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    Clinical Trial Results:
    Phase II study of cabazitaxel as 2nd-line treatment in patients with HER-2 negative metastatic breast cancer previously treated with taxanes.

    Summary
    EudraCT number
    2011-003625-97
    Trial protocol
    GR  
    Global end of trial date
    20 Jul 2017

    Results information
    Results version number
    v1(current)
    This version publication date
    04 Oct 2019
    First version publication date
    04 Oct 2019
    Other versions

    Trial information

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    Trial identification
    Sponsor protocol code
    HE11B11
    Additional study identifiers
    ISRCTN number
    -
    US NCT number
    NCT01693549
    WHO universal trial number (UTN)
    -
    Sponsors
    Sponsor organisation name
    Hellenic Cooperative Oncology Group
    Sponsor organisation address
    Hatzikostanti 18, Athens, Greece, 11524
    Public contact
    Clinical Trials, Hellenic Cooperative Oncology Group, hecogoff@otenet.gr
    Scientific contact
    Clinical Trials, Hellenic Cooperative Oncology Group, hecogoff@otenet.gr
    Paediatric regulatory details
    Is trial part of an agreed paediatric investigation plan (PIP)
    No
    Does article 45 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Does article 46 of REGULATION (EC) No 1901/2006 apply to this trial?
    No
    Results analysis stage
    Analysis stage
    Final
    Date of interim/final analysis
    27 Nov 2017
    Is this the analysis of the primary completion data?
    No
    Global end of trial reached?
    Yes
    Global end of trial date
    20 Jul 2017
    Was the trial ended prematurely?
    No
    General information about the trial
    Main objective of the trial
    The primary objective is to assess the clinical activity of cabazitaxel regarding the objective response rate (ORR).
    Protection of trial subjects
    The study was conducted in accordance with the ethical principles of the Declaration of Helsinki, the Good Clinical Practice guidelines and the local regulatory requirements.
    Background therapy
    -
    Evidence for comparator
    -
    Actual start date of recruitment
    03 Oct 2012
    Long term follow-up planned
    No
    Independent data monitoring committee (IDMC) involvement?
    No
    Population of trial subjects
    Number of subjects enrolled per country
    Country: Number of subjects enrolled
    Greece: 84
    Worldwide total number of subjects
    84
    EEA total number of subjects
    84
    Number of subjects enrolled per age group
    In utero
    0
    Preterm newborn - gestational age < 37 wk
    0
    Newborns (0-27 days)
    0
    Infants and toddlers (28 days-23 months)
    0
    Children (2-11 years)
    0
    Adolescents (12-17 years)
    0
    Adults (18-64 years)
    63
    From 65 to 84 years
    21
    85 years and over
    0

    Subject disposition

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    Recruitment
    Recruitment details
    Participants were enrolled in the study from 3 October 2012 until 11 November 2016 from 15 sites in Greece.

    Pre-assignment
    Screening details
    Patients were screened for eligibility before entering the study and signed the informed consent form which was obtained before any study procedure.

    Period 1
    Period 1 title
    overall trial (overall period)
    Is this the baseline period?
    Yes
    Allocation method
    Not applicable
    Blinding used
    Not blinded

    Arms
    Arm title
    Cabazitaxel
    Arm description
    -
    Arm type
    Experimental

    Investigational medicinal product name
    Cabazitaxel
    Investigational medicinal product code
    Other name
    Pharmaceutical forms
    Concentrate and solvent for solution for infusion
    Routes of administration
    Intravenous use
    Dosage and administration details
    Cabazitaxel was administered on day 1 of each cycle, at a dose of 25 mg/m2 intravenously in 1 hour, every 21 days.

