The he 30/02 trial was an open-label, randomized, multicenter, phase III trial of prophylactic vs. Hb-based ESA administration in patients with solid tumors. Eligible patients were required to have A histologically or cytologically confirmed solid malignancy, a scheduled chemotherapy duration of ≥3 months and an estimated life expectancy of ≥6 months. Patients were considered suitable for the study if they were treated with adjuvant chemotherapy with a curative intent or with first-line chemotherapy for advanced disease. The baseline Hb levels (prior to chemotherapy initiation) were required to be >11 mg/dl, to exclude patients with cancer-related anemia at diagnosis. At study entry, patients were also required to have normal folic acid (>2.5 ng/ml) and vitamin B12 (>200 pg/ml) levels, iron efficiency (transferrin saturation >15%, ferritin >50 ng/ml) and an Eastern Cooperative Oncology Group Performance status of 0–2. Patients with anemia from other causes (e.g., undergoing renal dialysis), as well as patients who had previously received ESAs for any reason or a blood transfusion within 1 month prior to evaluation, were excluded from the study.

The eligible patients were randomized in two groups: Patients in group A (experimental arm) received prophylactic ESA (epoetin α, epoetin β or darbepoetin α, according to the treating physician's choice in standard recommended doses) with iron supplementation (oral or intravenous), with a target Hb level of 14 mg/dl. If the Hb levels exceeded this threshold, ESA administration was discontinued and was resumed when Hb levels were decreased to <12 mg/dl. In group B, patients received only iron supplementation; ESA administration was initiated only if Hb levels were decreased to <11 mg/dl during chemotherapy and was continued with a target level of 13 mg/dl, at which point ESA support was withheld, only to be resumed when Hb levels again decreased to <11 mg/dl. In both groups, PRBC transfusion was allowed only when Hb levels were decreased to <9 mg/dl. ESA administration was to be continued for 4 weeks after cessation of chemotherapy. The study protocol is illustrated in Fig. 1.

The primary enDPoint of the study was safety, with emphasis on thrombosis-related adverse events, while the secondary endpoints included progression-free survival and OS. Toxicity was recorded and graded for severity according to the National Cancer Institute Common Toxicity Criteria for Solid Tumors, version 2.0 (http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ctcmanual_v4_10-4-99.pdf). The clinical protocol was approved by the Hellenic Cooperative Oncology Group (HeCOG) Protocol Review Committee and by the Institutional Review Board of ‘Agii Anargiri’ Cancer Hospital. All the patients provided written informed consent for the use of their biological material (blood samples). The trial was registered in the Australian New Zealand Clinical Trials Registry and allocated the registration no. ACTRN12614001082695.

The he 30/02 trial was designed to recruit 800 patients in order to assess differences in the primary endpoint of the study (safety) between the treatment arms, but was stopped prematurely due to the FDA recommendation in 2007, with 630 patients already enrolled.

Categorical variables are presented as frequencies and percentages, while various measures (mean, median and range) are used for continuous variables. The associations between categorical variables, such as clinical characteristics and toxicity data among patient cohorts were examined with the Chi-square test and the Fisher's exact test where appropriate.

For patients with advanced disease, OS was measured from the time of initiation of first-line treatment until death from any cause or date of the last contact. For patients with early disease, OS was measured from the date of initiation of adjuvant treatment.

In order to assess the differences in average Hb levels among the two cohorts, mixed models were used separately for the early- and advanced-disease patients. The models included time in weeks as a polynomial of third degree and an interaction term with the treatment group in order to take into consideration the trend and differences, respectively, in Hb temporal variation during the treatment period, while the compound symmetry structure was used for covariance matrix.

The survival status was updated in January, 2012. Time-to-event distributions were estimated using Kaplan-Meier curves and the log-rank test was used to examine differences. For all univariate tests, the significance level was set at α=0.05. SAS software was used for statistical analysis (SAS for Windows, version 9.3; SAS Institute Inc., Cary, NC, USA).

Between 2002 and 2007 (year of accrual suspension), 630 patients from 10 comprehensive cancer centers in Greece were randomized in the two study arms and followed up for a median of 85.4 months (range: 0.2–111.9 months). As shown in Fig. 2 (consort diagram), 314 patients had been randomized to receive prophylactic (group A) and 316 patients Hb-based (group B) ESA. In total, 66 patients were either lost to follow-up or had incomplete data; final safety and efficacy analysis was conducted on 605 and 564 patients, respectively. At the time of the data cut-off (January, 2012), 358 patients had relapsed and 380 patients had succumbed to the disease.

The major tumor types included colorectal (36.0%), breast (20.6%), non-prostate genitourinary (11.0%) and lung cancer (8.4%). Approximately half of the patients (51.0%) had advanced disease at diagnosis, 40.6% had Hb levels <12 mg/dl at baseline and 49.8% received ESAs prophylactically (group A, 1:1 randomization). As shown in Table I, there were no significant differences between groups A and B in basic clinical characteristics for patients who received adjuvant chemotherapy for potentially curable disease, or for those who received first-line chemotherapy for advanced cancer.

