CAFE Study - Cancer Patient Fracture Evaluation (CAFE)

• ClinicalTrials.gov Identifier: NCT00211237
• Recruitment Status: Completed
• First Posted: September 21, 2005
• Results First Posted: May 14, 2010
• Last Update Posted: January 5, 2021
• Sponsor: Medtronic Spine LLC
• Information provided by (Responsible Party): Medtronic Spinal and Biologics ( Medtronic Spine LLC )

Study Description

Brief Summary:

The primary objective of this study is to evaluate the safety and effectiveness of balloon kyphoplasty treatment for painful, acute, vertebral compression fractures (VCFs) as compared to standard non-surgical therapy in patients with cancer.

Condition or disease	Intervention/treatment	Phase
Cancer; Spinal Fractures	Device: Balloon Kyphoplasty; Other: Non Surgical Management	Not Applicable

Detailed Description:

1. STUDY OBJECTIVES AND ENDPOINTS

1.1. Objectives

The primary objective of this study is to evaluate the safety and effectiveness of balloon kyphoplasty treatment for painful, acute, VCFs as compared to standard non-surgical therapy in patients with cancer.

1.2. Primary Endpoint

The primary endpoint of the study is the improvement in functional status, as measured by the Roland-Morris Disability Questionnaire (RDQ) at 1 month. The primary hypothesis of the study is that the mean improvement will be larger in subjects initially assigned to management with balloon kyphoplasty. Note that all subjects will undergo 12 months of follow-up after initial treatment assignment.

1.3. Secondary Endpoints

The following secondary endpoints will also be examined. Comparisons will be made at each follow-up visit.

Safety:

• Rate of study treatment-related adverse events
• Change in neurological status

Clinical:

• Change in functional status as assessed with Karnofsky Performance Scale
• Change in quality of life as assessed by the SF-36v2™ Health Survey
• Change in back pain, as measured by a 10-point Numerical Rating Scale (NRS)
• Change in back-pain analgesics used
• Change in ambulation status
• Changes in activities of daily living
• Time to treatment failure

Radiographic:

• Change in spinal deformity, defined as the degree of spine angulation as assessed by an independent radiologist at the core laboratory
• Rate of subsequent vertebral body fractures, as assessed by independent radiologists at the core lab

In each case, the study hypothesis is that treatment with balloon kyphoplasty will result in an improvement in clinical or radiographic outcomes compared to baseline and compared to non-surgical treatment, with a preservation of outcomes in long-term follow-up.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 134 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: A Multicenter, Prospective, Randomized, Controlled Study to Compare Balloon Kyphoplasty to Non-surgical Fracture Management in the Treatment of Painful, Acute Vertebral Body Compression Fractures in Cancer Patients
• Study Start Date: May 2005
• Actual Primary Completion Date: April 2009
• Actual Study Completion Date: December 2009

Arms and Interventions

Arm	Intervention/treatment
Experimental: Balloon Kyphoplasty (BKP); The subjects assigned to this group will undergo the treatment with Balloon kyphoplasty for their painful VCFs.	Device: Balloon Kyphoplasty; Ballon Kyphoplasty is a minimally invasive technique aimed at reduction of VCFs using KyphX® Inflatable Bone Tamps followed by fracture fixation with KyphX® HV-R™ Bone Cement.; Other Name: KyphX Inflatable Bone Tamps
Active Comparator: Non Surgical Management; The subjects in this group will undergo the non-operative treatments aimed at alleviation of back pain and restoration of decreased function associated with VCFs.	Other: Non Surgical Management; Non-surgical treatment includes, but is not limited to, the following: back brace, pain medication, physical therapy, walking aids, bed rest, and radiation treatment.

Outcome Measures

Primary Outcome Measures :

1. The Functional Status, as Measured by the Roland-Morris Disability Questionnaire (RDQ) at 1 Month [ Time Frame: Baseline and 1 Month ]

   The full scale name is the Roland-Morris Disability Questionnaire; it is a validated measure of physical disability due to back pain.

