Window-of-opportunity trials, evaluating the engagement of drugs with their biological target in the time period between diagnosis and standard-of-care treatment, can help prioritise promising new systemic treatments for later-phase clinical trials. Renal cell carcinoma (RCC), the 7th commonest solid cancer in the UK, exhibits targets for multiple new systemic anti-cancer agents including DNA damage response inhibitors, agents targeting vascular pathways and immune checkpoint inhibitors. Here we present the trial protocol for the WIndow-of-opportunity clinical trial platform for evaluation of novel treatment strategies in REnal cell cancer (WIRE).
WIRE is a Phase II, multi-arm, multi-centre, non-randomised, proof-of-mechanism (single and combination investigational medicinal product [IMP]), platform trial using a Bayesian adaptive design. The Bayesian adaptive design leverages outcome information from initial participants during pre-specified interim analyses to determine and minimise the number of participants required to demonstrate efficacy or futility. Patients with biopsy-proven, surgically resectable, cT1b+, cN0–1, cM0–1 clear cell RCC and no contraindications to the IMPs are eligible to participate. Participants undergo diagnostic staging CT and renal mass biopsy followed by treatment in one of the treatment arms for at least 14 days. Initially, the trial includes five treatment arms with cediranib, cediranib + olaparib, olaparib, durvalumab and durvalumab + olaparib. Participants undergo a multiparametric MRI before and after treatment. Vascularised and de-vascularised tissue is collected at surgery. A ≥ 30% increase in CD8+ T-cells on immunohistochemistry between the screening and nephrectomy is the primary endpoint for durvalumab-containing arms. Meanwhile, a reduction in tumour vascular permeability measured by
WIRE is the first trial using a window-of-opportunity design to demonstrate pharmacological activity of novel single and combination treatments in RCC in the pre-surgical space. It will provide rationale for prioritising promising treatments for later phase trials and support the development of new biomarkers of treatment effect with its extensive translational agenda.
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Renal cell carcinoma (RCC) is the 12th commonest solid cancer globally (> 400,000 cases/year) and the 7th commonest in the United Kingdom (~ 14,000 cases/year) [
Surgery is the treatment of choice in medically-fit patients whose disease burden is amenable to resection [
The increasing number of possible single-agent and combination therapeutic options makes it very challenging to prioritise agents in combination for further development in large randomised clinical trials. Therefore, novel trial designs, such as this window-of-opportunity trial assessing promising new combination treatments in the period of time between diagnosis and surgery, are required to determine if the combination results in the hypothesised mechanistic pharmacology [
Genomic instability is a hallmark of cancer which chemo- and radiotherapy exploit while causing significant collateral damage to normal tissues [
Olaparib inhibits poly (ADP-ribose) polymerases (PARP 1–3) which are central to DNA damage repair and genomic stability. It inhibits the repair of single-strand DNA breaks specifically in cells deficient in homologous recombination, resulting in double strand-breaks, subsequent accumulation of mutations and cell death [
The WIRE trial aims to determine proof-of-mechanism for several agents (cediranib, olaparib and durvalumab) used as single or combination therapies by demonstrating engagement with the expected cellular pathways. Changes in capillary permeability will be determined in the cediranib, olaparib and cediranib + olaparib arms and changes to intra-tumoral CD8+ T-cell infiltration will be determined in the durvalumab and durvalumab + olaparib arms.
Secondary objectives will aim to investigate the safety of the investigational medicinal products (IMP) in the preoperative period and determine changes in primary tumour size and overall response measured according to the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 [
Exploratory objectives will aim to define the molecular biological response to the IMPs for candidate markers of biological effects in blood, urine, and tissue samples. Additionally, the relationship of the primary endpoints with genetic mutations in related genes will be investigated. Finally, the ability of automated histological image analysis and hyperpolarised [1-13C] pyruvate MRI imaging to detect biological treatment response will be explored.
WIRE is a Phase II, multi-arm, multi-centre, non-randomised, proof-of-mechanism (single and combination IMPs), platform trial using a Bayesian adaptive design (ClinicalTrials.gov Identifier: NCT03741426) with sample size chosen to control frequentist statistical characteristics. It will be conducted at academic medical centres in the United Kingdom.
The Bayesian adaptive design leverages outcome information from initial participants to determine the recruitment target for each treatment arm (see Fig. Bayesian adaptive trial design with interim analyses and decision boundaries for single-agent and combination-therapy arms. Green arrows denote efficacy, orange arrows denote futility
Potential participants will be identified during multi-disciplinary team case discussions and invited to participate in the trial during their standard clinical care visit. Participants will be provisionally assigned to the currently recruiting arm and provided a screening identifier. Upon successfully completing screening, participants will be allocated a trial identifier and continue with the arm allocated at screening. Participants may not cross to another arm or enter a reserve pool if they are ineligible for the current arm.
