Efficacy outcomes by baseline prostate-specific antigen quartile in the AFFIRM trial

Fred Saad, Johann de Bono, Neal Shore, Karim Fizazi, Yohann Loriot, Mohammad Hirmand, Billy Franks, Gabriel P Haas, Howard I Scher
European Urology 2015, 67 (2): 223-30

BACKGROUND: Enzalutamide significantly prolonged the survival of men with metastatic castration-resistant prostate cancer (PCa) after docetaxel in the randomised, phase 3, double-blind, placebo-controlled, multinational Patients with Progressive Castration-Resistant Prostate Cancer Previously Treated with Docetaxel-Based Chemotherapy (AFFIRM) trial (NCT00974311). Prostate-specific antigen (PSA) is commonly used as a marker of PCa disease burden, and the relationship of baseline PSA level to consequent treatment effect is of clinical interest.

OBJECTIVE: Exploratory analysis to evaluate any differences in patient characteristics and efficacy outcomes by baseline PSA level in the AFFIRM trial.

DESIGN, SETTING, AND PARTICIPANTS: Post hoc subanalysis of all randomised patients (n=1199) from the AFFIRM trial.

INTERVENTION: Participants were randomly assigned in a two-to-one ratio to receive oral enzalutamide 160 mg/d or placebo.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The major clinical efficacy end points were overall survival (OS), radiographic progression-free survival (rPFS), and time to PSA progression (TTPP) versus placebo; baseline characteristics, treatment duration, and subsequent antineoplastic therapy were compared by baseline PSA quartile.

RESULTS AND LIMITATIONS: Baseline PSA quartiles corresponded to the following PSA groups: <40 ng/ml (n=299), 40 to <111 ng/ml (n=300), 111 to <406 ng/ml (n=300), and ≥406 ng/ml (n=300). Enzalutamide consistently improved OS, rPFS, and TTPP compared with placebo across all subgroups, regardless of baseline PSA level. Hazard ratios for improvements in OS were 0.55 (95% confidence interval [CI], 0.36-0.85), 0.69 (95% CI, 0.47-1.02), 0.73 (95% CI, 0.53-1.01), and 0.53 (95% CI, 0.39-0.73) for PSA groups 1-4, respectively. The post hoc design of this analysis was not statistically powered to assess the relationship between baseline PSA and clinical efficacy outcomes.

CONCLUSIONS: This post hoc analysis of the AFFIRM trial demonstrates consistent benefits in OS, rPFS, and TTPP with enzalutamide regardless of baseline disease severity, as assessed by PSA.

PATIENT SUMMARY: Exploratory post hoc analysis of the AFFIRM trial showed that enzalutamide improves overall survival, radiographic progression-free survival, and time to prostate-specific antigen progression compared with placebo regardless of baseline disease severity, as assessed by prostate-specific antigen.

TRIAL REGISTRATION: identifier NCT00974311.

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