   The best score is 0 (no disability) and worst is 24 (maximum disability)

Secondary Outcome Measures :

1. Change in Roland-Morris Disability Questionnaire Score [ Time Frame: Baseline, 1 month, 3 months, 6 months, and 12 months ]
   Roland-Morris Disability Questionnaire (RMDQ) was used to assess the physical disability due to back pain. The best score is 0 (no disability) and worst is 24 (maximum disability).
2. Change in Functional Status Assessed With the Karnofsky Performance Scale [ Time Frame: Baseline and 1 month ]
   The Karnofsky Performance Scale rates a patient on an 11-step scale from 0 (dead) to 100 (normal, no complaints, no evidence of disease).
3. Change in Functional Status Assessed With the Karnofsky Performance Scale [ Time Frame: Baseline, 1 month, 3 months, 6 months, and 12 months ]
   The Karnofsky Performance Scale rates a patient on an 11-step scale from 0 (dead) to 100 (normal, no complaints, no evidence of disease).
4. Change in Back Pain [ Time Frame: Baseline and 1 month ]
   Back pain was assessed on a 10-point Numerical Rating Scale (NRS) from 0 (no pain) to 10 (worst possible pain).
5. Change in Back Pain [ Time Frame: Baseline, 1 month, 3 months, 6 months, and 12 months ]
   Back pain was assessed on a NRS from 0 (no pain) to 10 (worst possible pain).
6. Change in Quality of Life. [ Time Frame: Baseline and 1 month ]
   The SF-36 was used to assess quality of life. The SF-36 results were summarized into two components, a physical component summary score (PCS) (0-100) and a mental component summary score (MCS) (0-100). The higher the score, the better the quality of life.
7. Change in Quality of Life [ Time Frame: Baseline, 1 month, 3 months, 6 months, and 12 months ]
   The SF-36 were used to assess quality of life. The SF-36 results were summarized into two components, a physical component summary score (PCS) (0-100) and a mental component summary score (MCS) (0-100). The higher the score, the better the quality of life.
8. Change in Activities of Daily Living - Activities Reduced Due to Back Pain in Previous 2 Weeks [ Time Frame: Baseline and 1 month ]
   The Activities of Daily Living assessment comprised three questions about the effects of back pain or back problems over the previous 2-week period. The patient was asked if they had cut down on usual activities, the number of days in which the patient had cut down on usual activities and the number of days that the patient had spent at least half a day in bed because of back pain or back problems.
9. Change in Activities of Daily Living - Activities Reduced Due to Back Pain in Previous 2 Weeks [ Time Frame: Baseline, 1 month, 3 months, 6 months, and 12 months ]
   The Activities of Daily Living assessment comprised three questions about the effects of back pain or back problems over the previous 2-week period. The patient was asked if they had cut down on usual activities, the number of days in which the patient had cut down on usual activities and the number of days that the patient had spent at least half a day in bed because of back pain or back problems.
10. Change in Activities of Daily Living - Number of Days With Reduced Activities Due to Back Pain in Previous 2 Weeks [ Time Frame: Baseline and 1 month ]
    The Activities of Daily Living assessment comprised three questions about the effects of back pain or back problems over the previous 2-week period. The patient was asked if they had cut down on usual activities, the number of days in which the patient had cut down on usual activities and the number of days that the patient had spent at least half a day in bed because of back pain or back problems.
11. Change in Activities of Daily Living - Number of Days With Reduced Activities Due to Back Pain in Previous 2 Weeks [ Time Frame: Baseline, 1 month, 3 months, 6 months, and 12 months ]
    The Activities of Daily Living assessment comprised three questions about the effects of back pain or back problems over the previous 2-week period. The patient was asked if they had cut down on usual activities, the number of days in which the patient had cut down on usual activities and the number of days that the patient had spent at least half a day in bed because of back pain or back problems.
12. Change in Activities of Daily Living - Number of Days in Bed Due to Back Pain in Previous 2 Weeks [ Time Frame: Baseline and 1 month ]
    The Activities of Daily Living assessment comprised three questions about the effects of back pain or back problems over the previous 2-week period. The patient was asked if they had cut down on usual activities, the number of days in which the patient had cut down on usual activities and the number of days that the patient had spent at least half a day in bed because of back pain or back problems.
13. Change in Activities of Daily Living - Number of Days in Bed Due to Back Pain in Previous 2 Weeks [ Time Frame: Baseline, 1 month, 3 months, 6 months, and 12 months ]
    The Activities of Daily Living assessment comprised three questions about the effects of back pain or back problems over the previous 2-week period. The patient was asked if they had cut down on usual activities, the number of days in which the patient had cut down on usual activities and the number of days that the patient had spent at least half a day in bed because of back pain or back problems.
14. Ambulatory Status Change From Baseline to One Month [ Time Frame: 1 month ]
    Ambulatory status was assessed using a three-category system, fully ambulatory, ambulatory with assistance, or not ambulatory.
15. Ambulatory Status Change [ Time Frame: Baseline, 7 days, 1 month, 3 months, 6 months, and 12 months ]
    Ambulatory status was assessed using a three-category system, fully ambulatory, ambulatory with assistance, or not ambulatory.
16. Index Spinal Deformity Change Measured by Index Vertebral Body Angles From Baseline to 1 Month [ Time Frame: Baseline and 1 month ]
    Index spinal deformity was measured by Kyphotic angle, local Cobb angle, thoracic and lumbar Cobb angle, and anterior, middle and posterior vertebral body heights for each index VCF.
17. Index Spinal Deformity Change Measured by Index Vertebral Body Angles [ Time Frame: Baseline, post-operation, 1 month, and 12 months ]
    Index spinal deformity was measured by Kyphotic angle, local Cobb angle, thoracic and lumbar Cobb angle, and anterior, middle and posterior vertebral body heights for each index VCF.
18. Index Spinal Deformity Change Measured by Index Vertebral Body Height Ratio [ Time Frame: Baseline and 1 month ]
    Index spinal deformity was measured by Kyphotic angle, local Cobb angle, thoracic and lumbar Cobb angle, and anterior, middle and posterior vertebral body heights for each index VCF. Index Vertebral Body Height Ratio (VBHR) was defined as index vertebra height divided by the average of normal superior and inferior adjacent vertebrae.
19. Index Spinal Deformity Change Measured by Index Vertebral Body Height Ratio [ Time Frame: Baseline, post-operation, 1 month, and 12 months ]
    Index spinal deformity was measured by Kyphotic angle, local Cobb angle, thoracic and lumbar Cobb angle, and anterior, middle and posterior vertebral body heights for each index VCF. Index Vertebral Body Height Ratio (VBHR) was defined as index vertebra height divided by the average of normal superior and inferior adjacent vertebrae.
20. Back Pain Analgesics Used [ Time Frame: Baseline, 7 days, and 1 month ]
21. Back Pain Analgesics Used [ Time Frame: Baseline, 7 days, 1 month, 3 months, 6 months, and 12 months ]
22. Change in Neurology Status From Baseline (Motor Strength) [ Time Frame: 1 month ]

