Articles

Napabucasin versus placebo in refractory advanced

colorectal cancer: a randomised phase 3 trial
Derek J Jonker, Louise Nott, Takayuki Yoshino, Sharlene Gill, Jeremy Shapiro, Atsushi Ohtsu, John Zalcberg, Michael M Vickers, Alice C Wei,
Yuan Gao, Niall C Tebbutt, Ben Markman, Timothy Price, Taito Esaki, Sheryl Koski, Matthew Hitron, Wei Li, Youzhi Li, Nadine M Magoski,
Chiang J Li, John Simes, Dongsheng Tu, Christopher J O’Callaghan

Summary
Background Napabucasin is a first-in-class cancer stemness inhibitor that targets STAT3, which is a poor prognostic Lancet Gastroenterol Hepatol
factor in colorectal cancer. This study aimed to test napabucasin in advanced colorectal cancer. 2018
Published Online
January 31, 2018
Methods This study was a double-blind randomised phase 3 trial done at 68 centres in Canada, Australia, New Zealand,
http://dx.doi.org/10.1016/
and Japan. Patients with advanced colorectal cancer with a good Eastern Cooperative Oncology Group (ECOG) S2468-1253(18)30009-8
performance status (0–1) for whom all available standard therapies had failed were eligible for the study. Patients were Department of Medicine,
randomly assigned (1:1) to receive placebo or napabucasin through a web-based system with a permuted block method, Division of Medical Oncology,
after stratification by ECOG performance status, KRAS status, previous VEGF inhibitor treatment, and time from Ottawa Hospital Research
Institute, University of Ottawa,
diagnosis of metastatic disease. Napabucasin 480 mg or matching placebo was taken orally every 12 h. All patients
Ottawa, ON, Canada
received best supportive care. The primary endpoint was overall survival assessed in an intention-to-treat analysis. (D J Jonker MD, M M Vickers MD);
This is the final analysis of this trial, which is registered at ClinicalTrials.gov, number NCT01830621. Medical Oncology, Royal
Hobart Hospital, Hobart,
Australia (L Nott MBBS);
Findings Accrual began on April 15, 2013, and was stopped for futility on May 23, 2014, at which point 282 patients had
Department of
undergone randomisation (138 assigned to the napabucasin group and 144 to the placebo group). Overall survival did Gastroenterology &
not differ significantly between groups: median overall survival was 4·4 months (95% CI 3·7–4·9) in the napabucasin Gastrointestinal Oncology,
group and 4·8 months (4·0–5·3) in the placebo group (adjusted hazard ratio [HR] 1·13, 95% CI 0·88–1·46, p=0·34). National Cancer Center
Hospital East, Chiba, Japan
The safety population included 136 patients in the napabucasin group and 144 patients in the placebo group. More
(T Yoshino MD); Department of
patients who received napabucasin had any grade of treatment-related diarrhoea (108 [79%] of 136 patients), nausea Medicine, Division of Medical
(69 [51%]), and anorexia (52 [38%]) than did patients who received placebo (28 [19%] of 144 patients, 35 [24%], and Oncology, British Columbia
23 [16%], respectively). The most common severe (grade 3 or worse) treatment-related adverse events were abdominal Cancer Agency, University of
British Columbia, Vancouver,
pain (five [4%] patients receiving napabucasin vs five [3%] receiving placebo), diarrhoea (21 [15%] vs one [1%]), fatigue
BC, Canada (S Gill MD);
(14 [10%] vs eight [6%]), and dehydration (six [4%] vs one [1%]). 251 (89%) patients had data on pSTAT3 expression, of Department of Oncology,
whom 55 (22%) had pSTAT3-positive tumours (29 in the napabucasin group, 26 in the placebo group). In a prespecified Cabrini Hospital, Melbourne,
biomarker analysis of pSTAT3-positive patients, overall survival was longer in the napabucasin group than in the Australia (J Shapiro MBBS);
Department of
placebo group (median 5·1 months [95% CI 4·0–7·5] vs 3·0 months [1·7–4·1]; HR 0·41, 0·23–0·73, p=0·0025). Gastroenterology and
Gastrointestinal Oncology,
Interpretation Although there was no difference in overall survival between groups in the overall unselected National Cancer Center
population, STAT3 might be an important target for the treatment of colorectal cancer with elevated pSTAT3 Hospital East, Kashiwa, Japan
(Prof A Ohtsu MD); School of
expression. Nevertheless, these results require validation. Public Health & Preventive
Medicine, Monash University,
Funding Canadian Cancer Society Research Institute and Boston Biomedical. Melbourne, Australia
(Prof J Zalcberg MBBS); Division
of General Surgery, Princess
Introduction feature of colorectal cancer stem cells.8 Elevated Margaret Cancer Centre,
Colorectal cancer is a leading cause of death from cancer, expression of phosphorylated STAT3 (pSTAT3) is University of Toronto, Toronto,
with a fatality rate nearing 50%.1,2 When unresectable, associated with poor prognosis.9 ON, Canada (A C Wei MD);
standard treatments include chemotherapy (eg, fluoro- Napabucasin (BBI608, Boston Biomedical Inc/1Globe Clinical Development, Boston
Biomedical, Boston, MA, USA
pyrimidines, irinotecan, and oxaliplatin) and agents Health Institutes) is a small molecule inhibitor of (Y Gao PhD, M Hitron MD,
targeting EGFR (eg, cetuximab and panitumumab) and STAT3 and has been shown to block self-renewal and W Li PhD, Y Li MD); 1Globe
VEGF (eg, bevacizumab, aflibercept, ramucirumab, and induce death in cancer stem cells from colorectal Health Institute, Norwood,
regorafenib).3–7 However, no new biological pathways cancer and other types of cancer in preclinical studies.10 MA, USA (C J Li MD), Boston
Biomedical, Cambridge, MA,
have successfully been targeted in randomised trials for Results from early trials of napabucasin alone and USA; Department of
more than a decade. combined with chemotherapy in colorectal cancer Mathematics and Statistics
Cancer stem cells, or cancer cells with stemness suggest promising activity.11–13 The Canadian Cancer (Prof D Tu PhD) and
Department of Public Health
phenotype, have self-renewal capability and are respon- Trials Group (CCTG), the Australasian Gastrointestinal
Sciences
sible for malignant growth, recurrence, drug resistance, Trials Group (AGITG), and investigators from Japan (Prof C J O’Callaghan PhD),
and metastasis. Cancer stem cells are resistant to did this trial to compare napabucasin with placebo in Canadian Cancer Trials Group
chemotherapies and existing targeted agents. STAT3 is patients receiving best supportive care for refractory (N M Magoski MSc), Queens
University, Kingston, ON,
aberrantly activated in many cancers, and is a key advanced colorectal cancer.

