Cancer Risk– Does ezetimibe or ezetimibe/simvastatin increase it? Adam Polis, Merck NISS Observational Studies Workshop June 17, 2011
Focus WARNING: These trials were not observational studies. All were randomized, double-blind, controlled trials. Peto R et al. N Engl J Med. 2008; 359(13): 1357 -66 2
Outline • Background • Simvastatin + Ezetimibe in Aortic Stenosis (SEAS) Findings • What followed… • Peto paper • Reactions to Peto paper • Statistical Issues • Concluding Remarks 3
Background
Background-- Statins • What is a Statin? – Class of drug that improves cholesterol levels – First marketed statin was lovastatin • Developed by Merck • Initially sold in the US as MEVACOR® in 1987 – Other statins • • • Atorvastatin (LIPITOR®) Fluvastatin (LESCOL®) Pitavastatin (LIVALO®) Pravastatin (PRAVACHOL®) Rosuvastatin (CRESTOR®) Simvastatin (ZOCOR®) – Multiple trials with different statins showing positive effects on CVD risk and mortality 5
Background-- Simvastatin • Simvastatin is one of a number of –statins, and is primarily indicated for: – Reducing the risk of total mortality in patients at high risk for coronary events – Improving lipids (TC, LDL-C, Apo B, TG, HDL-C) in patients with primary hyperlipidemia and mixed dyslipidemia • • Marketed in the US as ZOCOR® Dosage strengths: 5, 10, 20, 40, and 80 mg* Developed by Merck Initial US approval 1991 *US label for ZOCOR® changed as of June 2011– no new patients on 80 mg. 6
Background-- Ezetimibe • Also indicated for improving lipids • Discovered and initially developed by Schering. Plough • Later co-developed and marketed as joint venture between Merck and Schering-Plough • Approved in US in 2002 and marketed as ZETIA® • Dosage strength: 10 mg 7
Background-- Ezetimibe • Ezetimibe can be taken alone or with a statin • Commonly used alone for patients who can not tolerate a statin • Used in combination with a statin as an alternative to increasing the statin dose • VYTORIN® is the name of the US marketed combination of ezetimibe and simvastatin – Dosage strengths: 10/10, 10/20, 10/40, 10/80 mg* *US label for VYTORIN® changed as of June 2011– no new patients on 10/80 mg 8
Background-- Ezetimibe • Initially approved and indicated for lipid efficacy, but no outcome data • SEAS, SHARP, and IMPROVE-IT SEAS SHARP IMPROVE-IT Enroll Start March 2001 June 2003 October 2005 Enroll Stop March 2004 2007 2013 est. Follow-up Stop Summer 2008 2010 5250 events 9
Background-- SEAS • Simvastatin + Ezetimibe in Aortic Stenosis • Primary Objective – In patients with asymptomatic aortic stenosis, to evaluate whether treatment with ezetimibe 10 mg/day and simvastatin 40 mg/day compared to placebo will reduce the risk of major cardiovascular events (MCE): • • Cardiovascular death Aortic valve replacement surgery (AVR) CHF as a result of progression of AS Non-fatal myocardial infarction CABG PCI Hospitalized unstable angina Non-hemorrhagic stroke Rossebø AB et al. N Engl J Med. 2008; 359(13): 1343 -56 10
Background-- SEAS • Rationale – Aortic-valve stenosis (AS) is a relatively common condition in the elderly • Associated with significant morbidity and mortality – Process of development of AS has similarities to development of atherosclerosis – Could cholesterol lowering impact on development of AS • Similar to known effect on atherosclerosis? Rossebø AB et al. N Engl J Med. 2008; 359(13): 1343 -56 11
Background-- SEAS • • Randomized, double blind, placebo controlled, multicenter 173 centers: Norway, Sweden, Denmark, Finland, Germany, UK, Ireland 4 -Week placebo/diet run-in 1873 patients (Minimum follow-up: 4 years) Rossebø AB et al. N Engl J Med. 2008; 359(13): 1343 -56 12
