Multiple Myeloma
Conditions
Keywords
Panobinostat, Lenalidomide, Dexamethasone
Brief summary
The purpose of this clinical research study is to find out the effects of a drug called panobinostat (LBH589) when given to people like you with multiple myeloma in combination with the drugs lenalidomide and dexamethasone. The safety of this combination of drugs will also be studied. Your physical state, changes in the state of your multiple myeloma, and laboratory findings taken while on-study will help us decide if panobinostat combined with dexamethasone and lenalidomide is safe and effective. This goal of this study therefore is to determine the activity of the combination of panobinostat thrice weekly every other week, lenalidomide, and weekly dexamethasone in a similar group of subjects. The doses of lenalidomide and dexamethasone will be that which is approved by the FDA for multiple myeloma and you will take each drug at a specific frequency over a 4 week (28 day) period. This period is called a study cycle.
Detailed description
The study drug, panobinostat, is made by Novartis Pharmaceuticals Corporation. Panobinostat has not yet been approved by the Food and Drug Administration (FDA) and thus is considered an experimental drug in this research study. Panobinostat is not available to you on the market (available for you to buy). It is only available in clinical trials for patients like you with your medical condition. Panobinostat is a drug that may slow down the growth of multiple myeloma or kill multiple myeloma cells by blocking certain enzymes (proteins produced by cells). Panobinostat has shown effects against cancers such as multiple myeloma in laboratory studies and in studies using animals; however, it is not known if this medicine will show the same activity in humans. As of 31st December 2009, a total of 1116 patients have already received treatment with panobinostat. Unlike panobinostat, lenalidomide (Revlimid©) and dexamethasone are approved by the FDA and are already available for purchase on the US market. Clinical trials have shown that lenalidomide, especially taken with dexamethasone, produces positive clinical responses with manageable side effects when given to subjects with multiple myeloma. In this study, subjects will take panobinostat capsules, lenalidomide, and dexamethasone all orally. The purpose of this combination is to interfere with the cancerous cells in multiple and different ways as each of these drugs acts differently on cancer cells. By combining the drugs and giving them at the same time, it might be possible to slow the progression of your disease, rather than if study drugs were given separately. Researchers have combined laboratory studies on animals with this drug combination and the combined effect has been shown to be worthwhile to justify clinical trials in humans.
Interventions
DRUGPanobinostat
Each cycle is 28 days. Panobinostat will be given 20 mg: Days 1,3,5,15,17,19.
DRUGLenalidomide
Each cycle is 28 days. Lenalidomide will be given 25 mg: Days 1-21.
DRUGDexamethasone
Each cycle is 28 days. Dexamethasone will be given for patients 75 years old and younger a dose of 40 mg on Days 1, 8 and 15. Dexamethasone will be given for patients older than 75 years old, 20 mg on Days 1, 8 and 15.
Sponsors
Novartis Pharmaceuticals
Ajai Chari
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Patients must have a history of symptomatic multiple myeloma according to the International Myeloma Working Group criteria (IMWG, 2003), as defined as the following three criteria: 1. Clonal plasma cells \>10% on bone marrow biopsy 2. A monoclonal protein (paraprotein) in either serum or urine(except in cases of non-secretory myeloma) 3. Evidence of end-organ damage felt related to the plasma cell disorder (related organ or tissue impairment, ROTI, commonly referred to by the acronym CRAB): * Hypercalcemia serum Ca ≥ 11.5 mg/dL or * Renal insufficiency attributable to myeloma. Serum creatinine \> 2mg/dL * Anemia: Normochromic, normocytic with a hemoglobin value \> 2g/dL below the lower limit of normal or a hemoglobin \<10 g/dL * Bone lesions (lytic lesions, severe osteopenia or pathologic fractures 2. Patients must have received at least one prior line of therapy. For example; One prior line of therapy may consist of all predetermined components of induction followed by autologous stem cell transplantation and maintenance. 