Stage IV Non-Small Cell Lung Cancer
Conditions
Brief summary
The core hypothesis to be tested is that the use of consolidative SBRT followed by maintenance chemotherapy in patients with less than or equal to 6 metastatic sites (primary + 5) will improve progression free survival (PFS) compared to maintenance chemotherapy alone.
Detailed description
This protocol is a randomized phase II trial of maintenance chemotherapy versus consolidative Stereotactic Body Radiation Therapy (SBRT) plus maintenance chemotherapy for patients with Stage IV non-small cell lung cancer (NSCLC). Prior to accrual on the trial, patients with Stage IV NSCLC will be treated with standard first-line chemotherapy. Patients who achieve a partial response or stable disease by imaging criteria with fewer than or equal to six sites of oligometastatic disease will be randomized to maintenance chemotherapy or consolidative SBRT to all sites of disease (followed by maintenance chemotherapy at the medical oncologist's discretion). Choices of first line and maintenance chemotherapy will be determined by the medical oncologist based on clinical appropriateness.
Interventions
RADIATIONStereotactic Body Radiation Therapy
Maintenance chemotherapy
Sponsors
University of Texas Southwestern Medical Center
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to 99 Years
Healthy volunteers
No
Inclusion criteria
1. Patients must have biopsy proven metastatic NSCLC (Stage IV). 2. Patients must have received first line chemotherapy, from 4-6 cycles, and achieved stable disease or a partial response. 3. Patients receiving first-line erlotinib, crizotinib for EGFR mutant-positive or EML4-ALK positive NSCLC will be excluded. 4. Age ≥ 18 years 5. Patients must have measurable disease at baseline. 6. Patients can have up to only 6 discrete active extracranial lesions (≤3 in the liver and ≤3 in the lung) identified by diagnostic CT or PET/CT scan or MRI within 8 weeks prior to the initiation of SBRT. 1. For patients who have received prior radiotherapy to the primary site in the lung, residual PET activity is difficult to interpret and will not be considered a site of active disease if the CT appearance is stable or improved over an interval of at least three months 2. Patients who previously received radiotherapy to the primary site will be ineligible if there is CT evidence of disease progression within the past 3 months. 3. Patients with previously un-irradiated primary sites will be potentially eligible, but special considerations apply (section 4.3.2). 4. Up to 2 contiguous vertebral metastases will be considered a single site of disease. 7. Patients must have a KPS \>60 8. AST, ALT & Alkaline phosphates must be ≤ 2.5X the upper limit of normal. Total bilirubin must be within the limit of normal. 9. Patients should have adequate bone marrow function as defined by peripheral granulocyte count of ≥1500/mm³. 10. Patients should have adequate renal function (serum creatinine ≤1.5 times the ULN). 11. Women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study participation, and for 90 days following completion of therapy. Should a woman become pregnant or suspect she is pregnant while participating in this study, she should inform her treating physician immediately. 11.1 A female of child-bearing potential is any woman (regardless of sexual orientation, having undergone a tubal ligation, or remaining celibate by choice) who meets the following criteria: * Has not undergone a hysterectomy or bilateral oophorectomy; or * Has not been naturally postmenopausal for at least 12 consecutive months (i.e., has had menses at any time in the preceding 12 consecutive months). 12. Patients who would be receiving SBRT for lung tumors who are known or suspected by the treating radiation oncologist to have compromised lung function must have a documented forced expiratory volume in 1 second (FEV1) ≥ 1L. 13. Patients must provide verbal and written informed consent to participate in the study.
Exclusion criteria
1. Patients who previously received radiotherapy to the primary site with CT evidence of disease progression at the primary site within 3 months following the initial radiotherapy. 2. Patients with untreated brain metastases Patients with serious, uncontrolled, concurrent infection(s). 3. Significant weight loss (\>10%) in the prior 3 months. 4. Because the tolerance dose of SBRT to the gastrointestinal tract is not established, patients with metastatic disease invading the esophagus, stomach, intestines, or mesenteric lymph nodes will not be eligible. 5. Patients with cutaneous metastasis of NSCLC. 6. Patients with more than 6 discrete extra-cranial lesions. 7. Participation in any investigational drug study within 4 weeks preceding the start of study treatment. 8. Unwillingness to participate or inability to comply with the protocol for the duration of the study. 9. Patients who are pregnant. Patients with reproductive capability will need to use adequate contraception during the time of participation in the study.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Progression Free Survival | 5 years | Evaluate the effect of SBRT with maintenance chemotherapy versus maintenance chemotherapy alone on progression free survival. Time to the development of new lesions, progression of existing lesions, or death, whichever came first, represented the primary end point of progression-free survival. All evaluations of disease response used RECIST (v1.1) criteria, in which progressive disease is defined as At least a 20% increase in the sum of diameters of target lesions, taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest on study. In addition to the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| In-field Local Control Versus Out-of-field Disease Progression | 5 years | Number of occurances of in-field local control and rate of out-of-field disease progression |
| Toxicities | 2 years | To evaluate the safety of SBRT with metastatic NSCLC after prior chemotherapy |
| Overall Survival | 5 years | To evaluate overall survival after SBRT followed by maintenance chemotherapy in comparison to maintenance chemotherapy alone. |