Background-- SEAS • SEAS Committees – SEAS Study Group Steering Committee • Norway: Terje R. Pedersen (Chairman), Anne B. Rossebø (Coordinator), Eva Gerdts, Terje Skjærpe, Ingar Holme (Statistician); Sweden: Ronnie Willenheimer, Kurt Boman; Denmark: Kristian Wachtell, Kenneth Egstrup; Finland: Y. Antero Kesäniemi; Germany: Christa Gohlke-Bärwolf, Christoph Nienaber; United Kingdom/Ireland: John Chambers, Simon Ray • Nonvoting members (Merck): Philippe Brudi (MSP), William Malbecq (CBARDS). – Independent Data Safety and Monitoring Board • United Kingdom: Desmond Julian (Chairman), Stuart J Pocock; Norway: John Kjekshus – Independent End Point Classification Committee • Denmark: Christian Hassager; Norway: Torstein Gundersen – Independent Echo Core Laboratory • Norway: Eva Gerdts – Monitoring offices, Merck Sharp & Dohme • Norway: Gro Karlsen; United States: Gail Mc. Peters – National Project Leaders, Merck Sharp & Dohme • Denmark: Gert S Andersen; Finland: Pekka Koskinen, I. Puhakainen; Germany: Andreas Ketter; H. Ansari Esfahani, M. Meergans; Ireland: Noeleen Farrelly, C. Parish; Norway: Vessa Larsen; Sweden: H. Boström, Lena Bergvall; United Kingdom: Kerin Wincott Rossebø AB et al. N Engl J Med. 2008; 359(13): 1343 -56 13
Background-- SHARP • Study of Heart And Renal Protection • Key outcome – Major atherosclerotic events (coronary death, MI, nonhaemorrhagic stroke, or any revascularization) • Subsidiary outcomes – Major vascular events (cardiac death, MI, any stroke, or any revascularization) – Components of major atherosclerotic events • Main renal outcome – End stage renal disease (dialysis or transplant) Baigent et. al. American Society for Nephrology, Nov. 2010. 14
Background-- SHARP • Rationale – Risk of vascular events is high among patients with chronic kidney disease – Lack of clear association between cholesterol level and vascular disease risk – Pattern of vascular disease is atypical, with a large proportion being non-atherosclerotic – Previous trials of LDL-lowering therapy in chronic kidney disease are inconclusive Baigent et. al. American Society for Nephrology, Nov. 2010. 15
Background-- SHARP • History of chronic kidney disease – not on dialysis: elevated creatinine on 2 occasions • Men: ≥ 1. 7 mg/d. L (150 µmol/L) • Women: ≥ 1. 5 mg/d. L (130 µmol/L) – on dialysis: haemodialysis or peritoneal dialysis • Age ≥ 40 years • No history of myocardial infarction or coronary revascularization • Uncertainty: LDL-lowering treatment not definitely indicated or contraindicated Baigent et. al. American Society for Nephrology, Nov. 2010. 16
Background-- SHARP Baigent et. al. American Society for Nephrology, Nov. 2010. 17
Background-- IMPROVE-IT • IMProved Reduction of Outcomes: Efficacy International Trial Cannon CP, et al. Am Heart J 2008; 156: 826 -32. Vytorin 18
Background-- IMPROVE-IT High Risk Patients With Acute Coronary Syndromes High-Risk STEMI NSTE / Unstable Angina According to IMPROVE-IT Entry Criteria Enrollment of new STEMI subjects was closed once they comprised ~30% of the population Randomized Treatment Assignment ≤ 10 Days of Hospital Presentation EZ/Simva Combo 10/40 mg Simva 40 mg n= ~18, 000 2. 5 Year Minimum Follow-up Primary Endpoint: CV Death, Nonfatal MI, Hospital Admission for Unstable Angina, Revascularization >30 Days, Nonfatal Stroke Cannon CP, et al. Am Heart J 2008; 156: 826 -32. 19
Simvastatin + Ezetimibe in Aortic Stenosis (SEAS) Findings
SEAS Findings-Primary Endpoint: Major CV Events Percentage of Patients With First Event 50 Intention-to-Treat Population Placebo 40 Hazard ratio: 0. 96, p=0. 591 30 EZ/Simva 10/40 mg 20 10 0 0 # of Patients at Risk EZ/Simva 10/40 mg Placebo 1 2 3 4 5 618 586 53 56 Years in Study 906 884 817 791 Rossebø AB et al. N Engl J Med. 2008; 359(13): 1343 -56 713 696 21
SEAS Findings– Key Secondary Endpoint: Ischemic CV Events Percentage of Patients With First Event 30 20 Intention to Treat Population Hazard ratio: 0. 78, p=0. 024 Placebo EZ/Simva 10/40 mg 10 0 0 1 # of patients at risk EZ/Simva 10/40 mg 917 Placebo 898 2 3 Years in Study 867 838 Rossebø AB et al. N Engl J Med. 2008; 359(13): 1343 -56 823 788 4 5 769 729 76 76 22
