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Patton T, Boehnke JR, Goyal R, Manca A, Marienfeld C, Martin NK, Nosyk B, Borquez A. Analyzing quality of life among people with opioid use disorder from the National Institute on Drug Abuse Data Share initiative: implications for decision making. Qual Life Res 2024; 33:2783-2796. [PMID: 39115618 PMCID: PMC11452457 DOI: 10.1007/s11136-024-03729-6] [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] [Accepted: 06/24/2024] [Indexed: 09/25/2024]
Abstract
PURPOSE We aimed to estimate health state utility values (HSUVs) for the key health states found in opioid use disorder (OUD) cost-effectiveness models in the published literature. METHODS Data obtained from six trials representing 1,777 individuals with OUD. We implemented mapping algorithms to harmonize data from different measures of quality of life (the SF-12 Versions 1 and 2 and the EQ-5D-3 L). We performed a regression analysis to quantify the relationship between HSUVs and the following variables: days of extra-medical opioid use in the past 30 days, injecting behaviors, treatment with medications for OUD, HIV status, and age. A secondary analysis explored the impact of opioid withdrawal symptoms. RESULTS There were statistically significant reductions in HSUVs associated with extra-medical opioid use (-0.002 (95% CI [-0.003,-0.0001]) to -0.003 (95% CI [-0.005,-0.002]) per additional day of heroin or other opiate use, respectively), drug injecting compared to not injecting (-0.043 (95% CI [-0.079,-0.006])), HIV-positive diagnosis compared to no diagnosis (-0.074 (95% CI [-0.143,-0.005])), and age (-0.001 per year (95% CI [-0.003,-0.0002])). Parameters associated with medications for OUD treatment were not statistically significant after controlling for extra-medical opioid use (0.0131 (95% CI [-0.0479,0.0769])), in line with prior studies. The secondary analysis revealed that withdrawal symptoms are a fundamental driver of HSUVs, with predictions of 0.817 (95% CI [0.768, 0.858]), 0.705 (95% CI [0.607, 0.786]), and 0.367 (95% CI [0.180, 0.575]) for moderate, severe, and worst level of symptoms, respectively. CONCLUSION We observed HSUVs for OUD that were higher than those from previous studies that had been conducted without input from people living with the condition.
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Affiliation(s)
- Thomas Patton
- Division of Infectious Diseases & Global Public Health, UC San Diego, 9500 Gilman Dr., La Jolla, San Diego, CA, 92093, USA.
| | - Jan R Boehnke
- School of Health Sciences, University of Dundee, Nethergate, Dundee, DD1 4HN, UK
| | - Ravi Goyal
- Division of Infectious Diseases & Global Public Health, UC San Diego, 9500 Gilman Dr., La Jolla, San Diego, CA, 92093, USA
| | - Andrea Manca
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK
| | - Carla Marienfeld
- UC San Diego Health Psychiatry, 8950 Villa La Jolla Drive, La Jolla, CA, 92037, USA
| | - Natasha K Martin
- Division of Infectious Diseases & Global Public Health, UC San Diego, 9500 Gilman Dr., La Jolla, San Diego, CA, 92093, USA
| | - Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada
| | - Annick Borquez
- Division of Infectious Diseases & Global Public Health, UC San Diego, 9500 Gilman Dr., La Jolla, San Diego, CA, 92093, USA
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2
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Cho D, Lord SJ, Ward R, IJzerman M, Mitchell A, Thomas DM, Cheyne S, Martin A, Morton RL, Simes J, Lee CK. Criteria for assessing evidence for biomarker-targeted therapies in rare cancers-an extrapolation framework. Ther Adv Med Oncol 2024; 16:17588359241273062. [PMID: 39229469 PMCID: PMC11369883 DOI: 10.1177/17588359241273062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 07/09/2024] [Indexed: 09/05/2024] Open
Abstract
Background Advances in targeted therapy development and tumor sequencing technology are reclassifying cancers into smaller biomarker-defined diseases. Randomized controlled trials (RCTs) are often impractical in rare diseases, leading to calls for single-arm studies to be sufficient to inform clinical practice based on a strong biological rationale. However, without RCTs, favorable outcomes are often attributed to therapy but may be due to a more indolent disease course or other biases. When the clinical benefit of targeted therapy in a common cancer is established in RCTs, this benefit may extend to rarer cancers sharing the same biomarker. However, careful consideration of the appropriateness of extending the existing trial evidence beyond specific cancer types is required. A framework for extrapolating evidence for biomarker-targeted therapies to rare cancers is needed to support transparent decision-making. Objectives To construct a framework outlining the breadth of criteria essential for extrapolating evidence for a biomarker-targeted therapy generated from RCTs in common cancers to different rare cancers sharing the same biomarker. Design A series of questions articulating essential criteria for extrapolation. Methods The framework was developed from the core topics for extrapolation identified from a previous scoping review of methodological guidance. Principles for extrapolation outlined in guidance documents from the European Medicines Agency, the US Food and Drug Administration, and Australia's Medical Services Advisory Committee were incorporated. Results We propose a framework for assessing key assumptions of similarity of the disease and treatment outcomes between the common and rare cancer for five essential components: prognosis of the biomarker-defined cancer, biomarker test analytical validity, biomarker actionability, treatment efficacy, and safety. Knowledge gaps identified can be used to prioritize future studies. Conclusion This framework will allow systematic assessment, standardize regulatory, reimbursement and clinical decision-making, and facilitate transparent discussions between key stakeholders in drug assessment for rare biomarker-defined cancers.
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Affiliation(s)
- Doah Cho
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Australia
- Faculty of Medicine and Health, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Locked Bag 77, Camperdown, NSW 1450, Australia
| | - Sarah J. Lord
- Faculty of Medicine and Health, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Robyn Ward
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia
| | - Maarten IJzerman
- Faculty of Medicine, Dentistry and Health Sciences, Centre for Health Policy, University of Melbourne Centre for Cancer Research, Parkville, VIC, Australia
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Andrew Mitchell
- Department of Health Economics Wellbeing and Society, The Australian National University, Canberra, ACT, Australia
| | - David M. Thomas
- Centre for Molecular Oncology, University of New South Wales, Sydney, NSW, Australia
| | - Saskia Cheyne
- Faculty of Medicine and Health, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Andrew Martin
- Faculty of Medicine and Health, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
- Centre for Clinical Research, University of Queensland, St Lucia, QLD, Australia
| | - Rachael L. Morton
- Faculty of Medicine and Health, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - John Simes
- Faculty of Medicine and Health, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Chee Khoon Lee
- Faculty of Medicine and Health, National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
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Simon F, Ligtvoet R, Robrecht S, Cramer P, Kutsch N, Fürstenau M, Goede V, von Tresckow J, Langerbeins P, Fink AM, Huber H, Tausch E, Schneider C, Wendtner CM, Ritgen M, Dreyling M, Müller L, Jacobasch L, Heinz WJ, Vehling-Kaiser U, Sivcheva L, Böttcher S, Dreger P, Illmer T, Gregor M, Staber PB, Stilgenbauer S, Niemann CU, Kater AP, Fischer K, Eichhorst B, Hallek M, Al-Sawaf O. End Point Surrogacy in First-Line Chronic Lymphocytic Leukemia. J Clin Oncol 2024:JCO2401192. [PMID: 39213466 DOI: 10.1200/jco.24.01192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/30/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024] Open
Abstract
PURPOSE Surrogate end points are commonly used to estimate treatment efficacy in clinical studies of chronic lymphocytic leukemia (CLL). This patient- and trial-level analysis describes the correlation between progression-free survival (PFS) and minimal residual disease (MRD) with overall survival (OS) in first-line trials for CLL. PATIENTS AND METHODS First, patient-level correlation was confirmed using source data from 12 frontline German CLL Study Group (GCLLSG)-trials. Additionally, a joint-frailty copula model was fitted to validate correlation in the setting of targeted therapies (TT). Second, a meta-analysis of first-line phase III trials in CLL from 2008 to 2024 was performed. Treatment effect correlation was quantified from seven GCLLSG and nine published trials, using hazard ratios (HRs) for time-to-event and odds ratios for binary end points. RESULTS The GCLLSG analysis set comprised 4,237 patients. Patient-level correlation for PFS/OS was strong with Spearman Rho >0.9. The joint-frailty copula indicated a weak correlation for chemotherapy/chemoimmunotherapy (C/CIT) with a tau of 0.52 (95% CI, 0.49 to 0.55) while the correlation was strong for TT (tau, 0.91 [95% CI, 0.89 to 0.93). The meta-analysis set contained a total of 8,065 patients including 5,198 (64%) patients treated with C/CIT and 2,867 (36%) treated with TT. Treatment-effect correlation of the HRs for PFS and OS was R = 0.75 (95% CI, 0.74 to 0.76, R2 = 0.56) while correlation of end-of-treatment MRD with PFS and OS was R = 0.88 (95% CI, -0.87 to 0.89; R2 = 0.78) and 0.71 (95% CI, 0.69 to 0.73; R2 = 0.5), respectively. CONCLUSION Patient-level correlation was confirmed in the setting of TTs while treatment-effect correlation between PFS and OS remains uncertain. MRD response status showed a high treatment-effect correlation with PFS but not OS, with the caveat of a limited number of randomized trials with available MRD data.
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Affiliation(s)
- Florian Simon
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Rudy Ligtvoet
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Sandra Robrecht
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Paula Cramer
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Nadine Kutsch
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Moritz Fürstenau
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Valentin Goede
- St Marienhospital Cologne, Oncogeriatric Unit, Department of Geriatric Medicine, Cologne, Germany
| | - Julia von Tresckow
- Clinic for Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Petra Langerbeins
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Anna-Maria Fink
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Henriette Huber
- Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
- Department of Internal Medicine III, Division of CLL, Ulm University, Ulm, Germany
| | - Eugen Tausch
- Department of Internal Medicine III, Division of CLL, Ulm University, Ulm, Germany
| | - Christof Schneider
- Department of Internal Medicine III, Division of CLL, Ulm University, Ulm, Germany
| | - Clemens M Wendtner
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Matthias Ritgen
- Department II of Internal Medicine, University of Schleswig-Holstein, Kiel, Germany
| | - Martin Dreyling
- Department of Medicine III, Ludwig-Maximilians-University Hospital, Munich, Germany
| | - Lothar Müller
- Study Centrum Unter Ems, Practice for Oncology and Hematology, Leer, Germany
| | | | - Werner J Heinz
- Caritas-Krankenhaus Bad Mergentheim, Medizinische Klinik II, Bad Mergentheim, Germany
| | | | - Liliya Sivcheva
- First Department of Internal Medicine, Multiprofile Hospital for Active Treatment - HristoBotev, Vratsa, Bulgaria
| | - Sebastian Böttcher
- Department of Medicine III Hematology, Oncology and Palliative Care, University Hospital, Rostock, Germany
| | - Peter Dreger
- Department of Hematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Illmer
- Praxis of Haematology and Oncology, Dresden, Germany
| | - Michael Gregor
- Division of Hematology, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Philipp B Staber
- Department of Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Stephan Stilgenbauer
- Department of Internal Medicine III, Division of CLL, Ulm University, Ulm, Germany
| | - Carsten U Niemann
- Department of Hematology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Arnon P Kater
- Academic Medical Department of Hematology, Cancer Center, Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Kirsten Fischer
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Barbara Eichhorst
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Michael Hallek
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Othman Al-Sawaf
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; German CLL Study Group, University of Cologne, Cologne, Germany
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4
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Ollendorf D, Henshall C, Phillips M, Synnott P, Sansom L, Tunis S. Putting meat on the bone: how to fast-track innovative medicines to those who need them and generate data to justify continued use. HEALTH AFFAIRS SCHOLAR 2024; 2:qxae095. [PMID: 39161949 PMCID: PMC11332269 DOI: 10.1093/haschl/qxae095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/24/2024] [Accepted: 08/07/2024] [Indexed: 08/21/2024]
Abstract
Regulatory agencies worldwide have taken significant steps to expedite approval and market authorization of medicines based on their potential to address areas of significant unmet medical need and severe disease burden. However, initial approval of such medicines is often accompanied by limited evidence of benefit, posing a conundrum for payers and health systems who may desire greater certainty of their value. This paper describes a system of "accelerated access" to manage these tensions and coordinate activities across stakeholders, based on discussions held at a multi-stakeholder convening in June 2023. We focus on 6 core, near-term actions that can be taken to improve the current system: clarifying criteria for expedited regulatory approval, enhancing stakeholder coordination, creating expedited pathways in payer and health technology assessment settings, developing joint regulatory/payer/health technology assessment guidance on study design and data needs, linking pricing policy to data uncertainty, and improving patient and public understanding of the processes involved as well as the risks and benefits of the relevant medicines. Many of these actions will require additional resources and personnel, and some will necessitate unprecedented levels of coordination. Nevertheless, each action is designed to work with minimal adjustments to the current system rather than demanding an entirely new approach.
