1
|
Hayward KS, Dalton EJ, Campbell BCV, Khatri P, Dukelow SP, Johns H, Walter S, Yogendrakumar V, Pandian JD, Sacco S, Bernhardt J, Parsons MW, Saver JL, Churilov L. Adaptive Trials in Stroke: Current Use and Future Directions. Neurology 2024; 103:e209876. [PMID: 39325999 PMCID: PMC11436319 DOI: 10.1212/wnl.0000000000209876] [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: 04/09/2024] [Accepted: 07/22/2024] [Indexed: 09/28/2024] Open
Abstract
Inclusion of adaptive design features in a clinical trial provides preplanned flexibility to dynamically modify a trial during its conduct while preserving validity and integrity. Adaptive trials are needed to accelerate the conduct of more efficient, informative, and ethical clinical research in the field of neurology. Stroke is a natural candidate for adoption of these innovative approaches to trial design. This Research Methods in Neurology article is informed by a scoping review that identified 45 completed or ongoing adaptive clinical trials in stroke that were appraised: 15 trials had published results with or without a published protocol and 30 ongoing trials (14 trials had a published protocol, and 16 trials were registered only). Interventions spanned acute (n = 28), rehabilitation (n = 8), prevention (n = 8), and rehabilitation and prevention (n = 1). A subsample of these trials was selected to illustrate the utility of adaptive design features and discuss why each adaptive feature was incorporated in the design to best achieve the aim; whether each individual feature was used and whether it resulted in expected efficiencies; and any learnings during preparation, conduct, or reporting. We then discuss the operational, ethical, and regulatory considerations that warrant careful consideration during adaptive trial planning and reflect on the workforce readiness to deliver adaptive trials in practice. We conclude that adaptive trials can be designed, funded, conducted, and published for a wide range of research questions and offer future directions to support adoption of adaptive trial designs in stroke and neurologic research more broadly.
Collapse
Affiliation(s)
- Kathryn S Hayward
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Emily J Dalton
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Bruce C V Campbell
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Pooja Khatri
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Sean P Dukelow
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Hannah Johns
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Silke Walter
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Vignan Yogendrakumar
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Jeyaraj D Pandian
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Simona Sacco
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Julie Bernhardt
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Mark W Parsons
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Jeffrey L Saver
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Leonid Churilov
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
2
|
van Steenwijk MPJ, van Rosmalen J, Kraemer CVE, Donker DW, Hermens JAJM, Kraaijeveld AO, Maas JJ, Akin S, Montenij LJ, Vlaar APJ, van den Bergh WM, Lansink-Hartgring AO, de Metz J, Voesten N, Boersma E, Scholten E, Beishuizen A, Lexis CPH, Peperstraete H, Schiettekatte S, Lorusso R, Gommers DAMPJ, Tibboel D, de Boer RA, Van Mieghem NMDA, Meuwese CL. A Randomized Embedded Multifactorial Adaptive Platform for Extra Corporeal Membrane Oxygenation (REMAP ECMO) - Design and Rationale of the Left Ventricular Unloading trial domain. Am Heart J 2024:S0002-8703(24)00272-2. [PMID: 39447716 DOI: 10.1016/j.ahj.2024.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 10/10/2024] [Accepted: 10/11/2024] [Indexed: 10/26/2024]
Abstract
BACKGROUND The use of Extracorporeal Membrane Oxygenation (ECMO) remains associated with high rates of complications, weaning failure and mortality which can be partly explained by a knowledge gap on how to properly manage patients on ECMO support. To address relevant patient management issues, we designed a "Randomized Embedded Multifactorial Adaptive Platform (REMAP)" in the setting of ECMO (REMAP ECMO) and a first embedded randomized controlled trial (RCT) investigating the effects of routine early left ventricular (LV) unloading through intra-aortic balloon pumping (IABP). METHODS REMAP ECMO describes a registry-based platform allowing for the embedding of multiple response adaptive RCTs (trial domains) which can perpetually address the effect of relevant patient management issues on ECMO weaning success. A first trial domain studies the effects of LV unloading by means of an IABP as an adjunct to veno-arterial (V-A) ECMO versus V-A ECMO alone on ECMO weaning success at 30 days in adult cardiogenic shock patients admitted to the Intensive Care Unit (ICU). The primary outcome of this trial is "successful weaning from ECMO" being defined as a composite of survival without the need for mechanical circulatory support, heart transplantation, or left ventricular assist device (LVAD) at 30 days after initiation of ECMO. Secondary outcomes include the need for interventional escalation of LV unloading strategy, mechanistic endpoints, survival characteristics until one year after ECMO initiation, and quality of life. Trial data will be analysed using a Bayesian statistical framework. The adaptive design allows for a high degree of flexibility, such as response adaptive randomization and early stopping of the trial for efficacy or futility. The REMAP ECMO LV unloading study is approved by the Medical Ethical Committee of the Erasmus Medical Center and is publicly registered. CONCLUSION This REMAP ECMO trial platform enables the efficient roll-out of multiple RCTs on relevant patient management issues. A first embedded trial domain will compare routine LV unloading by means of an IABP as an adjunct to V-A ECMO versus V-A ECMO alone. TRIAL REGISTRATION ClinicalTrials.gov, NCT05913622.
Collapse
Affiliation(s)
- Myrthe P J van Steenwijk
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus, MC, the Netherlands
| | - Joost van Rosmalen
- Departments of Biostatistics and Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Carlos V Elzo Kraemer
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Dirk W Donker
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands; Cardiovascular and Respiratory Physiology, University of Twente, Enschede, The Netherlands
| | - Jeannine A J M Hermens
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Adriaan O Kraaijeveld
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jacinta J Maas
- Department of Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Sakir Akin
- Department of Intensive Care, Haga Hospital, The Hague, The Netherlands
| | - Leon J Montenij
- Department of Intensive Care, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Jesse de Metz
- Department of Intensive Care, OLVG Amsterdam, Amsterdam, The Netherlands
| | - Niek Voesten
- Department of Intensive Care, Amphia Hospital Breda, Breda, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus, MC, the Netherlands
| | - Erik Scholten
- Department of Intensive Care, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Albertus Beishuizen
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Chris P H Lexis
- Department of Intensive Care and Cardiology, Maastricht UMC, Maastricht, The Netherlands
| | | | | | - Roberto Lorusso
- Department of Cardiothoracic Surgery and Cardiovascular Research Center, Maastricht UMC, Maastricht, The Netherlands
| | | | - Dick Tibboel
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus, MC, the Netherlands
| | | | - Christiaan L Meuwese
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus, MC, the Netherlands.
| |
Collapse
|
3
|
Ben-Eltriki M, Rafiq A, Paul A, Prabhu D, Afolabi MOS, Baslhaw R, Neilson CJ, Driedger M, Mahmud SM, Lacaze-Masmonteil T, Marlin S, Offringa M, Butcher N, Heath A, Kelly LE. Adaptive designs in clinical trials: a systematic review-part I. BMC Med Res Methodol 2024; 24:229. [PMID: 39367313 PMCID: PMC11451232 DOI: 10.1186/s12874-024-02272-9] [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: 01/02/2024] [Accepted: 06/28/2024] [Indexed: 10/06/2024] Open
Abstract
BACKGROUND Adaptive designs (ADs) are intended to make clinical trials more flexible, offering efficiency and potentially cost-saving benefits. Despite a large number of statistical methods in the literature on different adaptations to trials, the characteristics, advantages and limitations of such designs remain unfamiliar to large parts of the clinical and research community. This systematic review provides an overview of the use of ADs in published clinical trials (Part I). A follow-up (Part II) will compare the application of AD in trials in adult and pediatric studies, to provide real-world examples and recommendations for the child health community. METHODS Published studies from 2010 to April 2020 were searched in the following databases: MEDLINE (Ovid), Embase (Ovid), and International Pharmaceutical Abstracts (Ovid). Clinical trial protocols, reports, and a secondary analyses using AD were included. We excluded trial registrations and interventions other than drugs or vaccines to align with regulatory guidance. Data from the published literature on study characteristics, types of adaptations, statistical analysis, stopping boundaries, logistical challenges, operational considerations and ethical considerations were extracted and summarized herein. RESULTS Out of 23,886 retrieved studies, 317 publications of adaptive trials, 267 (84.2%) trial reports, and 50 (15.8%) study protocols), were included. The most frequent disease was oncology (168/317, 53%). Most trials included only adult participants (265, 83.9%),16 trials (5.4%) were limited to only children and 28 (8.9%) were for both children and adults, 8 trials did not report the ages of the included populations. Some studies reported using more than one adaptation (there were 390 reported adaptations in 317 clinical trial reports). Most trials were early in drug development (phase I, II (276/317, 87%). Dose-finding designs were used in the highest proportion of the included trials (121/317, 38.2 %). Adaptive randomization (53/317, 16.7%), with drop-the-losers (or pick-the-winner) designs specifically reported in 29 trials (9.1%) and seamless phase 2-3 design was reported in 27 trials (8.5%). Continual reassessment methods (60/317, 18.9%) and group sequential design (47/317, 14.8%) were also reported. Approximately two-thirds of trials used frequentist statistical methods (203/309, 64%), while Bayesian methods were reported in 24% (75/309) of included trials. CONCLUSION This review provides a comprehensive report of methodological features in adaptive clinical trials reported between 2010 and 2020. Adaptation details were not uniformly reported, creating limitations in interpretation and generalizability. Nevertheless, implementation of existing reporting guidelines on ADs and the development of novel educational strategies that address the scientific, operational challenges and ethical considerations can help in the clinical trial community to decide on when and how to implement ADs in clinical trials. STUDY PROTOCOL REGISTRATION: https://doi.org/10.1186/s13063-018-2934-7 .
Collapse
Affiliation(s)
- Mohamed Ben-Eltriki
- Department of Pharmacology and Therapeutics, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.
- George and for Fay Yee Centre Healthcare Innovation, Winnipeg, MB, Canada.
- Cochrane Hypertension Review Group, Therapeutic Initiative, University of British Columbia, Vancouver, BC, Canada.
| | - Aisha Rafiq
- Department of Pharmacology and Therapeutics, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Arun Paul
- Department of Pharmacology and Therapeutics, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Devashree Prabhu
- George and for Fay Yee Centre Healthcare Innovation, Winnipeg, MB, Canada
| | - Michael O S Afolabi
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Robert Baslhaw
- George and for Fay Yee Centre Healthcare Innovation, Winnipeg, MB, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Christine J Neilson
- Neil John Maclean Health Sciences Library, University of Manitoba, Winnipeg, MB, Canada
| | - Michelle Driedger
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Salaheddin M Mahmud
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | | | - Susan Marlin
- Clinical Trials Ontario, Toronto, Ontario, Canada
| | - Martin Offringa
- Department of Paediatrics, Management & Evaluation, Institute of Health Policy, University of Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nancy Butcher
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Anna Heath
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, Child Health Evaluative Sciences, University of Toronto, ScientistToronto, Ontario, Canada
- Department of Statistical Science, University College London, London, UK
| | - Lauren E Kelly
- Department of Pharmacology and Therapeutics, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.
- George and for Fay Yee Centre Healthcare Innovation, Winnipeg, MB, Canada.
- Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada.
- Departments of Pharmacology and Therapeutics, Community Health Sciences, University of Manitoba, 417-753 McDermot Ave, Winnipeg, Manitoba, R3E0T6, Canada.
| |
Collapse
|
4
|
Vignarajah M, Rochwerg B. Adaptive platform trials in critical care. JOURNAL OF INTENSIVE MEDICINE 2024; 4:478-479. [PMID: 39310060 PMCID: PMC11411421 DOI: 10.1016/j.jointm.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 09/25/2024]
Affiliation(s)
- Muralie Vignarajah
- Department of Surgery, Queen's University, K7L 3N6, Kingston, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, L8S 4L8, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, L8S 4L8, Hamilton, ON, Canada
| |
Collapse
|
5
|
Trikalinos TA. Broader Options for Experimental Clinical Research in Melanoma - Time for Adaptive Platform Trials? NEJM EVIDENCE 2024; 3:EVIDe2400284. [PMID: 39315868 DOI: 10.1056/evide2400284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/25/2024]
Affiliation(s)
- Thomas A Trikalinos
- Departments of Health Services, Policy, and Practice and Biostatistics, Brown University School of Public Health, Providence, RI
| |
Collapse
|
6
|
Zhang Q, Dimairo M, Julious SA, Lewis J, Yu Z. Reporting and communication of sample size calculations in adaptive clinical trials: a review of trial protocols and grant applications. BMC Med Res Methodol 2024; 24:216. [PMID: 39333920 PMCID: PMC11430544 DOI: 10.1186/s12874-024-02339-7] [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: 02/19/2024] [Accepted: 09/13/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND An adaptive design allows modifying the design based on accumulated data while maintaining trial validity and integrity. The final sample size may be unknown when designing an adaptive trial. It is therefore important to consider what sample size is used in the planning of the study and how that is communicated to add transparency to the understanding of the trial design and facilitate robust planning. In this paper, we reviewed trial protocols and grant applications on the sample size reporting for randomised adaptive trials. METHOD We searched protocols of randomised trials with comparative objectives on ClinicalTrials.gov (01/01/2010 to 31/12/2022). Contemporary eligible grant applications accessed from UK publicly funded researchers were also included. Suitable records of adaptive designs were reviewed, and key information was extracted and descriptively analysed. RESULTS We identified 439 records, and 265 trials were eligible. Of these, 164 (61.9%) and 101 (38.1%) were sponsored by industry and public sectors, respectively, with 169 (63.8%) of all trials using a group sequential design although trial adaptations used were diverse. The maximum and minimum sample sizes were the most reported or directly inferred (n = 199, 75.1%). The sample size assuming no adaptation would be triggered was usually set as the estimated target sample size in the protocol. However, of the 152 completed trials, 15 (9.9%) and 33 (21.7%) had their sample size increased or reduced triggered by trial adaptations, respectively. The sample size calculation process was generally well reported in most cases (n = 216, 81.5%); however, the justification for the sample size calculation parameters was missing in 116 (43.8%) trials. Less than half gave sufficient information on the study design operating characteristics (n = 119, 44.9%). CONCLUSION Although the reporting of sample sizes varied, the maximum and minimum sample sizes were usually reported. Most of the trials were planned for estimated enrolment assuming no adaptation would be triggered. This is despite the fact a third of reported trials changed their sample size. The sample size calculation was generally well reported, but the justification of sample size calculation parameters and the reporting of the statistical behaviour of the adaptive design could still be improved.
