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Chen Y, Martin P, Inoue LYT, Basu A, Carlson JJ. Tackling Challenges in Assessing the Economic Value of Tumor-Agnostic Therapies: A Cost-Effectiveness Analysis of Pembrolizumab as a Case Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:926-935. [PMID: 38548177 DOI: 10.1016/j.jval.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/01/2024] [Accepted: 03/13/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES Assessing the value of tumor-agnostic drugs (TAD) is challenging given the potential variability in treatment effects, trials with small sample sizes, different standards of care (SoC), and lack of comparative data from single-arm basket trials. Our study developed and applied novel methods to assess the value of pembrolizumab compared with SoC to inform coverage decisions. METHODS We developed a partitioned survival model to evaluate the cost-utility of pembrolizumab for previously treated patients with 8 advanced or metastatic microsatellite instability-high or mismatch repair-deficient cancers from a US commercial payer perspective. Efficacy of pembrolizumab was based on data from trials directly or with adjustment using Bayesian hierarchical models. Eight chemotherapy-based external control arms were constructed from the TriNetX electronic health record databases. Tumor-specific health-state utility values were applied. All costs were adjusted to 2022 US dollars. RESULTS At a lifetime horizon, pembrolizumab was associated with increased effectiveness compared with chemotherapies in colorectal (quality-adjusted life years [QALYs]: +0.64, life years [LYs]: +0.64), endometrial (QALYs: +3.79, LYs: +5.47), and small intestine cancers (QALYs: +1.73, LYs: +2.48), but not for patients with metastatic gastric, cholangiocarcinoma, pancreatic, ovarian, and brain cancers. Incremental cost-effectiveness ratios varied substantially across tumor types. Pembrolizumab was found to be cost-effective in treating colorectal and endometrial cancers (incremental cost-effectiveness ratios: $121 967 and $139 257, respectively), and not cost-effective for other assessed cancers at a $150 000 willingness-to-pay/QALY threshold, compared with SoC chemotherapies. CONCLUSIONS The cost-effectiveness of TADs can vary by cancers. Using analytic tools such as external controls and Bayesian hierarchical models can tackle several challenges in assessing the value of TADs and uncertainties from basket trials.
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Affiliation(s)
- Yilin Chen
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, USA.
| | - Peter Martin
- Kaiser Permanente Health Plan of Washington, Seattle, WA, USA
| | - Lurdes Y T Inoue
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Anirban Basu
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Josh J Carlson
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, USA
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Hogervorst MA, van Hattem CC, Sonke GS, Mantel-Teeuwisse AK, Goettsch WG, Bloem LT. Healthcare decision-making for tumour-agnostic therapies in Europe: lessons learned. Drug Discov Today 2024; 29:104031. [PMID: 38796096 DOI: 10.1016/j.drudis.2024.104031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/14/2024] [Accepted: 05/14/2024] [Indexed: 05/28/2024]
Abstract
The tumour-agnostic authorisations of larotrectinib and entrectinib shifted the paradigm for indication setting. European healthcare decision-makers agreed on their therapeutic potential but diverged primarily in identified uncertainties concerning basket trial designs and endpoints, prognostic value of neurotrophic tropomyosin receptor kinase (NTRK) gene fusions, and resistance mechanisms. In addition, assessments of relevant comparators, unmet medical needs (UMNs), and implementation of NTRK-testing strategies diverged. In particular, the tumour-specific reimbursement recommendations and guidelines do not reflect tumour-agnostic thinking. These differences indicate difficulties experienced in these assessments and provide valuable lessons for future disruptive therapies. As we discuss here, early multistakeholder dialogues concerning minimum evidence requirements and involving clinicians are essential.
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Affiliation(s)
- Milou A Hogervorst
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Christine C van Hattem
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Medical Oncology, University of Amsterdam, Amsterdam, the Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands
| | - Wim G Goettsch
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands; National Health Care Institute (ZIN), Diemen, the Netherlands
| | - Lourens T Bloem
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, the Netherlands.
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3
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Orbach D, Carton M, Khadir SK, Feuilly M, Kurtinecz M, Phil D, Vokuhl C, Koscielniak E, Pierron G, Lemelle L, Sparber-Sauer M. Therapeutic benefit of larotrectinib over the historical standard of care in patients with locally advanced or metastatic infantile fibrosarcoma (EPI VITRAKVI study). ESMO Open 2024; 9:103006. [PMID: 38657345 PMCID: PMC11061226 DOI: 10.1016/j.esmoop.2024.103006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 03/21/2024] [Accepted: 03/21/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Patients with infantile fibrosarcoma (IFS) have shown strong and long-lasting responses to larotrectinib, a tropomyosin receptor kinase inhibitor (TRKi), in single-arm clinical trials. Conventional chemotherapy has also shown important efficacy. But, until now, no comparative data exist. This study aims to assess the therapeutic benefit of larotrectinib over the current standard of care (SOC) of chemotherapy in paediatric patients with locally advanced or metastatic IFS. PATIENTS AND METHODS EPI VITRAKVI is a retrospective, observational, externally controlled study (NCT05236257). Data of patients aged ≤21 years with locally advanced or metastatic IFS treated with larotrectinib in the phase I/II SCOUT trial (NCT02637687) were compared with those of an external historical control group (data of Institut Curie and Cooperative Weichteilsarkom Studiengruppe) treated with a chemotherapy-based regimen. Between-group differences were assessed after balancing groups using inverse probability of treatment weighting (IPTW). RESULTS In total, 93 patients were compared, 51 in the larotrectinib arm and 42 in the external control arm. After therapy, 4 patients (7.8%) in the larotrectinib group had a medical treatment failure event [start of new systemic treatment (2 cases), mutilating surgery (2 cases)] versus 15 (35.7%) in the external control group [start of new systemic treatment (6 cases), mutilating surgery (5 cases), radiation therapy (2 cases), and death (2 cases)]. Larotrectinib was associated with an 80% reduced likelihood of encountering a medical treatment failure event, when compared to the external control group (weighted and stratified hazard ratio 0.20, 95% confidence interval 0.06-0.63, P = 0.0060). These results were confirmed by sensitivity analyses, including exact matching, and subgroup analyses for number of lines of treatment. CONCLUSIONS Treatment with larotrectinib reduced the need of subsequent therapies compared to SOC with chemotherapy in children with locally advanced or metastatic IFS, regardless of the line of treatment.
