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Blondeaux E, Xie W, Carmisciano L, Mura S, Sanna V, De Laurentiis M, Caputo R, Turletti A, Durando A, De Placido S, De Angelis C, Bisagni G, Gasparini E, Rimanti A, Puglisi F, Mansutti M, Landucci E, Fabi A, Arecco L, Perachino M, Bruzzone M, Boni L, Lambertini M, Del Mastro L, Regan MM. Intermediate clinical endpoints in early-stage breast cancer: an analysis of individual patient data from the Gruppo Italiano Mammella and Mammella Intergruppo trials. EClinicalMedicine 2024; 70:102501. [PMID: 38685923 PMCID: PMC11056413 DOI: 10.1016/j.eclinm.2024.102501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 05/02/2024] Open
Abstract
Background Intermediate clinical endpoints (ICEs) are frequently used as primary endpoint in randomised trials (RCTs). We aim to assess whether changes in different ICEs can be used to predict changes in overall survival (OS) in adjuvant breast cancer trials. Methods Individual patient level data from adjuvant phase III RCTs conducted by the Gruppo Italiano Mammella (GIM) and Mammella Intergruppo (MIG) study groups were used. ICEs were computed according to STEEP criteria. Using a two-stage meta-analytic model, we assessed the surrogacy of each ICE at both the outcome (i.e., OS and ICE are correlated irrespective of treatment) and trial (i.e., treatment effects on ICE and treatment effect on OS are correlated) levels. The following ICEs were considered as potential surrogate endpoints of OS: disease-free survival (DFS), distant disease-free survival (DDFS), distant relapse-free survival (DRFS), recurrence-free survival (RFS), recurrence-free interval (RFI), distant recurrence-free interval (DRFI), breast cancer-free interval (BCFI), and invasive breast cancer-free survival (IBCFS). The estimates of the degree of correlation were obtained by copula models and weighted linear regression. Kendall's τ and R2 ≥ 0.70 were considered as indicators of a clinically relevant surrogacy. Findings Among the 12,397 patients enrolled from November 1992 to July 2012 in six RCTs, median age at enrolment was 57 years (interquartile range (IQR) 49-65). After a median follow-up of 10.3 years (IQR 6.4-14.5), 2131 (17.2%) OS events were observed, with 1390 (65.2%) attributed to breast cancer. At the outcome-level, Kendall's τ ranged from 0.69 for BCFI to 0.84 for DRFS. For DFS, DDFS, DRFS, RFS, RFI, DRFI, BCFI, and IBCFS endpoints, over 95% of the 8-year OS variability was attributable to the variation of the 5-year ICE. At the trial-level, treatment effects for the different ICEs and OS were strongly correlated, with the highest correlation for RFS and DRFS and the lowest for BCFI. Interpretation Our results provide evidence supporting the use of DFS, DDFS, DRFS, RFS, RFI, DRFI, and IBCFS as primary endpoint in breast cancer adjuvant trials. Funding This analysis was supported by the Italian Association for Cancer Research ("Associazione Italiana per la Ricerca sul Cancro", AIRC; IG 2017/20760) and by Italian Ministry of Health-5 × 1000 funds (years 2021-2022).
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Affiliation(s)
- Eva Blondeaux
- U.O. Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Wanling Xie
- Division of Biostatistics, Dana-Farber Cancer Institute, Boston, USA
| | - Luca Carmisciano
- Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Pisa, Italy
| | - Silvia Mura
- Department of Medical Oncology, UOC Oncologia Medica, University Hospital of Sassari, Sassari, Italy
| | - Valeria Sanna
- Department of Medical Oncology, UOC Oncologia Medica, University Hospital of Sassari, Sassari, Italy
| | - Michelino De Laurentiis
- Istituto Nazionale per lo Studio e la Cura dei Tumouri, Fondazione Pascale IRCCS, Napoli, Italy
| | - Roberta Caputo
- Istituto Nazionale per lo Studio e la Cura dei Tumouri, Fondazione Pascale IRCCS, Napoli, Italy
| | - Anna Turletti
- Medical Oncology, Ospedale Martini ASL Città di Torino, Torino, Italy
| | - Antonio Durando
- Breast Unit, Città della Salute e della Scienza, Ospedale S. Anna, Torino, Italy
| | - Sabino De Placido
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Carmine De Angelis
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Giancarlo Bisagni
- Department of Oncology and Advanced Technology, Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Elisa Gasparini
- Department of Oncology and Advanced Technology, Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Anita Rimanti
- ASST Mantova, Azienda Ospedaliera Carlo Poma, Mantova, Italy
| | - Fabio Puglisi
- Department of Medical Oncology, Unit of Medical Oncology and Cancer Prevention, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Mauro Mansutti
- Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | | | - Alessandra Fabi
- Precision Medicine Breast Unit, Scientific Directorate, Department of Women, Children and Public Health Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Arecco
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Marta Perachino
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Marco Bruzzone
- U.O. Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Luca Boni
- U.O. Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Lambertini
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Lucia Del Mastro
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Internal Medicine and Medical Sciences (DiMI), School of Medicine, University of Genova, Genova, Italy
| | - Meredith M. Regan
- Division of Biostatistics, Dana-Farber Cancer Institute, Boston, USA
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Xie W, Ravi P, Buyse M, Halabi S, Kantoff P, Sartor O, Soule H, Clarke N, Dignam J, James N, Fizazi K, Gillessen S, Mottet N, Murphy L, Parulekar W, Sandler H, Tombal B, Williams S, Sweeney CJ. Validation of metastasis-free survival as a surrogate endpoint for overall survival in localized prostate cancer in the era of docetaxel for castration-resistant prostate cancer. Ann Oncol 2024; 35:285-292. [PMID: 38061427 PMCID: PMC10922430 DOI: 10.1016/j.annonc.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/20/2023] [Accepted: 11/29/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Prior work from the Intermediate Clinical Endpoints in Cancer of the Prostate (ICECaP) consortium (ICECaP-1) demonstrated that metastasis-free survival (MFS) is a valid surrogate for overall survival (OS) in localized prostate cancer (PCa). This was based on data from patients treated predominantly before 2004, prior to docetaxel being available for the treatment of metastatic castrate-resistant prostate cancer (mCRPC). We sought to validate surrogacy in a more contemporary era (ICECaP-2) with greater availability of docetaxel and other systemic therapies for mCRPC. PATIENTS AND METHODS Eligible trials for ICECaP-2 were those providing individual patient data (IPD) after publication of ICECaP-1 and evaluating adjuvant/salvage therapy for localized PCa, and which collected MFS and OS data. MFS was defined as distant metastases or death from any cause, and OS was defined as death from any cause. Surrogacy was evaluated using a meta-analytic two-stage validation model, with an R2 ≥ 0.7 defined a priori as clinically relevant. RESULTS A total of 15 164 IPD from 14 trials were included in ICECaP-2, with 70% of patients treated after 2004. The median follow-up was 8.3 years and the median postmetastasis survival was 3.1 years in ICECaP-2, compared with 1.9 years in ICECaP-1. For surrogacy condition 1, Kendall's tau was 0.92 for MFS with OS at the patient level, and R2 from weighted linear regression (WLR) of 8-year OS on 5-year MFS was 0.73 (95% confidence interval 0.53-0.82) at the trial level. For condition 2, R2 was 0.83 (95% confidence interval 0.64-0.89) from WLR of log[hazard ratio (HR)]-OS on log(HR)-MFS. The surrogate threshold effect on OS was an HR(MFS) of 0.81. CONCLUSIONS MFS remained a valid surrogate for OS in a more contemporary era, where patients had greater access to docetaxel and other systemic therapies for mCRPC. This supports the use of MFS as the primary outcome measure for ongoing adjuvant trials in localized PCa.
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Affiliation(s)
- W Xie
- Dana-Farber Cancer Institute, Boston, USA
| | - P Ravi
- Dana-Farber Cancer Institute, Boston, USA
| | - M Buyse
- International Drug Development Institute, Louvain-la-Neuve; I-BioStat, Hasselt University, Hasselt, Belgium
| | | | | | | | - H Soule
- Prostate Cancer Foundation, Santa Monica, USA
| | - N Clarke
- The Christie NHS Foundation Trust, Manchester, UK
| | - J Dignam
- University of Chicago, Chicago, USA
| | - N James
- The Institute of Cancer Research & The Royal Marsden NHS Foundation Trust, London, UK
| | - K Fizazi
- Institut Gustave Roussy, University of Paris Saclay, Villejuif, France
| | - S Gillessen
- Oncology Institute of Southern Switzerland, EOC, Bellinzona; Università della Svizzera Italiana, Lugano, Switzerland
| | - N Mottet
- Mutualite Francoise Loire, St Etienne, France
| | - L Murphy
- Medical Research Council at UCL, London, UK
| | - W Parulekar
- Queens University, Kingston, Ontario, Canada
| | - H Sandler
- Cedars-Sinai Medical Center, Los Angeles, USA
| | - B Tombal
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - S Williams
- Peter MacCallum Cancer Centre, Melbourne
| | - C J Sweeney
- South Australian Immunogenomics Cancer Institute, University of Adelaide, Adelaide, Australia.
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Thorlund K, Shephard C, Machado L, Bourgouin T, Hudson L, Ting E, Dempster W, Bick R. Adapting Health Technology Assessment agency standards for surrogate outcomes in early stage cancer trials: what needs to happen? Expert Rev Pharmacoecon Outcomes Res 2024; 24:331-342. [PMID: 38189086 DOI: 10.1080/14737167.2024.2302431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/03/2024] [Indexed: 01/09/2024]
Abstract
INTRODUCTION An avalanche of early stage cancer clinical trials is coming. The majority of these solely use surrogate outcomes that have not been validated against a target outcome of interest (e.g. overall survival). Current HTA guidance on surrogate outcome validation are not methodologically or practically conducive to this scenario. AREAS COVERED We provide a high-level overview of methods, approaches, and conceptual thinking for making better use of limited evidence within early stage cancer HTA submissions. We outline regulatory and HTA issues and emphasize how evidence transitions from one to another, what major gaps currently exist, and how these may be bridged. We summarize current methodologies and practices, their pros and cons. We outline how complementary measurements strengthen evaluations and address fallacies and biases of conventional statistical methods for surrogate outcomes validation. The value of real-world data to support some of the necessary validity components is discussed. Lastly, we address the importance of the patient voice for better understanding which surrogate outcomes may appropriately inform HTA. EXPERT OPINION Conventional surrogate outcome validation represents a fraught and sub-optimal framework for HTA purposes, particularly for early stage cancer. Tools for optimizing use of limited evidence exist. Education of stakeholders is highly needed.
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Affiliation(s)
- Kristian Thorlund
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Cal Shephard
- AstraZeneca Canada, Mississauga, Ontario, Canada
| | | | | | | | - Eon Ting
- AstraZeneca Canada, Mississauga, Ontario, Canada
| | | | - Robert Bick
- The CanCertainty Coalition, Toronto, Ontario, Canada
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Gao T, Yang Y, Zhang Z, Yang Y, Liu S, Hu Y, Zhu Y, Yang H, Fu J, Wang J, Lin T, Xi M, Li Q, Liu M, Zhao L. A Surrogate Endpoint for Overall Survival in Locally Advanced and Resectable Esophageal Squamous Cell Carcinoma: A Reanalysis of Data From the NEOCRTEC5010 Trial. Int J Radiat Oncol Biol Phys 2023; 117:809-820. [PMID: 37210047 DOI: 10.1016/j.ijrobp.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/27/2023] [Accepted: 05/13/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE This study aimed to investigate disease-free survival (DFS) as a surrogate endpoint for overall survival (OS) in patients with locally advanced and resectable esophageal squamous cell carcinoma. METHODS AND MATERIALS We re-analyzed patient data from the NEOCRTEC5010 randomized controlled trial (N = 451 patients) to compare their OS with that of an age- and sex-matched cohort from the general population of China. We used expected survival and the standardized mortality ratio, respectively, in our analysis of data collected from a neoadjuvant chemoradiation therapy (NCRT) plus surgery group and a surgery-only group. Published data from 6 randomized controlled trials and 20 retrospective studies were used to examine the correlation between DFS and OS at the trial level. RESULTS The annual hazard rate of disease progression decreased to 4.9% and 8.1% within 3 years in the NCRT and surgery groups, respectively. Patients who were disease-free at 36 months had a 5-year OS of 93.9% (95% CI, 89.7%-98.4%) in the NCRT group with a standardized mortality ratio of 1.1 (95% CI, 0.7-1.8; P = .5639). In contrast, the 5-year OS was only 12.9% (95% CI, 7.3%-22.6%) for patients in the NCRT group who exhibited disease progression within 36 months. At the trial level, DFS and OS were correlated with treatment effect (R2 = 0.605). CONCLUSIONS Disease-free status at 36 months is a valid surrogate endpoint for 5-year OS in patients with locally advanced and resectable esophageal squamous cell carcinoma. Patients who were disease-free at 36 months showed a favorable OS, which was indistinguishable from that of the age- and sex-matched comparison group from the general population; otherwise, their 5-year OS was extremely poor.
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Affiliation(s)
- Tiantian Gao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yong Yang
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China
| | - Zewei Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yuxian Yang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shiliang Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China
| | - Yonghong Hu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China
| | - Yujia Zhu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China
| | - Hong Yang
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China; Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Jianhua Fu
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China; Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Junye Wang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Ting Lin
- Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China; Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Mian Xi
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China
| | - Qiaoqiao Li
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China
| | - Mengzhong Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China.
| | - Lei Zhao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Guangdong Esophageal Cancer Institute, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China; Department of Radiation Oncology, Fujian Medical University Union Hospital, Fujian Key Laboratory of Intelligent Imaging and Precision Radiotherapy for Tumors (Fujian Medical University), Clinical Research Center for Radiology and Radiotherapy of Fujian Province (Digestive, Hematological and Breast Malignancies), Fuzhou, China.
