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Background: Abiraterone acetate plus prednisolone (herein referred to as abiraterone) or enzalutamide added at the start of androgen deprivation therapy improves outcomes for patients with metastatic prostate cancer. Here, we aimed to evaluate long-term outcomes and test whether combining enzalutamide with abiraterone and androgen deprivation therapy improves survival., Methods: We analysed two open-label, randomised, controlled, phase 3 trials of the STAMPEDE platform protocol, with no overlapping controls, conducted at 117 sites in the UK and Switzerland. Eligible patients (no age restriction) had metastatic, histologically-confirmed prostate adenocarcinoma; a WHO performance status of 0-2; and adequate haematological, renal, and liver function. Patients were randomly assigned (1:1) using a computerised algorithm and a minimisation technique to either standard of care (androgen deprivation therapy; docetaxel 75 mg/m 2 intravenously for six cycles with prednisolone 10 mg orally once per day allowed from Dec 17, 2015) or standard of care plus abiraterone acetate 1000 mg and prednisolone 5 mg (in the abiraterone trial) orally or abiraterone acetate and prednisolone plus enzalutamide 160 mg orally once a day (in the abiraterone and enzalutamide trial). Patients were stratified by centre, age, WHO performance status, type of androgen deprivation therapy, use of aspirin or non-steroidal anti-inflammatory drugs, pelvic nodal status, planned radiotherapy, and planned docetaxel use. The primary outcome was overall survival assessed in the intention-to-treat population. Safety was assessed in all patients who started treatment. A fixed-effects meta-analysis of individual patient data was used to compare differences in survival between the two trials. STAMPEDE is registered with ClinicalTrials.gov (NCT00268476) and ISRCTN (ISRCTN78818544)., Findings: Between Nov 15, 2011, and Jan 17, 2014, 1003 patients were randomly assigned to standard of care (n=502) or standard of care plus abiraterone (n=501) in the abiraterone trial. Between July 29, 2014, and March 31, 2016, 916 patients were randomly assigned to standard of care (n=454) or standard of care plus abiraterone and enzalutamide (n=462) in the abiraterone and enzalutamide trial. Median follow-up was 96 months (IQR 86-107) in the abiraterone trial and 72 months (61-74) in the abiraterone and enzalutamide trial. In the abiraterone trial, median overall survival was 76·6 months (95% CI 67·8-86·9) in the abiraterone group versus 45·7 months (41·6-52·0) in the standard of care group (hazard ratio [HR] 0·62 [95% CI 0·53-0·73]; p<0·0001). In the abiraterone and enzalutamide trial, median overall survival was 73·1 months (61·9-81·3) in the abiraterone and enzalutamide group versus 51·8 months (45·3-59·0) in the standard of care group (HR 0·65 [0·55-0·77]; p<0·0001). We found no difference in the treatment effect between these two trials (interaction HR 1·05 [0·83-1·32]; p interaction =0·71) or between-trial heterogeneity (I 2 p=0·70). In the first 5 years of treatment, grade 3-5 toxic effects were higher when abiraterone was added to standard of care (271 [54%] of 498 vs 192 [38%] of 502 with standard of care) and the highest toxic effects were seen when abiraterone and enzalutamide were added to standard of care (302 [68%] of 445 vs 204 [45%] of 454 with standard of care). Cardiac causes were the most common cause of death due to adverse events (five [1%] with standard of care plus abiraterone and enzalutamide [two attributed to treatment] and one (<1%) with standard of care in the abiraterone trial)., Interpretation: Enzalutamide and abiraterone should not be combined for patients with prostate cancer starting long-term androgen deprivation therapy. Clinically important improvements in survival from addition of abiraterone to androgen deprivation therapy are maintained for longer than 7 years., Funding: Cancer Research UK, UK Medical Research Council, Swiss Group for Clinical Cancer Research, Janssen, and Astellas., Competing Interests: Declaration of interests GA reports personal fees, grants, and travel support from Janssen and Astellas; personal fees or travel support from Pfizer, Ipsen, Novartis (Advanced Accelerator Applications), Abbott Laboratories, Ferring, ESSA Pharmaceuticals, Bayer Healthcare Pharmaceuticals, BeiGene, Takeda, AstraZeneca, and Sanofi Aventis; grant support from AstraZeneca, Innocrin Pharma, and Arno Therapeutics; receives a share of the royalty income from The Institute of Cancer Research Rewards to Discoverers Scheme for abiraterone; and holds a patent on plasma methylation signatures as biomarkers for prostate cancer (GB1915469.9). LM, AC, CB, CG, HR, CLA, CM, NP, CP, CD-M, DG, MRS, LCB, REL, and MKBP report research grants for the STAMPEDE trial from Janssen, Astellas, Novartis, Sanofi, and Clovis. NWC reports