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Fraterman I, Cerquin LE, de Ligt KM, van der Loo I, Wilgenhof S, van de Poll-Franse LV, Beets-Tan RGH, Tissier RLM, Trebeschi S. Muscle atrophy and organ enlargement associated with quality of life during systemic therapy for melanoma: findings from an AI-based body composition analysis. Eur Radiol 2024:10.1007/s00330-024-11289-z. [PMID: 39702633 DOI: 10.1007/s00330-024-11289-z] [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: 03/25/2024] [Revised: 09/26/2024] [Accepted: 11/13/2024] [Indexed: 12/21/2024]
Abstract
INTRODUCTION Health-related quality of life (HRQoL) is emerging as an endpoint, adjunct to survival, in cancer treatment. For this reason, the European Organization for Research and Treatment of Cancer (EORTC) has developed standardized quality-of-life questionnaires to collect patient-reported outcome measurement (PROM), which so far have been widely used in clinical trials to evaluate the impact of new drugs on cancer patients. However, while these questionnaires comprehensively describe patient functions, little is known about their association with patient characteristics. This study aims to bridge this gap and investigate the association between patient body composition and HRQoL. MATERIALS AND METHODS A retrospective cohort of melanoma patients treated with systemic therapy who completed HRQoL questionnaires and had regular imaging follow-ups was included. The primary endpoint was the association between n = 116 AI-measured longitudinal volumes of thoracic and abdominal organs, subcutaneous and visceral fat, skeleton and muscles (estimated by TotalSegmentator), and physical functioning (PF), role functioning (RF) and fatigue (FA) (estimated by the EORTC-QLQ-C30). RESULTS The n = 358 patients were included. Our findings show larger liver, spleen, and gallbladder volumes associated with decreased PF and RF and an increase in FA (p < 0.05). Furthermore, larger muscle volumes were associated with an increase in PF and RF and a decrease in FA (p < 0.01). DISCUSSION Our findings show significant associations between AI-measured body and organ analysis and HRQoL in patients with melanoma on systemic treatment. Future research is needed to understand the underlying cause and determine the possible predictive ability of these imaging features. KEY POINTS Question Are changes in body composition associated with changes in HRQoL in melanoma patients undergoing systemic therapy? Findings AI-based body composition analysis shows that larger muscle volumes are linked to improved HRQoL, while organ enlargement is associated with a decline in it. Clinical relevance Our findings indicate new imaging biomarkers that can help monitor patients and evaluate treatment responses. These biomarkers link patient function to physical changes during treatment, offering insights for creating response evaluation criteria that also consider improvements in quality of life.
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Affiliation(s)
- Itske Fraterman
- Department of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Laura Estacio Cerquin
- Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- GROW-Research Institute for Oncology & Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Kelly M de Ligt
- Department of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Iris van der Loo
- Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- GROW-Research Institute for Oncology & Reproduction, Maastricht University, Maastricht, The Netherlands
| | - Sofie Wilgenhof
- Department of Medical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Lonneke V van de Poll-Franse
- Department of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
- Department of Medical and Clinical Psychology, Center of Research On Psychological and Somatic Disorders (CoRPS), Tilburg University, Tilburg, The Netherlands
| | - Regina G H Beets-Tan
- GROW-Research Institute for Oncology & Reproduction, Maastricht University, Maastricht, The Netherlands
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Renaud L M Tissier
- Biostatistics Center, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Stefano Trebeschi
- Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
- GROW-Research Institute for Oncology & Reproduction, Maastricht University, Maastricht, The Netherlands.
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Klas K, Strzebonska K, Zaborowska L, Krawczyk T, Włodarczyk A, Bąk-Kuchejda U, Polak M, Van Wambeke S, Waligora M. Risk and Benefit for Basket Trials in Oncology: A Systematic Review and Meta-Analysis. Target Oncol 2024:10.1007/s11523-024-01107-3. [PMID: 39455508 DOI: 10.1007/s11523-024-01107-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2024] [Indexed: 10/28/2024]
Abstract
BACKGROUND Oncology research is increasingly adopting new clinical trial models that implement the concept of precision medicine. One of these is the basket clinical trial design. Basket clinical trials allow new treatments to be evaluated across multiple tumor types. Patients recruited to basket clinical trials share certain molecular characteristics of their cancer that are predictive of clinical benefit from the experimental treatment. OBJECTIVE Our aim was to describe the risks and benefits of basket clinical trials in oncology. METHODS Our study was prospectively registered in PROSPERO (CRD42023406401). We systematically searched PubMed, Embase, and ClinicalTrials.gov for reports of basket clinical trials in oncology published between 1 January, 2001, and 14 June, 2023. We measured the risk by treatment-related adverse events (grades 3, 4, and 5), and the benefit by objective response rate. We also extracted and analyzed data on progression-free survival and overall survival. When possible, data were meta-analyzed. RESULTS We included 126 arms of 75 basket clinical trials accounting for 7659 patients. The pooled objective response rate was 18.0% (95% confidence interval [CI] 14.8-21.1). The rate of treatment-related death was 0.7% (95% CI 0.4-1.0), while 30.4% (95% CI 24.2-36.7) of patients experienced grade 3/4 drug-related toxicity. The median progression-free survival was 3.1 months (95% CI 2.6-3.9), and the median overall survival was 8.9 months (95% CI 6.7-10.2). CONCLUSIONS Our results provide an empirical basis for communicating about the risks and benefits of basket clinical trials and for refining new models of clinical trials applied in precision medicine.
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Affiliation(s)
- Katarzyna Klas
- Research Ethics in Medicine Study Group (REMEDY), Department of Bioethics, Faculty of Health Sciences, Jagiellonian University Medical College, Michalowskiego 12, 31-126, Kraków, Poland
- Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Karolina Strzebonska
- Research Ethics in Medicine Study Group (REMEDY), Department of Bioethics, Faculty of Health Sciences, Jagiellonian University Medical College, Michalowskiego 12, 31-126, Kraków, Poland
| | - Lucja Zaborowska
- Research Ethics in Medicine Study Group (REMEDY), Department of Bioethics, Faculty of Health Sciences, Jagiellonian University Medical College, Michalowskiego 12, 31-126, Kraków, Poland
- Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, Kraków, Poland
- First Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Krawczyk
- Research Ethics in Medicine Study Group (REMEDY), Department of Bioethics, Faculty of Health Sciences, Jagiellonian University Medical College, Michalowskiego 12, 31-126, Kraków, Poland
- Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Alicja Włodarczyk
- Research Ethics in Medicine Study Group (REMEDY), Department of Bioethics, Faculty of Health Sciences, Jagiellonian University Medical College, Michalowskiego 12, 31-126, Kraków, Poland
| | - Urszula Bąk-Kuchejda
- Research Ethics in Medicine Study Group (REMEDY), Department of Bioethics, Faculty of Health Sciences, Jagiellonian University Medical College, Michalowskiego 12, 31-126, Kraków, Poland
- Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Maciej Polak
- Research Ethics in Medicine Study Group (REMEDY), Department of Bioethics, Faculty of Health Sciences, Jagiellonian University Medical College, Michalowskiego 12, 31-126, Kraków, Poland
- Department of Epidemiology and Population Studies, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | | | - Marcin Waligora
- Research Ethics in Medicine Study Group (REMEDY), Department of Bioethics, Faculty of Health Sciences, Jagiellonian University Medical College, Michalowskiego 12, 31-126, Kraków, Poland.
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Kabir E, Azam F, Khan T, Yasmin H, Chowdhury N, Ahmed S, Sagar B, Tahrim N. Modeling Overall Survival in Patients With Pancreatic Cancer From a Pooled Analysis of Phase II Trials. Cancer Med 2024; 13:e70289. [PMID: 39387320 PMCID: PMC11465028 DOI: 10.1002/cam4.70289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 06/08/2024] [Accepted: 09/21/2024] [Indexed: 10/15/2024] Open
Abstract
BACKGROUND We evaluated the validity of surrogacy of progression-free survival (PFS) or time-to-progression (TTP) and overall response rate (ORR) in phase II trials of pancreatic ductal adenocarcinoma (PDAC). In addition, we explored the impact of predictive variables on overall survival (OS) and developed an optimal OS model. METHODS We analyzed 1867 clinical endpoint from 619 phase II PDAC trials with a systematic search from PubMed. Endpoint correlations were determined by Spearman's rank correlation. The assessed predictive factors included PFS/TTP, treatment size, therapy type, stage, and previous treatment. The relationship between predictors and OS was explored by a gamma generalized linear model (GLM) with a log-link function and compared with linear models. RESULTS The Spearman rank correlation coefficient between PFS/TTP and OS was 0.88 (95% confidence interval [CI] 0.85-0.89; p < 0.0001; n = 610) and between ORR and OS was 0.58 (0.52-0.64; p < 0.0001; n = 514). Model comparison favored the GLM model over the linear model, offering more accurate predictions for higher OS values. Consequently, PFS/TTP was the strongest predictor (pseudo-R2 = 0.75), with 1 added median PFS/TTP month associated with 13% (95% CI 13%-14%) increase in median OS. Subgroup analysis revealed that chemotherapy conferred significantly longer OS compared to targeted therapy in 1-Agent and 2-Agent trials, exhibiting a "very large" and "medium" effect size, respectively (rank biserial, rrb = 0.40 [95% CI 0.22-0.56] and rrb = 0.29 [0.16-0.41], both p < 0.0001), although inconsistent efficacy in 3-Agent trials (rrb = 0.12 [-0.07-0.30], p = 0.21). CONCLUSIONS PFS/TTP is a more reliable surrogate than ORR and a strong predictor of OS in phase II trials of pancreatic cancer. Moreover, gamma GLM (log-link function) is a robust tool for modeling positively skewed survival data with non-constant variance, thus can be applied to other cancers' OS data of such nature.
