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Metcalfe A, Stephenson N, Cairncross ZF, Scime NV, Fidler‐Benaoudia M. Exclusion of pregnant and lactating persons from breast cancer clinical trials: a review of active trials registered on ClinicalTrials.gov. Acta Obstet Gynecol Scand 2024; 103:707-715. [PMID: 37377224 PMCID: PMC10993330 DOI: 10.1111/aogs.14599] [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: 03/06/2023] [Revised: 04/24/2023] [Accepted: 05/04/2023] [Indexed: 06/29/2023]
Abstract
INTRODUCTION Treatment of pregnancy-associated breast cancer is complex, as providers try to balance risks to the pregnant person and the developing fetus. Given increased case fatality and increasing incidence, there is a pressing need understand the efficacy and safety of different treatment regimens in this population; however, pregnant and lactating people have traditionally been excluded from participating in randomized controlled trials (RCTs). Given recent efforts to expand the inclusion criteria for oncology RCTs, this study aimed to review the inclusion/exclusion criteria of current breast cancer RCTs to assess what proportion of trials permitted enrollment of pregnant and lactating persons. MATERIAL AND METHODS We conducted a comprehensive search of ClinicalTrials.gov in January 2022 to identify interventional studies of breast cancer in adults that were actively recruiting. The primary outcomes were the exclusion of pregnant and lactating people. RESULTS The search identified 1706 studies, of which 1451 met eligibility criteria. Overall, 69.4% and 54.8% of studies excluded pregnant and lactating people, respectively. The exclusion of pregnant and lactating persons differed by study characteristics but extended across all trial designs, locations, phases and interventions. Exclusion of pregnant and lactating persons was most common in trials where the intervention was biological (86.3%), drug (83.5%) or radiation (81.5%). CONCLUSIONS The exclusion of pregnant and lactating people from clinical trials contributes to evidence gaps in how to treat this population. A paradigm shift is needed that focuses on how research can be used to protect pregnant people from future harms, instead of protecting pregnant people from research-related risks.
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Affiliation(s)
- Amy Metcalfe
- Department of Obstetrics and GynaecologyUniversity of CalgaryCalgaryAlbertaCanada
- Department of Community Health SciencesUniversity of CalgaryCalgaryAlbertaCanada
- Department of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Nikki Stephenson
- Department of Obstetrics and GynaecologyUniversity of CalgaryCalgaryAlbertaCanada
| | - Zoe F. Cairncross
- Department of Obstetrics and GynaecologyUniversity of CalgaryCalgaryAlbertaCanada
| | - Natalie V. Scime
- Department of Health & SocietyUniversity of Toronto ScarboroughTorontoOntarioCanada
| | - Miranda Fidler‐Benaoudia
- Department of Community Health SciencesUniversity of CalgaryCalgaryAlbertaCanada
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health ServicesCalgaryAlbertaCanada
- Department of OncologyUniversity of CalgaryCalgaryAlbertaCanada
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Liu Q, Mathur R, Xu Y, Torres AZ, Miksad RA, Liu C, Smithson H, Wang Y, Zhu H, Booth B, Huang SM, Zhi J, Sridhara R, Blumenthal GM, Larkins E, Mishra-Kalyani PS, Rivera DR, Kluetz PG, Sharon E. The Association Between Baseline Hepatic or Renal Function and Clinical Outcomes for Patients With Non-Small Cell Lung Cancer Treated With a PD-1/PD-L1 Blocking Antibody Using Real-World and Trial Data. Clin Pharmacol Ther 2023; 113:1139-1149. [PMID: 36790088 DOI: 10.1002/cpt.2874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
Clinical trials have demonstrated the benefit of PD-1/PD-L1 blocking antibodies for the treatment of patients with advanced non-small cell lung cancer (NSCLC) in defined patient populations that often exclude patients with moderate or severe hepatic or renal impairment. We assessed the association between overall survival (OS) and baseline organ function in patients with advanced NSCLC treated with PD-1/PD-L1 blocking antibodies in real-world data (RWD; patient-level data from electronic health records) and pooled clinical trial data submitted to the US Food and Drug Administration (FDA). The Kaplan-Meier estimator was used to estimate OS in different subgroups based on organ function. Unadjusted and adjusted Cox proportional hazards models were used to estimate the association between OS and organ function. In this hypothesis-generating study, baseline renal impairment did not appear to be associated with OS, while patients with baseline liver impairment had shorter OS. RWD provided information on a broader range of renal and hepatic function than was evaluated in clinical trials and hold promise to complement trial data in better understanding populations not represented in clinical trials.
