1. Results of the Prodige 2-ACCORD 12/0405 Randomized trial comparing two neoadjuvant chemo-radiotherapy (Cape 45 vs Capox 50) in patients with T3-4 rectal cancer.
Nice
Jean-Pierre GERARD, D. Azria, S. Gourgou-Bourgade, I. Martel-Laffay,
C. Hennequin, P.L. Etienne, V. Vendrely, T. Conroy, E. François, C. Montoto-Grillot,
for the FNCLCC - FFCD
No conflict of interest - Abstract # ASCO – Orlando – 30 May 2009
30/05/2009

2. Background (1) ■ Surgery "TME" (sharp dissection) cornerstone
of treatment of T3-4 M0 rectal cancer
■ German CAO/ARO Phase III trial (2004)
Preop CT-RT > postop (standard)
Local control - toxicity
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3. Background (2) Concurrent CT-RT > RT alone
FFCD (EORTC) phase III
RT CT - RT
ypCR 4% 11%
Loc rec 5 y 16% 7%
No change : sphincter preservation – survival
ASCO JCO 2006;24:4260
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4. 2005 : How to optimize neoadjuvant treatment for T3-4 Nx M0 rectal cancer ?
FFCD : RT 45 Gy/5 weeks - 5 FU 225 mg/m²
ACCORD 12/0405-Prodige 2
pragmatic approach : 2 modifications
RT dose increase : 50 Gy/5 weeks (BED + 15%)
CT intensification : Oxaliplatin (50 mg/m²)
Capecitabine (1600 mg/m²/d) = 5FU - LV
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5. Accord 12 inclusion criteria
As in FFCD 92.03
■ Adenocarcinoma of rectum
■ Accessible to digital examination
■ T3-4 resectable N0-2 M0
T2 distal anterior rectum
- Workup = EUS – MRI – CT (Th. Abd)
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6. Primary end point : Complete sterilization of operative specimen ypCR Dworak- Quirke
0 = no regression
1 = moderate pathological tumor response
2 = very few residual tumor cells
3 = no visible tumor cell (ypCR)
Dworak Int J Colorect Dis 1997;12:19 Quirke Lancet Oncol 2007;8:651
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7. Secondary end points ■ circumferential rectal margin (CRM)
- 0 to < 1 mm (R0)
- 0 to < 2 mm
■ - Toxicity – sphincter preservation (AR)
- Local control – DFS - ov. Survival
- Bowel – sexual functions
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8. Hypothesis – sample size
ypCR : 11% %
N = 590
for statistical power 85% (2 sided a = 0.05)
- 3 years enrollment
- Database locked march 2009
Stratification : center – T stage – T site
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9. ACCORD 12/0405-Prodige 2-Design of trial
T3 (4) M0 - Accessible DRE < 80 y (low ant T2)
45 Gy/5 w + Cap
50 Gy/5 w + Capox R
6 weeks TME
Adjuvant chemo left each institution (constant)
Hypothesis : ypCR = 11% % (590 pts)
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10. Capox 50 50 Gy/25F/5 weeks • Radiotherapy • Capecitabine 800/m²x2/Day1 2 3 4 5 ●
• Capecitabine
800/m²x2/Day
(1600mg/m²)
except WE
• Oxaliplatin IV
50 mg/m²(2h)
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11. Pathology
ypT0 N0 – R0
Quirke - Dworak
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12. November 2005 - July 2008 598 pts / 2,9 years
56 centers
Age : 63 y
M/F : 2/1
T3 : 87% T2 : 8%
T4 : 5%
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13. Flow-Chart 598 584 574 563 598 randomized patients RT45-Cap N= 299
RT50-CapOx N= 299
598
Eligible n= 293
584
Eligible n= 291
Surgery n= 287
574
Surgery n= 287
Operative specimen n= 285
563
Operative specimen n= 278
Adj. Chemotherapy 42%
Adj. Chemotherapy 30%
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14. Early toxicity G2-3-4 (CTC –NCI V3)
Adverse event Cape 45 (293) Capox 50 (291) p-value
All toxicity G % (32) 25% (74) <0.0001
Diarrhea G % % <
Haematol G % 5%
Hand. foot G2 < 1% 0%
Periph. neurop. G % 5% <0.002
RXT full dose 99% 90% *
Surgery % (287) 99% (287)
* < 44 Gy : 2%
Asco 2008
30/05/2009

