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Sampayo-Cordero M, Miguel-Huguet B, Malfettone A, López-Miranda E, Gion M, Abad E, Alcalá-López D, Pérez-Escuredo J, Pérez-García JM, Llombart-Cussac A, Cortés J. A single-arm study design with non-inferiority and superiority time-to-event endpoints: a tool for proof-of-concept and de-intensification strategies in breast cancer. Front Oncol 2023; 13:1048242. [PMID: 37496662 PMCID: PMC10368397 DOI: 10.3389/fonc.2023.1048242] [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: 09/19/2022] [Accepted: 06/19/2023] [Indexed: 07/28/2023] Open
Abstract
De-escalation trials in oncology evaluate therapies that aim to improve the quality of life of patients with low-risk cancer by avoiding overtreatment. Non-inferiority randomized trials are commonly used to investigate de-intensified regimens with similar efficacy to that of standard regimens but with fewer adverse effects (ESMO evidence tier A). In cases where it is not feasible to recruit the number of patients needed for a randomized trial, single-arm prospective studies with a hypothesis of non-inferiority can be conducted as an alternative. Single-arm studies are also commonly used to evaluate novel treatment strategies (ESMO evidence tier B). A single-arm design that includes both non-inferiority and superiority primary objectives will enable the ranking of clinical activity and other parameters such as safety, pharmacokinetics, and pharmacodynamics data. Here, we describe the statistical principles and procedures to support such a strategy. The non-inferiority margin is calculated using the fixed margin method. Sample size and statistical analyses are based on the maximum likelihood method for exponential distributions. We present example analyses in metastatic and adjuvant settings to illustrate the usefulness of our methodology. We also explain its implementation with nonparametric methods. Single-arm designs with non-inferiority and superiority analyses are optimal for proof-of-concept and de-escalation studies in oncology.
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Affiliation(s)
| | - Bernat Miguel-Huguet
- Gerència Territorial Metropolitana Sud, Institut Català De La Salud, Hospital Universitari De Bellvitge, Barcelona, Spain
| | | | - Elena López-Miranda
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - María Gion
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Elena Abad
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
| | | | | | - José Manuel Pérez-García
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- International Breast Cancer Center (IBCC), Quiron Group, Barcelona, Spain
| | - Antonio Llombart-Cussac
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- Hospital Arnau de Vilanova, FISABIO, Universidad Católica de Valencia, Valencia, Spain
| | - Javier Cortés
- Medica Scientia Innovation Research (MEDSIR), Barcelona, Spain
- International Breast Cancer Center (IBCC), Quiron Group, Barcelona, Spain
- Vall d´Hebron Institute of Oncology (VHIO), Barcelona, Spain
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Bregni G, Trevisi E, Saúde Conde R, Vanhooren M, Akin Telli T, Assaf I, Hendlisz A, Di Maio M, Sclafani F. Preexisting evidence and outcome of phase III trials in gastrointestinal oncology: a systematic review. J Natl Cancer Inst 2023; 115:505-513. [PMID: 36762842 PMCID: PMC10165488 DOI: 10.1093/jnci/djad030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/05/2023] [Accepted: 02/04/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND A minority of phase III trials in gastrointestinal oncology are positive. We assessed the association between their outcome and the level and characteristics of preexisting evidence. METHODS EMBASE, PubMed, and proceedings from international meetings were searched for phase III gastrointestinal cancer trials (gastroesophageal, hepatocellular, biliary tract, pancreatic, small bowel, colorectal, anal, stromal, and neuroendocrine) between January 2000 and June 2020. Trials investigating anticancer drugs for advanced disease, with superiority design and standard treatments as control were eligible. The highest level of preexisting evidence was retrieved from the main study report. RESULTS A total of 193 phase III trials were included, and 69 (35.8%) met their primary endpoint. Positivity rates were as follows: gastroesophageal 37%, colorectal 48%, pancreatic 17.1%, hepatocellular 20%, neuroendocrine 75%, and both biliary tract and GIST 60%. No information about preexisting evidence was found for 44 trials (22.8%). For the remaining 149, preexisting evidence consisted of phase II studies in 123 cases (82.6%) and phase I studies in 26 cases (17.4%). The probability of success was 34.1%, 35.8%, and 35.7%, respectively (P = .934). No parameter from prior studies predicted the outcome of phase III trials except β < .2 (P = .048). A numerically increased success rate was observed for phase III trials preceded by positive phase II studies (41.9% vs 18.5%, P = .2). CONCLUSIONS There does not appear to be an association between level of prior evidence and success of phase III gastrointestinal cancer trials. These data, along with the high phase III failure rate, highlight the need to improve the drug development process in this setting.
