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Study to Compare Cardiovascular Side Effects of Teysuno Versus Capecitabine (TOFFEE)

This study is currently recruiting participants.
See Contacts and Locations
Verified June 2017 by University of Edinburgh
NHS Lothian
Information provided by (Responsible Party):
University of Edinburgh Identifier:
First received: April 29, 2013
Last updated: June 5, 2017
Last verified: June 2017
Capecitabine is a chemotherapy drug used to treat many types of cancer including bowel and stomach cancer. Unfortunately a side effect of this drug is that it causes heart problems including heart attacks. An alternative drug, called teysuno is used extensively in other countries instead of capecitabine and appears to have less of a bad effect on the heart whilst still killing cancer cells. This study will investigate the effect of these two drugs on the heart and blood vessels and will be the first of its kind in humans.

Condition Intervention Phase
Gastrointestinal Cancer Cancer of Unknown Primary Site Pancreatic Cancer Bile Duct Neoplasms Drug: Teysuno Drug: Capecitabine Phase 2

Study Type: Interventional
Study Design: Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double (Investigator, Outcomes Assessor)
Primary Purpose: Treatment
Official Title: Toxicity OF Fluoropyrimidines: A Comparative Study of the Cardiotoxicity of capEcitabine and tEysuno

Resource links provided by NLM:

Further study details as provided by University of Edinburgh:

Primary Outcome Measures:
  • The primary endpoint of the study will be a difference in the duration of ST deviation pre-treatment and during treatment. [ Time Frame: Pre treatment and between day 5-7 ]
    This will be recorded using Del Mar Reynolds Lifecard CF/Lifecard 12 recorders, which will record 12 leads over 24 hours and continuously if the storage card is changed daily. Pre-treatment control ECGs will be recorded for 24 hours. Continuous 12-lead monitoring shall be recorded for three days between day 5 and 7 of treatment.

Estimated Enrollment: 60
Actual Study Start Date: February 5, 2014
Estimated Study Completion Date: December 31, 2018
Estimated Primary Completion Date: December 31, 2018 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Active Comparator: Capecitabine single agent
Capecitabine 1250 mg/m2 twice daily, days 1-14 every 21 days
Drug: Capecitabine
Other Name: Xeloda tablets
Active Comparator: Capecitabine /Oxaliplatin
Capecitabine 1000 mg/m2 twice daily, days 1-14 every 21 days (in frail or elderly patients, a CAP dose of 750 mg/m2 BD should be considered). Oxaliplatin will be given as an iv infusion at a dose of 130 mg/m2 over 2-6 hours on day 1.
Drug: Capecitabine
Other Name: Xeloda tablets
Active Comparator: Teysuno single agent
Teysuno will be administered at a dose of 30 mg/m2 twice daily, for 14 days, with a subsequent 7-day rest period. Patients will be assigned a dose on the basis of body surface area (BSA) and will receive one of the following doses twice daily: 40mg (BSA < 1.5 m2), 45 mg (BSA 1. 5 to < 1.7 m2), 55mg (BSA 1.7 - 1.9 m2),
Drug: Teysuno
Other Name: Tegafur / Gimeracil / Oteracil
Active Comparator: Teysuno/ Oxaliplatin
Teysuno will be administered orally at a dose of 25mg/m2 twice daily, days 1-14 every 21 days Patients will be assigned a dose on the basis of body surface area (BSA) and will receive one of the following doses twice daily: 35mg (BSA < 1.5 m2), 40mg (BSA 1.5 to < 1.7 m2), 45mg (BSA 1.7 - 1.9 m2), 50mg (BSA >1.9 m2). Oxaliplatin will be given as an iv infusion at a dose of 130 mg/m2 over 2-6 hours on day 1.
Drug: Teysuno
Other Name: Tegafur / Gimeracil / Oteracil

Detailed Description:

Fluoropyrimidines (FPs) are widely used chemotherapy agents for the management of patients with colorectal, breast, upper gastrointestinal, head and neck cancers. Capecitabine is an oral prodrug of 5-fluorouracil (5FU) which is used extensively in the UK but is associated with clinically overt cardiotoxicity in up to 9% of patients. Cardiotoxicity occurs more commonly in patients with cardiovascular disease and manifests as chest pain, myocardial infarction, congestive heart failure, or sudden death with a mortality as high as 30%. In a study of continuous ECG Holter monitoring in patients receiving 5FU infusion, the majority (68%) of patients had ischaemic ECG changes and 2 patients died suddenly. We conducted a national survey of UK oncologists and 60% felt that 5FU/capecitabine cardiotoxicity was a significant problem in their clinical practice.

