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Huss A, Klar M, Hasanov MF, Juhasz-Böss I, Bossart M. Prognostic factors and survival of patients with uterine sarcoma: a German unicenter analysis. Arch Gynecol Obstet 2023; 307:927-935. [PMID: 35780401 PMCID: PMC9984332 DOI: 10.1007/s00404-022-06515-2] [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: 01/12/2022] [Accepted: 03/08/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Uterine sarcoma (US) as a histologically heterogeneous group of tumors is rare and associated with poor prognosis. Prognostic factors based on systematic data collection need to be identified to optimize patients' treatment. METHODS This unicenter, retrospective cohort study includes 57 patients treated at the University Hospital Freiburg, Germany between 1999 and 2017. Progression-free survival (PFS) and overall survival (OS) were calculated and visualized in Kaplan-Meier curves. Prognostic factors were identified using log-rank test and Cox regression. RESULTS 44 Leiomyosarcoma (LMS), 7 low-grade endometrial stromal sarcoma (LG-ESS), 4 high-grade ESS and 2 undifferentiated US patients were identified. The median age at time of diagnosis was 51.0 years (range 18-83). The median follow-up time was 35 months. PFS for the total cohort was 14.0 (95%-Confidence-Interval (CI) 9.7-18.3) and OS 36.0 months (95%-CI 22.1-49.9). Tumor pathology was prognostically significant for OS with LG-ESS being the most favorable (mean OS 150.3 months). In the multivariate analysis, patients over 52 years showed a four times higher risk for tumor recurrence (hazard ratio (HR) 4.4; 95%-CI 1.5-12.9). Progesterone receptor negativity was associated with a two times higher risk for death (HR 2.8; 95%-CI 1.0-7.5). For LMS patients age ≥ 52 years (p = 0.04), clear surgical margins (p = 0.01), FIGO stage (p = 0.01) and no application of chemotherapy (p = 0.02) were statistically significant factors for OS. CONCLUSION Tumor histology, age at time of diagnosis and progesterone receptor status were prognostic factors for US. Unfavorable OS in LMS patients was associated with advanced FIGO stage, suboptimal cytoreduction and application of chemotherapy.
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Affiliation(s)
- Alexandra Huss
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany.
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Mir Fuad Hasanov
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Ingolf Juhasz-Böss
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Michaela Bossart
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106, Freiburg, Germany
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Edwards JM, Walters SJ, Kunz C, Julious SA. A systematic review of the "promising zone" design. Trials 2020; 21:1000. [PMID: 33276810 PMCID: PMC7718653 DOI: 10.1186/s13063-020-04931-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 11/25/2020] [Indexed: 12/01/2022] Open
Abstract
Introduction Sample size calculations require assumptions regarding treatment response and variability. Incorrect assumptions can result in under- or overpowered trials, posing ethical concerns. Sample size re-estimation (SSR) methods investigate the validity of these assumptions and increase the sample size if necessary. The “promising zone” (Mehta and Pocock, Stat Med 30:3267–3284, 2011) concept is appealing to researchers for its design simplicity. However, it is still relatively new in the application and has been a source of controversy. Objectives This research aims to synthesise current approaches and practical implementation of the promising zone design. Methods This systematic review comprehensively identifies the reporting of methodological research and of clinical trials using promising zone. Databases were searched according to a pre-specified search strategy, and pearl growing techniques implemented. Results The combined search methods resulted in 270 unique records identified; 171 were included in the review, of which 30 were trials. The median time to the interim analysis was 60% of the original target sample size (IQR 41–73%). Of the 15 completed trials, 7 increased their sample size. Only 21 studies reported the maximum sample size that would be considered, for which the median increase was 50% (IQR 35–100%). Conclusions Promising zone is being implemented in a range of trials worldwide, albeit in low numbers. Identifying trials using promising zone was difficult due to the lack of reporting of SSR methodology. Even when SSR methodology was reported, some had key interim analysis details missing, and only eight papers provided promising zone ranges.
