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Walker K, Hinsley S, Phillip R, Oughton JB, Murden G, Chalmers AJ, Faivre-Finn C, Greystoke A, Brown SR. Implementation of the Time-to-Event Continuous Reassessment Method Design in a Phase I Platform Trial Testing Novel Radiotherapy-Drug Combinations-CONCORDE. JCO Precis Oncol 2022; 6:e2200133. [PMID: 36446040 PMCID: PMC9812638 DOI: 10.1200/po.22.00133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 09/23/2022] [Accepted: 10/04/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE CONCORDE is the first phase I drug-radiotherapy (RT) combination platform in non-small-cell lung cancer, designed to assess multiple different DNA damage response inhibitors in combination with radical thoracic RT. Time-to-event continuous reassessment method (TiTE-CRM) methodology will inform dose escalation individually for each different DNA damage response inhibitor-RT combination and a randomized calibration arm will aid attribution of toxicities. We report in detail the novel statistical design and implementation of the TiTE-CRM in the CONCORDE trial. METHODS Statistical parameters were calibrated following recommendations by Lee and Cheung. Simulations were performed to assess the operating characteristics of the chosen models and were written using modified code from the R package dfcrm. RESULTS The results of the simulation work showed that the proposed statistical model setup can answer the research questions under a wide range of potential scenarios. The proposed models work well under varying levels of recruitment and with multiple adaptations to the original methodology. CONCLUSION The results demonstrate how TiTE-CRM methodology may be used in practice in a complex dose-finding platform study. We propose that this novel phase I design has potential to overcome some of the logistical barriers that for many years have prevented timely development of novel drug-RT combinations.
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Affiliation(s)
- Katrina Walker
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, England, United Kingdom
| | - Samantha Hinsley
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, England, United Kingdom
- Cancer Research UK Glasgow Clinical Trials Unit, Institute of Cancer Sciences, University of Glasgow, Scotland, United Kingdom
| | - Rachel Phillip
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, England, United Kingdom
| | - Jamie B. Oughton
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, England, United Kingdom
| | - Geraldine Murden
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, England, United Kingdom
| | - Anthony J. Chalmers
- Institute of Cancer Sciences, University of Glasgow, Scotland, United Kingdom
| | - Corinne Faivre-Finn
- The Christie NHS Foundation Trust/University of Manchester, Manchester, United Kingdom
| | | | - Sarah R. Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, England, United Kingdom
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Walls GM, Oughton JB, Chalmers AJ, Brown S, Collinson F, Forster MD, Franks KN, Gilbert A, Hanna GG, Hannaway N, Harrow S, Haswell T, Hiley CT, Hinsley S, Krebs M, Murden G, Phillip R, Ryan AJ, Salem A, Sebag-Montefoire D, Shaw P, Twelves CJ, Walker K, Young RJ, Faivre-Finn C, Greystoke A. CONCORDE: A phase I platform study of novel agents in combination with conventional radiotherapy in non-small-cell lung cancer. Clin Transl Radiat Oncol 2020; 25:61-66. [PMID: 33072895 PMCID: PMC7548952 DOI: 10.1016/j.ctro.2020.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 09/15/2020] [Accepted: 09/15/2020] [Indexed: 12/18/2022] Open
Abstract
Lung cancer is the leading cause of cancer mortality worldwide and most patients are unsuitable for 'gold standard' treatment, which is concurrent chemoradiotherapy. CONCORDE is a platform study seeking to establish the toxicity profiles of multiple novel radiosensitisers targeting DNA repair proteins in patients treated with sequential chemoradiotherapy. Time-to-event continual reassessment will facilitate efficient dose-finding.
