1
|
Fokas E, Smith JJ, Garcia-Aguilar J, Glynne-Jones R, Buyse M, Rödel C. Early Efficacy End Points in Neoadjuvant Rectal Cancer Trials: Surrogacy Revisited. J Clin Oncol 2024; 42:872-875. [PMID: 37890124 DOI: 10.1200/jco.23.01196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/07/2023] [Accepted: 09/13/2023] [Indexed: 10/29/2023] Open
Abstract
Trial-level surrogacy is critical before early response endpoints are used to approve new therapies.
Collapse
Affiliation(s)
- Emmanouil Fokas
- Department of Radiotherapy of Oncology, University of Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site: Frankfurt, Frankfurt, Germany
- Frankfurt Cancer Institute (FCI), Frankfurt, Germany
- Department of Radiation Oncology, Cyberknife and Radiotherapy, Faculty of Medicine, University Hospital Cologne, Cologne, Germany
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Glynne-Jones
- Department of Radiotherapy, Mount Vernon Centre for Cancer Treatment, Northwood, Middlesex, United Kingdom
| | - Marc Buyse
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt University, Diepenbeek, Belgium
- International Drug Development Institute, San Francisco, CA
| | - Claus Rödel
- Department of Radiotherapy of Oncology, University of Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site: Frankfurt, Frankfurt, Germany
- Frankfurt Cancer Institute (FCI), Frankfurt, Germany
| |
Collapse
|
2
|
Vinnat V, Annane D, Chevret S. Bayesian Sequential Design for Identifying and Ranking Effective Patient Subgroups in Precision Medicine in the Case of Counting Outcome Data with Inflated Zeros. J Pers Med 2023; 13:1560. [PMID: 38003875 PMCID: PMC10672716 DOI: 10.3390/jpm13111560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/23/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Precision medicine is revolutionizing health care, particularly by addressing patient variability due to different biological profiles. As traditional treatments may not always be appropriate for certain patient subsets, the rise of biomarker-stratified clinical trials has driven the need for innovative methods. We introduced a Bayesian sequential scheme to evaluate therapeutic interventions in an intensive care unit setting, focusing on complex endpoints characterized by an excess of zeros and right truncation. By using a zero-inflated truncated Poisson model, we efficiently addressed this data complexity. The posterior distribution of rankings and the surface under the cumulative ranking curve (SUCRA) approach provided a comprehensive ranking of the subgroups studied. Different subsets of subgroups were evaluated depending on the availability of biomarker data. Interim analyses, accounting for early stopping for efficacy, were an integral aspect of our design. The simulation study demonstrated a high proportion of correct identification of the subgroup which is the most predictive of the treatment effect, as well as satisfactory false positive and true positive rates. As the role of personalized medicine grows, especially in the intensive care setting, it is critical to have designs that can manage complicated endpoints and that can control for decision error. Our method seems promising in this challenging context.
Collapse
Affiliation(s)
- Valentin Vinnat
- ECSTRRA Team, INSERM U1153, Université Paris Cité, 75010 Paris, France;
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital, 78266 Garches, France;
| | - Sylvie Chevret
- ECSTRRA Team, INSERM U1153, Université Paris Cité, 75010 Paris, France;
- Institut Universitaire de France (IUF), 75231 Paris, France
| |
Collapse
|
3
|
Götte H, Kirchner M, Krisam J, Allignol A, Schüler A, Kieser M. Estimation of treatment effects in early-phase randomized clinical trials involving external control data. J Biopharm Stat 2023:1-20. [PMID: 37823377 DOI: 10.1080/10543406.2023.2256835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/04/2023] [Indexed: 10/13/2023]
Abstract
There are good reasons to perform a randomized controlled trial (RCT) even in early phases of clinical development. However, the low sample sizes in those settings lead to high variability of the treatment effect estimate. The variability could be reduced by adding external control data if available. For the common setting of suitable subject-level control group data only available from one external (clinical trial or real-world) data source, we evaluate different analysis options for estimating the treatment effect via hazard ratios. The impact of the external control data is usually guided by the level of similarity with the current RCT data. Such level of similarity can be determined via outcome and/or baseline covariate data comparisons. We provide an overview over existing methods, propose a novel option for a combined assessment of outcome and baseline data, and compare a selected set of approaches in a simulation study under varying assumptions regarding observable and unobservable confounder distributions using a time-to-event model. Our various simulation scenarios also reflect the differences between external clinical trial and real-world data. Data combinations via simple outcome-based borrowing or simple propensity score weighting with baseline covariate data are not recommended. Analysis options which conflate outcome and baseline covariate data perform best in our simulation study.
Collapse
Affiliation(s)
- Heiko Götte
- Global Biostatistics, Merck Healthcare KGaA, Darmstadt, Germany
| | - Marietta Kirchner
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Johannes Krisam
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Arthur Allignol
- HTA and Medical Affairs, Daiichi Sankyo Europe GmbH, Munich, Germany
| | - Armin Schüler
- Global Biostatistics, Merck Healthcare KGaA, Darmstadt, Germany
| | - Meinhard Kieser
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
4
|
Saad ED, Coart E, Deltuvaite-Thomas V, Garcia-Barrado L, Burzykowski T, Buyse M. Trial Design for Cancer Immunotherapy: A Methodological Toolkit. Cancers (Basel) 2023; 15:4669. [PMID: 37760636 PMCID: PMC10527464 DOI: 10.3390/cancers15184669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/12/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Immunotherapy with checkpoint inhibitors (CPIs) and cell-based products has revolutionized the treatment of various solid tumors and hematologic malignancies. These agents have shown unprecedented response rates and long-term benefits in various settings. These clinical advances have also pointed to the need for new or adapted approaches to trial design and assessment of efficacy and safety, both in the early and late phases of drug development. Some of the conventional statistical methods and endpoints used in other areas of oncology appear to be less appropriate in immuno-oncology. Conversely, other methods and endpoints have emerged as alternatives. In this article, we discuss issues related to trial design in the early and late phases of drug development in immuno-oncology, with a focus on CPIs. For early trials, we review the most salient issues related to dose escalation, use and limitations of tumor response and progression criteria for immunotherapy, the role of duration of response as an endpoint in and of itself, and the need to conduct randomized trials as early as possible in the development of new therapies. For late phases, we discuss the choice of primary endpoints for randomized trials, review the current status of surrogate endpoints, and discuss specific statistical issues related to immunotherapy, including non-proportional hazards in the assessment of time-to-event endpoints, alternatives to the Cox model in these settings, and the method of generalized pairwise comparisons, which can provide a patient-centric assessment of clinical benefit and be used to design randomized trials.
Collapse
Affiliation(s)
- Everardo D. Saad
- International Drug Development Institute, Louvain-la-Neuve (IDDI), 1340 Ottignies-Louvain-la-Neuve, Belgium; (E.C.); (V.D.-T.); (L.G.-B.); (T.B.); (M.B.)
| | - Elisabeth Coart
- International Drug Development Institute, Louvain-la-Neuve (IDDI), 1340 Ottignies-Louvain-la-Neuve, Belgium; (E.C.); (V.D.-T.); (L.G.-B.); (T.B.); (M.B.)
| | - Vaiva Deltuvaite-Thomas
- International Drug Development Institute, Louvain-la-Neuve (IDDI), 1340 Ottignies-Louvain-la-Neuve, Belgium; (E.C.); (V.D.-T.); (L.G.-B.); (T.B.); (M.B.)
| | - Leandro Garcia-Barrado
- International Drug Development Institute, Louvain-la-Neuve (IDDI), 1340 Ottignies-Louvain-la-Neuve, Belgium; (E.C.); (V.D.-T.); (L.G.-B.); (T.B.); (M.B.)
| | - Tomasz Burzykowski
- International Drug Development Institute, Louvain-la-Neuve (IDDI), 1340 Ottignies-Louvain-la-Neuve, Belgium; (E.C.); (V.D.-T.); (L.G.-B.); (T.B.); (M.B.)
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BioStat), Hasselt University, B-3500 Hasselt, Belgium
| | - Marc Buyse
- International Drug Development Institute, Louvain-la-Neuve (IDDI), 1340 Ottignies-Louvain-la-Neuve, Belgium; (E.C.); (V.D.-T.); (L.G.-B.); (T.B.); (M.B.)
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BioStat), Hasselt University, B-3500 Hasselt, Belgium
| |
Collapse
|
5
|
Ji S, Feng L, Fu Z, Wu G, Wu Y, Lin Y, Lu D, Song Y, Cui P, Yang Z, Sang C, Song G, Cai S, Li Y, Lin H, Zhang S, Wang X, Qiu S, Zhang X, Hua G, Li J, Zhou J, Dai Z, Wang X, Ding L, Wang P, Gao D, Zhang B, Rodriguez H, Fan J, Clevers H, Zhou H, Sun Y, Gao Q. Pharmaco-proteogenomic characterization of liver cancer organoids for precision oncology. Sci Transl Med 2023; 15:eadg3358. [PMID: 37494474 PMCID: PMC10949980 DOI: 10.1126/scitranslmed.adg3358] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/22/2023] [Indexed: 07/28/2023]
Abstract
Organoid models have the potential to recapitulate the biological and pharmacotypic features of parental tumors. Nevertheless, integrative pharmaco-proteogenomics analysis for drug response features and biomarker investigation for precision therapy of patients with liver cancer are still lacking. We established a patient-derived liver cancer organoid biobank (LICOB) that comprehensively represents the histological and molecular characteristics of various liver cancer types as determined by multiomics profiling, including genomic, epigenomic, transcriptomic, and proteomic analysis. Proteogenomic profiling of LICOB identified proliferative and metabolic organoid subtypes linked to patient prognosis. High-throughput drug screening revealed distinct response patterns of each subtype that were associated with specific multiomics signatures. Through integrative analyses of LICOB pharmaco-proteogenomics data, we identified the molecular features associated with drug responses and predicted potential drug combinations for personalized patient treatment. The synergistic inhibition effect of mTOR inhibitor temsirolimus and the multitargeted tyrosine kinase inhibitor lenvatinib was validated in organoids and patient-derived xenografts models. We also provide a user-friendly web portal to help serve the biomedical research community. Our study is a rich resource for investigation of liver cancer biology and pharmacological dependencies and may help enable functional precision medicine.