    The neurological examination included motor strength, sensory examination, reflexes below the level of the most cephalad index vertebral body fracture, and the presence of radicular pain. Evaluation criteria of motor strength (scored 0-5) for rectus abdominis, hip extensors and flexors, knee extensors and flexors, and foot plantar and dorsiflexors as following:

    absent voluntary contraction = 0, contractions unable to move joint = 1, movement with gravity eliminated = 2, movement against gravity = 3, movement against resistance = 4, full strength = 5

23. Change in Neurology Status From Baseline (Motor Strength)-Per Protocol [ Time Frame: 1 month, 3 months, 6 months, and 12 months ]

    The neurological examination included motor strength, sensory examination, reflexes below the level of the most cephalad index vertebral body fracture, and the presence of radicular pain. Evaluation criteria of motor strength (scored 0-5) for rectus abdominis, hip extensors and flexors, knee extensors and flexors, and foot plantar and dorsiflexors as following:

    absent voluntary contraction = 0, contractions unable to move joint = 1, movement with gravity eliminated = 2, movement against gravity = 3, movement against resistance = 4, full strength = 5

24. Change in Neurological Status From Baseline (Sensory Examination) [ Time Frame: 1 month ]
    The neurological examination included motor strength, sensory examination, reflexes below the level of the most cephalad index vertebral body fracture, and the presence of radicular pain. For sensory examination, the Investigator assessed sensory status at baseline and a change from baseline beginning with the most cephalad index level treated through L5.
25. Change in Neurological Status From Baseline (Sensory Examination) [ Time Frame: 1 months, 3 months, 6 months, and 12 months ]
    The neurological examination included motor strength, sensory examination, reflexes below the level of the most cephalad index vertebral body fracture, and the presence of radicular pain. For sensory examination, the Investigator assessed sensory status at baseline and a change from baseline beginning with the most cephalad index level treated through L5.
26. Change in Neurological Status From Baseline (Reflex Strength) [ Time Frame: 1 month ]

