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Randomized, Open-Label, Phase III Study Comparing Irinotecan With Paclitaxel in Patients With Advanced Gastric Cancer Without Severe Peritoneal Metastasis After Failure of Prior Combination Chemotherapy Using Fluoropyrimidine Plus Platinum: WJOG 4007 Trial
Abstract
This phase III study compared treatment with weekly paclitaxel and biweekly irinotecan in patients with advanced gastric cancer refractory to treatment with fluoropyrimidine plus platinum.
Patients were randomly assigned to receive either paclitaxel (80 mg/m2 on days 1, 8, and 15, every 4 weeks) or irinotecan (150 mg/m2 on days 1 and 15, every 4 weeks). Primary end point was overall survival (OS), and secondary end points were progression-free survival (PFS), response rate, adverse events, and proportion of patients who received third-line chemotherapy.
Of 223 patients, 219 were eligible for analysis. Median OS was 9.5 months in 108 patients allocated to the paclitaxel group and 8.4 months in 111 patients allocated to the irinotecan group (hazard ratio [HR], 1.13; 95% CI, 0.86 to 1.49; P = .38). Median PFS was 3.6 months in the paclitaxel group and 2.3 months in the irinotecan group (HR, 1.14; 95% CI, 0.88 to 1.49; P = .33). Response rate was 20.9% in the paclitaxel group and 13.6% in the irinotecan group (P = .24). Common grade 3 to 4 adverse events were neutropenia (paclitaxel group, 28.7%; irinotecan group, 39.1%), anemia (21.3%; 30.0%), and anorexia (7.4%; 17.3%). Treatment-related deaths occurred in two patients (1.8%) in the irinotecan group. Third-line chemotherapy was administered in 97 patients (89.8%) after paclitaxel treatment and in 80 patients (72.1%) after irinotecan treatment (P = .001).
The outcomes in patients with unresectable gastric cancer are extremely poor; median survival times of 3 to 5 months have been reported with best supportive care (BSC) alone.1–3 In randomized studies conducted in the 1990s, first-line chemotherapy for advanced gastric cancer provided survival benefit over BSC alone. After many clinical trials, at present, fluoropyrimidine plus platinum with or without epirubicin or docetaxel is regarded as standard first-line chemotherapy in the treatment of gastric cancer worldwide.4–9
Since S-1 was approved for treatment of advanced gastric cancer in Japan, several phase III studies have been conducted, such as the JCOG 9912 (Japan Clinical Oncology Group 9912; fluorouracil v S-1 v irinotecan plus cisplatin),10 SPIRITS (S-1 Plus Cisplatin Versus S-1 in a Randomized Controlled Trial in the Treatment for Stomach Cancer; S-1 v S-1 plus cisplatin),9 and GC0301/TOP-002 trials (Gastric Cancer 0301/Topotecin-002; S-1 v S-1 plus irinotecan).11 On the basis of these study results, S-1 plus cisplatin is accepted as standard first-line chemotherapy for advanced gastric cancer in Japan. Despite no robust evidence of survival benefit, > 70% of participants received second-line chemotherapy in these studies.9–11
Many phase II studies of second-line chemotherapy for advanced gastric cancer have been conducted.12–20 In evaluations of taxanes, administration of both paclitaxel (210 mg/m2) and docetaxel (60 mg/m2) on a triweekly schedule resulted in high rates of grade 3 or 4 neutropenia (37% to 88%),12–14 whereas lower rates of severe neutropenia (3% to 32%) were observed with weekly administration of paclitaxel (80 mg/m2).15–18 Regarding efficacy parameters, response rate (RR) and progression-free survival (PFS) were similar for patients on the triweekly and weekly schedules of paclitaxel. Two reports evaluated weekly paclitaxel as second-line chemotherapy, in which median overall survival (OS) was 5 and 6.9 months, respectively.15,16 In other studies, combination chemotherapy including biweekly administration of irinotecan (150 mg/m2) as second-line chemotherapy resulted in median OS of 8 to 10 months,19,20 although toxicity seemed to be more severe than that seen with weekly paclitaxel. Thus, weekly paclitaxel has become the preferable second-line chemotherapy in Japan.
At present, taxanes and irinotecan are two main options for treatment of advanced gastric cancer refractory to fluoropyrimidine plus platinum. However, to our knowledge, no randomized study has directly compared the efficacy of these two treatments. The West Japan Oncology Group (WJOG) conducted a phase III trial (WJOG 4007) comparing paclitaxel with irinotecan in patients with advanced gastric cancer.