Collapse
Affiliation(s)
- Shuyi Ji
- Center for Tumor Diagnosis & Therapy, Jinshan Hospital, Fudan University, Shanghai 201508, China
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
| | - Li Feng
- Institute of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China
| | - Zile Fu
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
| | - Gaohua Wu
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
| | - Yingcheng Wu
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
| | - Youpei Lin
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
| | - Dayun Lu
- Analytical Research Center for Organic and Biological Molecules, State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Yuanli Song
- Analytical Research Center for Organic and Biological Molecules, State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Peng Cui
- Burning Rock Biotech, Shanghai 201114, China
| | - Zijian Yang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
| | - Chen Sang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
| | - Guohe Song
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
| | - Shangli Cai
- Burning Rock Biotech, Shanghai 201114, China
| | | | - Hanqing Lin
- D1 Medical Technology, Shanghai 200235, China
| | - Shu Zhang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
| | - Xiaoying Wang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
| | - Shuangjian Qiu
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
| | - Xiaoming Zhang
- Key Laboratory of Molecular Virology & Immunology, Institut Pasteur of Shanghai, Chinese Academy of Sciences, Shanghai 200031, China
| | - Guoqiang Hua
- Department of Radiation Oncology, and Cancer Institute, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Junqiang Li
- D1 Medical Technology, Shanghai 200235, China
| | - Jian Zhou
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
- Key Laboratory of Medical Epigenetics and Metabolism, Institutes of Biomedical Sciences, Fudan University, Shanghai 200032, China
| | - Zhi Dai
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
| | - Xiangdong Wang
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital Institute for Clinical Science, Fudan University Shanghai Medical College, Shanghai, China
| | - Li Ding
- Department of Medicine, McDonnell Genome Institute, Siteman Cancer Center, Washington University, St. Louis, MO 63108, USA
| | - Pei Wang
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NewYork, NY 10029, USA
| | - Daming Gao
- State Key Laboratory of Cell Biology, CAS Center for Excellence in Molecular Cell Science, Shanghai Institute of Biochemistry and Cell Biology, Chinese Academy of Sciences, Shanghai 200031, China
| | - Bing Zhang
- Lester and Sue Smith Breast Center, Department of Molecular and Human Genetics, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Henry Rodriguez
- Office of Cancer Clinical Proteomics Research, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Jia Fan
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
- Department of Radiation Oncology, and Cancer Institute, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Hans Clevers
- Oncode Institute, Hubrecht Institute and University Medical Center Utrecht, Uppsalalaan 8, 3584CT Utrecht, the Netherlands
- Current Address: Roche Pharma Research and Early Development (pRED), Basel, Switzerland
| | - Hu Zhou
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
- Analytical Research Center for Organic and Biological Molecules, State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
- Shanghai Institute of Materia Medica-University of Ottawa Joint Research Center in Systems and Personalized Pharmacology
| | - Yidi Sun
- Institute of Neuroscience, CAS Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai 200031, China
| | - Qiang Gao
- Center for Tumor Diagnosis & Therapy, Jinshan Hospital, Fudan University, Shanghai 201508, China
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Key Laboratory of Carcinogenesis and Cancer Invasion of Ministry of Education, Fudan University, Shanghai 200032, China
- Key Laboratory of Medical Epigenetics and Metabolism, Institutes of Biomedical Sciences, Fudan University, Shanghai 200032, China
- State Key Laboratory of Genetic Engineering, Human Phenome Institute, Fudan University, Shanghai 200433, China
| |
Collapse
|
6
|
Ouma LO, Grayling MJ, Wason JMS, Zheng H. Bayesian modelling strategies for borrowing of information in randomised basket trials. J R Stat Soc Ser C Appl Stat 2022; 71:2014-2037. [PMID: 36636028 PMCID: PMC9827857 DOI: 10.1111/rssc.12602] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 09/01/2022] [Indexed: 02/01/2023]
Abstract
Basket trials are an innovative precision medicine clinical trial design evaluating a single targeted therapy across multiple diseases that share a common characteristic. To date, most basket trials have been conducted in early-phase oncology settings, for which several Bayesian methods permitting information sharing across subtrials have been proposed. With the increasing interest of implementing randomised basket trials, information borrowing could be exploited in two ways; considering the commensurability of either the treatment effects or the outcomes specific to each of the treatment groups between the subtrials. In this article, we extend a previous analysis model based on distributional discrepancy for borrowing over the subtrial treatment effects ('treatment effect borrowing', TEB) to borrowing over the subtrial groupwise responses ('treatment response borrowing', TRB). Simulation results demonstrate that both modelling strategies provide substantial gains over an approach with no borrowing. TRB outperforms TEB especially when subtrial sample sizes are small on all operational characteristics, while the latter has considerable gains in performance over TRB when subtrial sample sizes are large, or the treatment effects and groupwise mean responses are noticeably heterogeneous across subtrials. Further, we notice that TRB, and TEB can potentially lead to different conclusions in the analysis of real data.
Collapse
Affiliation(s)
- Luke O. Ouma
- Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
| | - Michael J. Grayling
- Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
| | - James M. S. Wason
- Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
| | - Haiyan Zheng
- MRC Biostatistics UnitUniversity of CambridgeCambridgeUK
| |
Collapse
|
7
|
Wang T, Denman D, Bacot SM, Feldman GM. Challenges and the Evolving Landscape of Assessing Blood-Based PD-L1 Expression as a Biomarker for Anti-PD-(L)1 Immunotherapy. Biomedicines 2022; 10:1181. [PMID: 35625917 PMCID: PMC9138337 DOI: 10.3390/biomedicines10051181] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 02/05/2023] Open
Abstract
While promising, PD-L1 expression on tumor tissues as assessed by immunohistochemistry has been shown to be an imperfect biomarker that only applies to a limited number of cancers, whereas many patients with PD-L1-negative tumors still respond to anti-PD-(L)1 immunotherapy. Recent studies using patient blood samples to assess immunotherapeutic responsiveness suggests a promising approach to the identification of novel and/or improved biomarkers for anti-PD-(L)1 immunotherapy. In this review, we discuss the advances in our evolving understanding of the regulation and function of PD-L1 expression, which is the foundation for developing blood-based PD-L1 as a biomarker for anti-PD-(L)1 immunotherapy. We further discuss current knowledge and clinical study results for biomarker identification using PD-L1 expression on tumor and immune cells, exosomes, and soluble forms of PD-L1 in the peripheral blood. Finally, we discuss key challenges for the successful development of the potential use of blood-based PD-L1 as a biomarker for anti-PD-(L)1 immunotherapy.
Collapse
Affiliation(s)
- Tao Wang
- Office of Biotechnology Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD 20993, USA; (D.D.); (S.M.B.); (G.M.F.)
| | | | | | | |
Collapse
|
8
|
Fokas E, Appelt A, Glynne-Jones R, Beets G, Perez R, Garcia-Aguilar J, Rullier E, Smith JJ, Marijnen C, Peters FP, van der Valk M, Beets-Tan R, Myint AS, Gerard JP, Bach SP, Ghadimi M, Hofheinz RD, Bujko K, Gani C, Haustermans K, Minsky BD, Ludmir E, West NP, Gambacorta MA, Valentini V, Buyse M, Renehan AG, Gilbert A, Sebag-Montefiore D, Rödel C. International consensus recommendations on key outcome measures for organ preservation after (chemo)radiotherapy in patients with rectal cancer. Nat Rev Clin Oncol 2021; 18:805-816. [PMID: 34349247 DOI: 10.1038/s41571-021-00538-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 02/07/2023]
Abstract
Multimodal treatment strategies for patients with rectal cancer are increasingly including the possibility of organ preservation, through nonoperative management or local excision. Organ preservation strategies can enable patients with a complete response or near-complete clinical responses after radiotherapy with or without concomitant chemotherapy to safely avoid the morbidities associated with radical surgery, and thus to maintain anorectal function and quality of life. However, standardization of the key outcome measures of organ preservation strategies is currently lacking; this includes a lack of consensus of the optimal definitions and selection of primary end points according to the trial phase and design; the optimal time points for response assessment; response-based decision-making; follow-up schedules; use of specific anorectal function tests; and quality of life and patient-reported outcomes. Thus, a consensus statement on outcome measures is necessary to ensure consistency and facilitate more accurate comparisons of data from ongoing and future trials. Here, we have convened an international group of experts with extensive experience in the management of patients with rectal cancer, including organ preservation approaches, and used a Delphi process to establish the first international consensus recommendations for key outcome measures of organ preservation, in an attempt to standardize the reporting of data from both trials and routine practice in this emerging area.
Collapse
Affiliation(s)
- Emmanouil Fokas
- Department of Radiotherapy of Oncology, University of Frankfurt, Frankfurt, Germany.
- German Cancer Research Center (DKFZ), Heidelberg, Germany.
- German Cancer Consortium (DKTK), Frankfurt, Germany.
- Frankfurt Cancer Institute (FCI), Frankfurt, Germany.
| | - Ane Appelt
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Robert Glynne-Jones
- Department of Radiotherapy, Mount Vernon Centre for Cancer Treatment, Northwood, UK
| | - Geerard Beets
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
- Department of Surgery, Netherlands Cancer Institute Amsterdam, Amsterdam, Netherlands
| | - Rodrigo Perez
- Department of Surgery, Angelita & Joaquim Institute, São Paulo, Brazil
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eric Rullier
- Department of Colorectal Surgery, Haut-Lévèque Hospital, Centre Hospitalier Universitaire (CHU) Bordeaux, Bordeaux, France
| | - J Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Corrie Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Femke P Peters
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Maxine van der Valk
- Department of Surgery, Netherlands Cancer Institute Amsterdam, Amsterdam, Netherlands
| | - Regina Beets-Tan
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Arthur S Myint
- The Clatterbridge Cancer Centre, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Simon P Bach
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - Michael Ghadimi
- Department of General, Visceral, and Paediatric Surgery, University Medical Center, Göttingen, Germany
| | - Ralf D Hofheinz
- Department of Medical Oncology, University Hospital Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Krzysztof Bujko
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Research Center (DKFZ) Heidelberg and German Consortium for Translational Cancer Research (DKTK) Partner Site Tübingen, Tübingen, Germany
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospital Leuven, Leuven, Belgium
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas P West
- Division of Pathology and Data Analytics, Leeds Institute of Medical Research at St. James's, School of Medicine, University of Leeds, Leeds, UK
| | - Maria A Gambacorta
- Department of Radiation Oncology and Medical Oncology, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vincenzo Valentini
- Department of Radiation Oncology and Medical Oncology, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marc Buyse
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt University, Diepenbeek, Belgium
- International Drug Development Institute, San Francisco, CA, USA
| | - Andrew G Renehan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, Manchester, UK
| | - Alexandra Gilbert
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | | | - Claus Rödel
- Department of Radiotherapy of Oncology, University of Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Frankfurt, Germany
- Frankfurt Cancer Institute (FCI), Frankfurt, Germany
| |
Collapse
|
9
|
Lévy V. Of some innovations in clinical trial design in hematology and oncology. Therapie 2021; 77:191-195. [PMID: 34922739 DOI: 10.1016/j.therap.2021.10.011] [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: 08/24/2021] [Accepted: 10/14/2021] [Indexed: 11/18/2022]
Abstract
The design of clinical trials, formalized in the immediate post-war period, has undergone major changes due to therapeutic innovations, particularly the arrival of targeted therapies in onco-hematology. The traditional phase I-II-III regimen is regularly questioned and multiple adaptations are proposed. This article proposes to expose some of these modifications and the issues they lead to.
