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Kuehne F, Arvandi M, Hess LM, Faries DE, Matteucci Gothe R, Gothe H, Beyrer J, Zeimet AG, Stojkov I, Mühlberger N, Oberaigner W, Marth C, Siebert U. Causal analyses with target trial emulation for real-world evidence removed large self-inflicted biases: systematic bias assessment of ovarian cancer treatment effectiveness. J Clin Epidemiol 2022; 152:269-280. [PMID: 36252741 DOI: 10.1016/j.jclinepi.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/17/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVES Drawing causal conclusions from real-world data (RWD) poses methodological challenges and risk of bias. We aimed to systematically assess the type and impact of potential biases that may occur when analyzing RWD using the case of progressive ovarian cancer. METHODS We retrospectively compared overall survival with and without second-line chemotherapy (LOT2) using electronic medical records. Potential biases were determined using directed acyclic graphs. We followed a stepwise analytic approach ranging from crude analysis and multivariable-adjusted Cox model up to a full causal analysis using a marginal structural Cox model with replicates emulating a reference randomized controlled trial (RCT). To assess biases, we compared effect estimates (hazard ratios [HRs]) of each approach to the HR of the reference trial. RESULTS The reference trial showed an HR for second line vs. delayed therapy of 1.01 (95% confidence interval [95% CI]: 0.82-1.25). The corresponding HRs from the RWD analysis ranged from 0.51 for simple baseline adjustments to 1.41 (95% CI: 1.22-1.64) accounting for immortal time bias with time-varying covariates. Causal trial emulation yielded an HR of 1.12 (95% CI: 0.96-1.28). CONCLUSION Our study, using ovarian cancer as an example, shows the importance of a thorough causal design and analysis if one is expecting RWD to emulate clinical trial results.
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Affiliation(s)
- Felicitas Kuehne
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Marjan Arvandi
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Lisa M Hess
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Raffaella Matteucci Gothe
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Holger Gothe
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria; Chair of Health Sciences/Public Health, Medical Faculty "Carl Gustav Carus", Technical University Dresden, Dresden, Germany
| | | | - Alain Gustave Zeimet
- Department of Obstetrics and Gynecology, Innsbruck Medical University, Innsbruck, Austria
| | - Igor Stojkov
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Nikolai Mühlberger
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Willi Oberaigner
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria; Institute for Clinical Epidemiology, Cancer Registry Tyrol, Tirol Kliniken, Innsbruck, Austria
| | - Christian Marth
- Department of Obstetrics and Gynecology, Innsbruck Medical University, Innsbruck, Austria
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria; Center for Health Decision Science and Departments of Epidemiology and Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Smith MA. Lessons learned from adult clinical experience to inform evaluations of VEGF pathway inhibitors in children with cancer. Pediatr Blood Cancer 2014; 61:1497-505. [PMID: 24760743 DOI: 10.1002/pbc.25036] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Accepted: 02/27/2014] [Indexed: 01/07/2023]
Abstract
Agents targeting the vascular endothelial growth factor (VEGF) pathway have been studied in adults with cancer for nearly two decades. It is important to assess the lessons learned from this adult experience and to see how these lessons can help inform pediatric development of agents in this class. The benefit achieved from the use of VEGF pathway targeted agents for adult cancers has primarily been to delay for several months disease progression and less commonly time to death for conditions in which cure is not a reasonable expectation. VEGF pathway targeted agents have shown no efficacy when applied in the adjuvant setting. For adults with advanced cancer, prolongation of survival by 2-3 months is considered an important achievement in some settings. However, the primary goal of pediatric oncology clinical research is to identify treatments that allow children to be cured of their cancer and to grow to adulthood without treatment-induced limitations that lower their quality of survival. An important question for the pediatric oncology research community, pharmaceutical companies, and regulatory agencies to address in planning for future clinical trials is whether existing data support a role for VEGF pathway targeted agents in contributing to a therapeutic pathway to cure for children with cancer.
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Bellmunt J, Pons F, Foreshew A, Fay AP, Powles T, Porta C, Bracarda S, Lampron ME, Cerbone L, Sternberg CN, Hutson TE, Choueiri TK. Sequential targeted therapy after pazopanib therapy in patients with metastatic renal cell cancer: efficacy and toxicity. Clin Genitourin Cancer 2014; 12:262-9. [PMID: 24795159 DOI: 10.1016/j.clgc.2014.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 02/24/2014] [Accepted: 03/02/2014] [Indexed: 02/06/2023]
Abstract
INTRODUCTION/BACKGROUND Patients with metastatic renal cell carcinoma (mRCC) in whom first-line therapies have failed might derive clinical benefit with sequential targeted agents. Limited data are available on the efficacy and toxicity of subsequent therapies after disease progression during pazopanib therapy. PATIENTS AND METHODS Patients with mRCC who received subsequent systemic treatment after pazopanib treatment failure were identified across 7 institutions. Pazopanib was given as first-line therapy in 28 patients and after cytokines therapy in 7 patients. Clinical outcome and toxicity analyses of 2 sequential treatment options (anti-vascular endothelial growth factor [VEGF] or mammalian target of rapamycin inhibitor [mTORi]) is presented. RESULTS Subsequent therapy was anti-VEGF in 22 patients and mTORi in 13. One patient who received bevacizumab and temsirolimus combination was excluded. VEGF-targeted therapies included sorafenib (n = 10), sunitinib (n = 3), bevacizumab (n = 2), cediranib (n = 4) and cabozantinib (n = 3). Patients treated with mTORi received everolimus. Median progression-free survival was 5.6 months from the start of subsequent therapy with anti-VEGF and 2.4 months with mTORi (P = .009). Overall survival (OS) was not significantly different (P = .68). Clinical benefit (including partial response and stable disease) on subsequent therapy was observed in 15 patients (64%) and 4 patients (31%) of anti-VEGF- and everolimus-treated patients, respectively (P = .021). CONCLUSION In this retrospective study, targeting VEGF was an effective strategy after disease progression during pazopanib treatment, although OS was not different among patients treated with VEGF or mTORi.
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Affiliation(s)
- Joaquim Bellmunt
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Hospital del Mar, Barcelona, Spain.
| | | | | | - André P Fay
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Camillo Porta
- IRCCS San Matteo University Hospital Fundantion, Pavia, Italy
| | | | - Megan E Lampron
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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