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Affiliation(s)
- D Orbach
- SIREDO Oncology Center (Care, Innovation and Research for Children and AYA with Cancer), PSL Research University, Institut Curie, Paris.
| | - M Carton
- Biometry Unit, Institut Curie, PSL Research University, Paris
| | | | - M Feuilly
- Bayer HealthCare SAS, La Garenne-Colombes, France
| | | | - D Phil
- Bayer U.S. LLC, Whippany, USA
| | - C Vokuhl
- Section of Pediatric Pathology, Department of Pathology, University Hospital Bonn, Bonn
| | - E Koscielniak
- Klinikum der Landeshauptstadt Stuttgart gKAöR, Olgahospital, Stuttgart Cancer Center, Zentrum für Kinder-, Jugend- und Frauenmedizin, Pädiatrie 5 (Pädiatrische Onkologie, Hämatologie, Immunologie), Stuttgart; Medizinische Fakultät der Universität Tübingen, Tübingen, Germany
| | - G Pierron
- Genetic Somatic Unit, PSL Research University, Institut Curie, Paris, France
| | - L Lemelle
- SIREDO Oncology Center (Care, Innovation and Research for Children and AYA with Cancer), PSL Research University, Institut Curie, Paris
| | - M Sparber-Sauer
- Klinikum der Landeshauptstadt Stuttgart gKAöR, Olgahospital, Stuttgart Cancer Center, Zentrum für Kinder-, Jugend- und Frauenmedizin, Pädiatrie 5 (Pädiatrische Onkologie, Hämatologie, Immunologie), Stuttgart; Medizinische Fakultät der Universität Tübingen, Tübingen, Germany
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Duan XP, Qin BD, Jiao XD, Liu K, Wang Z, Zang YS. New clinical trial design in precision medicine: discovery, development and direction. Signal Transduct Target Ther 2024; 9:57. [PMID: 38438349 PMCID: PMC10912713 DOI: 10.1038/s41392-024-01760-0] [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: 11/30/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 03/06/2024] Open
Abstract
In the era of precision medicine, it has been increasingly recognized that individuals with a certain disease are complex and different from each other. Due to the underestimation of the significant heterogeneity across participants in traditional "one-size-fits-all" trials, patient-centered trials that could provide optimal therapy customization to individuals with specific biomarkers were developed including the basket, umbrella, and platform trial designs under the master protocol framework. In recent years, the successive FDA approval of indications based on biomarker-guided master protocol designs has demonstrated that these new clinical trials are ushering in tremendous opportunities. Despite the rapid increase in the number of basket, umbrella, and platform trials, the current clinical and research understanding of these new trial designs, as compared with traditional trial designs, remains limited. The majority of the research focuses on methodologies, and there is a lack of in-depth insight concerning the underlying biological logic of these new clinical trial designs. Therefore, we provide this comprehensive review of the discovery and development of basket, umbrella, and platform trials and their underlying logic from the perspective of precision medicine. Meanwhile, we discuss future directions on the potential development of these new clinical design in view of the "Precision Pro", "Dynamic Precision", and "Intelligent Precision". This review would assist trial-related researchers to enhance the innovation and feasibility of clinical trial designs by expounding the underlying logic, which be essential to accelerate the progression of precision medicine.
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Affiliation(s)
- Xiao-Peng Duan
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Bao-Dong Qin
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Xiao-Dong Jiao
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Ke Liu
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zhan Wang
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yuan-Sheng Zang
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China.
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5
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Zhang Y, Chu C, Beckman RA, Gao L, Laird G, Yi B. A confirmatory basket design considering non-inferiority and superiority testing. J Biopharm Stat 2024; 34:205-221. [PMID: 36988397 DOI: 10.1080/10543406.2023.2192781] [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: 05/30/2022] [Accepted: 03/14/2023] [Indexed: 03/30/2023]
Abstract
For multiple rare diseases as defined by a common biomarker signature, or a disease with multiple disease subtypes of low frequency, it is often possible to provide confirmatory evidence for these disease or subtypes (baskets) as a combined group. A novel drug, as a second generation, may have marginal improvement in efficacy overall but superior efficacy in some baskets. In this situation, it is appealing to test hypotheses of both non-inferiority overall and superiority on certain baskets. The challenge is designing a confirmatory study efficient to address multiple questions in one trial. A two-stage adaptive design is proposed to test the non-inferiority hypothesis at the interim stage, followed by pruning and pooling before testing a superiority hypothesis at the final stage. Such a design enables an efficient and novel registration pathway, including an early claim of non-inferiority followed by a potential label extension with superiority on certain baskets and an improved benefit-risk profile demonstrated by longer term efficacy and safety data. Operating characteristics of this design are examined by simulation studies, and its appealing features make it ready for use in a confirmatory setting, especially in emerging markets, where both the need and the possibility for efficient use of resources may be the greatest.
