Oligometastases, Prostate Cancer
Conditions
Keywords
Prostate Cancer, Stereotactic Body Radiation Therapy, Stereotactic Ablative Radiotherapy, Oligometastasis
Brief summary
Men with oligometastatic prostate cancer lesions will be randomized (1:2) to observation versus SBRT. The study will NOT be blinded. Within three weeks of the initial treatment planning, SBRT (1-5 fractions) will be administered.
Detailed description
This research is being done to determine if we can improve the outcome of prostate cancer patients who have failed primary treatment - surgery or local radiation to the prostate - and have 3 or fewer bone metastases. Patients with metastatic prostate cancer disease will usually be placed on hormonal therapy which can work well for a period of time, but hormonal therapy can have side effects that greatly trouble men. Any effort to delay the start of hormonal therapy would be an advantage to the patient. Radiation treatment usually takes many weeks to deliver and is not given in a high enough doses to metastases to prevent them from coming back locally. Stereotactic body radiation therapy (SBRT) is highly focused radiation, given in a very dose intensive fashion and delivered in usually less than one week. Stereotactic body radiation has been shown to be very effective on bone metastases. Therefore, we are studying the effects of stereotactic body radiation treatment on patients with five or fewer prostate cancer bone metastases to determine if we can stall the use of hormonal therapy and/or prevent other bone metastases from developing elsewhere in the body. Additionally, fundamental analysis of the oligometastatic state with be achieved through correlation with investigational DCFPyL-positron emission tomography (PET) imaging, which can help us find cancer that has spread (metastatic disease) from its original site in people who have cancer in their prostate to other parts of their body. Specifically, 54 men with biochemically recurrent, oligometastatic prostate adenocarcinoma will be accrued across 3 centers in the United States. Patients were stratified by primary intervention (surgery vs radiotherapy), prior hormonal therapy, and PSA doubling time, then randomized 2:1 to SBRT or observation. The primary clinical endpoint is progression at 6 months from randomization with the hypothesis that SBRT to all metastases will forestall progression by disrupting the metastatic process. Secondary clinical endpoints include local control at 6 months post-SBRT, SBRT-associated toxicity and quality of life, and ADT-free survival (ADT-FS). Alterations in the biology of the oligometastatic state induced by stereotactic ablative radiotherapy (SABR) will be investigated using leading-edge correlatives, including: analysis of circulating tumor cells (CTCs; Epic Sciences, San Diego, CA), deep sequencing of circulating tumor DNA (ctDNA) using Cancer Personalized Profiling by deep sequencing (CAPP-Seq) to non-invasively assess tumor burden, and ImmunoSEQ profiling of T-cell repertoires to elucidate the immunological response to SABR (Adaptive Technologies, Seattle, WA). Lastly, the use of the Color Genomics platform (Burlingame, CA), a hereditary cancer assay assessing pathogenic mutations in 30 cancer predisposition genes that account for \>90% of the germline mutations known to occur in men with castrate resistant metastatic prostate cancer (mCRPC), will help inform and allow for efforts to advance a more personalized medicine approach to tailor screening and therapies in these men.
Interventions
RADIATIONSBRT
SBRT (1-5 fractions) will be administered.
Sponsors
National Cancer Institute (NCI)
Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
MALE
Age
18 Years to 100 Years
Healthy volunteers
No
Inclusion criteria
* Patient must have at least one and up to three asymptomatic metastatic tumor(s) of the bone or soft tissue develop within the past 6-months that are ≤ 5.0 cm or \<250 cm3. * Patient must have had their primary tumor treated with surgery and/or radiation. * Histologic confirmation of malignancy (primary or metastatic tumor). * PSADT \<15 months. PSA doubling time (PSADT) will be calculated using as many PSA values that are available from time of relapse (PSA \> 0.2). To calculate PSADT, the Memorial Sloan Kettering Cancer Center Prostate Cancer Prediction Tool will be used. It can be found at the following web site: https://www.mskcc.org/nomograms/prostate/psa-doubling-time. * Patient may have had prior systemic therapy and/or ADT associated with treatment of their primary prostate cancer. Patient may have had ADT associated with salvage radiation therapy (to the primary prostate cancer or pelvis is allowed). * PSA \>1 but \<50. * Testosterone \> 125 ng/dL. * Patient must have a life expectancy ≥ 12 months. * Patient must have an Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2. * Patient must have normal organ and marrow function as defined as: Leukocytes \>2,000/μL Absolute Neutrophil Count \>1,000/μL Platelets \>50,000/μL \- Patient must have the ability to understand and the willingness to sign a written informed consent document.
