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Patel K, Ivanov A, Jocelyn T, Hantel A, Garcia JS, Abel GA. Patient-Reported Outcomes in Phase 3 Clinical Trials for Blood Cancers: A Systematic Review. JAMA Netw Open 2024; 7:e2414425. [PMID: 38829615 PMCID: PMC11148691 DOI: 10.1001/jamanetworkopen.2024.14425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/01/2024] [Indexed: 06/05/2024] Open
Abstract
Importance Published research suggests that patient-reported outcomes (PROs) are neither commonly collected nor reported in randomized clinical trials (RCTs) for solid tumors. Little is known about these practices in RCTs for hematological malignant neoplasms. Objective To evaluate the prevalence of PROs as prespecified end points in RCTs of hematological malignant neoplasms, and to assess reporting of PROs in associated trial publications. Evidence Review All issues of 8 journals known for publishing high-impact RCTs (NEJM, Lancet, Lancet Hematology, Lancet Oncology, Journal of Clinical Oncology, Blood, JAMA, and JAMA Oncology) between January 1, 2018, and December 13, 2022, were searched for primary publications of therapeutic phase 3 trials for adults with hematological malignant neoplasms. Studies that evaluated pretransplant conditioning regimens, graft-vs-host disease treatment, or radiotherapy as experimental treatment were excluded. Data regarding trial characteristics and PROs were extracted from manuscripts and trial protocols. Univariable analyses assessed associations between trial characteristics and PRO collection or reporting. Findings Ninety RCTs were eligible for analysis. PROs were an end point in 66 (73%) trials: in 1 trial (1%) as a primary end point, in 50 (56%) as a secondary end point, and in 15 (17%) as an exploratory end point. PRO data were reported in 26 of 66 primary publications (39%): outcomes were unchanged in 18 and improved in 8, with none reporting worse PROs with experimental treatment. Trials sponsored by for-profit entities were more likely to include PROs as an end point (49 of 55 [89%] vs 17 of 35 [49%]; P < .001) but were not significantly more likely to report PRO data (20 of 49 [41%] vs 6 of 17 [35%]; P = .69). Compared with trials involving lymphoma (18 of 29 [62%]) or leukemia or myelodysplastic syndrome (18 of 28 [64%]), those involving plasma cell disorders or multiple myeloma (27 of 30 [90%]) or myeloproliferative neoplasms (3 of 3 [100%]) were more likely to include PROs as an end point (P = .03). Similarly, compared with trials involving lymphoma (3 of 18 [17%]) or leukemia or myelodysplastic syndrome (5 of 18 [28%]), those involving plasma cell disorders or multiple myeloma (16 of 27 [59%]) or myeloproliferative neoplasms (2 of 3 [67%]) were more likely to report PROs in the primary publication (P = .01). Conclusions and Relevance In this systematic review, almost 3 of every 4 therapeutic RCTs for blood cancers collected PRO data; however, only 1 RCT included PROs as a primary end point. Moreover, most did not report resulting PRO data in the primary publication and when reported, PROs were either better or unchanged, raising concern for publication bias. This analysis suggests a critical gap in dissemination of data on the lived experiences of patients enrolled in RCTs for hematological malignant neoplasms.
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Affiliation(s)
- Kishan Patel
- Department of Internal Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Alexandra Ivanov
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Tajmah Jocelyn
- Center for Clinical Investigation, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Andrew Hantel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jacqueline S. Garcia
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gregory A. Abel
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
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Liu ITT, Kesselheim AS, Cliff ERS. Clinical Benefit and Regulatory Outcomes of Cancer Drugs Receiving Accelerated Approval. JAMA 2024; 331:1471-1479. [PMID: 38583175 PMCID: PMC11000139 DOI: 10.1001/jama.2024.2396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/13/2024] [Indexed: 04/09/2024]
Abstract
Importance The US Food and Drug Administration's (FDA) accelerated approval pathway allows approval of investigational drugs treating unmet medical needs based on changes to surrogate measures considered "reasonably likely" to predict clinical benefit. Postapproval clinical trials are then required to confirm whether these drugs offer clinical benefit. Objective To determine whether cancer drugs granted accelerated approval ultimately demonstrate clinical benefit and to evaluate the basis of conversion to regular approval. Design, Setting, and Participants In this cohort study, publicly available FDA data were used to identify cancer drugs granted accelerated approval from 2013 to 2023. Main Outcomes and Measures Demonstrated improvement in quality of life or overall survival in accelerated approvals with more than 5 years of follow-up, as well as confirmatory trial end points and time to conversion for drug-indication pairs converted to regular approval. Results A total of 129 cancer drug-indication pairs were granted accelerated approval from 2013 to 2023. Among 46 indications with more than 5 years of follow-up (approved 2013-2017), approximately two-thirds (29, 63%) were converted to regular approval, 10 (22%) were withdrawn, and 7 (15%) remained ongoing after a median of 6.3 years. Fewer than half (20/46, 43%) demonstrated a clinical benefit in confirmatory trials. Time to withdrawal decreased from 9.9 years to 3.6 years, and time to regular approval increased from 1.6 years to 3.6 years. Among 48 drug-indication pairs converted to regular approval, 19 (40%) were converted based on overall survival, 21 (44%) on progression-free survival, 5 (10%) on response rate plus duration of response, 2 (4%) on response rate, and 1 (2%) despite a negative confirmatory trial. Comparing accelerated and regular approval indications, 18 of 48 (38%) were unchanged, while 30 of 48 (63%) had different indications (eg, earlier line of therapy). Conclusions and Relevance Most cancer drugs granted accelerated approval did not demonstrate benefit in overall survival or quality of life within 5 years of accelerated approval. Patients should be clearly informed about the cancer drugs that use the accelerated approval pathway and do not end up showing benefits in patient-centered clinical outcomes.