Eligible patients were age 20 to 75 years with histologically confirmed metastatic or recurrent gastric adenocarcinoma. Other inclusion criteria were Eastern Cooperative Oncology Group performance status (ECOG PS) of 0 to 2; disease progression confirmed by computed tomography (CT), endoscopy, or other imaging technique during or within 1 month after last dose of first-line chemotherapy with fluoropyrimidine plus platinum; no prior chemotherapy with taxanes or irinotecan; and no severe peritoneal metastasis. Severe peritoneal metastasis was defined as ileus or subileus suggested on barium enema examination and moderate to severe ascites exceeding the pelvic cavity on spine CT scan caused by peritoneal metastasis. In case of treatment with adjuvant or neoadjuvant chemotherapy consisting of fluoropyrimidine plus platinum, patients with disease progression during treatment or within 6 months after treatment completion were eligible. Adequate bone marrow, hepatic, and renal functions were also required.
WJOG 4007 was a prospective, multicenter, randomized, open-label, parallel-group phase III clinical trial conducted at 37 centers in Japan. The protocol was approved by the independent ethics committee or institutional review board of each participating institution. This trial was conducted in accordance with the Declaration of Helsinki. All patients provided written informed consent before study entry. The trial was registered with the University Hospital Medical Information Network.
After checking eligibility, patients were randomly assigned at a 1:1 ratio to receive either paclitaxel or irinotecan. Random assignment was carried out centrally at the data center using minimization method with the following adjustment factors: institution, ECOG PS (0 to 1 v 2), and measurable lesions (presence v absence). Neither investigators nor patients were blinded to the allocated treatment.
Paclitaxel (80 mg/m2) was administered intravenously on days 1, 8, and 15, every 4 weeks. Patients were premedicated with histamine receptor-1 and -2 blockers and dexamethasone for prophylaxis of allergic reactions 30 minutes before paclitaxel administration. Irinotecan (150 mg/m2) was administered intravenously on days 1 and 15, every 4 weeks. Dose reduction and/or cycle delays were permitted according to predefined toxicity criteria. Treatment continued until disease progression, occurrence of unacceptable serious toxicity, or patient refusal of further treatment. Subsequent chemotherapy was not specified.
Vital signs, ECOG PS, and laboratory tests were assessed within 7 days before study entry. Physical examinations and hematology and biochemistry tests were conducted during drug administration throughout the treatment course. Tumor assessments using CT scans of the chest, abdomen, and pelvis were performed within 28 days before study entry and repeated every 2 months after random assignment until discontinuation of protocol treatment. RECIST (version 1.0) was used to evaluate treatment responses.21 Safety assessments were repeated every 2 weeks until initiation of subsequent chemotherapy or 6 weeks after the last protocol treatment. Severity of adverse events was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (version 3.0). The WJOG Data and Safety Monitoring Committee reviewed serious adverse events for trial safety during the protocol treatment. Investigators assessed response, progression, and toxicities in their patients; independent central assessments of response and disease progression were not performed.
The primary end point was OS, defined as time from random assignment to death resulting from any cause. Secondary end points were PFS, defined as time from random assignment to disease progression or death resulting from any cause; RR; toxicity; and proportion of patients who received subsequent chemotherapy.
Previous single-arm studies showed median OS of 5 and 6.9 months in paclitaxel-15,16 and 8 and 10 months in irinotecan-containing regimen.19,20 Irinotecan was contraindicated for patients with severe peritoneal metastasis, because its biliary-excreted metabolites caused severe toxicities. In gastric cancer, peritoneal metastasis often developed along with disease progression, and we therefore speculated that subsequent irinotecan after paclitaxel would be more difficult to apply in patients compared with the reverse treatment sequence. On the basis of these previous results and our assumption, this study was designed to detect 50% improvement in median OS from 5 months in the paclitaxel group to 7.5 months in the irinotecan group (hazard ratio [HR], 0.67). Assuming accrual and follow-up periods of 36 and 12 months, respectively, and using a two-sided log-rank test with 5% α and 20% β errors, 220 patients were required for the study. No interim analyses were planned.
A full analysis set (FAS) included all randomly assigned patients who met the eligibility criteria (patients found to be ineligible after random assignment were excluded). The safety analysis set (SAS) included all randomly assigned patients who received ≥ one dose of study medication. OS and PFS were analyzed in the FAS and estimated using the Kaplan-Meier method. RR was assessed in patients with ≥ one measurable lesion at baseline. Toxicity was analyzed in the SAS.