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Affiliation(s)
| | - Faruque Azam
- School of PharmacyBRAC UniversityDhakaBangladesh
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Veas Rodríguez J, Prieto A, Vilaprinyo E, Bonet M, Diez M, Salud A, Montal R. Surrogate endpoints in phase III randomized trials of advanced gastroesophageal cancer: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2024; 201:104416. [PMID: 38871262 DOI: 10.1016/j.critrevonc.2024.104416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 06/05/2024] [Accepted: 06/06/2024] [Indexed: 06/15/2024] Open
Abstract
Overall survival (OS) is the most meaningful endpoint in clinical trials. However, owing to their limitations, surrogate endpoints are commonly used and validation studies are required to assess their reliability. Analysis of phase III randomized controlled trials (RCTs) of advanced gastroesophageal cancer (AGC) with > 100 patients, correlation coefficients (r), and determination coefficients (R²) between OS and surrogates were evaluated through meta-analyses. Progression-free survival (PFS), time to progression (TTP), and objective response rate (ORR) were examined to determine their correlations with OS. Analysis of 65 phase III RCTs (29,766 subjects) showed a moderate correlation between PFS/TTP and OS (r = 0.77, R² = 0.59), while ORR correlation was low (r = 0.56, R² = 0.31). Excluding immunotherapy trials improved the PFS/TTP and OS correlations (r = 0.83, R² = 0.70). These findings suggest the potential use of PFS/TTP in AGC phase III investigations, disregarding the use of ORR as a surrogate endpoint.
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Affiliation(s)
- Joel Veas Rodríguez
- Department of Medical Oncology, Arnau de Vilanova University Hospital, Lleida, Spain; Department of Medical Oncology, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom.
| | - Ana Prieto
- Department of Medical Oncology, Arnau de Vilanova University Hospital, Lleida, Spain
| | - Ester Vilaprinyo
- Department of Basic Medical Sciences, University of Lleida, IRBLLEIDA, Lleida, Spain
| | - Marta Bonet
- Department of Radiation Oncology, Arnau de Vilanova University Hospital, Lleida, Spain
| | - Marc Diez
- Department of Medical Oncology, Vall d' Hebron University Hospital, Barcelona, Spain
| | - Antonieta Salud
- Department of Medical Oncology, Arnau de Vilanova University Hospital, Lleida, Spain
| | - Robert Montal
- Department of Medical Oncology, Arnau de Vilanova University Hospital, Lleida, Spain
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Dutta R, Mohan A, Buros‐Novik J, Goldmacher G, Akala OO, Topp B. A bootstrapping method to optimize go/no-go decisions from single-arm, signal-finding studies in oncology. CPT Pharmacometrics Syst Pharmacol 2024; 13:1317-1326. [PMID: 38863167 PMCID: PMC11330177 DOI: 10.1002/psp4.13161] [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: 10/12/2023] [Revised: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 06/13/2024] Open
Abstract
Phase Ib trials are common in oncology development but often are not powered for statistical significance. Go/no-go decisions are largely driven by observed trends in response data. We applied a bootstrapping method to systematically compare tumor dynamic end points to historical control data to identify drugs with clinically meaningful efficacy. A proprietary mathematical model calibrated to phase Ib anti-PD-1 therapy trial data (KEYNOTE-001) was used to simulate thousands of phase Ib trials (n = 30) with a combination of anti-PD-1 therapy and four novel agents with varying efficacy. A redacted bootstrapping method compared these results to a simulated phase III control arm (N = 511) while adjusting for differences in trial duration and cohort size to determine the probability that the novel agent provides clinically meaningful efficacy. Receiver operating characteristic (ROC) analysis showed strong ability to separate drugs with modest (area under ROC [AUROC] = 83%), moderate (AUROC = 96%), and considerable efficacy (AUROC = 99%) from placebo in early-phase trials (n = 30). The method was shown to effectively move drugs with a range of efficacy through an in silico pipeline with an overall success rate of 93% and false-positive rate of 7.5% from phase I to phase III. This model allows for effective comparisons of tumor dynamics from early clinical trials with more mature historical control data and provides a framework to predict drug efficacy in early-phase trials. We suggest this method should be employed to improve decision making in early oncology trials.
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Affiliation(s)
- Raunak Dutta
- Modeling and SimulationVantage ResearchChennaiIndia
| | - Aparna Mohan
- Modeling and SimulationVantage ResearchChennaiIndia
| | | | | | | | - Brian Topp
- Oncology Early DevelopmentMerck & Co., Inc.RahwayNew JerseyUSA
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Baldwin D, Carmichael J, Cook G, Navani N, Peach J, Slater R, Wheatstone P, Wilkins J, Allen-Delingpole N, Kerr CEP, Siddiqui K. UK Stakeholder Perspectives on Surrogate Endpoints in Cancer, and the Potential for UK Real-World Datasets to Validate Their Use in Decision-Making. Cancer Manag Res 2024; 16:791-810. [PMID: 39044745 PMCID: PMC11264281 DOI: 10.2147/cmar.s441359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 06/24/2024] [Indexed: 07/25/2024] Open
Abstract
Duration of overall survival in patients with cancer has lengthened due to earlier detection and improved treatments. However, these improvements have created challenges in assessing the impact of newer treatments, particularly those used early in the treatment pathway. As overall survival remains most decision-makers' preferred primary endpoint, therapeutic innovations may take a long time to be introduced into clinical practice. Moreover, it is difficult to extrapolate findings to heterogeneous populations and address the concerns of patients wishing to evaluate everyday quality and extension of life. There is growing interest in the use of surrogate or interim endpoints to demonstrate robust treatment effects sooner than is possible with measurement of overall survival. It is hoped that they could speed up patients' access to new drugs, combinations, and sequences, and inform treatment decision-making. However, while surrogate endpoints have been used by regulators for drug approvals, this has occurred on a case-by-case basis. Evidence standards are yet to be clearly defined for acceptability in health technology appraisals or to shape clinical practice. This article considers the relevance of the use of surrogate endpoints in cancer in the UK context, and explores whether collection and analysis of real-world UK data and evidence might contribute to validation.
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Affiliation(s)
- David Baldwin
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Jonathan Carmichael
- Department of Oncology, The National Institute for Health Research Leeds In Vitro Diagnostics Co-Operative (NIHR Leeds MIC), Leeds, UK
| | - Gordon Cook
- Cancer Research UK Trials Unit, LICTR, University of Leeds & NIHR (Leeds) IVD MIC, Leeds, UK
| | - Neal Navani
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, UK
- Department of Thoracic Medicine, University College London Hospital, London, UK
| | - James Peach
- Human Centric Drug Discovery, Wood Centre for Innovation, Oxford, UK
| | | | - Pete Wheatstone
- Patient and Public Involvement and Engagement Group, DATA-CAN, London, UK
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Jiménez-Labaig P, Rullan A, Braña I, Hernando-Calvo A, Moreno V, Doger B, Bitar G, Ap Dafydd D, Melcher A, Harrington KJ. Intratumoral therapies in head and neck squamous cell carcinoma: A systematic review and future perspectives. Cancer Treat Rev 2024; 127:102746. [PMID: 38696902 DOI: 10.1016/j.ctrv.2024.102746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/20/2024] [Accepted: 04/25/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND Head and neck squamous cell carcinoma (HNSCC) presents an ideal scenario for intratumoral therapies (IT), due to its local recurrence pattern and frequent superficial extension. IT therapies aim to effect tumor regression by directly injecting antineoplastic agents into lesions. However, there is a lack of updated evidence regarding IT therapies in HNSCC. PATIENTS AND METHODS A systematic literature search (CRD42023462291) was conducted using WebOfScience, ClinicalTrials.gov, and conference abstracts from ESMO and ASCO, identifying for IT clinical trials in patients with HNSCC, from database creation to September 12th, 2023. Efficacy as well as safety (grade ≥ 3 treatment-related adverse events[trAEs]) were reported. RESULTS After evaluation of 1180 articles identified by the systematic search, 31 studies treating 948 patients were included. IT injectables were categorized as chemotherapies with or without electroporation (k = 4, N = 268), oncolytic viruses, plasmids, and bacteria-based (k = 16, N = 446), immunotherapies and EGFR-based therapies (k = 5, N = 160), radioenhancer particles (k = 2, N = 68), and calcium electroporation (k = 1, n = 6). EGFR-antisense plasmids, NBTXR3 radioenhancer and immune innate agonists show best overall response rates, at 83 %, 81 % and 44 % respectively. Eleven (35 %) studies added systemic therapy or radiotherapy to the IT injections. No study used predictive biomarkers to guide patient selection. 97 % studies were phase I-II. Safety-wise, electroporation and epinephrine-based injectable trials had significant local symptoms such as necrosis, fistula formation and post-injection dysphagia. Treatment-related tumor haemorrhages of various grades were described in several trials. Grade ≥ 3 trAEs attributable to the other therapies mainly comprised general symptoms such as fatigue. There were 3 injectable-related deaths across the systematic review. CONCLUSION This is the first review to summarize all available evidence of IT in HNSCC. As of today, IT therapies lack sufficient evidence to recommend their use in clinical practice. Continuing research on potential molecules, patient selection, safe administration of injections and controlled randomized trials are needed to assess their added benefit.
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Affiliation(s)
- Pablo Jiménez-Labaig
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, National Institute of Health Research Biomedical Research Centre, London, United Kingdom
| | - Antonio Rullan
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, National Institute of Health Research Biomedical Research Centre, London, United Kingdom
| | - Irene Braña
- Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain; Lung and Head & Neck Tumors Unit, Department of Medical Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Alberto Hernando-Calvo
- Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain; Early Phase Clinical Trials Unit (UITM), Department of Medical Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Victor Moreno
- START Madrid-FDJ, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Bernard Doger
- START Madrid-FDJ, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - George Bitar
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Derfel Ap Dafydd
- Department of Radiology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Alan Melcher
- The Institute of Cancer Research, National Institute of Health Research Biomedical Research Centre, London, United Kingdom
| | - Kevin J Harrington
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, London, United Kingdom; The Institute of Cancer Research, National Institute of Health Research Biomedical Research Centre, London, United Kingdom
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Huang Y, Yuan J. Improvement of assessment in surrogate endpoint and safety outcome of single-arm trials for anticancer drugs. Expert Rev Clin Pharmacol 2024; 17:477-487. [PMID: 38632893 DOI: 10.1080/17512433.2024.2344669] [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: 12/18/2023] [Accepted: 04/15/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Single-arm trials (SATs) and surrogate endpoints were adopted as pivotal evidence for accelerated approval of anticancer drugs for more than 30 years. However, concerns regarding clinical evidence quality in trials, particularly in the SATs of anticancer drugs have increasingly been raised. SAT may not always provide strong evidence due to the lack of control and endpoint of overall survival that is typically present in randomized controlled trials. AREAS COVERED Clinical trial endpoint adjudication is a crucial factor in surrogate outcome measurement to ensure the data quality of the clinical trial of anticancer drugs. In this review, we systematically discuss the characteristics of adjudications in assessments in surrogate endpoint and safety outcome respectively, which are essential for ensuring reliable and transparent outcomes. Endpoint adjudication effectively reduces potential bias and mitigates variance that may be introduced by investigators when analyzing the medical records for the surrogate endpoints. We analyze the advantages and disadvantages of each type of adjudicator and provide a summary of the roles of adjudicators. EXPERT OPINION By suggestion of improving data reliability and transparency in pivotal trials, this review aims to supply a strategy for better clinical investigation for anticancer drugs, ultimately leading to better patient outcomes.