3. Patient has relapsed or relapsed/refractory MM. 1. Relapsed is defined as the development of disease progression following the achievement of stable disease (SD) or better to the most recent anti-MM regimen. 2. Refractory is defined as experiencing less than a partial response (PR) to or progressive disease (PD) within 6 months after completion of the most recent anti-MM regimen. 4. Patients must currently have measureable disease, as defined as: 1. a. Serum M protein ≥ 1.0 g/dl (≥ 10 mg/l) 2. Urine M protein ≥ 200 mg/24h 3. Serum free light chain assay: involved FLC level ≥ 10mg/dl (≥ 100 mg/l) provided serum FLC ratio is abnormal 4. If no monoclonal protein is detected (non-secretory disease), then \> 30% monoclonal bone marrow plasma cells. 5. Patients must be suitable (according to their local product information) for treatment or re-treatment with lenalidomide & dexamethasone. Note: patients previously treated with lenalidomide & dexamethasone are eligible to participate in the trial. 6. Male or female adults ≥ 18 years old 7. ECOG Performance Status ≤ 2 8. Life expectancy \> 12 weeks 9. Patients must have the following laboratory values: 1. ANC ≥ 1.5 x 109/L for patients in whom \< 50% of bone marrow nucleated cells are plasma cells; or an ANC \> 1.0 x 109/Lfor patients in whom \> 50% of bone marrow nucleated cells are plasma cells. 2. Hemoglobin ≥ 9 g/dl 3. Platelets ≥ 75x 109/L for patients in whom \< 50% of bone marrow nucleated cells are plasma cells; or \> 50 x 109/L for patients in whom \> 50% of bone marrow nucleated cells are plasma cells. 4. Calculated CrCl ≥ 50 mL/min (MDRD Formula) 5. Hepatic: 6. AST and ALT ≤ 2.5 x ULN, 7. Serum bilirubin ≤ 1.5 x ULN 8. Electrolytes: 9. Serum potassium ≥ LLN, 10. Total serum calcium \[corrected for serum albumin\] or ionized calcium ≥LLN 11. Serum magnesium ≥ LLN 12. Serum phosphorus ≥ LLN 13. Normal thyroid function (TSH and free T4) (Clinically euthyroid patients are acceptable). 10. Able to sign informed consent and to comply with the protocol
Exclusion criteria
1. Patients who will need valproic acid for any medical condition during the study or within 5 days prior to first panobinostat treatment 2. Impaired cardiac function or clinically significant cardiac diseases, including any one of the following: 1. History or presence of sustained ventricular tachyarrhythmia. (Patients with a history of atrial arrhythmia are eligible but should be discussed with Novartis prior to enrollment) 2. Any history of ventricular fibrillation or torsade de pointes 3. Bradycardia defined as HR\< 50 bpm. Patients with pacemakers are eligible if resting HR ≥ 50 bpm. 4. Screening ECG with a QTc \> 450 msec 5. Right bundle branch block + left anterior hemiblock (bifascicular block) 6. Patients with myocardial infarction or unstable angina ≤ 6 months prior to starting study drug 7. Other clinically significant heart disease (e.g., CHF NY Heart Association class III or IV , uncontrolled hypertension, history of labile hypertension, or history of poor compliance with an antihypertensive regimen) 3. Impairment of GI function or GI disease that may significantly alter the absorption of panobinostat 4. Patients with diarrhea \> CTCAE grade 2 5. Other concurrent severe and/or uncontrolled medical conditions (e.g., uncontrolled diabetes or active or uncontrolled infection) including abnormal laboratory values, that could cause unacceptable safety risks or compromise compliance with the protocol 6. Patients using medications that have a relative risk of prolonging the QT interval or inducing torsade de pointes if treatment cannot be discontinued or switched to a different medication prior to starting study drug 7. Patients who have received targeted agents within 2 weeks or within 5 half-lives of the agent and active metabolites (whichever is longer) and who have not recovered from side effects of those therapies. 