Collapse
Affiliation(s)
- Vincent Lévy
- Département de recherche clinique, hôpital Avicenne, université Sorbonne Paris Nord, AP-HP, 93000 Bobigny, France.
| |
Collapse
|
10
|
Boissel JP, Pérol D, Décousus H, Klingmann I, Hommel M. Using numerical modeling and simulation to assess the ethical burden in clinical trials and how it relates to the proportion of responders in a trial sample. PLoS One 2021; 16:e0258093. [PMID: 34634062 PMCID: PMC8504716 DOI: 10.1371/journal.pone.0258093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 09/21/2021] [Indexed: 01/24/2023] Open
Abstract
In order to propose a more precise definition and explore how to reduce ethical losses in randomized controlled clinical trials (RCTs), we set out to identify trial participants who do not contribute to demonstrating that the treatment in the experimental arm is superior to that in the control arm. RCTs emerged mid-last century as the gold standard for assessing efficacy, becoming the cornerstone of the value of new therapies, yet their ethical grounds are a matter of debate. We introduce the concept of unnecessary participants in RCTs, the sum of non-informative participants and non-responders. The non-informative participants are considered not informative with respect to the efficacy measured in the trial in contrast to responders who carry all the information required to conclude on the treatment's efficacy. The non-responders present the event whether or not they are treated with the experimental treatment. The unnecessary participants carry the burden of having to participate in a clinical trial without benefiting from it, which might include experiencing side effects. Thus, these unnecessary participants carry the ethical loss that is inherent to the RCT methodology. On the contrary, responders to the experimental treatment bear its entire efficacy in the RCT. Starting from the proportions observed in a real placebo-controlled trial from the literature, we carried out simulations of RCTs progressively increasing the proportion of responders up to 100%. We show that the number of unnecessary participants decreases steadily until the RCT's ethical loss reaches a minimum. In parallel, the trial sample size decreases (presumably its cost as well), although the trial's statistical power increases as shown by the increase of the chi-square comparing the event rates between the two arms. Thus, we expect that increasing the proportion of responders in RCTs would contribute to making them more ethically acceptable, with less false negative outcomes.
Collapse
Affiliation(s)
| | - David Pérol
- Department of Biostatistics, Centre Léon Bérard, Lyon, France
| | - Hervé Décousus
- INSERM, CIC 1408—F Crin, INNOVTE, CHU Saint-Etienne, Hôpital Nord, Service Médecine Vasculaire et Thérapeutique, Saint Etienne, France
| | - Ingrid Klingmann
- European Forum for Good Clinical Practice (EFGCP), Brussels, Belgium
| | - Marc Hommel
- Novadiscovery, Lyon, France
- University Hospital Grenoble, Grenoble, EA 4407 AGEIS UGA, France
| |
Collapse
|
11
|
Lengliné E, Peron J, Vanier A, Gueyffier F, Kouzan S, Dufour P, Guillot B, Blondon H, Clanet M, Cochat P, Degos F, Chevret S, Grande M, Putzolu J. Basket clinical trial design for targeted therapies for cancer: a French National Authority for Health statement for health technology assessment. Lancet Oncol 2021; 22:e430-e434. [PMID: 34592192 DOI: 10.1016/s1470-2045(21)00337-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/27/2021] [Accepted: 06/01/2021] [Indexed: 11/16/2022]
Abstract
During the past decade, health technology assessment bodies have faced new challenges in establishing the benefits of new drugs for individuals and health-care systems. A topic of increasing importance to the field of oncology is the so-called agnostic regulatory approval of targeted therapies for cancer (independent of tumour location and histology) granted on the basis of basket trials. Basket trials in oncology offer the advantage of simultaneously evaluating treatments for multiple tumours, even rare cancers, in a single clinical trial. To address the novel challenges introduced by these trials, an interdisciplinary panel was convened on behalf of the Transparency Committee of the French National Authority for Health to clarify an approach designed to guarantee a transparent, reproducible, and fair assessment of histology-agnostic treatments for reimbursement by the French National Health Insurance Fund. The requirements of this approach include the need for randomisation, clinically relevant endpoints, appropriate correction for multiple significance testing, characterisation of subgroup heterogeneity, and validation of underlying biomarker assays. A prospectively designated external control is encouraged when the implementation of a direct comparison is deemed infeasible. We also underline the importance of recording outcomes from basket trials in a registry for use as future external controls.
Collapse
Affiliation(s)
| | - Julien Peron
- Medical Oncology Department, Cancer Institute of the Hospices Civils of Lyon, Lyon, France
| | - Antoine Vanier
- Unit of Methodology Biostatistics and Data Management, INSERM CIC1415, University Hospital of Tours, Tours, France
| | - François Gueyffier
- UMR 5558 CNRS Lyon, Claude Bernard University Lyon 1, Lyon, France; Public Health Department, Lyon University Hospitals, Lyon, France
| | - Serge Kouzan
- Pulmonary Department, Centre Regional Hospital, Chambery, France
| | - Patrick Dufour
- Medical and Surgical Division of Digestive Pathology, Hautepierre Hospital, Louis Pasteur University, Strasbourg, France
| | - Bernard Guillot
- Dermatology Department, Saint Eloi University Hospital, Montpellier, France
| | - Hugues Blondon
- Department of Gastroenterology and Hepatology, Versailles Hospital, Le Chesnay, France
| | - Michel Clanet
- Pharmaceuticals Assessment Department, French National Authority for Health, Saint-Denis, France
| | - Pierre Cochat
- Pharmaceuticals Assessment Department, French National Authority for Health, Saint-Denis, France
| | - Françoise Degos
- Pharmaceuticals Assessment Department, French National Authority for Health, Saint-Denis, France
| | - Sylvie Chevret
- Biostatistics Department, Saint-Louis Hospital, Paris, France
| | - Mathilde Grande
- Pharmaceuticals Assessment Department, French National Authority for Health, Saint-Denis, France
| | - Jade Putzolu
- Pharmaceuticals Assessment Department, French National Authority for Health, Saint-Denis, France.
| | | |
Collapse
|
12
|
Prostate Cancer Biomarkers: From diagnosis to prognosis and precision-guided therapeutics. Pharmacol Ther 2021; 228:107932. [PMID: 34174272 DOI: 10.1016/j.pharmthera.2021.107932] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 12/23/2022]
Abstract
Prostate cancer (PCa) is one of the most commonly diagnosed malignancies and among the leading causes of cancer-related death worldwide. It is a highly heterogeneous disease, ranging from remarkably slow progression or inertia to highly aggressive and fatal disease. As therapeutic decision-making, clinical trial design and outcome highly depend on the appropriate stratification of patients to risk groups, it is imperative to differentiate between benign versus more aggressive states. The incorporation of clinically valuable prognostic and predictive biomarkers is also potentially amenable in this process, in the timely prevention of metastatic disease and in the decision for therapy selection. This review summarizes the progress that has so far been made in the identification of the genomic events that can be used for the classification, prediction and prognostication of PCa, and as major targets for clinical intervention. We include an extensive list of emerging biomarkers for which there is enough preclinical evidence to suggest that they may constitute crucial targets for achieving significant advances in the management of the disease. Finally, we highlight the main challenges that are associated with the identification of clinically significant PCa biomarkers and recommend possible ways to overcome such limitations.
Collapse
|
13
|
Hey SP, Gerlach CV, Dunlap G, Prasad V, Kesselheim AS. The evidence landscape in precision medicine. Sci Transl Med 2021; 12:12/540/eaaw7745. [PMID: 32321867 DOI: 10.1126/scitranslmed.aaw7745] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 10/03/2019] [Indexed: 12/20/2022]
Abstract
Precision medicine is beginning to make an impact on the treatment of different diseases, but there are still challenges that must be overcome, such as the complexity of interventions, the need for marker validation, and the level of evidence necessary to demonstrate effectiveness. In this Perspective, we describe how evidence landscapes can help to address these challenges.
Collapse
Affiliation(s)
- Spencer Phillips Hey
- Harvard Center for Bioethics, Harvard Medical School, Boston, MA, USA. .,Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Cory V Gerlach
- Harvard Program in Therapeutic Sciences, Harvard Medical School, Boston, MA, USA.,Department of Medicine, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Garrett Dunlap
- Harvard Program in Therapeutic Sciences, Harvard Medical School, Boston, MA, USA.,Program in Biological and Biomedical Sciences, Harvard Medical School, Boston, MA, and Therapeutics Graduate Program, Harvard Medical School, Boston, MA, USA
| | - Vinay Prasad
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Department of Preventive Medicine and Public Health, and Center for Health Care Ethics, Oregon Health and Science University, Portland, OR, USA
| | - Aaron S Kesselheim
- Harvard Center for Bioethics, Harvard Medical School, Boston, MA, USA.,Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
14
|
Hutchinson N, Carlisle B, Doussau A, Bosan R, Gumnit E, MacPherson A, Fergusson DA, Kimmelman J. Patient Participation in Clinical Trials of Oncology Drugs and Biologics Preceding Approval by the US Food and Drug Administration. JAMA Netw Open 2021; 4:e2110456. [PMID: 34003270 PMCID: PMC8132139 DOI: 10.1001/jamanetworkopen.2021.10456] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
IMPORTANCE Several studies have estimated the financial inputs for successful drug development. Such analyses do not capture the large investment that patient study participants commit to drug development. OBJECTIVE To estimate the volume of patients required to achieve a first US Food and Drug Administration (FDA) approval for a new anticancer drug or biologic therapy. DESIGN, SETTING, AND PARTICIPANTS This cohort study included a random sample of prelicense oncology drugs and biologics with a trial site in the United States that were launched into clinical efficacy testing between January 1, 2006, and December 31, 2010. Drugs and biologics were identified using ClinicalTrials.gov registration records. Total patient enrollment was captured over an 8-year span, and each intervention was classified based on whether it received FDA approval and was deemed as having intermediate or substantial value according to the American Society of Clinical Oncology Value Framework (ASCO-VF) score. Secondarily, the association between patient numbers and intervention characteristics was tested. Data were analyzed in February 2020. MAIN OUTCOMES AND MEASURE The prespecified primary outcome was the number of patients enrolled in prelicense trials per FDA approval. RESULTS A total of 120 drugs and biologics were included in our study, with 84 (70.0%) targeted agents, 20 (16.7%) immunotherapies, and 71 (59.2%) novel agents. A total of 13 drugs and biologics (10.8%; 95% CI, 5.3%-16.8%) in our sample gained FDA approval within 8 years, of which 1 (7.7%) was deemed of intermediate value and 3 (23.1%) were deemed of substantial value using ASCO-VF scoring. Overall, 158 810 patients were enrolled in 1335 trials testing these drugs and biologics, 47 913 (30.2%) in trials that led to FDA approval and 110 897 (69.8%) in trials that did not. An estimated 12 217 (95% CI, 7970-22 215) patient study participants contributed to prelicense trials per FDA approval. The estimated number of patients needed to produce a single FDA-approved drug or biologic of intermediate or substantial ASCO-VF clinical value was 39 703 (95% CI, 19 391-177 991). CONCLUSIONS AND RELEVANCE The results of this cohort study make visible the substantial patient investment required for prelicense oncology drug development. Such analyses can be used to devise policies that maximize the clinical impact of research on a per-patient basis.
Collapse
Affiliation(s)
- Nora Hutchinson
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Québec, Canada
| | - Benjamin Carlisle
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Québec, Canada
| | - Adelaide Doussau
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Québec, Canada
| | - Rafia Bosan
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Québec, Canada
| | - Eli Gumnit
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Québec, Canada
| | - Amanda MacPherson
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Québec, Canada
| | - Dean A. Fergusson
- Centre for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jonathan Kimmelman
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Québec, Canada
| |
Collapse
|
15
|
Coart E, Saad ED. Considerations on the mechanics and sample sizes for early trials of targeted agents and immunotherapy in oncology. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2021. [DOI: 10.1080/23808993.2021.1915693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Elisabeth Coart
- Consulting Services & Research, International Drug Development Institute (IDDI), Louvain-la-Neuve, Belgium
| | - Everardo D. Saad
- Consulting Services & Research, International Drug Development Institute (IDDI), Louvain-la-Neuve, Belgium
| |
Collapse
|
16
|
Rodriguez H, Zenklusen JC, Staudt LM, Doroshow JH, Lowy DR. The next horizon in precision oncology: Proteogenomics to inform cancer diagnosis and treatment. Cell 2021; 184:1661-1670. [PMID: 33798439 DOI: 10.1016/j.cell.2021.02.055] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/13/2021] [Accepted: 02/26/2021] [Indexed: 12/18/2022]
Abstract
When it comes to precision oncology, proteogenomics may provide better prospects to the clinical characterization of tumors, help make a more accurate diagnosis of cancer, and improve treatment for patients with cancer. This perspective describes the significant contributions of The Cancer Genome Atlas and the Clinical Proteomic Tumor Analysis Consortium to precision oncology and makes the case that proteogenomics needs to be fully integrated into clinical trials and patient care in order for precision oncology to deliver the right cancer treatment to the right patient at the right dose and at the right time.