www.thelancet.com/gastrohep Published online January 31, 2018 http://dx.doi.org/10.1016/S2468-1253(18)30009-8 1

 Articles
Canada; Medical Oncology,
Austin Health, Heidelberg,
Australia (N C Tebbutt MBBS);
Monash Cancer Centre, Monash
Health, Melbourne, Australia
(B Markman MBBS); The Queen
Elizabeth Hospital and
University of Adelaide,
Adelaide, Australia
(Prof T Price MBBS);
Gastrointestinal and Medical
Oncology, National Kyushu
Cancer Center, Fukuoka, Japan
(T Esaki MD); Department of
Oncology, University of Alberta
Cross Cancer Institute,
Edmonton, AB, Canada
(S Koski MD); and NHMRC
Clinical Trials Centre, University
of Sydney, NSW, Australia
(Prof J Simes MD)
Correspondence to:
Dr Derek J Jonker, The Ottawa
Hospital, Ottawa,
ON K1H 8L6, Canada
djonker@toh.on.ca
For the protocol see
https://www.ctg.queensu.ca/
public/misc/
RedactedCO23protocol.pdf
2 www.thelancet.com/gastrohep Published online January 31, 2018 http://dx.doi.org/10.1016/S2468-1253(18)30009-8
Research in context
Evidence before this study
We searched PubMed with terms including [colorectal cancer],
[STAT3], and ([cancer stem cell] filtered for Clinical Trial),
restricted to articles in English. STAT3 is a gene transcription
factor that is overexpressed in colorectal cancer and believed
to be required to maintain the stem cell nature of colorectal
cancer. Data from multiple retrospective studies have
suggested a correlation between phosphorylated STAT3
(pSTAT3) expression in colorectal cancer and poor survival.
No randomised trials have successfully targeted STAT3 or
other stem cell markers of cancer.
Added value of this study
To our knowledge, this trial is the first randomised
prospective controlled trial of a cancer stem cell inhibitor. It is
also the first study to identify pSTAT3 as a marker of poor
Methods
Study design and participants
This study was a double-blind randomised phase 3 trial
of napabucasin plus best supportive care versus placebo
plus best supportive care in patients with pretreated
advanced colorectal cancer. The trial was done at
68 centres in Canada (32 centres), Australia (20 centres),
New Zealand (one centre), and Japan (15 centres). There
were other sites that activated but did not accrue any
patients, some because they were late to activate and the
trial accrued quickly. The protocol was approved by
institutional review boards of all participating centres
and participants gave written informed consent. The
protocol is available online.
Eligible patients were those with advanced
unresectable colorectal adenocarcinoma who had
previously been treated with a fluoropyrimidine,
irinotecan, and oxaliplatin and had treatment failure
(defined as unacceptable adverse events, tumour
progression during adjuvant treatment, or tumour
progression within 6 months of completion of adjuvant
treatment) or contraindications to these drugs. RAS
wild-type patients needed to have had treatment failure
with a previous EGFR inhibitor unless they had
documented unsuitability for an EGFR inhibitor.
Previous VEGF-targeting therapy was permitted, but
not required. Eligible patients needed to have
measurable disease in accordance with the Response
Evaluation Criteria in Solid Tumors version 1.114 and
an Eastern Cooperative Oncology Group (ECOG)
performance status of 0 to 1, be aged 18 years or older,
have adequate bone marrow, kidney, and liver function,
have no serious concurrent illness, and to have
provided consent for use of archival tissue. Patients
were ineligible if gastrointestinal disorders impeded
absorption. A complete list of inclusion and exclusion
criteria is available in the protocol.
prognosis in colorectal cancer. Although the study found that
there was no survival benefit with the pSTAT3 inhibitor
napabucasin compared with placebo in the unselected patient
population, it showed that patients who expressed pSTAT3 in
archival tumour and stromal tissue may have an overall
survival benefit when treated the drug. Our findings suggest
this pathway could be targeted to treat patients with
colorectal cancer.
Implications of all the available evidence
STAT3 might be a potential new target for the treatment of
colorectal cancer with elevated pSTAT3 expression.
Ongoing studies will explore combinations of napabucasin
with chemotherapy in colorectal cancer and other types
of cancer.
Randomisation and masking
Patients were stratified according to ECOG performance
status (0 vs 1), KRAS status (mutant vs wild type), previous
VEGF inhibitor treatment (yes vs no), and time
from diagnosis of metastatic disease (<18 months vs
≥18 months), and assigned via block randomisation
(permuted block size 4) to napabucasin or placebo in
a 1:1 ratio. Randomisation was done with a CCTG
web-based system and the randomisation schedule was
generated by the CCTG central randomisation manager.
Investigating centres entered data including stratification
factors electronically into the CCTG database and only a
drug box number was provided to them electronically to
ensure that patients and investigators at both CCTG
and investigating centres were masked to treatment
allocation. Use of a visually identical placebo control
provided further assurance that patients and all CCTG
and site staff were masked to allocation.
Procedures
All patients received best supportive care. Napabucasin
480 mg or matching placebo was taken orally twice per
day, 1 h before or 2 h after meals, at intervals of about 12 h.
Dose reductions and dose interruptions were permitted
for intolerable gastrointestinal adverse events to as low as
80 mg once per day with re-escalation permitted. Dose
modifications are described in detail in the protocol. Use
of antidiarrhoeal drugs and antiemetics were encouraged
as needed. Treatment was continuous until progression
or unacceptable toxicity, but continuation beyond
progression was permitted if a patient was deemed to be
deriving clinical benefit.
Patients underwent clinical assessment every 4 weeks,
including blood counts and biochemistry investigations.
Radiological tumour assessments were done every
8 weeks until progression. Archival tissue and blood
samples at 4, 8, and 12 weeks were collected for banking.

