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Veterans Affairs Seamless Phase II/III Randomized Trial of STAndard Systemic theRapy With or Without PET-directed Local Therapy for OligoRecurrenT Prostate Cancer (VA STARPORT)

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ClinicalTrials.gov Identifier: NCT04787744
Recruitment Status : Recruiting
First Posted : March 9, 2021
Last Update Posted : February 11, 2022
Sponsor:
Information provided by (Responsible Party):
VA Office of Research and Development

Brief Summary:
The primary goal of this study is to determine if adding PET-directed local therapy improves disease control compared to standard systemic therapy alone in Veterans with oligorecurrent prostate cancer on PET/CT. The investigators will conduct a multi-institutional phase II/III randomized trial comparing SST with or without PET-directed local therapy using radiation or surgery to all metastases and if a local recurrence is present.

Condition or disease Intervention/treatment Phase
Prostate Cancer Oligometastasis Oligorecurrence Recurrent Prostate Cancer Metastatic Prostate Cancer Procedure: PET-directed Local Therapy using Surgery Radiation: PET-directed Local Therapy using Radiation Other: Salvage Local Therapy for locally recurrent disease Drug: Goserelin, Histrelin, Leuprolide & Triptorelin Drug: ADT + Nilutamide, Flutamide, & Bicalutamide Drug: Degarelix & Relugolix Drug: ADT + Docetaxel +/- prednisone Drug: ADT + Abiraterone + Prednisone Drug: ADT + Abiraterone + Methylprednisolone Drug: ADT + Apalutamide Drug: ADT + Enzalutamide Phase 2 Phase 3

Detailed Description:

Prostate Cancer is the most commonly diagnosed cancer among Veterans, comprising 30% of new cancer diagnoses in the VA. Eighty-five percent of men present with localized prostate cancer, which is typically treated with active surveillance or curative local therapy using surgery or radiation therapy. Unfortunately, twenty percent of Veterans undergoing curative local therapy will develop metastatic recurrence. These men typically receive palliative systemic hormonal therapy to control the participants disease. Despite this, over half of men will have cancer progression within 1-2 years and half will die within 5 years.

Two diverging paradigms have been studied in recent years to improve the survival of men with recurrent metastatic prostate cancer. First, a subset of patients has oligorecurrent disease, defined as 1-5 sites of metastases. These patients are hypothesized to have an intermediate clinical state in which ablative local therapy with surgery or radiation to all metastatic sites of disease (metastasis-directed therapy; MDT) can lead to durable disease control and potentially cure in select patients. Recent Phase II randomized trials have demonstrated improved long-term progression-free survival with MDT in the absence of systemic therapy.

Yet, 75% of patients receiving MDT for oligorecurrent cancer develop progression in new areas, arguing that systemic therapy is needed to treat occult metastases. This is supported by data demonstrating that earlier palliative hormonal therapy is associated with improved survival. In fact, the second approach that has been studied in recent years, is whether escalating hormonal therapy by adding novel androgen receptor axis targeted agents or chemotherapy improves outcomes in men with metastatic prostate cancer. Multiple phase III randomized trials demonstrate that escalating hormonal therapy with these novel therapeutic agents improves progression-free survival and overall survival dramatically. Therefore, these agents have been integrated as an option into today's standard systemic therapy (SST) for metastatic recurrence.

Given the promise of MDT to induce long-term cancer control and the effectiveness of SST to prevent further cancer progression, there is an urgent need to determine whether adding MDT to SST improves disease outcomes further. Additionally, prior studies have excluded patients with local recurrence. However, these comprise a large proportion of Veterans with oligorecurrent prostate cancer.

The primary goal of the investigators study is to determine if adding PET-directed local therapy (treatment of local recurrence on PET/CT and/or MDT) improves disease control compared to SST alone in Veterans with oligorecurrent prostate cancer. The investigators will conduct a multi-institutional phase II/III randomized trial comparing SST with or without PET-directed local therapy. Other goals of the study are to determine any differences in patterns of cancer progression, survival, and quality of life. The investigators also will determine if certain mutations present in tumor DNA can predict if Veterans will benefit from PET-directed local therapy and encourage banking of tumor tissues for future analyses in a separate tumor registry study (VA MAPP).

