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Stewart DJ, Bradford JP, Sehdev S, Ramsay T, Navani V, Rawson NSB, Jiang DM, Gotfrit J, Wheatley-Price P, Liu G, Kaplan A, Spadafora S, Goodman SG, Auer RAC, Batist G. New Anticancer Drugs: Reliably Assessing "Value" While Addressing High Prices. Curr Oncol 2024; 31:2453-2480. [PMID: 38785465 PMCID: PMC11119944 DOI: 10.3390/curroncol31050184] [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: 02/27/2024] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/25/2024] Open
Abstract
Countries face challenges in paying for new drugs. High prices are driven in part by exploding drug development costs, which, in turn, are driven by essential but excessive regulation. Burdensome regulation also delays drug development, and this can translate into thousands of life-years lost. We need system-wide reform that will enable less expensive, faster drug development. The speed with which COVID-19 vaccines and AIDS therapies were developed indicates this is possible if governments prioritize it. Countries also differ in how they value drugs, and generally, those willing to pay more have better, faster access. Canada is used as an example to illustrate how "incremental cost-effectiveness ratios" (ICERs) based on measures such as gains in "quality-adjusted life-years" (QALYs) may be used to determine a drug's value but are often problematic, imprecise assessments. Generally, ICER/QALY estimates inadequately consider the impact of patient crossover or long post-progression survival, therapy benefits in distinct subpopulations, positive impacts of the therapy on other healthcare or societal costs, how much governments willingly might pay for other things, etc. Furthermore, a QALY value should be higher for a lethal or uncommon disease than for a common, nonlethal disease. Compared to international comparators, Canada is particularly ineffective in initiating public funding for essential new medications. Addressing these disparities demands urgent reform.
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Affiliation(s)
- David J. Stewart
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - John-Peter Bradford
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Sandeep Sehdev
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
| | - Vishal Navani
- Division of Medical Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Nigel S. B. Rawson
- Canadian Health Policy Institute, Toronto, ON M5V 0A4, Canada;
- Macdonald-Laurier Institute, Ottawa, ON K1N 7Z2, Canada
| | - Di Maria Jiang
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Princess Margaret Cancer Center, Toronto, ON M5G 2M9, Canada
| | - Joanna Gotfrit
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
| | - Paul Wheatley-Price
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Geoffrey Liu
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Princess Margaret Cancer Center, Toronto, ON M5G 2M9, Canada
| | - Alan Kaplan
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Family Physicians Airway Group of Canada, Markham, ON L3R 9X9, Canada
| | - Silvana Spadafora
- Algoma District Cancer Program, Sault Ste Marie, ON P6B 0A8, Canada;
| | - Shaun G. Goodman
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- St. Michael’s Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, Toronto, ON M5B 1W8, Canada
| | - Rebecca A. C. Auer
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Department of Surgery, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada
| | - Gerald Batist
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
- Centre for Translational Research, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
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Khodair AI, El-Hallouty SM, Cagle-White B, Abdel Aziz MH, Hanafy MK, Mowafy S, Hamdy NM, Kassab SE. Camptothecin structure simplification elaborated new imidazo[2,1-b]quinazoline derivative as a human topoisomerase I inhibitor with efficacy against bone cancer cells and colon adenocarcinoma. Eur J Med Chem 2024; 265:116049. [PMID: 38185054 DOI: 10.1016/j.ejmech.2023.116049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/17/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024]
Abstract
Camptothecin is a pentacyclic natural alkaloid that inhibits the hTop1 enzyme involved in DNA transcription and cancer cell growth. Camptothecin structure pitfalls prompted us to design new congeners using a structure simplification strategy to reduce the ring extension number from pentacyclic to tetracyclic while maintaining potential stacking of the new compounds with the DNA base pairs at the Top1-mediated cleavage complex and aqueous solubility, as well as minimizing compound-liver toxicity. The principal axis of this study was the verification of hTop1 inhibiting activity as a possible mechanism of action and the elaboration of new simplified inhibitors with improved pharmacodynamic and pharmacokinetic profiling using three structure panels (A-C) of (isoquinolinoimidazoquinazoline), (imidazoquinazoline), and (imidazoisoquinoline), respectively. DNA relaxation assay identified five compounds as hTop1 inhibitors belonging to the imidazoisoquinolines 3a,b, the imidazoquinazolines 12, and the isoquinolinoimidazoquinazolines 7a,b. In an MTT cytotoxicity assay against different cancer cell lines, compound 12 was the most potent against HOS bone cancer cells (IC50 = 1.47 μM). At the same time, the other inhibitors had no detectable activity against any cancer cell type. Compound (12) demonstrated great penetrating power in the HOS cancer cells' 3D-multicellular tumor spheroid model. Bioinformatics research of the hTop1 gene revealed that the TP53 cell proliferative gene is in the network of hTop1. The finding is confirmed empirically using the gene expression assay that proved the increase in p53 expression. The impact of structure simplification on compound 12 profile, characterized by the absence of acute oral liver toxicity when compared to Doxorubicin as a standard inhibitor, the lethal dose measured on Swiss Albino female mice and reported at LD50 = 250 mg/kg, and therapeutic significance in reducing colon adenocarcinoma tumor volume by 75.36 % after five weeks of treatment with compound 12. The molecular docking solutions of the active CPT-based derivative 12 and the inactive congener 14 into the active site of hTop1 and the activity cliffing of such MMP directed us to recommend the addition of HBD and HBA variables to compound 12 imidazoquinazoline core scaffold to enhance the potency via hydrogen bond formation with the major groove amino acids (Asp533, Lys532) as well as maintaining the hydrogen bond with the minor groove amino acid Arg364.