Key inclusion criteria include age ≥ 18 years, biopsy-proven, surgically resectable, cT1b+, cN0–1, cM0–1 ccRCC, Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1, at least one measurable lesion according to RECIST 1.1, adequate organ and bone marrow function and contraception. Patients may not have been exposed to any PARP, tyrosine kinase, immune checkpoint or mammalian target of rapamycin (mTOR) inhibitors.
Key exclusion criteria include cT1a, N0, M0 ccRCC, brain metastasis, spinal cord compression unless definitely treated and non-progressive for 28 days and leptomeningeal involvement. Furthermore, patients with a bodyweight ≤30 kg, contraindication for any of the trial compounds, other invasive malignancy within the last 2 years, concurrent participation in another interventional clinical trial, cardio- or cerebrovascular complications within the last 12 months, immunosuppression or active infection, pregnancy or contraindications for MRI are excluded from participation. Women of childbearing potential must use two highly effective forms of contraception from consent until 3 months after the end of the trial.
Detailed reference values for adequate organ and bone marrow function as well as in- and exclusion criteria specific to individual treatment arms can be found in the Additional file
A trial entrant will provide written informed consent before any trial-specific intervention in accordance with the principles of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use – Good Clinical Practice (IHC-GCP) [
This trial includes five sequential treatment arms: 1) cediranib; 2) cediranib + olaparib; 3) olaparib; 4) durvalumab and 5) olaparib + durvalumab. IMPs for the individual arms are summarized in Table Treatment Arms in the WIRE trial. bd: twice daily, IMP: Investigational Medicinal Product, i.v.: intravenous, od: once daily. Dose reductions permissible in case of toxicity Arm IMP Dosing, Stopping and Dose Adjustments 1 Cediranib 20 mg oral od, until 36 h before surgery, single reduction to 15 mg od 2 Cediranib + Olaparib Cediranib 20 mg oral od and Olaparib 300 mg oral bd, stopping and dose adjustments as in single-agent arms 3 Olaparib 300 mg oral bd, until morning of surgery, two reductions to 250 mg bd and 200 mg bd 4 Durvalumab 1500 mg i.v. (single infusion) 5 Olaparib + Durvalumab Olaparib 300 mg oral bd and Durvalumab 1500 mg i.v. (single infusion). Stopping and dose adjustment for Olaparib as in single-agent arm above.
Regardless of the treatment arm, patients will undergo nephrectomy between 17 and 28 days after the first day of IMP (Fig.
In the case of toxicity, oral IMPs may be interrupted and can be dose-reduced as detailed in Table
Participants will have their IMP discontinued if they experience unacceptable toxicity despite dose reductions, disease progression per RECIST 1.1, pregnancy, weight loss to ≤30 kg or withdraw consent. Participants receiving olaparib will have their IMP discontinued if they develop myelodysplastic syndrome or acute myeloid leukemia.
All routinely used supportive care will be allowed during WIRE, except for certain medications prohibited and restricted for safety or efficacy reasons. These are detailed in the Additional file
Figure Timeline of interventions and assessments for the WIRE trial. *Optional, **Only in patients with cM1 disease. US: ultrasound
Reduction in tumour vascular permeability by > 30% measured by median
Adverse events assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) Toxicity Criteria (Version 5.0) Tumour size change between pre- and post-treatment MRI Tumour response according to RECIST v1.1 on pre- and post-treatment MRI in participants with M0 disease and pre-and post-treatment contrast-enhanced CT in participants with M1 disease Changes in
Exploratory outcomes will include the assessment of blood, urine, tissue and imaging-based biomarkers of drug mechanism and treatment response.
Primary endpoints will be assessed centrally for all trial sites when the number of participants required for an interim or final analysis has been reached.
All pseudo-anonymised imaging data will be transferred to the trial radiologist for the measurement of the tissue transfer constant
The CD8+ T-cell count will be established centrally following transfer of the formalin-fixed paraffin-embedded tissue blocks. Following slicing of the block, endogenous peroxidase suppression and heat-mediated antigen retrieval, the mouse monoclonal anti-human CD8 (DAKO Cytomation, Glostrup, Denmark, 1:100 dilution) will be the primary antibody. Slides will be scanned and two board-certified uro-pathologists will quantify the CD8+ T-cells in ten random fields of view per tumour sample, expressed as the median number of cells/mm2 before and after treatment.