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Roy S, Romero T, Michalski JM, Feng FY, Efstathiou JA, Lawton CA, Bolla M, Maingon P, de Reijke T, Joseph D, Ong WL, Sydes MR, Dearnaley DP, Tree AC, Carrier N, Nabid A, Souhami L, Incrocci L, Heemsbergen WD, Pos FJ, Zapatero A, Guerrero A, Alvarez A, San-Segundo CG, Maldonado X, Reiter RE, Rettig MB, Nickols NG, Steinberg ML, Valle LF, Ma TM, Farrell MJ, Neilsen BK, Juarez JE, Deng J, Vangala S, Avril N, Jia AY, Zaorsky NG, Sun Y, Spratt D, Kishan AU. Biochemical Recurrence Surrogacy for Clinical Outcomes After Radiotherapy for Adenocarcinoma of the Prostate. J Clin Oncol 2023; 41:5005-5014. [PMID: 37639648 PMCID: PMC10642893 DOI: 10.1200/jco.23.00617] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/30/2023] [Accepted: 07/12/2023] [Indexed: 08/31/2023] Open
Abstract
PURPOSE The surrogacy of biochemical recurrence (BCR) for overall survival (OS) in localized prostate cancer remains controversial. Herein, we evaluate the surrogacy of BCR using different surrogacy analytic methods. MATERIALS AND METHODS Individual patient data from 11 trials evaluating radiotherapy dose escalation, androgen deprivation therapy (ADT) use, and ADT prolongation were obtained. Surrogate candidacy was assessed using the Prentice criteria (including landmark analyses) and the two-stage meta-analytic approach (estimating Kendall's tau and the R2). Biochemical recurrence-free survival (BCRFS, time from random assignment to BCR or any death) and time to BCR (TTBCR, time from random assignment to BCR or cancer-specific deaths censoring for noncancer-related deaths) were assessed. RESULTS Overall, 10,741 patients were included. Dose escalation, addition of short-term ADT, and prolongation of ADT duration significantly improved BCR (hazard ratio [HR], 0.71 [95% CI, 0.63 to 0.79]; HR, 0.53 [95% CI, 0.48 to 0.59]; and HR, 0.54 [95% CI, 0.48 to 0.61], respectively). Adding short-term ADT (HR, 0.91 [95% CI, 0.84 to 0.99]) and prolonging ADT (HR, 0.86 [95% CI, 0.78 to 0.94]) significantly improved OS, whereas dose escalation did not (HR, 0.98 [95% CI, 0.87 to 1.11]). BCR at 48 months was associated with inferior OS in all three groups (HR, 2.46 [95% CI, 2.08 to 2.92]; HR, 1.51 [95% CI, 1.35 to 1.70]; and HR, 2.31 [95% CI, 2.04 to 2.61], respectively). However, after adjusting for BCR at 48 months, there was no significant treatment effect on OS (HR, 1.10 [95% CI, 0.96 to 1.27]; HR, 0.96 [95% CI, 0.87 to 1.06] and 1.00 [95% CI, 0.90 to 1.12], respectively). The patient-level correlation (Kendall's tau) for BCRFS and OS ranged between 0.59 and 0.69, and that for TTBCR and OS ranged between 0.23 and 0.41. The R2 values for trial-level correlation of the treatment effect on BCRFS and TTBCR with that on OS were 0.563 and 0.160, respectively. CONCLUSION BCRFS and TTBCR are prognostic but failed to satisfy all surrogacy criteria. Strength of correlation was greater when noncancer-related deaths were considered events.
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Affiliation(s)
- Soumyajit Roy
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL
| | - Tahmineh Romero
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jeff M. Michalski
- Department of Radiation Oncology, Washington University, St Louis, MO
| | - Felix Y. Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Jason A. Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Colleen A.F. Lawton
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Michel Bolla
- Radiotherapy Department, University Hospital, Grenoble, France
| | - Philippe Maingon
- Department of Oncology, Hematology, and Supportive Care, Sorbonne University, Paris, France
| | - Theo de Reijke
- Department of Urology, Prostate Cancer Network in the Netherlands, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - David Joseph
- Department of Medicine and Surgery, University of Western Australia, Perth, WA, Australia
| | - Wee Loon Ong
- Alfred Health Radiation Oncology, Monash University, Melbourne, VIC, Australia
| | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - David P. Dearnaley
- Division of Radiotherapy and Imaging, The Institute of Cancer Research and Department of Urology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alison C. Tree
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Nathalie Carrier
- Clinical Research Center, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Abdenour Nabid
- Department of Radiation Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Luis Souhami
- Department of Radiation Oncology, McGill University Health Centre, Montréal, QC, Canada
| | - Luca Incrocci
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Wilma D. Heemsbergen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Floris J. Pos
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | | | - Ana Alvarez
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Robert E. Reiter
- Department of Urology, University of California Los Angeles, Los Angeles, CA
| | - Matthew B. Rettig
- Department of Medical Oncology, University of California Los Angeles, Los Angeles, CA
| | - Nicholas G. Nickols
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Michael L. Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Luca F. Valle
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - T. Martin Ma
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Matthew J. Farrell
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Beth K. Neilsen
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Jesus E. Juarez
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Jie Deng
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Sitaram Vangala
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Norbert Avril
- Department of Radiology, Division of Nuclear Medicine, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - Angela Y. Jia
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Nicholas G. Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Yilun Sun
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
- Department of Population Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Daniel Spratt
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Amar U. Kishan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
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Pinto CA, Balantac Z, Mt-Isa S, Liu X, Bracco OL, Clarke H, Tervonen T. Regulatory benefit-risk assessment of oncology drugs: A systematic review of FDA and EMA approvals. Drug Discov Today 2023; 28:103719. [PMID: 37467877 DOI: 10.1016/j.drudis.2023.103719] [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: 04/25/2023] [Revised: 06/30/2023] [Accepted: 07/13/2023] [Indexed: 07/21/2023]
Abstract
The European Medicines Agency (EMA) and FDA have policy goals of strengthening benefit-risk (B-R) capabilities; but how this has been translating into regulatory practice is unclear. A systematic review of oncology drug approvals between 2015 and 2020 was conducted with approvals identified through review of FDA and EMA annual reports, with extraction of information on submission, clinical program and B-R assessment from publicly available review documents. Data were extracted from 236 reviews (EMA: 66 new submissions, 100 label extensions; FDA: 70 new submissions). The standard of evidence for B-R assessments seems to have diversified over time; yet, despite policy targets to extend their use, these assessments rarely include patient experience or real-world data.
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Affiliation(s)
- Cathy Anne Pinto
- Biostatistics and Research Decision Sciences (BARDS), Department of Epidemiology, Merck & Co., Rahway, NJ, USA.
| | | | | | - Xinyue Liu
- Biostatistics and Research Decision Sciences (BARDS), Department of Epidemiology, Merck & Co., Rahway, NJ, USA
| | - Oswaldo L Bracco
- Clinical Safety and Risk Management, Merck & Co., Rahway, NJ, USA
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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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8
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Zhang Z, Pan Q, Lu M, Zhao B. Intermediate endpoints as surrogates for outcomes in cancer immunotherapy: a systematic review and meta-analysis of phase 3 trials. EClinicalMedicine 2023; 63:102156. [PMID: 37600482 PMCID: PMC10432823 DOI: 10.1016/j.eclinm.2023.102156] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/22/2023] Open
Abstract
Background Cancer immunotherapy shows unique efficacy kinetics that differs from conventional treatment. These characteristics may lead to the prolongation of trial duration, hence reliable surrogate endpoints are urgently needed. We aimed to systematically evaluate the study-level performance of commonly reported intermediate clinical endpoints for surrogacy in cancer immunotherapy. Methods We searched the Embase, PubMed, and Cochrane databases, between database inception and October 18, 2022, for phase 3 randomised trials investigating the efficacy of immunotherapy in patients with advanced solid tumours. An updated search was done on July, 15, 2023. No language restrictions were used. Eligible trials had to set overall survival (OS) as the primary or co-primary endpoint and report at least one intermediate clinical endpoint including objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), and 1-year overall survival. Other key inclusion and exclusion criteria included: (1) adult patients (>18 years old) with advanced solid tumour; (2) no immunotherapy conducted in the control arms; (3) follow-up is long enough to achieve OS; (4) data should be public available. A two-stage meta-analytic approach was conducted to evaluate the magnitude of the association between these intermediate endpoints and OS. A surrogate was identified if the coefficient of determination (R2) was 0.7 or greater. Leave-one-out cross-validation and pre-defined subgroup analysis were conducted to examine the heterogeneity. Potential publication bias was evaluated using the Egger's and Begg's tests. This trial was registered with PROSPERO, number CRD42022381648. Findings 52,342 patients with 15 types of tumours from 77 phase 3 studies were included. ORR (R2 = 0.11; 95% CI, 0.00-0.24), DCR (R2 = 0.01; 95% CI, 0.00-0.01), and PFS (R2 = 0.40; 95% CI, 0.23-0.56) showed weak associations with OS. However, a strong correlation was observed between 1-year survival and clinical outcome (R2 = 0.74; 95% CI, 0.64-0.83). These associations remained relatively consistent across pre-defined subgroups stratified based on tumour types, masking methods, line of treatments, drug targets, treatment strategies, and follow-up durations. No significant heterogeneities or publication bias were identified. Interpretation 1-year milestone survival was the only identified surrogacy endpoint for outcomes in cancer immunotherapy. Ongoing investigations and development of new endpoints and incorporation of biomarkers are needed to identify potential surrogate markers that can be more robust than 1-year survival. This work may provide important references in assisting the design and interpretation of future clinical trials, and constitute complementary information in drafting clinical practice guidelines. Funding None.
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Affiliation(s)
- Zhishan Zhang
- Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
| | - Qunxiong Pan
- Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
| | - Mingdong Lu
- The Second Affiliated Hospital & Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Bin Zhao
- Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
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Jommi C, Galeone C. The Evaluation of Drug Innovativeness in Italy: Key Determinants and Internal Consistency. PHARMACOECONOMICS - OPEN 2023; 7:373-381. [PMID: 36763319 PMCID: PMC10169980 DOI: 10.1007/s41669-023-00393-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Innovative medicines are provided with dedicated funds and immediate market access in Italy. Innovativeness evaluation considers unmet need, added therapeutic value, and quality of the evidence. OBJECTIVE We aimed to evaluate the internal consistency and drivers of the innovativeness appraisal process. METHODS Appraisal reports on innovativeness refer to 1997-2021. We used both a descriptive approach and probabilistic multivariate analysis, using logistic regression models to compute odds ratios and 95% confidence intervals. The dependent variable is innovativeness status (innovative vs. non-innovative; full innovativeness vs. conditional innovativeness). Explanatory variables, besides the three above-mentioned domains, are the year of evaluation, drug type, target disease and population, and the number and type of available studies. RESULTS Among the 141 medicines scrutinized, 31.9%, 29.8%, and 38.3% were evaluated as fully innovative, conditionally innovative, and non-innovative, respectively. Added therapeutic value and the quality of the evidence were associated with the odds of receiving innovative status, and full compared with conditional innovativeness; unmet need was not a predictive variable. Other factors played a minor role: medicines for both solid tumours and rare diseases are more likely to be judged innovative; conditional innovativeness is more probable for medicines for rare diseases. CONCLUSIONS Innovativeness status is driven by the added therapeutic value and quality of evidence. The appraisal process is internally consistent and predictable. This provides industry with a clear indication of what is needed to ensure that access to their medicines is prioritized.
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Affiliation(s)
- Claudio Jommi
- Department of Pharmaceutical Sciences, Università del Piemonte Orientale, Novara, Italy.
- Cergas (Centre for Research on Health and Social Care Management), SDA Bocconi, Bocconi University, Milan, Italy.
| | - Carlotta Galeone
- Biostatistics & Outcome Research, Statinfo, Milan, Italy
- Bicocca Applied Statistics Center (B-ASC), Università degli Studi di Milano-Bicocca, Milan, Italy
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Neyt M, Devos C, Thiry N, Silversmit G, De Gendt C, Van Damme N, Castanares-Zapatero D, Hulstaert F, Verleye L. Belgian observational survival data (incidence years 2004-2017) and expenditure for innovative oncology drugs in twelve cancer indications. Eur J Cancer 2023; 182:23-37. [PMID: 36731327 DOI: 10.1016/j.ejca.2022.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/19/2022] [Accepted: 12/28/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The Food and Drug Administration and European Medicines Agency typically approve market access for cancer drugs based on surrogate end-points, which do not always translate into substantiated improvements in outcomes that matter the most to patients, i.e. survival and quality of life. These drugs often, also, have a high price tag. We assessed whether there was an increase in cancer drug expenditure for a broad selection of indications, and whether this correlates with increased overall survival. METHODS This cohort study used Belgian Cancer Registry data from 125,692 patients (12 cancer indications, incidence period 2004-2017), which was linked to reimbursement and survival data. This reliably represents the Belgian situation. One-to-five year observed survival probability, median survival time, oncology drug expenditure and mean oncology drug cost per patient were reviewed. FINDINGS In almost all indications, total expenditure and average treatment cost for oncology drugs increased over the years (2004-2017). In contrast, mixed findings are observed for the evolution in overall survival probability and median survival time. While an absolute improvement in the 3-year survival probability of about 10% is noticed in non-small-cell lung cancer and chronic myeloid leukaemia, improvements in about half of the other indications are limited or even absent. INTERPRETATION The Belgian observational data indicate that assuming 'innovative' oncology drugs always add value in terms of improved survival is often unjustified. The literature also highlights the problem of using surrogate end-points, and the lack of comparative evidence showing an added value of oncology drugs for both survival and quality of life at market approval or during the post-marketing phase. Comparative studies should be conducted in the pre-marketing phase that are suitable for registration purposes, aid reimbursement decisions and support physicians and patients when making treatment decisions.
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Affiliation(s)
- Mattias Neyt
- Belgian Health Care Knowledge Centre (KCE), Belgium.
| | - Carl Devos
- Belgian Health Care Knowledge Centre (KCE), Belgium
| | - Nancy Thiry
- Belgian Health Care Knowledge Centre (KCE), Belgium
| | | | | | | | | | | | - Leen Verleye
- Belgian Health Care Knowledge Centre (KCE), Belgium
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11
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Immune-related adverse events as potential surrogates of immune checkpoint inhibitors' efficacy: a systematic review and meta-analysis of randomized studies. ESMO Open 2023; 8:100787. [PMID: 36842300 PMCID: PMC9984799 DOI: 10.1016/j.esmoop.2023.100787] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 12/03/2022] [Accepted: 01/04/2023] [Indexed: 02/28/2023] Open
Abstract
BACKGROUND Immune-related adverse events (irAEs) are frequently reported during immune checkpoint inhibitor (ICI) therapy and are associated with long-term outcomes. It is unknown if the irAE occurrence is a valid surrogate of ICIs' efficacy. METHODS We identified articles reporting the results of randomized trials of experimental ICI therapy in solid tumors with a systematic search. The control arms could be placebo, cytotoxic/targeted therapy, or ICI therapy. We extracted the hazard ratios for overall survival (OS) with the number of OS events per arm and the number and percentages of overall and specific irAEs of grade 1-2 and grade 3-4 per arm. We estimated the treatment effect on the potential surrogate outcome with the odds ratio of the irAE rate between the experimental and the control arm. The statistical analysis consisted of weighted linear regression on a logarithmic scale between treatment effects on irAE rate and treatment effects on OS. RESULTS Sixty-two randomized trials were included for a total of 79 contrasts and 42 247 patients. The analyses found no significant association between the treatment effects for overall grade 1-2 or grade 3-4 irAE rates or specific (skin, gastrointestinal, endocrine) irAE rates. In the non-small-cell lung cancer (NSCLC) trial subset, we observed a negative association between treatment effects on overall grade 1-2 irAEs and treatment effects on OS in studies with patients selected for programmed death-ligand 1 expression (R2 = 0.55; 95% confidence interval 0.20-0.95; R = -0.69). In the melanoma trial subset, a negative association was shown between treatment effects on gastrointestinal grade 3-4 irAEs and treatment effects on OS in trials without an ICI-based control arm (R2 = 0.77; 95% confidence interval 0.24-0.99; R = -0.89). CONCLUSIONS We found low-strength correlations between the ICI therapy effects on overall or specific irAE rates and the treatment effects on OS in several cancer types.