The primary analysis was planned for 1 year after enrollment of the last patient or approximately 205 events, whichever came first. An independent statistician and data analysis center performed the primary analysis for OS with unstratified log-rank test in the FAS population. All investigators remained blinded to the data until the analysis was completed. Cox proportional hazards models were used to calculate HRs and CIs. Fisher's exact test was used to assess differences in RR, incidence of adverse events, and proportion of patients who received third-line chemotherapy. Exploratory subgroup analyses of OS were performed using stratification and prognostic variables.
Between August 2007 and August 2010, 223 patients were enrolled from 37 centers in Japan. Of these patients, 111 were allocated to the paclitaxel group and 112 to the irinotecan group (Fig 1). Four patients, who either had received prior fluoropyrimidine monotherapy (paclitaxel group, n = 2; irinotecan group, n = 1) or had radiologically unconfirmed disease progression (paclitaxel group, n = 1), were ineligible for the study. Thus, the FAS consisted of 108 patients in the paclitaxel group and 111 patients in the irinotecan group. After random assignment, three patients in the paclitaxel group and two in the irinotecan group did not receive the protocol treatment. Thus, the SAS consisted of 108 patients in the paclitaxel group and 110 patients in the irinotecan group. Baseline characteristics of patients in the FAS were well balanced between the two treatment groups (Table 1). ECOG PS scores of 0 or 1 were found in a majority of patients. The most common first-line chemotherapy was S-1 plus cisplatin (88.6%), followed by capecitabine plus cisplatin with or without anti–epidermal growth factor receptor or anti–vascular endothelial growth factor antibodies (9.6%) and S-1 plus oxaliplatin (1.8%). One or more measurable lesions were present in approximately 80% of patients, and mild or moderate peritoneal metastasis was detected in approximately 25% of patients in both groups. Two or more metastatic sites were found in < 50% of patients.
Fig 1. CONSORT diagram.
|
| Characteristic | Weekly Paclitaxel (n = 108) | Irinotecan (n = 111) | ||
|---|---|---|---|---|
| No. | % | No. | % | |
| Sex | ||||
| Male | 84 | 77.7 | 87 | 78.4 |
| Female | 24 | 22.2 | 24 | 21.6 |
| Age, years | ||||
| Median | 64.5 | 65 | ||
| Range | 37-75 | 38-75 | ||
| ECOG PS | ||||
| 0 to 1 | 104 | 96.3 | 107 | 96.4 |
| 2 | 4 | 3.7 | 4 | 3.6 |
| Prior gastrectomy | ||||
| Yes | 37 | 34.3 | 39 | 35.1 |
| No | 71 | 65.7 | 72 | 64.9 |
| Prior chemotherapy | ||||
| S-1 plus cisplatin | 92 | 85.2 | 102 | 91.9 |
| Capecitabine plus cisplatin | 13 | 12.4 | 8 | 7.2 |
| S-1 plus oxaliplatin | 3 | 2.8 | 1 | 0.9 |
| Target lesion | ||||
| Yes | 91 | 84.3 | 88 | 79.3 |
| No | 17 | 15.7 | 23 | 20.7 |
| Histology | ||||
| Intestinal | 54 | 50.0 | 54 | 48.6 |
| Diffuse | 54 | 50.0 | 57 | 51.4 |
| Peritoneal metastasis | ||||
| Yes | 28 | 25.9 | 28 | 25.2 |
| No | 80 | 74.1 | 83 | 74.8 |
| No. of metastatic sites | ||||
| One | 57 | 52.8 | 64 | 57.7 |
| Two or more | 51 | 47.2 | 47 | 42.3 |
Abbreviation: ECOG PS, Eastern Cooperative Oncology Group performance status.
Median number of administrations was 11.5 (range, one to 46) in the paclitaxel group and 4.5 (range, one to 39) in the irinotecan group. Reasons for discontinuation of treatment included: disease progression (86.7%), adverse events (7.3%), withdrawal of consent (3.2%), and other reasons (2.8%). The proportion of patients in whom treatment was discontinued because of toxicity was 5.6% in the paclitaxel group and 9.1% in the irinotecan group.
Third-line chemotherapy was administered to 97 patients (89.8%) in the paclitaxel group and 80 patients (72.1%) in the irinotecan group (P = .001). In the paclitaxel group, third-line chemotherapy containing irinotecan was used in 81 patients (75.0%), and in the irinotecan group, a taxane-containing regimen was used in 67 patients (60.4%). Including later lines, 87 patients (80.6%) in the paclitaxel group received irinotecan, and 75 patients (67.6%) in the irinotecan group received paclitaxel.
