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Trial details imported from ClinicalTrials.gov

For full trial details, please see the original record at https://clinicaltrials.gov/study/NCT04821622




Registration number
NCT04821622
Ethics application status
Date submitted
25/03/2021
Date registered
29/03/2021

Titles & IDs
Public title
Study of Talazoparib With Enzalutamide in Men With DDR Gene Mutated mCSPC
Scientific title
TALAPRO-3: A PHASE 3, RANDOMIZED, DOUBLE-BLIND, STUDY OF TALAZOPARIB WITH ENZALUTAMIDE VERSUS PLACEBO WITH ENZALUTAMIDE IN MEN WITH DDR GENE MUTATED METASTATIC CASTRATION-SENSITIVE PROSTATE CANCER
Secondary ID [1] 0 0
TALAPRO-3
Secondary ID [2] 0 0
C3441052
Universal Trial Number (UTN)
Trial acronym
Linked study record

Health condition
Health condition(s) or problem(s) studied:
Prostate Cancer 0 0
Condition category
Condition code
Cancer 0 0 0 0
Prostate

Intervention/exposure
Study type
Interventional
Description of intervention(s) / exposure
Treatment: Drugs - talazoparib plus enzalutamide
Treatment: Drugs - Placebo plus enzalutamide

Experimental: Arm 1 - Talazoparib plus enzalutamide

Active comparator: Arm 2 - Placebo plus enzalutamide


Treatment: Drugs: talazoparib plus enzalutamide
experimental arm

Treatment: Drugs: Placebo plus enzalutamide
Active comparator arm

Intervention code [1] 0 0
Treatment: Drugs
Comparator / control treatment
Control group

Outcomes
Primary outcome [1] 0 0
radiological Progression-Free Survival
Timepoint [1] 0 0
randomization up to 3 years
Secondary outcome [1] 0 0
Overall Survival
Timepoint [1] 0 0
randomization up to 4 years
Secondary outcome [2] 0 0
Objective response in measurable soft tissue disease
Timepoint [2] 0 0
randomization up to 3 years
Secondary outcome [3] 0 0
Duration of response in measurable soft tissue disease
Timepoint [3] 0 0
randomization up to 3 years
Secondary outcome [4] 0 0
Prostate Specific Antigen (PSA) response
Timepoint [4] 0 0
randomization up to 3 years
Secondary outcome [5] 0 0
Time to PSA progression
Timepoint [5] 0 0
randomization up to 3 years
Secondary outcome [6] 0 0
Time to initiation of antineoplastic therapy
Timepoint [6] 0 0
randomization up to 3 years
Secondary outcome [7] 0 0
Time to first symptomatic skeletal event
Timepoint [7] 0 0
randomization up to 3 years
Secondary outcome [8] 0 0
Opiate use for prostate cancer pain
Timepoint [8] 0 0
randomization up to 3 years
Secondary outcome [9] 0 0
Incidence of adverse events
Timepoint [9] 0 0
randomization up to 3 years
Secondary outcome [10] 0 0
Pharmacokinetic assessment of talazoparib
Timepoint [10] 0 0
Weeks 5, 9, 13, and 17
Secondary outcome [11] 0 0
Pharmacokinetic assessment of enzalutamide and its metabolite
Timepoint [11] 0 0
Weeks 5, 9, 13, and 17
Secondary outcome [12] 0 0
Relationship between ctDNA burden and outcome
Timepoint [12] 0 0
randomization up to 3 years
Secondary outcome [13] 0 0
Patient-reported outcomes in pain symptoms - change from baseline
Timepoint [13] 0 0
randomization up to 3 years
Secondary outcome [14] 0 0
Patient-reported outcomes in pain symptoms - time to deterioration
Timepoint [14] 0 0
randomization up to 3 years
Secondary outcome [15] 0 0
Patient-reported outcomes in cancer specific general health status - change from baseline
Timepoint [15] 0 0
randomization up to 3 years
Secondary outcome [16] 0 0
Patient-reported outcomes in cancer specific global health status/QoL - change from baseline
Timepoint [16] 0 0
randomization up to 3 years
Secondary outcome [17] 0 0
Patient-reported outcomes in cancer specific global health status/QoL - time to definitive deterioration
Timepoint [17] 0 0
randomization up to 3 years
Secondary outcome [18] 0 0
Patient-reported outcomes in cancer specific symptoms - time to definitive deterioration
Timepoint [18] 0 0
randomization up to 3 years
Secondary outcome [19] 0 0
Patient-reported outcome: cancer specific functioning, and symptoms - change from baseline
Timepoint [19] 0 0
randomization up to 3 years