Exclusion criteria
* No more than 3 years of ADT is allowed, with the most recent ADT treatment having occurred greater than 6 months prior to enrollment. * DCFPyL-PET/MRI or DCFPyL-PET/CT scan within the past 6 months with results that demonstrate more disease lesions than baseline CT/Bone Scan * Castration-resistant prostate cancer (CRPC). * Suspected pulmonary and/or liver metastases (greater \>10 mm in largest axis). * Patient receiving any other investigational agents. * Patient is participating in a concurrent treatment protocol. * Total bilirubin \> 3 times the upper limit of normal. * Liver Transaminases \> 5-times the upper limit of normal. * Unable to lie flat during or tolerate PET/MRI, PET/CT or SBRT. * Liver Transaminases \> 5-times the upper limit of normal. * Prior salvage treatment to the primary prostate cancer or pelvis is allowed. * Refusal to sign informed consent.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Progression at 6 Months | 6 months | Number of participants who progressed at 6 months. Progression is defined as either: 1) a ≥ 25% increase in PSA from nadir (and by ≥ 2 ng/mL), requiring confirmation ≥ 4 weeks later (PCWG2 criteria); and/or, 2) clinical/radiographic-progression defined as symptomatic progression (worsening disease-related symptoms or new cancer-related complications), or radiologic progression (on CT scan: ≥ 20% enlargement in sum diameter of soft-tissue target lesions \[RECIST1.1 criteria\]; on bone scan: ≥ 1 new bone lesions),initiation of ADT or death due to any cause, whichever occurs first. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Local Control of SBRT Group | 6 months | Number of lesions that did not increase in size by at least 20% or more on CT from baseline to 6 months. |
| Toxicity as Assessed by Number of Participants With Adverse Events Grade 3 or Higher | up to 6 months | Number of participants experiencing adverse events Grade 3 or higher, as defined by CTCAE. |
| Toxicity as Assessed by Number of Participants With Adverse Events Grades 1 or 2 | up to 6 months | Number of participants experiencing adverse events Grades 1 or 2, as defined by CTCAE |
| Time to Local Progression | up to 6 months | Number of months until local progression in patients with oligometastatic disease. |
| Change of DCFPyL-PET/MRI Positive Lesions | 6 months | 18F-DCFPyL Positron Emission Tomography (PET)/MRI or -PET/CT positive sites that are positive for new or progressive metastatic disease by bone scan/CT at 6-months following SBRT. |
| Change in Survival of Two Groups as Assessed by PSA Level | Baseline and 6 months | The PSA levels in blood will be measured in units of nanograms per milliliter (ng/mL). |
| Androgen Deprivation Therapy-free Survival | 6 month | Androgen Deprivation Therapy-free survival will be assessed using the number of participants deceased at 6 months. |
| Change in Quality of Life as Assessed by Brief Pain Inventory | Baseline and 6 months | We will assess quality of life following completion of Stereotactic Body Radiation Therapy via Brief Pain Inventory questionnaire made up of 9 questions. Each question scores from 0-10, with higher scores mean worse outcome or more pain. An overall score, calculated by adding the scores for questions 2, 3, 4 and 5 and then dividing by 4, will be calculated pre-treatment and at the time of day 180. The change in score (between baseline and 6 months) will be evaluated. |
Countries
United States
Participant flow
Pre-assignment details
26 Excluded from 80, these are: 19 Did not meet inclusion criteria; 5 Declined to participate; 2 Insurance denied
Participants by arm
| Arm | Count |
|---|---|
| Observational (no SBRT) Evaluating males with oligometastatic prostate cancer lesions randomized to observation
Observational (no SBRT): These patients will not receive SBRT. They will be observed. | 18 |
| SBRT Evaluating males with oligometastatic prostate cancer lesions randomized to stereotactic body radiation therapy (SBRT).
