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The Prevention of Progression to Pancreatic Cancer Trial (The 3P-C Trial)

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ClinicalTrials.gov Identifier: NCT04207944
Recruitment Status : Recruiting
First Posted : December 23, 2019
Last Update Posted : March 30, 2021
Sponsor:
Collaborators:
Johns Hopkins University
Massachusetts General Hospital
Memorial Sloan Kettering Cancer Center
National Cancer Institute (NCI)
Information provided by (Responsible Party):
Duke University

Brief Summary:

This is a multi-center randomized double-blind placebo controlled trial of patients with high-risk intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. The primary objective is to evaluate the effect of sulindac on the presence or absence of progression of IPMN after 3 years of treatment.

Patients without contraindications will be considered to be eligible and will be required to have a cross-sectional imaging study of the pancreas (pancreas protocol CT or CT angiogram of the pancreas) within 3 months of study entry to document residual IPMNs and to rule out any evidence of pancreatic cancer. Patients will be randomized to receive either sulindac (200 mg p.o. BID) plus standard radiographic and endoscopic surveillance or placebo plus standard radiographic and endoscopic surveillance. Randomization will be stratified by (1) whether the patient had high-grade dysplasia identified in the initial resection specimen (resected patients only) and (2) whether the patient is taking metformin at the time of randomization.


Condition or disease Intervention/treatment Phase
IPMN IPMN, Pancreatic Drug: Sulindac 400 MG Other: Placebo Phase 2

Detailed Description:

This is a phase 2 multicenter, randomized, double-blind, placebo-controlled clinical trial of patients who have high-risk intraductal papillary mucinous neoplasms (IPMN) of the pancreas. Patients will be randomized in a 1:1 fashion and stratified by whether the patient had high-grade dysplasia (yes vs. no vs. no resection) identified in the initial resection specimen (for resected subjects), and whether or not the patient is taking metformin at the time of randomization. Patients will be required to have undergone a pancreas CT or CT angiogram of the pancreas in accordance with the standard practice at the enrolling institution within 3 months of study entry. The CT imaging study will be used to document baseline IPMN characteristics and to ensure that there is no evidence of a preexisting pancreatic cancer.

Following randomization, patients will take the study drug or placebo BID for 3 years. Both the study drug arm and the placebo arm will undergo standard laboratory, radiographic, and endoscopic assessment for IPMN progression. Every 6 months, patients will undergo assessment of serum CMP, CBC, and CA19-9. EUS will be performed 6 months after randomization (+/- 4 weeks) and then annually. Pancreatic CT will be performed 1 year after randomization (+/- 4 weeks) and then annually. The intent of these timings is to have the EUS and CT be on an alternating 6-month schedule per standard of care.

Patients, nurses, and physicians will be blinded to the randomization. Study drug will be provided to patients in the outpatient clinic. Pill diaries will be provided at the time that the study drugs are given and will be evaluated every 6 months, at the time of routine follow-up.

Safety and efficacy will be assessed throughout the treatment period. Assessment for study drug complications will be made by phone call every other month (in between routine follow-up) and at routine follow-up every 6 months by the attending surgeon or designee, until the end of the study. If a complication is identified, the study drug will be discontinued. Patient evaluations will be scheduled bi-annually for the primary endpoint and off-schedule evaluations may be made to address symptoms or clinical concerns as they arise.

The investigators plan to accrue 200 patients during a period of 2 years and will follow all patients for 3 additional years, for a total trial duration of 5 years.

