51
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Delorme J, Charvet V, Wartelle M, Lion F, Thuillier B, Mercier S, Soria JC, Azoulay M, Besse B, Massard C, Hollebecque A, Verlingue L. Natural Language Processing for Patient Selection in Phase I or II Oncology Clinical Trials. JCO Clin Cancer Inform 2021; 5:709-718. [PMID: 34197179 DOI: 10.1200/cci.21.00003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Early discontinuation affects more than one third of patients enrolled in early-phase oncology clinical trials. Early discontinuation is deleterious both for the patient and for the study, by inflating its duration and associated costs. We aimed at predicting the successful screening and dose-limiting toxicity period completion (SSD) from automatic analysis of consultation reports. MATERIALS AND METHODS We retrieved the consultation reports of patients included in phase I and/or phase II oncology trials for any tumor type at Gustave Roussy, France. We designed a preprocessing pipeline that transformed free text into numerical vectors and gathered them into semantic clusters. These document-based semantic vectors were then fed into a machine learning model that we trained to output a binary prediction of SSD status. RESULTS Between September 2012 and July 2020, 56,924 consultation reports were used to build the dictionary and 1,858 phase I or II inclusion reports were used to train (72%), validate (14%), and test (14%) a random forest model. Preprocessing could efficiently cluster words with semantic proximity. On the unseen test cohort of 264 consultation reports, the performances of the model reached: F1 score 0.80, recall 0.81, and area under the curve 0.88. Using this model, we could have reduced the screen fail rate (including dose-limiting toxicity period) from 39.8% to 12.8% (relative risk, 0.322; 95% CI, 0.209 to 0.498; P < .0001) within the test cohort. Most important semantic clusters for predictions comprised words related to hematologic malignancies, anatomopathologic features, and laboratory and imaging interpretation. CONCLUSION Machine learning with semantic conservation is a promising tool to assist physicians in selecting patients prone to achieve SSD in early-phase oncology clinical trials.
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Affiliation(s)
| | - Valentin Charvet
- Telecom Paris Tech, Paris, France.,Department of Computing Science, University of Glasgow, Glasgow, Scotland
| | | | - François Lion
- Informatic Team (DTNSI), Gustave Roussy, Villejuif, France
| | - Bruno Thuillier
- Drug Development Department (DITEP), Gustave Roussy, Villejuif, France
| | - Sandrine Mercier
- Drug Development Department (DITEP), Gustave Roussy, Villejuif, France
| | - Jean-Charles Soria
- Drug Development Department (DITEP), Gustave Roussy, Villejuif, France.,University Paris-Saclay, Gif-sur-Yvette, France.,Medical Oncology Department, Gustave Roussy, Villejuif, France
| | - Mikael Azoulay
- Informatic Team (DTNSI), Gustave Roussy, Villejuif, France
| | - Benjamin Besse
- University Paris-Saclay, Gif-sur-Yvette, France.,Medical Oncology Department, Gustave Roussy, Villejuif, France
| | - Christophe Massard
- Drug Development Department (DITEP), Gustave Roussy, Villejuif, France.,University Paris-Saclay, Gif-sur-Yvette, France
| | | | - Loic Verlingue
- Drug Development Department (DITEP), Gustave Roussy, Villejuif, France.,University Paris-Saclay, Gif-sur-Yvette, France.,INSERM UMR1030, Molecular Radiotherapy and Therapeutic Innovations, Gustave Roussy, Villejuif, France
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Lazar V, Magidi S, Girard N, Savignoni A, Martini JF, Massimini G, Bresson C, Berger R, Onn A, Raynaud J, Wunder F, Berindan-Neagoe I, Sekacheva M, Braña I, Tabernero J, Felip E, Porgador A, Kleinman C, Batist G, Solomon B, Tsimberidou AM, Soria JC, Rubin E, Kurzrock R, Schilsky RL. Digital Display Precision Predictor: the prototype of a global biomarker model to guide treatments with targeted therapy and predict progression-free survival. NPJ Precis Oncol 2021; 5:33. [PMID: 33911192 PMCID: PMC8080819 DOI: 10.1038/s41698-021-00171-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 03/26/2021] [Indexed: 12/28/2022] Open
Abstract
The expanding targeted therapy landscape requires combinatorial biomarkers for patient stratification and treatment selection. This requires simultaneous exploration of multiple genes of relevant networks to account for the complexity of mechanisms that govern drug sensitivity and predict clinical outcomes. We present the algorithm, Digital Display Precision Predictor (DDPP), aiming to identify transcriptomic predictors of treatment outcome. For example, 17 and 13 key genes were derived from the literature by their association with MTOR and angiogenesis pathways, respectively, and their expression in tumor versus normal tissues was associated with the progression-free survival (PFS) of patients treated with everolimus or axitinib (respectively) using DDPP. A specific eight-gene set best correlated with PFS in six patients treated with everolimus: AKT2, TSC1, FKB-12, TSC2, RPTOR, RHEB, PIK3CA, and PIK3CB (r = 0.99, p = 5.67E-05). A two-gene set best correlated with PFS in five patients treated with axitinib: KIT and KITLG (r = 0.99, p = 4.68E-04). Leave-one-out experiments demonstrated significant concordance between observed and DDPP-predicted PFS (r = 0.9, p = 0.015) for patients treated with everolimus. Notwithstanding the small cohort and pending further prospective validation, the prototype of DDPP offers the potential to transform patients' treatment selection with a tumor- and treatment-agnostic predictor of outcomes (duration of PFS).