8. Patients who have received either immunotherapy within \< 8 weeks; chemotherapy within \< 4 weeks; or radiation therapy to \> 30% of marrow-bearing bone within \< 2 weeks prior to starting study treatment; or who have not yet recovered from side effects of such therapies. 9. Subject has received a cumulative dose of corticosteroids more than the equivalent of ≥ 140 mg of prednisone within the 2-week period before Cycle 1 Day 1. 10. Patients who have undergone major surgery ≤ 4 weeks prior to starting study drug or who have not recovered from side effects of such therapy 11. Women who are pregnant or breast feeding or women of childbearing potential (WOCBP) not using an effective method of birth control. WOCBP are defined as sexually mature women who have not undergone a hysterectomy or who have not been naturally postmenopausal for at least 12 consecutive months (i.e., who has had menses any time in the preceding 12 consecutive months). Women of childbearing potential must have a negative serum pregnancy test within 24hrs of receiving the first dose of study medication. 12. Male patients whose sexual partners are WOCBP not using effective birth control 13. Patients with a prior malignancy with in the last 5 years (except for basal or squamous cell carcinoma, or in situ cancer of the cervix) 14. Patients with known positivity for human immunodeficiency virus (HIV) ) or hepatitis C; baseline testing for HIV and hepatitis C is not required 15. Patients with any significant history of non-compliance to medical regimens or unwilling or unable to comply with the instructions given to him/her by the study staff. 16. Patients with a history of Deep Vein Thrombosis or thromboembolism within \< 6 months prior to starting study treatment 17. Patients for whom prophylactic anticoagulation therapy (eg. 325mg aspirin PO daily or warfarin (Coumadin®) 1-2 mg/day, or any other coumarin-derivative anticoagulants) is not an option. 18. Patients who have received allogeneic stem cell transplantation \< 12 months prior to entering the study 19. Patients who have had prior allogeneic stem cell transplantation and show evidence of active graft-versus-host disease that requires immunosuppressive therapy. 20. All patients must agree to follow the requirements for lenalidomide counseling, pregnancy testing and birth control. For women of childbearing potential (WOCBP) this includes pregnancy testing prior to prescribing lenalidomide and to either commit to continued abstinence from heterosexual intercourse or begin acceptable methods of birth control for 28 days prior to prescribing lenalidomide, during therapy and for 28 days after the last dose of lenalidomide. WOCBP must also agree to ongoing pregnancy testing. Men must agree to use a latex condom during sexual contact with a WOCBP even if they have had a successful vasectomy and must agree not to donate semen during study drug therapy and for a period of time after therapy. All patients must abstain from donating blood, agree not to share lenalidomide with others and be counseled about the risks of lenalidomide. See Appendix 2 requirements including the definition of WOCBP.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| The Best Overall Response Rate (ORR) | up to 4 years | The primary endpoint will be the best overall response rate (ORR). Per Response Evaluation Criteria In Solid Tumors Criteria (RECIST v1.0) for target lesions and assessed by MRI: Complete Response (CR), Disappearance of all target lesions; Partial Response (PR), \>=30% decrease in the sum of the longest diameter of target lesions; Overall Response (OR) = CR + PR. |
