Transcript nsabp c-07 (n = 892)

Validation of the 12-gene colon cancer
Recurrence Score (RS) in NSABP C-07 as a
predictor of recurrence in stage II and III colon
cancer patients treated with 5FU/LV (FU) and
5FU/LV + oxaliplatin (FU+Ox)
O’Connell MJ,1 Lee M,2 Lopatin M,2 Yothers G,1 Clark-Langone
K,2 Millward C,2 Paik S,1 Sharif S,1 Shak S,2 Wolmark N1
1National
Surgical Adjuvant Breast and Bowel Project, Pittsburgh, PA;
2Genomic Health, Inc., Redwood City, CA
Background
The Need for Validated Biomarkers for Optimal
Management of Resected Colon Cancer
• For patients with stage III colon cancer, current practice guidelines1
recommend 5-FU/LV + oxaliplatin for adjuvant therapy, and in the US, a
growing majority of stage II colon cancer patients receive this regimen2
−
−
•
However, oxaliplatin likely benefits only a fraction of treated patients (6-7%)4,5
and comes with significant toxicity, including the prospect of long-term
peripheral neuropathy3-7
Conventional clinical and pathologic risk factors do not adequately discriminate
risk and expected absolute benefit of oxaliplatin to guide decision-making
A more accurate assessment of both recurrence risk and absolute
treatment benefit can better inform adjuvant decision-making in resected
colon cancer, particularly for stage II patients with T3 MMR-Proficient
tumors and for stage IIIA/B patients
Genomic Markers for Risk Assessment
in Stage II/III Colon Cancer
• 12-gene Oncotype DX Colon Cancer Recurrence Score (RS) assay
(Genomic Health, Inc., Redwood City, CA) is a validated predictor of
recurrence risk in stage II colon cancer patients
• Development: 1,851 patients with stage II and stage III colon cancer in four
independent studies8
• Validation: >2000 stage II colon cancer patients in QUASAR and CALGB
9581 clinical studies9, 10
• Captures the activity of 2 key biological pathways: stromal response and cell
cycle
• Provides quantitative recurrence risk information not available with
conventional risk factors
• Improves discrimination of absolute treatment benefit with 5FU-based
adjuvant chemotherapy as a function of risk9
• This prospectively defined validation study in NSABP C-07 represents
the first test of RS in stage II and III colon cancer patients treated with
5FU versus 5FU+oxaliplatin.
The 12-Gene Oncotype DX
Colon Cancer Recurrence Score8
Recurrence Genes
STROMAL
FAP
INHBA
BGN
Reference Genes
CELL CYCLE
Ki-67
C-MYC
MYBL2
GADD45B
Recurrence Score =
– 0.15 × Stromal Group
– 0.30 × Cell Cycle Group
+ 0.15 × GADD45B
* GADD45B is a marker of genotoxic stress and a regulator of stromal response gene activity.