    Number of subjects in period 1
    Cabazitaxel
    Started
    84
    Completed
    25
    Not completed
    59
         Adverse event, serious fatal
    2
         Physician decision
    2
         Consent withdrawn by subject
    3
         Adverse event, non-fatal
    4
         Death
    1
         Other
    3
         Progression
    44

    Baseline characteristics

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    Baseline characteristics reporting groups
    Reporting group title
    overall trial
    Reporting group description
    -

    Reporting group values
    overall trial Total
    Number of subjects
    84 84
    Age categorical
    Units: Subjects
        Adults (18-64 years)
    63 63
        From 65-84 years
    21 21
        85 years and over
    0 0
    Age continuous
    Units: years
        median (full range (min-max))
    57.5 (33.5 to 74.9) -
    Gender categorical
    Units: Subjects
        Female
    84 84
        Male
    0 0
    Subject analysis sets

    Subject analysis set title
    Response evaluable population
    Subject analysis set type
    Sub-group analysis
    Subject analysis set description
    Analysis of response was additionally conducted in the subgroup of patients with measurable disease who received at least 2 cycles of cabazitaxel. In addition, cases with early disease progression (prior to cycle 2) were not excluded from this subgroup of patients.

    Subject analysis sets values
    Response evaluable population
    Number of subjects
    78
    Age categorical
    Units: Subjects
        Adults (18-64 years)
    59
        From 65-84 years
    19
        85 years and over
    Age continuous
    Units: years
        median (full range (min-max))
    57.5 (33.5 to 74.9)
    Gender categorical
    Units: Subjects
        Female
    78
        Male
    0

    End points

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    End points reporting groups
    Reporting group title
    Cabazitaxel
    Reporting group description
    -

    Subject analysis set title
    Response evaluable population
    Subject analysis set type
    Sub-group analysis
    Subject analysis set description
    Analysis of response was additionally conducted in the subgroup of patients with measurable disease who received at least 2 cycles of cabazitaxel. In addition, cases with early disease progression (prior to cycle 2) were not excluded from this subgroup of patients.

    Primary: Objective response rate

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    End point title
    Objective response rate [1]
    End point description
    The primary endpoint of the clinical study was to evaluate the activity of cabazitaxel as 2nd line treatment in HER2-negative metastatic breast cancer patients.The objective response rate (ORR) was assessed according to response evaluation criteria in solid tumours (RECIST) guidelines.
    End point type
    Primary
    End point timeframe
    Tumor response was assessed every 8 weeks through week 24 and every 3 months thereafter, until treatment completion
    Notes
    [1] - No statistical analyses have been specified for this primary end point. It is expected there is at least one statistical analysis for each primary end point.
    Justification: Since this was a single arm study and all patients received the same treatment, no comparisons between groups were applicable. The percentage of patients with a confirmed complete or partial response was estimated using descriptive statistics in the entire study cohort and in the response evaluable population.
    End point values
    Cabazitaxel Response evaluable population
    Number of subjects analysed
    84
    78
    Units: percentage of patients with CR or PR
        Objective response rate (%)
    23
    24
    No statistical analyses for this end point

    Secondary: Overall survival

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    End point title
    Overall survival
    End point description
    Overall survival was calculated from the date of patient's entry into the study to the date of death. Alive patients were censored at the date of their last contact.
    End point type
    Secondary
    End point timeframe
    Patients were followed-up for a median of 32.2 months (95% CI 21.02-40.07).
    End point values
    Cabazitaxel
    Number of subjects analysed
    84
    Units: months
        median (confidence interval 95%)
    15.2 (11.21 to 21.54)
    Attachments
    Kaplan-Meier with respect to OS
    No statistical analyses for this end point

    Secondary: Safety profile

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    End point title
    Safety profile
    End point description
    The safety profile was assessed in the safety population consisting of all enrolled patients that received at least one dose of the study drug.
    End point type
    Secondary
    End point timeframe
    All AEs were followed until resolution or until 30 days after the last dose of study treatment.
    End point values
    Cabazitaxel
    Number of subjects analysed
    84
    Units: number of patients
        Any adverse event
    72
        Adverse events ≥ grade 3
    36
        Adverse events ≥ grade 4
    17
        Fatal adverse events
    2
        Serious adverse events
    20
    No statistical analyses for this end point