| Overall Response Rate for Len Refractory Patients | up to 4 years | The primary endpoint will be the best overall response rate (ORR) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Response Rates for Len Refractory Patients | up to 4 years | Response Rates evaluated using the International Uniform Response Criteria the International Myeloma Working Group (2003). CR-Negative immunofixation on the serum and urine and Disappearance of any soft tissue plasmacytomas and 5% plasma cells in bone marrow VGPR-Serum and urine M-component detectable by immunofixation but not on electrophoresis or 90 or greater reduction in serum M-component plus urine M-component \<100 mg per 24 h PR-50% reduction of serum M-protein and reduction in 24-h urinary M-protein by 90% or to \<200 mg per 24 h MR-≥ 25% but \< 49% reduction of serum M protein and reduction in 24 hour urine M protein by 50 - 89%, which still exceeds 200 mg/24hrs. In addition; if present at baseline, 25-49% reduction in the size of soft tissue plasmacytomas also required No increase in size or number of lytic bone lesions. SD-Not meeting criteria for CR, VGPR, PR or progressive disease PD-Laboratory or Biochemical Relapse increase of 25% from baseline |
| Clinical Benefit Rate for Len Refractory Patients | up to 4 years | The number of response rates in Lens Refractory participants that have achieved MR, PR, VGPR, CR |
| Clinical Benefit Rate | up to 4 years | The number of response rates in participants that have achieved MR, PR, VGPR, CR |
| Disease Control Rate for Lens Refractory Rate | up to 4 years | The number of response rates in Len refractory participants with SD, MR, PR, VGPR, or CR |
| Disease Control Rate | up to 4 years | The number of response rates participants with SD, MR, PR, VGPR, or CR |
| Response Rates | up to 4 years | Response Rates evaluated using the International Uniform Response Criteria the International Myeloma Working Group (2003). CR-Negative immunofixation on the serum and urine and Disappearance of any soft tissue plasmacytomas and 5% plasma cells in bone marrow VGPR-Serum and urine M-component detectable by immunofixation but not on electrophoresis or 90 or greater reduction in serum M-component plus urine M-component \<100 mg per 24 h PR-50% reduction of serum M-protein and reduction in 24-h urinary M-protein by 90% or to \<200 mg per 24 h MR-≥ 25% but \< 49% reduction of serum M protein and reduction in 24 hour urine M protein by 50 - 89%, which still exceeds 200 mg/24hrs. In addition; if present at baseline, 25-49% reduction in the size of soft tissue plasmacytomas also required No increase in size or number of lytic bone lesions. SD-Not meeting criteria for CR, VGPR, PR or progressive disease PD-Laboratory or Biochemical Relapse increase of 25% from baseline |
Countries
United States
Participant flow
Recruitment details
Recruitment began in July 2012 with enrollment from Sept 2012 to August 2015. 41 subjects signed consent (7 screened failed, 32 received study treatment, 5 non-evaluables). 27 out of the 32 subjects are evaluable.
Participants by arm
| Arm | Count |
|---|---|
| Panobinostat, Lenalidomide and Dexamethasone All patients will receive oral panobinostat, lenalidomide and dexamethasone as per protocol.
Panobinostat, Lenalidomide and Dexamethasone: Each cycle is 28 days. Panobinostat will be given 20 mg: Days 1,3,5,15,17,19. Lenalidomide will be given 25 mg: Days 1-21. Dexamethasone will be given for patients 75 years old and younger a dose of 40 mg on Days 1, 8 and 15. Dexamethasone will be given for patients older than 75 years old, 20 mg on Days 1, 8 and 15. | 27 |
| Total | 27 |
Withdrawals & dropouts
| Period | Reason | FG000 |
|---|---|---|
| Overall Study | Non-evaluables | 5 |
| Overall Study | Physician Decision | 2 |
| Overall Study | Progressive Disease | 22 |
| Overall Study | Withdrawal by Subject | 1 |
Baseline characteristics
| Characteristic | Panobinostat, Lenalidomide and Dexamethasone |
|---|---|
| Age >65 years | 14 Participants |
| Age, Continuous | 64 years |
| Best response at last treatment Complete response | 2 Participants |
