Information on COVID-19

 Please review this page for updates on COVID-19; we are continuously updating information as the situation develops.

There have been recent updates on the following sections:

• Guidance for management of patients on abiraterone, enzalutamide, metformin and progynova. 
• New section on SAE reporting
• New section on recording protocol deviations

COVID-19 VACCINE

The STAMPEDE Team recommend that everyone on the STAMPEDE trial have a Covid vaccine if they are advised to do so by their hospital doctor or GP. The Covid vaccines are NOT live vaccines and therefore considered safe for patients undergoing cancer treatment. Please discuss with your treating team regarding the timing of the vaccine according to your treatment schedule.

KEY POINTS REGARDING FOLLOW UP

• At the present time we do not recommend that patients stop their trial treatment but we will continue to monitor the situation closely. If treatment is interrupted, please document any treatment breaks on the appropriate follow-up CRF and deviation log.

• Please also continue to send in SAE CRFs and the team will acknowledge receipt in the normal way.

• Active consideration should be given to patients obtaining local blood tests and the results sent in to the treating centre. All trial consultations can be carried out by phone and this should be encouraged to minimise the need for patients to travel to hospital.

• Drug supply can be sent out by post/courier depending on the IMP or consideration given to “fly by” medication pick up whereby patients wait in the car and drug is taken out to them to minimise exposure in at risk individuals. Patients may wait in their car and receive a text from pharmacy when their prescription is ready.

• We recognize that the usual recommendation to consider upfront Docetaxel in metastatic patients may not be appropriate in light of the ongoing situation. Similarly, the timelines for any radical radiotherapy may also shift. We support clinical teams in making these decisions as per local guidelines and advice.
• Upfront Abiraterone is permitted for men with metastatic disease entering the trial. At present this is not funded by the NHS apart from men with high risk disease in Scotland. We have written to NHS England (and similar letters sent to NHS Wales, Scotland and Northern Ireland) urgently requesting that upfront Abiraterone is funded for all men with metastatic disease. We are hopeful that this will lead to a rapid change in policy and will inform you if this occurs. Potentially eligible men, for whom Docetaxel was not considered due to COVID-19 may need therefore to be identified.
• We appreciate that some visits will need to be postponed (and will fall outside the stipulated visit windows). Please document where this occurs and let us know.

• Please add any protocol deviations to CRFs and your site deviation log labelled as COVID-19 where this is the underlying cause.

MORE DETAILED ADVICE ON EACH POINT

TRIAL TREATMENT

• There is currently no evidence that any of the treatments used in STAMPEDE either increase the risk of infection with COVID-19 or are dangerous to continue if a patient has COVID-19 symptoms but remains well enough to stay at home.

• If any patient becomes unwell with suspected COVID-19 infection, it is at the discretion of the treating clinician to decide whether to continue or with-hold any STAMEPEDE medication. We will continue to monitor the situation closely.

• If treatment is interrupted, please document any treatment breaks on the appropriate follow-up CRF.

Abiraterone,  Prednisolone and Enzalutamide:

1.1 - Continued access to abiraterone and enzalutamide for Patients randomised to arms G & J

From protocol 22 onwards patients who have not met the criteria for stopping treatment in arm G and arm J (please refer to protocol 21 section 8.1.1. Stopping Research Treatment: Abiraterone, Enzalutamide + Abiraterone) will have continued access to these treatments through the trial, as long as there is no other available option outside of the trial. If a therapeutic alternative becomes commercialized and available for these patients according to local guidelines, patients should switch to this option and the treatment access through the trial should be stopped. Patients on Arm J can choose to continue on both or either treatment alone. There will be limited data collected on these patients, which will include SAE reporting (please see section 11) and an end of treatment CRF if a patient comes off either abiraterone or enzalutamide or both. No data collection is required for any other patients in arms G or J or the contemporaneous control arm A patients randomised between November-2011 and March-2016.

Local guidelines for abiraterone and enzalutamide treatment should be followed for safety assessments, dose reductions or stopping of treatment due to toxicity. Local guidelines should align with previously published guidelines, namely NICE guidance, St Luke’s SACT policy or EAU guidelines. Sites are required to confirm which guidelines they follow and if none of these three are adhered to, sites are required to provide their local guidelines for review and recording by the MRC CTU and the TMG.

Due to current NHS commissioning of AR therapy, patients allocated to Arms G and J do not fall under the provision of AR therapies. Therefore, the trial will continue to provide access to abiraterone and/or enzalutamide for those patients who are still on treatment. If this situation changes, patients will be transferred to NHS provision.