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 464 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Intervention Model Description: Prospective, open-label, multi-center seamless phase II to phase III randomized clinical trial designed to compare SST with or without PET-directed local therapy.
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Veterans Affairs Seamless Phase II/III Randomized Trial of STAndard Systemic theRapy With or Without PET-directed Local Therapy for OligoRecurrenT Prostate Cancer (VA STARPORT)
Actual Study Start Date : July 1, 2021
Estimated Primary Completion Date : July 1, 2025
Estimated Study Completion Date : December 1, 2025

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Prostate Cancer

Arm Intervention/treatment
Active Comparator: Standard Systemic Therapy (SST)
All Veterans will receive SST
Drug: Goserelin, Histrelin, Leuprolide & Triptorelin
Androgen deprivation therapy (ADT) using an LHRH agonist

Drug: ADT + Nilutamide, Flutamide, & Bicalutamide
ADT adding anti-androgen therapy to an LHRH agonist

Drug: Degarelix & Relugolix
ADT using an LHRH Antagonist.

Drug: ADT + Docetaxel +/- prednisone
Enhanced SST using chemohormonal therapy

Drug: ADT + Abiraterone + Prednisone
Enhanced SST using Abiraterone + Prednisone

Drug: ADT + Abiraterone + Methylprednisolone
Enhanced SST using Abiraterone + Methylprednisolone

Drug: ADT + Apalutamide
Enhanced SST using ADT + Apalutamide

Drug: ADT + Enzalutamide
Enhanced SST using ADT + Enzalutamide

Experimental: SST + PET-directed local therapy

In addition to SST, all Veterans will receive PET-directed local therapy to all metastases using surgery or radiation. The selection of surgery or radiation to each metastasis will be determined using shared decision-making between the physician and Veteran.

For Veterans with a local recurrence, this will be treated with salvage local therapy.

Procedure: PET-directed Local Therapy using Surgery
Surgery will be used to treat metastases.

Radiation: PET-directed Local Therapy using Radiation

Radiation therapy will be used to treat metastases.

Radiation options include:

  1. Stereotactic body radiotherapy (SBRT) using 1-10 fractions
  2. Conventionally fractionated radiotherapy using elective nodal radiotherapy and a simultaneous integrated boost to involved nodes

The selection of the form of metastasis-directed radiotherapy for each metastasis will be determined using shared decision-making between the treating physician and the Veteran.


Other: Salvage Local Therapy for locally recurrent disease
For Veterans who have a local recurrence in addition to oligorecurrent metastatic lesions, they will undergo salvage local therapy using brachytherapy, SBRT, surgery, cryotherapy or HIFU. The selection of modality of salvage local therapy will be determined using shared decision-making between the treating physician and Veteran.

Drug: Goserelin, Histrelin, Leuprolide & Triptorelin
Androgen deprivation therapy (ADT) using an LHRH agonist

Drug: ADT + Nilutamide, Flutamide, & Bicalutamide
ADT adding anti-androgen therapy to an LHRH agonist

Drug: Degarelix & Relugolix
ADT using an LHRH Antagonist.

Drug: ADT + Docetaxel +/- prednisone
Enhanced SST using chemohormonal therapy

Drug: ADT + Abiraterone + Prednisone
Enhanced SST using Abiraterone + Prednisone

Drug: ADT + Abiraterone + Methylprednisolone
Enhanced SST using Abiraterone + Methylprednisolone

Drug: ADT + Apalutamide
Enhanced SST using ADT + Apalutamide

Drug: ADT + Enzalutamide
Enhanced SST using ADT + Enzalutamide




Primary Outcome Measures :
  1. Castration-resistant prostate cancer-free survival (CRPC-free survival) [ Time Frame: 4 years ]
    CRPC-free survival is a time-to-event outcome defined as the length of time from randomization to the first occurrence of failure. The following are forms of failure in the setting of a castrate testosterone level: PSA progression, radiographic progression, symptomatic skeletal event due to progression, and death.


Secondary Outcome Measures :
  1. Radiographic progression-free survival (rPFS) [ Time Frame: 4 years ]
    rPFS is a time-to-event outcome defined as the length of time from randomization to radiographic progression of prostate cancer or death.