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Affiliation(s)
- Yaohua Zhang
- Department of Biometrics, Vertex Pharmaceuticals Inc, Boston, Massachusetts, USA
| | - Chenghao Chu
- Department of Biometrics, Vertex Pharmaceuticals Inc, Boston, Massachusetts, USA
| | - Robert A Beckman
- Departments of Oncology and of Biostatistics Bioinformatics, and Biomathematics, Lombardi Comprehensive Cancer Center and Innovation Center for Biomedical Informatics, Georgetown University Medical Center, Washington, USA
| | - Lei Gao
- Department of Biostatisticis and Programming, Moderna, Cambridge, Massachusetts, USA
| | - Glen Laird
- Department of Biometrics, Vertex Pharmaceuticals Inc, Boston, Massachusetts, USA
| | - Bingming Yi
- Department of Biometrics, Vertex Pharmaceuticals Inc, Boston, Massachusetts, USA
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Lu CC, Beckman RA, Li XN, Zhang W, Jiang Q, Marchenko O, Sun Z, Tian H, Ye J, Yuan SS, Yung G. Tumor-Agnostic Approvals: Insights and Practical Considerations. Clin Cancer Res 2024; 30:480-488. [PMID: 37792436 DOI: 10.1158/1078-0432.ccr-23-1340] [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: 05/05/2023] [Revised: 07/05/2023] [Accepted: 10/03/2023] [Indexed: 10/05/2023]
Abstract
Since the first approval of a tumor-agnostic indication in 2017, a total of seven tumor-agnostic indications involving six drugs have received approval from the FDA. In this paper, the master protocol subteam of the Statistical Methods in Oncology Scientific Working Group, Biopharmaceutical Session, American Statistical Association, provides a comprehensive summary of these seven tumor-agnostic approvals, describing their mechanisms of action; biomarker prevalence; study design; companion diagnostics; regulatory aspects, including comparisons of global regulatory requirements; and health technology assessment approval. Also discussed are practical considerations relating to the regulatory approval of tumor-agnostic indications, specifically (i) recommendations for the design stage to mitigate the risk that exceptions may occur if a treatment is initially hypothesized to be effective for all tumor types and (ii) because drug development continues after approval of a tumor-agnostic indication, recommendations for further development of tumor-specific indications in first-line patients in the setting of a randomized confirmatory basket trial, acknowledging the challenges in this area. These recommendations and practical considerations may provide insights for the future development of drugs for tumor-agnostic indications.
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Affiliation(s)
| | - Robert A Beckman
- Departments of Oncology and of Biostatistics, Bioinformatics, and Biomathematics, Lombardi Comprehensive Cancer Center and Innovation Center for Biomedical Informatics, Georgetown University Medical Center, Washington, DC
| | | | | | - Qi Jiang
- Biometrics, Seagen, Bothell, Washington
| | - Olga Marchenko
- Statistics and Data Insights, Bayer, Whippany, New Jersey
| | - Zhiping Sun
- Biostatistics and Research Decision Sciences, Merck & Co., Inc., Rahway, New Jersey
| | - Hong Tian
- Global Statistics and Data Sciences, BeiGene, Fulton, Maryland
| | - Jingjing Ye
- Global Statistics and Data Sciences, BeiGene, Fulton, Maryland
| | - Shuai Sammy Yuan
- Oncology Statistics, GlaxoSmithKline, Collegeville, Pennsylvania
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Siu DHW, Lin FPY, Cho D, Lord SJ, Heller GZ, Simes RJ, Lee CK. Framework for the Use of External Controls to Evaluate Treatment Outcomes in Precision Oncology Trials. JCO Precis Oncol 2024; 8:e2300317. [PMID: 38190581 DOI: 10.1200/po.23.00317] [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: 06/19/2023] [Revised: 09/03/2023] [Accepted: 10/13/2023] [Indexed: 01/10/2024] Open
Abstract
Advances in genomics have enabled anticancer therapies to be tailored to target specific genomic alterations. Single-arm trials (SATs), including those incorporated within umbrella, basket, and platform trials, are widely adopted when it is not feasible to conduct randomized controlled trials in rare biomarker-defined subpopulations. External controls (ECs), defined as control arm data derived outside the clinical trial, have gained renewed interest as a strategy to supplement evidence generated from SATs to allow comparative analysis. There are increasing examples demonstrating the application of EC in precision oncology trials. The prospective application of EC in conducting comparative studies is associated with distinct methodological challenges, the specific considerations for EC use in biomarker-defined subpopulations have not been adequately discussed, and a formal framework is yet to be established. In this review, we present a framework for conducting a prospective comparative analysis using EC. Key steps are (1) defining the purpose of using EC to address the study question, (2) determining if the external data are fit for purpose, (3) developing a transparent study protocol and a statistical analysis plan, and (iv) interpreting results and drawing conclusions on the basis of a prespecified hypothesis. We specify the considerations required for the biomarker-defined subpopulations, which include (1) specifying the comparator and biomarker status of the comparator group, (2) defining lines of treatment, (3) assessment of the biomarker testing panels used, and (4) assessment of cohort stratification in tumor-agnostic studies. We further discuss novel clinical trial designs and statistical techniques leveraging EC to propose future directions to advance evidence generation and facilitate drug development in precision oncology.