15. Surgical toxicity Event Cape 45 (287) Capox 50 (287) p-value
Ant. Resect % (211) % (218) NS
Fistula (sgy) (AR) 3% (7) 2% (5)
2nd surg % %
G2-3-4 med.compl % (59) % (52)
Hospital stay (days)
Death 60 days % (1) % (1)
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16. Primary end point – operative specimen Sterilization ypCR (Dworak-Quirke)
Cape 45 (282) Capox 50 (276) p-value
no visible cell (ypCR) 14% (40) % (53)
No + few residual cell 30% (85) % (113)
ypT % % ns
yp N % % ns
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17. Circumferential rectal margin - CRM
Margin Cape 45 (162) Capox 50 (147) p-value
0-1 mm 12% (19) 7% (11)
0-2 mm 19% (31) 9% (14)
Pelvic local control ??
30/05/2009

18. Subgroup analysis : ypCR
Cape Capox 50
T2 (42) 36% %
T3 (509) 13% %
T4 (32) 7% %
Full dose RXT (558) 14% %
Occult M1 (surg) 4% %
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19. Weaknesses and limitations of study
Short Follow up (12m) no clinical end point (loc. DFS)
Primary end point : not significant (ypCR) (0.11)
ypCR : not a good surrogate end point
Two modifications : RT dose – oxaliplatin
BUT : good overview of French clinical practice
56 institutions (30 academic)
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20. Summary Main results "Capox 50"
Early G3-4 toxicity : increased 25%
Surgery performed : no detriment 99%
Operative death (60 days) : low 0.3%
Sphincter preservation : no increase 75%
CRM "negative" trend %
ypCR trend %
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21. Rectal Cancer T3-4 M0 STAR (747) ACCORD (598)
RT Oxali (60 mg) RT50 + Capox
G3-4 toxicity %
ypCR % (increase)
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22. Rectal Cancer T3-4 M0 STAR (747) ACCORD (598)
RT Oxali (60 mg) RT50 + Capox
G3-4 toxicity 24% (increase) %
ypCR % (no difference) % (increase)
30/05/2009

