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Gharzai LA, Jiang R, Wallington D, Jones G, Birer S, Jairath N, Jaworski EM, McFarlane MR, Mahal BA, Nguyen PL, Sandler H, Morgan TM, Reichert ZR, Alumkal JJ, Mehra R, Kishan AU, Fizazi K, Halabi S, Schaeffer EM, Feng FY, Elliott D, Dess RT, Jackson WC, Schipper MJ, Spratt DE. Intermediate clinical endpoints for surrogacy in localised prostate cancer: an aggregate meta-analysis. Lancet Oncol 2021; 22:402-410. [PMID: 33662287 PMCID: PMC10949134 DOI: 10.1016/s1470-2045(20)30730-0] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/23/2020] [Accepted: 11/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The international Intermediate Clinical Endpoints in Cancer of the Prostate working group has established metastasis-free survival as a surrogate for overall survival in localised prostate cancer based on the findings of 19 predominantly radiotherapy-based trials. We sought to comprehensively assess aggregate trial-level performance of commonly reported intermediate clinical endpoints across all randomised trials in localised prostate cancer. METHODS For this meta-analysis, we searched PubMed for all trials in localised or biochemically recurrent prostate cancer published between Jan 1, 1970, and Jan 15, 2020. Eligible trials had to be randomised, therapeutic, reporting overall survival and at least one intermediate clinical endpoint, and with a sample size of at least 70 participants. Trials of metastatic disease were excluded. Intermediate clinical endpoints included biochemical failure, local failure, distant metastases, biochemical failure-free survival, progression-free survival, and metastasis-free survival. Candidacy for surrogacy was assessed using the second condition of the meta-analytical approach (ie, correlation of the treatment effect of the intermediate clinical endpoint and overall survival), using R2 weighted by the inverse variance of the log intermediate clinical endpoint hazard ratio. The intermediate clinical endpoint was deemed to be a surrogate for overall survival if R2 was 0·7 or greater. FINDINGS 75 trials (53 631 patients) were included in our analysis. Median follow-up was 9·1 years (IQR 5·7-10·6). Biochemical failure (R2 0·38 [95% CI 0·11-0·64]), biochemical failure-free survival (R2 0·12 [0·0030-0·33]), biochemical failure and clinical failure (R2 0·28 [0·0045-0·65]), and local failure (R2 0·085 [0·00-0·37]) correlated poorly with overall survival. Progression-free survival (R2 0·46 [95% CI 0·22-0·67]) showed moderate correlation with overall survival, and metastasis-free survival (R2 0·78 [0·59-0·89]) correlated strongly. INTERPRETATION Intermediate clinical endpoints based on biochemical and local failure did not meet the second condition of the meta-analytical approach and are not surrogate endpoints for overall survival in localised prostate cancer. Our findings validate metastasis-free survival as the only identified surrogate endpoint for overall survival to date. FUNDING Prostate Cancer Foundation and National Institutes of Health.
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Affiliation(s)
- Laila A Gharzai
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Ralph Jiang
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - David Wallington
- Department of Radiation Oncology, Western Michigan University, Kalamazoo, MI, USA
| | - Gavin Jones
- Department of Radiation Oncology, University of Kentucky, Lexington, KY, USA
| | - Samuel Birer
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Neil Jairath
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | | | - Matthew R McFarlane
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Brandon A Mahal
- Department of Radiation Oncology, University of Miami, Miami, FL, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Howard Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Zachery R Reichert
- Department of Medical Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Joshi J Alumkal
- Department of Medical Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Rohit Mehra
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Amar U Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Karim Fizazi
- Department of Cancer Medicine, Institut Gustave-Roussy, Villejuif, France
| | - Susan Halabi
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | | | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - David Elliott
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - William C Jackson
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Matthew J Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA; Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
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Statistical aspects in adjuvant and neoadjuvant trials for gastrointestinal cancer in 2020: focus on time-to-event endpoints. Curr Opin Oncol 2020; 32:384-390. [PMID: 32541329 DOI: 10.1097/cco.0000000000000636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Clinical-trial design, analysis, and interpretation entails the use of efficient and reliable endpoints. Statistical issues related to endpoints warrant continued attention, as they may have a substantial impact on the conduct of clinical trials and on interpretation of their results. RECENT FINDINGS We review concepts and discuss recent developments related to the use of time-to-event endpoints in studies on adjuvant and neoadjuvant therapy for colon, pancreatic, and gastric adenocarcinomas. The definition of endpoints has varied to a considerable extent in these settings. Although these variations are relevant in interpreting results from individual trials, they probably have a small impact when considered in aggregate. In terms of surrogacy, most published reports so far have used aggregated data. A few studies based on the preferred method of a metaanalysis of individual-patient data have shown that disease-free survival (DFS) is a surrogate for overall survival in the adjuvant therapy of stage III colon cancer and in gastric cancer, whereas DFS with a landmark of six months is a surrogate for overall survival in the neoadjuvant therapy of adenocarcinoma of the esophagus, gastroesophageal junction, or stomach. SUMMARY Testing novel agents in gastrointestinal cancer requires continued attention to statistical issues related to endpoints.