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Affiliation(s)
- Derrick H W Siu
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
- Department of Medical Oncology, Illawarra Cancer Care Centre, Wollongong, NSW, Australia
| | - Frank P Y Lin
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Doah Cho
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Sarah J Lord
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
- School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - Gillian Z Heller
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
- Mathematics and Statistics, Macquarie University, Macquarie Park, NSW, Australia
| | - R John Simes
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Chee Khoon Lee
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
- Cancer Care Centre, St George Hospital, Kogarah, NSW, Australia
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Lemaitre F, Florentin V, Blin O, Bayle A, Benito S, Chauny JV, Galaup A, Korchagina D, Lang M, Le Tourneau C, Pelloux H, Picard N, Guilhaumou R. Can precision medicine be integrated into routine therapeutic decisions at the bedside of patients? Therapie 2024; 79:13-22. [PMID: 38065821 DOI: 10.1016/j.therap.2023.11.007] [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: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 02/27/2024]
Abstract
Therapeutic strategies are shifting from a "one-size-fits-all" population-based approach to a stratified approach targeting groups with similar characteristics, or even individuals, tailoring treatments to the unique characteristics of each patient. Since such strategies rely on increasingly complex knowledge and healthcare technologies, along with an understanding of the tools of precision medicine, the appropriate dissemination and use of these strategies involves a number of challenges for the medical community. Having evaluation methodologies that have been jointly designed with the institutional, industrial, academic stakeholders, and also patients, like streamlining the processes and externally validating performances, could enhance the relevance of the "evaluation" aspect of precision medicine. Creating a network of expert precision-medicine centers and ensuring that precision-medicine procedures are reimbursed by social security would guarantee fair and sustainable access. Finally, training healthcare professionals, creating interfaces between precision-medicine expert centers and primary care professionals as well as patients, and integrating individual patient data into medical records are all key drivers that will enable information from precision-medicine to be made available and guarantee the proper use of these approaches.
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Affiliation(s)
- Florian Lemaitre
- Inserm, EHESP, Irset (institut de recherche en santé, environnement et travail), UMR S 1085, CHU de Rennes, université Rennes, 35000 Rennes, France.
| | - Virginie Florentin
- Direction médecine personnalisée, Roche SAS, 92600 Boulogne-Billancourt, France
| | - Olivier Blin
- Inserm 1106, service de pharmacologie clinique et pharmacosurveilleance, en delegation Tafalgie Therapeutics, UMR, Aix-Marseille université, AP-HM, 13385 Marseille, France
| | - Arnaud Bayle
- Bureau biostatistique et epidémiologie, Gustave-Roussy, université Paris-Saclay, 94800 Villejuif, France; Inserm, CESP U1018 Oncostat, labelisé Ligue contre le cancer, université Paris-Saclay, 94800 Villejuif, France
| | | | - Jean-Vannak Chauny
- Direction accès au marché & affaires publiques, Amgen, 92100 Boulogne-Billancourt, France
| | | | | | | | - Christophe Le Tourneau
- Institut Curie, Paris, France; Inserm U900, Saint-Cloud, France; Université Paris-Saclay, 75005 Paris, France
| | - Hervé Pelloux
- Parasitology-Mycology laboratory, University Grenoble-Alpes, University Hospital Grenoble-Alpes, 38043 Grenoble, France
| | - Nicolas Picard
- Service de pharmacologie, toxicologie et pharmacovigilance, centre de biologie et de recherche en santé (CBRS), CHU de Limoges, 87042 Limoges, France
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Lemaitre F, Florentin V, Blin O, Bayle A, Benito S, Chauny JV, Galaup A, Korchagina D, Lang M, Le Tourneau C, Pelloux H, Picard N, Guilhaumou R. Comment faire entrer la médecine de précision dans la décision thérapeutique de routine au lit du malade ? Therapie 2024; 79:1-11. [PMID: 38129247 DOI: 10.1016/j.therap.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Florian Lemaitre
- Inserm, EHESP, Institut de recherche en santé, environnement et travail (Irset) - UMR S 1085, université de Rennes, CHU de Rennes, 35000 Rennes, France.
| | - Virginie Florentin
- Direction médecine personnalisée, Roche SAS, 92600 Boulogne-Billancourt, France
| | - Olivier Blin
- Inserm 1106, service de pharmacologie clinique et pharmacosurveilleance, en delegation Tafalgie Therapeutics, UMR, Aix-Marseille université, AP-HM, 13385 Marseille, France
| | - Arnaud Bayle
- Bureau biostatistique et epidémiologie, Gustave-Roussy, université Paris-Saclay, 94800 Villejuif, France; Inserm, CESP U1018 Oncostat, labelisé Ligue contre le cancer, université Paris-Saclay, 94800 Villejuif, France
| | | | - Jean-Vannak Chauny
- Direction accès au marché & affaires publiques, Amgen, 92100 Boulogne-Billancourt, France
| | | | | | | | - Christophe Le Tourneau
- Institut Curie, 75000 Paris, France; Inserm U900, 92210 Saint-Cloud, France; Université Paris-Saclay, 75005 Paris, France
| | - Hervé Pelloux
- Parasitology-Mycology laboratory, University Grenoble-Alpes, University Hospital Grenoble-Alpes, 38043 Grenoble, France
| | - Nicolas Picard
- Service de pharmacologie, toxicologie et pharmacovigilance, centre de biologie et de recherche en santé (CBRS), CHU de Limoges, 87042 Limoges, France
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Wagner E, Luykx JJ, Strube W, Hasan A. Challenges, unmet needs and future directions - a critical evaluation of the clinical trial landscape in schizophrenia research. Expert Rev Clin Pharmacol 2024; 17:11-18. [PMID: 38087450 DOI: 10.1080/17512433.2023.2293996] [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: 10/16/2023] [Accepted: 12/08/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Developing novel antipsychotic mechanisms of action and repurposing established compounds for the treatment of schizophrenia is of utmost importance to improve relevant symptom domains and to improve the risk/benefit ratio of antipsychotic compounds. Novel trial design concepts, pathophysiology-based targeted treatment approaches, or even the return to old values may improve schizophrenia outcomes in the future. AREAS COVERED In this review of the clinical trial landscape in schizophrenia, we present an overview of the challenges and gaps in current clinical trials and elaborate on potential solutions to improve the outcomes of people with schizophrenia. EXPERT OPINION The classic parallel group design may limit substantial advantages in drug approval or repurposing. Collaborative approaches between regulatory authorities, industry, academia, and funding agencies are needed to overcome barriers in clinical schizophrenia research to allow for meaningful outcome improvements for the patients.