Collapse
Affiliation(s)
- Qiang Zhang
- Sheffield Centre for Health and Related Research (SCHARR), School of Medicine and Population Health, University of Sheffield, Sheffield, S1 4DA, UK.
| | - Munyaradzi Dimairo
- Sheffield Centre for Health and Related Research (SCHARR), School of Medicine and Population Health, University of Sheffield, Sheffield, S1 4DA, UK
| | - Steven A Julious
- Sheffield Centre for Health and Related Research (SCHARR), School of Medicine and Population Health, University of Sheffield, Sheffield, S1 4DA, UK
| | - Jen Lewis
- Sheffield Centre for Health and Related Research (SCHARR), School of Medicine and Population Health, University of Sheffield, Sheffield, S1 4DA, UK
| | - Zihang Yu
- Sheffield Centre for Health and Related Research (SCHARR), School of Medicine and Population Health, University of Sheffield, Sheffield, S1 4DA, UK
- Department of Biostatistics, University of Washington, Seattle, WA, 98195, USA
| |
Collapse
|
7
|
Behal ML, Flannery AH, Miano TA. The times are changing: A primer on novel clinical trial designs and endpoints in critical care research. Am J Health Syst Pharm 2024; 81:890-902. [PMID: 38742701 PMCID: PMC11383190 DOI: 10.1093/ajhp/zxae134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Indexed: 05/16/2024] Open
Affiliation(s)
- Michael L Behal
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN, USA
| | - Alexander H Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Todd A Miano
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, and Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
8
|
Jones TW, Hendrick T, Chase AM. Heterogeneity, Bayesian thinking, and phenotyping in critical care: A primer. Am J Health Syst Pharm 2024; 81:812-832. [PMID: 38742459 DOI: 10.1093/ajhp/zxae139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Indexed: 05/16/2024] Open
Abstract
PURPOSE To familiarize clinicians with the emerging concepts in critical care research of Bayesian thinking and personalized medicine through phenotyping and explain their clinical relevance by highlighting how they address the issues of frequent negative trials and heterogeneity of treatment effect. SUMMARY The past decades have seen many negative (effect-neutral) critical care trials of promising interventions, culminating in calls to improve the field's research through adopting Bayesian thinking and increasing personalization of critical care medicine through phenotyping. Bayesian analyses add interpretive power for clinicians as they summarize treatment effects based on probabilities of benefit or harm, contrasting with conventional frequentist statistics that either affirm or reject a null hypothesis. Critical care trials are beginning to include prospective Bayesian analyses, and many trials have undergone reanalysis with Bayesian methods. Phenotyping seeks to identify treatable traits to target interventions to patients expected to derive benefit. Phenotyping and subphenotyping have gained prominence in the most syndromic and heterogenous critical care disease states, acute respiratory distress syndrome and sepsis. Grouping of patients has been informative across a spectrum of clinically observable physiological parameters, biomarkers, and genomic data. Bayesian thinking and phenotyping are emerging as elements of adaptive clinical trials and predictive enrichment, paving the way for a new era of high-quality evidence. These concepts share a common goal, sifting through the noise of heterogeneity in critical care to increase the value of existing and future research. CONCLUSION The future of critical care medicine will inevitably involve modification of statistical methods through Bayesian analyses and targeted therapeutics via phenotyping. Clinicians must be familiar with these systems that support recommendations to improve decision-making in the gray areas of critical care practice.
Collapse
Affiliation(s)
- Timothy W Jones
- Department of Pharmacy, Piedmont Eastside Medical Center, Snellville, GA
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| | - Tanner Hendrick
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Aaron M Chase
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| |
Collapse
|
9
|
Blackwell SE. Using the 'Leapfrog' Design as a Simple Form of Adaptive Platform Trial to Develop, Test, and Implement Treatment Personalization Methods in Routine Practice. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2024; 51:686-701. [PMID: 38316652 PMCID: PMC11379800 DOI: 10.1007/s10488-023-01340-4] [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] [Accepted: 12/21/2023] [Indexed: 02/07/2024]
Abstract
The route for the development, evaluation and dissemination of personalized psychological therapies is complex and challenging. In particular, the large sample sizes needed to provide adequately powered trials of newly-developed personalization approaches means that the traditional treatment development route is extremely inefficient. This paper outlines the promise of adaptive platform trials (APT) embedded within routine practice as a method to streamline development and testing of personalized psychological therapies, and close the gap to implementation in real-world settings. It focuses in particular on a recently-developed simplified APT design, the 'leapfrog' trial, illustrating via simulation how such a trial may proceed and the advantages it can bring, for example in terms of reduced sample sizes. Finally it discusses models of how such trials could be implemented in routine practice, including potential challenges and caveats, alongside a longer-term perspective on the development of personalized psychological treatments.
Collapse
Affiliation(s)
- Simon E Blackwell
- Department of Clinical Psychology and Experimental Psychopathology, Georg-Elias-Mueller-Institute of Psychology, University of Göttingen, Kurze-Geismar-Str.1, 37073, Göttingen, Germany.
| |
Collapse
|
10
|
Geng LN, Bonilla H, Hedlin H, Jacobson KB, Tian L, Jagannathan P, Yang PC, Subramanian AK, Liang JW, Shen S, Deng Y, Shaw BJ, Botzheim B, Desai M, Pathak D, Jazayeri Y, Thai D, O’Donnell A, Mohaptra S, Leang Z, Reynolds GZM, Brooks EF, Bhatt AS, Shafer RW, Miglis MG, Quach T, Tiwari A, Banerjee A, Lopez RN, De Jesus M, Charnas LR, Utz PJ, Singh U. Nirmatrelvir-Ritonavir and Symptoms in Adults With Postacute Sequelae of SARS-CoV-2 Infection: The STOP-PASC Randomized Clinical Trial. JAMA Intern Med 2024; 184:1024-1034. [PMID: 38848477 PMCID: PMC11161857 DOI: 10.1001/jamainternmed.2024.2007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/30/2024] [Indexed: 06/09/2024]
Abstract
Importance There is an urgent need to identify treatments for postacute sequelae of SARS-CoV-2 infection (PASC). Objective To assess the efficacy of a 15-day course of nirmatrelvir-ritonavir in reducing the severity of select PASC symptoms. Design, Setting, and Participants This was a 15-week blinded, placebo-controlled, randomized clinical trial conducted from November 2022 to September 2023 at Stanford University (California). The participants were adults with moderate to severe PASC symptoms of 3 months or longer duration. Interventions Participants were randomized 2:1 to treatment with oral nirmatrelvir-ritonavir (NMV/r, 300 mg and 100 mg) or with placebo-ritonavir (PBO/r) twice daily for 15 days. Main Outcomes and Measures Primary outcome was a pooled severity of 6 PASC symptoms (fatigue, brain fog, shortness of breath, body aches, gastrointestinal symptoms, and cardiovascular symptoms) based on a Likert scale score at 10 weeks. Secondary outcomes included symptom severity at different time points, symptom burden and relief, patient global measures, Patient-Reported Outcomes Measurement Information System (PROMIS) measures, orthostatic vital signs, and sit-to-stand test change from baseline. Results Of the 155 participants (median [IQR] age, 43 [34-54] years; 92 [59%] females), 102 were randomized to the NMV/r group and 53 to the PBO/r group. Nearly all participants (n = 153) had received the primary series for COVID-19 vaccination. Mean (SD) time between index SARS-CoV-2 infection and randomization was 17.5 (9.1) months. There was no statistically significant difference in the model-derived severity outcome pooled across the 6 core symptoms at 10 weeks between the NMV/r and PBO/r groups. No statistically significant between-group differences were found at 10 weeks in the Patient Global Impression of Severity or Patient Global Impression of Change scores, summative symptom scores, and change from baseline to 10 weeks in PROMIS fatigue, dyspnea, cognitive function, and physical function measures. Adverse event rates were similar in NMV/r and PBO/r groups and mostly of low grade. Conclusions and Relevance The results of this randomized clinical trial showed that a 15-day course of NMV/r in a population of patients with PASC was generally safe but did not demonstrate a significant benefit for improving select PASC symptoms in a mostly vaccinated cohort with protracted symptom duration. Further studies are needed to determine the role of antivirals in the treatment of PASC. Trial Registration ClinicalTrials.gov Identifier: NCT05576662.
Collapse
Affiliation(s)
- Linda N. Geng
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Hector Bonilla
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Haley Hedlin
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Karen B. Jacobson
- Department of Medicine, Stanford University School of Medicine, Stanford, California
- Kaiser Permanente Northern California Division of Research, Oakland
| | - Lu Tian
- Department of Biomedical Data Science, Stanford School of Medicine, Stanford, California
| | - Prasanna Jagannathan
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Phillip C. Yang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Aruna K. Subramanian
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Jane W. Liang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Sa Shen
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Yaowei Deng
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Blake J. Shaw
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Bren Botzheim
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Manisha Desai
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Divya Pathak
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Yasmin Jazayeri
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Daniel Thai
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Andrew O’Donnell
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Sukanya Mohaptra
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Zenita Leang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Erin F. Brooks
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ami S. Bhatt
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Robert W. Shafer
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Mitchell G. Miglis
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California
| | - Tom Quach
- Stanford University, Stanford, California
| | | | - Anindita Banerjee
- Pfizer Research and Development, Pfizer Inc, Cambridge, Massachusetts
| | - Rene N. Lopez
- Clinical Research Collaborations COE, Worldwide Medical and Safety, Pfizer Inc, Groton, Connecticut
| | - Magdia De Jesus
- Strategic Planning, Worldwide Medical and Safety, Pfizer Inc, New York, New York
| | - Lawrence R. Charnas
- Clinical Research Collaborations COE, Worldwide Medical and Safety, Pfizer Inc, Groton, Connecticut
| | - Paul J. Utz
- Department of Medicine, Stanford University School of Medicine, Stanford, California
- Institute for Immunity, Transplantation and Infection, Stanford University, Stanford, California
| | - Upinder Singh
- Department of Medicine, Stanford University School of Medicine, Stanford, California
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
11
|
Marschner IC, Schou IM. Analysis of Nonconcurrent Controls in Adaptive Platform Trials: Separating Randomized and Nonrandomized Information. Biom J 2024; 66:e202300334. [PMID: 39104093 DOI: 10.1002/bimj.202300334] [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: 11/28/2023] [Revised: 06/09/2024] [Accepted: 07/01/2024] [Indexed: 08/07/2024]
Abstract
Adaptive platform trials allow treatments to be added or dropped during the study, meaning that the control arm may be active for longer than the experimental arms. This leads to nonconcurrent controls, which provide nonrandomized information that may increase efficiency but may introduce bias from temporal confounding and other factors. Various methods have been proposed to control confounding from nonconcurrent controls, based on adjusting for time period. We demonstrate that time adjustment is insufficient to prevent bias in some circumstances where nonconcurrent controls are present in adaptive platform trials, and we propose a more general analytical framework that accounts for nonconcurrent controls in such circumstances. We begin by defining nonconcurrent controls using the concept of a concurrently randomized cohort, which is a subgroup of participants all subject to the same randomized design. We then use cohort adjustment rather than time adjustment. Due to flexibilities in platform trials, more than one randomized design may be in force at any time, meaning that cohort-adjusted and time-adjusted analyses may be quite different. Using simulation studies, we demonstrate that time-adjusted analyses may be biased while cohort-adjusted analyses remove this bias. We also demonstrate that the cohort-adjusted analysis may be interpreted as a synthesis of randomized and indirect comparisons analogous to mixed treatment comparisons in network meta-analysis. This allows the use of network meta-analysis methodology to separate the randomized and nonrandomized components and to assess their consistency. Whenever nonconcurrent controls are used in platform trials, the separate randomized and indirect contributions to the treatment effect should be presented.
Collapse
Affiliation(s)
- Ian C Marschner
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - I Manjula Schou
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
12
|
Portefaix A, Dhelens C, Recher M, Cour-Andlauer F, Naudin J, Mortamet G, Joram N, Tissières P, Ginhoux T, Kassai B, Boutitie F, Maucort-Boulch D, Javouhey E. High-dose intravenous immunoglobulin versus albumin 4% in paediatric toxic shock syndrome: a randomised controlled feasibility study. Arch Dis Child 2024; 109:717-723. [PMID: 38360044 PMCID: PMC11347220 DOI: 10.1136/archdischild-2022-325274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/26/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE Toxic shock syndrome (TSS) is a rare disease responsible for significant morbidity and mortality. Intravenous immunoglobulin (IG) therapy in paediatric TSS could improve shock and organ failure, but more consistent efficacy and safety data are needed. Our objective was to determine whether a randomised clinical trial (RCT) assessing intravenous IG in TSS in children is feasible. METHODS We performed a multicentre, feasibility, double-blind RCT assessing efficacy of high-dose intravenous IG versus albumin 4% (control group) within the first 12 hours of shock onset. Included patients were aged above 1 month and below 18 years with suspected TSS and septic shock. Feasibility was assessed by measuring inclusion rate, protocol compliance and missing data regarding death and the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) Score. Other secondary clinical outcomes were evaluated during hospital stay, at 60 day and 1 year. RESULTS 28 patients, admitted in 6 paediatric intensive care units during 36 consecutive months and followed for 1 year, received the allocated treatment: 13 in intravenous IG group, 15 in control group. The median age was 10.6 years and the sex ratio was 1. Inclusion rate was above 50%, protocol deviations were below 30% and missing data regarding death and PELOD-2 Score below 10%. No difference concerning secondary clinical outcomes between groups was observed, and more adverse events were reported in the control group. CONCLUSION It seems to be feasible to conduct an RCT assessing intravenous IG efficacy and safety in paediatric TSS but must be realised internationally, with choice of a clinically relevant endpoint and a specific design in order to be realistic. TRIAL REGISTRATION NUMBER NCT02219165.