Eligibility
Key inclusion criteria
1. Male participants at least 18 years of age at screening (20 years for Japan, 19 years for Republic of Korea).
2. Histologically or cytologically confirmed adenocarcinoma of the prostate without neuroendocrine differentiation, small cell or signet cell features. If the participant does not have a prior histological diagnosis, a baseline de novo biopsy must be used to confirm the diagnosis and may also be used to support biomarker analysis.
3. Confirmation of DDR gene mutation status by prospective or historical analysis (with sponsor pre-approval) of blood (liquid biopsy) and/or de novo or archival tumor tissue using FoundationOne Liquid CDx or FoundationOne CDx.
4. Willing to provide tumor tissue when available (de novo or archived) for retrospective molecular profiling analysis, if not already provided as part of inclusion criterion 3.
5. Unless prohibited by local regulations or ethics committee decision, consent to a saliva sample collection for retrospective sequencing of the same DDR genes tested on tumor tissue and blood (liquid biopsy), or a subset thereof, and to serve as a germline control in identifying tumor mutations.
6. Ongoing ADT with a GnRH agonist or antagonist for participants who have not undergone bilateral orchiectomy must be initiated before randomization and must continue throughout the study.
7. Metastatic prostate cancer documented by positive bone scan (for bone disease) or metastatic lesions on CT or MRI scan (for soft tissue). Participants whose disease spread is limited to regional pelvic lymph nodes are not eligible. Note: a finding of superscan at baseline is exclusionary.
8. Prior treatment of mCSPC with docetaxel is not permitted.
9. Treatment with estrogens, cyproterone acetate, or first-generation anti-androgens is allowed until randomization.
10. Other prior therapy allowed for mCSPC; =3 months of ADT (chemical or surgical) with or without approved NHT in mCSPC (ie, abiraterone + prednisone, apalutamide, or enzalutamide), if required prior to randomization, with no radiographic evidence of disease progression or rising PSA levels prior to Day 1.
11. Participant may have received palliative radiation or surgery for symptomatic control secondary to prostate cancer, which should have been completed at least 2 weeks prior to randomization. NOTE: Radical prostatectomy or definitive radiotherapy to the primary tumor for metastatic castration-sensitive prostate cancer with curative intent is not permitted.
12. ECOG performance status 0 or 1.
13. Adequate organ function within 28 days before the first study treatment on Day 1, defined by the following:

* ANC =1500/µL, platelets =100,000/µL, or hemoglobin =9 g/dL (may not have received growth factors or blood transfusions within 14 days before obtaining the hematology laboratory tests at screening).
* Total serum bilirubin <1.5 × ULN (<3 × ULN for participants with documented Gilbert syndrome or for whom indirect bilirubin concentrations suggest an extrahepatic source of elevation).
* AST or ALT <2.5 × ULN (<5 × ULN if liver function abnormalities are due to hepatic metastasis).
* Albumin >2.8 g/dL.
* eGFR =30 mL/min/1.73 m2 by the MDRD equation.
14. Sexually active participants that in the opinion of the investigator are capable of ejaculating, must agree to use a condom when having sex with a partner (female or male) from the time of the first dose of study treatment through 4 months after last dose of study treatment (or, if talazoparib/placebo has been stopped more than a month earlier than enzalutamide, through 3 months after last dose of enzalutamide). Must also agree for female partner of childbearing potential to use an additional highly effective form of contraception from the time of the first dose of study treatment through 4 months after last dose of study treatment (or, if talazoparib / placebo has been stopped more than a month earlier than enzalutamide, through 3 months after last dose of enzalutamide) when having sex.
15. Must agree not to donate sperm from the first dose of study treatment to 4 months after the last dose of study treatment (or, if talazoparib/placebo has been stopped more than a month earlier than enzalutamide, through 3 months after last dose of enzalutamide).
16. Participants who are willing and able to comply with all scheduled visits, treatment plan, laboratory tests, lifestyle considerations, and other study procedures, including being able to manage electronic diaries. The PRO assessments are not required to be completed if a patient does not understand the language(s) available for a specific questionnaire and/or cannot complete the specific questionnaire independently.
17. Capable of giving signed informed consent.
18. For France only: Participants affiliated with the social security system or beneficiaries of an equivalent system.
Minimum age
18 Years
Maximum age
No limit
Sex
Males
Can healthy volunteers participate?
No
Key exclusion criteria
1. Other acute or chronic medical (concurrent disease, infection, including chronic stable HIV, HBV, or HCV infection, or co-morbidity) or psychiatric condition including recent (within the past year) or active suicidal ideation/behavior or laboratory abnormality that interferes with a participant's ability to participate in the study, may increase the risk of associated with study participation or study treatment administration, or may interfere with the interpretation of study results, and, in the investigator's judgment, make the participant inappropriate for entry into the study. HIV/HBV/HCV testing is not required unless mandated by local health authority.
2. History of seizure or any condition (as assessed by investigator) that may predispose to seizure (eg, prior cortical stroke, significant brain trauma), including any history of loss of consciousness or transient ischemic attack within 12 months of randomization.
3. Major surgery (as defined by the investigator) within 4 weeks before randomization.
4. Known or suspected brain metastasis or active leptomeningeal disease.
5. Symptomatic or impending spinal cord compression or cauda equina syndrome.
6. Any history of MDS, AML, or prior malignancy except for the following:

* Carcinoma in situ or non-melanoma skin cancer.
* A cancer diagnosed and treated =3 years before randomization with no subsequent evidence of recurrence.
* American Joint Committee on Cancer Stage 0 or Stage 1 cancer <3 years before randomization that has a remote probability of recurrence in the opinion of the investigator and the sponsor.
7. In the opinion of the investigator, any clinically significant gastrointestinal disorder affecting absorption.
8. Clinically significant cardiovascular disease, including any of the following:

* Myocardial infarction or symptomatic cardiac ischemia within 6 months before randomization.
* Congestive heart failure New York Heart Association class III or IV.
* History of clinically significant ventricular arrhythmias (eg, sustained ventricular tachycardia, ventricular fibrillation, torsade de pointes) within 1 year before screening.
* History of Mobitz II second degree or third-degree heart block unless a permanent pacemaker is in place.
* Hypotension as indicated by systolic blood pressure <86 mm Hg at screening.
* Bradycardia as indicated by a heart rate of <45 beats per minute on the screening electrocardiogram.
* Uncontrolled hypertension as indicated by systolic blood pressure >170 mm Hg or diastolic blood pressure >105 mm Hg at screening. However, participants can be rescreened after adequate control of blood pressure is achieved.
9. Active COVID-19 infection detected by viral test or based on clinical diagnosis (as assessed by investigator). Asymptomatic participants with no active COVID-19 infection detected but positive antibody tests, indicating past infection are allowed.
10. Prior ADT in the adjuvant/neoadjuvant setting, where the completion of ADT was less than 12 months prior to randomization and the total duration of ADT exceeded 36 months.
11. Participant received treatment with systemic glucocorticoids greater than the equivalent of 10 mg per day of prednisone within 4 weeks prior to randomization, intended for the treatment of prostate cancer.
12. Any previous treatment with DNA-damaging cytotoxic chemotherapy (ie, platinum based therapy) within 5 years prior to randomization, except for indications other than prostate cancer.
13. Prior treatment with a PARPi, or known or possible hypersensitivity to enzalutamide, any of enzalutamide capsule excipients or to any talazoparib/placebo capsule excipients.
14. Prior treatment in any setting with NHT, except as described in Inclusion Criterion #10.
15. Current use of potent P-gp inhibitors within 7 days prior to randomization.
16. Treatment with any investigational study intervention within 4 weeks before randomization. Exception: COVID-19 vaccines authorized under an emergency use authorization (or equivalent) can be administered without a washout period.
17. Baseline 12-lead ECG that demonstrates clinically relevant abnormalities that may affect participant safety or interpretation of study results (eg, QTcF interval >470 msec, complete LBBB, signs of an acute or indeterminate age myocardial infarction, ST-T interval changes suggestive of myocardial ischemia, second or third degree AV block, or serious bradyarrhythmias or tachyarrhythmias). If the baseline uncorrected QT interval is >470 msec, this interval should be rate-corrected using the Fridericia method and the resulting QTcF should be used for decision making and reporting. If QTc exceeds 470 msec, or QRS exceeds 120 msec, the ECG should be repeated 2 more times and the average of the 3 QTc or QRS values should be used to determine the participant's eligibility. Computer-interpreted ECGs should be overread by a physician experienced in reading ECGs before excluding participants.
18. Investigator site staff or Sponsor employees directly involved in the conduct of the study, site staff otherwise supervised by the investigator, and their respective family members.
19. For France only: Persons deprived of their liberty by a judicial or administrative decision, persons undergoing psychiatric care, as well as adults subject to a legal protection measure (guardianship, curatorship, and safeguard of justice) covered by Articles 1121-6 to 1121-8 of the Public Health Code.