personal fees from Janssen and Astellas. AS reports grants or contracts with the National Institute for Health Research, John Black Charitable Foundation, and Prostate Cancer Foundation. RJJ reports research grants from Astellas, Clovis, Exelixis, Bayer, and Roche; and advisory board participation and speaker's honoraria from Janssen, Astellas, Bayer, Novartis, Pfizer, Merck Serono, MSD, Roche, Ipsen, and Bristol Myers Squibb. CCP reports consulting fees from Advanced Accelerator Applications, ITM Radiopharma, Myovant, and Clarity Pharmaceuticals; and speaker's honoraria from Janssen and Bayer. SG reports consulting fees from Tolremo; payment or honoraria for lectures, presentations, speaker's bureaus, manuscript writing, educational events, and honoraria from Silvio Grasso Consulting, WebMD (Medscape), European Society of Medical Oncology, Orikata, Swiss Group for Clinical Cancer Research, Beijing United Family Hospital and Clinics, Deutchland European School of Oncology, Swiss Academy of Multidisciplinary Oncology, PeerVoice, and Radiotelevisione Svizzera Italiana; travel support from Proteomedix and AstraZeneca; a patent for biomarker discovery (WO 2009138392 A1); advisory board participation for Janssen, MSD, Bayer, Roche, Astellas, Pfizer, Telixpharma, Bristol Myers Squibb, Advanced Accelerator Applications, Orion, Novartis, Modra Pharmaceuticals, AstraZeneca, Myriad Genetic, and Amgen; and a scientific committee role for Pfizer. CG reports institution funding from Astellas, Clovis Oncology, Janssen, Novartis, Pfizer, and Sanofi Genzyme; and charitable funding from Cancer Research UK and Medical Research Council. SC reports consulting fees from Telix, Novartis (Advanced Accelerator Applications), Huma, Remedy Bio, and Curesponse; payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing, or educational events from Bayer, Janssen, Astellas, Amgen, and Advanced Accelerator Applications; participation on a data safety monitoring board or advisory board for Amgen, Janssen, and Bayer; and stocks in Huma and Remedy Bio. JMO reports a grant from Prostate Cancer UK. AB reports speaker's fees from Janssen, Astellas, Bristol Myers Squibb, Roche, MSD, and Bayer; support for attending meetings and travel from Janssen and Bayer; and participation on a data safety monitoring board or advisory board for Janssen, Bristol Myers Squibb, and AstraZeneca. NS reports support for travel expenses from Janssen-Cilag. JT reports support from Janssen and Astellas for conference attendance; and participation in advisory boards for Janssen and Astellas. PD reports payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing, or educational events from Pfizer, Bristol Myers Squibb, Ipsen, EUSA Pharma, and EISAI; support for attending meetings or travel from Janssen and Ipsen; and participation on a data safety monitoring board or advisory board for Pfizer and EUSA Pharma. OP reports support for educational meetings and conference attendance from Janssen and Astellas. AR reports sponsorships for attending a conference from Janssen. AHM reports sponsorship to attend an educational meeting from Astellas. RC reports consulting fees from Astellas, Bayer, Novartis, Janssen, Sanofi, Pfizer, MSD, Bristol Myers Squibb, Roche, Debiopharm, AstraZeneca, Ipsen, and Merck; payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing, or educational events from Ipsen, Astellas, Janssen, Roche, and Merck; and participation as a board member for the Swiss Group for Clinical Cancer Research. DPD reports consulting fees and participation on an advisory board for Janssen; and a patent for a localisation and stabilisation device (EP1933709B1). MRS reports speaker fees from Eisai and being a non-paid member of independent data monitoring committees for academic sponsors. NDJ reports research grants for the STAMPEDE trial from Janssen, Astellas, Novartis, Sanofi, Clovis, and Cancer Research UK; and consulting and lecture fees from Astellas and Janssen. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Results from large randomised controlled trials have shown that adding docetaxel to the standard of care (SOC) for men initiating hormone therapy for prostate cancer (PC) prolongs survival for those with metastatic disease and prolongs failure-free survival for those without. To date there has been no formal assessment of whether funding docetaxel in this setting represents an appropriate use of UK National Health Service (NHS) resources., Objective: To assess whether administering docetaxel to men with PC starting long-term hormone therapy is cost-effective in a UK setting., Design, Setting, and Participants: We modelled health outcomes and costs in the UK NHS using data collected within the STAMPEDE trial, which enrolled men with high-risk, locally advanced metastatic or recurrent PC starting first-line hormone therapy., Intervention: SOC was hormone therapy for ≥2 yr