| Best response at last treatment Minimal Response | 9 Participants |
| Best response at last treatment Partial Response | 5 Participants |
| Best response at last treatment Progressive disease | 1 Participants |
| Best response at last treatment Stable Disease | 6 Participants |
| Best response at last treatment Very Good Partial Response | 4 Participants |
| Dex in last len-containing regimen | 23 Participants |
| Dex in most recent prior regimen | 21 Participants |
| Doses of lenalidomide at time of PD on len 10 | 7 Participants |
| Doses of lenalidomide at time of PD on len 15 | 5 Participants |
| Doses of lenalidomide at time of PD on len 25 | 7 Participants |
| Doses of lenalidomide at time of PD on len 5 | 1 Participants |
| Doses of lenalidomide at time of PD on len Not Len Refractory Patients | 5 Participants |
| Doses of lenalidomide at time of PD on len unknown | 2 Participants |
| FISH Any abnormality | 22 Participants |
| FISH Any high risk abnormality | 17 Participants |
| FISH chr1 amplification | 12 Participants |
| FISH del(13q) | 5 Participants |
| FISH del(17p) | 5 Participants |
| FISH Normal | 2 Participants |
| FISH t(11;14) | 5 Participants |
| FISH t(4;14) | 4 Participants |
| Immunoglobulin subtype IgA | 8 Participants |
| Immunoglobulin subtype IgG | 14 Participants |
| Immunoglobulin subtype IgM | 1 Participants |
| Immunoglobulin subtype None | 4 Participants |
| ISS Staging missing | 12 Participants |
| ISS Staging Stage 1 | 5 Participants |
| ISS Staging Stage 2 | 5 Participants |
| ISS Staging Stage 3 | 5 Participants |
| Len in most recent prior regimen | 13 Participants |
| Median cumulative duration of prior lenalidomide (len) months | 13 months |
| Median time since diagnosis | 4 years |
| Pom in most recent prior regimen | 3 Participants |
| Prior len regimens | 1 regimens |
| Prior regimens | 3 years |
| Prior therapy | 3 regimens |
| Prior Therapy, Exposed Autologous stem cell transplant | 20 Participants |
| Prior Therapy, Exposed Bortezomib | 27 Participants |
| Prior Therapy, Exposed Carfilzomib | 8 Participants |
| Prior Therapy, Exposed Dexamethasone | 27 Participants |
| Prior Therapy, Exposed Lenalidomide | 27 Participants |
| Prior Therapy, Exposed Pomalidomide | 10 Participants |
| Prior Therapy, Exposed Thalidomide | 6 Participants |
| Prior therapy, Refractory Bortezomib | 14 Participants |
| Prior therapy, Refractory Carfilzomib | 7 Participants |
| Prior therapy, Refractory Dexamethasone | 19 Participants |
| Prior therapy, Refractory Lenalidomide | 22 Participants |
| Prior therapy, Refractory Pomalidomide | 19 Participants |
| Prior therapy, Refractory Thalidomide | 2 Participants |
| Progressed while on last len regimen | 22 Participants |
| Sex: Female, Male Female | 11 Participants |
| Sex: Female, Male Male | 16 Participants |
| The Eastern Cooperative Oncology Group (ECOG) Performance 0 | 16 Participants |
| The Eastern Cooperative Oncology Group (ECOG) Performance 1 | 11 Participants |
| The Eastern Cooperative Oncology Group (ECOG) Performance 2 | 0 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 1 / 41 |
| other Total, other adverse events | 38 / 41 |
| serious Total, serious adverse events | 14 / 41 |
Outcome results
Primary
Overall Response Rate for Len Refractory Patients
The primary endpoint will be the best overall response rate (ORR)
Time frame: up to 4 years
Population: Only Len Refractory Patients
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Panobinostat, Lenalidomide and Dexamethasone | Overall Response Rate for Len Refractory Patients | 8 Participants |
Primary
The Best Overall Response Rate (ORR)
The primary endpoint will be the best overall response rate (ORR). Per Response Evaluation Criteria In Solid Tumors Criteria (RECIST v1.0) for target lesions and assessed by MRI: Complete Response (CR), Disappearance of all target lesions; Partial Response (PR), \>=30% decrease in the sum of the longest diameter of target lesions; Overall Response (OR) = CR + PR.