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Affiliation(s)
- Ian T. T. Liu
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Aaron S. Kesselheim
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Edward R. Scheffer Cliff
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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Gassner T, Chittilappilly C, Pirich T, Neuditschko B, Hackner K, Lind J, Aksoy O, Graichen U, Klee S, Herzog F, Wiesner C, Errhalt P, Pecherstorfer M, Podar K, Vallet S. Favorable impact of PD1/PD-L1 antagonists on bone remodeling: an exploratory prospective clinical study and ex vivo validation. J Immunother Cancer 2024; 12:e008669. [PMID: 38702145 PMCID: PMC11086513 DOI: 10.1136/jitc-2023-008669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Skeletal morbidity in patients with cancer has a major impact on the quality of life, and preserving bone health while improving outcomes is an important goal of modern antitumor treatment strategies. Despite their widespread use in early disease stages, the effects of immune checkpoint inhibitors (ICIs) on the skeleton are still poorly defined. Here, we initiated a comprehensive investigation of the impact of ICIs on bone health by longitudinal assessment of bone turnover markers in patients with cancer and by validation in a novel bioengineered 3D model of bone remodeling. METHODS An exploratory longitudinal study was conducted to assess serum markers of bone resorption (C-terminal telopeptide, CTX) and formation (procollagen type I N-terminal propeptide, PINP, and osteocalcin, OCN) before each ICI application (programmed cell death 1 (PD1) inhibitor or programmed death-ligand 1 (PD-L1) inhibitor) for 6 months or until disease progression in patients with advanced cancer and no evidence of bone metastases. To validate the in vivo results, we evaluated osteoclast (OC) and osteoblast (OB) differentiation on treatment with ICIs. In addition, their effect on bone remodeling was assessed by immunohistochemistry, confocal microscopy, and proteomics analysis in a dynamic 3D bone model. RESULTS During the first month of treatment, CTX levels decreased sharply but transiently. In contrast, we observed a delayed increase of serum levels of PINP and OCN after 4 months of therapy. In vitro, ICIs impaired the maturation of preosteoclasts by inhibiting STAT3/NFATc1 signaling but not JNK, ERK, and AKT while lacking any direct effect on osteogenesis. However, using our bioengineered 3D bone model, which enables the simultaneous differentiation of OB and OC precursor cells, we confirmed the uncoupling of the OC/OB activity on exposure to ICIs by demonstrating impaired OC maturation along with increased OB differentiation. CONCLUSION Our study indicates that the inhibition of the PD1/PD-L1 signaling axis interferes with bone turnover and may exert a protective effect on bone by indirectly promoting osteogenesis.