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Affiliation(s)
- Elias Wagner
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- Evidence-based psychiatry and psychotherapy, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Jurjen J Luykx
- Department of Psychiatry, Amsterdam University Medical Center, Amsterdam, the Netherlands
- Bipolar Outpatient Clinic, GGZ inGeest Mental Health Care, Amsterdam, The Netherlands
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Wolfgang Strube
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Alkomiet Hasan
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- DZPG (German Center for Mental Health), partner site München/Augsburg, Augsburg, Germany
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Carnero-Montoro E, Alarcón-Riquelme ME. A basket genetic trial of the vasculitides. Nat Rev Rheumatol 2023; 19:541-542. [PMID: 37438403 DOI: 10.1038/s41584-023-00996-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Affiliation(s)
- Elena Carnero-Montoro
- GENYO (Center for Genomics and Oncological Research), Pfizer-University of Granada-Andalusian Regional Government, Granada, Spain
| | - Marta E Alarcón-Riquelme
- GENYO (Center for Genomics and Oncological Research), Pfizer-University of Granada-Andalusian Regional Government, Granada, Spain.
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Goldberger Z, Hauert S, Chang K, Kurtanich T, Alpar AT, Repond G, Wang Y, Gomes S, Krishnakumar R, Siddarth P, Swartz MA, Hubbell JA, Briquez PS. Membrane-localized neoantigens predict the efficacy of cancer immunotherapy. Cell Rep Med 2023; 4:101145. [PMID: 37552990 PMCID: PMC10439248 DOI: 10.1016/j.xcrm.2023.101145] [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: 04/09/2022] [Revised: 12/24/2022] [Accepted: 07/13/2023] [Indexed: 08/10/2023]
Abstract
Immune checkpoint immunotherapy (ICI) can re-activate immune reactions against neoantigens, leading to remarkable remission in cancer patients. Nevertheless, only a minority of patients are responsive to ICI, and approaches for prediction of responsiveness are needed to improve the success of cancer treatments. While the tumor mutational burden (TMB) correlates positively with responsiveness and survival of patients undergoing ICI, the influence of the subcellular localizations of the neoantigens remains unclear. Here, we demonstrate in both a mouse melanoma model and human clinical datasets of 1,722 ICI-treated patients that a high proportion of membrane-localized neoantigens, particularly at the plasma membrane, correlate with responsiveness to ICI therapy and improved overall survival across multiple cancer types. We further show that combining membrane localization and TMB analyses can enhance the predictability of cancer patient response to ICI. Our results may have important implications for establishing future clinical guidelines to direct the choice of treatment toward ICI.
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Affiliation(s)
- Zoe Goldberger
- Pritzker School of Molecular Engineering, University of Chicago, Chicago, IL, USA; Department of Bioengineering, McGill University, Montreal, QC, Canada
| | - Sylvie Hauert
- Pritzker School of Molecular Engineering, University of Chicago, Chicago, IL, USA
| | - Kevin Chang
- Pritzker School of Molecular Engineering, University of Chicago, Chicago, IL, USA
| | - Trevin Kurtanich
- Pritzker School of Molecular Engineering, University of Chicago, Chicago, IL, USA
| | - Aaron T Alpar
- Pritzker School of Molecular Engineering, University of Chicago, Chicago, IL, USA
| | - Grégoire Repond
- Pritzker School of Molecular Engineering, University of Chicago, Chicago, IL, USA
| | - Yue Wang
- Pritzker School of Molecular Engineering, University of Chicago, Chicago, IL, USA
| | - Suzana Gomes
- Pritzker School of Molecular Engineering, University of Chicago, Chicago, IL, USA
| | | | - Prabha Siddarth
- Semel Institute for Neuroscience & Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
| | - Melody A Swartz
- Pritzker School of Molecular Engineering, University of Chicago, Chicago, IL, USA; Ben May Department of Cancer Research, University of Chicago, Chicago, IL, USA; Committee on Immunology, University of Chicago, Chicago, IL, USA; Committee on Cancer Biology, University of Chicago, Chicago, IL, USA
| | - Jeffrey A Hubbell
- Pritzker School of Molecular Engineering, University of Chicago, Chicago, IL, USA; Committee on Immunology, University of Chicago, Chicago, IL, USA; Committee on Cancer Biology, University of Chicago, Chicago, IL, USA.
| | - Priscilla S Briquez
- Pritzker School of Molecular Engineering, University of Chicago, Chicago, IL, USA; Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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13
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Ghinea N, Lipworth W, Kerridge I, Zalcberg JR. How therapeutic advances have transformed the medical landscape: a primer for clinicians. Intern Med J 2023; 53:1306-1310. [PMID: 37255280 DOI: 10.1111/imj.16142] [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: 02/20/2023] [Accepted: 05/26/2023] [Indexed: 06/01/2023]
Abstract
Novel medicines are entering the market rapidly and are increasingly being used alone or in combination to treat illnesses of every sort. While transforming the lives of many patients, these new therapies have also forced us to reconsider the way we evaluate, use and fund medicines. This article offers a primer to help practitioners understand how the therapeutic landscape is changing and how this might impact the evidence generation, access to interventions, patient experience and quality of care.