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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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Singh J, Bourke S, Dyer M, Devlin N, Longworth L. An Analysis of 5-Level Version of EQ-5D Adjusting for Treatment Switching: The Case of Patients With Epidermal Growth Factor Receptor T790M-Positive Nonsmall Cell Lung Cancer Treated With Osimertinib. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1205-1211. [PMID: 35379563 DOI: 10.1016/j.jval.2022.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 10/29/2021] [Accepted: 01/07/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Treatment switching from control to treatment after disease progression is common in oncology trials. Analyses of survival data typically adjust for this bias, but such adjustments are rarely performed in analyses of patient-reported outcomes. This analysis aimed to examine the impact of adjusting for treatment switching on estimated treatment effects on 5-level version of EQ-5D (EQ-5D-5L) utilities and quality-adjusted life-years (QALYs). The AURA3 trial (NCT02151981) was a randomized controlled trial comparing osimertinib with platinum-based doublet chemotherapy (standard care) in patients with locally advanced or metastatic epidermal growth factor receptor mutant- and T790M-positive nonsmall cell lung cancer whose disease has progressed with previous epidermal growth factor receptor tyrosine kinase inhibitor therapy. METHODS Descriptive analyses were used to compare treatment arms. The primary analysis used a 2-stage least squares instrumental variable regression to estimate treatment effect adjusting for treatment crossover. Time to deterioration, defined from baseline to minimally important deterioration in EQ-5D-5L utility, was assessed using a rank preserving structural failure time model. RESULTS Intention-to-treat analysis of imputed data showed incremental QALYs for osimertinib of 0.23 at 60 weeks. Accounting for treatment switching increased this to 0.52 in the primary analysis and to 0.63 QALYs in sensitivity analysis at 150 weeks. Time to deterioration analysis showed longer health-related quality of life maintenance with osimertinib, of 12.76 weeks, although this was at the borderline of statistical significance (acceleration factor, ψ = -0.275; 95% confidence interval -0.50 to 0.00). CONCLUSIONS This analysis demonstrates methods to adjust for treatment switching in the analysis of EQ-5D-5L from clinical trials. Failure to account for crossover substantially underestimated the QALY gain for osimertinib.
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Affiliation(s)
| | - Siobhan Bourke
- PHMR Limited, Berkeley Works, London, England, UK; Department of Health Services Research and Policy, The Australian National University, Canberra, Australia
| | | | - Nancy Devlin
- Centre for Health Policy, University of Melbourne, Parkville, Australia
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A systematic literature review of revealed preferences of decision-makers for recommendations of cancer drugs in health technology assessment. Int J Technol Assess Health Care 2022; 38:e36. [PMID: 35382919 DOI: 10.1017/s0266462322000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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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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Rizzo A, Oderda M, Mollica V, Merler S, Morelli F, Fragomeno B, Taveri E, Sorgentoni G, Santoni M, Massari F. A meta-analysis on overall survival and safety outcomes in patients with nonmetastatic castration-resistant prostate cancer treated with novel hormonal agents. Anticancer Drugs 2022; 33:e43-e51. [PMID: 34387593 DOI: 10.1097/cad.0000000000001168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Several novel androgen receptor (AR)-inhibitors have been introduced for nonmetastatic castration-resistant prostate cancer (nmCRPC) treatment, with the improvement of survival outcomes which need to be balanced against the risk of adverse events. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating enzalutamide, apalutamide and darolutamide in nmCRPC patients, to assess overall survival (OS), incidence and risk of adverse drug events, adverse-events-related death and adverse-events-related treatment discontinuation. We selected three RCTs (SPARTAN, PROSPER and ARAMIS). New hormonal agents administration resulted in better OS, despite the increased risk of several any grade and grade 3-4 adverse events. In the decision-making process, careful evaluation of expected adverse events, patients' comorbidities and maintenance of quality of life are mandatory.
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Affiliation(s)
- Alessandro Rizzo
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna
| | - Marco Oderda
- Department of Urology, San Giovanni Battista Hospital, Città della Salute e della Scienza, University of Turin, Turin
| | - Veronica Mollica
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna
| | - Sara Merler
- U.O.C. Oncology, Azienda Ospedaliera Universitaria Integrata, University and Hospital Trust of Verona, Verona
| | - Franco Morelli
- Medical Oncology Department, Casa Sollievo Della Sofferenza Hospital, IRCCS, San Giovanni Rotondo
| | - Benedetta Fragomeno
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna
| | - Elena Taveri
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna
| | | | | | - Francesco Massari
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna
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Lux MP, Ciani O, Dunlop WCN, Ferris A, Friedlander M. The Impasse on Overall Survival in Oncology Reimbursement Decision-Making: How Can We Resolve This? Cancer Manag Res 2021; 13:8457-8471. [PMID: 34795526 PMCID: PMC8592394 DOI: 10.2147/cmar.s328058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022] Open
Abstract
Mature overall survival (OS) data are often unavailable at the time of regulatory and reimbursement decisions for a new cancer treatment. For patients with early-stage cancers treated with potentially curative treatments, demonstrating an OS benefit may take years and may be confounded by subsequent lines of therapy or crossover to the investigational treatment. For patients with advanced-stage cancers, mature OS data may be available but difficult to interpret for similar reasons. There are strong opinions about approval and reimbursement in the absence of mature OS data, with concerns over delay in patient access set against concerns about uncertainty in long-term benefit. This position paper reflects our individual views as patient advocate, clinician or health economist on one aspect of this debate. We look at payer decisions in the absence of mature OS data, considering when and how non-OS trial outcomes could inform decision-making and how uncertainty can be addressed beyond the trial, supporting these views with evidence from the literature. We consider when it is reasonable for payers to expect or not expect mature OS data at the initial reimbursement decision (based on criteria such as cancer stage and treatment efficacy) acknowledging that there are settings in which mature OS data are expected. We propose flexible strategies for generating and appraising patient-relevant evidence, including context-relevant endpoints and quality of life measures, when survival rates are good and mature OS data are not expected. We note that fair reimbursement is important; this means valuing patient benefit as shown through prespecified endpoints and reappraising if there is ongoing uncertainty or failure to show a sustained benefit. We suggest that reimbursement systems continue to evolve to align with scientific advances, because innovation is only meaningful if readily accessible to patients. The proposed strategies have the potential to promote thorough assessment of potential benefit to patients and lead to timely access to effective medicines.
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Affiliation(s)
- Michael Patrick Lux
- Department of Gynecology and Obstetrics, Frauenklinik St. Louise Paderborn, St. Josefs-Krankenhaus Salzkotten, Frauen- und Kinderklinik St. Louise Paderborn, Paderborn, Germany
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management, SDA Bocconi, Milan, Italy
| | | | | | - Michael Friedlander
- Prince of Wales Clinical School, University of New South Wales and Department of Medical Oncology, The Prince of Wales Hospital, Sydney, NSW, Australia
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Dawoud D, Naci H, Ciani O, Bujkiewicz S. Raising the bar for using surrogate endpoints in drug regulation and health technology assessment. BMJ 2021; 374:n2191. [PMID: 34526320 DOI: 10.1136/bmj.n2191] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Dalia Dawoud
- Science, Evidence and Analytics Directorate, Science Policy and Research Programme, National Institute for Health and Care Excellence, London, UK
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management, SDA Bocconi, Milan, Italy
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Sylwia Bujkiewicz
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK
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19
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Surrogate Endpoints in Oncology: Overview of Systematic Reviews and Their Use for Health Decision Making in Mexico. Value Health Reg Issues 2021; 26:75-88. [PMID: 34130223 DOI: 10.1016/j.vhri.2021.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 01/28/2021] [Accepted: 04/08/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The use of surrogate endpoints (SEs) for cancer drug approval in health systems is common. The objectives of this study were to identify systematic reviews (SRs) that evaluated the correlation of SEs with overall survival (OS) in cancer drugs to analyze the applications of approved cancer drugs with SEs in Mexico and to apply the validation framework proposed by the Institute for Quality and Efficiency in Health Care (IQWiG). METHODS An overview of SRs was conducted according to Cochrane Collaboration methodology. Applications for approved cancer drugs with SEs in Mexico were analyzed. The IQWiG validation framework was applied to evaluate the SEs identified in the overview and in the applications in Mexico. RESULTS A total of 85 SRs that assessed 192 SEs for different types of cancer were selected. According to the IQWiG model, only 2.5% of the SEs analyzed in the overview and only one of the applications in Mexico could be used as surrogates for OS because the reliability (methodological quality) of the SRs and the strength of the correlation of SEs with OS was mostly low (92%) and low (correlation coefficient r ≤ 0.7; 50.5%), respectively. Of the total number of cancer drugs approved in Mexico, 19.4% used SEs. CONCLUSIONS Most SEs for different types of cancer could not be used as surrogates for OS according to the IQWiG model, and their use for the approval of cancer drugs in Mexico is generally not justified.
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20
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Geybels M, Wolthers BO, Kreiner FF, Rasmussen S, Bauer R. Surrogate endpoint evaluation using data from one large global randomized controlled trial. BMC Med Inform Decis Mak 2021; 21:164. [PMID: 34016120 PMCID: PMC8139150 DOI: 10.1186/s12911-021-01516-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Robust identification of surrogate endpoints can help accelerate the development of pharmacotherapies for diseases traditionally evaluated using true endpoints associated with prolonged follow-up. The meta-analysis-based surrogate endpoint evaluation (SEE) integrates data from multiple, usually smaller, trials to statistically confirm a surrogate endpoint as a robust proxy for the true endpoint. To test the applicability of SEE when only a single, larger trial is available, we analysed the cardiovascular (CV) survival endpoint from the large multinational trial LEADER (9340 subjects) that confirmed the CV safety of a diabetes drug (liraglutide). We evaluated if using country as a trial unit adequately facilitated the meta-analysis and calculation of R2 by country group. METHODS Data were grouped by country, ensuring at least 30 CV deaths (497 in total) in each of the nine resulting by-country groups. In a two-step SEE on the grouped dataset, we first fitted the group-specific Cox proportional hazard models; next, on the trial-level, we regressed the estimated hazard ratio (HR; liraglutide vs placebo) of the true endpoints (CV death: 497 events, or all-cause death: 828 events) on the HR of the surrogate endpoint (major CV adverse event [MACE]: 1302 events) and derived the group-specific R2 and its 95% confidence interval (CI). RESULTS Group-level surrogacy of MACE was supported for CV death but not for all-cause death, with [Formula: see text] values of 0.85 [0.63;1.00]95% CI and 0.23 [0.00;0.67]95% CI, respectively. Sensitivity analyses using different grouping approaches (e.g. grouping by region) corroborated the robustness of the conclusions as well as the appropriateness of the data-grouping approaches. CONCLUSIONS We derived a specific grouping approach to successfully apply SEE on data from a single trial. This may allow for the statistically robust identification and validation of surrogate endpoints based on the abundance of large monolithic outcome trials conducted as part of drug development programmes in, for example, diabetes.
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Affiliation(s)
- Milan Geybels
- Novo Nordisk A/S, Vandtårnsvej 110-114, 2860, Søborg, Denmark
| | | | | | - Søren Rasmussen
- Novo Nordisk A/S, Vandtårnsvej 110-114, 2860, Søborg, Denmark
| | - Robert Bauer
- Novo Nordisk A/S, Vandtårnsvej 110-114, 2860, Søborg, Denmark
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21
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Ciani O, Grigore B, Blommestein H, de Groot S, Möllenkamp M, Rabbe S, Daubner-Bendes R, Taylor RS. Validity of Surrogate Endpoints and Their Impact on Coverage Recommendations: A Retrospective Analysis across International Health Technology Assessment Agencies. Med Decis Making 2021; 41:439-452. [PMID: 33719711 PMCID: PMC8108112 DOI: 10.1177/0272989x21994553] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/21/2021] [Indexed: 12/03/2022]
Abstract
BACKGROUND Surrogate endpoints (i.e., intermediate endpoints intended to predict for patient-centered outcomes) are increasingly common. However, little is known about how surrogate evidence is handled in the context of health technology assessment (HTA). OBJECTIVES 1) To map methodologies for the validation of surrogate endpoints and 2) to determine their impact on acceptability of surrogates and coverage decisions made by HTA agencies. METHODS We sought HTA reports where evaluation relied on a surrogate from 8 HTA agencies. We extracted data on the methods applied for surrogate validation. We assessed the level of agreement between agencies and fitted mixed-effects logistic regression models to test the impact of validation approaches on the agency's acceptability of the surrogate endpoint and their coverage recommendation. RESULTS Of the 124 included reports, 61 (49%) discussed the level of evidence to support the relationship between the surrogate and the patient-centered endpoint, 27 (22%) reported a correlation coefficient/association measure, and 40 (32%) quantified the expected effect on the patient-centered outcome. Overall, the surrogate endpoint was deemed acceptable in 49 (40%) reports (k-coefficient 0.10, P = 0.004). Any consideration of the level of evidence was associated with accepting the surrogate endpoint as valid (odds ratio [OR], 4.60; 95% confidence interval [CI], 1.60-13.18, P = 0.005). However, we did not find strong evidence of an association between accepting the surrogate endpoint and agency coverage recommendation (OR, 0.71; 95% CI, 0.23-2.20; P = 0.55). CONCLUSIONS Handling of surrogate endpoint evidence in reports varied greatly across HTA agencies, with inconsistent consideration of the level of evidence and statistical validation. Our findings call for careful reconsideration of the issue of surrogacy and the need for harmonization of practices across international HTA agencies.