In August 2011, after a median follow-up period of 17.6 months, 203 deaths (92.7%) were reported in the patient cohort. For the primary end point of OS, no statistically significant difference was observed between paclitaxel and irinotecan groups (HR, 1.13; 95% CI, 0.86 to 1.49; two-sided P = .38). Median OS was 9.5 months (95% CI, 8.4 to 10.7) in the paclitaxel group and 8.4 months (95% CI, 7.6 to 9.8) in the irinotecan group (Fig 2A). Median PFS was 3.6 months (95% CI, 3.3 to 3.8) in the paclitaxel group and 2.3 months (95% CI, 2.2 to 3.1) in the irinotecan group. This difference was not statistically significant (HR, 1.14; 95% CI, 0.88 to 1.49; two-sided P = .33; Fig 2B). RR was 20.9% (19 of 91 patients) in the paclitaxel group and 13.6% (12 of 88) in the irinotecan group (Fisher's exact P = .24).
Fig 2. Kaplan-Meier curves of (A) overall and (B) progression-free survival.
Results of the subgroup analysis of OS are shown in Figure 3. Although treatment with weekly paclitaxel conferred a slight survival advantage in almost all subgroups, no significant interactions were observed in any subgroup. In an exploratory analysis, OS was analyzed in patients who received irinotecan and paclitaxel during second- and later-line chemotherapies. Median OS was 10.1 months in each group, and the survival curves of these two subgroups almost overlapped (HR, 0.96; 95% CI, 0.69 to 1.32; two-sided P = .96).
Fig 3. Forest plot of subgroup analyses. ECOG PS, Eastern Cooperative Oncology Group performance status.
Table 2 lists adverse events and the proportion of patients experiencing adverse events during treatment in the SAS. The most common grade 3 or 4 adverse events were leukopenia (20.4%), neutropenia (28.7%), and anemia (21.3%) in the paclitaxel group. Leukopenia (19.1%), neutropenia (39.1%), anemia (30.0%), anorexia (17.3%), and hyponatremia (15.5%) were common in the irinotecan group. Grade 3 or 4 sensory neuropathy was observed in the paclitaxel group (7.4%) only. Grade 3 or 4 febrile neutropenia was more prevalent in the irinotecan group (9.1%) than in the paclitaxel group (2.8%). Three (2.7%) and four deaths (3.6%) resulting from any cause occurred within 30 days after the last administration in the paclitaxel and irinotecan groups, respectively. Treatment-related death confirmed by the independent data safety monitoring committee was observed in two patients (1.8%) in the irinotecan group. Causes of death included serious pneumonia in one patient and gastric perforation in the other.
|
| Adverse Event | Weekly Paclitaxel (n = 108) | Irinotecan (n = 110) | ||||||
|---|---|---|---|---|---|---|---|---|
| All Grade | Grade 3 to 4 | All Grade | Grade 3 to 4 | |||||
| No. | % | No. | % | No. | % | No. | % | |
| Leukocytopenia | 88 | 81.4 | 22 | 20.4 | 76 | 69.4 | 21 | 19.1 |
| Neutropenia | 85 | 78.7 | 31 | 28.7 | 77 | 70.0 | 43 | 39.1 |
| Hemoglobin | 69 | 63.9 | 23 | 21.3 | 84 | 76.4 | 33 | 30.0 |
| Thrombocytopenia | 6 | 5.6 | 1 | 0.9 | 15 | 13.6 | 2 | 1.8 |
| Febrile neutropenia | 3 | 2.8 | 3 | 2.8 | 10 | 9.1 | 10 | 9.1 |
| Nausea | 33 | 30.6 | 2 | 1.9 | 61 | 55.5 | 5 | 4.5 |
| Vomiting | 22 | 20.4 | 3 | 2.8 | 40 | 36.4 | 1 | 0.9 |
| Anorexia | 50 | 46.3 | 8 | 7.4 | 78 | 70.1 | 19 | 17.3 |
| Diarrhea | 21 | 19.4 | 1 | 0.9 | 49 | 44.5 | 5 | 4.5 |
| Neuropathy (sensory) | 62 | 57.4 | 8 | 7.4 | 2 | 1.8 | 0 | 0 |
| Bilirubin | 10 | 9.3 | 3 | 2.8 | 21 | 19.1 | 4 | 3.6 |
| AST | 32 | 29.6 | 4 | 3.7 | 42 | 38.2 | 9 | 8.2 |
| ALT | 24 | 22.2 | 3 | 2.8 | 41 | 37.3 | 3 | 2.7 |
| Hyponatremia | 21 | 19.4 | 4 | 3.7 | 35 | 31.8 | 17 | 15.5 |
| Treatment-related death | 0 | 0 | 0 | 0 | 2 | 1.8 | 2 | 1.8 |
To our knowledge, this was the first randomized phase III trial comparing paclitaxel and irinotecan in second-line chemotherapy for advanced gastric cancer. No statistically significant differences were observed between paclitaxel and irinotecan for the primary end point of OS or for other parameters evaluated in this study, including PFS and RR. Activity, feasibility, and tolerability of paclitaxel and irinotecan were comparable for second-line treatment of advanced gastric cancer.