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Affiliation(s)
- Vladimir Lazar
- Worldwide Innovative Network (WIN) Association - WIN Consortium, Villejuif, France.
| | - Shai Magidi
- Worldwide Innovative Network (WIN) Association - WIN Consortium, Villejuif, France
| | | | | | | | | | - Catherine Bresson
- Worldwide Innovative Network (WIN) Association - WIN Consortium, Villejuif, France
| | | | - Amir Onn
- Sheba Medical Center, Tel-Hashomer, Israel
| | | | - Fanny Wunder
- Worldwide Innovative Network (WIN) Association - WIN Consortium, Villejuif, France
| | - Ioana Berindan-Neagoe
- Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
- The Oncology Institute "Prof. Dr. Ion Chiricuta", Cluj-Napoca, Romania
| | - Marina Sekacheva
- I.M Sechenov First Medical State University, Moscow, Russian Federation
| | - Irene Braña
- Vall d'Hebron Hospital Campus and Institute of Oncology (VHIO), IOB-Quiron, UVic-UCC, Barcelona, Spain
| | - Josep Tabernero
- Vall d'Hebron Hospital Campus and Institute of Oncology (VHIO), IOB-Quiron, UVic-UCC, Barcelona, Spain
| | - Enriqueta Felip
- Vall d'Hebron Hospital Campus and Institute of Oncology (VHIO), IOB-Quiron, UVic-UCC, Barcelona, Spain
| | | | - Claudia Kleinman
- Segal Cancer Centre, Jewish General Hospital, McGill University, Montréal, and NCE Exactis Innovations, Montreal, QC, Canada
| | - Gerald Batist
- Segal Cancer Centre, Jewish General Hospital, McGill University, Montréal, and NCE Exactis Innovations, Montreal, QC, Canada
| | | | | | | | - Eitan Rubin
- Ben-Gurion University of the Negev, Beer-Sheeva, Israel
| | - Razelle Kurzrock
- University of California San Diego, Moores Cancer Center, San Diego, CA, USA
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53
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Zhang SX, Fergusson D, Kimmelman J. Proportion of Patients in Phase I Oncology Trials Receiving Treatments That Are Ultimately Approved. J Natl Cancer Inst 2021; 112:886-892. [PMID: 32239146 DOI: 10.1093/jnci/djaa044] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/04/2020] [Accepted: 03/24/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Phase I oncology trials are often regarded as a therapeutic option for patients. However, such claims have relied on surrogate measures of benefit, such as objective response. METHODS Using a systematic search of publications, we assessed the therapeutic value of phase I cancer trial participation by determining the probability that patients will receive active doses of treatments that eventually receive FDA approval or a National Comprehensive Cancer Network (NCCN) guideline recommendation for their indication. ClinicalTrials.gov, PubMed, American Society of Clinical Oncology reports, NCCN guidelines, and Drugs@FDA were searched between May 1, 2018, and July 31, 2018. All statistical tests were 2-sided. RESULTS A total of 1000 phase I oncology trials initiated between 2005 and 2010 and enrolling 32 582 patients were randomly sampled from 3229 eligible trials on ClinicalTrials.gov. A total of 386 (1.2%) patients received a treatment that was approved by the US Food and Drug Administration for their malignancy at a dose delivered in the trial; including NCCN guideline recommendations, the number and proportion are 1168 (3.6%). Meta-regression showed a statistically significantly greater proportion of patients receiving a drug that was ultimately FDA approved in biomarker trials (rate ratio = 4.49, 95% confidence interval [CI] = 1.53 to 13.23; P = .006) and single-indication trials (rate ratio = 3.32, 95% CI = 1.21 to 9.15; P = .02); proportions were statistically significantly lower for combination vs monotherapy trials (rate ratio = 0.09, 95% CI = 0.01 to 0.68; P = .02). CONCLUSIONS One in 83 patients in phase I cancer trials received a treatment that was approved for their indication at the doses received. Given published estimates of serious adverse event rates of 10%-19%, this represents low therapeutic value for phase I trial participation.
