Pantoprazole Prophylaxis Against Delayed CINV for Patients Receiving Breast Cancer Chemotherapy (PantoCIN)

Phase II, Randomised, Double-blinded, Placebo Controlled, Crossover Trial to Assess Pantoprazole's Effectiveness as Prophylaxis Against Delayed CINV in Patients Receiving Adjuvant or Neoadjuvant Breast Cancer Chemotherapy

This study explores whether a commonly used medication called Pantoprazole can help prevent delayed nausea and vomiting from chemotherapy for early breast cancer.

Delayed nausea, and occasionally vomiting, can occur after breast cancer chemotherapy, affecting quality of life. A potential cause of these delayed side effects is that the chemotherapy may cause stomach irritation. Pantoprazole is commonly used to treat stomach irritation by reducing stomach acid, which may in turn improve nausea and/or vomiting.

Patients undergoing breast cancer chemotherapy before or after primary surgery will be invited to participate in the study. They will be asked how much nausea or vomiting they have with and without Pantoprazole from Day 2 until 5 after they receive chemotherapy. All participants will still receive all of the usual anti-sickness medications, which are very effective in preventing sickness in the first 24 hours after treatment, but not for delayed symptoms.

Information from the study may lead to a change in practice with patients using Pantoprazole to reduce the risks of delayed nausea and vomiting.

Study Overview

• Status: Completed
• Conditions: Breast Cancer; Chemotherapy-induced Nausea and Vomiting; Oncology
• Intervention / Treatment: Drug: Placebo; Drug: Pantoprazole 40mg

Detailed Description

Breast Cancer is the most common cancer type in women in New Zealand and has the second highest mortality (Ministry of Health NZ) Many women with early breast cancer still receive chemotherapy, before or after surgery and delayed nausea is a particular challenge. Ensuring tolerable therapy is critical to improving outcomes, by enabling patients to complete optimal anti-cancer therapy and to improve quality of life during therapy. Despite recent advances in antiemetic regimens, recent trials showed that rates of delayed Chemotherapy-Induced Nausea and Vomiting (CINV) are is in excess of 50%, with significant impacts on quality of life during treatment. This suggests that different mechanisms than those targeted by centrally acting anti-emetics account for such symptoms. There is strong evidence that chemotherapy regimens can result in gastrointestinal mucosal injury and dyspepsia. A number of studies have shown chemotherapy-induced dyspepsia can be relieved by a proton pump inhibitor, but none have reported their use as prophylaxis for delayed CINV, which may be a linked symptom. Proton pump inhibitors are widely used in the treatment of non-malignant dyspeptic conditions and are the most potent medications at reducing gastric acid secretions. They are considered safe in short-term use and are commonly used in clinical practice in cancer patients as well as the wider population. The pharmacokinetics Pantoprazole make it the ideal PPI for this study. The experience of New Zealand Medical Oncologists is that delayed nausea is often completely resolved by the delayed use of a PPI when symptoms occur. In this study we hope to see a 30% difference in the rates of delayed nausea by using a drug which is readily available and of very low cost. This will be the first time it has been used as preventive therapy in this setting. If this benefit occurs, it would significantly improve the treatment journey and may improve compliance to anti-cancer therapies.

• Study Type: Interventional
• Enrollment (Actual): 160
• Phase: Phase 2

Contacts and Locations

Study Locations

• New Zealand
  • Auckland, New Zealand
    • Auckland City Hospital
  • Christchurch, New Zealand
    • Christchurch Hospital
  • Dunedin, New Zealand
    • Dunedin Hospital
  • Hamilton, New Zealand
    • Waikato Hospital
  • New Plymouth, New Zealand
    • Taranaki Base Hospital
  • Palmerston North, New Zealand
    • Palmerston North Hospital
  • Rotorua, New Zealand, 3010
    • Rotorua Hospital
  • Tauranga, New Zealand
    • Tauranga Hospital
  • Wellington, New Zealand
    • Wellington Hospital
  • Whangarei, New Zealand, 0148
    • Whangarei 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. Men or women who are being considered for adjuvant or neoadjuvant chemotherapy with either FEC or AC or TC chemotherapy and have been deemed by their treating Oncologist as being fit for treatment. The scheduled length of each chemotherapy cycle must be 14-21 days.
2. Age ≥18 years.
3. Willing to comply with all study requirements, including treatment (being able to swallow tablets), timing and nature of required assessments.
4. All patients must be able to speak and read in English to ensure consent is informed and documentation of patient-reported outcome measures can be adhered to.

5. Signed, written informed consent.

   -

Exclusion Criteria:

1. Patients who are receiving therapy to reduce gastric acid (including proton pump Inhibitors (e.g. Omeprazole, Pantoprazole, Lansoprazole, Esomeprazole or Histamine type-2 receptor antagonists e.g. Ranitidine)) at the time of enrolment will be excluded from the trial.
2. Patients with pre-existing hypomagnesemia as defined by the reference range at the investigating sites laboratory.
3. Patients with a history of cardiac arrhythmias including atrial fibrillation or paroxysmal tachycardias.
4. Patients with known metastatic disease.
5. The presence of any serious medical or psychiatric conditions, which might limit the ability of the patient to comply with follow up.
6. The presence of any psychological, familial, sociological or geographical condition potentially hampering compliance with the study protocol and follow up schedule, including alcohol dependence or drug abuse.

7. Pregnancy, lactation or inadequate contraception. Women must be postmenopausal, infertile, or use a reliable means of contraception. Women of childbearing potential must have a negative pregnancy test done within 7 days prior to registration.