Patient-reported quality of life was assessed at baseline
and at weeks 4, 8, 12, 16, and 24 after randomisation15
by use of the European Organisation for Research and
Treatment of Cancer (EORTC) quality-of-life questionnaire
(QLQ-C30) version 3.0 and Health Utilities Index (HUI3).
Outcomes
The primary endpoint was overall survival. Secondary
endpoints included progression-free survival, objective
response rate, disease control (ie, the proportion of
patients achieving complete remission, partial remission,
or stable disease), quality of life, and adverse events.
Other secondary endpoints, which are not reported here,
were health utilities, health economics evaluation, and
the exposure-response relationship of napabucasin. The
protocol also prespecified that biomarker analyses would
be done for pSTAT3 expression by immunohistochemistry
in formalin-fixed, paraffin-embedded archival tissue by
Clarient (Aliso Viejo, CA, USA), masked to treatment
allocation (appendix p 1). In this report, pSTAT3-positivity
was defined as cancer cell nuclear staining of 5%
or greater plus a stroma staining score of at least 2.
Two additional biomarker analyses were also prespecified:
pSTAT3-positivity defined only by cancer cell nuclear
staining of 5% or greater and nuclear β-catenin and these
will be reported separately. Adverse events were assessed
in accordance with the Common Terminology Criteria
for Adverse Events version 3.0.
Statistical analysis
Our a-priori estimates showed that 650 accrued patients
over 26 months with 12 months of additional follow-up
would yield 615 overall survival events, providing
90% power, with a two-sided α of 5%, to detect a 23%
reduction in the risk of death (hazard ratio [HR] 0·77),
corresponding to an increase in median survival from
4·6 to 6·0 months.
Two interim analyses were planned. An interim
futility analysis was planned for 10 weeks after the
96th patient had been randomised and was based on
the proportion of patients who had achieved disease
control. An independent data safety monitoring
committee (DSMC) would stop the trial if both the ratio
of the difference in disease control between napabucasin
and placebo over the disease control in placebo group
was less than 30% and the absolute difference in
disease control between the groups was less than 10%.
A second interim analysis for futility and superiority of
overall survival was planned after 50% of required
deaths (308 deaths) had been observed.
All patients who underwent randomisation were
included in the efficacy analysis in their assigned group
(ie, analysis by intention to treat). The safety analysis
was done on an on-treatment basis, with comparisons
of patients who received at least one dose of
napabucasin with those who received at least one dose
of placebo. Time-to-event variables were summarised
www.thelancet.com/gastrohep Published online January 31, 2018 http://dx.doi.org/10.1016/S2468-1253(18)30009-8
Articles
with Kaplan-Meier plots. The primary comparisons of
the treatment groups were done with the stratified log-
rank test adjusted for stratification factors. HRs with
95% CIs were calculated from stratified Cox regression
models with treatment group as the single factor.16 For
QLQ-C30, scores for the primary quality-of-life domains
of interest (physical function and global health status)
were standardised to range from 0 to 100, with higher
scores representing better quality of life. Deterioration
in quality of life was defined a priori as a decline of
10 points or more from baseline. Discrete variables were
compared with Fisher’s exact test and continuous and
ordinal categorical variables were compared with the
Wilcoxon test. Exploratory analyses of the effect of other
potential prognostic factors that were specified a priori
were done via a multivariable Cox regression model
stratified by ECOG performance status at randomisation.
All p values were two-sided, and no adjustment was
made for multiple comparisons. Statistical analyses
were done with SAS version 9.4. This study is registered See Online for appendix
with ClinicalTrials.gov, number NCT01830621.
Role of the funding source
The study was designed by members of the CCTG and
the AGITG. Napabucasin and placebo were supplied by
Boston Biomedical. Pretrial biomarker development
was done by Boston Biomedical (CJL, YG, YL, WL). The
CCTG collected, managed, and analysed the data. CCTG
maintains full unrestricted rights to publication of the
study data. The first draft of the manuscript was written
by DJJ then submitted to all authors (including CJL, MH,
YG, YL, and WL associated with Boston Biomedical) for
comment and revision. DT, CJO’C, NMM, and DJJ had
full access to the raw data and DJJ had final responsibility
for the decision to submit for publication.
Results
Accrual began on April 15, 2013, and was stopped for
futility on May 23, 2014, following DSMC review of the
first interim analysis, at which point 282 patients had
undergone randomisation (138 assigned to receive
napabucasin and 144 assigned to receive placebo).
Patients were unmasked and removed from study
therapy unless they were deriving benefit in the opinion
of the investigator and the patient. The final analysis
used cleaned data observed on or before the prespecified
clinical cutoff, Aug 26, 2015. At that time, the median
follow-up was 19·4 months (IQR 17·8–21·6) and
258 patients had died. Because of the premature trial
closure, the second interim analysis plan was modified
to include data up to a clinical cutoff of May 23, 2014,
from patients enrolled on or before March 28, 2014.
This analysis was intended to assess the efficacy in
patients who had the opportunity for 2 months of
exposure to study therapy before the DSMC decision.
The final analysis was modified to be done when 90% of
the events (195 deaths in patients who underwent
3
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282 patients randomly assigned