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Statistical Considerations for Trials in Adjuvant Treatment of Colorectal Cancer. Cancers (Basel) 2020; 12:cancers12113442. [PMID: 33228149 PMCID: PMC7699469 DOI: 10.3390/cancers12113442] [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: 09/16/2020] [Revised: 10/29/2020] [Accepted: 11/17/2020] [Indexed: 12/26/2022] Open
Abstract
The design of the best possible clinical trials of adjuvant interventions in colorectal cancer will entail the use of both time-tested and novel methods that allow efficient, reliable and patient-relevant therapeutic development. The ultimate goal of this endeavor is to safely and expeditiously bring to clinical practice novel interventions that impact patient lives. In this paper, we discuss statistical aspects and provide suggestions to optimize trial design, data collection, study implementation, and the use of predictive biomarkers and endpoints in phase 3 trials of systemic adjuvant therapy. We also discuss the issues of collaboration and patient centricity, expecting that several novel agents with activity in the (neo)adjuvant therapy of colon and rectal cancers will become available in the near future.
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Cooper K, Tappenden P, Cantrell A, Ennis K. A systematic review of meta-analyses assessing the validity of tumour response endpoints as surrogates for progression-free or overall survival in cancer. Br J Cancer 2020; 123:1686-1696. [PMID: 32913287 PMCID: PMC7687906 DOI: 10.1038/s41416-020-01050-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/29/2020] [Accepted: 08/18/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Tumour response endpoints, such as overall response rate (ORR) and complete response (CR), are increasingly used in cancer trials. However, the validity of response-based surrogates is unclear. This systematic review summarises meta-analyses assessing the association between response-based outcomes and overall survival (OS), progression-free survival (PFS) or time-to-progression (TTP). METHODS Five databases were searched to March 2019. Meta-analyses reporting correlation or regression between response-based outcomes and OS, PFS or TTP were summarised. RESULTS The systematic review included 63 studies across 20 cancer types, most commonly non-small cell lung cancer (NSCLC), colorectal cancer (CRC) and breast cancer. The strength of association between ORR or CR and either PFS or OS varied widely between and within studies, with no clear pattern by cancer type. The association between ORR and OS appeared weaker and more variable than that between ORR and PFS, both for associations between absolute endpoints and associations between treatment effects. CONCLUSIONS This systematic review suggests that response-based endpoints, such as ORR and CR, may not be reliable surrogates for PFS or OS. Where it is necessary to use tumour response to predict treatment effects on survival outcomes, it is important to fully reflect all statistical uncertainty in the surrogate relationship.
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Affiliation(s)
- Katy Cooper
- ScHARR, University of Sheffield, Sheffield, UK.
| | | | | | - Kate Ennis
- ScHARR, University of Sheffield, Sheffield, UK
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Endpoint surrogacy in oncology Phase 3 randomised controlled trials. Br J Cancer 2020; 123:333-334. [PMID: 32451466 PMCID: PMC7403397 DOI: 10.1038/s41416-020-0896-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/01/2020] [Indexed: 12/17/2022] Open
Abstract
Endpoint surrogacy is an important concept in oncology trials. Using a surrogate endpoint like progression-free survival as the primary endpoint-instead of overall survival-would lead to a potential faster drug approval and therefore more cancer patients with an earlier opportunity to receive the newly approved drugs.