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Affiliation(s)
- Sean X Zhang
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Canada
| | - Dean Fergusson
- Ottawa Hospital Research Institute, Department of Medicine, Surgery, and the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Jonathan Kimmelman
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Canada
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Cohen-Rabbie S, Berges AC, Rekić D, Parkinson J, Dota C, Tomkinson HK. QT Prolongation Risk Assessment in Oncology: Lessons Learned From Small-Molecule New Drug Applications Approved During 2011-2019. J Clin Pharmacol 2021; 61:1106-1117. [PMID: 33624833 DOI: 10.1002/jcph.1844] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/19/2021] [Indexed: 12/19/2022]
Abstract
The International Conference on Harmonisation (ICH) E14 guidance provides recommendations to assess the potential of a drug to delay cardiac repolarization (QT prolongation), including general guidelines for cases in which a conventional thorough QT study (TQT) might not be feasible. These guidelines have been updated through the ICH question-and-answer process, with the last revision in 2015. We conducted a comprehensive analysis of QT prolongation evaluation of small-molecule new drug applications (NDAs) approved in oncology between 2011 and 2019 to extract learning experience. The following information was analysed: (1) methods to assess QT prolongation, (2) electrocardiogram data collection, (3) QT-related label language, and (4) postmarketing requirements. Overall, every NDA included a QT assessment. The concentration-QTc modeling approach (studies in which QT was not the primary objective) was the most common approach (59%), followed by the TQT and the dedicated QT studies (20% and 21%, respectively). The quality and quantity of the QT assessments were different across NDAs, which suggested relatively large flexibility in the designs and approaches to characterizing QT liability. The QT-related label language reflected the QT results, but also the safety events and the study design limitations because of the oncology settings. There was no delay in approval because of less robust QTc studies as long as the benefit-to-risk ratio of the drug was acceptable, and the implications were reflected in the label. This work offers a structured understanding of the QT evaluation criteria by the Food and Drug Administration and can assist in planning QT prolongation assessments in oncology settings.
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Affiliation(s)
- Sarit Cohen-Rabbie
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Science, AstraZeneca, BioPharmaceuticals R&D, Cambridge, UK
| | - Alienor C Berges
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Science, AstraZeneca, BioPharmaceuticals R&D, Cambridge, UK
| | - Dinko Rekić
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Science, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - Joanna Parkinson
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Science, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - Corina Dota
- Patient Safety Center of Excellence, Oncology R&D, Gothenburg, Sweden
| | - Helen K Tomkinson
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Science, AstraZeneca, BioPharmaceuticals R&D, Cambridge, UK
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55
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van Nieuwenhuijzen N, Frunt R, May AM, Minnema MC. Therapeutic outcome of early-phase clinical trials in multiple myeloma: a meta-analysis. Blood Cancer J 2021; 11:44. [PMID: 33649328 PMCID: PMC7921415 DOI: 10.1038/s41408-021-00441-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/03/2021] [Accepted: 02/10/2021] [Indexed: 01/31/2023] Open
Abstract
Great progress in the treatment of patients with multiple myeloma (MM) has been made due to the development of novel drugs. Patients with relapsed/refractory MM (RRMM) can be enrolled in early-phase clinical trials, but their performance across the last decade is unknown. We conducted a meta-analysis on the overall response rate (ORR) and toxicity. PubMed, Embase, and Cochrane Library were systematically searched for phase I and phase II trials investigating an experimental compound as a single agent or in combination with dexamethasone, published from January 1, 2010 to July 1, 2020. Eighty-eight articles were included, describing 61 phase I trials involving 1835 patients and 37 phase II trials involving 2644 patients. There was a high degree of heterogeneity. Using a random-effects model, the 95% CIs of the estimated ORR were 8-17% for phase I trials and 18-28% for phase II trials. There were significant subgroup differences in ORR between the years of publication in phase I trials and between drug classes in both phase I and phase II trials. The ORR in early-phase clinical trials in RRMM is substantial, especially in phase II trials, but due to high heterogeneity a general assessment of clinical benefit before participation is difficult to offer to patients.
