Johansson et al. (2021): Vitamin D Supplementation and Disease-Free Survival in Stage II Melanoma: A Randomized Placebo Controlled Trial

Reference ↗
Title	Vitamin D Supplementation and Disease-Free Survival in Stage II Melanoma: A Randomized Placebo Controlled Trial
Topic	Vitamin D
Author	Johansson, H, Spadola, G, Tosti, G, Mandalà, M, Minisini, AM, Queirolo, P, Aristarco, V, Baldini, F, Cocorocchio, E, Albertazzi, E, Zichichi, L, Cinieri, S, Jemos, C, Mazzarol, G, Gnagnarella, P, Macis, D, Tedeschi, I, Salè, EO, Stucci, LS, Bonanni, B, Testori, A, Pennacchioli, E, Ferrucci, PF, Gandini, S
Year	2021
Journal	nutritients
DOI	https://doi.org/10.3390/nu13061931

Brief summary

104 patients with surgically removed melanomas were included in the study. Divided equally and randomly into 2 arms, one half received 100,000 I.U. vitamin D3 every 50 days for 3 years and the other half received a placebo. The time to relapse was investigated. At the end of the study, no differences were found between the arms in this respect. In further analyses, benefits were only found for patients with a low tumor thickness alone and in combination with a high serum vitamin D level after 12 months of supplementation. It is unclear why most of the reported results of the study were calculated “after 12 months of supplementation”, although the intervention took place over 3 years.

In der Studie von wurden 104 Patienten mit operativ entfernten Melanomen eingeschlossen. Gleichmäßig und zufällig in 2 Arme eingeteilt, erhielt die eine Hälfte alle 50 Tage 100.000 I.E. Vitamin D3 über 3 Jahre und die andere Hälfte ein Placebo. Untersucht wurde die Zeit bis zu einem Rückfall. Am Ende der Studie konnten diesbezüglich keine Unterschiede zwischen den Armen gefunden werden. In weiteren Analysen konnten nur Vorteile gefunden werden für Patienten mit einer geringen Tumordicke allein und in Kombination mit einem hohen Serum Vitamin D Wert nach 12 Monaten Supplementierung. Unklar ist, warum die meisten berichteten Ergebnisse der Studie „nach 12 Monaten Supplementierung“ berechnet wurden, obwohl die Intervention über 3 Jahre stattfand.

Study Design

Prospective / Retrospective Prospective: forward-looking, examples include clinical trials, cohort studies, and long-term observational studies;</br>Retrospective: backward-looking, relying on existing data, examples include case-control studies and retrospective cohort studies	Prospective
Monocentric / Multicentric Monocentric: conducted in one center/ hospital; </br>Multicentric: conducted in multiple centers/ hospitals	Multicentric
Blinding No: Open, all parties are aware of group assignments;</br>Single: one party is unaware of group assignments (generally participants);</br>Double: two parties are unaware of group assignments (generally the participants and the researchers); </br>Triple: concealing group assignment from additional parties	Double
Is randomized	Yes
Cross-over Participants alternate between different treatment groups or conditions over a specified period, allowing each participant to serve as their own control	No
Number of arms	2

Study characteristics

Inclusion criteria	Aged 75 years or younger with recent resected stage II cutaneous malignant melanoma; Hematopoietic, hepatic, and renal functionality within normal ranges
Exclusion criteria	Current use of at least 600 IU/day of supplemental vitamin D or high-dose calcium therapy within the prior 6 month and any prior cancer or other significant diseases that could hamper the participant’s safety or preclude the benefit of vitamin D supplementation
N randomized	114
Analysis PP: Per Protocol analysis, i.e. only participants included who adhered to the study protocol.</br>ITT: Intention-to-treat analysis, i.e. all randomized participants included regardless of any drop-outs or changes in assignment.</br>mITT: modified Intention-to-treat analysis can refer to analyses in which participants with missing outcome data are excluded or it can refer to analyses in which only participants who received at least one treatment dose are included. In this case, participants dropped out of the study prematurely for reasons unrelated to the treatment.	PP Analysis
Specifications on analyses	NI
Countries of data collection	Italy
LoE Level of evidence	Level 2 Oxford 2011
Outcome timeline Data collection times	T0: Baseline 13 follow-up visits (4th, 8th, 12th, 16th, 20th, 24th, 28th, 32nd, 36th, 42nd, 48th, 54th, and 60th month)