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Gyawali B, Hey SP, Kesselheim AS. Evaluating the evidence behind the surrogate measures included in the FDA's table of surrogate endpoints as supporting approval of cancer drugs. EClinicalMedicine 2020; 21:100332. [PMID: 32382717 PMCID: PMC7201012 DOI: 10.1016/j.eclinm.2020.100332] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In July 2018, the FDA first published a table listing all surrogate measures that it has used, and may accept for future use, in regulatory approval. However, the strength of surrogacy for those measures was not formally assessed. Using the case example of breast cancer, we aimed to evaluate the strength of correlation of surrogate measures listed in the FDA's Table with overall survival. METHODS This cross-sectional study of the FDA's Table of Surrogate Endpoints was conducted in May 2019. All surrogate measures listed in the FDA table as appropriate for accelerated or regular approval for breast cancer were extracted. We identified studies evaluating the correlation of treatment benefit in the surrogate with treatment benefit in overall survival and extracted results from the correlation analysis. FINDINGS Five surrogate endpoints were listed for breast cancer in the FDA website: pathological complete response rates (pCR), event-free survival (EFS), disease-free survival (DFS), objective response rates (ORR), and progression-free survival (PFS), of which pCR was listed as appropriate only for accelerated approval, while the rest were considered appropriate for accelerated or regular approval. No correlation study evaluated the correlation of treatment effects on EFS with that on OS. The results from correlation studies evaluating pCR, DFS, ORR, and PFS suggest that the treatment effects on none of these surrogate measures were strongly correlated with treatment effects on OS (r<0.85 or R2 < 0.7, except for DFS in HER2 positive early breast cancer (R2 = 0.75). INTERPRETATION Using breast cancer as an example, we evaluated the underlying evidence for the surrogate endpoints for solid tumors listed in the FDA's Table of Surrogate Endpoints and found weak or missing correlations of treatment effects on these surrogates with treatment effects on OS . Surrogate measures should be predictive of clinical benefit to be useful in supporting regular FDA approval. FUNDING Work on this project was funded by the Arnold Ventures. Dr. Kesselheim is also supported by the Harvard-MIT Center for Regulatory Science. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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Affiliation(s)
- Bishal Gyawali
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, US
- Department of Oncology, Department of Public Health Sciences and Division of Cancer Care and Epidemiology, Queen's University, Kingston, Canada
- Corresponding author.
| | - Spencer P. Hey
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, US
- Harvard Center for Bioethics, Harvard Medical School, Boston, MA, US
| | - Aaron S. Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, US
- Harvard Center for Bioethics, Harvard Medical School, Boston, MA, US
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Progression-free survival as a surrogate for overall survival in oncology trials: a methodological systematic review. Br J Cancer 2020; 122:1707-1714. [PMID: 32214230 PMCID: PMC7250908 DOI: 10.1038/s41416-020-0805-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 01/16/2020] [Accepted: 02/28/2020] [Indexed: 02/08/2023] Open
Abstract
Background Progression-free survival (PFS) is a surrogate endpoint widely used for overall survival (OS) in oncology. Validation of PFS as a surrogate must be done for each indication and each intervention. We aimed to identify all studies evaluating the validity of PFS as a surrogate for OS in oncology, and to describe their methodological characteristics. Methods We conducted a systematic review by searching MEDLINE via PubMed and the Cochrane Library with no limitation on time, selected relevant studies and extracted data in duplicate on how surrogacy was evaluated (meta-analytic approach, assessment of correlation and level of evaluation). Results We identified 91 studies evaluating the validity of PFS as a surrogate for OS in 24 cancer localisations. Although a meta-analytic approach was used in 83 (91%) studies, the methods used to validate PFS as a surrogate of OS were heterogeneous across studies. Of the 47 studies concluding that PFS is a good surrogate for OS, for 15 (32%), there was no quantitative argument for surrogacy. Conclusions Although most studies used a meta-analytic approach as recommended, our methodological review highlights heterogeneity in methods and reporting, which stresses the importance of developing and applying clear recommendations in this area.