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Key Words
- ATM, Ataxia telangiectasia mutated
- ATR, Ataxia telangiectasia and Rad3 related
- CRT, Chemoradiotherapy
- CT, Computed tomography
- CTCAE, Common terminology criteria for adverse events
- CTRad, Clinical and Translational Radiotherapy Research Working Group
- Continual reassessment method
- DDRi, DNA damage response inhibitor
- DLT, Dose limiting toxicity
- DNA damage repair inhibitor
- DNA, Deoxyribonucleic acid
- DNA-PK, DNA-dependent protein kinase
- ECOG, Eastern Cooperative Oncology Group
- EORTC, European Organisation for Research and Treatment of Cancer
- ICRU, International Commission on Radiation Units and Measurements
- IMPs, Investigational medicinal products
- LA, Locally advanced
- MRC, Medical Research Council
- NCRI, National Cancer Research Institute
- NSCLC, Non-small cell lung cancer
- Non-small cell lung cancer
- PARP, Poly (ADP-ribose) polymerase
- PET, Positron emission tomography
- PFS, Progression free survival
- PROMs, Patient-reported outcome measures
- Platform trial
- RECIST, Response evaluation criteria in solid tumours
- RP2D, Recommended phase II dose
- RT, Radiotherapy
- SACT, Systemic anti-cancer therapy
- SRC, Safety review committee
- Sequential chemoradiotherapy
- TNM, Tumour node metastasis
- TiTE-CRM, Time to event continual reassessment method
- cfDNA, Cell-free DNA
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Affiliation(s)
- Gerard M. Walls
- Patrick G Johnston Centre for Cancer Research, Queen’s University Belfast, Northern Ireland, UK
| | - Jamie B. Oughton
- Leeds Institute of Clinical Trials Research, University of Leeds, England, UK
| | | | - Sarah Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, England, UK
| | - Fiona Collinson
- Leeds Institute of Clinical Trials Research, University of Leeds, England, UK
| | | | - Kevin N. Franks
- St James’ Institute of Oncology, University of Leeds, England, UK
| | | | - Gerard G. Hanna
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia
| | | | - Stephen Harrow
- The Beatson West of Scotland Cancer Centre, Glasgow, Scotland, UK
| | | | | | - Samantha Hinsley
- Leeds Institute of Clinical Trials Research, University of Leeds, England, UK
- Institute of Cancer Sciences, University of Glasgow, Scotland, UK
| | - Matthew Krebs
- Faculty of Biology, Medicine and Health, University of Manchester, England, UK
| | - Geraldine Murden
- Leeds Institute of Clinical Trials Research, University of Leeds, England, UK
| | - Rachel Phillip
- Leeds Institute of Clinical Trials Research, University of Leeds, England, UK
| | - Anderson J. Ryan
- Oxford Institute for Radiation Oncology, University of Oxford, Oxford, England, UK
| | - Ahmed Salem
- The Christie NHS Foundation Trust/University of Manchester, Manchester, England, UK
| | | | - Paul Shaw
- Velindre University NHS Trust, Cardiff, Wales, UK
| | - Chris J. Twelves
- St James’ Institute of Oncology, University of Leeds, England, UK
| | - Katrina Walker
- Leeds Institute of Clinical Trials Research, University of Leeds, England, UK
| | - Robin J. Young
- Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield, England, UK
| | - Corinne Faivre-Finn
- Oxford Institute for Radiation Oncology, University of Oxford, Oxford, England, UK
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Faivre-Finn C, Brown S, Ryan A, Greystoke A. The UK at the Forefront of Innovative Drug-Radiotherapy Combination Clinical Trials: Introducing the CONCORDE Platform. Clin Oncol (R Coll Radiol) 2020; 32:358-362. [PMID: 32107107 DOI: 10.1016/j.clon.2020.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 01/28/2020] [Indexed: 01/25/2023]
Affiliation(s)
- C Faivre-Finn
- The Christie NHS Foundation Trust/University of Manchester, Manchester, UK.
