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Bennett-Guerrero E, Romeiser JL, DeMaria S, Nadler JW, Quinn TD, Ponnappan SK, Yang J, Sasson AR. General Anesthetics in CAncer REsection Surgery (GA-CARES) randomized multicenter trial of propofol vs volatile inhalational anesthesia: protocol description. Perioper Med (Lond) 2023; 12:2. [PMID: 36631831 PMCID: PMC9832634 DOI: 10.1186/s13741-022-00290-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/17/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Studies indicate that patients can be "seeded" with their own cancer cells during oncologic surgery and that the immune response to these circulating cancer cells might influence the risk of cancer recurrence. Preliminary data from animal studies and some retrospective analyses suggest that anesthetic technique might affect the immune response during surgery and hence the risk of cancer recurrence. In 2015, experts called for prospective scientific inquiry into whether anesthetic technique used in cancer resection surgeries affects cancer-related outcomes such as recurrence and mortality. Therefore, we designed a pragmatic phase 3 multicenter randomized controlled trial (RCT) called General Anesthetics in Cancer Resection (GA-CARES). METHODS After clinical trial registration and institutional review board approval, patients providing written informed consent were enrolled at five sites in New York (NY) State. Eligible patients were adults with known or suspected cancer undergoing one of eight oncologic surgeries having a high risk of cancer recurrence. Exclusion criteria included known or suspected history of malignant hyperthermia or hypersensitivity to either propofol or volatile anesthetic agents. Patients were randomized (1:1) stratified by center and surgery type using REDCap to receive either propofol or volatile agent for maintenance of general anesthesia (GA). This pragmatic trial, which seeks to assess the potential impact of anesthetic type in "real world practice", did not standardize any aspect of patient care. However, potential confounders, e.g., use of neuroaxial anesthesia, were recorded to confirm the balance between study arms. Assuming a 5% absolute difference in 2-year overall survival rates (85% vs 90%) between study arms (primary endpoint, minimum 2-year follow-up), power using a two-sided log-rank test with type I error of 0.05 (no planned interim analyses) was calculated to be 97.4% based on a target enrollment of 1800 subjects. Data sources include the National Death Index (gold standard for vital status in the USA), NY Cancer Registry, and electronic harvesting of data from electronic medical records (EMR), with minimal manual data abstraction/data entry. DISCUSSION Enrollment has been completed (n = 1804) and the study is in the follow-up phase. This unfunded, pragmatic trial, uses a novel approach for data collection focusing on electronic sources. TRIAL REGISTRATION Registered (NCT03034096) on January 27, 2017, prior to consent of the first patient on January 31, 2017.
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Affiliation(s)
- Elliott Bennett-Guerrero
- grid.36425.360000 0001 2216 9681Department of Anesthesiology, Renaissance School of Medicine at Stony, Brook University, Stony Brook, NY USA
| | - Jamie L. Romeiser
- grid.36425.360000 0001 2216 9681Department of Anesthesiology, Renaissance School of Medicine at Stony, Brook University, Stony Brook, NY USA
| | - Samuel DeMaria
- grid.59734.3c0000 0001 0670 2351Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Jacob W. Nadler
- grid.412750.50000 0004 1936 9166Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, New York, NY USA
| | - Timothy D. Quinn
- grid.240614.50000 0001 2181 8635Department of Anesthesiology, Preoperative Medicine and Pain Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY USA
| | - Sanjeev K. Ponnappan
- grid.273206.20000 0001 2173 8133Department of Anesthesiology, Long Island Jewish Medical Center at Northwell Health, New Hyde Park, NY USA
| | - Jie Yang
- grid.36425.360000 0001 2216 9681Department of Family, Population and Preventive Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY USA
| | - Aaron R. Sasson
- grid.36425.360000 0001 2216 9681Department of Surgery/Surgical Oncology, Renaissance School of Medicine at Stony, Brook University, Stony Brook, NY USA
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Rai SN, Qian C, Pan J, Seth A, Srivastava DK, Bhatnagar A. Statistical design of Phase II/III clinical trials for testing therapeutic interventions in COVID-19 patients. BMC Med Res Methodol 2020. [PMID: 32867708 DOI: 10.21203/rs.3.rs-30558/v2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Because of unknown features of the COVID-19 and the complexity of the population affected, standard clinical trial designs on treatments may not be optimal in such patients. We propose two independent clinical trials designs based on careful grouping of patient and outcome measures. METHODS Using the World Health Organization ordinal scale on patient status, we classify treatable patients (Stages 3-7) into two risk groups. Patients in Stages 3, 4 and 5 are categorized as the intermediate-risk group, while patients in Stages 6 and 7 are categorized as the high-risk group. To ensure that an intervention, if