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Affiliation(s)
- Giacomo Bregni
- Department of Digestive Oncology, Institut Jules Bordet, The Brussels University Hospital (HUB), Brussels, Belgium
- Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Elena Trevisi
- Oncology Institute of Southern Switzerland—EOC, Bellinzona, Switzerland
| | - Rita Saúde Conde
- Department of Digestive Oncology, Institut Jules Bordet, The Brussels University Hospital (HUB), Brussels, Belgium
| | - Michele Vanhooren
- Department of Digestive Oncology, Institut Jules Bordet, The Brussels University Hospital (HUB), Brussels, Belgium
| | - Tugba Akin Telli
- Department of Digestive Oncology, Institut Jules Bordet, The Brussels University Hospital (HUB), Brussels, Belgium
| | - Irene Assaf
- Department of Digestive Oncology, Institut Jules Bordet, The Brussels University Hospital (HUB), Brussels, Belgium
| | - Alain Hendlisz
- Department of Digestive Oncology, Institut Jules Bordet, The Brussels University Hospital (HUB), Brussels, Belgium
- Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Massimo Di Maio
- Department of Oncology, University of Turin, at A.O. Ordine Mauriziano Hospital, Turin, Italy
| | - Francesco Sclafani
- Department of Digestive Oncology, Institut Jules Bordet, The Brussels University Hospital (HUB), Brussels, Belgium
- Université Libre de Bruxelles (ULB), Brussels, Belgium
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Ye X, Schreck KC, Ozer BH, Grossman SA. High-grade glioma therapy: adding flexibility in trial design to improve patient outcomes. Expert Rev Anticancer Ther 2022; 22:275-287. [PMID: 35130447 DOI: 10.1080/14737140.2022.2038138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Outcomes for patients with high grade gliomas have changed little over the past thirty years. This realization prompted renewed efforts to increase flexibility in the design and conduct of clinical brain tumor trials. AREAS COVERED This manuscript reviews the development of clinical trial methods, challenges and considerations of flexible clinical trial designs, approaches to improve identification and testing of active agents for high grade gliomas, and evaluation of their delivery to the central nervous system. EXPERT OPINION Flexibility can be introduced in clinical trials in several ways. Flexible designs tout smaller sample sizes, adaptive modifications, fewer control arms, and inclusion of multiple arms in one study. Unfortunately, modifications in study designs cannot address two challenges that are largely responsible for the lack of progress in treating high grade gliomas: 1) the identification of active pharmaceutical agents and 2) the delivery of these agents to brain tumor tissue in therapeutic concentrations. To improve the outcomes of patients with high grade gliomas efforts must be focused on the pre-clinical screening of drugs for activity, the ability of these agents to achieve therapeutic concentrations in non-enhancing tumors, and a willingness to introduce novel compounds in minimally pre-treated patient populations.
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Affiliation(s)
- Xiaobu Ye
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore MD, USA
| | - Karisa C Schreck
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore MD, USA
| | - Byram H Ozer
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore MD, USA
| | - Stuart A Grossman
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore MD, USA
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Balasubramanian A, Gunjur A, Hafeez U, Menon S, Cher LM, Parakh S, Gan HK. Inefficiencies in phase II to phase III transition impeding successful drug development in glioblastoma. Neurooncol Adv 2021; 3:vdaa171. [PMID: 33543145 PMCID: PMC7850118 DOI: 10.1093/noajnl/vdaa171] [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] [Indexed: 12/14/2022] Open
Abstract
Background Improving outcomes of patients with glioblastoma (GBM) represents a significant challenge in neuro-oncology. We undertook a systematic review of key parameters of phase II and III trials in GBM to identify and quantify the impact of trial design on this phenomenon. Methods Studies between 2005 and 2019 inclusive were identified though MEDLINE search and manual bibliography searches. Phase II studies (P2T) were restricted to those referenced by the corresponding phase III trials (P3T). Clinical and statistical characteristics were extracted. For each P3T, corresponding P2T data was “optimally matched,” where same drug was used in similar schedule and similar population; “suboptimally matched” if dis-similar schedule and/or treatment setting; or “lacking.” Phase II/III transition data were compared by Pearson Correlation, Fisher’s exact or chi-square testing. Results Of 20 P3Ts identified, 6 (30%) lacked phase II data. Of the remaining 14 P3T, 9 had 1 prior P2T, 4 had 2 P2T, and 1 had 3 P2T, for a total of 20 P3T-P2T pairs (called dyads). The 13 “optimally matched” dyads showed strong concordance for mPFS (r2 = 0.95, P < .01) and mOS (r2 = 0.84, P < .01), while 7 “suboptimally matched” dyads did not (P > .05). Overall, 7 P3Ts underwent an ideal transition from P2T to P3T. “Newly diagnosed” P2Ts with mPFS < 14 months and/or mOS< 22 months had subsequent negative P3Ts. “Recurrent” P2Ts with mPFS < 6 months and mOS< 12 months also had negative P3Ts. Conclusion Our findings highlight the critical role of optimally designed phase II trials in informing drug development for GBM.