| | - S Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - A Ryan
- Cancer Research UK and Medical Research Council Oxford Institute for Radiation Oncology, The Department of Oncology, University of Oxford, Oxford, UK
| | - A Greystoke
- Newcastle University, Newcastle upon Tyne, UK
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Verkooijen HM, Kerkmeijer LGW, Fuller CD, Huddart R, Faivre-Finn C, Verheij M, Mook S, Sahgal A, Hall E, Schultz C. R-IDEAL: A Framework for Systematic Clinical Evaluation of Technical Innovations in Radiation Oncology. Front Oncol 2017; 7:59. [PMID: 28421162 PMCID: PMC5378068 DOI: 10.3389/fonc.2017.00059] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 03/16/2017] [Indexed: 12/02/2022] Open
Abstract
The pace of innovation in radiation oncology is high and the window of opportunity for evaluation narrow. Financial incentives, industry pressure, and patients' demand for high-tech treatments have led to widespread implementation of innovations before, or even without, robust evidence of improved outcomes has been generated. The standard phase I-IV framework for drug evaluation is not the most efficient and desirable framework for assessment of technological innovations. In order to provide a standard assessment methodology for clinical evaluation of innovations in radiotherapy, we adapted the surgical IDEAL framework to fit the radiation oncology setting. Like surgery, clinical evaluation of innovations in radiation oncology is complicated by continuous technical development, team and operator dependence, and differences in quality control. Contrary to surgery, radiotherapy innovations may be used in various ways, e.g., at different tumor sites and with different aims, such as radiation volume reduction and dose escalation. Also, the effect of radiation treatment can be modeled, allowing better prediction of potential benefits and improved patient selection. Key distinctive features of R-IDEAL include the important role of predicate and modeling studies (Stage 0), randomization at an early stage in the development of the technology, and long-term follow-up for late toxicity. We implemented R-IDEAL for clinical evaluation of a recent innovation in radiation oncology, the MRI-guided linear accelerator (MR-Linac). MR-Linac combines a radiotherapy linear accelerator with a 1.5-T MRI, aiming for improved targeting, dose escalation, and margin reduction, and is expected to increase the use of hypofractionation, improve tumor control, leading to higher cure rates and less toxicity. An international consortium, with participants from seven large cancer institutes from Europe and North America, has adopted the R-IDEAL framework to work toward coordinated, evidence-based introduction of the MR-Linac. R-IDEAL holds the promise for timely, evidence-based introduction of radiotherapy innovations with proven superior effectiveness, while preventing unnecessary exposure of patients to potentially harmful interventions.
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Affiliation(s)
| | | | - Clifton D. Fuller
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robbert Huddart
- Department of Radiation Oncology, The Royal Marsden Hospital, The Institute of Cancer Research, London, UK
| | - Corinne Faivre-Finn
- The University of Manchester, Institute of Cancer Sciences, Manchester Cancer Research Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Marcel Verheij
- Department of Radiation Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Stella Mook
- Imaging Division, University Medical Center Utrecht, Utrecht, Netherlands
| | - Arjun Sahgal
- Radiation Oncology, Sunnybrook Hospital, Toronto, ON, Canada
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Chris Schultz
- Radiation Oncology, Froedtert and Medical College of Wisconsin, Milwaukee, WI, USA
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Harrow S, Hanna GG, Faivre-Finn C, McDonald F, Chalmers AJ. The Challenges Faced in Developing Novel Drug Radiation Combinations in Non-small Cell Lung Cancer. Clin Oncol (R Coll Radiol) 2016; 28:720-725. [PMID: 27591000 DOI: 10.1016/j.clon.2016.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 07/29/2016] [Accepted: 08/05/2016] [Indexed: 02/07/2023]
Abstract
Lung cancer is the most common cancer diagnosed in the UK. Outcomes for patients with this disease remain poor and new strategies to treat this disease require investigation. One potential option is to combine novel agents with radiotherapy in clinical studies. Here we discuss some of the important issues to consider when combining novel agents with radiotherapy, together with potential solutions as discussed at a recent Clinical Translational Radiotherapy Group (CTRad) workshop.