  2. Clinical progression-free survival (cPFS) [ Time Frame: 4 years ]
    cPFS is a time-to-event outcome defined as the length of time from randomization to radiographic progression on conventional imaging, symptomatic skeletal event due to progression, or death.

  3. Freedom from index lesion progression (FFILP) [ Time Frame: 4 years ]
    FFILP is a time-to-event outcome defined as the length of time from randomization to progression of any of the enrollment index oligorecurrent lesions.

  4. New metastasis-free survival (MFS) [ Time Frame: 4 years ]
    New MFS is a time-to-event outcome (MFS) defined as the length of time from randomization to the development of a new metastasis that was not present at the time of enrollment, or death.

  5. Prostate cancer-specific survival (PCSS) [ Time Frame: 4 years ]
    PCSS is a time-to-event outcome defined as the length of time from randomization to death from prostate cancer.

  6. Overall survival (OS) [ Time Frame: 4 years ]
    OS is a time-to-event outcome defined as the length of time from randomization to death from any cause.

  7. Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 toxicity [ Time Frame: 4 years ]
    Toxicities will be evaluated based on system organ class and a higher number in the grading system is reflective of more severe toxicity.

  8. Patient-reported quality of life measured by the EORTC QLQ-C30 3.0 [ Time Frame: 2 years ]
    The QLQ-C30 is composed of 30 items. These include five functional scales, three symptom scales, a global health status/QoL scale, and six single items. Raw scores will be converted to standardized scores ranging from 0 to 100. A higher score represents a higher ("better") level of functioning, or a higher ("worse") level of symptoms.

  9. Expanded Prostate cancer Index Composite Short Form (EPIC-26) [ Time Frame: 2 years ]
    EPIC-26 contains 26 items in 5 domains (Urinary Incontinence, Urinary Irritative/Obstructive, Bowel, Sexual, and Hormonal). Raw scores are transformed linearly to a 0-100 scale, with higher scores representing better HRQOL.

  10. Patient-reported health-related quality of life measured by the EQ5D-5L [ Time Frame: 2 years ]
    EQ5D-5l consists of 5 dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and each dimension has 5 levels. The digits for the 5 dimensions is combined to describe the health state (higher total reflect a higher health state). There is also a vertical visual analogue scale to be used as a quantitative measure that reflects the patient's own judgement with the endpoints labelled as "The best health you can imagine" and "The worst health you can imagine."



Information from the National Library of Medicine

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, Learn About Clinical Studies.


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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   Male
Gender Based Eligibility:   Yes
Gender Eligibility Description:   Male with prostate cancer.
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Ability to provide Informed Consent for participation in the study.
  • ECOG Performance Status </= 2 at time of enrollment.
  • Prior localized prostate cancer, confirmed histologically or cytologically, and defined as:

    • Any T-classification, Gleason Grade Group, and pre-treatment PSA at the time of initial curative-intent treatment are acceptable.
    • Nx, N0, or N1 N-classification at the time of curative-intent local therapy
    • No metastatic disease at the time of intent treatment are acceptable
    • No metastatic disease at the time of initial curative-intent treatment are acceptable
  • Prior curative-intent local therapy for localized prostate cancer with either upfront definitive radiotherapy or prostatectomy with or without post-operative radiotherapy.
  • PSA suspicious for biochemical recurrence after local therapy, with lab value(s) taken within 90 days prior to enrollment or prior to start of SST (if current SST has already started), and meeting one of the three below categories:

    • PSA >/= 0.2 ng/ml x 2 after prostatectomy +/- post-operative radiotherapy
    • Elevation of PSA >/= 2 ng/ml above the nadir after definitive radiotherapy
    • Two consecutively rising PSAs with evidence of metastasis on the imaging studies.
  • Serum testosterone obtained within 90 days prior to enrollment.