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Affiliation(s)
- Tamara Gassner
- Department of Basic and Translational Oncology and Hematology, Division of Molecular Oncology and Hematology, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
| | - Christina Chittilappilly
- Department of Basic and Translational Oncology and Hematology, Division of Molecular Oncology and Hematology, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
| | - Theo Pirich
- Department of Basic and Translational Oncology and Hematology, Division of Molecular Oncology and Hematology, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
| | - Benjamin Neuditschko
- Institute Krems Bioanalytics, IMC University of Applied Sciences, Krems an der Donau, Austria
| | - Klaus Hackner
- Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
- Division of Pneumology, University Hospital Krems, Krems an der Donau, Austria
| | - Judith Lind
- Department of Basic and Translational Oncology and Hematology, Division of Molecular Oncology and Hematology, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
| | - Osman Aksoy
- Department of Basic and Translational Oncology and Hematology, Division of Molecular Oncology and Hematology, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
| | - Uwe Graichen
- Department of General Health Studies, Division Biostatistics and Data Sciences, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
| | - Sascha Klee
- Department of General Health Studies, Division Biostatistics and Data Sciences, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
| | - Franz Herzog
- Institute Krems Bioanalytics, IMC University of Applied Sciences, Krems an der Donau, Austria
| | - Christoph Wiesner
- Department of Medical and Pharmaceutical Biotechnology, IMC University of Applied Sciences, Krems an der Donau, Austria
| | - Peter Errhalt
- Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
- Division of Pneumology, University Hospital Krems, Krems an der Donau, Austria
| | - Martin Pecherstorfer
- Division of Internal Medicine 2, University Hospital Krems, Krems an der Donau, Austria
- Karl Landsteiner Institute of Supportive Cancer Therapy, Karl Landsteiner Gesellschaft, St. Poelten, Austria
| | - Klaus Podar
- Department of Basic and Translational Oncology and Hematology, Division of Molecular Oncology and Hematology, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
- Division of Internal Medicine 2, University Hospital Krems, Krems an der Donau, Austria
| | - Sonia Vallet
- Department of Basic and Translational Oncology and Hematology, Division of Molecular Oncology and Hematology, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
- Division of Internal Medicine 2, University Hospital Krems, Krems an der Donau, Austria
- Karl Landsteiner Institute of Supportive Cancer Therapy, Karl Landsteiner Gesellschaft, St. Poelten, Austria
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Raez LE, Kang H, Ohe Y, Khanal M, Han Y, Szymczak S, Barker SS, Gilligan AM. Patient-reported outcomes with selpercatinib treatment in patients with RET-driven cancers in the phase I/II LIBRETTO-001 trial. ESMO Open 2024; 9:103444. [PMID: 38749381 PMCID: PMC11108846 DOI: 10.1016/j.esmoop.2024.103444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/04/2024] [Accepted: 04/04/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND This post-hoc retrospective study describes long-term patient-reported outcomes (PROs) for REarranged during Transfection (RET)-altered non-small-cell lung cancer (NSCLC), medullary thyroid cancer (MTC), non-MTC thyroid cancer (TC), and tumor agnostic (TA) patients (Data cut-off: January 2023) from the LIBRETTO-001 trial. PATIENTS AND METHODS Patients completed the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 30 (QLQ-C30). Patients with MTC also completed a modified version of the Systemic Therapy-Induced Diarrhea Assessment Tool (mSTIDAT). The proportion of patients with improved, stable, or worsened status after baseline was reported. PROs were summarized at 3 years (cycle 37) post-baseline for the NSCLC and MTC cohorts, and at 2 years (cycle 25) post-baseline for the TC and TA cohorts. Time-to-event outcomes (time to first improvement or worsening and duration of improvement) were reported. RESULTS The baseline assessment was completed by 200 (63.3%), 209 (70.8%), 50 (76.9%), and 38 (73.1%) patients in the NSCLC, MTC, TC, and TA cohorts, respectively. The total compliance rate was 80%, 82%, 70%, and 85%, respectively. Approximately 75% (NSCLC), 81% (MTC), 75% (TC), and 40% (TA) of patients across all cohorts reported improved or stable QLQ-C30 scores at year 3 (NSCLC and MTC) or year 2 (TC and TA) with continuous selpercatinib use. Across cohorts, the median time to first improvement ranged from 2.0 to 19.4 months, the median duration of improvement ranged from 1.9 to 28.2 months, and the median time to first worsening ranged from 5.6 to 44.2 months. The total compliance rate for the mSTIDAT was 83.7% and the proportion of patients with MTC who reported diarrhea on the mSTIDAT was reduced from 80.8% at baseline to 35.6% at year 3. CONCLUSIONS A majority of patients with RET-driven cancers improved or remained stable on most QLQ-C30 domains, demonstrating favorable health-related quality of life as measured by the QLQ-C30 during long-term treatment with selpercatinib.
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Affiliation(s)
- L E Raez
- Memorial Cancer Institute/Florida Atlantic University (FAU), Thoracic Oncology, Boca Raton, Florida, USA
| | - H Kang
- Department of Medicine, University of California, San Francisco, San Francisco, USA
| | - Y Ohe
- National Cancer Center Hospital, Department of Thoracic Oncology, Tokyo, Japan
| | - M Khanal
- Real World and Access Analytics, Statistics, Eli Lilly and Company, Indianapolis, USA
| | - Y Han
- Real World and Access Analytics, Statistics, Eli Lilly and Company, Indianapolis, USA
| | - S Szymczak
- Clinical Research, Oncology, Eli Lilly and Company Poland, Lilly Corporate Center, Indianapolis, USA
| | - S S Barker
- Medical Affairs, Eli Lilly and Company, Indianapolis, USA
| | - A M Gilligan
- Value Evidence Outcomes Research and Oncology, Eli Lilly and Company, Indianapolis, USA.