Collapse
Affiliation(s)
- Henry Rodriguez
- Office of Cancer Clinical Proteomics Research, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Jean Claude Zenklusen
- Center for Cancer Genomics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Louis M Staudt
- Center for Cancer Genomics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - James H Doroshow
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA; Office of the Director, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Douglas R Lowy
- Office of the Director, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
17
|
Ravi R, Kesari HV. Novel Study Designs in Precision Medicine - Basket, Umbrella and Platform Trials. Curr Rev Clin Exp Pharmacol 2021; 17:114-121. [PMID: 34455953 DOI: 10.2174/1574884716666210316114157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 11/22/2022]
Abstract
The concept of 'one size fits all' - one treatment for patients with a particular disease, seems to be outdated. The advent of precision medicine has prompted profound changes in clinical research and it allows researchers to predict, more accurately, the prevention and treatment strategies for a specific disease population. Novel study designs are, therefore, essential to establish safe and effective personalized medicine. Basket, umbrella and platform trial designs (collectively referred to as master protocols) are biomarker enrichment designs that allow for testing more than one hypothesis within a protocol, thus accelerating drug development. These trial designs tailor intervention strategies based on patient's risk factor(s) that can help predict whether they will respond to a specific treatment. Basket trials evaluate therapy for various diseases that share a common molecular alteration while umbrella trials evaluate multiple targeted therapies for a single disease that is stratified into subgroups based on different molecular alterations/ risk factors. These designs are complex and their major limitations stem from the fact that it would be inappropriate to completely replace histological typing with molecular profiling alone. However, in the upcoming decades, these trial designs are likely to gain popularity and improve the efficiency of clinical research. This article briefly overviews the characteristics of master protocol designs with examples of completed and ongoing clinical trials utilizing these study designs.
Collapse
Affiliation(s)
- Renju Ravi
- Department of Clinical Pharmacology, Seth GS Medical College & KEM Hospital, Mumbai. India
| | - Harshad V Kesari
- Department of Pharmacology and Therapeutics, Seth GS Medical College & KEM Hospital, Mumbai. India
| |
Collapse
|
18
|
Advani D, Sharma S, Kumari S, Ambasta RK, Kumar P. Precision Oncology, Signaling and Anticancer Agents in Cancer Therapeutics. Anticancer Agents Med Chem 2021; 22:433-468. [PMID: 33687887 DOI: 10.2174/1871520621666210308101029] [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: 10/21/2020] [Revised: 01/05/2021] [Accepted: 01/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The global alliance for genomics and healthcare facilities provides innovational solutions to expedite research and clinical practices for complex and incurable health conditions. Precision oncology is an emerging field explicitly tailored to facilitate cancer diagnosis, prevention and treatment based on patients' genetic profile. Advancements in "omics" techniques, next-generation sequencing, artificial intelligence and clinical trial designs provide a platform for assessing the efficacy and safety of combination therapies and diagnostic procedures. METHOD Data were collected from Pubmed and Google scholar using keywords: "Precision medicine", "precision medicine and cancer", "anticancer agents in precision medicine" and reviewed comprehensively. RESULTS Personalized therapeutics including immunotherapy, cancer vaccines, serve as a groundbreaking solution for cancer treatment. Herein, we take a measurable view of precision therapies and novel diagnostic approaches targeting cancer treatment. The contemporary applications of precision medicine have also been described along with various hurdles identified in the successful establishment of precision therapeutics. CONCLUSION This review highlights the key breakthroughs related to immunotherapies, targeted anticancer agents, and target interventions related to cancer signaling mechanisms. The success story of this field in context to drug resistance, safety, patient survival and in improving quality of life is yet to be elucidated. We conclude that, in the near future, the field of individualized treatments may truly revolutionize the nature of cancer patient care.
Collapse
Affiliation(s)
- Dia Advani
- Molecular Neuroscience and Functional Genomics Laboratory Shahbad Daulatpur, Bawana Road, Delhi 110042. India
| | - Sudhanshu Sharma
- Molecular Neuroscience and Functional Genomics Laboratory Shahbad Daulatpur, Bawana Road, Delhi 110042. India
| | - Smita Kumari
- Molecular Neuroscience and Functional Genomics Laboratory Shahbad Daulatpur, Bawana Road, Delhi 110042. India
| | - Rashmi K Ambasta
- Molecular Neuroscience and Functional Genomics Laboratory Shahbad Daulatpur, Bawana Road, Delhi 110042. India
| | - Pravir Kumar
- Molecular Neuroscience and Functional Genomics Laboratory Shahbad Daulatpur, Bawana Road, Delhi 110042. India
| |
Collapse
|
19
|
Chen AP, Kummar S, Moore N, Rubinstein LV, Zhao Y, Williams PM, Palmisano A, Sims D, O'Sullivan Coyne G, Rosenberger CL, Simpson M, Raghav KPS, Meric-Bernstam F, Leong S, Waqar S, Foster JC, Konaté MM, Das B, Karlovich C, Lih CJ, Polley E, Simon R, Li MC, Piekarz R, Doroshow JH. Molecular Profiling-Based Assignment of Cancer Therapy (NCI-MPACT): A Randomized Multicenter Phase II Trial. JCO Precis Oncol 2021; 5:PO.20.00372. [PMID: 33928209 PMCID: PMC8078898 DOI: 10.1200/po.20.00372] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/10/2020] [Accepted: 11/24/2020] [Indexed: 12/19/2022] Open
Abstract
This trial assessed the utility of applying tumor DNA sequencing to treatment selection for patients with advanced, refractory cancer and somatic mutations in one of four signaling pathways by comparing the efficacy of four study regimens that were either matched to the patient's aberrant pathway (experimental arm) or not matched to that pathway (control arm). MATERIALS AND METHODS Adult patients with an actionable mutation of interest were randomly assigned 2:1 to receive either (1) a study regimen identified to target the aberrant pathway found in their tumor (veliparib with temozolomide or adavosertib with carboplatin [DNA repair pathway], everolimus [PI3K pathway], or trametinib [RAS/RAF/MEK pathway]), or (2) one of the same four regimens, but chosen from among those not targeting that pathway. RESULTS Among 49 patients treated in the experimental arm, the objective response rate was 2% (95% CI, 0% to 10.9%). One of 20 patients (5%) in the experimental trametinib cohort had a partial response. There were no responses in the other cohorts. Although patients and physicians were blinded to the sequencing and random assignment results, a higher pretreatment dropout rate was observed in the control arm (22%) compared with the experimental arm (6%; P = .038), suggesting that some patients may have had prior tumor mutation profiling performed that led to a lack of participation in the control arm. CONCLUSION Further investigation, better annotation of predictive biomarkers, and the development of more effective agents are necessary to inform treatment decisions in an era of precision cancer medicine. Increasing prevalence of tumor mutation profiling and preference for targeted therapy make it difficult to use a randomized phase II design to evaluate targeted therapy efficacy in an advanced disease setting.
Collapse
Affiliation(s)
- Alice P. Chen
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | - Shivaani Kummar
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
- Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | - Nancy Moore
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | | | - Yingdong Zhao
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | - P. Mickey Williams
- Molecular Characterization Laboratory, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Alida Palmisano
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
- General Dynamics Information Technology (GDIT), Falls Church, VA
| | - David Sims
- Molecular Characterization Laboratory, Frederick National Laboratory for Cancer Research, Frederick, MD
| | | | | | - Mel Simpson
- Applied/Developmental Research Directorate, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Kanwal P. S. Raghav
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Funda Meric-Bernstam
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Saiama Waqar
- Department of Medical Oncology, Washington University School of Medicine, St Louis, MO
| | - Jared C. Foster
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | - Mariam M. Konaté
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | - Biswajit Das
- Molecular Characterization Laboratory, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Chris Karlovich
- Molecular Characterization Laboratory, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Chih-Jian Lih
- Molecular Characterization Laboratory, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Eric Polley
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Richard Simon
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | - Ming-Chung Li
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | - Richard Piekarz
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| | - James H. Doroshow
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
- Center for Cancer Research, National Cancer Institute, Bethesda, MD
| |
Collapse
|
20
|
Statistical Considerations for Trials in Adjuvant Treatment of Colorectal Cancer. Cancers (Basel) 2020; 12:cancers12113442. [PMID: 33228149 PMCID: PMC7699469 DOI: 10.3390/cancers12113442] [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: 09/16/2020] [Revised: 10/29/2020] [Accepted: 11/17/2020] [Indexed: 12/26/2022] Open
Abstract
The design of the best possible clinical trials of adjuvant interventions in colorectal cancer will entail the use of both time-tested and novel methods that allow efficient, reliable and patient-relevant therapeutic development. The ultimate goal of this endeavor is to safely and expeditiously bring to clinical practice novel interventions that impact patient lives. In this paper, we discuss statistical aspects and provide suggestions to optimize trial design, data collection, study implementation, and the use of predictive biomarkers and endpoints in phase 3 trials of systemic adjuvant therapy. We also discuss the issues of collaboration and patient centricity, expecting that several novel agents with activity in the (neo)adjuvant therapy of colon and rectal cancers will become available in the near future.
Collapse
|
21
|
Zhang Q, Fu Q, Bai X, Liang T. Molecular Profiling-Based Precision Medicine in Cancer: A Review of Current Evidence and Challenges. Front Oncol 2020; 10:532403. [PMID: 33194591 PMCID: PMC7652987 DOI: 10.3389/fonc.2020.532403] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 08/26/2020] [Indexed: 12/16/2022] Open
Abstract
Matched therapy based on next-generation sequencing is now a part of routine care to guide the treatment of patients with advanced solid tumors. However, whether and to what extent patients can benefit from this strategy on a large scale remains uncertain. In the past decade, several clinical studies were performed in this field, among which only one was a randomized trial. We reviewed the literature on this topic and summarize the existing data about the efficacy of this treatment strategy. Currently, the evidence is promising but not solid. Multiple ongoing trials are also summarized. We also discuss the limitations of this treatment strategy and certain unsolved important problems, including how to select the sample and target level, how to interpret the results, and the problem of drug accessibility. All these issues should receive more attention in future clinical trial design and the application of target therapy in cancer treatment.
