Administration and Radiation Protection
Alpharadin can be prepared and shipped ready for use anywhere in the world. The half-life of 223Ra provides sufficient time for its preparation, distribution (including long-distance shipment), and administration to patients. In clinical trials, treatment is on an outpatient basis, administered by IV injection once a month for 4 or 6 months.[40,43,45] No imaging dose or premedications are required. No comparative effectiveness trials have been conducted comparing the cost of treatment with Alpharadin to that of other therapies.
Handling of alpharadin and radiation protection
The ultra-short penetration of alpha particles, the fact that alpha radiation is readily blocked (eg, by a sheet of paper) along with the favorably low γ-irradiation, allow for ease of handling of alpharadin and administration through simple plastic tubing. There is no requirement for complex shielding or handling during shipping or administration, and no radiation protection procedures are required. Alpharadin requires no additional specialized detection equipment. Standard equipment for contamination monitoring can be used; no specialized alpha-monitoring equipment is required. For Alpharadin waste disposal, radioactive waste should be stored for 4 months, then discarded as normal clinical waste.
In contrast, alpha-emitters are more toxic and mutagenic than beta-emitters in terms of effects on single cells. The high-LET of alpha particles does, therefore, have the potential to induce development of secondary hematologic or solid malignancies. It is possible to compensate for these adverse properties in targeted therapy because of the potential to irradiate much smaller volumes of normal cells when alpha-emitters are targeted against tumor cells. Furthermore, it is unlikely that isotope therapy will result in significant increased rates of hematologic malignancies. This is because development of secondary hematologic and solid cancers takes approximately 10 and 20 or more years, respectively, yet the median survival time of patients with CRPC is short, ranging from 18 to 24 months.
Clinical Development of Alpharadin
Phase I studies
ATI-BC-1. The main goals of this phase I study, results of which were published in Clinical Cancer Research in 2005, were to assess the safety and tolerability of 223Ra in patients with CRPC and patients with breast cancer who had skeletal metastases. In addition, pain palliation was evaluated. A total of 15 prostate cancer and 10 breast cancer patients were enrolled, each receiving a single IV injection of 223Ra. Groups of five patients were included at each of the dosages (46, 93, 163, 213, or 250 kBq/kg) and followed for 8 weeks. Palliative response was evaluated according to the pain scale of the European Organisation for Research and Treatment of Cancer (EORTC)QLQ C30 questionnaire at baseline and at 1, 4, and 8 weeks after injection. Weekly blood sampling during follow-up revealed mild and reversible myelosuppression, with the nadir occurring 2 to 4 weeks after the injection. Importantly, for thrombocytes only grade 1 toxicity was reported. Grade 3 neutropenia and leukopenia occurred in two and three patients, respectively. Mild, transient diarrhea was observed in 10 of the 25 patients. Nausea and vomiting were more frequently observed in the highest dosage group, due to nonspecific uptake of 223Ra by the gut. Serum alkaline phosphatase decreased, with nadir averages of 29.5% in females and 52.1% in males. Pain relief (defined as a decrease in pain score of > 10 on the EORTC QLQ-C 30 questionnaire) was reported by 52%, 60%, and 56% of the patients after 7 days, 4 weeks, and 8 weeks, respectively. Radium-223 cleared rapidly from blood and was below 1% of initial level at 24 hours. Post-treatment bone scans, which imaged the small gamma component in Alpharadin, showed accumulation of 223Ra in the skeletal metastases. Elimination was mainly intestinal. Median survival time was 20 months. The investigators concluded that 223Ra was well tolerated at therapeutically relevant dosages. As a result of the findings in this study, phase II studies were initiated.
BC1-05. This open-label, phase I, dosimetry, biodistribution, and pharmacokinetics (PK) study assessed Alpharadin in six patients with CRPC and bone metastases. Patients received two infusions of 223Ra at a dose of 100 kBq/kg, 6 weeks apart. The trial revealed that 223Ra was rapidly eliminated from blood and sequestered to bone/bone metastases (about 60% at 4 hr) and excreted into the small intestine. The kidneys were spared, receiving only a low radiation dose with less than 5% urinary excretion and no hepatobiliary excretion. The highest calculated absorbed doses were to osteogenic cells, red marrow, and lower large intestine wall. Because of the very short range of alpha particles (2 to 10 cell diameters), however, only a small volume of red marrow would have received a significant radiation dose, possibly accounting for the favorable hematologic safety profile.
BC1-08. This open-label, phase I, dose-escalation study recruited 10 patients with progressive CRPC and more than two bone metastases to assess safety, pharmacokinetics, biodistribution, radiation dosimetry, and toxicity of Alpharadin. Patients received one treatment at the cohort-defined dose (50, 100, or 200 kBq/kg), followed by one optional treatment 6 weeks later at 50 kBq/kg. Total body clearance was largely determined by transit through the gut. Radium-223 was seen in small bowel within 10 minutes of dosing, with subsequent fecal transit to the colon. Six patients received a second injection. Four patients did not receive a second dose due to disease progression (two patients), grade 3 anemia (one patient) and an unrelated AE (one patient). Drug-related AEs reported were one patient with grade 3 anemia; one with grade 3 thrombocytopenia (> 7 days); and one with grade 3/4 neutropenia (> 14 days), grade 3 diarrhea, and grade 3 nausea.