Study design
Purpose of the study
Treatment
Allocation to intervention
Randomised controlled trial
Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Masking / blinding
Blinded (masking used)
Who is / are masked / blinded?
The people receiving the treatment/s
The people administering the treatment/s
The people assessing the outcomes
The people analysing the results/data
Intervention assignment
Parallel
Other design features
Phase
Phase 3
Type of endpoint/s
Statistical methods / analysis

Recruitment
Recruitment status
Active, not recruiting
Data analysis
Reason for early stopping/withdrawal
Other reasons
Date of first participant enrolment
Anticipated
Actual
Date of last participant enrolment
Anticipated
Actual
Date of last data collection
Anticipated
Actual
Sample size
Target
Accrual to date
Final
Recruitment in Australia
Recruitment state(s)
NSW,QLD,SA,VIC
Recruitment hospital [1] 0 0
Chris O'Brien Lifehouse - Camperdown
Recruitment hospital [2] 0 0
Cancer Care Wollongong Pty Limited - Wollongong
Recruitment hospital [3] 0 0
Southern Medical Day Care Centre - Wollongong
Recruitment hospital [4] 0 0
Gallipoli Medical Research Foundation, Greenslopes Private Hospital - Brisbane
Recruitment hospital [5] 0 0
Gold Coast University Hospital - Southport
Recruitment hospital [6] 0 0
The Queen Elizabeth Hospital - Woodville South
Recruitment hospital [7] 0 0
Epworth Freemasons-Epworth HealthCare - East Melbourne
Recruitment hospital [8] 0 0
Cabrini Hospital - Malvern
Recruitment hospital [9] 0 0
Western Health, Sunshine Hospital - St Albans
Recruitment postcode(s) [1] 0 0
2050 - Camperdown
Recruitment postcode(s) [2] 0 0
2500 - Wollongong
Recruitment postcode(s) [3] 0 0
4120 - Brisbane
Recruitment postcode(s) [4] 0 0
4215 - Southport
Recruitment postcode(s) [5] 0 0
5011 - Woodville South
Recruitment postcode(s) [6] 0 0
3002 - East Melbourne
Recruitment postcode(s) [7] 0 0
3144 - Malvern
Recruitment postcode(s) [8] 0 0
3021 - St Albans
Recruitment outside Australia
Country [1] 0 0
United States of America
State/province [1] 0 0
Alabama
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United States of America
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Arizona
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California
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Florida
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Georgia
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Illinois
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Louisiana
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Michigan
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Oregon
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Pennsylvania
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South Carolina
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Tennessee
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Texas
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Utah
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Argentina
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Buenos Aires
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Argentina
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RÍO Negro
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Argentina
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Tucuman
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Gent
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Liege
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Merksem
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Plovdiv
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Shumen
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Sofia
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Stara Zagora
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Anhui
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Gansu
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Guangdong
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China
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Henan
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Zhejiang
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Chongqing
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Olomouc
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Czechia
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Ostrava - Poruba
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Czechia
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Praha 10
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Czechia
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Praha 5
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Czechia
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Praha 8- Liben
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Helsinki
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Kuopio
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Tampere
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Turku
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France
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Bretagne
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ILE DE France
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France
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Angers Cedex 9
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Bayonne
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Brest
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Lille
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LYON Cedex 08
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Paris cedex 18
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France
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Paris
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France
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Pierre-Benite
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Quint Fonsegrives
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France
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Reims Cedex
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France
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Saint Gregoire
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France
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Strasbourg
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France
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Vandoeuvre-Les-Nancy
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Villejuif Cedex
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Germany
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Niedersachsen
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Germany
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Nordrhein-westfalen
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Germany
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Thüringen
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Germany
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Berlin
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Germany
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Duisburg
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Germany
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Frankfurt
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Germany
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Goettingen
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Germany
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Heidelberg
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Germany
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Jena
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Germany
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Leipzig
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Germany
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Nuertingen
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Germany
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Tuebingen
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Hungary
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Budapest
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India
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Delhi
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India
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Gujarat
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India
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Haryana
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India
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Maharashtra
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India
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Uttar Pradesh
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India
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WEST Bengal