ATP5E
GPX1
PGK1
UBB
VDAC2
Development and Validation of
the 12-Gene Colon Cancer Recurrence Score
Colon Cancer Technical Feasibility
Development Studies (Surgery)
NSABP C-01/C-02 (n = 270)
Cleveland Clinic (n = 765)
Development Studies (5FU/LV)
NSABP C-04 (n = 308)
NSABP C-06 (n = 508)
Selection of Final Gene List & Algorithm
Standardization and Validation of Analytical Methods
Clinical Validation Study – Stage II Colon Cancer
QUASAR (N = 1436)
Confirmation Study – Stage II Colon Cancer
CALGB 9581 (N = 690)
Clinical Validation Study – Stage II/III Colon Cancer
5FU vs 5FU+Oxaliplatin
NSABP C-07 (N = 892)
NSABP C-07: A Key US Trial Which Established Efficacy
of Addition of Oxaliplatin to 5FU-based Adjuvant
Chemotherapy in Resected Colon Cancer
• Phase III intergroup study3
– Randomization: 5FU vs. 5FU+oxaliplatin (FLOX)
– 2,409 evaluable patients enrolled between 2000 and 2002
– Prospectively collected tissue samples
– In combination with MOSAIC, established benefit of adding
oxaliplatin to 5FU in adjuvant therapy of colon cancer
Study Design and Methods
Study Objectives
Prospectively-designed study using archived tissue with pre-specified
endpoints, analytical methods and analysis plan (a “ProspectiveRetrospective” study 11)
• Primary Objective:
‒ Determine whether there is a significant relationship between the
continuous 12-gene RS and recurrence risk in stage II/III patients
treated with 5FU or 5FU+oxaliplatin
• Secondary Objectives
− Determine whether the RS provides significant information beyond
number of nodes examined, pathologic T stage, tumor grade and
mismatch repair (MMR) status
− Compare recurrence risk between high and low RS groups defined
using pre-specified cut-points
Quantitative Gene Expression Analysis
• Standardized Oncotype DX Colon Cancer Assay performed using RTPCR from 25 μm of manually microdissected, fixed, paraffin embedded
primary colon cancer tissue
− Expression of 7 cancer-related genes and 5 reference genes
analyzed by TaqMan assays
− RT-PCR performed in triplicate qPCR wells (2 ng RNA input per 10
μL-reaction)
• The 12-gene RS was calculated using the same pre-specified gene list
and algorithm as previously validated in QUASAR and CALGB 9581
Pathology Analysis
• MMR protein status (D= Deficient; P= Proficient) was assessed
centrally at NSABP by IHC for MLH1 and MSH2
• T-stage, number of lymph nodes examined and number of lymph
nodes involved by colon carcinoma were obtained from the NSABP
clinical database
• Tumor grade and tumor type were assessed centrally according to
the College of American Pathologists Consensus Statement, with
mucinous carcinomas characterized as high tumor grade7
All centrally-performed pathology and assay procedures were prespecified and conducted without knowledge of the clinical
characteristics or outcomes
Statistical Analysis
• Primary endpoint: Recurrence Free Interval (RFI)
‒ Time from randomization to first colon cancer recurrence
‒ Recurrence at the time of death (e.g. on autopsy) was considered a
recurrence event on the date of death
‒ Deaths without evidence of recurrence were censored
‒ Second primary cancers were neither considered as events nor censored
• Secondary endpoints
‒ Disease-Free Survival (DFS): time from randomization to first colon cancer
recurrence, second primary cancer or death from any cause
‒ Overall Survival (OS): time from randomization to death from any cause
• Multivariable Cox proportional hazards regression models were utilized.
• A likelihood-ratio test was used to determine if RS is significantly
associated with outcome after controlling for effects of nodal status,
treatment and other clinical and pathologic covariates.
Study Population
Parent C-07 study
n=2,409
Eligible patients with available tumor tissue
n=1,860 (77%)
Randomly selected 50% of patients with available tissue
with stratification on recurrence status and stage
Study Cohort (n=929)
37 excluded (4%):
9 insufficient tissue
19 ineligible histology
9 RNA quality/quantity
Final evaluable
population (n=892)
Demographic and Clinical Patient
Characteristics
Variable
Race
Gender
Age
Stage
T-stage
MMR status
Nodes examined
Value
FU
N=449
FU+Oxali
N=443
All
N=892
White
Female
Average, years
89%
43%
59
88%
42%
58
88%
42%
58
70+ years
16%
18%
17%
II
29%
30%
30%
III A/B
46%
45%
46%
III C
24%
25%
25%
T4 in stage II
5%
8%
6%
T3-T4 in stage III
85%
84%
85%
MMR-D in stage II*
21%
16%
18%
MMR-D in stage III*
8%
10%
9%
≥12 in Stage II
≥12 in Stage III
64%
59%
60%
63%
62%
61%
* In patients with known MMR status. MMR status was available for 80% of all patients.
• Treatment arms are well balanced with respect to clinical and pathologic
covariates
Demographics and Clinical Characteristics
• The demographic and clinical characteristics of patients in this study
were similar to those of patients in the parent C-07 trial
•
Patient characteristics in this study were also similar to those of C-07
patients not included in this study
• Median FU 8.6 yrs; 865 (97%) of 892 evaluable patients had complete
follow-up at 3 years and 840 (94%) had complete follow-up at 5 years.