    • For patients who have a history of prior therapy with SST agents for prostate cancer, a total testosterone >/= 100 ng/dl after completion of prior SST and either before the start of current SST or within 30 days of starting current SST is also required if the patient has already started SST for recurrence.
    • For patients who have no prior history of therapy with SST agents and have already started SST for recurrence, this pre-SST testosterone is not required.
  • CT or MRI abdomen/pelvis performed within 90 days prior to enrollment or prior to start of SST if already on SST for recurrence. The results from the CT component of the PET/CT can be used to fulfill this criterion. This is optional for patients who have a PSMA PET/CT.
  • Technetium (Tc99m-MDP) or sodium fluoride (NaF) bone scan (sodium fluoride preferred) performed within 90 days prior to enrollment or prior to start of SST if already on SST for recurrence. This is optional for patients who have a PSMA PET/CT.
  • FDA-approved standard of care PET/CT (currently PSMA, Fluciclovine, choline) performed within 90 days prior to enrollment or prior to start of SST if already on SST for recurrence. -1-5 lesions suspicious for nodal recurrence or metastasis from prostate cancer as determined by the investigator based on the above imaging studies.
  • Has already undergone NPOP sequencing or is willing to undergo NPOP sequencing for prostate cancer. For participants on SST at the time of enrollment only.
  • Has been on SST for </= 180 days. For participants with local recurrence on imaging.
  • Patients with local recurrence in the prostate, SV, or prostate bed are eligible as long as there is at least 1 nodal or distant metastatic recurrence.
  • Biopsy must confirm local recurrence for patients who have had prior curative-intent radiation to the prostate, SV, or prostate bed.
  • Candidate for salvage local therapy as determined by a urologist or radiation oncologist (depending on the respective modality to be used to treat the local recurrence).

Exclusion Criteria:

  • Any current or prior evidence of castration-resistant prostate cancer, defined as two consecutive rises in serum PSA, obtained at a minimum of 1-week interval, with the final PSA value >/= 1 ng/ml, while having a total testosterone < 50 ng/dl).
  • Prior malignancy, except the following:

    • Adequately treated non-melanomatous skin cancer;
    • Adequately treated Stage 0, I, or II cancer from which the patient is currently in complete remission; or
    • Any other cancer from which the patient has been disease free for three years.
  • Presence of a symptomatic metastasis that requires palliative radiotherapy.
  • Any known brain metastases, presence of leptomeningeal disease, malignant spinal cord compression, or malignant cauda equina syndrome.
  • Prior nodal, bone, or visceral metastasis after curative-intent therapy other than those identified on the enrollment imaging studies, whether treated or untreated.
  • Prior radiation therapy to any sites requiring PET-directed local therapy or salvage local therapy that will lead to prohibitively high risk of toxicity from subsequent local therapy, as determined by the treating radiation oncologist (if radiation is intended as the study local therapy) or surgeon/urologist (if surgery is intended as the study local therapy).
  • Any other previous or current condition, which, in the judgement of the Site Investigator, is likely to interfere with any STARPORT treatments or assessments.

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): NCT04787744


Contacts
Layout table for location contacts
Contact: Abhishek Solanki, MD MS (708) 202-8387 ext 27091 Abhishek.Solanki@va.gov
Contact: Christopher A Schroth, MS (818) 235-7848 christopher.schroth@va.gov