Napabucasin Placebo
(n=138) (n=144)
Sex
Female 47 (34%) 51 (35%)
138 randomly assigned to napabucasin 144 randomly assigned to placebo Male 91 (66%) 93 (65%)
Age (years)
2 withdrew before Median (range) 64 (32–85) 64 (37–81)
receiving <65 years 73 (53%) 82 (57%)
intervention
ECOG performance
0 37 (27%) 42 (29%)
2 ineligible† 4 ineligible† 1 101 (73%) 102 (71%)
2 no oxaliplatin 3 no oxaliplatin
received received KRAS status
1 no irinotecan Wild-type 71 (51%) 76 (53%)
received
Mutant 67 (49%) 68 (47%)
Previous anti-VEGF therapy 123 (89%) 127 (88%)
136 received intervention 144 received intervention Time from diagnosis to metastases
<18 months 20 (14%) 19 (13%)
≥18 months 118 (86%) 125 (87%)
136 off study therapy 144 off study therapy
Primary
Colon only 83 (60%) 91 (63%)
10 alive 14 alive Rectum included 55 (40%) 53 (37%)
Liver metastases 101 (73%) 102 (71%)
Prior chemotherapy
138 included in intention-to-treat 144 included in intention-to-treat
analysis analysis Thymidylate synthase inhibitor 138 (100%) 144 (100%)
Irinotecan 136 (99%) 143 (99%)
Oxaliplatin 131 (95%) 138 (96%)
Figure 1: Trial profile
Patient status shown is as of Aug 26, 2015, when the final analysis was done. Data were not collected before Prior bevacizumab 117 (85%) 121 (84%)
randomisation. *Patients withdrew from the study between randomisation and the first dose of study drug; Prior regorafenib 58 (42%) 58 (40%)
one patient declined to start therapy within the allotted timeframe and another detiorated to such an extent that
Prior cetuximab or panitumumab 69 (50%) 76 (53%)
they could no longer participate in the study. †Patients were reassessed for eligibility after randomisation;
these patients were initially ruled to be unsuitable for the required previous chemotherapies, this was later Prior radiotherapy 49 (36%) 51 (35%)
determined to be incorrect and this was deemed to constitute a violation of the eligibility criteria. Region
Canada 64 (46%) 77 (53%)
randomisation on or before March 28, 2014) had been Australasia 52 (38%) 45 (31%)
observed. With 195 events there was 70% post-hoc power
Japan 22 (16%) 22 (15%)
to detect an HR of 0·7 with a two-sided α of 0·05.
Of the 282 patients who underwent randomisation, Data are n (%) unless stated otherwise. ECOG=Eastern Cooperative Oncology Group.
280 received at least one dose of study therapy (136 in the Table 1: Patient characteristics at baseline
napabucasin group and 144 in the placebo group;
figure 1). Six patients were found to be ineligible (two in
the napabucasin group and four in the placebo group) eight (6%) patients receiving placebo. Dose reductions
after randomisation because they had not received were needed by 64 (47%) patients in the napabucasin
previous oxaliplatin or irinotecan. However, all patients group versus 27 (19%) in the placebo group. The most
were included in the intention-to-treat analyses. The common reasons for napabucasin dose reduction were
two groups were similar with respect to baseline diarrhoea, which occurred in 35 (26%) of 136 patients
characteristics (table 1). and nausea, which occurred in 12 (9%) patients.
Median time on treatment was 7·0 weeks (IQR 2·9–8·1) 128 patients in the napabucasin group and
for napabucasin and 6·6 weeks (3·7–8·1) for placebo. 130 patients in the placebo group died. Overall survival
Median total dose was 26 880 mg (11 360–51 240) for did not differ significantly between the study groups
napabucasin and 40 320 mg (24 280–54 240) for placebo. (figure 2A). Median overall survival was 4·4 months
Median dose intensity was 877 mg per day (480–950) (95% CI 3·7–4·9) in the napabucasin group and
for napabucasin versus 949 mg per day (896–959) 4·8 months (4·0–5·3) in the placebo group (adjusted
for placebo. 90% or more of planned dose intensity HR 1·13, 95% CI 0·88–1·46, stratified log-rank
was received by 70 (51%) of 136 patients receiving p=0·34). Similarly, overall survival did not differ
napabucasin versus 117 (81%) of 144 receiving placebo. between groups for the subset of patients who were
Less than 60% of planned dose intensity was received enrolled 2 months before the premature trial closure
by 39 (29%) patients receiving napabucasin versus and cessation of therapy (adjusted HR 1·08, 0·80–1·44,

4 www.thelancet.com/gastrohep Published online January 31, 2018 http://dx.doi.org/10.1016/S2468-1253(18)30009-8

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p=0·63). There were no significant differences in the

A
main analysis after adjustment for additional factors, 100 Napabucasin
including sex, age, number of sites of disease, presence Placebo
of liver metastases, and site of primary disease. There 80
were no clinically defined subgroups for whom an