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Affiliation(s)
- Julia M Edwards
- School of Health and Related Research, The University of Sheffield, Sheffield, UK.
| | - Stephen J Walters
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Cornelia Kunz
- Boehringer Ingelheim, Biberach an der Riss, Biberach, Germany
| | - Steven A Julious
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
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Michiels S, Wason J. Overestimated treatment effects in randomised phase II trials: What's up doctor? Eur J Cancer 2019; 123:116-117. [PMID: 31678769 DOI: 10.1016/j.ejca.2019.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/26/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Stefan Michiels
- Service de Biostatistique et D'Épidémiologie, Gustave Roussy, Université Paris-Saclay, 94805 Villejuif, France; CESP INSERM U1018, Université Paris-Sud, Université Paris-Saclay, 94805 Villejuif, France.
| | - James Wason
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK; MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
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Renfro LA, Ji L, Piao J, Onar-Thomas A, Kairalla JA, Alonzo TA. Trial Design Challenges and Approaches for Precision Oncology in Rare Tumors: Experiences of the Children's Oncology Group. JCO Precis Oncol 2019; 3:PO.19.00060. [PMID: 32923863 PMCID: PMC7446492 DOI: 10.1200/po.19.00060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2019] [Indexed: 12/18/2022] Open
Abstract
In the United States, cancer remains the leading cause of disease-related death in children. Although survival from any pediatric cancer has improved dramatically during past decades, a number of cancers continue to yield dismal prognoses, which has motivated the continued study of novel therapeutic strategies. Furthermore, even patients cured of pediatric cancer often experience severe adverse effects of treatment and other long-term health implications, such as cardiotoxicity or loss of fertility. For these patients, improved risk stratification to identify those who could safely receive alternate or less-intensive therapy without affecting prognosis is a key objective. Fortunately, pediatric cancers are rare overall, but even among patients with the same narrow cancer type, there is often broad heterogeneity in terms of prognosis, molecular features or pathology, current treatment strategies, and scientific objectives. As a result, the design of clinical trials in the pediatric cancer setting is challenged by a number of practical issues that must be addressed to ensure trial feasibility for this vulnerable group of patients. In this review, we discuss some of the unique trial design considerations often encountered in any rare tumor setting through the lens of our experiences as faculty statisticians for the Children's Oncology Group, the largest organization in the world dedicated exclusively to pediatric cancer research and clinical trials. These topics include risk stratification within individual trials, relaxation of trial operating characteristics and parameters, use of historical controls, and address of noninferiority-type objectives in small cohorts. We review each in terms of practical motivation, present challenges, and potential solutions described in the literature and implemented in selected example trials from the Children's Oncology Group.
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Affiliation(s)
| | - Lingyun Ji
- University of Southern California, Los Angeles, CA
| | - Jin Piao
- University of Southern California, Los Angeles, CA
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Bayar MA, Le Teuff G, Koenig F, Le Deley MC, Michiels S. Group sequential adaptive designs in series of time-to-event randomised trials in rare diseases: A simulation study. Stat Methods Med Res 2019; 29:1483-1498. [PMID: 31354106 DOI: 10.1177/0962280219862313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In rare diseases, fully powered large trials may not be doable in a reasonable time frame even with international collaborations. In a previous work, we proposed an approach based on a series of smaller parallel group two-arm randomised controlled trials (RCT) performed over a long research horizon. Within the series of trials, the treatment selected after each trial becomes the control treatment of the next one. We concluded that running more trials with smaller sample sizes and relaxed α-levels leads in the long term and under reasonable assumptions to larger survival benefits with a moderate increase of risk as compared to traditional designs based on larger but fewer trials designed to meet stringent evidence criteria. We now extend this quantitative framework with more 'flexible' designs including interim analyses for futility and/or efficacy, and three-arm adaptive designs with treatment selection at interim. In the simulation study, we considered different disease severities, accrual rates, and hypotheses of how treatments improve over time. For each design, we estimated the long-term survival benefit as the relative difference in hazard rates between the end and the start of the research horizon, and the risk defined as the probability of selecting at the end of the research horizon a treatment inferior to the initial control. We assessed the impact of the α-level and the choice of the stopping rule on the operating characteristics. We also compared the performance of series based on two- vs. three-arm trials. We show that relaxing α-levels within the limit of 0.1 is associated with larger survival gains and moderate increase of risk which remains within acceptable ranges. Including an interim analysis with a futility rule is associated with an additional survival gain and a better risk control as compared to series with no interim analysis, when the α-level is below or equal to 0.1, whereas the benefit of including an interim analysis is rather small for higher α-levels. Including an interim analysis for efficacy yields almost no additional gain. Series based on three-arm trials are associated with a systematic improvement in terms of survival gain and risk control as compared to series of two-arm trials.