deemed efficacious, is promptly made available to vulnerable patients, we propose a group sequential design incorporating four factors stratification, two interim analyses, and a toxicity monitoring rule for the intermediate-risk group. The primary response variable (binary variable) is based on the proportion of patients discharged from hospital by the 15th day. The goal is to detect a significant improvement in this response rate. For the high-risk group, we propose a group sequential design incorporating three factors stratification, and two interim analyses, with no toxicity monitoring. The primary response variable for this design is 30 day mortality, with the goal of detecting a meaningful reduction in mortality rate. RESULTS Required sample size and toxicity boundaries are calculated for each scenario. Sample size requirements for designs with interim analyses are marginally greater than ones without. In addition, for both the intermediate-risk group and the high-risk group, the required sample size with two interim analyses is almost identical to analyses with just one interim analysis. CONCLUSIONS We recommend using a binary outcome with composite endpoints for patients in Stage 3, 4 or 5 with a power of 90% to detect an improvement of 20% in the response rate, and a 30 day mortality rate outcome for those in Stage 6 or 7 with a power of 90% to detect 15% (effect size) reduction in mortality rate. For the intermediate-risk group, two interim analyses for efficacy evaluation along with toxicity monitoring are encouraged. For the high-risk group, two interim analyses without toxicity monitoring is advised.
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Affiliation(s)
- Shesh N Rai
- Biostatistics and Bioinformatics Facility, James Graham Brown Cancer Center, University of Louisville, Louisville, KY, 40202, USA.
- Department of Biostatistics and Bioinformatics, University of Louisville, Louisville, KY, 40202, USA.
| | - Chen Qian
- Biostatistics and Bioinformatics Facility, James Graham Brown Cancer Center, University of Louisville, Louisville, KY, 40202, USA
- Department of Biostatistics and Bioinformatics, University of Louisville, Louisville, KY, 40202, USA
| | - Jianmin Pan
- Biostatistics and Bioinformatics Facility, James Graham Brown Cancer Center, University of Louisville, Louisville, KY, 40202, USA
| | - Anand Seth
- SK Patent Associates, LLC, Dublin, OH, 43016, USA
| | - Deo Kumar Srivastava
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Aruni Bhatnagar
- Department of Medicine, Christina Lee Brown Envirome Institute, University of Louisville, Louisville, KY, 40202, USA.
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Rai SN, Qian C, Pan J, Seth A, Srivastava DK, Bhatnagar A. Statistical design of Phase II/III clinical trials for testing therapeutic interventions in COVID-19 patients. BMC Med Res Methodol 2020; 20:220. [PMID: 32867708 PMCID: PMC7456751 DOI: 10.1186/s12874-020-01101-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/13/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Because of unknown features of the COVID-19 and the complexity of the population affected, standard clinical trial designs on treatments may not be optimal in such patients. We propose two independent clinical trials designs based on careful grouping of patient and outcome measures. METHODS Using the World Health Organization ordinal scale on patient status, we classify treatable patients (Stages 3-7) into two risk groups. Patients in Stages 3, 4 and 5 are categorized as the intermediate-risk group, while patients in Stages 6 and 7 are categorized as the high-risk group. To ensure that an intervention, if deemed efficacious, is promptly made available to vulnerable patients, we propose a group sequential design incorporating four factors stratification, two interim analyses, and a toxicity monitoring rule for the intermediate-risk group. The primary response variable (binary variable) is based on the proportion of patients discharged from hospital by the 15th day. The goal is to detect a significant improvement in this response rate. For the high-risk group, we propose a group sequential design incorporating three factors stratification, and two interim analyses, with no toxicity monitoring. The primary response variable for this design is 30 day mortality, with the goal of detecting a meaningful reduction in mortality rate. RESULTS Required sample size and toxicity boundaries are calculated for each scenario. Sample size requirements for designs with interim analyses are marginally greater than ones without. In addition, for both the intermediate-risk group and the high-risk group, the required sample size with two interim analyses is almost identical to analyses with just one interim analysis. CONCLUSIONS We recommend using a binary outcome with composite endpoints for patients in Stage 3, 4 or 5 with a power of 90% to detect an improvement of 20% in the response rate, and a 30 day mortality rate outcome for those in Stage 6 or 7 with a power of 90% to detect 15% (effect size) reduction in mortality rate. For the intermediate-risk group, two interim analyses for efficacy evaluation along with toxicity monitoring are encouraged. For the high-risk group, two interim analyses without toxicity monitoring is advised.
