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Veas Rodríguez J, Prieto A, Vilaprinyo E, Bonet M, Diez M, Salud A, Montal R. Surrogate endpoints in phase III randomized trials of advanced gastroesophageal cancer: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2024; 201:104416. [PMID: 38871262 DOI: 10.1016/j.critrevonc.2024.104416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 06/05/2024] [Accepted: 06/06/2024] [Indexed: 06/15/2024] Open
Abstract
Overall survival (OS) is the most meaningful endpoint in clinical trials. However, owing to their limitations, surrogate endpoints are commonly used and validation studies are required to assess their reliability. Analysis of phase III randomized controlled trials (RCTs) of advanced gastroesophageal cancer (AGC) with > 100 patients, correlation coefficients (r), and determination coefficients (R²) between OS and surrogates were evaluated through meta-analyses. Progression-free survival (PFS), time to progression (TTP), and objective response rate (ORR) were examined to determine their correlations with OS. Analysis of 65 phase III RCTs (29,766 subjects) showed a moderate correlation between PFS/TTP and OS (r = 0.77, R² = 0.59), while ORR correlation was low (r = 0.56, R² = 0.31). Excluding immunotherapy trials improved the PFS/TTP and OS correlations (r = 0.83, R² = 0.70). These findings suggest the potential use of PFS/TTP in AGC phase III investigations, disregarding the use of ORR as a surrogate endpoint.
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Affiliation(s)
- Joel Veas Rodríguez
- Department of Medical Oncology, Arnau de Vilanova University Hospital, Lleida, Spain; Department of Medical Oncology, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom.
| | - Ana Prieto
- Department of Medical Oncology, Arnau de Vilanova University Hospital, Lleida, Spain
| | - Ester Vilaprinyo
- Department of Basic Medical Sciences, University of Lleida, IRBLLEIDA, Lleida, Spain
| | - Marta Bonet
- Department of Radiation Oncology, Arnau de Vilanova University Hospital, Lleida, Spain
| | - Marc Diez
- Department of Medical Oncology, Vall d' Hebron University Hospital, Barcelona, Spain
| | - Antonieta Salud
- Department of Medical Oncology, Arnau de Vilanova University Hospital, Lleida, Spain
| | - Robert Montal
- Department of Medical Oncology, Arnau de Vilanova University Hospital, Lleida, Spain
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Sherry AD, Msaouel P, Kupferman GS, Lin TA, Abi Jaoude J, Kouzy R, El-Alam MB, Patel R, Koong A, Lin C, Passy AH, Miller AM, Beck EJ, Fuller CD, Meirson T, McCaw ZR, Ludmir EB. Towards Treatment Effect Interpretability: A Bayesian Re-analysis of 194,129 Patient Outcomes Across 230 Oncology Trials. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.07.23.24310891. [PMID: 39108512 PMCID: PMC11302607 DOI: 10.1101/2024.07.23.24310891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Abstract
Most oncology trials define superiority of an experimental therapy compared to a control therapy according to frequentist significance thresholds, which are widely misinterpreted. Posterior probability distributions computed by Bayesian inference may be more intuitive measures of uncertainty, particularly for measures of clinical benefit such as the minimum clinically important difference (MCID). Here, we manually reconstructed 194,129 individual patient-level outcomes across 230 phase III, superiority-design, oncology trials. Posteriors were calculated by Markov Chain Monte Carlo sampling using standard priors. All trials interpreted as positive had probabilities > 90% for marginal benefits (HR < 1). However, 38% of positive trials had ≤ 90% probabilities of achieving the MCID (HR < 0.8), even under an enthusiastic prior. A subgroup analysis of 82 trials that led to regulatory approval showed 30% had ≤ 90% probability for meeting the MCID under an enthusiastic prior. Conversely, 24% of negative trials had > 90% probability of achieving marginal benefits, even under a skeptical prior, including 12 trials with a primary endpoint of overall survival. Lastly, a phase III oncology-specific prior from a previous work, which uses published summary statistics rather than reconstructed data to compute posteriors, validated the individual patient-level data findings. Taken together, these results suggest that Bayesian models add considerable unique interpretative value to phase III oncology trials and provide a robust solution for overcoming the discrepancies between refuting the null hypothesis and obtaining a MCID.
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Affiliation(s)
- Alexander D Sherry
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pavlos Msaouel
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabrielle S Kupferman
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy A Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph Abi Jaoude
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| | - Ramez Kouzy
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Molly B El-Alam
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roshal Patel
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Alex Koong
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christine Lin
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Adina H Passy
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Avital M Miller
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Esther J Beck
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C David Fuller
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tomer Meirson
- Davidoff Cancer Center, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel
| | - Zachary R McCaw
- Insitro, South San Francisco, CA, USA
- Department of Biomedical Informatics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ethan B Ludmir
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Bommier C, Maurer MJ, Lambert J. What clinicians should know about surrogate end points in hematologic malignancies. Blood 2024; 144:11-20. [PMID: 38603637 DOI: 10.1182/blood.2023022269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 03/14/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
ABSTRACT Use of surrogates as primary end points is commonplace in hematology/oncology clinical trials. As opposed to prognostic markers, surrogates are end points that can be measured early and yet can still capture the full effect of treatment, because it would be captured by the true outcome (eg, overall survival). We discuss the level of evidence of the most commonly used end points in hematology and share recommendations on how to apply and evaluate surrogate end points in research and clinical practice. Based on the statistical literature, this clinician-friendly review intends to build a bridge between clinicians and surrogacy specialists.