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Affiliation(s)
- Adithya Balasubramanian
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Ashray Gunjur
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Umbreen Hafeez
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia.,Olivia Newton-John Cancer Research Institute and La Trobe University School of Cancer Medicine, Heidelberg, Victoria, Australia
| | - Siddharth Menon
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia.,Olivia Newton-John Cancer Research Institute and La Trobe University School of Cancer Medicine, Heidelberg, Victoria, Australia
| | - Lawrence M Cher
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Sagun Parakh
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia.,Olivia Newton-John Cancer Research Institute and La Trobe University School of Cancer Medicine, Heidelberg, Victoria, Australia
| | - Hui Kong Gan
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia.,Olivia Newton-John Cancer Research Institute and La Trobe University School of Cancer Medicine, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia
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Sampayo-Cordero M, Miguel-Huguet B, Pérez-García J, Páez D, Guerrero-Zotano ÁL, Garde-Noguera J, Aguirre E, Holgado E, López-Miranda E, Huang X, Malfettone A, Llombart-Cussac A, Cortés J. Inclusion of non-inferiority analysis in superiority-based clinical trials with single-arm, two-stage Simon's design. Contemp Clin Trials Commun 2020; 20:100678. [PMID: 33336109 PMCID: PMC7733004 DOI: 10.1016/j.conctc.2020.100678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/02/2020] [Accepted: 11/22/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Non-inferiority (NI) analysis is not usually considered in the early phases of clinical development. In some negative phase II trials, a post-hoc NI analysis justified additional phase III trials that were successful. However, the risk of false positive achievements was not controlled in these early phase analyses. We propose to preplan NI analyses in superiority-based Simon's two-stage designs to control type I and II error rates. METHODS Simulations have been proposed to assess the control of type I and II errors rates with this method. A total of 12,768 two-stage Simon's design trials were constructed based on different assumptions of rejection response probability, desired response probability, type I and II errors, and NI margins. P-value and type II error were calculated with stochastic ordering using Uniformly Minimum Variance Unbiased Estimator. Type I and II errors were simulated using the Monte Carlo method. The agreement between calculated and simulated values was analyzed with Bland-Altman plots. RESULTS We observed the same level of agreement between calculated and simulated type I and II errors from both two-stage Simon's superiority designs and designs in which NI analysis was allowed. Different examples has been proposed to explain the utility of this method. CONCLUSION Inclusion of NI analysis in superiority-based single-arm clinical trials may be useful for weighing additional factors such as safety, pharmacokinetics, pharmacodynamic, and biomarker data while assessing early efficacy. Implementation of this strategy can be achieved through simple adaptations to existing designs for one-arm phase II clinical trials.