    Secondary: Progression Free Survival

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    End point title
    Progression Free Survival
    End point description
    Progression free survival (PFS) was calculated from the date of study entry to the date of first documented progression, death from any cause or last contact.
    End point type
    Secondary
    End point timeframe
    Patients were followed up for a median of 32.2 months (95% CI 21.02-40.07).
    End point values
    Cabazitaxel
    Number of subjects analysed
    84
    Units: months
        median (confidence interval 95%)
    3.7 (2.23 to 4.36)
    Attachments
    Kaplan-Meier curve with respect to PFS.
    No statistical analyses for this end point

    Secondary: Duration of response

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    End point title
    Duration of response
    End point description
    Duration of response (DOR) was measured as the time interval between the date of onset of a complete or partial response and the date of progression, death from any cause or last contact, whichever occurred first.
    End point type
    Secondary
    End point timeframe
    Tumor response was assessed every 8 weeks though week 24 and every 3 months thereafter, until treatment completion.
    End point values
    Cabazitaxel
    Number of subjects analysed
    19 [2]
    Units: months
        median (full range (min-max))
    5.6 (0.7 to 51.3)
    Notes
    [2] - DOR was only analysed for patients that achieved a complete or partial response.
    No statistical analyses for this end point

    Adverse events

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    Adverse events information
    Timeframe for reporting adverse events
    pEvaluation of Adverse Events will be performed every 21 days (per cycle) during treatment assessed up to 30 months.
    Assessment type
    Systematic
    Dictionary used for adverse event reporting
    Dictionary name
    MedDRA
    Dictionary version
    20.0
    Reporting groups
    Reporting group title
    Cabazitaxel
    Reporting group description
    Cabazitaxel (XRP6258) will be administered on day 1 each cycle, every 21 days, at a dose of 25 mg/m^2 by i.v. route in 1 hour. Treatment could be continued until patient's consent withdrawal, intolerable toxicity or documented disease progression.