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Affiliation(s)
- Ahmed I Khodair
- Chemistry Department, Faculty of Science, Kafrelsheikh University, 33516, Kafrelsheikh, Egypt.
| | - Salwa M El-Hallouty
- Drug Bioassay-Cell Culture Laboratory, Department of Pharmacognosy, National Research Centre, Dokki, Giza 12622, Egypt
| | - Brittnee Cagle-White
- Department of Pharmaceutical Sciences and Health Outcomes, Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, TX 75799, USA
| | - May H Abdel Aziz
- Department of Pharmaceutical Sciences and Health Outcomes, Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, TX 75799, USA
| | - Mahmoud Kh Hanafy
- Drug Bioassay-Cell Culture Laboratory, Department of Pharmacognosy, National Research Centre, Dokki, Giza 12622, Egypt; Research Centre for Idling Brain Science, Department of Biochemistry, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, 930-0194, Japan
| | - Samar Mowafy
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, Misr International University, Cairo, 11431, Egypt
| | - Nadia M Hamdy
- Biochemistry Dept., Faculty of Pharmacy, Ain Shams University, Cairo, 11566, Egypt.
| | - Shaymaa E Kassab
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, Damanhour University, Damanhour, El-Buhaira, 22516, Egypt.
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Kale VP, Bebenek I, Ghantous H, Kapeghian J, Singh BP, Thomas LJ. Practical Considerations in Determining Adversity and the No-Observed-Adverse-Effect-Level (NOAEL) in Nonclinical Safety Studies: Challenges, Perspectives and Case Studies. Int J Toxicol 2022; 41:143-162. [PMID: 35230174 DOI: 10.1177/10915818211073047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Determining the adverse nature of findings from nonclinical safety studies often poses a challenge for the key stakeholders responsible for interpreting the results of definitive toxicity studies in support of pharmaceutical product development. Although there are instances in which responses to treatment clearly indicate intolerability or tissue injury associated with dysfunction; in practice, more often there is uncertainty in characterizing an effect of drug treatment as adverse or not. This is due to the inherent variability in responses of biological test systems to toxicological insults, leaving the ultimate analyses of adversity to individual interpretation and subjectivity. This article is a follow-up to the workshop entitled, "Adverse or Not Adverse?: Thinking process behind adversity determination during nonclinical drug development," conducted at the 58th Annual Meeting of the Society of Toxicology, March 2019 in Baltimore, MD. In this paper, we further discuss and incorporate the perspectives of authors representing different roles, such as Study Director, Study Pathologist, Pharmacology/Toxicology Reviewer (U.S. Food and Drug Administration), and Sponsor in the determination and use of adversity. We also present a practical stepwise approach as an aid in this assessment, and further apply these principles to discuss 10 case studies with different therapeutic modalities and unique challenges.
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Affiliation(s)
| | - Ilona Bebenek
- Food and Drug Administration, Silver Spring, MD, USA
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Tcheou J, Raskin A, Singh G, Kawabata H, Bielak D, Sun W, González-Domínguez I, Sather DN, García-Sastre A, Palese P, Krammer F, Carreño JM. Safety and Immunogenicity Analysis of a Newcastle Disease Virus (NDV-HXP-S) Expressing the Spike Protein of SARS-CoV-2 in Sprague Dawley Rats. Front Immunol 2021; 12:791764. [PMID: 34868082 PMCID: PMC8637447 DOI: 10.3389/fimmu.2021.791764] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/02/2021] [Indexed: 01/14/2023] Open
Abstract
Despite global vaccination efforts, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to evolve and spread globally. Relatively high vaccination rates have been achieved in most regions of the United States and several countries worldwide. However, access to vaccines in low- and mid-income countries (LMICs) is still suboptimal. Second generation vaccines that are universally affordable and induce systemic and mucosal immunity are needed. Here we performed an extended safety and immunogenicity analysis of a second-generation SARS-CoV-2 vaccine consisting of a live Newcastle disease virus vector expressing a pre-fusion stabilized version of the spike protein (NDV-HXP-S) administered intranasally (IN), intramuscularly (IM), or IN followed by IM in Sprague Dawley rats. Local reactogenicity, systemic toxicity, and post-mortem histopathology were assessed after the vaccine administration, with no indication of severe local or systemic reactions. Immunogenicity studies showed that the three vaccination regimens tested elicited high antibody titers against the wild type SARS-CoV-2 spike protein and the NDV vector. Moreover, high antibody titers were induced against the spike of B.1.1.7 (alpha), B.1.351 (beta) and B.1.617.2 (delta) variants of concern (VOCs). Importantly, robust levels of serum antibodies with neutralizing activity against the authentic SARS-CoV-2 USA-WA1/2020 isolate were detected after the boost. Overall, our study expands the pre-clinical safety and immunogenicity characterization of NDV-HXP-S and reinforces previous findings in other animal models about its high immunogenicity. Clinical testing of this vaccination approach is ongoing in different countries including Thailand, Vietnam, Brazil and Mexico.
