Epoetin Alfa or Darbepoetin Alfa in Treating Patients With Anemia Caused by Chemotherapy

OBJECTIVES:

Primary

* Compare the relative efficacy of four different erythropoietic agent dosing schedules comprising epoetin alfa or darbepoetin alfa, in terms of the proportion of patients with chemotherapy-associated anemia who achieve a weekly and overall hematopoietic response.

Secondary

* Compare the effect of these regimens on the mean hemoglobin increment measured weekly from baseline to 15 weeks in patients with a baseline hemoglobin of less than or equal to 10.5 g/dL.
* Compare the time required to achieve hemoglobin levels within the goal range 11.0-12.0 g/dL in patients treated with these regimens.
* Compare the effect of these regimens on the proportion of patients requiring red blood cell transfusions and on the number of transfusions required.
* Compare the weekly change in hemoglobin in patients treated with these regimens.
* Compare the need for dose reduction in patients treated with these regimens.
* Compare the adverse event profiles of these regimens in these patients.
* Compare quality of life of patients treated with these regimens.

OUTLINE: This is a randomized, unblinded, pilot study. Patients are stratified according to severity of anemia (mild \[hemoglobin ≥ 9.5 g/dL\] vs severe \[hemoglobin < 9.5 g/dL\]), platinum-containing regimen (yes vs no), and tumor type (nonmyeloid hematologic malignancy vs solid tumor). Patients are randomized to 1 of 4 treatment arms.

* Arm I: Patients receive epoetin alfa subcutaneously (SC) on day 1. Treatment repeats weekly for up to 15 courses in the absence of disease progression or unacceptable toxicity.
* Arm II: Patients receive epoetin alfa SC on day 1 (at a higher dose than in arm I). Treatment repeats every 3 weeks for up to 5 courses in the absence of disease progression or unacceptable toxicity.
* Arm III: Patients receive epoetin alfa SC on day 1 (at a higher dose than in arm II). Treatment repeats every 3 weeks for up to 5 courses in the absence of disease progression or unacceptable toxicity.
* Arm IV: Patients receive darbepoetin alfa SC on day 1. Treatment repeats every 3 weeks for up to 5 courses in the absence of disease progression or unacceptable toxicity.

Hemoglobin levels are monitored throughout the study on a weekly basis and before each drug dose is administered. Drug dosing is adjusted (e.g., held, reduced, resumed at a lower dose) as needed to maintain hemoglobin values within the desired ranges.

Quality of life is assessed at baseline and at weeks 4, 7, 10, 13, and 16.

After completion of study treatment, patients are followed at 30 days.

PROJECTED ACCRUAL: A total of 320 patients will be accrued for this study.

• darbepoetin alfa (Drug)
• epoetin alfa (Drug)
• fatigue assessment and management (Procedure)
• quality-of-life assessment (Procedure)

Primary outcomes

• The Percentage of Participants Who Exhibit a Hematopoietic Response [20 weeks]: A hematopoietic response was defined as Hb rise >2 g/dL from baseline or achieving Hb ≥ 11.5 g/dL, whichever occurs first, in the absence of RBC transfusions within 14 days of measurement) during the treatment period

