Evaluating intermittent androgen-deprivation therapy phase III clinical trials

The devil is in the details

Maha Hussain, Catherine Tangen, Celestia Higano, Nicholas Vogelzang, Ian Thompson

Research output: Contribution to journalArticle

17 Citations (Scopus)

Abstract

Purpose: Intermittent androgen deprivation (IAD) has been widely tested in prostate cancer. However, phase III trials testing continuous androgen deprivation (CAD) versus IAD have reached inconclusive and seemingly contradictory results. Different design and conduct issues must be critically evaluated to better interpret the results. Patients and Methods: Seven published phase III trials were examined for prespecified design and outcomes. Treatment specifications; primary end point; superiority versus noninferiority design assumptions, including magnitude of assumed versus observed noninferiority margin (NIM); duration of follow-up; and quality-of-life (QOL) outcomes were considered in terms of the results and conclusions reported. Results: Five trials had a superiority and three had a noninferiority primary hypothesis. Only three trials had a uniform population and overall survival (OS) end point. All trials observed better outcomes in terms of OS and progression-free survival (PFS) than assumed at time of study design, translating into prespecified NIMs or hazard ratios that reflected larger absolute differences in OS or PFS between arms. Lower-than-expected event rates also reduced statistical power for the trials. Other factors, including length of follow-up, cause of death, QOL, and primary end point, and their impact on trial interpretation are discussed. Conclusion: No trial to date has demonstrated survival superiority of IAD compared with CAD. Trials concluding IAD is noninferior to CAD were based on wide NIMs that included clinically important survival differences, not likely to be considered comparable by physicians or patients. Interim analyses relying on short follow-up and including a majority of non-prostate cancer deaths will favor a noninferiority conclusion and should be interpreted cautiously. Adequate follow-up is required to ensure capture of prostate cancer deaths in both superiority and noninferiority trials.

Original languageEnglish (US)
Pages (from-to)280-285
Number of pages6
JournalJournal of Clinical Oncology
Volume34
Issue number3
DOIs
StatePublished - Jan 20 2016
Externally publishedYes

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Phase III Clinical Trials
Androgens
Survival
Therapeutics
Disease-Free Survival
Prostatic Neoplasms
Quality of Life
Time and Motion Studies
Cause of Death
Physicians
Population

ASJC Scopus subject areas

  • Cancer Research
  • Oncology

Cite this

Evaluating intermittent androgen-deprivation therapy phase III clinical trials : The devil is in the details. / Hussain, Maha; Tangen, Catherine; Higano, Celestia; Vogelzang, Nicholas; Thompson, Ian.

In: Journal of Clinical Oncology, Vol. 34, No. 3, 20.01.2016, p. 280-285.

Research output: Contribution to journalArticle

Hussain, Maha ; Tangen, Catherine ; Higano, Celestia ; Vogelzang, Nicholas ; Thompson, Ian. / Evaluating intermittent androgen-deprivation therapy phase III clinical trials : The devil is in the details. In: Journal of Clinical Oncology. 2016 ; Vol. 34, No. 3. pp. 280-285.
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abstract = "Purpose: Intermittent androgen deprivation (IAD) has been widely tested in prostate cancer. However, phase III trials testing continuous androgen deprivation (CAD) versus IAD have reached inconclusive and seemingly contradictory results. Different design and conduct issues must be critically evaluated to better interpret the results. Patients and Methods: Seven published phase III trials were examined for prespecified design and outcomes. Treatment specifications; primary end point; superiority versus noninferiority design assumptions, including magnitude of assumed versus observed noninferiority margin (NIM); duration of follow-up; and quality-of-life (QOL) outcomes were considered in terms of the results and conclusions reported. Results: Five trials had a superiority and three had a noninferiority primary hypothesis. Only three trials had a uniform population and overall survival (OS) end point. All trials observed better outcomes in terms of OS and progression-free survival (PFS) than assumed at time of study design, translating into prespecified NIMs or hazard ratios that reflected larger absolute differences in OS or PFS between arms. Lower-than-expected event rates also reduced statistical power for the trials. Other factors, including length of follow-up, cause of death, QOL, and primary end point, and their impact on trial interpretation are discussed. Conclusion: No trial to date has demonstrated survival superiority of IAD compared with CAD. Trials concluding IAD is noninferior to CAD were based on wide NIMs that included clinically important survival differences, not likely to be considered comparable by physicians or patients. Interim analyses relying on short follow-up and including a majority of non-prostate cancer deaths will favor a noninferiority conclusion and should be interpreted cautiously. Adequate follow-up is required to ensure capture of prostate cancer deaths in both superiority and noninferiority trials.",
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