Phase 0 clinical trials in oncology: a paradigm shift for early drug development?

IDEAL-D Framework for Device Innovation: A Consensus Statement on the Preclinical Stage

OBJECTIVE

To extend the IDEAL framework for device innovation, IDEAL-D, to include the preclinical stage of development (stage 0).

BACKGROUND

In previous work, the IDEAL collaboration has proposed frameworks for new surgical techniques and complex therapeutic technologies, the central tenet being that development and evaluation can and should proceed together in an ordered and logical manner that balances innovation and safety.

METHODS

Following agreement at the IDEAL Collaboration Council, a multidisciplinary working group was formed comprising 12 representatives from healthcare, academia, industry, and a patient advocate. The group conducted a series of discussions following the principles used in the development of the original IDEAL framework. Importantly, IDEAL aims for maximal transparency, optimal validity in the evaluation of primary effects, and minimization of potential risk to patients or others. The proposals were subjected to further review and editing by members of the IDEAL Council before a final consensus version was adopted.

RESULTS

In considering which studies are required before a first-in-human study, we have: (1) classified devices according to what they do and the risks they carry, (2) classified studies according to what they show about the device, and (3) made recommendations based on the principle that the more invasive and high risk a device is, the greater proof required of their safety and effectiveness before progression to clinical studies (stage 1).

CONCLUSIONS

The proposed recommendations for preclinical evaluation of medical devices represent a proportionate and pragmatic approach that balances the de-risking of first-in-human translational studies against the benefits of rapid translation of new devices into clinical practice.

A Review on: Phase '0' Clinical Trials or Exploratory Investigational New Drug

In a move to speed up the development of new medicines, the Food and Drug Administration announced in January 2006 the creation of the exploratory Investigational New Drug (IND), the so-called phase '0' clinical trials. This guidance is intended to clarify what preclinical and clinical approaches, as well as chemistry, manufacturing, and controls information, should be considered when planning exploratory studies in humans, including studies of closely related drugs or therapeutic biological products, under an IND application (21 CFR 312). Existing regulations allow a great deal of flexibility in the amount of data that needs to be submitted with an IND application, depending on the goals of the proposed investigation, the specific human testing proposed, and the expected risks. The agency believes that sponsors have not taken full advantage of that flexibility and often provide more supporting information in INDs than is required by regulations. This guidance is intended to clarify what manufacturing controls, preclinical testing, and clinical approaches can be considered when planning limited, early exploratory IND studies in humans.

Experimental Therapeutic Trial Design for Pediatric Brain Tumors

Pediatric brain tumors are the leading cause of cancer-related death during childhood. Since the first pediatric brain tumor clinical trials, the field has seen improved outcomes in some, but not all tumor types. In the past few decades, a number of promising new therapeutic agents have emerged, yet only a few of these agents have been incorporated into clinical trials for pediatric brain tumors. In this review, the authors discuss the process of and challenges in pediatric clinical trial design; this will allow for highly efficient and effective clinical trials with appropriate endpoints to ensure rapid and safe investigation of novel therapeutics for children with brain tumors.

Conduct, Oversight, and Ethical Considerations of Clinical Trials in Companion Animals with Cancer: Report of a Workshop on Best Practice Recommendations

Development of effective and safe treatments for companion animals with cancer requires the collaboration of numerous animal health professionals and the full engagement of animal owners. Establishing ‘Best Practice Recommendations’ for clinical trials in veterinary oncology represents an important step toward meeting the goal of rigorous clinical trial design and conduct that is required to establish valid evidence. Likewise, optimizing patient welfare and owner education and advocacy is crucial to meet the unique ethical obligations to both owners and animals enrolled in these clinical trials and to ensure trust in the team conducting the research. To date, ‘Best Practice Recommendations’ for clinical trial conduct have not been reported for veterinary oncology. This document summarizes the consensus of a workshop held in November, 2014 to identify relevant ethical principles and to ensure responsible conduct of clinical research in companion animals with cancer. It is intended as a working document that will be updated as advances in science and ethical considerations require. To the extent possible, existing guidelines for the conduct and oversight of clinical trials in humans have been adapted for veterinary trials to avoid duplicative effort and to facilitate integration of clinical trials such that translational research with benefits for both companion animals and humans are encouraged.