When we planned this study, OS in patients who received second-line chemotherapy seemed to be longer than OS in patients who received BSC alone in previous trials.12–16,19,20 Because > 70% of patients were receiving second-line chemotherapy as part of routine clinical practice at that time, conducting a trial of second-line chemotherapy compared with BSC alone was difficult in Japan. Since then, the survival benefit of second-line chemotherapy over BSC has been demonstrated in two randomized trials22,23: the AIO (Arbeitsgemeinschaft Internistische Onkologie) trial using irinotecan and Korean trial using irinotecan or docetaxel during the same time period as this WJOG 4007 study. On the basis of these results, second-line chemotherapy using irinotecan or docetaxel has been recognized as the standard of care for patients with gastric cancer. However, further comparison between irinotecan and taxane regimens would be valuable for strategic planning of treatment in patients with advanced gastric cancer.
In the Korean trial, choice of chemotherapy regimen—docetaxel or irinotecan—depended on investigator discretion. A subgroup analysis showed no significant difference in survival between regimens (median OS: docetaxel, 5.2 months v irinotecan, 6.6 months; P = .116).23 In addition, Ji et al24 conducted a retrospective analysis of 725 patients with gastric cancer treated with second-line chemotherapy; they found no relevant difference in OS between taxane and irinotecan treatment. In our exploratory subgroup analysis, no interaction was observed among several clinical factors; results favored neither paclitaxel nor irinotecan. Thus, either taxane or irinotecan can be recommended as a treatment option for second-line chemotherapy in patients with advanced gastric cancer.
Longer OS was achieved in this study than in previous phase III studies.22,23 Many patients in good condition with small tumor burdens were enrolled onto our study. ECOG PS of 0 or 1 was recorded in almost all patients, and only one metastatic site was detected in > half of all patients. Additionally, excluding patients with severe peritoneal metastasis resulted in a lower proportion of patients (25.6%) with peritoneal metastasis, compared with those in the AIO (43%) and Korean (45%) trials.22,23 These are well known as prognostic factors in advanced gastric cancer, and these patient-selection biases might have led to longer survival in our study.
In gastric cancer, peritoneal metastasis often develops along with disease progression, and irinotecan would be toxic for patients with severe peritoneal metastasis. Indeed, the proportion of patients receiving subsequent irinotecan after second-line paclitaxel was only 24% in the previous report.16 In this study, excluding patients with severe peritoneal metastasis seemed to result in a high proportion of patients (> 70%) receiving third-line chemotherapy, whereas 30% to 40% of patients did so in previous studies.23,24 Although evidence is limited with regard to the efficacy of third-line chemotherapy in advanced gastric cancer, this therapy may have contributed to prolonged OS, and the unexpected higher proportion of those receiving third-line chemotherapy might have diluted a difference in OS between the paclitaxel and irinotecan groups.
Overall toxicity in both treatment arms was acceptable for second-line chemotherapy. In the paclitaxel group, common grade 3 or 4 toxicities (≥ 10%) included leukocytopenia, neutropenia, and anemia. Grade 3 sensory neuropathy, which was specific to paclitaxel, occurred at an incidence < 10% in this study. These toxicity profiles and severity levels are consistent with those in previous reports.15,16 In the irinotecan group, leukocytopenia, neutropenia, anemia, anorexia, and hyponatremia were commonly observed. Frequency and severity of these toxicities were also consistent with those in previous reports.22,23 Severe diarrhea, which is a well-known adverse reaction to irinotecan, generally occurs less frequently in Asian patients than in Western patients. In fact, grade 3 or 4 diarrhea was observed in 4.5% of patients in this trial, 8% of those in the Korean trial,23 and 26% of those in the AIO trial.22 Although ethnic diversity in metabolism of irinotecan has been suggested, the dosage of irinotecan is commonly higher in Western countries than in Asian countries. This may explain the different incidence of severe diarrhea between this and other studies.