Collapse
Affiliation(s)
- Aurélie Portefaix
- Clinical Investigation Center, Hospices Civils de Lyon, Lyon Bron, France
- EMET LBBE, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Carole Dhelens
- Pharmacie FRIPHARM, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Morgan Recher
- Services de Réanimation Pédiatrique, CHU Lille, F59000-Lille, France
- METRICS, Universite Lille Nord de France, Villeneuve-d'Ascq, Hauts-de-France, France
| | - Fleur Cour-Andlauer
- Réanimation Pédiatrique, Centre Hospitalier Universitaire de Lyon, Bron, France
| | - Jérôme Naudin
- Service de Réanimation Pédiatrique, Hôpital Universitaire Robert-Debré, Paris, Île-de-France, France
| | | | - Nicolas Joram
- Réanimation Pédiatrique, CHU Nantes, Nantes, Pays de la Loire, France
| | - Pierre Tissières
- Paediatric Intensive Care Unit, Hospital Bicetre, Le Kremlin-Bicetre, Île-de-France, France
- Institute for Integrative Cell Biology, Gif-sur-Yvette, Île-de-France, France
| | - Tiphanie Ginhoux
- Clinical Investigation Center, Hospices Civils de Lyon, Lyon Bron, France
| | - Behrouz Kassai
- Clinical Investigation Center, Hospices Civils de Lyon, Lyon Bron, France
- Université Lyon 1, CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France
| | - Florent Boutitie
- Biostatistics, Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | | | - Etienne Javouhey
- Hospices Civils de Lyon, Lyon, Auvergne-Rhône-Alpes, France
- EA 7426 Joint Research Unit HCL-bioMérieux, Université Claude Bernard Lyon 1, Villeurbanne, Auvergne-Rhône-Alpes, France
| |
Collapse
|
13
|
Kawano-Dourado L, Molina-Molina M, Sellares J, Enghelmayer JI. The Relevance of REMAP-ILD for Ibero-American Countries: A Randomized Embedded Multifactorial Adaptive Platform (REMAP) Trial in the Field of Interstitial Lung Diseases (ILDs). Arch Bronconeumol 2024; 60:463-465. [PMID: 38816284 DOI: 10.1016/j.arbres.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 06/01/2024]
Affiliation(s)
- Leticia Kawano-Dourado
- Hcor Research Institute, Hcor Hospital, Sao Paulo, Brazil; Pulmonary Division, Heart Institute (InCor), University of Sao Paulo, Sao Paulo, Brazil; MAGIC Evidence Ecosystem Foundation, Oslo, Norway.
| | - Maria Molina-Molina
- ILD Unit, Respiratory Department, University Hospital of Bellvitge, IDIBELL, Hospitalet de Llobregat, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBER), Spain
| | - Jacobo Sellares
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBER), Spain; Servei de Pneumologia, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Facultat de Medicina, Universitat de Vic (UVIC), Vic, Spain
| | - Juan I Enghelmayer
- Hospital de Clínicas, Universidad de Buenos Aires, Argentina; Fundación FUNEF, Buenos Aires, Argentina
| |
Collapse
|
14
|
Dhaenens BAE, Heimann G, Bakker A, Nievo M, Ferner RE, Evans DG, Wolkenstein P, Leubner J, Potratz C, Carton C, Iloeje U, Kirk G, Blakeley JO, Plotkin S, Fisher MJ, Kim A, Driever PH, Azizi AA, Widemann BC, Gross A, Parke T, Legius E, Oostenbrink R. Platform trial design for neurofibromatosis type 1, NF2-related schwannomatosis and non-NF2-related schwannomatosis: A potential model for rare diseases. Neurooncol Pract 2024; 11:395-403. [PMID: 39006526 PMCID: PMC11241353 DOI: 10.1093/nop/npae001] [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] [Indexed: 07/16/2024] Open
Abstract
Background Neurofibromatosis type 1, NF2-related schwannomatosis and non-NF2-related schwannomatosis (grouped under the abbreviation "NF") are rare hereditary tumor predisposition syndromes. Due to the low prevalence, variability in the range, and severity of manifestations, as well as limited treatment options, these conditions require innovative trial designs to accelerate the development of new treatments. Methods Within European Patient-Centric Clinical Trial Platforms (EU-PEARL), we designed 2 platform-basket trials in NF. The trials were designed by a team of multidisciplinary NF experts and trial methodology experts. Results The trial will consist of an observational and a treatment period. The observational period will serve as a longitudinal natural history study. The platform trial design and randomization to a sequence of available interventions allow for the addition of interventions during the trial. If a drug does not meet the predetermined efficacy endpoint or reveals unacceptable toxicities, participants may stop treatment on that arm and re-enter the observational period, where they can be re-randomized to a different treatment arm if eligible. Intervention-specific eligibility criteria and endpoints are listed in intervention-specific-appendices, allowing the flexibility and adaptability needed for highly variable and rare conditions like NF. Conclusions These innovative platform-basket trials for NF may serve as a model for other rare diseases, as they will enhance the chance of identifying beneficial treatments through optimal learning from a small number of patients. The goal of these trials is to identify beneficial treatments for NF more rapidly and at a lower cost than traditional, single-agent clinical trials.
Collapse
Affiliation(s)
- Britt A E Dhaenens
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- ENCORE Expertise Centre for Neurodevelopmental Disorders, Erasmus MC, Rotterdam, The Netherlands
| | - Günter Heimann
- Biostatistics & Pharmacometrics, Novartis Pharma AG, Basel, Switzerland
| | | | - Marco Nievo
- Children's Tumor Foundation, New York, New York, USA
| | - Rosalie E Ferner
- Neurofibromatosis Service, Department of Neurology, Guy's and St. Thomas' NHS Foundation Trust London, Great Maze Pond, London, UK
| | - D Gareth Evans
- Centre for Genomic Medicine, Division of Evolution, Infection and Genomic Sciences, University of Manchester, St Mary's Hospital, Manchester, UK
| | | | - Jonas Leubner
- Department of Pediatric Neurology, Charité Universitätsmedizin Berlin-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Cornelia Potratz
- Department of Pediatric Neurology, Charité Universitätsmedizin Berlin-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | | | - Uchenna Iloeje
- Medical Affairs, SpringWorks Therapeutics, Stamford, Connecticut, USA
| | | | - Jaishri O Blakeley
- Department of Neurology, Neuro-Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Scott Plotkin
- Cancer Center and Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael J Fisher
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - AeRang Kim
- Division of Oncology, Children's National Hospital, Washington DC, District of Columbia, USA
| | - Pablo Hernáiz Driever
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Amedeo A Azizi
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Wien, Austria
| | - Brigitte C Widemann
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - Andrea Gross
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | | | - Eric Legius
- Department of Human Genetics, KU Leuven, Leuven, Belgium
- Department of Clinical Genetics, UZ Leuven, Leuven, Belgium
- Full Member of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS), Nijmegen, The Netherlands (E.L., R.O.)
| | - Rianne Oostenbrink
- Department of General Paediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- ENCORE Expertise Centre for Neurodevelopmental Disorders, Erasmus MC, Rotterdam, The Netherlands
- Full Member of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS), Nijmegen, The Netherlands
| |
Collapse
|
15
|
Montgomery TL, Peipert D, Krementsov DN. Modulation of multiple sclerosis risk and pathogenesis by the gut microbiota: Complex interactions between host genetics, bacterial metabolism, and diet. Immunol Rev 2024; 325:131-151. [PMID: 38717158 PMCID: PMC11338732 DOI: 10.1111/imr.13343] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2024]
Abstract
Multiple sclerosis (MS) is an autoimmune disease of the central nervous system, affecting nearly 2 million people worldwide. The etiology of MS is multifactorial: Approximately 30% of the MS risk is genetic, which implies that the remaining ~70% is environmental, with a number of factors proposed. One recently implicated risk factor for MS is the composition of the gut microbiome. Numerous case-control studies have identified changes in gut microbiota composition of people with MS (pwMS) compared with healthy control individuals, and more recent studies in animal models have begun to identify the causative microbes and underlying mechanisms. Here, we review some of these mechanisms, with a specific focus on the role of host genetic variation, dietary inputs, and gut microbial metabolism, with a particular emphasis on short-chain fatty acid and tryptophan metabolism. We put forward a model where, in an individual genetically susceptible to MS, the gut microbiota and diet can synergize as potent environmental modifiers of disease risk and possibly progression, with diet-dependent gut microbial metabolites serving as a key mechanism. We also propose that specific microbial taxa may have divergent effects in individuals carrying distinct variants of MS risk alleles or other polymorphisms, as a consequence of host gene-by-gut microbiota interactions. Finally, we also propose that the effects of specific microbial taxa, especially those that exert their effects through metabolites, are highly dependent on the host dietary intake. What emerges is a complex multifaceted interaction that has been challenging to disentangle in human studies, contributing to the divergence of findings across heterogeneous cohorts with differing geography, dietary preferences, and genetics. Nonetheless, this provides a complex and individualized, yet tractable, model of how the gut microbiota regulate susceptibility to MS, and potentially progression of this disease. Thus, we conclude that prophylactic or therapeutic modulation of the gut microbiome to prevent or treat MS will require a careful and personalized consideration of host genetics, baseline gut microbiota composition, and dietary inputs.
Collapse
Affiliation(s)
- Theresa L. Montgomery
- Department of Biomedical and Health Sciences, University of Vermont, Burlington, VT 05405, USA
| | - Dan Peipert
- Department of Biomedical and Health Sciences, University of Vermont, Burlington, VT 05405, USA
| | - Dimitry N. Krementsov
- Department of Biomedical and Health Sciences, University of Vermont, Burlington, VT 05405, USA
| |
Collapse
|
16
|
Bethe U, Pana ZD, Drosten C, Goossens H, König F, Marchant A, Molenberghs G, Posch M, Van Damme P, Cornely OA. Innovative approaches for vaccine trials as a key component of pandemic preparedness - a white paper. Infection 2024:10.1007/s15010-024-02347-1. [PMID: 39017997 DOI: 10.1007/s15010-024-02347-1] [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: 05/21/2024] [Accepted: 07/04/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND WHO postulates the application of adaptive design features in the global clinical trial ecosystem. However, the adaptive platform trial (APT) methodology has not been widely adopted in clinical research on vaccines. METHODS The VACCELERATE Consortium organized a two-day workshop to discuss the applicability of APT methodology in vaccine trials under non-pandemic as well as pandemic conditions. Core aspects of the discussions are summarized in this article. RESULTS An "ever-warm" APT appears ideally suited to improve efficiency and speed of vaccine research. Continuous learning based on accumulating APT trial data allows for pre-planned adaptations during its course. Given the relative design complexity, alignment of all stakeholders at all stages of an APT is central. Vaccine trial modelling is crucial, both before and in a pandemic emergency. Various inferential paradigms are possible (frequentist, likelihood, or Bayesian). The focus in the interpandemic interval may be on research gaps left by industry trials. For activation in emergency, template Disease X protocols of syndromal design for pathogens yet unknown need to be stockpiled and updated regularly. Governance of a vaccine APT should be fully integrated into supranational pandemic response mechanisms. DISCUSSION A broad range of adaptive features can be applied in platform trials on vaccines. Faster knowledge generation comes with increased complexity of trial design. Design complexity should not preclude simple execution at trial sites. Continuously generated evidence represents a return on investment that will garner societal support for sustainable funding. Adaptive design features will naturally find their way into platform trials on vaccines.
Collapse
Affiliation(s)
- Ullrich Bethe
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Faculty of Medicine and University Hospital Cologne, University of Cologne, Herderstrasse 52, 50931, Cologne, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Department I of Internal Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
- Partner Site Bonn-Cologne, German Centre for Infection Research (DZIF), Cologne, Germany
| | - Zoi D Pana
- Medical School, European University of Cyprus, Nicosia, Cyprus
| | - Christian Drosten
- Institute of Virology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute and Biobank Antwerp, University of Antwerp, Wilrijk, Belgium
| | - Franz König
- Center for Medical Data Science, Institute of Medical Statistics, Medical University of Vienna, Vienna, Austria
| | - Arnaud Marchant
- European Plotkin Institute for Vaccinology, Université libre de Bruxelles, Brussels, Belgium
| | - Geert Molenberghs
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Data Science Institute, KU Leuven and Hasselt University, Wilrijk, Belgium
| | - Martin Posch
- Center for Medical Data Science, Institute of Medical Statistics, Medical University of Vienna, Vienna, Austria
| | - Pierre Van Damme
- Centre for the Evaluation of Vaccination, VACCINOPOLIS, Vaccine and Infectious Disease Institute, University of Antwerp, Wilrijk, Belgium
| | - Oliver A Cornely
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Faculty of Medicine and University Hospital Cologne, University of Cologne, Herderstrasse 52, 50931, Cologne, Germany.
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Department I of Internal Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany.
- Partner Site Bonn-Cologne, German Centre for Infection Research (DZIF), Cologne, Germany.
| |
Collapse
|
17
|
Kawano-Dourado L, Kulkarni T, Ryerson CJ, Rivera-Ortega P, Baldi BG, Chaudhuri N, Funke-Chambour M, Hoffmann-Vold AM, Johannson KA, Khor YH, Montesi SB, Piccari L, Prosch H, Molina-Molina M, Sellares Torres J, Bauer-Ventura I, Rajan S, Jacob J, Richards D, Spencer LG, Wendelberger B, Jensen T, Quintana M, Kreuter M, Gordon AC, Martinez FJ, Kaminski N, Cornelius V, Lewis R, Adams W, Jenkins G. Adaptive multi-interventional trial platform to improve patient care for fibrotic interstitial lung diseases. Thorax 2024; 79:788-795. [PMID: 38448221 PMCID: PMC11287572 DOI: 10.1136/thorax-2023-221148] [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: 11/02/2023] [Accepted: 02/06/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Fibrotic interstitial lung diseases (fILDs) are a heterogeneous group of lung diseases associated with significant morbidity and mortality. Despite a large increase in the number of clinical trials in the last 10 years, current regulatory-approved management approaches are limited to two therapies that prevent the progression of fibrosis. The drug development pipeline is long and there is an urgent need to accelerate this process. This manuscript introduces the concept and design of an innovative research approach to drug development in fILD: a global Randomised Embedded Multifactorial Adaptive Platform in fILD (REMAP-ILD). METHODS Description of the REMAP-ILD concept and design: the specific terminology, design characteristics (multifactorial, adaptive features, statistical approach), target population, interventions, outcomes, mission and values, and organisational structure. RESULTS The target population will be adult patients with fILD, and the primary outcome will be a disease progression model incorporating forced vital capacity and mortality over 12 months. Responsive adaptive randomisation, prespecified thresholds for success and futility will be used to assess the effectiveness and safety of interventions. REMAP-ILD embraces the core values of diversity, equity, and inclusion for patients and researchers, and prioritises an open-science approach to data sharing and dissemination of results. CONCLUSION By using an innovative and efficient adaptive multi-interventional trial platform design, we aim to accelerate and improve care for patients with fILD. Through worldwide collaboration, novel analytical methodology and pragmatic trial delivery, REMAP-ILD aims to overcome major limitations associated with conventional randomised controlled trial approaches to rapidly improve the care of people living with fILD.