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Affiliation(s)
- Shesh N Rai
- Biostatistics and Bioinformatics Facility, James Graham Brown Cancer Center, University of Louisville, Louisville, KY, 40202, USA.
- Department of Biostatistics and Bioinformatics, University of Louisville, Louisville, KY, 40202, USA.
| | - Chen Qian
- Biostatistics and Bioinformatics Facility, James Graham Brown Cancer Center, University of Louisville, Louisville, KY, 40202, USA
- Department of Biostatistics and Bioinformatics, University of Louisville, Louisville, KY, 40202, USA
| | - Jianmin Pan
- Biostatistics and Bioinformatics Facility, James Graham Brown Cancer Center, University of Louisville, Louisville, KY, 40202, USA
| | - Anand Seth
- SK Patent Associates, LLC, Dublin, OH, 43016, USA
| | - Deo Kumar Srivastava
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, 38105, USA
| | - Aruni Bhatnagar
- Department of Medicine, Christina Lee Brown Envirome Institute, University of Louisville, Louisville, KY, 40202, USA.
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Arabi YM, Asiri AY, Assiri AM, Aziz Jokhdar HA, Alothman A, Balkhy HH, AlJohani S, Al Harbi S, Kojan S, Al Jeraisy M, Deeb AM, Memish ZA, Ghazal S, Al Faraj S, Al-Hameed F, AlSaedi A, Mandourah Y, Al Mekhlafi GA, Sherbeeni NM, Elzein FE, Almotairi A, Al Bshabshe A, Kharaba A, Jose J, Al Harthy A, Al Sulaiman M, Mady A, Fowler RA, Hayden FG, Al-Dawood A, Abdelzaher M, Bajhmom W, Hussein MA. Treatment of Middle East respiratory syndrome with a combination of lopinavir/ritonavir and interferon-β1b (MIRACLE trial): statistical analysis plan for a recursive two-stage group sequential randomized controlled trial. Trials 2020; 21:8. [PMID: 31900204 PMCID: PMC6942374 DOI: 10.1186/s13063-019-3846-x] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 10/24/2019] [Indexed: 11/17/2022] Open
Abstract
The MIRACLE trial (MERS-CoV Infection tReated with A Combination of Lopinavir/ritonavir and intErferon-β1b) investigates the efficacy of a combination therapy of lopinavir/ritonavir and recombinant interferon-β1b provided with standard supportive care, compared to placebo provided with standard supportive care, in hospitalized patients with laboratory-confirmed MERS. The MIRACLE trial is designed as a recursive, two-stage, group sequential, multicenter, placebo-controlled, double-blind randomized controlled trial. The aim of this article is to describe the statistical analysis plan for the MIRACLE trial. The primary outcome is 90-day mortality. The primary analysis will follow the intention-to-treat principle. The MIRACLE trial is the first randomized controlled trial for MERS treatment. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02845843. Registered on 27 July 2016.
