Modafinil in Treating Children With Memory and Attention Problems Caused by Cancer Treatment for a Brain Tumor

OBJECTIVES:

Primary

* Determine whether a 6-week drug trial of modafinil, compared to placebo, is associated with improvement in neurocognitive function as defined by direct assessment of attention in children with cognitive impairment after treatment for a primary brain tumor.

Secondary

* Determine whether modafinil, compared to placebo, is associated with improved executive function, as assessed using the BRIEF executive function and hippocampal learning and executive function tasks from the CogState battery. Determine whether modafinil, compared to placebo, is associated with improved attention, as assessed by the Conners' (3rd Edition) 3 Parent Rating Scale (CPRS-3) - Short Form.
* Determine whether modafinil, compared to placebo, is associated with reduced fatigue as assessed using the PedsQL Multidimensional Fatigue Scale.
* Evaluate the safety of modafinil in this population.

OUTLINE: This is a multicenter study. Participants are randomized to 1 of 2 treatment arms.

* Arm I: Participants receive modafinil orally (PO) once daily (QD) on days 1-42.
* Arm II: Participants receive placebo PO QD on days 1-42. Participants complete a semi-automated, computerized cognitive-testing system (CogState) designed to assess psychomotor, attention/vigilance, memory, and other components of executive function by presenting different tasks, each with its own set of rules, at baseline and after completion of study therapy. Participants also complete the PedsQL Multidimensional Fatigue Scale (Peds QL-MFS).

Parents or legal guardians complete the PedsQL-MFS, the Conners Parent Reported Scale (CPR-3), and the Behavior Rating Inventory of Executive Function (BRIEF) at baseline and after completion of study therapy.

Clinical and/or research staff administer the Systematic Assessment for Treatment Emergency Events (SAFTEE), a semi-structured interview designed to elicit adverse events, at baseline and periodically during study.

After completion of study therapy, participants are followed up for 30 days.

• modafinil (Drug): Given PO
• placebo (Other): Given PO

Primary outcomes

• Change in Age-Adjusted Scores at Week Six From Baseline in the Attention Task of the CogState Battery [Baseline and 6 weeks]: CogState Battery. CogState is a semi-automated, computerized cognitive testing system that was developed as a rapid and accurate test of cognitive function specifically for repeated assessment that is sensitive to the effects of medication in children over the age of 5 years and in adults from different language, cultural and socio-economic backgrounds. The CogState tasks to assess processing speed, visual attention, working memory and executive function were used. The CogState battery was administered in the following order: Detection Task, Identification Task, One Card Learning Task, One Back Task, and lastly, the Modified Groton Maze Learning Task. It was administered at baseline and 6 weeks. A positive change from baseline is an improvement. There is not a minimum or maximum since the value is reported as a z-score, but with the mean = 0 and the SD = 1, the range should be between -3 and 3.

Secondary outcomes

• Number of Reported Adverse Events (AEs) [30 days post intervention]: AEs gathered using SAFTEE (Systematic Assessment for Treatment Emergent Effects) and participant report on daily log.
• Change in Working Memory Score at 6 Weeks From Baseline as Assessed on BRIEF [Baseline and 6 weeks]: Behavior Rating Inventory of Executive Function (BRIEF). The BRIEF is a behavior rating scale designed to assess executive functions in the home and school environments. The measure was selected to provide parent-reported outcomes of problems related to attention, memory and executive function that occur in everyday life. The instrument was utilized to measure the change in working memory, according to the parent's perspective only, from baseline to 6 weeks. Scores are linear transformations of raw scores into T scores (mean = 50, SD = 10); higher scores indicate greater difficulties. The baseline score was subtracted from the 6 week score. Positive change from baseline is an improvement. The total scale ranges from 0 to 172. A T score >60 on the BRIEF working memory subscale indicates cognitive impairment.
• Change in PedsQL Score at 6 Weeks From Baseline [Baseline and 6 weeks]: PedsQL is Pediatric Quality of Life Inventory Multi-dimensional Fatigue Scale. This scale is designed as a generic symptom-specific instrument to measure fatigue. Higher scores indicate fewer symptoms of fatigue. It was administered at baseline and 6 weeks. The score is the sum of the answers. The baseline score was subtracted from the 6 week score. A positive change indicates worsening. The scale total score range is from 0-72 for both the parent and patient reported instruments.