SBRT: SBRT (1-5 fractions) will be administered. | 36 |
| Total | 54 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Overall Study | Withdrawal by Subject | 1 | 0 |
Baseline characteristics
| Characteristic | Observational (no SBRT) | Total | SBRT |
|---|---|---|---|
| Age, Continuous | 68 Years | 68 Years | 68 Years |
| Baseline prostate-specific antigen doubling time (PSADT) | 6 months | 8 months | 8 months |
| Baseline prostate-specific antigen (PSA) | 7 ng/dl | 6 ng/dl | 6 ng/dl |
| Gleason score 3+3=6 | 0 Participants | 3 Participants | 3 Participants |
| Gleason score 3+4=7 | 4 Participants | 12 Participants | 8 Participants |
| Gleason score 4+3=7 | 4 Participants | 18 Participants | 14 Participants |
| Gleason score 4+4=8 | 1 Participants | 5 Participants | 4 Participants |
| Gleason score 4+5=9 | 8 Participants | 12 Participants | 4 Participants |
| Gleason score 5+4=9 | 0 Participants | 3 Participants | 3 Participants |
| Gleason score 5+5=10 | 1 Participants | 1 Participants | 0 Participants |
| Had received prior ADT | 5 Participants | 33 Participants | 28 Participants |
| Initial management Radiotherapy | 3 Participants | 9 Participants | 6 Participants |
| Initial management Surgery | 15 Participants | 45 Participants | 30 Participants |
| Initial N stage (extent of spread to the lymph nodes N0 | 16 Participants | 47 Participants | 31 Participants |
| Initial N stage (extent of spread to the lymph nodes N1 | 1 Participants | 3 Participants | 2 Participants |
| Initial N stage (extent of spread to the lymph nodes NX | 1 Participants | 4 Participants | 3 Participants |
| Initial T stage (extent of the tumor) cT1c | 1 Participants | 4 Participants | 3 Participants |
| Initial T stage (extent of the tumor) cT2a | 0 Participants | 2 Participants | 2 Participants |
| Initial T stage (extent of the tumor) cT2b | 1 Participants | 1 Participants | 0 Participants |
| Initial T stage (extent of the tumor) cT3a | 1 Participants | 2 Participants | 1 Participants |
| Initial T stage (extent of the tumor) pT2 | 6 Participants | 18 Participants | 12 Participants |
| Initial T stage (extent of the tumor) pT3a | 8 Participants | 18 Participants | 10 Participants |
| Initial T stage (extent of the tumor) pT3b | 1 Participants | 9 Participants | 8 Participants |
| Race and Ethnicity Not Collected | — | 0 Participants | — |
| Region of Enrollment United States | 18 Participants | 54 Participants | 36 Participants |
| Sex: Female, Male Female | 0 Participants | 0 Participants | 0 Participants |
| Sex: Female, Male Male | 18 Participants | 54 Participants | 36 Participants |
| Time to first recurrence | 22 month | 22 month | 22 month |
| Tumor margin status Not applicable | 3 Participants | 9 Participants | 6 Participants |
| Tumor margin status R0 | 10 Participants | 30 Participants | 20 Participants |
| Tumor margin status R1 | 5 Participants | 15 Participants | 10 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 18 | 0 / 36 |
| other Total, other adverse events | 14 / 18 | 36 / 36 |
| serious Total, serious adverse events | 0 / 18 | 0 / 36 |
Outcome results
Primary
Progression at 6 Months
Number of participants who progressed at 6 months. Progression is defined as either: 1) a ≥ 25% increase in PSA from nadir (and by ≥ 2 ng/mL), requiring confirmation ≥ 4 weeks later (PCWG2 criteria); and/or, 2) clinical/radiographic-progression defined as symptomatic progression (worsening disease-related symptoms or new cancer-related complications), or radiologic progression (on CT scan: ≥ 20% enlargement in sum diameter of soft-tissue target lesions \[RECIST1.1 criteria\]; on bone scan: ≥ 1 new bone lesions),initiation of ADT or death due to any cause, whichever occurs first.