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Affiliation(s)
- Oriana Ciani
- />Centre for Research on Health and Social Care Management, SDA Bocconi, Milan, Lombardia, Italy
- />Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, Devon, UK
| | - Bogdan Grigore
- Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, Devon, UK
| | - Hedwig Blommestein
- Institute for Medical Technology Assessment, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Saskia de Groot
- Institute for Medical Technology Assessment, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Meilin Möllenkamp
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
| | - Stefan Rabbe
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
| | - Rita Daubner-Bendes
- />Syreon Research Institute, Budapest, Hungary
- />MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, Scotland, UK
| | - Rod S. Taylor
- />Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, Devon, UK
- />MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, Scotland, UK
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22
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Gyawali B, de Vries EGE, Dafni U, Amaral T, Barriuso J, Bogaerts J, Calles A, Curigliano G, Gomez-Roca C, Kiesewetter B, Oosting S, Passaro A, Pentheroudakis G, Piccart M, Roitberg F, Tabernero J, Tarazona N, Trapani D, Wester R, Zarkavelis G, Zielinski C, Zygoura P, Cherny NI. Biases in study design, implementation, and data analysis that distort the appraisal of clinical benefit and ESMO-Magnitude of Clinical Benefit Scale (ESMO-MCBS) scoring. ESMO Open 2021; 6:100117. [PMID: 33887690 PMCID: PMC8086024 DOI: 10.1016/j.esmoop.2021.100117] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/16/2021] [Accepted: 03/22/2021] [Indexed: 12/15/2022] Open
Abstract
Background The European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) is a validated, widely used tool developed to score the clinical benefit from cancer medicines reported in clinical trials. ESMO-MCBS scores assume valid research methodologies and quality trial implementation. Studies incorporating flawed design, implementation, or data analysis may generate outcomes that exaggerate true benefit and are not generalisable. Failure to either indicate or penalise studies with bias undermines the intention and diminishes the integrity of ESMO-MCBS scores. This review aimed to evaluate the adequacy of the ESMO-MCBS to address bias generated by flawed design, implementation, or data analysis and identify shortcomings in need of amendment. Methods As part of a refinement of the ESMO-MCBS, we reviewed trial design, implementation, and data analysis issues that could bias the results. For each issue of concern, we reviewed the ESMO-MCBS v1.1 approach against standards derived from Helsinki guidelines for ethical human research and guidelines from the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use, the Food and Drugs Administration, the European Medicines Agency, and European Network for Health Technology Assessment. Results Six design, two implementation, and two data analysis and interpretation issues were evaluated and in three, the ESMO-MCBS provided adequate protections. Seven shortcomings in the ability of the ESMO-MCBS to identify and address bias were identified. These related to (i) evaluation of the control arm, (ii) crossover issues, (iii) criteria for non-inferiority, (iv) substandard post-progression treatment, (v) post hoc subgroup findings based on biomarkers, (vi) informative censoring, and (vii) publication bias against quality-of-life data. Conclusion Interpretation of the ESMO-MCBS scores requires critical appraisal of trials to understand caveats in trial design, implementation, and data analysis that may have biased results and conclusions. These will be addressed in future iterations of the ESMO-MCBS. We reviewed trial design, implementation, and data analysis issues that could bias the results of trials. These issues could skew the results of ESMO-MCBS scores. Six design, two implementation, and two analysis issues were reviewed, and seven shortcomings were identified. These issues will be addressed in future versions of the MCBS scale. Interpretation of MCBS scores requires critical appraisal of trials.
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Affiliation(s)
- B Gyawali
- Department of Oncology, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada; Division of Cancer Care and Epidemiology, Queen's University, Kingston, Ontario, Canada.
| | - E G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - U Dafni
- Laboratory of Biostatistics, School of Health Sciences, National and Kapodistrian University of Athens, Athens; Frontier Science Foundation-Hellas, Athens, Greece
| | - T Amaral
- Skin Cancer Center, Department of Dermatology, Eberhard Karls University, Tuebingen, Germany
| | - J Barriuso
- The Christie NHS Foundation Trust and Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - J Bogaerts
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - A Calles
- Medical Oncology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - G Curigliano
- Department of Oncology and Hemato-Oncology, University of Milan, Milan; European Institute of Oncology, IRCCS, Milan, Italy
| | - C Gomez-Roca
- Institut Universitaire du Cancer de Toulouse (IUCT), Toulouse, France
| | - B Kiesewetter
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - S Oosting
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A Passaro
- Division of Thoracic Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - M Piccart
- Jules Bordet Institute, Université Libre de Bruxelles, Brussels, Belgium
| | - F Roitberg
- WHO Cancer Management Consultant, Geneva, Switzerland; Instituto do Cancer do Estado de São Paulo (ICESP HCFMUSP), São Paulo, Brazil
| | - J Tabernero
- Vall d'Hebron Hospital Campus and Institute of Oncology (VHIO), UVic-UCC, IO-Quiron, Barcelona, Spain
| | - N Tarazona
- Department of Medical Oncology, Biomedical Research Institute INCLIVA, CIBERONC, University of Valencia, Valencia, Spain
| | - D Trapani
- European Institute of Oncology, IRCCS, Milan, Italy
| | - R Wester
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - G Zarkavelis
- University of Ioannina-Department of Medical Oncology, Ioannina, Greece
| | - C Zielinski
- Central European Cooperative Oncology Group and Central European Cancer Center, Wiener Privatklinik, Vienna, Austria
| | - P Zygoura
- Frontier Science Foundation-Hellas, Athens, Greece
| | - N I Cherny
- Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
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23
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Taylor RS, Walker S, Ciani O, Warren F, Smart NA, Piepoli M, Davos CH. Exercise-based cardiac rehabilitation for chronic heart failure: the EXTRAMATCH II individual participant data meta-analysis. Health Technol Assess 2020; 23:1-98. [PMID: 31140973 DOI: 10.3310/hta23250] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Current national and international guidelines on the management of heart failure (HF) recommend exercise-based cardiac rehabilitation (ExCR), but do not differentiate this recommendation according to patient subgroups. OBJECTIVES (1) To obtain definitive estimates of the impact of ExCR interventions compared with no exercise intervention (control) on mortality, hospitalisation, exercise capacity and health-related quality of life (HRQoL) in HF patients; (2) to determine the differential (subgroup) effects of ExCR in HF patients according to their age, sex, left ventricular ejection fraction, HF aetiology, New York Heart Association class and baseline exercise capacity; and (3) to assess whether or not the change in exercise capacity mediates for the impact of the ExCR on final outcomes (mortality, hospitalisation and HRQoL), and determine if this is an acceptable surrogate end point. DESIGN This was an individual participant data (IPD) meta-analysis. SETTING An international literature review. PARTICIPANTS HF patients in randomised controlled trials (RCTs) of ExCR. INTERVENTIONS ExCR for at least 3 weeks compared with a no-exercise control, with 6 months' follow-up. MAIN OUTCOME MEASURES All-cause and HF-specific mortality, all-cause and HF-specific hospitalisation, exercise capacity and HRQoL. DATA SOURCES IPD from eligible RCTs. REVIEW METHODS RCTs from the Exercise Training Meta-Analysis of Trials for Chronic Heart Failure (ExTraMATCH/ExTraMATCH II) IPD meta-analysis and a 2014 Cochrane systematic review of ExCR (Taylor RS, Sagar VA, Davies EJ, Briscoe S, Coats AJ, Dalal H, et al. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev 2014;4:CD003331). RESULTS Out of the 23 eligible RCTs (4398 patients), 19 RCTs (3990 patients) contributed data to this IPD meta-analysis. There was a wide variation in exercise programme prescriptions across included studies. Compared with control, there was no statistically significant difference in pooled time-to-event estimates in favour of ExCR, although confidence intervals (CIs) were wide: all-cause mortality had a hazard ratio (HR) of 0.83 (95% CI 0.67 to 1.04); HF-related mortality had a HR of 0.84 (95% CI 0.49 to 1.46); all-cause hospitalisation had a HR of 0.90 (95% CI 0.76 to 1.06); and HF-related hospitalisation had a HR of 0.98 (95% CI 0.72 to 1.35). There was a statistically significant difference in favour of ExCR for exercise capacity and HRQoL. Compared with the control, improvements were seen in the 6-minute walk test (6MWT) (mean 21.0 m, 95% CI 1.57 to 40.4 m) and Minnesota Living with Heart Failure Questionnaire score (mean -5.94, 95% CI -1.0 to -10.9; lower scores indicate improved HRQoL) at 12 months' follow-up. No strong evidence for differential intervention effects across patient characteristics was found for any outcomes. Moderate to good levels of correlation (R 2 trial > 50% and p > 0.50) between peak oxygen uptake (VO2peak) or the 6MWT with mortality and HRQoL were seen. The estimated surrogate threshold effect was an increase of 1.6 to 4.6 ml/kg/minute for VO2peak. LIMITATIONS There was a lack of consistency in how included RCTs defined and collected the outcomes: it was not possible to obtain IPD from all includable trials for all outcomes and patient-level data on exercise adherence was not sought. CONCLUSIONS In comparison with the no-exercise control, participation in ExCR improved the exercise and HRQoL in HF patients, but appeared to have no effect on their mortality or hospitalisation. No strong evidence was found of differential intervention effects of ExCR across patient characteristics. VO2peak and 6MWT may be suitable surrogate end points for the treatment effect of ExCR on mortality and HRQoL in HF. Future studies should aim to achieve a consensus on the definition of outcomes and promote reporting of a core set of HF data. The research team also seeks to extend current policies to encourage study authors to allow access to RCT data for the purpose of meta-analysis. STUDY REGISTRATION This study is registered as PROSPERO CRD42014007170. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Rod S Taylor
- Institute of Health Research, University of Exeter Medical School, Exeter, UK.,Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Sarah Walker
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Oriana Ciani
- Institute of Health Research, University of Exeter Medical School, Exeter, UK.,Centre for Research on Health and Social Care Management, Bocconi University, Milan, Italy
| | - Fiona Warren
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Neil A Smart
- School of Science and Technology, University of New England, Armidale, NSW, Australia
| | - Massimo Piepoli
- Heart Failure Unit, Cardiology, Guglielmo da Saliceto Hospital, Piacenza, Italy
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24
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Cheng S, Cheung MC, Jiang DM, McDonald E, Arciero VS, Ezeife DA, Rahmadian A, Chambers A, Sabarre KA, Parmar A, Chan KKW. Are Surrogate Endpoints Unbiased Metrics in Clinical Benefit Scores of the ASCO Value Framework? J Natl Compr Canc Netw 2020; 17:1489-1496. [PMID: 31805528 DOI: 10.6004/jnccn.2019.7333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 06/18/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clinical benefit scores (CBS) are key elements of the ASCO Value Framework (ASCO-VF) and are weighted based on a hierarchy of efficacy endpoints: hazard ratio for death (HR OS), median overall survival (mOS), HR for disease progression (HR PFS), median progression-free survival (mPFS), and response rate (RR). When HR OS is unavailable, the other endpoints serve as "surrogates" to calculate CBS. CBS are computed from PFS or RR in 39.6% of randomized controlled trials. This study examined whether surrogate-derived CBS offer unbiased scoring compared with HR OS-derived CBS. METHODS Using the ASCO-VF, CBS for advanced disease settings were computed for randomized controlled trials of oncology drug approvals by the FDA, European Medicines Agency, and Health Canada in January 2006 through December 2017. Mean differences of surrogate-derived CBS minus HR OS-derived CBS assessed the tendency of surrogate-derived CBS to overestimate or underestimate clinical benefit. Spearman's correlation evaluated the association between surrogate- and HR OS-derived CBS. Mean absolute error assessed the average difference between surrogate-derived CBS relative to HR OS-derived CBS. RESULTS CBS derived from mOS, HR PFS, mPFS, and RR overestimated HR OS-derived CBS in 58%, 68%, 77%, and 55% of pairs and overall by an average of 5.62 (n=90), 6.86 (n=110), 29.81 (n=101), and 3.58 (n=108), respectively. Correlation coefficients were 0.80 (95% CI, 0.70-0.86), 0.38 (0.20-0.53), 0.20 (0.00-0.38), and 0.01 (-0.18 to 0.19) for mOS-, HR PFS-, mPFS-, and RR-derived CBS, respectively, and mean absolute errors were 11.32, 12.34, 40.40, and 18.63, respectively. CONCLUSIONS Based on the ASCO-VF algorithm, HR PFS-, mPFS-, and RR-derived CBS are suboptimal surrogates, because they were shown to be biased and poorly correlated to HR OS-derived CBS. Despite lower weighting than OS in the ASCO-VF algorithm, PFS still overestimated CBS. Simple rescaling of surrogate endpoints may not improve their validity within the ASCO-VF given their poor correlations with HR OS-derived CBS.
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Affiliation(s)
- Sierra Cheng
- aOdette Cancer Centre, Sunnybrook Health Sciences Centre, and
| | - Matthew C Cheung
- aOdette Cancer Centre, Sunnybrook Health Sciences Centre, and.,bDepartment of Medicine, University of Toronto
| | | | - Erica McDonald
- aOdette Cancer Centre, Sunnybrook Health Sciences Centre, and
| | | | | | | | | | | | - Ambika Parmar
- aOdette Cancer Centre, Sunnybrook Health Sciences Centre, and
| | - Kelvin K W Chan
- aOdette Cancer Centre, Sunnybrook Health Sciences Centre, and.,bDepartment of Medicine, University of Toronto.,dCanadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
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25
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Huang M, O’Shaughnessy J, Zhao J, Haiderali A, Cortes J, Ramsey S, Briggs A, Karantza V, Aktan G, Qi CZ, Gu C, Xie J, Yuan M, Cook J, Untch M, Schmid P, Fasching PA. Evaluation of Pathologic Complete Response as a Surrogate for Long-Term Survival Outcomes in Triple-Negative Breast Cancer. J Natl Compr Canc Netw 2020; 18:1096-1104. [DOI: 10.6004/jnccn.2020.7550] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/18/2020] [Indexed: 11/17/2022]
Abstract
Background: Pathologic complete response (pCR) is a common efficacy endpoint in neoadjuvant therapy trials for triple-negative breast cancer (TNBC). Previous studies have shown that pCR is strongly associated with improved long-term survival outcomes, including event-free survival (EFS) and overall survival (OS). However, the trial-level associations between treatment effect on pCR and long-term survival outcomes are not well established. This study sought to evaluate these associations by incorporating more recent clinical trials in TNBC. Methods: A literature review identified published randomized controlled trials (RCTs) of neoadjuvant therapy for TNBC that reported results for both pCR and EFS/OS. Meta-regression models were performed to evaluate the association of treatment effect on pCR and EFS/OS. Sensitivity analyses were conducted to assess the impact of divergent study designs. Results: Ten comparisons from 8 RCTs (N=2,478 patients) were identified from the literature review. The log (odds ratio) of pCR was a significant predictor of the log (hazard ratio) of EFS (P=.003), with a coefficient of determination of 0.68 (95% CI, 0.41–0.95). There was a weaker association between pCR and OS (P=.18), with a coefficient of determination of 0.24 (95% CI, 0.01–0.77). Consistent results were found in the exploratory analysis and sensitivity analyses. Conclusions: This is the first study that has shown a trial-level association between pCR and survival outcomes in TNBC. By incorporating the most up-to-date RCTs, this study showed a significant trial-level association between pCR and EFS. A positive association between pCR and OS was also recorded.