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Affiliation(s)
- Daniel Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA 02111, United States
- Institute for Clinical and Economic Review, Boston, MA 02108, United States
| | | | - Marie Phillips
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA 02111, United States
| | - Patricia Synnott
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA 02111, United States
| | - Lloyd Sansom
- University of South Australia, Kent Town, South Australia 5071, Australia
| | - Sean Tunis
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA 02111, United States
- Rubix Health, LLC, Baltimore, MD 21210, United States
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5
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Zhu YY, Wang WX, Cheuk SK, Feng GR, Li XG, Peng JY, Liu Y, Yu SR, Tang JL, Chow SC, Li JB. A landscape of methodology and implementation of adaptive designs in cancer clinical trials. Crit Rev Oncol Hematol 2024; 200:104402. [PMID: 38848881 DOI: 10.1016/j.critrevonc.2024.104402] [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: 01/23/2024] [Revised: 05/06/2024] [Accepted: 05/23/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND The use of adaptive designs in cancer trials has considerably increased worldwide in recent years, along with the release of various guidelines for their application. This systematic review aims to comprehensively summarize the key methodological and executive features of adaptive designs in cancer clinical trials. METHODS A comprehensive search from PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted to screen eligible clinical trials that employed adaptive designs and were conducted in cancer patients. The methodological and executive characteristics of adaptive designs were the main measurements extracted. Descriptive analyses, primarily consisting of frequency and percentage, were employed to analyzed and reported the data. RESULTS A total of 180 cancer clinical trials with adaptive designs were identified. The first three most common type of adaptive design was the group sequential design (n=114, 63.3 %), adaptive dose-finding design (n=22, 12.2 %), and adaptive platform design (n=16, 8.9 %). The results showed that 4.4 % (n=8) of trials conducted post hoc modifications, and around 29.4 % (n=53) did not provide the methods for controlling type I errors. Among phase II or above trials, 79.9 % (112/140) applied the surrogate endpoint as the primary outcome in these trials. Importantly, 27.2 % (49/180) of trials did not report clear information on the independent data monitoring committee (iDMC), and 13.3 % (n=24) without clear information on interim analyses. Interim analyses suggested 34.4 % (62/180) of trials being stopped for futility, 10.6 % (n=19) for efficacy, and 2.2 % (n=4) for safety concerns in the early stage. CONCLUSIONS This study emphasizes adaptive designs in cancer trials face significant challenges in their design or strict implementation according to protocol, which might significantly compromise the validity and integrity of trials. It is thus important for researchers, sponsors, and policymakers to actively oversee and guide their application.
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Affiliation(s)
- Ying-Ying Zhu
- Clinical Research Design Division, Clinical Research Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, PR China
| | - Wen-Xuan Wang
- School of Public Health, Sun Yat-sen University, Guangzhou, PR China; Department of Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou, PR China
| | - Shui-Kit Cheuk
- School of Public Health, Sun Yat-sen University, Guangzhou, PR China; Department of Epidemiology and Health Statistics, School of Public Health, Peking University, Beijing, PR China
| | - Guan-Rui Feng
- Department of Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou, PR China
| | - Xing-Ge Li
- School of Public Health, Sun Yat-sen University, Guangzhou, PR China
| | - Jia-Ying Peng
- School of Public Health, Sun Yat-sen University, Guangzhou, PR China
| | - Ying Liu
- School of Public Health, Sun Yat-sen University, Guangzhou, PR China
| | - Shao-Rui Yu
- Department of Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou, PR China
| | - Jin-Ling Tang
- Shenzhen Institute of Advanced Technology of the Chinese Academy of Sciences, Shenzhen, PR China
| | - Shein-Chung Chow
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA.
| | - Ji-Bin Li
- Department of Clinical Research, Sun Yat-sen University Cancer Center, Guangzhou, PR China; State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, PR China.
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6
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Baldwin D, Carmichael J, Cook G, Navani N, Peach J, Slater R, Wheatstone P, Wilkins J, Allen-Delingpole N, Kerr CEP, Siddiqui K. UK Stakeholder Perspectives on Surrogate Endpoints in Cancer, and the Potential for UK Real-World Datasets to Validate Their Use in Decision-Making. Cancer Manag Res 2024; 16:791-810. [PMID: 39044745 PMCID: PMC11264281 DOI: 10.2147/cmar.s441359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 06/24/2024] [Indexed: 07/25/2024] Open
Abstract
Duration of overall survival in patients with cancer has lengthened due to earlier detection and improved treatments. However, these improvements have created challenges in assessing the impact of newer treatments, particularly those used early in the treatment pathway. As overall survival remains most decision-makers' preferred primary endpoint, therapeutic innovations may take a long time to be introduced into clinical practice. Moreover, it is difficult to extrapolate findings to heterogeneous populations and address the concerns of patients wishing to evaluate everyday quality and extension of life. There is growing interest in the use of surrogate or interim endpoints to demonstrate robust treatment effects sooner than is possible with measurement of overall survival. It is hoped that they could speed up patients' access to new drugs, combinations, and sequences, and inform treatment decision-making. However, while surrogate endpoints have been used by regulators for drug approvals, this has occurred on a case-by-case basis. Evidence standards are yet to be clearly defined for acceptability in health technology appraisals or to shape clinical practice. This article considers the relevance of the use of surrogate endpoints in cancer in the UK context, and explores whether collection and analysis of real-world UK data and evidence might contribute to validation.
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Affiliation(s)
- David Baldwin
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Jonathan Carmichael
- Department of Oncology, The National Institute for Health Research Leeds In Vitro Diagnostics Co-Operative (NIHR Leeds MIC), Leeds, UK
| | - Gordon Cook
- Cancer Research UK Trials Unit, LICTR, University of Leeds & NIHR (Leeds) IVD MIC, Leeds, UK
| | - Neal Navani
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
- Department of Thoracic Medicine, University College London Hospital, London, UK
| | - James Peach
- Human Centric Drug Discovery, Wood Centre for Innovation, Oxford, UK
| | | | - Pete Wheatstone
- Patient and Public Involvement and Engagement Group, DATA-CAN, London, UK
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7
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Manyara AM, Davies P, Stewart D, Weir CJ, Young AE, Blazeby J, Butcher NJ, Bujkiewicz S, Chan AW, Dawoud D, Offringa M, Ouwens M, Hróbjartsson A, Amstutz A, Bertolaccini L, Bruno VD, Devane D, Faria CDCM, Gilbert PB, Harris R, Lassere M, Marinelli L, Markham S, Powers JH, Rezaei Y, Richert L, Schwendicke F, Tereshchenko LG, Thoma A, Turan A, Worrall A, Christensen R, Collins GS, Ross JS, Taylor RS, Ciani O. Reporting of surrogate endpoints in randomised controlled trial reports (CONSORT-Surrogate): extension checklist with explanation and elaboration. BMJ 2024; 386:e078524. [PMID: 38981645 PMCID: PMC11231881 DOI: 10.1136/bmj-2023-078524] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 07/11/2024]
Affiliation(s)
- Anthony Muchai Manyara
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Global Health and Ageing Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Philippa Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Amber E Young
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Blazeby
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Nancy J Butcher
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Sylwia Bujkiewicz
- Biostatistics Research Group, Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - An-Wen Chan
- Women's College Research Institute, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dalia Dawoud
- Science, Evidence, and Analytics Directorate, Science Policy and Research Programme, National Institute for Health and Care Excellence, London, UK
- Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network, Odense University hospital, Odense, Denmark
| | - Alain Amstutz
- CLEAR Methods Centre, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Luca Bertolaccini
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Vito Domenico Bruno
- IRCCS Galeazzi-Sant'Ambrogio Hospital, Department of Minimally Invasive Cardiac Surgery, Milan, Italy
| | - Declan Devane
- University of Galway, Galway, Ireland
- Health Research Board-Trials Methodology Research Network, University of Galway, Galway, Ireland
| | - Christina D C M Faria
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Marissa Lassere
- St George Hospital and School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - Lucio Marinelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Sarah Markham
- Patient author, UK
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - John H Powers
- George Washington University School of Medicine, Washington, DC, USA
| | - Yousef Rezaei
- Heart Valve Disease Research Centre, Rajaie Cardiovascular Medical and Research Centre, Iran University of Medical Sciences, Tehran, Iran
- Ardabil University of Medical Sciences, Ardabil, Iran
- Behyan Clinic, Pardis New Town, Tehran, Iran
| | - Laura Richert
- University of Bordeaux, Centre d'Investigation Clinique-Epidémiologie Clinique 1401, Research in Clinical Epidemiology and in Public Health and European Clinical Trials Platform & Development/French Clinical Research Infrastructure Network, Institut National de la Santé et de la Recherche Médicale/Institut Bergonié/Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | | | - Larisa G Tereshchenko
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Alparslan Turan
- Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, OH, USA
| | | | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen and Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Gary S Collins
- UK EQUATOR Centre, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joseph S Ross
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Robertson Centre for Biostatistics, School of Health and Well Being, University of Glasgow, Glasgow, UK
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management, Bocconi University, Milan 20136, Italy
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8
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Manyara AM, Davies P, Stewart D, Weir CJ, Young AE, Blazeby J, Butcher NJ, Bujkiewicz S, Chan AW, Dawoud D, Offringa M, Ouwens M, Hróbjartsson A, Amstutz A, Bertolaccini L, Bruno VD, Devane D, Faria CDCM, Gilbert PB, Harris R, Lassere M, Marinelli L, Markham S, Powers JH, Rezaei Y, Richert L, Schwendicke F, Tereshchenko LG, Thoma A, Turan A, Worrall A, Christensen R, Collins GS, Ross JS, Taylor RS, Ciani O. Reporting of surrogate endpoints in randomised controlled trial protocols (SPIRIT-Surrogate): extension checklist with explanation and elaboration. BMJ 2024; 386:e078525. [PMID: 38981624 PMCID: PMC11231880 DOI: 10.1136/bmj-2023-078525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 07/11/2024]
Affiliation(s)
- Anthony Muchai Manyara
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Global Health and Ageing Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Philippa Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Amber E Young
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Blazeby
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Nancy J Butcher
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Sylwia Bujkiewicz
- Biostatistics Research Group, Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - An-Wen Chan
- Women's College Research Institute, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dalia Dawoud
- Science, Evidence, and Analytics Directorate, Science Policy and Research Programme, National Institute for Health and Care Excellence, London, UK
- Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network, Odense University hospital, Odense, Denmark
| | - Alain Amstutz
- CLEAR Methods Centre, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Luca Bertolaccini
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Vito Domenico Bruno
- IRCCS Galeazzi-Sant'Ambrogio Hospital, Department of Minimally Invasive Cardiac Surgery, Milan, Italy
| | - Declan Devane
- University of Galway, Galway, Ireland
- Health Research Board-Trials Methodology Research Network, University of Galway, Galway, Ireland
| | - Christina D C M Faria
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Marissa Lassere
- St George Hospital and School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - Lucio Marinelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Sarah Markham
- Patient author, UK
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - John H Powers
- George Washington University School of Medicine, Washington, DC, USA
| | - Yousef Rezaei
- Heart Valve Disease Research Centre, Rajaie Cardiovascular Medical and Research Centre, Iran University of Medical Sciences, Tehran, Iran
- Ardabil University of Medical Sciences, Ardabil, Iran
- Behyan Clinic, Pardis New Town, Tehran, Iran
| | - Laura Richert
- University of Bordeaux, Centre d'Investigation Clinique-Epidémiologie Clinique 1401, Research in Clinical Epidemiology and in Public Health and European Clinical Trials Platform & Development/French Clinical Research Infrastructure Network, Institut National de la Santé et de la Recherche Médicale/Institut Bergonié/Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | | | - Larisa G Tereshchenko
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Alparslan Turan
- Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, OH, USA
| | | | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen and Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Gary S Collins
- UK EQUATOR Centre, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joseph S Ross
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Robertson Centre for Biostatistics, School of Health and Well Being, University of Glasgow, Glasgow, UK
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management, Bocconi University, Milan 20136, Italy
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9
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Franklin M, Hinde S, Hunter RM, Richardson G, Whittaker W. Is Economic Evaluation and Care Commissioning Focused on Achieving the Same Outcomes? Resource-Allocation Considerations and Challenges Using England as a Case Study. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:435-445. [PMID: 38467989 PMCID: PMC11178631 DOI: 10.1007/s40258-024-00875-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 03/13/2024]
Abstract
Commissioning describes the process of contracting appropriate care services to address pre-identified needs through pre-agreed payment structures. Outcomes-based commissioning (i.e., paying services for pre-agreed outcomes) shares a common goal with economic evaluation: achieving value for money for relevant outcomes (e.g., health) achieved from a finite budget. We describe considerations and challenges as to the practical role of relevant outcomes for evaluation and commissioning, seeking to bridge a gap between economic evaluation evidence and care commissioning. We describe conceptual (e.g., what are 'relevant' outcomes) alongside practical considerations (e.g., quantifying and using relevant endpoint or surrogate outcomes) and pertinent issues when linking outcomes to commissioning-based payment mechanisms, using England as a case study. Economic evaluation often focuses on a single endpoint health-focused maximand, e.g., quality-adjusted life-years (QALYs), whereas commissioning often focuses on activity-based surrogate outcomes (e.g., health monitoring), as easier-to-measure key performance indicators that are more acceptable (e.g., by clinicians) and amenable to being linked with payment structures. However, payments linked to endpoint and/or surrogate outcomes can lead to market inefficiencies; for example, when surrogates do not have the intended causal effect on endpoint outcomes or when service activity focuses on only people who can achieve prespecified payment-linked outcomes. Accounting for and explaining direct links from commissioners' payment structures to surrogate and then endpoint economic outcomes is a vital step to bridging a gap between economic evaluation approaches and commissioning. Decision-analytic models could aid this but they must be designed to account for relevant surrogate and endpoint outcomes, the payments assigned to such outcomes, and their interaction with the system commissioners purport to influence.
