Prevention of Pegfilgrastim-induced Bone Pain (PIP): A URCC CCOP Randomized, Double-blind,...
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Transcript of Prevention of Pegfilgrastim-induced Bone Pain (PIP): A URCC CCOP Randomized, Double-blind,...
Prevention of Pegfilgrastim-induced Bone Pain (PIP): A URCC CCOP Randomized, Double-blind, Placebo-controlled Trial of 510 Cancer Patients
Jeffrey J. Kirshner, Charles E. Heckler, Shaker R. Dakhil, Judith O. Hopkins, Cynthia Coles, Gary R. Morrow. Hematology-Oncology Associates of Central NY CCOP, East Syracuse, NY, U. of Rochester Cancer Center, Rochester, NY, Wichita CCOP, Wichita, KS, SECCC, Winston-Salem, NC, Metro-Minnesota CCOP, Minneapolis, MN
Disclosures
• None to report for any of the investigators
Background• The development of G-CSF,
particularly pegfilgrastim, has enabled oncologists to maintain dose intensity and to utilize “dose-dense” chemotherapy ( by limiting the severity and duration of neutropenia)
• This may lead to an improvement in patient survival
• The toxicity of pegfilgrastim is minimal and usually limited to bone pain
Background
• The incidence of pegfilgrastim-induced bone pain ranges from 26-59 % and can be “severe” in up to 24 % of patients
• Discontinuation of pegfilgrastim could lead to less effective chemotherapy dosing and a decrease in patient survival
Community Based Survey of 100 Patients (Kirshner, et al: Community Oncology 2007)
• 59% incidence of pegfilgrastim-induced pain• 24% incidence of severe pain (>5/10)• NSAIDs seemed to be the most effective
analgesic for relief of pain, particularly naproxen
“An Ounce of Prevention Is Worth a Pound of Cure”• It is better to prevent pain than to treat it
once it occurs• This could improve QOL and possibly
keep more patients on their chemotherapy schedule
• NSAIDs seem to be somewhat effective in relieving pegfilgrastim-induced pain
• NSAIDs have few side-effects and are relatively inexpensive
Study Objectives• To determine if naproxen can reduce the
incidence, severity and duration of pegfilgrastim-induced pain
• To better assess the true incidence of this pain in a large cross-section of patients treated by community oncologists
• To determine if there are risk factors which predict the development of such pain
• To determine if there are factors which predict efficacy of naproxen
Study Design
Prior to first dose of pegfilgrastim
• Consent
• Questionnaires
• Randomize to naproxen/placebo
[Baseline]
Prior to first dose of pegfilgrastim
• Consent
• Questionnaires
• Randomize to naproxen/placebo
[Baseline]
Study participation ends
• Complete and mail outcome questionnaires
[Outcome]
Study participation ends
• Complete and mail outcome questionnaires
[Outcome]
Day 2, 3 or 4 of chemotherapy cycle
• pegfilgrastim administered SC
• Begin Study Medication
• Return Baseline questionnaires
• Outcome questionnaires
Day 2, 3 or 4 of chemotherapy cycle
• pegfilgrastim administered SC
• Begin Study Medication
• Return Baseline questionnaires
• Outcome questionnaires
Phone Call 3-5 days after pegfilgrastim administration
Phone Call 3-5 days after pegfilgrastim administration
5 to 8 days of naproxen sodium or placebo
5 to 8 days of naproxen sodium or placebo
Study Drug
• Naproxen 500 mg or matching placebo was begun at BID dosing on the morning of pegfilgrastim administration
• Drug was continued for a minimum of 5 days and up to 8 days if pain continued
Questionnaires• Patient rated their pain on a daily
basis, using a scale of 0-10 (Brief Pain Inventory)
• Quality of Life (QOL) assessments before and after treatment, utilizing “Symptom Inventory”
• Any additional medications to control pain were documented (additional NSAIDs were excluded)
Statistical Measures
• Primary outcome was measurement of the AUC from baseline to Day 5 (Day 1= Day of pegfilgrastim administration)
• Incidence of any pain and severe pain (>5/10) was measured as well as duration of pain
AUC=13.5
Area Under Curve (AUC)
Eligibility• Diagnosis of non-myeloid malignancy,
scheduled to receive chemotherapy and receive a first dose of pegfilgrastim (6mg sq) on Day 2, 3 or 4 of chemotherapy cycle
• No history of active or past gastrointestinal bleeding
• No heart surgery within the past 6 months
• No allergies to NSAIDs
Eligibility
• Not currently taking any NSAID or steroid medication
• Not taking any medication for pre-existing chronic pain
• Not taking therapeutic doses of warfarin
• Normal renal function (creatinine < 1.5 X ULN)
Eligibility
• Not pregnant or nursing• Able to understand English• 18 years of age or older• Must give written informed consent
Demographics at Randomization
N=510; 257(Drug), 253 (Placebo).