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Affiliation(s)
- Miguel Sampayo-Cordero
- Medica Scientia Innovation Research (MedSIR), Barcelona, Spain
- Medica Scientia Innovation Research (MedSIR), Ridgewood, NJ, USA
| | | | - José Pérez-García
- Medica Scientia Innovation Research (MedSIR), Barcelona, Spain
- IOB, Institute of Oncology, QuironSalud Group, Barcelona and Madrid, Spain
| | - David Páez
- Medica Scientia Innovation Research (MedSIR), Barcelona, Spain
- Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | | | - Esther Holgado
- Medica Scientia Innovation Research (MedSIR), Barcelona, Spain
- Ramón y Cajal University Hospital, Madrid, Spain
| | - Elena López-Miranda
- Medica Scientia Innovation Research (MedSIR), Barcelona, Spain
- Ramón y Cajal University Hospital, Madrid, Spain
| | - Xin Huang
- Pfizer Global Research and Development, La Jolla, USA
| | - Andrea Malfettone
- Medica Scientia Innovation Research (MedSIR), Barcelona, Spain
- Medica Scientia Innovation Research (MedSIR), Ridgewood, NJ, USA
| | - Antonio Llombart-Cussac
- Medica Scientia Innovation Research (MedSIR), Barcelona, Spain
- FISABIO - Hospital Arnau de Vilanova, Valencia, Spain
| | - Javier Cortés
- Medica Scientia Innovation Research (MedSIR), Barcelona, Spain
- IOB, Institute of Oncology, QuironSalud Group, Barcelona and Madrid, Spain
- Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
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When are results of single-arm studies dramatic? Nat Rev Clin Oncol 2020; 17:651-652. [PMID: 32859976 DOI: 10.1038/s41571-020-00429-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Novel Nuclear Medicine Imaging Applications in Immuno-Oncology. Cancers (Basel) 2020; 12:cancers12051303. [PMID: 32455666 PMCID: PMC7281332 DOI: 10.3390/cancers12051303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/11/2020] [Accepted: 05/19/2020] [Indexed: 12/12/2022] Open
Abstract
The global immuno-oncology pipeline has grown progressively in recent years, leading cancer immunotherapy to become one of the main issues of the healthcare industry. Despite their success in the treatment of several malignancies, immune checkpoint inhibitors (ICIs) perform poorly in others. Again, ICIs action depends on such a multitude of clinico-pathological features, that the attempt to predict responders/long-responders with ad-hoc built immunograms revealed to be quite complex. In this landscape, the role of nuclear medicine might be crucial, with first interesting evidences coming from small case series and pre-clinical studies. Positron-emission tomography (PET) techniques provide functional information having a predictive and/or prognostic value in patients treated with ICIs or adoptive T-cell therapy. Recently, a characterization of the tumor immune microenvironment (TiME) pattern itself has been shown to be feasible through the use of different radioactive tracers or image algorithms, thus adding knowledge about tumor heterogeneity. Finally, nuclear medicine exams permit an early detection of immune-related adverse events (irAEs), with on-going clinical trials investigating their correlation with patients’ outcome. This review depicts the recent advances in molecular imaging both in terms of non-invasive diagnosis of TiME properties and benefit prediction from immunotherapeutic agents.
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Metaxas Y, Früh M, Eboulet EI, Grosso F, Pless M, Zucali PA, Ceresoli GL, Mark M, Schneider M, Maconi A, Perrino M, Biaggi-Rudolf C, Froesch P, Schmid S, Waibel C, Appenzeller C, Rauch D, von Moos R. Lurbinectedin as second- or third-line palliative therapy in malignant pleural mesothelioma: an international, multi-centre, single-arm, phase II trial (SAKK 17/16). Ann Oncol 2020; 31:495-500. [PMID: 32085891 DOI: 10.1016/j.annonc.2019.12.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/20/2019] [Accepted: 12/24/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Systemic second- and third-line therapies for malignant pleural mesothelioma (MPM) result in a median progression-free survival (mPFS) of <2 months and median overall survival (mOS) of 6-9 months. Lurbinectedin binds to the DNA of the regulatory region while inhibiting tumour-associated macrophage transcription. In early trials, encouraging outcomes occurred in patients (pts) with MPM treated with lurbinectedin. We aimed to generate lurbinectedin efficacy and safety data among pts with progressive MPM. PATIENTS AND METHODS Pts with progressing MPM treated with first-line platinum-pemetrexed chemotherapy with or without immunotherapy received lurbinectedin monotherapy. Treatment was given intravenously at 3.2 mg/m2 dose every 3 weeks until progression or unacceptable toxicity. Using Simon's two-stage design, the primary endpoint, progression-free survival (PFS) at 12 weeks (PFS12wks), was met if achieved by ≥21 pts (p0 ≤35% versus p1 ≥55%). RESULTS Forty-two pts from nine centres across Switzerland and Italy were recruited. Histology was epithelioid in 33 cases, sarcomatoid in 5, and biphasic in 4. Overall 10/42 (23.8%) underwent prior immunotherapy and 14/42 (33.3%) had progressed ≤6 months after first-line chemotherapy. At data cut-off PFS12wks was met by 22/42 pts (52.4%; 90% confidence interval (CI): 38.7% to 63.5%; P = 0.015) with an mPFS of 4.1 months and mOS of 11.1 months. The best response was complete and partial remission observed in one patient each and stable disease in 20 pts. The duration of disease control was 6.6 months (95% CI: 5.2-7.4). No significant difference in PFS12wks, mPFS, and mOS was recorded in epithelioid versus non-epithelioid cases and pts with prior immunotherapy versus those without. Similar mPFS but shorter mOS were observed among pts who progressed within ≤6 months after first-line chemotherapy. Lurbinectedin-related grade 3-4 toxicity was seen in 21 pts, mostly being neutropenia (23.8%) and fatigue (16.7%). CONCLUSIONS The primary efficacy endpoint was reached with acceptable toxicity. Lurbinectedin showed promising activity regardless of histology, prior immunotherapy, or outcome on prior treatment. CLINICALTRIALS. GOV IDENTIFIER NCT03213301.
