1
|
Tidwell RSS, Thall PF, Yuan Y. Lessons Learned From Implementing a Novel Bayesian Adaptive Dose-Finding Design in Advanced Pancreatic Cancer. JCO Precis Oncol 2021; 5:PO.21.00212. [PMID: 34805718 PMCID: PMC8594665 DOI: 10.1200/po.21.00212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/03/2021] [Accepted: 10/04/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Novel Bayesian adaptive designs provide an effective way to improve clinical trial efficiency. These designs are superior to conventional methods, but implementing them can be challenging. The aim of this article was to describe what we learned while applying a novel Bayesian phase I-II design in a recent trial. METHODS The primary goal of the trial was to optimize radiation therapy (RT) dose among three levels (low, standard, and high), given either with placebo (P) or an investigational agent (A), for treating locally advanced, radiation-naive pancreatic cancer, deemed appropriate for RT rather than surgery. Up to 48 patients were randomly assigned fairly between RT plus P and RT plus A, with RT dose-finding done within each arm using the late-onset efficacy-toxicity design on the basis of two coprimary end points, tumor response and dose-limiting toxicity, both evaluated at up to 90 days. The random assignment was blinded, but within each arm, unblinded RT doses were chosen adaptively using software developed within the institution. RESULTS Implementing the design involved double-blind balance-restricted random assignment, real-time assessment of patient outcomes to evaluate the efficacy-toxicity trade-off for each RT dose in each arm to optimize each patient's RT dose adaptively, and transition from a single-center trial to a multicenter trial. We present lessons learned and illustrative documentation. CONCLUSION Implementing novel Bayesian adaptive trial designs requires close collaborations between physicians, pharmacists, statisticians, data managers, and sponsors. The process is difficult but manageable and essential for efficient trial conduct. Close collaboration during trial conduct is a key component of any trial that includes real-time adaptive decision rules.
Collapse
Affiliation(s)
- Rebecca S S Tidwell
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Peter F Thall
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ying Yuan
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
2
|
The Bayesian Design of Adaptive Clinical Trials. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020530. [PMID: 33435249 PMCID: PMC7826635 DOI: 10.3390/ijerph18020530] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/31/2020] [Accepted: 01/06/2021] [Indexed: 01/13/2023]
Abstract
This paper presents a brief overview of the recent literature on adaptive design of clinical trials from a Bayesian perspective for statistically not so sophisticated readers. Adaptive designs are attracting a keen interest in several disciplines, from a theoretical viewpoint and also—potentially—from a practical one, and Bayesian adaptive designs, in particular, have raised high expectations in clinical trials. The main conceptual tools are highlighted here, with a mention of several trial designs proposed in the literature that use these methods, including some of the registered Bayesian adaptive trials to this date. This review aims at complementing the existing ones on this topic, pointing at further interesting reading material.
Collapse
|
3
|
Dehbi HM, Lowe DM, O'Quigley J. Early phase dose-finding trials in virology. Stat Med 2020; 40:240-253. [PMID: 33053601 DOI: 10.1002/sim.8771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 11/10/2022]
Abstract
Little has been published in terms of dose-finding methodology in virology. Aside from a few papers focusing on HIV, the considerable progress in dose-finding methodology of the last 25 years has focused almost entirely on oncology. While adverse reactions to cytotoxic drugs may be life threatening, for anti-viral agents we anticipate something different: side effects that provoke the cessation of treatment. This would correspond to treatment failure. On the other hand, success would not be yes/no but would correspond to a range of responses, from small, no more than say 20% reduction in viral load to the complete elimination of the virus. Less than total success matters since this may allow the patient to achieve immune-mediated clearance. The motivation for this article is an upcoming dose-finding trial in chronic norovirus infection. We propose a novel methodology whose goal is twofold: first, to identify the dose that provides the most favorable distribution of treatment outcomes, and, second, to do this in a way that maximizes the treatment benefit for the patients included in the study.
