Description:
This randomized phase II clinical trial studies the side effects and how well proton beam or
intensity-modulated radiation therapy works in preserving brain function in patients with IDH
mutant grade II or III glioma. Proton beam radiation therapy uses tiny charged particles to
deliver radiation directly to the tumor and may cause less damage to normal tissue.
Intensity-modulated or photon beam radiation therapy uses high-energy x-ray beams shaped to
treat the tumor and may also cause less damage to normal tissue. Patients will be more likely
to be randomized to proton beam radiation therapy. It is not yet known if proton beam
radiation therapy is more effective than photon-based beam intensity-modulated radiation
therapy in treating patients with glioma.
Title
- Brief Title: Proton Beam or Intensity-Modulated Radiation Therapy in Preserving Brain Function in Patients With IDH Mutant Grade II or III Glioma
- Official Title: A Phase II Randomized Trial of Proton Vs. Photon Therapy (IMRT) for Cognitive Preservation in Patients With IDH Mutant, Low to Intermediate Grade Gliomas
Clinical Trial IDs
- ORG STUDY ID:
NRG-BN005
- SECONDARY ID:
NCI-2017-00203
- SECONDARY ID:
NRG-BN005
- SECONDARY ID:
NRG-BN005
- SECONDARY ID:
NRG-BN005
- SECONDARY ID:
U10CA180868
- NCT ID:
NCT03180502
Conditions
- 1p/19q Co-deletion
- Anaplastic Astrocytoma
- Diffuse Astrocytoma
- Glioma
- IDH1 Gene Mutation
- IDH2 Gene Mutation
- Oligoastrocytoma
- Oligodendroglioma
- WHO Grade III Glioma
Interventions
Drug | Synonyms | Arms |
---|
Temozolomide | CCRG-81045, Imidazo[5,1-d]-1,2,3,5-tetrazine-8-carboxamide, 3, 4-dihydro-3-methyl-4-oxo-, M & B 39831, M and B 39831, Methazolastone, RP-46161, SCH 52365, Temcad, Temodal, Temodar, Temomedac | Arm I (photon-based IMRT, temozolomide) |
Purpose
This randomized phase II clinical trial studies the side effects and how well proton beam or
intensity-modulated radiation therapy works in preserving brain function in patients with IDH
mutant grade II or III glioma. Proton beam radiation therapy uses tiny charged particles to
deliver radiation directly to the tumor and may cause less damage to normal tissue.
Intensity-modulated or photon beam radiation therapy uses high-energy x-ray beams shaped to
treat the tumor and may also cause less damage to normal tissue. Patients will be more likely
to be randomized to proton beam radiation therapy. It is not yet known if proton beam
radiation therapy is more effective than photon-based beam intensity-modulated radiation
therapy in treating patients with glioma.
Detailed Description
PRIMARY OBJECTIVES:
I. To determine whether proton therapy, compared to intensity-modulated radiation therapy
(IMRT), preserves cognitive outcomes over time as measured by the Clinical Trial Battery
Composite (CTB COMP) score (calculated from the Hopkins Verbal Learning Test Revised
[HVLT-R]) Total Recall, HVLT-R Delayed Recall, HVLT-R Delayed Recognition, Controlled Oral
Word Association (COWA) test, Trail Making Test (TMT) part A and part B.
SECONDARY OBJECTIVES:
I. To assess whether treatment with proton therapy preserves neurocognitive function as
measured separately by each test, HVLT-R, TMT parts A & B, and COWA.
II. To document and compare treatment related symptoms, overall symptom impact, and disease
related factor groupings, utilizing the M.D. Anderson Symptom Inventory Brain Tumor
(MDASI-BT), for both treatment arms.
III. To assess whether treatment with proton therapy, compared to IMRT, results in superior
quality of life as measured by the Linear Analog Scale Assessment (LASA) scale.
IV. To compare local control patterns of failure and overall and progression-free survival
between the two treatment arms.
V. To assess adverse events.
TERTIARY OBJECTIVES:
I. To assess the impact of chemotherapy use on cognitive outcomes, symptom outcomes and
quality of life.