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Affiliation(s)
- Côme Bommier
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
- Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments Team, INSERM, U1153, Assistance Publique-Hôpitaux de Paris Hôpital St Louis, Université Paris Cité, Paris, France
| | - Matthew John Maurer
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Jerome Lambert
- Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments Team, INSERM, U1153, Assistance Publique-Hôpitaux de Paris Hôpital St Louis, Université Paris Cité, Paris, France
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Sherry AD, Msaouel P, Miller AM, Lin TA, Kupferman GS, Jaoude JA, Kouzy R, El-Alam MB, Patel R, Koong A, Lin C, Meirson T, McCaw ZR, Ludmir EB. Bayesian Interim Analysis and Efficiency of Phase III Randomized Trials. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.27.24309608. [PMID: 38978666 PMCID: PMC11230311 DOI: 10.1101/2024.06.27.24309608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
IMPORTANCE Improving the efficiency of interim assessments in phase III trials should reduce trial costs, hasten the approval of efficacious therapies, and mitigate patient exposure to disadvantageous randomizations. OBJECTIVE We hypothesized that in silico Bayesian early stopping rules improve the efficiency of phase III trials compared with the original frequentist analysis without compromising overall interpretation. DESIGN Cross-sectional analysis. SETTING 230 randomized phase III oncology trials enrolling 184,752 participants. PARTICIPANTS Individual patient-level data were manually reconstructed from primary endpoint Kaplan-Meier curves. INTERVENTIONS Trial accruals were simulated 100 times per trial and leveraged published patient outcomes such that only the accrual dynamics, and not the patient outcomes, were randomly varied. MAIN OUTCOMES AND MEASURES Early stopping was triggered per simulation if interim analysis demonstrated ≥ 85% probability of minimum clinically important difference/3 for efficacy or futility. Trial-level early closure was defined by stopping frequencies ≥ 0.75. RESULTS A total of 12,451 simulations (54%) met early stopping criteria. Trial-level early stopping frequency was highly predictive of the published outcome (OR, 7.24; posterior probability of association, >99.99%; AUC, 0.91; P < 0.0001). Trial-level early closure was recommended for 82 trials (36%), including 62 trials (76%) which had performed frequentist interim analysis. Bayesian early stopping rules were 96% sensitive (95% CI, 91% to 98%) for detecting trials with a primary endpoint difference, and there was a high level of agreement in overall trial interpretation (Bayesian Cohen's κ, 0.95; 95% CrI, 0.92 to 0.99). However, Bayesian interim analysis was associated with >99.99% posterior probability of reducing patient enrollment requirements ( P < 0.0001), with an estimated cumulative enrollment reduction of 20,543 patients (11%; 89 patients averaged equally over all studied trials) and an estimated cumulative cost savings of 851 million USD (3.7 million USD averaged equally over all studied trials). CONCLUSIONS AND RELEVANCE Bayesian interim analyses may improve randomized trial efficiency by reducing enrollment requirements without compromising trial interpretation. Increased utilization of Bayesian interim analysis has the potential to reduce costs of late-phase trials, reduce patient exposures to ineffective therapies, and accelerate approvals of effective therapies. KEY POINTS Question: What are the effects of Bayesian early stopping rules on the efficiency of phase III randomized oncology trials?Findings: Individual-patient level outcomes were reconstructed for 184,752 patients from 230 trials. Compared with the original interim analysis strategy, in silico Bayesian interim analysis reduced patient enrollment requirements and preserved the original trial interpretation. Meaning: Bayesian interim analysis may improve the efficiency of conducting randomized trials, leading to reduced costs, reduced exposure of patients to disadvantageous treatments, and accelerated approval of efficacious therapies.
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Mansour N, Heinrich K, Zhang D, Winkelmann M, Ingenerf M, Gold L, Klambauer K, Rudelius M, Klauschen F, von Bergwelt-Baildon M, Ricke J, Heinemann V, Westphalen CB, Kunz WG. Patient eligibility for trials with imaging response assessment at the time of molecular tumor board presentation. Cancer Imaging 2024; 24:70. [PMID: 38849902 PMCID: PMC11157753 DOI: 10.1186/s40644-024-00708-5] [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: 12/01/2023] [Accepted: 05/11/2024] [Indexed: 06/09/2024] Open
Abstract
PURPOSE To assess the eligibility of patients with advanced or recurrent solid malignancies presented to a molecular tumor board (MTB) at a large precision oncology center for inclusion in trials with the endpoints objective response rate (ORR) or duration of response (DOR) based on Response Evaluation Criteria in Solid Tumors (RECIST version 1.1). METHODS Prospective patients with available imaging at the time of presentation in the MTB were included. Imaging data was reviewed for objectifiable measurable disease (MD) according to RECIST v1.1. Additionally, we evaluated the patients with MD for representativeness of the identified measurable lesion(s) in relation to the overall tumor burden. RESULTS 262 patients with different solid malignancies were included. 177 patients (68%) had MD and 85 (32%) had non-measurable disease (NMD) at the time point of MTB presentation in accordance with RECIST v1.1. MD was not representative of the overall tumor burden in eleven patients (6%). The main reasons for NMD were lesions with longest diameter shorter than 10 mm (22%) and non-measurable peritoneal carcinomatosis (18%). Colorectal cancer and malignant melanoma displayed the highest rates of MD (> 75%). In contrast, gastric cancer, head and neck malignancies, and ovarian carcinoma had the lowest rates of MD (< 55%). In case of MD, the measurable lesions were representative of the overall tumor burden in the vast majority of cases (94%). CONCLUSION Approximately one third of cancer patients with advanced solid malignancies are not eligible for treatment response assessment in trials with endpoints ORR or DOR at the time of MTB presentation. The rate of patients eligible for trials with imaging endpoints differs significantly based on the underlying malignancy and should be taken under consideration during the planning of new precision oncology trials.
