第II相では、全登録例100例のうち、50例がA群に、50例がB群に割り付けられた。このうち、A群では治療非施行1例が、B群では治療非施行1例あった。
第III相では、全登録例131例のうち、66例が標準治療A群(以下、A群とする)に、65例が試験治療B群(以下、B群とする)に割り付けられた。このうち、A群では治療非施行1例及び不適格例1例が、B群では治療非施行1例があった。
割り付け調整因子およびその他の因子については以下の通りであった
・PS(0 vs. 1):PS(0)はA群22例(34.4%)、B群21例(32.8%)、PS(1)はA群42例(65.6%)、B群43例(67.2%)であった。
・組織型(扁平上皮癌 vs. 非扁平上皮癌):扁平上皮癌はA群14例(21.9%)、B群12例(18.8%)、非扁平上皮癌はA群50例(78.1%)、B群52例(81.3%)であった。
・性別(男性 vs. 女性):男性はA群44例(68.8%)、B群45例(70.3%)、女性はA群20例(31.3%)、B群19例(29.7%)であった。
・EGFR遺伝子変異あるいはALK遺伝子転座(なし vs. あり vs. 不明):なしはA群41例(64.1%)、B群41例(64.1%)、ありはA群14例(21.9%)、B群13例(20.3%)、不明はA群9例(14.1%)、B群10例(15.6%)であった。
・臨床病期(IIIB期、IIIC期、IV期、術後再発):IIIB期はA群5例(7.8%)、B群2例(3.1%)、IIIC期はA群0例、B群0例、IVA期はA群29例(45.3%)、B群29例(45.3%)、IVB期はA群30例(46.9%)、B群33例(51.6%)であった。
・前化学療法レジメン数(1、2):レジメン数1はA群57例(89.1%)、B群58例(90.6%)、レジメン数2はA群7例(10.9%)、B群6例(9.4%)であった。
・喫煙歴(なし、あり):なしはA群15例(23.4%)、B群12例(18.8%)、ありはA群49例(76.6%)、B群52例(81.3%)であった。
・PD-L1(28-8)発現率(0、1~49、50%以上の3カテゴリー):測定有はA群28例(43.8%)、B群23例(35.9%)であった。発現率のカテゴリー別では、発現率0%はA群12例(42.9%)、B群10例(43.5%)、発現率1~49%はA群13例(46.4%)、B群10例(43.5%)、発現率50%以上はA群3例(10.7%)、B群2例(8.7%)、判定不能はA群0例、B群1例(4.3%)であった。
In Phase II, of the 100 patients enrolled, 50 patients were assigned to Group A and 50 patients to Group B. Of these, there was one treatment-naive patient in Group A and one treatment-naive patient in Group B.
In Phase III, of the 131 patients enrolled, 66 patients were assigned to the standard treatment group A (hereinafter referred to as "Group A") and 65 patients to study treatment group B (hereinafter referred to as "Group B"). Of these, one treatment-naive patient and one ineligible patient were in Group A, and one treatment-naive patient was in Group B.
Assignment adjustment factors and other factors were as follows;
- PS (0 vs. 1): PS (0) was observed in 22 patients (34.4%) in Group A and in 21 patients (32.8%) in Group B. PS (1) was observed in 42 patients (65.6%) in Group A and in 43 patients (67.2%) in Group B.
- Histological type (squamous cell carcinoma vs. non-squamous cell carcinoma): Squamous cell carcinoma was observed in 14 patients (21.9%) in Group A and in 12 patients (18.8%) in Group B. Non-squamous cell carcinoma was observed in 50 patients (78.1%) in Group A and in 52 patients (81.3%) in Group B.
- Sex (male vs. female): There were 44 male patients (68.8%) in Group A and 45 male patients (70.3%) in Group B. There were 20 female patients (31.3%) in Group A and 19 female patients (29.7%) in Group B.
- EGFR gene mutation or ALK gene translocation (absence vs. presence vs. unknown): Absence was observed in 41 patients (64.1%) in Group A and in 41 patients (64.1%) in Group B. Presence was observed in 14 patients (21.9%) in Group A and in 13 patients (20.3%) in Group B. Unknown was observed in nine patients (14.1%) in Group A and in 10 patients (15.6%) in Group B.
- Clinical stage (stage IIIB, stage IIIC, stage IV, postoperative recurrence): Stage IIIB was observed in five patients (7.8%) in Group A and in two patients (3.1%) in Group B. Stage IIIC was not observed in any patients in either Group A or Group B. Stage IVA was observed in 29 patients (45.3%) in Group A and in 29 patients (45.3%) in Group B. Stage IVB was observed in 30 patients (46.9%) in Group A and in 33 patients (51.6%) in Group B.