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Affiliation(s)
- Yafang Huang
- School of General Practice and Continuing Education, Capital Medical University, Beijing, China
| | - Jinqiu Yuan
- Clinical Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
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Zheng X, Lu T, Wu S, Lin X, Bai J, Chen X, Miao Q, Yan J, Jiang K, Zhang L, Zheng X, Wang H, Xu Y, Xiao W, Li C, Peng W, Ding J, Zhong Q, Zou Z, Yang S, Li Y, Chen S, Zhang Q, Yan J, Tang G, Cai Y, kang M, Mok TSK, Lin G. A novel approach to evaluation of tumor response for advanced pulmonary adenocarcinoma using the intertumoral heterogeneity response score. MedComm (Beijing) 2024; 5:e493. [PMID: 38463396 PMCID: PMC10924640 DOI: 10.1002/mco2.493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/19/2024] [Accepted: 01/28/2024] [Indexed: 03/12/2024] Open
Abstract
Treatment response and prognosis estimation in advanced pulmonary adenocarcinoma are challenged by the significant heterogeneity of the disease. The current Response Evaluation Criteria in Solid Tumors (RECIST) criteria, despite providing a basis for solid tumor response evaluation, do not fully encompass this heterogeneity. To better represent these nuances, we introduce the intertumoral heterogeneity response score (THRscore), a measure built upon and expanding the RECIST criteria. This retrospective study included patients with 3-10 measurable advanced lung adenocarcinoma lesions who underwent first-line chemotherapy or targeted therapy. The THRscore, derived from the coefficient of variation in size for each measurable tumor before and 4-6 weeks posttreatment, unveiled a correlation with patient outcomes. Specifically, a high THRscore was associated with shorter progression-free survival, lower tumor response rate, and a higher tumor mutation burden. These associations were further validated in an external cohort, confirming THRscore's effectiveness in stratifying patients based on progression risk and treatment response, and enhancing the utility of RECIST in capturing complex tumor behaviors in lung adenocarcinoma. These findings affirm the promise of THRscore as an enhanced tool for tumor response assessment in advanced lung adenocarcinoma, extending the RECIST criteria's utility.
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Affiliation(s)
- Xinlong Zheng
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Tao Lu
- Department of RadiologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Shiwen Wu
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Xiaoyan Lin
- Department of OncologyFujian Medical University Union HospitalFuzhouChina
| | - Jing Bai
- Department of ResearchGeneplus‐Beijing InstituteBeijingChina
| | - Xiaohui Chen
- Department of Thoracic SurgeryClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Qian Miao
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Jianqun Yan
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Kan Jiang
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Longfeng Zhang
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Xiaobing Zheng
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Haibo Wang
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Yiquan Xu
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Weijin Xiao
- Department of PathologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Cao Li
- Department of PathologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Wenying Peng
- The Second Department of OncologyYunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer CenterKunmingChina
| | - Jianming Ding
- Department of Radiation OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Qiaofeng Zhong
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Zihua Zou
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Shanshan Yang
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Yujing Li
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Sihui Chen
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Qiuyu Zhang
- Institute of ImmunotherapyFujian Medical UniversityFuzhouChina
| | - Jianfeng Yan
- College of ChemistryFuzhou UniversityFuzhouChina
| | - Guofeng Tang
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Yuandong Cai
- College of ChemistryFuzhou UniversityFuzhouChina
| | - Miao kang
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
| | - Tony S. K. Mok
- Department of Clinical OncologyState Key Laboratory of Translational OncologyChinese University of Hong KongShatin, Hong Kong Special Administrative RegionChina
| | - Gen Lin
- Department of Thoracic OncologyClinical Oncology School of Fujian Medical University, Fujian Cancer HospitalFuzhouChina
- Fujian Key Laboratory of Advanced Technology for Cancer Screening and Early Diagnosis, Fujian Cancer HospitalFuzhouChina
- Interdisciplinary Institute for Medical EngineeringFuzhou UniversityFuzhouChina
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10
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Huang L, Kang D, Zhao C, Liu X. Correlation between surrogate endpoints and overall survival in unresectable hepatocellular carcinoma patients treated with immune checkpoint inhibitors: a systematic review and meta-analysis. Sci Rep 2024; 14:4327. [PMID: 38383730 PMCID: PMC10881995 DOI: 10.1038/s41598-024-54945-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/19/2024] [Indexed: 02/23/2024] Open
Abstract
This study aimed to assess the therapeutic effect of immune checkpoint inhibitors (ICIs) in patients with unresectable hepatocellular carcinoma (uHCC) and investigate the correlation between surrogate endpoints and overall survival (OS). A systematic literature search included phase I, II, and III clinical trials comparing ICIs to placebo or other therapies for uHCC treatment. Correlations between OS and surrogate endpoints were evaluated using meta-regression analyses and calculating the surrogate threshold effect (STE). The correlation analysis showed a weak association between OS and progression-free survival (PFS), with an R2 value of 0.352 (95% CI: 0.000-0.967). However, complete response (CR) exhibited a strong correlation with OS (R2 = 0.905, 95% CI: 0.728-1.000). Subgroup analyses revealed high correlations between OS and PFS, CR, stable disease (SD), and DC in phase III trials (R2: 0.827-0.922). For the ICI + IA group, significant correlations were observed between OS and SD, progressive disease (PD), and grade 3-5 immune-related adverse events (irAEs) (R2: 0.713-0.969). Analyses of the correlation between survival benefit and risk of mortality across various time points showed a strong association within the first year (R2: 0.724-0.868) but a weak association beyond one year (R2: 0.406-0.499). In ICI trials for uHCC, PFS has limited utility as a surrogate endpoint for OS, while CR exhibits a strong correlation with OS. Subgroup analyses highlight high correlations between OS and PFS, SD, and DC in phase III trials. Notably, the ICI + IA group shows significant associations between OS and SD, PD, and grade 3-5 irAEs. These findings offer valuable insights for interpreting trial outcomes and selecting appropriate endpoints in future clinical studies involving ICIs for uHCC patients.
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Affiliation(s)
- Litao Huang
- Chinese Evidence-Based Medicine Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Deying Kang
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, 610041, China
- Department of Evidence-Based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chongyang Zhao
- Department of Evidence-Based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xueting Liu
- Discipline Construction Department, West China Hospital, Sichuan University, Chengdu, 610041, China.
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11
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Shahnam A, Nindra U, Desai J, Hui R, Buyse M, Hopkins AM, Sorich MJ. Time to deterioration of patient-reported outcomes as a surrogate of overall survival: a meta-analysis. J Natl Cancer Inst 2023; 115:1475-1482. [PMID: 37540222 DOI: 10.1093/jnci/djad152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/06/2023] [Accepted: 07/31/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Overall survival is the optimal marker of treatment efficacy in randomized clinical trials (RCTs) but can take considerable time to mature. Progression-free survival (PFS) has served as an early surrogate of overall survival but is imperfect. Time to deterioration in quality of life (QOL) measures could be a surrogate for overall survival. METHODS Phase 3 RCTs in solid malignancies that reported overall survival, PFS, and time to deterioration in QOL or physical function published between January 1, 2010, and June 30, 2022, were evaluated. Weighted regression analysis was used to assess the relationship between PFS, time to deterioration in QOL, and time to deterioration in physical function with overall survival. The coefficient of determination (R2) was used to quantify surrogacy. RESULTS In total, 138 phase 3 RCTs were included. Of these, 47 trials evaluated immune checkpoint inhibitors and 91 investigated non-immune checkpoint inhibitor agents. Time to deterioration in QOL (137 RCTs) and time to deterioration in physical function (75 RCTs) performed similarly to PFS as surrogates for overall survival (R2 = 0.18 vs R2 = 0.19 and R2 = 0.10 vs R2 = 0.09, respectively). For immune checkpoint inhibitor studies, time to deterioration in physical function had a higher association with overall survival than with PFS (R2 = 0.38 vs R2 = 0.19), and PFS and time to deterioration in physical function did not correlate with each other (R2 = 0). When time to deterioration in physical function and PFS are used together, the coefficient of determination increased (R2 = 0.57). CONCLUSIONS Time to deterioration in physical function appears to be an overall survival surrogate measure of particular importance for immune checkpoint inhibitor treatment efficacy. The combination of time to deterioration in physical function with PFS may enable better prediction of overall survival treatment benefit in RCTs of immune checkpoint inhibitors than either PFS or time to deterioration in physical function alone.
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Affiliation(s)
- Adel Shahnam
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Udit Nindra
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Jayesh Desai
- Department of Medical Oncology, Peter McCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Rina Hui
- Centre of Cancer Medicine, University of Hong Kong, Hong Kong
| | - Marc Buyse
- International Drug Development Institute, Brussels, Belgium
| | - Ashley M Hopkins
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Michael J Sorich
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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12
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Avorn J. Surrogate Measures of Drug Efficacy-A Finger Pointing at the Moon. JAMA Netw Open 2023; 6:e238835. [PMID: 37115553 DOI: 10.1001/jamanetworkopen.2023.8835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Affiliation(s)
- Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Program on Regulation, Therapeutics, and Law, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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13
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Etekal T, Koehn K, Sborov DW, McClune B, Prasad V, Haslam A, Berger K, Booth C, Al Hadidi S, Abdallah AO, Goodman A, Mohyuddin GR. Time-to-event surrogate end-points in multiple myeloma randomised trials from 2005 to 2019: A surrogacy analysis. Br J Haematol 2023; 200:587-594. [PMID: 36495317 DOI: 10.1111/bjh.18568] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/25/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022]
Abstract
Use of surrogate end-points such as progression-free survival (PFS) and other time-to-event (TTE) end-points is common in multiple myeloma (MM) clinical trials. This systematic review characterises all published randomised controlled trials (RCTs) in MM using PFS or other TTE end-points between 2005 and 2019 and assesses strength of surrogacy of PFS for overall survival (OS). The association between OS hazard ratios (HRs) and PFS HRs was evaluated with linear regression, and the coefficient of determination with Pearson's correlation. We identified 88 RCTs of which 67 (76%) used PFS as the primary/co-primary end-point. One trial indicated whether progression was biochemical or clinical. Of the variance in OS, 39% was due to variance in PFS. Correlation between PFS and OS was weak (0.62, 95% confidence interval [CI] 0.38-0.78). In newly diagnosed MM, 43% of the variance in OS was due to changes in PFS. The correlation between PFS and OS was weak (0.65, 95% CI 0.30-0.84). In relapsed/refractory MM, 58% of the variance in OS was due to changes in PFS. Correlation between PFS and OS was medium (0.76, 95% CI 0.42-0.91). We demonstrate that PFS and progression characteristics are characterised poorly in MM trials and that PFS is a poor surrogate for OS in MM.
