The DANTE trial protocol: a randomised phase III trial to evaluate the Duration of ANti-PD-1 monoclonal antibody Treatment in patients with metastatic mElanoma

Abstract

Background Immunotherapy is revolutionising the treatment of patients diagnosed with melanoma and other cancers. The first immune checkpoint inhibitor, ipilimumab (targeting cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4)), showed a survival advantage over standard chemotherapy. Subsequently the anti-programmed cell death protein 1 (PD-1) antibodies, nivolumab and pembrolizumab were shown to be more effective than ipilimumab. Ipilimumab combined with nivolumab gives an incremental gain in overall survival compared with nivolumab alone but increases the risk of severe, potentially life-threatening toxicities. In contrast to ipilimumab monotherapy, anti-PD-1 antibodies are licensed to be continued until disease progression. Follow-up of patients recruited to the first trials evaluating 2 years of pembrolizumab showed that three-quarters of responding patients continue responding after stopping treatment. Suggestive of early response, we hypothesised that continuing anti-PD-1 treatment beyond 1 year in progression-free patients may be unnecessary and so designed the DANTE trial. Methods DANTE is a multicentre, randomised, phase III, non-inferiority trial to evaluate the duration of anti-PD-1 therapy in patients with metastatic (unresectable stage III and stage IV) melanoma. It uses a two-stage recruitment strategy, registering patients before they complete 1 year of first-line anti-PD-1 +/− CTLA-4 therapy and randomising eligible patients who have received 12 months of treatment and are progression-free at 1 year. At randomisation, 1208 patients are assigned (1:1) to either 1) continue anti-PD-1 treatment until disease progression/ unacceptable toxicity/ for at least 2 years in the absence of disease progression/ unacceptable toxicity or 2) to stop treatment. Randomisation stratifies for baseline prognostic factors. The primary outcome is progression-free survival at 3, 6, 9 and 12 months and then, 6-monthly for up to 4-years. Secondary outcomes collected at all timepoints include overall survival, response-rate and duration and safety, with quality of life and cost-effectiveness outcomes collected 3-monthly for up to 18-months. Sub-studies include a qualitative analysis of patient acceptance of randomisation and sample collection to inform future translational studies into response/ toxicity biomarkers. Discussion DANTE is a unique prospective trial investigating the optimal duration of anti-PD-1 therapy in metastatic melanoma patients. Outcomes will inform future use of these high burden drugs. Trial registration ISRCTN15837212, 31 July 2018.

What is the optimal duration of immune checkpoint inhibitors in malignant tumors?

“…The DANTE trial was designed to determine whether time-limited therapy could improve clinical outcomes by reducing toxicities while maintaining treatment benefits. The results supported time-limited therapy for patients with metastatic melanoma continuously remaining progression-free after two years of ICIs ( 54 ). The Dutch Safe Stop trial will confirm the feasibility of early discontinuation of ICIs by assessing sustaining response rates after discontinuing first-line nivolumab or pembrolizumab monotherapy in patients with advanced melanoma who achieve CR or PR ( 3 ).…”

Checkpoint Inhibitors Immunotherapy in Metastatic Melanoma: When to Stop Treatment?

“…The DANTE (duration of ANti-PD-1 monoclonal antibody treatment in patients with metastatic melanoma) trial is currently ongoing in the UK and is expected to mature in 2027. This is a multicenter phase-III trial that randomizes patients to either discontinue anti-PD-1 therapy at 12 months or continue until disease progression or unacceptable toxicity, or a minimum of 2 years of treatment [ 38 ]. Another similar multicenter prospective study, the Safe Stop trial, is ongoing in the Netherlands.…”

Pembrolizumab for advanced non-small cell lung cancer (NSCLC): Impact of autoimmune comorbidity and outcomes following treatment completion

“…There are ongoing prospective trials aiming to answer this question, including one assessing whether 1 year of immunotherapy treatment for metastatic melanoma is equivalent to 2 years. 15…”