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Affiliation(s)
- Niels van Nieuwenhuijzen
- Department of Hematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rowan Frunt
- Department of Hematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anne M May
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Monique C Minnema
- Department of Hematology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
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56
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Yap TA, Siu LL, Calvo E, Lolkema MP, LoRusso PM, Soria JC, Plummer R, de Bono JS, Tabernero J, Banerji U. SARS-CoV-2 vaccination and phase 1 cancer clinical trials. Lancet Oncol 2021; 22:298-301. [PMID: 33571468 PMCID: PMC7906739 DOI: 10.1016/s1470-2045(21)00017-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 01/28/2023]
Affiliation(s)
- Timothy A Yap
- Investigational Cancer Therapeutics (Phase I Program), University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Lillian L Siu
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Emiliano Calvo
- Early Phase Clinical Drug Development in Oncology, START Madrid-CIOCC, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - Martijn P Lolkema
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Patricia M LoRusso
- Early Phase Clinical Trials Program, Yale University Medical Center, New Haven, CT, USA
| | - Jean-Charles Soria
- Department of Drug Development, Gustave Roussy Cancer Institute, University Paris Saclay, Villejuif, France
| | - Ruth Plummer
- Northern Institute for Cancer Care, Freeman Hospital and Newcastle University, Newcastle upon Tyne, UK
| | - Johann S de Bono
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
| | - Josep Tabernero
- Department of Medical Oncology, Vall d'Hebron Institute of Oncology, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Udai Banerji
- The Institute of Cancer Research, London, UK; Royal Marsden NHS Foundation Trust, London, UK
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57
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Dunleavy L, Collingridge Moore D, Korfage I, Payne S, Walshe C, Preston N. What should we report? Lessons learnt from the development and implementation of serious adverse event reporting procedures in non-pharmacological trials in palliative care. BMC Palliat Care 2021; 20:19. [PMID: 33472621 PMCID: PMC7819235 DOI: 10.1186/s12904-021-00714-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 01/13/2021] [Indexed: 11/30/2022] Open
Abstract
Background/aims Serious adverse event reporting guidelines have largely been developed for pharmaceutical trials. There is evidence that serious adverse events, such as psychological distress, can also occur in non-pharmaceutical trials. Managing serious adverse event reporting and monitoring in palliative care non-pharmaceutical trials can be particularly challenging. This is because patients living with advanced malignant or non-malignant disease have a high risk of hospitalisation and/or death as a result of progression of their disease rather than due to the trial intervention or procedures. This paper presents a number of recommendations for managing serious adverse event reporting that are drawn from two palliative care non-pharmacological trials. Methods The recommendations were iteratively developed across a number of exemplar trials. This included examining national and international safety reporting guidance, reviewing serious adverse event reporting procedures from other pharmacological and non-pharmacological trials, a review of the literature and collaboration between the ACTION study team and Data Safety Monitoring Committee. These two groups included expertise in oncology, palliative care, statistics and medical ethics and this collaboration led to the development of serious adverse event reporting procedures. Results The recommendations included; allowing adequate time at the study planning stage to develop serious adverse event reporting procedures, especially in multi-national studies or research naïve settings; reviewing the level of trial oversight required; defining what a serious adverse event is in your trial based on your study population; development and implementation of standard operating procedures and training; refining the reporting procedures during the trial if necessary and publishing serious adverse events in findings papers. Conclusions There is a need for researchers to share their experiences of managing this challenging aspect of trial conduct. This will ensure that the processes for managing serious adverse event reporting are continually refined and improved so optimising patient safety. Trial registration ACTION trial registration number: ISRCTN63110516 (date of registration 03/10/2014). Namaste trial registration number: ISRCTN14948133 (date of registration 04/10/2017). Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00714-5.
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Affiliation(s)
- Lesley Dunleavy
- International Observatory on End of Life Care, Faculty of Health and Medicine, Division of Health Research, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, UK.
| | - Danni Collingridge Moore
- International Observatory on End of Life Care, Faculty of Health and Medicine, Division of Health Research, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, UK
| | - Ida Korfage
- Department of Public Health, Erasmus MC, Rotterdam, Netherlands
| | - Sheila Payne
- International Observatory on End of Life Care, Faculty of Health and Medicine, Division of Health Research, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, UK
| | - Catherine Walshe
- International Observatory on End of Life Care, Faculty of Health and Medicine, Division of Health Research, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, UK
| | - Nancy Preston
- International Observatory on End of Life Care, Faculty of Health and Medicine, Division of Health Research, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, UK
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Mittapalli RK, Yin D, Beaupre D, Palaparthy R. Starting dose selection and dose escalation for oncology small molecule first-in-patient trials: learnings from a survey of FDA-approved drugs. Cancer Chemother Pharmacol 2020; 87:23-30. [PMID: 33237334 DOI: 10.1007/s00280-020-04202-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/10/2020] [Indexed: 12/19/2022]
Abstract
The ideal starting dose for an oncology first-in-patient (FIP) trial should be low enough to be safe but not too far removed from therapeutically relevant doses. A low starting dose combined with small dose increments could lead to a lengthy dose escalation and could expose patients unnecessarily to sub-therapeutic dosing. In the current analyses, we reviewed 59 approved small molecule oncology drugs (SMOD) with the overarching goals to assess the current approaches of FIP starting dose selection and dose escalation, and to identify potential opportunities for improving trial efficiency and minimizing number of patients receiving sub-therapeutic dose levels. Of 59 SMODs, the majority (~ 66%) were kinase inhibitors and ~ 73% were approved for solid tumor indications. Most of the trials used a 3 + 3 design for dose escalation and had a median (range) of 4 cohorts (0-11) to reach MTD from the starting dose. The maximum tolerated dose (MTD) or recommended phase 2 dose (RP2D) to starting dose ratio was highly variable with a median (range) of 8 (0.25-125). About 71% of the FIP trials had < 6 dose escalation steps to reach MTD or RP2D (with 15% ≤ 2 dose escalations), but the remaining 29% of trials had ≥ 6 dose escalation steps to reach MTD or RP2D suggesting that there is still room for increasing efficiency by reducing the number of dose escalation steps, reducing the variability in MTD to starting dose ratio, and consequently reducing significant number of patients exposed at sub-therapeutic doses in the dose escalation phase of FIP study.