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Affiliation(s)
- Y Metaxas
- Department of Oncology/Haematology, Kantonsspital Graubünden, Chur, Switzerland.
| | - M Früh
- Department of Medical Oncology and Haematology, Kantonsspital St. Gallen, St Gallen, Switzerland; University of Bern, Bern, Switzerland
| | | | - F Grosso
- Mesothelioma Unit - Oncology, SS. Antonio and C. Arrigo Hospital, Alessandria, Italy
| | - M Pless
- Department of Medical Oncology and Haematology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - P A Zucali
- Humanitas Cancer Centre, Humanitas Research Hospital, Rozzano, Italy
| | - G L Ceresoli
- Oncology Unit, Humanitas Clinic Gavazzeni, Bergamo, Italy
| | - M Mark
- Department of Oncology/Haematology, Kantonsspital Graubünden, Chur, Switzerland
| | | | - A Maconi
- Scientific Research and Development Department, SS Antonio e Biagio e Cesare Arrigo, General Hospital, Alessandria, Italy
| | - M Perrino
- Humanitas Cancer Centre, Humanitas Research Hospital, Rozzano, Italy
| | | | - P Froesch
- Department of Oncology, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - S Schmid
- Department of Medical Oncology and Haematology, Kantonsspital St. Gallen, St Gallen, Switzerland
| | - C Waibel
- Division of Haematology and Oncology, Kantonsspital Baden, Baden, Switzerland
| | - C Appenzeller
- Department of Medical Oncology and Haematology, Kantonsspital St. Gallen, St Gallen, Switzerland
| | - D Rauch
- Oncology Centre, Hospital STS AG, Thun, Switzerland
| | - R von Moos
- Department of Oncology/Haematology, Kantonsspital Graubünden, Chur, Switzerland
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Grayling MJ, Dimairo M, Mander AP, Jaki TF. A Review of Perspectives on the Use of Randomization in Phase II Oncology Trials. J Natl Cancer Inst 2019; 111:1255-1262. [PMID: 31218346 PMCID: PMC6910171 DOI: 10.1093/jnci/djz126] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/05/2019] [Accepted: 06/12/2019] [Indexed: 12/21/2022] Open
Abstract
Historically, phase II oncology trials assessed a treatment's efficacy by examining its tumor response rate in a single-arm trial. Then, approximately 25 years ago, certain statistical and pharmacological considerations ignited a debate around whether randomized designs should be used instead. Here, based on an extensive literature review, we review the arguments on either side of this debate. In particular, we describe the numerous factors that relate to the reliance of single-arm trials on historical control data and detail the trial scenarios in which there was general agreement on preferential utilization of single-arm or randomized design frameworks, such as the use of single-arm designs when investigating treatments for rare cancers. We then summarize the latest figures on phase II oncology trial design, contrasting current design choices against historical recommendations on best practice. Ultimately, we find several ways in which the design of recently completed phase II trials does not appear to align with said recommendations. For example, despite advice to the contrary, only 66.2% of the assessed trials that employed progression-free survival as a primary or coprimary outcome used a randomized comparative design. In addition, we identify that just 28.2% of the considered randomized comparative trials came to a positive conclusion as opposed to 72.7% of the single-arm trials. We conclude by describing a selection of important issues influencing contemporary design, framing this discourse in light of current trends in phase II, such as the increased use of biomarkers and recent interest in novel adaptive designs.