Time frame: 6 months
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Observational (no SBRT) | Progression at 6 Months | 11 Participants |
| SBRT | Progression at 6 Months | 7 Participants |
Secondary
Androgen Deprivation Therapy-free Survival
Androgen Deprivation Therapy-free survival will be assessed using the number of participants deceased at 6 months.
Time frame: 6 month
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Observational (no SBRT) | Androgen Deprivation Therapy-free Survival | 0 Participants |
| SBRT | Androgen Deprivation Therapy-free Survival | 0 Participants |
Secondary
Change in Quality of Life as Assessed by Brief Pain Inventory
We will assess quality of life following completion of Stereotactic Body Radiation Therapy via Brief Pain Inventory questionnaire made up of 9 questions. Each question scores from 0-10, with higher scores mean worse outcome or more pain. An overall score, calculated by adding the scores for questions 2, 3, 4 and 5 and then dividing by 4, will be calculated pre-treatment and at the time of day 180. The change in score (between baseline and 6 months) will be evaluated.
Time frame: Baseline and 6 months
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Observational (no SBRT) | Change in Quality of Life as Assessed by Brief Pain Inventory | 0 score on a scale |
| SBRT | Change in Quality of Life as Assessed by Brief Pain Inventory | 0 score on a scale |
Secondary
Change in Survival of Two Groups as Assessed by PSA Level
The PSA levels in blood will be measured in units of nanograms per milliliter (ng/mL).
Time frame: Baseline and 6 months
Population: Data was not collected
Secondary
Change of DCFPyL-PET/MRI Positive Lesions
18F-DCFPyL Positron Emission Tomography (PET)/MRI or -PET/CT positive sites that are positive for new or progressive metastatic disease by bone scan/CT at 6-months following SBRT.
Time frame: 6 months
Population: Data was not collected for this outcome measure
Secondary
Local Control of SBRT Group
Number of lesions that did not increase in size by at least 20% or more on CT from baseline to 6 months.
Time frame: 6 months
Population: Data for this outcome measure was not collected from the Observation arm.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| SBRT | Local Control of SBRT Group | 89 lesions |
Secondary
Time to Local Progression
Number of months until local progression in patients with oligometastatic disease.
Time frame: up to 6 months
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Observational (no SBRT) | Time to Local Progression | 5.8 Months |
| SBRT | Time to Local Progression | 6 Months |
Secondary
Toxicity as Assessed by Number of Participants With Adverse Events Grade 3 or Higher
Number of participants experiencing adverse events Grade 3 or higher, as defined by CTCAE.
Time frame: up to 6 months
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Observational (no SBRT) | Toxicity as Assessed by Number of Participants With Adverse Events Grade 3 or Higher | 3 months | 0 participants |
| Observational (no SBRT) | Toxicity as Assessed by Number of Participants With Adverse Events Grade 3 or Higher | 6 months | 0 participants |
| SBRT | Toxicity as Assessed by Number of Participants With Adverse Events Grade 3 or Higher | 3 months | 0 participants |
| SBRT | Toxicity as Assessed by Number of Participants With Adverse Events Grade 3 or Higher | 6 months | 0 participants |
Secondary
Toxicity as Assessed by Number of Participants With Adverse Events Grades 1 or 2
Number of participants experiencing adverse events Grades 1 or 2, as defined by CTCAE
Time frame: up to 6 months
Population: 2 from observation group discontinued intervention because of progression prior to 90 days.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Observational (no SBRT) | Toxicity as Assessed by Number of Participants With Adverse Events Grades 1 or 2 | 3 month | 11 participants |
| Observational (no SBRT) | Toxicity as Assessed by Number of Participants With Adverse Events Grades 1 or 2 | 6 month | 3 participants |
| SBRT | Toxicity as Assessed by Number of Participants With Adverse Events Grades 1 or 2 | 6 month | 15 participants |
| SBRT | Toxicity as Assessed by Number of Participants With Adverse Events Grades 1 or 2 | 3 month | 30 participants |