Overall survival (%)

apparent benefit from napabucasin could be identified 60
(appendix p 2). Rectal primary disease was associated
with shorter overall survival when treated with 40
napabucasin than with placebo.
133 progression events occurred in the napabucasin 20
group and 141 events occurred in the placebo group. HR 1·13 (95% CI 0·88–1·46), p=0·34
Progression-free survival did not differ between the 0
0 2 4 6 8 10 12 14
study groups, with median progression-free survival of Number at risk
1·8 months (95% CI 1·7–1·8) in both groups (figure 2B; (number censored)
adjusted HR 0·97, 95% CI 0·76–1·26, log-rank p=0·84). Napabucasin 138 102 (5) 71 (5) 45 (5) 27 (5) 19 (5) 13 (5) 10 (5)
Placebo 144 121 (2) 81 (7) 51 (8) 37 (8) 25 (8) 18 (8) 12 (8)
Similarly, progression-free survival did not differ for the
subset of patients enrolled 2 months before the premature B
trial closure and cessation of therapy (adjusted HR 1·02, 100 HR 0·97 (95% CI 0·76–1·26), p=0·84
0·78–1·31, p=0·91). There were no significant differences
in the main analysis between groups after adjustment for 80
Progression-free survival (%)

additional factors including sex, age, number of sites of

disease, presence of liver metastases, and site of primary 60

disease. In a planned subset analysis based on multiple

40
baseline factors, progression-free survival was significantly
longer with napabucasin than with placebo among the
20
60 patients of Asian descent from Japan and other regions
(26 assigned napabucasin and 34 assigned placebo), with a
0
median progression-free survival of 1·9 months (1·8–3·4) 0 2 4 6 8 10 12
in the napabucasin group and 1·8 months (1·4–1·9) in Time (months)
Number at risk
the placebo group (placebo group (HR 0·44, 95% CI (number censored)
0·24–0·87, p=0·0031); in appendix p 2). Napabucasin 138 36 (4) 12 (4) 7 (4) 5 (4) 4 (4) 2 (4)
Placebo 144 35 (2) 14 (2) 4 (3) 2 (3) 0 (3) 0 (3)
90 patients in the napabucasin group and 99 in
the placebo group were evaluable for a response.
Figure 2: Survival outcomes
No objective responses occurred. Among all patients (A) Overall survival and (B) progression-free survival in the intention-to-treat population.
who underwent randomisation, 17 (12%) of 138 patients
in the napabucasin group and 20 (14%) of 144 patients in function (p=0·049), role function (p=0·027), global
the placebo group achieved stable disease, giving an function (p=0·030), fatigue (p=0·032), and appetite
odds ratio of 0·98 (95% CI 0·48–2·00, p=0·96) for (p=0·012).
disease control. Among patients evaluable for safety, grade 3 adverse
To be evaluable for quality-of-life analysis, patients events of any causality occurred in 78 (57%) of 136 patients
must have had a baseline assessment and at least one treated with napabucasin and 58 (40%) of 144 patients
post-baseline assessment. Reasons given for failure to treated with placebo (p=0·0058). Treatment-related
complete assessments included the patient not keeping adverse events are shown in table 2. Diarrhoea of any
their appointment (62 patients), institutional error grade, severe diarrhoea, and any grade of nausea,
(42 patients), the patient attending their appointment anorexia, and urine discolouration were more common
but being too unwell to participate, the patient refusing with napabucasin (table 2). Four (3%) of 136 patients
to participate (18 patients), and other reasons, which receiving napabucasin and one (1%) of 144 patients
allowed a text field entry (245 patients). Among patients receiving placebo discontinued treatment because of
who were evaluable, deterioration in physical function toxicity. No deaths were attributed to napabucasin
(appendix p 3) occurred in 20 (54%) of 37 patients or placebo.
receiving napabucasin versus nine (23%) of 40 patients 251 (89%) of 282 patients had samples available that
receiving placebo at 16 weeks (p=0·0052). Quality of life were successfully stained for pSTAT3 expression.
did not differ between the groups at 8 weeks (data not We found no significant differences in baseline
shown). Global health status was not significantly characteristics between the napabucasin and placebo
different between groups. Domains with greater groups within this population of patients (appendix p 4).
deterioration during the study with napabucasin than 55 (22%) of these 251 patients were pSTAT3 positive (29 in
with placebo included diarrhoea (p<0·0001), physical the napabucasin group and 26 in the placebo group).

www.thelancet.com/gastrohep Published online January 31, 2018 http://dx.doi.org/10.1016/S2468-1253(18)30009-8 5

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Napabucasin (n=136) Placebo (n=144)

1–2 3 4 5 1–2 3 4 5
Overall 90 (66%) 40 (29%) 1 (1%) 0 68 (47%) 14 (10%) 0 0
Anaemia 0 0 0 0 0 1 (1%) 0 0
Long QT interval 0 0 0 0 0 1 (1%) 0 0
Abdominal pain 27 (20%) 5 (4%) 0 0 8 (6%) 5 (3%) 0 0
Stomach pain 2 (1%) 1 (1%) 0 0 3 (2%) 0 0 0
Diarrhoea 87 (64%) 21 (15%) 0 0 27 (19%) 1 (1%) 0 0
Nausea 66 (49%) 3 (2%) 0 0 33 (23%) 2 (1%) 0 0
Vomiting 42 (31%) 6 (4%) 0 0 27 (19%) 1 (1%) 0 0
Oedema, limbs 2 (1%) 0 0 0 4 (3%) 0 0 0
Fatigue 40 (29%) 14 (10%) 0 0 19 (13%) 8 (6%) 0 0
Urinary tract infection 0 0 0 0 0 1 (1%) 0 0
Weight loss 14 (10%) 0 0 0 5 (3%) 0 0 0
Anorexia 49 (36%) 3 (2%) 0 0 20 (14%) 3 (2%) 0 0
Dehydration 4 (3%) 6 (4%) 0 0 0 1 (1%) 0 0
Hyperkalaemia 0 0 1 (1%) 0 0 0 0 0
Bone pain 0 0 0 0 0 1 (1%) 0 0
Lower limb muscle weakness 1 (1%) 0 0 0 0 1 (1%) 0 0
Dizziness 3 (2%) 1 (1%) 0 0 3 (2%) 0 0 0
Acute kidney injury 1 (1%) 1 (1%) 0 0 0 0 0 0
Urine discolouration 29 (21%) 0 0 0 4 (3%) 0 0 0
Hypotension 0 1 (1%) 0 0 0 0 0 0