SEAS Findings-Clinical Adverse Events (AE) All Patients as Treated Population Placebo EZ/ Simva N=929 N=943 n (%) Any AE 852 (91. 7) 854 (90. 6) Any serious AE (SAE) 463 (49. 8) 468 (49. 6) 70 (7. 5) 105 (11. 1) Recurrent, same site 5 (0. 5) 3 (0. 3) New cancer 65 (7. 0) 102 (10. 8) Drug related AE 110 (11. 8) 134 (14. 2) 3 (0. 3) 5 (0. 5) 122 (13. 1) 144 (15. 3) D/c due to drug related AE 29 (3. 1) 46 (4. 9) D/c due to SAE 79 (8. 5) 77 (8. 2) D/c due to drug related SAE 1 (0. 1) 2 (0. 2) Total Cancer Drug related SAE D/c due to AE Rossebø AB et al. N Engl J Med. 2008; 359(13): 1343 -56 p= 0. 01 23
SEAS Findings-Any Cancer 24
SEAS Findings-Cancer Mortality Percentage of Patients With First Event Intention-to-Treat Population 10 Hazard ratio: 1. 67 P=0. 05 Unadjusted P=0. 06 with Yates continuity correction EZ/Simva 10/40 mg n=39 (4. 1 %) 5 Placebo n=23 (2. 5 %) 0 0 1 # of patients at risk EZ/Simva 10/40 mg 930 Placebo 916 2 3 4 Years in Study 912 890 884 865 855 835 5 89 94 25 Rossebø AB et al. N Engl J Med. 2008; 359(13): 1343 -56
What followed…
Reaction to SEAS Results • SEAS Steering Committee (SC) surprised by both efficacy and safety findings • Primary concern: what to tell patients on VYTORIN and how to advise physicians – 1. 4 M prescriptions written for VYTORIN in April of 2008 • Realization that cancer finding could be false-positive and external information/data was needed: – Cholesterol Treatment Trialist (CTT) cumulative meta-analysis – Ongoing trials: SHARP + IMPROVE-IT 27
Reaction to SEAS Results • Terje Pedersen (SEAS SC Chair) contacted the SCs for SHARP and IMPROVE-IT to discuss +/- of looking at cancer data in SHARP + IMPROVE-IT • Agreement by SCs and Data Safety Monitoring Committees to perform analysis of cancer data in SHARP and IMPROVE-IT • Analysis performed by independent, academic organization (Clinical Trial Study Unit, Oxford University) – They were sent the data for all 3 trials – They decided independently on analysis approach and data conventions 28
CTT Meta-Analysis 29 Baigent C et al. Lancet. 2005; 366(9493): 1267 -78
CTT: Cancer Incidence per mmol/L LDL-C Reduction by Site 30 Baigent C et al. Lancet. 2005; 366(9493): 1267 -78
CTT: Cancer Incidence per mmol/L LDL-C Reduction per Year 31 Baigent C et al. Lancet. 2005; 366(9493): 1267 -78
Peto Paper
Peto Paper 33 Peto R et al. N Engl J Med. 2008; 359(13): 1357 -66
Peto Paper • Will highlight some analyses in paper • Statistical Methods – Log-rank, stratifying by year, and using continuity correction for chi-square statistic – Cox regression was used in SEAS paper – Site specific cancer p-values were adjusted for multiplicity – Subgroup analyses were adjusted for multiplicity by using 99% CIs • Paper makes the important points: – Unplanned and unexpected finding from SEAS was hypothesis-generating – Analysis of SHARP + IMPROVE-IT done to support or refute hypothesis – Primary approach not to combine all 3 studies, but also done to show robustness of findings • SHARP + IMPROVE-IT: 20, 617 patients and 36, 501 patient-years vs. SEAS with 1873 patients and 7636 patient-years 34 Peto R et al. N Engl J Med. 2008; 359(13): 1357 -66
Cancer Onset– Number of Patients with Cancer Onset in Trials Statin Alone vs. Control from CTT 0 -1 >1 -2 >2 -3 >3 -4 >4 Year of Onset 35 Peto R et al. N Engl J Med. 2008; 359(13): 1357 -66
Relative Risk of Cancer Per Year– Ezetimibe and Simvastatin 36 Peto R et al. N Engl J Med. 2008; 359(13): 1357 -66
Relative Risk of Cancer by Outcome = 99% CI Difference between hypothesis-generating total and the hypothesis-testing total: 2 = 7. 5 (P = 0. 006) 37 Peto R et al. N Engl J Med. 2008; 359(13): 1357 -66