Hypotheses for this toxicity include ischaemia secondary to coronary artery spasm, direct endothelial cell toxicity, myocardial toxicity and interactions with the coagulation system. Studies implicate a catabolite of 5FU, in particular fluoro-alanine (FBAL). FBAL is further metabolized to fluoroacetate (FAC), a cardiac toxin that inhibits mitochondrial aconitase, resulting in cell death.

Teysuno is an oral fluoropyrimidine that has recently obtained a European licence. It is a combination of tegafur (5-FU prodrug), gimeracil (dihydropyrimidine dehydrogenase (DPD) inhibitor) and oteracil (phosphorylation inhibitor). There have been no reports of cardiac toxicity with teysuno. The incorporation of a DPD inhibitor should reduce FBAL concentrations which may prevent FP cardiotoxicity. However, this remains to be established.


Ages Eligible for Study:   18 Years to 100 Years   (Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Male or female patients at least 18 years or over with no upper age limit.
  • Confirmed advanced or metastatic oesophageal, gastric, gastro-oesophageal, small bowel, colorectal, hepatobiliary or pancreatic cancer or cancer of unknown primary.
  • Suitable for treatment with fluoropyrimidine, either alone or in combination with oxaliplatin.
  • WHO performance status (PS) 0, 1 or 2 and considered by responsible consultant to be fit to undergo planned chemotherapy and cardiac investigations.
  • Baseline laboratory tests (within 1 week prior to starting treatment):

    • Neutrophils >1.5 x109 /L and platelet count > 100 x109 /L
    • Serum bilirubin <1.5 x upper limit of normal (ULN), alkaline phosphatase <5x ULN, and serum transaminase (either AST or ALT) <3 x ULN
    • Estimated glomerular filtration rate (eGFR) >30 mL/min (Patients with eGFR 30-50 mL/min will be included but should be treated at a reduced dose (see master prescription chart).
  • For women of childbearing potential; negative pregnancy test and adequate contraceptive precautions.
  • Effective contraception for male patients if the risk of conception exists.
  • Written informed consent for participation in the trial.

Exclusion Criteria:

  • Patients who are unfit for the chemotherapy regimens in this protocol, such as:

    • Known intolerance to CAP or other FPs
    • Severe uncontrolled concurrent medical illness likely to interfere with protocol treatments
    • Poorly controlled angina or MI in previous 6 months
    • Any psychiatric or neurological condition which is felt likely to compromise the patient's ability to give informed consent or to comply with oral medication
    • Partial or complete bowel obstruction
    • Pre-existing neuropathy > grade 1 if combination therapy proposed
  • Patients on therapeutic anticoagulation (warfarin or LMWH).
  • Patients unable to lie flat.
  • Patients unable to withstand the visits and cardiovascular investigations proposed within the study.
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its identifier: NCT01845337

Contact: Sally Clive, MBChB MD 0131 537 2263 ext 32263
Contact: Alan Christie, MBChB 0131 537 1925 ext 31925

United Kingdom
Edinburgh Cancer Centre Recruiting
Edinburgh, Scotland, United Kingdom, EH4 2XU
Contact: Sally Clive, MBChB    0131 777 350      
Principal Investigator: Sally Clive, MBChB MD         
Sub-Investigator: Alan Christie, MBChB         
Sponsors and Collaborators
University of Edinburgh
NHS Lothian
Principal Investigator: Sally Clive, MBChB University of Edinburgh
  More Information

Responsible Party: University of Edinburgh Identifier: NCT01845337     History of Changes
Other Study ID Numbers: 2012-005282-12
Study First Received: April 29, 2013
Last Updated: June 5, 2017
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Undecided

Additional relevant MeSH terms:
Pancreatic Neoplasms
Gastrointestinal Neoplasms
Bile Duct Neoplasms
Neoplasms, Unknown Primary
Digestive System Neoplasms
Neoplasms by Site
Endocrine Gland Neoplasms
Digestive System Diseases
Pancreatic Diseases
Endocrine System Diseases
Gastrointestinal Diseases
Biliary Tract Neoplasms
Bile Duct Diseases
Biliary Tract Diseases
Neoplasm Metastasis
Neoplastic Processes
Pathologic Processes
Antimetabolites, Antineoplastic
Molecular Mechanisms of Pharmacological Action
Antineoplastic Agents processed this record on September 21, 2017