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Affiliation(s)
- Matthew Franklin
- Sheffield Centre for Health and Related Research (SCHARR), Division of Population Health, School of Medicine and Population Health, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Sebastian Hinde
- Centre for Health Economics (CHE), University of York, Heslington, York, YO10 5DD, UK
| | - Rachael Maree Hunter
- Research Department of Primary Care and Population Health, Royal Free Medical School, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Gerry Richardson
- Centre for Health Economics (CHE), University of York, Heslington, York, YO10 5DD, UK
| | - William Whittaker
- Division of Population Health, Health Services Research & Primary Care, Alliance Manchester Business School, Institute for Health Policy and Organisation, Oxford Road, Manchester, M13 9PL, UK
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10
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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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11
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Untch M, Pérol D, Mayer EL, Cortes J, Nusch A, Cameron D, Barrios C, Delea T, Danyliv A, Mishra N, Gupta R, Pathak P, Fasching PA. Disease-free survival as a surrogate for overall survival in HR+/HER2- early breast cancer: A correlation analysis. Eur J Cancer 2024; 202:113977. [PMID: 38460476 DOI: 10.1016/j.ejca.2024.113977] [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: 11/10/2023] [Revised: 02/19/2024] [Accepted: 02/21/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Overall survival (OS) is a universally accepted measure of clinical benefit; however, prolonged follow-up is needed to observe sufficient events. Disease-free survival (DFS) has been widely adopted as a primary endpoint for early breast cancer (EBC) trials, as follow-up is comparatively shorter. Here, we present an analysis evaluating DFS as a surrogate for OS for adjuvant treatment of hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) EBC. METHODS A systematic literature review which included randomized controlled trials (RCTs) with ≥80% of adult patients with HR+/HER2- EBC was conducted. The RCTs evaluated various systemic therapeutic categories; key inclusion criteria included reporting of DFS and OS hazard ratios (HRs) and mature OS data. Spearman rank correlation and weighted linear regression analyses evaluated DFS and OS HR correlation. A scenario analysis tested base-case analysis robustness, and a parallel analysis using patient-level data was conducted. RESULTS The base case (N = 14 RCTs) showed an unweighted Spearman coefficient of 0.81 between OS and DFS (weighted: 0.81), with 84% of the variability in OS explained by DFS differences (R2 from weighted regression). The surrogate threshold effect (Burzykowski T, Buyse M. Pharm Stat. 2006;5:173-186) was 0.82 for DFS/OS HR. Scenario analysis (n = 9 RCTs), which excluded chemotherapy trials, and patient-level analysis using FACE trial data were consistent with the base-case analysis. CONCLUSIONS These analyses support DFS as a reliable surrogate endpoint for OS in adjuvant HR+/HER2- EBC trials. Using DFS as a surrogate measure will permit timelier access to novel treatments for patients with HR+/HER2- EBC.
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Affiliation(s)
- Michael Untch
- Interdisciplinary Breast Cancer Center, Helios Klinikum Berlin-Buch, Berlin, Germany.
| | | | - Erica L Mayer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Javier Cortes
- International Breast Cancer Center (IBCC), Grupo Quiron, Madrid & Barcelona, Spain
| | - Arnd Nusch
- Practice for Hematology and Internal Oncology, Velbert, Germany
| | - David Cameron
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, UK
| | - Carlos Barrios
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | | | | | | | - Rhea Gupta
- Novartis Healthcare Pvt Ltd, Hyderabad, India
| | - Purnima Pathak
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Peter A Fasching
- University Hospital Erlangen, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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12
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Dimopoulos M, Sonneveld P, Manier S, Lam A, Roccia T, Schecter JM, Cost P, Pacaud L, Poirier A, Tremblay G, Lan T, Valluri S, Kumar S. Progression-free survival as a surrogate endpoint for overall survival in patients with relapsed or refractory multiple myeloma. BMC Cancer 2024; 24:541. [PMID: 38684948 PMCID: PMC11057089 DOI: 10.1186/s12885-024-12263-0] [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: 12/15/2023] [Accepted: 04/15/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES The goal of the research was to assess the quantitative relationship between median progression-free survival (PFS) and median overall survival (OS) specifically among patients with relapsed/refractory multiple myeloma (RRMM) based on published randomized controlled trials (RCTs). METHODS Two bibliographic databases (PubMed and Embase, 1970-2017) were systematically searched for RCTs in RRMM that reported OS and PFS, followed by an updated search of studies published between 2010 and 2022 in 3 databases (Embase, MEDLINE, and EBM Reviews, 2010-2022). The association between median PFS and median OS was assessed using the nonparametric Spearman rank and parametric Pearson correlation coefficients. Subsequently, the quantitative relationship between PFS and OS was assessed using weighted least-squares regression adjusted for covariates including age, sex, and publication year. Study arms were weighted by the number of patients in each arm. RESULTS A total of 31 RCTs (56 treatment arms, 10,450 patients with RRMM) were included in the analysis. The average median PFS and median OS were 7.1 months (SD 5.5) and 28.1 months (SD 11.8), respectively. The Spearman and Pearson correlation coefficients between median PFS and median OS were 0.80 (P < 0.0001) and 0.79 (P < 0.0001), respectively. In individual treatment arms of RRMM trials, each 1-month increase in median PFS was associated with a 1.72-month (95% CI 1.26-2.17) increase in median OS. CONCLUSION Analysis of the relationship between PFS and OS incorporating more recent studies in RRMM further substantiates the use of PFS to predict OS in RRMM.
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Affiliation(s)
- Meletios Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | | | | | | | | | - Abbey Poirier
- Cytel Inc. Health Economics & Outcomes Research, Waltham, MA, USA
| | - Gabriel Tremblay
- Cytel Inc. Health Economics & Outcomes Research, Waltham, MA, USA
| | - Tommy Lan
- Cytel Inc. Health Economics & Outcomes Research, Waltham, MA, USA
| | | | - Shaji Kumar
- Department of Hematology, Mayo Clinic, Rochester, MN, USA.
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13
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Suzuki H, Aono N, Zhang Y, Yuri K, Bassole Epse Brou MAM, Takemura S, Higashiyama A, Tabuchi T, Fujiyoshi A. Comparison of Publications on Heated Tobacco Products With Conventional Cigarettes and Implied Desirability of the Products According to Tobacco Industry Affiliation: A Systematic Review. Nicotine Tob Res 2024; 26:520-526. [PMID: 37950902 DOI: 10.1093/ntr/ntad205] [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: 02/28/2023] [Revised: 08/01/2023] [Accepted: 10/01/2023] [Indexed: 11/13/2023]
Abstract
INTRODUCTION Heated tobacco products (HTPs) have been advertised as "reduced-harm" tobacco products compared to conventional cigarettes (CC); however, no direct evidence supporting HTPs being desirable for human health exists. A previous systematic review reported that evidence on HTPs published in 2017 or earlier was primarily drawn from industry-related papers. We aimed to investigate whether tobacco industry-affiliated studies are more likely to conclude that HTPs are more desirable than CC. METHODS PubMed and Ichushi-Web were searched up to March 15, 2022, for studies on HTPs published in 2017 or after. We selected studies that assessed any measures of HTPs and CC, including secondary analyses using gray literature in English or Japanese. We excluded review articles except for a meta-analysis that met the aforementioned criteria. Data on the authors' affiliations, grant, conflict of interest, category of research subjects, and interpretation were extracted. Research members in two groups independently assessed the papers; discrepancies were solved by discussion between the groups. RESULTS Overall, 134 studies met the criteria. Eighty-seven (64.9%) of them were affiliated with the tobacco industry. Of the 134 studies, 56.3% (49/87) of the industry-affiliated studies versus 19.1% (9/47) of nonindustry-affiliated studies concluded that HTPs were more desirable than CC (p < .01). No study investigated clinically relevant outcomes, such as disease occurrence. CONCLUSIONS Publications on HTPs in the biomedical literature from January 2017 to March 2022 were dominated by tobacco industry-affiliated studies. More than half of them concluded that HTPs were more desirable than CC compared to independent studies. IMPLICATIONS Tobacco industry advertises HTPs as "reduced-harm" tobacco products compared to CC. HTP users tend to consider HTPs as alternative tobacco products less harmful than CC (ie, products for "harm reduction"). Our results demonstrated that papers written by tobacco industry-affiliated authors concluded that HTPs were more desirable than CC compared to papers by independent authors. However, all their judgments were based on surrogate outcomes. Surrogate outcomes are not necessarily linked to clinically relevant outcomes such as disease occurrence. Further studies on HTPs using clinically relevant outcomes are warranted by independent authors from tobacco industry.
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Affiliation(s)
- Harumitsu Suzuki
- Department of Hygiene, Wakayama Medical University, Wakayama, Japan
| | - Naoki Aono
- Department of Hygiene, Wakayama Medical University, Wakayama, Japan
| | - Yan Zhang
- Department of Hygiene, Wakayama Medical University, Wakayama, Japan
| | - Kuniko Yuri
- Department of Hygiene, Wakayama Medical University, Wakayama, Japan
| | | | - Shigeki Takemura
- Department of Hygiene, Wakayama Medical University, Wakayama, Japan
| | - Aya Higashiyama
- Department of Hygiene, Wakayama Medical University, Wakayama, Japan
| | - Takahiro Tabuchi
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
| | - Akira Fujiyoshi
- Department of Hygiene, Wakayama Medical University, Wakayama, Japan
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14
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Fokas E, Smith JJ, Garcia-Aguilar J, Glynne-Jones R, Buyse M, Rödel C. Early Efficacy End Points in Neoadjuvant Rectal Cancer Trials: Surrogacy Revisited. J Clin Oncol 2024; 42:872-875. [PMID: 37890124 DOI: 10.1200/jco.23.01196] [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: 06/02/2023] [Revised: 08/07/2023] [Accepted: 09/13/2023] [Indexed: 10/29/2023] Open
Abstract
Trial-level surrogacy is critical before early response endpoints are used to approve new therapies.
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Affiliation(s)
- Emmanouil Fokas
- Department of Radiotherapy of Oncology, University of Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site: Frankfurt, Frankfurt, Germany
- Frankfurt Cancer Institute (FCI), Frankfurt, Germany
- Department of Radiation Oncology, Cyberknife and Radiotherapy, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Glynne-Jones
- Department of Radiotherapy, Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex, United Kingdom
| | - Marc Buyse
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt University, Diepenbeek, Belgium
- International Drug Development Institute, San Francisco, CA
| | - Claus Rödel
- Department of Radiotherapy of Oncology, University of Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site: Frankfurt, Frankfurt, Germany
- Frankfurt Cancer Institute (FCI), Frankfurt, Germany
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15
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Huang M, Fasching PA, Haiderali A, Xue W, Pan W, Karantza V, Yang F, Truscott J, Xin Y, O'Shaughnessy J. Association between event-free survival and overall survival in early-stage triple-negative breast cancer. Future Oncol 2024; 20:335-348. [PMID: 37602372 DOI: 10.2217/fon-2023-0315] [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] [Indexed: 08/22/2023] Open
Abstract
Aim: This study evaluated event-free survival (EFS) as a surrogate outcome for overall survival (OS) in neoadjuvant therapy for early-stage triple-negative breast cancer (eTNBC). Methods: Meta-regression analyses based on a targeted literature review were used to evaluate the individual- and trial-level associations between EFS and OS. Results: In the individual-level analyses, 3-year EFS was a significant predictor of 5-year OS (p < 0.01; coefficient of determinations [R2]: 0.82 [95% CI: 0.68-0.91]). Additionally, there was a statistically significant association between the treatment effect on EFS and OS at the trial level (p < 0.001; R2: 0.64 [95% CI: 0.45-0.82]). Conclusion: This study demonstrates significant associations between EFS and OS and suggests that EFS is a valid surrogate for OS following neoadjuvant therapy for eTNBC.
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Affiliation(s)
| | - Peter A Fasching
- Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Department of Gynecology & Obstetrics, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | | | | | | | | | | | | | | | - Joyce O'Shaughnessy
- Baylor University Medical Center, Texas Oncology & US Oncology, Dallas, TX, USA
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16
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Gladwell D, Ciani O, Parnaby A, Palmer S. Surrogacy and the Valuation of ATMPs: Taking Our Place in the Evidence Generation/Assessment Continuum. PHARMACOECONOMICS 2024; 42:137-144. [PMID: 37991631 DOI: 10.1007/s40273-023-01334-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 11/23/2023]
Abstract
Medical technology is advancing rapidly, but established methods for health technology assessment are struggling to keep up. This challenge is particularly stark for the assessment of advanced therapy medicinal products-therapies often launched on the basis of single-arm studies powered to a surrogate primary endpoint. The most robust surrogacy methods investigate trial-level correlations between the treatment effect on the surrogate and the outcome of ultimate interest. However, these methods are often impossible with the evidence usually available for advanced therapy medicinal products at the time of the launch (randomized controlled trials are necessary for these advanced methods). Additionally, these surrogacy relationships are usually considered to be technology specific, adding uncertainty for any approach that primarily relies on historic data to estimate the surrogacy relationship for novel interventions such as advanced therapy medicinal products. The literature has already highlighted the need for early dialogue, staged assessment processes, and pricing arrangements that responsibly share the risk between the manufacturer and payer. However, it is our view that in addition to these critical developments, the modeling methods employed could also improve. Currently, health technology assessment practitioners typically either ignore the surrogate and simply extrapolate the endpoint of greatest patient relevance irrespective of the degree of maturity or assume historic surrogate relationships apply to the novel technology. In this opinion piece, we outline an additional avenue. By drawing on the understanding of the mechanism of action and insights generated earlier in the evidence generation/assessment continuum, cost-effectiveness modelers can make better use of the wider data available. These efforts are expected to reduce uncertainty at the time of the initial launch of pharmaceutical products and increase the value of subsequent data collection efforts.
