ptk/zk: an oral multi-vegf receptor inhibitor
DESCRIPTION
A Randomized, Double-blind, Placebo-controlled Phase III Study in Patients with Metastatic Colorectal Cancer Receiving First-line Chemotherapy with FOLFOX 4 and PTK/ZK or Placebo (CONFIRM-1). - PowerPoint PPT PresentationTRANSCRIPT
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A Randomized, Double-blind, Placebo-controlled Phase III Study in Patients with Metastatic Colorectal
Cancer Receiving First-line Chemotherapy with FOLFOX 4 and PTK/ZK or Placebo
(CONFIRM-1)
J R Hecht, T Trarbach, E Jaeger, J Hainsworth, R Wolff, K Lloyd, G Bodoky, M Borner, D Laurent, C Jacques
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PTK/ZK: An Oral Multi-VEGF Receptor Inhibitor
Potent inhibitor of all known VEGF receptors
Also inhibits PDGFR and c-Kit
Half life of 3 to 6 hours
Oral once-daily dosing Fit of PTK/ZK (green)
into the ATP binding site
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VEGF-AVEGF-CVEGF-D
VEGF-A VEGF-BPlGF
VEGF-CVEGF-D
VEGFR-1/Flt-1 VEGFR-2/KDR VEGFR-3/Flt-4
PTK/ZK
Extracellular
Intracellular
Angiogenesis Angiogenesis LymphangiogenesisTumor metastasis
PTK/ZK Inhibits All Known Receptors of VEGF
Endothelial Cell
PTK/ZK PTK/ZK
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Proof of Concept in mCRC
Baseline
Day 2 PTK/ZK
Morgan B, et al. J Clin Oncol. 2003;21: 3955-3964 Steward W, et al. ASCO 2004
Baseline
Tumor vascularity and permeability decreased rapidly with PTK/ZK and correlated with clinical benefit
Subsequent PTK/ZK-FOLFOX combination showed promising activity
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1168 Patients
Stratification Factors:PS: 0, 1-2
LDH: ≤, >1.5 x ULN
FOLFOX 4 +PTK/ZK 1250 mg po qd
CONFIRM-1 Trial Design
FOLFOX 4 +Placebo
Multinational randomized phase III trial in previously untreated mCRC
RANDOMIZED
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Main Eligibility Criteria
Metastatic colorectal cancer patients
No prior chemotherapy for metastatic disease
Prior adjuvant chemotherapy allowed (> 6 mo)
Measurable disease per RECIST criteria
WHO PS 0-2
Adequate hematological and organ function
No exclusions for prior coagulopathy or bleeding
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Primary Study Objectives
Progression-free survival Independent central radiological review
Primary analysis Investigator assessment Statistical hypothesis
25% reduction in risk of progression (HR 0.75)
Overall survival Statistical hypothesis
One-year OS rate from 71% to 76% (HR 0.80)
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Patient Characteristics
CharacteristicsFOLFOX 4 + PTK/ZK
N=585FOLFOX 4 + Placebo
N=583
Median Age (yrs) 59 61
Male / Female (%) 63 / 37 60 / 40
WHO PS 0 / 1 / 2 (%) 55 / 41 / 4 54 / 40 / 6
Colon / Rectum (%) 71 / 26 68 / 30
Liver Metastasis (%) 80 74
Lung Metastasis (%) 26 31
Number of Organs Involved (%)
1 46 43
2 33 34
> 3 19 22
Median LDH at Baseline 0.95 x ULN 0.95 x ULN
Prior Adjuvant Chemotherapy (%) 26 28
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Patient Disposition
FOLFOX 4 + PTK/ZK
N= 585
(%)
FOLFOX 4 + Placebo
N=583
(%)
Patients ongoing 25 32
Patients discontinued due to:
Progressive disease 33 42
Adverse event 21 11
Withdrawal of consent 12 7
Other reasons 9 8
1168 patients were randomized between February 2003 and May 2004
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Safety
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Grade 3/4 NCI Adverse Events in >5% of Patients
Adverse Events
FOLFOX 4 + PTK/ZK
N=579
(%)
FOLFOX 4 + Placebo
N=574
(%)
Grade 3 Grade 4 Grade 3 Grade 4
Neutropenia 17 14 21 11
Thrombocytopenia 6 <1 4 <1
Diarrhea 15 <1 10 <1
Nausea 9 N/A 5 N/A
Vomiting 7 <1 6 <1
Abdominal pain 4 <1 5 <1
Peripheral neuropathy 9 <1 7 <1
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Grade 3/4 NCI Adverse Events in >5% of Patients
Adverse Events
FOLFOX 4 + PTK/ZK
N=579
(%)
FOLFOX 4 + Placebo
N=574
(%)
Grade 3 Grade 4 Grade 3 Grade 4
Hypertension 21 <1 6 <1
Dizziness 7 <1 2 0
Venous thrombosis 7 <1 4 <1
Pulmonary embolism N/A 6 N/A 1
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Other Clinically Important Adverse Events
Adverse Events
FOLFOX 4 + PTK/ZK
N=579
(%)
FOLFOX 4 + Placebo
N=574
(%)
Bleeding (gr 3-4) 2.9 2.8
Arterial thrombosis (gr 3-4) 1.9 1.4
Bowel perforation 0.2 0.7
Reversible posterior encephalopathy
0.5 0
Deaths of any cause within 28 days of last study drug administration
5 6
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Efficacy
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Response Rate
FOLFOX 4 + PTK/ZK
N=585
(%)
FOLFOX 4 + Placebo
N=583
(%)P-value
CR 3 3 N.S.