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Affiliation(s)
- Tommy Etekal
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Kelly Koehn
- Division of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Lawrence, Kansas, USA
| | - Douglas W Sborov
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
| | - Brian McClune
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
| | - Vinay Prasad
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California, USA
| | - Alyson Haslam
- Department of Epidemiology/Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Katherine Berger
- Patient Advocate, University of Hartford, West Hartford, Connecticut, USA
| | - Christopher Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Samer Al Hadidi
- Myeloma Institute, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Al-Ola Abdallah
- Division of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Lawrence, Kansas, USA
| | - Aaron Goodman
- Division of Blood and Marrow Transplantation, University of California San Diego, La Jolla, California, USA
| | - Ghulam Rehman Mohyuddin
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
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14
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Sachdev A, Sharpe I, Bowman M, Booth CM, Gyawali B. Objective response rate of placebo in randomized controlled trials of anticancer medicines. EClinicalMedicine 2023; 55:101753. [PMID: 36444211 PMCID: PMC9700265 DOI: 10.1016/j.eclinm.2022.101753] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Spontaneous regression of advanced solid tumors is infrequent but may occur. Quantifying response rates from placebo in cancer drug trials may provide important information for physicians, patients, and regulators. We aimed to provide a pooled placebo response rate from drug trials in advanced solid tumors. METHODS We pooled the overall response rate (ORR), complete response rate (CR) and partial response rates (PR) in the placebo arm of placebo-controlled randomized controlled trials (RCTs) of cancer drugs for advanced solid tumors published during 2015-2021 using random-effects model. FINDINGS 45 phase 3 RCTs including 5684 patients on placebo met our inclusion criteria and formed the study cohort. The pooled overall ORR, CR and PR rates in the placebo arm were 1% (95% CI, 0%-2%), 0% (95% CI, 0%-0%), and 1% (95% CI, 0%-2%) respectively. Higher placebo responses were observed in prostate cancer and sarcoma trials. INTERPRETATION Overall, 1% patients with advanced solid tumors can expect to achieve some response even in absence of treatment. However, complete regression without treatment is extremely rare, almost zero percent. This information will be helpful to patients in their decisions, as well as regulators in evaluating cancer drugs' efficacy based on response rates alone. FUNDING None.
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Affiliation(s)
- Arushi Sachdev
- School of Medicine, Queen's University, Kingston, Canada
| | - Isobel Sharpe
- Department of Public Health Sciences, Queen's University, Kingston, Canada
| | - Meghan Bowman
- Department of Public Health Sciences, Queen's University, Kingston, Canada
| | - Christopher M. Booth
- Department of Public Health Sciences, Queen's University, Kingston, Canada
- Department of Oncology, Queen's University, Kingston, Canada
- Division of Cancer Care and Epidemiology, Queen's University, Kingston, Canada
| | - Bishal Gyawali
- Department of Public Health Sciences, Queen's University, Kingston, Canada
- Department of Oncology, Queen's University, Kingston, Canada
- Division of Cancer Care and Epidemiology, Queen's University, Kingston, Canada
- Corresponding author. Cancer Care and Epidemiology, Queen's Cancer Research Institute, Queen's University, 10 Stuart Street, Level 2, Kingston, ON, Canada K7L 3N6. @oncology_bg
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15
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Cabibbo G, Bruix J. Radiological endpoints as surrogates for survival benefit in hepatocellular carcinoma trials: All that glitters is not gold. J Hepatol 2023; 78:8-11. [PMID: 36323356 DOI: 10.1016/j.jhep.2022.10.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/12/2022] [Accepted: 10/16/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Giuseppe Cabibbo
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties PROMISE, University of Palermo, Palermo, Italy.
| | - Jordi Bruix
- BCLC Group, Liver Unit, Hospital Clinic Barcelona, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain.
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16
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Wojciechowski S, Majchrzak-Górecka M, Biernat P, Odrzywołek K, Pruss Ł, Zych K, Jan Majta, Milanowska-Zabel K. Machine learning on the road to unlocking microbiota's potential for boosting immune checkpoint therapy. Int J Med Microbiol 2022; 312:151560. [PMID: 36113358 DOI: 10.1016/j.ijmm.2022.151560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 07/15/2022] [Accepted: 08/31/2022] [Indexed: 10/14/2022] Open
Abstract
The intestinal microbiota is a complex and diverse ecological community that fulfills multiple functions and substantially impacts human health. Despite its plasticity, unfavorable conditions can cause perturbations leading to so-called dysbiosis, which have been connected to multiple diseases. Unfortunately, understanding the mechanisms underlying the crosstalk between those microorganisms and their host is proving to be difficult. Traditionally used bioinformatic tools have difficulties to fully exploit big data generated for this purpose by modern high throughput screens. Machine Learning (ML) may be a potential means of solving such problems, but it requires diligent application to allow for drawing valid conclusions. This is especially crucial as gaining insight into the mechanistic basis of microbial impact on human health is highly anticipated in numerous fields of study. This includes oncology, where growing amounts of studies implicate the gut ecosystems in both cancerogenesis and antineoplastic treatment outcomes. Based on these reports and first signs of clinical benefits related to microbiota modulation in human trials, hopes are rising for the development of microbiome-derived diagnostics and therapeutics. In this mini-review, we're inspecting analytical approaches used to uncover the role of gut microbiome in immune checkpoint therapy (ICT) with the use of shotgun metagenomic sequencing (SMS) data.
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Affiliation(s)
| | | | | | - Krzysztof Odrzywołek
- Ardigen, Podole 76, 30-394 Kraków, Poland; Institute of Computer Science, Faculty of Computer Science, Electronics and Telecommunications, AGH University of Science and Technology, Mickiewicza 30, 30-059 Kraków, Poland
| | - Łukasz Pruss
- Ardigen, Podole 76, 30-394 Kraków, Poland; Department of Biochemistry, Molecular Biology and Biotechnology, Faculty of Chemistry, Wroclaw University of Science and Technology, 50-373 Wroclaw, Poland
| | | | - Jan Majta
- Ardigen, Podole 76, 30-394 Kraków, Poland; Department of Computational Biophysics and Bioinformatics, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Krakow, Poland
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17
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de Baat EC, Mulder RL, Armenian S, Feijen EA, Grotenhuis H, Hudson MM, Mavinkurve-Groothuis AM, Kremer LC, van Dalen EC. Dexrazoxane for preventing or reducing cardiotoxicity in adults and children with cancer receiving anthracyclines. Cochrane Database Syst Rev 2022; 9:CD014638. [PMID: 36162822 PMCID: PMC9512638 DOI: 10.1002/14651858.cd014638.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND This review is the third update of a previously published Cochrane Review. The original review, looking at all possible cardioprotective agents, was split and this part now focuses on dexrazoxane only. Anthracyclines are effective chemotherapeutic agents in the treatment of numerous malignancies. Unfortunately, their use is limited by a dose-dependent cardiotoxicity. In an effort to prevent or reduce this cardiotoxicity, different cardioprotective agents have been studied, including dexrazoxane. OBJECTIVES To assess the efficacy of dexrazoxane to prevent or reduce cardiotoxicity and determine possible effects of dexrazoxane on antitumour efficacy, quality of life and toxicities other than cardiac damage in adults and children with cancer receiving anthracyclines when compared to placebo or no additional treatment. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase to May 2021. We also handsearched reference lists, the proceedings of relevant conferences and ongoing trials registers. SELECTION CRITERIA Randomised controlled trials (RCTs) in which dexrazoxane was compared to no additional therapy or placebo in adults and children with cancer receiving anthracyclines. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, data extraction, risk of bias and GRADE assessment of included studies. We analysed results in adults and children separately. We performed analyses according to the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS For this update, we identified 548 unique records. We included three additional RCTs: two paediatric and one adult. Therefore, we included a total of 13 eligible RCTs (five paediatric and eight adult). The studies enrolled 1252 children with leukaemia, lymphoma or a solid tumour and 1269 participants, who were mostly diagnosed with breast cancer. In adults, moderate-quality evidence showed that there was less clinical heart failure with the use of dexrazoxane (risk ratio (RR) 0.22, 95% confidence interval (CI) 0.11 to 0.43; 7 studies, 1221 adults). In children, we identified no difference in clinical heart failure risk between treatment groups (RR 0.20, 95% CI 0.01 to 4.19; 3 studies, 885 children; low-quality evidence). In three paediatric studies assessing cardiomyopathy/heart failure as the primary cause of death, none of the children had this outcome (1008 children, low-quality evidence). In the adult studies, different definitions for subclinical myocardial dysfunction and clinical heart failure combined were used, but pooled analyses were possible: there was a benefit in favour of the use of dexrazoxane (RR 0.37, 95% CI 0.24 to 0.56; 3 studies, 417 adults and RR 0.46, 95% CI 0.33 to 0.66; 2 studies, 534 adults, respectively, moderate-quality evidence). In the paediatric studies, definitions of subclinical myocardial dysfunction and clinical heart failure combined were incomparable, making pooling impossible. One paediatric study showed a benefit in favour of dexrazoxane (RR 0.33, 95% CI 0.13 to 0.85; 33 children; low-quality evidence), whereas another study showed no difference between treatment groups (Fischer exact P = 0.12; 537 children; very low-quality evidence). Overall survival (OS) was reported in adults and overall mortality in children. The meta-analyses of both outcomes showed no difference between treatment groups (hazard ratio (HR) 1.04, 95% 0.88 to 1.23; 4 studies; moderate-quality evidence; and HR 1.01, 95% CI 0.72 to 1.42; 3 studies, 1008 children; low-quality evidence, respectively). Progression-free survival (PFS) was only reported in adults. We subdivided PFS into three analyses based on the comparability of definitions, and identified a longer PFS in favour of dexrazoxane in one study (HR 0.62, 95% CI 0.43 to 0.90; 164 adults; low-quality evidence). There was no difference between treatment groups in the other two analyses (HR 0.95, 95% CI 0.64 to 1.40; 1 study; low-quality evidence; and HR 1.18, 95% CI 0.97 to 1.43; 2 studies; moderate-quality evidence, respectively). In adults, there was no difference in tumour response rate between treatment groups (RR 0.91, 95% CI 0.79 to 1.04; 6 studies, 956 adults; moderate-quality evidence). We subdivided tumour response rate in children into two analyses based on the comparability of definitions, and identified no difference between treatment groups (RR 1.01, 95% CI 0.95 to 1.07; 1 study, 206 children; very low-quality evidence; and RR 0.92, 95% CI 0.84 to 1.01; 1 study, 200 children; low-quality evidence, respectively). The occurrence of secondary malignant neoplasms (SMN) was only assessed in children. The available and worst-case analyses were identical and showed a difference in favour of the control group (RR 3.08, 95% CI 1.13 to 8.38; 3 studies, 1015 children; low-quality evidence). In the best-case analysis, the direction of effect was the same, but there was no difference between treatment groups (RR 2.51, 95% CI 0.96 to 6.53; 4 studies, 1220 children; low-quality evidence). For other adverse effects, results also varied. None of the studies evaluated quality of life. If not reported, the number of participants for an analysis was unclear. AUTHORS' CONCLUSIONS Our meta-analyses showed the efficacy of dexrazoxane in preventing or reducing cardiotoxicity in adults treated with anthracyclines. In children, there was a difference between treatment groups for one cardiac outcome (i.e. for one of the definitions used for clinical heart failure and subclinical myocardial dysfunction combined) in favour of dexrazoxane. In adults, no evidence of a negative effect on tumour response rate, OS and PFS was identified; and in children, no evidence of a negative effect on tumour response rate and overall mortality was identified. The results for adverse effects varied. In children, dexrazoxane may be associated with a higher risk of SMN; in adults this was not addressed. In adults, the quality of the evidence ranged between moderate and low; in children, it ranged between low and very low. Before definitive conclusions on the use of dexrazoxane can be made, especially in children, more high-quality research is needed. We conclude that if the risk of cardiac damage is expected to be high, it might be justified to use dexrazoxane in children and adults with cancer who are treated with anthracyclines. However, clinicians and patients should weigh the cardioprotective effect of dexrazoxane against the possible risk of adverse effects, including SMN, for each individual. For children, the International Late Effects of Childhood Cancer Guideline Harmonization Group has developed a clinical practice guideline.