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Elbaz J, Haslam A, Prasad V. An empirical analysis of overall survival in drug approvals by the US FDA (2006-2023). Cancer Med 2024; 13:e7190. [PMID: 38659418 PMCID: PMC11043668 DOI: 10.1002/cam4.7190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/18/2024] [Accepted: 04/03/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND The US Food and Drug Administration (FDA) has expanded the use of surrogate markers in drugs approved for oncology/hematology indications. This has likely resulted in a greater number of approvals and possibly drugs coming to market faster, but it is unknown whether these drugs also improve overall survival (OS) for patients taking them. METHODS We sought to estimate the percentage of oncology drugs that have shown to improve OS in a cross-sectional analysis of US FDA oncology drug approvals (2006-2023). We searched for OS data in registration trials and the peer-reviewed literature. RESULTS We found 392 oncology drug approvals. Eighty-seven (22%) drug approvals were based on OS, 147 drug approvals were later tested for OS benefit (38% of all approvals and 48% of drugs approved on a surrogate), and 130 (33%) have yet to be tested for OS benefit. Of the 147 drug approvals later tested for OS, 109 (28% of all approvals and 74% of drugs later tested for OS) have yet to show OS benefit, whereas 38 (10% of all approvals and 26% of drugs later tested for OS benefit) were later shown to have OS benefit. In total, 125 out of 392 (32%) drugs approved for any indication have been shown to improve OS benefit at some point, and 267 (68%) have yet to show approval. CONCLUSION About 32% of all oncology drug approvals have evidence for an improvement in OS. Higher standards are needed in drug regulation to ensure that approved drugs are delivering better patient outcomes, specifically in regards to survival.
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Affiliation(s)
| | - Alyson Haslam
- University of California San FranciscoSan FranciscoCaliforniaUSA
| | - Vinay Prasad
- University of California San FranciscoSan FranciscoCaliforniaUSA
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6
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Booth CM, Eisenhauer EA, Gyawali B, Tannock IF. Progression-Free Survival Should Not Be Used as a Primary End Point for Registration of Anticancer Drugs. J Clin Oncol 2023; 41:4968-4972. [PMID: 37733981 DOI: 10.1200/jco.23.01423] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/23/2023] Open
Affiliation(s)
- Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada
- Department of Oncology, Queen's University, Kingston, Canada
- Department of Public Health Sciences, Queen's University, Kingston, Canada
| | | | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada
- Department of Oncology, Queen's University, Kingston, Canada
- Department of Public Health Sciences, Queen's University, Kingston, Canada
| | - Ian F Tannock
- Division of Medical Oncology, Princess Margaret Cancer Centre and University of Toronto, Toronto, Canada
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7
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Wright K, Mittal A, Gyawali B. Surrogate endpoints for HTA decisions of breast cancer drugs: utility and pitfalls. Curr Opin Oncol 2023; 35:513-521. [PMID: 37621175 DOI: 10.1097/cco.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
PURPOSE OF REVIEW Health technology assessment (HTA) of cancer drugs is important to identify whether drugs should be publicly funded. With increasing use of surrogate end points in clinical trials including breast cancer, a review of literature was done to synthesize evidence for validation of these surrogate end points and their potential role in HTA decisions pertaining to breast cancer. FINDINGS Disease free survival (DFS) in human epidermal receptor 2 (HER2) positive early breast cancer remains the only validated surrogate end point. Other surrogate end points like pathological complete response (pCR) and event free survival (EFS) in early breast cancer (EBC) and objective response rate (ORR) and progression free survival (PFS) in advanced disease have not been validated for overall survival (OS). Moreover, surrogate end points for quality of life (QOL) have not been established and drugs that improve PFS can have detrimental effect on QOL. End points like pCR have excellent prognostic utility in individual patients but have weak correlation with survival at trial level. SUMMARY Most surrogate end points used in breast cancer do not predict OS or QOL which makes it challenging to use them for decisions regarding public funding of cancer drugs. These findings are relevant to HTA agencies prior to making drug reimbursement decisions.
