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APPROACH: Multimodal Approach in Patients With mHSPC. Randomized Trial of APA+ADT vs APA-ADT and Local Treatment

Sponsor
Fondazione IRCCS Istituto Nazionale dei Tumori, Milano (Other)
Overall Status
Not yet recruiting
CT.gov ID
NCT05649943
Collaborator
ASST Santi Paolo e Carlo (Other), European Institute of Oncology (Other)
566
Enrollment
3
Locations
2
Arms
71
Anticipated Duration (Months)
188.7
Patients Per Site
2.7
Patients Per Site Per Month

Study Details

Study Description

Brief Summary

Italian multicenter study, will enroll ~566 pts with oligometastatic hormone sensitive prostate cancer who are candidates to receive treatment with apalutamide.

After 6 months from the start of treatment, patients will be randomized to receive local treatment based on the investigator's choice ( either one between primary radiotherapy or cytoreductive prostatectomy), in addition to apalutamide, or to continue just with medical therapy.

Condition or Disease Intervention/Treatment Phase
  • Drug: APA + ADT
  • Procedure: Local Treatmetn RT or RP
 N/A

Detailed Description

Primary end point: To determine whether treatment with apalutamide in combination with androgen-deprivative therapy for 6 months followed by locoregional treatment with radiotherapy or radical prostatectomy has better efficacy than medical treatment with apalutamide + ADT alone in terms of radiographic progression-free survival (rPFS), specifically time to radiographic progression in soft tissue per RECIST 1.1 or in bone per PCWG3 criteria by investigator, or death. Secondary end points: To evaluate tumor shrinkage after locoregional approach and to evaluate short and long term side effects after locoregional surgery or RT, time to PSA progression, time to castration resistance, cancer specific survival, overall survival and quality of life according to EPIC-26 and EQ-5D-5L questionnaires.

Study Design

Study Type:
Interventional
Anticipated Enrollment :
566 participants
Allocation:
Randomized
Intervention Model:
Parallel Assignment
Intervention Model Description:
RandomizedRandomized
Masking:
None (Open Label)
Primary Purpose:
Treatment
Official Title:
APPROACH : Multimodal Approach in Patients With mHSPC. A Pragmatic Randomized Trial of Apalutamide Plus Androgen Deprivation Therapy (APA-ADT) Versus APA-ADT Plus Local Treatment. A Meet-URO 29 Study
Anticipated Study Start Date :
Feb 2, 2023
Anticipated Primary Completion Date :
Jan 1, 2027
Anticipated Study Completion Date :
Jan 1, 2029

Arms and Interventions

Arm Intervention/Treatment
Other: APA + ADT + RP/RT

Apalutamide 240 mg, four 60 mg tablets as an oral single daily dose, according to clinical practice, plus Androgen Deprivation Therapy (ADT) plus clinician-driven choice local treatment with Radiotherapy or Radical Prostatectomy, six months after starting treatment with apalutamide

Drug: APA + ADT
All participants will receive apalutamide 240 mg (4 x 60 mg) tablets orally once daily. Apalutamide is distributed in Italy under the trade name of Erleada® 60 mg. All patients not undergoing surgical castration should also continue medical castration by taking a gonadotropin-releasing hormone (GnRHa) analogue during treatment.
Other Names:
  • Apalutamide 240 mg + Androgen Deprivation Therapy

    • Procedure: Local Treatmetn RT or RP
    Patients who will undergo radiotherapy as a local treatment must be treated according to the following scheme: External beam radiotherapy administered at 36 Gy in six consecutive weekly fractions of 6 Gy, or 55 Gy in 20 daily fractions of 2・75 Gy over 4 weeks. Radiation therapy will be given with the patient supine and with a full bladder and an empty rectum. The planned target volume is prostate only, with an 8 mm margin posteriorly and a 10 mm margin elsewhere. No RT on lymph nodes is foreseen. RT should begin 6 months after the first dose of apalutamide (+/- 2 weeks). Radical prostatectomy should be performed 6 months after the first dose of apalutamide (+/- 2 weeks).
    Other Names:
  • Local treatment with radiotherapy or radical prostatectomy, clinician-driven choice

    		•
    Other: APA + ADT

    Apalutamide 240 mg, four 60 mg tablets as an oral single daily dose, according to clinical practice, plus Androgen Deprivation Therapy (ADT)

    Drug: APA + ADT
    All participants will receive apalutamide 240 mg (4 x 60 mg) tablets orally once daily. Apalutamide is distributed in Italy under the trade name of Erleada® 60 mg. All patients not undergoing surgical castration should also continue medical castration by taking a gonadotropin-releasing hormone (GnRHa) analogue during treatment.
    Other Names:
  • Apalutamide 240 mg + Androgen Deprivation Therapy

    		•

    Outcome Measures

    Primary Outcome Measures

    1. Radiographic Progression-Free Survival (rPFS) [Up to 48 months]

      Evaluation of the efficacy of treatment with APA+ADT for 6 months followed by locoregional treatment with radiotherapy or radical prostatectomy compared to treatment with APA+ ADT alone in terms of Radiographic Progression-Free Survival (rPFS) in patients with hormone prostate adenocarcinoma -susceptible with low-volume metastatic disease.