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Affiliation(s)
- Nabeel Mansour
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Kathrin Heinrich
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
| | - Danmei Zhang
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK partner site Munich), Heidelberg, Germany
| | - Michael Winkelmann
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Maria Ingenerf
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Lukas Gold
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Konstantin Klambauer
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Martina Rudelius
- Institute of Pathology, Ludwig-Maximilians-Universität Munich, Munich, Germany
| | - Frederick Klauschen
- Institute of Pathology, Ludwig-Maximilians-Universität Munich, Munich, Germany
| | - Michael von Bergwelt-Baildon
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK partner site Munich), Heidelberg, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Volker Heinemann
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
| | - C Benedikt Westphalen
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
- Comprehensive Cancer Center München-LMU (CCCM LMU), LMU Munich, Munich, Germany.
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Shahzad M, Naci H, Esselen KM, Dottino JA, Wagner AK. Regulatory histories of recently withdrawn ovarian cancer treatment indications of 3 PARP inhibitors in the US and Europe: lessons for the accelerated approval pathway. J Pharm Policy Pract 2024; 17:2351003. [PMID: 38841118 PMCID: PMC11151792 DOI: 10.1080/20523211.2024.2351003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Background Withdrawals of drug indications may reveal potential inadequacies in the regulatory approval processes of new drugs. Understanding potential weaknesses of the regulatory approval process is paramount given the increasing use of expedited pathways. In this paper, we focus on three poly-ADP-ribose polymerase inhibitors (olaparib, rucaparib and niraparib) for the treatment of women with heavily pretreated, recurrent ovarian cancer, which were eventually withdrawn. Methods We use a comparative case study approach to evaluate the regulatory histories of these drug indications in the US and Europe. Results Two drug indications benefited from the FDA's accelerated approval pathway, which explicitly lowers the bar for evidence of efficacy at the time of approval. Following accelerated approval, manufacturers are mandated to conduct post-marketing studies to confirm clinical benefit. The FDA granted accelerated approval to olaparib and rucaparib based on data on surrogate endpoints and converted the approval to regular approval after the submission of additional data on surrogate endpoints from one of two required confirmatory trials, that is, without data on clinical benefit. Niraparib directly received regular approval based only on data on a surrogate endpoint. By contrast, the EMA granted conditional marketing authorisation to rucaparib and was quicker to restrict usage than the FDA. Conclusion The regulatory histories of these drug indications highlight the need to reform the accelerated approval pathway by ensuring that post-marketing requirements are followed, and that regular approval is only based on evidence of clinical benefit.
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Affiliation(s)
- Mahnum Shahzad
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | | | | | - Anita K. Wagner
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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Haskell-Mendoza AP, Reason EH, Gonzalez AT, Jackson JD, Sankey EW, Srinivasan ES, Herndon JE, Fecci PE, Calabrese E. Automated segmentation of ablated lesions using deep convolutional neural networks: A basis for response assessment following laser interstitial thermal therapy. Neuro Oncol 2024; 26:1152-1162. [PMID: 38170451 PMCID: PMC11145442 DOI: 10.1093/neuonc/noad261] [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: 09/20/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Laser interstitial thermal therapy (LITT) of intracranial tumors or radiation necrosis enables tissue diagnosis, cytoreduction, and rapid return to systemic therapies. Ablated tissue remains in situ, resulting in characteristic post-LITT edema associated with transient clinical worsening and complicating post-LITT response assessment. METHODS All patients receiving LITT at a single center for tumors or radiation necrosis from 2015 to 2023 with ≥9 months of MRI follow-up were included. An nnU-Net segmentation model was trained to automatically segment contrast-enhancing lesion volume (CeLV) of LITT-treated lesions on T1-weighted images. Response assessment was performed using volumetric measurements. RESULTS Three hundred and eighty four unique MRI exams of 61 LITT-treated lesions and 6 control cases of medically managed radiation necrosis were analyzed. Automated segmentation was accurate in 367/384 (95.6%) images. CeLV increased to a median of 68.3% (IQR 35.1-109.2%) from baseline at 1-3 months from LITT (P = 0.0012) and returned to baseline thereafter. Overall survival (OS) for LITT-treated patients was 39.1 (9.2-93.4) months. Lesion expansion above 40% from volumetric nadir or baseline was considered volumetric progression. Twenty-one of 56 (37.5%) patients experienced progression for a volumetric progression-free survival of 21.4 (6.0-93.4) months. Patients with volumetric progression had worse OS (17.3 vs 62.1 months, P = 0.0015). CONCLUSIONS Post-LITT CeLV expansion is quantifiable and resolves within 6 months of LITT. Development of response assessment criteria for LITT-treated lesions is feasible and should be considered for clinical trials. Automated lesion segmentation could speed the adoption of volumetric response criteria in clinical practice.