• Recurrences
• 31 (12%) of 264 stage II patients
• 214 (34%) of 628 stage III patients
Oxaliplatin Effect Similar to the Parent Study
Proportion Recurrence Free
1.0
Stage II
0.8
Stage III
0.6
0.4
HR = 0.80 for
5FU+Ox vs. 5FU
Solid: 5FU
Dashed: 5FU+Ox
0.2
0.0
0
1
2
3
4
5
6
7
8
9
10
Years
• Similar to the parent study, most of the oxaliplatin effect was observed
in stage III patients, though the interaction of treatment and stage was
not significant (p=0.36)
Pre-Specified Primary Analysis:
Recurrence Score Predicts Recurrence Risk
in Stage II & III Colon Cancer Patients in
NSABP C-07 (n=892)
Variable
Value
HR
HR 95% CI
<0.001
Stage
(by nodal status)
Treatment
RS
p-value
Stage III A/B vs. II
2.53
(1.70,3.78)
Stage III C vs. II
5.29
(3.54,7.90)
FU+Oxali vs. FU
0.76
(0.59,0.98)
0.033
per 25 units
1.96
(1.50,2.55)
<0.001
• Continuous RS is significantly associated with risk of recurrence
controlling for effects of treatment and stage (by nodal status)
• Interaction of RS and nodal status not significant (p=0.90)
• Interaction of RS and treatment not significant (p=0.48)
• Interaction of RS and age not significant (p=0.76)
Primary Analysis: Recurrence Score Predicts
Recurrence Risk in Stage II & III Colon
Cancer Patients in NSABP C-07 (n=892)
Solid: 5FU
Dashed:
5FU+Ox
p<0.001
Stage III C
Stage III A/B
Stage II
Solid: 5FU
Dashed: 5FU+Ox
• With similar relative benefit of oxaliplatin added to adjuvant 5FU across the range
of RS, absolute benefit of oxaliplatin increases with increasing RS, most
apparently in stage II and stage IIIA/B patients
5-year Recurrence Risk in 5FU treated arm
Cox Regression Analysis (n=892)
Stage II
Stage IIIA/B
Stage IIIC
RS Group*
% pts
Average Risk
95% CI
% pts
Average Risk
95% CI
% pts
Average Risk
95% CI
Low
39%
9% (6-13%)
41%
21% (16-26%)
33%
40% (32-48%)
Intermediate
36%
13% (8-17%)
34%
29% (24-34%)
37%
51% (43-59%)
High
25%
18% (12-25%)
25%
38% (30-46%)
30%
64% (55-74%)
* Pre-specified RS Groups: Low (RS<30), Intermediate (30≤RS<41), High (RS≥41).
• Recurrence risk is significantly higher in High vs. Low RS group:
HR = 2.11, p<0.001
RS Groups and Treatment in Stage II
Kaplan-Meier Analysis
1.0
Proportion Recurrence Free
0.8
0.6
KM Estimates (95% CI) of
5-year Recurrence Risk
0.4
N
events
Low RS Group
10
N
Pts
103
FU
FU + Oxali
7% (3%, 17%)
12% (5%, 27%)
Int RS Group
9
94
8% (3%, 22%)
10% (4%, 22%)
High RS Group
12
67
Risk Group
0.2
Solid: FU
Dashed: FU+Ox
23% (12%, 42%) 9% (3%, 25%)
0.0
0
1
2
3
4
5
Years
6
7
8
9
10
RS Groups and Treatment in Stage III A/B
Kaplan-Meier Analysis
1.0
Proportion Recurrence Free
0.8
0.6
KM Estimates (95% CI) of
5-year Recurrence Risk
0.4
N
events
Low RS Group
31
N
Pts
169
19% (12%,28%) 17% (10%,27%)
Int RS Group
38
138
30% (20%,42%) 19% (11%,30%)
High RS Group
40
102
43% (31%,57%) 31% (20%,46%)
6
7
8
Risk Group
0.2
Solid: FU
Dashed: FU+Ox
FU
FU + Oxali
0.0
0
1
2
3
4
5
Years
9
10
RS Groups and Treatment in Stage III C
Kaplan-Meier Analysis
KM Estimates (95% CI) of
5-year Recurrence Risk
1.0
N
events
Low RS Group
29
N
Pts
73
41% (28%, 57%) 38% (23%, 58%)
Int RS Group
36
81
48% (32%, 67%) 40% (28%, 54%)
High RS Group
40
65
67% (52%, 82%) 59% (42%, 76%)
7
8
Risk Group
Proportion Recurrence Free
0.8
FU
FU + Oxali