The application of human phase 0 microdosing trials: A systematic review and perspectives

A decreasing number of new therapeutic drugs reaching the clinic has led to the publication of regulatory guidelines on human microdosing trials by the European Medicines Agency in 2004 and the US Food and Drug Administration in 2006. Microdosing trials are defined by the administration of 1/100th of the therapeutic dose and designed to investigate basic drug properties. This review investigates the current application of phase 0 trials in medical research. Thirty-three studies found in PubMed and EMBASE were systematically reviewed for aim and analytical method. Pharmacokinetic studies have been a major focus of phase 0 trials, but drug distribution, drug-drug interactions, imaging and pharmacogenomics have also been investigated. Common analytical methods were tandem mass liquid chromatography, accelerator mass spectrometry and positron emission tomography. New ongoing trials are investigating the pharmacodynamics and chemoresistance of marketed drugs, suggesting that the application of phase 0 trials is still evolving.

The role of clinical trials in veterinary oncology

Clinical trials for companion animals are becoming more common and more accessible to pet owners as veterinary oncologists seek to expand their knowledge of tumor biology in companion animal species and improve the way they diagnose and treat cancer for these animals. Many owners enroll their pets because they wish to participate in clinical cancer research that may ultimately benefit pets and people. Understanding the goals, benefits, and risks of clinical trials participation provides the knowledge needed by primary care veterinarians to counsel their clients as to whether clinical trial participation is a good choice for them and their pets.

[Phase 0 exploratory clinical trials: literature review 2006-2009]

Currently in oncology a novel agent entering development has only 5% chance of making it to commercial use. One of the ways to mitigate this problem would be to conduct exploratory or 'phase 0' clinical trials, conducted before phase 1 dose-escalation safety and tolerance studies. These phase 0 studies are a first administration of the novel agent to humans, at limited doses, on a small number of patients and over a short period. The objectives are to validate preclinical development and to acquire pharmacokinetic and pharmacodynamic data in order to better justify the scientific rational. In this article, we focus on phase 0 trials and their usefulness for the development of new drugs in oncology. We performed a literature review of questions related to phase 0 trials in articles published during 2006 to 2009. Thirty articles on phase 0 clinical trials have been published. The affected fields are oncology and pharmacology. Phase 0 clinical trials are discussed in the literature in terms of theoretical issues and from academic, pharmaceutical industry and patient point of views. If phase 0 clinical trials are a future prospect for drug development against cancer, the clinical applications of these trials need to be specified.

Src kinase: a therapeutic opportunity in endocrine-responsive and resistant breast cancer

The intracellular kinase, Src, interacts with a diverse array of signaling elements, including the estrogen receptor to regulate breast cancer progression. Recent evidence has also implicated Src in mediating the response of breast cancer to endocrine agents and in the acquisition of antihormone resistance, a significant limiting factor to the clinical effectiveness of systemic endocrine therapy. A number of pharmacological inhibitors of Src kinase have been developed that are effective at suppressing breast cancer growth and invasion in vitro and inhibiting disease spread in vivo. Significantly, there appears to be added benefit when these agents are given in combination with anti-estrogens in endocrine-sensitive and -resistant models. These new findings suggest that Src inhibitors might have therapeutic value in breast cancer patients to improve endocrine response and circumvent resistance.

Bridging the translation gap - new hopes, new challenges

The complexity of modern biomedical research continues to increase. Research-to-practice gaps are now widely pervasive; these widening fissures between the disciplines of research and clinical medicine can only be abridged if the translational processes are methodically backed up by robust methods, many of which are yet to be developed. This primarily relates to the development of biomarkers, biostatistical methods, accelerated human study designs including phase 0 trials and smarter decision-making tools among other features. This brief review highlights the tribulations that have contributed to the lack of technology transfer including lapses in communication between researchers and practitioners, and related factors in service deliverance such as the health care policies, public awareness, and financing. The paper also underscores the heightened attentiveness about the problem in recent years which has, in turn, paved the road for better opportunities to enable cross-fertilization of ideas, collaboration across multiple disciplines and centers, training of students, residents and junior researchers, and promotion of practical research goals.