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Affiliation(s)
- Narcyz Ghinea
- Department of Philosophy, Macquarie University, Sydney, New South Wales, Australia
| | - Wendy Lipworth
- Department of Philosophy, Macquarie University, Sydney, New South Wales, Australia
| | - Ian Kerridge
- Department of Philosophy, Macquarie University, Sydney, New South Wales, Australia
- Sydney Health Ethics, School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - John R Zalcberg
- Department of Medical Oncology, Alfred Health and School of Public Health, Monash University, Melbourne, Victoria, Australia
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14
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Carton M, Del Castillo JP, Colin JB, Kurtinecz M, Feuilly M, Pierron G, Arvis P, Khadir SK, Sparber-Sauer M, Orbach D. Larotrectinib versus historical standard of care in patients with infantile fibrosarcoma: protocol of EPI-VITRAKVI. Future Oncol 2023; 19:1645-1653. [PMID: 37133249 DOI: 10.2217/fon-2023-0114] [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: 05/04/2023] Open
Abstract
The EPI VITRAKVI study is a retrospective study designed to place the results of the single-arm Phase I/II larotrectinib SCOUT trial into context by comparison with external historical controls. Its primary objective is to compare the time to medical treatment failure between larotrectinib and the historical standard of care (chemotherapy) in patients with infantile fibrosarcoma. External historical cohorts have been selected by using objective criteria. The Inverse Probability of Treatment Weighting method will be used to adjust for potential confounding. The current publication illustrates how an external control arm study can complement data from a single-arm trial and addresses uncertainties encountered in the assessment of therapies targeting rare abnormalities where randomized controlled trials are considered not feasible. Clinical Trial Registration: NCT05236257 (ClinicalTrials.gov).
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Affiliation(s)
- Matthieu Carton
- Biometry Unit, Institut Curie, PSL Research University, Paris, 75005, France
| | - Johanna Peña Del Castillo
- Klinikum der Landeshauptstadt Stuttgart gKAöR, Olgahospital, Stuttgart Cancer Center, Zentrum für Kinder-, Jugend- und Frauenmedizin, Pädiatrie 5 (Pädiatrische Onkologie, Hämatologie, Immunologie), Stuttgart, 70174, Germany
| | | | | | - Marion Feuilly
- Bayer HealthCare SAS, La Garenne-Colombes, 92035, France
| | - Gaëlle Pierron
- Genetic Somatic Unit, PSL Research University, Institut Curie, Paris, 75005, France
| | | | | | - Monika Sparber-Sauer
- Klinikum der Landeshauptstadt Stuttgart gKAöR, Olgahospital, Stuttgart Cancer Center, Zentrum für Kinder-, Jugend- und Frauenmedizin, Pädiatrie 5 (Pädiatrische Onkologie, Hämatologie, Immunologie), Stuttgart, 70174, Germany
- Medizinische Fakultät der Universität Tübingen, Tübingen, 72076, Germany
| | - Daniel Orbach
- SIREDO Oncology Center (Care, Innovation & Research for Children & AYA with Cancer), PSL Research University, Institut Curie, Paris, 75005, France
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15
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Scarpa JR, Elemento O. Multi-omic molecular profiling and network biology for precision anaesthesiology: a narrative review. Br J Anaesth 2023:S0007-0912(23)00125-3. [PMID: 37055274 DOI: 10.1016/j.bja.2023.03.006] [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: 11/11/2022] [Revised: 02/21/2023] [Accepted: 03/04/2023] [Indexed: 04/15/2023] Open
Abstract
Technological advancement, data democratisation, and decreasing costs have led to a revolution in molecular biology in which the entire set of DNA, RNA, proteins, and various other molecules - the 'multi-omic' profile - can be measured in humans. Sequencing 1 million bases of human DNA now costs US$0.01, and emerging technologies soon promise to reduce the cost of sequencing the whole genome to US$100. These trends have made it feasible to sample the multi-omic profile of millions of people, much of which is publicly available for medical research. Can anaesthesiologists use these data to improve patient care? This narrative review brings together a rapidly growing literature in multi-omic profiling across numerous fields that points to the future of precision anaesthesiology. Here, we discuss how DNA, RNA, proteins, and other molecules interact in molecular networks that can be used for preoperative risk stratification, intraoperative optimisation, and postoperative monitoring. This literature provides evidence for four fundamental insights: (1) Clinically similar patients have different molecular profiles and, as a consequence, different outcomes. (2) Vast, publicly available, and rapidly growing molecular datasets have been generated in chronic disease patients and can be repurposed to estimate perioperative risk. (3) Multi-omic networks are altered in the perioperative period and influence postoperative outcomes. (4) Multi-omic networks can serve as empirical, molecular measurements of a successful postoperative course. With this burgeoning universe of molecular data, the anaesthesiologist-of-the-future will tailor their clinical management to an individual's multi-omic profile to optimise postoperative outcomes and long-term health.
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Affiliation(s)
- Joseph R Scarpa
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
| | - Olivier Elemento
- Caryl and Israel Englander Institute for Precision Medicine, Weill Cornell Medicine, Cornell University, New York, NY, USA
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16
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Wang J, Hesketh RL. 18F-NaF PET-CT versus 99mTc SPECT in bone metastasis assessment. Lancet Oncol 2023; 24:e68. [PMID: 36725148 DOI: 10.1016/s1470-2045(23)00003-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 01/04/2023] [Indexed: 02/01/2023]
Affiliation(s)
- Jiazheng Wang
- Clinical and Technical Support, Philips Healthcare, Beijing, China.