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Italy
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BO
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Italy
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CR
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Italy
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FC
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Italy
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FG
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Italy
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Naples
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Italy
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PN
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Italy
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TN
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Italy
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TO
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Italy
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Arezzo
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Italy
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Bari
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Italy
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Bergamo
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Italy
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Brescia
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Italy
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Meldola
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Italy
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Verona
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Japan
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Aichi
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Japan
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Aomori
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Japan
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Chiba
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Japan
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Ehime
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Japan
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Fukuoka
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Japan
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Hiroshima
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Japan
State/province [123] 0 0
Hokkaido
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Japan
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Ishikawa
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Japan
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Kanagawa
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Japan
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Osaka
Country [127] 0 0
Japan
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Shizuoka
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Japan
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Tokyo
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Japan
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Kagoshima
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Japan
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Kumamoto
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Japan
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Tokushima
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Japan
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Yamagata
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Korea, Republic of
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Gyeonggi-do
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Korea, Republic of
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Jeollanam-do
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Korea, Republic of
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Kyonggi-do
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Korea, Republic of
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Seoul-teukbyeolsi
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Korea, Republic of
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Daegu
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Korea, Republic of
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Seoul
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Mexico
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Estado DE Mexico
Country [140] 0 0
Mexico
State/province [140] 0 0
Guanajuato
Country [141] 0 0
Mexico
State/province [141] 0 0
Nuevo LEÓN
Country [142] 0 0
Mexico
State/province [142] 0 0
Oaxaca
Country [143] 0 0
Mexico
State/province [143] 0 0
Veracruz
Country [144] 0 0
Netherlands
State/province [144] 0 0
Utrecht
Country [145] 0 0
Netherlands
State/province [145] 0 0
Den Haag
Country [146] 0 0
Norway
State/province [146] 0 0
Gjoevik
Country [147] 0 0
Russian Federation
State/province [147] 0 0
Kaluga Region
Country [148] 0 0
Russian Federation
State/province [148] 0 0
Saint-petersburg
Country [149] 0 0
Russian Federation
State/province [149] 0 0
Stavropol Region
Country [150] 0 0
Russian Federation
State/province [150] 0 0
Chelyabinsk
Country [151] 0 0
Russian Federation
State/province [151] 0 0
Ivanovo
Country [152] 0 0
Russian Federation
State/province [152] 0 0
Moscow
Country [153] 0 0
Russian Federation
State/province [153] 0 0
Omsk
Country [154] 0 0
Russian Federation
State/province [154] 0 0
Saint-Petersburg
Country [155] 0 0
Russian Federation
State/province [155] 0 0
Samara
Country [156] 0 0
Russian Federation
State/province [156] 0 0
Ufa
Country [157] 0 0
Russian Federation
State/province [157] 0 0
Vologda
Country [158] 0 0
Russian Federation
State/province [158] 0 0
Yaroslavl
Country [159] 0 0
Slovakia
State/province [159] 0 0
Banska Bystrica
Country [160] 0 0
Slovakia
State/province [160] 0 0
Bratislava
Country [161] 0 0
Slovakia
State/province [161] 0 0
Kosice
Country [162] 0 0
Slovakia
State/province [162] 0 0
Nitra
Country [163] 0 0
Slovakia
State/province [163] 0 0
Poprad
Country [164] 0 0
Slovakia
State/province [164] 0 0
Presov
Country [165] 0 0
Slovakia
State/province [165] 0 0
Trencin
Country [166] 0 0
South Africa
State/province [166] 0 0
Gauteng
Country [167] 0 0
Spain
State/province [167] 0 0
Alicante
Country [168] 0 0
Spain
State/province [168] 0 0
Asturias
Country [169] 0 0
Spain
State/province [169] 0 0
Barcelona [barcelona]
Country [170] 0 0
Spain
State/province [170] 0 0
Barcelona
Country [171] 0 0
Spain
State/province [171] 0 0
Galicia
Country [172] 0 0
Spain
State/province [172] 0 0
Madrid, Comunidad DE
Country [173] 0 0
Spain
State/province [173] 0 0
Navarra
Country [174] 0 0
Spain
State/province [174] 0 0
Tarragona
Country [175] 0 0
Spain
State/province [175] 0 0
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Country [176] 0 0
Spain
State/province [176] 0 0
Cordoba
Country [177] 0 0
Spain
State/province [177] 0 0
Madrid
Country [178] 0 0
Spain
State/province [178] 0 0
Sevilla
Country [179] 0 0
Spain
State/province [179] 0 0
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Country [180] 0 0
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State/province [180] 0 0
Kaohsiung
Country [181] 0 0
Taiwan
State/province [181] 0 0
Taichung
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Taiwan
State/province [182] 0 0
Tainan
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Taiwan
State/province [183] 0 0
Taipei
Country [184] 0 0
Taiwan
State/province [184] 0 0
Taoyuan City
Country [185] 0 0
Turkey
State/province [185] 0 0
Ankara
Country [186] 0 0
Turkey
State/province [186] 0 0
Adana
Country [187] 0 0
Turkey
State/province [187] 0 0
Edirne
Country [188] 0 0
Turkey
State/province [188] 0 0
Istanbul
Country [189] 0 0
Turkey
State/province [189] 0 0
Malatya
Country [190] 0 0
Ukraine
State/province [190] 0 0
Dnipropetrovska Oblast
Country [191] 0 0
Ukraine
State/province [191] 0 0
KYIV Region
Country [192] 0 0
Ukraine
State/province [192] 0 0
Kyivska Oblast
Country [193] 0 0
Ukraine
State/province [193] 0 0
Dnipro
Country [194] 0 0
Ukraine
State/province [194] 0 0
Ivano-Frankivsk
Country [195] 0 0
Ukraine
State/province [195] 0 0
Kharkiv
Country [196] 0 0
Ukraine
State/province [196] 0 0
Lviv
Country [197] 0 0
United Kingdom
State/province [197] 0 0
Devon
Country [198] 0 0
United Kingdom
State/province [198] 0 0
Kent
Country [199] 0 0
United Kingdom
State/province [199] 0 0
Lancashire
Country [200] 0 0
United Kingdom
State/province [200] 0 0
Midlothian
Country [201] 0 0
United Kingdom
State/province [201] 0 0
South Yorkshire
Country [202] 0 0
United Kingdom
State/province [202] 0 0
Birmingham
Country [203] 0 0
United Kingdom
State/province [203] 0 0
Glasgow
Country [204] 0 0
United Kingdom
State/province [204] 0 0
London
Country [205] 0 0
United Kingdom
State/province [205] 0 0
Manchester