and radiotherapy in some patients. Docetaxel (75mg/m 2 ) was administered alongside SOC for six three-weekly cycles., Outcome Measurements and Statistical Analysis: The model generated lifetime predictions of costs, changes in survival duration, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs)., Results and Limitations: The model predicted that docetaxel would extend survival (discounted quality-adjusted survival) by 0.89 yr (0.51) for metastatic PC and 0.78 yr (0.39) for nonmetastatic PC, and would be cost-effective in metastatic PC (ICER £5514/QALY vs SOC) and nonmetastatic PC (higher QALYs, lower costs vs SOC). Docetaxel remained cost-effective in nonmetastatic PC when the assumption of no survival advantage was modelled., Conclusions: Docetaxel is cost-effective among patients with nonmetastatic and metastatic PC in a UK setting. Clinicians should consider whether the evidence is now sufficiently compelling to support docetaxel use in patients with nonmetastatic PC, as the opportunity to offer docetaxel at hormone therapy initiation will be missed for some patients by the time more mature survival data are available., Patient Summary: Starting docetaxel chemotherapy alongside hormone therapy represents a good use of UK National Health Service resources for patients with prostate cancer that is high risk or has spread to other parts of the body., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Long-term hormone therapy has been the standard of care for advanced prostate cancer since the 1940s. STAMPEDE is a randomised controlled trial using a multiarm, multistage platform design. It recruits men with high-risk, locally advanced, metastatic or recurrent prostate cancer who are starting first-line long-term hormone therapy. We report primary survival results for three research comparisons testing the addition of zoledronic acid, docetaxel, or their combination to standard of care versus standard of care alone., Methods: Standard of care was hormone therapy for at least 2 years; radiotherapy was encouraged for men with N0M0 disease to November, 2011, then mandated; radiotherapy was optional for men with node-positive non-metastatic (N+M0) disease. Stratified randomisation (via minimisation) allocated men 2:1:1:1 to standard of care only (SOC-only; control), standard of care plus zoledronic acid (SOC + ZA), standard of care plus docetaxel (SOC + Doc), or standard of care with both zoledronic acid and docetaxel (SOC + ZA + Doc). Zoledronic acid (4 mg) was given for six 3-weekly cycles, then 4-weekly until 2 years, and docetaxel (75 mg/m(2)) for six 3-weekly cycles with prednisolone 10 mg daily. There was no blinding to treatment allocation. The primary outcome measure was overall survival. Pairwise comparisons of research versus control had 90% power at 2·5% one-sided α for hazard ratio (HR) 0·75, requiring roughly 400 control arm deaths. Statistical analyses were undertaken with standard log-rank-type methods for time-to-event data, with hazard ratios (HRs) and 95% CIs derived from adjusted Cox models. This trial is registered at ClinicalTrials.gov (NCT00268476) and ControlledTrials.com (ISRCTN78818544)., Findings: 2962 men were randomly assigned to four groups between Oct 5, 2005, and March 31, 2013. Median age was 65 years (IQR 60-71). 1817 (61%) men had M+ disease, 448 (15%) had N+/X M0, and 697 (24%) had N0M0. 165 (6%) men were previously treated with local therapy, and median prostate-specific antigen was 65 ng/mL (IQR 23-184). Median follow-up was 43 months (IQR 30-60). There were 415 deaths in the control group (347 [84%] prostate cancer). Median overall survival was 71 months (IQR 32 to not reached) for SOC-only, not reached (32 to not reached) for SOC + ZA (HR 0·94, 95% CI 0·79-1·11; p=0·450), 81 months (41 to not reached) for SOC + Doc (0·78, 0·66-0·93; p=0·006), and 76 months (39 to not reached) for SOC + ZA + Doc (0·82, 0·69-0·97; p=0·022). There was no evidence of heterogeneity in treatment effect (for any of the treatments) across prespecified subsets. Grade 3-5 adverse events were reported for 399 (32%) patients receiving SOC, 197 (32%) receiving SOC + ZA, 288 (52%) receiving SOC + Doc, and 269 (52%) receiving SOC + ZA + Doc., Interpretation: Zoledronic acid showed no evidence of survival improvement and should not be part of standard of care for this population. Docetaxel chemotherapy, given at the time of long-term hormone therapy initiation, showed evidence of improved survival accompanied by an increase in adverse events. Docetaxel treatment should become part of standard of care for adequately fit men commencing long-term hormone therapy., Funding: Cancer Research UK, Medical Research Council, Novartis, Sanofi-Aventis, Pfizer, Janssen, Astellas, NIHR Clinical Research Network, Swiss Group for Clinical Cancer Research., (Copyright © 2016 James et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.)