified Brief Pain Inventory (BPI), in women with early-stage breast cancer and aromatase inhibitor (AI)-associated arthralgia. Secondary * To assess the proportion of patients who report improved versus deteriorated joint pain with omega-3-fatty acid versus placebo. * To assess the proportion of patients who report improved versus deteriorated joint stiffness with omega-3-fatty acid versus placebo. * To assess whether patients receiving omega-3-fatty acid compared to placebo have decreased analgesic use and increased AI adherence. * To assess whether patients receiving omega-3-fatty acid compared to placebo have improved functioning, pain, and stiffness in the knees/hips (as measured by the Western Ontario and McMaster Universities Osteoarthritis, WOMAC) score. * To assess whether patients receiving omega-3-fatty acid have improved functioning, pain, and stiffness in the hands (as measured by the Modified Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands, M-SACRAH). * To assess whether patients receiving omega-3-fatty acid compared to placebo have improved functional quality of life as measured by the Functional Assessment of Cancer Therapy-Endocrine Subscale (FACT-ES) Trial Outcome Index (TOI). * To assess whether patients receiving omega-3-fatty acid report changes for the better versus worse compared to placebo as measured by the Global Rating of Change Scale. * To identify minimally important change in the WOMAC, M-SACRAH, and the FACT-ES Trial Outcome Index (TOI) using a little better or a little worse responses on the patient-reported global rating of change in joint pain and joint stiffness. * To assess whether patients receiving omega-3-fatty acid compared to placebo have an improved lipid profile as measured by triglycerides, HDL, and LDL. * To assess the toxicity of omega-3-fatty acid compared to placebo in this setting. * To assess whether there is a difference in serum-free and total estradiol levels before and after treatment with omega-3-fatty acid compared to placebo. * To explore whether CYP19A1 genotype correlates with severity of joint symptoms or predicts response to omega-3-fatty acid. (exploratory) * To explore changes in hormonal and inflammatory serum biomarkers, such as IL6, TNF-α, and CRP. * To assess whether there is a relationship between change in serum docosahexaenoic acid (DHA) and EPA and resolution of joint symptoms. * To establish a cohort of patients (placebo group) to better characterize the natural history of the syndrome. OUTLINE: This is a multicenter study. Patients are stratified according to prior osteoarthritis (yes vs no) and prior taxane use (yes vs no). Patients are randomized to 1 of 2 treatment arms. * Arm I: Patients receive oral omega-3-fatty acid twice daily (BID) or three times daily (TID) for 24 weeks in the absence of disease progression or unacceptable toxicity. * Arm II: Patients receive oral placebo BID or TID for 24 weeks in the absence of disease progression or unacceptable toxicity. Patients undergo blood sample collection at baseline and at 12 and 24 weeks for biomarker and DNA analysis. Patients complete the Brief Pain Inventory Short Form (BPI-SF), the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index, the Modified-Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (M-SACRAH), the FACT-ES Trial Outcome Index, and the Omega-3-fatty acid Dietary Intake questionnaires at baseline and at 6, 12, and 24 weeks.
Interventions
DIETARY_SUPPLEMENTomega-3 fatty acid
Given orally
OTHERplacebo
Given orally
Sponsors
National Cancer Institute (NCI)
SWOG Cancer Research Network
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
TRIPLE (Subject, Caregiver, Investigator)
Eligibility
Sex/Gender
FEMALE
Age
18 Years to 120 Years
Healthy volunteers
No
Inclusion criteria
DISEASE CHARACTERISTICS: * Histologically confirmed primary invasive adenocarcinoma of the breast * Stage I, II, or IIIA disease * No metastatic disease * Must have undergone modified radical mastectomy or breast-sparing surgery and recovered * Estrogen-receptor positive (ER+) and/or progesterone-receptor positive (PR+) * Currently taking a third-generation aromatase inhibitor (AI) \[e.g., anastrozole (Arimidex®), letrozole (Femara®), or exemestane (Aromasin®)\] for ≥ 90 days prior to registration with plans to continue for ≥ 180 days after registration * Must have completed the S092 Brief Pain Inventory (BPI)-Short Form within the past 14 days, and must have a worst pain/stiffness of ≥ 5 on the BPI (item #2) that has started or increased with AI therapy PATIENT CHARACTERISTICS: * Postmenopausal * Zubrod performance status 0-2 * Willing to submit blood for serum-free estradiol, total estradiol, serum inflammatory markers (IL6, TNF-α, CRP), DHA and EPA, lipid profile (LDL, HDL, triglycerides), and DNA analysis (CYP19A1) * Able to complete study questionnaires in English * At least 5 years since other malignancy except adequately treated basal cell or squamous cell skin cancer, in situ cervical cancer, ductal carcinoma in situ of the breast or adequately treated stage I or II cancer from which the patient is currently in complete remission * Patients must not have a known allergy to soy, given that the placebo is suspended in soybean oil PRIOR CONCURRENT THERAPY: * See Disease Characteristics * At least 3 months since prior omega-3 fatty acid supplements and must agree to refrain from omega-3-fatty acid supplements from sources outside of this study * More than 28 days since prior investigational agents * No other medical therapy, alternative therapy, or physical therapy for joint pain/stiffness within the past 30 days * Patients must not be on anticoagulation medication (i.e., heparin/warfarin) because of increased risk of bleeding within 28 days prior to registration * Patients must not have a history of bone fracture or surgery of the afflicted knees and/or hands within 6 months prior to registration * Patients must not be on narcotics within 14 days of registration * Patients may have received corticosteroid treatment; however, the following criteria apply: * Patients must not have received oral or intramuscular corticosteroids within the 28 days prior to registration * Patients must not have received intra-articular steroids to the study, or any other, joint within 28 days prior to registration * Patients must not have received topical analgesics (e.g., capsaicin preparations) to the study joint or any other analgesics (e.g., opiates, tramadol; with the exception of nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen) within 14 days prior to registration
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Week 12 Brief Pain Inventory (BPI) Worst Pain/Stiffness Score | 12 weeks post-registration | Linear regression model-adjusted week 12 mean score by treatment group. Purpose: To assess the severity of pain Population: Patients with pain from chronic diseases or conditions such as cancer, osteoarthritis and low back pain, or with pain from acute conditions such as postoperative pain Responsiveness: Responds to both behavioral and pharmacological pain interventions Method: Self-report or interview Scoring: Higher scores indicate more pain Range: 0-10 |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Up to 25 weeks | Only adverse events that are possibly, probably or definitely related to study drug are reported. |
| Week 12 Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Score | 12 weeks post-registration | Linear regression model-adjusted week 12 mean score by treatment group The WOMAC measures five items for pain (score range 0-20), two for stiffness (score range 0-8), and 17 for functional limitation (score range 0-68). Higher scores indicate higher symptom burden. |
| Week 12 Modified Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (M-SACRAH) Score | 12 weeks post-registration | Linear regression model-adjusted week 12 mean score by treatment group. Higher scores represent higher symptom burden. Range is 0 to 100. |
| Week 12 Functional Assessment of Cancer Therapy-Endocrine Symptoms (FACT-ES) Score | 12 weeks post-registration | FACT-ES measures physical, social and family, emotional, and functional well-being and endocrine symptoms. The FACT scaleshave five response levels (not at all to very much), where higher scores reflect better well-being and fewer symptoms. This scale provided a measure of the broader impact of join pain and stiffness symptoms. Score range is 0 to 220. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Arm I (Omega-3-fatty Acid) Patients receive oral omega-3-fatty acid twice daily (BID) or three times daily (TID) for 24 weeks in the absence of disease progression or unacceptable toxicity | 122 |
| Arm II (Placebo) Patients receive oral placebo BID or TID for 24 weeks in the absence of disease progression or unacceptable toxicity | 127 |
| Total | 249 |
Baseline characteristics
| Characteristic | Total | Arm II (Placebo) | Arm I (Omega-3-fatty Acid) |
|---|---|---|---|
| Age, Continuous | 59.2 years | 59.1 years | 59.5 years |
| Ethnicity (NIH/OMB) Hispanic or Latino | 16 Participants | 9 Participants | 7 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 225 Participants | 113 Participants | 112 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 8 Participants | 5 Participants | 3 Participants |
| Osteoarthritis No | 192 Participants | 98 Participants | 94 Participants |
| Osteoarthritis Yes | 57 Participants | 29 Participants | 28 Participants |
| Race/Ethnicity, Customized Asian | 4 Participants | 3 Participants | 1 Participants |
| Race/Ethnicity, Customized Black | 20 Participants | 15 Participants | 5 Participants |
| Race/Ethnicity, Customized Multiracial | 2 Participants | 1 Participants | 1 Participants |
| Race/Ethnicity, Customized Native American | 1 Participants | 1 Participants | 0 Participants |
| Race/Ethnicity, Customized Unknown | 5 Participants | 3 Participants | 2 Participants |
| Race/Ethnicity, Customized White | 217 Participants | 104 Participants | 113 Participants |
| Sex: Female, Male Female | 249 Participants | 127 Participants | 122 Participants |
| Sex: Female, Male Male | 0 Participants | 0 Participants | 0 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 70 / 117 | 74 / 124 |
| serious Total, serious adverse events | 0 / 117 | 0 / 124 |
Outcome results
Primary
Week 12 Brief Pain Inventory (BPI) Worst Pain/Stiffness Score
Linear regression model-adjusted week 12 mean score by treatment group. Purpose: To assess the severity of pain Population: Patients with pain from chronic diseases or conditions such as cancer, osteoarthritis and low back pain, or with pain from acute conditions such as postoperative pain Responsiveness: Responds to both behavioral and pharmacological pain interventions Method: Self-report or interview Scoring: Higher scores indicate more pain Range: 0-10
Time frame: 12 weeks post-registration
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Arm I (Omega-3-fatty Acid) | Week 12 Brief Pain Inventory (BPI) Worst Pain/Stiffness Score | 5.3 BPI score |
| Arm II (Placebo) | Week 12 Brief Pain Inventory (BPI) Worst Pain/Stiffness Score | 5.47 BPI score |
p-value: 0.5895% CI: [-0.79, 0.44]Regression, Linear
Secondary
Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug
Only adverse events that are possibly, probably or definitely related to study drug are reported.