Collapse
Affiliation(s)
- Hakim-Moulay Dehbi
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - David M Lowe
- Institute of Immunity and Transplantation, Royal Free Hospital, London, UK
| | - John O'Quigley
- Department of Statistical Science, University College London, London, UK
| |
Collapse
|
4
|
Lee YC, Wang L, Kohn EC, Rubinstein L, Ivy SP, Harris PJ, Lheureux S. Evaluation of toxicities related to novel therapy in clinical trials for women with gynecologic cancer. Cancer 2020; 126:2139-2145. [PMID: 32097505 PMCID: PMC10693932 DOI: 10.1002/cncr.32783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 12/30/2019] [Accepted: 01/26/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Women with gynecologic cancer may be at increased risk for adverse events (AEs) due to peritoneal disease burden and prior treatment (surgery, chemotherapy, and pelvic radiotherapy). This study compared the toxicity profiles of patients with and without gynecologic cancer enrolled in phase 1 trials. METHODS This was a retrospective analysis of the National Cancer Institute phase 1 database for all trials enrolling 1 or more patients with gynecologic cancer over 2 decades (1995-2015). Clinical parameters collected included demographics, cancer history, trial information, AEs, and responses. AEs (according to the Common Terminology Criteria for Adverse Events) were documented for each patient during treatment, and they were counted once and analyzed on the basis of the highest grade and drug attribution. Multiple regression models were used to compare AEs at the baseline and during treatment. RESULTS A total of 4269 patients enrolled in 150 trials were divided into 3 groups: 1) women with gynecologic cancer (n = 685), 2) women with nongynecologic cancer (n = 1698), and 3) men with cancer (n = 1886). The median age was 58 years. The mean number of total AEs reported during treatment was highest for women with gynecologic cancer (17.1 vs 14.7 vs 13.5; P < .001), even though they were similar at the baseline (7.0 vs 7.4 vs 7.0; P = .09). The mean number of drug-related AEs was also highest for women with gynecologic cancer (8.3 vs 6.9 vs 6.2; P < .001). Grade 3 to 5 AEs were similar (2.3 vs 2.3 vs 2.1); however, grade 2 AEs were more frequent in women with gynecologic cancer (4.6 vs 3.9 vs 3.5). Treatment discontinuations due to AEs were similar (9% vs 9% vs 10%). CONCLUSIONS Women with gynecologic cancer experienced more frequent low-grade AEs during treatment, and this warrants attention to support their symptom burden. Study dose management should be considered for recurrent grade 2 AEs, particularly during continuous therapy.
Collapse
Affiliation(s)
- Yeh Chen Lee
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Lisa Wang
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Elise C. Kohn
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland
| | - Lawrence Rubinstein
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland
| | - S. Percy Ivy
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland
| | - Pamela J. Harris
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland
| | - Stephanie Lheureux
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
5
|
Krause A, Henrich A, Dingemanse J. The Case for an Unblinded Modeler in Early Clinical Development. J Clin Pharmacol 2019; 60:369-377. [PMID: 31552685 DOI: 10.1002/jcph.1526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/02/2019] [Indexed: 11/05/2022]
Abstract
The current trend for clinical pharmacology is toward more complex studies (eg, umbrella protocols covering single and multiple ascending doses, food effect, metabolism pathways), requiring many decisions to be made during their conduct. This article discusses guidance of such early clinical studies by modeling and simulation. The ability to make use of all available information each time new data become available during the study requires the modeling scientist to be unblinded. This must of course not jeopardize the blinding of the clinical team, and this article discusses how unblinding can be prevented. Although modeling and simulation are established for guidance of the drug development process overall, they are not frequently used for guidance on a small scale, that is, during studies with the largest uncertainty, the first-in-human studies. Application of a quantitative model backbone makes early clinical drug development a more efficient process and provides additional safety for healthy subjects and patients. Real clinical impact is illustrated by 3 case studies that show different contributions from unblinded modeling: dose escalation based on safety data, modeling and predicting with explicit incorporation of in vitro data, and dose escalation supported by unblinded analysis of adverse event data, which resulted in new insights of the clinical team without being unblinded and made it possible to proceed with dose escalation and to extend the study with an up-titration group.