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Affiliation(s)
| | - Abhenil Mittal
- Division of Hematology and Oncology, Department of Medicine, Princess Margaret Cancer Center, University of Toronto, Toronto, Ontario
| | - Bishal Gyawali
- Department of Oncology, Queen's University
- Department of Public Health Sciences
- Division of Cancer Care and Epidemiology, Queen's University, Kingston, Canada
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García-Fumero R, Fernández-López C, Calleja-Hernández MÁ, Expósito-Ruiz M, Espín J, Expósito-Hernández J. Clinical Outcomes of First-line Therapies for Advanced Non-Small Cell Lung Cancer: A Systematic Review of Trials Published Between 2010 and 2020. Am J Clin Oncol 2023; 46:433-438. [PMID: 37522643 DOI: 10.1097/coc.0000000000001031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
OBJECTIVES To analyze the evolution of clinical outcomes derived from clinical trials on first-line therapies for advanced or metastatic non-small cell lung cancer (NSCLC) published between 2010 and 2020, focusing on how these outcomes impact survival rates and management of patients. METHODS A systematic review of phase III and pivotal phase II clinical trials was conducted by a structured search on Medline and Embase. A comprehensive set of variables was collected to assess their influence on survival rates. We also estimated the clinical benefit by applying the ESMO-MCBS v1.1 and extracted the authors' conclusions. RESULTS Sixty-six studies involving 34,951 patients were included. Best survival outcomes were found for nonsquamous non-small cell lung cancer (OS and progression-free survival medians: 19.4 and 10.2 mo) and for those expressing molecular targets (OS and progression-free survival medians: 23.8 and 11.0 mo). No significant influence on survival rates was observed for industry funding and disease stage (IIIB/IV vs. IV). ESMO-MCBS v1.1 was applied in 45 positive studies and resulted in a meaningful clinical benefit score in 37.8%. Quality of life (QoL) was reported in 57.6% of the original publications and showed statistical significance favoring the experimental arm in 33.3%. Positive authors' conclusions (75.7% of trials) were based on OS and/or QoL in 34% and on surrogate endpoints in 66%. CONCLUSIONS Extended survival times and a steady improvement in QoL have been observed. However, there were more than twice as many studies reporting positive authors' conclusions as studies meeting the ESMO threshold for meaningful clinical benefit.
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Affiliation(s)
| | | | | | | | - Jaime Espín
- Andalusian School of Public Health/Escuela Andaluza de Salud Pública (EASP), Granada
- CIBER of Epidemiology and Public Health (CIBERESP), Spain
- Instituto de Investigación Biosanitaria ibs
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Cliff ERS, Kesselheim AS, Feldman WB. Ensuring Ethical Postprogression Therapy for Patients in Randomized Trial Control Arms. J Clin Oncol 2023; 41:3984-3987. [PMID: 37343194 DOI: 10.1200/jco.22.02675] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 04/26/2023] [Accepted: 05/10/2023] [Indexed: 06/23/2023] Open
Abstract
@Eddie_Cliff et al explore the scientific & ethical reasons why patients randomized to the control arm of trials should 'crossover' to receive the investigational therapy if their disease progresses
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Affiliation(s)
- Edward R Scheffer Cliff
- Program on Regulation, Therapeutics and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - William B Feldman
- Program on Regulation, Therapeutics and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Servetto A, Di Maio M, Salomone F, Napolitano F, Paratore C, Di Costanzo F, Viscardi G, Santaniello A, Formisano L, Bianco R. Analysis of phase III clinical trials in metastatic NSCLC to assess the correlation between QoL results and survival outcomes. BMC Med 2023; 21:234. [PMID: 37400832 DOI: 10.1186/s12916-023-02953-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/20/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND In addition to improving survival outcomes, new oncology treatments should lead to amelioration of patients' quality of life (QoL). Herein, we examined whether QoL results correlated with PFS and OS outcomes in phase III randomized controlled trials (RCTs) investigating new systemic treatments in metastatic non-small cell lung cancer (NSCLC). METHODS The systematic search of PubMed was conducted in October 2022. We identified 81 RCTs testing novel drugs in metastatic NSCLC and published in the English language in a PubMed-indexed journal between 2012 and 2021. Only trials reporting QoL results and at least one survival outcome between OS and PFS were selected. For each RCT, we assessed whether global QoL was "superior," "inferior," or with "non-statistically significant difference" in the experimental arm compared to the control arm. RESULTS Experimental treatments led to superior QoL in 30 (37.0%) RCTs and inferior QoL in 3 (3.7%) RCTs. In the remaining 48 (59.3%) RCTs, a statistically significant difference between the experimental and control arms was not found. Of note, we found a statistically significant association between QoL and PFS improvements (X2 = 3.93, p = 0.0473). In more detail, this association was not significant in trials testing immunotherapy or chemotherapy. On the contrary, in RCTs testing target therapies, QoL results positively correlated with PFS outcomes (p = 0.0196). This association was even stronger in the 32 trials testing EGFR or ALK inhibitors (p = 0.0077). On the other hand, QoL results did not positively correlate with OS outcomes (X2 = 0.81, p = 0.368). Furthermore, we found that experimental treatments led to superior QoL in 27/57 (47.4%) trials with positive results and in 3/24 (12.5%) RCTs with negative results (p = 0.0028). Finally, we analyzed how QoL data were described in publications of RCTs in which QoL outcomes were not improved (n = 51). We found that a favorable description of QoL results was associated with sponsorship by industries (p = 0.0232). CONCLUSIONS Our study reveals a positive association of QoL results with PFS outcomes in RCTs testing novel treatments in metastatic NSCLC. This association is particularly evident for target therapies. These findings further emphasize the relevance of an accurate assessment of QoL in RCTs in NSCLC.