Secondary outcomes

• Weekly Change in Hemoglobin Levels [Baseline and Week 4, 7, 10, 13, 16]: To compare the effects of the 3 different epoetin alfa dosing schedules and an every-3-weeks darbepoetin alfa schedule
• Time Required to Achieve Hemoglobin Levels >= 11.5 g/dL [16 weeks]: To compare the effects of the 3 different epoetin alfa dosing schedules and a darbepoetin alfa schedule
• Mean Hemoglobin Change From Week 1 to Week 16 [Week 1 and Week 16]: To compare the effects of the 3 different epoetin alfa dosing schedules and an every-3-weeks darbepoetin alfa schedule. The positive numbers represent hemoglobin increases and negative numbers represent hemoglobin decreases.
• The Percentage of Participants Requiring Red Blood Cell (RBC) Transfusions [16 weeks]: To compare the effects of the 3 different epoetin alfa dosing schedules and a darbepoetin alfa schedule
• The Total RBC Transfusion Needed [16 weeks]: To compare the effects of the 3 different epoetin alfa dosing schedules and a darbepoetin alfa schedule
• The Percentage of Participants With Dose Omitted Due to Hematologic Reason [16 Weeks]: To compare the effects of the 3 different epoetin alfa dosing schedules and a darbepoetin alfa schedule
• The Percentage of Participants Reported Grade 3 or 4 Adverse Events [16 weeks]: To compare the effects of the 3 different epoetin alfa dosing schedules and a darbepoetin alfa schedule. Adverse events were measured by Common Terminology Criteria for Adverse Events (CTCAE) v3.0.
• Quality of Life as Measured by Functional Assessment of Cancer Therapy Scales for Anemia (FACT-AN) Over All Follow-up Evaluations [Weeks 4, 7, 10, 13 and 16]: To compare the effects of the 3 different epoetin alfa dosing schedules and a darbepoetin alfa schedule. FACT-AN consist of Fatigue concerns subscale and non-fatigue concerns subscale. FACT Total Anemia score was calculated by adding the two subscales scores and transformed into 0-100 scale. FACT Total Anemia, Fatigue concerns scale and Non-Fatigue concerns scale are all ranges: 0 (Worst QOL) to 100 (Best QOL). Average scores across all time points for each subscale and total scale were calculated.
• Quality of Life as Measured by Linear Analogue Self Assessment Over All Follow-up Evaluation [Weeks 4, 7, 10, 13 and 16]: To compare the effects of the 3 different epoetin alfa dosing schedules and a darbepoetin alfa schedule. Linear Analogue Self Assessment (LASA) consists of 10 single-item numeric analogue scales on a scale of 0 to 10. Higher scores indicate better quality of life (QOL) on overall QOL, mental, physical, emotional spiritual QOL and Social activity; and constant pain, highest pain severity, level of fatigue and anxiety. Average scores across all time points for each item were calculated.
• Quality of Life as Measured by Brief Fatigue Inventory Overall All Follow-up Evaluations [Weeks 4, 7, 10, 13 and 16]: To compare the effects of the 3 different epoetin alfa dosing schedules and a darbepoetin alfa schedule. Brief Fatigue Inventory (BFI) consist of 3 single-item numeric analogue scales on a scale of 0 to 10; and an interference scale formed by 6 single-item numeric scales on a scale of 0 to 10. Higher scores indicate fatigue as bad as you can imagine for fatigue now, usual fatigue and worse fatigue; and completely interferes for BFI interference. Average scores across all time points for fatigue now, usual fatigue, worst fatigue and BFI interference subscale were calculated.
• Quality of Life as Measured by Symptom Distress Scale (SDS) Over All Follow-up Evaluations [Weeks 4, 7, 10, 13 and 16]: To compare the effects of the 3 different epoetin alfa dosing schedules and a darbepoetin alfa schedule. SDS Scale range: 1 (No Symptom), 5 (Worst Symptom). Average scores across all time points for each item were calculated.

Sex: All, ages: 18 Years to 120 Years

DISEASE CHARACTERISTICS:

* Diagnosis of solid tumor or nonmyeloid hematologic malignancy (e.g., plasma cell dyscrasia or lymphoproliferative disorder)

  * No nonmelanomatous skin cancer
* Hemoglobin ≤ 10.5 g/dL
* Ferritin > 20 ng/mL (i.e., not obviously iron deficient)
* Planning to receive ≥ 12 weeks of anticancer chemotherapy

  * Biological therapy (e.g., hypomethylating agents, monoclonal antibodies, or small molecule pathway inhibitors) with an individual or cumulative regimen incidence of grade 3 or 4 anemia > 10% is considered chemotherapy for purposes of this study
* No known anemia secondary to any of the following:

  * Cyanocobalamin (vitamin B_12) or folic acid deficiency
  * Gastrointestinal bleeding within the past 2 weeks
  * Hemolysis
  * Myelodysplastic syndromes, myeloproliferative disorders, or acute myeloid leukemia
* No primary hematologic disorder causing chronic moderate to severe anemia (e.g., congenital dyserythropoietic anemia, homozygous hemoglobin S disease or compound heterozygous sickling states, or thalassemia major)

  * Carriers of these disease states allowed provided they are not anemic prior to cancer diagnosis

PATIENT CHARACTERISTICS:

* ECOG performance status 0-2
* Life expectancy ≥ 6 months
* Not pregnant or nursing

  * No delivery of a baby of ≥ 18 weeks estimated gestational age within the past 3 months (90 days)
* Negative pregnancy test
* Fertile patients must use effective contraception
* Weight > 40.0 kg and < 150.0 kg
* No known hypersensitivity to epoetin alfa, darbepoetin alfa, mammalian-cell derived products, or human albumin
* No uncontrolled hypertension, defined as systolic blood pressure (BP) ≥ 180 mm Hg and/or diastolic BP ≥ 100 mm Hg, despite medical therapy
* No pulmonary emboli and/or deep vein thrombosis within the past 12 months

  * Patients actively receiving warfarin for a minimum of 4 weeks are exempted from this requirement
  * Prior superficial thrombophlebitis allowed
* No cerebrovascular accident, ischemic stroke, acute coronary syndrome (e.g., unstable angina or Q-wave or non-Q wave myocardial infarction), or other arterial or venous thrombotic events within the past 6 months
* No history of chronic hypercoagulable disorders (e.g., activated protein C resistance, anti-cardiolipin disorder, protein C deficiency, or protein S deficiency)

  * Patients receiving anticoagulation therapy (warfarin or acetylsalicyclic acid \[aspirin\] at a dose of ≥ 325 mg/day) for these conditions are eligible provided therapy is continued during the study period
* History of previously treated seizures allowed provided the patient has been seizure-free for a minimum of 3 months

PRIOR CONCURRENT THERAPY:

* See Disease Characteristics
* More than 1 year since prior peripheral blood stem cell, bone marrow, or cord blood transplantation
* More than 14 days since prior red blood cell transfusion
* More than 14 days since prior major surgery, including, but not limited to, any of the following:

  * Amputation
  * Invasion of a body cavity or of the central nervous system using a scalpel, saw, or laser cutting tool
  * Resection of a body part (or parts), whether solid or liquid tissue or both, that includes ≥ 1% of a patient's preoperative weight
  * The following are not considered major surgery:

    * Diagnostic/therapeutic thoracentesis or paracentesis
    * Diagnostic skin biopsy
    * Digit or fingernail/thumbnail resection or laceration repair under local anesthesia
    * Diagnostic fat aspiration
    * Otic irrigation to remove cerumen impaction
    * Tympanocentesis
    * Uncomplicated dental extraction
    * Uncomplicated tonsillectomy
    * Laser corneal remodeling for refraction purposes
    * Cosmetic or therapeutic eyelid surgery
    * Bone marrow aspiration and biopsy
* More than 10 weeks since prior darbepoetin alfa, epoetin alfa, or any investigational form of erythropoietin (e.g., gene-activated erythropoietin or novel erythropoiesis stimulating protein)
* No planned stem cell transplantation within the next 4 months (18 weeks)

