A Safety and Effectiveness Study of Pre-operative Artesunate in Stage II/III Colorectal Cancer (NeoART)

Phase II Randomised, Double Blind, Placebo Controlled Trial of Neoadjuvant Artesunate in Stage II/III Colorectal Cancer

This study evaluates the safety and effectiveness of pre-operative artesunate given orally once a day for 14 days prior to surgery in patients with Stage II/III colorectal cancer.

Artesunate is an established antimalarial drug with an excellent safety profile, is well tolerated and affordable. A number of laboratory studies and one small pilot clinical study in patients with colorectal cancer have shown that artesunate can reduce the proliferation and growth of cancer cells.

Two hundred patients diagnosed with Stage II/III operable colorectal cancer will be randomly allocated to receive oral artesunate 200mg daily or a matching placebo for 14 days prior to surgery. Patients will be followed up closely for 5 years to see if giving artesunate preoperatively reduces the risk of cancer recurring after surgery.

Study Overview

• Status: Recruiting
• Conditions: Colorectal Cancer; Bowel Cancer
• Intervention / Treatment: Drug: Artesunate 200mg; Drug: Placebo

Detailed Description

Artesunate is an established antimalarial drug belonging to the artemisinin class of drugs, has an excellent safety profile, is well tolerated and affordable. In last two decades, artemisinins have shown potent and broad anticancer properties in a range of cell lines and animal models, supporting the hypothesis that artemisinins have the potential to be an effective anti-cancer therapy. Multiple potential mechanisms of action include anti-proliferative effects through cell-cycle disruption, reactive oxygen species (ROS) -induced DNA damage, induction of apoptosis, anti-angiogenesis, immunomodulation and induced radiosensitivity.

Despite a multi-modality treatment approach to colorectal cancer, 5 year overall survival does not currently exceed 60%. Neoadjuvant pre-operative therapy may be more effective at eradicating micrometastases compared to adjuvant therapy delivered following the delay and immunological stress of surgery. However current neoadjuvant chemotherapy regimens are often associated with significant side effects and may result in a delay in surgery whilst patients recover. A well tolerated, affordable, novel anticancer agent that could be given to patients whilst they wait for surgery, without causing a surgical delay due to treatment related toxicity, would have a significant clinical impact on patient care.

The NeoART trial is a phase II multicentre randomised, double blind, placebo controlled trial (RCT) for patients undergoing primary surgery for Stage II/III colorectal cancers. Patients are randomised (1:1 ratio) to receive either a two week course of neoadjuvant artesunate 200mg once daily or matching placebo. Both patients and health care professionals are blinded to treatment allocation arm to minimise outcome-reporting bias. The primary endpoint of the trial is recurrence free survival two years after surgery. Secondary endpoints include 2 and 5 year overall survival, treatment related toxicity, tolerability and patient quality of life. A translational sub-study looking at predictive and prognostic biomarkers is also planned.

• Study Type: Interventional
• Enrollment (Anticipated): 200
• Phase: Phase 2

Contacts and Locations

• Study Contact: Name: Professor Sanjeev Krishna, FRCP, ScD, FMedSci; Phone Number: ++44(0)208 725 5836; Email: s.krishna@sgul.ac.uk
• Study Contact Backup: Name: Dr Yolanda Augustin, MBBS, MRCP, FRCR, MSc; Phone Number: ++44(0)2087255722; Email: yaugusti@sgul.ac.uk

Study Locations

• United Kingdom
  • Barking, United Kingdom
    • Recruiting
    • Barking, Havering and Redbridge University Hospitals NHS Trust
    • Contact: Nirooshun Dr Rajendran; Phone Number: 3615 01708 435000; Email: nirooshun.rajendran@bhrhospitals.nhs.uk
    • Contact: Alison Ray; Phone Number: 3615 01708 435000; Email: alison.ray@bhrhospitals.nhs.uk
  • Chertsey, United Kingdom
    • Recruiting
    • Ashford & St Peters Hospital NHS Foundation Trust
    • Contact: Pasha Mr Nisar; Phone Number: 01932 722318; Email: pasha.nisar@asph.nhs.uk
    • Contact: Victoria Frost; Phone Number: 01932 723534; Email: victoria.frost@asph.nhs.uk
  • Derby, United Kingdom, DE22 3NE
    • Recruiting
    • University Hospitals of Derby and Burton NHS Foundation Trust
    • Contact: Stelios Vakis; Phone Number: 01283 566333; Email: s.vakis@nhs.net
    • Contact: Helen Cox; Phone Number: 01283 56633; Email: helena.cox1@nhs.net
  • London, United Kingdom, SW17 0RE
    • Active, not recruiting
    • St George's University Hospitals NHS Fundation Trust
  • Norwich, United Kingdom, NR4 7UY
    • Recruiting
    • Norfolk & Norwich University Hospitlas NHS FT
    • Contact: Adam Stearns; Phone Number: 01603 287372; Email: adam.stearns@nnuh.nhs.uk
    • Contact: Cheryl Websdale; Phone Number: 01603 288894
  • Shrewsbury, United Kingdom
    • Recruiting
    • Shrewsbury and Telford Hospital NHS Trust
    • Contact: Jon Mr Lacy-Colson; Phone Number: 1460 01743 261000; Email: jon.lacy-colson@sath.nhs.uk
    • Contact: Sally Potts; Phone Number: 1692 01743 261000
  • Kent
    • Gillingham, Kent, United Kingdom, ME7 5NY
      • Completed
      • Medway Maritime Hospital
    • Maidstone, Kent, United Kingdom, ME16 9QQ
      • Completed
      • Kent Oncology Centre, Maidstone Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion criteria