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Affiliation(s)
- Michael J Grayling
- Correspondence to: Michael J. Grayling, Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Rd, Newcastle upon Tyne NE2 4AX, UK (e-mail: )
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Liang F, Wu Z, Mo M, Zhou C, Shen J, Wang Z, Zheng Y. Comparison of treatment effect from randomised controlled phase II trials and subsequent phase III trials using identical regimens in the same treatment setting. Eur J Cancer 2019; 121:19-28. [DOI: 10.1016/j.ejca.2019.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022]
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Sampayo-Cordero M, Miguel-Huguet B, Pardo-Mateos A, Malfettone A, Pérez-García J, Llombart-Cussac A, Cortés J, Moltó-Abad M, Muñoz-Delgado C, Pérez-Quintana M, Pérez-López J. Agreement between results of meta-analyses from case reports and clinical studies, regarding efficacy and safety of idursulfase therapy in patients with mucopolysaccharidosis type II (MPS-II). A new tool for evidence-based medicine in rare diseases. Orphanet J Rare Dis 2019; 14:230. [PMID: 31639024 PMCID: PMC6805333 DOI: 10.1186/s13023-019-1202-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/13/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND A preliminary exploratory study shows solid agreement between the results of case reports and clinical study meta-analyses in mucopolysaccharidosis Type I (MPS-I) adult patients. The aim of the present study is to confirm previous results in another patient population, suffering from mucopolysaccharidosis Type II (MPS-II). METHODS A systematic review and meta-analysis of case reports published by April 2018 was conducted for MPS-II patients treated with enzyme replacement therapy (ERT). The study is reported in accordance with PRISMA and MOOSE guidelines (PROSPERO database code CRD42018093408). The assessed population and outcomes were the same as previously analyzed in a meta-analysis of MPS-II clinical studies. The primary endpoint was the percent of clinical cases showing improvement in efficacy outcome, or no harm in safety outcome after ERT initiation. A restrictive procedure to aggregate case reports, by selecting standardized and well-defined outcomes, was proposed. Different sensitivity analyses were able to evaluate the robustness of results. RESULTS Every outcome classified as "acceptable evidence group" in our case report meta-analysis had been graded as "moderate strength of evidence" in the aforementioned meta-analysis of clinical studies. Sensitivity, specificity, and positive-negative predictive values for results of both meta-analyses reached 100%, and were deemed equivalent. CONCLUSIONS Aggregating case reports quantitatively, rather than analyzing them qualitatively, may improve conclusions in rare diseases and personalized medicine. Additionally, we propose some methods to evaluate publication bias and heterogeneity of the included studies in a meta-analysis of case reports.
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Affiliation(s)
- Miguel Sampayo-Cordero
- Medica Scientia Innovation Research (MedSIR), Rambla de Catalunya 2, 2D, 08007, Barcelona, Spain.
| | | | | | - Andrea Malfettone
- Medica Scientia Innovation Research (MedSIR), Rambla de Catalunya 2, 2D, 08007, Barcelona, Spain
| | - José Pérez-García
- Medica Scientia Innovation Research (MedSIR), Rambla de Catalunya 2, 2D, 08007, Barcelona, Spain
- IOB, Institute of Oncology, QuironSalud Group, Madrid & Barcelona, Spain
| | - Antonio Llombart-Cussac
- Medica Scientia Innovation Research (MedSIR), Rambla de Catalunya 2, 2D, 08007, Barcelona, Spain
- FISABIO - Hospital Arnau de Vilanova, Valencia, Spain
| | - Javier Cortés
- Medica Scientia Innovation Research (MedSIR), Rambla de Catalunya 2, 2D, 08007, Barcelona, Spain
- IOB, Institute of Oncology, QuironSalud Group, Madrid & Barcelona, Spain
| | - Marc Moltó-Abad
- Unit of Rare Diseases, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Marta Pérez-Quintana
- Department of Internal Medicine, Hospital San Juan de Dios, Aljarafe, Seville, Spain
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Hettle R, Corbett M, Hinde S, Hodgson R, Jones-Diette J, Woolacott N, Palmer S. The assessment and appraisal of regenerative medicines and cell therapy products: an exploration of methods for review, economic evaluation and appraisal. Health Technol Assess 2018; 21:1-204. [PMID: 28244858 DOI: 10.3310/hta21070] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The National Institute for Health and Care Excellence (NICE) commissioned a 'mock technology appraisal' to assess whether changes to its methods and processes are needed. This report presents the findings of independent research commissioned to inform this appraisal and the deliberations of a panel convened by NICE to evaluate the mock appraisal. METHODS Our research included reviews to identify issues, analysis methods and conceptual differences and the relevance of alternative decision frameworks, alongside the development of an exemplar case study of chimeric antigen receptor (CAR) T-cell therapy for treating acute lymphoblastic leukaemia. RESULTS An assessment of previous evaluations of regenerative medicines found that, although there were a number of evidential challenges, none was unique to regenerative medicines or was beyond the scope of existing methods used to conceptualise decision uncertainty. Regarding the clinical evidence for regenerative medicines, the issues were those associated with a limited evidence base but were not unique to regenerative medicines: small non-randomised studies, high variation in response and the intervention