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Affiliation(s)
- Esmée C de Baat
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Renée L Mulder
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Saro Armenian
- Population Sciences, City of Hope National Medical Center, Duarte, USA
| | | | - Heynric Grotenhuis
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Ito Y, Awano N, Takahashi N, Izumo T, Kunitoh H. Association between tumor response to systemic therapy and patient-reported disease symptoms. Jpn J Clin Oncol 2022; 52:1423-1429. [PMID: 36062454 DOI: 10.1093/jjco/hyac142] [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: 06/23/2022] [Accepted: 08/12/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The association of treatment-induced tumor shrinkage with symptom palliation for patients with lung cancer remains unknown. We investigated this correlation using the Edmonton Symptom Assessment System-Revised. METHODS Using the in-hospital cancer registry, we identified patients receiving chemotherapy and/or immunotherapy for newly diagnosed advanced or metastatic lung cancer. Tumor response and post-treatment Edmonton Symptom Assessment System-Revised were obtained after 2-3 treatment cycles. Patients were divided into groups with or without >30% unidirectional tumor shrinkage (objective response [OR] or non-OR [N-OR] groups, respectively). They were further classified as good-objective response (>50% unidirectional tumor shrinkage), moderate-objective response (30-50% shrinkage), progressive disease (>20% tumor growth or new lesion) or stable disease (SD; N-objective response and non-progressive disease). The primary endpoint was change in the total Edmonton Symptom Assessment System-Revised score from baseline. The Mann-Whitney U test was used for analysis. RESULTS In total, 113 patients were enrolled. The total Edmonton Symptom Assessment System-Revised score was significantly more improved in the OR group versus the N-OR group (median: 5 vs. 2, respectively; P = 0.013). This association was more prominent in patients with small-cell lung cancer and large-cell neuroendocrine tumor than those with other histology. Sensitivity analyses showed that the total Edmonton Symptom Assessment System-Revised score was more improved in the OR group versus the SD group (median: 5 vs. 3, respectively; P = 0.029) and in the 'good-OR' group versus the 'moderate-OR and SD' group (median: 7.5 vs. 2, respectively; P = 0.003), suggesting that greater tumor shrinkage led to more symptom amelioration. CONCLUSIONS Tumor shrinkage was associated with Edmonton Symptom Assessment System-Revised score improvement in patients with lung cancer receiving systemic therapy.
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Affiliation(s)
- Yu Ito
- Department of Respiratory Medicine, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Nobuyasu Awano
- Department of Respiratory Medicine, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Naoko Takahashi
- Department of Palliative Care, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Takehiro Izumo
- Department of Respiratory Medicine, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hideo Kunitoh
- Department of Medical Oncology, Japanese Red Cross Medical Center, Tokyo, Japan
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Implications of Oncology Trial Design and Uncertainties in Efficacy-Safety Data on Health Technology Assessments. Curr Oncol 2022; 29:5774-5791. [PMID: 36005193 PMCID: PMC9406873 DOI: 10.3390/curroncol29080455] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Advances in cancer medicines have resulted in tangible health impacts, but the magnitude of benefits of approved cancer medicines could vary greatly. Health Technology Assessment (HTA) is a multidisciplinary process used to inform resource allocation through a systematic value assessment of health technology. This paper reviews the challenges in conducting HTA for cancer medicines arising from oncology trial designs and uncertainties of safety-efficacy data. Methods: Multiple databases (PubMed, Scopus and Google Scholar) and grey literature (public health agencies and governmental reports) were searched to inform this policy narrative review. Results: A lack of robust efficacy-safety data from clinical trials and other relevant sources of evidence has made HTA for cancer medicines challenging. The approval of cancer medicines through expedited pathways has increased in recent years, in which surrogate endpoints or biomarkers for patient selection have been widely used. Using these surrogate endpoints has created uncertainties in translating surrogate measures into patient-centric clinically (survival and quality of life) and economically (cost-effectiveness and budget impact) meaningful outcomes, with potential effects on diverting scarce health resources to low-value or detrimental interventions. Potential solutions include policy harmonization between regulatory and HTA authorities, commitment to generating robust post-marketing efficacy-safety data, managing uncertainties through risk-sharing agreements, and using value frameworks. Conclusion: A lack of robust efficacy-safety data is a central problem for conducting HTA of cancer medicines, potentially resulting in misinformed resource allocation.
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Ree AH, Mælandsmo GM, Flatmark K, Russnes HG, Gómez Castañeda M, Aas E. Cost-effectiveness of molecularly matched off-label therapies for end-stage cancer - the MetAction precision medicine study. Acta Oncol 2022; 61:955-962. [PMID: 35943168 DOI: 10.1080/0284186x.2022.2098053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Precision cancer medicine (PCM), frequently used for the expensive and often modestly efficacious off-label treatment with medications matched to the tumour genome of end-stage cancer, challenges healthcare resources. We compared the health effects, costs and cost-effectiveness of our MetAction PCM study with corresponding data from comparator populations given best supportive care (BSC) in two external randomised controlled trials. METHODS We designed three partitioned survival models to evaluate the healthcare costs and quality-adjusted life years (QALYs) as the main outcomes. Cost-effectiveness was calculated as the incremental cost-effectiveness ratio (ICER) of PCM relative to BSC with an annual willingness-to-pay (WTP) threshold of EUR 56,384 (NOK 605,000). One-way and probabilistic sensitivity analyses addressed uncertainty. RESULTS We estimated total healthcare costs (relating to next-generation sequencing (NGS) equipment and personnel wages, molecularly matched medications to the patients with an actionable tumour target and follow-up of the responding patients) and the health outcomes for the MetAction patients versus costs (relating to estimated hospital admission) and outcomes for the BSC cases. The ICERs for incremental QALYs were twice or more as high as the WTP threshold and relatively insensitive to cost decrease of the NGS procedures, while reduction of medication prices would contribute significantly towards a cost-effective PCM strategy. CONCLUSIONS The models suggested that the high ICERs of PCM were driven by costs of the NGS diagnostics and molecularly matched medications, with a likelihood for the strategy to be cost-effective defying WTP constraints. Reducing drug expenses to half the list price would likely result in an ICER at the WTP threshold. This can be an incentive for a public-private partnership for sharing drug costs in PCM, exemplified by ongoing European initiatives. CLINICALTRIALS.GOV, IDENTIFIER NCT02142036.
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Affiliation(s)
- Anne Hansen Ree
- Department of Oncology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Gunhild M Mælandsmo
- Department of Tumor Biology, Oslo University Hospital, Oslo, Norway.,Institute for Medical Biology, University of Tromsø - The Arctic University of Norway, Tromsø, Norway
| | - Kjersti Flatmark
- Department of Tumor Biology, Oslo University Hospital, Oslo, Norway.,Institute for Medical Biology, University of Tromsø - The Arctic University of Norway, Tromsø, Norway.,Department of Gastroenterological Surgery, Oslo University Hospital, Oslo, Norway
| | - Hege G Russnes
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Pathology, Oslo University Hospital, Oslo, Norway.,Department of Cancer Genetics, Oslo University Hospital, Oslo, Norway
| | | | - Eline Aas
- Institute of Health and Society, University of Oslo, Oslo, Norway.,Health Service Research Unit, Akershus University Hospital, Lørenskog, Norway.,Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
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21
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Zhang Y, Naci H, Wagner AK, Xu Z, Yang Y, Zhu J, Ji J, Shi L, Guan X. Overall Survival Benefits of Cancer Drugs Approved in China From 2005 to 2020. JAMA Netw Open 2022; 5:e2225973. [PMID: 35947385 PMCID: PMC9366546 DOI: 10.1001/jamanetworkopen.2022.25973] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Of approximately 9 million patients with cancer in China in 2020, more than half were diagnosed with late-stage cancers. Recent regulatory reforms in China have focused on improving the availability of new cancer drugs. However, evidence on the clinical benefits of new cancer therapies authorized in China is not available. OBJECTIVE To characterize the clinical benefits of cancer drugs approved in China, as defined by the availability and magnitude of statistically significant overall survival (OS) results. DESIGN, SETTING, AND PARTICIPANTS This mixed-methods study comprising a systematic review and cross-sectional analysis identified antineoplastic agents approved in China between January 1, 2005, and December 31, 2020, using publicly available data and regulatory review documents issued by the National Medical Products Administration. The literature published up to June 30, 2021, was reviewed to collect results on end points used in pivotal trials supporting cancer drug approvals. MAIN OUTCOMES AND MEASURES The primary outcome measure was a documented statistically significant positive OS difference between a new cancer therapy and a comparator treatment. Secondary outcome measures were the magnitude of OS benefit and other primary efficacy measures in pivotal trials. RESULTS Between 2005 and 2020, 78 cancer drugs corresponding to 141 indications were authorized in China, including 20 drugs (25.6%) (for 30 indications) approved in China only. Of all indications, 26 (18.4%) were evaluated in single-arm or dose-optimization trials, most of which were authorized after 2017. By June 30, 2021, 34 drug indications (24.1%) had a documented lack of OS gain. For 68 indications (48.2%) that had documented evidence of OS benefit, the median magnitude of OS improvement was 4.1 (range, 1.0-35.0) months. After a median follow-up of 1.9 (range, 1.0-11.1) years from approval, OS data for 13 indications (9.2%) were either not reported or were still not mature. Fewer than one-third of cancer drug indications approved in China only had documented evidence of OS benefits (9 of 30 [30.0%]), whereas more than one-half of the cancer drug indications also available in the US or Europe had OS benefits (59 of 111 [53.1%]). CONCLUSIONS AND RELEVANCE In this study, almost half of cancer drug indications approved in China had demonstrated OS gain. With the increase of cancer drug approvals based on single-arm trials or immature survival data in recent years, these findings highlight the need to routinely monitor the clinical benefits of new cancer therapies in China.