| Duration of Maintenance Chemotherapy | 5 years | To evaluate the duration of maintenance chemotherapy and time to initiation of third line systemic agent (chemotherapy or biologic agent) |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Maintenance Chemotherapy FDA approved drugs for the study population: Bevacizumab, Docetaxel, Erlotinib, Gemcitabine, Pemetrexed
Maintenance chemotherapy: Maintenance chemotherapy | 15 |
| Stereotactic Body Radiation Therapy Consolidative Stereotactic Body Radiation Therapy (SBRT) plus maintenance chemotherapy
Stereotactic Body Radiation Therapy
Maintenance chemotherapy: Maintenance chemotherapy | 14 |
| Total | 29 |
Baseline characteristics
| Characteristic | Maintenance Chemotherapy | Stereotactic Body Radiation Therapy | Total |
|---|---|---|---|
| Age, Customized Age | 70.0 years | 63.5 years | 66 years |
| Histology Nonsquamous | 12 Participants | 13 Participants | 25 Participants |
| Histology Squamous | 3 Participants | 1 Participants | 4 Participants |
| Induction chemotherapy, median cycles | 4 cycles | 4.5 cycles | 4 cycles |
| Previously treated brain metastases No | 10 Participants | 8 Participants | 18 Participants |
| Previously treated brain metastases Yes | 5 Participants | 6 Participants | 11 Participants |
| Race and Ethnicity Not Collected | — | — | 0 Participants |
| Region of Enrollment United States | 15 Participants | 14 Participants | 29 Participants |
| Sex: Female, Male Female | 4 Participants | 5 Participants | 9 Participants |
| Sex: Female, Male Male | 11 Participants | 9 Participants | 20 Participants |
| Sites of disease prior to induction chemotherapy | 2 sites of disease | 3 sites of disease | 3 sites of disease |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 3 / 15 | 3 / 14 |
| other Total, other adverse events | 15 / 15 | 14 / 14 |
| serious Total, serious adverse events | 6 / 15 | 8 / 14 |
Outcome results
Primary
Progression Free Survival
Evaluate the effect of SBRT with maintenance chemotherapy versus maintenance chemotherapy alone on progression free survival. Time to the development of new lesions, progression of existing lesions, or death, whichever came first, represented the primary end point of progression-free survival. All evaluations of disease response used RECIST (v1.1) criteria, in which progressive disease is defined as At least a 20% increase in the sum of diameters of target lesions, taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest on study. In addition to the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm.
Time frame: 5 years
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Maintenance Chemotherapy | Progression Free Survival | 3.5 months |
| Stereotactic Body Radiation Therapy | Progression Free Survival | 9.7 months |
p-value: 0.0195% CI: [0.113, 0.815]Log Rank
Secondary
Duration of Maintenance Chemotherapy
To evaluate the duration of maintenance chemotherapy and time to initiation of third line systemic agent (chemotherapy or biologic agent)
Time frame: 5 years
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Maintenance Chemotherapy | Duration of Maintenance Chemotherapy | 3 cycles |
| Stereotactic Body Radiation Therapy | Duration of Maintenance Chemotherapy | 5 cycles |
Secondary
In-field Local Control Versus Out-of-field Disease Progression
Number of occurances of in-field local control and rate of out-of-field disease progression
Time frame: 5 years
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Maintenance Chemotherapy | In-field Local Control Versus Out-of-field Disease Progression | Progression in brain | 4 Patients |
| Maintenance Chemotherapy | In-field Local Control Versus Out-of-field Disease Progression | Progression in liver | 0 Patients |
| Maintenance Chemotherapy | In-field Local Control Versus Out-of-field Disease Progression | Progression in lung | 8 Patients |
| Maintenance Chemotherapy | In-field Local Control Versus Out-of-field Disease Progression | Progression in bone | 1 Patients |
| Maintenance Chemotherapy | In-field Local Control Versus Out-of-field Disease Progression | Progression in pancreas | 0 Patients |
| Maintenance Chemotherapy | In-field Local Control Versus Out-of-field Disease Progression | In-field progression | 7 Patients |
| Stereotactic Body Radiation Therapy | In-field Local Control Versus Out-of-field Disease Progression | Progression in pancreas | 1 Patients |
| Stereotactic Body Radiation Therapy | In-field Local Control Versus Out-of-field Disease Progression | Progression in brain | 1 Patients |
| Stereotactic Body Radiation Therapy | In-field Local Control Versus Out-of-field Disease Progression | Progression in bone | 1 Patients |
| Stereotactic Body Radiation Therapy | In-field Local Control Versus Out-of-field Disease Progression | Progression in liver | 2 Patients |
| Stereotactic Body Radiation Therapy | In-field Local Control Versus Out-of-field Disease Progression | In-field progression | 0 Patients |
| Stereotactic Body Radiation Therapy | In-field Local Control Versus Out-of-field Disease Progression | Progression in lung | 0 Patients |
Secondary
Overall Survival
To evaluate overall survival after SBRT followed by maintenance chemotherapy in comparison to maintenance chemotherapy alone.
Time frame: 5 years
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Maintenance Chemotherapy | Overall Survival | 189 days |
| Stereotactic Body Radiation Therapy | Overall Survival | 203.5 days |
Secondary
Toxicities
To evaluate the safety of SBRT with metastatic NSCLC after prior chemotherapy
Time frame: 2 years
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Maintenance Chemotherapy | Toxicities | Grade 3 toxicities probably or definitely attributed to study | 2 adverse events |
| Maintenance Chemotherapy | Toxicities | Grade 4 toxicities probably or definitely attributed to study | 1 adverse events |
| Maintenance Chemotherapy | Toxicities | Grade 5 toxicities probably or definitely attributed to study | 0 adverse events |
| Stereotactic Body Radiation Therapy | Toxicities | Grade 3 toxicities probably or definitely attributed to study | 4 adverse events |
| Stereotactic Body Radiation Therapy | Toxicities | Grade 4 toxicities probably or definitely attributed to study | 0 adverse events |
| Stereotactic Body Radiation Therapy | Toxicities | Grade 5 toxicities probably or definitely attributed to study | 0 adverse events |