Collapse
Affiliation(s)
- Leticia Kawano-Dourado
- Hcor Research Institute, Hcor Hospital, Sao Paulo, Brazil
- Pulmonary Division, Heart Institute (InCor), University of Sao Paulo, Sao Paulo, Brazil
- MAGIC Evidence Ecosystem Foundation, Oslo, Norway
| | - Tejaswini Kulkarni
- The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Christopher J Ryerson
- Department of Medicine and Centre of Heart Lung Innovations, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pilar Rivera-Ortega
- Interstitial Lung Disease Unit, Respiratory Medicine, Manchester University NHS Foundation Trust, Manchester, UK
| | - Bruno Guedes Baldi
- Pulmonary Division, Heart Institute (InCor), University of Sao Paulo, Sao Paulo, Brazil
| | - Nazia Chaudhuri
- Department of Health and Life Sciences, School of Medicine, University of Ulster, Londonderry, UK
| | - Manuela Funke-Chambour
- Department for Pulmonology, Allergology and clinical Immunology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Anna-Maria Hoffmann-Vold
- Department of Rheumatology, Oslo University Hospital, Oslo, Norway
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kerri A Johannson
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yet Hong Khor
- Respiratory Research@Alfred, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Sydney B Montesi
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lucilla Piccari
- Department of Pulmonology, Hospital del Mar, Barcelona, Spain
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - María Molina-Molina
- Servei de Pneumologia, Grup de Recerca Pneumològic, Institut d'Investigacions Biomèdiques de Bellvitge (IDIBELL), Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Jacobo Sellares Torres
- Grup de Treball de Malalties Pulmonars Intersticials. Pneumology Service, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Iazsmin Bauer-Ventura
- Rheumatology Division, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Sujeet Rajan
- Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Joseph Jacob
- Centre for Medical Imaging and Computing, University College London, London, UK
- Department of Respiratory Medicine, University College London, London, UK
| | - Duncan Richards
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lisa G Spencer
- Liverpool Interstitial Lung Disease Service, Aintree Hospital, Liverpool University Hospitals NHS Foundation Trust Library and Knowledge Service, Liverpool, UK
| | | | | | | | - Michael Kreuter
- Mainz Center for Pulmonary Medicine, Department of Pulmology, Mainz University Medical Center and Department of Pulmonary, Critical Care & Sleep Medicine, Marienhaus Clinic Mainz, Mainz, Germany
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York City, New York, USA
| | - Naftali Kaminski
- Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Roger Lewis
- Berry Consultants, Los Angeles, California, USA
| | - Wendy Adams
- Action for Pulmonary Fibrosis Foundation, London, UK
| | - Gisli Jenkins
- Margaret Turner Warwick Centre for Fibrosing Lung Disease, National Heart and Lung Institute, Imperial College London, London, UK
| |
Collapse
|
18
|
Angus DC, Huang AJ, Lewis RJ, Abernethy AP, Califf RM, Landray M, Kass N, Bibbins-Domingo K. The Integration of Clinical Trials With the Practice of Medicine: Repairing a House Divided. JAMA 2024; 332:153-162. [PMID: 38829654 DOI: 10.1001/jama.2024.4088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Importance Optimal health care delivery, both now and in the future, requires a continuous loop of knowledge generation, dissemination, and uptake on how best to provide care, not just determining what interventions work but also how best to ensure they are provided to those who need them. The randomized clinical trial (RCT) is the most rigorous instrument to determine what works in health care. However, major issues with both the clinical trials enterprise and the lack of integration of clinical trials with health care delivery compromise medicine's ability to best serve society. Observations In most resource-rich countries, the clinical trials and health care delivery enterprises function as separate entities, with siloed goals, infrastructure, and incentives. Consequently, RCTs are often poorly relevant and responsive to the needs of patients and those responsible for care delivery. At the same time, health care delivery systems are often disengaged from clinical trials and fail to rapidly incorporate knowledge generated from RCTs into practice. Though longstanding, these issues are more pressing given the lessons learned from the COVID-19 pandemic, heightened awareness of the disproportionate impact of poor access to optimal care on vulnerable populations, and the unprecedented opportunity for improvement offered by the digital revolution in health care. Four major areas must be improved. First, especially in the US, greater clarity is required to ensure appropriate regulation and oversight of implementation science, quality improvement, embedded clinical trials, and learning health systems. Second, greater adoption is required of study designs that improve statistical and logistical efficiency and lower the burden on participants and clinicians, allowing trials to be smarter, safer, and faster. Third, RCTs could be considerably more responsive and efficient if they were better integrated with electronic health records. However, this advance first requires greater adoption of standards and processes designed to ensure health data are adequately reliable and accurate and capable of being transferred responsibly and efficiently across platforms and organizations. Fourth, tackling the problems described above requires alignment of stakeholders in the clinical trials and health care delivery enterprises through financial and nonfinancial incentives, which could be enabled by new legislation. Solutions exist for each of these problems, and there are examples of success for each, but there is a failure to implement at adequate scale. Conclusions and Relevance The gulf between current care and that which could be delivered has arguably never been wider. A key contributor is that the 2 limbs of knowledge generation and implementation-the clinical trials and health care delivery enterprises-operate as a house divided. Better integration of these 2 worlds is key to accelerated improvement in health care delivery.
Collapse
Affiliation(s)
- Derek C Angus
- JAMA , Chicago, Illinois
- University of Pittsburgh Schools of the Health Sciences, Pittsburgh, Pennsylvania
| | | | - Roger J Lewis
- JAMA , Chicago, Illinois
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Amy P Abernethy
- Verily Life Sciences, San Francisco, California
- Now with Highlander Health, Dallas, Texas
| | | | - Martin Landray
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Protas, Manchester, United Kingdom
| | - Nancy Kass
- Johns Hopkins University, Baltimore, Maryland
| | | |
Collapse
|
19
|
Barrett JS, Lasater K, Russell S, McCune S, Miller TM, Sibbald D. Bringing platform trials closer to reality by enabling with digital research environment (DRE) connectivity. Contemp Clin Trials 2024; 142:107559. [PMID: 38714286 DOI: 10.1016/j.cct.2024.107559] [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: 06/05/2023] [Revised: 02/28/2024] [Accepted: 04/30/2024] [Indexed: 05/09/2024]
Abstract
Platform trials are generally regarded as an innovative approach to address clinical valuation of early stage candidates, regardless of modality as the evidence evolves. As a type of randomized clinical trial (RCT) design construct in which multiple interventions are evaluated concurrently against a common control group allowing new interventions to be added and the control group to be updated throughout the trial, they provide a dynamic and efficient mechanism to compare and potentially discriminate new treatment candidates. Their recent use in the evaluation of new therapies for COVID-19 has spurred new interest in the approach. The paucity of platform trials is less influenced by the novelty and operational requirements as opposed to concerns regarding the sharing of intellectual property (IP) and the lack of infrastructure to operationalize the conduct in the context of IP and data sharing. We provide a mechanism how this can be accomplished through the use of a digital research environment (DRE) providing a safe and secure platform for clinical researchers, quantitative and physician scientists to analyze and develop tools (e.g., models) on sensitive data with the confidence that the data and models developed are protected. A DRE, in this context, expands on the concept of a trusted research environment (TRE) by providing remote access to data alongside tools for analysis in a securely controlled workspace, while allowing data and tools to be findable, accessible, interoperable, and reusable (FAIR), version-controlled, and dynamically grow in size or quality as a result of each treatment evaluated in the trial.
Collapse
Affiliation(s)
| | - Kara Lasater
- Aridhia Digital Research Environment, Glasgow, United Kingdom
| | - Scott Russell
- Aridhia Digital Research Environment, Glasgow, United Kingdom
| | - Susan McCune
- PPD Clinical Research Business, Thermo Fisher Scientific, Wilmington, NC, USA
| | - Timothy M Miller
- Enterprise Science and Innovation Partnerships, Thermo Fisher Scientific, Wilmington, NC, USA
| | - David Sibbald
- Aridhia Digital Research Environment, Glasgow, United Kingdom
| |
Collapse
|
20
|
Malhotra S, Cameron AI, Gotham D, Burrone E, Gardner PJ, Loynachan C, Morin S, Scott CP, Pérez-Casas C. Novel approaches to enable equitable access to monoclonal antibodies in low- and middle-income countries. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003418. [PMID: 38950021 PMCID: PMC11216602 DOI: 10.1371/journal.pgph.0003418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
Monoclonal antibodies (mAbs) are revolutionizing management of non-communicable diseases in high-income countries and are increasingly being advanced for a range of infectious diseases (IDs). However, access to existing mAbs is limited in low- and middle-income countries (LMICs), and investment in developing fit-for-purpose mAbs for IDs that disproportionately affect LMICs has been limited. Underlying these access barriers are systemic challenges, including a lack of commercial incentives to target LMIC markets and complexity in manufacturing and regulatory processes. Novel strategies are needed to overcome systemic access barriers for mAbs. We outline key areas where new approaches could address these barriers, based on a multistakeholder consultation in March 2023. Three disease-market archetypes are identified to guide thinking about business models tailored to different contexts. New business models are needed to incentivize development and manufacturing of ID mAbs and to ensure mAbs are optimized with a target product profile and cost of goods that enable use in diverse LMIC settings. Lessons can be applied from voluntary licensing strategies and product development partnerships that have shown success in catalysing development and affordable supply for a range of infectious diseases. Technology transfer will be key to expand LMIC research and manufacturing capacity and to enable sustainable and diversified supply. Improved market intelligence, demand aggregation mechanisms, and portfolio-based manufacturing models could be used to de-risk commercial investment and establish a sustainable manufacturing ecosystem for affordable mAbs. Novel regulatory approaches and robust technology transfer may reduce data requirements and timelines for biosimilar approvals. Trailblazer products, with coordinated "end-to-end" support from funders, can demonstrate proof of concept for pathways to accessible mAbs across a broader range of LMICs. Research funders; local, regional, global health agencies; and, private sector partners should commit to implementing innovative partnerships and end-to-end strategies that enable equitable access to mAbs for infectious diseases in LMICs.
Collapse
Affiliation(s)
- Shelly Malhotra
- Global Access, IAVI, New York, New York, United States of America
| | | | | | - Esteban Burrone
- Strategy, Policy and Market Access, Medicines Patent Pool, Geneva, Switzerland
| | | | | | - Sébastien Morin
- Strategy, Policy and Market Access, Medicines Patent Pool, Geneva, Switzerland
| | | | | |
Collapse
|
21
|
Hogg RE, Wickens R, O'Connor S, Gidman E, Ward E, Treanor C, Peto T, Burton B, Knox P, Lotery AJ, Sivaprasad S, Donnelly M, Rogers CA, Reeves BC. Home-monitoring for neovascular age-related macular degeneration in older adults within the UK: the MONARCH diagnostic accuracy study. Health Technol Assess 2024; 28:1-136. [PMID: 39023220 PMCID: PMC11261425 DOI: 10.3310/cyra9912] [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] [Indexed: 07/20/2024] Open
Abstract
Background Most neovascular age-related macular degeneration treatments involve long-term follow-up of disease activity. Home monitoring would reduce the burden on patients and those they depend on for transport, and release clinic appointments for other patients. The study aimed to evaluate three home-monitoring tests for patients to use to detect active neovascular age-related macular degeneration compared with diagnosing active neovascular age-related macular degeneration by hospital follow-up. Objectives There were five objectives: Estimate the accuracy of three home-monitoring tests to detect active neovascular age-related macular degeneration. Determine the acceptability of home monitoring to patients and carers and adherence to home monitoring. Explore whether inequalities exist in recruitment, participants' ability to self-test and their adherence to weekly testing during follow-up. Provide pilot data about the accuracy of home monitoring to detect conversion to neovascular age-related macular degeneration in fellow eyes of patients with unilateral neovascular age-related macular degeneration. Describe challenges experienced when implementing home-monitoring tests. Design Diagnostic test accuracy cohort study, stratified by time since starting treatment. Setting Six United Kingdom Hospital Eye Service macular clinics (Belfast, Liverpool, Moorfields, James Paget, Southampton, Gloucester). Participants Patients with at least one study eye being monitored by hospital follow-up. Reference standard Detection of active neovascular age-related macular degeneration by an ophthalmologist at hospital follow-up. Index tests KeepSight Journal: paper-based near-vision tests presented as word puzzles. MyVisionTrack®: electronic test, viewed on a tablet device. MultiBit: electronic test, viewed on a tablet device. Participants provided test scores weekly. Raw scores between hospital follow-ups were summarised as averages. Results Two hundred and ninety-seven patients (mean age 74.9 years) took part. At least one hospital follow-up was available for 317 study eyes, including 9 second eyes that became eligible during follow-up, in 261 participants (1549 complete visits). Median testing frequency was three times/month. Estimated areas under receiver operating curves were < 0.6 for all index tests, and only KeepSight Journal summary score was significantly associated with the lesion activity (odds ratio = 3.48, 95% confidence interval 1.09 to 11.13, p = 0.036). Older age and worse deprivation for home address were associated with lower participation (χ2 = 50.5 and 24.3, respectively, p < 0.001) but not ability or adherence to self-testing. Areas under receiver operating curves appeared higher for conversion of fellow eyes to neovascular age-related macular degeneration (0.85 for KeepSight Journal) but were estimated with less precision. Almost half of participants called a study helpline, most often due to inability to test electronically. Limitations Pre-specified sample size not met; participants' difficulties using the devices; electronic tests not always available. Conclusions No index test provided adequate test accuracy to identify lesion diagnosed as active in follow-up clinics. If used to detect conversion, patients would still need to be monitored at hospital. Associations of older age and worse deprivation with study participation highlight the potential for inequities with such interventions. Provision of reliable electronic testing was challenging. Future work Future studies evaluating similar technologies should consider: Independent monitoring with clear stopping rules based on test performance. Deployment of apps on patients' own devices since providing devices did not reduce inequalities in participation and complicated home testing. Alternative methods to summarise multiple scores over the period preceding a follow-up. Trial registration This trial is registered as ISRCTN79058224. Funding This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 15/97/02) and is published in full in Health Technology Assessment; Vol. 28, No. 32. See the NIHR Funding and Awards website for further award information.