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Affiliation(s)
| | - Ellery H Reason
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Joshua D Jackson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Eric W Sankey
- Department of Neurosurgery, Piedmont Athens Regional Medical Center, Athens, Georgia, USA
| | - Ethan S Srinivasan
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - James E Herndon
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Peter E Fecci
- The Preston Robert Tisch Brain Tumor Center, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Evan Calabrese
- Department of Radiology, Division of Neuroradiology, Duke University Medical Center, Durham, North Carolina, USA
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Wallach JD, Yoon S, Doernberg H, Glick LR, Ciani O, Taylor RS, Mooghali M, Ramachandran R, Ross JS. Associations Between Surrogate Markers and Clinical Outcomes for Nononcologic Chronic Disease Treatments. JAMA 2024; 331:1646-1654. [PMID: 38648042 PMCID: PMC11036312 DOI: 10.1001/jama.2024.4175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/04/2024] [Indexed: 04/25/2024]
Abstract
Importance Surrogate markers are increasingly used as primary end points in clinical trials supporting drug approvals. Objective To systematically summarize the evidence from meta-analyses, systematic reviews and meta-analyses, and pooled analyses (hereafter, meta-analyses) of clinical trials examining the strength of association between treatment effects measured using surrogate markers and clinical outcomes in nononcologic chronic diseases. Data sources The Food and Drug Administration (FDA) Adult Surrogate Endpoint Table and MEDLINE from inception to March 19, 2023. Study Selection Three reviewers selected meta-analyses of clinical trials; meta-analyses of observational studies were excluded. Data Extraction and Synthesis Two reviewers extracted correlation coefficients, coefficients of determination, slopes, effect estimates, or results from meta-regression analyses between surrogate markers and clinical outcomes. Main Outcomes and Measures Correlation coefficient or coefficient of determination, when reported, was classified as high strength (r ≥ 0.85 or R2 ≥ 0.72); primary findings were otherwise summarized. Results Thirty-seven surrogate markers listed in FDA's table and used as primary end points in clinical trials across 32 unique nononcologic chronic diseases were included. For 22 (59%) surrogate markers (21 chronic diseases), no eligible meta-analysis was identified. For 15 (41%) surrogate markers (14 chronic diseases), at least 1 meta-analysis was identified, 54 in total (median per surrogate marker, 2.5; IQR, 1.3-6.0); among these, median number of trials and patients meta-analyzed was 18.5 (IQR, 12.0-43.0) and 90 056 (IQR, 20 109-170 014), respectively. The 54 meta-analyses reported 109 unique surrogate marker-clinical outcome pairs: 59 (54%) reported at least 1 r or R2, 10 (17%) of which reported at least 1 classified as high strength, whereas 50 (46%) reported slopes, effect estimates, or results of meta-regression analyses only, 26 (52%) of which reported at least 1 statistically significant result. Conclusions and Relevance Most surrogate markers used as primary end points in clinical trials to support FDA approval of drugs treating nononcologic chronic diseases lacked high-strength evidence of associations with clinical outcomes from published meta-analyses.
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Affiliation(s)
- Joshua D. Wallach
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, Connecticut
| | - Samuel Yoon
- Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Harry Doernberg
- Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Laura R. Glick
- Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Oriana Ciani
- Center for Research on Health and Social Care Management, SDA Bocconi School of Management, Milan, Italy
| | - Rod S. Taylor
- MRC/CSO Social and Public Health Sciences Unit, School of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
- Robertson Centre for Biostatistics, School of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Maryam Mooghali
- Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Reshma Ramachandran
- Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale National Clinicians Scholars Program, Yale School of Medicine, New Haven, Connecticut
| | - Joseph S. Ross
- Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale National Clinicians Scholars Program, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, Yale–New Haven Health System, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale–New Haven Health System, New Haven, Connecticut
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Mooghali M, Mitchell AP, Skydel JJ, Ross JS, Wallach JD, Ramachandran R. Characterization of accelerated approval status, trial endpoints and results, and recommendations in guidelines for oncology drug treatments from the National Comprehensive Cancer Network: cross sectional study. BMJ MEDICINE 2024; 3:e000802. [PMID: 38596814 PMCID: PMC11002412 DOI: 10.1136/bmjmed-2023-000802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/24/2024] [Indexed: 04/11/2024]
Abstract
Objectives To evaluate National Comprehensive Cancer Network (NCCN) guideline recommendations for oncology drug treatments that have been granted accelerated approval, and to determine whether recommendations are updated based on the results of confirmatory trials after approval and based on status updates from the US Food and Drug Administration (FDA). Design Cross sectional study. Setting US FDA and NCCN guidelines. Population Oncology therapeutic indications (ie, specific oncological conditions for which the drug is recommended) that have been granted accelerated approval in 2009-18. Main outcome measures NCCN guideline reporting of accelerated approval status and postapproval confirmatory trials, and guideline recommendation alignment with postapproval confirmatory trial results and FDA status updates. Results 39 oncology drug treatments were granted accelerated approval for 62 oncological indications. Although all indications were recommended in NCCN guidelines, accelerated approval status was reported for 10 (16%) indications. At least one postapproval confirmatory trial was identified for all 62 indications, 33 (53%) of which confirmed benefit; among these indications, NCCN guidelines maintained the previous recommendation or strengthened the category of evidence for 27 (82%). Postapproval confirmatory trials failed to confirm benefit for 12 (19%) indications; among these indications, NCCN guidelines removed the previous recommendation or weakened the category of evidence for five (42%). NCCN guidelines reflected the FDA's decision to convert 30 (83%) of 36 indications from accelerated to traditional approval, of which 20 (67%) had guideline updates before the FDA's conversion decision. NCCN guidelines reflected the FDA's decision to withdraw seven (58%) of 12 indications from the market, of which four (57%) had guidelines updates before the FDA's withdrawal decision. Conclusions NCCN guidelines always recommend drug treatments that have been granted accelerated approval for oncological indications, but do not provide information about their accelerated approval status, including surrogate endpoint use and status of postapproval confirmatory trials. NCCN guidelines consistently provide information on postapproval trial results confirming clinical benefit, but not on postapproval trials failing to confirm clinical benefit. NCCN guidelines more frequently update recommendation for indications converted to traditional approval than for those approvals that were withdrawn.