subject to continuing development. The relative treatment effects generated from single-arm trials are likely to be optimistic unless it is certain that the historical data have accurately estimated the efficacy of the control agent. Pivotal trials may use surrogate end points, which, on average, overestimate treatment effects. To reduce overall uncertainty, multivariate meta-analysis of all available data should be considered. Incorporating indirectly relevant but more reliable (more mature) data into the analysis can also be considered; such data may become available as a result of the evolving regulatory pathways being developed by the European Medicines Agency. For the exemplar case of CAR T-cell therapy, target product profiles (TPPs) were developed, which considered the 'curative' and 'bridging to stem-cell transplantation' treatment approaches separately. Within each TPP, three 'hypothetical' evidence sets (minimum, intermediate and mature) were generated to simulate the impact of alternative levels of precision and maturity in the clinical evidence. Subsequent assessments of cost-effectiveness were undertaken, employing the existing NICE reference case alongside additional analyses suggested within alternative frameworks. The additional exploratory analyses were undertaken to demonstrate how assessments of cost-effectiveness and uncertainty could be impacted by alternative managed entry agreements (MEAs), including price discounts, performance-related schemes and technology leasing. The panel deliberated on the range of TPPs, evidence sets and MEAs, commenting on the likely recommendations for each scenario. The panel discussed the challenges associated with the exemplar and regenerative medicines more broadly, focusing on the need for a robust quantification of the level of uncertainty in the cost-effective estimates and the potential value of MEAs in limiting the exposure of the NHS to high upfront costs and loss associated with a wrong decision. CONCLUSIONS It is to be expected that there will be a significant level of uncertainty in determining the clinical effectiveness of regenerative medicines and their long-term costs and benefits, but the existing methods available to estimate the implications of this uncertainty are sufficient. The use of risk sharing and MEAs between the NHS and manufacturers of regenerative medicines should be investigated further. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Robert Hettle
- Centre for Health Economics, University of York, York, UK
| | - Mark Corbett
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Robert Hodgson
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Nerys Woolacott
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, UK
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Sampayo-Cordero M, Miguel-Huguet B, Pardo-Mateos A, Moltó-Abad M, Muñoz-Delgado C, Pérez-López J. Agreement between the results of meta-analyses from case reports and from clinical studies regarding the efficacy of laronidase therapy in patients with mucopolysaccharidosis type I who initiated enzyme replacement therapy in adult age: An example of case reports meta-analyses as an useful tool for evidence-based medicine in rare diseases. Mol Genet Metab 2018; 123:69-75. [PMID: 29336994 DOI: 10.1016/j.ymgme.2018.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/04/2018] [Accepted: 01/04/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Case reports might have a prominent role in the rare diseases field, due to the small number of patients affected by one such disease. A previous systematic review regarding the efficacy of laronidase therapy in patients with mucopolysaccharidosis type I (MPS-I) who initiated enzyme replacement therapy (ERT) in adult age has been published. The review included a meta-analysis of 19 clinical studies and the description of eleven case reports. It was of interest to perform a meta-analysis of those case reports to explore the role of such meta-analyses as a tool for evidence-based medicine in rare diseases. METHODS The study included all case reports with standard treatment regimen. Primary analysis was the percentage of case reports showing an improvement in a specific outcome. Only when that percentage was statistically higher than 5%, the improvement was confirmed as such. The outcomes that accomplished this criterion were ranked and compared to the GRADE criteria obtained by those same outcomes in the previous meta-analysis of clinical studies. RESULTS There were three outcomes that had a significant improvement: Urine glycosaminoglycans, liver volume and 6-minute walking test. Positive and negative predictive values, sensitivity and specificity for the results of the meta-analysis of case reports as compared to that of clinical studies were 100%, 88.9%, 75% and 100%, respectively. Accordingly, absolute (Rho=0.82, 95%CI: 0.47 to 0.95) and relative agreement (Kappa=0.79, 95%CI: 0.593 to 0.99) between the number of case reports with improvement in a specific outcome and the GRADE evidence score for that outcome were good. Sensitivity analysis showed that agreement between the meta-analysis of case reports and that of the clinical studies were good only when using a strong confirmatory strategy for outcome improvement in case reports. CONCLUSIONS We found an agreement between the results of meta-analyses from case reports and from clinical studies in the efficacy of laronidase therapy in patients with MPS-I who initiated ERT in adult age. This agreement suggests that combining case reports quantitatively, rather than analyzing them separately or qualitatively, may improve conclusions in the field of rare diseases.