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Affiliation(s)
- Qi Liu
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Yuan Xu
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | | | - Chao Liu
- BeiGene USA, Inc, Fulton, Maryland, USA
| | - Haixia Smithson
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yaning Wang
- Greaterna Science and Technology, Shanghai, China
| | - Hao Zhu
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Brian Booth
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Shiew-Mei Huang
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jizu Zhi
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | | | - Erin Larkins
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Donna R Rivera
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Paul G Kluetz
- US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Elad Sharon
- National Cancer Institute, Bethesda, Maryland, USA
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Sridhara R, Marchenko O, Jiang Q, Barksdale E, Chen J, Dreyer N, Fashoyin-Aje L, Garrett-Mayer E, Gormley N, Gwise T, Hess L, Mandrekar S, Pignatti F, Rantell K, Raven A, Shen YL, Singh H, Tendler CL, Theoret M, Pazdur R. Evaluation of Treatment Effect in Underrepresented Population in Cancer Trials: Discussion with International Regulators. Stat Biopharm Res 2022. [DOI: 10.1080/19466315.2022.2128404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | - Nicole Gormley
- Oncology Center of Excellence, US FDA, Silver Spring, MD
| | - Thomas Gwise
- Office of Biostatistics, CDER US FDA, Silver Spring, MD
| | | | | | | | | | | | - Yuan-Li Shen
- Office of Biostatistics, CDER US FDA, Silver Spring, MD
| | - Harpreet Singh
- Oncology Center of Excellence, US FDA, Silver Spring, MD
| | | | - Marc Theoret
- Oncology Center of Excellence, US FDA, Silver Spring, MD
| | - Richard Pazdur
- Oncology Center of Excellence, US FDA, Silver Spring, MD
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Gerber DE, Singh H, Larkins E, Ferris A, Forde PM, Selig W, Roy UB. A New Approach to Simplifying and Harmonizing Cancer Clinical Trials-Standardizing Eligibility Criteria. JAMA Oncol 2022; 8:1333-1339. [PMID: 35925576 PMCID: PMC9934063 DOI: 10.1001/jamaoncol.2022.1664] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Clinical trial sponsors rely on eligibility criteria to control the characteristics of patients in their studies, promote the safety of participants, and optimize the interpretation of results. However, in recent years, complex and often overly restrictive inclusion and exclusion criteria have created substantial barriers to patient access to novel therapies, hindered trial recruitment and completion, and limited generalizability of trial results. A LUNGevity Foundation working group developed a framework for lung cancer clinical trial eligibility criteria. The goals of this framework are to (1) simplify eligibility criteria, (2) facilitate stakeholders' (patients, clinicians, and sponsors) search for appropriate trials, and (3) harmonize trial populations to support intertrial comparisons of treatment effects. Observations Clinicians and representatives from the pharmaceutical industry, the National Cancer Institute, the US Food and Drug Administration (FDA), the European Medicines Agency, and the LUNGevity Foundation undertook a process to identify and prioritize key items for inclusion in trial eligibility criteria. The group generated a prioritized library of terms to guide investigators and sponsors in the design of first-line, advanced non-small cell lung cancer clinical trials intended to support marketing application. These recommendations address disease stage and histologic features, enrollment biomarkers, performance status, organ function, brain metastases, and comorbidities. This effort forms the basis for a forthcoming FDA draft guidance for industry. Conclusions and Relevance As an initial step, the recommended cross-trial standardization of eligibility criteria may harmonize trial populations. Going forward, by connecting diverse stakeholders and providing formal opportunity for public input, the emerging FDA draft guidance may also provide an opportunity to revise and simplify long-standing approaches to trial eligibility. This work serves as a prototype for similar efforts now underway for other cancers.
