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Results of a randomised phase III trial (EORTC 62012) of single agent doxorubicin versus doxorubicin plus ifosfamide as first line chemotherapy for patients with advanced , soft tissue sarcoma: a survival study by the EORTC Soft Tissue and Bone Sarcoma Group.
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Results of a randomised phase III trial (EORTC 62012) of single agent doxorubicin versus doxorubicin plus ifosfamide as first line chemotherapy for patients with advanced, soft tissue sarcoma: a survival study by the EORTC Soft Tissue and Bone Sarcoma Group. Ian Judson, Jaap Verweij, Hans Gelderblom, Jorg- Thomas Hartmann, Patrick Schöffski, Jean-Yves Blay, Angelo Paolo dei Tos, Sandrine Marreaud, Saskia Litiere, Winette van der Graaf
Rationale of the study • The outcome of patients with soft tissue sarcomas with locally advanced unresectable primary tumors and/or metastatic disease is poor. • Systemic treatment is usually given in this situation with a palliative intent, but has toxicity. • There is (transatlantic) debate about the best first-line treatment in this situation: single agent doxorubicin or a combination of doxorubicin and ifosfamide
Rationale of the study (II) Which situation justifies which treatment, especially the more toxic combination treatment? And in designing studies with new drugs/treatments: what will be the standard treatment arm to compare with?
Previous studies EORTC study: randomized phase III trial (all grades) 663 pts (Santoro, et al 1995) A: doxorubicin 75 mg/m2 B: cyclophosphamide, vincristine, doxorubicin, and dacarbazine (CYVADIC) C: doxorubicin 50 mg/m2 plus ifosfamide 5 g/m2 Results: Overall Response rate: 24% median overall survival: Arm A: Doxorubicine : 23.3% 52 weeks Arm B: CYVADIC: 28.4% 51 weeks Arm C: Dox-IFOS: 28.1% 55 weeks
Several phase 2 studies: • Doxorubine 75 mg/m2 plus ifosfamide 10 g/m2 plus G-CSF. RR 66% in 33 pts, febrile neutropenia 31% of cycles (Patel, Am J Clin Oncol,1998) • High grade: Epirubicin 90 mg/m2 plus ifosfamide 12.5 g/m2 .RR 52% (Reichardt, J Clin Oncol, 1998). • Doxorubicin 90 mg/m2 plus ifosfamide 10 g/m2. RR 55%, grade 4 BM toxicity and sepsis (Leyvraz, Ann Oncol 1998)
The design • Stratification: • Age (<50 vs ≥50) • PS (0 vs 1) • Liver metastases (0 vs +) • Histological grade (2 vs 3) Doxorubicin 75 mg/m2 d 1 or as a 72 hour continousi.v. infusion R New Treatment: B Doxorubicin 25 mg/m2 d 1-3 + Ifosfamide2.5 g/m2 d 1-4 + Neulasta 6mg s.c. d5
End-points of the study The primary end point: overall-survival The secondary end points: response (RECIST) toxicity (CTC 2.0) treatment related mortality Early stopping rule: as PFS was used as surrogate for OS a failure to produce a significant improvement in PFS (at least 50% increase) would predict a likely failure
Statistical assumption • Improvement of survival is clinically significant if 1yr survival is at least 10% higher in the combination arm (60 versus 50%), corresponding with a HR of 0.737 or less. Two-sided logrank test (alpha=0.05, beta 0.2).
Inclusion criteria • Histological STS: advanced unresectable or metastatic disease. Surgery (for primary or metastatic disease) after chemotherapy following response allowed. • Histological grade 2 and 3 • Following tumor types: - leiomyosarcoma - malignant fibrous histiocytoma - liposarcoma (Myxoid/round cell, pleomorphic or dediferentiated) - synovial sarcoma - myxofibrosarcoma - fibrosarcoma - angiosarcoma - malignant peripheral nerve sheath tumor - epithelioid sarcoma
Inclusion criteria (continued) • Tumor material available for central review • Measurable disease according to RECIST 1.0 • No prior chemotherapy for advanced disease • Prior adjuvant chemotherapy allowed unless disease progression within 6 months following end of treatment • Age 18-60 years • WHO PS 0 or 1 • ANC higher than 2.0 and Platelets above 100 • Serum creatinine lower than 120 or clearance higher than 65, two functioning kidneys • Bilirubin less than 30 umol/l, albumin above 25 • No other serious illness • Normal LVEF • No symptomatic or known brain metastases • No prior or second primary malignancies (except CIS cervix or BCC)
Study status Accrual: • 455 patients entered the study • 38 centers in 9 countries • Start: 4-2003 (start EORTC), 5-2008 (NCIC- 13 patients) • Study Closure: 5-2010 Clinical cut-off • 5-7-2012 • Median follow-up: 56 months
The patient population Total randomized, N=455 Doxorubicin, N=228 Doxorubicin + Ifosfamide, N=227 3 did not start treatment 2 started other arm Ineligible, n = 7 Ineligible, n = 8 5 did not start treatment 1 started other arm 215 eligible patients started allocated treatment 217 eligible patients started allocated treatment
Overall survival HR = 0.83 (95.5% CI 0.67 – 1.03) Stratified logrank test, p = 0.076
Median overall survival: Doxorubicin: 12.8 months (95.5 CI 10.5-14.3) Doxorubicin-ifosfamide: 14.3 months (95.5% CI 12.5-16.5). Survival at 1-year: Doxorubicin: 51% (95.5% CI 44-58) Doxorubicin-ifosfamide: 60% (95.5% CI 53-66)
Progression free survival HR = 0.74 (95% CI 0.60 – 0.90) Stratified logrank test, p = 0.003
Median PFS Median PFS in the doxorubicin arm: 4.6 months (95% CI 2.9 – 5.6), in the combination arm 7.4 months (95% CI 6.6 – 8.3).
Best overall response Significant difference between the two arms: p < 0.001
Conclusions In this group of patients all below 60, median age 48 years The combination of doxorubicin and ifosfamide: • doubled the response rate • improved PFS significantly • it did not significantly improve survival • It was considerably more toxic than doxorubicin alone.
This study supports personalised medicine in daily practice... • The standard treatment in the palliative setting remains single agent doxorubicin • If surgery for unresectable tumors or curative metastasectomy is considered, combination therapy gives the highest chance of response • In highly symptomatic disease in patients without co-morbidity combination treatment is optional and pro’s and cons should – as always- be discussed with the patient. • ….and since we have the results of this study, these discussions can be more balanced than before.
Acknowledgements • Patients and their families • Investigators of all participating hospitals of EORTC, NCIC • The membership of the EORTC STBSG • EORTC Headquarters