Participants will be replaced and not evaluated for the primary endpoint if they have not received at least 14 days of IMP and/or a single infusion of durvalumab, had to interrupt the IMP for > 7 consecutive days, had a compliance rate of < 70% in the 7 days preceding the pre-surgical imaging, had no pre-surgical imaging or had surgery more than 28 days after the first day of IMP.
All trial-related information will be stored securely at the trial site and transferred pseudo-anonymised through an encrypted electronic case report form (eCRF). The eCRF has inbuilt mechanisms to validate the integrity of data entries. Data will be checked for clarity, errors and completeness ahead of data export by two independent staff members. A pseudo-anonymised copy of imaging data used to obtain the primary endpoint will be retained centrally.
During screening, patients will undergo urine and blood collection followed by ultrasound-guided, multi-regional biopsy of the renal tumour. The biopsy procedure will be carried out by a consultant interventional radiologist. Additional blood and urine samples will be collected after 14 days of IMP and immediately before surgery. At surgery, samples will be collected from the vascularized (i.e. during the nephrectomy) and devascularised (i.e. ex vivo) tumour. 3D-printed, patient-specific tumour moulds will be used to collect devascularised samples from locations spatially registered to pre-surgical imaging at one of the trial sites. If lesions have a major axis > 20 cm, biopsies will be taken without the mould. All trial samples will be stored and analysed in a pseudo-anonymised manner.
The translational analysis aims to explore potential future endpoint markers and determine the response of molecular markers in DDR-, immune-, apoptosis- and cell-cycle pathways.
DNA and RNA analyses in tissue, blood and urine will attempt to explore signatures of response and resistance to IMPs and confirm the IMP’s mechanism of action. Additionally, intratumor genetic heterogeneity will be assessed from multi-regional tumour biopsies and compared to the genetic landscape observed in cell-free tumour DNA. Furthermore, WIRE aims to investigate the applicability of the NEAT (N-cadherin, EPCAM, Age, mTOR) proteomic score [
Up to a maximum of 76 evaluable participants will be recruited into the initial five arms and across all stages.
Each monotherapy arm will enrol a maximum of 12 evaluable participants with interim analyses after 6 and 9 evaluable participants have primary outcome data available.
The null hypothesis is 20% or less of participants show a response on the primary outcome. The alternative hypothesis is that more than 20% of participants show a response:H0:
The IMP will be recommended as promising (null hypothesis rejected) if the arm stops after stage 1 or 2 for efficacy (see Interim Analyses). If the IMP continues to stage 3, a
The overall type I error rate for monotherapy arms is 20%; the overall power is 92% when
Although 20% type I error rate is higher than traditional in phase II, each monotherapy is tested again within the combination IMP arms.
The null hypothesis is 30% or less of participants show a response on the primary outcome. The alternative hypothesis is that more than 30% of participants show a response:
H0: H1:
with the power calculated as the probability of rejecting H0 when
The combination will be recommended as promising (null hypothesis rejected) if the arm stops after stage 1 or 2 for efficacy (see Interim Analyses). If the combination continues to stage 3, a
The overall type I error rate for combination IMP arms is 10%; the overall power is 93% when p = 0.6.
Simulation code in R to recreate the statistical properties is provided as Additional file
Interim data analyses at predefined points will decide whether the recruitment of additional patients into an arm should occur. The Bayesian analysis will use a Beta (0.3, 0.7) prior for the biological response rate (the p parameter). Through updating this prior with the observed number of biological responders using a Beta-Binomial conjugate distribution we will calculate a Beta posterior distribution p.
For monotherapy arms, if the calculated posterior probability of the biological response rate being above 0.2 is above 98%, the arm will be closed early for efficacy. If the predictive probability that the IMP would be found to be promising (i.e. the final one-sided
For combination IMP arms, if the calculated posterior probability of the biological response rate being above 0.3 is above 98%, the arm will be closed early for efficacy. If the predictive probability that the IMP would be found to be promising (i.e. the final one-sided p-value would be ≤0.05) if the full enrolment of 20 was reached is < 2%, then the arm will be closed early for futility.
The final p-value thresholds are chosen to control the overall type I error rate at 20% for monotherapy arms and 10% for combination arms.
We note that the efficacy stopping rule is provided as a recommendation to the IDMC (see Additional file
The recruitment targets for the interim analyses are summarised in Fig.