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Affiliation(s)
| | | | | | - Marc Moltó-Abad
- Unit of Rare Diseases, Hospital Vall d'Hebron, Barcelona, Spain
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Woolacott N, Corbett M, Jones-Diette J, Hodgson R. Methodological challenges for the evaluation of clinical effectiveness in the context of accelerated regulatory approval: an overview. J Clin Epidemiol 2017; 90:108-118. [DOI: 10.1016/j.jclinepi.2017.07.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 06/22/2017] [Accepted: 07/07/2017] [Indexed: 12/25/2022]
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Grossman SA, Schreck KC, Ballman K, Alexander B. Point/counterpoint: randomized versus single-arm phase II clinical trials for patients with newly diagnosed glioblastoma. Neuro Oncol 2017; 19:469-474. [PMID: 28388713 PMCID: PMC5464324 DOI: 10.1093/neuonc/nox030] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Stuart A Grossman
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
| | - Karisa C Schreck
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland, USA
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Pinker K, Riedl C, Weber WA. Evaluating tumor response with FDG PET: updates on PERCIST, comparison with EORTC criteria and clues to future developments. Eur J Nucl Med Mol Imaging 2017; 44:55-66. [PMID: 28361188 DOI: 10.1007/s00259-017-3687-3] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 12/19/2022]
Abstract
Eighteen years ago, the EORTC PET criteria standardized for the first time response assessment by FDG PET. Response assessment by FDG PET has been further developed and refined by PERCIST (PET response criteria in solid tumors). This review describes the data underlying these two systems for assessing tumor response on FDG PET/CT. It also summarizes recent clinical studies that have compared EORTC criteria and PERCIST with each other as well as with the anatomically based "response criteria in solid tumors" (RECIST). These studies have shown that response assessment by EORTC criteria and PERCIST leads to very similar response classifications. In contrast, there are significant differences between response assessment by PERCIST and RECIST. Preliminary data also suggest that response assessment by PERCIST is better correlated with patient outcome and may be a better predictor for the effectiveness of new anti-cancer therapies than RECIST. If correct, this could have a significant impact on oncologic drug development. However, confirmation of the better predictive value of response assessment by PERCIST by data from randomized trials is still lacking.
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Affiliation(s)
- Katja Pinker
- Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, 1250 1st Av, New York, NY, 10065, USA
| | - Christopher Riedl
- Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, 1250 1st Av, New York, NY, 10065, USA
| | - Wolfgang A Weber
- Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, 1250 1st Av, New York, NY, 10065, USA.
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Factors associated with failure of oncology drugs in late-stage clinical development: A systematic review. Cancer Treat Rev 2016; 52:12-21. [PMID: 27883925 DOI: 10.1016/j.ctrv.2016.10.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 10/26/2016] [Accepted: 10/27/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND We aimed to describe the reasons for failure of experimental anticancer drugs in late-stage clinical development. MATERIAL AND METHODS We searched the PharmaProjects database (https://citeline.com/products/pharmaprojects/) for anticancer drugs discontinued between 01/01/2009 and 06/30/2014. Drug programs that reached phase III trials, but never gained Food and Drug Administration (FDA) approval were compared to 37 anti-cancer drugs achieving FDA approval in this time period. RESULTS Forty-two drugs fit our criteria for development failures. These failed drugs (49% targeted, 23% cytotoxics, and 28% other) were tested in 43 cancer indications (drug programs). Only 16% (7/43) of failed drug programs adopted a biomarker-driven rationale for patient selection versus 57% (21/37) of successful drug programs (P<0.001). Phase II trial information was available in 32 of 43 failed drug programs and in 32 of 37 successful programs. Nine of the 32 trials (28%) of failed drugs versus 28 of 32 trials (87%) of successful drugs (P<0.001) achieved proof of concept (single agent response rate (RR) ⩾20% or combination therapy showing a ⩾20% RR increase above the median historical RR without the experimental agent (with a minimal absolute increase of 5%) or a randomized phase II trial showing significance (P⩽0.05) for its primary outcome). No pattern of study sites, trial design or funding characteristics emerged from the failed drug analysis. CONCLUSION For drugs that reached Phase III, lack of a biomarker-driven strategy and failure to attain proof of concept in phase II are potential risk factors for later discontinuation, especially for targeted agents.
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