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Affiliation(s)
- Min Huang
- 1Merck & Co., Inc., Kenilworth, New Jersey
| | - Joyce O’Shaughnessy
- 2Baylor University Medical Center, Texas Oncology, and U.S. Oncology, Dallas, Texas
| | - Jing Zhao
- 1Merck & Co., Inc., Kenilworth, New Jersey
| | | | - Javier Cortes
- 3IOB Institute of Oncology, Quironsalud Group, Madrid and Barcelona, Spain
- 4Vall d’Hebron Institute of Oncology, Barcelona, Spain
| | - Scott Ramsey
- 5Fred Hutchinson Cancer Research Center, and University of Washington, Seattle, Washington
| | - Andrew Briggs
- 6London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Chenyang Gu
- 8Analysis Group, Inc., Los Angeles, California
| | - Jipan Xie
- 8Analysis Group, Inc., Los Angeles, California
| | - Muhan Yuan
- 7Analysis Group, Inc., Boston, Massachusetts
| | - John Cook
- 9Complete HEOR Solutions, North Wales, Pennsylvania
| | - Michael Untch
- 10Department of Gynecology, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Peter Schmid
- 11Barts Cancer Institute, Queen Mary University of London, London, United Kingdom; and
| | - Peter A. Fasching
- 12Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
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26
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Xie W, Regan MM, Buyse M, Halabi S, Kantoff PW, Sartor O, Soule H, Berry D, Clarke N, Collette L, D'Amico A, Lourenco RDA, Dignam J, Eisenberger M, James N, Fizazi K, Gillessen S, Loriot Y, Mottet N, Parulekar W, Sandler H, Spratt DE, Sydes MR, Tombal B, Williams S, Sweeney CJ. Event-Free Survival, a Prostate-Specific Antigen-Based Composite End Point, Is Not a Surrogate for Overall Survival in Men With Localized Prostate Cancer Treated With Radiation. J Clin Oncol 2020; 38:3032-3041. [PMID: 32552276 DOI: 10.1200/jco.19.03114] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Recently, we have shown that metastasis-free survival is a strong surrogate for overall survival (OS) in men with intermediate- and high-risk localized prostate cancer and can accelerate the evaluation of new (neo)adjuvant therapies. Event-free survival (EFS), an earlier prostate-specific antigen (PSA)-based composite end point, may further expedite trial completion. METHODS EFS was defined as the time from random assignment to the date of first evidence of disease recurrence, including biochemical failure, local or regional recurrence, distant metastasis, or death from any cause, or was censored at the date of last PSA assessment. Individual patient data from trials within the Intermediate Clinical Endpoints in Cancer of the Prostate-ICECaP-database with evaluable PSA and disease follow-up data were analyzed. We evaluated the surrogacy of EFS for OS using a 2-stage meta-analytic validation model by determining the correlation of EFS with OS (patient level) and the correlation of treatment effects (hazard ratios [HRs]) on both EFS and OS (trial level). A clinically relevant surrogacy was defined a priori as an R2 ≥ 0.7. RESULTS Data for 10,350 patients were analyzed from 15 radiation therapy-based trials enrolled from 1987 to 2011 with a median follow-up of 10 years. At the patient level, the correlation of EFS with OS was 0.43 (95% CI, 0.42 to 0.44) as measured by Kendall's tau from a copula model. At the trial level, the R2 was 0.35 (95% CI, 0.01 to 0.60) from the weighted linear regression of log(HR)-OS on log(HR)-EFS. CONCLUSION EFS is a weak surrogate for OS and is not suitable for use as an intermediate clinical end point to substitute for OS to accelerate phase III (neo)adjuvant trials of prostate cancer therapies for primary radiation therapy-based trials.
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Affiliation(s)
- Wanling Xie
- Division of Biostatistics, Dana-Farber Cancer Institute, Boston, MA
| | - Meredith M Regan
- Division of Biostatistics, Dana-Farber Cancer Institute, Boston, MA
| | - Marc Buyse
- International Drug Development Institute, Louvain la Neuve, Belgium
| | - Susan Halabi
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Philip W Kantoff
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Oliver Sartor
- Departments of Medicine & Urology, Tulane University, New Orleans, LA
| | | | - Donald Berry
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Noel Clarke
- Urological Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Laurence Collette
- European Organisation for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Anthony D'Amico
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, NSW, Australia
| | - James Dignam
- Department of Public Health Science, University of Chicago, Chicago, IL
| | - Mario Eisenberger
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Nicholas James
- University Hospitals Birmingham, Birmingham, United Kingdom
| | - Karim Fizazi
- Department of Cancer Medicine, Institut Gustave Roussy, Villejuif, France
| | - Silke Gillessen
- Division of Cancer Sciences, University of Manchester and The Christie, Manchester, United Kingdom
| | - Yohann Loriot
- Department of Cancer Medicine, Institut Gustave Roussy, Villejuif, France
| | - Nicolas Mottet
- Urology Oncology, University Jean Monnet, St Etienne, France
| | - Wendy Parulekar
- Canadian Cancer Trials Group, Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
| | - Howard Sandler
- Radiation Oncology, Cedars Sinai Medical Center, Los Angeles, CA
| | | | - Matthew R Sydes
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Bertrand Tombal
- Institut de Recherche Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Scott Williams
- Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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Taylor RS, Taylor RJ, Bayliss S, Hagström H, Nasr P, Schattenberg JM, Ishigami M, Toyoda H, Wai-Sun Wong V, Peleg N, Shlomai A, Sebastiani G, Seko Y, Bhala N, Younossi ZM, Anstee QM, McPherson S, Newsome PN. Association Between Fibrosis Stage and Outcomes of Patients With Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis. Gastroenterology 2020; 158:1611-1625.e12. [PMID: 32027911 DOI: 10.1053/j.gastro.2020.01.043] [Citation(s) in RCA: 568] [Impact Index Per Article: 142.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/19/2020] [Accepted: 01/22/2020] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Biopsy-confirmed liver fibrosis is a prognostic factor for patients with nonalcoholic fatty liver disease (NAFLD). We performed a systematic review to quantify the prognostic value of fibrosis stage in patients with NAFLD and the subgroup of patients with nonalcoholic steatohepatitis (NASH) and to assess the evidence that change in fibrosis stage is a surrogate endpoint. METHODS We searched the MEDLINE, Embase, Cochrane Library, and trial registry databases through August 2018 for prospective or retrospective cohort studies of liver-related clinical events and outcomes in adults with NAFLD or NASH. We collected data on mortality (all cause and liver related) and morbidity (cirrhosis, liver cancer, and all liver-related events) by stage of fibrosis, determined by biopsy, for patients with NAFLD or NASH. Using fibrosis stage 0 as a reference population, we calculated fibrosis stage-specific relative risk (RR) and 95% confidence interval (CI) values for mortality and morbidities. We performed fixed-effect and random-effect model meta-analyses. Metaregression was used to examine associations among study design (prospective vs retrospective cohort), overall risk of bias (medium or high), and mean duration of follow-up (in years). RESULTS Our meta-analysis included 13 studies, comprising 4428 patients with NAFLD; 2875 of these were reported to have NASH. Compared with no fibrosis (stage 0), unadjusted risk increased with increasing stage of fibrosis (stage 0 vs 4): all-cause mortality RR, 3.42 (95% CI, 2.63-4.46); liver-related mortality RR, 11.13 (95% CI, 4.15-29.84); liver transplant RR, 5.42 (95% CI, 1.05-27.89); and liver-related events RR, 12.78 (95% CI, 6.85-23.85). The magnitude of RR did not differ significantly after adjustment for confounders, including age or sex in the subgroup of NAFLD patients with NASH. Three studies examined the effects of increasing fibrosis on quality of life had inconsistent findings. CONCLUSIONS In a systematic review and meta-analysis, we found biopsy-confirmed fibrosis to be associated with risk of mortality and liver-related morbidity in patients with NAFLD, with and without adjustment for confounding factors and in patients with reported NASH. Further studies are needed to assess the association between fibrosis stage and patient quality of life and establish that change in liver fibrosis stage is a valid endpoint for use in clinical trials.
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Affiliation(s)
- Rod S Taylor
- Institute of Health and Well Being, University of Glasgow, United Kingdom.
| | | | - Sue Bayliss
- Institute of Applied Health Research, University of Birmingham, United Kingdom
| | - Hannes Hagström
- Unit of Hepatology, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Patrik Nasr
- Department of Gastroenterology and Hepatology, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Jorn M Schattenberg
- University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hidenori Toyoda
- Department of Gastroenterology and Hepatology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Noam Peleg
- Department of Gastroenterology and Hepatology, Rabin Medical Center, Beilinson Hospital, Petach-Tikva Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medicine D, Rabin Medical Center, Beilinson hospital, Petach-Tikva
| | - Amir Shlomai
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Giada Sebastiani
- Department of Medicine, McGill University Health Centre, Montréal, Quebec, Canada
| | - Yuya Seko
- Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Neeraj Bhala
- Institute of Applied Health Research, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, United Kingdom
| | - Zobair M Younossi
- Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia
| | - Quentin M Anstee
- Institute of Clinical and Translational Research, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne, United Kingdom; Newcastle National Institute of Health Research Biomedical Research Centre and Liver Transplant Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, United Kingdom
| | - Stuart McPherson
- Liver Transplant Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust; Institute of Clinical and Translational Research, Newcastle University, Newcastle-upon-Tyne, United Kingdom; Newcastle National Institute of Health Research Biomedical Research Centre, Newcastle-upon-Tyne, United Kingdom
| | - Philip N Newsome
- National Institute for Health Research Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, United Kingdom; Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom; Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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Progression-free survival as a surrogate for overall survival in oncology trials: a methodological systematic review. Br J Cancer 2020; 122:1707-1714. [PMID: 32214230 PMCID: PMC7250908 DOI: 10.1038/s41416-020-0805-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 01/16/2020] [Accepted: 02/28/2020] [Indexed: 02/08/2023] Open
Abstract
Background Progression-free survival (PFS) is a surrogate endpoint widely used for overall survival (OS) in oncology. Validation of PFS as a surrogate must be done for each indication and each intervention. We aimed to identify all studies evaluating the validity of PFS as a surrogate for OS in oncology, and to describe their methodological characteristics. Methods We conducted a systematic review by searching MEDLINE via PubMed and the Cochrane Library with no limitation on time, selected relevant studies and extracted data in duplicate on how surrogacy was evaluated (meta-analytic approach, assessment of correlation and level of evaluation). Results We identified 91 studies evaluating the validity of PFS as a surrogate for OS in 24 cancer localisations. Although a meta-analytic approach was used in 83 (91%) studies, the methods used to validate PFS as a surrogate of OS were heterogeneous across studies. Of the 47 studies concluding that PFS is a good surrogate for OS, for 15 (32%), there was no quantitative argument for surrogacy. Conclusions Although most studies used a meta-analytic approach as recommended, our methodological review highlights heterogeneity in methods and reporting, which stresses the importance of developing and applying clear recommendations in this area.
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Wilking N, Bucsics A, Kandolf Sekulovic L, Kobelt G, Laslop A, Makaroff L, Roediger A, Zielinski C. Achieving equal and timely access to innovative anticancer drugs in the European Union (EU): summary of a multidisciplinary CECOG-driven roundtable discussion with a focus on Eastern and South-Eastern EU countries. ESMO Open 2019; 4:e000550. [PMID: 31798977 PMCID: PMC6863652 DOI: 10.1136/esmoopen-2019-000550] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 12/19/2022] Open
Abstract
The Central European Cooperative Oncology Group (CECOG) and ‘ESMO Open—Cancer Horizons’ roundtable discussion brought together stakeholders from several European Union (EU) countries involved in drug development, drug authorisation and reimbursement or otherwise affected by delayed and unequal access to innovative anticancer drugs. The approval process of drugs is well established and access delays can be caused directly or indirectly by national or regional decision-making processes on reimbursement. The two key aspects for those involved in reimbursement decisions are first the level of evidence required to decide and second pricing, which can be challenging for some innovative oncology compounds, especially in Eastern and South-Eastern European countries. Other important factors include: available healthcare budget; the structure and sophistication of healthcare authorities and health technology assessment processes; societal context and political will. From the point of view of the pharmaceutical industry, better alignment between stakeholders in the process and adaptive pathway initiatives is desirable. Key aspects for patients are improved access to clinical trials, preapproval availability and reports on real-world evidence. Restricted access limits oncologists’ daily work in Eastern and South-Eastern EU countries. The roundtable discussion suggested considering the sequencing of regulatory approval and reimbursement decisions together with more flexible contracting as a possible way forward. The panel concluded that early and regular dialogue between all stakeholders including regulators, payers, patient stakeholders and industry is required to improve the situation.
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Affiliation(s)
| | - Anna Bucsics
- Mechanism of Coordinated Access to Orphan Medicinal Products, Vienna, Austria
| | | | | | - Andrea Laslop
- Scientific Office, Austrian Federal Office for Safety in Health Care, Vienna, Austria
| | - Lydia Makaroff
- Fight Bladder Cancer, Chinnor, United Kingdom and World Bladder Cancer Patient Coalition, Brussels, Belgium
| | - Alexander Roediger
- EFPIA Oncology Platform, Brussels, Belgium and Oncology Policy Europe, Middle East, Africa and Canada, MSD, Kriens, Switzerland
| | - Christoph Zielinski
- Central European Cooperative Oncology Group (CECOG) and Vienna Cancer Center, Vienna Hospital Association, Vienna, Austria
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The use of validated and nonvalidated surrogate endpoints in two European Medicines Agency expedited approval pathways: A cross-sectional study of products authorised 2011-2018. PLoS Med 2019; 16:e1002873. [PMID: 31504034 PMCID: PMC6736244 DOI: 10.1371/journal.pmed.1002873] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 08/07/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND In situations of unmet medical need or in the interests of public health, expedited approval pathways, including conditional marketing authorisation (CMA) and accelerated assessment (AA), speed up European Medicines Agency (EMA) marketing authorisation recommendations for medicinal products. CMAs are based on incomplete benefit-risk assessment data and authorisation remains conditional until regulator-imposed confirmatory postmarketing measures are fulfilled. For products undergoing AA, complete safety and efficacy data should be available, and postauthorisation measures may include only standard requirements of risk management and pharmacovigilance plans. In the pivotal trials supporting products assessed by expedited pathways, surrogate endpoints reduce drug development time compared with waiting for the intended clinical outcomes. Whether surrogate endpoints supporting products authorised through CMA and AA pathways reliably predict clinical benefits of therapy has not been studied systematically. Our objectives were to determine the extent to which surrogate endpoints are used and to assess whether their validity had been confirmed according to published hierarchies. METHODS AND FINDINGS We used European Public Assessment Reports (EPARs) to identify the primary endpoints in the pivotal trials supporting products authorised through CMA or AA pathways during January 1, 2011 to December 31, 2018. We excluded products that were vaccines, topical, reversal, or bleeding prophylactic agents or withdrawn within the study time frame. Where pivotal trials reported surrogate endpoints, we conducted PubMed searches for evidence of validity for predicting clinical outcomes. We used 2 published hierarchies to assess validity level. Surrogates with randomised controlled trials supporting the surrogate-clinical outcome relationship were rated as 'validated'. Fifty-one products met the inclusion criteria; 26 underwent CMAs, and 25 underwent AAs. Overall, 26 products were for oncology indications, 10 for infections, 8 for genetic disorders, and 7 for other systems disorders. Five products (10%), all AAs, were authorised based on pivotal trials reporting clinical outcomes, and 46 (90%) were authorised based on surrogate endpoints. No studies were identified that validated the surrogate endpoints. Among a total of 49 products with surrogate endpoints reported, most were rated according to the published hierarchies as being 'reasonably likely' (n = 30; 61%) or of having 'biological plausibility' (n = 46; 94%) to predict clinical outcomes. EPARs did not consistently explain the nature of the pivotal trial endpoints supporting authorisations, whether surrogate endpoints were validated or not, or describe the endpoints to be reported in the confirmatory postmarketing studies. Our study has limitations: we may have overlooked relevant validation studies; the findings apply to 2 expedited pathways and may not be generalisable to products authorised through the standard assessment pathway. CONCLUSIONS The pivotal trial evidence supporting marketing authorisations for products granted CMA or AA was based dominantly on nonvalidated surrogate endpoints. EPARs and summary product characteristic documents, including patient information leaflets, need to state consistently the nature and limitations of endpoints in pivotal trials supporting expedited authorisations so that prescribers and patients appreciate shortcomings in the evidence about actual clinical benefit. For products supported by nonvalidated surrogate endpoints, postauthorisation measures to confirm clinical benefit need to be imposed by the regulator on the marketing authorisation holders.