Characteristics of participants

Setting Refers to cancer therapy setting.</br>- Curative therapy: aims to completely eradicate a disease and achieve a full recovery; </br>- Neo-adjuvant therapy: form of curative therapy, given before the primary treatment for cancer (usually surgery); </br>- Adjuvant therapy: form of curative therapy, given after the primary treatment for cancer (usually surgery); </br>- Palliative therapy: focuses on providing relief from symptoms and improving the quality of life for patients, without necessarily targeting the underlying disease; </br>- Active surveillance: involves close monitoring of disease progression without any intervention (typically used for prostate cancer);</br>- No therapy setting: Patients who completed therapy/are currently not in cancer treatment, cancer survivors.	NI
Types of cancer "Other Cancers" means that only a subpopulation was specified, but further unspecified cancer types were included	Skin Cancer – Melanoma
Cancer stages Early Stage: generally refers to cancer that is localized to the area where it started, mostly stages I and II;</br>Advanced Stage: cancer that has spread beyond its original site, mostly stages III and IV, with stage IV indicating distant metastasis	Early Stage
Specifications on cancer stages	Stage II
Comorbidities	NI
Current cancer therapies	NI
Specifications on cancer therapies	NI
Previous cancer therapies
Gender	Mixed
Gender specifications	57% male, 43% female
Age groups	Adults (18+)
Age groups specification	Median: 51

Arms

Arm type Active control: group receives active treatment; </br>Passive control: for example treatment as usual, waiting control, no treatment	Intervention
Number of participants (arm) N randomized	52
Drop-out Number of participants who left the study for any reason or did not provide information on every data collection date	Not arm specified before analysis: 10
Drop-out reasons	Not arm specified: 1 pregnancy, 2 voluntary withdrawal,1 osteoporosis treatment
Intervention	Vitamin D
Dosage and regime	Oral solution in ampoule containing 100,000 IU of vitamin D3 (an average of 2000 IU/day), every 50 days, for 3 years
One-time application	No
Duration in days For long-term interventions, the number of days is an estimation.</br>A value of -999 indicates that the exact duration cannot be extracted from the study due to ambiguous or incomplete information. See Outcome timeline or Dosage and regime for further information.	1,096
Side effects / Interactions	No severe adverse events: 7% grade 1–2 adverse events, no grade 3–4 events, neither of the events were linked to 25OHD serum levels

Arm type Active control: group receives active treatment; </br>Passive control: for example treatment as usual, waiting control, no treatment	Placebo
Number of participants (arm) N randomized	52
Drop-out Number of participants who left the study for any reason or did not provide information on every data collection date	Not arm specified before analysis: 10
Drop-out reasons	Not arm specified: 1 pregnancy, 2 voluntary withdrawal,1 osteoporosis treatment
Intervention	Placebo
Dosage and regime	Oral solution in ampoule containing placebo, every 50 days, for 3 years
One-time application	No
Duration in days For long-term interventions, the number of days is an estimation.</br>A value of -999 indicates that the exact duration cannot be extracted from the study due to ambiguous or incomplete information. See Outcome timeline or Dosage and regime for further information.	1,096
Side effects / Interactions	No severe adverse events: 7% grade 1–2 adverse events, no grade 3–4 events

Outcomes

DFS (Disease-Free Survival)

Outcome type As specificed by the authors	Primary
Outcome specification	NI
Type of measurement	Observation
Results during intervention - Results during intervention means that the time of data collection is during or shortly after the period of the intervention (e.g. on the last day or a few days after). The results therefore still relate to the direct effects of the intervention.</br>- Results after intervention means there is a longer break between the time of data collection and the end of the intervention, e.g. more than a week. The results relate more to long-term effects.</br>- If a categorization in Results during vs. after intervention is not possible (e.g. survival data), the results are summarized under Results after intervention under the headline "Overall".	After a median follow-up of 3 years: no difference by treatment in disease-free survival
Results after intervention - Results during intervention means that the time of data collection is during or shortly after the period of the intervention (e.g. on the last day or a few days after). The results therefore still relate to the direct effects of the intervention.</br>- Results after intervention means there is a longer break between the time of data collection and the end of the intervention, e.g. more than a week. The results relate more to long-term effects.</br>- If a categorization in Results during vs. after intervention is not possible (e.g. survival data), the results are summarized under Results after intervention under the headline "Overall".	NA