Funding & Sponsors
Primary sponsor type
Commercial sector/industry
Name
Pfizer
Address
Country
Other collaborator category [1] 0 0
Commercial sector/industry
Name [1] 0 0
Astellas Pharma Inc
Address [1] 0 0
Country [1] 0 0

Ethics approval
Ethics application status

Summary
Brief summary
Trial website
Trial related presentations / publications
Public notes

Contacts
Principal investigator
Name 0 0
Pfizer CT.gov Call Center
Address 0 0
Pfizer
Country 0 0
Phone 0 0
Fax 0 0
Email 0 0
Contact person for public queries
Name 0 0
Address 0 0
Country 0 0
Phone 0 0
Fax 0 0
Email 0 0
Contact person for scientific queries

Data sharing statement
Will individual participant data (IPD) for this trial be available (including data dictionaries)?
Yes
What data in particular will be shared?
Pfizer will provide access to individual de-identified participant data and related study documents (e.g. protocol, Statistical Analysis Plan (SAP), Clinical Study Report (CSR)) upon request from qualified researchers, and subject to certain criteria, conditions, and exceptions. Further details on Pfizer's data sharing criteria and process for requesting access can be found at: https://www.pfizer.com/science/clinical_trials/trial_data_and_results/data_requests.
When will data be available (start and end dates)?
Available to whom?
Available for what types of analyses?
How or where can data be obtained?
IPD available at link: https://www.pfizer.com/science/clinical_trials/trial_data_and_results/data_requests


What supporting documents are/will be available?

No Supporting Document Provided



Results publications and other study-related documents

No documents have been uploaded by study researchers.