      1. Supply for pharmacy:

• Arm G: Please request 6 months supply for pharmacy for all patients – this is shipped from Belgium so it is important  to ensure you have sufficient stock
• Arm J: Please review your stock levels of Abiraterone and Enzalutamide, the distributor is located in Wales so there are no immediate issues but we will monitor this closely.
• Please remember that both Enzalutamide and Abiraterone have handling warnings. Women who are or who may become pregnant should not handle Abiraterone acetate or AEzalutamide without gloves. The Enzalutamide trial stock does not currently have this warning on the label so please make sure this is communicated.

      2. Safety checks and treatment administration:

• Treating physicians can consider 3 monthly safety tests (K+, LFTs and BP) during this time if the benefit of reduced visits outweighs the risks of less frequent follow-up. However, 3 monthly testing would still be considered a deviation from the protocol and should be marked as such on the deviation log. If patients are unable to perform safety blood tests when the physician considers these necessary, treatment should be discontinued until the necessary safety investigations are available.
• Physicians can consider extending prescriptions to give a 4-month supply as allowed by their pharmacy in order to reduce patient visits.
• Patients on Abiraterone or Abiraterone and Enzalutamide can be encouraged to buy home blood pressure monitoring equipment (available from all major pharmacies or from online outlets) and record their blood pressure on a regular basis; this should be shared with the research team for review.
• Local teams should consider and discuss with the patient the risks and benefits of attending for safety blood tests versus pausing treatment.
• If the patient is unable to complete safety blood tests they should pause treatment.
• If the patient has been stable on treatment there is unlikely to be significant impact from pausing treatment for 1-2 months, we know the medications continue to act in the body for a period after treatment has stopped.
• If the patient requires a pause in treatment, and has been on Abiraterone and Prednisolone (with or without Enzalutamide) they should continue Prednisolone. This is because their body will be reliant on the steroid tablets, and they could experience an Addisonian crisis if these are stopped suddenly. Prednisolone can be posted to the patient and does not require safety tests.
• If a patient pauses treatment due to being unable to complete safety tests during the Covid-19 crisis, then once they are able to complete the safety tests they can restart treatment, provided the local clinician feels it remains in the patients best interests.  Thereafter normal rules would apply as to when the patient should stop (i.e.: once meeting all three categories of progression, see protocol for further guidance).

Metformin

• This drug has no known interactions with COVID-19. The drug is supplied through hospital stock and sufficient supplies should be available locally. However, please check this with your local pharmacy team.
• If patients develop vomiting and/or diarrhoea (5-10% of COVID-19 patients appear to have GI symptoms) they should stop taking Metformin until any clinical uncertainty has resolved.
• While the COVID pandemic is in effect, if considered appropriate 3 months’ worth of metformin can be dispensed to a patient at any point of their follow up schedule, as long as the site investigator deems it safe to do so.

• Arm K dispensing:

  • Up to 1-month supply for patients when starting in STAMPEDE, until at least 24 weeks of on research treatment
  • Up to 3-months supply for patients, if there are no ongoing toxicities after 24 weeks on research treatment
  • Up to 6-months supply for patients if there are no ongoing toxicities after 104 weeks on research treatment

• For patients who have been on trial Metformin for 12 months and tolerated the treatment well, a 6 month prescription of Metformin could be dispensed to work alongside the blood testing timelines.
• If a patient is unable to complete their 6 monthly safety tests (renal function) they should stop taking Metformin until they have had the opportunity for medical review. For most patients, blood tests for cancer monitoring will remain essential and hence we do not anticipate this should be a problem. For additional guidance on treatment breaks whilst taking Metformin please refer to section 6.2.6 of the STAMPEDE protocol v19.0 June 2018.
• Patients who have stopped Metformin do not need to attend for metabolic blood profile tests during this period.
• As noted above, consideration should be given to obtaining blood tests as close as possible to the patient’s home and all follow up switched to telephone based.

Transdermal Oestradiol

• This drug has no known interaction with COVID-19
• It is important that patients with locally advanced and metastatic prostate cancer remain on ADT with effectively suppressed testosterone levels and as such the regular blood tests for patients on tE2 remain important.
• It may be that sites are able to dispense longer prescriptions or utilise alternative delivery services to supply patients with their medication - see general comments above.
• While the COVID pandemic is in effect, if considered appropriate 3 months’ worth of Transdermal Oestradiol can be dispensed to a patient at any point of their follow up schedule, as long as the site investigator deems it safe to do so.