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Affiliation(s)
- Yichen Zhang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Huseyin Naci
- LSE Health, Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Anita K. Wagner
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Ziyue Xu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Yu Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Jun Zhu
- Beijing Cancer Hospital, Beijing, China
| | - Jiafu Ji
- Beijing Cancer Hospital, Beijing, China
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- International Research Centre for Medicinal Administration, Peking University, Beijing, China
| | - Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- International Research Centre for Medicinal Administration, Peking University, Beijing, China
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22
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Ooki A, Morita S, Tsuji A, Iwamoto S, Hara H, Tanioka H, Satake H, Kataoka M, Kotaka M, Kagawa Y, Nakamura M, Shingai T, Ishikawa M, Miyake Y, Suto T, Hashiguchi Y, Yabuno T, Ando M, Sakamoto J, Yamaguchi K. Impact of early tumor shrinkage on quality of life in patients treated with first-line cetuximab plus chemotherapy for unresectable metastatic colorectal cancer: results of Phase II QUACK trial. BMC Cancer 2022; 22:711. [PMID: 35765021 PMCID: PMC9238042 DOI: 10.1186/s12885-022-09811-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 05/11/2022] [Indexed: 12/09/2022] Open
Abstract
Purpose Although early tumor shrinkage (ETS) is a predictor of improved overall survival (OS), the association between ETS and health-related quality of life (HRQOL) remains unclear for patients with metastatic colorectal cancer (mCRC) treated with first-line cetuximab plus chemotherapy. Methods The data were collected from a prospective trial that assessed HRQOL using the EORTC QLQ-C30. The impact of ETS on HRQOL was estimated using a linear mixed-effects model for repeated measures. Results ETS was achieved in 82 (64.1%) of 128 mCRC patients treated with first-line cetuximab plus chemotherapy, and these patients had a significantly longer OS than those without ETS (HR, 0.38; 95% CI, 0.20–0.72; P = .002). Asymptomatic patients with ETS had a favorable OS, while symptomatic patients without ETS had a worse OS (2-year OS rates, 77.8% vs. 42.5%). Symptomatic patients with ETS had similar outcomes as asymptomatic patients without ETS (2-year OS rates, 64.1% vs. 67.0%). For symptomatic patients, ETS was associated with improved HRQOL scores between baseline and 8 weeks: the mean changes for patients with and without ETS were 5.86 and -4.94 for global health status (GHS)/QOL, 26.73 and 3.79 for physical functioning, and 13.58 and -3.10 for social functioning, respectively. The improved HRQOL was comparable to that of asymptomatic patients without ETS. For asymptomatic patients, ETS showed a decreased deterioration in HRQOL. Conclusion Our findings highlight the importance of ETS for HRQOL and prognostic estimates, and assessing ETS may provide clinically useful information for physicians and patients to make more informed decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09811-x.
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Affiliation(s)
- Akira Ooki
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University, Kyoto, Japan
| | - Akihito Tsuji
- Department of Medical Oncology, Kagawa University, Kita, Japan
| | - Shigeyoshi Iwamoto
- Department of Surgery, Kansai Medical University Kouri Hospital, Neyagawa, Japan
| | - Hiroki Hara
- Department of Gastroenterology, Saitama Cancer Center, Saitama, Japan
| | - Hiroaki Tanioka
- Department of Clinical Oncology, Kawasaki Medical School, Kurashiki, Japan
| | - Hironaga Satake
- Cancer Treatment Center, Kansai Medical University Hospital, Osaka, Japan
| | - Masato Kataoka
- Department of Surgery, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | | | | | - Masato Nakamura
- Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Tatsushi Shingai
- Department of Surgery, Osaka Saiseikai Senri Hospital, Suita, Japan
| | - Masashi Ishikawa
- Department of Surgery, Shikoku Central Hospital, Shikokuchuo, Japan
| | - Yasuhiro Miyake
- Department of Surgery, Osaka Minato Central Hospital, Osaka, Japan
| | - Takeshi Suto
- Department of Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Yojiro Hashiguchi
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Taichi Yabuno
- Department of Surgery, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Masahiko Ando
- Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | | | - Kensei Yamaguchi
- Department of Gastroenterological Chemotherapy, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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23
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Goring S, Varol N, Waser N, Popoff E, Lozano-Ortega G, Lee A, Yuan Y, Eccles L, Tran P, Penrod JR. Correlations between objective response rate and survival-based endpoints in first-line advanced non-small cell lung Cancer: A systematic review and meta-analysis. Lung Cancer 2022; 170:122-132. [PMID: 35767923 DOI: 10.1016/j.lungcan.2022.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION The study objective was to estimate the relationship between objective response and survival-based endpoints by drug class, in first-line advanced non-small cell lung cancer (aNSCLC). MATERIALS AND METHODS A systematic literature review identified randomized controlled trials (RCTs) of first-line aNSCLC therapies reporting overall survival (OS), progression-free survival (PFS), and/or objective response rate (ORR). Trial-level and arm-level linear regression models were fit, accounting for inclusion of immunotherapy (IO)-based or chemotherapy-only RCT arms. Weighted least squares-based R2 were calculated along with 95% confidence intervals (CIs). For the main trial-level analysis of OS vs. ORR, the surrogate threshold effect was estimated. Exploratory analyses involved further stratification by: IO monotherapy vs. chemotherapy, dual-IO therapy vs. chemotherapy, and IO + chemotherapy vs. chemotherapy. RESULTS From 17,040 records, 57 RCTs were included. In the main analysis, trial-level associations between OS and ORR were statistically significant in both the IO-based and chemotherapy-only strata, with R2 estimates of 0.54 (95% CI: 0.26-0.81) and 0.34 (0.05-0.63), respectively. OS gains associated with a given ORR benefit were statistically significantly larger within IO vs. chemotherapy comparisons compared to chemotherapy vs. chemotherapy comparisons (p < 0.001). Exploratory analysis suggested a trend by IO type: for a given change in ORR, 'pure' IO (IO monotherapy and dual-IO) vs. chemotherapy RCTs tended to have a larger OS benefit than IO + chemotherapy vs. chemotherapy RCTs. For ORR vs. PFS, trial-level correlations were strong in the IO-based vs. chemotherapy (R2 = 0.84; 0.72-0.95), and chemotherapy vs. chemotherapy strata (R2 = 0.69; 0.49-0.88). For OS vs. PFS, correlations were moderate in both strata (R2 = 0.49; 0.20-0.78 and R2 = 0.49; 0.23-0.76). CONCLUSION The larger OS benefit per unit of ORR benefit in IO-based RCTs compared to chemotherapy-only RCTs provides an important addition to the established knowledge regarding the durability and depth of response in IO-based treatments.
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Affiliation(s)
- Sarah Goring
- Broadstreet HEOR, 201-343 Railway St, Vancouver, BC, Canada.
| | - Nebibe Varol
- Bristol Myers Squibb Pharmaceuticals Ltd, Sanderson Rd, Denham, Uxbridge, England, UK.
| | | | - Evan Popoff
- Broadstreet HEOR, 201-343 Railway St, Vancouver, BC, Canada.
| | | | - Adam Lee
- Bristol Myers Squibb Pharmaceuticals Ltd, Sanderson Rd, Denham, Uxbridge, England, UK.
| | - Yong Yuan
- Bristol Myers Squibb Pharmaceuticals Ltd, 3401 Princeton Pike, Lawrenceville, NJ, USA.
| | - Laura Eccles
- Bristol Myers Squibb Pharmaceuticals Ltd, 3401 Princeton Pike, Lawrenceville, NJ, USA.
| | - Phuong Tran
- Bristol Myers Squibb Pharmaceuticals Ltd, 3401 Princeton Pike, Lawrenceville, NJ, USA.
| | - John R Penrod
- Bristol Myers Squibb Pharmaceuticals Ltd, 3401 Princeton Pike, Lawrenceville, NJ, USA.
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Dello Russo C, Navarra P. Local Investigators Significantly Overestimate Overall Response Rates Compared to Blinded Independent Central Reviews in Uncontrolled Oncology Trials: A Comprehensive Review of the Literature. Front Pharmacol 2022; 13:858354. [PMID: 35652050 PMCID: PMC9149259 DOI: 10.3389/fphar.2022.858354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/11/2022] [Indexed: 11/26/2022] Open
Abstract
Several drugs gained market authorization based on the demonstration of improved progression-free survival (PFS), adopted as a primary endpoint in Phase 3 clinical trials. In addition, an increasing number of drugs have been granted accelerated approval, and sometimes regular approval, by the main regulatory agencies based on the evaluation of the overall response rate in Phase 1 and 2 clinical trials. However, while the overall survival is an unbiased measure of drug efficacy, these outcomes rely on the assessment of radiological images and patients’ categorization using standardized response criteria. The evaluation of these outcomes may be influenced by subjective factors, particularly when the analysis is performed locally. In fact, blinding of treatment is not always possible in modern oncology trials. Therefore, a blinded independent central review is often adopted to overcome the problem of expectation bias associated with local investigator assessments. In this regard, we have recently observed that local investigators tend to overestimate the overall response rate in comparison to central reviewers in Phase 2 clinical trials, whereas we did not find any significant evaluation bias between local investigators and central reviews when considering progression-free survival in both Phase 2 and 3 trials. In the present article, we have tried to understand the reasons behind this discrepancy by reviewing the available evidence in the literature. In addition, a further analysis of Phase 2 and 3 clinical trials that included the evaluation of both endpoints showed that local investigators significantly overestimate overall response rates compared to blinded independent central reviews in uncontrolled oncology trials.