A Statistical Analysis Plan (SAP) will define appropriate 95% two-sided Confidence Intervals for primary and secondary endpoint quantities prior to the first interim analysis. The extent of missing data will be reported however no imputation of missing data is planned.
The full protocol and participant level-data will not be made available. A more detailed description of the development of the Bayesian adaptive statistics used in the design of this trial will be available in an independent publication. Statistical code will be made available upon reasonable request.
Adverse events will be monitored and recorded from the time of consent until 90 days after the last administration of IMP. Any adverse event will be recorded in the patient notes and the eCRF. The principal investigators will report serious adverse events (SAEs) to the chief investigator within 24 h of awareness. The chief investigator will subsequently assess SAEs for expectedness and relatedness prior to onwards notification to the sponsor within a further 24 h. The chief investigator will additionally report SAEs to AstraZeneca within 24 h. The CI must report suspected unexpected serious adverse reactions (SUSARs) to the Medicines and Healthcare products Regulatory Agency (MHRA) and the ethics committee within 7 to 15 days depending on the severity. Reporting of SAEs which are attributable to any of the IMPs (i.e. serious adverse reactions) and SUSARs continues beyond the 90-day monitoring period and after withdrawal of consent by the participant, where investigators become aware of any new events.
More details on trial oversight are available in the Additional file
The clinical and exploratory endpoints are anticipated to be of great interest to the RCC research community due to the novel combinations being used. The results will be reported at major oncology conferences and then published in high-impact journals. Patient facing publications will be made available to interested trial participants and via our website.
Here we present an adaptive and expandable phase II clinical trial platform to demonstrate proof-of-mechanism for single-agent and combination treatments in ccRCC.
The Bayesian statistics-based adaptive trial design optimises the number of trial participants in each arm, ensuring that no more participants than necessary are recruited to demonstrate proof of mechanism or futility of any arm [
The window-of-opportunity design of this trial exposes patients to the trial medication for a brief period, prior to standard-of-care nephrectomy. While this will allow measuring the engagement of IMPs with their biological target, this trial is neither designed nor powered to accrue evidence of long-term treatment benefit, although there may be unmeasurable survival advantages for patients. Therefore, larger studies in patients who are not surgical candidates will be required to investigate survival benefits of promising treatment arms. Furthermore, the brief treatment may lead to an underestimation of the treatment effects.
A limitation inherent to the window-of-opportunity design is the risk of delaying standard-of-care treatment when serious adverse reactions occur. This risk is mitigated by the strict inclusion criteria, close oncology supervision to pre-empt and identify early any significant toxicity events, and the Bayesian adaptive trial design which leverages information gained during interim analyses to reduce the number of participants compared to conventional trial designs. This is also an advantage compared to other, slowly accruing window-of-opportunity trials. The risk of delaying surgery is discussed with potential participants in detail. On the other hand, an advantage of the window-of-opportunity design is that it increases the possibility to detect biological treatment effects quickly and in a small number of patients. Specifically, examining previously untreated patients who will undergo standard-of-care nephrectomy allows the investigation of IMPs in the absence of mutations induced by previous treatment(s) as well as access to tissue at surgery for extensive translational analyses.
This is the first clinical trial we are aware of using this pre-surgical window-of-opportunity to investigate novel agents and combination therapies in RCC with a Bayesian design. In the future, additional treatment arms may be added to this trial. In addition to studying new systemic anti-cancer agents, synergistic effects between radiation therapy localised to the tumour and DDR inhibition could be investigated.
In summary, WIRE will provide an important impetus for future phase II/III clinical trials to prioritise treatment regimens that show biological efficacy. Additionally, it will be able to inform the optimal choice of treatment response biomarkers.
Version 3.0 of the trial protocol (05/12/2019) has received ethical approval and is in date as of publication of this trial protocol. Recruitment for WIRE commenced on the 12/08/2020 and is estimated to be completed in 12/2022.
We thank Prof Kevin Brindle, Dr. Nitzan Rosenfeld, Dr. Christopher Smit, Mr. Tevita Aho, Mr. Antony Riddick, Mr. James Armitage and Dr. Jessica Brown for their support in the development of the WIRE trial protocol.
Sponsor
The trial is sponsored by Cambridge University Hospitals NHS Foundation Trust (CUH) and University of Cambridge (UoC). The sponsors will retain full control of the data, its analysis and interpretation, writing of the report. Sponsor contact: Cambridge University Hospitals NHS Foundation Trust, Research and Development Department, Box 277, Cambridge Biomedical Campus, Hills Road, Cambridge CB2 0QQ.