Locations
Layout table for location information
United States, California
VA Long Beach Healthcare System, Long Beach, CA Recruiting
Long Beach, California, United States, 90822
Contact: Robert Kwon, MD    562-826-5606    Robert.Kwon1@va.gov   
VA Greater Los Angeles Healthcare System, West Los Angeles, CA Recruiting
West Los Angeles, California, United States, 90073
Contact: Nicholas Nickols, MD    310-478-3711 ext 44127    nicholas.nickols@va.gov   
United States, Florida
Bay Pines VA Healthcare System, Pay Pines, FL Recruiting
Bay Pines, Florida, United States, 33744
Contact: Ryan Burri, MD    727-398-6661 ext 13912    ryan.burri@va.gov   
United States, Illinois
Edward Hines Jr. VA Hospital, Hines, IL Recruiting
Hines, Illinois, United States, 60141-5000
Contact: Abhishek Solanki, MD MS    708-202-8387 ext 27091    Abhishek.Solanki@va.gov   
Principal Investigator: Abhishek Solanki, MD MS         
United States, Indiana
Richard L. Roudebush VA Medical Center, Indianapolis, IN Recruiting
Indianapolis, Indiana, United States, 46202-2884
Contact: Ronald Shapiro, MD    317-988-3652    ronald.shapiro@va.gov   
United States, Massachusetts
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA Recruiting
Boston, Massachusetts, United States, 02130
Contact: Sonny Batra, MD    857-404-1215    Sonny.Batra@va.gov   
United States, Michigan
VA Ann Arbor Healthcare System, Ann Arbor, MI Recruiting
Ann Arbor, Michigan, United States, 48105
Contact: David Elliot, MD    734-845-3914    david.elliott1@va.gov   
United States, Minnesota
Minneapolis VA Health Care System, Minneapolis, MN Not yet recruiting
Minneapolis, Minnesota, United States, 55417
Contact: Mark Klein, MD       Mark.Klein2@va.gov   
United States, Missouri
Kansas City VA Medical Center, Kansas City, MO Recruiting
Kansas City, Missouri, United States, 64128
Contact: John Park, MD    816-922-2880    john.park@va.gov   
St. Louis VA Medical Center John Cochran Division, St. Louis, MO Recruiting
Saint Louis, Missouri, United States, 63106
Contact: Anthony Apicelli, MD    314-652-4100 ext 56324    anthony.apicelli@va.gov   
United States, New Jersey
East Orange Campus of the VA New Jersey Health Care System, East Orange, NJ Recruiting
East Orange, New Jersey, United States, 07018
Contact: Nisha Word, MD    973-676-1000    Nisha.Word@va.gov   
United States, North Carolina
Durham VA Medical Center, Durham, NC Recruiting
Durham, North Carolina, United States, 27705
Contact: Rhonda Bitting, MD    415-516-8256    rhonda.bitting@va.gov   
United States, Ohio
Louis Stokes VA Medical Center, Cleveland, OH Recruiting
Cleveland, Ohio, United States, 44106
Contact: Aryavarta Kumar, MD    216-536-1201    aryavarta.kumar@va.gov   
United States, Texas
Michael E. DeBakey VA Medical Center, Houston, TX Recruiting
Houston, Texas, United States, 77030
Contact: Albert Chen, MD    713-794-7190    albert.chen3@va.gov   
United States, Virginia
Hunter Holmes McGuire VA Medical Center, Richmond, VA Recruiting
Richmond, Virginia, United States, 23249
Contact: Hann-Hsiang Chao, MD    804-675-5000 ext 3750    hann-hsiang.chao@va.gov   
United States, Wisconsin
Clement J. Zablocki VA Medical Center, Milwaukee, WI Recruiting
Milwaukee, Wisconsin, United States, 53295-1000
Contact: Lindsay Puckett, MD    414-384-2000 ext 42590    Lindsay.Puckett@va.gov   
Sponsors and Collaborators
VA Office of Research and Development
Investigators
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Principal Investigator: Abhishek Solanki, MD MS Edward Hines Jr. VA Hospital, Hines, IL
Layout table for additonal information
Responsible Party: VA Office of Research and Development
ClinicalTrials.gov Identifier: NCT04787744    
Other Study ID Numbers: ONCA-026-20S
CX002277-01 ( Other Grant/Funding Number: VA Clinical Science Research & Development )
First Posted: March 9, 2021    Key Record Dates
Last Update Posted: February 11, 2022
Last Verified: January 2022
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Product Manufactured in and Exported from the U.S.: No
Keywords provided by VA Office of Research and Development:
Prostate Cancer
Metastasis
Oligorecurrence
PET-directed local therapy
Standard Systemic Therapy
SBRT
Oligometastasis
Oligorecurrent
Metastasis-directed therapy
Salvage Local Therapy
Recurrent Prostate Cancer
Fluciclovine
PSMA
Choline
Additional relevant MeSH terms:
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Prostatic Neoplasms
Genital Neoplasms, Male
Urogenital Neoplasms
Neoplasms by Site
Neoplasms
Prostatic Diseases
Prednisone
Methylprednisolone
Docetaxel
Leuprolide
Goserelin
Bicalutamide
Triptorelin Pamoate
Flutamide
Nilutamide
Relugolix
Antineoplastic Agents
Tubulin Modulators
Antimitotic Agents
Mitosis Modulators
Molecular Mechanisms of Pharmacological Action
Anti-Inflammatory Agents
Glucocorticoids
Hormones
Hormones, Hormone Substitutes, and Hormone Antagonists
Physiological Effects of Drugs
Antineoplastic Agents, Hormonal
Antiemetics
Autonomic Agents
Peripheral Nervous System Agents