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Affiliation(s)
- Cinzia Dello Russo
- Section of Pharmacology, Department of Healthcare Surveillance and Bioethics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy.,MRC Centre for Drug Safety Science and Wolfson Centre for Personalized Medicine, Institute of Systems Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, United Kingdom
| | - Pierluigi Navarra
- Section of Pharmacology, Department of Healthcare Surveillance and Bioethics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy
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25
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Daniele P, Mamolo C, Cappelleri JC, Bell T, Neuhof A, Tremblay G, Musat M, Forsythe A. Response rates and minimal residual disease outcomes as potential surrogates for progression-free survival in newly diagnosed multiple myeloma. PLoS One 2022; 17:e0267979. [PMID: 35550641 PMCID: PMC9098007 DOI: 10.1371/journal.pone.0267979] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 04/19/2022] [Indexed: 11/18/2022] Open
Abstract
Progression-free survival (PFS) is a common primary endpoint in newly diagnosed multiple myeloma (NDMM). Patients with NDMM typically have longer PFS and are more likely to achieve minimal residual disease (MRD) or complete response (CR) compared to patients with relapsed or refractory multiple myeloma. Response-based surrogate endpoints may hold value given the longer follow-up time required to evaluate PFS in NDMM. In this work, systematic literature reviews of Medline, Embase, and Cochrane databases (2010-06/2020) and relevant congresses (2018-2020) were performed to identify randomized clinical trials (RCTs) and real-world studies in NDMM reporting median PFS and objective response. Associations between PFS and each response endpoint were evaluated using Pearson's product-moment correlation weighted by sample size in each RCT arm. Unadjusted and adjusted weighted linear regression models were applied to estimate the gain in median PFS associated with each response endpoint. Statistically significant correlations were identified for median PFS with overall response rate (ORR; Pearson r = 0.59), CR (r = 0.48), stringent CR (sCR; r = 0.68), and MRD (r = 0.69). The unadjusted models estimated 0.50 (95% CI: 0.36, 0.64; p<0.001), 0.42 (95% CI: 0.25, 0.58; p<0.001), 1.05 (95% CI: 0.58, 1.52; p<0.001), and 0.35 (95% CI: 0.12, 0.58; p = 0.006) months of median PFS gained per point of ORR, CR, sCR, and MRD, respectively. Associations for median PFS remained statistically significant in models adjusted for age and treatment type with ORR (0.35, 95% CI: 0.21, 0.49; p<0.001), and adjusted for age and International Staging System risk stage with CR (0.29, 95% CI: 0.16, 0.41; p<0.001). Due to small sample size, adjusted models could not be constructed for sCR or MRD. Nevertheless, evidence of significant survival benefit (p<0.05) associated with MRD negativity and sCR was identified across real-world studies. These findings provide support for the use of response outcomes as surrogate endpoints to estimate PFS benefit in NDMM.
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Affiliation(s)
- Patrick Daniele
- Purple Squirrel Economics, a Cytel Company, Montreal, Canada
| | - Carla Mamolo
- Pfizer Inc., Groton, Connecticut, United States of America
| | | | - Timothy Bell
- Pfizer Inc., New York, New York, United States of America
| | | | | | - Mihaela Musat
- Purple Squirrel Economics, a Cytel Company, New York, New York, United States of America
| | - Anna Forsythe
- Purple Squirrel Economics, a Cytel Company, New York, New York, United States of America
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26
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Rui M, Wang Z, Fei Z, Wu Y, Wang Y, Sun L, Shang Y, Li H. The Relationship Between Short-Term Surrogate Endpoint Indicators and mPFS and mOS in Clinical Trials of Malignant Tumors: A Case Study of Approved Molecular Targeted Drugs for Non-Small-Cell Lung Cancer in China. Front Pharmacol 2022; 13:862640. [PMID: 35370659 PMCID: PMC8966682 DOI: 10.3389/fphar.2022.862640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: Due to the initiation of the priority review program in China, many antitumor drugs have been approved for marketing based on phase II clinical trials and short-term surrogate endpoint indicators. This study used approved targeted drugs for the treatment of non-small-cell lung cancer (NSCLC) in China as an example to evaluate the association between short-term surrogate endpoints [objective response rate (ORR) and disease control rate (DCR)] and median progression-free survival (mPFS) and median overall survival (mOS). Methods: Five databases, i.e., MEDLINE, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang Data were searched, for phase II or phase III clinical trials of all molecular targeted drugs that have been marketed in China for the treatment of NSCLC. After screening the literature and extracting information, both univariate and multivariate linear regression were performed on the short-term surrogate indicators and mPFS and mOS to explore the relationship. Results: A total of 63 studies were included (25 studies with only ORR, DCR, and mPFS and 39 studies with ORR, DCR, mPFS, and mOS). In terms of the targeted drugs for the treatment of NSCLC, in addition to the good but not excellent linear relationship between DCR and mOS (0.4 < R2 adj = 0.5653 < 0.6), all other short-term surrogate endpoint indicators had excellent linear relationships with mPFS and mOS (R2 adj≥0.6), while mPFS and mOS had the most excellent linear relationships (R2 adj = 0.8036). Conclusion: For targeted drugs for the treatment of NSCLC, short-term surrogate endpoint indicators such as ORR and DCR may be reliable surrogate indicators for mPFS and mOS. However, whether short-term surrogate endpoint indicators can be used to predict final endpoints remains to be verified.
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Affiliation(s)
- Mingjun Rui
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Zijing Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Zhengyang Fei
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Yao Wu
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Yingcheng Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Lei Sun
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Ye Shang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
| | - Hongchao Li
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, China
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27
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Murphy P, Glynn D, Dias S, Hodgson R, Claxton L, Beresford L, Cooper K, Tappenden P, Ennis K, Grosso A, Wright K, Cantrell A, Stevenson M, Palmer S. Modelling approaches for histology-independent cancer drugs to inform NICE appraisals: a systematic review and decision-framework. Health Technol Assess 2022; 25:1-228. [PMID: 34990339 DOI: 10.3310/hta25760] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The first histology-independent marketing authorisation in Europe was granted in 2019. This was the first time that a cancer treatment was approved based on a common biomarker rather than the location in the body at which the tumour originated. This research aims to explore the implications for National Institute for Health and Care Excellence appraisals. METHODS Targeted reviews were undertaken to determine the type of evidence that is likely to be available at the point of marketing authorisation and the analyses required to support National Institute for Health and Care Excellence appraisals. Several challenges were identified concerning the design and conduct of trials for histology-independent products, the greater levels of heterogeneity within the licensed population and the use of surrogate end points. We identified approaches to address these challenges by reviewing key statistical literature that focuses on the design and analysis of histology-independent trials and by undertaking a systematic review to evaluate the use of response end points as surrogate outcomes for survival end points. We developed a decision framework to help to inform approval and research policies for histology-independent products. The framework explored the uncertainties and risks associated with different approval policies, including the role of further data collection, pricing schemes and stratified decision-making. RESULTS We found that the potential for heterogeneity in treatment effects, across tumour types or other characteristics, is likely to be a central issue for National Institute for Health and Care Excellence appraisals. Bayesian hierarchical methods may serve as a useful vehicle to assess the level of heterogeneity across tumours and to estimate the pooled treatment effects for each tumour, which can inform whether or not the assumption of homogeneity is reasonable. Our review suggests that response end points may not be reliable surrogates for survival end points. However, a surrogate-based modelling approach, which captures all relevant uncertainty, may be preferable to the use of immature survival data. Several additional sources of heterogeneity were identified as presenting potential challenges to National Institute for Health and Care Excellence appraisal, including the cost of testing, baseline risk, quality of life and routine management costs. We concluded that a range of alternative approaches will be required to address different sources of heterogeneity to support National Institute for Health and Care Excellence appraisals. An exemplar case study was developed to illustrate the nature of the assessments that may be required. CONCLUSIONS Adequately designed and analysed basket studies that assess the homogeneity of outcomes and allow borrowing of information across baskets, where appropriate, are recommended. Where there is evidence of heterogeneity in treatment effects and estimates of cost-effectiveness, consideration should be given to optimised recommendations. Routine presentation of the scale of the consequences of heterogeneity and decision uncertainty may provide an important additional approach to the assessments specified in the current National Institute for Health and Care Excellence methods guide. FURTHER RESEARCH Further exploration of Bayesian hierarchical methods could help to inform decision-makers on whether or not there is sufficient evidence of homogeneity to support pooled analyses. Further research is also required to determine the appropriate basis for apportioning genomic testing costs where there are multiple targets and to address the challenges of uncontrolled Phase II studies, including the role and use of surrogate end points. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 76. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Peter Murphy
- Centre for Reviews and Dissemination, University of York, York, UK
| | - David Glynn
- Centre for Health Economics, University of York, York, UK
| | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Robert Hodgson
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Lindsay Claxton
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Lucy Beresford
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Katy Cooper
- School of Health and Related Research (ScHARR) Technology Assessment Group, University of Sheffield, Sheffield, UK
| | - Paul Tappenden
- School of Health and Related Research (ScHARR) Technology Assessment Group, University of Sheffield, Sheffield, UK
| | - Kate Ennis
- School of Health and Related Research (ScHARR) Technology Assessment Group, University of Sheffield, Sheffield, UK
| | | | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR) Technology Assessment Group, University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR) Technology Assessment Group, University of Sheffield, Sheffield, UK
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, UK
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Yang S, Lin H, Song J. Efficacy and safety of various primary treatment strategies for very early and early hepatocellular carcinoma: a network meta-analysis. Cancer Cell Int 2021; 21:681. [PMID: 34923980 PMCID: PMC8684647 DOI: 10.1186/s12935-021-02365-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/25/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Several treatments are available for treatment of early and very early-stage Hepatocellular Carcinoma, also known as small Hepatocellular Carcinoma (SHCC). However, there is no consensus with regards to the efficacies of these methods. We aimed at identifying the most effective initial treatment strategy for SHCC through Bayesian network meta-analyses. METHODS Studies published between January, 2010, and February, 2021 were searched in EMBASE, Cochrane Library, PubMed and Web of science databases, and conference proceedings for trials. The included studies reported the survival outcomes of very early and early Hepatocellular Carcinoma patients subjected to radiofrequency ablation (RFA), microwave ablation (MWA), surgical resection (SR), transarterial chemoembolization (TACE), percutaneous ethanol injection (PEI), minimally invasive liver surgery (MIS), stereotactic body radiotherapy (SBRT) and cryoablation (CA). Then, data were extracted from studies that met the inclusion criteria. Patient survival data were retrieved from the published Kaplan-Meier curves and pooled. A Bayesian random-effects model was used to combine direct and indirect evidence. RESULTS A total of 2058 articles were retrieved and screened, from which 45 studies assessing the efficacies of 8 different treatments in 11,364 patients were selected. The included studies had high methodological quality. Recurrence free survival* (progression/recurrence/relapse/disease/tumor-free survival were combined and redefined as RFS*) and overall survival (OS) outcomes were highest in MIS-treated patients (HR 0·57, 95% confidence intervals [CI] 0·38-0·85; HR 0.48,95% CI 0.36-0.64, respectively), followed by SR-treated patients (HR 0.60, 95% CI 0.50-0.74; HR 0.62, 95% CI 0.55-0.72, respectively). TACE was highly efficacious (58.9%) at decreasing the rates of major complications. Similar findings were obtained through sensitivity analysis, and in most of the prognostic subgroups. CONCLUSIONS MIS and SR exhibited the highest clinical efficacies, however, they were associated with higher rates of complications. Ablation is effective in small tumors, whereas SBRT is a relatively promising treatment option for SHCC. More well-designed, large-scale randomized controlled trials should be performed to validate our findings.