Patients received chemotherapy for a median of 18.6 weeks (range: 1–202 weeks). The most commonly used cytotoxic agents were antimetabolites (5-fluorouracil, 44.9%; gemcitabine, 12.5%; and methotrexate, 8.3%), platinum analogs (carboplatin, 21.9%; cisplatin, 6.8%; and oxaliplatin, 3.0%), alkylating agents (cyclophosphamide, 11.3%), anthracyclines (epiroubicin, 13.3%), camptothecins (irinotecan, 21.6%) and taxanes (paclitaxel, 22.9%; and docetaxel, 11.4%).

As shown in Fig. 3, prophylactic ESA administration, compared with Hb-based administration, was associated with a significant increase in Hb levels throughout the first 25 weeks of chemotherapy in the advanced-disease patient cohort and a non-significant (trend) increase in those with early disease (P=0.0011 for patients with advanced disease and P=0.0987 for patients with early disease). Considering the first 12 weeks of treatment, statistical significance was reached in both cohorts (P<0.001 for patients with advanced disease and P=0.002 for patients treated with a curative intent). Of note, the increase in Hb levels in response to ESA support did not differ significantly between the two treatment groups, although numerically it was more prominent in the group of patients who received chemotherapy with a curative intent (Fig. 3A) compared with those who received chemotherapy for advanced disease (Fig. 3B) (P=0.363 for the first 12 weeks and P=0.167 for the first 25 weeks). During the chemotherapy courses, the Hb levels also started to rise in the Hb-based ESA administration patient group, since longer duration of chemotherapy was associated with an additive myelosuppressive effect and consequent anemia that prompted ESA administration as per protocol, resulting in intercepted curves with time progression (Fig. 3).

OF the 605 patients who were evaluable for safety and toxicity, 284 had received adjuvant treatment with curative intent and 321 had received first-line treatment for advanced disease (Table II). Among patients treated with adjuvant chemotherapy, those who received ESA prophylactically (group A), compared with those who received ESA with an Hb-based algorithm (group B), exhibited A significantly lower incidence of overall (grades 1–4) anemia (2.9 vs. 9.0%, respectively; P=0.0428) and A marginally lower incidence of severe (grades 3–4) anemia (0.0 vs. 3.5%, respectively; P=0.0604). However, the same patient group exhibited a higher incidence of overall deep venous thrombosis, albeit not at a significant level (all grades: 9.3 vs. 4.2%, respectively; P=0.0993); the differences in the incidence of stroke, pulmonary embolism, or myocardial infarction (all grades) between the two groups were not significant (P>0.9999, P=0.3654 and P=0.34, respectively; data not shown). However, an increased incidence of all grades of a composite outcome encompassing all thrombosis-related events (deep venous thrombosis, pulmonary embolism, myocardial infarction and stroke), was recorded as a non-significant trend (all grades: 12.9 vs. 6.3%, P=0.0692; grades 3–4: 2.9 vs. 2.1%; P=0.7198), (Table IIA).

Among patients treated with first-line chemotherapy for advanced disease (Table IIB), those who received ESA prophylactically, compared with those who received ESA with an Hb-based algorithm, exhibited A significantly lower incidence of overall (grades 1–4) anemia (5.6 vs. 13.8%, respectively; P=0.0138) and severe (grades 3–4) anemia (3.1 vs. 8.8%, respectively; P=0.0342), as well as of overall and severe fatigue (all grades: 10.5 vs. 27.7%, respectively, P<0.0001; grades 3–4: 3.1 vs. 8.2%, respectively, P=0.0545). The same patient group also experienced a non-significant trend for more events of deep venous thrombosis (all grades: P=0.2277) and stroke (all grades: P=0.1737), but not of pulmonary embolism (all grades: P=0.9999) or myocardial infarction (all grades: P=0.74; data not shown) resulting in a marginally significant increase in the incidence of the composite outcome of all thrombosis-related events (all grades: 17.9 vs. 10.1 %, P=0.043, grades 3–4: 9.9 vs. 4.4%, P=0.099).

Notably, the aforementioned differences were more prominent in the group of patients who were treated with first-line chemotherapy for advanced disease, compared with those who were treated with adjuvant chemotherapy with a curative intent; this observation was consistent throughout the main adverse events associated with thrombosis (deep venous thrombosis, stroke, myocardial infarction and pulmonary embolism) (Table II).

At the time of data cut-off (January, 2012), 358 patients had relapsed and 380 patients had succumbed to the disease. In the whole study cohort and in the per-protocol treated patients, there were no significant differences in clinical outcomes (disease or progression-free and overall survival) with respect to the presence or absence of anemia at study entry and the administration of ESA in a prophylactic or Hb-based manner. The percentages of patients that were event-free at 3 years did not differ (65.7 vs. 64.7%). The median OS in the group of patients who received adjuvant treatment with A curative intent has not yet been reached [95% confidence interval (CI): 87.9 months-not estimated] for those who received ESA prophylactically (95% CI: 80.8-not estimated) or those who received ESA in a Hb-based manner (log-rank test P=0.6008, Fig. 4A). The median OS in the group of patients who received chemotherapy for advanced disease was 17.4 months (95% CI: 13.8–21.8) for those who received ESA prophylactically and 13.4 months (95% CI: 11.2–16.3) for those who received ESA in a Hb-based manner (log-rank test P=0.7216, Fig. 4B).