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Affiliation(s)
- S Harrow
- Department of Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK.
| | - G G Hanna
- Centre for Cancer Research and Cell Biology, Queen's University of Belfast, Belfast, UK
| | - C Faivre-Finn
- The University of Manchester, Manchester Academic Health Science Centre, Institute of Cancer Sciences, Manchester Cancer Research Centre, Manchester, UK
| | | | - A J Chalmers
- Department of Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, UK; Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
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Hanna GG, Illidge T. Radiotherapy and Immunotherapy Combinations in Non-small Cell Lung Cancer: A Promising Future? Clin Oncol (R Coll Radiol) 2016; 28:726-731. [PMID: 27519157 DOI: 10.1016/j.clon.2016.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/18/2016] [Accepted: 07/28/2016] [Indexed: 12/12/2022]
Abstract
The goal of re-programming the host immune system to target malignancy with durable anti-tumour clinical responses has been speculated for decades. In the last decade such speculation has been transformed into reality with unprecedented and durable responses to immune checkpoint inhibitors seen in solid tumours. This mini-review considers the mechanism of action of immune modulating agents and the potential for combination with radiotherapy in the treatment of non-small cell lung cancer.
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Affiliation(s)
- G G Hanna
- Centre for Cancer Research and Cell Biology, Queen's University of Belfast, Belfast, UK.
| | - T Illidge
- Institute of Cancer Sciences, Manchester Cancer Research Centre, Manchester Academic Health Sciences Centre, University of Manchester, The Christie Hospital, Manchester, UK
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van Vulpen M, Wang L, Orton CG. Within the next five years, adaptive hypofractionation will become the most common form of radiotherapy. Med Phys 2016; 43:3941. [DOI: 10.1118/1.4951735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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9
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Martin AGR, Thomas SJ, Harden SV, Burnet NG. Evaluating competing and emerging technologies for stereotactic body radiotherapy and other advanced radiotherapy techniques. Clin Oncol (R Coll Radiol) 2015; 27:251-9. [PMID: 25727646 DOI: 10.1016/j.clon.2015.01.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 01/09/2015] [Accepted: 01/29/2015] [Indexed: 12/12/2022]
Abstract
Stereotactic body radiotherapy (SBRT) refers to the precise irradiation of an image-defined extracranial lesion, using a high total radiation dose delivered in a small number of fractions. A significant proportion of SBRT treatment has been successfully delivered using conventional gantry-based linear accelerators with appropriate image guidance and motion management techniques, although a number of specialist systems are also available. Evaluating the competing SBRT technologies is difficult due to frequent refinements to all major platforms. Comparison of geometric accuracy or treatment planning performance can be hard to interpret and may not provide much useful information. Nevertheless, a general specification overview can provide information that may help radiotherapy providers decide on an appropriate system for their centre. A number of UK randomised controlled trials (RCTs) have shown that better radiotherapy techniques yield better results. RCTs should play an important part in the future evaluation of SBRT, especially where there is a smaller volume of existing data, and where outcomes from conventional radiotherapy are very good. RCT comparison of SBRT with surgery is more difficult due to the radically different treatment arms, although successful recruitment can be possible if the lessons from previous failed trials are learned. The evaluation of new technology poses a number of challenges to the conventional RCT methodology, and there may be situations where it is genuinely not possible, with careful observational studies or decision modelling being more appropriate. Further development in trial design may have an important role in providing clinical evidence in a more timely manner.
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Affiliation(s)
- A G R Martin
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - S J Thomas
- Medical Physics Department, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S V Harden
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - N G Burnet
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; University of Cambridge, Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
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Affiliation(s)
- Corinne Faivre-Finn
- Institute of Cancer Sciences, The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, M20 4BX, UK.
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Machtay M, Bradley JD, Curran WJ. Clinical trials in thoracic radiation oncology: as easy as 1, 2, 3. Int J Radiat Oncol Biol Phys 2014; 90:490-2. [PMID: 25304945 DOI: 10.1016/j.ijrobp.2014.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 05/13/2014] [Accepted: 05/13/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Mitchell Machtay
- University Hospitals Case Medical Center/Case-Western Reserve University, Cleveland, Ohio.
| | | | - Walter J Curran
- Emory Healthcare/Emory University School of medicine, Atlanta, Georgia
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