Collapse
Affiliation(s)
- Qi Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- The Key Laboratory of Pancreatic Diseases of Zhejiang Province, Hangzhou, China
- The Innovation Center for the Study of Pancreatic Diseases of Zhejiang Province, Hangzhou, China
- Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Qihan Fu
- The Key Laboratory of Pancreatic Diseases of Zhejiang Province, Hangzhou, China
- The Innovation Center for the Study of Pancreatic Diseases of Zhejiang Province, Hangzhou, China
- Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
- Department of Medical Oncology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- The Key Laboratory of Pancreatic Diseases of Zhejiang Province, Hangzhou, China
- The Innovation Center for the Study of Pancreatic Diseases of Zhejiang Province, Hangzhou, China
- Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- The Key Laboratory of Pancreatic Diseases of Zhejiang Province, Hangzhou, China
- The Innovation Center for the Study of Pancreatic Diseases of Zhejiang Province, Hangzhou, China
- Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| |
Collapse
|
22
|
Grayling MJ, Dimairo M, Mander AP, Jaki TF. A Review of Perspectives on the Use of Randomization in Phase II Oncology Trials. J Natl Cancer Inst 2019; 111:1255-1262. [PMID: 31218346 PMCID: PMC6910171 DOI: 10.1093/jnci/djz126] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/05/2019] [Accepted: 06/12/2019] [Indexed: 12/21/2022] Open
Abstract
Historically, phase II oncology trials assessed a treatment's efficacy by examining its tumor response rate in a single-arm trial. Then, approximately 25 years ago, certain statistical and pharmacological considerations ignited a debate around whether randomized designs should be used instead. Here, based on an extensive literature review, we review the arguments on either side of this debate. In particular, we describe the numerous factors that relate to the reliance of single-arm trials on historical control data and detail the trial scenarios in which there was general agreement on preferential utilization of single-arm or randomized design frameworks, such as the use of single-arm designs when investigating treatments for rare cancers. We then summarize the latest figures on phase II oncology trial design, contrasting current design choices against historical recommendations on best practice. Ultimately, we find several ways in which the design of recently completed phase II trials does not appear to align with said recommendations. For example, despite advice to the contrary, only 66.2% of the assessed trials that employed progression-free survival as a primary or coprimary outcome used a randomized comparative design. In addition, we identify that just 28.2% of the considered randomized comparative trials came to a positive conclusion as opposed to 72.7% of the single-arm trials. We conclude by describing a selection of important issues influencing contemporary design, framing this discourse in light of current trends in phase II, such as the increased use of biomarkers and recent interest in novel adaptive designs.
Collapse
Affiliation(s)
- Michael J Grayling
- Correspondence to: Michael J. Grayling, Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Rd, Newcastle upon Tyne NE2 4AX, UK (e-mail: )
| | | | | | | |
Collapse
|
23
|
Fokas E, Fietkau R, Hartmann A, Hohenberger W, Grützmann R, Ghadimi M, Liersch T, Ströbel P, Grabenbauer GG, Graeven U, Hofheinz RD, Köhne CH, Wittekind C, Sauer R, Kaufmann M, Hothorn T, Rödel C. Neoadjuvant rectal score as individual-level surrogate for disease-free survival in rectal cancer in the CAO/ARO/AIO-04 randomized phase III trial. Ann Oncol 2019; 29:1521-1527. [PMID: 29718095 DOI: 10.1093/annonc/mdy143] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Surrogate end points in rectal cancer after preoperative chemoradiation are lacking as their statistical validation poses major challenges, including confirmation based on large phase III trials. We examined the prognostic role and individual-level surrogacy of neoadjuvant rectal (NAR) score that incorporates weighted cT, ypT and ypN categories for disease-free survival (DFS) in 1191 patients with rectal carcinoma treated within the CAO/ARO/AIO-04 phase III trial. Patients and methods Cox regression models adjusted for treatment arm, resection status, and NAR score were used in multivariable analysis. The four Prentice criteria (PC1-4) were used to assess individual-level surrogacy of NAR for DFS. Results After a median follow-up of 50 months, the addition of oxaliplatin to fluorouracil-based chemoradiotherapy (CRT) significantly improved 3-year DFS [75.9% (95% confidence interval [CI] 72.30% to 79.50%) versus 71.3% (95% CI 67.60% to 74.90%); P = 0.034; PC 1) and resulted in a shift toward lower NAR groups (P = 0.034, PC 2) compared with fluorouracil-only CRT. The 3-year DFS was 91.7% (95% CI 88.2% to 95.2%), 81.8% (95% CI 78.4% to 85.1%), and 58.1% (95% CI 52.4% to 63.9%) for low, intermediate, and high NAR score, respectively (P < 0.001; PC 3). NAR score remained an independent prognostic factor for DFS [low versus high NAR: hazard ratio (HR) 4.670; 95% CI 3.106-7.020; P < 0.001; low versus intermediate NAR: HR 1.971; 95% CI 1.303-2.98; P = 0.001] in multivariable analysis. Notwithstanding the inherent methodological difficulty in interpretation of PC 4 to establish surrogacy, the treatment effect on DFS was captured by NAR, supporting satisfaction of individual-level PC 4. Conclusion Our study validates the prognostic role and individual-level surrogacy of NAR score for DFS within a large randomized phase III trial. NAR score could help oncologists to speed up response-adapted therapeutic decision, and further large phase III trial data sets should aim to confirm trial-level surrogacy.
Collapse
Affiliation(s)
- E Fokas
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg; German Cancer Consortium (DKTK), Partner Site: Frankfurt, Germany.
| | - R Fietkau
- Department of Radiation Therapy, University of Erlangen-Nürnberg, Erlangen, Germany
| | - A Hartmann
- Institute of Pathology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - W Hohenberger
- Department of General and Visceral, University of Erlangen-Nürnberg, Erlangen, Germany
| | - R Grützmann
- Department of General and Visceral, University of Erlangen-Nürnberg, Erlangen, Germany
| | - M Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - T Liersch
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - P Ströbel
- Institute of Pathology, University Medical Center Göttingen, Göttingen, Germany
| | - G G Grabenbauer
- Department of Radiation Oncology and Radiotherapy, DiaCura & Klinikum Coburg, Coburg, Germany
| | - U Graeven
- Department of Hematology/Oncology, Kliniken Maria Hilf GmbH Mönchengladbach, Mönchengladbach, Germany
| | - R-D Hofheinz
- Department of Medical Oncology, University Hospital Mannheim, Mannheim, Germany
| | - C-H Köhne
- Department of Medical Oncology, University of Oldenburg, Oldenburg, Germany
| | - C Wittekind
- Institute of Pathology, University of Leipzig, Leipzig, Germany
| | - R Sauer
- Department of Radiation Therapy, University of Erlangen-Nürnberg, Erlangen, Germany
| | - M Kaufmann
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - T Hothorn
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - C Rödel
- Department of Radiotherapy and Oncology, University of Frankfurt, Frankfurt, Germany; German Cancer Research Center (DKFZ), Heidelberg; German Cancer Consortium (DKTK), Partner Site: Frankfurt, Germany
| | | |
Collapse
|
24
|
Drumond N. Future Perspectives for Patient-Centric Pharmaceutical Drug Product Design with Regard to Solid Oral Dosage Forms. J Pharm Innov 2019. [DOI: 10.1007/s12247-019-09407-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Abstract
Purpose
Additional costs for healthcare provision are expected for cases where the level of care provided is not according to the patient’s needs and demands. To address these issues and reduce costs, fundamental changes need to be made on how healthcare provision is administered to patients, which raises the opportunity for the implementation of patient-centric systems.
Methods
This review addresses the importance of implementing a patient-centric approach in current healthcare provision and emphasizes the need to adjust current development and business models for a successful application of patient-centric care.
Results
To increase awareness and avoid confusion, the purpose of patient-centric pharmaceutical drug product design is reviewed in detail and future market opportunities for patient-centric drug products are discussed.
Conclusions
With regard to solid oral dosage forms, the subject of patient-centric pharmaceutical drug product design will focus more on the customization of existing technologies (e.g., dosage form size reduction) to address the needs of specific patient populations such as pediatrics, geriatrics, dysphagia patients, or the cognitively impaired.
Collapse
|
25
|
Abstract
New therapies that promote antitumour immunity have been recently developed. Most of these immunomodulatory approaches have focused on enhancing T-cell responses, either by targeting inhibitory pathways with immune checkpoint inhibitors, or by targeting activating pathways, as with chimeric antigen receptor T cells or bispecific antibodies. Although these therapies have led to unprecedented successes, only a minority of patients with cancer benefit from these treatments, highlighting the need to identify new cells and molecules that could be exploited in the next generation of immunotherapy. Given the crucial role of innate immune responses in immunity, harnessing these responses opens up new possibilities for long-lasting, multilayered tumour control.
Collapse
|
26
|
Adashek JJ, LoRusso PM, Hong DS, Kurzrock R. Phase I trials as valid therapeutic options for patients with cancer. Nat Rev Clin Oncol 2019; 16:773-778. [PMID: 31477881 DOI: 10.1038/s41571-019-0262-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2019] [Indexed: 12/17/2022]
Abstract
For many years, oncology phase I trials have been referred to as 'toxicity trials' and have been believed to have low clinical utility other than that of establishing the adverse event profile of novel therapeutic agents. The traditional distinction of clinical trials into three phases has been challenged in the past few years by the introduction of targeted therapies and immunotherapies into the routine management of patients with cancer. This transformation has especially affected early phase trials, leading to the current situation in which response rates are increasingly reported from phase I trials. In this Perspectives, we highlight key elements of phase I trials and discuss how each one of them contributes to a new paradigm whereby preliminary measurements of the clinical benefit from a novel treatment can be obtained in current phase I trials, which can therefore be considered to have a therapeutic intent.
Collapse
Affiliation(s)
- Jacob J Adashek
- Department of Internal Medicine, University of South Florida, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - David S Hong
- Department of Investigational Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy, Department of Medicine, University of California San Diego Moores Cancer Center, La Jolla, CA, USA.
| |
Collapse
|
27
|
Phillips PPJ, Mitnick CD, Neaton JD, Nahid P, Lienhardt C, Nunn AJ. Keeping phase III tuberculosis trials relevant: Adapting to a rapidly changing landscape. PLoS Med 2019; 16:e1002767. [PMID: 30901331 PMCID: PMC6430373 DOI: 10.1371/journal.pmed.1002767] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In a Collection Review, Patrick Phillips and colleagues discuss developments in clinical trial design for the evaluation of TB therapeutics.
Collapse
Affiliation(s)
- Patrick P. J. Phillips
- School of Medicine, UCSF Center for TB, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Carole D. Mitnick
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - James D. Neaton
- School of Public Health, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Payam Nahid
- School of Medicine, UCSF Center for TB, University of California San Francisco, San Francisco, California, United States of America
| | - Christian Lienhardt
- Unité Mixte Internationale TransVIHMI (UMI 233 IRD, U1175 INSERM, Université de Montpellier), Institut de Recherche pour le Développement Montpellier, Montpellier, France
| | - Andrew J. Nunn
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| |
Collapse
|
28
|
Mandel JJ, Yust-Katz S, Patel AJ, Cachia D, Liu D, Park M, Yuan Y, Kent TA, de Groot JF. Inability of positive phase II clinical trials of investigational treatments to subsequently predict positive phase III clinical trials in glioblastoma. Neuro Oncol 2019; 20:113-122. [PMID: 29016865 DOI: 10.1093/neuonc/nox144] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Glioblastoma is the most common primary malignant brain tumor in adults, but effective therapies are lacking. With the scarcity of positive phase III trials, which are increasing in cost, we examined the ability of positive phase II trials to predict statistically significant improvement in clinical outcomes of phase III trials. Methods A PubMed search was conducted to identify phase III clinical trials performed in the past 25 years for patients with newly diagnosed or recurrent glioblastoma. Trials were excluded if they did not examine an investigational chemotherapy or agent, if they were stopped early owing to toxicity, if they lacked prior phase II studies, or if a prior phase II study was negative. Results Seven phase III clinical trials in newly diagnosed glioblastoma and 4 phase III clinical trials in recurrent glioblastoma met the inclusion criteria. Only 1 (9%) phase III study documented an improvement in overall survival and changed the standard of care. Conclusion The high failure rate of phase III trials demonstrates the urgent need to increase the reliability of phase II trials of treatments for glioblastoma. Strategies such as the use of adaptive trial designs, Bayesian statistics, biomarkers, volumetric imaging, and mathematical modeling warrant testing. Additionally, it is critical to increase our expectations of phase II trials so that positive findings increase the probability that a phase III trial will be successful.