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Affiliation(s)
- Mohamed Amine Bayar
- Service de Biostatistique et d'Épidémiologie, Gustave Roussy, Villejuif, France.,CESP, Faculté de médecine - Université Paris-Sud, Faculté de médecine - INSERM, Université Paris-Saclay, Villejuif, France
| | - Gwénaël Le Teuff
- Service de Biostatistique et d'Épidémiologie, Gustave Roussy, Villejuif, France.,CESP, Faculté de médecine - Université Paris-Sud, Faculté de médecine - INSERM, Université Paris-Saclay, Villejuif, France
| | - Franz Koenig
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Marie-Cécile Le Deley
- Service de Biostatistique et d'Épidémiologie, Gustave Roussy, Villejuif, France.,CESP, Faculté de médecine - Université Paris-Sud, Faculté de médecine - INSERM, Université Paris-Saclay, Villejuif, France.,Unité de Méthodologie et Biostatistique, Centre Oscar Lambret, Lille, France
| | - Stefan Michiels
- Service de Biostatistique et d'Épidémiologie, Gustave Roussy, Villejuif, France.,CESP, Faculté de médecine - Université Paris-Sud, Faculté de médecine - INSERM, Université Paris-Saclay, Villejuif, France
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Fletcher JI, Ziegler DS, Trahair TN, Marshall GM, Haber M, Norris MD. Too many targets, not enough patients: rethinking neuroblastoma clinical trials. Nat Rev Cancer 2018; 18:389-400. [PMID: 29632319 DOI: 10.1038/s41568-018-0003-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Neuroblastoma is a rare solid tumour of infancy and early childhood with a disproportionate contribution to paediatric cancer mortality and morbidity. Combination chemotherapy, radiation therapy and immunotherapy remains the standard approach to treat high-risk disease, with few recurrent, actionable genetic aberrations identified at diagnosis. However, recent studies indicate that actionable aberrations are far more common in relapsed neuroblastoma, possibly as a result of clonal expansion. In addition, although the major validated disease driver, MYCN, is not currently directly targetable, multiple promising approaches to target MYCN indirectly are in development. We propose that clinical trial design needs to be rethought in order to meet the challenge of providing rigorous, evidence-based assessment of these new approaches within a fairly small patient population and that experimental therapies need to be assessed at diagnosis in very-high-risk patients rather than in relapsed and refractory patients.
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Affiliation(s)
- Jamie I Fletcher
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW, Australia
- School of Women's and Children's Health, UNSW Sydney, Kensington, NSW, Australia
| | - David S Ziegler
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW, Australia
- School of Women's and Children's Health, UNSW Sydney, Kensington, NSW, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Toby N Trahair
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW, Australia
- School of Women's and Children's Health, UNSW Sydney, Kensington, NSW, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Glenn M Marshall
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Michelle Haber
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW, Australia
- School of Women's and Children's Health, UNSW Sydney, Kensington, NSW, Australia
| | - Murray D Norris
- Children's Cancer Institute Australia, Lowy Cancer Research Centre, UNSW Sydney, Kensington, NSW, Australia.
- University of New South Wales Centre for Childhood Cancer Research, UNSW Sydney, Kensington, NSW, Australia.
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Saad ED, Paoletti X, Burzykowski T, Buyse M. Precision medicine needs randomized clinical trials. Nat Rev Clin Oncol 2017; 14:317-323. [DOI: 10.1038/nrclinonc.2017.8] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Parmar MKB, Sydes MR, Morris TP. How do you design randomised trials for smaller populations? A framework. BMC Med 2016; 14:183. [PMID: 27884190 PMCID: PMC5123370 DOI: 10.1186/s12916-016-0722-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/19/2016] [Indexed: 11/10/2022] Open
Abstract
How should we approach trial design when we can get some, but not all, of the way to the numbers required for a randomised phase III trial?We present an ordered framework for designing randomised trials to address the problem when the ideal sample size is considered larger than the number of participants that can be recruited in a reasonable time frame. Staying with the frequentist approach that is well accepted and understood in large trials, we propose a framework that includes small alterations to the design parameters. These aim to increase the numbers achievable and also potentially reduce the sample size target. The first step should always be to attempt to extend collaborations, consider broadening eligibility criteria and increase the accrual time or follow-up time. The second set of ordered considerations are the choice of research arm, outcome measures, power and target effect. If the revised design is still not feasible, in the third step we propose moving from two- to one-sided significance tests, changing the type I error rate, using covariate information at the design stage, re-randomising patients and borrowing external information.We discuss the benefits of some of these possible changes and warn against others. We illustrate, with a worked example based on the Euramos-1 trial, the application of this framework in designing a trial that is feasible, while still providing a good evidence base to evaluate a research treatment.This framework would allow appropriate evaluation of treatments when large-scale phase III trials are not possible, but where the need for high-quality randomised data is as pressing as it is for common diseases.
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Affiliation(s)
- Mahesh K B Parmar
- London Hub for Trials Methodology Research, MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, UK
| | - Matthew R Sydes
- London Hub for Trials Methodology Research, MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, UK
| | - Tim P Morris
- London Hub for Trials Methodology Research, MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, UK. .,Medical Statistics Dept., London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
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