Time frame: Up to 25 weeks
Population: All participants receiving at least some protocol treatment
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Arm I (Omega-3-fatty Acid) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Dyspepsia | 1 Participants |
| Arm I (Omega-3-fatty Acid) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Pain in extremity | 1 Participants |
| Arm I (Omega-3-fatty Acid) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Diarrhea | 1 Participants |
| Arm I (Omega-3-fatty Acid) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Peripheral motor neuropathy | 0 Participants |
| Arm I (Omega-3-fatty Acid) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Pain | 0 Participants |
| Arm I (Omega-3-fatty Acid) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Rash maculo-papular | 0 Participants |
| Arm I (Omega-3-fatty Acid) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Arthralgia | 0 Participants |
| Arm II (Placebo) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Rash maculo-papular | 1 Participants |
| Arm II (Placebo) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Arthralgia | 1 Participants |
| Arm II (Placebo) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Diarrhea | 0 Participants |
| Arm II (Placebo) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Dyspepsia | 0 Participants |
| Arm II (Placebo) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Pain | 1 Participants |
| Arm II (Placebo) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Pain in extremity | 0 Participants |
| Arm II (Placebo) | Number of Patients With Adverse Events That Are Possibly, Probably or Definitely Related to Study Drug | Peripheral motor neuropathy | 1 Participants |
Secondary
Week 12 Functional Assessment of Cancer Therapy-Endocrine Symptoms (FACT-ES) Score
FACT-ES measures physical, social and family, emotional, and functional well-being and endocrine symptoms. The FACT scaleshave five response levels (not at all to very much), where higher scores reflect better well-being and fewer symptoms. This scale provided a measure of the broader impact of join pain and stiffness symptoms. Score range is 0 to 220.
Time frame: 12 weeks post-registration
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Arm I (Omega-3-fatty Acid) | Week 12 Functional Assessment of Cancer Therapy-Endocrine Symptoms (FACT-ES) Score | 95 FACT-ES score |
| Arm II (Placebo) | Week 12 Functional Assessment of Cancer Therapy-Endocrine Symptoms (FACT-ES) Score | 92.8 FACT-ES score |
p-value: 0.2195% CI: [-1.16, 5.44]Regression, Linear
Secondary
Week 12 Modified Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (M-SACRAH) Score
Linear regression model-adjusted week 12 mean score by treatment group. Higher scores represent higher symptom burden. Range is 0 to 100.
Time frame: 12 weeks post-registration
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Arm I (Omega-3-fatty Acid) | Week 12 Modified Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (M-SACRAH) Score | 28.8 M-SACRAH score |
| Arm II (Placebo) | Week 12 Modified Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (M-SACRAH) Score | 28.1 M-SACRAH score |
p-value: 0.7795% CI: [-4.17, 5.6]Regression, Linear
Secondary
Week 12 Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Score
Linear regression model-adjusted week 12 mean score by treatment group The WOMAC measures five items for pain (score range 0-20), two for stiffness (score range 0-8), and 17 for functional limitation (score range 0-68). Higher scores indicate higher symptom burden.
Time frame: 12 weeks post-registration
| Arm | Measure | Value (MEAN) |
|---|---|---|
| Arm I (Omega-3-fatty Acid) | Week 12 Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Score | 34.5 WOMAC score |
| Arm II (Placebo) | Week 12 Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Score | 36.7 WOMAC score |
p-value: 0.4295% CI: [-7.3, 3.04]Regression, Linear