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Affiliation(s)
| | | | | | - Stephen Palmer
- Centre for Health Economics (CHE), University of York, York, UK
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Maher TM, Stowasser S, Voss F, Bendstrup E, Kreuter M, Martinez FJ, Sime PJ, Stock C. Decline in forced vital capacity as a surrogate for mortality in patients with pulmonary fibrosis. Respirology 2023; 28:1147-1153. [PMID: 37646126 DOI: 10.1111/resp.14579] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 08/08/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Surrogate endpoints enable determination of meaningful treatment effects more efficiently than applying the endpoint of ultimate interest. We used data from trials of nintedanib in subjects with pulmonary fibrosis to assess decline in forced vital capacity (FVC) as a surrogate for mortality. METHODS Data from the nintedanib and placebo groups of trials in subjects with idiopathic pulmonary fibrosis, other forms of progressive pulmonary fibrosis, and pulmonary fibrosis due to systemic sclerosis (NCT00514683, NCT01335464, NCT01335477, NCT01979952, NCT02999178, NCT02597933) were pooled. Using joint models for longitudinal and time-to-event data, we assessed the association between decline in FVC % predicted and time to death over 52 weeks. The rate of change in FVC % predicted and the current value of FVC % predicted were modelled longitudinally and estimates applied as predictors in time-to-event models. RESULTS Among 2583 subjects with pulmonary fibrosis, both a greater rate of decline in FVC % predicted and a lower current value of FVC % predicted were associated with an increased risk of death over 52 weeks (HR 1.79 [95% CI: 1.57, 2.03] and HR 1.24 [1.17, 1.32] per 5-percentage point decrease, respectively). Associations between the rate of change in FVC % predicted and the risk of death were consistent between patients with IPF and other ILDs. CONCLUSION Data from clinical trials in subjects with pulmonary fibrosis of diverse aetiology demonstrate a strong association between decline in FVC % predicted and mortality over 52 weeks, supporting FVC decline as a surrogate for mortality in these patients.
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Affiliation(s)
- Toby M Maher
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Imperial College London, London, UK
| | - Susanne Stowasser
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Florian Voss
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
| | - Elisabeth Bendstrup
- Centre for Rare Lung Diseases, Department of Respiratory Diseases and Allergy and Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Care Medicine, Thoraxklinik, University of Heidelberg, Member of the German Center for Lung Research, Heidelberg, Germany
| | | | - Patricia J Sime
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Christian Stock
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany
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Cresswell K, Anderson S, Montgomery C, Weir CJ, Atter M, Williams R. Evaluation of Digitalisation in Healthcare and the Quantification of the "Unmeasurable". J Gen Intern Med 2023; 38:3610-3615. [PMID: 37715095 PMCID: PMC10713954 DOI: 10.1007/s11606-023-08405-y] [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: 05/12/2023] [Accepted: 08/29/2023] [Indexed: 09/17/2023]
Abstract
Evaluating healthcare digitalisation, where technology implementation and adoption transforms existing socio-organisational processes, presents various challenges for outcome assessments. Populations are diverse, interventions are complex and evolving over time, meaningful comparisons are difficult as outcomes vary between settings, and outcomes take a long time to materialise and stabilise. Digitalisation may also have unanticipated impacts. We here discuss the limitations of evaluating the digitalisation of healthcare, and describe how qualitative and quantitative approaches can complement each other to facilitate investment and implementation decisions. In doing so, we argue how existing approaches have focused on measuring what is easily measurable and elevating poorly chosen values to inform investment decisions. Limited attention has been paid to understanding processes that are not easily measured even though these can have significant implications for contextual transferability, sustainability and scale-up of interventions. We use what is commonly known as the McNamara Fallacy to structure our discussions. We conclude with recommendations on how we envisage the development of mixed methods approaches going forward in order to address shortcomings.
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Affiliation(s)
| | - Stuart Anderson
- School of Informatics, The University of Edinburgh, Edinburgh, UK
| | - Catherine Montgomery
- Institute for the Study of Science, Technology and Innovation, The University of Edinburgh, Edinburgh, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Marek Atter
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Robin Williams
- Institute for the Study of Science, Technology and Innovation, The University of Edinburgh, Edinburgh, UK
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19
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Oei EHG, Runhaar J. Imaging of early-stage osteoarthritis: the needs and challenges for diagnosis and classification. Skeletal Radiol 2023; 52:2031-2036. [PMID: 37154872 PMCID: PMC10509094 DOI: 10.1007/s00256-023-04355-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/10/2023]
Abstract
In an effort to boost the development of new management strategies for OA, there is currently a shift in focus towards the diagnosis and treatment of early-stage OA. It is important to distinguish diagnosis from classification of early-stage OA. Diagnosis takes place in clinical practice, whereas classification is a process to stratify participants with OA in clinical research. For both purposes, there is an important opportunity for imaging, especially with MRI. The needs and challenges differ for early-stage OA diagnosis versus classification. Although it fulfils the need of high sensitivity and specificity for making a correct diagnosis, implementation of MRI in clinical practice is challenged by long acquisition times and high costs. For classification in clinical research, more advanced MRI protocols can be applied, such as quantitative, contrast-enhanced, or hybrid techniques, as well as advanced image analysis methods including 3D morphometric assessments of joint tissues and artificial intelligence approaches. It is necessary to follow a step-wise and structured approach that comprises, technical validation, biological validation, clinical validation, qualification, and cost-effectiveness, before new imaging biomarkers can be implemented in clinical practice or clinical research.
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Affiliation(s)
- Edwin H. G. Oei
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, PO-Box 2040, 3000 CA Rotterdam, the Netherlands
| | - Jos Runhaar
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, PO-Box 2040, 3000 CA Rotterdam, the Netherlands
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Ciani O, Manyara AM, Davies P, Stewart D, Weir CJ, Young AE, Blazeby J, Butcher NJ, Bujkiewicz S, Chan AW, Dawoud D, Offringa M, Ouwens M, Hróbjartssson A, Amstutz A, Bertolaccini L, Bruno VD, Devane D, Faria CD, Gilbert PB, Harris R, Lassere M, Marinelli L, Markham S, Powers JH, Rezaei Y, Richert L, Schwendicke F, Tereshchenko LG, Thoma A, Turan A, Worrall A, Christensen R, Collins GS, Ross JS, Taylor RS. A framework for the definition and interpretation of the use of surrogate endpoints in interventional trials. EClinicalMedicine 2023; 65:102283. [PMID: 37877001 PMCID: PMC10590868 DOI: 10.1016/j.eclinm.2023.102283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 10/26/2023] Open
Abstract
Background Interventional trials that evaluate treatment effects using surrogate endpoints have become increasingly common. This paper describes four linked empirical studies and the development of a framework for defining, interpreting and reporting surrogate endpoints in trials. Methods As part of developing the CONSORT (Consolidated Standards of Reporting Trials) and SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) extensions for randomised trials reporting surrogate endpoints, we undertook a scoping review, e-Delphi study, consensus meeting, and a web survey to examine current definitions and stakeholder (including clinicians, trial investigators, patients and public partners, journal editors, and health technology experts) interpretations of surrogate endpoints as primary outcome measures in trials. Findings Current surrogate endpoint definitional frameworks are inconsistent and unclear. Surrogate endpoints are used in trials as a substitute of the treatment effects of an intervention on the target outcome(s) of ultimate interest, events measuring how patients feel, function, or survive. Traditionally the consideration of surrogate endpoints in trials has focused on biomarkers (e.g., HDL cholesterol, blood pressure, tumour response), especially in the medical product regulatory setting. Nevertheless, the concept of surrogacy in trials is potentially broader. Intermediate outcomes that include a measure of function or symptoms (e.g., angina frequency, exercise tolerance) can also be used as substitute for target outcomes (e.g., all-cause mortality)-thereby acting as surrogate endpoints. However, we found a lack of consensus among stakeholders on accepting and interpreting intermediate outcomes in trials as surrogate endpoints or target outcomes. In our assessment, patients and health technology assessment experts appeared more likely to consider intermediate outcomes to be surrogate endpoints than clinicians and regulators. Interpretation There is an urgent need for better understanding and reporting on the use of surrogate endpoints, especially in the setting of interventional trials. We provide a framework for the definition of surrogate endpoints (biomarkers and intermediate outcomes) and target outcomes in trials to improve future reporting and aid stakeholders' interpretation and use of trial surrogate endpoint evidence. Funding SPIRIT-SURROGATE/CONSORT-SURROGATE project is Medical Research Council Better Research Better Health (MR/V038400/1) funded.
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Affiliation(s)
- Oriana Ciani
- Centre for Research on Health and Social Care Management, SDA Bocconi School of Management, Milan, Italy
| | - Anthony M. Manyara
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Philippa Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Christopher J. Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Jane Blazeby
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Nancy J. Butcher
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Sylwia Bujkiewicz
- Biostatistics Research Group, Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - An-Wen Chan
- Women's College Research Institute, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Dalia Dawoud
- Science, Evidence and Analytics Directorate, Science Policy and Research Programme, National Institute for Health and Care Excellence, London, UK
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | | | - Asbjørn Hróbjartssson
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Alain Amstutz
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Luca Bertolaccini
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Vito Domenico Bruno
- Department of Minimally Invasive Cardiac Surgery, IRCCS Galeazzi – Sant’Ambrogio Hospital, Milan, Italy
| | - Declan Devane
- University of Galway, Galway, Ireland
- Health Research Board-Trials Methodology Research Network, University of Galway, Galway, Ireland
| | - Christina D.C.M. Faria
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Ray Harris
- Patient and Public Involvement Partner, UK
| | - Marissa Lassere
- St George Hospital and School of Population Health, The University of New South Wales, Sydney, Australia
| | - Lucio Marinelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Sarah Markham
- Department of Biostatistics, King's College London, London, UK
| | - John H. Powers
- George Washington University School of Medicine, Washington, USA
| | - Yousef Rezaei
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Ardabil University of Medical Sciences, Ardabil, Iran
- Behyan Clinic, Pardis New Town, Tehran, Iran
| | - Laura Richert
- University Bordeaux, INSERM, Institut Bergonié, CHU Bordeaux, BPH U1219, CIC-EC 1401, RECaP and Euclid/F-CRIN, Bordeaux, France
| | | | - Larisa G. Tereshchenko
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, OH, USA
| | | | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen & Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Gary S. Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joseph S. Ross
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Rod S. Taylor
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Rastogi A, Sudhayakumar A, Schaper NC, Jude EB. A paradigm shift for cardiovascular outcome evaluation in diabetes: Major adverse cardiovascular events (MACE) to major adverse vascular events (MAVE). Diabetes Metab Syndr 2023; 17:102875. [PMID: 37844433 DOI: 10.1016/j.dsx.2023.102875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND AND AIMS Drugs for diabetes are required to demonstrate cardiovascular safety through CV outcome trials (CVOT). The pre-defined end-points for cardiovascular outcome studies may not be sufficient to capture all clinically relevant atherosclerotic cardio vascular disease (ASCVD) events particularly peripheral arterial disease (PAD). METHODS We planned a scoping review and searched database to identify CVOT conducted in population with diabetes measuring lower limb events due to PAD as the primary outcome measure. We also searched CVOT for reported differential cardiovascular outcomes in population with PAD. RESULTS We identified that CV outcomes are measured as 3 point major adverse cardiovascular outcomes (3P-MACE) that includes nonfatal MI and nonfatal stroke or 4P-MACE that included additional unstable angina which is further expanded to 5P-MACE by the inclusion of hospitalization for heart failure (HHF). These CV end points are captured as surrogate for CV mortality based on the biological plausibility of relation between the surrogate and final outcome from pathophysiological studies. We found the prevalence of PAD is no lesser than other CV events in people with diabetes. Moreover, PAD contributes to the significant morbidity associated with diabetes as a surrogate for mortality. However, none of the CVOT with anti-diabetic drugs include PAD events as primary outcome measure despite the inclusion of 6-25 % participants with PAD in major CVOT. PAD outcomes are objectively measurable with tibial arterial waveforms and clinical end-point as lower extremity amputation. PAD outcomes do improve with treatment including intensive glycemic control and novel oral anticoagulants. We suggest the inclusion of PAD to MACE as a pre-specified outcome for a comprehensive capture of major adverse vascular event in future studies for people with diabetes. CONCLUSIONS MACE should be expanded to include PAD event as major adverse vascular event in cardiovascular outcome studies since PAD is clinically relevant and objectively measurable in diabetes.
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Affiliation(s)
- Ashu Rastogi
- Dept of Endocrinology, PGIMER, Chandigarh, 160012, India.
| | | | - Nicolaas C Schaper
- Division of Endocrinology, Department Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Edward B Jude
- Tameside and Glossop Integrated Care NHS Foundation Trust and University of Manchester, Ashton under Lyne, UK
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22
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Garside J, Shen Q, Westermayer B, van de Ven M, Kroep S, Chirikov V, Juhasz-Böss I. Association Between Intermediate End Points, Progression-free Survival, and Overall Survival in First-line Advanced or Recurrent Endometrial Cancer. Clin Ther 2023; 45:983-990. [PMID: 37689551 DOI: 10.1016/j.clinthera.2023.07.025] [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: 04/04/2023] [Revised: 07/26/2023] [Accepted: 07/30/2023] [Indexed: 09/11/2023]
Abstract
PURPOSE Advanced/recurrent endometrial cancer is associated with poor long-term outcomes. Clinical studies of novel regimens are ongoing, but given that data on overall survival (OS) take a long time to mature, surrogate end points are often used to support clinical-research interpretation. The aim of this study was to explore the correlation between progression-free survival (PFS)/time to progression (TTP) and OS across multiple time points in the first-line treatment of advanced/recurrent endometrial cancer. METHODS This study comprised meta-analyses of Phase 2/3 randomized, controlled trials of first-line treatments in patients with advanced primary or first-recurrent endometrial cancer identified via systematic literature review. The strength of the surrogacy relationship was assessed by correlation analyses (estimated with Spearman and Pearson correlation coefficients) and weighted linear regression. FINDINGS Data from 15 studies were included. PFS and TTP (TTP was reported in one study only) were highly correlated with future OS at multiple time points (Spearman values, 0.83-0.90; Pearson values, 0.86-0.93), suggesting that a change in PFS/TTP would likely be correlated with a change in OS in the same direction. On weighted linear regression, a 10% increase in PFS/TTP probability was significantly associated with a 9.3% to 13.3% increase in the probability of future OS. The strong positive association between PFS/TTP and OS was supported by findings from sensitivity analyses based on identified sources of interstudy heterogeneity. IMPLICATIONS PFS/TTP is a good potential candidate for predicting long-term OS outcomes in trials of first-line treatment in patients with advanced/recurrent endometrial cancer. The findings from this report may help to inform health-authority and clinical decision makers that PFS/TTP improvements are likely to translate into subsequent OS improvements once data mature.