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Affiliation(s)
- Maryam Mooghali
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, CT, USA
| | - Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Joseph S Ross
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health; and Center for Outcomes Research and Evaluation, Yale New Haven Health System, New Haven, CT, USA
| | - Joshua D Wallach
- Department of Epidemiology, Rollins School of Public Health, Atlanta, GA, USA
| | - Reshma Ramachandran
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale Collaboration for Regulatory Rigor, Integrity, and Transparency, Yale School of Medicine, New Haven, CT, USA
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10
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Elbaz J, Haslam A, Prasad V. An empirical analysis of overall survival in drug approvals by the US FDA (2006-2023). Cancer Med 2024; 13:e7190. [PMID: 38659418 PMCID: PMC11043668 DOI: 10.1002/cam4.7190] [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: 12/27/2023] [Revised: 03/18/2024] [Accepted: 04/03/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND The US Food and Drug Administration (FDA) has expanded the use of surrogate markers in drugs approved for oncology/hematology indications. This has likely resulted in a greater number of approvals and possibly drugs coming to market faster, but it is unknown whether these drugs also improve overall survival (OS) for patients taking them. METHODS We sought to estimate the percentage of oncology drugs that have shown to improve OS in a cross-sectional analysis of US FDA oncology drug approvals (2006-2023). We searched for OS data in registration trials and the peer-reviewed literature. RESULTS We found 392 oncology drug approvals. Eighty-seven (22%) drug approvals were based on OS, 147 drug approvals were later tested for OS benefit (38% of all approvals and 48% of drugs approved on a surrogate), and 130 (33%) have yet to be tested for OS benefit. Of the 147 drug approvals later tested for OS, 109 (28% of all approvals and 74% of drugs later tested for OS) have yet to show OS benefit, whereas 38 (10% of all approvals and 26% of drugs later tested for OS benefit) were later shown to have OS benefit. In total, 125 out of 392 (32%) drugs approved for any indication have been shown to improve OS benefit at some point, and 267 (68%) have yet to show approval. CONCLUSION About 32% of all oncology drug approvals have evidence for an improvement in OS. Higher standards are needed in drug regulation to ensure that approved drugs are delivering better patient outcomes, specifically in regards to survival.
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Affiliation(s)
| | - Alyson Haslam
- University of California San FranciscoSan FranciscoCaliforniaUSA
| | - Vinay Prasad
- University of California San FranciscoSan FranciscoCaliforniaUSA
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11
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Thorlund K, Shephard C, Machado L, Bourgouin T, Hudson L, Ting E, Dempster W, Bick R. Adapting Health Technology Assessment agency standards for surrogate outcomes in early stage cancer trials: what needs to happen? Expert Rev Pharmacoecon Outcomes Res 2024; 24:331-342. [PMID: 38189086 DOI: 10.1080/14737167.2024.2302431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/03/2024] [Indexed: 01/09/2024]
Abstract
INTRODUCTION An avalanche of early stage cancer clinical trials is coming. The majority of these solely use surrogate outcomes that have not been validated against a target outcome of interest (e.g. overall survival). Current HTA guidance on surrogate outcome validation are not methodologically or practically conducive to this scenario. AREAS COVERED We provide a high-level overview of methods, approaches, and conceptual thinking for making better use of limited evidence within early stage cancer HTA submissions. We outline regulatory and HTA issues and emphasize how evidence transitions from one to another, what major gaps currently exist, and how these may be bridged. We summarize current methodologies and practices, their pros and cons. We outline how complementary measurements strengthen evaluations and address fallacies and biases of conventional statistical methods for surrogate outcomes validation. The value of real-world data to support some of the necessary validity components is discussed. Lastly, we address the importance of the patient voice for better understanding which surrogate outcomes may appropriately inform HTA. EXPERT OPINION Conventional surrogate outcome validation represents a fraught and sub-optimal framework for HTA purposes, particularly for early stage cancer. Tools for optimizing use of limited evidence exist. Education of stakeholders is highly needed.
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Affiliation(s)
- Kristian Thorlund
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Cal Shephard
- AstraZeneca Canada, Mississauga, Ontario, Canada
| | | | | | | | - Eon Ting
- AstraZeneca Canada, Mississauga, Ontario, Canada
| | | | - Robert Bick
- The CanCertainty Coalition, Toronto, Ontario, Canada
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12
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Michaeli DT, Michaeli T, Albers S, Michaeli JC. Clinical benefit, development, innovation, trials, epidemiology, and price for cancer drugs and indications with multiple special FDA designations. J Natl Cancer Inst 2024; 116:216-229. [PMID: 37824202 DOI: 10.1093/jnci/djad212] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/18/2023] [Accepted: 09/29/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND This study analyzes the development, US Food and Drug Administration (FDA) approval, benefits, innovation, trials, epidemiology, and price of cancer drugs with multiple special designations: orphan, fast track, accelerated approval, priority review, and breakthrough therapy. METHODS In total, 355 FDA-approved cancer drug indications with 841 special designations were identified (2012-2022). Trial, epidemiology, and price data were collected from FDA labels, the Global Burden of Disease study, and Medicare and Medicaid. The association between efficacy outcomes and indications' number of special designations were compared in meta-analyses. RESULTS Median development times were 7.3, 7.8, and 5.4 months (P = .027) for drugs with 0 to 1, 2 to 3, and 4 to 5 special designations, respectively. Multiple special designations were associated with higher biotechnological and clinical innovation. Median patient enrollment in trials were 615, 471, 398, 168, 104, and 120 (P < .001) for indications with 0 to 5 special designations. Drugs for rare diseases supported by open-label phase 1/2 trials of single-arm design were granted more special designations. Hazard ratios for overall survival (0.80 vs 0.73 vs 0.73 vs 0.69 vs 0.56 vs 0.52; P = .003) and progression-free survival (0.70 vs 0.61 vs 0.59 vs 0.44 vs 0.37 vs 0.67; P < .001) substantially declined while tumor response increased with more special designations. Mean monthly prices increased for drugs with 0 to 4 but not 5 special designations ($21 596 vs $14 753 vs $32 410 vs $41 240 vs $38 703 vs $19 184). CONCLUSIONS Multiple special designations are associated with faster clinical development and greater benefits for patients with unmet needs but also with nonrobust trial evidence and a tendency toward higher drug prices.