    Secondary Outcome Measures

    1. Local event - free survival [Up to 48 months]

      Defined as the absence of one of the following conditions in the follow up: urinary retention, hydronephrosis, acute or chronic renal failure exacerbation, intestinal obstruction

    2. Local treatment - free survival [Up to 48 months]

      Defined as the absence of the need for one of the following interventions: trans-urethral resection of the prostate, placement of a ureteral stent or nephrostomy for hydronephrosis, bladder catheterization, surgery for intestinal obstruction/colostomy

    Eligibility Criteria

    Criteria

    Ages Eligible for Study:
    18 Years and Older
    Sexes Eligible for Study:
    Male
    Accepts Healthy Volunteers:
    No
    Inclusion Criteria:

    • Age > 18

    • Histologically confirmed diagnosis of prostate adenocarcinoma

    • Metastatic disease documented by ≥1 bone lesion with Technetium 99m (99mTc) bone scan. Individuals with only one bone lesion should have confirmation of that lesion on CT or MRI.

    • Eastern Cooperative Oncology Group Performance Status (ECOG PS) Grade ≤ 2

    • No previous treatment with antiandrogens or GnRH analogues, or a treatment ≤ 3 months.

    • No previous systemic or local treatment for prostate adenocarcinoma, including pelvic radiotherapy.

    • Laboratory values at the time of screening:

    1. Neutrophils ≥ 1500/μL b. Hemoglobin ≥ 9.0 mg/μL (no transfusions in the past 28 days) c. Platelets ≥ 100,000/μL d. Creatinine ≤ 2 x upper limit of normal and serum albumin ≥ 3.0 g/dL f. Total bilirubin ≤ 1.5 x upper limit of normal [NOTE: In subjects with Gilbert syndrome, if total bilirubin is >1.5 x ULN, measure direct and indirect bilirubin, and if direct bilirubin is ≤ 1.5 x ULN subjects may be eligible]; g. AST and ALT ≤ 2.5 x upper limit of normal

    • Able to swallow Apalutamide tablets whole.

    • All subjects must sign an Informed Consent Form indicating that they understand the purpose of the study and its procedures and intend to participate. The subject must be willing and must be able to comply with the restrictions specified in this protocol.

    Inclusion criteria for cytoreductive surgery:

    • Age >18 years

    • Clinical stage cT3

    • Robot-assisted radical prostatectomy with iliac obturator lymphadenectomy

    • Surgical piece management criteria similar to Proteus criteria.

    Exclusion Criteria:

    • Pathologic findings consistent with small cell, ductal, or neuroendocrine prostate cancer.

    • Known brain metastases.

    • Lymph node metastases only.

    • Visceral metastases.

    • Patients not eligible for surgery or radiotherapy.

    • Unacceptable increase in cardiovascular risk, defined as the occurrence of at least one of the following episodes in the 6 months prior to randomization: unstable angina, myocardial infarction, symptomatic congestive heart failure, clinically significant thromboembolic events (e.g., pulmonary embolism), or clinically significant ventricular arrhythmias .

    • Uncontrolled high blood pressure (systolic blood pressure > 160 mmHg or diastolic blood pressure > 100 mmHg).

    • Previous treatment with antiandrogens, GnRH analogues, or other systemic treatments for adenocarcinoma of the prostate.

    • Previous local treatment with surgery and/or radiotherapy.

    • Visceral metastases, ≥ 4 bone metastases or bone metastases other than the spine or from the pelvis.

    • Any prior malignancy (except adequately treated basal cell carcinoma or a squamous cell skin carcinoma, superficial bladder carcinoma, or any other in situ carcinoma currently in complete remission) within 5 years of randomization.

    • Known allergies, hypersensitivity or intolerance to the excipients of Apalutamide.

    • Patients who, within 28 days prior to randomisation, have received:

    1. transfusions (red blood cells and/or platelets);

    2. hematopoietic growth factors;

    3. major surgery.

    • Symptomatic and/or chronic viral hepatitis; chronic liver disease; moderate or severe liver failure (class B and C according to the Child-Pugh scale); encephalopathy, ascites or thrombo-haemorrhagic disorders secondary to liver failure.

    • Gastrointestinal disorders affecting drug absorption

    • Active infections requiring systemic therapy such as human immunodeficiency virus (HIV);

    • Any condition or situation which, in the judgment of the investigator, precludes participation in this trial.

    Exclusion criteria for cytoreductive surgery:
    • Contraindication for surgery

    Contacts and Locations

    Locations

    Site City State Country Postal Code
    1 European Institute of Oncology Milano Lombardia Italy 20141
    2 ASST Santi Paolo e Carlo Milano Lombardia Italy 20153
    3 Istituto Tumori Milano Milan Mi Italy 20156

    Sponsors and Collaborators

    • Fondazione IRCCS Istituto Nazionale dei Tumori, Milano
    • ASST Santi Paolo e Carlo
    • European Institute of Oncology

    Investigators

    • Principal Investigator: Valentina Guadalupi, MD, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano

    Study Documents (Full-Text)

    None provided.

    More Information

    Publications

    Responsible Party:
    Fondazione IRCCS Istituto Nazionale dei Tumori, Milano
    ClinicalTrials.gov Identifier:
    NCT05649943
    Other Study ID Numbers:
    • APP
    First Posted:
    Dec 14, 2022
    Last Update Posted:
    Jan 18, 2023
    Last Verified:
    Dec 1, 2022
    Studies a U.S. FDA-regulated Drug Product:
    No
    Studies a U.S. FDA-regulated Device Product:
    No
    Additional relevant MeSH terms:
    Hypersensitivity
    Androgens

    Study Results

    No Results Posted as of Jan 18, 2023