- Number of prior chemotherapy regimens (1, 2): Regimen (1) was observed in 57 patients (89.1%) in Group A and in 58 patients (90.6%) in Group B. Regimen (2) was observed in seven patients (10.9%) in Group A and in six patients (9.4%) in Group B.
- Smoking history (absence, presence): Absence was observed in 15 patients (23.4%) in Group A, and in 12 patients (18.8%) in Group B. Presence was observed in 49 patients (76.6%) in Group A, and in 52 patients (81.3%) in Group B.
- PD-L1 (28-8) expression rate (three categories: 0, 1-49, and >= 50%): 28 patients (43.8%) in Group A and 23 patients (35.9%) in Group B were measurable. By expression rate category, the rate was 0% in 12 patients (42.9%) in Group A and in 10 patients (43.5%) in Group B. The rate was between 1% and 49% in 13 patients (46.4%) in Group A and in 10 patients (43.5%) in Group B. The rate was >= 50% in three patients (10.7%) in Group A and in two patients (8.7%) in Group B. No patients in Group A and one patient (4.3%) in Group B were indeterminable.
Of the 131 patients enrolled, 66 patients were assigned to standard treatment group A (hereinafter referred to as Group A) and 65 patients to study treatment group B (hereinafter referred to as Group B). Of these, one treatment-naive and one ineligible patient were excluded from Group A, and one treatment-naive patient was excluded from Group B, therefore FAS was 64 patients in Group A and 64 patients in Group B.
As part of the safety analysis, the number of protocol treatment courses was calculated for all treated patients. The median number of the previous courses was 2.0 in Group A and 4.0 in Group B. The minimum and maximum values were one course and 28 courses in Group A, one course and 31 courses in Group B, respectively.
Sixty of 64 FAS patients in Group A and 62 of 64 FAS patients in Group B discontinued the study treatment. The most common reason for discontinuation was failure of protocol treatment in both Groups A and B [46 patients (71.9%) in Group A and 33 patients (51.6%) in Group B]. The next most common reason was patient preference (not related to adverse events) in seven patients (10.9%) in Group A, and unable to continue protocol treatment due to adverse events in 25 patients (39.1%) in Group B.
Phase II part:
- The primary endpoint of the incidence of Grade >= 3 pneumonitis (within 12 weeks) and its 80% confidence interval (CI) were 12.2% (6.6, 20.5) in standard treatment group A (hereinafter referred to as Group A) and 12.2% (6.6, 20.5) in study treatment group B (hereinafter referred to as Group B). At the time of the interim analysis, there was 1 case of Grade 3 or higher pulmonary inflammation in Group A (N=49), and 5 cases were treated as "yes" because they had not yet reached 12 weeks from enrollment; in Group B (N=49), there were 0 cases of Grade 3 or higher pulmonary inflammation, and 6 cases were treated as "yes" because they had not reached 12 weeks from enrollment.
- The incidence of adverse events was evaluated as the secondary endpoint, and adverse events of Grade 3 or higher are listed below in order of frequency in each group.
In Group A, hypoalbuminemia occurred in two patients (4.2%) and other events that occurred in one patient were increased aspartate aminotransferase, hypokalemia, hypercalcemia, hyperglycemia, and anorexia.
In Group B, decreased neutrophil count occurred in 39 patients (79.6%), decreased white blood cell count in 32 patients (65.3%), febrile neutropenia in 10 patients (20.4%), and anemia in six patients (12.2%). Events that occurred in three patients (6.1%) were increased aspartate aminotransferase and hyperglycemia; events that occurred in two patients (4.1%) were hypoalbuminemia, hyponatremia, fatigue, and rash; and events that occurred in one patient (2.0%) were decreased platelet count, increased alanine aminotransferase, pyrexia, nausea, anorexia, and lung infection.
Phase III part:
- The incidence of adverse events was evaluated as the secondary endpoint. In Group A, common events included hypoalbuminemia in 33 patients (50.8%), malaise in 20 patients (30.8%), anemia in 17 patients (26.2%), and increased creatinine in 17 patients (26.2%). In Group B, hematologic toxicity such as decreased neutrophil count in 60 patients (93.8%), decreased white blood cell count in 57 patients (89.1%), and anemia in 46 patients (71.9%) occurred, and hypoalbuminemia occurred in 43 patients (67.2%), malaise in 37 patients (57.8%), and anorexia in 31 patients (48.4%).