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Affiliation(s)
- David E. Gerber
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas USA
| | - Harpreet Singh
- Food and Drug Administration, Silver Spring, Maryland USA
| | - Erin Larkins
- Food and Drug Administration, Silver Spring, Maryland USA
| | | | - Patrick M. Forde
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland USA
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Smeltzer MP, Scagliotti GV, Wakelee HA, Mitsudomi T, Roy UB, Clark RC, Arndt R, Pruett CD, Kelly KL, Ujhazy P, Johnson ML, Eralp Y, Barrios CH, Barlesi F, Hirsch FR, Bunn PA. International Association for the Study of Lung Cancer (IASLC) Study of the Impact of COVID-19 on International Lung Cancer Clinical Trials. J Thorac Oncol 2022; 17:651-660. [PMID: 35183774 PMCID: PMC8851565 DOI: 10.1016/j.jtho.2022.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION To evaluate the effects of the global coronavirus disease 2019 (COVID-19) pandemic on lung cancer trials, we surveyed investigators and collected aggregate enrollment data for lung cancer trials across the world before and during the pandemic. METHODS A Data Collection Survey collected aggregate monthly enrollment numbers from 294 global lung cancer trials for 2019 to 2020. A 64-question Action Survey evaluated the impact of COVID-19 on clinical trials and identified mitigation strategies implemented. RESULTS Clinical trial enrollment declined from 2019 to 2020 by 14% globally. Most reductions in enrollment occurred in April to June where we found significant decreases in individual site enrollment (p = 0.0309). Enrollment was not significantly different in October 2019 to December of 2019 versus 2020 (p = 0.25). The most frequent challenges identified by the Action Survey (N = 172) were fewer eligible patients (63%), decrease in protocol compliance (56%), and suspension of trials (54%). Patient-specific challenges included access to trial site (49%), ability to travel (54%), and willingness to visit the site (59%). The most frequent mitigation strategies included modified monitoring requirements (47%), telehealth visits (45%), modified required visits (25%), mail-order medications (25%), and laboratory (27%) and radiology (21%) tests at nonstudy facilities. Sites that felt the most effective mitigation strategies were telehealth visits (85%), remote patient-reported symptom collection (85%), off-site procedures (85%), and remote consenting (89%). CONCLUSIONS The COVID-19 pandemic created many challenges for lung cancer clinical trials conduct and enrollment. Mitigation strategies were used and, although the pandemic worsened, trial enrollment improved. A more flexible approach may improve enrollment and access to clinical trials, even beyond the pandemic.
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Affiliation(s)
- Matthew P Smeltzer
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee.
| | - Giorgio V Scagliotti
- A.O.U. San Luigi Gonzaga Hospital, Department of Oncology, University of Torino, Orbassano, Italy
| | | | - Tetsuya Mitsudomi
- Division of Thoracic Surgery, Department of Surgery, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | | | | | - Renee Arndt
- Cancer Technology Applications, LLC, San Diego, California
| | | | - Karen L Kelly
- Department of Medicine, Division of Hematology Oncology, University of California Davis Health, Sacramento, California
| | - Peter Ujhazy
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, Maryland
| | - Melissa L Johnson
- Sarah Cannon Research Institute, Nashville, Tennessee; Tennessee Oncology, PLLC, Nashville, Tennessee
| | - Yesim Eralp
- Maslak Acibadem Hospital, Acibadem University, Istanbul, Turkey
| | - Carlos H Barrios
- Latin American Cooperative Oncology Group (LACOG) Oncoclínicas Group, Porto Alegre, Brazil
| | - Fabrice Barlesi
- Department of Medical Oncology, Gustave Roussy, Villejuif, France; Centre de Recherche en Cancérologie de Marseille (CRCM), Centre National de la Recherche Scientifique (CNRS), Institut National de la Santé et de la Recherche Médicale (INSERM), Aix-Marseille University, Marseille, France
| | - Fred R Hirsch
- Center for Thoracic Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Paul A Bunn