II. To assess dose-response relationships between neuro-anatomic dosimetry and cognitive
outcomes within and between treatment arms.
III. To evaluate the association between tumor molecular status and cognition at baseline and
within and between treatment arms over time.
IV. To assess patterns of failure and pseudo progression as a function of radiation delivery
type and dose received.
V. To assess local control, overall survival and, progression free survival in IDH mutant
grade II and III tumors.
VI. To collect blood samples for future studies seeking to correlate changes in peripheral
blood biomarkers (genes, micro ribonucleic acid [RNA], proteins, lymphocyte count, melatonin,
etc) and the study endpoints.
VII. To document and compare the impact of low to intermediate gliomas and therapy on
patients' work and activity participation (The Work Productivity and Activity Impairment
[WPAI:GH] Questionnaire: General Health version 2.0) as well as the relationship between
changes in patients' work and activity participation and neurocognitive function and patient
reported symptoms and interference.
OUTLINE: Patients are randomized to 1 of 2 treatment arms.
ARM I: Patients undergo photon-based IMRT once daily (QD), 5 days a week for 6 weeks for a
total of 30 fractions. Beginning 4 weeks after completion of radiation therapy, patients
receive standard of care temozolomide for 5 days. Treatment repeats every 28 days for up to
12 courses in the absence of disease progression of unacceptable toxicity.
ARM II: Patients undergo proton beam radiation therapy QD, 5 days a week for 6 weeks for a
total of 30 fractions. Beginning 4 weeks after completion of radiation therapy, patients
receive standard of care temozolomide for 5 days. Treatment repeats every 28 days for up to
12 courses in the absence of disease progression of unacceptable toxicity.
After completion of study treatment, patients are followed up at 6 and 12 months and then
yearly for 10 years.
Trial Arms
Name | Type | Description | Interventions |
---|
Arm I (photon-based IMRT, temozolomide) | Active Comparator | Patients undergo photon-based IMRT QD, 5 days a week for 6 weeks for a total of 30 fractions. Beginning 4 weeks after completion of radiation therapy, patients receive standard of care temozolomide for 5 days. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression of unacceptable toxicity. | |
Arm II (proton beam radiation therapy, temozolomide) | Experimental | Patients undergo proton beam radiation therapy QD, 5 days a week for 6 weeks for a total of 30 fractions. Beginning 4 weeks after completion of radiation therapy, patients receive standard of care temozolomide for 5 days. Treatment repeats every 28 days for up to 12 courses in the absence of disease progression of unacceptable toxicity. | |
Eligibility Criteria
Inclusion Criteria:
- Prior to STEP 1 REGISTRATION
- Tumor tissue must be available for submission for central pathology review
- Documentation from the enrolling site confirming the presence of IDH mutation and
1p/19q status; the provided information must document assays performed in clinical
laboratory improvement amendments (CLIA)-approved laboratories
- Only English speaking patients are eligible to participate as the cognitive and
quality of life assessments are available only in English
- The patient or a legally authorized representative must provide study-specific
informed consent prior to study entry
- Karnofsky performance status of >= 70 within 30 days prior to registration
- Absolute neutrophil count (ANC) >= 1,500 cells/mm^3
- Platelets >= 100,000 cells/mm^3
- Hemoglobin >= 10.0 g/dl (Note: The use of transfusion or other intervention to achieve
hemoglobin [Hgb] >= 10.0 g/dl is acceptable)
- Bilirubin =< 1.5 upper limit of normal (ULN)
- Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) =< 3 x ULN
- BUN < 30 mg/dl
- Serum creatinine < 1.5 mg/dl
- Post-operative magnetic resonance (MR) imaging with contrast is mandatory obtained for
radiation therapy planning; enrolling sites are highly encouraged to obtain thin-slice
(<1.5 mm) 3D T1 pre and post contrast and Axial T2/FLAIR sequences for planning
purposes
- Prior to STEP 2 REGISTRATION
- The following baseline neurocognitive assessments must be completed and uploaded prior
to step 2 registration: HVLT-R, TMT Parts A and B, and COWA
- Completion of all items on the following baseline quality of life forms: MDASI-BT,
LASA QOL, WPAI-GH and Employment Questionnaire. These quality of life forms will be
required and data entered at step 2 registration.