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Affiliation(s)
- Daniel Tobias Michaeli
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
- TUM School of Management, Technical University of Munich, Munich, Germany
| | - Thomas Michaeli
- Department of Personalized Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- German Cancer Research Center-Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany
- Division of Personalized Medical Oncology, German Cancer Research Center, Heidelberg, Germany
| | - Sebastian Albers
- Department of Orthopaedics and Sport Orthopaedics, School of Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Julia Caroline Michaeli
- Department of Obstetrics and Gynaecology, LMU University Hospital, LMU Munich, Munich, Germany
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13
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Shahnam A, Hitchen N, Nindra U, Manoharan S, Desai J, Tran B, Solomon B, Luen SJ, Hui R, Hopkins AM, Sorich MJ. Objective response rate and progression-free survival as surrogates for overall survival treatment effect: A meta-analysis across diverse tumour groups and contemporary therapies. Eur J Cancer 2024; 198:113503. [PMID: 38134560 DOI: 10.1016/j.ejca.2023.113503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Overall survival (OS) results from randomized control trials (RCT) provide the strongest evidence for efficacy of anti-cancer treatments but can take a considerable amount of time to mature. Progression free survival (PFS) and objective response rate (ORR) are used as an early surrogate of OS treatment effect however their validity remains unclear. Our study aims to comprehensively evaluate ORR and PFS as surrogates for OS treatment effect across tumor groups and treatment types. MATERIAL AND METHODS Phase 3 RCTs in solid malignancies that reported OS/PFS and ORR published between 1st of January 2010 and 30th of June 2022 were evaluated. The relationship of surrogate endpoints and OS treatment effect was assessed via weighted linear regression. The coefficient of determination (R2) quantified the fit of the regression model. RESULTS 675 phase 3 RCT comprising of 350 112 patients were analysed. ORR (R2 of 0.10) and PFS (R2 of 0.38) were poor surrogate markers of OS treatment effect. The strength of surrogacy differed within treatment and tumour groups. PFS had the highest R2 for chemotherapy (0.56) and lowest for targeted therapy (0.40). PFS had the highest level of surrogacy for melanoma (R2 = 0.72) and pancreatic cancer (R2 = 0.70) compared to other tumour groups. Importantly ORR and PFS were also poorly correlated to each other (R2 = 0.33). CONCLUSIONS ORR and PFS were poor trial-level surrogate markers of OS. The surrogacy performance of ORR and PFS differed by treatment and malignancy sub-type.
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Affiliation(s)
- Adel Shahnam
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia.
| | - Nadia Hitchen
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia
| | - Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Sathya Manoharan
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jayesh Desai
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Ben Tran
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Benjamin Solomon
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Stephen J Luen
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, VIC, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Rina Hui
- The Centre of Cancer Medicine, University Hong Kong, Hong Kong
| | - Ashley M Hopkins
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Michael J Sorich
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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14
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Zhu X, Chen Y. Bridging the new drug access gap between China and the United States and its related policies. Front Pharmacol 2024; 14:1296737. [PMID: 38259295 PMCID: PMC10800674 DOI: 10.3389/fphar.2023.1296737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/21/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction: The access gap for novel pharmaceuticals between China and the developed countries is a major public health issue in China. It is crucial to understand the determinants of this gap to ensure timely access to new drugs and enhance patient health. Methods: We included all new drugs approved by the US Food and Drug Administration (FDA) between 2012 and 2019, and collected their approval timings in China. Major factors of interest comprised orphan designation and expedited review pathways granted by the FDA, along with the proportion of Asian subjects in the pivotal trial supporting the FDA approval and whether the trial included study sites in China. The elapsed time from the FDA approval to the market authorization in China constituted the time-to-event outcome, and Cox proportional-hazards regression was used for multivariate analysis. Results: A total of 327 new drugs were approved by the FDA between 2012 and 2019, among which 41.3% were found to be authorized in China as of 1 November 2023. The median lag time for the mutually approved drugs was 3.5 years. The Cox model found that orphan drugs had lower likelihood of being approved in China (HR = 0.59, 95% CI 0.39-0.89; p = 0.011), while the FDA's Breakthrough-Therapy drugs (HR = 2.33, 95% CI 1.39-3.89; p = 0.001) and Fast-Track drugs (HR = 1.58, 95% CI 1.05-2.38; p = 0.028) had shorter lag times. In the pivotal trials that supported the FDA approvals, a higher proportion of Asian subjects was associated with faster drug entry into the Chinese market (HR = 1.02, 95% CI 1.01-1.03; p < 0.001), and the inclusion of study sites in China mainland was likewise conducive to reducing the drug lag (HR = 5.30, 95% CI 3.20-8.77; p < 0.001). After the trials with China-based sites supported the FDA approvals, 77.8% of the trials also supported the subsequent approvals in China. Discussion: China's involvement in global drug co-development can streamline clinical development, by reducing repeated trials solely in the Chinese population. This is primarily due to the openness of the Chinese drug agency towards overseas clinical data and is a positive sign that encourages global drug developers to include Chinese patients in their development plans as early as possible.