Collapse
Affiliation(s)
- Ruth E Hogg
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Robin Wickens
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Sean O'Connor
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Eleanor Gidman
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Elizabeth Ward
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Charlene Treanor
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Ben Burton
- James Paget University Hospitals NHS Trust, Great Yarmouth, UK
| | - Paul Knox
- University of Liverpool, Liverpool, UK
| | - Andrew J Lotery
- Department of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Michael Donnelly
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Chris A Rogers
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | | |
Collapse
|
22
|
Zipfel S, Lutz W, Schneider S, Schramm E, Delgadillo J, Giel KE. The Future of Enhanced Psychotherapy: Towards Precision Psychotherapy. PSYCHOTHERAPY AND PSYCHOSOMATICS 2024; 93:230-236. [PMID: 38934154 DOI: 10.1159/000539022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 04/18/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Stephan Zipfel
- Department of Psychosomatic Medicine, Medical University Hospital Tübingen, Tübingen, Germany
- Center of Excellence in Eating Disorders (KOMET), Tübingen, Germany
- German Center for Mental Health (DZPG), Tübingen, Germany
| | - Wolfgang Lutz
- German Center for Mental Health (DZPG), Tübingen, Germany
- Department of Psychology, University of Trier, Trier, Germany
| | - Silvia Schneider
- German Center for Mental Health (DZPG), Bochum, Germany
- Mental Health Research and Treatment Center, Ruhr University Bochum, Bochum, Germany
| | - Elisabeth Schramm
- German Center for Mental Health (DZPG), Tübingen, Germany
- Department of Psychiatry and Psychotherapy, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jaime Delgadillo
- Clinical and Applied Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
| | - Katrin E Giel
- Department of Psychosomatic Medicine, Medical University Hospital Tübingen, Tübingen, Germany
- Center of Excellence in Eating Disorders (KOMET), Tübingen, Germany
- German Center for Mental Health (DZPG), Tübingen, Germany
| |
Collapse
|
23
|
Emens LA, Romero PJ, Anderson AC, Bruno TC, Capitini CM, Collyar D, Gulley JL, Hwu P, Posey AD, Silk AW, Wargo JA. Challenges and opportunities in cancer immunotherapy: a Society for Immunotherapy of Cancer (SITC) strategic vision. J Immunother Cancer 2024; 12:e009063. [PMID: 38901879 PMCID: PMC11191773 DOI: 10.1136/jitc-2024-009063] [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] [Accepted: 04/24/2024] [Indexed: 06/22/2024] Open
Abstract
Cancer immunotherapy has flourished over the last 10-15 years, transforming the practice of oncology and providing long-term clinical benefit to some patients. During this time, three distinct classes of immune checkpoint inhibitors, chimeric antigen receptor-T cell therapies specific for two targets, and two distinct classes of bispecific T cell engagers, a vaccine, and an oncolytic virus have joined cytokines as a standard of cancer care. At the same time, scientific progress has delivered vast amounts of new knowledge. For example, advances in technologies such as single-cell sequencing and spatial transcriptomics have provided deep insights into the immunobiology of the tumor microenvironment. With this rapid clinical and scientific progress, the field of cancer immunotherapy is currently at a critical inflection point, with potential for exponential growth over the next decade. Recognizing this, the Society for Immunotherapy of Cancer convened a diverse group of experts in cancer immunotherapy representing academia, the pharmaceutical and biotechnology industries, patient advocacy, and the regulatory community to identify current opportunities and challenges with the goal of prioritizing areas with the highest potential for clinical impact. The consensus group identified seven high-priority areas of current opportunity for the field: mechanisms of antitumor activity and toxicity; mechanisms of drug resistance; biomarkers and biospecimens; unique aspects of novel therapeutics; host and environmental interactions; premalignant immunity, immune interception, and immunoprevention; and clinical trial design, endpoints, and conduct. Additionally, potential roadblocks to progress were discussed, and several topics were identified as cross-cutting tools for optimization, each with potential to impact multiple scientific priority areas. These cross-cutting tools include preclinical models, data curation and sharing, biopsies and biospecimens, diversification of funding sources, definitions and standards, and patient engagement. Finally, three key guiding principles were identified that will both optimize and maximize progress in the field. These include engaging the patient community; cultivating diversity, equity, inclusion, and accessibility; and leveraging the power of artificial intelligence to accelerate progress. Here, we present the outcomes of these discussions as a strategic vision to galvanize the field for the next decade of exponential progress in cancer immunotherapy.
Collapse
Affiliation(s)
| | | | - Ana Carrizosa Anderson
- The Gene Lay Institute of Immunology and Inflammation, Ann Romney Center for Neurologic Diseases, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Tullia C Bruno
- Department of Immunology, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christian M Capitini
- Department of Pediatrics and Carbone Cancer Center, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Deborah Collyar
- Patient Advocates in Research (PAIR), Danville, California, USA
| | - James L Gulley
- Center for Immuno-Oncology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Avery D Posey
- Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ann W Silk
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer A Wargo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
24
|
Sasaki M, Sato H, Uemura Y, Mikami A, Ichihara N, Fujitani S, Kondo M, Doi Y, Morino E, Tokita D, Ohmagari N, Sugiura W, Hirakawa A. How Much More Efficient Are Adaptive Platform Trials Than Multiple Stand-Alone Trials? A Comprehensive Simulation Study for Streamlining Drug Development During a Pandemic. Clin Pharmacol Ther 2024; 115:1372-1382. [PMID: 38441177 DOI: 10.1002/cpt.3224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/12/2024] [Indexed: 05/14/2024]
Abstract
With the coronavirus disease 2019 (COVID-19) pandemic, there is growing interest in utilizing adaptive platform clinical trials (APTs), in which multiple drugs are compared with a single common control group, such as a placebo or standard-of-care group. APTs evaluate several drugs for one disease and accept additions or exclusions of drugs as the trials progress; however, little is known about the efficiency of APTs over multiple stand-alone trials. In this study, we simulated the total development period, total sample size, and statistical operating characteristics of APTs and multiple stand-alone trials in drug development settings for hospitalized patients with COVID-19. Simulation studies using selected scenarios reconfirmed several findings regarding the efficiency of APTs. The APTs without staggered addition of drugs showed a shorter total development period than stand-alone trials, but the difference rapidly diminished if patient's enrollment was accelerated during the trials owing to the spread of infection. APTs with staggered addition of drugs still have the possibility of reducing the total development period compared with multiple stand-alone trials in some cases. Our study demonstrated that APTs could improve efficiency relative to multiple stand-alone trials regarding the total development period and total sample size without undermining statistical validity; however, this improvement varies depending on the speed of patient enrollment, sample size, presence/absence of family-wise error rate adjustment, allocation ratio between drug and placebo groups, and interval of staggered addition of drugs. Given the complexity of planning and implementing APT, the decision to implement APT during a pandemic must be made carefully.
Collapse
Affiliation(s)
- Masanao Sasaki
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Hiroyuki Sato
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yukari Uemura
- Biostatistics Section, Department of Data Science, Center of Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ayako Mikami
- Center for Clinical Research, National Center for Child Health and Development, Tokyo, Japan
| | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shigeki Fujitani
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masashi Kondo
- Center for Clinical Trial and Research Support, Fujita Health University School of Medicine, Aichi, Japan
- Department of Respiratory Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Yohei Doi
- Departments of Microbiology and Infectious Diseases, Fujita Health University School of Medicine, Aichi, Japan
| | - Eriko Morino
- Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Daisuke Tokita
- Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Wataru Sugiura
- Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| |
Collapse
|
25
|
Espinosa-Pereiro J, Alagna R, Saluzzo F, González-Moreno J, Heinrich N, Sánchez-Montalvá A, Cirillo DM. A Systematic Review of Potential Biomarkers for Bacterial Burden and Treatment Efficacy Assessment in Tuberculosis Platform-Based Clinical Trials. J Infect Dis 2024; 229:1584-1595. [PMID: 37956107 DOI: 10.1093/infdis/jiad482] [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: 06/05/2023] [Revised: 09/28/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
Adaptive platform trials can be more efficient than classic trials for developing new treatments. Moving from culture-based to simpler- or faster-to-measure biomarkers as efficacy surrogates may enhance this advantage. We performed a systematic review of treatment efficacy biomarkers in adults with tuberculosis. Platform trials can span different development phases. We grouped biomarkers as: α, bacterial load estimates used in phase 2a trials; β, early and end-of treatment end points, phase 2b-c trials; γ, posttreatment or trial-level estimates, phase 2c-3 trials. We considered as analysis unit (biomarker entry) each combination of biomarker, predicted outcome, and their respective measurement times or intervals. Performance metrics included: sensitivity, specificity, area under the receiver-operator curve (AUC), and correlation measures, and classified as poor, promising, or good. Eighty-six studies included 22 864 participants. From 1356 biomarker entries, 318 were reported with the performance metrics of interest, with 103 promising and 41 good predictors. Group results were: α, mycobacterial RNA and lipoarabinomannan (LAM) in sputum, and host metabolites in urine; β, mycobacterial RNA and host transcriptomic or cytokine signatures for early treatment response; and γ, host transcriptomics for recurrence. A combination of biomarkers from different categories could help in designing more efficient platform trials. Efforts to develop efficacy surrogates should be better coordinated.
Collapse
Affiliation(s)
- Juan Espinosa-Pereiro
- Infectious Diseases Department, Vall d'Hebrón University Hospital, Universitat Autónoma de Barcelona, Barcelona, Spain
- International Health Program, Catalan Institute of Health, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infeccioass, Instituto de Salud Carlos III, Madrid, Spain
| | - Riccardo Alagna
- San Raffaele Scientific Institute, Milan, Italy
- Qiagen, Srl, Milan, Italy
| | | | | | - Norbert Heinrich
- Center for International Health, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
- German Center for Infection Research, Munich, Germany
- Division of Infectious Diseases and Tropical Medicine, University Hospital, Ludwig Maximilian University Munich (DZIF), Partner Site Munich, Munich, Germany
| | - Adrián Sánchez-Montalvá
- Infectious Diseases Department, Vall d'Hebrón University Hospital, Universitat Autónoma de Barcelona, Barcelona, Spain
- International Health Program, Catalan Institute of Health, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infeccioass, Instituto de Salud Carlos III, Madrid, Spain
- Grupo de Estudio de Micobacterias, Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica, Madrid, Spain
| | | |
Collapse
|
26
|
Lee SY. Using Bayesian statistics in confirmatory clinical trials in the regulatory setting: a tutorial review. BMC Med Res Methodol 2024; 24:110. [PMID: 38714936 PMCID: PMC11077897 DOI: 10.1186/s12874-024-02235-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
Bayesian statistics plays a pivotal role in advancing medical science by enabling healthcare companies, regulators, and stakeholders to assess the safety and efficacy of new treatments, interventions, and medical procedures. The Bayesian framework offers a unique advantage over the classical framework, especially when incorporating prior information into a new trial with quality external data, such as historical data or another source of co-data. In recent years, there has been a significant increase in regulatory submissions using Bayesian statistics due to its flexibility and ability to provide valuable insights for decision-making, addressing the modern complexity of clinical trials where frequentist trials are inadequate. For regulatory submissions, companies often need to consider the frequentist operating characteristics of the Bayesian analysis strategy, regardless of the design complexity. In particular, the focus is on the frequentist type I error rate and power for all realistic alternatives. This tutorial review aims to provide a comprehensive overview of the use of Bayesian statistics in sample size determination, control of type I error rate, multiplicity adjustments, external data borrowing, etc., in the regulatory environment of clinical trials. Fundamental concepts of Bayesian sample size determination and illustrative examples are provided to serve as a valuable resource for researchers, clinicians, and statisticians seeking to develop more complex and innovative designs.
Collapse
Affiliation(s)
- Se Yoon Lee
- Department of Statistics, Texas A &M University, 3143 TAMU, College Station, TX, 77843, USA.
| |
Collapse
|
27
|
Polley MYC, Schwartz D, Karrison T, Dignam JJ. Leveraging external control data in the design and analysis of neuro-oncology trials: Pearls and perils. Neuro Oncol 2024; 26:796-810. [PMID: 38254183 PMCID: PMC11066907 DOI: 10.1093/neuonc/noae005] [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: 07/13/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Randomized controlled trials have been the gold standard for evaluating medical treatments for many decades but they are often criticized for requiring large sample sizes. Given the urgent need for better therapies for glioblastoma, it has been argued that data collected from patients treated with the standard regimen can provide high-quality external control data to supplement or replace concurrent control arm in future glioblastoma trials. METHODS In this article, we provide an in-depth appraisal of the use of external control data in the context of neuro-oncology trials. We describe several clinical trial designs with particular attention to how external information is utilized and address common fallacies that may lead to inappropriate adoptions of external control data. RESULTS Using 2 completed glioblastoma trials, we illustrate the use of an assessment tool that lays out a blueprint for assembling a high-quality external control data set. Using statistical simulations, we draw caution from scenarios where these approaches can fall short on controlling the type I error rate. CONCLUSIONS While this approach may hold promise in generating informative data in certain settings, this sense of optimism should be tampered with a healthy dose of skepticism due to a myriad of design and analysis challenges articulated in this review. Importantly, careful planning is key to its successful implementation.
Collapse
Affiliation(s)
- Mei-Yin C Polley
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania, USA
| | - Daniel Schwartz
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Theodore Karrison
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania, USA
| | - James J Dignam
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania, USA
| |
Collapse
|
28
|
Gumber L, Agbeleye O, Inskip A, Fairbairn R, Still M, Ouma L, Lozano-Kuehne J, Bardgett M, Isaacs JD, Wason JM, Craig D, Pratt AG. Operational complexities in international clinical trials: a systematic review of challenges and proposed solutions. BMJ Open 2024; 14:e077132. [PMID: 38626966 PMCID: PMC11029458 DOI: 10.1136/bmjopen-2023-077132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 02/27/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE International trials can be challenging to operationalise due to incompatibilities between country-specific policies and infrastructures. The aim of this systematic review was to identify the operational complexities of conducting international trials and identify potential solutions for overcoming them. DESIGN Systematic review. DATA SOURCES Medline, Embase and Health Management Information Consortium were searched from 2006 to 30 January 2023. ELIGIBILITY CRITERIA All studies reporting operational challenges (eg, site selection, trial management, intervention management, data management) of conducting international trials were included. DATA EXTRACTION AND SYNTHESIS Search results were independently screened by at least two reviewers and data were extracted into a proforma. RESULTS 38 studies (35 RCTs, 2 reports and 1 qualitative study) fulfilled the inclusion criteria. The median sample size was 1202 (IQR 332-4056) and median number of sites was 40 (IQR 13-78). 88.6% of studies had an academic sponsor and 80% were funded through government sources. Operational complexities were particularly reported during trial set-up due to lack of harmonisation in regulatory approvals and in relation to sponsorship structure, with associated budgetary impacts. Additional challenges included site selection, staff training, lengthy contract negotiations, site monitoring, communication, trial oversight, recruitment, data management, drug procurement and distribution, pharmacy involvement and biospecimen processing and transport. CONCLUSIONS International collaborative trials are valuable in cases where recruitment may be difficult, diversifying participation and applicability. However, multiple operational and regulatory challenges are encountered when implementing a trial in multiple countries. Careful planning and communication between trials units and investigators, with an emphasis on establishing adequately resourced cross-border sponsorship structures and regulatory approvals, may help to overcome these barriers and realise the benefits of the approach. OPEN SCIENCE FRAMEWORK REGISTRATION NUMBER: osf-registrations-yvtjb-v1.