23. When analysing the results of ACCORD 12 trial
with reference to the STAR trial
the following comments and suggestions
can be made regarding :
(1) Oxaliplatin (2) Dose of RT (3) Capecitabine
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24. (1) Oxaliplatin increases toxicity (diarrhea) without
impact on ypCR (not radiosensitizer) (occult. M1 ?)
(2) 50 Gy/5 weeks compatible with surgery and
increase ypCR and CRM "negative" (RX dose effect)
(3) Capecitabine has the same activity as 5FU
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25. Oxaliplatin not a good radiosensitizer
Folkword – Radiat Oncol 2008;86:428
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26. Proposal : "Cape 50" regimen
■ For T3-4 Nx M0 rectal cancers (resectable)
Good option for neoadjuvant treatment
- RT 50 Gy/5 weeks (2 Gy/fraction/25 F)
- Capecitabine 1600 mg/m² (RT days)
■ How to fight distant metastases ? (oxaliplatin)
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27. SPONSOR - PARTNER Monitoring : J. Genève, M. Torres, F. Do Nascimento,
S.Levêque, F. Nait-Atmane, AC Le Gall (FNCLCC, BECT, Paris)
FFCD : M. Moreau, C. Choine-Pourret, F. Guiliani-Kpodoh, A. Kodjo, S. Ngassam, H. Fattouh, N. Le Provost
Data center : Huguet Helena
Supported by a Clinical Research Hospital Program GRANT (PHRC 2004) from the French Ministry of Health
Grants from Roche and sanofi-aventis
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28. ACKNOWLEDGEMENTS "Patients and families"
Co-investigators : Pr CONROY Centre Alexis Vautrin (NANCY) ; Dr BOUCHE Centre Hospitalier R. Debré (REIMS) ; Dr DENIS Hôpital Pasteur (COLMAR) ; Dr MIRABEL Centre Oscar Lambret (LILLE) ; Dr BERDAH Clinique Ste Marguerite (HYERES) ; Dr LLEDO Clinique St Jean (LYON) ; Pr MAHE Centre René Gauducheau (NANTES - St HERBLAIN) ; Pr BECOUARN Institut Bergonié (BORDEAUX) ; Dr ROMESTAING Centre Hospitalier Lyon Sud (LYON) ; Dr BOIGE Institut Gustave Roussy (VILLEJUIF) ; Dr MOUREAU - ZABOTTO Institut Paoli Calmettes (MARSEILLE) ; Dr GALAIS Centre François Baclesse (CAEN) ; Dr DUPUIS Clinique Victor Hugo (LE MANS) ; Dr GUICHARD Polyclinique Nord Aquitaine (BORDEAUX) ; Dr SEITZ Centre hospitalier La Timone (MARSEILLE) ; Dr OLLIER Centre Paul Strauss (STRASBOURG) ; Dr RIVES Institut Claudius Regaud (TOULOUSE) ; Dr CHARNEAU Centre hospitalier (BOULOGNE SUR MER) ; Dr DEBRIGODE Centre Hospitalier Carémeau (NIMES) ; Pr. MICHEL Centre hospitalier Ch. Nicolle (ROUEN) ; Dr TAIEB Centre hospitalier La Pitié (PARIS) ; Dr ZAWADI Centre Hospitalier Les Oudairies (LA ROCHE SUR YON) ; Dr JOUVE CHU La Bocage (DIJON) ; Dr GUICHARD Polyclinique des 4 pavillons (LORMONT) ; Dr MARTIN Centre Bourgogne (LILLE) ; Dr GASMI Hôpital Nord (MARSEILLE) ; Dr VIE Centre Maurice Tubiana (CAEN) ; Dr BONNICHON-LAMICHHANE Clinique Tivoli (BORDEAUX) ; Dr LELOUP Centre Hospitalier "La Source" (ORLEANS) ; Dr NOIRCLERC Centre Hospitalier (MULHOUSE) ; Dr CVITKOVIC Centre René Huguenin (ST CLOUD) ; Dr AZZEDINE Centre Hospitalier (AVIGNON) ; Dr STREMSDOERFER Hôpital Pierre Oudot (BOURGOIN JALLIEU) ; Dr CLIPPE Centre hospitalier (VALENCE) ; Dr MORAILLON Clinique Générale (VALENCE) ; Dr KLEIN Centre d'Oncologie St Yves (VANNES) ; DR GARGOT Centre hospitalier (BLOIS) ; Dr AUBY Centre Hospitalier R. Boulin (LIBOURNE) ; Dr ROCHER Clinique Ste Marie (CHALON SUR SAONE) ; Dr APARICIO Centre hospitalier –Bichat (PARIS) ; Pr LAGRANGE Hôpital Henri Mondor (CRETEIL) ; Dr MONNIER Centre Hospitalier A. Boulloche (MONTBELLIARD) ; Dr NGUYEN Centre Hospitalier (BEAUVAIS) ; Dr PLATINI Hôpital du Bon Secours (METZ) ; Pr NGUYEN Institut Jean Godinot (REIMS) ; Pr PEZET CHU Hôtel Dieu (CLERMONT-FERRAND) ; Dr PAPADOPOULOU Centre Hospitalier (ANNECY) - FRANCE
Taux de succès attendus (% pièces stérilisées) :
Bras A (50 Gy + capecitabine/oxaliplatine) = 20%
Bras B (45 Gy + capecitabine) = 11%
Mettre en évidence une différence d’au- moins 9% avec un risque alpha bi-latéral de 5% et une puissance de 85% (béta = 15%), il faut inclure 590 patients.
Une analyse intermédiaire est prévue après l’évaluation de 354 patients.
590 patients were needed Secondary endpoints included toxicity, conservative surgery, local relapse and survival. This report presents early toxicities in the first 150 patients
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29. 30/05/2009

30. GRECCAR 1 - Ph. Rouanet et al.
Low rectal cancer (APR ?) u T2-3
RXT 63 Gy
RXT 45 Gy + 5FU (CI) R
Rest 4-6 w surgery - CT if ypN1-2
End point : conservative surgery
: 207 pts (13 centers)
30/05/2009

31. GRECCAR 1 - Results RT63 (100) RT45 + FU (95) CR resp. DRE 80% 87% APR
18%
ypT0 8%
15%
ypN0
60%
66%
3y Loc Rec.
2y Met
20%
21%
3y ov. Surv.
91%
90%
30/05/2009