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Affiliation(s)
- Jamie Garside
- Department of Value Evidence and Outcomes, GSK, London, United Kingdom.
| | - Qin Shen
- Department of Value Evidence and Outcomes, GSK, Collegeville, Pennsylvania
| | | | | | - Sonja Kroep
- OPEN Health, Evidence and Access, Rotterdam, The Netherlands
| | | | - Ingolf Juhasz-Böss
- Department of Obstetrics and Gynecology, Medical Center, University of Freiburg, Freiburg, Germany
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Manyara AM, Davies P, Stewart D, Weir CJ, Young AE, Wells V, Blazeby J, Butcher NJ, Bujkiewicz S, Chan AW, Collins GS, Dawoud D, Offringa M, Ouwens M, Ross JS, Taylor RS, Ciani O. Definitions, acceptability, limitations, and guidance in the use and reporting of surrogate end points in trials: a scoping review. J Clin Epidemiol 2023; 160:83-99. [PMID: 37380118 DOI: 10.1016/j.jclinepi.2023.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE To synthesize the current literature on the use of surrogate end points, including definitions, acceptability, and limitations of surrogate end points and guidance for their design/reporting, into trial reporting items. STUDY DESIGN AND SETTING Literature was identified through searching bibliographic databases (until March 1, 2022) and gray literature sources (until May 27, 2022). Data were thematically analyzed into four categories: (1) definitions, (2) acceptability, (3) limitations and challenges, and (4) guidance, and synthesized into reporting guidance items. RESULTS After screening, 90 documents were included: 79% (n = 71) had data on definitions, 77% (n = 69) on acceptability, 72% (n = 65) on limitations and challenges, and 61% (n = 55) on guidance. Data were synthesized into 17 potential trial reporting items: explicit statements on the use of surrogate end point(s) and justification for their use (items 1-6); methodological considerations, including whether sample size calculations were informed by surrogate validity (items 7-9); reporting of results for composite outcomes containing a surrogate end point (item 10); discussion and interpretation of findings (items 11-14); plans for confirmatory studies, collecting data on the surrogate end point and target outcome, and data sharing (items 15-16); and informing trial participants about using surrogate end points (item 17). CONCLUSION The review identified and synthesized items on the use of surrogate end points in trials; these will inform the development of the Standard Protocol Items: Recommendations for Interventional Trials-SURROGATE and Consolidated Standards of Reporting Trials-SURROGATE extensions.
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Affiliation(s)
- Anthony Muchai Manyara
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK.
| | - Philippa Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Amber E Young
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Valerie Wells
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Jane Blazeby
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Bristol NIHR Biomedical Research Centre, Bristol, UK; University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Nancy J Butcher
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Sylwia Bujkiewicz
- Biostatistics Research Group, Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - An-Wen Chan
- Women's College Research Institute, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Gary S Collins
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Dalia Dawoud
- Science, Evidence and Analytics Directorate, Science Policy and Research Programme, National Institute for Health and Care Excellence, London, UK
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada; Department of Paediatrics, University of Toronto, Toronto, Canada
| | | | - Joseph S Ross
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA; Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK; Robertson Centre for Biostatistics, School of Health and Well Being, University of Glasgow, Glasgow, UK
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management, SDA Bocconi School of Management, Milan, Italy
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Ostoros G, Hettle R, Georgoulia N, Berktas M, Chander P, Diaz Perez I, Couto AM, Eichinger C, Field P, Morten P. Association between event-free survival and overall survival after neoadjuvant treatment for non-small cell lung cancer: a systematic review and meta-analysis. Expert Rev Anticancer Ther 2023; 23:1305-1313. [PMID: 37850939 DOI: 10.1080/14737140.2023.2272645] [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: 05/16/2023] [Accepted: 10/11/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND We wanted to evaluate if event-free survival (EFS) is a reliable surrogate for overall survival (OS) in patients with resectable non-small cell lung cancer (r-NSCLC) receiving neoadjuvant therapy. We conducted a systematic literature review and meta-analysis to investigate the statistical association between EFS and OS. RESEARCH DESIGN AND METHODS Electronic databases were searched on 30 July 2021 to identify sources reporting both EFS and OS data in patients with stage I-IIIB r-NSCLC receiving neoadjuvant therapy. Correlation and regression analyses evaluated the association between the effect of treatment on EFS and OS using log-hazard ratios (HRs). Sources in which the entire population had epidermal growth factor receptor mutations were excluded from the analyses. RESULTS We identified 74 sources, of which 8 reported EFS and OS HRs from randomized controlled trials. Based on these, we found a positive linear correlation and a strong association between EFS and OS log-HRs (weighted Pearson's correlation coefficient r = 0.864; 95% confidence interval 0.809-0.992; P = 0.006; random-effects meta-regression, R2 = 0.777). CONCLUSIONS We found a strong association between treatment effects for EFS and OS, indicating that improvements in EFS are likely to be predictive of improvements in OS. EFS may therefore be a reliable surrogate for OS after neoadjuvant therapy in r-NSCLC.
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Affiliation(s)
- Gyula Ostoros
- National Korányi Institute of Pulmonology, Budapest, Hungary
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Potential surrogate outcomes in individuals at high risk for incident knee osteoarthritis. Osteoarthritis Cartilage 2023; 31:414-420. [PMID: 36646305 DOI: 10.1016/j.joca.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 12/22/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To study potential surrogate outcomes for osteoarthritis (OA) incidence by evaluating the association of short-term changes in clinical and imaging biomarkers with long-term clinical knee OA incidence. DESIGN Middle-aged women with overweight/obesity, but free of knee symptoms were recruited through their general practitioners. At baseline, after 2.5 years, and after 6.5 years, questionnaires, physical examination, radiographs, and Magnetic resonance imaging (MRI) scans were obtained. The percentage of knees with a minimal clinically important difference for knee pain severity, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain/stiffness/function, and joint space narrowing, and of those with progression/regression of medial knee alignment, chronic knee pain, radiographic osteophytes, and cartilage defects, bone marrow lesions, osteophytes, and effusion/synovitis on MRI were determined. For each of these potential surrogate outcomes with ≥10% improvement or progression in the population over 2.5 years, the association with incident clinical knee OA, defined using the combined ACR-criteria, after 6.5 years was determined. RESULTS Most pre-defined potential surrogate outcomes showed ≥10% change in the population over 2.5 years, but only worsening of TF cartilage defects, worsening of TF osteophytes on MRI, and an increase in pain severity were significantly associated with greater clinical knee OA incidence after 6.5 years. These potential surrogate outcomes had high specificity and negative predictive value (89-91%) and low sensitivity and positive predictive value (20-28%) CONCLUSIONS: Worsening of TF cartilage defects and TF osteophytes on MRI, and increased pain severity could be seen as surrogate outcomes for long-term OA incidence. However, higher positive predictive values seem warranted for the applicability of these factors in future preventive trials.
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Miyamoto Y, Kiyohara Y, Kohsaka S, Iwagami M, Tsugawa Y, Briasoulis A, Kuno T. Evaluation of heart failure admission as a surrogate for mortality in randomized clinical trials: A meta-analysis. Eur J Clin Invest 2023:e13970. [PMID: 36798990 DOI: 10.1111/eci.13970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 02/07/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Heart failure (HF) admission is used as a study endpoint in clinical trials. However, it remains unclear whether it can be a valid surrogate endpoint for mortality. OBJECTIVES To validate whether HF admission is a valid surrogate for mortality. METHODS In PubMed and EMBASE, randomized controlled trials (RCTs) of interventions to treat patients with heart failure at the enrolment were searched on 13 April 2022. We extracted RCTs in which event numbers of both HF admission and all-cause mortality were reported as either primary or secondary outcomes. Trial-level correlations (R-squared) between HF admission and mortality were assessed. We performed subgroup analyses by study year, follow-up duration, baseline HF with reduced ejection fraction (HFrEF) or HF with preserved ejection fraction (HFpEF), and whether the intervention was pharmacological. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. RESULTS A total of 117 RCTs met the criteria for inclusion. Overall, the trial-level R-squared between HF admission and all-cause mortality was 0.39 (95% confidence interval (CI), 0.26 to 0.53). However, in the subgroup analyses, the trial-level R-squared was increased when the follow-up duration was ≥24 months (0.70 [95% CI: 0.55, 0.85]), when intervention was pharmacological (0.51 [95% CI: 0.34, 0.68]) and when the baseline HF type was HFrEF (0.57 [95% CI: 0.42, 0.73]). CONCLUSIONS Our findings indicate that HF admission may not always be a valid surrogate for mortality in patients with HF. Rather, the surrogacy of HF admission may be dependent on clinical background and interventions.
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Affiliation(s)
- Yoshihisa Miyamoto
- National Cancer Center Institute for Cancer Control, Tokyo, Japan.,Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuko Kiyohara
- Department of Medicine, Yokohama Rosai Hospital, Yokohama, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Masao Iwagami
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba, Japan.,Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Alexandros Briasoulis
- Division of Cardiology, Heart Failure and Transplantation, University of Iowa, Iowa City, Iowa, USA.,National Kapodistrian University of Athens, Athens, Greece
| | - Toshiki Kuno
- National Kapodistrian University of Athens, Athens, Greece.,Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
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Dell’Amore A, Campisi A, Bertolaccini L, Chen C, Gabryel P, Ji C, Piwkowski C, Spaggiari L, Fang W, Rea F. A Multicenter Retrospective Cohort Study on Superior Vena Cava Resection in Non-Small-Cell Lung Cancer Surgery. Cancers (Basel) 2022; 14:cancers14246138. [PMID: 36551624 PMCID: PMC9776451 DOI: 10.3390/cancers14246138] [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: 11/03/2022] [Revised: 12/07/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Surgery for non-small-cell lung cancers (NSCLCs) invading the superior vena cava (SVC) is rarely performed due to surgical complexities and reported poor prognoses. Different methods have been described to reconstruct the SVC, such as direct suture, patch use or prosthesis, according to its circumferential involvement. The aim of our study was to analyze the short- and long-term results of different types of SVC resection and reconstruction for T4 NSCLCs. METHODS Between January 2000 and December 2019, 80 patients received an anatomical lung resection with SVC surgery in this multicenter retrospective study. The partial resection and direct suture or patch reconstruction group included 64 patients, while the complete resection and prosthesis reconstruction group included 16 patients. The primary endpoints were as follows: long-term survival and disease-free survival. The secondary endpoints were as follows: perioperative complications and 30- and 90-day mortality. Unpaired t-tests or Mann-Whitney U tests for non-parametric variables were applied to discrete or continuous data, and the chi-square test was applied to dichotomous or categorical data. Survival rates were calculated using the Kaplan-Meier method and compared using the log-rank test. RESULTS No differences were found between the two groups in terms of general characteristics and surgical, oncological and survival outcomes. In particular, there were no differences in terms of early (50.0% vs. 68.8%, p = 0.178) and late complication frequency (12.5% vs. 12.5%, p = 1.000), 30- and 90-day mortality, R status, recurrence, overall survival (33.89 ± 40.35 vs. 35.70 ± 51.43 months, p = 0.432) and disease-free survival (27.56 ± 40.36 vs. 31.28 ± 53.08 months, p = 0.668). The multivariate analysis demonstrated that age was the only independent predictive factor for overall survival. CONCLUSIONS According to our results, SVC resection has good oncological and survival outcomes, regardless of the proportion of circumferential involvement and the type of reconstruction.
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Affiliation(s)
- Andrea Dell’Amore
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery and Vascular Sciences, Padua University Hospital, University of Padua, 35128 Padua, Italy
- Correspondence: (A.D.); (A.C.)
| | - Alessio Campisi
- Thoracic Surgery Department, University and Hospital Trust–Ospedale Borgo Trento, 37126 Verona, Italy
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200032, China
- Correspondence: (A.D.); (A.C.)
| | - Luca Bertolaccini
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Chunji Chen
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200032, China
| | - Piotr Gabryel
- Department of Thoracic Surgery, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Chunyu Ji
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200032, China
| | - Cezary Piwkowski
- Department of Thoracic Surgery, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Lorenzo Spaggiari
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy
| | - Wentao Fang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200032, China
| | - Federico Rea
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery and Vascular Sciences, Padua University Hospital, University of Padua, 35128 Padua, Italy
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Ciani O, Manyara AM, Chan AW, Taylor RS. Surrogate endpoints in trials: a call for better reporting. Trials 2022; 23:991. [PMID: 36503559 PMCID: PMC9743760 DOI: 10.1186/s13063-022-06904-7] [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: 04/30/2022] [Accepted: 11/08/2022] [Indexed: 12/14/2022] Open
Abstract
Using a surrogate endpoint as a substitute for a patient-relevant final outcome enables randomised controlled trials (RCTs) to be conducted more efficiently. However, the use of surrogates remains controversial and there is currently no guideline for the reporting of RCTs using surrogate endpoints; therefore, we seek to develop SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) and CONSORT (Consolidated Standards of Reporting Trials) extensions to improve the reporting of these trials. We would like to invite interested individuals (trial methodologists, journal editors, healthcare industry, regulators and payers, and patient/public representative groups), particularly those with experience in the use of surrogate endpoints in trials.