Phase II studies
BC1-02. This randomized, placebo-controlled, multicenter, phase II study of Alpharadin in patients with CRPC and symptomatic bone metastases was published in Lancet Oncology in 2007. Patients with CRPC and bone pain needing EBRT were assigned to four IV injections of 223Ra at 50 kBq/kg (33 patients) or placebo (31 patients), given every 4 weeks. Primary endpoints were change in bone alkaline phosphatase (ALP) concentration and time to SREs. Secondary endpoints included toxic effects, time to prostate-specific antigen (PSA) progression, and OS.
Median relative change in bone ALP during treatment was −65.6% and 9.3% in the 223Ra group and placebo group, respectively (P < .0001). Hematologic toxic effects did not differ significantly between the treatment and placebo groups. No patient discontinued 223Ra because of treatment toxicity. Median time to PSA progression was 26 weeks (16 to 39) vs 8 weeks (4 to 12; P = .048) for 223Ra vs placebo, respectively. Median OS was 65.3 weeks for 223Ra and 46.4 weeks for placebo (P = .066, log rank). The investigators concluded that 223Ra was well tolerated with minimum myelotoxicity, and had a significant effect on bone ALP concentrations. There are, however, no data that evaluate long-term administration of Alpharadin beyond what is demonstrated in the phase I studies.
BC1-03. This double-blind, dose-response, phase II, multicenter study (n = 100) of 223Ra reported on the palliation of painful bone metastases in CRPC patients. It showed no evidence of a dose effect following evaluation of median change in baseline from diary pain ratings (using visual analogue scores) at 223Ra doses of 5, 25, 50, and 100 kBq/kg. Most AEs were gastrointestinal, including nausea, vomiting, diarrhea, and constipation. Minor decreases in platelet counts, white blood cell (WBC) counts, and neutrophils were reported in the 50 and 100 kBq/kg groups.
BC1-04. This double-blind, randomized, dose-finding, phase II study of Alpharadin for the treatment of patients with CRPC and painful bone metastases randomized 75 patients (25 in each group) to receive a dose of 25, 50, or 80 kBq/kg. Bone markers, PSA levels, safety, and survival data were assessed. Change in PSA level over a 24-week period was found to be dose-dependent. The most common AEs reported were gastrointestinal and musculoskeletal. Patients were not treated with antiemetics in this study. Grade 3 or 4 thrombocytopenia occurred in two patients. No patients discontinued due to an AE. Grade 3 or 4 neutropenia was not observed. These hematologic results could be based on disease burden, as patients with marrow invasion may be at higher risk for thrombocytopenia. The difference in disease stage (typically very advanced in patients who have received strontium) is an important difference between patients treated with Alpharadin and patients treated with strontium, and it may account for some of the increased thrombocytopenia seen in the strontium patients. It is difficult to quantify these differences when comparing studies, however, since they were separated by many years.
Summary of phase I and II clinical trials
Overall safety and tolerability were evaluated in 292 patients across all phase I and II trials. Five trials were assessed: two phase I trials (Alpharadin n = 37) and three phase II trials (Alpharadin, n = 255; placebo, n = 31). Alpharadin was administered (single or repeated injections) at doses of 5 kBq/kg to 250 kBq/kg. Efficacy results were shown to confer an OS benefit in patients with CRPC and bone-predominant disease, as well as improvement in disease-related biomarkers (bone and PSA), and in pain. Alpharadin was also found to be safe and well tolerated. Of note, none of these studies demonstrated a dose-limiting toxicity, implying that further dose escalation is possible.
Alpharadin also showed promising preliminary results in a phase IIa trial in patients with bone metastases from breast cancer no longer responding to endocrine therapy. The data showed that Alpharadin reduced the levels of bone alkaline phosphatase (bALP) and urine N-telopeptide (uNTX), key markers of bone turnover associated with bone metastases in breast cancer.
Phase III: the ALSYMPCA trial
Alpharadin successfully met the primary endpoint of OS in ALSYMPCA (Alpharadin in Symptomatic Prostate Cancer Patients), a double-blind, randomized, multicenter, phase III study of Alpharadin in the treatment of bone metastases resulting from CRPC.
The 922-patient ALSYMPCA study was stopped early after a preplanned efficacy interim analysis, following a recommendation from an Independent Data Monitoring Committee, on the basis of achieving a statistically significant improvement in OS (two-sided P value = .0022, hazard ratio [HR] = 0.699; median OS, 14.0 months for Alpharadin vs 11.2 months for placebo). Earlier phase II results of the trial showed an increased survival time of 4.5 months. The lower figure of 2.8 months increased survival in phase III is probably a result of too short follow-up, because of the early termination of the study. Survival time for patients who were still alive could not be calculated. Algeta SAS of Norway and its partner Bayer Healthcare are preparing to file regulatory submissions for Alpharadin in the US and Europe in mid 2012.