- Financial clearance for proton therapy treatment prior to step 2 registration
- Centrally reviewed histologically proven diagnosis of supratentorial, Word Health
Organization (WHO) grade II or III astrocytoma, oligodendroglioma or oligoastrocytoma,
with IDH mutation
Exclusion Criteria:
- Definitive clinical or radiologic evidence of metastatic disease; if applicable
- Prior invasive malignancy (except non-melanomatous skin cancer) unless disease free
for a minimum of 3 years; (for example, carcinoma in situ of the breast, oral cavity
or cervix are permissible)
- Prior cranial radiotherapy or radiotherapy to the head and neck where potential field
overlaps would exist
- Prior chemotherapy or radiotherapy for any brain tumor
- Histologic diagnosis of glioblastoma (WHO grade IV) or pilocytic astrocytoma (WHO
grade I)
- Definitive evidence of multifocal disease
- Planned use of cytotoxic chemotherapy during radiation (only adjuvant temozolomide
therapy will be used on this protocol)
- Patients with infra-tentorial tumors are not eligible
- Prior history of neurologic or psychiatric disease believed to impact cognitive
function
- The use of memantine during or following radiation is NOT allowed
- Severe, active co-morbidity defined as follows:
- Unstable angina or congestive heart failure requiring hospitalization within 6
months prior to enrollment
- Transmural myocardial infarction within the last 6 months prior to step 2
registration; evidence of recent myocardial infarction or ischemia by the
findings of S-T elevations of >= 2 mm using the analysis of an electrocardiogram
(EKG) performed within 28 days prior to step 2 registration (Note: EKG to be
performed only if clinical suspicion of cardiac issue)
- New York Heart Association grade II or greater congestive heart failure requiring
hospitalization within 12 months prior to step 2 registration
- Serious and inadequately controlled arrhythmia at step 2 registration
- Serious or non-healing wound, ulcer or bone fracture or history of abdominal
fistula, intra-abdominal abscess requiring major surgical procedure, open biopsy
or significant traumatic injury within 28 days prior to step 2 registration, with
the exception of the craniotomy for surgical resection
- Acute bacterial or fungal infection requiring intravenous antibiotics at the time
of step 2 registration
- Hepatic insufficiency resulting in clinical jaundice and/or coagulation defects;
note, however, that laboratory tests for coagulation parameters are not required
for entry into this protocol
- Chronic obstructive pulmonary disease exacerbation or other respiratory illness
requiring hospitalization or precluding study therapy at the time of step 2
registration
- Human immunodeficiency virus (HIV) positive with CD4 count < 200
cells/microliter; acquired immune deficiency syndrome (AIDS) based upon current
Centers for Disease Control and Prevention (CDC) definition; note, however, that
HIV testing is not required for entry into this protocol
- Any other severe immunocompromised condition
- Active connective tissue disorders, such as lupus or scleroderma, that in the
opinion of the treating physician may put the patient at high risk for radiation
toxicity
- End-stage renal disease (i.e., on dialysis or dialysis has been recommended)
- Any other major medical illnesses or psychiatric treatments that in the
investigator's opinion will prevent administration or completion of protocol
therapy
- Inability to undergo MRI with and without contrast (e.g. claustrophobia, non-MRI
compatible implant or foreign body, gadolinium allergy or renal dysfunction preventing
the patient from receiving gadolinium- institutional guidelines should be used to
determine if patients are at risk for renal dysfunction); note that patients with
severe claustrophobia are permitted on this study if they are willing and able to
undergo MRI with adequate sedation or anesthesia
Maximum Eligible Age: | N/A |
Minimum Eligible Age: | 18 Years |
Eligible Gender: | All |
Healthy Volunteers: | No |
Primary Outcome Measures
Measure: | Change in cognition as measured by the CTB COMP score |
Time Frame: | Baseline to up to 10 years |
Safety Issue: | |