    Serious adverse events
    Cabazitaxel
    Total subjects affected by serious adverse events
         subjects affected / exposed
    20 / 84 (23.81%)
         number of deaths (all causes)
    55
         number of deaths resulting from adverse events
    2
    Investigations
    Neutrophil count decreased
         subjects affected / exposed
    3 / 84 (3.57%)
         occurrences causally related to treatment / all
    3 / 3
         deaths causally related to treatment / all
    0 / 0
    Vascular disorders
    Thrombosis
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Nervous system disorders
    Cerebral disorder
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Headache
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Blood and lymphatic system disorders
    Leukopenia
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    Thrombocytopenia
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    Febrile neutropenia
         subjects affected / exposed
    6 / 84 (7.14%)
         occurrences causally related to treatment / all
    8 / 8
         deaths causally related to treatment / all
    0 / 1
    Anaemia
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    2 / 2
         deaths causally related to treatment / all
    0 / 0
    General disorders and administration site conditions
    Fatigue
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    Ear and labyrinth disorders
    Vertigo
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Gastrointestinal disorders
    Epigastric pain
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Abdominal pain
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Vomiting
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Neutropenic enterocolitis
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    Respiratory, thoracic and mediastinal disorders
    Dyspnoea exacerbated
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Dyspnoea
         subjects affected / exposed
    2 / 84 (2.38%)
         occurrences causally related to treatment / all
    0 / 2
         deaths causally related to treatment / all
    0 / 0
    Renal and urinary disorders
    Hematuria
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    Acute kidney injury
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Impaired renal function
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Infections and infestations
    Skin infection
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    1 / 1
         deaths causally related to treatment / all
    0 / 0
    Septic shock
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    1 / 1
         deaths causally related to treatment / all
    1 / 1
    Metabolism and nutrition disorders
    Hypocalcaemia
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences causally related to treatment / all
    0 / 1
         deaths causally related to treatment / all
    0 / 0
    Frequency threshold for reporting non-serious adverse events: 0%
    Non-serious adverse events
    Cabazitaxel
    Total subjects affected by non serious adverse events
         subjects affected / exposed
    69 / 84 (82.14%)
    Vascular disorders
    Hypertension
         subjects affected / exposed
    6 / 84 (7.14%)
         occurrences all number
    8
    General disorders and administration site conditions
    Edema limbs
         subjects affected / exposed
    2 / 84 (2.38%)
         occurrences all number
    2
    Fatigue
         subjects affected / exposed
    26 / 84 (30.95%)
         occurrences all number
    35
    Fever
         subjects affected / exposed
    5 / 84 (5.95%)
         occurrences all number
    11
    Flu like symptoms
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Gait disturbance
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Pain - other
    Additional description: due to right ureteral dilatation
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Axillary pain
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Pain
    Additional description: other - In right and left supraclavicular area
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Immune system disorders
    Allergic reaction
         subjects affected / exposed
    2 / 84 (2.38%)
         occurrences all number
    2
    Respiratory, thoracic and mediastinal disorders
    Cough
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Epistaxis
         subjects affected / exposed
    3 / 84 (3.57%)
         occurrences all number
    3
    Nasal congestion
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Voice alteration
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Psychiatric disorders
    Personality disorder
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Investigations
    Alanine aminotransferase increased
         subjects affected / exposed
    5 / 84 (5.95%)
         occurrences all number
    5
    Alkaline phosphatase increased
         subjects affected / exposed
    9 / 84 (10.71%)
         occurrences all number
    9
    Aspartate aminotransferase increased
         subjects affected / exposed
    12 / 84 (14.29%)
         occurrences all number
    14
    Blood bilirubin increased
         subjects affected / exposed
    6 / 84 (7.14%)
         occurrences all number
    6
    Cholesterol high
         subjects affected / exposed
    9 / 84 (10.71%)
         occurrences all number
    11
    CPK increased
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Creatinine increased
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    GGT increased
         subjects affected / exposed
    15 / 84 (17.86%)
         occurrences all number
    23
    LDH increased
         subjects affected / exposed
    5 / 84 (5.95%)
         occurrences all number
    9
    Lymphocyte count decreased
         subjects affected / exposed
    8 / 84 (9.52%)
         occurrences all number
    17
    Neutrophil count decreased
         subjects affected / exposed
    24 / 84 (28.57%)
         occurrences all number
    44
    Platelet count decreased
         subjects affected / exposed
    19 / 84 (22.62%)
         occurrences all number
    48
    White blood cell count decreased
         subjects affected / exposed
    27 / 84 (32.14%)
         occurrences all number
    62
    Lymphocyte count increased
         subjects affected / exposed
    2 / 84 (2.38%)
         occurrences all number
    5