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Affiliation(s)
- Oriana Ciani
- grid.7945.f0000 0001 2165 6939SDA Bocconi School of Management, Milan, Italy
| | - Anthony M. Manyara
- grid.416221.20000 0000 8625 3965MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - An-Wen Chan
- grid.17063.330000 0001 2157 2938Women’s College Institute Research Institute and Department of Medicine, University of Toronto, Toronto, Canada
| | - Rod S. Taylor
- grid.8756.c0000 0001 2193 314XMRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Berkeley Square, 99 Berkeley St, Glasgow, G3 7HR Scotland, UK
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Villain N, Planche V, Levy R. High-clearance anti-amyloid immunotherapies in Alzheimer's disease. Part 1: Meta-analysis and review of efficacy and safety data, and medico-economical aspects. Rev Neurol (Paris) 2022; 178:1011-1030. [PMID: 36184326 DOI: 10.1016/j.neurol.2022.06.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/25/2022] [Accepted: 06/15/2022] [Indexed: 12/14/2022]
Abstract
In 2021, aducanumab, an immunotherapy targeting amyloid-β, was approved for Alzheimer's disease (AD) by the US Food and Drug Administration thanks to positive results on a putative biological surrogate marker. This approval has raised an unprecedented controversy. It was followed by a refusal of the European Medicine Agency, which does not allow the marketing of drugs solely on biological arguments and raised safety issues, and important US coverage limitations by the Centers for Medicare & Medicaid Services. Two other anti-amyloid immunotherapies showed significant results regarding a clinical outcome in phase 2 trials, and five drugs are being studied in phase 3 trials. Compared to those tested in previous trials of the 2010s, the common feature and novelty of these anti-amyloid immunotherapies is their ability to induce a high clearance of amyloid load, as measured with positron emission tomography, in the brain of early-stage biomarker-proven AD patients. Here, we review the available evidence regarding efficacy and safety data and medico-economical aspects for high-clearance anti-amyloid immunotherapies. We also perform frequentist and Bayesian meta-analyses of the clinical efficacy and safety of the highest dose groups from the two aducanumab phase 3 trials and the donanemab and lecanemab phase 2 trials. When pooled together, the data from high-clearance anti-amyloid immunotherapies trials confirm a statistically significant clinical effect of these drugs on cognitive decline after 18 months (difference in cognitive decline measured with CDR-SB after 18 months between the high dose immunotherapy groups vs. placebo = -0.24 points; P=0.04, frequentist random-effect model), with results on ADAS-Cog being the most statistically robust. However, this effect remains below the previously established minimal clinically relevant values. In parallel, the drugs significantly increased the occurrence of amyloid-related imaging abnormalities-edema (ARIA-E: risk ratio=13.39; P<0.0001), ARIA-hemorrhage (risk ratio=2.78; P=0.0002), and symptomatic and serious ARIA (7/1321=0.53% in the high dose groups versus 0/1446 in the placebo groups; risk ratio=6.44; P=0.04). The risk/benefit ratio of high-clearance immunotherapies in early AD is so far questionable after 18 months. Identifying subgroups of better responders, the perspective of combination therapies, and a longer follow-up may help improve their clinical relevance. Finally, the preliminary evidence from medico-economical analyses seems to indicate that the current cost of aducanumab in the US is not in reasonable alignment with its clinical benefits.
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Affiliation(s)
- N Villain
- Assistance Publique - Hôpitaux de Paris, Department of Neurology, Institute of Memory and Alzheimer's Disease, Pitié-Salpêtrière Hospital, Paris, France; Sorbonne Université, Inserm U1127, CNRS 7225, Institut du Cerveau - ICM, Paris, France.
| | - V Planche
- CNRS, IMN, UMR 5293, University Bordeaux, 33000 Bordeaux, France; Pôle de Neurosciences Cliniques, Centre Mémoire Ressources Recherches, CHU de Bordeaux, 33000 Bordeaux, France
| | - R Levy
- Assistance Publique - Hôpitaux de Paris, Department of Neurology, Institute of Memory and Alzheimer's Disease, Pitié-Salpêtrière Hospital, Paris, France; Sorbonne Université, Inserm U1127, CNRS 7225, Institut du Cerveau - ICM, Paris, France
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Stathi A, Withall J, Greaves CJ, Thompson JL, Taylor G, Medina-Lara A, Green C, Snowsill T, Johansen-Berg H, Bilzon J, Gray S, Cross R, Western MJ, Koning JLD, Ladlow P, Bollen JC, Moorlock SJ, Guralnik JM, Rejeski WJ, Hillsdon M, Fox KR. A group-based exercise and behavioural maintenance intervention for adults over 65 years with mobility limitations: the REACT RCT. PUBLIC HEALTH RESEARCH 2022. [DOI: 10.3310/mqbw6832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background
Mobility limitation in older age reduces quality of life, generates substantial health- and social-care costs, and increases mortality.
Objective
The REtirement in ACTion (REACT) trial aimed to establish whether or not a community-based active ageing intervention could prevent decline in physical functioning in older adults already at increased risk of mobility limitation.
Design
A multicentre, pragmatic, two-arm, parallel-group randomised controlled trial with parallel process and health economic evaluations.
Setting
Urban and semi-rural locations across three sites in England.
Participants
Physically frail or pre-frail older adults (aged ≥ 65 years; Short Physical Performance Battery score of 4–9). Recruitment was primarily via 35 primary care practices.
Interventions
Participants were randomly assigned to receive brief advice (three healthy ageing education sessions) or a 12-month, group-based, multimodal exercise and behavioural maintenance programme delivered in fitness and community centres. Randomisation was stratified by site and used a minimisation algorithm to balance age, sex and Short Physical Performance Battery score. Data collection and analyses were blinded.
Main outcome measures
The primary outcome was change in lower limb physical function (Short Physical Performance Battery score) at 24 months, analysed using an intention-to-treat analysis. The economic evaluation adopted the NHS and Personal Social Services perspective.
Results
Between June 2016 and October 2017, 777 participants (mean age 77.6 years, standard deviation 6.8 years; 66% female; mean Short Physical Performance Battery score 7.37, standard deviation 1.56) were randomised to the intervention arm (n = 410) or the control arm (n = 367). Data collection was completed in October 2019. Primary outcome data at 24 months were provided by 628 (80.8%) participants. At the 24-month follow-up, the Short Physical Performance Battery score was significantly greater in the intervention arm (mean 8.08, standard deviation 2.87) than in the control arm (mean 7.59, standard deviation 2.61), with an adjusted mean difference of 0.49 (95% confidence interval 0.06 to 0.92). The difference in lower limb function between intervention and control participants was clinically meaningful at both 12 and 24 months. Self-reported physical activity significantly increased in the intervention arm compared with the control arm, but this change was not observed in device-based physical activity data collected during the trial. One adverse event was related to the intervention. Attrition rates were low (19% at 24 months) and adherence was high. Engagement with the REACT intervention was associated with positive changes in exercise competence, relatedness and enjoyment and perceived physical, social and mental well-being benefits. The intervention plus usual care was cost-effective compared with care alone over the 2 years of REACT; the price year was 2019. In the base-case scenario, the intervention saved £103 per participant, with a quality-adjusted life-year gain of 0.04 (95% confidence interval 0.006 to 0.074) within the 2-year trial window. Lifetime horizon modelling estimated that further cost savings and quality-adjusted life-year gains were accrued up to 15 years post randomisation.
Conclusion
A relatively low-resource, 1-year multimodal exercise and behavioural maintenance intervention can help older adults to retain physical functioning over a 24-month period. The results indicate that the well-established trajectory of declining physical functioning in older age is modifiable.
Limitations
Participants were not blinded to study arm allocation. However, the primary outcome was independently assessed by blinded data collectors. The secondary outcome analyses were exploratory, with no adjustment for multiple testing, and should be interpreted accordingly.
Future work
Following refinements guided by the process evaluation findings, the REACT intervention is suitable for large-scale implementation. Further research will optimise implementation of REACT at scale.
Trial registration
This trial is registered as ISRCTN45627165.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Afroditi Stathi
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | | | - Colin J Greaves
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Janice L Thompson
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Gordon Taylor
- University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | | | - Colin Green
- University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Tristan Snowsill
- University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Heidi Johansen-Berg
- Wellcome Centre for Integrative Neuroimaging, Oxford Centre for Functional MRI of the Brain, Wellcome Centre for Integrative Neuroimaging, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - James Bilzon
- Department for Health, University of Bath, Bath, UK
| | - Selena Gray
- Faculty of Health and Applied Sciences, University of the West of England Bristol, Bristol, UK
| | - Rosina Cross
- Department for Health, University of Bath, Bath, UK
| | | | | | - Peter Ladlow
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Loughborough, UK
| | - Jessica C Bollen
- University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Sarah J Moorlock
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Jack M Guralnik
- Department of Epidemiology and Public Health, University of Maryland, School of Medicine, Baltimore, MD, USA
| | - W Jack Rejeski
- Department of Health and Exercise Science, Wake Forest University, Worrell Professional Centre, Winston-Salem, NC, USA
| | - Melvyn Hillsdon
- College of Life and Environmental Sciences, University of Exeter, Exeter, UK
| | - Kenneth R Fox
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, UK
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Mikhael J, Fowler J, Shah N. Chimeric Antigen Receptor T-Cell Therapies: Barriers and Solutions to Access. JCO Oncol Pract 2022; 18:800-807. [PMID: 36130152 DOI: 10.1200/op.22.00315] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapies are relatively new treatments for patients with heavily pretreated hematologic malignancies. Although these innovative therapies can offer substantial benefit to patients with limited alternative treatment options, patient-access barriers exist. Conventional clinical trials are time-consuming and may be limited by strict patient eligibility criteria, resources, and availability of enrollment slots. Because of the complexity of the CAR-T administration process, treatment delivery can be associated with additional burden for the patient, including requiring patients to reside close to treatment centers and remain with a caregiver after infusion. Manufacturing of CAR-T cells is completed in specialized facilities and depends on the availability of reagents, manufacturing workforce, and timely transportation. CAR-T therapy is costly, and many US health plans restrict coverage of cell and gene therapies. Several of the existing challenges because of these barriers have been exacerbated during the COVID-19 pandemic. This review discusses these barriers and proposes some potential solutions to improving patient access, including innovation in clinical trial design and manufacturing, location of treatment delivery, and key stakeholder opinions regarding treatment and reimbursement. We propose a call to action for key stakeholder groups to address these barriers to CAR-T therapy to expand treatment access for patients. Future collaboration between key stakeholders, including payers, regulatory agencies, and industry/academia, will be critical to continue to address these barriers and enhance patient access to these therapies.
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Affiliation(s)
- Joseph Mikhael
- Translational Genomics Research Institute (TGen), Applied Cancer Research and Drug Discovery Division, Phoenix, AZ
| | | | - Nina Shah
- Bone Marrow Transplantation and Hematologic Malignancy Unit, Division of Hematology-Oncology, University of California, San Francisco, San Francisco, CA
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Poad H, Khan S, Wheaton L, Thomas A, Sweeting M, Bujkiewicz S. The Validity of Surrogate Endpoints in Sub Groups of Metastatic Colorectal Cancer Patients Defined by Treatment Class and KRAS Status. Cancers (Basel) 2022; 14:5391. [PMID: 36358810 PMCID: PMC9654686 DOI: 10.3390/cancers14215391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/14/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
Background and Aim: Findings from the literature suggest that the validity of surrogate endpoints in metastatic colorectal cancer (mCRC) may depend on a treatments' mechanism of action. We explore this and the impact of Kirsten rat sarcoma (KRAS) status on surrogacy patterns in mCRC. Methods: A systematic review was undertaken to identify randomized controlled trials (RCTs) for pharmacological therapies in mCRC. Bayesian meta-analytic methods for surrogate endpoint evaluation were used to evaluate surrogate relationships across all RCTs, by KRAS status and treatment class. Surrogate endpoints explored were progression free survival (PFS) as a surrogate endpoint for overall survival (OS), and tumour response (TR) as a surrogate for PFS and OS. Results: 66 RCTs were identified from the systematic review. PFS showed a strong surrogate relationship with OS across all data and in subgroups by KRAS status. The relationship appeared stronger within individual treatment classes compared to the overall analysis. The TR-PFS and TR-OS relationships were found to be weak overall but stronger within the Epidermal Growth Factor Receptor + Chemotherapy (EGFR + Chemo) treatment class; both overall and in the wild type (WT) patients for TR-PFS, but not in patients with the mutant (MT) KRAS status where data were limited. Conclusions: PFS appeared to be a good surrogate endpoint for OS. TR showed a moderate surrogate relationship with PFS and OS for the EGFR + Chemo treatment class. There was some evidence of impact of the mechanism of action on the strength of the surrogacy patterns in mCRC, but little evidence of the impact of KRAS status on the validity of surrogate endpoints.
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Affiliation(s)
- Heather Poad
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK
| | - Sam Khan
- Leicester Cancer Research Centre, University of Leicester, Leicester LE1 7RH, UK
| | - Lorna Wheaton
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK
| | - Anne Thomas
- Leicester Cancer Research Centre, University of Leicester, Leicester LE1 7RH, UK
| | - Michael Sweeting
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK
| | - Sylwia Bujkiewicz
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK
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Han L, Wang X, Cai T. Identifying surrogate markers in real-world comparative effectiveness research. Stat Med 2022; 41:5290-5304. [PMID: 36062392 DOI: 10.1002/sim.9569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 11/09/2022]
Abstract
In comparative effectiveness research (CER), leveraging short-term surrogates to infer treatment effects on long-term outcomes can guide policymakers evaluating new treatments. Numerous statistical procedures for identifying surrogates have been proposed for randomized clinical trials (RCTs), but no methods currently exist to evaluate the proportion of treatment effect (PTE) explained by surrogates in real-world data (RWD), which have become increasingly common. To address this knowledge gap, we propose inverse probability weighted (IPW) and doubly robust (DR) estimators of an optimal transformation of the surrogate and the corresponding PTE measure. We demonstrate that the proposed estimators are consistent and asymptotically normal, and the DR estimator is consistent when either the propensity score model or outcome regression model is correctly specified. Our proposed estimators are evaluated through extensive simulation studies. In two RWD settings, we show that our method can identify and validate surrogate markers for inflammatory bowel disease (IBD).