S.U. has drafted the manuscript and supported the development of the protocol and radiology manual of the WIRE trial. S.J.W is the principal investigator for the Cambridge site, medical oncology lead and translational lead of the trial, has contributed the development of the trial protocol and the writing of this manuscript. G.D.S. is the chief investigator, conceived the trial and had the idea for this manuscript. F.A.G. and E.S. are the trial radiologists, have supported the development of the protocol and radiology manual. A.Y.W is the trial pathologist, supported the development of the protocol and laboratory manual. H. M and J. W are the trial statisticians and have supported the development of the protocol and statistical analysis plan. G.Y. (senior), R. S (senior), M.G.T. (senior) and J.A.N.S. are trial coordinators and supported the development and running of the trial. A.C. is the trial pharmacist and supported the design of the trial. J.S., T.E. and M.C.O. provided scientific input. T.J.M, K.F., A.W. and A.M. supported the design of the trial. A.P. and B.V. are the leading trial oncologists at secondary trial sites and supported the design of the trial. M.S. and G.O. are the leading trial urological surgeons at secondary trial sites and supported the design of the trial. All authors have critically reviewed the manuscript. The author(s) read and approved the final manuscript.
The trial is sponsored by Cambridge University Hospitals NHS Foundation Trust (CUH) and University of Cambridge (UoC). The trial will be part funded by AstraZeneca UK and Cancer Research UK. Olaparib, cediranib and durvalumab will be supplied free of charge by AstraZeneca UK. This work is supported by The Mark Foundation Institute for Integrated Cancer Medicine (MFICM). MFICM is hosted at the University of Cambridge, with funding from The Mark Foundation for Cancer Research (NY, USA) and the Cancer Research UK Cambridge Centre [C9685/A25177] (UK). This research was supported by the NIHR Cambridge Biomedical Research Centre (BRC-1215-20014). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
Not applicable.
This trial has received ethical approval from the London - Harrow Research Ethics Committee (19/LO/1461) and the Health Research Authority (HRA) in the United Kingdom. Written informed consent to participate will be obtained from all participants.
Not applicable.
This trial received funding from AstraZeneca, Cambridge, UK. G.D.S. declares educational grants from Pfizer, AstraZeneca, and Intuitive Surgical; consultancy fees from Pfizer, Merck, EUSA Pharma, and CMR Surgical; travel expenses from Pfizer; and speaker fees from Pfizer. S.J.W. has received travel support from Ipsen. E.S. declares being a co-founder and shareholder of Lucida Medical, consultancy fees from Amazon and speaker fees from GSK. S.U., M.G.T, R.S., G.Y. and J.A.N.S. declare no competing interests. T.E. was employed by and has stock in AstraZeneca, is employed by and has stock in Roche, has received research support from AstaZeneca, Bayer and Pfizer. K.F. has received advisory, consultancy or speaker fees from ESAI, Ipsen, Roche, Novartis, Merck, Pfizer, Eusa, BMS, conference support from Novartis, Ipsen and EUSA and institutional research funding from Roche, Merck, Exelixis. B.V. has received advisory, consultancy or speaker fees from Bristol Myers Squibb (BMS), Eisai, EUSA pharma, Ipsen, Merck Sorono, Merck Sharp & Dohme (MSD), Pfizer; conference support from Ipsen and Institutional research funding from Exelixis, Ipsen, MSD, Pfizer. A.P. has received advisory, consultancy or speaker fees from Eisai, BMS, Ipsen, MSD, Novartis, Roche, Astellas, Bayer, and Pfizer. Conference support from Pfizer, Ipsen, MSD, Roche, Astellas. Research funding from MSD. F.A.G. has research grants from GSK, research support from GE Healthcare and has consulted for AstraZeneca. M.C.O. has received research funding from Lilly. JS is an employee and stockholder in AstraZeneca, Cambridge, UK and a stockholder in GSK.
Clear cell Renal Cell Carcinoma
Dynamic Contrast Enhanced Magnetic Resonance Imaging
DNA Damage Response inhibitor
Electronic Case Report Form
Eastern Cooperative Oncology Group
Independent Data Monitoring Committee
Immuno Histochemistry
Investigational Medicinal Product
Overall survival
Poly (ADP-Ribose) Polymerase
Progression-Free Survival
Recponse Criteria in Solid Tumours
Serious Adverse Event
Suspected Unexpected Serious Adverse Reaction
Tyrosine Kinase Inhibitor
Vascular Endothelial Growth Factor (Receptor)
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