    The neurological examination included motor strength, sensory examination, reflexes below the level of the most cephalad index vertebral body fracture, and the presence of radicular pain. Evaluation criteria of reflexes (scored 0-3) for patellar and Achilles reflexes as following:

    absent = 0, hypoactive = 1, normal = 2, brisk or clonus = 3

27. Change in Neurological Status From Baseline (Reflex Strength) [ Time Frame: 1 months, 3 months, 6 months, and 12 months ]

    The neurological examination included motor strength, sensory examination, reflexes below the level of the most cephalad index vertebral body fracture, and the presence of radicular pain. Evaluation criteria of reflexes (scored 0-3) for patellar and Achilles reflexes as following:

    absent = 0, hypoactive = 1, normal = 2, brisk or clonus = 3

28. Change in Neurological Status From Baseline (Limb Strength) [ Time Frame: 1 month ]
    The neurological examination included motor strength, sensory examination, reflexes below the level of the most cephalad index vertebral body fracture, and the presence of radicular pain. Radicular lower limb pain was assessed the presence of paresthesia, weakness, and/or painful straight leg raising (SLR).
29. Change in Neurological Status From Baseline (Limb Strength) [ Time Frame: 1 months, 3 months, 6 months, and 12 months ]
    The neurological examination included motor strength, sensory examination, reflexes below the level of the most cephalad index vertebral body fracture, and the presence of radicular pain. Radicular lower limb pain was assessed the presence of paresthesia, weakness, and/or painful straight leg raising (SLR).
30. Rate of Study Treatment-related Adverse Events Within 30 Days of Baseline [ Time Frame: 1 month ]

    The study treatment-related AEs were defined as follows:

    1. Related defined as the AE had a direct relationship to a Sponsor medical device used in the study patient.
    2. Possibly related defined as the AE may have had a relationship to a Sponsor medical device but an alternative cause may be equally or less likely associated.
    3. Unrelated defined as the AE was due to the underlying indication or disease state or to concomitant medication or therapy not related to any Sponsor device.
    4. Unknown defined as the relationship of the AE to a Sponsor device could not be determined.
31. Rate of Study Treatment-related Adverse Events Till Study Completion [ Time Frame: 12 months ]

    The study treatment-related AEs were defined as follows:

    1. Related defined as the AE had a direct relationship to a Sponsor medical device used in the study patient.
    2. Possibly related defined as the AE may have had a relationship to a Sponsor medical device but an alternative cause may be equally or less likely associated.
    3. Unrelated defined as the AE was due to the underlying indication or disease state or to concomitant medication or therapy not related to any Sponsor device.
    4. Unknown defined as the relationship of the AE to a Sponsor device could not be determined.
32. Rate of Subsequent Vertebral Body Fractures [ Time Frame: 1 month ]
33. Rate of Subsequent Vertebral Body Fractures [ Time Frame: 1 month and 12 months ]
    Based on patients with at least 7 analyzable vertebrae.

Eligibility Criteria

• Ages Eligible for Study: 21 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

1. One to 3 painful (pain on palpation/percussion over fractured vertebral body) VCF(s), T5-L5, with either bone marrow edema imaged by magnetic resonance imaging (MRI) or a fracture imaged by plain radiographs using the method of Genant

2. Pain NRS score ≥4 on a scale of 0 to 10

   • When the patient is newly diagnosed with multiple myeloma, the pain assessment must not be done until after completion of at least one pulse of steroid therapy or one week after the initiation of active multiple myeloma therapy.
3. Roland Morris Disability Questionnaire score ≥ 10 on a scale of 0 to 24
4. Patients must be at least 21 years old.
5. No change in chemotherapy regimen (change in dose(s) permitted) for 1 month prior to enrollment
6. No change in chemotherapy regimen (change in dose(s) permitted) planned for at least 1 month following enrollment
7. No major surgery to the spine planned for at least 1 month following enrollment
8. Life expectancy of ≥ 3 months
9. Patient has sufficient mental capacity to comply with the protocol requirements
10. Patient has stated availability for all study visits
11. Patient is able to understand the risks and benefits of participating in the study and is willing to provide written informed consent.