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Affiliation(s)
- Yaseen M. Arabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Intensive Care Department, Ministry of the National Guard - Health Affairs, ICU 1425, P.O. Box 22490, Riyadh, 11426 Saudi Arabia
| | - Ayed Y. Asiri
- Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Abdullah M. Assiri
- Infection Prevention and Control, Assistant Deputy Minister, Preventive Health, Ministry of Health, Riyadh, Saudi Arabia
| | | | - Adel Alothman
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Medicine, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Hanan H. Balkhy
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Infection Prevention and Control, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Sameera AlJohani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pathology and Laboratory Medicine, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Shmeylan Al Harbi
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Suleiman Kojan
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Medicine, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Majed Al Jeraisy
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Ahmad M. Deeb
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Research Office, Riyadh, Saudi Arabia
- Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Ziad A. Memish
- Prince Mohammed bin Abdulaziz Hospital, Ministry of Health & College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia USA
| | - Sameeh Ghazal
- Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Sarah Al Faraj
- Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Fahad Al-Hameed
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Jeddah, Saudi Arabia
| | - Asim AlSaedi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- Department of Infection Prevention and Control, Ministry of the National Guard - Health Affairs, Jeddah, Saudi Arabia
| | - Yasser Mandourah
- Military Medical Services, Ministry of Defense, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ghaleb A. Al Mekhlafi
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | | | - Fatehi Elnour Elzein
- Infectious Diseases Division, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abdullah Almotairi
- Department of Critical Care Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ali Al Bshabshe
- Department of Critical Care Medicine, King Khalid University, Aseer Central Hospital, Abha, Saudi Arabia
| | - Ayman Kharaba
- Department of Critical Care, King Fahad Hospital, Ohoud Hospital, Al-Madinah Al-Monawarah, Saudi Arabia
| | - Jesna Jose
- Department Biostatistics and Bioinformatics, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | | | - Ahmed Mady
- Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
- Department of Anesthesiology and Intensive Care, Tanta University Hospitals, Tanta, Egypt
| | - Robert A. Fowler
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine and Department of Medicine, Sunnybrook Hospital, Bayview Avenue, Room D478, Toronto, 2075 Canada
| | - Frederick G. Hayden
- International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC), Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia USA
| | - Abdulaziz Al-Dawood
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Intensive Care Department, Ministry of the National Guard - Health Affairs, ICU 1425, P.O. Box 22490, Riyadh, 11426 Saudi Arabia
| | - Mohamed Abdelzaher
- Critical Care Medicine Department, King Abdullah Medical Complex, Jeddah, Saudi Arabia
- Critical Care Medicine Department, Cairo University Hospital, Cairo, Egypt
| | - Wail Bajhmom
- Internal Medicine Department, King Fahad General Hospital, Ministry of Health, Jeddah, Saudi Arabia
| | - Mohamed A. Hussein
- Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- Department Biostatistics and Bioinformatics, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - and the Saudi Critical Care Trials group
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Intensive Care Department, Ministry of the National Guard - Health Affairs, ICU 1425, P.O. Box 22490, Riyadh, 11426 Saudi Arabia
- Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia
- Infection Prevention and Control, Assistant Deputy Minister, Preventive Health, Ministry of Health, Riyadh, Saudi Arabia
- Deputy Minister for Public Health, Ministry of Health, Riyadh, Saudi Arabia
- Department of Medicine, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- Department of Infection Prevention and Control, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- Department of Pathology and Laboratory Medicine, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Pharmaceutical Care Department, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Research Office, Riyadh, Saudi Arabia
- Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- Prince Mohammed bin Abdulaziz Hospital, Ministry of Health & College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia USA
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- Intensive Care Department, Ministry of the National Guard - Health Affairs, Jeddah, Saudi Arabia
- Department of Infection Prevention and Control, Ministry of the National Guard - Health Affairs, Jeddah, Saudi Arabia
- Military Medical Services, Ministry of Defense, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
- Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
- Infectious Diseases Division, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
- Department of Critical Care Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
- Department of Critical Care Medicine, King Khalid University, Aseer Central Hospital, Abha, Saudi Arabia
- Department of Critical Care, King Fahad Hospital, Ohoud Hospital, Al-Madinah Al-Monawarah, Saudi Arabia
- Department Biostatistics and Bioinformatics, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Intensive Care Unit, King Saud Medical City, Riyadh, Saudi Arabia
- Infectious Disease, King Saud Medical City, Riyadh, Saudi Arabia
- Intensive Care Department, King Saud Medical City, Riyadh, Saudi Arabia
- Department of Anesthesiology and Intensive Care, Tanta University Hospitals, Tanta, Egypt
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine and Department of Medicine, Sunnybrook Hospital, Bayview Avenue, Room D478, Toronto, 2075 Canada
- International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC), Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia USA
- Critical Care Medicine Department, King Abdullah Medical Complex, Jeddah, Saudi Arabia
- Critical Care Medicine Department, Cairo University Hospital, Cairo, Egypt
- Internal Medicine Department, King Fahad General Hospital, Ministry of Health, Jeddah, Saudi Arabia
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