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Bachy E, Seymour JF, Feugier P, Offner F, López-Guillermo A, Belada D, Xerri L, Catalano JV, Brice P, Lemonnier F, Martin A, Casasnovas O, Pedersen LM, Dorvaux V, Simpson D, Leppa S, Gabarre J, da Silva MG, Glaisner S, Ysebaert L, Vekhoff A, Intragumtornchai T, Le Gouill S, Lister A, Estell JA, Milone G, Sonet A, Farhi J, Zeuner H, Tilly H, Salles G. Sustained Progression-Free Survival Benefit of Rituximab Maintenance in Patients With Follicular Lymphoma: Long-Term Results of the PRIMA Study. J Clin Oncol 2019; 37:2815-2824. [PMID: 31339826 PMCID: PMC6823890 DOI: 10.1200/jco.19.01073] [Citation(s) in RCA: 162] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The PRIMA study (ClinicalTrials.gov identifier: NCT00140582) established that 2 years of rituximab maintenance after first-line immunochemotherapy significantly improved progression-free survival (PFS) in patients with follicular lymphoma compared with observation. Here, we report the final PFS and overall survival (OS) results from the PRIMA study after 9 years of follow-up and provide a final overview of safety. METHODS Patients (> 18 years of age) with previously untreated high-tumor-burden follicular lymphoma were nonrandomly assigned to receive one of three immunochemotherapy induction regimens. Responding patients were randomly assigned (stratified by induction regimen, response to induction treatment, treatment center, and geographic region) 1:1 to receive 2 years of rituximab maintenance (375 mg/m2, once every 8 weeks), starting 8 weeks after the last induction treatment, or observation (no additional treatment). All patients in the extended follow-up provided their written informed consent (data cutoff: December 31, 2016). RESULTS In total, 1,018 patients completed induction treatment and were randomly assigned to rituximab maintenance (n = 505) or observation (n = 513). Consent for the extended follow-up was provided by 607 patients (59.6%) of 1,018 (rituximab maintenance, n = 309; observation, n = 298). After data cutoff, median PFS was 10.5 years in the rituximab maintenance arm compared with 4.1 years in the observation arm (hazard ratio, 0.61; 95% CI, 0.52 to 0.73; P < .001). No OS difference was seen in patients randomly assigned to rituximab maintenance or observation (hazard ratio, 1.04; 95% CI, 0.77 to 1.40; P = .7948); 10-year OS estimates were approximately 80% in both study arms. No new safety signals were observed. CONCLUSION Rituximab maintenance after induction immunochemotherapy provides a significant long-term PFS, but not OS, benefit over observation.
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Affiliation(s)
- Emmanuel Bachy
- Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Institut National de la Santé et de la Recherche Médicale (INSERM) 1052, Pierre-Bénite, France
| | - John F Seymour
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia
| | - Pierre Feugier
- Centre Hospitalier Régional Universitaire de Nancy, Université de Lorraine, INSERM 1256, Nancy, France
| | | | | | - David Belada
- Charles University, Hradec Králové, Czech Republic
| | - Luc Xerri
- Institut Paoli-Calmettes, Aix-Marseille Université, Marseille, France
| | - John V Catalano
- Frankston Hospital and Monash University, Frankston, Victoria, Australia
| | - Pauline Brice
- Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - François Lemonnier
- Hôpitaux Universitaires Henri Mondor, Université Paris-Est Créteil, INSERM U955, Créteil, France
| | - Alejandro Martin
- Hospital Universitario de Salamanca-Institute for Biomedical Research of Salamanca, Centro de Investigación Biomédica en Red de Cáncer, Salamanca, Spain
| | - Olivier Casasnovas
- Department of Haematology and INSERM 1231, University Hospital F. Mitterrand, Dijon, France
| | | | - Véronique Dorvaux
- Hôpital de Mercy Centre Hospitalier Régional Metz-Thionville, Metz, France
| | | | - Sirpa Leppa
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | | | | | - Loic Ysebaert
- Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Anne Vekhoff
- Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Steven Le Gouill
- Centre Hospitalier Universitaire de Nantes, Centre de Recherche en Cancérologie et Immunologie Nantes Angers, INSERM, Université de Nantes, Nantes, France
| | - Andrew Lister
- Queen Mary University of London, London, United Kingdom
| | - Jane A Estell
- Concord Hospital, Concord, University of Sydney, New South Wales, Australia
| | | | | | - Jonathan Farhi
- Centre Hospitalier Universitaire d'Angers, Angers, France
| | | | | | - Gilles Salles
- Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Institut National de la Santé et de la Recherche Médicale (INSERM) 1052, Pierre-Bénite, France
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Drummond MF, Neumann PJ, Sullivan SD, Fricke FU, Tunis S, Dabbous O, Toumi M. Analytic Considerations in Applying a General Economic Evaluation Reference Case to Gene Therapy. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:661-668. [PMID: 31198183 DOI: 10.1016/j.jval.2019.03.012] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/22/2019] [Accepted: 03/25/2019] [Indexed: 05/05/2023]
Abstract
The concept of a reference case, first proposed by the US Panel on Cost-Effectiveness in Health and Medicine, has been used to specify the required methodological features of economic evaluations of healthcare interventions. In the case of gene therapy, there is a difference of opinion on whether a specific methodological reference case is required. The aim of this article was to provide a more detailed analysis of the characteristics of gene therapy and the extent to which these characteristics warrant modifications to the methods suggested in general reference cases for economic evaluation. We argue that a completely new reference case is not required, but propose a tailored checklist that can be used by analysts and decision makers to determine which aspects of economic evaluation should be considered further, given the unique nature of gene therapy.
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Affiliation(s)
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
| | - Sean D Sullivan
- CHOICE Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Frank-Ulrich Fricke
- Fakultät Betriebswirtschaft, Technische Hochschule Nürnberg Georg Simon Ohm, Nürnberg, Germany
| | - Sean Tunis
- Center for Medical Technology Policy, Baltimore, MD, USA
| | | | - Mondher Toumi
- Public Health Department, Aix-Marseille University, Marseille, France
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Martini A, Jia R, Ferket BS, Waingankar N, Plimack ER, Crabb SJ, Harshman LC, Yu EY, Powles T, Rosenberg JE, Pal SK, Vaishampayan UN, Necchi A, Wiklund NP, Mehrazin R, Mazumdar M, Sfakianos JP, Galsky MD. Tumor downstaging as an intermediate endpoint to assess the activity of neoadjuvant systemic therapy in patients with muscle-invasive bladder cancer. Cancer 2019; 125:3155-3163. [PMID: 31150110 DOI: 10.1002/cncr.32169] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/23/2019] [Accepted: 02/24/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Achieving a pathologic complete response (pCR) with neoadjuvant chemotherapy (NAC) in patients with muscle-invasive bladder cancer (MIBC) has been associated with improved overall survival (OS). This study was aimed at evaluating the impact of pathologic downstaging (pDS; ie, a pT stage at least 1 stage lower than the pre-NAC cT stage) on the OS of patients with MIBC treated with NAC. METHODS The Retrospective International Study of Cancers of the Urothelial Tract (RISC) and the National Cancer Database (NCDB) were queried for cT2-4N0M0 patients treated with NAC. A multivariable Cox model including either pDS or pCR was generated. A nested model was built to evaluate the added value of pDS (excluding patients achieving a pCR) to a model including pCR alone. C indices were computed to assess discrimination. NCDB was used for validation. The treatment effect of NAC versus cystectomy alone in achieving pDS was estimated through an inverse probability-weighted regression adjustment. RESULTS Overall, 189 and 2010 patients from the RISC and NCDB cohorts, respectively, were included; pDS and pCR were achieved by 33% and 35% and by 20% and 15% in RISC and NCDB, respectively. In both data sets, pDS and pCR were associated with better OS and C indices. Adding pDS excluding pCR to the model with pCR fit the data better (likelihood ratio, P = .019 for RISC and P < .001 for NCDB), and it yielded better discrimination (incremental C index, 4.2 for RISC and 1.6 for NCDB). The treatment effect of NAC in achieving pDS was 2.07-fold (P < .001) in comparison with cystectomy alone. CONCLUSIONS A decrease of at least 1 stage from the cT stage to the pT stage is associated with improved OS in patients with MIBC treated with NAC.
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Affiliation(s)
- Alberto Martini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rachel Jia
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bart S Ferket
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nikhil Waingankar
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York.,Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Simon J Crabb
- University of Southampton, Southampton, United Kingdom
| | | | - Evan Y Yu
- University of Washington, Seattle, Washington
| | - Thomas Powles
- Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | | | - Sumanta K Pal
- City of Hope Comprehensive Cancer Center, Duarte, California
| | | | | | - N Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Matthew D Galsky
- Division of Hematology and Oncology, Department of Medicine, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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Fernández-López C, Calleja-Hernández MÁ, Balbino JE, Cabeza-Barrera J, Expósito-Hernández J. Trends in endpoint selection and result interpretation in advanced non-small cell lung cancer clinical trials published between 2000 and 2012: A retrospective cohort study. Thorac Cancer 2019; 10:904-908. [PMID: 30868737 PMCID: PMC6449273 DOI: 10.1111/1759-7714.13024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 01/31/2019] [Accepted: 02/01/2019] [Indexed: 11/30/2022] Open
Abstract
Background The objective of this review was to investigate trends in clinical trial design, specifically, the primary outcomes used, interpretation of results, and the magnitude of the benefits described in phase III controlled clinical trials in the first‐line treatment of patients with advanced non‐small cell lung cancer (NSCLC). Methods Seventy‐six trials published between 2000 and 2012 were selected from a total of 122 identified in a structured search. Results Overall survival (OS) was evaluated as the primary study endpoint in 50 (65.8%) trials, followed by progression‐free survival (PFS) in 15 (19.7%), and other variables, such as toxicity, quality of life (QoL), and response rate in 11 (14.5%). Ten (66.7%) out of 15 clinical trials using PFS as the primary endpoint were published between 2010 and 2012. Median overall survival (mOS) was 9.90 months (interquartile range: 3.5) with an increase of 0.384 months per year of publication (P < 0.001). A statistically significant improvement in mOS was obtained in only 13 (18.8%) trials. A total of 41 (53.9%) studies concluded that the result was positive. Of these, only 16 (39.1%) showed a statistically significant benefit in OS. QoL was assessed in 46 trials (60.5%) and of these, 10 (21.7%) reported significant improvements. Conclusions These findings raise important questions about how clinical benefits are measured in clinical trials in advanced NSCLC. Appropriate clinically relevant outcome variables should be established and validated, and post‐marketing studies should be requested by regulatory authorities to ensure meaningful clinical benefits in OS and QoL.
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Affiliation(s)
| | | | - Jaime Espín Balbino
- Andalusian School of Public Health (EASP), Granada, Spain.,Health Research Institute of Granada (ibs.GRANADA), University Hospitals of Granada/University of Granada, Granada, Spain
| | - José Cabeza-Barrera
- Department of Pharmacy, Biosanitary Research Institute of Granada, San Cecilio University Hospital, Granada, Spain
| | - José Expósito-Hernández
- Department of Oncology, University Hospitals of Granada, Health Research Institute of Granada (ibs.GRANADA), Spain
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Xie W, Halabi S, Tierney JF, Sydes MR, Collette L, Dignam JJ, Buyse M, Sweeney CJ, Regan MM. A Systematic Review and Recommendation for Reporting of Surrogate Endpoint Evaluation Using Meta-analyses. JNCI Cancer Spectr 2019; 3:pkz002. [PMID: 31360890 PMCID: PMC6649812 DOI: 10.1093/jncics/pkz002] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/12/2018] [Accepted: 01/03/2019] [Indexed: 12/11/2022] Open
Abstract
Background Meta-analysis of randomized controlled trials (RCTs) has been widely conducted for the evaluation of surrogate endpoints in oncology, but little attention has been given to the adequacy of reporting and interpretation. This review evaluated the reporting quality of published meta-analyses on surrogacy evaluation and developed recommendations for future reporting. Methods We searched PubMed through August 2017 to identify studies that evaluated surrogate endpoints using the meta-analyses of RCTs in oncology. Both individual patient data (IPD) and aggregate data (AD) meta-analyses were included for the review. Results Eighty meta-analyses were identified: 22 used IPD and 58 used AD from multiple RCTs. We observed variability and reporting deficiencies in both IPD and AD meta-analyses, especially on reporting of trial selection, endpoint definition, study and patient characteristics for included RCTs, and important statistical methods and results. Based on these findings, we proposed a checklist and recommendations to improve completeness, consistency, and transparency of reports of meta-analytic surrogacy evaluation. We highlighted key aspects of the design and analysis of surrogate endpoints and presented explanations and rationale why these items should be clearly reported in surrogacy evaluation. Conclusions Our reporting of surrogate endpoint evaluation using meta-analyses (ReSEEM) guidelines and recommendations will improve the quality in reporting and facilitate the interpretation and reproducibility of meta-analytic surrogacy evaluation. Also, they should help promote greater methodological consistency and could also serve as an evaluation tool in the peer review process for assessing surrogacy research.
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Affiliation(s)
- Wanling Xie
- Correspondence to: Wanling Xie, MS, Department of Data Sciences, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215 (e-mail: )
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Solà-Morales O, Volmer T, Mantovani L. Perspectives to mitigate payer uncertainty in health technology assessment of novel oncology drugs. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2019; 7:1562861. [PMID: 30719243 PMCID: PMC6346722 DOI: 10.1080/20016689.2018.1562861] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 12/09/2018] [Accepted: 12/20/2018] [Indexed: 05/03/2023]
Abstract
Reimbursement decisions on new oncology drugs are now often made while uncertainty remains about a drug's risk-benefit profile. One consequence of this is a delay in patient access to valuable new medicines. We share our perspectives on strategies to mitigate sources of uncertainty in the health technology assessment process. These include flexible approaches for evaluating the additional benefit, such as better use of surrogate endpoints and health-related quality of life data, and renewed research efforts to define the optimal target population and generate real-world evidence post-authorisation.