• Arm L dispensing:

  • Up to 1-month of supply for patients on the induction regimen
  • Up to 2-months of supply for patients on follow-up with “poorly controlled” hormone levels (i.e. recent out of range oestradiol and testosterone readings and/or elevated PSA levels)
  • Up to 6-months supply for patients on follow-up with "well controlled" hormone levels (i.e. low and stable PSA and testosterone readings and those whose oestradiol has remained below 2000)

Accessing Trial Treatment and Prescriptions

• Strategies suggested by sites that are permissible in STAMPEDE for accessing Trial treatment:
  • Patients may wait in their car and receive a text from pharmacy when their prescription is ready
  • It is permissible to post Progynova and Metformin by Royal Mail or other postage services. At the present time, we don’t recommend posting Abiraterone or Enzalutamide.
  • If NHS staff are willing and able to take IMP to the patient’s home address this is acceptable, suitable precautions should be applied to avoid transmission.

• Sites may use their clinical judgement to assure regular therapy continues as per the protocol and the patients’ needs.

• Where a courier or postal delivery is to be used, verbal consent from the patient to provide their address to the courier must be obtained and documented. Drug can be sent  by any method deemed suitable by the site, provided mechanisms are in place to confirm receipt by the patient (a follow up telephone call would be appropriate if the patient cannot sign for the delivery).  The nominated address for the delivery should be recorded in the patient’s notes.  Temperature monitoring is not required.

SAE REPORTING

• The STAMPEDE team understand the difficulty of reporting SAEs at this unprecedented time. The current MHRA guidance is now that sites should report events within 24 hours of awareness of the event to the sponsor. They do also state “Particular attention should be paid to timely reporting of suspected unexpected serious adverse reactions (SUSARs) which put participant safety at risk on a trial or have the potential to impact participants of other trials. Every effort should be made to notify MHRA in this case”. We understand sites may not be aware of the events to be able to report within the 24 hour required timeline and therefore please can sites ensure that a systematic review occurs when there is capacity and the research team is in place to ensure any SAEs are reported to the MRC CTU within the 24 hour timeline.

PATIENT MANAGEMENT AND FOLLOW-UP ASSESSMENTS

• Follow-up visits can be conducted via phone to reduce patient exposure wherever necessary and this is preferable to postponing these assessments. Please use the STAMPEDE Telephone Follow-Up Checklist for guidance.
• For telephone follow-up, sites should annotate next to any missed assessments (e.g. blood tests, scans, BP) to confirm the reason they have been missed and these will not be queried as missing data. It is acceptable for patients to self-measure blood pressure using home equipment. If there is concern that readings are unacceptably high then this needs to be checked either via the GP or a hospital visit.

PROTOCOL DEVIATIONS

We understand there will be some necessary changes on how patients are followed up during this period, we will work closely with you to try and aid where we can.

The MHRA have given clear guidance about recording deviations, as there is a high probability of these occurring while research teams deal with the challenges of the COVID-19 pandemic. To aid in the identification and tracking of these please follow the below guidance:

Ensure all deviations are recorded using the Site Deviation Log

Examples of deviations that will need to be logged include:

• Follow up visits not completed
• Missed safety tests

These deviations should also be captured on CRFs by indicating when data points have been missed due to the current COVID-19 pandemic, by clearly writing “COVID-19” next to the field with the missing data. Deviation logs where possible should be sent to the STAMPEDE team on a periodic basis. This will enable the study team to assess the impact of this challenging period on the study results at the time of analysis. If you have any questions about how to use the log or a query about how to classify a deviation, please do not hesitate to get in touch with the team.

SAMPLE COLLECTION

Please continue to collect Metabolic Sub-Study blood samples as normal.

Please note, if you require additional kits please inform the STAMPEDE team at MRCCTU.stampede@ucl.ac.uk or Michelle at The Manchester Cancer Research Centre Biobank at michelle.greenhalgh2@nhs.net

Samples will be shipped in batches, along with the sample transfer log and freezer box map, to the central biobank once sites have filled two freezer boxes with samples. Once two freezer boxes are filled, please liaise with the team to organise shipment.

Please document on the relevant CRF where samples have been missed, and reasons causing the missed sample.

CONTACT WITH THE CTU TEAM/RETURNING DATA

• The CTU team are now all working remotely, and will be until at least January 2021, but can still be contacted on the normal telephone numbers and via the trial mailbox.
• Wherever possible, please scan any completed data i.e. CRFs, DCFs or consent forms and send them to us via Galaxkey (if you do not already have an account please let us know and we can set you up with one) or an alternative secure mechanism, until further notice. If this is not possible, please let the STAMPEDE team know and an alternative mechanism will be sought; until then, however, please store all completed CRFs, DCFs or consent forms securely at your site for the time being, and do not post any to the MRC CTU at UCL, as we have limited access to the office, which therefore means there is a delay in us receiving it if sent via post.
• Please also continue to send in SAE CRFs securely via email and the team will acknowledge receipt in the normal way.
• Please add any protocol deviations to CRFs and the site deviation log labelled as COVID-19 where this is the underlying cause.