1. Aged 18 or over
2. Histologically proven single primary site colorectal adenocarcinoma or high grade dysplasia plus unequivocal radiological evidence of invasive cancer
3. Stage II/III colorectal cancer planned for surgical resection and no clinical indication for neoadjuvant preoperative chemotherapy/chemoradiation therapy
4. WHO performance status 0,1 or 2
5. Adequate full blood count: White Cell Count (WCC) >3.0 x 10^9 /l; Platelets >100 x 10^9/l; Haemoglobin (Hb) >80g/L
6. Adequate renal function: Glomerular Filtration Rate >30ml/min by Cockcroft-Gault formula
7. Adequate hepatobiliary function : Bilirubin < 3 x Upper limit normal
8. Female participants of child bearing potential must have a negative pregnancy test < 72 hours prior to initiating study intervention and agree to avoid pregnancy using adequate, medically approved contraceptive precautions for up to 6 weeks after the last dose of study treatment intervention
9. Male participants with a partner of childbearing potential must agree to use adequate, medically approved contraceptive precautions during and for up to 6 weeks after the last dose of the study treatment intervention
10. Patient able and willing to provide written, informed consent for the study.

Exclusion criteria

1. Contraindication to the use of artesunate due to hypersensitivity
2. Pregnancy or lactation
3. Male or female participants unwilling to use an effective method of birth control (either hormonal in the form of contraceptive pill or barrier method of birth control accompanied by the use of a proprietary spermicidal foam/gel or film); or agreement of true abstinence from time to consent is signed until 6 weeks after the last dose of study treatment intervention (i.e. withdrawal, calendar, ovulation, symptothermal and post ovulation methods are not considered acceptable methods)
4. History of immunosuppression
5. History of hearing or balance problems
6. Weight < 52kg or > 110kg
7. Other planned intervention, apart from standard of care
8. Any other malignant disease diagnosis within the preceding 2 years with the exception of non-melanomatous skin cancer and carcinoma in situ
9. Lactose intolerance

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Artesunate; Artesunate 200mg oral tablets once daily for 14 days.	Drug: Artesunate 200mg; Artesunate 200mg PO OD for 14 days prior to colorectal resection surgery
Placebo Comparator: Matching placebo; Matching placebo oral tablets once daily for 14 days.	Drug: Placebo; Matched placebo PO OD for 14 days prior to colorectal resection surgery