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Burzykowski T, Coart E, Saad ED, Shi Q, Sommeijer DW, Bokemeyer C, Díaz-Rubio E, Douillard JY, Falcone A, Fuchs CS, Goldberg RM, Hecht JR, Hoff PM, Hurwitz H, Kabbinavar FF, Koopman M, Maughan TS, Punt CJA, Saltz L, Schmoll HJ, Seymour MT, Tebbutt NC, Tournigand C, Van Cutsem E, de Gramont A, Zalcberg JR, Buyse M. Evaluation of Continuous Tumor-Size-Based End Points as Surrogates for Overall Survival in Randomized Clinical Trials in Metastatic Colorectal Cancer. JAMA Netw Open 2019; 2:e1911750. [PMID: 31539075 PMCID: PMC6755539 DOI: 10.1001/jamanetworkopen.2019.11750] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Tumor measurements can be used to estimate time to nadir and depth of nadir as potential surrogates for overall survival (OS). OBJECTIVE To assess time to nadir and depth of nadir as surrogates for OS in metastatic colorectal cancer. DESIGN, SETTING, AND PARTICIPANTS Pooled analysis of 20 randomized clinical trials within the Aide et Recherche en Cancerologie Digestive database, which contains academic and industry-sponsored trials, was conducted. Three sets of comparisons were performed: chemotherapy alone, antiangiogenic agents, and anti-epidermal growth factor receptor agents in first-line treatment for patients with metastatic colorectal cancer. MAIN OUTCOMES AND MEASURES Surrogacy of time to nadir and depth of nadir was assessed at the trial level based on joint modeling of relative tumor-size change vs baseline and OS. Treatment effects on time to nadir and on depth of nadir were defined in terms of between-arm differences in time to nadir and in depth of nadir, and both were assessed in linear regressions for their correlation with treatment effects (hazard ratios) on OS within each set. The strengths of association were quantified using sample-size-weighted coefficients of determination (R2), with values closer to 1.00 indicating stronger association. At the patient level, the correlation was assessed between modeled relative tumor-size change and OS. RESULTS For 14 chemotherapy comparisons in 4289 patients, the R2 value was 0.63 (95% CI, 0.30-0.96) for the association between treatment effects on time to nadir and OS and 0.08 (95% CI, 0-0.37) for depth of nadir and OS. For 11 antiangiogenic agent comparisons (4854 patients), corresponding values of R2 were 0.25 (95% CI, 0-0.72) and 0.06 (95% CI, 0-0.35). For 8 anti-epidermal growth factor receptor comparisons (2684 patients), corresponding values of R2 were 0.24 (95% CI, 0-0.83) and 0.21 (95% CI, 0-0.78). CONCLUSIONS AND RELEVANCE In contrast with early reports favoring depth of response as a surrogate, these results suggest that neither time to nadir nor depth of nadir is an acceptable surrogate for OS in the first-line treatment of metastatic colorectal cancer.
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Affiliation(s)
- Tomasz Burzykowski
- International Drug Development Institute, Louvain-la-Neuve, Belgium
- Hasselt University, Diepenbeek, Belgium
| | - Elisabeth Coart
- International Drug Development Institute, Louvain-la-Neuve, Belgium
| | - Everardo D. Saad
- International Drug Development Institute, Louvain-la-Neuve, Belgium
| | - Qian Shi
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Dirkje W. Sommeijer
- The University of Sydney, Camperdown, New South Wales, Australia
- Academic Medical Centre, Amsterdam, the Netherlands
- Flevohospital, Almere, the Netherlands
| | - Carsten Bokemeyer
- Department of Internal Medicine II and Clinic, University of Hamburg, Hamburg, Germany
| | - Eduardo Díaz-Rubio
- Hospital Clinico San Carlos and Centro de Investigación Biomédica en Red Cáncer, CIBERONC, Madrid, Spain
| | | | | | | | | | - J. Randolph Hecht
- David Geffen School of Medicine, University of California, Los Angeles
| | - Paulo M. Hoff
- Instituto de Câncer do Estado de São Paulo, São Paulo, Brazil
| | | | | | - Miriam Koopman
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Timothy S. Maughan
- Cancer Research UK and the Medical Research Council Oxford Institute for Radiation Oncology, Oxford, United Kingdom
| | - Cornelis J. A. Punt
- Amsterdam University Medical Centrum, Department of Medical Oncology, University of Amsterdam, Amsterdam, the Netherlands
| | - Leonard Saltz
- Memorial Sloan-Kettering Cancer Center, New York, New York
| | | | | | | | | | - Eric Van Cutsem
- Division of Digestive Oncology, University Hospitals Gasthuisberg Leuven, Leuven, Belgium
| | - Aimery de Gramont
- Katholieke Universiteit, Leuven, Belgium
- Franco-British Institute, Levallois-Perret, France
| | - John R. Zalcberg
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
| | - Marc Buyse
- Hasselt University, Diepenbeek, Belgium
- International Drug Development Institute Inc, San Francisco, California
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