- Particularly serious adverse events of Grade 5 included pneumonitis [one event (1.5%)] in Group A and myocarditis [one event (1.6%)] in Group B. Events of Grade 4 included endophthalmitis [one event (1.5%)], sepsis [one event (1.5%)], increased CPK [one event (1.5%)], recurrent non-small-cell lung cancer [one event (1.5%)], intracranial tumor hemorrhage [one event (1.5%)], and stroke [one event (1.5%)] in Group A, and recurrent non-small-cell lung cancer [two events (3.1%)], myasthenia gravis [one event (1.6%)], and impaired liver function [one event (1.6%)] in Group B. Among serious adverse events (urgently reported), Grade 3 or higher pulmonary inflammation occurred in 2 patients (3.1%) in Group A and 2 patients (3.1%) in Group B.
- The main immune-related adverse reactions were as follows;
Adverse reactions in Group A included pneumonitis in eight patients (12.3%), malaise in seven patients (10.8%), increased aspartate aminotransferase in five patients (7.7%), and other events that occurred in four patients (6.2%) were diarrhea, pyrexia, increased alanine aminotransferase, increased creatinine, and anorexia.
Adverse reactions in Group B included malaise in 17 patients (26.6%). Events that occurred in 10 patients (15.6%) were increased aspartate aminotransferase and increased alanine aminotransferase; an event that occurred in nine patients (14.1%) was anorexia; events that occurred in eight patients (12.5%) were hypoalbuminemia and pneumonitis; events that occurred in six patients (9.4%) were increased creatinine and maculo-papular rash; events that occurred in five patients (7.8%) were pyrexia, fatigue, hyponatremia, and acneiform rash; and events that occurred in four patients (6.3%) were diarrhea and oral mucositis.
Phase II part:
- Six-month progression-free survival rate was evaluated as the primary endpoint. The number of events was 29 in Group A and 16 in Group B. The 6-month progression-free survival rate and its 80% CI were 22.4% [13.2, 33.2)] in Group A and 64.4% [53.4, 73.5] in Group B, respectively.
- Response rate was evaluated as the secondary endpoint. The number, proportion, and its 95% CI of patients with a best overall response of either complete response (CR) or partial response (PR) were five patients in Group A (10.2% [3.4, 22.2]) and 12 patients in Group B (24.5% [13.3, 38.9]).
Phase III part:
- Overall survival was evaluated as the primary endpoint. The number of events was 42 (65.6%) in Group A and 33 (51.6%) in Group B. The median survival and its 95% CI were 14.7 months [11.4, 18.7] in Group A and 23.1 months [16.7, -] in Group B. Twelve-month survival rate and its 95% CI were 58.6% [45.1, 69.8] in Group A, 71.4% [58.5, 80.9] in Group B, and 24-month survival rate and its 95% CI were 32.9% [21.1, 45.3] in Group A and 47.7% [34.3, 60.0] in Group B. For the stratified log-rank test, the difference was statistically significant (p = 0.0310) at the 5% significance level of alpha (one sided). Using the stratified Cox regression model, the adjusted hazard ratio of Group B against Group A and its 90% CI were 0.63 [0.42, 0.95]. Therefore, study treatment B significantly improved overall survival compared with standard treatment A.
- The subgroup analysis of overall survival was conducted as the exploratory analysis of the primary endpoint. The subgroup factors were histological type (squamous cell carcinoma, non-squamous cell carcinoma), PS (0, 1), clinical stage (stage IIIB, stage IV, postoperative recurrence), sex (male, female), EGFR gene mutation or ALK gene translocation (absence, presence), number of prior chemotherapy regimens (1, 2), smoking history (absence, presence), and PD-L1 (28-8) expression rate (three categories: 0, 1-49, and >= 50%). In the subgroup analysis, study treatment B also significantly improved overall survival compared with standard treatment A, except for the number of prior chemotherapy regimens (2) and PD-L1 (28-8) expression rate (>= 50%), where the number of patients was small. There appeared to be no interaction between subgroup factor.
- Progression-free survival was evaluated as the secondary endpoint. The number of events was 54 (84.4%) in Group A and 55 (85.9%) in Group B. The median progression-free survival and its 95% CI were 3.1 months [2.0, 3.9] in Group A and 6.7 months [3.8, 9.4] in Group B. Six-month progression-free survival rate and its 95% CI were 26.4% [16.0, 37.9] in Group A, 56.3% [43.3, 67.4] in Group B, Twelve-month progression-free survival rate and its 95% CI were 15.8% [7.9, 26.3] in Group A and 22.6% [13.2, 33.5] in Group B, and 24-month progression-free survival rate and its 95% CI were 12.1% [5.2, 22.0] in Group A and 15.4% [7.6, 25.7] in Group B. For the stratified log-rank test, the difference was statistically significant (p = 0.0095) at the 5% significance level of alpha (two sided). Using the stratified Cox regression model, the adjusted hazard ratio of Group B against Group A and its 95% CI were 0.58 [0.39, 0.88]. Therefore, study treatment B significantly improved progression-free survival compared with standard treatment A.
