Clinical Outcomes and Survival Following Treatment of Metastatic Castrate-Refractory Prostate Cancer With Docetaxel Alone or With Strontium-89, Zoledronic Acid, or Both - The TRAPEZE Randomized Clinical Trial

Bony metastatic castrate-refractory prostate cancer (CRPC) has a poor prognosis and high morbidity. Zoledronic acid (ZA) is commonly combined with docetaxel in practice but lacks evidence that combining is effective, and strontium-89 (Sr89) is generally used palliatively in patients unfit for chemotherapy. Phase 2 analysis of the TRAPEZE trial confirmed combining the agents was safe and feasible, and the objectives of phase 3 include assessment of the treatments on survival. 

Objective:  To determine clinical effectiveness and cost-effectiveness of combining docetaxel, ZA, and Sr89, all having palliative benefits and used in bony metastatic CRPC to control bone symptoms and, for docetaxel, to prolong survival.

Design, Setting, and Participants:  The TRAPEZE trial is a 2 × 2 factorial trial comparing docetaxel alone or with ZA, Sr89, or both. A cohort of 757 participants were recruited between February 2005 and February 2012 from hospitals in the United Kingdom. Overall, 169 participants (45%) had received palliative radiotherapy, and the median (IQR) prostate-specific antigen level was 146 (51-354). Follow-ups were performed for at least 12 months. 

Interventions:  Up to 10 cycles of docetaxel alone; docetaxel with ZA; docetaxel with a single Sr89 dose after 6 cycles; or docetaxel with both ZA and Sr89.

Main Outcomes and Measures  Primary outcomes included clinical progression-free survival (CPFS) (pain progression, skeletal-related events [SREs], or death) and cost-effectiveness. Secondary outcomes included SRE-free interval, pain progression–free interval, total SREs, and overall survival (OS).

Results:  Overall, of 757 participants, 349 (46%) completed docetaxel treatment. Median (IQR) age was 68 (63-73) years. Clinical progression-free survival did not reach statistical significance for either Sr89 or ZA. Cox regression analysis adjusted for all stratification variables showed benefit of Sr89 on CPFS (hazard ratio [HR], 0.85; 95% CI, 0.73-0.99; P = .03) and confirmed no effect of ZA (HR, 0.98; 95% CI, 0.85-1.14; P = .81); ZA had a significant effect on SRE-free interval (HR, 0.78; 95% CI, 0.65-0.95; P = .01). For OS, there was no effect of either Sr89 (HR, 0.92; 95% CI, 0.79-1.08; P = 0.34) or ZA (HR, 0.99; 95% CI, 0.84-1.16; P = 0.91).

Conclusions and Relevance:  Strontium-89 combined with docetaxel improved CPFS but did not improve OS, SRE-free interval, or total SREs; ZA did not improve CPFS or OS but did significantly improve median SRE-free interval and reduced total SREs by around one-third, suggesting a role as postchemotherapy maintenance therapy.

JAMA Oncol. Published online January 21, 2016. doi:10.1001/jamaoncol.2015.5570 // Trial Registration Identifier: ISRCTN12808747


Nicholas D. James, PhD, FRCR, FRCP1; Sarah J. Pirrie, MSc2; Ann M. Pope, PhD2; Darren Barton, BSc2; Lazaros Andronis, PhD3; Ilias Goranitis, PhD3; Stuart Collins, PhD†4; Adam Daunton, MBChB, MRCP1; Duncan McLaren, MBBS, BSc, FRCR, FRCP(Ed)5; Joe O’Sullivan, MD, FRCPI, FFRRCSI, FRCR6; Christopher Parker, MD, FRCR7; Emilio Porfiri, MD, PhD1; John Staffurth, MD, FRCR, FRCP8; Andrew Stanley, MPhil9; James Wylie, MBBS, MRCP, FRCR10; Sharon Beesley, MBChB, MRCP, FRCR11; Alison Birtle, MD, MRCP, FRCR12; Janet Brown, MD13; Prabir Chakraborti, MBBS, MS, FRCS, FRCR14; Syed Hussain, MD, FRCS15; Martin Russell, MBChB, MRCP(UK), FRCR, FRCPSG16; Lucinda J. Billingham, BSc, MSc, PhD2


1University Hospital Birmingham NHS Foundation Trust, Birmingham, England 

2Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, England 

3Health Economics Unit, University of Birmingham, England 

4Cancer Research UK Clinical Trials Unit, Birmingham, England 

5Department of Clinical Oncology, Western General Hospital, Edinburgh, Scotland 

6Northern Ireland Cancer Centre, Belfast City Hospital, Belfast, Northern Ireland 

7The Institute of Cancer Research & Royal Marsden NHS Foundation Trust, Sutton, England 

8Institute of Cancer and Genetics, Cardiff University, Cardiff, Wales 

9Department of Oncology Pharmacy, Birmingham City Hospital, Birmingham, England 

10Department of Clinical Oncology, The Christie Hospital, Manchester, England 

11Department of Clinical Oncology, Kent Oncology Centre, Maidstone, England 

12Rosemere Cancer Centre, Royal Preston Hospital, Lancashire, England 

13Cancer Research UK Clinical Centre at Leeds, University of Leeds, St James’ University Hospital, Leeds, England 

14Department of Oncology, Royal Derby Hospital, Derby, England 

15Institute of Translational Medicine, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, England 

16Beatson West of Scotland Cancer Centre, Glasgow, Scotland