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Affiliation(s)
- Alberto Servetto
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy
| | - Massimo Di Maio
- Department of Oncology, University of Turin, Division of Medical Oncology, Ordine Mauriziano Hospital, Turin, Italy
| | - Fabio Salomone
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy
| | - Fabiana Napolitano
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy
| | - Chiara Paratore
- Department of Oncology, University of Turin, Division of Medical Oncology, Ordine Mauriziano Hospital, Turin, Italy
- Department of Oncology, ASL TO4, Ivrea Community Hospital, Ivrea, Italy
| | - Fabrizio Di Costanzo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy
| | - Giuseppe Viscardi
- Department of Pneumology and Oncology, AORN Ospedali Dei Colli-Monaldi, Naples, Italy
| | - Antonio Santaniello
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy
| | - Luigi Formisano
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy
| | - Roberto Bianco
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini 5, Naples, Italy.
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Ge C, Guo K, Li Y, Li G, Zhang H, Yang J, Liu Y, Yin C, Liu S, Xie S, Chen X. Analysis of patient-reported outcomes in the approval of novel oncology drugs in the United States, 2017-2022. EClinicalMedicine 2023; 59:101953. [PMID: 37089618 PMCID: PMC10113764 DOI: 10.1016/j.eclinm.2023.101953] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 04/25/2023] Open
Abstract
Background With the growing notion of patient-focused drug development, the quality of life and other patient-reported outcomes (PROs) of cancer patients are gaining considerable attention. Several drug regulatory agencies, including the U.S. Food and Drug Administration (FDA), are calling attention to PROs. This review aims to comprehensively characterise the application of PROs and regulatory considerations for PROs in the FDA-approved novel oncology drugs. Methods The FDA review documents and labels for novel oncology drugs approved from July 2017 to July 2022 were retrieved. We collected and analysed drug approval information, types of endpoints for PROs, PRO measures, designs of trials including PROs, and regulatory comments on PRO-related contents. Findings Results demonstrated that PROs were used more commonly for solid tumours than hematologic malignancies, which might be correlated with the disease characteristics. We further categorised and analysed existing PRO measures, providing insight for tool selection in future oncology trial design. Our findings also indicated that PROs currently do not play a significant role in oncology drug approvals. The major deficiencies related to PROs commented on by FDA reviewers were analysed, followed by recommendations for improvements. Interpretation This review demonstrates that PROs currently do not play a significant role in oncology drug marketing review, and how they can be used to support the approval of new oncology drugs is still in the exploratory stage. This current situation is not only related to the deficiencies in the design and implementation of PRO-related contents in oncology trials, but more importantly, it is a reminder that we should pay more attention to patient experience in the development of oncology drugs. Funding This study was not supported by any funding.
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Affiliation(s)
- Chenghao Ge
- Tsinghua Clinical Research Institute, School of Medicine, Tsinghua University, Beijing, China
| | - Kaiyuan Guo
- School of Medicine, Tsinghua University, Beijing, China
| | - Yi Li
- Tsinghua Clinical Research Institute, School of Medicine, Tsinghua University, Beijing, China
| | - Guanqiao Li
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Hong Zhang
- Center for Drug Evaluation, National Medical Products Administration, Beijing, China
| | - Jiaxuan Yang
- School of Medicine, Tsinghua University, Beijing, China
| | - Yang Liu
- Tsinghua Clinical Research Institute, School of Medicine, Tsinghua University, Beijing, China
| | - Chen Yin
- Tsinghua Clinical Research Institute, School of Medicine, Tsinghua University, Beijing, China
| | - Sen Liu
- Tsinghua Clinical Research Institute, School of Medicine, Tsinghua University, Beijing, China
| | - Songmei Xie
- Center for Drug Evaluation, National Medical Products Administration, Beijing, China
- Corresponding author.
| | - Xiaoyuan Chen
- Tsinghua Clinical Research Institute, School of Medicine, Tsinghua University, Beijing, China
- Office of Clinical Trial Institute, Beijing Tsinghua Changgung Hospital, Beijing, China
- Corresponding author. Tsinghua Clinical Research Institute, Tsinghua University, Beijing, China.