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Affiliation(s)
- Larry Han
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Xuan Wang
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Tianxi Cai
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Ciani O, Grigore B, Taylor RS. Development of a framework and decision tool for the evaluation of health technologies based on surrogate endpoint evidence. HEALTH ECONOMICS 2022; 31 Suppl 1:44-72. [PMID: 35608044 PMCID: PMC9546394 DOI: 10.1002/hec.4524] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/28/2021] [Accepted: 04/02/2022] [Indexed: 05/27/2023]
Abstract
In the drive toward faster patient access to treatments, health technology assessment (HTA) agencies and payers are increasingly faced with reliance on evidence based on surrogate endpoints, increasing decision uncertainty. Despite the development of a small number of evaluation frameworks, there remains no consensus on the detailed methodology for handling surrogate endpoints in HTA practice. This research overviews the methods and findings of four empirical studies undertaken as part of COMED (Pushing the Boundaries of Cost and Outcome Analysis of Medical Technologies) program work package 2 with the aim of analyzing international HTA practice of the handling and considerations around the use of surrogate endpoint evidence. We have synthesized the findings of these empirical studies, in context of wider contemporary body of methodological and policy-related literature on surrogate endpoints, to develop a web-based decision tool to support HTA agencies and payers when faced with surrogate endpoint evidence. Our decision tool is intended for use by HTA agencies and their decision-making committees together with the wider community of HTA stakeholders (including clinicians, patient groups, and healthcare manufacturers). Having developed this tool, we will monitor its use and we welcome feedback on its utility.
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Affiliation(s)
- Oriana Ciani
- Centre for Research on Health and Social Care ManagementSDA BocconiMilanLombardiaItaly
- Evidence Synthesis & Modelling for Health ImprovementCollege of Medicine and HealthUniversity of ExeterExeterDevonUK
| | - Bogdan Grigore
- Exeter Test GroupCollege of Medicine and HealthUniversity of ExeterExeterDevonUK
| | - Rod S. Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for BiostatisticsInstitute of Health and Well BeingUniversity of GlasgowGlasgowScotlandUK
- College of Medicine and HealthUniversity of ExeterExeterDevonUK
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Implications of Oncology Trial Design and Uncertainties in Efficacy-Safety Data on Health Technology Assessments. Curr Oncol 2022; 29:5774-5791. [PMID: 36005193 PMCID: PMC9406873 DOI: 10.3390/curroncol29080455] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Advances in cancer medicines have resulted in tangible health impacts, but the magnitude of benefits of approved cancer medicines could vary greatly. Health Technology Assessment (HTA) is a multidisciplinary process used to inform resource allocation through a systematic value assessment of health technology. This paper reviews the challenges in conducting HTA for cancer medicines arising from oncology trial designs and uncertainties of safety-efficacy data. Methods: Multiple databases (PubMed, Scopus and Google Scholar) and grey literature (public health agencies and governmental reports) were searched to inform this policy narrative review. Results: A lack of robust efficacy-safety data from clinical trials and other relevant sources of evidence has made HTA for cancer medicines challenging. The approval of cancer medicines through expedited pathways has increased in recent years, in which surrogate endpoints or biomarkers for patient selection have been widely used. Using these surrogate endpoints has created uncertainties in translating surrogate measures into patient-centric clinically (survival and quality of life) and economically (cost-effectiveness and budget impact) meaningful outcomes, with potential effects on diverting scarce health resources to low-value or detrimental interventions. Potential solutions include policy harmonization between regulatory and HTA authorities, commitment to generating robust post-marketing efficacy-safety data, managing uncertainties through risk-sharing agreements, and using value frameworks. Conclusion: A lack of robust efficacy-safety data is a central problem for conducting HTA of cancer medicines, potentially resulting in misinformed resource allocation.
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Drummond M, Tarricone R, Torbica A. European union regulation of health technology assessment: what is required for it to succeed? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:913-915. [PMID: 35348920 DOI: 10.1007/s10198-022-01458-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 06/14/2023]
Affiliation(s)
| | - Rosanna Tarricone
- CERGAS, SDA Bocconi School of Management, Milan, Italy
- Department of Social and Political Science, Bocconi University, Milan, Italy
| | - Aleksandra Torbica
- CERGAS, SDA Bocconi School of Management, Milan, Italy
- Department of Social and Political Science, Bocconi University, Milan, Italy
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Affiliation(s)
| | - Anthony M Manyara
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Ahmed HA, Ismael S, Salman M, Devlin P, McDonald MP, Liao FF, Ishrat T. Direct AT2R Stimulation Slows Post-stroke Cognitive Decline in the 5XFAD Alzheimer's Disease Mice. Mol Neurobiol 2022; 59:4124-4140. [PMID: 35486224 PMCID: PMC10947502 DOI: 10.1007/s12035-022-02839-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/01/2022] [Indexed: 10/18/2022]
Abstract
Alzheimer's disease (AD), currently the single leading cause of death still on the rise, almost always coexists alongside vascular cognitive impairment (VCI). In fact, the ischemic disease affects up to 90% of AD patients, with strokes and major infarctions representing over a third of vascular lesions. Studies also confirmed that amyloid plaques, typical of AD, are much more likely to cause dementia if strokes or cerebrovascular damage also exist, leading to the term "mixed pathology" cognitive impairment. Although its incidence is expected to grow, there are no satisfactory treatments. There is hence an urgent need for safe and effective therapies that preserve cognition, maintain function, and prevent the clinical deterioration that results from the progression of this irreversible, neurodegenerative disease. To our knowledge, this is the first study to investigate the effects of long-term treatment with C21, a novel angiotensin II type 2 receptor (AT2R) agonist, on the development of "mixed pathology" cognitive impairment. This was accomplished using a unique model that employs the fundamental elements of both AD and VCI. Treatment with C21/vehicle was started 1 h post-stroke and continued for 5 weeks in mice with concurrent AD pathology. Efficacy was established through a series of functional tests assessing various aspects of cognition, including spatial learning, short-term/working memory, long-term/reference memory, and cognitive flexibility, in addition to the molecular markers characteristic of AD. Our findings demonstrate that C21 treatment preserves cognitive function, maintains cerebral blood flow, and reduces Aβ accumulation and toxic tau phosphorylation in AD animals post-stroke.
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Affiliation(s)
- Heba A Ahmed
- Department of Anatomy and Neurobiology, College of Medicine, The University of Tennessee Health Science Center, 875 Monroe Avenue, Wittenborg Bldg, Room-231, Memphis, TN, 38163, USA
| | - Saifudeen Ismael
- Department of Anatomy and Neurobiology, College of Medicine, The University of Tennessee Health Science Center, 875 Monroe Avenue, Wittenborg Bldg, Room-231, Memphis, TN, 38163, USA
| | - Mohd Salman
- Department of Anatomy and Neurobiology, College of Medicine, The University of Tennessee Health Science Center, 875 Monroe Avenue, Wittenborg Bldg, Room-231, Memphis, TN, 38163, USA
| | - Patrick Devlin
- Department of Anatomy and Neurobiology, College of Medicine, The University of Tennessee Health Science Center, 875 Monroe Avenue, Wittenborg Bldg, Room-231, Memphis, TN, 38163, USA
| | - Michael P McDonald
- Department of Anatomy and Neurobiology, College of Medicine, The University of Tennessee Health Science Center, 875 Monroe Avenue, Wittenborg Bldg, Room-231, Memphis, TN, 38163, USA
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, 38163, USA
- Neuroscience Institute, University of Tennessee Health Science Center, Memphis, TN, 38163, USA
| | - Francesca-Fang Liao
- Neuroscience Institute, University of Tennessee Health Science Center, Memphis, TN, 38163, USA
- Department of Pharmacology, The University of Tennessee Health Science Center, Memphis, TN, 38163, USA
| | - Tauheed Ishrat
- Department of Anatomy and Neurobiology, College of Medicine, The University of Tennessee Health Science Center, 875 Monroe Avenue, Wittenborg Bldg, Room-231, Memphis, TN, 38163, USA.
- Neuroscience Institute, University of Tennessee Health Science Center, Memphis, TN, 38163, USA.
- Pharmaceutical Sciences, The University of Tennessee Health Science Center, Memphis, TN, 38163, USA.
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Weir CJ, Taylor RS. Informed decision-making: Statistical methodology for surrogacy evaluation and its role in licensing and reimbursement assessments. Pharm Stat 2022; 21:740-756. [PMID: 35819121 PMCID: PMC9546435 DOI: 10.1002/pst.2219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 01/10/2023]
Abstract
The desire, by patients and society, for faster access to therapies has driven a long tradition of the use of surrogate endpoints in the evaluation of pharmaceuticals and, more recently, biologics and other innovative medical technologies. The consequent need for statistical validation of potential surrogate outcome measures is a prime example on the theme of statistical support for decision-making in health technology assessment (HTA). Following the pioneering methodology based on hypothesis testing that Prentice presented in 1989, a host of further methods, both frequentist and Bayesian, have been developed to enable the value of a putative surrogate outcome to be determined. This rich methodological seam has generated practical methods for surrogate evaluation, the most recent of which are based on the principles of information theory and bring together ideas from the causal effects and causal association paradigms. Following our synopsis of statistical methods, we then consider how regulatory authorities (on licensing) and payer and HTA agencies (on reimbursement) use clinical trial evidence based on surrogate outcomes. We review existing HTA surrogate outcome evaluative frameworks. We conclude with recommendations for further steps: (1) prioritisation by regulators and payers of the application of formal surrogate outcome evaluative frameworks, (2) application of formal Bayesian decision-analytic methods to support reimbursement decisions, and (3) greater utilization of conditional surrogate-based licensing and reimbursement approvals, with subsequent reassessment of treatments in confirmatory trials based on final patient-relevant outcomes.
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Affiliation(s)
| | - Rod S. Taylor
- Institute of Health & WellbeingUniversity of GlasgowGlasgowUK
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Ciani O, Manyara A, Taylor RS. Need for better reporting of trials with surrogate endpoints: SPIRIT|CONSORT-SURROGATE extensions. J Epidemiol Community Health 2022; 76:jech-2022-219294. [PMID: 35750481 PMCID: PMC9380472 DOI: 10.1136/jech-2022-219294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | - Anthony Manyara
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
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Sanna L, Todea A. Risk assessment tools for survival prognosis: An era of new surrogacy endpoints for clinical outcome measurement in pulmonary arterial hypertension clinical trials? Respir Med Res 2022; 81:100893. [PMID: 35523041 DOI: 10.1016/j.resmer.2022.100893] [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: 10/19/2021] [Revised: 02/08/2022] [Accepted: 02/17/2022] [Indexed: 11/19/2022]
Abstract
Developing a new medication in a rare disease indication like pulmonary arterial hypertension (PAH) is very challenging. This is especially true now that clinical trials often employ time to clinical worsening (TTCW) as an endpoint (thus requiring a relatively large and lengthy trial) and since patients are more frequently prescribed combination therapy. During the last few decades, several tools have been developed to predict mortality in PAH and have demonstrated generally good discrimination. The objective of this review article is to assess the available data on the different tools and methods described in the literature and identify potential candidates that could be used as surrogate endpoints in pivotal randomized clinical trials in future. Some of these tools have been validated in various registries and in post-hoc analyses of clinical trial data, but none have been assessed in a prospective clinical trial and we still lack the evidence necessary for endorsement by health authorities. In this review, we identify several promising options that warrant further investigation as potential surrogate endpoints in clinical trials to replace TTCW or 6-minute walk distance. Prospective inclusion of such tools in new clinical trials may help build a stronger surrogacy for prognosis of disease progression and mortality.
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Affiliation(s)
- Lilian Sanna
- Actelion Pharmaceuticals Ltd, Allschwil, Switzerland.
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Runhaar J, Bierma-Zeinstra SM. The Challenges in the Primary Prevention of Osteoarthritis. Clin Geriatr Med 2022; 38:259-271. [DOI: 10.1016/j.cger.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Cost-effectiveness of a physical activity and behaviour maintenance programme on functional mobility decline in older adults: an economic evaluation of the REACT (Retirement in Action) trial. Lancet Public Health 2022; 7:e327-e334. [PMID: 35325628 PMCID: PMC8967720 DOI: 10.1016/s2468-2667(22)00030-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 01/10/2022] [Accepted: 01/27/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Mobility limitations in older populations have a substantial impact on health outcomes, quality of life, and social care costs. The Retirement in Action (REACT) randomised controlled trial assessed a 12-month community-based group physical activity and behaviour maintenance intervention to help prevent decline in physical functioning in older adults at increased risk of mobility limitation. We aimed to do an economic evaluation of the REACT trial to investigate whether the intervention is cost-effective. METHODS In this health economic evaluation, we did cost-effectiveness and cost-utility analyses of the REACT programme versus standard care on the basis of resource use, primary outcome, and health-related quality-of-life data measured in the REACT trial. We also developed a decision analytic Markov model that forecasts the mobility of recipients beyond the 24-month follow-up of the trial and translated this into future costs and potential benefit to health-related quality of life using the National Health Service and Personal Social Services perspective. Participants completed questionnaire booklets at baseline, and at 6, 12, and 24 months after randomisation, which included a resource use questionnaire and the EQ-5D-5L and 36-item short-form survey (SF-36) health-related quality-of-life instruments. The cost of delivering the intervention was estimated by identifying key resources, such as REACT session leader time, time of an individual to coordinate the programme, and venue hire. EQ-5D-5L and SF-36 responses were converted to preference-based utility values, which were used to estimate quality-adjusted life-years (QALYs) over the 24-month trial follow-up using the area-under-the-curve method. We used generalised linear models to examine the effect of the REACT programme on costs and QALYs and adjust for baseline covariates. Costs and QALYs beyond 12 months were discounted at 3·5% per year. This is a pre-planned analysis of the REACT trial; the trial itself is registered with ISRCTN (ISRCTN45627165). FINDINGS The 12-month REACT programme was estimated to cost £622 per recipient to deliver. The most substantial cost components are the REACT session leader time (£309 per participant), venue hire (£109), and the REACT coordinator time (£80). The base-case analysis of the trial-based economic evaluation showed that reductions in health and social care usage due to the REACT programme could offset the REACT delivery costs (£3943 in the intervention group vs £4043 in the control group; difference: -£103 [95% CI -£695 to £489]) with a health benefit of 0·04 QALYs (0·009-0·071; 1·354 QALYs in the intervention group vs 1·314 QALYs in the control group) within the 24-month timeframe of the trial. INTERPRETATION The REACT programme could be considered a cost-effective approach for improving the health-related quality of life of older adults at risk of mobility limitations. FUNDING National Institute for Health Research Public Health Research Programme.