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 200 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Investigator)
Primary Purpose: Prevention
Official Title: Preventing an Incurable Disease: The Prevention of Progression to Pancreatic Cancer Trial (The 3P-C Trial)
Actual Study Start Date : July 10, 2020
Estimated Primary Completion Date : January 31, 2025
Estimated Study Completion Date : January 31, 2025

Resource links provided by the National Library of Medicine

Drug Information available for: Sulindac

Arm Intervention/treatment
Experimental: Sulindac
Patients will be randomized to receive standard radiographic/endoscopic surveillance plus sulindac. The sulindac starting dose is 200 mg by mouth 2x daily. Patients will continue drug for 3 years during follow-up.
Drug: Sulindac 400 MG
Patients will be randomized to receive standard radiographic/endoscopic surveillance plus sulindac. The sulindac starting dose is 200 mg by mouth 2x daily. Randomization will be performed at Duke and stratified by (1) the presence of high-grade dysplasia on the operative pathologic report and (2) the use of metformin at the time of enrollment. Patients will be provided the study drugs by a Duke, MSK, MGH, or JHH pharmacist. Patients will continue drug/placebo for 3 years during follow-up.

Placebo Comparator: Placebo
Patients will be randomized to receive standard radiographic/endoscopic surveillance plus placebo. Patients will continue placebo for 3 years during follow-up.
Other: Placebo
Patients will be randomized to receive standard radiographic/endoscopic surveillance plus sulindac. The sulindac starting dose is 200 mg by mouth 2x daily. Randomization will be performed at Duke and stratified by (1) the presence of high-grade dysplasia on the operative pathologic report and (2) the use of metformin at the time of enrollment. Patients will be provided the study drugs by a Duke, MSK, MGH, or JHH pharmacist. Patients will continue drug/placebo for 3 years during follow-up.




Primary Outcome Measures :
  1. Percent of patients with IPMN progression as measured by a composite of several indicators [ Time Frame: 3 years ]

    Patients will be determined to have progressed if they have:

    1. New cystic lesion(s) of the pancreas >1 cm in diameter (or initial lesion(s) <5 mm that are now >1cm),
    2. Doubling of the diameter of any preexisting cyst initially measuring ≥5 mm
    3. Increase in diameter of the main pancreatic duct by >3mm
    4. Pancreatic resection
    5. The development of an invasive cancer.


Secondary Outcome Measures :
  1. Percent of patients with cyst progression as measured by radiographic images [ Time Frame: 3 years ]
    1. All initial and follow-up CT imaging will be quantitatively assessed for radiographic changes associated with progression. Utilizing a recently described radiomics approach to the evaluation of imaging in patients with IPMN, the investigators will further explore the set of 256 imaging features that broadly describe variation in radiographic enhancement patterns (i.e. heterogeneity). Using image analysis techniques, the investigators will derive quantitative measurements of the cyst wall and will determine the presence and degree of solid enhancing component suggestive of malignancy.


Other Outcome Measures:
  1. Percent of patients with Inflammatory Marker Progression [ Time Frame: 3 years ]
    2. Cyst fluid obtained at the time of annual EUS will be used to determine whether cyst fluid inflammatory marker analysis can identify progression. Antibody bead array analysis will be used to assess whether previously developed biomarker models for high-risk IPMN (IL-4/sFASL and MMP-9/CA72-4) can identify patients with an increased risk of radiographic progression.



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Ages Eligible for Study:   21 Years to 85 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  1. Subject is a man or woman between the ages of 21 and 85 years.
  2. Subject has high-risk IPMN as defined below.

    1. Patient has undergone partial pancreatectomy for non-invasive IPMN AND has residual cyst(s) > 1 cm
    2. Patient has a radiographic lesion of the pancreas consistent with IPMN as documented by:

    i. Cyst fluid CEA > 192 ng/ml OR MRI confirmation of communication with main pancreatic duct AND has any of the following worrisome features:

    • Cyst > 3 cm
    • Thickened/enhancing cyst walls
    • Main pancreatic duct > 5mm
    • Abrupt change in caliber of pancreatic duct with distal atrophy
  3. Subjects has ECOG of 0-2
  4. Subject is medically fit to undergo EUS.
  5. Female subjects who are of childbearing potential or are capable of becoming pregnant must be willing to use appropriate methods of contraception for the length of the study.
  6. Subject is able to provide written informed consent.

