Additional Treatments to the Local Tumour for Metastatic Prostate Cancer: Assessment of Novel Treatment Algorithms (IP2-ATLANTA)

Local Cytoreductive Treatments for Men With Newly Diagnosed Metastatic Prostate Cancer in Addition to Standard of Care Treatment

Local cytoreductive treatments for men with newly diagnosed metastatic prostate cancer in addition to standard of care treatment

Study Overview

• Status: Active, not recruiting
• Conditions: Prostate Cancer; Metastatic Prostate Cancer
• Intervention / Treatment: Combination product: Standard of Care; Procedure: Minimally Invasive Ablative Therapy (MIAT); Procedure: Radical Therapy (Prostatectomy or Radiotherapy)

Detailed Description

TITLE: Additional Treatments to the Local tumour for metastatic prostate cancer: Assessment of Novel Treatment Algorithms (ATLANTA)

OBJECTIVES: To determine whether the addition of local treatment to the prostate (minimally invasive therapy or radical therapy [prostatectomy or radiotherapy]), including selective metastases-directed therapy, improves oncological outcomes in men receiving standard of care treatment for newly diagnosed metastatic prostate cancer

PHASE: Phase II Randomised Control Trial (RCT) incorporating an internal pilot

DESIGN: Three-arm unblinded randomised controlled trial using a positive control

SAMPLE SIZE: 432

POPULATION: Men who are willing to undergo local therapy to the prostate and selective metastases-directed therapy for metastatic prostate cancer in addition to standard care systemic treatment.

STUDY HYPOTHESIS: We hypothesise that men with metastatic disease who undergo treatment of the local tumour in the form of either radical therapy (prostatectomy or radiotherapy) or minimally invasive ablative therapy (MIAT), combined with metastases directly therapy, will have improved survival compared to those who receive standard of treatment alone. We will be investigating this newly evolving treatment paradigm in a formal randomised control trial (RCT).

TREATMENT/MAIN STUDY PROCEDURES: (including treatment duration and follow-up) Our pragmatic design ensures all eligible patients can be approached and randomised as there is no requirement for fitness to undergo RP. The design also incorporates the latest approach for standard of care as well as management of lymph nodes.

Arm 1*: Standard of Care (SOC) treatment as determined by treating physician (positive control) (androgen deprivation with or without Docetaxel chemotherapy or other systemic/local directed standard of care treatment including but not limited to Abiraterone or Enzalutamide). Radiotherapy in this arm defined as palliative/cytoreductive in high volume metastases or to mirror STAMPEDE local radiotherapy arm in low volume metastases.

Arm 2**: Minimally Invasive Ablative Therapy (MIAT) to local tumour / prostate in addition to SOC systemic treatment. Predominantly cryotherapy but based on disease characteristics, HIFU also. Metastases directed therapy declared prior to randomisation.

Arm 3**: Radical therapy (Prostatectomy or External beam radiotherapy [60Gy x 20 or 74Gy + in 32-37 weeks]) in addition to SOC systemic treatment. Modality based on physician and patient preference and patient co-morbidities. Metastases directed therapy declared prior to randomisation.

FOLLOW-UP DURATION: Until progression or minimum 2-years or maximum 4 years whichever is first (or 6 months for the Pilot if the trial does not progress to Phase II).

Prior to enrolment all patients must undergo Standard of Care (SOC) staging investigations for localised and metastatic disease and will need to have histologically proven local disease within the prostate. There will be no restriction on the type of biopsy used for diagnosis.

*ADT but not chemotherapy may be initiated prior to recruitment.The decision as to which SOC systemic therapy regimen will be used is by the treating clinician and/or clinical team (to be declared upfront prior to randomisation). If radiotherapy is planned for local disease in some cases in the SOC arm then this will be declared upfront prior to randomisation by the treating physician. Similarly, if lymph node radiotherapy is to be advocated then this is to be declared upfront prior to randomisation by the treating physician and can be applied to any one of the three arms. Randomisation into a treatment arm would occur at the time of recruitment which would be within 3 months of starting SOC systemic therapy.

Extra blood and urine samples will be identified using a special study number assigned to each patient, in such a way that the scientists analysing them will not be able to find out patients identity.