   -

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Other: Pantoprazole/Placebo; Participants will take one 40 mg capsule of Pantoprazole daily for 5 days at the beginning of cycle 1 then they will take one capsule of matched Placebo daily for 5 days at the beginning of cycle 2	Drug: Placebo; Matched placebo; Drug: Pantoprazole 40mg; Proton pump inhibitor, drug action is to irreversibly block the hydrogen-potassium adenosine triphosphatase enzyme system (the 'proton pump') of the gastric parietal cell. This reduces basal and stimulated gastric acid secretion therefore raising gastric pH.; Other Names: Apo-Pantoprazole
Other: Placebo/Pantoprazole; Participants will take one capsule of matched Placebo daily for 5 days at the beginning of cycle 1 then they will take one 40 mg capsule of Pantoprazole daily for 5 days at the beginning of cycle 2	Drug: Placebo; Matched placebo; Drug: Pantoprazole 40mg; Proton pump inhibitor, drug action is to irreversibly block the hydrogen-potassium adenosine triphosphatase enzyme system (the 'proton pump') of the gastric parietal cell. This reduces basal and stimulated gastric acid secretion therefore raising gastric pH.; Other Names: Apo-Pantoprazole

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Reduce the incidence of delayed CINV in patients receiving adjuvant or neoadjuvant breast cancer chemotherapy	To determine whether Pantoprazole can reduce the incidence of delayed CINV in patients receiving adjuvant or neoadjuvant breast cancer chemotherapy (as measured on day 5 using the MASCC Antiemesis Tool (MAT) to assess nausea over days 2-5 of each chemotherapy cycle) as compared to placebo. Specifically, the primary endpoint will be the complete absence of both nausea and vomiting during days 2-5.	Measured on day 5, after chemotherapy

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Nausea MAT scores	Whether Pantoprazole improves nausea MAT scores over days 2-5	Days 2-5 following chemotherapy for cycle 1 and 2 (each cycle is either 14 or 21 days)
Vomiting MAT scores	Whether Pantoprazole reduces the number of episodes of vomiting (MAT) over days 2-5	Days 2-5 following chemotherapy for cycle 1 and 2 (each cycle is either 14 or 21 days)
Heartburn improvement	Whether Pantoprazole improves heartburn score (measured using the FSSG for reflux and/or dyspepsia) as self-reported on day 5 regarding days 2-5.	Days 2-5 following chemotherapy for cycle 1 and 2 (each cycle is either 14 or 21 days)
Heartburn and Nausea scores	Whether FSSG scores (heartburn) are associated with the MAT nausea scores reported by the patient over days 2-5.	Days 2-5 following chemotherapy for cycle 1 and 2 (each cycle is either 14 or 21 days), using a regression model, with allowance for a possible non-linear relationship.
Use of breakthrough medications	Whether Pantoprazole lowers the requirement for breakthrough medications (as self-recorded by the patients on days 2-5).	Days 2-5 following chemotherapy for cycle 1 and 2 (each cycle is either 14 or 21 days)
Patient preference	Whether Pantoprazole is preferred by patients over Placebo (by using a patient preference survey at the end of cycle 2).	end of chemotherapy cycle 2 (cycle 2 is either 14 or 21 days)
Adverse events	To assess whether adverse events (including hypomagnesemia, diarrhoea, abdominal pain and headache as defined by CT CAE version 4.03) are more common on Pantoprazole than on Placebo.	From date of consent to 28 days after the last study treatment

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Effect of chemotherapy regimen impacts use of Pantoprazole in terms of delayed CINV	Whether the chosen chemotherapy regimen (FEC vs AC vs TC) has an impact on the benefits of Pantoprazole in terms of delayed CINV, (as measured on day 5 using the MASCC Antiemesis Tool (MAT) to assess nausea over days 2-5 of each chemotherapy cycle) as compared to placebo.	Measured on day 5, after chemotherapy
Cycle effect	To determine whether there is a cycle effect with respect to the incidence of delayed CINV as measured with the MAT (as measured on day 5 using the MASCC Antiemesis Tool (MAT) to assess nausea over days 2-5 of each chemotherapy cycle).	Cycle 1 to end of cycle 2 (each cycle is either 14 or 21 days)

Collaborators and Investigators

• Sponsor: University of Auckland, New Zealand
• Investigators: Principal Investigator: Ricard Isaacs, MBChB FRACP, Midcentral Regional Cancer Centre Services; Principal Investigator: Navin Wewala, MBChB FRACP, Midcentral Regional Cancer Centre Services

Publications and helpful links

Helpful Links

• Cancer Trials New Zealand website study record
• Breast Cancer Foundation website study record (Co-funder)

Study record dates

Study Major Dates

• Study Start (Actual): June 10, 2019
• Primary Completion (Actual): October 15, 2021
• Study Completion (Actual): October 15, 2021

Study Registration Dates

• First Submitted: March 28, 2019
• First Submitted That Met QC Criteria: May 9, 2019
• First Posted (Actual): May 14, 2019

Study Record Updates

• Last Update Posted (Actual): May 25, 2022
• Last Update Submitted That Met QC Criteria: May 23, 2022
• Last Verified: May 1, 2022

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Skin Diseases; Neoplasms; Neoplasms by Site; Signs and Symptoms, Digestive; Breast Diseases; Breast Neoplasms; Vomiting; Molecular Mechanisms of Pharmacological Action; Enzyme Inhibitors; Gastrointestinal Agents; Anti-Ulcer Agents; Proton Pump Inhibitors; Pantoprazole
• Other Study ID Numbers: CTNZ-2017-01

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

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