Relative Risk of Fatal Cancer by Year = 99% CI Trend test: 2 = 1. 35 (P = 0. 25) 38 Peto R et al. N Engl J Med. 2008; 359(13): 1357 -66
Peto Paper-- Conclusions • Data do not support hypothesis generated in SEAS • While excess risk of death due to cancer, not hypothesis generated in SEAS and not plausible based upon other evidence – Did not see excess of cancers, which would be expected if causing excess deaths due to cancer • DSMBs for SHARP and IMPROVE-IT agreed each trial could continue • Need to perform unblinded analysis of SHARP and IMPROVE-IT result of increased public scrutiny of products’ efficacy and safety – Such a need could be diminished by conducting larger, more definitive outcome trials earlier in product lifecycle 39 Peto R et al. N Engl J Med. 2008; 359(13): 1357 -66
Reactions to Peto Paper
Reactions to Peto Paper– Drazen et. al. • Drazen et. al. N Engl J Med. 2008 Sep 25; 359(13): 1398 -9 (Editorial) – Randomized trial most reliable tool, but sometimes find unexpected results • • – Can be due to chance Require further study to figure out SHARP + IMPROVE-IT data did not confirm cancer risk observed in SEAS, but 3 trials combined show increase risk of mortality due to cancer 1. 2. Need to be cautious of interpretation of unplanned, data-driven finding But should not ignore: • Agree SHARP and IMPROVE-IT should continue, but patients should be carefully followed • Other additional data sets on ezetimibe should be evaluated for cancer risk 41
Reactions to Peto Paper-- Fleming • Fleming TR. N Engl J Med 2008; 359: 1400 -1402 (Editorial) – Recommends the use of 3 criteria to assess the credibility of exploratory safety findings: 1. 2. 3. – Statistical—Is it statistically unlikely that such events can be explained by chance, i. e. p-value? Is the safety risk biologically plausible? Can one identify independent, prospectively obtained data to confirm the finding? Statistical – – – SEAS data correctly not included with SHARP and IMPROVE-IT to evaluate hypothesis; inclusion causes regression to mean effect Cancer events: HR 0. 96; 95% CI: 0. 82 to 1. 12 rules out increased risk greater than 12% Cancer-related deaths: HR 1. 34; 95% CI: 0. 98 to 1. 84, relative increase could be as large as 84% 42
Reactions to Peto Paper-- Fleming • Concerned by: 1. 2. 3. • Risks of misinterpreting the interim findings from SHARP and IMPROVE-IT Disrupting ongoing trials Interim data from ongoing trials should be limited to Data Monitoring Committees Concludes – – Additional data needed to adequately address question regarding increased risk of cancer-related death due to ezetimibe/simvastatin Data should come from prospective randomized clinical trial designed to assess safety Fleming TR. N Engl J Med 2008; 359: 1400 -1402 43
Reactions to Peto Paper-- Nissen • Nissen Letter to Editor – – – • Premature unblinding of clinical trial data is unreliable way to evaluate drug safety Critical of duration of follow-up (median 12 months) in IMPROVE-IT Disagrees with conclusion that there is no credible evidence of cancer risk with ezetimibe Collins and Peto’s Response – – Not in the interest of public health to label potentially useful drugs unsafe without credible evidence Four times as many cancers in SHARP and IMPROVE-IT compared to SEAS, but no treatment difference found Nissen SE. N Engl J Med. 2009 Jan 1; 360(1): 86 -7; author reply 87. 44
Reactions to Peto Paper– Califf et. al. • Take opportunity to comment that improvements could be made to drug development and conduct of outcome trials – Ezetimibe and Ezetimibe/Simvastatin approved with: • • • Reasons a public statement made prior to scientific presentation – – – • Mostly short-term trials Exposure limited for patients with more severe disease Limited adverse event database No outcome data Transparency in industry-funded trials Alerting patients and providers would allow a more informed decisions Findings are material information to Merck and SP shareholders Sponsors needed to inform global regulators about SEAS results and SHARP + IMPROVE-IT analysis Califf RM, et. al. N Engl J Med. 2009 Aug 13; 361(7): 712 -7. 45