Sex: All, ages: 6 Years to 19 Years

INCLUSION CRITERIA:

* Age ≥ 6 years and ≤ 18 years 10 months at the time of study entry (so that participants will be < 19 at the 6 week evaluation, which is the upper age limit for which the included instruments are valid).
* Diagnosis of a primary brain tumor treated with at least one of the following:

  1. neurosurgical resection of the brain tumor;
  2. cranial irradiation; or
  3. any chemotherapy to treat the brain tumor.
* Off-treatment and progression-free for at least 12 months and ≤ 14 years. Treatment cessation is defined as the final dose of chemotherapy, the last dose (fraction) of radiation or date of surgery, whichever occurred last.
* Parent/Legal Guardian and child able to read English or Spanish.
* Vision and hearing (eyeglasses and/or hearing aid permissible) sufficient for valid test administration and cooperation with examinations.
* Availability of a reliable parent or legal guardian who is willing and able to complete all of the outcome measures and fulfill the requirements of the study, including administration of medications and accompanying the participant to all study visits.
* Females of childbearing potential must have a negative pregnancy test result and must agree to use a medically acceptable method of contraception throughout the entire study period and for 30 days after the last dose of study drug.
* Childbearing potential is defined as girls who are >Tanner stage 2, except for those who have documented pan pituitary insufficiency or other hormonal state incompatible with pregnancy.
* Urine pregnancy tests are acceptable.

EXCLUSION CRITERIA:

* Off treatment > 14 years
* Inability to perform the testing procedure (for example, because of aphasia, motor deficits affecting the dominant hand, or IQ < 70)
* Known cardiac disorders including arrhythmias, hypertension requiring treatment or structural heart disease
* Diagnosis of narcolepsy, sick sinus syndrome, arrhythmia or prolonged QTc
* History of stroke or head injury associated with loss of consciousness within 12 months of registration
* History of grade 2 depression or anxiety or treatment with antidepressants, antipsychotics or MAO inhibitors within 30 days of registration
* Concurrent treatment with any medications or substances that are potent inhibitors or inducers of CYP3A4, hepatic enzyme inducing antiepileptic drugs (EIAEDs),or other drugs known to affect the metabolism of modafinil. Examples include but are not limited to itraconazole, ketoconazole, doxycycline, rifampin, St. John's wort, phenytoin, phenobarbital, diazepam, tricyclic antidepressants.
* If patients were previously taking, EIAEDs, they must be off for > 2 weeks prior to study enrollment.
* Treatment with other stimulant medications within 14 days of registration; however, a diagnosis of ADHD does NOT exclude a child from participation
* Participants with known hypersensitivity to modafinil, armodafinil or any of its components

Participant flow

Outcome results

• Change in Age-Adjusted Scores at Week Six From Baseline in the Attention Task of the CogState Battery (Primary), Mean, Z Score: Arm I - Modafinil -0.16 +/- 0.71; Arm II - Placebo 0.14 +/- 1.06
• Number of Reported Adverse Events (AEs) (Secondary), Number, Adverse Events: Arm I - Modafinil 76; Arm II - Placebo 26
• Change in Working Memory Score at 6 Weeks From Baseline as Assessed on BRIEF (Secondary), Mean, T Score: Arm I - Modafinil -4.1 +/- 7.4; Arm II - Placebo -4.5 +/- 9.2
• Change in PedsQL Score at 6 Weeks From Baseline (Secondary), Mean, Scores on a scale: Arm I - Modafinil 11.3 +/- 17.6; Arm II - Placebo 11.4 +/- 15.9

Adverse events

Time frame: 6 weeks

Serious adverse events by term

Other adverse events by term

• Jeffrey P. Krischer, MD, PhD, Study chair, University of South Florida
• Nicole J. Ullrich, MD, PhD, Study chair, Boston Children's Hospital

NIH grants: U10CA081920