Adverse events are reported at the worst grade that they occurred. Table shows all adverse events occurring in ≥10% in either study group and all grade 3–5 events.

Table 2: Adverse events deemed at least possibly related to napabucasin or placebo by investigator

Among patients who received placebo, positivity for Discussion

pSTAT3 was a significant poor prognostic factor.
Median overall survival was 3·0 months (95% CI
1·7–4·1) for patients with pSTAT3-positive tumours
versus 4·9 months (4·5–6·1; HR 2·3, 95% CI 1·5–3·6,
p<0·0001) for patients with pSTAT3-negative tumours
(figure 3A).
Among patients with pSTAT3-positive tumours,
median overall survival was 5·1 months (9 4·0–7·5)
with napabucasin versus 3·0 months (1·7–4·1) with
placebo (HR 0·41, 0·23–0·73, p=0·0025; figure 3B).
By contrast, in patients with pSTAT3-negative tumours,
napabucasin was associated with reduced overall
survival (median 4·0 months [95% CI 3·3–5·0] for
pSTAT3-negative patients vs 4·9 months [4·5–6·1] for
pSTAT3-negative patients; HR 1·38, 95% CI 1·03–1·85,
p=0·033; figure 3C). The adjusted p value of interaction
between overall survival benefit from napabucasin
treatment and pSTAT3 status was p<0·0001 (adjusted
HR 0·28, 0·14–0·55).
Positive pSTAT3 expression was not a predictive
factor for progression-free survival benefit from
napabucasin (median 1·8 months [1·1–1·9] for
napabucasin vs 1·8 months [1·7–1·9] for placebo,
adjusted interaction p=0·77). Only two patients in the
napabucasin group and one patient in the placebo
group achieved disease control, which made any
analysis unstable.
In this study of patients with pretreated advanced
colorectal cancer, napabucasin did not improve overall
survival or progression-free survival in unselected
patients compared with placebo. Nevertheless, in the
preplanned biomarker analysis, the expression of
pSTAT3 detected by immunohistochemistry was both a
prognostic marker and a predictive biomarker of benefit
from napabucasin. These results prospectively show for
the first time that positive tumour expression of
pSTAT3 is a poor prognostic factor in patients with
metastatic colorectal cancer. Of the 251 biomarker-
evaluable patients with treatment-refractory disease,
the 55 (22%) patients with pSTAT3-positive tumours
had significantly shorter overall survival than patients
with pSTAT3-negative tumours. In patients with
pSTAT3-positive disease, overall survival was longer in
the napabucasin group than in the placebo group.
The test for interaction between pSTAT3 expression
and benefit from napabucasin was also significant and
remained so when adjusted for other biomarker-
predefined subgroups.
Cancer stem cells are an attractive target for cancer
treatment. STAT3 upregulates genes responsible for the
maintenance of cancer stem cells. Elevated pSTAT3 is
associated with poor prognosis in colorectal cancer,
because of its effects on tumour cells (promoting
proliferation, cell survival, angiogenesis, and invasion),

6 www.thelancet.com/gastrohep Published online January 31, 2018 http://dx.doi.org/10.1016/S2468-1253(18)30009-8

 Articles

and tumour stromal cells (STAT3 suppression of

A
antitumour response of the innate and adaptive 100 HR 2·3 (95% CI 1·5–3·6), p<0·0001 pSTAT3-negative tumours
immune systems). Napabucasin inhibits STAT3, pSTAT3-postive tumours
blocking its pleiotropic effects, including cancer stem 80
cell self-renewal. Despite the effects on overall survival

Overall survival (%)

in patients with pSTAT3-positive tumours, napabucasin 60
did not improve progression-free survival. This effect is
consistent with the mechanism of action of napabucasin: 40
as cancer stem cells represent only a minority of the
tumour cells, it would be anticipated that inhibition of 20
this cellular compartment would not affect progression-
free survival in the short term. 0
0 4 8 12 16 20
Napabucasin 480 mg twice per day was safe, with low Number at risk
rates of serious toxic effects. Grade 1–2 nausea, anorexia, (number censored)
and diarrhoea were common, but generally rapidly pSTAT3 negative 100 60 (6) 29 (6) 13 (6) 13 (5) 10 (5)
pSTAT3 postive 26 10 (0) 2 (0) 0 (0) 18 (8) 12 (8)
reversible upon dose adjustment or discontinuation.
Tolerability of the chosen dose was an issue, with a B
100 HR 0·41 (95% CI 0·23–0·73), p=0·0025 Napabucasin
substantial proportion of patients requiring dose Placebo
adjustments. Physical function was worse at 16 weeks
80
for patients receiving napabucasin, which might be
Overall survival (%)