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Recurrence free survival at 2 years	2 years following study randomisation.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Recurrence free survival at 5 years		5 years from study randomisation
Overall survival at 2 and 5 years		2 and 5 years from study randomisation
Colon cancer specific death at 2 and 5 years		2 and 5 years from study randomisation
Number of patients experiencing artesunate drug related toxicity as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment at Day 7 following start of study intervention (artesunate/matching placebo)
Number of patients experiencing artesunate drug related toxicity as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment at Day 14 following start of study intervention (artesunate/matching placebo)
Number of patients experiencing artesunate drug related toxicity as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment at Day 42 following start of study intervention (artesunate/matching placebo)
Adverse events affecting patients as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment at Day 7 following study intervention
Adverse events affecting patients as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment at Day 14 following study intervention
Adverse events affecting patients as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment at Day 42 following study intervention
Adverse events affecting patients as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment 6 months following study intervention
Adverse events affecting patients as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment 12 months following study intervention
Adverse events affecting patients as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment 18 months following study intervention
Adverse events affecting patients as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment 24 months following study intervention
Adverse events affecting patients as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment 30 months following study intervention
Adverse events affecting patients as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment 36 months following study intervention
Adverse events affecting patients as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment 42 months following study intervention
Adverse events affecting patients as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment 48 months following study intervention
Adverse events affecting patients as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment 54 months following study intervention
Adverse events affecting patients as assessed by Common Terminology Criteria for Adverse Events (CTCAE) v4.0		Assessment 60 months following study intervention
Pathological assessment of tumour regression (involvement of lymph nodes; serosa; resection margin)		Post surgical pathology review (following Day 14 of study intervention)
Patient quality of life	Using validated quality of life self-administered questionnaires	Assessment at Day 1 of study intervention
Patient quality of life	Using validated quality of life self-administered questionnaires	Assessment at Day 7 of study intervention
Patient quality of life	Using validated quality of life self-administered questionnaires	Assessment at Day 14 of study intervention
Patient quality of life	Using validated quality of life self-administered questionnaires	Assessment at Day 42 of study intervention
Surgical complications	Number of patients with surgery related adverse events as assessed by CTCAE v4.0	From time of surgery up to 3 months post surgery
Predictive value of tumour marker Carcinoma Embryonic Antigen (CEA) kinetics in terms of predicting response to artesunate therapy		Assessment at Day 1 of study intervention
Predictive value of tumour marker Carcinoma Embryonic Antigen (CEA) kinetics in terms of predicting response to artesunate therapy		Assessment at Day 7 of study intervention
Predictive value of tumour marker Carcinoma Embryonic Antigen (CEA) kinetics in terms of predicting response to artesunate therapy		Assessment at Day 14 of study intervention
Predictive value of tumour marker Carcinoma Embryonic Antigen (CEA) kinetics in terms of predicting response to artesunate therapy		Assessment at Day 42 of study intervention
Immunohistochemical analyses of paraffin-embedded tumour sections to assess Kirsten rat sarcoma viral oncogene homolog (Kras) mutation status	Number of patients with Kras mutant tumours	Pre and post intervention tumour samples from patients (Day 0 and Day 15)
Immunohistochemical analyses of paraffin-embedded tumour sections to assess Mismatch Repair (MMR) status	Number of patients with Mismatch Repair (MMR) mutant tumours	Pre and post intervention tumour samples from patients (Day 0 and Day 15)
Immunohistochemical analyses of paraffin-embedded tumour for v-Raf murine sarcoma viral oncogene homolog B (BRAF) mutation status	Number of patients with BRAF mutant tumours	Pre and post intervention tumour samples from patients (Day 0 and Day 15)
Immunohistochemical analyses of paraffin-embedded tumour for Platelet derived growth factor (PDGF) expression	Number of patients whose tumours show PDGF upregulation/downregulation following treatment intervention	Pre and post intervention tumour samples from patients (Day 0 and Day 15)
Immunohistochemical analyses of paraffin-embedded tumour for Platelet derived growth factor receptor (PDGFR) expression	Number of patients whose tumours show PDGFR upregulation/downregulation following study intervention	Pre and post intervention tumour samples from patients (Day 0 and Day 15)
Immunohistochemical analyses of paraffin-embedded tumour for Vascular endothelial Growth Factor (VEGF) expression	Number of patients whose tumours show VEGF upregulation/downregulation following study intervention	Pre and post intervention tumour samples from patients (Day 0 and Day 15)
Immunohistochemical analyses of paraffin-embedded tumour on Vascular endothelial Growth Factor Receptor (VEGFR) expression	Number of patients whose tumours show VEGFR upregulation/downregulation following study intervention	Pre and post intervention tumour samples from patients (Day 0 and Day 15)
Determination of proliferative activity (Ki-67 staining, Cluster of Differentiation 31 protein (CD31) staining)	Number of patients whose tumours show an increase or reduction in proliferation markers Ki67 and CD31 following study intervention	Pre and post intervention tumour samples from patients (Day 0 and Day 15)
Determination of activation of the Deoxyribonucleic acid damage response (DDR) pathway	Number of patients whose tumour samples show activation of the DDR pathway following study intervention	Pre and post intervention tumour samples from patients (Day 0 and Day 15)
Wnt/β-catenin proliferation pathway protein expression (e.g. c-myc and cyclinD1 proteins)	Number of patients who show an increase or a decrease in expression of proteins involved in the Wnt/β-catenin proliferation pathway (e.g. c-myc and cyclinD1 proteins) following study intervention	Pre and post intervention tumour samples from patients (Day 0 and Day 15)

Collaborators and Investigators

• Sponsor: St George's, University of London
• Investigators: Principal Investigator: Professor Sanjeev Krishna, BMBCh, DPhil, ScD, St George's University Hospitals NHS Foundation Trust

Study record dates

Study Major Dates

• Study Start (Actual): April 26, 2017
• Primary Completion (Anticipated): December 31, 2022
• Study Completion (Anticipated): October 31, 2025

Study Registration Dates

• First Submitted: November 18, 2015
• First Submitted That Met QC Criteria: December 14, 2015
• First Posted (Estimate): December 17, 2015

Study Record Updates

• Last Update Posted (Actual): October 12, 2022
• Last Update Submitted That Met QC Criteria: October 11, 2022
• Last Verified: October 1, 2021

More Information

Terms related to this study

• Keywords: Neoadjuvant; Artesunate; Artemisinins; Pre-operative; Antimalarial
• Additional Relevant MeSH Terms: Digestive System Diseases; Neoplasms; Neoplasms by Site; Gastrointestinal Neoplasms; Digestive System Neoplasms; Gastrointestinal Diseases; Colonic Diseases; Intestinal Diseases; Intestinal Neoplasms; Rectal Diseases; Colorectal Neoplasms; Anti-Infective Agents; Antiviral Agents; Antineoplastic Agents; Antiprotozoal Agents; Antiparasitic Agents; Antimalarials; Anthelmintics; Schistosomicides; Antiplatyhelmintic Agents; Artesunate
• Other Study ID Numbers: 15.0154

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No