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Laviano A. Sarcopenia, biological age and treatment eligibility in patients with cancer. Curr Opin Clin Nutr Metab Care 2023; 26:59-63. [PMID: 36542536 DOI: 10.1097/mco.0000000000000888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Cancer incidence will dramatically increase, especially among older adults, during the next few decades. This may lead to bankruptcy of the healthcare systems worldwide if the current approach to treatment eligibility is not improved. In fact, current treatment personalization is mostly focusing on the genetic and molecular characteristics of cancer cells, whereas clinical characterization of patients is still dependent on gross variables (i.e. chronological age, BMI, comorbidities, Performance Status and so on). This could have contributed to the poor performance of many anticancer drugs in the real-world setting when compared with the results obtained in prospective, randomized clinical trials. RECENT FINDINGS The role of chronological age in identifying patients with increased likelihood to respond to therapies has been challenged, pointing to biological age (i.e. accumulated damage to biological systems over the life course, leading to loss of reserve and capacity to respond to challenges) as a robust predictor of outcome encompassing genetic, phenotypic and clinical factors. Sarcopenia has been proposed as a reliable clinical index of biological age, but the complexity of body composition changes occurring during tumour growth appears to preclude its routine use when assessing eligibility in cancer patients. SUMMARY Integration of sarcopenia measures within scores of allostatic load may further increase the clinical relevance of changes of body composition, highlight its sensitivity to early nutritional intervention leading to mitigation of accelerated ageing, and contribute to wide delivery of precision oncology.
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Affiliation(s)
- Alessandro Laviano
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
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Salomone F, Di Costanzo F, Pecoraro G, Viscardi G, Viggiano A, Napolitano F, Santaniello A, Formisano L, Bianco R, Servetto A. Health-related quality of life is underestimated and underreported in phase III clinical trials in NSCLC. Lung Cancer 2022; 174:36-44. [PMID: 36302311 DOI: 10.1016/j.lungcan.2022.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/07/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
Major associations of medical oncologists remark that novel anticancer treatments should guarantee improvement of survival outcomes as well as of patients' quality of life (QoL). Herein, we investigated QoL assessment and reporting in phase III randomized controlled trials (RCTs) testing new drugs in metastatic non-small cell lung cancer (NSCLC), published between 2010 and 2021. We selected 172 RCTs for further analysis. Only 2/172 (1.2%) trial included QoL among primary study endpoints. Of note, 40/172 (23.3%) trials did not include QoL assessment among endpoints. The majority of RCTs (102/172, 59.3%) did not report QoL results in primary publications. Particularly, RCTs testing immunotherapy, target therapy and chemotherapy did not disclose QoL data in primary publications in 97.0%, 51.5% and 46.5% of cases, respectively. Next, we found that only 43/95 (45.3%) positive studies reported QoL results in primary articles. Of the 102 trials missing QoL data in primary manuscripts, only 21 (20.6%) disclosed QoL results in a secondary publication. Finally, we found a common fail in adherence to CONSORT-PROs items in publications reporting QoL results. In summary, our study reveals a relevant inadequate assessment and under-reporting of QoL in RCTs of novel systemic treatments for patients with metastatic NSCLC.
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Affiliation(s)
- Fabio Salomone
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Fabrizio Di Costanzo
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giovanna Pecoraro
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuseppe Viscardi
- Department of Pneumology and Oncology, AORN Ospedali dei Colli-Monaldi, Naples, Italy
| | - Angela Viggiano
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Fabiana Napolitano
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Antonio Santaniello
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Luigi Formisano
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Roberto Bianco
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy.
| | - Alberto Servetto
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy.