related to tolerability. Many subsequent and ongoing

60
studies with napabucasin have selected a dose of 240 mg
twice per day. 40
In pSTAT3-negative patients, napabucasin mono-
therapy resulted in significantly worse overall survival 20
versus placebo. Evaluation of ongoing studies of
monotherapy and combinations with chemotherapy will 0
be important to determine whether the detrimental effect 0 2 4 6 8 10 12 14
applies to other settings or combinations. Number at risk
(number censored)
This study was closed early, with patients unmasked Napabucasin 29 (0) 36 (0) 21 (0) 12 (0) 8 (0) 7 (0) 4 (0) 3 (0)
and study therapy stopped. Consequently, some patients Placebo 26 (0) 18 (0) 10 (0) 6 (0) 2 (0) 0 (0) 0 (0) 0 (0)
received as little as one day of therapy. In all analyses,
this situation biases against the identification of a C
100 HR 1·38 (95% CI 1·03–1·85), p=0·033 Napabucasin
treatment effect. Napabucasin may have a larger Placebo
treatment effect than demonstrated in patients with 80
pSTAT3-positive tumours, as suggested in our exploratory
Overall survival (%)

minimum effective treatment analysis (appendix p 5). 60

Additional studies to validate our findings are needed to
established the true magnitude of the treatment effect. 40
Little is known about pSTAT3 expression over time or in
different disease sites. For most patients in this study, 20
pSTAT3 testing was done for primary tumours, and
pSTAT3 positivity was identified in 55 (22%) of 251 patients 0
evaluable for pSTAT3 expression. It is possible that the 0 2 4 6 8 10 12 14
Time (months)
proportion of patients with positive pSTAT3 expression is Number at risk
greater in earlier disease stages than in later stages. (number censored)
Napabucasin 96 68 (4) 45 (4) 30 (4) 17 (4) 11 (4) 8 (4) 6 (4)
The concordance of pSTAT3 expression between primary Placebo 100 85 (2) 60 (6) 38 (6) 29 (6) 20 (6) 13 (6) 10 (6)
tumours and metastases also needs investigation, with the
sparse data available suggesting low concordance between Figure 3: Overall survival in pSTAT3 substudy
paired primaries and metastases.17 (A) Overall survival in patients in the placebo group by tumour pSTAT3 status. (B) Overall survival in patients with
pSTAT3-positive tumours by treatment group. (C) Overall survival in patients with pSTAT3-negative tumours by
A potential limitation of this study is that the tumour treatment group. p<0·0001 for interaction between pSTAT3 positivity and benefit from treatment.
molecular characterisation included KRAS testing, but pSTAT3=phosphorylated signal transducer and activator of transcription-3. HR=hazard ratio.
not extended RAS testing. The definition of sidedness
was also limited to rectum versus colon, rather than the Our results suggest that napabucasin might be an
preferred definition of right versus left, divided at the effective STAT3 inhibitor in patients with tumours
transverse colon. Further investigations of molecular positive for pSTAT3, and further investigation of
characterisation and sidedness are being done. napabucasin as monotherapy in advanced colorectal

www.thelancet.com/gastrohep Published online January 31, 2018 http://dx.doi.org/10.1016/S2468-1253(18)30009-8 7