No significant difference in arms for any characteristic.
Accrual from 7/08-12/09
N %
Female: 437 86%
African American: 33 6%
Asian: 14 3%
Caucasian: 455 89%
Other: 8 2%
Breast: 341 67%
Gynecological: 29 6%
Hematological: 35 7%
Lung: 53 10%
Other: 50 10%
Married: 360 71%
Some College: 344 68%
High school or less: 160 32%
Mean (Min-Max)
Age: 56.2 (22-89)
Patient Population• URCC CCOP
Research Base Study at 17 CCOP’s throughout the U.S.
• Accrual ranged from 1 to 110 at the sites
Central Illinois CCOP Gulf Coast MBCCOP North Shore University Hospital CCOP
Columbia River CCOP Hawaii MBCCOP Northwest CCOP
Columbus CCOP Hematology-Oncology of CNY CCOP Southeast Cancer Control Consortium
Dayton Clinical Oncology Program Kalamazoo CCOP University of Illinois at Chicago MBCCOP
Evanston CCOP Kansas City CCOP Upstate Carolina CCOP
Grand Rapids CCOP Marshfield Clinic Research Foundation CCOP Virginia Mason Research Center CCOP
Greenville CCOP Metro-Minnesota CCOP Wichita CCOP
Nevada Cancer Research Foundation CCOP
CCOPs
URCC
University of Rochester Cancer CenterCommunity Clinical Oncology Research Base
Map of Affiliates (2009)
Participant Flow
257 Randomized to Drug
253 Randomized to Control
N = 232 Analyzed N = 229 Analyzed
1 Ineligible
24 Did Not Complete Outcome Measures
510 Participants
24 Did Not Complete Outcome Measures
ResultsAUC for Pain was reduced from 7.7 (placebo group) to 6.0 (naproxen group)
p=0.037
Drug Placebo PPain 65.6% 76.3% 0.01Severe Pain 17.6% 24.5% 0.06
Incidence of Pain
Average Pain across Days
Repeated Measures Analysis:
P(Arm)=0.04
P(Arm*Day)=0.31
(Curves don’t have significantly different shapes.)
N=461
Duration of Pain
• 2.40 days (placebo) vs. 1.92 days (naproxen)
• P= 0.005
Risk Factors for Pain
• No relationship to age, types of cancer nor chemotherapy
• Suggestion that pegfilgrastim induced pain may be more frequent in African-Americans (but only 33 patients): AUC 12.88 vs 6.48
Relationship to Efficacy of Naproxen• No effect of age, race, type of cancer
nor chemotherapy regimen
Adverse Events
• None reported on either study arm• Specifically, no reports of
gastrointestinal bleeding or GI distress
Conclusions• Naproxen 500 mg BID is effective in
reducing the incidence, severity and duration of pegfilgrastim induced bone pain
• It should be considered for patients beginning pegfilgrastim, providing there are no contraindications
• A significant percentage of patients still will experience pegfilgrastim induced pain and there is a need to develop more effective preventive treatments
Acknowledgments
• NCI DCP- CCOP Program (PHS Grants: 1R25CA10618 and U10CA37420)
• CCOP Investigators and Staff• Patients, Family and Friends