Exclusion Criteria:

  1. Subject has pathologic evidence of pancreatic cancer.
  2. Subject takes an NSAID 3 or more times per week.
  3. Subject has a history of or currently has known allergy to NSAIDs or a contraindication to use of NSAIDs in the opinion of the treating investigator.
  4. Subject has a history of gastric ulcer, non-iatrogenic intestinal perforation, gastrointestinal bleeding from NSAID use for which intervention was required, renal insufficiency (eGFR <60 mL/minute/1.73 m2), venous thromboembolism, cirrhosis, asthma, or any other condition that serves as a contraindication to the use of sulindac.
  5. Myocardial infarction or coronary artery bypass grafting within six months of study entry.
  6. Congestive Heart Failure.
  7. Severe adverse drug reaction to iodinated contrast agents that cannot be managed with routine premedication prior to imaging.
  8. Prior diagnosis or active treatment for (other) prior malignancy (except in situ cancers) within the previous 3 years.
  9. History of medical procedure that would prevent an endoscopic ultrasound from being performed (such as gastric bypass, prior total gastrectomy).
  10. Subject is lactating or pregnant.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT04207944


Contacts
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Contact: Peter Allen, MD 919-684-6858 peter.allen@duke.edu
Contact: Elizabeth Bronson 919-668-2382 elizabeth.bronson@duke.edu

Locations
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United States, Maryland
Johns Hopkins University Recruiting
Baltimore, Maryland, United States, 21287
Contact: Jin He, MD    410-614-7551    jhe11@jhmi.edu   
Contact: Neda Amini       namini3@jhmi.edu   
United States, Massachusetts
Massachusetts General Hospital Recruiting
Boston, Massachusetts, United States, 02114
Contact: Carlos Fernandez, MD    617-726-5644    cfernandez@mgh.harvard.edu   
Contact: Caitlin Stafford       CSTAFFORD2@PARTNERS.ORG   
United States, New York
Memorial Sloan Kettering Recruiting
New York, New York, United States, 10021
Contact: Kevin Soares, MD    212-639-3195    soaresk@mskcc.org   
Contact: Daniel Townend       townendd@mskcc.org   
United States, North Carolina
Duke University Medical Center Recruiting
Durham, North Carolina, United States, 27710
Contact: Elizabeth Bronson    919-737-4914    elizabeth.bronson@duke.edu   
Contact: Stacy Murray    919-684-7983    stacy.murray@duke.edu   
Principal Investigator: Peter Allen, MD         
Sponsors and Collaborators
Duke University
Johns Hopkins University
Massachusetts General Hospital
Memorial Sloan Kettering Cancer Center
National Cancer Institute (NCI)
Investigators
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Principal Investigator: Peter Allen, MD Duke University
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Responsible Party: Duke University
ClinicalTrials.gov Identifier: NCT04207944    
Other Study ID Numbers: Pro00103684
1R01CA235677-01A1 ( U.S. NIH Grant/Contract )
First Posted: December 23, 2019    Key Record Dates
Last Update Posted: March 30, 2021
Last Verified: March 2021
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No
Plan Description: Data will only be shared through publication.

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Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No
Product Manufactured in and Exported from the U.S.: Yes
Additional relevant MeSH terms:
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Pancreatic Intraductal Neoplasms
Pancreatic Neoplasms
Pancreatic Diseases
Digestive System Neoplasms
Neoplasms by Site
Neoplasms
Endocrine Gland Neoplasms
Digestive System Diseases
Endocrine System Diseases
Neoplasms, Ductal, Lobular, and Medullary
Neoplasms, Glandular and Epithelial
Neoplasms by Histologic Type
Sulindac
Anti-Inflammatory Agents, Non-Steroidal
Analgesics, Non-Narcotic
Analgesics
Sensory System Agents
Peripheral Nervous System Agents
Physiological Effects of Drugs
Anti-Inflammatory Agents
Antirheumatic Agents
Antineoplastic Agents
Cyclooxygenase Inhibitors
Enzyme Inhibitors
Molecular Mechanisms of Pharmacological Action