| | - Richard L Hesketh
- Department of Radiology, University College London Hospital, London, UK
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Kang J, Cairns J. Exploring uncertainty and use of real-world data in the National Institute for Health and Care Excellence single technology appraisals of targeted cancer therapy. BMC Cancer 2022; 22:1268. [PMID: 36471259 PMCID: PMC9724266 DOI: 10.1186/s12885-022-10350-8] [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: 06/14/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Dealing with uncertainty is one of the critical topics in health technology assessment. The greater decision uncertainty in appraisals, the less clear the clinical- and cost-effectiveness of the health technology. Although the development of targeted cancer therapies (TCTs) has improved patient health care, additional complexity has been introduced in drug appraisals due to targeting more specific populations. Real-world data (RWD) are expected to provide helpful information to fill the evidence gaps in appraisals. This study compared appraisals of TCTs with those of non-targeted cancer therapies (non-TCTs) regarding sources of uncertainty and reviewed how RWD have been used to supplement the information in these appraisals. METHODS This study reviews single technology appraisals (STAs) of oncology medicines performed by the National Institute for Health and Care Excellence (NICE) over 11 years up to December 2021. Three key sources of uncertainty were identified for comparison (generalisability of clinical trials, availability of direct treatment comparison, maturity of survival data in clinical trials). To measure the intensity of use of RWD in appraisals, three components were identified (overall survival, volume of treatment, and choice of comparators). RESULTS TCTs received more recommendations for provision through the Cancer Drugs Fund (27.7, 23.6% for non-TCT), whereas similar proportions were recommended for routine commissioning. With respect to sources of uncertainty, the external validity of clinical trials was greater in TCT appraisals (p = 0.026), whereas mature survival data were available in fewer TCT appraisals (p = 0.027). Both groups showed similar patterns of use of RWD. There was no clear evidence that RWD have been used more intensively in appraisals of TCT. CONCLUSIONS Some differences in uncertainty were found between TCT and non-TCT appraisals. The appraisal of TCT is generally challenging, but these challenges are neither new nor distinctive. The same sources of uncertainty were often found in the non-TCT appraisals. The uncertainty when appraising TCT stems from insufficient data rather than the characteristics of the drugs. Although RWD might be expected to play a more active role in appraisals of TCT, the use of RWD has generally been limited.
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Affiliation(s)
- Jiyeon Kang
- grid.8991.90000 0004 0425 469XDepartment of Health Service Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock place, London, WC1H 9SH UK ,grid.7914.b0000 0004 1936 7443Centre for Cancer Biomarkers (CCBIO), University of Bergen, Bergen, Norway
| | - John Cairns
- grid.8991.90000 0004 0425 469XDepartment of Health Service Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock place, London, WC1H 9SH UK ,grid.7914.b0000 0004 1936 7443Centre for Cancer Biomarkers (CCBIO), University of Bergen, Bergen, Norway
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Innovations in Clinical Development in Rare Diseases of Children and Adults: Small Populations and/or Small Patients. Paediatr Drugs 2022; 24:657-669. [PMID: 36241954 DOI: 10.1007/s40272-022-00538-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2022] [Indexed: 10/17/2022]
Abstract
Many of the afflictions of children are rare diseases. This creates numerous drug development challenges related to small populations, including limited information about the disease state, enrollment challenges, and diminished incentives for pediatric development of novel therapies by pharmaceutical and biotechnology sponsors. We review selected innovations in clinical development that may partially mitigate some of these difficulties, starting with the concept of development efficiency for individual clinical trials, clinical programs (involving multiple trials for a single drug), and clinical portfolios of multiple drugs, and decision analysis as a tool to optimize efficiency. Development efficiency is defined as the ability to reach equally rigorous or more rigorous conclusions in less time, with fewer trial participants, or with fewer resources. We go on to discuss efficient methods for matching targeted therapies to biomarker-defined subgroups, methods for eliminating or reducing the need for natural history data to guide rare disease development, the use of basket trials to enhance efficiency by grouping multiple similar disease applications in a single clinical trial, and the use of alternative data sources including historical controls to augment or replace concurrent controls in clinical studies. Greater understanding and broader application of these methods could lead to improved therapies and/or more widespread and rapid access to novel therapies for rare diseases in both children and adults.
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19
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D'Aiello A, Halmos B. Tissue-agnostic RET inhibition: can you trust your target? Lancet Oncol 2022; 23:1235-1237. [DOI: 10.1016/s1470-2045(22)00556-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/26/2022]
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20
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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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21
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Cho D, Cheyne S, Lord SJ, Simes J, Lee CK. Extrapolating evidence for molecularly targeted therapies from common to rare cancers: a scoping review of methodological guidance. BMJ Open 2022; 12:e058350. [PMID: 35820758 PMCID: PMC9274540 DOI: 10.1136/bmjopen-2021-058350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Cancer is increasingly classified according to biomarkers that drive tumour growth and therapies developed to target them. In rare biomarker-defined cancers, randomised controlled trials to adequately assess targeted therapies may be infeasible. Extrapolating existing evidence of targeted therapy from common cancers to rare cancers sharing the same biomarker may reduce evidence requirements for regulatory approval in rare cancers. It is unclear whether guidelines exist for extrapolation. We sought to identify methodological guidance for extrapolating evidence from targeted therapies used for common cancers to rare biomarker-defined cancers. DESIGN Scoping review. DATA SOURCES Websites of health technology assessment agencies, regulatory bodies, research groups, scientific societies and industry. EBM Reviews-Cochrane Methodology Register and Health Technology Assessment, Embase and MEDLINE databases (1946 to 11 May 2022). ELIGIBILITY CRITERIA Papers proposing a framework or recommendations for extrapolating evidence for rare cancers, small populations and biomarker-defined cancers. DATA EXTRACTION AND SYNTHESIS We extracted framework details where available and guidance for components of extrapolation. We used these components to structure and summarise recommendations. RESULTS We identified 23 papers. One paper provided an extrapolation framework but was not cancer specific. Extrapolation recommendations addressed six distinct components: strategies for grouping cancers as the same biomarker-defined disease; analytical validation requirements of a biomarker test to use across cancer types; strategies to generate control data when a randomised concurrent control arm is infeasible; sources to inform biomarker clinical utility assessment in the absence of prospective clinical evidence; requirements for surrogate endpoints chosen for the rare cancer; and assessing and augmenting safety data in the rare cancer. CONCLUSIONS In the absence of an established framework, our recommendations for components of extrapolation can be used to guide discussions about interpreting evidence to support extrapolation. The review can inform the development of an extrapolation framework for biomarker-targeted therapies in rare cancers.