Collapse
Affiliation(s)
- Leher Gumber
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Northumbria Healthcare NHS Foundation Trust, Northumbria, UK
| | - Opeyemi Agbeleye
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alex Inskip
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ross Fairbairn
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Madeleine Still
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Ouma
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Jingky Lozano-Kuehne
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Michelle Bardgett
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Musculoskeletal Unit, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - James Ms Wason
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Dawn Craig
- NIHR Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Arthur G Pratt
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Musculoskeletal Unit, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| |
Collapse
|
29
|
Bacon SL, Lavoie KL. Stretching the Scope of Behavioral Interventions: Proceedings of the 4th International Behavioural Trials Network Hybrid Meeting. Ann Behav Med 2024; 58:375-400. [PMID: 38602545 DOI: 10.1093/abm/kaad059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024] Open
Affiliation(s)
- Simon L Bacon
- Department of Health, Kinesiology, and Applied Physiology, Concordia University, Montreal, Canada
- Montreal Behavioural Medicine Centre, Centre integré universitaire de santé et services sociaux du Nord-de-l'Île-de-Montréal (CIUSSS-NIM), Montreal, Canada
| | - Kim L Lavoie
- Department of Health, Kinesiology, and Applied Physiology, Concordia University, Montreal, Canada
- Department of Psychology, University of Quebec at Montreal (UQAM), Montreal, Canada
| |
Collapse
|
30
|
Novak I, Jackman M, Griffin AR, Blatch-Williams R, Norfolk E, Lind K, Polybank D, Mc Namara M. Revving up possibilities: can psychostimulants enhance physical function in children with cerebral palsy? Pediatr Res 2024; 95:1184-1185. [PMID: 38167643 DOI: 10.1038/s41390-023-03010-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/15/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Iona Novak
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia.
| | - Michelle Jackman
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| | - Alexandra R Griffin
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Remy Blatch-Williams
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| | - Esther Norfolk
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| | - Karin Lind
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| | - Daniel Polybank
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| | - Maria Mc Namara
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
31
|
Griessbach A, Schönenberger CM, Taji Heravi A, Gloy V, Agarwal A, Hallenberger TJ, Schandelmaier S, Janiaud P, Amstutz A, Covino M, Mall D, Speich B, Briel M. Characteristics, Progression, and Output of Randomized Platform Trials: A Systematic Review. JAMA Netw Open 2024; 7:e243109. [PMID: 38506807 PMCID: PMC10955344 DOI: 10.1001/jamanetworkopen.2024.3109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/24/2024] [Indexed: 03/21/2024] Open
Abstract
Importance Platform trials have become increasingly common, and evidence is needed to determine how this trial design is actually applied in current research practice. Objective To determine the characteristics, progression, and output of randomized platform trials. Evidence Review In this systematic review of randomized platform trials, Medline, Embase, Scopus, trial registries, gray literature, and preprint servers were searched, and citation tracking was performed in July 2022. Investigators were contacted in February 2023 to confirm data accuracy and to provide updated information on the status of platform trial arms. Randomized platform trials were eligible if they explicitly planned to add or drop arms. Data were extracted in duplicate from protocols, publications, websites, and registry entries. For each platform trial, design features such as the use of a common control arm, use of nonconcurrent control data, statistical framework, adjustment for multiplicity, and use of additional adaptive design features were collected. Progression and output of each platform trial were determined by the recruitment status of individual arms, the number of arms added or dropped, and the availability of results for each intervention arm. Findings The search identified 127 randomized platform trials with a total of 823 arms; most trials were conducted in the field of oncology (57 [44.9%]) and COVID-19 (45 [35.4%]). After a more than twofold increase in the initiation of new platform trials at the beginning of the COVID-19 pandemic, the number of platform trials has since declined. Platform trial features were often not reported (not reported: nonconcurrent control, 61 of 127 [48.0%]; multiplicity adjustment for arms, 98 of 127 [77.2%]; statistical framework, 37 of 127 [29.1%]). Adaptive design features were only used by half the studies (63 of 127 [49.6%]). Results were available for 65.2% of closed arms (230 of 353). Premature closure of platform trial arms due to recruitment problems was infrequent (5 of 353 [1.4%]). Conclusions and Relevance This systematic review found that platform trials were initiated most frequently during the COVID-19 pandemic and declined thereafter. The reporting of platform features and the availability of results were insufficient. Premature arm closure for poor recruitment was rare.
Collapse
Affiliation(s)
- Alexandra Griessbach
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christof Manuel Schönenberger
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ala Taji Heravi
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Viktoria Gloy
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Arnav Agarwal
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Stefan Schandelmaier
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Perrine Janiaud
- Pragmatic Evidence Lab, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alain Amstutz
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Manuela Covino
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - David Mall
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Benjamin Speich
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Matthias Briel
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
32
|
The Rise of Adaptive Platform Trials in Critical Care. Am J Respir Crit Care Med 2024; 209:491-496. [PMID: 38271622 PMCID: PMC10919116 DOI: 10.1164/rccm.202401-0101cp] [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: 01/10/2024] [Accepted: 01/25/2024] [Indexed: 01/27/2024] Open
Abstract
As durable learning research systems, adaptive platform trials represent a transformative new approach to accelerating clinical evaluation and discovery in critical care. This Perspective provides a brief introduction to the concept of adaptive platform trials, describes several established and emerging platforms in critical care, and surveys some opportunities and challenges for their implementation and impact.
Collapse
|
33
|
Mack DP, Upton J, Patel N, Turner PJ. Flex-IT! Applying "Platform Trials" Methodology to Immunotherapy for Food Allergy in Research and Clinical Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:554-561. [PMID: 38218449 DOI: 10.1016/j.jaip.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/27/2023] [Accepted: 01/09/2024] [Indexed: 01/15/2024]
Abstract
There is an increasing trend in the management of food allergy toward active treatment using allergen immunotherapy (AIT). Although AIT is efficacious, treatment-related adverse events are common, particularly with oral immunotherapy in those with high levels of allergen-specific IgE sensitization. In clinical practice, these adverse events inevitably create challenges: clinicians and patients routinely face decisions whether to alter the dose itself, the frequency of dosing, and the pace of escalation, or indeed discontinue AIT altogether. Flexibility is therefore needed to adapt treatment, particularly in clinical practice, so that participants are "treated-to-target." For example, this may entail a significant change in the dosing protocol or even switching from one route of administration to another in response to frequent adverse events. We refer to this approach as flexible immunotherapy. However, there is little evidence to inform clinicians as to what changes to treatment are most likely to result in treatment success. Classical clinical trials rely, by necessity, on relatively rigid updosing protocols. To provide an evidence base to optimize AIT, the food allergy community should adopt adaptive platform trials, where a "master protocol" facilitates more efficient evaluation, including longer-term outcomes of multiple interventions. Within a single clinical trial, participants are able to switch between different treatment arms; interventions can be added or dropped without compromising the integrity of the trial. Developing platform trials for food AIT may initially be costly, but they represent a significant opportunity to grow the evidence base (with respect to both treatment outcomes and biomarker discovery) at scale. In addition, they could help understand longitudinal disease trajectories that are difficult to study in clinical trials for food allergy due to the time needed to demonstrate changes in efficacy. Finally, their adoption would achieve greater collaboration and consistency in approaches to proactive management of food allergy in routine clinical practice. As a community, we need to actively pursue this with funders and established research collaborations to deliver the very best outcomes for our patients and their families.
Collapse
Affiliation(s)
- Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Julia Upton
- SickKids Food Allergy and Anaphylaxis Programme, Division of Immunology and Allergy, Department of Pediatrics, the Hospital for Sick Children, Toronto, Ontario, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nandinee Patel
- National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, United Kingdom.
| |
Collapse
|
34
|
Meizoso JP, Byrne J, Ho VP, Neal MD, Stein DM, Haut ER. Advanced and alternative research methods for the acute care surgeon scientist. Trauma Surg Acute Care Open 2024; 9:e001320. [PMID: 38390469 PMCID: PMC10882373 DOI: 10.1136/tsaco-2023-001320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 02/24/2024] Open
Abstract
Clinical research has evolved significantly over the last few decades to include many advanced and alternative study designs to answer unique questions. Recognizing a potential knowledge gap, the AAST Associate Member Council and Educational Development Committee created a research course at the 2022 Annual Meeting in Chicago to introduce junior researchers to these methodologies. This manuscript presents a summary of this AAST Annual Meeting session, and reviews topics including hierarchical modeling, geospatial analysis, patient-centered outcomes research, mixed methods designs, and negotiating complex issues in multicenter trials.
Collapse
Affiliation(s)
- Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - James Byrne
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Deborah M Stein
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
- R. Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
35
|
Montesi SB, Gomez CR, Beers M, Brown R, Chattopadhyay I, Flaherty KR, Garcia CK, Gomperts B, Hariri LP, Hogaboam CM, Jenkins RG, Kaminski N, Kim GHJ, Königshoff M, Kolb M, Kotton DN, Kropski JA, Lasky J, Magin CM, Maher TM, McCormick M, Moore BB, Nickerson-Nutter C, Oldham J, Podolanczuk AJ, Raghu G, Rosas I, Rowe SM, Schmidt WT, Schwartz D, Shore JE, Spino C, Craig JM, Martinez FJ. Pulmonary Fibrosis Stakeholder Summit: A Joint NHLBI, Three Lakes Foundation, and Pulmonary Fibrosis Foundation Workshop Report. Am J Respir Crit Care Med 2024; 209:362-373. [PMID: 38113442 PMCID: PMC10878386 DOI: 10.1164/rccm.202307-1154ws] [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: 07/06/2023] [Accepted: 12/19/2023] [Indexed: 12/21/2023] Open
Abstract
Despite progress in elucidation of disease mechanisms, identification of risk factors, biomarker discovery, and the approval of two medications to slow lung function decline in idiopathic pulmonary fibrosis and one medication to slow lung function decline in progressive pulmonary fibrosis, pulmonary fibrosis remains a disease with a high morbidity and mortality. In recognition of the need to catalyze ongoing advances and collaboration in the field of pulmonary fibrosis, the NHLBI, the Three Lakes Foundation, and the Pulmonary Fibrosis Foundation hosted the Pulmonary Fibrosis Stakeholder Summit on November 8-9, 2022. This workshop was held virtually and was organized into three topic areas: 1) novel models and research tools to better study pulmonary fibrosis and uncover new therapies, 2) early disease risk factors and methods to improve diagnosis, and 3) innovative approaches toward clinical trial design for pulmonary fibrosis. In this workshop report, we summarize the content of the presentations and discussions, enumerating research opportunities for advancing our understanding of the pathogenesis, treatment, and outcomes of pulmonary fibrosis.
Collapse
Affiliation(s)
| | - Christian R. Gomez
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Michael Beers
- Pulmonary and Critical Care Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Brown
- Program in Neurotherapeutics, University of Massachusetts Chan Medical School, Worchester, Massachusetts
| | | | | | - Christine Kim Garcia
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York
| | | | - Lida P. Hariri
- Division of Pulmonary and Critical Care Medicine and
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Cory M. Hogaboam
- Women’s Guild Lung Institute, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - R. Gisli Jenkins
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Naftali Kaminski
- Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Grace Hyun J. Kim
- Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, and
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Melanie Königshoff
- Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Martin Kolb
- Division of Respirology, McMaster University, Hamilton, Ontario, Canada
| | - Darrell N. Kotton
- Center for Regenerative Medicine, Boston University and Boston Medical Center, Boston, Massachusetts
| | - Jonathan A. Kropski
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joseph Lasky
- Pulmonary Fibrosis Foundation, Chicago, Illinois
- Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Chelsea M. Magin
- Department of Bioengineering
- Department of Pediatrics
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, and
| | - Toby M. Maher
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | | | | | | | - Anna J. Podolanczuk
- Division of Pulmonary and Critical Care, Weill Cornell Medical College, New York, New York
| | - Ganesh Raghu
- Division of Pulmonary, Sleep and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Ivan Rosas
- Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas; and
| | - Steven M. Rowe
- Department of Medicine and
- Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - David Schwartz
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Cathie Spino
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - J. Matthew Craig
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Fernando J. Martinez
- Division of Pulmonary and Critical Care, Weill Cornell Medical College, New York, New York
| |
Collapse
|
36
|
Deisenhofer AK, Barkham M, Beierl ET, Schwartz B, Aafjes-van Doorn K, Beevers CG, Berwian IM, Blackwell SE, Bockting CL, Brakemeier EL, Brown G, Buckman JEJ, Castonguay LG, Cusack CE, Dalgleish T, de Jong K, Delgadillo J, DeRubeis RJ, Driessen E, Ehrenreich-May J, Fisher AJ, Fried EI, Fritz J, Furukawa TA, Gillan CM, Gómez Penedo JM, Hitchcock PF, Hofmann SG, Hollon SD, Jacobson NC, Karlin DR, Lee CT, Levinson CA, Lorenzo-Luaces L, McDanal R, Moggia D, Ng MY, Norris LA, Patel V, Piccirillo ML, Pilling S, Rubel JA, Salazar-de-Pablo G, Schleider JL, Schnurr PP, Schueller SM, Siegle GJ, Uher R, Watkins E, Webb CA, Wiltsey Stirman S, Wynants L, Youn SJ, Zilcha-Mano S, Lutz W, Cohen ZD. Implementing precision methods in personalizing psychological therapies: Barriers and possible ways forward. Behav Res Ther 2024; 172:104443. [PMID: 38086157 DOI: 10.1016/j.brat.2023.104443] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 12/26/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | - Claudi L Bockting
- AmsterdamUMC, Department of Psychiatry, Research Program Amsterdam Public Health and Centre for Urban Mental Health, University of Amsterdam, the Netherlands
| | | | | | | | | | | | | | - Kim de Jong
- Leiden University, Institute of Psychology, USA
| | | | | | | | | | | | | | - Jessica Fritz
- University of Cambridge, UK; Philipps University of Marburg, Germany
| | | | - Claire M Gillan
- School of Psychology, Trinity College Institute for Neuroscience, And Global Brain Health Institute, Trinity College Dublin, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Mei Yi Ng
- Florida International University, USA
| | | | | | | | | | | | | | - Jessica L Schleider
- Stony Brook University and Feinberg School of Medicine Northwestern University, USA
| | - Paula P Schnurr
- National Center for PTSD and Geisel School of Medicine at Dartmouth, USA
| | | | | | | | | | | | | | | | - Soo Jeong Youn
- Reliant Medical Group, OptumCare and Harvard Medical School, USA
| | | | | | - Zachary D Cohen
- University of California, Los Angeles and University of Arizona, USA.
