By Jay Grisolano, PhD and Emily Benesh, PhD
Today was an exciting day for physicians and patients experiencing newly-diagnosed metastatic prostate cancer. At the ASCO 2017 meeting, data were presented on LATITUDE, a randomized Phase III trial comparing Zytiga (abiraterone acetate, Janssen)/prednisone plus androgen deprivation therapy (ADT) versus placebos plus ADT in newly-diagnosed high-risk metastatic hormone-naive prostate cancer (mHSPC), concurrent with a publication in the New England Journal of Medicine1, which will transform the prostate cancer treatment landscape.
The prostate cancer competitive landscape is one of the most highly dynamic and complex in all of oncology. In both early stage high-risk and treatment-naïve metastatic disease, hormone therapies are the mainstay systemic treatments for newly-diagnosed patients. In fact, ADT has been standard of care for newly diagnosed mHSPC patients for decades. Despite the durable efficacies and minimal side effects of hormonal agents, some patients fail treatment and become castrate-resistant.
Zytiga improved the treatment options for metastatic castrate resistant prostate cancer (mCRPC) patients when it was initially approved by the FDA as a second-line therapy in 2011. The label was expanded in late 2012 to include front-line treatment in the mCRPC space. Zytiga is a second-generation hormone therapy that inhibits androgen-production in the microenvironment by blocking CYP17A1 protein production in the testes, adrenal glands, and the tumor itself2.
Since their initial approvals, Zytiga and its second-generation hormone therapy competitor, Xtandi (enzalutamide, Astellas/Medivation; approved in April 2012), an androgen receptor antagonist, have eaten up mCRPC market-share. According to Kantar Health’s CancerMPact, Treatment Architecture module, in 2016, Zytiga and Xtandi captured over 70% share of the United States, EU5, and Japanese first-line mCRPC markets for both asymptomatic and symptomatic diseases2; Zytiga sees utilization in over 100 other countries across the world3.
Having demonstrated efficacy in the mCRPC setting, Janssen now aims to move Zytiga even earlier in the treatment paradigm: into the metastatic, hormone-naïve setting. No other next-generation hormone therapies or cutting-edge systemic therapies have been approved for use in this space2.
In 2016, nearly 70% of mHSPC patients in the U.S. were treated with traditional hormone therapies [Luteinizing Hormone Releasing Hormone (LHRH) agonists or anti-androgens]2. Importantly, roughly 20% of patients received off-label second-generation hormone therapy (namely, Zytiga or Xtandi), either as a monotherapy or in combination with traditional hormone treatments2. This suggests that awareness about the utility of second-generation hormone therapies is high and that uptake of these agents in the hormone-sensitive metastatic prostate cancer space will be rapid upon approval.
Janssen has strong previous data supporting the use of second-generation hormone therapies in the metastatic hormone-sensitive space. In a Phase II study, Zytiga and prednisone were added to a first-generation LHRH agonist in 37 patients with high-risk localized prostate cancer4. High-risk was defined as patients with Stage T1c/T2 disease and a Gleason score of at least eight, or patients with at least Stage T2b/T2c disease with a Gleason score of at least 7 and a PSA level > 10 ng/mL. Patients were randomized 2:1 to receive either: Zytiga/prednisone/LHRH agonist or LHRH agonist alone. The percentage of patients with preoperative prostate-specific antigen (PSA) less than 0.1 ng/mL was significantly increased in the Zytiga/prednisone/LHRH agonist arm compared to the control arm (68% versus 0%, p<0.0001). In addition, there was a numerical increase and decrease, respectively, in the percent of patients with near complete cytoreductions (< 6 mm scattered cells; 24% versus 8%, p=0.10) and lymph node infiltration (25% versus 50%, p=0.10) in the Zytiga/prednisone/LHRH agonist arm compared to controls. The safety profile was similar to what has been observed in the mCRPC setting. These results showed that the addition of Zytiga and prednisone to standard hormonal therapy can add significant efficacy even in a hormone-sensitive population.
In February 2013, Janssen initiated a randomized, double-blind, global (including Japan) Phase III trial (LATITUDE, CR100900; NCT01715285) of Zytiga in newly-diagnosed, high-risk metastatic patients who are hormone-naïve. Patients must have been diagnosed within three months of randomization and have not yet received any treatment for their prostate cancer [with the exception of fewer than three months of ADT received since diagnosis]. Patients were considered high-risk if they met at least two of the following requirements: Gleason score of at least 8, presence of at least three lesions on a bone scan, or presence of measurable visceral metastasis.
Patients were randomized 1:1 to receive either: Zytiga/prednisone/ADT (either LHRH agonists or surgical castration) or placebo/ADT. Co-primary endpoints were overall survival (OS) and radiographic progression-free survival (rPFS); secondary endpoints included time to next skeletal-related event, time to prostate-specific androgen progression, time to next therapy, time to initiation of chemotherapy, changes in mRNA and miRNA levels, and safety. The trial intended to accrue 1,200 patients and have three analyses: interim one – after 50% of total projected events (426 events), interim two – after 65% of events (554 events) and a final analysis – after a total of 852 events. The trial would be considered positive if P values for overall survival were lower than 0.011, 0.022 and 0.049 for interim one, two and the final analysis, respectively.