Collapse
Affiliation(s)
- Jacob J Mandel
- Baylor College of Medicine, Department of Neurology, Houston, Texas, USA
| | - Shlomit Yust-Katz
- Rabin Medical Center, Department of Neurosurgery, Petah Tikva, Israel
| | - Akash J Patel
- Baylor College of Medicine, Department of Neurology, Houston, Texas, USA
| | - David Cachia
- Medical University of South Carolina, Department of Neurosurgery, Charleston, South Carolina, USA
| | - Diane Liu
- The University of Texas MD Anderson Cancer Center, Department of Biostatistics, Houston, Texas, USA
| | - Minjeong Park
- The University of Texas MD Anderson Cancer Center, Department of Biostatistics, Houston, Texas, USA
| | - Ying Yuan
- The University of Texas MD Anderson Cancer Center, Department of Biostatistics, Houston, Texas, USA
| | - Thomas A Kent
- Baylor College of Medicine, Department of Neurology, Houston, Texas, USA
| | - John F de Groot
- The University of Texas MD Anderson Cancer Center, Department of Neuro-Oncology, Houston, Texas, USA
| |
Collapse
|
29
|
Harding T, Baughn L, Kumar S, Van Ness B. The future of myeloma precision medicine: integrating the compendium of known drug resistance mechanisms with emerging tumor profiling technologies. Leukemia 2019; 33:863-883. [PMID: 30683909 DOI: 10.1038/s41375-018-0362-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/25/2018] [Accepted: 11/12/2018] [Indexed: 02/07/2023]
Abstract
Multiple myeloma (MM) is a hematologic malignancy that is considered mostly incurable in large part due to the inability of standard of care therapies to overcome refractory disease and inevitable drug-resistant relapse. The post-genomic era has been a productive period of discovery where modern sequencing methods have been applied to large MM patient cohorts to modernize our current perception of myeloma pathobiology and establish an appreciation for the vast heterogeneity that exists between and within MM patients. Numerous pre-clinical studies conducted in the last two decades have unveiled a compendium of mechanisms by which malignant plasma cells can escape standard therapies, many of which have potentially quantifiable biomarkers. Exhaustive pre-clinical efforts have evaluated countless putative anti-MM therapeutic agents and many of these have begun to enter clinical trial evaluation. While the palette of available anti-MM therapies is continuing to expand it is also clear that malignant plasma cells still have mechanistic avenues by which they can evade even the most promising new therapies. It is therefore becoming increasingly clear that there is an outstanding need to develop and employ precision medicine strategies in MM management that harness emerging tumor profiling technologies to identify biomarkers that predict efficacy or resistance within an individual's sub-clonally heterogeneous tumor. In this review we present an updated overview of broad classes of therapeutic resistance mechanisms and describe selected examples of putative biomarkers. We also outline several emerging tumor profiling technologies that have the potential to accurately quantify biomarkers for therapeutic sensitivity and resistance at genomic, transcriptomic and proteomic levels. Finally, we comment on the future of implementation for precision medicine strategies in MM and the clear need for a paradigm shift in clinical trial design and disease management.
Collapse
Affiliation(s)
- Taylor Harding
- Department of Genetics, Cell Biology & Development, University of Minnesota, Minneapolis, MN, USA
| | - Linda Baughn
- Department of Laboratory Medicine and Pathology, Division of Laboratory Genetics, Mayo Clinic, Rochester, MN, USA
| | - Shaji Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Brian Van Ness
- Department of Genetics, Cell Biology & Development, University of Minnesota, Minneapolis, MN, USA.
| |
Collapse
|
30
|
Weymann D, Pataky R, Regier DA. Economic Evaluations of Next-Generation Precision Oncology: A Critical Review. JCO Precis Oncol 2018; 2:1-23. [DOI: 10.1200/po.17.00311] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose Precision oncology has the potential to improve patient health and reduce treatment costs. Yet the up-front cost of genomic testing with next-generation sequencing (NGS) technologies can be prohibitive. Our study is a structured review of economic evaluations of precision oncology informed by NGS. The aim is to characterize the availability and scope of economic evidence. Materials and Methods We searched Medline (PubMed), Embase (Ovid), and Web of Science databases for English-language full-text peer-reviewed articles published between 2000 and 2016. We focused our search on articles that estimated the benefit of precision oncology in relation to its costs. We excluded studies that did not undertake full economic evaluations or did not focus on NGS technologies. We reviewed all included studies and summarized key methodological and empirical study characteristics. Results Fifty-five economic evaluations met our inclusion criteria. The number of published studies increased steadily, from three studies between 2005 and 2007 to 26 between 2014 and 2016. Most studies evaluated multiplex panels (86%). We found testing was frequently used to predict prognosis (67%), to diagnose patients (24%), or to identify targeted therapeutic options (7%). Methods and cost effectiveness differed according to NGS technology, test strategy, and cancer type. Deterministic and probabilistic analyses were typically used to characterize parameter and decision uncertainty (91% and 75%). Conclusion Although the availability of economic evidence examining precision oncology increased over time, methods used often did not align with current guidelines. Future evaluations should undertake extensive sensitivity analysis to address all sources of uncertainty associated with rapidly changing NGS technologies. Furthermore, additional research is needed evaluating the cost effectiveness of more comprehensive next-generation technologies before implementing these on a wider scale.
Collapse
Affiliation(s)
- Deirdre Weymann
- All authors, Canadian Centre for Applied Research in Cancer Control, BC Cancer; and Dean A. Regier, University of British Columbia, Vancouver, British Columbia, Canada
| | - Reka Pataky
- All authors, Canadian Centre for Applied Research in Cancer Control, BC Cancer; and Dean A. Regier, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dean A. Regier
- All authors, Canadian Centre for Applied Research in Cancer Control, BC Cancer; and Dean A. Regier, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
31
|
Mozgunov P, Jaki T, Paoletti X. Randomized dose-escalation designs for drug combination cancer trials with immunotherapy. J Biopharm Stat 2018; 29:359-377. [PMID: 30352007 DOI: 10.1080/10543406.2018.1535503] [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: 12/11/2022]
Abstract
This work considers Phase I cancer dual-agent dose-escalation clinical trials in which one of the compounds is an immunotherapy. The distinguishing feature of trials considered is that the dose of one agent, referred to as a standard of care, is fixed and another agent is dose-escalated. Conventionally, the goal of a Phase I trial is to find the maximum tolerated combination (MTC). However, in trials involving an immunotherapy, it is also essential to test whether a difference in toxicities associated with the MTC and the standard of care alone is present. This information can give useful insights about the interaction of the compounds and can provide a quantification of the additional toxicity burden and therapeutic index. We show that both, testing for difference between toxicity risks and selecting MTC can be achieved using a Bayesian model-based dose-escalation design with two modifications. Firstly, the standard of care administrated alone is included in the trial as a control arm and each patient is randomized between the control arm and one of the combinations selected by a model-based design. Secondly, a flexible model is used to allow for toxicities at the MTC and the control arm to be modeled directly. We compare the performance of two-parameter and four-parameter logistic models with and without randomization to a current standard of such trials: a one-parameter model. It is found that at the cost of a small reduction in the proportion of correct selections in some scenarios, randomization provides a significant improvement in the ability to test for a difference in the toxicity risks. It also allows a better fitting of the combination-toxicity curve that leads to more reliable recommendations of the combination(s) to be studied in subsequent phases.
Collapse
Affiliation(s)
- Pavel Mozgunov
- a Department of Mathematics and Statistics , Bailrigg, Lancaster , Lancaster University , UK
| | - Thomas Jaki
- a Department of Mathematics and Statistics , Bailrigg, Lancaster , Lancaster University , UK
| | - Xavier Paoletti
- b Service de Biostatistique et d'Epidémiologie & CESP OncoStat, INSERM , Institut Gustave Roussy, Université Paris-11 , Villejuif , France
| |
Collapse
|
32
|
Les méthodes adaptatives et l’évaluation des nouvelles approches thérapeutiques : de nouveaux enjeux méthodologiques. Bull Cancer 2018; 105:741-742. [DOI: 10.1016/j.bulcan.2018.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/12/2018] [Indexed: 11/19/2022]
|
33
|
Chae YK, Pan AP, Davis AA, Patel SP, Carneiro BA, Kurzrock R, Giles FJ. Path toward Precision Oncology: Review of Targeted Therapy Studies and Tools to Aid in Defining "Actionability" of a Molecular Lesion and Patient Management Support. Mol Cancer Ther 2018; 16:2645-2655. [PMID: 29203694 DOI: 10.1158/1535-7163.mct-17-0597] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 08/04/2017] [Accepted: 08/16/2017] [Indexed: 11/16/2022]
Abstract
Precision medicine trials and targeted therapies have shifted to the forefront of oncology. Although targeted therapies have shown initial promise, implementation across the broad landscape of oncology has many challenges. These limitations include an incomplete understanding of the functional significance of variant alleles as well as the need for clinical research and practice models that are more patient-centered and account for the complexity of individual patient tumors. Furthermore, successful implementation of targeted therapies will also be predicated on efforts to standardize the framework for patient management support. Here, we review current implementations of targeted therapies in precision oncology and discuss how "actionability" is defined for molecular targets in cancer therapeutics. We also comment on the growing need for bioinformatics tools and data platforms to complement advances in precision oncology. Finally, we discuss current frameworks for integrating precision oncology into patient management and propose an integrated model that combines features of molecular tumor boards and decision support systems. Mol Cancer Ther; 16(12); 2645-55. ©2017 AACRSee related article by Pilié et al., p. 2641.
Collapse
Affiliation(s)
- Young Kwang Chae
- Developmental Therapeutics Program, Division of Hematology Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alan P Pan
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew A Davis
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sandip P Patel
- Center for Personalized Cancer Therapy, Moores Cancer Center at the University of California San Diego, La Jolla, California
| | - Benedito A Carneiro
- Developmental Therapeutics Program, Division of Hematology Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy, Moores Cancer Center at the University of California San Diego, La Jolla, California
| | - Francis J Giles
- Developmental Therapeutics Program, Division of Hematology Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
34
|
Accelerating evidence gathering and approval of precision medicine therapies: the FDA takes aim at rare mutations. Genet Med 2018; 21:542-544. [PMID: 29988078 PMCID: PMC6752286 DOI: 10.1038/s41436-018-0099-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 06/07/2018] [Indexed: 11/25/2022] Open
|
35
|
Foroughi S, Wong HL, Gately L, Lee M, Simons K, Tie J, Burgess AW, Gibbs P. Re-inventing the randomized controlled trial in medical oncology: The registry-based trial. Asia Pac J Clin Oncol 2018; 14:365-373. [PMID: 29947051 DOI: 10.1111/ajco.12992] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/29/2018] [Indexed: 01/09/2023]
Abstract
Substantial progress has recently been made in optimizing the management of cancer patients, resulting in major gains in survival and quality of life. Much of this progress has resulted from the serial testing of promising treatment strategies, typically using prospective randomized controlled trials to compare outcomes achieved with the new approach versus the current standard(s) of care. However, there is an ever-expanding list of important questions that are difficult to investigate, particularly with respect to determining the optimal sequencing and combination of proven active agents. With the rapidly growing list of clinical, pathologic and molecular characteristics that promise to predict treatment benefit and/or risk for defined patient subsets, many new questions regarding how best to personalize our approach to treatment selection are emerging. These questions can be investigated in the context of registry-based randomized clinical trials. Recently, the potential of registry-based randomized clinical trials was demonstrated in cardiology, highlighting the ability to rapidly recruit large numbers of patients to a trial addressing an important clinical question, with minimal cost and high external validity. In this review, we discuss the challenges and limitations of conventional clinical trials in multidisciplinary cancer care, describe the potential advantages of registry-based randomized trials, and highlight several registry-based oncology studies that are already underway to demonstrate the feasibility of this approach.