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Affiliation(s)
- Rajendar K Mittapalli
- Clinical Pharmacology, Early Clinical Development, Pfizer Inc., 10777 Science Center Drive, San Diego, CA, 92121, USA.
| | - Donghua Yin
- Clinical Pharmacology, Early Clinical Development, Pfizer Inc., 10777 Science Center Drive, San Diego, CA, 92121, USA
| | - Darrin Beaupre
- Clinical Development, Early Oncology Development and Clinical Research, Pfizer Inc., San Diego, CA, USA
| | - Rameshraja Palaparthy
- Clinical Pharmacology, Early Clinical Development, Pfizer Inc., 10777 Science Center Drive, San Diego, CA, 92121, USA
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Berman R, Davies A, Cooksley T, Gralla R, Carter L, Darlington E, Scotté F, Higham C. Supportive Care: An Indispensable Component of Modern Oncology. Clin Oncol (R Coll Radiol) 2020; 32:781-788. [PMID: 32814649 PMCID: PMC7428722 DOI: 10.1016/j.clon.2020.07.020] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/14/2020] [Accepted: 07/29/2020] [Indexed: 12/15/2022]
Abstract
The advent of new cancer therapies, alongside expected growth and ageing of the population, better survival rates and associated costs of care, is uncovering a need to more clearly define and integrate supportive care services across the whole spectrum of the disease. The current focus of cancer care is on initial diagnosis and treatment, and end of life care. The Multinational Association of Supportive Care in Cancer defines supportive care as 'the prevention and management of the adverse effects of cancer and its treatment'. This encompasses the entire cancer journey, and necessitates involvement and integration of most clinical specialties. Optimal supportive care can assist in accurate diagnosis and management, and ultimately improve outcomes. A national strategy to implement supportive care is needed to acknowledge evolving oncology practice, changing disease patterns and the changing patient demographic.
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Affiliation(s)
- R Berman
- The Christie NHS Foundation Trust, Manchester, UK.
| | - A Davies
- Royal Surrey NHS Foundation Trust, Guildford, UK
| | - T Cooksley
- The Christie NHS Foundation Trust, Manchester, UK
| | - R Gralla
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - L Carter
- The Christie NHS Foundation Trust, Manchester, UK
| | - E Darlington
- The Christie NHS Foundation Trust, Manchester, UK
| | - F Scotté
- Gustave Roussy Cancer Institute, Interdisciplinary Cancer Course Department (DIOPP), Villejuif, France
| | - C Higham
- The Christie NHS Foundation Trust, Manchester, UK
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60
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Watson JA, Lamb T, Holmes J, Warrell DA, Thwin KT, Aung ZL, Oo MZ, Nwe MT, Smithuis F, Ashley EA. A Bayesian phase 2 model based adaptive design to optimise antivenom dosing: Application to a dose-finding trial for a novel Russell's viper antivenom in Myanmar. PLoS Negl Trop Dis 2020; 14:e0008109. [PMID: 33196672 PMCID: PMC7704047 DOI: 10.1371/journal.pntd.0008109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 11/30/2020] [Accepted: 10/10/2020] [Indexed: 01/15/2023] Open
Abstract
For most antivenoms there is little information from clinical studies to infer the relationship between dose and efficacy or dose and toxicity. Antivenom dose-finding studies usually recruit too few patients (e.g. fewer than 20) relative to clinically significant event rates (e.g. 5%). Model based adaptive dose-finding studies make efficient use of accrued patient data by using information across dosing levels, and converge rapidly to the contextually defined 'optimal dose'. Adequate sample sizes for adaptive dose-finding trials can be determined by simulation. We propose a model based, Bayesian phase 2 type, adaptive clinical trial design for the characterisation of optimal initial antivenom doses in contexts where both efficacy and toxicity are measured as binary endpoints. This design is illustrated in the context of dose-finding for Daboia siamensis (Eastern Russell's viper) envenoming in Myanmar. The design formalises the optimal initial dose of antivenom as the dose closest to that giving a pre-specified desired efficacy, but resulting in less than a pre-specified maximum toxicity. For Daboia siamensis envenoming, efficacy is defined as the restoration of blood coagulability within six hours, and toxicity is defined as anaphylaxis. Comprehensive simulation studies compared the expected behaviour of the model based design to a simpler rule based design (a modified '3+3' design). The model based design can identify an optimal dose after fewer patients relative to the rule based design. Open source code for the simulations is made available in order to determine adequate sample sizes for future adaptive snakebite trials. Antivenom dose-finding trials would benefit from using standard model based adaptive designs. Dose-finding trials where rare events (e.g. 5% occurrence) are of clinical importance necessitate larger sample sizes than current practice. We will apply the model based design to determine a safe and efficacious dose for a novel lyophilised antivenom to treat Daboia siamensis envenoming in Myanmar.