| |
Collapse
|
37
|
Abdilleh K, Khalid O, Ladnier D, Wan W, Seepo S, Rupp G, Corelj V, Worman ZF, Sain D, DiGiovanna J, Press B, Chandrashekhar S, Collisson E, Cui KY, Maitra A, Rejto PA, White KP, Matrisian L, Doss S. Pancreatic Cancer Action Network's SPARK: A Cloud-Based Patient Health Data and Analytics Platform for Pancreatic Cancer. JCO Clin Cancer Inform 2024; 8:e2300119. [PMID: 38166233 PMCID: PMC10803046 DOI: 10.1200/cci.23.00119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/06/2023] [Accepted: 11/03/2023] [Indexed: 01/04/2024] Open
Abstract
PURPOSE Pancreatic cancer currently holds the position of third deadliest cancer in the United States and the 5-year survival rate is among the lowest for major cancers at just 12%. Thus, continued research efforts to better understand the clinical and molecular underpinnings of pancreatic cancer are critical to developing both early detection methodologies as well as improved therapeutic options. This study introduces Pancreatic Cancer Action Network's (PanCAN's) SPARK, a cloud-based data and analytics platform that integrates patient health data from the PanCAN's research initiatives and aims to accelerate pancreatic cancer research by making real-world patient health data and analysis tools easier to access and use. MATERIALS AND METHODS The SPARK platform integrates clinical, molecular, multiomic, imaging, and patient-reported data generated from PanCAN's research initiatives. The platform is built on a cloud-based infrastructure powered by Velsera. Cohort exploration and browser capabilities are built using Velsera ARIA, a specialized product for leveraging clinicogenomic data to build cohorts, query variant information, and drive downstream association analyses. Data science and analytic capabilities are also built into the platform allowing researchers to perform simple to complex analysis. RESULTS Version 1 of the SPARK platform was released to pilot users, who represented diverse end users, including molecular biologists, clinicians, and bioinformaticians. Included in the pilot release of SPARK are deidentified clinical (including treatment and outcomes data), molecular, multiomic, and whole-slide pathology images for over 600 patients enrolled in PanCAN's Know Your Tumor molecular profiling service. CONCLUSION The pilot release of the SPARK platform introduces qualified researchers to PanCAN real-world patient health data and analytical resources in a centralized location.
Collapse
Affiliation(s)
| | - Omar Khalid
- Pancreatic Cancer Action Network, Manhattan Beach, CA
| | | | | | | | | | | | | | | | | | | | | | - Eric Collisson
- University of California San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | | | - Anirban Maitra
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Sudheer Doss
- Pancreatic Cancer Action Network, Manhattan Beach, CA
| |
Collapse
|
38
|
Pierce JB, Applefeld WN, Senman B, Loriaux DB, Lawler PR, Katz JN. Design and Execution of Clinical Trials in the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:193-209. [PMID: 37973354 DOI: 10.1016/j.ccc.2023.09.003] [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] [Indexed: 11/19/2023]
Abstract
Clinical practice in the contemporary cardiac intensive care unit (CICU) has evolved significantly over the last several decades. With more frequent multisystem organ failure, increasing use of advanced respiratory support, and the advent of new mechanical circulatory support platforms, clinicians in the CICU are increasingly managing patients with complex comorbid disease in addition to their high-acuity cardiovascular illnesses. Here, the authors discuss challenges associated with traditional trial design in the CICU setting and review novel clinical trial designs that may facilitate better evidence generation in the CICU.
Collapse
Affiliation(s)
- Jacob B Pierce
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Willard N Applefeld
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Balimkiz Senman
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Daniel B Loriaux
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Patrick R Lawler
- McGill University Health Centre, Montreal, Quebec, Canada; Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Jason N Katz
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
39
|
Thomas SP, Novak I, Ritterband-Rosenbaum A, Lind K, Webb A, Gross P, McNamara M. The critical need to accelerate cerebral palsy research with consumer engagement, global networks, and adaptive designs. J Pediatr Rehabil Med 2024; 17:9-17. [PMID: 38552123 PMCID: PMC10977364 DOI: 10.3233/prm-240014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/22/2024] [Indexed: 04/02/2024] Open
Abstract
The prevalence of cerebral palsy (CP) varies globally, with higher rates and burden of disease in low- and middle-income countries. CP is a lifelong condition with no cure, presenting diverse challenges such as motor impairment, epilepsy, and mental health disorders. Research progress has been made but more is needed, especially given consumer demands for faster advancements and improvements in the scientific evidence base for interventions. This paper explores three strategies to accelerate CP research: consumer engagement, global clinical trial networks, and adaptive designs. Consumer engagement involving individuals with lived experience enhances research outcomes. Global clinical trial networks provide efficiency through larger and more diverse participant pools. Adaptive designs, unlike traditional randomized controlled trials, allow real-time modifications based on interim analyses, potentially answering complex questions more efficiently. The establishment of a CP Global Clinical Trials Network, integrating consumer engagement, global collaboration, and adaptive designs, marks a paradigm shift. The Network aims to address consumer-set research priorities. While challenges like ethical considerations and capacity building exist, the potential benefits for consumers, clinicians, researchers, and funding bodies are substantial. This paper underscores the urgency of transforming CP research methodologies for quicker translation of novel treatments into clinical practice to improve quality of life for those with CP.
Collapse
Affiliation(s)
- Sruthi P. Thomas
- H. Ben Taub Department of Physical Medicine and Rehabilitation and Departments of Neurosurgery and Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Iona Novak
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, Specialty of Child and Adolescent Health, Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, Australia
| | | | - Karin Lind
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, Specialty of Child and Adolescent Health, Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Annabel Webb
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, Specialty of Child and Adolescent Health, Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Paul Gross
- Cerebral Palsy Research Network, Greensville, SC, USA
| | - Maria McNamara
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, Specialty of Child and Adolescent Health, Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - the CP Global Clinical Trials Network
- H. Ben Taub Department of Physical Medicine and Rehabilitation and Departments of Neurosurgery and Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Faculty of Medicine and Health, Specialty of Child and Adolescent Health, Cerebral Palsy Alliance Research Institute, Sydney Medical School, The University of Sydney, Sydney, Australia
- Elsass Foundation, Charlottenlund, Denmark
- Cerebral Palsy Research Network, Greensville, SC, USA
| |
Collapse
|
40
|
Onar-Thomas A. Bayesian Adaptive Randomization: Full of Promise With a Helping of Caution. J Clin Oncol 2023; 41:5497-5500. [PMID: 37944091 DOI: 10.1200/jco.23.01485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/01/2023] [Accepted: 09/20/2023] [Indexed: 11/12/2023] Open
|
41
|
Rahman R, Trippa L, Lee EQ, Arrillaga-Romany I, Fell G, Touat M, McCluskey C, Wiley J, Gaffey S, Drappatz J, Welch MR, Galanis E, Ahluwalia MS, Colman H, Nabors LB, Hepel J, Elinzano H, Schiff D, Chukwueke UN, Beroukhim R, Nayak L, McFaline-Figueroa JR, Batchelor TT, Rinne ML, Kaley TJ, Lu-Emerson C, Mellinghoff IK, Bi WL, Arnaout O, Peruzzi PP, Haas-Kogan D, Tanguturi S, Cagney D, Aizer A, Doherty L, Lavallee M, Fisher-Longden B, Dowling S, Geduldig J, Watkinson F, Pisano W, Malinowski S, Ramkissoon S, Santagata S, Meredith DM, Chiocca EA, Reardon DA, Alexander BM, Ligon KL, Wen PY. Inaugural Results of the Individualized Screening Trial of Innovative Glioblastoma Therapy: A Phase II Platform Trial for Newly Diagnosed Glioblastoma Using Bayesian Adaptive Randomization. J Clin Oncol 2023; 41:5524-5535. [PMID: 37722087 DOI: 10.1200/jco.23.00493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/17/2023] [Accepted: 07/24/2023] [Indexed: 09/20/2023] Open
Abstract
PURPOSE The Individualized Screening Trial of Innovative Glioblastoma Therapy (INSIGhT) is a phase II platform trial that uses response adaptive randomization and genomic profiling to efficiently identify novel therapies for phase III testing. Three initial experimental arms (abemaciclib [a cyclin-dependent kinase [CDK]4/6 inhibitor], neratinib [an epidermal growth factor receptor [EGFR]/human epidermal growth factor receptor 2 inhibitor], and CC-115 [a deoxyribonucleic acid-dependent protein kinase/mammalian target of rapamycin inhibitor]) were simultaneously evaluated against a common control arm. We report the results for each arm and examine the feasibility and conduct of the adaptive platform design. PATIENTS AND METHODS Patients with newly diagnosed O6-methylguanine-DNA methyltransferase-unmethylated glioblastoma were eligible if they had tumor genotyping to identify prespecified biomarker subpopulations of dominant glioblastoma signaling pathways (EGFR, phosphatidylinositol 3-kinase, and CDK). Initial random assignment was 1:1:1:1 between control (radiation therapy and temozolomide) and the experimental arms. Subsequent Bayesian adaptive randomization was incorporated on the basis of biomarker-specific progression-free survival (PFS) data. The primary end point was overall survival (OS), and one-sided P values are reported. The trial is registered with ClinicalTrials.gov (identifier: NCT02977780). RESULTS Two hundred thirty-seven patients were treated (71 control; 73 abemaciclib; 81 neratinib; 12 CC-115) in years 2017-2021. Abemaciclib and neratinib were well tolerated, but CC-115 was associated with ≥ grade 3 treatment-related toxicity in 58% of patients. PFS was significantly longer with abemaciclib (hazard ratio [HR], 0.72; 95% CI, 0.49 to 1.06; one-sided P = .046) and neratinib (HR, 0.72; 95% CI, 0.50 to 1.02; one-sided P = .033) relative to the control arm but there was no PFS benefit with CC-115 (one-sided P = .523). None of the experimental therapies demonstrated a significant OS benefit (P > .05). CONCLUSION The INSIGhT design enabled efficient simultaneous testing of three experimental agents using a shared control arm and adaptive randomization. Two investigational arms had superior PFS compared with the control arm, but none demonstrated an OS benefit. The INSIGhT design may promote improved and more efficient therapeutic discovery in glioblastoma. New arms have been added to the trial.
Collapse
Affiliation(s)
- Rifaquat Rahman
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Eudocia Q Lee
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | - Mehdi Touat
- Brigham and Women's Hospital, Boston, MA
- Sorbonne Universite, Hôpitaux Universitaires La Pitié Salpêtrière, Paris, France
| | | | | | | | | | - Mary R Welch
- Division of Neuro-Oncology, Department of Neurology and Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian, New York, NY
| | | | | | - Howard Colman
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | | | | | | | - Ugonma N Chukwueke
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Rameen Beroukhim
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Lakshmi Nayak
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Tracy T Batchelor
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | - Wenya Linda Bi
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | - Daphne Haas-Kogan
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Shyam Tanguturi
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Ayal Aizer
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | | | | | - David A Reardon
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Brian M Alexander
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Keith L Ligon
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Patrick Y Wen
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| |
Collapse
|
42
|
Niazi SK. Support for Removing Pharmacodynamic and Clinical Efficacy Testing of Biosimilars: A Critical Analysis. Clin Pharmacol Drug Dev 2023; 12:1134-1141. [PMID: 37963837 DOI: 10.1002/cpdd.1349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 10/25/2023] [Indexed: 11/16/2023]
|
43
|
Lewis A, Young MJ, Rohaut B, Jox RJ, Claassen J, Creutzfeldt CJ, Illes J, Kirschen M, Trevick S, Fins JJ. Ethics Along the Continuum of Research Involving Persons with Disorders of Consciousness. Neurocrit Care 2023; 39:565-577. [PMID: 36977963 PMCID: PMC11023737 DOI: 10.1007/s12028-023-01708-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/23/2023] [Indexed: 03/30/2023]
Abstract
Interest in disorders of consciousness (DoC) has grown substantially over the past decade and has illuminated the importance of improving understanding of DoC biology; care needs (use of monitoring, performance of interventions, and provision of emotional support); treatment options to promote recovery; and outcome prediction. Exploration of these topics requires awareness of numerous ethics considerations related to rights and resources. The Curing Coma Campaign Ethics Working Group used its expertise in neurocritical care, neuropalliative care, neuroethics, neuroscience, philosophy, and research to formulate an informal review of ethics considerations along the continuum of research involving persons with DoC related to the following: (1) study design; (2) comparison of risks versus benefits; (3) selection of inclusion and exclusion criteria; (4) screening, recruitment, and enrollment; (5) consent; (6) data protection; (7) disclosure of results to surrogates and/or legally authorized representatives; (8) translation of research into practice; (9) identification and management of conflicts of interest; (10) equity and resource availability; and (11) inclusion of minors with DoC in research. Awareness of these ethics considerations when planning and performing research involving persons with DoC will ensure that the participant rights are respected while maximizing the impact and meaningfulness of the research, interpretation of outcomes, and communication of results.
Collapse
Affiliation(s)
- Ariane Lewis
- NYU Langone Medical Center, 530 First Avenue, Skirball-7R, New York, NY, 10016, USA.
| | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin Rohaut
- Inserm, CNRS, APHP - Hôpital de la Pitié Salpêtrière, Paris Brain Institute - ICM, DMU Neuroscience, Sorbonne University, Paris, France
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Claire J Creutzfeldt
- Harborview Medical Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, Seattle, WA, USA
| | - Judy Illes
- University of British Columbia, Vancouver, BC, Canada
| | | | | | - Joseph J Fins
- Weill Cornell Medical College, New York, NY, USA
- Yale Law School, New Haven, CT, USA
- Rockefeller University, New York, NY, USA
| |
Collapse
|
44
|
Morè S, Corvatta L, Manieri VM, Morsia E, Poloni A, Offidani M. Novel Immunotherapies and Combinations: The Future Landscape of Multiple Myeloma Treatment. Pharmaceuticals (Basel) 2023; 16:1628. [PMID: 38004493 PMCID: PMC10675193 DOI: 10.3390/ph16111628] [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: 09/27/2023] [Revised: 11/06/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023] Open
Abstract
In multiple myeloma impressive outcomes have improved with the introduction of new therapeutic approaches, mainly those including naked monoclonal antibodies such as daratumumab and isatuximab. However, moving to earlier lines of therapy with effective anti-myeloma drugs led to an increase in the number of patients who developed multi-refractoriness to them early on. Currently, triple- or multi-refractory MM represents an unmet medical need, and their management remains a complicated challenge. The recent approval of new immunotherapeutic approaches such as conjugated monoclonal antibodies, bispecific antibodies, and CAR T cells could be a turning point for these heavily pretreated patients. Nevertheless, several issues regarding their use are unsolved, such as how to select patients for each strategy or how to sequence these therapies within the MM therapeutic landscape. Here we provide an overview of the most recent data about approved conjugated monoclonal antibody belantamab, mafodotin, bispecific antibody teclistamab, and other promising compounds under development, mainly focusing on the ongoing clinical trials with monoclonal antibody combination approaches in advanced and earlier phases of MM treatment.