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Affiliation(s)
- Xingyue Zhu
- Department of Pharmacy Administration, School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou, China
| | - Yang Chen
- The Third People’s Hospital of Chengdu, Chengdu, Sichuan, China
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15
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Mazza GL. Can time to deterioration in patient-reported outcomes be a surrogate for overall survival? J Natl Cancer Inst 2023; 115:1442-1444. [PMID: 37659104 DOI: 10.1093/jnci/djad162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/29/2023] [Indexed: 09/04/2023] Open
Affiliation(s)
- Gina L Mazza
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA
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16
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Shahnam A, Nindra U, Desai J, Hui R, Buyse M, Hopkins AM, Sorich MJ. Time to deterioration of patient-reported outcomes as a surrogate of overall survival: a meta-analysis. J Natl Cancer Inst 2023; 115:1475-1482. [PMID: 37540222 DOI: 10.1093/jnci/djad152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/06/2023] [Accepted: 07/31/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Overall survival is the optimal marker of treatment efficacy in randomized clinical trials (RCTs) but can take considerable time to mature. Progression-free survival (PFS) has served as an early surrogate of overall survival but is imperfect. Time to deterioration in quality of life (QOL) measures could be a surrogate for overall survival. METHODS Phase 3 RCTs in solid malignancies that reported overall survival, PFS, and time to deterioration in QOL or physical function published between January 1, 2010, and June 30, 2022, were evaluated. Weighted regression analysis was used to assess the relationship between PFS, time to deterioration in QOL, and time to deterioration in physical function with overall survival. The coefficient of determination (R2) was used to quantify surrogacy. RESULTS In total, 138 phase 3 RCTs were included. Of these, 47 trials evaluated immune checkpoint inhibitors and 91 investigated non-immune checkpoint inhibitor agents. Time to deterioration in QOL (137 RCTs) and time to deterioration in physical function (75 RCTs) performed similarly to PFS as surrogates for overall survival (R2 = 0.18 vs R2 = 0.19 and R2 = 0.10 vs R2 = 0.09, respectively). For immune checkpoint inhibitor studies, time to deterioration in physical function had a higher association with overall survival than with PFS (R2 = 0.38 vs R2 = 0.19), and PFS and time to deterioration in physical function did not correlate with each other (R2 = 0). When time to deterioration in physical function and PFS are used together, the coefficient of determination increased (R2 = 0.57). CONCLUSIONS Time to deterioration in physical function appears to be an overall survival surrogate measure of particular importance for immune checkpoint inhibitor treatment efficacy. The combination of time to deterioration in physical function with PFS may enable better prediction of overall survival treatment benefit in RCTs of immune checkpoint inhibitors than either PFS or time to deterioration in physical function alone.
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Affiliation(s)
- Adel Shahnam
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Jayesh Desai
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Rina Hui
- Centre of Cancer Medicine, University of Hong Kong, Hong Kong
| | - Marc Buyse
- International Drug Development Institute, Brussels, Belgium
| | - Ashley M Hopkins
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Michael J Sorich
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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17
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Zhu X, Liu B. Review time of oncology drugs and its underlying factors: an exploration in China. Front Pharmacol 2023; 14:1151784. [PMID: 38027001 PMCID: PMC10654631 DOI: 10.3389/fphar.2023.1151784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction: How the launch delay of drugs and other factors of interest can influence the length of the review period by drug agencies is still unknown, and understanding this can help better strike the trade-off related to review speed. Methods: We included all new oncology drug applications submitted to China's National Medical Product Administration (NMPA) between 1 January 2018 and 31 December 2021, and ultimately succeeded in achieving marketing approval. For each drug, the length of the NMPA review process and other major characteristics were collected, including the registration class, approval class, priority review designation, and launch delay relative to the United States, as well as the number of patients enrolled, comparator, and primary endpoint of the pivotal trials supporting the approval. Linear regression model was employed to analyze the effects of factors of interest on the NMPA review time. Results: From 2018 to 2021, NMPA received 137 oncology applications that were ultimately approved. Half of the approvals [76 (55.5%)] were first licensed in the US, leaving a median launch delay of 2.71 years (IQR, 1.03-5.59) in China. In the pivotal studies, the median enrollment was 361 participants (IQR, 131-682), and the use of control groups [90 (65.7%)] and surrogate endpoints [101 (73.7%)] was prevalent. The median review time was 304 days (IQR, 253-376). Multivariate analysis for log-transformed review time showed that larger enrollment (> 92) was associated with a drop of 20.55% in review time (coefficient = -0.230; 95% CI, -0.404 to -0.055; p = 0.010); and a short delay (0 < delay ≤ 1.95 years) was associated with a drop of 17.63% in review time (coefficient = -0.194; 95% CI, -0.325 to -0.062; p = 0.004). Discussion: The short launch delay relative to the US was one important driver to the review speed of NMPA, which might suggest its latent regulatory reliance on the other global regulator during the post-marketing period when new information on the drug's clinical benefit was still lacking.