It is difficult to compare the results of phase III studies that have evaluated samarium, strontium, and Alpharadin, due to the different eras in which these trials were performed. Although the entry hematologic parameters are similar in all studies, extent of disease in the bone marrow is difficult to quantitate. The 89Sr studies by Porter et al and the 153Sm studies by Sartor were performed before docetaxel-based chemotherapy was approved by the FDA for treatment of CRPC in 2004. A total of 12% of patients in the 153Sm study had received prior chemotherapy.
At the time of the initial strontium studies, chemotherapy was not standard treatment, and the number of patients treated with chemotherapy in the Porter et al study was not reported. Entry criteria for hematologic function in Porter et al study were a WBC count greater than 3.5 × 109 per liter and a platelet count greater than 150 × 109 per liter. There is no way to quantitate the amount of bone marrow involvement in the strontium study or the ALSYMPCA study.
Ongoing trial NCT00699751
Other ongoing studies include Alpharadin in combination with docetaxel in patients with CRPC and bone metastases as well as single-agent Alpharadin in patients with metastatic breast cancer and bone metastases. Outcomes from clinical trials will provide insight into the effect of Alpharadin on OS, and will reveal important biodistribution, dosimetry, and safety data.
Data from ongoing trials will continue to add to our knowledge about the efficacy and safety of Alpharadin in treating patients with CRPC and bone metastases. Currently in development are studies to improve survival in patients with bone metastases from advanced prostate cancer and breast cancer. Studies are also underway evaluating the potential for Alpharadin to be used in patients with other cancers that have a propensity to metastasize to the bone (eg, lung).
A multidisciplinary team approach is used to administer Alpharadin to patients with CRPC and bone metastases. The goal is for the urologist and medical oncologist to collaborate in determining patient eligibility to receive Alpharadin, as well as in post-treatment follow-up. Once the patient is deemed suitable for treatment, a radiation oncologist or nuclear medicine physician would administer the Alpharadin infusion with careful assessment and monitoring for minimal expected toxicities. The ability to administer concomitant or subsequent therapies is a crucial question that remains to be addressed, particularly with recent approval of agents such as abiraterone (Zytiga), cabazitaxel, sipuleucel-T, and the probable approval of MDV3100.
Summary and Conclusion
Alpha-pharmaceuticals deliver high-LET radiation to the target, with large amounts of energy per unit track length and short ranges (< 100 μm). Using alpha-pharmaceuticals to treat patients with CRPC and bone metastases allows highly targeted, localized delivery of the radiation to the metastases.
Alpharadin is an alpha-emitter with a mechanism of action that has a potent and highly targeted antitumor effect on bone metastases. It is a calcium mimetic that targets new bone growth in and around metastases. It emits high-energy alpha particles that induce primarily nonreparable, double-stranded DNA breaks in target cells. The short path length of the alpha particles keeps toxicity to adjacent healthy tissue (particularly the bone marrow) at a minimum.
Preclinical studies with Alpharadin revealed important efficacy and safety data related to the compound and provided the rationale for proceeding to clinical trials.
Clinical studies indicate that Alpharadin has a favorable safety profile and is efficacious in patients with CRPC and bone metastases. The phase II BC1-02 (placebo-controlled) study showed it had statistically significant effects on bone markers, was associated with a decrease in PSA levels and improvement of OS, had a highly tolerable safety profile (with fewer AEs/ serious AEs when compared to placebo), and had no significant hematologic safety issues. Hematologic AEs were typically mild (Common Toxicity Criteria toxicity grades 1 and 2) and transient; no patient withdrew due to hematologic toxicity. Treatment with Alpharadin up to 12 weeks is thus deemed safe and highly efficacious.
Data from ongoing trials will continue to add to our knowledge regarding the efficacy and safety of Alpharadin in treating patients with bone metastases. These include the ALSYMPCA double-blind, randomized, multicenter, phase III study, which has a primary endpoint of OS; a trial of Alpharadin in combination with docetaxel, which will assess safety and tolerability, as well as preliminary efficacy; and a study of Alpharadin (as a single agent) in patients with breast cancer and bone metastases, which is focusing on its effect on bone markers.
Financial Disclosure: Dr. Petrylak receives grant support from Dendreon, Sanofi, Pfizer, AstraZeneca, GlaxoSmithKline, Rogensen Institute, and Boehringer Ingelheim. He is a paid consultant for Bayer, Pfizer, Ferring, Millennium, Novartis, Dendreon, Johnson & Johnson, and GlaxoSmithKline, and serves on the scientific advisory boards of Bellicum and Egenix. Dr. Cheetham has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.