- Response rate was evaluated as the secondary endpoint. Regarding the best overall response, CR was not observed in any patients in Group A and in one patient (1.8%) in Group B, PR was observed in eight patients in Group A (14.0%) and in 22 patients in Group B (40.0%), and the response rate and its 95% CI were eight patients in Group A (14.0%, 95% CI [6.3, 25.8]) and 23 patients in Group B (41.8%, 95% CI [28.7, 55.9]). The Fisher's exact test for the response rate was p = 0.0014, indicating a statistically significant difference. Therefore, study treatment B significantly improved the response rate compared with standard treatment A.
The combination of nivolumab and docetaxel was associated with increased adverse events compared to nivolumab alone. However, the combination of nivolumab and docetaxel was considered to be a significantly better and more promising treatment than nivolumab monotherapy, as the primary endpoint was met and study treatment B was significantly better than standard treatment A in the secondary efficacy endpoint.
A phaseII/III study comparing nivolumab (NIV) with nivolumab (NIV) plus docetaxel (DTX) in patients with previously treated advanced non-small-cell lung cancer: a randomized phase II/III trial(CONDUCT study) (TORG1630)
ニボルマブ静脈内投与及びドセタキセル静脈内投与の併用療法
NIV vs NIV+DTX Phase II/III (CONDUCT study) (TORG1630)
1.組織診または細胞診で非小細胞肺癌であることが確認されている
2.少なくとも1レジメンの化学療法歴のあるIIIB期、IV期、または術後再発である。
3.前治療歴が2レジメン以内である症例。EGFR遺伝子変異陽性症例に対するEGFR-TKI治療、ALK遺伝子転座陽性症例に対するALK-TKI治療はレジメン数にカウントしない。
4.同意取得日の年齢が20歳以上である。
5.Performance status (PS)はECOGの規準で0-1である。
6.試験参加について患者本人から文書で同意が得られている。
1.Histologically or cytologically confirmed NSCLC.
2.Previously treated, at least one regimen cytotoxic chemotherapy, and stage III or IV or post operation recurrence.
3.Less than 2 regimen previous chemotherapy. EGFR-TKI and ALK-TKI are not regarded as regimen.
4.Aged 20 years or older.
5.ECOG performance status 0 to 1.
6.Written informed consent.
主たる除外基準 / Exclusion Criteria
1.ドセタキセルの投与を受けた治療歴がある。
2.PD-1、PD-L1または細胞障害性Tリンパ球4(CTLA-4)などのT細胞副調節蛋白(免疫チェックポイント)をターゲットとする抗体/薬剤を用いた治療歴がある。
3.活動性の重複がんを有する(同時性重複がん/多発がんおよび無病期間が5年以内の異時性重複がん/多発がん。ただし局所治療により治癒と判断されるCarcinoma in situ(上皮内癌)や粘膜内癌相当の病変は活動性の重複がん/多発がんに含めない)。
4.有症状の脳転移を有する(ただし、臨床的に安定している脳転移症例では登録可とする)。
5.胸部CTで明らかな間質性肺炎または肺線維症(放射線肺臓炎、放射線肺線維症を含む)を有する。
1.Previously treated by docetaxel.
2.Previously treated by antibody targeting to PD-1, PD-L1, PD-L2, CD137, or CTLA-4.
3.Synchronous or metachronous (within 5 years) malignancies, except for carcinoma in situ or mucosal tumors curatively treated with local therapy.
4.Active CNS metastasis or meningitis carcinomatous. (If patients were received brain radiation, and stable clinically, it is eligible.)
5.Evident interstitial pneumonia in CT.
arm A:nivolumab given on day 1 and day15 every 4 weeks until disease progression or unmanageable toxicity.
arm B:nivolumab given on day 1 and day15 and docetaxel given on day 1, every 4 weeks until disease progression or unmanageable toxicity.
介入コード / Code
介入キーワード /Keyword
主たる評価項目 / Primary Outcome(s)
第II相部分:6か月無増悪生存割合、Grade3以上肺臓炎発生割合
第III相部分:全生存期間
PhaseII:Progression-free survival rate of 6 months, Pneumonitis rate Grade3 or more
PhaseIII:Overall survival