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Feenstra T, Corro-Ramos I, Hamerlijnck D, van Voorn G, Ghabri S. Four Aspects Affecting Health Economic Decision Models and Their Validation. PHARMACOECONOMICS 2022; 40:241-248. [PMID: 34913142 DOI: 10.1007/s40273-021-01110-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 06/14/2023]
Abstract
Health care decision makers in many jurisdictions use cost-effectiveness analysis based on health economic decision models for policy decisions regarding coverage and price negotiation for medicines and medical devices. While validation of health economic decision models has always been considered important, many reviews of model-based cost-effectiveness studies report limitations regarding their validation. The current opinion paper discusses four aspects of current health economic decision modeling with relevance for future directions in model validation: increased use of complex models, international cooperation, open-source modeling, and stakeholder involvement. First, new, more complex clinical study designs and treatment strategies may require relatively complex model structures and/or input data analyses. Simultaneously, more widespread technical knowledge along with wider data availability have led to a broader range of model types. This puts extra requirements on model validation and transparency. Second, increased international cooperation of policy makers and, in particular, health technology assessment (HTA) authorities in performing model assessments is discussed in relation to the repeated use of health economic models (multi-use disease models). We argue such coordinated efforts may benefit model validity. Third, open-source modeling is discussed as one possible answer to increased transparency requirements. Finally, involvement of all relevant stakeholders throughout the whole decision process is an ongoing development that necessarily also includes health economic modeling. We argue this implies that model validity should be considered in a broader perspective, with more focus on conceptual modeling, model transparency, accuracy requirements, and choice of relevant model outcomes than previously.
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Affiliation(s)
- Talitha Feenstra
- Groningen University, Groningen Research Institute of Pharmacy, Groningen, The Netherlands.
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.
| | - Isaac Corro-Ramos
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | | | - Salah Ghabri
- Department of Economic and Public Health Evaluation, French National Authority for Health (Haute Autorité de Santé, HAS), Saint-Denis La Plaine, France
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Wilkinson J, Stocking K. Study design flaws and statistical challenges in evaluating fertility treatments. REPRODUCTION AND FERTILITY 2022; 2:C9-C21. [PMID: 35128452 PMCID: PMC8812412 DOI: 10.1530/raf-21-0015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/21/2021] [Indexed: 12/16/2022] Open
Abstract
Health interventions should be tested before being introduced into clinical practice, to find out whether they work and whether they are harmful. However, research studies will only provide reliable answers to these questions if they are appropriately designed and analysed. But these are not trivial tasks. We review some methodological challenges that arise when evaluating fertility interventions and explain the implications for a non-statistical audience. These include flexibility in outcomes and analyses; use of surrogate outcomes instead of live birth; use of inappropriate denominators; evaluating cumulative outcomes and time to live birth; allowing each patient or couple to contribute to a research study more than once. We highlight recurring errors and present solutions. We conclude by highlighting the importance of collaboration between clinical and methodological experts, as well as people with experience of subfertility, for realising high-quality research. Lay summary We do research to find out whether fertility treatments are beneficial and to make sure they don't cause harm. However, research will only provide reliable answers if it is done properly. It is not unusual for researchers to make mistakes when they are designing research studies and analysing the data that we get from them. In this review, we describe some of the mistakes people make when they do research about fertility treatments and explain how to avoid them. These include challenges which arise due to the large number of things that can be measured and reported when looking to see if fertility treatments work; failure to check whether the treatment increases the number of live births; failing to include all study participants in calculations;challenges in studies where participants may have more than one treatment attempt. We conclude by highlighting the importance of collaboration between clinical and methodological experts, as well as people with experience of fertility problems.
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Affiliation(s)
- Jack Wilkinson
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
| | - Katie Stocking
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
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Lee YC, Chao YT, Lin PJ, Yang YY, Yang YC, Chu CC, Wang YC, Chang CH, Chuang SL, Chen WC, Sun HJ, Tsou HC, Chou CF, Yang WS. Quality assurance of integrative big data for medical research within a multihospital system. J Formos Med Assoc 2022; 121:1728-1738. [DOI: 10.1016/j.jfma.2021.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 11/25/2022] Open
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Eastell R, Vittinghoff E, Lui LY, McCulloch CE, Pavo I, Chines A, Khosla S, Cauley JA, Mitlak B, Bauer DC, Bouxsein M, Black DM. Validation of the Surrogate Threshold Effect for Change in Bone Mineral Density as a Surrogate Endpoint for Fracture Outcomes: The FNIH-ASBMR SABRE Project. J Bone Miner Res 2022; 37:29-35. [PMID: 34490915 PMCID: PMC9291617 DOI: 10.1002/jbmr.4433] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/12/2021] [Accepted: 08/29/2021] [Indexed: 12/01/2022]
Abstract
The surrogate threshold effect (STE) is defined as the minimum treatment effect on a surrogate that is reliably predictive of a treatment effect on the clinical outcome. It provides a framework for implementing a clinical trial with a surrogate endpoint. The aim of this study was to update our previous analysis by validating the STE for change in total hip (TH) BMD as a surrogate for fracture risk reduction; the novelty of this study was this validation. To do so, we used individual patient data from 61,415 participants in 16 RCTs that evaluated bisphosphonates (nine trials), selective estrogen receptor modulators (four trials), denosumab (one trial), odanacatib (one trial), and teriparatide (one trial) to estimate trial-specific treatment effects on TH BMD and all, vertebral, hip, and nonvertebral fractures. We then conducted a random effects meta-regression of the log relative fracture risk reduction against 24-month change in TH BMD, and computed the STE as the intersection of the upper 95% prediction limit of this regression with the line of no fracture reduction. We validated the STE by checking whether the number of fractures in each trial provided 80% power and determining what proportion of trials with BMD changes ≥ STE reported significant reductions in fracture risk. We applied this analysis to (i) the trials on which we estimated the STE; and (ii) trials on which we did not estimate the STE. We found that the STEs for all, vertebral, hip, and nonvertebral fractures were 1.83%, 1.42%, 3.18%, and 2.13%, respectively. Among trials used to estimate STE, 27 of 28 were adequately powered, showed BMD effects exceeding the STE, and showed significant reductions in fracture risk. Among the validation set of 11 trials, 10 met these criteria. Thus STE differs by fracture type and has been validated in trials not used to develop the approach. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Richard Eastell
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK
| | - Eric Vittinghoff
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Li-Yung Lui
- California Pacific Medical Center, San Francisco, CA, USA
| | - Charles E McCulloch
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Imre Pavo
- Eli Lilly and Company, Lilly Research Centre, Windlesham, UK
| | | | | | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Douglas C Bauer
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Mary Bouxsein
- Center for Advanced Orthopedic Studies, Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Dennis M Black
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
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Smith N, Fu AC, Fisher T, Meletiche D, Pawar V. Oncology drugs and added benefit: insights from 3 European health technology assessment agencies on the role of efficacy endpoints. J Med Econ 2022; 25:1-6. [PMID: 34809504 DOI: 10.1080/13696998.2021.2009711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE This study aimed to understand the impact of different efficacy endpoints on reimbursement decisions made by health technology assessment (HTA) bodies. MATERIALS AND METHODS European Medicines Agency (EMA) oncology product marketing authorizations were screened to identify products that completed review by 3 HTA bodies during 2016-2019: United Kingdom's National Institute for Health and Care Excellence, Germany's Gemeinsamer Bundesausschuss, and France's Haute Autorité de Santé. Each decision's endpoint information, including overall survival (OS) and progression-free survival (PFS), was extracted. Each endpoint's influence on added benefits rating (the degree of added benefit as judged by the HTA agency) and full reimbursement (i.e. reimbursed population to label) decisions was tested using bivariate analyses. RESULTS An increasing trend was observed toward HTA submissions with immature OS data (36.8% and 71.4% in 2016 and 2019, respectively), which was a predictor of limited added benefit (p < .001). Regarding data availability, 63% of submissions provided OS, 2% provided PFS without OS; and 35% provided neither. OS availability significantly influenced added benefit (p < .001) but not full reimbursement (p > .05) decisions, whereas PFS without OS had no significant impact compared with either OS or PFS data for either outcome (p = .99). CONCLUSIONS The trend toward fewer products filing mature OS data over time suggests sponsors may be increasingly confident achieving reimbursement with surrogate endpoint data, although mature OS data provided the strongest correlation to positive reimbursement decisions. Notably, in some locally advanced settings, OS data maturity will take a long time to obtain. To expedite patient access to new medicines, payers should consider the acceptance of surrogate endpoints predictive of clinical benefit.
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Affiliation(s)
| | - An-Chen Fu
- EMD Serono Research & Development Institute, Inc, Billerica, MA, USA (an affiliate of Merck KGaA)
| | - Tim Fisher
- EMD Serono Research & Development Institute, Inc, Rockland, MA, USA (an affiliate of Merck KGaA)
| | | | - Vivek Pawar
- EMD Serono Research & Development Institute, Inc, Billerica, MA, USA (an affiliate of Merck KGaA)
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Glycated hemoglobin as a surrogate for evaluating the effectiveness of drugs in diabetes mellitus trials: a systematic review and trial-level meta-analysis. Int J Technol Assess Health Care 2021; 38:e12. [PMID: 34933703 DOI: 10.1017/s0266462321001689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The objective of this study was to investigate whether glycated hemoglobin (HbA1c) is a valid surrogate for evaluating the effectiveness of antihyperglycemic drugs in diabetes mellitus (DM) trials. METHODS We conducted a systematic review of placebo-controlled randomized clinical trials (RCTs) evaluating the effect of a treatment on HbA1c (mean difference between groups) and clinical outcomes (relative risk of mortality, myocardial infarction, stroke, heart failure, and/or kidney injury) in patients with DM. Then, we investigated the association between treatment effects on HbA1c and clinical outcomes using regression analysis at the trial level. Lastly, we interpreted the correlation coefficients (R) using the cut-off points suggested by the Institute for Quality and Efficiency in Healthcare (IQWiG). HbA1c was considered a valid surrogate if it demonstrated a strong association: lower limit of the 95 percent confidence interval (95 percent CI) of R greater than or equal to .85. RESULTS Nineteen RCTs were identified. All studies included adults with type 2 DM. None of the associations evaluated was strong enough to validate HbA1c as a surrogate for any clinical outcome: mortality (R = .34; 95 percent CI -.14 to .69), myocardial infarction (R = .20; -.30 to .61), heart failure (R = .08; -.40 to .53), kidney injury (R = -.04; -.52 to .47), and stroke (R = .81; .54 to .93). CONCLUSIONS The evidence from multiple placebo-controlled RCTs does not support the use of HbA1c as a surrogate to measure the effectiveness of antihyperglycemic drugs in DM studies.
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Tafuri G, Bracco A, Grueger J. Access and pricing of medicines for patients with rare diseases in the European Union: an industry perspective. Expert Rev Pharmacoecon Outcomes Res 2021; 22:381-389. [PMID: 34930086 DOI: 10.1080/14737167.2022.2020105] [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: 11/04/2022]
Abstract
INTRODUCTION The EU Orphan Regulation has successfully stimulated R&D of medicines for rare diseases, resulting in substantial increase of orphan designations and authorized orphan medicinal products in the EU during the last decade. Despite such important advances, access to treatment across the 27 EU Member States is still highly variable. AREAS COVERED We provide an overview of the current situation of patient access to orphan drugs in the EU. We discuss the EU policy landscape regarding joint assessment and pricing & reimbursement negotiations of medicinal products, price and sustainability of orphan drugs for health care systems and the importance of Real-World Data and registry infrastructures for rare diseases. Additionally, we provide recommendations for areas of improvement throughout the lifecycle of orphan drugs, aiming to preserve a positive R&D climate for rare diseases in the EU and accelerate patient access. EXPERT OPINION The EU needs to maintain a strong patient-centric pharmaceutical ecosystem that encourages long-term investments and rewards innovation in areas of high unmet medical need. Areas of potential improvement range from enhanced alignment of regulatory and HTA evidence requirements and use of specific value frameworks for the assessment of orphan drugs to the development of registry infrastructures and innovative performance-based pricing agreements.
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Affiliation(s)
- Giovanni Tafuri
- Apellis Switzerland GmbH, Zählerweg 10, 6300 Zug, Switzerland
| | - Andrea Bracco
- Apellis Switzerland GmbH, Zählerweg 10, 6300 Zug, Switzerland
| | - Jens Grueger
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, USA.,Boston Consulting Group, Zurich, Switzerland
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