Data from the first interim analysis of the LATITUDE trial were reported in a plenary session on June 4, 2017 at the 53rd annual meeting of the American Society for Clinical Oncology (ASCO) held in Chicago, Illinois5. The trial had accrued 1,199 patients. At the first interim analysis 406 events had occurred: 169 occurred in the Zytiga arm, while 237 events occurred in the placebo controls. The median follow-up time was 30.4 months.
As the discussant, Eric Small, MD, stated, “LATITUDE was a profoundly positive study.”
The Zytiga/prednisone/ADT arm had a 38% reduction in risk of death when compared to the control (OS: not reached vs. 34.7 months, HR: 0.62, 95% CI: 0.51-0.76; P<0.0001). The 3-year OS rate was 66% in the Zytiga arm versus 49% in the placebo arm. Overall survival benefit persisted across all of the pre-specified subgroups (e.g., ECOG status and visceral disease).
Additionally, patients in the Zytiga arm experienced a 53% reduction in the risk of radiographic progression (rPFS: 33.0 vs. 14.8 months, HR: 0.47, 95% CI: 0.39-0.55; P<0.001). All secondary endpoints were statistically improved in the Zytiga arm. Zytiga patients had an astounding 70% reduced risk of time to PSA progression (33.2 vs. 7.4 months, HR: 0.30, 95% CI: 0.26-0.35; P<0.0001). As mentioned by the discussant, given the concern of patients regarding PSA levels, this finding is expected to greatly improve quality of life for this population. Patients in the Zytiga arm receive fewer subsequent, post-study, life-prolonging therapies, suggesting that OS benefit was due to Zytiga and not subsequent treatment. Adverse events in the Zytiga arm were manageable and consistent with studies in mCRPC patients. Elevated rates of hypertension, hypokalemia, ALT and AST increases, and cardiac disorders were observed with Zytiga use. Taken together, these data were sufficiently positive to support early termination of the trial, un-blinding of participants and cross-over of placebo receiving patients to the Zytiga arm.
On May 26, 2017 Janssen announced that they filed for approval of Zytiga for mHSPC to the Ministry of Health Labor and Welfare in Japan3. Given the unmet need of development of resistance to ADT in mHSPC patients, the previous enthusiastic global uptake of Zytiga in metastatic CRPC, and the current off-label use of second-generation hormones in hormone-sensitive disease, it is expected that Zytiga will have rapid uptake upon approval for mHSPC patients.
The approval of Zytiga will have practice-altering effects on the metastatic prostate cancer landscape; Zytiga will likely become the new standard of care for high-risk mHSPC patients. Furthermore, data presented yesterday from the Phase III STAMPEDE trial suggest that Zytiga will soon move into early-stage/low-risk disease, as well. In a population that was 48% low-risk (N0M0 or N+M0) overall survival was significantly improved (HR: 0.63, 95% CI: 0.52-0.76; P=0.00000015)6. Thus, the reach of Zytiga is expected to continue expanding in earlier settings of the prostate cancer treatment landscape.
It is important to note that data reported from the Phase III CHAARTED study showed that addition of docetaxel to ADT in castration-naïve metastatic prostate cancer significantly improved survival outcomes in the overall population of patients (51.2 versus 34.4 months, HR: 0.73, P<0.0001) as well as in those with high-volume disease7, providing evidence for use of docetaxel in this setting Questions remain about how physicians will use Zytiga versus docetaxel in metastatic prostate cancer patients. Cross-trial comparisons between LATITUDE and CHAARTED show nearly identical improvements in risk of death for patients receiving Zytiga versus docetaxel with ADT (HR of 0.62 versus 0.63, respectively). Physicians may prefer the improved toxicity profile of Zytiga over docetaxel, but may also consider cost in treatment choice. Notably, duration of therapy with Zytiga has a median of 33 months in LATITUDE, while docetaxel was given for 6 cycles, or 4.5 months, in CHAARTED, potentially impacting cost as well as convenience to the patient. Another concern is that if Zytiga is used in an earlier setting, what will be used for subsequent treatment if the patient becomes mCRPC. Only time will tell regarding whether physicians will re-treat with the same general mechanism of action, the sequencing of the agents, and whether a space will open for another novel mechanism of action for use with progressed patients.
While Zytiga is poised to be first-to-market, several other second-generation agents have ongoing Phase III trials for use in first-line hormone-sensitive metastatic prostate cancer. Phase III trials testing combinations of androgen-deprivation therapy plus either apalutamide (ARN-509/JNJ-927, Aragon Pharmaceuticals/Janssen; TITAN/NCT02489318 initiated November, 2015), Xtandi (NCT02677896 initiated March 2016), and darolutamide (ODM-201, Bayer; ARASENS/NCT02799602 initiated June 2016) have the promise of bringing several competitors to the market in the near future. Competition in this space is likely to be intense, but Zytiga may have an advantage by being first-to-market.
In any case, today was a bright day for the field of prostate cancer and for prostate cancer patients.