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Affiliation(s)
- Doah Cho
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Saskia Cheyne
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Sarah J Lord
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
- School of Medicine, The University of Notre Dame Australia, Sydney Campus, Darlinghurst, New South Wales, Australia
| | - John Simes
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Chee Khoon Lee
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
- Cancer Care Centre, St George Hospital, Kogarah, New South Wales, Australia
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22
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Julian E, Gianfrate F, Sola-Morales O, Mol P, Bergmann JF, Salmonson T, Hebborn A, Grande M, Ruof J. How can a joint European health technology assessment provide an 'additional benefit' over the current standard of national assessments? : Insights generated from a multi-stakeholder survey in hematology/oncology. HEALTH ECONOMICS REVIEW 2022; 12:30. [PMID: 35652987 PMCID: PMC9161501 DOI: 10.1186/s13561-022-00379-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/27/2022] [Indexed: 05/03/2023]
Abstract
OBJECTIVES We conducted a multi-stakeholder survey to determine key areas where a joint European health technology assessment (HTA) could provide 'additional benefit' compared to the status quo of many parallel independent national and subnational assessments. METHODS Leveraging three iterative Delphi cycles, a semiquantitative questionnaire was developed covering evidence challenges and heterogeneity of value drivers within HTAs across Europe with a focus on hematology/oncology. The questionnaire consisted of five sections: i) background information; ii) value drivers in HTA assessments today; iii) evolving evidence challenges; iv) heterogeneity of value drivers across Europe; v) impact of Europe's Beating Cancer Plan (EBCP). The questionnaire was circulated across n = 189 stakeholder institutions comprising HTA and regulatory bodies, clinical oncology associations, patient representatives, and industry associations. RESULTS N = 30 responses were received (HTA bodies: 9; regulators: 10; patients' and physicians' associations: 3 each; industry: 5). Overall, 17 countries and EU level institutions were represented in the responses. Consistency across countries and stakeholder groups was high. Most relevant value drivers in HTAs today (scale 1, low to 5, high) were clinical trial design (mean 4.45), right endpoints (mean 4.40), and size of comparative effect (mean 4.33). Small patient numbers (mean 4.28) and innovative study designs (mean 4.1) were considered the most relevant evolving evidence challenges. Heterogeneity between regulatory and HTA evidence requirements and heterogeneity of the various national treatment standards and national HTA evidence requirements was high. All clinical and patient participants stated to have been with EBCP initiatives. CONCLUSIONS For a European HTA to provide an 'additional benefit' over the multitude of existing national assessments key methodological and process challenges need to be addressed. These include approaches to address uncertainty in clinical development; comparator choice; consistency in approaching patient-relevant endpoints; and a transparent and consistent management of both HTA and regulatory procedures as well as their interface, including all involved stakeholder groups.
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Affiliation(s)
| | | | | | - Peter Mol
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | | | | | - Jörg Ruof
- r-connect ltd, Basel, Switzerland.
- Medical School of Hanover, Hanover, Germany.
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Popat S, Ramagopalan SV, Ray J, Roze S, Subbiah V. Assessment of tumour-agnostic therapies in basket trials. Lancet Oncol 2022; 23:e7. [DOI: 10.1016/s1470-2045(21)00714-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
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24
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Bayle A, Italiano A, Massard C, Blay JY, Marabelle A. Basket trial health technology assessment requirements and limited access to innovations in oncology: The French paradox. Eur J Cancer 2022; 162:128-129. [PMID: 34983014 DOI: 10.1016/j.ejca.2021.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 01/12/2023]
Affiliation(s)
- Arnaud Bayle
- Drug Development Department (DITEP), Gustave Roussy, Villejuif, France; Oncostat U1018, Inserm, Université Paris-Saclay, Équipe Labellisée Ligue Contre le Cancer, Villejuif, France.
| | - Antoine Italiano
- Drug Development Department (DITEP), Gustave Roussy, Villejuif, France; Early Phase Trials and Sarcoma Units, Department of Medical Oncology, Institut Bergonié, Bordeaux, France; University of Bordeaux, Bordeaux, France; SCOPP (French Academic Association for Early Phase Trial in Oncology), France; Société Française d'Immunotherapie des Cancers (FITC) France.
| | - Christophe Massard
- Centre Eugène Marquis, Rennes, France; SCOPP (French Academic Association for Early Phase Trial in Oncology), France; Société Française d'Immunotherapie des Cancers (FITC) France.
| | - Jean-Yves Blay
- Department of Cancer Medicine, Léon Bérard Cancer Center, Lyon, France; SCOPP (French Academic Association for Early Phase Trial in Oncology), France; Société Française d'Immunotherapie des Cancers (FITC) France.
| | - Aurelien Marabelle
- Drug Development Department (DITEP), Gustave Roussy, Villejuif, France; Société Française d'Immunotherapie des Cancers (FITC) France; INSERM U1015 & CIC1428, Universite Paris Saclay, Villejuif, France.
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25
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Collignon O, Posch M, Schiel A. Assessment of tumour-agnostic therapies in basket trials. Lancet Oncol 2022; 23:e8. [DOI: 10.1016/s1470-2045(21)00717-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 12/22/2022]
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