Collapse
Affiliation(s)
- Andreas Krause
- Idorsia Pharmaceuticals Ltd, Clinical Pharmacology, Allschwil, Switzerland
| | - Andrea Henrich
- Idorsia Pharmaceuticals Ltd, Clinical Pharmacology, Allschwil, Switzerland
| | - Jasper Dingemanse
- Idorsia Pharmaceuticals Ltd, Clinical Pharmacology, Allschwil, Switzerland
| |
Collapse
|
6
|
Pallmann P, Bedding AW, Choodari-Oskooei B, Dimairo M, Flight L, Hampson LV, Holmes J, Mander AP, Odondi L, Sydes MR, Villar SS, Wason JMS, Weir CJ, Wheeler GM, Yap C, Jaki T. Adaptive designs in clinical trials: why use them, and how to run and report them. BMC Med 2018; 16:29. [PMID: 29490655 PMCID: PMC5830330 DOI: 10.1186/s12916-018-1017-7] [Citation(s) in RCA: 349] [Impact Index Per Article: 58.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 01/30/2018] [Indexed: 12/11/2022] Open
Abstract
Adaptive designs can make clinical trials more flexible by utilising results accumulating in the trial to modify the trial's course in accordance with pre-specified rules. Trials with an adaptive design are often more efficient, informative and ethical than trials with a traditional fixed design since they often make better use of resources such as time and money, and might require fewer participants. Adaptive designs can be applied across all phases of clinical research, from early-phase dose escalation to confirmatory trials. The pace of the uptake of adaptive designs in clinical research, however, has remained well behind that of the statistical literature introducing new methods and highlighting their potential advantages. We speculate that one factor contributing to this is that the full range of adaptations available to trial designs, as well as their goals, advantages and limitations, remains unfamiliar to many parts of the clinical community. Additionally, the term adaptive design has been misleadingly used as an all-encompassing label to refer to certain methods that could be deemed controversial or that have been inadequately implemented.We believe that even if the planning and analysis of a trial is undertaken by an expert statistician, it is essential that the investigators understand the implications of using an adaptive design, for example, what the practical challenges are, what can (and cannot) be inferred from the results of such a trial, and how to report and communicate the results. This tutorial paper provides guidance on key aspects of adaptive designs that are relevant to clinical triallists. We explain the basic rationale behind adaptive designs, clarify ambiguous terminology and summarise the utility and pitfalls of adaptive designs. We discuss practical aspects around funding, ethical approval, treatment supply and communication with stakeholders and trial participants. Our focus, however, is on the interpretation and reporting of results from adaptive design trials, which we consider vital for anyone involved in medical research. We emphasise the general principles of transparency and reproducibility and suggest how best to put them into practice.
Collapse
Affiliation(s)
- Philip Pallmann
- Department of Mathematics & Statistics, Lancaster University, Lancaster, LA1 4YF UK
| | | | - Babak Choodari-Oskooei
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | | | - Laura Flight
- Medical Statistics Group, University of Sheffield, Sheffield, UK
| | - Lisa V. Hampson
- Department of Mathematics & Statistics, Lancaster University, Lancaster, LA1 4YF UK
- Statistical Innovation Group, Advanced Analytics Centre, AstraZeneca, Cambridge, UK
| | - Jane Holmes
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | | | - Lang’o Odondi
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Sofía S. Villar
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - James M. S. Wason
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Christopher J. Weir
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Graham M. Wheeler
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Cancer Research UK & UCL Cancer Trials Centre, University College London, London, UK
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Thomas Jaki
- Department of Mathematics & Statistics, Lancaster University, Lancaster, LA1 4YF UK
| |
Collapse
|
7
|
Quinn K, Traboni C, Penchala SD, Bouliotis G, Doyle N, Libri V, Khoo S, Ashby D, Weber J, Nicosia A, Cortese R, Pessi A, Winston A. A first-in-human study of the novel HIV-fusion inhibitor C34-PEG 4-Chol. Sci Rep 2017; 7:9447. [PMID: 28842581 PMCID: PMC5572697 DOI: 10.1038/s41598-017-09230-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 07/17/2017] [Indexed: 11/10/2022] Open
Abstract
Long-acting injectable antiretroviral (LA-ARV) drugs with low toxicity profiles and propensity for drug-drug interactions are a goal for future ARV regimens. C34-PEG4-Chol is a novel cholesterol tagged LA HIV-fusion-inhibitor (FI). We assessed pre-clinical toxicology and first-in-human administration of C34-PEG4-Chol. Pre-clinical toxicology was conducted in 2 species. HIV-positive men were randomised to a single subcutaneous dose of C34-PEG4-Chol at incrementing doses or placebo. Detailed clinical (including injection site reaction (ISR) grading), plasma pharmacokinetic (time-to-minimum-effective-concentration (MEC, 25 ng/mL) and pharmacodynamic (plasma HIV RNA) parameters were assessed. In both mice and dogs, no-observed-adverse effect level (NOAEL) was observed at a 12 mg/kg/dose after two weeks. Of 5 men enrolled, 3 received active drug (10 mg, 10 mg and 20 mg). In 2 individuals grade 3 ISR occurred and the study was halted. Both ISR emerged within 12 hours of active drug dosing. No systemic toxicities were observed. The time-to-MEC was >72 and >96 hours after 10 and 20 mg dose, respectively, and mean change in HIV RNA was −0.9 log10 copies/mL. These human pharmacodynamic and pharmacokinetic data, although limited to 3 subjects, of C34-PEG-4-Chol suggest continuing evaluation of this agent as a LA-ARV. However, alternative administration routes must be explored.