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Affiliation(s)
- Oriol Solà-Morales
- Health Innovation Technology Transfer and International, University of Catalonia, Barcelona, Spain
- CONTACT Oriol Solà-Morales Health Innovation Technology Transfer and International, University of Catalonia, Escoles Pies 40, Biaxos, BarcelonaE-08017, Spain
| | | | - Lorenzo Mantovani
- Centre for Public Health Research, University of Milan–Bicocca, Milan, Italy
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Cherny NI, de Vries EGE, Dafni U, Garrett-Mayer E, McKernin SE, Piccart M, Latino NJ, Douillard JY, Schnipper LE, Somerfield MR, Bogaerts J, Karlis D, Zygoura P, Vervita K, Pentheroudakis G, Tabernero J, Zielinski C, Wollins DS, Schilsky RL. Comparative Assessment of Clinical Benefit Using the ESMO-Magnitude of Clinical Benefit Scale Version 1.1 and the ASCO Value Framework Net Health Benefit Score. J Clin Oncol 2018; 37:336-349. [PMID: 30707056 DOI: 10.1200/jco.18.00729] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To better understand the European Society for Medical Oncology-Magnitude of Clinical Benefit Scale version 1.1 (ESMO-MCBS v1.1) and the ASCO Value Framework Net Health Benefit score version 2 (ASCO-NHB v2), ESMO and ASCO collaborated to evaluate the concordance between the frameworks when used to assess clinical benefit attributable to new therapies. METHODS The 102 randomized controlled trials in the noncurative setting already evaluated in the field testing of ESMO-MCBS v1.1 were scored using ASCO-NHB v2 by its developers. Measures of agreement between the frameworks were calculated and receiver operating characteristic curves used to define thresholds for the ASCO-NHB v2 corresponding to ESMO-MCBS v1.1 categories. Studies with discordant scoring were identified and evaluated to understand the reasons for discordance. RESULTS The correlation of the 102 pairs of scores for studies in the noncurative setting is estimated to be 0.68 (Spearman's rank correlation coefficient; overall survival, 0.71; progression-free survival, 0.67). Receiver operating characteristic curves identified thresholds for ASCO-NHB v2 for facilitating comparisons with ESMO-MCBS v1.1 categories. After applying pragmatic threshold scores of 40 or less (ASCO-NHB v2) and 2 or less (ESMO-MCBS v1.1) for low benefit and 45 or greater (ASCO-NHB v2) and 4 to 5 (ESMO-MCBS v1.1) for substantial benefit, 37 discordant studies were identified. Major factors that contributed to discordance were different approaches to evaluation of relative and absolute gain for overall survival and progression-free survival, crediting tail of the curve gains, and assessing toxicity. CONCLUSION The agreement between the frameworks was higher than observed in other studies that sought to compare them. The factors that contributed to discordant scores suggest potential approaches to improve convergence between the scales.
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Affiliation(s)
| | | | - Urania Dafni
- National and Kapodistrian University of Athens, Athens, Greece.,Frontier Science Foundation-Hellas, Hellas, Greece
| | | | | | - Martine Piccart
- Jules Bordet Institute Université Libre de Bruxelles, Brussels, Belgium
| | - Nicola J Latino
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | | | - Lowell E Schnipper
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | | | - Jan Bogaerts
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | | | | | | | | | - Josep Tabernero
- Vall d'Hebron University Hospital and Institute of Oncology, Barcelona, Spain
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CHALLENGES AND METHODOLOGIES IN USING PROGRESSION FREE SURVIVAL AS A SURROGATE FOR OVERALL SURVIVAL IN ONCOLOGY. Int J Technol Assess Health Care 2018; 34:300-316. [PMID: 29987997 DOI: 10.1017/s0266462318000338] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES A primary outcome in oncology trials is overall survival (OS). However, to estimate OS accurately requires a sufficient number of patients to have died, which may take a long time. If an alternative end point is sufficiently highly correlated with OS, it can be used as a surrogate. Progression-free survival (PFS) is the surrogate most often used in oncology, but does not always satisfy the correlation conditions for surrogacy. We analyze the methodologies used when extrapolating from PFS to OS. METHODS Davis et al. previously reviewed the use of surrogate end points in oncology, using papers published between 2001 and 2011. We extend this, reviewing papers published between 2012 and 2016. We also examine the reporting of statistical methods to assess the strength of surrogacy. RESULTS The findings from 2012 to 2016 do not differ substantially from those of 2001 to 2011: the same factors are shown to affect the relationship between PFS and OS. The proportion of papers reporting individual patient data (IPD), strongly recommended for full assessment of surrogacy, remains low: 33 percent. A wide range of methods has been used to determine the appropriateness of surrogates. While usually adhering to reporting standards, the standard of scholarship appears sometimes to be questionable and the reporting of results often haphazard. CONCLUSIONS Standards of analysis and reporting PFS to OS surrogate studies should be improved by increasing the rigor of statistical reporting and by agreeing to a minimum set of reporting guidelines. Moreover, the use of IPD to assess surrogacy should increase.
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Ciani O, Piepoli M, Smart N, Uddin J, Walker S, Warren FC, Zwisler AD, Davos CH, Taylor RS. Validation of Exercise Capacity as a Surrogate Endpoint in Exercise-Based Rehabilitation for Heart Failure. JACC-HEART FAILURE 2018; 6:596-604. [DOI: 10.1016/j.jchf.2018.03.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 03/27/2018] [Indexed: 11/30/2022]
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Morrell L, Wordsworth S, Schuh A, Middleton MR, Rees S, Barker RW. Will the reformed Cancer Drugs Fund address the most common types of uncertainty? An analysis of NICE cancer drug appraisals. BMC Health Serv Res 2018; 18:393. [PMID: 29855313 PMCID: PMC5984433 DOI: 10.1186/s12913-018-3162-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 04/30/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND One of the functions of the reformed Cancer Drugs Fund in England is as a managed access fund, providing conditional funding for cancer drugs where there is uncertainty in the economic case, and where that uncertainty can be addressed by data collection during two years' use in the NHS. Our study characterises likely sources of such uncertainty, through a review of recent NICE Technology Appraisals. METHODS Discussions of uncertainty in NICE Appraisal Committees were extracted from published Single Technology Appraisals of cancer drugs, 2014-2016, and categorised inductively. The location of the comments within the structured Appraisal document was used as a proxy for the degree of concern shown by the Committee. RESULTS Twenty-nine appraisals were analysed, of which 23 (79%) were recommended for funding. Six main sources of uncertainty were identified. Immaturity of survival data, and issues relating to comparators, were common sources of uncertainty regardless of degree of concern. Uncertainties relating to quality of life, and the patient population in the trial, were discussed frequently but rarely occurred in the more uncertain appraisals. Concerns with trial design, and cost uncertainty, were less common, but a high proportion contributed to the most uncertain appraisals. Funding decisions were not driven by uncertainty in the evidence base, but by the expected cost per QALY relative to acceptance thresholds, and the resultant level of uncertainty in the decision. CONCLUSIONS The reformed CDF is an improvement on its predecessor. However the main types of uncertainty seen in recent cancer appraisals will not readily be resolved solely by 2 years' RWD collection in the reformed CDF; where there are no ongoing trials to provide longer-term data, randomised trials rather than RWD may be needed to fully resolve questions of relative efficacy. Other types of uncertainty, and concerns with generalisability, may be more amenable to the RWD approach, and it is these that we expect to be the focus of data collection arrangements in the reformed CDF.
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Affiliation(s)
- Liz Morrell
- Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation, Radcliffe Department of Medicine, University of Oxford, Room 4403, Level 4, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU UK
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Headington, Oxford, OX3 7LF UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Headington, Oxford, OX3 7LF UK
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Anna Schuh
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Headington, Oxford, OX3 7DQ UK
| | - Mark R. Middleton
- Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Headington, Oxford, OX3 7DQ UK
| | - Sian Rees
- Health Experiences Institute, Nuffield Department of Primary Care Health Sciences, University of Oxford, 23-38 Hythe Bridge Street, Oxford, OX1 2ET UK
| | - Richard W. Barker
- Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation, Radcliffe Department of Medicine, University of Oxford, Room 4403, Level 4, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU UK
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Cicero G, De Luca R, Dieli F. Progression-free survival as a surrogate endpoint of overall survival in patients with metastatic colorectal cancer. Onco Targets Ther 2018; 11:3059-3063. [PMID: 29872317 PMCID: PMC5975605 DOI: 10.2147/ott.s151276] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background In many clinical trials designed to assess the efficacy of anticancer treatments, overall survival (OS) is often used as a primary endpoint despite its several points of weakness. Methods This study evaluated the role of progression-free survival (PFS) in the first three lines of treatment as a potential surrogate endpoint of OS in patients with metastatic colorectal cancer (MCRC). One hundred and twenty patients with MCRC were enrolled in this study. The median PFS of the first-, second-, and third-lines of treatment and the OS were evaluated. The correlation between the time to progression and the OS was analyzed. The median PFS of the three lines of treatment were 8.5, 5, and 3 months, respectively. Results The median OS was 32.4 months. A modest correlation was found between the PFS to the first-line treatment with Folfox–avastin and OS. Similar data were obtained with the second-line treatment. However, no correlation was found between the PFS and OS during the third-line treatment. The regression analysis revealed that PFS is predictive of OS. Conclusion In brief, the PFS of the first- and second-lines of treatment could be a good candidate as a surrogate endpoint of OS in patients with MCRC.
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Affiliation(s)
- Giuseppe Cicero
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, University of Palermo, Palermo, Italy
| | - Rossella De Luca
- Department of Surgical, Oncological and Oral Sciences, Section of Medical Oncology, University of Palermo, Palermo, Italy
| | - Francesco Dieli
- Central Laboratory of Advanced Diagnosis and Biomedical Research (CLADIBIOR), University of Palermo, Palermo, Italy
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Ferrara R, Pilotto S, Caccese M, Grizzi G, Sperduti I, Giannarelli D, Milella M, Besse B, Tortora G, Bria E. Do immune checkpoint inhibitors need new studies methodology? J Thorac Dis 2018; 10:S1564-S1580. [PMID: 29951307 PMCID: PMC5994495 DOI: 10.21037/jtd.2018.01.131] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 01/19/2018] [Indexed: 12/26/2022]
Abstract
Immune checkpoint inhibitors (ICI) have widely reshaped the treatment paradigm of advanced cancer patients. Although multiple studies are currently evaluating these drugs as monotherapies or in combination, the choice of the most accurate statistical methods, endpoints and clinical trial designs to estimate the benefit of ICI remains an unsolved methodological issue. Considering the unconventional patterns of response or progression [i.e., pseudoprogression, hyperprogression (HPD)] observed with ICI, the application in clinical trials of novel response assessment tools (i.e., iRECIST) able to capture delayed benefit of immunotherapies and/or to quantify tumor dynamics and kinetics over time is an unmet clinical need. In addition, the proportional hazard model and the conventional measures of survival [i.e., median overall or progression free survival (PFS) and hazard ratios (HR)] might usually result inadequate in the estimation of the long-term benefit observed with ICI. For this reason, innovative methodologies such as milestone analysis, restricted mean survival time (RMST), parametric models (i.e., Weibull distribution, weighted log rank test), should be systematically investigated in clinical trials in order to adequately quantify the fraction of patients who are "cured", represented by the tails of the survival curves. Regarding predictive biomarkers, in particular PD-L1 expression, the integration and harmonization of the existing assays are urgently needed to provide clinicians with reliable diagnostic tests and to improve patient selection for immunotherapy. Finally, developing original and high-quality study designs, such as adaptive or basket biomarker enriched clinical trials, included in large collaborative platforms with multiple active sites and cross-sector collaboration, represents the successful strategy to optimally assess the benefit of ICI in the next future.
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Affiliation(s)
- Roberto Ferrara
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
| | - Sara Pilotto
- U.O.C. Oncology, University of Verona, Comprehensive Cancer Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Mario Caccese
- U.O.C. Oncology, University of Verona, Comprehensive Cancer Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giulia Grizzi
- U.O.C. Oncology, University of Verona, Comprehensive Cancer Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | | | | | - Benjamin Besse
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
| | - Giampaolo Tortora
- U.O.C. Oncology, University of Verona, Comprehensive Cancer Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Emilio Bria
- U.O.C. Oncology, University of Verona, Comprehensive Cancer Center, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Savina M, Gourgou S, Italiano A, Dinart D, Rondeau V, Penel N, Mathoulin-Pelissier S, Bellera C. Meta-analyses evaluating surrogate endpoints for overall survival in cancer randomized trials: A critical review. Crit Rev Oncol Hematol 2018; 123:21-41. [DOI: 10.1016/j.critrevonc.2017.11.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 09/25/2017] [Accepted: 11/18/2017] [Indexed: 12/27/2022] Open
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Hettle R, Corbett M, Hinde S, Hodgson R, Jones-Diette J, Woolacott N, Palmer S. The assessment and appraisal of regenerative medicines and cell therapy products: an exploration of methods for review, economic evaluation and appraisal. Health Technol Assess 2018; 21:1-204. [PMID: 28244858 DOI: 10.3310/hta21070] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The National Institute for Health and Care Excellence (NICE) commissioned a 'mock technology appraisal' to assess whether changes to its methods and processes are needed. This report presents the findings of independent research commissioned to inform this appraisal and the deliberations of a panel convened by NICE to evaluate the mock appraisal. METHODS Our research included reviews to identify issues, analysis methods and conceptual differences and the relevance of alternative decision frameworks, alongside the development of an exemplar case study of chimeric antigen receptor (CAR) T-cell therapy for treating acute lymphoblastic leukaemia. RESULTS An assessment of previous evaluations of regenerative medicines found that, although there were a number of evidential challenges, none was unique to regenerative medicines or was beyond the scope of existing methods used to conceptualise decision uncertainty. Regarding the clinical evidence for regenerative medicines, the issues were those associated with a limited evidence base but were not unique to regenerative medicines: small non-randomised studies, high variation in response and the intervention subject to continuing development. The relative treatment effects generated from single-arm trials are likely to be optimistic unless it is certain that the historical data have accurately estimated the efficacy of the control agent. Pivotal trials may use surrogate end points, which, on average, overestimate treatment effects. To reduce overall uncertainty, multivariate meta-analysis of all available data should be considered. Incorporating indirectly relevant but more reliable (more mature) data into the analysis can also be considered; such data may become available as a result of the evolving regulatory pathways being developed by the European Medicines Agency. For the exemplar case of CAR T-cell therapy, target product profiles (TPPs) were developed, which considered the 'curative' and 'bridging to stem-cell transplantation' treatment approaches separately. Within each TPP, three 'hypothetical' evidence sets (minimum, intermediate and mature) were generated to simulate the impact of alternative levels of precision and maturity in the clinical evidence. Subsequent assessments of cost-effectiveness were undertaken, employing the existing NICE reference case alongside additional analyses suggested within alternative frameworks. The additional exploratory analyses were undertaken to demonstrate how assessments of cost-effectiveness and uncertainty could be impacted by alternative managed entry agreements (MEAs), including price discounts, performance-related schemes and technology leasing. The panel deliberated on the range of TPPs, evidence sets and MEAs, commenting on the likely recommendations for each scenario. The panel discussed the challenges associated with the exemplar and regenerative medicines more broadly, focusing on the need for a robust quantification of the level of uncertainty in the cost-effective estimates and the potential value of MEAs in limiting the exposure of the NHS to high upfront costs and loss associated with a wrong decision. CONCLUSIONS It is to be expected that there will be a significant level of uncertainty in determining the clinical effectiveness of regenerative medicines and their long-term costs and benefits, but the existing methods available to estimate the implications of this uncertainty are sufficient. The use of risk sharing and MEAs between the NHS and manufacturers of regenerative medicines should be investigated further. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Robert Hettle
- Centre for Health Economics, University of York, York, UK
| | - Mark Corbett
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Robert Hodgson
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Nerys Woolacott
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, UK
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Harshman LC, Xie W, Moreira RB, Bossé D, Ruiz Ares GJ, Sweeney CJ, Choueiri TK. Evaluation of disease-free survival as an intermediate metric of overall survival in patients with localized renal cell carcinoma: A trial-level meta-analysis. Cancer 2017; 124:925-933. [PMID: 29266178 DOI: 10.1002/cncr.31154] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 10/25/2017] [Accepted: 10/25/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Overall survival (OS) is a critical endpoint in adjuvant trials but requires long durations to events and significant patient resources. In the current study, the authors assessed whether disease-free survival (DFS) can be an early clinical surrogate for OS in the adjuvant setting for localized renal cell carcinoma (RCC). METHODS Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the authors performed a systematic literature review of PubMed and the American Society of Clinical Oncology, European Society for Medical Oncology, and ClinicalTrial.gov Web sites (1996-2016). Inclusion in the current study required randomized controlled trials (RCTs) of adjuvant systemic therapy for localized RCC after nephrectomy with ≥3 years of outcomes data. Data regarding hazard ratios (HRs) and 5-year event-free rates from Kaplan-Meier estimates were extracted. A trial-level meta-analysis correlated estimates of 5-year DFS and 5-year OS as well as treatment effects (HRs) on these endpoints, weighted by the number of DFS events. R-squared ≥ 0.7 was prespecified as being indicative of a strong correlation and the potential for surrogacy. RESULTS Thirteen RCTs encompassing 6473 patients who were treated with a variety of systemic therapies met eligibility. Only a modest correlation was observed between 5-year DFS and 5-year OS rates (R-squared, 0.48; 95% confidence interval, 0.14-0.67) and between treatment effects as measured by DFS and OS HRs (R-squared, 0.44; 95% confidence interval, 0.00-0.69). CONCLUSIONS Across RCTs of adjuvant systemic therapy for localized RCC, there was no strong correlation noted between 5-year DFS and 5-year OS rates or between treatment effects on these endpoints. These results highlight the need to identify alternative and more rapid clinical or biologic endpoints to hasten drug development and improve clinical outcomes. Cancer 2018;124:925-33. © 2017 American Cancer Society.