• Study Type: Interventional
• Enrollment (Actual): 433
• Phase: Phase 2

Contacts and Locations

Study Locations

• United Kingdom
  • Birkenhead, United Kingdom, CH49 5PE
    • Wirral University Teaching Hospital, Wirral University Teaching Hospital NHS Foundation Trust
  • Bodelwyddan, United Kingdom, LL18 5UJ
    • Glan Clwyd Hospital
  • Dartford, United Kingdom
    • Darent Valley Hospital
  • Exeter, United Kingdom, EX2 5DW
    • Royal Devon and Exeter NHS Trust
  • High Wycombe, United Kingdom
    • Buckinghamshire Healthcare NHS Trust
  • Isleworth, United Kingdom, TW7 6AF
    • West Middlesex University Hospital
  • King's Lynn, United Kingdom, PE30 4ET
    • Queen Elizabeth Hospital, Kings Lynn
  • London, United Kingdom, SW10 9NH
    • Chelsea and Westminster Hospital
  • London, United Kingdom
    • University College London Hospital
  • London, United Kingdom
    • North Middlesex University Hospital
  • London, United Kingdom, W6 8RF
    • Imperial College Healthcare NHS Trust
  • London, United Kingdom
    • St George'S University Hospital
  • London, United Kingdom, SW3 6JJ
    • The Royal Marsden NHS Foundation Trust, Chelsea Research Centre
  • London, United Kingdom
    • Northwick Park, London North West Healthcare NHS Trust
  • Newcastle, United Kingdom, NE7 7DM
    • Freeman Hospital, Newcastle, Newcastle upon Tyne Hospitals NHS Foundation Trust
  • Oxford, United Kingdom
    • Oxford University Hospital
  • Southampton, United Kingdom, SO16 6YD
    • Southampton General Hospital, University Hospital Southampton NHS Foundation Trust (UHS)
  • Sunderland, United Kingdom, SR4 7TP
    • Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust
  • Thornton Heath, United Kingdom, CR7 7YE
    • Croydon University Hospital
  • Westcliff-on-Sea, United Kingdom
    • Southend University Hospital
  • Wirral, United Kingdom
    • Clatterbridge Cancer Centre

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 14 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Diagnosed with prostate cancer within 6 months of screening visit
2. Metastatic disease (Any T, Any N, M1+) of any grade, stage or Prostate Specific Antigen (PSA) level.
3. Fit to undergo standard of care treatment for metastatic disease and both minimally invasive therapy and prostate radiotherapy/prostatectomy.
4. Performance status 0-2
5. Histologically proven local tumour

Exclusion Criteria:

1. Patient did not undergo and/or is unable to undergo standard of care baseline imaging tests for confirmation of metastatic status (CT abdomen/pelvis AND chest Xray (or CT chest) AND radioisotope bone scan (or whole body imaging such as MRI or PET imaging as alternative to all preceding scans mentioned here) AND prostate MRI.
2. Prior exposure to long-term androgen deprivation therapy or hormonal therapy for the treatment of prostate cancer unless started within 6 months of screening visit.
3. Prior chemotherapy or local or systemic therapy for treatment of prostate cancer (apart from ADT or hormonal therapy as outlined above)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Factorial Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Control Arm: Standard of Care (SOC); Standard of Care (SOC) treatment as determined by treating physician (positive control) (androgen deprivation with or without docetaxel chemotherapy or other systemic standard of care treatment including but not limited to Abiraterone or Enzalutamide). Radiotherapy to the prostate in this arm is defined as cytoreductive (for symptom control) in high volume (>/=4) metastases or to mirror current accepted local radiotherapy dose regimens for men with low volume metastases (<4 metastases). Metastases directed therapy will not be permitted in the control arm. Palliative radiotherapy for symptom control or for prevention of fracture will be permitted as standard clinical practice.	Combination product: Standard of Care; Androgen deprivation with or without docetaxel chemotherapy, Abiraterone, Enzalutamide or any other proven agent) treatment as determined by treating physician (positive control).
Active Comparator: Intervention Arm 1: Minimally Invasive Ablative Therapy (MIAT); MIAT to prostate in form of cryotherapy or high intensity focused ultrasound (HIFU), in addition to SOC systemic treatment. No local prostate radiotherapy will be given as part of this intervention. Radiotherapy can be given subsequently for palliative reasons. Metastatic directed therapy will be available for use in this arm (if declared at randomisation).	Combination product: Standard of Care; Androgen deprivation with or without docetaxel chemotherapy, Abiraterone, Enzalutamide or any other proven agent) treatment as determined by treating physician (positive control).; Procedure: Minimally Invasive Ablative Therapy (MIAT); MIAT includes High intensity focused ultrasound (HIFU) or Cryotherapy to the prostate. Metastatic Directed Therapy available for use.; Other Names: Metastatic Directed Therapy (MDT)
Active Comparator: Intervention Arm 2: Radical Therapy; Radical therapy in form of prostatectomy (any approach) or external beam radiotherapy (radical dose) in addition to SOC systemic treatment. Modality based on physician and patient preference and patient co-morbidities. For patients undergoing radical prostatectomy no local prostate radiotherapy will be given as part of the intervention. Radiotherapy can be given subsequently for palliative reasons. Radical radiotherapy doses in this arm will be higher than SOC. Metastatic directed therapy will be available for use in this arm (if declared at randomisation).	Combination product: Standard of Care; Androgen deprivation with or without docetaxel chemotherapy, Abiraterone, Enzalutamide or any other proven agent) treatment as determined by treating physician (positive control).; Procedure: Radical Therapy (Prostatectomy or Radiotherapy); Radical therapy includes: Prostatectomy (any surgical approach) or External beam radiotherapy (High dose). Metastatic Directed Therapy available for use.; Other Names: Metastatic Directed Therapy (MDT)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Prostate cancer on post-standard of care prostate biopsy.	Proportion of patients with complete pathological response, measured on post SOC (systemic therapy) prostate biopsies (Internal Pilot).	6 months
Safety (Adverse Events)	Safety (Adverse Events), measured using the Common Terminology Criteria for Adverse Events (CTCAE) v5.0, Grade 1-5.	2-4 years (continuous)
Progression-free survival (PFS)	Progression-free survival (PFS), measured as a composite outcome of Biochemical failure (PSA progression value) or Local progression or Lymph node progression or Bone metastases progression (new sites) or Progression or development of new distant metastases, defined as lymph nodes outside the pelvis, bone or organ involvement or Skeletal-related events confirmed as progression as in the Systemic Therapy in Advancing Or Metastatic Prostate Cancer: Evaluation Of Drug Efficacy (STAMPEDE) RCT).	2-4 years