    Nervous system disorders
    Dizziness
         subjects affected / exposed
    2 / 84 (2.38%)
         occurrences all number
    2
    Headache
         subjects affected / exposed
    4 / 84 (4.76%)
         occurrences all number
    13
    Loss of consciousness
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Peripheral motor neuropathy
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Peripheral sensory neuropathy
         subjects affected / exposed
    10 / 84 (11.90%)
         occurrences all number
    13
    Somnolence
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Blood and lymphatic system disorders
    Anaemia
         subjects affected / exposed
    36 / 84 (42.86%)
         occurrences all number
    68
    Lymphopenia
         subjects affected / exposed
    2 / 84 (2.38%)
         occurrences all number
    2
    Leukocytosis
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Eye disorders
    Blurred vision
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Eye pain
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Gastrointestinal disorders
    Constipation
         subjects affected / exposed
    4 / 84 (4.76%)
         occurrences all number
    10
    Diarrhoea
         subjects affected / exposed
    15 / 84 (17.86%)
         occurrences all number
    19
    Flatulence
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Gastrointestinal pain
         subjects affected / exposed
    7 / 84 (8.33%)
         occurrences all number
    11
    Mucositis oral
         subjects affected / exposed
    3 / 84 (3.57%)
         occurrences all number
    3
    Nausea
         subjects affected / exposed
    10 / 84 (11.90%)
         occurrences all number
    13
    Vomiting
         subjects affected / exposed
    7 / 84 (8.33%)
         occurrences all number
    8
    Skin and subcutaneous tissue disorders
    Alopecia
         subjects affected / exposed
    8 / 84 (9.52%)
         occurrences all number
    8
    Nail discoloration
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Nail loss
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Palmar-plantar erythrodysaesthesia syndrome
         subjects affected / exposed
    2 / 84 (2.38%)
         occurrences all number
    2
    Pruritus
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Redness
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Onycholysis
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Renal and urinary disorders
    Haematuria
         subjects affected / exposed
    4 / 84 (4.76%)
         occurrences all number
    6
    Proteinuria
         subjects affected / exposed
    3 / 84 (3.57%)
         occurrences all number
    3
    Renal colic
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Musculoskeletal and connective tissue disorders
    Low back pain
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Psoriatic arthritis
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Arthralgia
         subjects affected / exposed
    3 / 84 (3.57%)
         occurrences all number
    3
    Bone pain
         subjects affected / exposed
    9 / 84 (10.71%)
         occurrences all number
    17
    Buttock pain
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Muscle weakness
    Additional description: Lower limb
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Myalgia
         subjects affected / exposed
    2 / 84 (2.38%)
         occurrences all number
    2
    Infections and infestations
    Bladder infection
         subjects affected / exposed
    2 / 84 (2.38%)
         occurrences all number
    3
    Flu
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    4
    Viral infection
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    3
    Laryngitis
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Upper respiratory tract infection
         subjects affected / exposed
    4 / 84 (4.76%)
         occurrences all number
    5
    Urinary tract infection
         subjects affected / exposed
    2 / 84 (2.38%)
         occurrences all number
    2
    Pyuria
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Metabolism and nutrition disorders
    Polydipsia
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Anorexia
         subjects affected / exposed
    4 / 84 (4.76%)
         occurrences all number
    4
    Hypercalcaemia
         subjects affected / exposed
    3 / 84 (3.57%)
         occurrences all number
    3
    Hyperglycaemia
         subjects affected / exposed
    10 / 84 (11.90%)
         occurrences all number
    14
    Hyperkalaemia
         subjects affected / exposed
    2 / 84 (2.38%)
         occurrences all number
    8
    Hypermagnesaemia
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    2
    Hypernatraemia
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    1
    Hypertriglyceridaemia
         subjects affected / exposed
    9 / 84 (10.71%)
         occurrences all number
    11
    Hyperuricaemia
         subjects affected / exposed
    8 / 84 (9.52%)
         occurrences all number
    9
    Hypoalbuminaemia
         subjects affected / exposed
    3 / 84 (3.57%)
         occurrences all number
    3
    Hypocalcaemia
         subjects affected / exposed
    4 / 84 (4.76%)
         occurrences all number
    8
    Hypoglycaemia
         subjects affected / exposed
    3 / 84 (3.57%)
         occurrences all number
    5
    Hypokalaemia
         subjects affected / exposed
    4 / 84 (4.76%)
         occurrences all number
    5
    Hypomagnesaemia
         subjects affected / exposed
    1 / 84 (1.19%)
         occurrences all number
    2
    Hyponatraemia
         subjects affected / exposed
    3 / 84 (3.57%)
         occurrences all number
    3

    More information

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    Substantial protocol amendments (globally)

    Were there any global substantial amendments to the protocol? Yes
    Date
    Amendment
    08 Jul 2013
    Primary prophylaxis with Pegfilgrastim was recommended in all patients, due to the high incidence of Cabazitaxel-associated neutropenia.

    Interruptions (globally)

    Were there any global interruptions to the trial? No

    Limitations and caveats

    Limitations of the trial such as small numbers of subjects analysed or technical problems leading to unreliable data.
    None reported
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