Participant flow

Outcome results

• The Percentage of Participants Who Exhibit a Hematopoietic Response (Primary), Number, Percentage of participants: Epoetin Alfa - 40k Weekly 68.9; Epoetin Alfa - 80k Every 3 Weeks 61.7; Epoetin Alfa - 120k Every 3 Weeks 65.5; Darbepoetin Alfa - 500 mcg Every 3 Weeks 66.7 (p >0.41)
• Weekly Change in Hemoglobin Levels (Secondary), Mean, g/dL: Epoetin Alfa - 40k Weekly 1.0 +/- 1.26; Epoetin Alfa - 80k Every 3 Weeks 0.6 +/- 1.02; Epoetin Alfa - 120k Every 3 Weeks 0.7 +/- 1.21; Darbepoetin Alfa - 500 mcg Every 3 Weeks 0.4 +/- 1.21
• Time Required to Achieve Hemoglobin Levels >= 11.5 g/dL (Secondary), Median, days: Epoetin Alfa - 40k Weekly 32 (28 to 37); Epoetin Alfa - 80k Every 3 Weeks 50 (35 to 68); Epoetin Alfa - 120k Every 3 Weeks 49 (35 to 77); Darbepoetin Alfa - 500 mcg Every 3 Weeks 49 (35 to 64) (p >0.13)
• Mean Hemoglobin Change From Week 1 to Week 16 (Secondary), Mean, g/dL: Epoetin Alfa - 40k Weekly 11.0 +/- 1.03; Epoetin Alfa - 80k Every 3 Weeks 10.3 +/- 1.04; Epoetin Alfa - 120k Every 3 Weeks 10.6 +/- 0.8; Darbepoetin Alfa - 500 mcg Every 3 Weeks 10.7 +/- 0.96
• The Percentage of Participants Requiring Red Blood Cell (RBC) Transfusions (Secondary), Number, percentage of participants: Epoetin Alfa - 40k Weekly 27.9; Epoetin Alfa - 80k Every 3 Weeks 33.3; Epoetin Alfa - 120k Every 3 Weeks 22.4; Darbepoetin Alfa - 500 mcg Every 3 Weeks 29.8 (p >0.49)
• The Total RBC Transfusion Needed (Secondary), Mean, g/dL: Epoetin Alfa - 40k Weekly 1.1 +/- 2.33; Epoetin Alfa - 80k Every 3 Weeks 1.2 +/- 2.67; Epoetin Alfa - 120k Every 3 Weeks 0.6 +/- 1.20; Darbepoetin Alfa - 500 mcg Every 3 Weeks 1.1 +/- 2.31
• The Percentage of Participants With Dose Omitted Due to Hematologic Reason (Secondary), Number, percentage of Participants: Epoetin Alfa - 40k Weekly 63.9; Epoetin Alfa - 80k Every 3 Weeks 30; Epoetin Alfa - 120k Every 3 Weeks 34.5; Darbepoetin Alfa - 500 mcg Every 3 Weeks 45.6
• The Percentage of Participants Reported Grade 3 or 4 Adverse Events (Secondary), Number, percentage of participants: Epoetin Alfa - 40k Weekly 22; Epoetin Alfa - 80k Every 3 Weeks 22; Epoetin Alfa - 120k Every 3 Weeks 17; Darbepoetin Alfa - 500 mcg Every 3 Weeks 13 (p >0.56)
• Quality of Life as Measured by Functional Assessment of Cancer Therapy Scales for Anemia (FACT-AN) Over All Follow-up Evaluations (Secondary), Mean, units on a scale: Epoetin Alfa - 40k Weekly 48.6 +/- 17.13; Epoetin Alfa - 80k Every 3 Weeks 52.0 +/- 20.75; Epoetin Alfa - 120k Every 3 Weeks 52.6 +/- 23.12; Darbepoetin Alfa - 500 mcg Every 3 Weeks 49.8 +/- 19.66
• Quality of Life as Measured by Linear Analogue Self Assessment Over All Follow-up Evaluation (Secondary), Mean, units on a scale: Epoetin Alfa - 40k Weekly 6.4 +/- 1.59; Epoetin Alfa - 80k Every 3 Weeks 6.5 +/- 2.00; Epoetin Alfa - 120k Every 3 Weeks 6.6 +/- 2.17; Darbepoetin Alfa - 500 mcg Every 3 Weeks 6.1 +/- 1.61
• Quality of Life as Measured by Brief Fatigue Inventory Overall All Follow-up Evaluations (Secondary), Mean, units on a scale: Epoetin Alfa - 40k Weekly 4.8 +/- 2.25; Epoetin Alfa - 80k Every 3 Weeks 4.6 +/- 2.44; Epoetin Alfa - 120k Every 3 Weeks 4.6 +/- 2.53; Darbepoetin Alfa - 500 mcg Every 3 Weeks 4.7 +/- 2.25
• Quality of Life as Measured by Symptom Distress Scale (SDS) Over All Follow-up Evaluations (Secondary), Mean, units on a scale: Epoetin Alfa - 40k Weekly 1.6 +/- 0.64; Epoetin Alfa - 80k Every 3 Weeks 1.5 +/- 0.67; Epoetin Alfa - 120k Every 3 Weeks 1.6 +/- 0.56; Darbepoetin Alfa - 500 mcg Every 3 Weeks 1.6 +/- 0.73

Adverse events

Time frame: 16 Weeks

Serious adverse events by term

Other adverse events by term

7 more terms not shown.

• Charles L. Loprinzi, M.D., Study chair, Mayo Clinic

NIH grants: P30CA015083