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Affiliation(s)
- Xingyue Zhu
- Department of Pharmacy Administration, School of Medicine and Health Management, Guizhou Medical University, Guiyang, China
| | - Bao Liu
- Department of Health Economics, School of Public Health, Fudan University, Shanghai, China
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18
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Cimino J, Braun C. Design a Clinical Research Protocol: Influence of Real-World Setting. Healthcare (Basel) 2023; 11:2254. [PMID: 37628452 PMCID: PMC10454664 DOI: 10.3390/healthcare11162254] [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: 06/26/2023] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
The design of a clinical research protocol to evaluate new therapies, devices, patient quality of life, and medical practices from scratch is probably one of the greatest challenges for the majority of novice researchers. This is especially true since a high-quality methodology is required to achieve success and effectiveness in academic and hospital research centers. This review discusses the concrete steps and necessary guidelines needed to create and structure a research protocol. Along with the methodology, some administrative challenges (ethics, regulatory and people-management barriers) and possible time-saving recommendations (standardized procedures, collaborative training, and centralization) are discussed.
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Affiliation(s)
- Jonathan Cimino
- Clinical Research Unit, Fondation Hôpitaux Robert Schuman, 44 Rue d’Anvers, 1130 Luxembourg, Luxembourg;
- Hôpitaux Robert Schuman, 9 Rue Edward Steichen, 2540 Luxembourg, Luxembourg
| | - Claude Braun
- Clinical Research Unit, Fondation Hôpitaux Robert Schuman, 44 Rue d’Anvers, 1130 Luxembourg, Luxembourg;
- Hôpitaux Robert Schuman, 9 Rue Edward Steichen, 2540 Luxembourg, Luxembourg
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19
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Grant MJ, Woodard GA, Goldberg SB. The Evolving Role for Systemic Therapy in Resectable Non-small Cell Lung Cancer. Hematol Oncol Clin North Am 2023; 37:513-531. [PMID: 37024389 DOI: 10.1016/j.hoc.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
During the last 2 decades, the understanding of non-small cell lung cancer (NSCLC) has evolved from a purely histologic classification system to a more complex model synthesizing clinical, histologic, and molecular data. Biomarker-driven targeted therapies have been approved by the United States Food and Drug Administration for patients with metastatic NSCLC harboring specific driver alterations in EGFR, HER2, KRAS, BRAF, MET, ALK, ROS1, RET, and NTRK. Novel immuno-oncology agents have contributed to improvements in NSCLC-related survival at the population-level. However, only in recent years has this nuanced understanding of NSCLC permeated into the systemic management of patients with resectable tumors.
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Affiliation(s)
- Michael J Grant
- Yale Cancer Center, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA; Department of Medicine (Medical Oncology), Yale School of Medicine, 330 Cedar Street, Rm BB 205, New Haven, CT 06520, USA.
| | - Gavitt A Woodard
- Yale Cancer Center, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA; Department of Surgery, Yale School of Medicine, PO Box 208028, New Haven, CT 06520, USA
| | - Sarah B Goldberg
- Yale Cancer Center, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA; Department of Medicine (Medical Oncology), Yale School of Medicine, 330 Cedar Street, Rm BB 205, New Haven, CT 06520, USA
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20
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Etekal T, Koehn K, Sborov DW, McClune B, Prasad V, Haslam A, Berger K, Booth C, Al Hadidi S, Abdallah AO, Goodman A, Mohyuddin GR. Time-to-event surrogate end-points in multiple myeloma randomised trials from 2005 to 2019: A surrogacy analysis. Br J Haematol 2023; 200:587-594. [PMID: 36495317 DOI: 10.1111/bjh.18568] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/25/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022]
Abstract
Use of surrogate end-points such as progression-free survival (PFS) and other time-to-event (TTE) end-points is common in multiple myeloma (MM) clinical trials. This systematic review characterises all published randomised controlled trials (RCTs) in MM using PFS or other TTE end-points between 2005 and 2019 and assesses strength of surrogacy of PFS for overall survival (OS). The association between OS hazard ratios (HRs) and PFS HRs was evaluated with linear regression, and the coefficient of determination with Pearson's correlation. We identified 88 RCTs of which 67 (76%) used PFS as the primary/co-primary end-point. One trial indicated whether progression was biochemical or clinical. Of the variance in OS, 39% was due to variance in PFS. Correlation between PFS and OS was weak (0.62, 95% confidence interval [CI] 0.38-0.78). In newly diagnosed MM, 43% of the variance in OS was due to changes in PFS. The correlation between PFS and OS was weak (0.65, 95% CI 0.30-0.84). In relapsed/refractory MM, 58% of the variance in OS was due to changes in PFS. Correlation between PFS and OS was medium (0.76, 95% CI 0.42-0.91). We demonstrate that PFS and progression characteristics are characterised poorly in MM trials and that PFS is a poor surrogate for OS in MM.
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Affiliation(s)
- Tommy Etekal
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Kelly Koehn
- Division of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Lawrence, Kansas, USA
| | - Douglas W Sborov
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
| | - Brian McClune
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
| | - Vinay Prasad
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California, USA
| | - Alyson Haslam
- Department of Epidemiology/Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Katherine Berger
- Patient Advocate, University of Hartford, West Hartford, Connecticut, USA
| | - Christopher Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Samer Al Hadidi
- Myeloma Institute, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Al-Ola Abdallah
- Division of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Lawrence, Kansas, USA
| | - Aaron Goodman
- Division of Blood and Marrow Transplantation, University of California San Diego, La Jolla, California, USA
| | - Ghulam Rehman Mohyuddin
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
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