0.6
0.4
0.2
Solid: FU
Dashed: FU+Ox
0.0
0
1
2
3
4
5
Years
6
9
10
Contribution of RS Beyond
Clinical and Pathologic Covariates
Pre-specified Multivariate Analysis (n=892)
Variable
Value
HR
HR 95% CI
Stage
(by nodal status)
Treatment
MMR
T-stage
P value
<0.001
Stage III A/B vs. II
0.97
(0.55,1.71)
Stage III C vs. II
2.07
(1.16,3.68)
FU+Oxali vs. FU
0.82
(0.64,1.06)
0.12
MMR-D vs. MMR-P
0.27
(0.12,0.62)
<0.001
3.04
(1.84,5.02)
<0.001
T4 st II & T3-T4 st III vs.
T3 st II & T1-T2 st III
Nodes examined
<12 vs. ≥12
1.51
(1.17,1.95)
0.002
Tumor grade
High vs. Low
1.36
(1.02,1.82)
0.041
RS
per 25 units
1.57
(1.19,2.08)
0.001
•
RS is significantly associated with risk of recurrence after controlling for
effects of T and N stage, MMR status, number of nodes examined, grade
and treatment
Recurrence Score and Alternative endpoints
Disease
Free
Survival
Overall
Survival
Variable
RS per 25 units
Variable
RS per 25 units
HR
HR 95% CI P value
1.60 (1.28,1.99) <0.001
HR
HR 95% CI P value
1.89 (1.46,2.44) <0.001
• RS is significantly associated with DFS and OS after controlling for
nodal status and treatment
Summary
• NSABP C-07, a randomized phase III clinical trial, provided an ideal
opportunity to test RS for prediction of recurrence risk and its relationship
with absolute treatment benefit from oxaliplatin in resected colon cancer.
•
The relationship of a marker with treatment benefit can only be evaluated
through analysis of large, randomized trials.
• RS predicts recurrence risk in stage II and III colon cancer patients
treated with 5FU or 5FU+oxaliplatin, capturing underlying biology and
providing risk information beyond conventional factors
•
•
As expected, RS performs similarly in stage II and stage III colon cancer
RS predicts recurrence risk beyond T and N stage, MMR status, number of
nodes examined, grade and treatment
• With similar relative risk reduction observed for oxaliplatin across the
range of RS, RS enables better discrimination of absolute oxaliplatin
benefit as a function of risk
•
Absolute benefits of oxaliplatin increases with increasing RS, most
apparently in stage II and stage IIIA/B patients
• RS also predicts DFS and OS
Conclusions
• RS was validated as a predictor of recurrence risk in stage II and stage
III colon cancer patients treated with 5FU or 5FU + oxaliplatin
• First prospective study with stage III patients
• Consistent results for RS in stage II across 3 prospective studies
• As in stage II colon cancer, incorporating RS into the clinical context
can guide adjuvant therapy decisions for certain patients with stage III
colon cancer
• In particular, for certain stage IIIA/B patients, the finding of low RS
disease (RS < 30), and thus low recurrence risk and low absolute
oxaliplatin benefit, may not justify the risk of potential toxicity from
adding oxaliplatin
• Analysis of new genes as potential predictors of oxaliplatin sensitivity
and resistance is in progress
• Risk stratification through anatomic staging, RS and potentially other
factors may enable clinical trial designs targeted to more homogeneous,
well-defined low- and high-risk patient populations in the adjuvant
setting.
References
1.
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