Risk of Bias Assessment: Cochrane RoB tool 2.0
Bias arising from the randomization process	some concerns
Bias due to deviation from intended intervention (assignment to intervention)	low risk
Bias due to deviation from intended intervention (adhering to intervention)	NA
Bias due to missing outcome data	low risk
Bias in measurement of the outcome	low risk
Bias in selection of the reported result	low risk
Other sources of bias	NA
Overall RoB judgment	some concerns

Vitamin D level

Outcome type As specificed by the authors	Secondary
Outcome specification	Time of serum 25OHD levels and percentage of patients that reached the 25OHD cut-off level of sufficiency (>30 ng/mL from August to November and >20 ng/mL from January to July) during the 1st year
Type of measurement	Blood Test
Results during intervention - Results during intervention means that the time of data collection is during or shortly after the period of the intervention (e.g. on the last day or a few days after). The results therefore still relate to the direct effects of the intervention.</br>- Results after intervention means there is a longer break between the time of data collection and the end of the intervention, e.g. more than a week. The results relate more to long-term effects.</br>- If a categorization in Results during vs. after intervention is not possible (e.g. survival data), the results are summarized under Results after intervention under the headline "Overall".	Majority of participants: low levels of 25OHD (80%); Serum levels of 25OHD sharply rose already after 4 months of supplementation in the intervention arm (Median: 33 ng/mL), compared to the placebo arm (Median: 19 ng/mL), the increase persisted with the duration of the treatment (42 ng/mL vs. 22 ng/mL after 3 years treatment) Additionally: difference in 25OHD increase by Breslow thickness: patients with Breslow thickness below 3 mm had a doubling of 25OHD serum levels from baseline after 12 months, patients with greater thickness experienced a much lower increases in 25OHD by time
Results after intervention - Results during intervention means that the time of data collection is during or shortly after the period of the intervention (e.g. on the last day or a few days after). The results therefore still relate to the direct effects of the intervention.</br>- Results after intervention means there is a longer break between the time of data collection and the end of the intervention, e.g. more than a week. The results relate more to long-term effects.</br>- If a categorization in Results during vs. after intervention is not possible (e.g. survival data), the results are summarized under Results after intervention under the headline "Overall".	NA

Risk of Bias Assessment: Cochrane RoB tool 2.0
Bias arising from the randomization process	NA
Bias due to deviation from intended intervention (assignment to intervention)	NA
Bias due to deviation from intended intervention (adhering to intervention)	NA
Bias due to missing outcome data	NA
Bias in measurement of the outcome	NA
Bias in selection of the reported result	NA
Other sources of bias	NA
Overall RoB judgment	NA

Funding and Conflicts of Interest

Funding	Supported by the Foundation Umberto Veronesi; partially supported by the Italian Ministry of Health with Ricerca Corrente and 5×1000 funds
Conflicts of Interest	According to authors no conflict of interest

Further points for assessing the study

Sample

Power analysis performed	No
- Sample size corresponds to power analysis	NA
- Reasons for insufficient sample size based on power analysis	NA
If no power analysis performed: at least moderate sample size (n >= 30 per arm)	Yes
Ethnicity mentioned	No

Alternative Explanation

Other explanations for an effect besides the investigated intervention	NI
- Possibility of attention effects	NA
- Possibility of placebo effects	NA
- Other reasons	NA

Statistics

Correct use of parametric and non-parametric tests Testing for normal distribution only necessary if parametric tests are used, NI: use of parametric tests without report of normal distribution testing	Yes
Correction for multiple testing	NA
Measurement of compliance	Yes
Consistent reporting in numbers (figures, flowchart, abstract, results)	Yes
Comprehensive and coherent reporting	No
Cross-over	No
- Sufficient washout period	NA
- Tested for carry-over effects	NA
- Tested for sequence effects	NA

Interpretation of results

Effect sizes reported (clinical vs. statistical significance)	No
Side effects systematically recorded	Yes
Side effects considered in result interpretation	No
Ethics votum	Yes

Additional Notes

PRO:

• Ethics vote
• Randomization with stratification
• Adherence tested by serum concentration
• Comparability of the groups given

CONTRA:

• Further drop-out over time, without information in the flowchart
• Intervention length 3 years, but additional analyses to DFS analyses with supplementation after one year
• No precise indication of the side effects that occurred
• No report on power analysis, but in the discussion it is reported that the study is “underpowered” for the primary endpoint
• Lack of scientific data on the selected dose regimen