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Affiliation(s)
- Sha Yang
- Department of Surgery, Children's Hospital of Chongqing Medical University, Chongqing, People's Republic of China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, People's Republic of China
- National Clinical Research Center for Child Health and Disorders, Chongqing, People's Republic of China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, People's Republic of China
- Chongqing Key Laboratory of Pediatrics, Chongqing, People's Republic of China
- Chongqing Engineering Research Center of Stem Cell Therapy, Chongqing, People's Republic of China
- Children S Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Huapeng Lin
- Department of Intensive Care Unit, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianning Song
- Department of General Surgery, Guiqian International General Hospital, 1 Dongfeng Dadao, Wudang District, Guiyang, Guizhou, 550018, People's Republic of China.
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Rizzo A, Mollica V, Massari F. Randomized Clinical Trials in the Era of Precision Oncology-The Role of End Points, Industry Funding, and Medical Writing Integrity. JAMA Oncol 2021; 7:1577. [PMID: 34436578 DOI: 10.1001/jamaoncol.2021.3335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alessandro Rizzo
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italia
| | - Veronica Mollica
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italia
| | - Francesco Massari
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italia
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30
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Bruix J, Chan SL, Galle PR, Rimassa L, Sangro B. Systemic treatment of hepatocellular carcinoma: An EASL position paper. J Hepatol 2021; 75:960-974. [PMID: 34256065 DOI: 10.1016/j.jhep.2021.07.004] [Citation(s) in RCA: 234] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/22/2021] [Accepted: 07/05/2021] [Indexed: 12/12/2022]
Abstract
The last 5 years have witnessed relevant advances in the systemic treatment of hepatocellular carcinoma. New data have emerged since the development of the EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma in 2018. Drugs licensed in some countries now include 4 oral multi-tyrosine kinase inhibitors (sorafenib, lenvatinib, regorafenib and cabozantinib), 1 anti-angiogenic antibody (ramucirumab) and 4 immune checkpoint inhibitors, alone or in combination (atezolizumab in combination with bevacizumab, ipilimumab in combination with nivolumab, nivolumab and pembrolizumab in monotherapy). Prolonged survival in excess of 2 years can be expected in most patients with sensitive tumours and well-preserved liver function that renders them fit for sequential therapies. With different choices available in any given setting, the robustness of the evidence of efficacy and a correct matching of the safety profile of a given agent with patient characteristics and preferences are key in making sound therapeutic decisions. The recommendations in this document amend the previous EASL Clinical Practice Guidelines and aim to help clinicians provide the best possible care for patients today. In view of several ongoing and promising trials, further advances in systemic therapy of hepatocellular carcinoma are foreseen in the near future and these recommendations will have to be updated regularly.
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Affiliation(s)
- Jordi Bruix
- BCLC Group, Liver Unit, Hospital Clínic, University of Barcelona, IDIBAPS, CIBEREHD, Barcelona, Spain
| | - Stephen L Chan
- Department of Clinical Oncology, State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, China
| | | | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Bruno Sangro
- Liver Unit and HPB Oncology Area, Clinica Universidad de Navarra-IDISNA and CIBEREHD, Pamplona, Spain.
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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: 29] [Impact Index Per Article: 9.7] [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.
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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.
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Mohyuddin GR, Koehn K, Abdallah A, Sborov D, Rajkumar SV, Kumar S, McClune B. Use of endpoints in multiple myeloma randomized controlled trials over the last 15 years: A systematic review. Am J Hematol 2021; 96:690-697. [PMID: 33735453 DOI: 10.1002/ajh.26166] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 01/12/2023]
Abstract
Surrogate endpoints are being used more frequently in randomized controlled trials, even though they do not consistently corelate with patient outcomes. We systemically evaluated the use of surrogate endpoints in multiple myeloma randomized controlled trials over the past 15 years. We searched three databases (Pubmed, Embase, Cochrane) for multiple myeloma randomized controlled trials from January 1, 2005 to December 30, 2019. The primary outcome of our study was the proportion of randomized controlled trials that used overall survival as their primary endpoint. Secondary outcomes included the use of surrogate endpoints, and trends over time, and whether they differed based on study sponsorship. We included 151 randomized controlled trials in our analysis. The primary endpoint was overall survival (OS) in 17 (11.3%) of studies, progression free survival (PFS) or event-defined endpoints in 91 studies (60.3%) and response-based endpoints in 44 studies (29.1%). Quality of life was a primary endpoint in only three studies (2%). The use of OS as a primary endpoint decreased from 28.5% of trials from 2005 to 2009 to 5.5% from 2015 to 2019. There has been a decrease in the clinically meaningful endpoint of OS over the past 15 years in multiple myeloma randomized controlled trials. Use of quality of life as a primary endpoint remains exceedingly low. It remains paramount to recognize that the use of surrogate endpoints is imperfect, and care based upon them requires constant physician and patient re-analysis.
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Affiliation(s)
- Ghulam Rehman Mohyuddin
- Department of Hematological Malignancies and Cellular Therapeutics Kansas University Medical Center Westwood Kansas USA
| | - Kelly Koehn
- Department of Hematological Malignancies and Cellular Therapeutics Kansas University Medical Center Westwood Kansas USA
| | - Al‐Ola Abdallah
- Department of Hematological Malignancies and Cellular Therapeutics Kansas University Medical Center Westwood Kansas USA
| | - Douglas Sborov
- Division of Hematology and Hematologic Malignancies University of Utah Salt Lake City Utah USA
| | - S. Vincent Rajkumar
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Shaji Kumar
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Brian McClune
- Division of Hematology and Hematologic Malignancies University of Utah Salt Lake City Utah USA
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Perego G, Petrelli F. Surrogate endpoints for new anti-cancer drugs approvals: Are we follow the right way? J Oncol Pharm Pract 2020; 27:448-449. [PMID: 33375904 DOI: 10.1177/1078155220984834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Dello Russo C, Cappoli N, Pilunni D, Navarra P. Local Investigators Significantly Overestimate Overall Response Rates Compared to Blinded Independent Central Reviews in Phase 2 Oncology Trials. J Clin Pharmacol 2020; 61:810-819. [PMID: 33244770 DOI: 10.1002/jcph.1790] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/18/2020] [Indexed: 11/11/2022]
Abstract
The overall response rate (ORR) is a largely adopted outcome measure in early-phase oncology trials. ORR is highly relevant in cancer drug development at the time of deciding whether to move to confirmatory phase 3 trials; moreover, ORR is gaining increasing relevance in fast-track registration procedures. No systematic analysis has been conducted so far to investigate whether a discrepancy exists between ORR assessed by local investigators and those assessed by blinded reviewers in phase 2 oncology trials. In this study, we carried out a search in the clinicaltrials.gov and EudraCT databases, looking at the trials reporting the results of both investigator-assessed and independently-assessed ORR. A discrepancy index was obtained by calculating the ratio of each investigator-assessed ORR on the corresponding independently assessed ORR, so that a discrepancy index >1 indicates that the investigator was "more optimistic," whereas a discrepancy index <1 indicates the opposite. We also analyzed different subgroups (by tumor type, by drug type, by year). Twenty trials met the search criteria; in some cases, >1 comparison was conducted in the trial, so that the total number of comparisons analyzed was 33. The estimated mean discrepancy index was 1.175 (95% confidence interval, 1.083-1.264; n = 33). In conclusion, local investigators significantly overestimate ORR compared to paired blinded reviewers in phase 2 oncology trials. This may represent a risk in drug development, when deciding whether to move to confirmatory, more expensive phase 3 trials. Blinded independent central review should be used in ORR assessment if a more conservative estimate of treatment efficacy is required, as in the case of fast-track drug developments leading to accelerated approvals of cancer therapies.
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Affiliation(s)
- Cinzia Dello Russo
- Department of Healthcare Surveillance and Bioethics, Section of Pharmacology, Università Cattolica del Sacro Cuore-Fondazione Policlinico Universitario A. , Gemelli IRCCS, Rome, Italy
| | - Natalia Cappoli
- Department of Healthcare Surveillance and Bioethics, Section of Pharmacology, Università Cattolica del Sacro Cuore-Fondazione Policlinico Universitario A. , Gemelli IRCCS, Rome, Italy
| | - Daniela Pilunni
- Postgraduate School of Hospital Pharmacy, Sapienza University, Rome, Italy
| | - Pierluigi Navarra
- Department of Healthcare Surveillance and Bioethics, Section of Pharmacology, Università Cattolica del Sacro Cuore-Fondazione Policlinico Universitario A. , Gemelli IRCCS, Rome, Italy
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