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14
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Laviano A. High protein diet in digestive cancers. Curr Opin Clin Nutr Metab Care 2022; 25:348-353. [PMID: 35787591 DOI: 10.1097/mco.0000000000000857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
PURPOSE OF REVIEW Recent advances in the nutritional management of patients with digestive cancers suggest that modulation of protein intake may significantly contribute to achieve nutritional and clinical benefits. By reviewing the available evidence, a quantitatively and qualitatively optimal protein intake could be derived. RECENT FINDINGS High protein diets (i.e., 1-1.5 g/kg body weight/day) appear key to maintain the adequate nutritional status, and may also contribute to achieve clinical benefits. This target appears particularly relevant in patients with digestive cancers at risk or already malnourished, or in older patients. During active cancer treatments, protein intake should be closer to the upper limit of the recommended intake. Also, high protein intake should be maintained beyond the periods of catabolic crisis associated with active treatments. In contrast with general reasoning, animal proteins should represent the majority of the recommended intake. Based on the available evidence, the intake of no specific amino acid can be strongly recommended to enhance anabolic potentials or the immune modulating effects of high protein diets. SUMMARY High protein intake, mostly based on animal proteins, should be recommended to patients with digestive cancers. However, this target should be translated into clinical prescription after considering the clinical and metabolic needs of the patients. The quest for the optimal protein intake of patients with cancer at different time points of their clinical journey is still open.
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Affiliation(s)
- Alessandro Laviano
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
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Gyawali B, Eisenhauer E, Brundage M. Analysis of Quality-of-Life Outcomes by Drug Class in Cancer Clinical Trials-Reply. JAMA Oncol 2022; 8:1517-1518. [PMID: 36006636 DOI: 10.1001/jamaoncol.2022.3524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen's University, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | | | - Michael Brundage
- Division of Cancer Care and Epidemiology, Queen's University, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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King-Kallimanis BL, Basu-Roy U, Nolte S. Analysis of Quality-of-Life Outcomes by Drug Class in Cancer Clinical Trials. JAMA Oncol 2022; 8:1517. [PMID: 36006651 DOI: 10.1001/jamaoncol.2022.3521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | | | - Sandra Nolte
- Medical Clinic, Department of Psychosomatic Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Defining clinically important overall survival thresholds: lessons from quality of life. Nat Rev Clin Oncol 2022; 19:613-614. [PMID: 35896739 DOI: 10.1038/s41571-022-00667-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Strzebonska K, Blukacz M, Wasylewski MT, Polak M, Gyawali B, Waligora M. Risk and benefit for umbrella trials in oncology: a systematic review and meta-analysis. BMC Med 2022; 20:219. [PMID: 35799149 PMCID: PMC9264503 DOI: 10.1186/s12916-022-02420-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 05/30/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Umbrella clinical trials in precision oncology are designed to tailor therapies to the specific genetic changes within a tumor. Little is known about the risk/benefit ratio for umbrella clinical trials. The aim of our systematic review with meta-analysis was to evaluate the efficacy and safety profiles in cancer umbrella trials testing targeted drugs or a combination of targeted therapy with chemotherapy. METHODS Our study was prospectively registered in PROSPERO (CRD42020171494). We searched Embase and PubMed for cancer umbrella trials testing targeted agents or a combination of targeted therapies with chemotherapy. We included solid tumor studies published between 1 January 2006 and 7 October 2019. We measured the risk using drug-related grade 3 or higher adverse events (AEs), and the benefit by objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). When possible, data were meta-analyzed. RESULTS Of the 6207 records identified, we included 31 sub-trials or arms of nine umbrella trials (N = 1637). The pooled overall ORR was 17.7% (95% confidence interval [CI] 9.5-25.9). The ORR for targeted therapies in the experimental arms was significantly lower than the ORR for a combination of targeted therapy drugs with chemotherapy: 13.3% vs 39.0%; p = 0.005. The median PFS was 2.4 months (95% CI 1.9-2.9), and the median OS was 7.1 months (95% CI 6.1-8.4). The overall drug-related death rate (drug-related grade 5 AEs rate) was 0.8% (95% CI 0.3-1.4), and the average drug-related grade 3/4 AE rate per person was 0.45 (95% CI 0.40-0.50). CONCLUSIONS Our findings suggest that, on average, one in five cancer patients in umbrella trials published between 1 January 2006 and 7 October 2019 responded to a given therapy, while one in 125 died due to drug toxicity. Our findings do not support the expectation of increased patient benefit in cancer umbrella trials. Further studies should investigate whether umbrella trial design and the precision oncology approach improve patient outcomes.
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Affiliation(s)
- Karolina Strzebonska
- Research Ethics in Medicine Study Group (REMEDY), Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Mateusz Blukacz
- Institute of Psychology, University of Silesia, Katowice, Poland
- Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Mateusz T. Wasylewski
- Research Ethics in Medicine Study Group (REMEDY), Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Maciej Polak
- Research Ethics in Medicine Study Group (REMEDY), Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
- Department of Epidemiology and Population Studies, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Bishal Gyawali
- Department of Oncology and the Department of Public Health Sciences, Queen’s University, Kingston, Ontario Canada
| | - Marcin Waligora
- Research Ethics in Medicine Study Group (REMEDY), Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
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