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Affiliation(s)
- James A. Watson
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Thomas Lamb
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - David A. Warrell
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | | | - Min Zaw Oo
- University of Medicine 2, Yangon, Myanmar
| | - Myat Thet Nwe
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar
| | - Frank Smithuis
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar
| | - Elizabeth A. Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar
- Lao-Oxford-Mahosot Hospital Wellcome Trust Research Unit, Vientiane, Laos
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Abstract
End-of-life care of critically ill adult patients with advanced or incurable cancers is imbued with major ethical challenges. Oncologists, hospitalists, and intensivists can inadvertently subjugate themselves to the perceived powers of autonomous patients. Therapeutic illusion and poor insight by surrogates in physicians' ability to offer accurate prognosis, missed opportunities and miscommunication by clinicians, and lack of systematic or protocolized approach represent important barriers to high-quality palliative care. Enhanced collaboration, models that allow clinicians and surrogates to share the burdens of decision, and institutional support for early integration of palliative care can foster an ethical climate.
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Affiliation(s)
- Jamie C Riches
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Louis P Voigt
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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62
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Patterson C, Barber FD. Clinical Trial Subinvestigator: An Emerging Role for Oncology Nurse Practitioners. Clin J Oncol Nurs 2020; 24:479-481. [PMID: 32945784 DOI: 10.1188/20.cjon.479-481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Phase 1 clinical trials are essential to improving outcomes in cancer care. The investigational agents in these trials may be associated with adverse events that can contribute to symptom burden and declining performance status for trial participants. The emerging role for oncology nurse practitioners (ONPs) as subinvestigators offers a unique practice setting for advanced practice nurses. In this role, ONPs provide expert oncology care, are responsible for swift recognition and management of adverse events, and ensure adherence to the clinical trial protocol.
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63
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Tao DL, Kartika T, Tran A, Prasad V. Phase I trials and therapeutic intent in the age of precision oncology: What is a patient's chance of response? Eur J Cancer 2020; 139:20-26. [PMID: 32957010 DOI: 10.1016/j.ejca.2020.04.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 01/25/2023]
Abstract
The advancement of therapeutic strategies in oncology such as precision oncology has generated significant interest in better estimating the response of modern phase I cancer clinical trials. These estimates have varied widely. In this commentary, we provide an umbrella review of phase I response rates and discuss methodological reasons for variation in prior estimates which include limited use of unpublished data, the inclusion of expansion cohorts that artificially raise response rates of cumulative response rates, varying enrolment of haematologic malignancies, and increased next in class drugs.
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Affiliation(s)
- Derrick L Tao
- Division of Internal Medicine, Oregon Health & Science University, USA
| | - Thomas Kartika
- Division of Internal Medicine, Oregon Health & Science University, USA
| | - Audrey Tran
- School of Medicine, Oregon Health & Science University, USA
| | - Vinay Prasad
- Department of Epidemiology & Biostatistics, University of California, San Francisco, USA.
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64
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Criscitiello C, Marra A, Morganti S, Zagami P, Viale G, Esposito A, Curigliano G. Pretreatment Blood Parameters Predict Efficacy from Immunotherapy Agents in Early Phase Clinical Trials. Oncologist 2020; 25:e1732-e1742. [PMID: 32785940 DOI: 10.1634/theoncologist.2020-0518] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/21/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Peripheral blood parameters are correlated to immune-checkpoint inhibitor efficacy in solid tumors, such as melanoma and non-small cell lung cancer. Few data are currently available on the prognostic role of these immune-inflammatory biomarkers for other solid tumors and immunotherapy combinations. MATERIAL AND METHODS From August 2014 to May 2019, 153 patients with metastatic solid tumors were enrolled in phase I clinical trials testing immunotherapy both as single agents and as combinations. Primary endpoint was to evaluate the impact of baseline blood parameters on progression-free survival (PFS) and overall survival (OS). RESULTS The most common tumor types were gastrointestinal, breast, and gynecological cancers (22.9%, 22.2%, and 15.0%, respectively). Higher lactate dehydrogenase (LDH) and derived neutrophil-to-lymphocyte ratio (dNLR) were independently associated with reduced PFS (hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.30-2.99; p = .001, and HR, 2.29; 95% CI, 1.39-3.77; p = .001, respectively) and reduced OS (HR, 2.04; 95% CI, 1.26-3.28; p = .004, and HR, 2.06; 95% CI, 1.12-3.79; p = .02, respectively). In the subgroup analysis, (single agent vs. combination), patients at "good" (dNLR <3 and LDH < upper limit of normal [ULN]) and "intermediate and poor" (dNLR >3 and/or LDH > ULN) risk had higher and lower PFS, respectively (p for interaction = .002). Conversely, patients receiving monotherapy presented statistically significant difference in OS according to the risk group, whereas this effect was not observed for those treated with combinations (p for interaction = .004). CONCLUSION Elevated LDH and dNLR are associated with poorer survival outcomes in patients treated with immunotherapy in phase I clinical trials, regardless of tumor type. These parameters represent an easy tool that might be considered as stratification factors in immunotherapy-based clinical trials. IMPLICATIONS FOR PRACTICE In this retrospective cohort study of 153 patients with metastatic solid tumors treated with immunotherapy in the context of phase I clinical trials, elevated baseline lactate dehydrogenase and derived neutrophil-to-lymphocyte ratio were associated with reduced survival regardless of tumor subtype. If prospectively validated, these parameters might represent low-cost and easy biomarkers that could help patient selection for early phase immunotherapy trials and be applied as a stratification factor in randomized studies testing immunotherapy agents.