Collapse
Affiliation(s)
- Siavash Foroughi
- Systems Biology and Personalised Medicine Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia.,Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
| | - Hui-Li Wong
- Systems Biology and Personalised Medicine Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia.,Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
| | - Lucy Gately
- Systems Biology and Personalised Medicine Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia.,Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia
| | - Margaret Lee
- Systems Biology and Personalised Medicine Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia.,Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia.,Department of Medical Oncology, Eastern Health, Box Hill, Victoria, Australia.,Department of Medical Oncology, Western Health, St Albans, Victoria, Australia
| | - Koen Simons
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.,Western Centre for Health, Research and Education, Western Health, St Albans, Victoria, Australia
| | - Jeanne Tie
- Systems Biology and Personalised Medicine Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia.,Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia.,Department of Medical Oncology, Western Health, St Albans, Victoria, Australia.,Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Antony Wilks Burgess
- Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia.,Department of Surgery, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Structural Biology Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Peter Gibbs
- Systems Biology and Personalised Medicine Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia.,Department of Medical Biology, The University of Melbourne, Parkville, Victoria, Australia.,Department of Medical Oncology, Western Health, St Albans, Victoria, Australia
| |
Collapse
|
36
|
Paoletti X, Postel-Vinay S. Phase I–II trial designs: how early should efficacy guide the dose recommendation process? Ann Oncol 2018; 29:540-541. [DOI: 10.1093/annonc/mdy044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
37
|
Kather JN, Halama N, Jaeger D. Genomics and emerging biomarkers for immunotherapy of colorectal cancer. Semin Cancer Biol 2018; 52:189-197. [PMID: 29501787 DOI: 10.1016/j.semcancer.2018.02.010] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/19/2018] [Accepted: 02/28/2018] [Indexed: 02/06/2023]
Abstract
Colorectal cancer (CRC) is a common and lethal disease with a high therapeutic need. For most patients with metastatic CRC, chemotherapy is the only viable option. Currently, immunotherapy is restricted to the particular genetic subgroup of mismatch-repair deficient (MMRd)/microsatellite instable (MSI) CRC. Anti-PD1 therapy was recently FDA-approved as a second-line treatment in this subgroup. However, in a metastatic setting, these MMRd/MSI tumors are vastly outnumbered by mismatch-repair proficient (MMRp)/microsatellite stable (MSS) tumors. These MMRp/MSS tumors do not meaningfully respond to any traditional immunotherapy approach including checkpoint blockade, adoptive cell transfer and vaccination. This resistance to immunotherapy is due to a complex tumor microenvironment that counteracts antitumor immunity through a combination of poorly antigenic tumor cells and an immunosuppressive tumor microenvironment. To find ways of overcoming immunotherapy resistance in the majority of CRC patients, it is necessary to analyze the immunological makeup in an in-depth and personalized way and in the context of their tumor genetic makeup. Flexible, biomarker-guided early-phase immunotherapy trials are needed to optimize this workflow. In this review, we detail key mechanisms for immune evasion and emerging immune biomarkers for personalized immunotherapy in CRC. Also, we present a template for biomarker-guided clinical trials that are needed to move new immunotherapy approaches closer to clinical application.
Collapse
Affiliation(s)
- Jakob Nikolas Kather
- Department of Medical Oncology and Internal Medicine VI, National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany; Applied Tumor Immunity, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Niels Halama
- Department of Medical Oncology and Internal Medicine VI, National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany; Applied Tumor Immunity, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Dirk Jaeger
- Department of Medical Oncology and Internal Medicine VI, National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany; Applied Tumor Immunity, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| |
Collapse
|
38
|
Lam M, Loree JM, Pereira AAL, Chun YS, Kopetz S. Accelerating Therapeutic Development through Innovative Trial Design in Colorectal Cancer. Curr Treat Options Oncol 2018; 19:11. [PMID: 29488033 DOI: 10.1007/s11864-018-0524-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OPINION STATEMENT Current trial design is challenged by the advancement of technologies that have enabled deeper understanding of the molecular drivers of colorectal cancer (CRC). The speed of trial testing and the ability to test larger volumes of promising novel agents in the face of smaller populations identified by molecular profiling are challenges posed to clinical studies. Master protocols that utilize umbrella designs are equipped to deal with potential biomarker and matched treatments simultaneously. Although complex in nature, they increase trial efficiency by utilizing shared screening platforms, test multiple treatments together, and simplify regulatory submission and reporting under a common protocol. Emerging technologies such as circulating tumor DNA (ctDNA) may help speed up adjuvant trials. These studies have been traditionally slow to complete due to low event rates and the high numbers needed to recruit. ctDNA used as a surrogate for minimal residual disease (MRD) and as an early marker of relapse may help counter some of these factors that deter innovation in this setting. Finally, in the era of precision medicine, surgery should not be forgotten as the only potentially curative option to date in metastatic disease. Five-year overall survival following resection of liver metastasis exceeds what can be achieved with chemotherapy alone in selected cases. Surgical advances have lowered morbidity and allow for greater resection volumes and repeated interventions. Although historically challenging, a well-designed randomized surgical intervention trial would greatly facilitate moving single-institution guidelines reported by case series into wider clinical practice.
Collapse
Affiliation(s)
- Michael Lam
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard-Unit 0426, Houston, TX, 77030, USA
| | - Jonathan M Loree
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard-Unit 0426, Houston, TX, 77030, USA
| | - Allan Anderson Lima Pereira
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard-Unit 0426, Houston, TX, 77030, USA
| | - Yun Shin Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Scott Kopetz
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard-Unit 0426, Houston, TX, 77030, USA.
| |
Collapse
|
39
|
Blucher AS, Choonoo G, Kulesz-Martin M, Wu G, McWeeney SK. Evidence-Based Precision Oncology with the Cancer Targetome. Trends Pharmacol Sci 2017; 38:1085-1099. [PMID: 28964549 PMCID: PMC5759325 DOI: 10.1016/j.tips.2017.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/17/2017] [Accepted: 08/29/2017] [Indexed: 11/16/2022]
Abstract
A core tenet of precision oncology is the rational choice of drugs to interact with patient-specific biological targets of interest, but it is currently difficult for researchers to obtain consistent and well-supported target information for pharmaceutical drugs. We review current drug-target interaction resources and critically assess how supporting evidence is handled. We introduce the concept of a unified Cancer Targetome to aggregate drug-target interactions in an evidence-based framework. We discuss current unmet needs and the implications for evidence-based clinical omics. The focus of this review is precision oncology but the discussion is highly relevant to targeted therapies in any area.
Collapse
Affiliation(s)
- Aurora S Blucher
- Division of Bioinformatics and Computational Biology, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Gabrielle Choonoo
- Division of Bioinformatics and Computational Biology, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA; Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Molly Kulesz-Martin
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA; Department of Dermatology and Department of Cell and Developmental Biology, Oregon Health & Science University, Portland, OR, USA
| | - Guanming Wu
- Division of Bioinformatics and Computational Biology, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Shannon K McWeeney
- Division of Bioinformatics and Computational Biology, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA; Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA.
| |
Collapse
|
40
|
Novel Early Phase Clinical Trial Design in Oncology. Pharmaceut Med 2017. [DOI: 10.1007/s40290-017-0205-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
41
|
Mayawala K, Tse A, Rubin EH, Jain L, de Alwis DP. Dose Finding Versus Speed in Seamless Immuno-Oncology Drug Development. J Clin Pharmacol 2017; 57 Suppl 10:S143-S145. [PMID: 28921649 DOI: 10.1002/jcph.1001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 07/18/2017] [Indexed: 02/01/2023]
Affiliation(s)
- Kapil Mayawala
- Quantitative Pharmacology and Pharmacometrics, PPDM, Kenilworth, NJ, USA
| | - Archie Tse
- Oncology Early Development, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Eric H Rubin
- Oncology Early Development, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Lokesh Jain
- Quantitative Pharmacology and Pharmacometrics, PPDM, Kenilworth, NJ, USA
| | - Dinesh P de Alwis
- Quantitative Pharmacology and Pharmacometrics, PPDM, Kenilworth, NJ, USA
| |
Collapse
|
42
|
Personalised Interventions-A Precision Approach for the Next Generation of Dietary Intervention Studies. Nutrients 2017; 9:nu9080847. [PMID: 28792454 PMCID: PMC5579640 DOI: 10.3390/nu9080847] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 07/23/2017] [Accepted: 08/01/2017] [Indexed: 12/13/2022] Open
Abstract
Diet is a key modifiable risk factor for non-communicable diseases. However, we currently are not benefitting from the full potential of its protective effects. This is due to a number of reasons, including high individual variability in response to certain diets. It is now well acknowledged that in order to gain the full benefit of dietary regimes it is essential to take into account individual responses. With this in mind, the present review examines the concept of precision nutrition and the performance of n-of-1 studies, and discusses the development of certain approaches that will be critical for development of the concepts.
Collapse
|
43
|
Moreno L, Pearson ADJ, Paoletti X, Jimenez I, Geoerger B, Kearns PR, Zwaan CM, Doz F, Baruchel A, Vormoor J, Casanova M, Pfister SM, Morland B, Vassal G. Early phase clinical trials of anticancer agents in children and adolescents - an ITCC perspective. Nat Rev Clin Oncol 2017; 14:497-507. [PMID: 28508875 DOI: 10.1038/nrclinonc.2017.59] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In the past decade, the landscape of drug development in oncology has evolved dramatically; however, this paradigm shift remains to be adopted in early phase clinical trial designs for studies of molecularly targeted agents and immunotherapeutic agents in paediatric malignancies. In drug development, prioritization of drugs on the basis of knowledge of tumour biology, molecular 'drivers' of disease and a drug's mechanism of action, and therapeutic unmet needs are key elements; these aspects are relevant to early phase paediatric trials, in which molecular profiling is strongly encouraged. Herein, we describe the strategy of the Innovative Therapies for Children with Cancer (ITCC) Consortium, which advocates for the adoption of trial designs that enable uninterrupted patient recruitment, the extrapolation from studies in adults when possible, and the inclusion of expansion cohorts. If a drug has neither serious dose-related toxicities nor a narrow therapeutic index, then studies should generally be started at the adult recommended phase II dose corrected for body surface area, and act as dose-confirmation studies. The use of adaptive trial designs will enable drugs with promising activity to progress rapidly to randomized studies and, therefore, will substantially accelerate drug development for children and adolescents with cancer.