Collapse
Affiliation(s)
- Killian Quinn
- Department of Medicine, Imperial College London, London, W2 1NY, UK
| | | | | | | | - Nicki Doyle
- Department of Medicine, Imperial College London, London, W2 1NY, UK
| | - Vincenzo Libri
- Institute of Neurology, University College London, London, WC1N 3BG, UK
| | - Saye Khoo
- Department of Pharmacology, University of Liverpool, Liverpool, L69 3BX, UK
| | - Deborah Ashby
- School of Public Health, Imperial College London, London, UK
| | - Jonathan Weber
- Department of Medicine, Imperial College London, London, W2 1NY, UK
| | - Alfredo Nicosia
- JV Bio, Via Gaetano Salvatore 486, 80145, Napoli, Italy.,CEINGE, Via Gaetano Salvatore 486, 80145, Napoli, Italy
| | - Riccardo Cortese
- JV Bio, Via Gaetano Salvatore 486, 80145, Napoli, Italy.,CEINGE, Via Gaetano Salvatore 486, 80145, Napoli, Italy
| | - Antonello Pessi
- JV Bio, Via Gaetano Salvatore 486, 80145, Napoli, Italy. .,CEINGE, Via Gaetano Salvatore 486, 80145, Napoli, Italy. .,PeptiPharma, Viale Città D'Europa 679, 00144, Roma, Italy.
| | - Alan Winston
- Department of Medicine, Imperial College London, London, W2 1NY, UK.
| |
Collapse
|
8
|
Mason AJ, Gonzalez-Maffe J, Quinn K, Doyle N, Legg K, Norsworthy P, Trevelion R, Winston A, Ashby D. Developing a Bayesian adaptive design for a phase I clinical trial: a case study for a novel HIV treatment. Stat Med 2016; 36:754-771. [PMID: 27891651 PMCID: PMC5412923 DOI: 10.1002/sim.7169] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 08/09/2016] [Accepted: 10/21/2016] [Indexed: 01/30/2023]
Abstract
The design of phase I studies is often challenging, because of limited evidence to inform study protocols. Adaptive designs are now well established in cancer but much less so in other clinical areas. A phase I study to assess the safety, pharmacokinetic profile and antiretroviral efficacy of C34-PEG4 -Chol, a novel peptide fusion inhibitor for the treatment of HIV infection, has been set up with Medical Research Council funding. During the study workup, Bayesian adaptive designs based on the continual reassessment method were compared with a more standard rule-based design, with the aim of choosing a design that would maximise the scientific information gained from the study. The process of specifying and evaluating the design options was time consuming and required the active involvement of all members of the trial's protocol development team. However, the effort was worthwhile as the originally proposed rule-based design has been replaced by a more efficient Bayesian adaptive design. While the outcome to be modelled, design details and evaluation criteria are trial specific, the principles behind their selection are general. This case study illustrates the steps required to establish a design in a novel context. Copyright © 2016 John Wiley & Sons, Ltd.
Collapse
Affiliation(s)
- Alexina J Mason
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, U.K
| | - Juan Gonzalez-Maffe
- Imperial Clinical Trials Unit, Imperial College London, 68 Wood Lane, London W12 7RH, U.K
| | - Killian Quinn
- Section of Infectious Diseases, Department of Medicine, Imperial College London, London, W2 1PG, U.K
| | - Nicki Doyle
- Section of Infectious Diseases, Department of Medicine, Imperial College London, London, W2 1PG, U.K
| | - Ken Legg
- Section of Infectious Diseases, Department of Medicine, Imperial College London, London, W2 1PG, U.K
| | - Peter Norsworthy
- Section of Infectious Diseases, Department of Medicine, Imperial College London, London, W2 1PG, U.K
| | | | - Alan Winston
- Section of Infectious Diseases, Department of Medicine, Imperial College London, London, W2 1PG, U.K
| | - Deborah Ashby
- Imperial Clinical Trials Unit, Imperial College London, 68 Wood Lane, London W12 7RH, U.K
| |
Collapse
|