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Affiliation(s)
- Carmen Criscitiello
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
| | - Antonio Marra
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Haemato-Oncology, University of Milano, Milan, Italy
| | - Stefania Morganti
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Haemato-Oncology, University of Milano, Milan, Italy
| | - Paola Zagami
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Haemato-Oncology, University of Milano, Milan, Italy
| | - Giulia Viale
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Giuseppe Curigliano
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Haemato-Oncology, University of Milano, Milan, Italy
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65
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Turner JH. Ethics of Pharma Clinical Trials in the Era of Precision Oncology. Cancer Biother Radiopharm 2020; 36:1-9. [PMID: 32935997 DOI: 10.1089/cbr.2020.4129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Pharmaceutical industry clinical trials are ethically problematic: human research subjects are being used as a means to the end of demonstrating statistically significant efficacy of novel anticancer agents to achieve regulatory registration and marketing approval. Randomized controlled trial design is inequitable since control arm patients are denied access to the postulated best treatment. Most pharma studies do not provide clinically meaningful benefit of increased overall survival and enhanced quality of life (QOL) to cohorts and are not reliably generalizable to real-world patients. Precision oncology now enables prospective identification of patients expressing a specific cancer biomarker to determine their particular eligibility for evaluation of efficiency of molecular-targeted treatments. A patient-centered approach, collecting prospective real-world data in large populations, could provide real-world evidence of cost-effective, sustained clinical benefits of survival and QOL, while preserving the ethical beneficent compact between patient and doctor.
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Affiliation(s)
- J Harvey Turner
- Department of Nuclear Medicine, Fiona Stanley Fremantle Hospitals Group, The University of Western Australia, Murdoch, Australia
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66
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Gerasimov E, Donoghue M, Bilenker J, Watt T, Goodman N, Laetsch TW. Before It's Too Late: Multistakeholder Perspectives on Compassionate Access to Investigational Drugs for Pediatric Patients With Cancer. Am Soc Clin Oncol Educ Book 2020; 40:1-10. [PMID: 32412804 DOI: 10.1200/edbk_278995] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients and their families, physicians, drug companies, and regulatory agencies have common goals: to find effective therapies for life-threatening conditions. In oncology, the lines between clinical research and treatment are often blurred; parents and physicians of patients who have exhausted standard-of-care treatments and cannot participate in a clinical trial are likely to consider seeking compassionate use access to investigational drugs; however, knowledge and perspectives about compassionate use may differ among these groups. There are unique considerations associated with providing compassionate use to children diagnosed with cancer, including evaluation for potential developmental toxicities, the need for pediatric-specific dosing and formulations, informed consent, and, when appropriate, patient assent. Positive impacts of providing access to investigational therapies to children include potential treatment benefits to patients who obtain investigational agents as well as benefits to future patients if data from expanded access support drug development for childhood cancer. Challenges for physicians seeking compassionate use access to investigational drugs for their patients include obtaining the drug sponsor's agreement to provide the investigational drug as well as lack of knowledge about the process and regulatory requirements. Clinical trials in oncology provide the possibility of therapeutic benefit for pediatric patients; when feasible and warranted, these benefits should also be available to patients on a compassionate use basis outside of trials.
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Affiliation(s)
| | | | | | - Tanya Watt
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX.,Pauline Allen Gill Center for Cancer and Blood Disorders, Children's Health, Dallas, TX
| | | | - Theodore W Laetsch
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX.,Pauline Allen Gill Center for Cancer and Blood Disorders, Children's Health, Dallas, TX.,Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX
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67
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Gambardella V, Tarazona N, Cejalvo JM, Lombardi P, Huerta M, Roselló S, Fleitas T, Roda D, Cervantes A. Personalized Medicine: Recent Progress in Cancer Therapy. Cancers (Basel) 2020; 12:E1009. [PMID: 32325878 PMCID: PMC7226371 DOI: 10.3390/cancers12041009] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/05/2020] [Accepted: 04/15/2020] [Indexed: 01/01/2023] Open
Abstract
Translational research has revolutionized how we develop new treatments for cancer patients. The change from an organ-centric concept guiding treatment choice towards deep molecular analysis, driving a personalized approach, is one of the most important advances of modern oncology. Several tools such as next generation sequencing and RNA sequencing have greatly improved the capacity to detect predictive and prognostic molecular alterations. Detection of gene mutations, amplifications, and fusions has therefore altered the history of several diseases in both a localized and metastatic setting. This shift in perspective, in which attention is focused on the specific molecular alterations of the tumor, has opened the door to personalized treatment. This situation is reflected in the increasing number of basket trials selecting specific molecular targets. Nonetheless, some weaknesses need to be addressed. The complexity of cancer cells enriched with concomitant molecular alterations complicates identification of the driver. Moreover, tumor heterogeneity could be responsible for the lack of benefit when targeted agents are used. In light of this, there is growing interest in the role of multidisciplinary committees or molecular tumor boards to try to enhance selection. The aim of this review is to critically analyze the evolution of cancer treatment towards a precision approach, underlining some recent successes and unexpected failures.