Collapse
Affiliation(s)
- Lucas Moreno
- Paediatric Phase I-II Clinical Trials Unit, Paediatric Haematology &Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Andrew D J Pearson
- Paediatric Drug Development, Children and Young People's Unit, The Royal Marsden NHS Foundation Trust, Sutton, UK; and at the Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research, Sutton, UK
| | - Xavier Paoletti
- Biostatistics and Epidemiology, INSERM U1018, Gustave Roussy, Paris, France
| | - Irene Jimenez
- Department of Paediatric, Adolescents and Young Adults Oncology, Institut Curie; and at the University Paris Descartes, Paris, France
| | - Birgit Geoerger
- Department of Paediatric and Adolescent Oncology, CNRS UMR 8203 Vectorology and Anticancer Treatments, Gustave Roussy, University Paris-Sud, Villejuif, France
| | - Pamela R Kearns
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - C Michel Zwaan
- Department of Paediatric Oncology/Haematology, Erasmus MC/Sophia Children's Hospital, Rotterdam, Netherlands
| | - Francois Doz
- Department of Paediatric, Adolescents and Young Adults Oncology, Institut Curie; and at the University Paris Descartes, Paris, France
| | - Andre Baruchel
- Department of Paediatric Haematology, Hôpital Robert Debré, AP-HP; and at the University Paris Diderot, Paris, France
| | - Josef Vormoor
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University; and at the Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Michela Casanova
- Paediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stefan M Pfister
- German Cancer Research Center (DKFZ); German Cancer Consortium (DKTK); and at the Heidelberg University Hospital, Heidelberg, Germany
| | - Bruce Morland
- Department of Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK
| | - Gilles Vassal
- Department of Clinical Research, Gustave Roussy, Paris-Sud University, Paris, France
| |
Collapse
|
44
|
Vivot A, Boutron I, Béraud-Chaulet G, Zeitoun JD, Ravaud P, Porcher R. Evidence for Treatment-by-Biomarker interaction for FDA-approved Oncology Drugs with Required Pharmacogenomic Biomarker Testing. Sci Rep 2017; 7:6882. [PMID: 28761069 PMCID: PMC5537292 DOI: 10.1038/s41598-017-07358-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 06/22/2017] [Indexed: 01/21/2023] Open
Abstract
For oncology drugs that were approved by the US Food and Drug Administration (FDA) and required pharmacogenomic biomarker testing, we describe 1) the use of enrichment (biomarker-positive patients) and a randomized controlled design by pre-approval trials and 2) the treatment-by-biomarker interaction. From the 137 drugs included in the FDA table, we selected the 22 oncology drugs with required genetic testing in their labels. These drugs corresponded to 35 approvals supported by 80 clinical studies included in the FDA medical officer reviews of efficacy. For two thirds of approvals (24/35, 69%), all clinical studies were restricted to biomarker-positive patients (enriched). Among the 11 remaining approvals with at least one non-enriched trial, for five approvals, the non-enriched studies were non-randomized. The treatment-by-biomarker interaction was statistically significant for three approvals and missing for two. Among the six approvals with a non-enriched randomized controlled trial, three featured a statistically significant treatment-by-biomarker interaction (p < 0.10), for an enhanced treatment effect in the biomarker-positive subgroup. For two thirds of FDA approvals of anticancer agents, the requirement for predictive biomarker testing was based on clinical development restricted to biomarker-positive patients. We found only few cases with clinical evidence that biomarker-negative patients would not benefit from treatment.
Collapse
Affiliation(s)
- Alexandre Vivot
- Clinical Epidemiology Unit, Hôtel-Dieu Hospital, Greater Paris University Hospital (AP-HP), Paris, France.
- Epidemiology and Statistics Sorbonne Paris Cité Research Center (CRESS), INSERM, Paris Descartes University, Paris, UMR1153, France.
| | - Isabelle Boutron
- Clinical Epidemiology Unit, Hôtel-Dieu Hospital, Greater Paris University Hospital (AP-HP), Paris, France
- Epidemiology and Statistics Sorbonne Paris Cité Research Center (CRESS), INSERM, Paris Descartes University, Paris, UMR1153, France
- School of Medicine, Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Geoffroy Béraud-Chaulet
- Clinical Epidemiology Unit, Hôtel-Dieu Hospital, Greater Paris University Hospital (AP-HP), Paris, France
- Epidemiology and Statistics Sorbonne Paris Cité Research Center (CRESS), INSERM, Paris Descartes University, Paris, UMR1153, France
| | - Jean-David Zeitoun
- Epidemiology and Statistics Sorbonne Paris Cité Research Center (CRESS), INSERM, Paris Descartes University, Paris, UMR1153, France
- Gastroenterology and Nutrition Department, Saint-Antoine Hospital, Greater Paris University Hospital (AP-HP), Paris, France
- Proctology Department, Croix Saint-Simon Hospital, Paris, France
| | - Philippe Ravaud
- Clinical Epidemiology Unit, Hôtel-Dieu Hospital, Greater Paris University Hospital (AP-HP), Paris, France
- Epidemiology and Statistics Sorbonne Paris Cité Research Center (CRESS), INSERM, Paris Descartes University, Paris, UMR1153, France
- School of Medicine, Paris Descartes University, Sorbonne Paris Cité, Paris, France
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Raphaël Porcher
- Clinical Epidemiology Unit, Hôtel-Dieu Hospital, Greater Paris University Hospital (AP-HP), Paris, France
- Epidemiology and Statistics Sorbonne Paris Cité Research Center (CRESS), INSERM, Paris Descartes University, Paris, UMR1153, France
- School of Medicine, Paris Descartes University, Sorbonne Paris Cité, Paris, France
| |
Collapse
|
45
|
González-Calle V, Keane N, Braggio E, Fonseca R. Precision Medicine in Myeloma: Challenges in Defining an Actionable Approach. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:621-630. [PMID: 28743429 DOI: 10.1016/j.clml.2017.06.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/08/2017] [Indexed: 12/18/2022]
Abstract
Recently, large sequencing studies have provided insights into the mutational landscape of multiple myeloma (MM), identifying actionable mutations and giving a precious opportunity for exploring new targeted therapies. The main goal of precision medicine, matching patients with the right drug, seems to be closer than ever. However, no targeted therapies in MM are approved yet. Several clinical trials testing targeted drugs and enrolling patients with MM are currently ongoing and will provide predictive biomarkers that might support clinical decision making. In this review, we evaluate the evidence supporting the implementation of precision medicine in MM and we discuss the challenges that should be dealt with in this imminent and promising new era.
Collapse
Affiliation(s)
| | - Niamh Keane
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Esteban Braggio
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ
| | - Rafael Fonseca
- Division of Hematology and Oncology, Mayo Clinic, Scottsdale, AZ.
| |
Collapse
|
46
|
Earl H, Molica S, Rutkowski P. Spotlight on landmark oncology trials: the latest evidence and novel trial designs. BMC Med 2017; 15:111. [PMID: 28571584 PMCID: PMC5454584 DOI: 10.1186/s12916-017-0884-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 05/23/2017] [Indexed: 12/18/2022] Open
Abstract
The era of precision oncology is marked with prominent successes in the therapy of advanced soft tissue sarcomas, breast cancer, ovarian cancer and haematological neoplasms, among others. Moreover, recent trials of immune checkpoint inhibitors in melanoma, non-small cell lung carcinoma, and head and neck cancers have significantly influenced the therapeutic landscape by providing promising evidence for immunotherapy efficacy in the adjuvant setting in high-risk locoregional disease. To speed up the introduction of targeted therapy for cancer patients, novel phase II trials are being designed, and may likely form the basis for the 'landmark trials' of the future. A special article collection in BMC Medicine, "Spotlight on landmark oncology trials", features articles from invited experts on recent clinical practice-changing trials.
Collapse
Affiliation(s)
- Helena Earl
- University of Cambridge Department of Oncology, NIHR Cambridge Biomedical Research Centre, and Hon Consultant in Medical Oncology, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Stefano Molica
- Department Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, 88100, Catanzaro, Italy
| | - Piotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Institute - Oncology Center, Roentgena 5, 02-781, Warsaw, Poland.
| |
Collapse
|
47
|
Kulasingam V, Prassas I, Diamandis EP. Towards personalized tumor markers. NPJ Precis Oncol 2017; 1:17. [PMID: 29872704 PMCID: PMC5871887 DOI: 10.1038/s41698-017-0021-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/21/2017] [Accepted: 04/25/2017] [Indexed: 01/06/2023] Open
Abstract
The cancer biomarker discovery pipeline is progressing slowly. The difficulties of finding novel and effective biomarkers for diagnosis and management of cancer patients are well-known. We speculate that it is unlikely to discover new serological biomarkers characterized by high sensitivity and specificity. This projection is supported by recent findings that cancers are genetically highly heterogeneous. Here, we propose a new way of improving the landscape of cancer biomarker research. There are currently hundreds, if not thousands, of described biomarkers which perform at high specificity (> 90%), but at relatively low sensitivity (< 30%). We call these “rare tumor markers.” Borrowing from the principles of precision medicine, we advocate that among these low sensitivity markers, some may be useful to specific patients. We suggest screening new patients for hundreds to thousands of cancer biomarkers to identify a few that are informative, and then use them clinically. This is similar to what we currently do with genomics to identify personalized therapies. We further suggest that this approach may explain as to why some biomarkers are elevated in only a small group of patients. It is likely that these differences in expression are linked to specific genomic alterations, which could then be found with genomic sequencing.
Collapse
Affiliation(s)
- Vathany Kulasingam
- 1Department of Clinical Biochemistry, University Health Network, Toronto, ON Canada.,2Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON Canada
| | - Ioannis Prassas
- 3Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON Canada
| | - Eleftherios P Diamandis
- 1Department of Clinical Biochemistry, University Health Network, Toronto, ON Canada.,2Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON Canada.,3Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON Canada
| |
Collapse
|
48
|
Pinker K, Riedl C, Weber WA. Evaluating tumor response with FDG PET: updates on PERCIST, comparison with EORTC criteria and clues to future developments. Eur J Nucl Med Mol Imaging 2017; 44:55-66. [PMID: 28361188 DOI: 10.1007/s00259-017-3687-3] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 12/19/2022]
Abstract
Eighteen years ago, the EORTC PET criteria standardized for the first time response assessment by FDG PET. Response assessment by FDG PET has been further developed and refined by PERCIST (PET response criteria in solid tumors). This review describes the data underlying these two systems for assessing tumor response on FDG PET/CT. It also summarizes recent clinical studies that have compared EORTC criteria and PERCIST with each other as well as with the anatomically based "response criteria in solid tumors" (RECIST). These studies have shown that response assessment by EORTC criteria and PERCIST leads to very similar response classifications. In contrast, there are significant differences between response assessment by PERCIST and RECIST. Preliminary data also suggest that response assessment by PERCIST is better correlated with patient outcome and may be a better predictor for the effectiveness of new anti-cancer therapies than RECIST. If correct, this could have a significant impact on oncologic drug development. However, confirmation of the better predictive value of response assessment by PERCIST by data from randomized trials is still lacking.
Collapse
Affiliation(s)
- Katja Pinker
- Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, 1250 1st Av, New York, NY, 10065, USA
| | - Christopher Riedl
- Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, 1250 1st Av, New York, NY, 10065, USA
| | - Wolfgang A Weber
- Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, 1250 1st Av, New York, NY, 10065, USA.
| |
Collapse
|