Reactions to Peto Paper-- Califf • SHARP and IMPROVE-IT leaders need to ask DSMBs – OK to continue studies? • – Yes, with increased surveillance of cancer-related events in IMPROVE-IT OK to release further info. to investigators and subjects? • • More difficult decision to make SEAS results could influence: 1. Performance of SHARP and IMPROVE-IT 2. Impact how patients are treated outside of these trials • Decision– 1. Pool cancer data from SHARP and IMPROVE-IT and analyze by independent statisticians with experience with CV and cancer data 2. Results from this analysis along with SEAS results were presented at the press conference Califf RM, et. al. N Engl J Med. 2009 Aug 13; 361(7): 712 -7. 46
Reactions to Peto Paper-- Califf • Recommendations for improving conduct of outcome trials 1. 2. 3. 4. Improve requirements for Data Safety Monitoring Committees House the data in not-for-profit institutions Chair of steering committee should be recognized as leader in field of study with clinical trial experience Reform Securities and Exchange Commission regulations around reporting of results from major clinical trials Califf RM, et. al. N Engl J Med. 2009 Aug 13; 361(7): 712 -7. 47
Reactions to Peto Paper • Congressional Inquiry – Interesting and worth checking out on the Clinical Trial Service Unit’s (at Oxford University) web site: http: //www. ctsu. ox. ac. uk/news/ctsu-response • FDA review of the data – August 2008 sent out a preliminary communication of an association between VYTORIN and increased cancer risk based on SEAS data – December 2009 • Unlikely that ZETIA or VYTORIN increase the risk of cancer • Not advising patients to stop using these meds, but weigh risk/benefit http: //www. fda. gov/drugsafety/postmarketdrugsafetyinformationforpatient sandproviders/drugsafetyinformationforheathcareprofessionals/ucm 194964. htm 48
SHARP: Cancer incidence Proportion suffering event (%) 25 20 Risk ratio 0. 99 (0. 87 – 1. 13) Logrank p=0. 89 15 Eze/simv Placebo 10 5 0 0 1 2 3 Years of follow-up Baigent et. al. American Society for Nephrology, Nov. 2010. 4 5 49
Statistical Issues
Statistical Issues • Ezetimibe studies were not Observational Studies – Similar issues can arise in prospective, randomized, controlled trials when see unexpected result or perform post hoc analyses • Regression to the mean – Avoided by not combining all 3 trials together – SEAS considered as hypothesis-generating; SHARP + IMPROVE-IT to test the hypothesis – Barnett, et. al. International Journal of Epidemiology 2005; 34: 215– 220 • Multiplicity – Initial finding of increased cancer rate in SEAS was not pre-specified, many AEs from the trial evaluated – Comparisons of cancer rates by site of cancer were adjusted by multiplying unadjusted p-value by number of comparisons (Hochberg, Tamhane. Multiple comparison procedures. New York: Wiley, 1987) 51
Statistical Issues • Unplanned Interim Analysis and Risk of Misinterpreting Findings – – Fleming, et. al. , Clinical Trials 2008; 5: 157– 167. Treatment effect fluctuates over time Multiple unplanned or unadjusted looks increase type I error When duration of exposure is important, early look could be misleading 52
Concluding Remarks