Collapse
Affiliation(s)
- Sonia Morè
- Clinica di Ematologia Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Laura Corvatta
- U.O.C. Medicina, Ospedale Profili, 60044 Fabriano, Italy
| | | | - Erika Morsia
- Clinica di Ematologia Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Antonella Poloni
- Clinica di Ematologia Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Massimo Offidani
- Clinica di Ematologia Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| |
Collapse
|
45
|
Walker S, Spillane E, Stringer K, Trepte L, Davies SM, Bresson J, Sandall J, Shennan A. OptiBreech collaborative care versus standard care for women with a breech-presenting fetus at term: A pilot parallel group randomised trial to evaluate the feasibility of a randomised trial nested within a cohort. PLoS One 2023; 18:e0294139. [PMID: 37967120 PMCID: PMC10650999 DOI: 10.1371/journal.pone.0294139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 10/18/2023] [Indexed: 11/17/2023] Open
Abstract
OptiBreech collaborative care is a multi-disciplinary care pathway for breech presentation at term, with continuity from a breech specialist midwife, including where chosen, for vaginal breech birth (VBB). Pilot randomised trial using unblinded 1:1 parallel group allocation to OptiBreech versus standard care, within a cohort. Participants were women with a breech-presenting fetus > 33 weeks, at four sites in England, January-June 2022. A two-stage consent process was used. Participants consented to undergo random selection to be offered a 'new care process', with a choice to accept it, or not. Primary objectives were to identify recruitment, acceptance, and attrition rates. Randomisation procedures and potential primary outcomes for a substantive study were also feasibility-tested. 68 women were randomised between January-June 2022. The consent process was acceptable to participants, but randomisation was unacceptable to women who specifically sought OptiBreech care. Two women withdrew due to concerns about sharing personal information. More women planned a VBB when randomised to OptiBreech Care (23.5% vs 0, p = .002, 95% CI = 9.3%,37.8%). Women randomised to OptiBreech care had: lower rates of cephalic presentation at birth (38.2% vs 54.5%), higher rates of vaginal birth (32.4% vs 24.2%), lower rates of in-labour caesarean birth (20.6% vs 36.4%), lower rates of neonatal intensive care (5.9% vs 9.1%), and lower rates of severe neonatal morbidity (2.9% vs 9.1%). Randomisation was stopped on the advice of the steering committee before the planned sample of 104, as lack of access to VBB within standard care prohibited comparison of outcomes. Demand for VBB is sufficient for a cohort study, but comparison of outcomes by 1:1 randomisation is not feasible. OptiBreech care would be best evaluated using stepped wedge cluster randomisation. Funded by the United Kingdom National Institute for Health and Care Research (NIHR300582). Clinical trial registration: ISRCTN 14521381.
Collapse
Affiliation(s)
- Shawn Walker
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
- Women’s and Children’s Services, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Emma Spillane
- Kingston Maternity, Kingston Hospital NHS Foundation Trust, Kingston upon Thames, Surrey, United Kingdom
| | - Kate Stringer
- Women’s Services, Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Redhill, United Kingdom
| | - Lauren Trepte
- Women’s and Children’s Services, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Siân M. Davies
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
| | - Jacana Bresson
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
| | - Jane Sandall
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
| | - Andrew Shennan
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
| | | |
Collapse
|
46
|
Wang Z, Wang X, Xu W, Li Y, Lai R, Qiu X, Chen X, Chen Z, Mi B, Wu M, Wang J. Translational Challenges and Prospective Solutions in the Implementation of Biomimetic Delivery Systems. Pharmaceutics 2023; 15:2623. [PMID: 38004601 PMCID: PMC10674763 DOI: 10.3390/pharmaceutics15112623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/03/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Biomimetic delivery systems (BDSs), inspired by the intricate designs of biological systems, have emerged as a groundbreaking paradigm in nanomedicine, offering unparalleled advantages in therapeutic delivery. These systems, encompassing platforms such as liposomes, protein-based nanoparticles, extracellular vesicles, and polysaccharides, are lauded for their targeted delivery, minimized side effects, and enhanced therapeutic outcomes. However, the translation of BDSs from research settings to clinical applications is fraught with challenges, including reproducibility concerns, physiological stability, and rigorous efficacy and safety evaluations. Furthermore, the innovative nature of BDSs demands the reevaluation and evolution of existing regulatory and ethical frameworks. This review provides an overview of BDSs and delves into the multifaceted translational challenges and present emerging solutions, underscored by real-world case studies. Emphasizing the potential of BDSs to redefine healthcare, we advocate for sustained interdisciplinary collaboration and research. As our understanding of biological systems deepens, the future of BDSs in clinical translation appears promising, with a focus on personalized medicine and refined patient-specific delivery systems.
Collapse
Affiliation(s)
- Zhe Wang
- Department of Pathology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen 518033, China; (Z.W.); (R.L.)
| | - Xinpei Wang
- School of Pharmaceutical Sciences, Shenzhen Campus of Sun Yat-sen University, Shenzhen 518107, China; (X.W.); (W.X.); (Y.L.); (X.Q.); (X.C.); (Z.C.)
| | - Wanting Xu
- School of Pharmaceutical Sciences, Shenzhen Campus of Sun Yat-sen University, Shenzhen 518107, China; (X.W.); (W.X.); (Y.L.); (X.Q.); (X.C.); (Z.C.)
| | - Yongxiao Li
- School of Pharmaceutical Sciences, Shenzhen Campus of Sun Yat-sen University, Shenzhen 518107, China; (X.W.); (W.X.); (Y.L.); (X.Q.); (X.C.); (Z.C.)
| | - Ruizhi Lai
- Department of Pathology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen 518033, China; (Z.W.); (R.L.)
| | - Xiaohui Qiu
- School of Pharmaceutical Sciences, Shenzhen Campus of Sun Yat-sen University, Shenzhen 518107, China; (X.W.); (W.X.); (Y.L.); (X.Q.); (X.C.); (Z.C.)
| | - Xu Chen
- School of Pharmaceutical Sciences, Shenzhen Campus of Sun Yat-sen University, Shenzhen 518107, China; (X.W.); (W.X.); (Y.L.); (X.Q.); (X.C.); (Z.C.)
| | - Zhidong Chen
- School of Pharmaceutical Sciences, Shenzhen Campus of Sun Yat-sen University, Shenzhen 518107, China; (X.W.); (W.X.); (Y.L.); (X.Q.); (X.C.); (Z.C.)
| | - Bobin Mi
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China;
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan 430022, China
| | - Meiying Wu
- School of Pharmaceutical Sciences, Shenzhen Campus of Sun Yat-sen University, Shenzhen 518107, China; (X.W.); (W.X.); (Y.L.); (X.Q.); (X.C.); (Z.C.)
| | - Junqing Wang
- School of Pharmaceutical Sciences, Shenzhen Campus of Sun Yat-sen University, Shenzhen 518107, China; (X.W.); (W.X.); (Y.L.); (X.Q.); (X.C.); (Z.C.)
| |
Collapse
|
47
|
Borgeaud M, Sandoval J, Obeid M, Banna G, Michielin O, Addeo A, Friedlaender A. Novel targets for immune-checkpoint inhibition in cancer. Cancer Treat Rev 2023; 120:102614. [PMID: 37603905 DOI: 10.1016/j.ctrv.2023.102614] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/06/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023]
Abstract
Immune-checkpoint inhibitors have revolutionized cancer therapy, yet many patients either do not derive any benefit from treatment or develop a resistance to checkpoint inhibitors. Intrinsic resistance can result from neoantigen depletion, defective antigen presentation, PD-L1 downregulation, immune-checkpoint ligand upregulation, immunosuppression, and tumor cell phenotypic changes. On the other hand, extrinsic resistance involves acquired upregulation of inhibitory immune-checkpoints, leading to T-cell exhaustion. Current data suggest that PD-1, CTLA-4, and LAG-3 upregulation limits the efficacy of single-agent immune-checkpoint inhibitors. Ongoing clinical trials are investigating novel immune-checkpoint targets to avoid or overcome resistance. This review provides an in-depth analysis of the evolving landscape of potentially targetable immune-checkpoints in cancer. We highlight their biology, emphasizing the current understanding of resistance mechanisms and focusing on promising strategies that are under investigation. We also summarize current results and ongoing clinical trials in this crucial field that could once again revolutionize outcomes for cancer patients.
Collapse
Affiliation(s)
| | | | - Michel Obeid
- Centre Hospitalier Universitaire Vaudois, Switzerland
| | - Giuseppe Banna
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | | | | | - Alex Friedlaender
- Geneva University Hospitals, Switzerland; Clinique Générale Beaulieu, Geneva, Switzerland.
| |
Collapse
|
48
|
Blackwell SE, Schönbrodt FD, Woud ML, Wannemüller A, Bektas B, Braun Rodrigues M, Hirdes J, Stumpp M, Margraf J. Demonstration of a 'leapfrog' randomized controlled trial as a method to accelerate the development and optimization of psychological interventions. Psychol Med 2023; 53:6113-6123. [PMID: 36330836 PMCID: PMC10520605 DOI: 10.1017/s0033291722003294] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/14/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The scale of the global mental health burden indicates the inadequacy not only of current treatment options, but also the pace of the standard treatment development process. The 'leapfrog' trial design is a newly-developed simple Bayesian adaptive trial design with potential to accelerate treatment development. A first leapfrog trial was conducted to provide a demonstration and test feasibility, applying the method to a low-intensity internet-delivered intervention targeting anhedonia. METHODS At the start of this online, single-blind leapfrog trial, participants self-reporting depression were randomized to an initial control arm comprising four weeks of weekly questionnaires, or one of two versions of a four-week cognitive training intervention, imagery cognitive bias modification (imagery CBM). Intervention arms were compared to control on an ongoing basis via sequential Bayesian analyses, based on a primary outcome of anhedonia at post-intervention. Results were used to eliminate and replace arms, or to promote them to become the control condition based on pre-specified Bayes factor and sample size thresholds. Two further intervention arms (variants of imagery CBM) were added into the trial as it progressed. RESULTS N = 188 participants were randomized across the five trial arms. The leapfrog methodology was successfully implemented to identify a 'winning' version of the imagery CBM, i.e. the version most successful in reducing anhedonia, following sequential elimination of the other arms. CONCLUSIONS The study demonstrates feasibility of the leapfrog design and provides a foundation for its adoption as a method to accelerate treatment development in mental health. Registration: clinicaltrials.gov, NCT04791137.
Collapse
Affiliation(s)
- Simon E. Blackwell
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Felix D. Schönbrodt
- Department of Psychology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Marcella L. Woud
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Andre Wannemüller
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Büsra Bektas
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Max Braun Rodrigues
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Josefine Hirdes
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Michael Stumpp
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Jürgen Margraf
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| |
Collapse
|
49
|
Hirsch G, Velentgas P, Curtis JR, Larholt K, Park JJH, Pashos CL, Trinquart L. Extending the vision of adaptive point-of-care platform trials to improve targeted use of drug therapy regimens: An agile approach in the learning healthcare system toolkit. Contemp Clin Trials 2023; 133:107327. [PMID: 37652359 DOI: 10.1016/j.cct.2023.107327] [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: 04/13/2023] [Revised: 07/24/2023] [Accepted: 08/28/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVES Improving the targeted use of drug regimens requires robust real-world evidence (RWE) to address the uncertainties that remain regarding their real-world performance following market entry. However, challenges in the current state of RWE production limit its impact on clinical decisions, as well as its operational scalability and sustainability. We propose an adaptive point-of-care (APoC) platform trial as an approach to RWE production that improves both clinical and operational efficiencies. METHODS AND FINDINGS We explored design innovations, operational challenges, and infrastructure needs within a multi-stakeholder consortium to evaluate the potential of an APoC platform trial for studying chronic disease treatment regimens using rheumatoid arthritis as a case study. The concept integrates elements from adaptive clinical trials (dynamic treatment regimen strategies) and point-of-care trials (research embedded into routine clinical care) under a perpetual platform infrastructure. The necessary components to implement an APoC platform trial within outpatient settings exist, and present an opportunity for a cross-disciplinary, multi-stakeholder approach. Effective engagement of key stakeholders involved in and impacted by the platform is critical to success. Our collaborative design process identified three high-impact stakeholder-engagement areas: (1) focus on research question(s), (2) design and implementation planning such that it is feasible and fit-for-purpose, and (3) measurement, or meaningful metrics for both clinical (patient outcomes) and system (operational efficiencies) impact. CONCLUSIONS An APoC platform trial for rheumatoid arthritis integrating innovative design elements in a scalable infrastructure has the potential to reduce important uncertainties about the real-world performance of biomedical innovations and improve clinical decisions.
Collapse
Affiliation(s)
- Gigi Hirsch
- Center for Biomedical System Design & NEWDIGS, Tufts Medical Center, Boston, MA, USA.
| | | | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Illumination Health, Hoover, AL, USA
| | - Kay Larholt
- Center for Biomedical System Design & NEWDIGS, Tufts Medical Center, Boston, MA, USA
| | - Jay J H Park
- Core Clinical Sciences Inc, Vancouver, BC, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Ludovic Trinquart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| |
Collapse
|
50
|
Agarwal A, Marion J, Nagy P, Robinson M, Walkey A, Sevransky J. How Electronic Medical Record Integration Can Support More Efficient Critical Care Clinical Trials. Crit Care Clin 2023; 39:733-749. [PMID: 37704337 DOI: 10.1016/j.ccc.2023.03.006] [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] [Indexed: 09/15/2023]
Abstract
Large volumes of data are collected on critically ill patients, and using data science to extract information from the electronic medical record (EMR) and to inform the design of clinical trials represents a new opportunity in critical care research. Using improved methods of phenotyping critical illnesses, subject identification and enrollment, and targeted treatment group assignment alongside newer trial designs such as adaptive platform trials can increase efficiency while lowering costs. Some tools such as the EMR to automate data collection are already in use. Refinement of data science approaches in critical illness research will allow for better clinical trials and, ultimately, improved patient outcomes.
Collapse
Affiliation(s)
- Ankita Agarwal
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
| | | | - Paul Nagy
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew Robinson
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan Walkey
- Department of Medicine - Section of Pulmonary, Allergy, Critical Care and Sleep Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jonathan Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA.
| |
Collapse
|