- University of Colorado School of Medicine, Aurora, Colorado
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Ardizzoni A, Azevedo S, Rubio-Viqueira B, Rodríguez-Abreu D, Alatorre-Alexander J, Smit HJM, Yu J, Syrigos K, Trunzer K, Patel H, Tolson J, Cardona A, Perez-Moreno PD, Newsom-Davis T. Primary results from TAIL: a global single-arm safety study of atezolizumab monotherapy in a diverse population of patients with previously treated advanced non-small cell lung cancer. J Immunother Cancer 2021; 9:jitc-2020-001865. [PMID: 33737339 PMCID: PMC7978274 DOI: 10.1136/jitc-2020-001865] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Atezolizumab treatment improves survival, with manageable safety, in patients with previously treated advanced/metastatic non-small cell lung cancer. The global phase III/IV study TAIL (NCT03285763) was conducted to evaluate the safety and efficacy of atezolizumab monotherapy in a clinically diverse population of patients with previously treated non-small cell lung cancer, including those not eligible for pivotal trials. METHODS Patients with stage IIIB/IV non-small cell lung cancer whose disease progressed after 1-2 lines of chemotherapy were eligible for this open-label, single-arm, multicenter study, including those with severe renal impairment, an Eastern Cooperative Oncology Group performance status of 2, prior anti-programmed death 1 (PD-1) therapy, and autoimmune disease. Atezolizumab was administered intravenously (1200 mg every 3 weeks). Coprimary endpoints were treatment-related serious adverse events and immune-related adverse events. RESULTS 619 patients enrolled and 615 received atezolizumab. At data cutoff, the median follow-up was 12.6 months (95% CI 11.9 to 13.1). Treatment-related serious adverse events occurred in 7.8% and immune-related adverse events in 8.3% of all patients and as follows, respectively, in these subgroups: renal impairment (n=78), 11.5% and 12.8%; Eastern Cooperative Oncology Group performance status of 2 (n=61), 14.8% and 8.2%; prior anti-PD-1 therapy (n=39), 5.1% and 7.7%; and autoimmune disease (n=30), 6.7% and 10.0%. No new safety signals were reported. In the overall population, the median overall survival was 11.1 months (95% CI 8.9 to 12.9), the median progression-free survival was 2.7 months (95% CI 2.1 to 2.8) and the objective response rate was 11%. CONCLUSIONS This study confirmed the benefit-risk profile of atezolizumab monotherapy in a clinically diverse population of patients with previously treated non-small cell lung cancer. These safety and efficacy outcomes may inform treatment decisions for patients generally excluded from checkpoint inhibitor trials.
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Affiliation(s)
- Andrea Ardizzoni
- Department of Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sergio Azevedo
- Oncology Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Belen Rubio-Viqueira
- Department of Medical Oncology, Hospital Universitario Quirónsalud Madrid, Madrid, Spain
| | - Delvys Rodríguez-Abreu
- Department of Medical Oncology, Hospital Universitario Insular de Gran Canaria, Las Palmas, Canarias, Spain
| | | | - Hans J M Smit
- Department of Pulmonary Diseases, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital, affiliated to Shandong University, Jinan, Shandong, China
| | - Konstantinos Syrigos
- 3rd Department of Medicine, National and Kapodistrian University of Athens, Athens, Attica, Greece
| | - Kerstin Trunzer
- Department of Oncology Biomarker Development, F. Hoffmann-La Roche Ltd, Basel, Basel-Stadt, Switzerland
| | - Hina Patel
- Department of Safety Science Oncology, Genentech Inc, South San Francisco, California, USA
| | - Jonathan Tolson
- Department of Global Product Development, F. Hoffmann-La Roche Ltd, Basel, Basel-Stadt, Switzerland
| | - Andres Cardona
- Department of Product Development Biometrics, F. Hoffmann-La Roche Ltd, Basel, Basel-Stadt, Switzerland
| | - Pablo D Perez-Moreno
- Department of Product Development, Genentech Inc, South San Francisco, California, USA
| | - Tom Newsom-Davis
- Department of Oncology, Chelsea and Westminster Hospital, London, UK
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