Time frame: up to 4 years
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Panobinostat, Lenalidomide and Dexamethasone | The Best Overall Response Rate (ORR) | 11 Participants |
Secondary
Clinical Benefit Rate
The number of response rates in participants that have achieved MR, PR, VGPR, CR
Time frame: up to 4 years
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Panobinostat, Lenalidomide and Dexamethasone | Clinical Benefit Rate | 20 Participants |
Secondary
Clinical Benefit Rate for Len Refractory Patients
The number of response rates in Lens Refractory participants that have achieved MR, PR, VGPR, CR
Time frame: up to 4 years
Population: Only Len Refractory Patients
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Panobinostat, Lenalidomide and Dexamethasone | Clinical Benefit Rate for Len Refractory Patients | 15 Participants |
Secondary
Disease Control Rate
The number of response rates participants with SD, MR, PR, VGPR, or CR
Time frame: up to 4 years
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Panobinostat, Lenalidomide and Dexamethasone | Disease Control Rate | 26 Participants |
Secondary
Disease Control Rate for Lens Refractory Rate
The number of response rates in Len refractory participants with SD, MR, PR, VGPR, or CR
Time frame: up to 4 years
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Panobinostat, Lenalidomide and Dexamethasone | Disease Control Rate for Lens Refractory Rate | 21 Participants |
Secondary
Response Rates
Response Rates evaluated using the International Uniform Response Criteria the International Myeloma Working Group (2003). CR-Negative immunofixation on the serum and urine and Disappearance of any soft tissue plasmacytomas and 5% plasma cells in bone marrow VGPR-Serum and urine M-component detectable by immunofixation but not on electrophoresis or 90 or greater reduction in serum M-component plus urine M-component \<100 mg per 24 h PR-50% reduction of serum M-protein and reduction in 24-h urinary M-protein by 90% or to \<200 mg per 24 h MR-≥ 25% but \< 49% reduction of serum M protein and reduction in 24 hour urine M protein by 50 - 89%, which still exceeds 200 mg/24hrs. In addition; if present at baseline, 25-49% reduction in the size of soft tissue plasmacytomas also required No increase in size or number of lytic bone lesions. SD-Not meeting criteria for CR, VGPR, PR or progressive disease PD-Laboratory or Biochemical Relapse increase of 25% from baseline
Time frame: up to 4 years
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Panobinostat, Lenalidomide and Dexamethasone | Response Rates | Complete Response (CR) | 2 Participants |
| Panobinostat, Lenalidomide and Dexamethasone | Response Rates | Very Good Partial Response (VGPR) | 4 Participants |
| Panobinostat, Lenalidomide and Dexamethasone | Response Rates | Partial Response (PR) | 5 Participants |
| Panobinostat, Lenalidomide and Dexamethasone | Response Rates | Minimal Response (MR) | 9 Participants |
| Panobinostat, Lenalidomide and Dexamethasone | Response Rates | Stable Disease (SD) | 6 Participants |
| Panobinostat, Lenalidomide and Dexamethasone | Response Rates | Progressive Disease (PD) | 1 Participants |
Secondary
Response Rates for Len Refractory Patients
Response Rates evaluated using the International Uniform Response Criteria the International Myeloma Working Group (2003). CR-Negative immunofixation on the serum and urine and Disappearance of any soft tissue plasmacytomas and 5% plasma cells in bone marrow VGPR-Serum and urine M-component detectable by immunofixation but not on electrophoresis or 90 or greater reduction in serum M-component plus urine M-component \<100 mg per 24 h PR-50% reduction of serum M-protein and reduction in 24-h urinary M-protein by 90% or to \<200 mg per 24 h MR-≥ 25% but \< 49% reduction of serum M protein and reduction in 24 hour urine M protein by 50 - 89%, which still exceeds 200 mg/24hrs. In addition; if present at baseline, 25-49% reduction in the size of soft tissue plasmacytomas also required No increase in size or number of lytic bone lesions. SD-Not meeting criteria for CR, VGPR, PR or progressive disease PD-Laboratory or Biochemical Relapse increase of 25% from baseline
Time frame: up to 4 years
| Arm | Measure | Group | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|---|
| Panobinostat, Lenalidomide and Dexamethasone | Response Rates for Len Refractory Patients | Complete Response | 1 Participants |
| Panobinostat, Lenalidomide and Dexamethasone | Response Rates for Len Refractory Patients | Very Good Partial Response | 4 Participants |
| Panobinostat, Lenalidomide and Dexamethasone | Response Rates for Len Refractory Patients | Partial Response | 3 Participants |
| Panobinostat, Lenalidomide and Dexamethasone | Response Rates for Len Refractory Patients | Minimal Response | 7 Participants |
| Panobinostat, Lenalidomide and Dexamethasone | Response Rates for Len Refractory Patients | Stable Disease | 6 Participants |
| Panobinostat, Lenalidomide and Dexamethasone | Response Rates for Len Refractory Patients | Progressive Disease | 1 Participants |