Concluding Remarks • Good example of unexpected challenges one can face • In medical setting, putting the patient first is critically important perspective to have • World renown experts (SEAS, SHARP, and IMPROVE-IT SCs and DSMBs) deciding best course of action and world renown experts conducting the analysis • Conduct outcome study earlier in product life cycle • Performing the unblinded interim analysis is/was controversial – Without doing so, patients and physicians likely would have been left to think ezetimibe increases the risk of cancer – The way in which the interim was performed does not appear to have effected the conduct of the trials – Without other randomized controlled trials, a potential link between ezetimibe and cancer may have had to rely on an observational study, subject to all the biases inherent in such studies 54
References 1. Baigent C, Keech A, Kearney PM, Blackwell L, Buck G, Pollicino C, Kirby A, Sourjina T, Peto R, Collins R, Simes R; Cholesterol Treatment Trialists' (CTT) Collaborators. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90, 056 participants in 14 randomised trials of statins. Lancet. 2005; 366(9493): 1267 -78. 2. Barnett AG, van der Pols JC, and Dobson AJ. Regression to the mean: what it is and how to deal with it. International Journal of Epidemiology 2005; 34: 215– 220. 3. Califf RM, Harrington RA, Blazing MA. Premature release of data from clinical trials of ezetimibe. N Engl J Med. 2009 Aug 13; 361(7): 712 -7. 4. Cannon CP, Giugliano RP, Blazing MA, et al. Rationale and design of IMPROVEIT (IMProved Reduction of Outcomes: Vytorin Efficacy International Trial): comparison of ezetimibe/simvastatin versus simvastatin monotherapy on cardiovascular outcomes in patients with acute coronary syndromes. Am Heart J 2008; 156: 826 -32. 5. Drazen JM, D'Agostino RB, Ware JH, Morrissey S, Curfman GD. Ezetimibe and cancer--an uncertain association. N Engl J Med. 2008 Sep 25; 359(13): 1398 -9. Epub 2008 Sep 2. 6. Fleming TR. Identifying and Addressing Safety Signals in Clinical Trials. N Engl J Med 2008; 359: 1400 -1402. 55
References 7. Fleming TR, Sharples K, Mc. Call J, Moore A, Rodgers A, and Stewart R. Maintaining confidentiality of interim data to enhance trial integrity and credibility. Clinical Trials 2008; 5: 157– 167. 8. Nissen SE. Comment on: Analyses of cancer data from three ezetimibe trials. N Engl J Med. 2009 Jan 1; 360(1): 86 -7; author reply 87. 9. Peto R, Emberson J, Landray M, Baigent C, Collins R, Clare R, Califf R. Analyses of cancer data from three ezetimibe trials. N Engl J Med. 2008 Sep 25; 359(13): 1357 -66. Epub 2008 Sep 2. 10. Rossebø AB, Pedersen TR, Boman K, Brudi P, Chambers JB, Egstrup K, Gerdts E, Gohlke-Bärwolf C, Holme I, Kesäniemi YA, Malbecq W, Nienaber CA, Ray S, Skjaerpe T, Wachtell K, Willenheimer R; SEAS Investigators. Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis. N Engl J Med. 2008; 359(13): 1343 -56. 11. Sharp Collaborative Group. Study of Heart and Renal Protection (SHARP): randomized trial to assess the effects of lowering low-density lipoprotein cholesterol among 9, 438 patients with chronic kidney disease. Am Heart J. 2010 Nov; 160(5): 785 -794. e 10. Epub 2010 Sep 18. 56
Backups
SEAS– Secondary Objectives • In patients with asymptomatic AS, to evaluate whether treatment with ezetimibe 10 mg/day and simvastatin 40 mg/day compared to placebo will reduce the risk of: • The composite endpoint of aortic valve events (AVEs): – AVR surgery, – CHF as a result of progression of AS, – Cardiovascular death • The composite endpoint of ischemic cardiovascular events (ICEs): – – – Cardiovascular death Nonfatal MI CABG PCI Hospitalized unstable angina Nonhemorrhagic stroke 58 Rossebø AB et al. N Engl J Med. 2008; 359(13): 1343 -56
SEAS– Secondary Objectives • In patients with asymptomatic AS • To evaluate whether treatment with ezetimibe 10 mg/day and simvastatin 40 mg/day will retard the progression of AS based on echocardiographic measurements compared to placebo • Assess the safety of ezetimibe 10 mg/day and simvastatin 40 mg/day 59 Rossebø AB et al. N Engl J Med. 2008; 359(13): 1343 -56
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