 Articles
cancer is warranted in these patients. Additionally,
STAT3 is a mediator of chemotherapy resistance,18–22 and
napabucasin in combination with chemotherapy has
shown signs of anticancer activity irrespective of pSTAT3
status.23 As such, further study of napabucasin in
combination with chemotherapy is underway in phase 3
trials in all patients with advanced colorectal cancer
(NCT02753127).
Contributions
DJJ, CJO’C, CJL, and DT conceived and designed the study. DJJ, LN, TY,
SG, JSh, AO, JZ, MMV, ACW, YG, NCT, BM, TE, SK, TP, and JSi
recruited patients. CJL, YL, YG, and WL contributed to the biomarker
development. DT, CJO’C, and NMM collected and assembled the data.
All authors contributed to the data analysis and interpretation and
manuscript writing, and approved the final manuscript.
Declaration of interests
WL and MH are employees of, and hold intellectual property with,
Boston Biomedical. YL and YG were employees at the time of the study
of, and have intellectual property with, Boston Biomedical and are
current employees of 1Globe Health Institute. CJL was an employee of
Boston Biomedical at the time of the study and is an employee of and
holds patents with 1Globe Health Institute. TP reports non-financial
support from Roche and Merck and grants from Amgen. SG has
received honoraria from Amgen, Bristol-Myers Squibb, and Taiho
Pharmaceuticals. JSh has received travel, accommodation, or other
expenses from Amgen and Merck. TY has received grants from
GlaxoSmithKline KK and Nippon Boehringer Ingelheim and honoraria
from Taiho, Chugai, and Eli Lilly. AO reports grants from Bristol-Myers
Squibb. JZ has received personal fees from Bayer, Roche, Amgen, Pfizer,
Specialized Therapeutics, and Merck Serono, travel support from Merck
Serono and Ipsen, and grants from Bayer, Roche, Amgen, Pfizer, Merck
Serono, Novartis, Bristol-Myers Squibb, AstraZeneca, and Shire.
NCT has received honoraria from Merck Serono, Amgen, and Roche.
ACW has received honoraria from Sanofi, Celgene, and Shire. SK has
received honoraria from Celgene. MMV has had advisory roles with
Ipsen, Celgene, and Amgen. TE has received honoraria from Chugai
Pharma, Eli Lilly, Taiho Pharmaceutical, Merck Serono, Ono
Pharmaceutical, Nihon Kayahu, and Eisai and institutional funding from
Eli Lilly, Taiho Pharmaceutical, Merck Serono, Novartis, Daiichi Sankyo,
Dainippon Sumitomo Pharma, AstraZeneca, Boehringer Ingelheim,
MSD, Pfizer, and GlaxoSmithKline. JSi, DJJ, DT, NMM, CJO’C, LN, and
BM declare no competing interests.
Acknowledgments
Funding for this study was supported by the Canadian Cancer Society
Research Institute and Boston Biomedical. A list of additional
participating investigators is available in the appendix.
References
1 Canadian Cancer Society’s Advisory Committee on Cancer Statistics.
Canadian cancer statistics 2016. Toronto: Canadian Cancer Society,
2016.
2 American Cancer Society. Cancer facts & figures 2016.
Atlanta: American Cancer Society, 2016.
3 Hurwitz H, Fehrenbacher L, Novotny W, et al. Bevacizumab plus
irinotecan, fluorouracil, and leucovorin for metastatic colorectal
cancer. N Engl J Med 2004; 350: 2335–42.
4 Cunningham D, Pyrhönen S, James RD, et al. Randomised trial of
irinotecan plus supportive care versus supportive care alone after
fluorouracil failure for patients with metastatic colorectal cancer.
Lancet 1998; 352: 1413–18.
8 www.thelancet.com/gastrohep Published online January 31, 2018 http://dx.doi.org/10.1016/S2468-1253(18)30009-8
5 Goldberg RM, Sargent DJ, Morton RF, et al. A randomized
controlled trial of fluorouracil plus leucovorin, irinotecan, and
oxaliplatin combinations in patients with previously untreated
metastatic colorectal cancer. J Clin Oncol 2004; 22: 23–30.
6 Van Cutsem E, Peeters M, Siena S, et al. Open-label phase III trial
of panitumumab plus best supportive care with best supportive care
alone in patients with chemotherapy-refractory metastatic colorectal
cancer. J Clin Oncol 2007; 25: 1658–64.
7 Jonker DJ, O’Callaghan CJ, Karapetis CS, et al. Cetuximab for the
treatment of colorectal cancer. N Engl J Med 2007; 357: 2040–48.
8 Lin L, Liu A, Peng Z, Lin HJ, Li PK, Lin J. STAT3 is necessary for
proliferation and survival in colon cancer-initiating cells.
Cancer Res 2011; 71: 7226–37.
9 Morikawa T, Baba Y, Yamauchi M, et al. STAT3 expression,
molecular features, inflammation patterns, and prognosis in a
database of 724 colorectal cancers. Clin Cancer Res 2011; 17: 1452–62.
10 Li Y, Rogoff HA, Keates S, et al. Suppression of cancer relapse and
metastasis by inhibiting cancer stemness. Proc Natl Acad Sci USA
2015; 112: 1839–44.
11 Ciombor KK, Edenfield WJ, Hubbard JM, et al. A phase 1b/2 study
of cancer stemness inhibitor BBI608 administered with
panitumumab in KRAS wild-type patients with metastatic colorectal
cancer. Proc Am Soc Clin Oncol 2015; 33 (suppl): abstr 3617.
12 Hubbard JM, Jonker DJ, O’Neil BH, et al. A phase 1b study of
first-in-class cancer stemness inhibitor BBI608 in combination with
FOLFIRI with and without Bevacizumab in patients with advanced
colorectal cancer. Proc Am Soc Clin Oncol 2015;
33 (suppl): abstr 3616.
13 Jonker DJ, Stephenson J, Edenfield WJ, et al. A phase I extension
study of BBI608, a first-in-class cancer stem cell (CSC) inhibitor, in
patients with advanced solid tumors. Proc Am Soc Clin Oncol 2014;
32 (suppl): abstr 2546.
14 Eisenhauer E, Therasse P, Bogaerts J, et al. New response
evaluation criteria in solid tumors: revised RECIST guideline
(version 1.1). Eur J Cancer 2009; 45: 228–47.
15 Aaronson NK, Ahmedzai S, Bergman B, et al. The European
organization for research and treatment of cancer QLQC30:
a quality-of-life instrument for use in international clinical trials in
oncology. J Natl Cancer Inst 1993; 85: 365–76.
16 Klein JP, Moeschberger ML. Survival analysis: techniques for
censored and truncated data. New York: Springer, 1997.
17 Yokom D, Sud S, Marginean H, et al. Signal transducer and
activator of transcription-3 (STAT3) expression concordance in
paired primary and metastatic colorectal cancers (mCRC)
Ann Oncol 2016; 27 (suppl 6): 123.
18 Zhao C, Li H, Lin HJ, Yang S, Lin J, Liang G. Feedback activation of
STAT3 as a cancer drug-resistance mechanism. Trends Pharmacol Sci
2016; 37: 47–61.
19 Kim BH, Yi EH, Ye SK. Signal transducer and activator of
transcription 3 as a therapeutic target for cancer and the tumor
microenvironment. Arch Pharm Res 2016; 39: 1085–99.
20 Spitzner M, Ebner R, Wolff HA, Ghadimi BM, Wienands J,
Grade M. STAT3: a novel molecular mediator of resistance to
chemoradiotherapy. Cancer 2014; 6: 1986–2011.
21 Tan FH, Putoczki TL, Stylli SS, Luwor RB. The role of STAT3
signaling in mediating tumor resistance to cancer therapy.
Curr Drug Targets 2014; 15: 1341–53.
22 Spitzner M, Roesler B, Bielfeld C, et al. STAT3 inhibition sensitizes
colorectal cancer to chemoradiotherapy in vitro and in vivo.
Int J Cancer 2014; 134: 997–1007.
23 Bendell JC, O’Neil BH, Starodub A, et al. Cancer stemness
inhibition and chemosensitization: phase 1b/II study of cancer
stemness inhibitor napabucasin (BBI-608) with FOLFIRI +/-
bevacizumab (Bev) administered to colorectal cancer (CRC) patients
(pts). Proc Am Soc Clin Oncol 2017; 35 (suppl 4S): abstr 593.