Description: | Assessed with a general linear model with maximum likelihood estimation. Three models will be conducted. Baseline CTB COMP score, treatment arm, time, treatment by time interaction (if significant) and stratification factors will be included in the model for the primary endpoint. A second model will be built with these same variables and relevant covariates, such as total volume of intracranial disease, gross tumor volume (GTV) and clinical tumor volume (CTV) size, histology, anti-epileptic use, and disease response to therapy (as measured by Response Assessment in Neuro-Oncology [RANO] criteria |
Secondary Outcome Measures
Measure: | Change in quality of life as measured by the LASA scale |
Time Frame: | Up to 10 years |
Safety Issue: | |
Description: | The change from baseline to each follow-up time point (calculated as baseline score subtracted from follow-up score) will be compared between treatment arms using a t-test, or Wilcoxon test if the data is not normally distributed. A one-sided alpha=0.05 will be used for the LASA. A general linear model with maximum likelihood estimation will be used to assess symptom and QOL trends across time. |
Measure: | Change in symptoms as measured by MDASI-BT |
Time Frame: | Baseline to up to 10 years |
Safety Issue: | |
Description: | The change from baseline to each follow-up time point (calculated as baseline score subtracted from follow-up score) will be compared between treatment arms using a t-test, or Wilcoxon test if the data is not normally distributed. A reduced one-sided significance level will be used for the multiple comparisons in the MDASI-BT using the Bonferroni adjustment (alpha=0.017 for disease related factors and alpha=0.025 for treatment related symptoms and overall impact). A general linear model with maximum likelihood estimation will be used to assess symptom trends across time. |
Measure: | Cognition as measured by COWA |
Time Frame: | Up to 10 years |
Safety Issue: | |
Description: | The COWA will be analyzed using a general linear model with maximum likelihood estimation. Standardized scores will be used. |
Measure: | Cognition as measured by TMT parts A and B |
Time Frame: | Up to 10 years |
Safety Issue: | |
Description: | The TMT parts A & B will be analyzed using a general linear model with maximum likelihood estimation. Standardized scores will be used. |
Measure: | Cognition as measured by HVLT-R |
Time Frame: | Up to 10 years |
Safety Issue: | |
Description: | The HVLT-R will be analyzed using a general linear model with maximum likelihood estimation. Standardized scores will be used. |
Measure: | Incidence of adverse events (AEs) graded according to the National Cancer Institute's Common Terminology for Adverse Events version 4.0 |
Time Frame: | Up to 10 years |
Safety Issue: | |
Description: | Counts of all AEs by grade will be provided by treatment arm. Counts and frequencies will be provided for the worst grade AE experienced by the patient by treatment arm. Grade 3+ treatment related AEs will be compared between arms using a chi-square test, or Fisher's exact test if cell frequencies are < 5, at the one-sided 0.05 significance level. |
Measure: | Local control as assessed by RANO criteria |
Time Frame: | Up to 10 years |
Safety Issue: | |
Description: | Local control will be estimated using cumulative incidence, treating death prior to an event as a competing risk. Gray's test will be used to compare local control rates between arms. Cause-specific Cox proportional hazards models will be used for local control, adjusting for treatment arm and stratification factors. A two-sided significance level of 0.05 will be used for comparisons between arms. |
Measure: | Overall survival (OS) |
Time Frame: | From randomization to the date of death, assessed up to 10 years |
Safety Issue: | |
Description: | OS will be estimated using the Kaplan-Meier method and compared between arms using the log rank test. Cox proportional hazards models will be used for OS adjusting for treatment arm and stratification factors. |
Measure: | Progression-free survival (PFS) |
Time Frame: | From date of randomization to date of progression or death, whichever occurs first, assessed up to 10 years |
Safety Issue: | |
Description: | A confidence interval will be used to determine if the PFS rate in the proton arm is greater than that in the photon at 1 year. PFS will be estimated using the Kaplan-Meier method and compared between arms using the log rank test. Cox proportional hazards models will be used for PFS adjusting for treatment arm and stratification factors. |
Details
Phase: | Phase 2 |
Primary Purpose: | Interventional |
Overall Status: | Recruiting |
Lead Sponsor: | NRG Oncology |
Last Updated
June 1, 2021