Our study has several limitations. Participants were all Japanese; tumor biology may differ from that in Western patients.25 In addition, a majority of patients received S-1 plus cisplatin as first-line chemotherapy, whereas S-1 is not popular in Western countries. However, a large, global phase III study (FLAGS [First-Line Therapy in Patients With Advanced Gastric Cancer Study] trial) demonstrated S-1 plus cisplatin to be similar in efficacy to fluorouracil plus cisplatin.7 This difference in regimens used as first-line chemotherapy may have had little influence on interpretation of results of our study. Because patients with severe peritoneal metastasis were excluded from our study to avoid confounding effects of serious adverse events resulting from irinotecan, our results are not applicable to patients with severe peritoneal metastasis. Another trial is needed to determine the most appropriate treatment in such patients. As for statistical consideration, our hypothesis was 50% improvement in median OS in the irinotecan group over weekly paclitaxel group, and this resulted in a relatively small sample size. Therefore, if a small but true benefit existed in either group, this study may have been underpowered to detect it.
In conclusion, no difference in OS between paclitaxel and irinotecan groups was observed in this study. Both are considered reasonable second-line treatment options. The differences in toxicity profile and treatment schedule between both treatments will help in choosing either irinotecan or paclitaxel. Currently, several randomized trials investigating additional benefits of molecular targeting agents in second-line chemotherapy are planned or being conducted using weekly paclitaxel or irinotecan as a platform or reference regimen. The findings of our study are relevant to these future trials.
Written on behalf of the West Japan Oncology Group.
Supported by Yakult Honsha and Daiichisankyo.
Presented at the 48th Annual Meeting of the American Society of Clinical Oncology, Chicago, IL, June 1-5, 2012, and European Society of Medical Oncology Congress, Vienna, Austria, September 28-October 2, 2012.
Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.
Clinical trial information: University Hospital Medical Information Network–Clinical Trials Registry Japan No. 000001252.
Although all authors completed the disclosure declaration, the following author(s) and/or an author's immediate family member(s) indicated a financial or other interest that is relevant to the subject matter under consideration in this article. Certain relationships marked with a “U” are those for which no compensation was received; those relationships marked with a “C” were compensated. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.
Employment or Leadership Position: None Consultant or Advisory Role: None Stock Ownership: None Honoraria: Tomohiro Nishina, Yakult Pharmaceutical Industry, Bristol-Myers Squibb; Satoshi Morita, Bristol-Myers Squibb, Yakult Pharmaceutical Industry, Daiichi Sankyo; Narikazu Boku, Daiichi Sankyo, Yakult Pharmaceutical Industry; Ichinosuke Hyodo, Yakult Pharmaceutical Industry Research Funding: Naotoshi Sugimoto, Yakult Pharmaceutical Industry; Taito Esaki, Yakult Pharmaceutical Industry; Ichinosuke Hyodo, Yakult Pharmaceutical Industry, Daiichi Sankyo Expert Testimony: None Patents: None Other Remuneration: None
Conception and design: Shuichi Hironaka, Satoshi Morita, Narikazu Boku, Ichinosuke Hyodo
Administrative support: Takashi Ura, Isamu Okamoto, Narikazu Boku
Provision of study materials or patients: Shuichi Hironaka, Tomohiro Nishina, Toshikazu Moriwaki, Kensei Yamaguchi, Yasuo Hamamoto
Collection and assembly of data: Shuichi Hironaka, Shinya Ueda, Hirofumi Yasui, Tomohiro Nishina, Masahiro Tsuda, Takehiko Tsumura, Naotoshi Sugimoto, Hideki Shimodaira, Shinya Tokunaga, Toshikazu Moriwaki, Taito Esaki, Michitaka Nagase, Kazumasa Fujitani, Kensei Yamaguchi, Takashi Ura, Yasuo Hamamoto
Data analysis and interpretation: Shuichi Hironaka, Satoshi Morita, Isamu Okamoto, Ichinosuke Hyodo
Manuscript writing: All authors
Final approval of manuscript: All authors
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Acknowledgment
We thank Y. Hirai, N. Ozumi, K. Nonogaki, and S. Nakamura, MD, for data management and all members of the data safety monitoring committee and audit committee of the West Japan Oncology Group.