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Affiliation(s)
- Lauren C Harshman
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Wanling Xie
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Raphael B Moreira
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Oncoclinic Group, Alemao Oswaldo Cruz Hospital, Sao Paulo, Brazil
| | - Dominick Bossé
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Gustavo J Ruiz Ares
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Department of Clinical Oncology, University Hospital 12 de Octubre, Madrid, Spain
| | - Christopher J Sweeney
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Toni K Choueiri
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
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Saad ED, Buyse M. Exploratory analysis of the association of depth of response and survival in patients with metastatic non-small-cell lung cancer treated with a targeted therapy or immunotherapy. Ann Oncol 2017; 28:2629-2630. [PMID: 28945844 DOI: 10.1093/annonc/mdx456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- E D Saad
- International Drug Development Institute, Louvain-la-Neuve, Belgium
| | - M Buyse
- International Drug Development Institute, San Francisco, USA; Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BioStat), Hasselt University, Hasselt, Belgium.
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Davis C, Naci H, Gurpinar E, Poplavska E, Pinto A, Aggarwal A. Availability of evidence of benefits on overall survival and quality of life of cancer drugs approved by European Medicines Agency: retrospective cohort study of drug approvals 2009-13. BMJ 2017; 359:j4530. [PMID: 28978555 PMCID: PMC5627352 DOI: 10.1136/bmj.j4530] [Citation(s) in RCA: 359] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective To determine the availability of data on overall survival and quality of life benefits of cancer drugs approved in Europe.Design Retrospective cohort study.Setting Publicly accessible regulatory and scientific reports on cancer approvals by the European Medicines Agency (EMA) from 2009 to 2013.Main outcome measures Pivotal and postmarketing trials of cancer drugs according to their design features (randomisation, crossover, blinding), comparators, and endpoints. Availability and magnitude of benefit on overall survival or quality of life determined at time of approval and after market entry. Validated European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS) used to assess the clinical value of the reported gains in published studies of cancer drugs.Results From 2009 to 2013, the EMA approved the use of 48 cancer drugs for 68 indications. Of these, eight indications (12%) were approved on the basis of a single arm study. At the time of market approval, there was significant prolongation of survival in 24 of the 68 (35%). The magnitude of the benefit on overall survival ranged from 1.0 to 5.8 months (median 2.7 months). At the time of market approval, there was an improvement in quality of life in seven of 68 indications (10%). Out of 44 indications for which there was no evidence of a survival gain at the time of market authorisation, in the subsequent postmarketing period there was evidence for extension of life in three (7%) and reported benefit on quality of life in five (11%). Of the 68 cancer indications with EMA approval, and with a median of 5.4 years' follow-up (minimum 3.3 years, maximum 8.1 years), only 35 (51%) had shown a significant improvement in survival or quality of life, while 33 (49%) remained uncertain. Of 23 indications associated with a survival benefit that could be scored with the ESMO-MCBS tool, the benefit was judged to be clinically meaningful in less than half (11/23, 48%).Conclusions This systematic evaluation of oncology approvals by the EMA in 2009-13 shows that most drugs entered the market without evidence of benefit on survival or quality of life. At a minimum of 3.3 years after market entry, there was still no conclusive evidence that these drugs either extended or improved life for most cancer indications. When there were survival gains over existing treatment options or placebo, they were often marginal.
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Affiliation(s)
- Courtney Davis
- Department of Global Health and Social Medicine, King's College London, London WC2R 2LS, UK
| | - Huseyin Naci
- LSE Health, Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Evrim Gurpinar
- LSE Health, Department of Health Policy, London School of Economics and Political Science, London, UK
| | | | - Ashlyn Pinto
- LSE Health, Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Institute of Cancer Policy, King's College London, London, UK
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Woolacott N, Corbett M, Jones-Diette J, Hodgson R. Methodological challenges for the evaluation of clinical effectiveness in the context of accelerated regulatory approval: an overview. J Clin Epidemiol 2017; 90:108-118. [DOI: 10.1016/j.jclinepi.2017.07.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 06/22/2017] [Accepted: 07/07/2017] [Indexed: 12/25/2022]
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Xie W, Regan MM, Buyse M, Halabi S, Kantoff PW, Sartor O, Soule H, Clarke NW, Collette L, Dignam JJ, Fizazi K, Paruleker WR, Sandler HM, Sydes MR, Tombal B, Williams SG, Sweeney CJ. Metastasis-Free Survival Is a Strong Surrogate of Overall Survival in Localized Prostate Cancer. J Clin Oncol 2017; 35:3097-3104. [PMID: 28796587 DOI: 10.1200/jco.2017.73.9987] [Citation(s) in RCA: 316] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose Adjuvant therapy for intermediate-risk and high-risk localized prostate cancer decreases the number of deaths from this disease. Surrogates for overall survival (OS) could expedite the evaluation of new adjuvant therapies. Methods By June 2013, 102 completed or ongoing randomized trials were identified and individual patient data were collected from 28 trials with 28,905 patients. Disease-free survival (DFS) and metastasis-free survival (MFS) were determined for 21,140 patients from 24 trials and 12,712 patients from 19 trials, respectively. We evaluated the surrogacy of DFS and MFS for OS by using a two-stage meta-analytic validation model by determining the correlation of an intermediate clinical end point with OS and the correlation of treatment effects on both the intermediate clinical end point and OS. Results Trials enrolled patients from 1987 to 2011. After a median follow-up of 10 years, 45% of 21,140 men and 45% of 12,712 men experienced a DFS and MFS event, respectively. For DFS and MFS, 61% and 90% of the patients, respectively, were from radiation trials, and 63% and 66%, respectively, had high-risk disease. At the patient level, Kendall's τ correlation with OS was 0.85 and 0.91 for DFS and MFS, respectively. At the trial level, R2 was 0.86 (95% CI, 0.78 to 0.90) and 0.83 (95% CI, 0.71 to 0.88) from weighted linear regression of 8-year OS rates versus 5-year DFS and MFS rates, respectively. Treatment effects-measured by log hazard ratios-for the surrogates and OS were well correlated ( R2, 0.73 [95% CI, 0.53 to 0.82] for DFS and 0.92 [95% CI, 0.81 to 0.95] for MFS). Conclusion MFS is a strong surrogate for OS for localized prostate cancer that is associated with a significant risk of death from prostate cancer.
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Affiliation(s)
- Wanling Xie
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Meredith M Regan
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Marc Buyse
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Susan Halabi
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Philip W Kantoff
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Oliver Sartor
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Howard Soule
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Noel W Clarke
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Laurence Collette
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - James J Dignam
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Karim Fizazi
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Wendy R Paruleker
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Howard M Sandler
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Matthew R Sydes
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Bertrand Tombal
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Scott G Williams
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Christopher J Sweeney
- Wanling Xie, Meredith M. Regan, and Christopher J. Sweeney, Dana-Farber Cancer Institute, Boston, MA; Marc Buyse, International Drug Development Institute; Bertrand Tombal, Université Catholique de Louvain, Louvain-la-Neuve; Laurence Collette, European Organisation for Research and Treatment of Cancer, Brussels, Belgium; Susan Halabi, Duke University Medical Center, Durham, NC; Philip W. Kantoff, Memorial Sloan Kettering Cancer Center, New York, NY; Oliver Sartor, Tulane Medical School, New Orleans, LA; Howard Soule, Prostate Cancer Foundation, Santa Monica; Howard M. Sandler, Cedars-Sinai Medical Center, Los Angeles, CA; Noel W. Clarke, The Christie NHS Foundation Trust, Manchester; Matthew R. Sydes, University College London, London, United Kingdom; James J. Dignam, University of Chicago, Chicago, IL; Karim Fizazi, Institut Gustave-Roussy, Villejuif, France; Wendy R. Paruleker, Canadian Cancer Trials Group, Kingston, Ontario, Canada; and Scott G. Williams, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Laporte S, Chapelle C, Bertoletti L, Ollier E, Zufferey P, Lega JC, Merah A, Décousus H, Schulman S, Meyer G, Cucherat M, Mismetti P. Assessment of clinically relevant bleeding as a surrogate outcome for major bleeding: validation by meta-analysis of randomized controlled trials. J Thromb Haemost 2017; 15:1547-1558. [PMID: 28544422 DOI: 10.1111/jth.13740] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Indexed: 01/27/2023]
Abstract
Essentials Surrogacy of clinically relevant bleeding (CRB) for major bleeding has never been validated. Our meta-analysis evaluated CRB surrogacy in trials of new versus traditional anticoagulants. Surrogacy was not validated in orthopedic surgery, venous thromboembolism or atrial fibrillation The difficulty in demonstrating the surrogacy may reflect a lack of homogeneity in its definition SUMMARY: Background Clinically relevant bleeding (CRB), comprising major bleeding and clinically relevant non-major bleeding, has been used as a surrogate for major bleeding in most anticoagulant trials. The validity of this surrogate to estimate trade-off between thrombotic and bleeding events in clinical trials was never assessed. Methods We systematically reviewed randomized phase III trials comparing new anticoagulants with the standard of care for venous thromboembolism prevention following major orthopedic surgery, venous thromboembolism (VTE) treatment, or stroke and systemic embolism prevention in atrial fibrillation (AF), and reporting both major bleeding and CRB rates. The validity of CRB as a surrogate for major bleeding was assessed according to the strength of the association between the relative risks of major bleeding and CRB, measured by the use of R2trial and its 95% confidence interval (CI). Results In the postoperative prophylactic setting (13 studies), major bleeding and CRB rates were 1.12% and 3.56%, respectively, and R2trial was 0.69 (95% CI 0.34-0.93). For acute VTE studies (n = 12), major bleeding and CRB rates were 1.87% and 9.07%; the corresponding R2trial values were 0.28 (95% CI 0.01-0.80) and 0.68 (95% CI 0.09-1.00) when only double-blind studies were considered (n = 7). For AF studies (n = 7; 22 strata), major bleeding and CRB rates were 4.82% and 15.3%, and R2trial was 0.59 (95% CI 0.15-0.82). Conclusion Despite an apparent correlation between CRB and major bleeding in major orthopedic surgery, AF, and double-blind acute VTE studies, the wide CIs suggest that CRB might not be an acceptable surrogate outcome in any of these settings.
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Affiliation(s)
- S Laporte
- SAINBIOSE U1059, Université Jean Monnet, Université de Lyon, INSERM, Saint-Etienne, France
- Unité de Recherche Clinique, Innovation, Pharmacologie, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, France
| | - C Chapelle
- Unité de Recherche Clinique, Innovation, Pharmacologie, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, France
| | - L Bertoletti
- SAINBIOSE U1059, Université Jean Monnet, Université de Lyon, INSERM, Saint-Etienne, France
- Service de Médecine Vasculaire et Thérapeutique, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, France
| | - E Ollier
- SAINBIOSE U1059, Université Jean Monnet, Université de Lyon, INSERM, Saint-Etienne, France
- Laboratoire de Pharmacologie, Toxicologie et Gaz du sang, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, France
| | - P Zufferey
- SAINBIOSE U1059, Université Jean Monnet, Université de Lyon, INSERM, Saint-Etienne, France
- Unité de Recherche Clinique Innovation, Pharmacologie, and Service d'Anesthésie Réanimation, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, France
| | - J-C Lega
- Département de Médecine Interne et Pathologie Vasculaire, Hôpital Lyon Sud, CHU Lyon, Pierre-Bénite, France
- UMR CNRS 5558 Evaluation et Modelisation des Effets Therapeutiques, Université Claude Bernard Lyon 1, Lyon, France
| | - A Merah
- Inserm CIE1408, F-CRIN INNOVTE Network, Paris, France
| | - H Décousus
- Inserm CIE1408, F-CRIN INNOVTE Network, Paris, France
| | - S Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - G Meyer
- Hopital Européen Georges Pompidou, APHP, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMRs 970, CIE1418, F-CRIN INNOVTE Network, Paris, France
| | - M Cucherat
- UMR CNRS 5558 Evaluation et Modelisation des Effets Therapeutiques, Université Claude Bernard Lyon 1, Lyon, France
| | - P Mismetti
- SAINBIOSE U1059, Université Jean Monnet, Université de Lyon, INSERM, Saint-Etienne, France
- Unité de Recherche Clinique, Innovation, Pharmacologie, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, France
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