Exclusion Criteria:

1. Patients with primary tumors of the bone (e.g., osteosarcoma) or solitary plasmacytoma at site of the index VCF. Patients with these tumors in anatomic sites other than the index VCF are eligible.
2. Concurrent Phase I investigational anti-cancer treatment
3. Significant clinical morbidities (aside from the index fracture(s) and cancer) that may potentially interfere with the collection of data concerning pain and function
4. VCF morphology deemed unsuitable for balloon kyphoplasty
5. Additional non-kyphoplasty surgical treatment is required for the index fracture
6. Patients requiring the use of high-dose steroid (≥ 100 mg prednisone or 20 mg dexamethasone per day), intravenous (IV) pain medication, or nerve block to control chronic back pain unrelated to index VCF(s). Patients who receive high-dose steroids for treatment of their cancer (for at least 30 days) are eligible.
7. Patients with a platelet count of < 20,000 measured at the time of hospital admission for the procedure
8. Spinal cord compression or canal compromise requiring decompression
9. Patients with osteoblastic tumors at the site of index VCF. Patients with osteoblastic tumors outside of vertebral levels intended for kyphoplasty may be enrolled.
10. Medical/surgical conditions contrary to the balloon kyphoplasty procedure (e.g., in the presence of active or incompletely treated local infection)
11. Known allergy to bone cement or contrast medium used in the treatment of study subjects
12. MRI contraindication (e.g., cerebral aneurysm clips, pacemaker, implanted biostimulators, cochlear implants, penile prosthesis)
13. Positive baseline pregnancy test (for women of child-bearing potential)
14. Patients who may require allogeneic bone marrow transplantation during the course of the study.

Other Reasons for Lack of Enrollment:

A. Patient is afraid to have surgery

B. Patient is afraid to have anesthesia

C. Patient/family is not willing to participate in research

D. Patient is not willing to be randomized

Contacts and Locations

Locations

United States, California

Valley Radiology Inc., UCSD

Escondido, California, United States, 92025

United States, Colorado

Boulder Neurosurgical Associates

Boulder, Colorado, United States, 80304

United States, Florida

H. Lee Moffitt Cancer Center

Tampa, Florida, United States, 33612

United States, Maryland

Sibley Memorial Hospital

Chevy Chase, Maryland, United States, 20815

Greater Oncology Associates

Silver Spring, Maryland, United States, 20910

United States, Michigan

Karmanos Cancer Center

Detroit, Michigan, United States, 48201

United States, Ohio

Cleveland Clinic

Cleveland, Ohio, United States, 44195

United States, Texas

University of Texas MD Anderson Cancer Center

Houston, Texas, United States, 77030

United States, Utah

University of Utah

Salt Lake City, Utah, United States, 84132

Australia, Victoria

St. Vincent's Hospital

Fitzroy, Victoria, Australia, 3065

The Alfred Hospital

Melbourne, Victoria, Australia, 3004

Belgium

Institut Jules Bordet

Brussels, Belgium

Canada, Alberta

Foothills Hospital

Calgary, Alberta, Canada, T2N2T9

Canada, Ontario

Toronto Western Hospital

Toronto, Ontario, Canada, M5T 2S8

Canada, Quebec

Montreal General Hospital

Montreal, Quebec, Canada, H3G 1A4

Germany

Charité Virchow-Klinikum

Berlin, Germany

Medizinische Hochschule

Hannover, Germany

Hungary

National Center for Spinal Disorders

Budapest, Hungary

Sweden

Akademiska Sjukhuset

Uppsala, Sweden

United Kingdom

Royal London

London, United Kingdom

Sponsors and Collaborators

Medtronic Spine LLC

Investigators

• Principal Investigator: James Berenson, M.D.; Institute for Myeloma & Bone Cancer Research
• Principal Investigator: Frank Vrionis, M.D.; H. Lee Moffitt Cancer Center

More Information

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

Berenson J, Pflugmacher R, Jarzem P, Zonder J, Schechtman K, Tillman JB, Bastian L, Ashraf T, Vrionis F; Cancer Patient Fracture Evaluation (CAFE) Investigators. Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial. Lancet Oncol. 2011 Mar;12(3):225-35. doi: 10.1016/S1470-2045(11)70008-0. Epub 2011 Feb 16.

• Responsible Party: Medtronic Spine LLC
• ClinicalTrials.gov Identifier: NCT00211237
• Other Study ID Numbers: SP0401 - CAFE Study
• First Posted: September 21, 2005
• Results First Posted: May 14, 2010
• Last Update Posted: January 5, 2021
• Last Verified: June 2017

Keywords provided by Medtronic Spinal and Biologics ( Medtronic Spine LLC ):

Balloon Kyphoplasty; Cancer; Vertebral Compression Fracture; Back Pain; Spine

Additional relevant MeSH terms:

Fractures, Bone; Spinal Fractures; Wounds and Injuries; Spinal Injuries; Back Injuries