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Urinary side effects	Urinary side effects, measured using the IPSS questionnaire, Score 0-35.	Baseline, week 26, 52, then at 24 months.
Sexual side effects	Sexual side effects, measured using the IIEF15 questionnaire, Score 0-75.	Baseline, week 26, 52, then at 24 months.
Rectal side effects	Rectal side effects, measured using the EPIC bowel and bladder questionnaire, Score 14-113.	Baseline, week 26, 52, then at 24 months.
Progression (Biochemical / Radiological / Clinical)	Progression on PSA and imaging and impact of clinical features on progression, measured using PSA blood tests	Baseline, week 12, 26, 34, 52 then every every 24 weeks for remaining years 2 to 4 and Imaging tests at baseline and if progression is suspected by a clinician
Health-related quality-of-life	Health-related quality-of-life, measured using EuroQol (EQ-5D-5L) questionnaire, Score 0-100.	Baseline, week 26, 52, then at 24 months.

Collaborators and Investigators

• Sponsor: Imperial College London
• Collaborators: Wellcome Trust
• Investigators: Principal Investigator: Hashim U Ahmed, FRCS Urol, Imperial College London

Publications and helpful links

General Publications

• Connor MJ, Shah TT, Smigielska K, Day E, Sukumar J, Fiorentino F, Sarwar N, Gonzalez M, Falconer A, Klimowska-Nassar N, Evans M, Naismith OF, Thippu Jayaprakash K, Price D, Gayadeen S, Basak D, Horan G, McGrath J, Sheehan D, Kumar M, Ibrahim A, Brock C, Pearson RA, Anyamene N, Heath C, Shergill I, Rai B, Hellawell G, McCracken S, Khoubehi B, Mangar S, Khoo V, Dudderidge T, Staffurth JN, Winkler M, Ahmed HU. Additional Treatments to the Local tumour for metastatic prostate cancer-Assessment of Novel Treatment Algorithms (IP2-ATLANTA): protocol for a multicentre, phase II randomised controlled trial. BMJ Open. 2021 Feb 25;11(2):e042953. doi: 10.1136/bmjopen-2020-042953.

Helpful Links

• ATLANTA Clinical Trial Website

Study record dates

Study Major Dates

• Study Start (Actual): April 10, 2019
• Primary Completion (Estimated): August 31, 2026
• Study Completion (Estimated): January 31, 2027

Study Registration Dates

• First Submitted: November 12, 2018
• First Submitted That Met QC Criteria: November 30, 2018
• First Posted (Actual): December 4, 2018

Study Record Updates

• Last Update Posted (Actual): March 25, 2025
• Last Update Submitted That Met QC Criteria: February 5, 2025
• Last Verified: February 1, 2025

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Urogenital Diseases; Genital Diseases; Genital Neoplasms, Male; Urogenital Neoplasms; Neoplasms by Site; Neoplasms; Genital Diseases, Male; Prostatic Diseases; Male Urogenital Diseases; Prostatic Neoplasms
• Other Study ID Numbers: 18HH4804

Drug and device information, study documents

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