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ADAURA
- Thread starter scarbrtj
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Or survival
Immediate hormonal therapy compared with observation after radical prostatectomy and pelvic lymphadenectomy in men with node-positive prostate cancer - PubMed
Immediate antiandrogen therapy after radical prostatectomy and pelvic lymphadenectomy improves survival and reduces the risk of recurrence in patients with node-positive prostate cancer.pubmed.ncbi.nlm.nih.gov
Oh, the Messing trial. It does indeed deserve a very special spot in the library of "How to run a trial in the wrong way..."
The Messing-trial was performed in the pre-PSA-era. Meaning you either got ADT immediately after surgery (experimental) or you didn't (control). When did you get ADT if you were in the control arm? When your hip broke due to the metastasis chewing through it...
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Scarb, I am pretty certain that ADAURA will show an OS benefit down the road. It is clear.
But what is also clear is the fact that the ADAURA population is very different than the population we are treating.
1. Bad disease control in the control group --> perhaps due to understaging or bad surgery?
2. Low rates of adjuvant chemotherapy in both groups --> another indicator of "bad practice". And no, it's not an indicator of not-healthy-patients. Over two thirds of them were PS0, yet less than half got chemotherapy. Bearing in mind the typical EGFR-positive-NSCLC-patient (--> non-smoker) this certainly raises doubts
3. Underutilization of EGFR-therapy in the control group upon progression.
What would happen in an ideal trial, where:
1. Patients in the control group would have adequate disease control, like what we know from registries and other trials.
2. 75-80% of patients got adjuvant chemotherapy
3. Virtually all patients in the control group would receive Osimertinib upon first progression
???
-->
1. Overall higher DFS in both groups, especially in the control group --> difference in DFS shrinks
2. Overall higher DFS in both groups, especially in the control group --> difference in DFS shrinks
3. Rates of disease control in the control group after failure much better --> potential influence of already established DFS-difference on OS shrinks.
The best way to test the Number 3 hypothesis is to look at the rates of disease control upon progression.
If the patients on the control group would be able to get EGFR-directed therapy their disease control rate AFTER progression would be BETTER than the disease control rate of the adjuvant Osimertinib group (who would have exhausted EGFR-directed-therapy) and would be left with chemotherapy and/or IO (which doesn't work well in EGFR-NSCLC anyways). Let's wait for that data.
But what is also clear is the fact that the ADAURA population is very different than the population we are treating.
1. Bad disease control in the control group --> perhaps due to understaging or bad surgery?
2. Low rates of adjuvant chemotherapy in both groups --> another indicator of "bad practice". And no, it's not an indicator of not-healthy-patients. Over two thirds of them were PS0, yet less than half got chemotherapy. Bearing in mind the typical EGFR-positive-NSCLC-patient (--> non-smoker) this certainly raises doubts
3. Underutilization of EGFR-therapy in the control group upon progression.
What would happen in an ideal trial, where:
1. Patients in the control group would have adequate disease control, like what we know from registries and other trials.
2. 75-80% of patients got adjuvant chemotherapy
3. Virtually all patients in the control group would receive Osimertinib upon first progression
???
-->
1. Overall higher DFS in both groups, especially in the control group --> difference in DFS shrinks
2. Overall higher DFS in both groups, especially in the control group --> difference in DFS shrinks
3. Rates of disease control in the control group after failure much better --> potential influence of already established DFS-difference on OS shrinks.
The best way to test the Number 3 hypothesis is to look at the rates of disease control upon progression.
If the patients on the control group would be able to get EGFR-directed therapy their disease control rate AFTER progression would be BETTER than the disease control rate of the adjuvant Osimertinib group (who would have exhausted EGFR-directed-therapy) and would be left with chemotherapy and/or IO (which doesn't work well in EGFR-NSCLC anyways). Let's wait for that data.
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Ultrafractionation with PULSAR on CyberZapTron!
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Yowsa. Every time I think I have a great idea someone came up with it first. If you look at some of the “new radiobiology” there is a possibility the sweet spot doses could be more in the 0.1-1 Gy range for some tumors versus SABR type doses.
Bob Timmerman, man. A decade ahead of us all his whole career.
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Similar trial that showed a PFS benefit, though not so large, but no OS benfit:
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Timmerman really needs to drop his focus on "new biology" and spend all his efforts studying something truly innovative such as if 1 x 30 Gy is a more convenient stereo regimen than 12 Gy x 4.
In the metastatic setting, those treated with Osi didn't have much a tail on their survival curves, as opposed to trials in immunotherapy in patients with a high TPS. Is Osi curative, or just delaying the inevitable
While it's hard to extrapolate metastatic patients to the adjuvant setting, one has to wonder whether those with microscopic disease following surgery who receive Osi will suffer the same fate: 2 years of disease control followed by development of resistance mechanisms. The best trial for a drug like this would be adjuvant vs. salvage (especially considering the price). If it turns out there is no benefit to early vs. late, it would probably be best to treat stage III EGFR+ patients with PORT and save the Osi for a rainy day.