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Affiliation(s)
- Valentina Gambardella
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (V.G.); (N.T.); (J.M.C.); (M.H.); (S.R.); (T.F.)
- Instituto de Salud Carlos III, CIBERONC, 28220 Madrid, Spain
| | - Noelia Tarazona
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (V.G.); (N.T.); (J.M.C.); (M.H.); (S.R.); (T.F.)
- Instituto de Salud Carlos III, CIBERONC, 28220 Madrid, Spain
| | - Juan Miguel Cejalvo
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (V.G.); (N.T.); (J.M.C.); (M.H.); (S.R.); (T.F.)
| | - Pasquale Lombardi
- Department of Oncology, University of Turin; Candiolo Cancer Institute - FPO- IRCCS, 10060 Candiolo (TO), Italy;
| | - Marisol Huerta
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (V.G.); (N.T.); (J.M.C.); (M.H.); (S.R.); (T.F.)
| | - Susana Roselló
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (V.G.); (N.T.); (J.M.C.); (M.H.); (S.R.); (T.F.)
- Instituto de Salud Carlos III, CIBERONC, 28220 Madrid, Spain
| | - Tania Fleitas
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (V.G.); (N.T.); (J.M.C.); (M.H.); (S.R.); (T.F.)
- Instituto de Salud Carlos III, CIBERONC, 28220 Madrid, Spain
| | - Desamparados Roda
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (V.G.); (N.T.); (J.M.C.); (M.H.); (S.R.); (T.F.)
- Instituto de Salud Carlos III, CIBERONC, 28220 Madrid, Spain
| | - Andres Cervantes
- Department of Medical Oncology, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (V.G.); (N.T.); (J.M.C.); (M.H.); (S.R.); (T.F.)
- Instituto de Salud Carlos III, CIBERONC, 28220 Madrid, Spain
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Tarantino P, Trapani D, Curigliano G. Conducting phase 1 cancer clinical trials during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related disease pandemic. Eur J Cancer 2020; 132:8-10. [PMID: 32305011 PMCID: PMC7136890 DOI: 10.1016/j.ejca.2020.03.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Paolo Tarantino
- European Institute of Oncology, IRCCS, Milan, Italy; University of Milan, Milan, Italy
| | | | - Giuseppe Curigliano
- European Institute of Oncology, IRCCS, Milan, Italy; University of Milan, Milan, Italy.
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Mazzarella L, Morganti S, Marra A, Trapani D, Tini G, Pelicci P, Curigliano G. Master protocols in immuno-oncology: do novel drugs deserve novel designs? J Immunother Cancer 2020; 8:e000475. [PMID: 32238471 PMCID: PMC7174064 DOI: 10.1136/jitc-2019-000475] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2020] [Indexed: 12/31/2022] Open
Abstract
The rapid rise to fame of immuno-oncology (IO) drugs has generated unprecedented interest in the industry, patients and doctors, and has had a major impact in the treatment of most cancers. An interesting aspect in the clinical development of many IO agents is the increasing reliance on nonconventional trial design, including the so-called 'master protocols' that incorporate various adaptive features and often heavily rely on biomarkers to select patient populations most likely to benefit. These novel designs promise to maximize the clinical benefit that can be reaped from clinical research, but are not without costs. Their acceptance as solid evidence basis for use outside of the research context requires profound cultural changes by multiple stakeholders, including regulatory bodies, decision-makers, statisticians, researchers, doctors and, most importantly, patients. Here we review characteristics of recent and ongoing trials testing IO drugs with unconventional design, and we highlight trends and critical aspects.
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Affiliation(s)
- Luca Mazzarella
- Division of Early Drug Development for Innovative Therapies, IEO European Institute of Oncology IRCCS, Milan, Italy
- Experimental Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Stefania Morganti
- Division of Early Drug Development for Innovative Therapies, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Antonio Marra
- Division of Early Drug Development for Innovative Therapies, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Dario Trapani
- Division of Early Drug Development for Innovative Therapies, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Giulia Tini
- Experimental Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Piergiuseppe Pelicci
- Experimental Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, Universita degli Studi di Milano, Milan, Italy
| | - Giuseppe Curigliano
- Division of Early Drug Development for Innovative Therapies, IEO European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, Universita degli Studi di Milano, Milan, Italy
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