PR 39 43 N.S.
SD 37 33 N.S.
PD 16 15 N.S.
UNK 6 6 N.S.
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0
25
50
75
100
0 2 4 6 8 10 12Time since randomization, months
Progression-free survival,
%
Progression-Free Survival: Central Assessment (Primary Analysis)*
HR 0.88
(95% CI) (0.74, 1.03)
P-value 0.118
PTK/ZK + FOLFOX4Placebo + FOLFOX4
*If assessment is delayed or missed, date of PDis adjusted to previous planned assessment date
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Progression-Free Survival: Investigator Assessment
HR 0.82
(95% CI) (0.69, 0.97)
P-value 0.019
0
25
50
75
100
0 2 4 6 8 10 12Time since randomization, months
Progression-free survival, %
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PFS:Hazard Ratio
0.80.60.4 1.61.41.2
Overall
1.0
0.118
1.8
HR P-value
In favor of PTK/ZK In favor of placebo
0.88Central
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PFS:Hazard Ratio
0.80.60.4 1.61.41.2
Overall
1.0
0.118
0.026
1.8
HR P-value
In favor of PTK/ZK In favor of placebo
0.88
0.83
Central
Investigator
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High LDH, PS 1-2
PFS by Pre-Planned Stratum:Hazard Ratio
0.80.60.4 1.61.41.2
Low LDH, PS 0
Overall Population
1.0
High LDH, PS 0
Low LDH, PS 1-2
1.8
In favor of PTK/ZK In favor of placebo
CentralInvestigator
0.118
0.026
HR P-value
0.88
0.83
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Progression-Free Survival:Exploratory Analysis in Patients with High LDH (n=316)
0
25
50
75
100
0 2 4 6 8 10
Time since randomization, months
Progression-free survival, %
Central Assessment Investigator Assessment
0
25
50
75
100
0 2 4 6 8 10
Time since randomization, months
Progression-free survival, %PTK/ZK + FOLFOX4Placebo + FOLFOX4
PTK/ZK + FOLFOX4Placebo + FOLFOX4
HR 0.68(95% CI) (0.50, 0.92)P-value 0.012
HR 0.60(95% CI) (0.44, 0.82)P-value 0.001
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Future Directions
CONFIRM 1 overall survival data expected second half
2006
CONFIRM 2 final results expected 2006
FOLFOX +/- PTK/ZK in second-line CRC
Optimize dosing schedule to reduce early treatment
discontinuation and improve efficacy
Explore the biology and clinical relevance of predictive
factors such as LDH in CRC
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Conclusions
PFS based on central review showed a modest benefit of adding PTK/ZK to FOLFOX which did not reach statistical significance
Preplanned secondary analysis of PFS based on investigator assessment showed a statistically significant improvement favoring PTK/ZK
PTK/ZK in combination with FOLFOX is generally well tolerated
High LDH levels may predict which patients are most likely to benefit from PTK/ZK
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Acknowledgments
UCLA/TORI Dennis Slamon Nancy Ryba David Reese David Chan, Ravi Patel NCCRA Mike and Michele Richman
University of Essen Krankenhaus Nordwest, Frankfurt Sarah Cannon Cancer Center MD Anderson Cancer Center Virginia Cancer Institute Szent Laszlo Hospital, Budapest Institute for Medical Oncology,
Bern
The Patients and Their Families
The Investigators in Over 200 Medical Centers Worldwide
Novartis David Lebwohl Andrea Kay Bee-Lian Chen Andrew Henry Eric Masson
Schering AG Germany Andrea Wagner Christine Gonschorek Michael Kretschmann Martina Poethig Silke Zaun