While it's hard to extrapolate metastatic patients to the adjuvant setting, one has to wonder whether those with microscopic disease following surgery who receive Osi will suffer the same fate: 2 years of disease control followed by development of resistance mechanisms. The best trial for a drug like this would be adjuvant vs. salvage (especially considering the price). If it turns out there is no benefit to early vs. late, it would probably be best to treat stage III EGFR+ patients with PORT and save the Osi for a rainy day.
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Only radiation oncologists run adjuvant vs salvage trials (at least as has happened in Prostate)
What's the rationale for medical oncologists (*cough* pharma *cough*) to run the trial you request? Medical oncologists aren't actively working to reduce their footprint in cancer therapy.
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I posted two trials, RADIANT and ADJUVANT-CTONG which seem to support the idea that a pfs benefit in this population does not equate to an OS benefit.
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While the Messing trial certainly may not be directly applicable in the PSA era, My hunch is that it would show a cancer specific survival benefit (albeit less of one) even in today's era. Why? Because pretty much every study looking at ADT has suggested earlier and more intensive ADT = better cancer survival. Probably not worth the overtreatment in those that never biochemically recur or recur with slowly doubling PSAs, but there you have it.
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I don't think I can agree with that.
The EPC trial for instance, which is the largest project with over 8000 men, randomized patients to adjuvant bicalutamide 150 mg/d versus nothing after s.o.c. and failed to show an overall survival benefit post-prostatectomy. Bicalutamide merely enhanced PFS.
Bicalutamide 150 mg plus standard care vs standard care alone for early prostate cancer - PubMed
This ongoing programme is clarifying the role of early or adjuvant antiandrogen therapy in prostate cancer. Patients with localized disease do not appear to derive clinical benefit from added bicalutamide. However, adding bicalutamide 150 mg to standard care provides significant clinical...
pubmed.ncbi.nlm.nih.gov
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I don't think I can agree with that.
The EPC trial for instance, which is the largest project with over 8000 men, randomized patients to adjuvant bicalutamide 150 mg/d versus nothing after s.o.c. and failed to show an overall survival benefit post-prostatectomy. Bicalutamide merely enhanced PFS.
Bicalutamide 150 mg plus standard care vs standard care alone for early prostate cancer - PubMed
This ongoing programme is clarifying the role of early or adjuvant antiandrogen therapy in prostate cancer. Patients with localized disease do not appear to derive clinical benefit from added bicalutamide. However, adding bicalutamide 150 mg to standard care provides significant clinical...
I don't think I can agree with that.
The EPC trial for instance, which is the largest project with over 8000 men, randomized patients to adjuvant bicalutamide 150 mg/d versus nothing after s.o.c. and failed to show an overall survival benefit post-prostatectomy. Bicalutamide merely enhanced PFS.
Bicalutamide 150 mg plus standard care vs standard care alone for early prostate cancer - PubMed
This ongoing programme is clarifying the role of early or adjuvant antiandrogen therapy in prostate cancer. Patients with localized disease do not appear to derive clinical benefit from added bicalutamide. However, adding bicalutamide 150 mg to standard care provides significant clinical...
1. Crap ADT. 2. Mostly low risk prostate cancer in that group. A magic pill that cured all prostate cancer would have a minimal survival impact. There did appear to be a benefit in T3 or greater (I.e half of men getting treatment now).
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Then it falls upon the urologists to design and successfully carry out a well designed randomized trial on the role of ADT as adjuvant treatment after resection of high-risk prostate cancer demonstrating an overall survival benefit. Until that happens, ADT use in that constellation cannot be recommended and is actually not recommended by any guideline.
Radiation oncologists have carried out dozens of randomized trials on ADT together with RT in prostate cancer.
These trials have proven when and why and to what extent ADT is beneficial with RT. Why should we expect less from the urologists?
From the combined EAU-EANM-ESTRO-ESUR-SIOG Guideline 2020
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Reasonable take. And those trials were done and mostly negative, though once again this was mostly in the low risk patient era. More recently CALGB study showed ?mild OS (secondary endpoint) benefit for neoadjuvant chemohormonal therapy in high risk disease. https://ascopubs.org/doi/full/10.1200/JCO.20.00315.
Worth the toxicity? The authors suggest no and most Urologists I've spoken with agree. The 5 year BPFS in surgery alone though was 75%, which is higher then most would expect for high risk disease,, making it tough to show much of a benefit without significantly longer followup.
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We don't have anything that has improved DMFS or OS in high-risk patients for sometime. BPFS not a good marker for DMFS/OS (See Dan Spratt's rants on this on Twitter).
Relevant twitter thread discussing this trial:
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RTOG 0521 suggests there may be a role for docetaxel in high risk prostate cancer. Although technically did not meet its primary endpoint, there was an overall survival benefit in favor of the doce arm that may play out with longer follow up. https://ascopubs.org/doi/full/10.1200/jco.18.02158
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That trial lead to it being included in the nccn awhile back as cat1. It is now a footnote only because some European data wasn't confirmatory (iirc the Europe data wasn't as pure, some int risk disease included etc)
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Another victim of a one-sided test. Better systemic agents on the horizon.