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MESH Headings
- Administration, Intranasal
- Animals
- Antibodies, Neutralizing/immunology
- Antibodies, Viral/immunology
- COVID-19/immunology
- COVID-19/prevention & control
- COVID-19 Vaccines/administration & dosage
- COVID-19 Vaccines/genetics
- COVID-19 Vaccines/immunology
- Immunogenicity, Vaccine
- Injections, Intramuscular
- Newcastle disease virus/genetics
- Newcastle disease virus/immunology
- Rats
- Rats, Sprague-Dawley
- SARS-CoV-2/genetics
- SARS-CoV-2/immunology
- Safety
- Spike Glycoprotein, Coronavirus/genetics
- Spike Glycoprotein, Coronavirus/immunology
- Vaccination
- Vaccines, Synthetic/administration & dosage
- Vaccines, Synthetic/genetics
- Vaccines, Synthetic/immunology
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Affiliation(s)
- Johnstone Tcheou
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ariel Raskin
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Gagandeep Singh
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Hisaaki Kawabata
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Dominika Bielak
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Weina Sun
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Irene González-Domínguez
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - D Noah Sather
- Center for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Adolfo García-Sastre
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Global Health and Emerging Pathogens Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Peter Palese
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Florian Krammer
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Juan Manuel Carreño
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Acute toxicity evaluation of a novel ceramide analog for the treatment of breast cancer. Toxicol Rep 2021; 8:1521-1526. [PMID: 34401362 PMCID: PMC8355835 DOI: 10.1016/j.toxrep.2021.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/21/2021] [Accepted: 07/30/2021] [Indexed: 12/03/2022] Open
Abstract
Novel ceramide drug for breast cancer. Toxicological profile was studied. Single dose of 80 mg/kg dose was safe. Single dose of 120 mg/kg caused minor liver and cardiac tissue damage.
We have previously reported that treating triple-negative tumor bearing nude mice with intraperitoneal (ip) 10 mg/kg body weight of (S,E)-3-hydroxy-2-(2-hydroxybenzylidene)amino-N-tetradecylpropanamide, a ceramide analog, 5 days per week for 3 weeks, was shown not only to suppress tumor growth but also to reduce metastasis. Studies reported here focus on determining the toxicity of this drug in the nude mice. During the first study, treated animals (single intraperitoneal (ip) injection, 0, 40, 80 and 120 mg/kg body weight) were closely monitored for 14 days for any signs of illness or death. No mice were lost in any animal groups; however, hepatic serum enzymes were elevated, and hepatic and heart tissue damages were found in the highest dosage group. The subsequent study was performed using a lower dosage range (single ip injection, 0, 25, 50 and 75 mg/kg body weight), which resulted in no significant toxicity. All tested parameters were within normal ranges, with no observed irregularities. Our findings show that a single ip dose of this ceramide analog induced liver and heart toxicity at 120 mg/kg but not at doses of 80 mg/kg body weight or lower.
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Pegylation of phenothiazine – A synthetic route towards potent anticancer drugs. J Adv Res 2021; 37:279-290. [PMID: 35499049 PMCID: PMC9040145 DOI: 10.1016/j.jare.2021.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 11/22/2022] Open
Abstract
Antitumor activity of two PEGylated phenotiazines was investigated The compounds showed cytotoxic activity against six tumor lines They inhibited the tumor growth in experimental mice The PEGylation improved the phenothiazine biocompatibility A synergistic effect of PEG and phenothiazine toward properties improvement was proved
Introduction Cancer is a big challenge of the 21 century, whose defeat requires efficient antitumor drugs. Objectives The paper aims to investigate the synergistic effect of two structural building blocks, phenothiazine and poly(ethylene glycol), towards efficient antitumor drugs. Methods Two PEGylated phenothiazine derivatives were synthetized by attaching poly(ethylene glycol) of 550 Da to the nitrogen atom of phenothiazine by ether or ester linkage. Their antitumor activity has been investigated on five human tumour lines and a mouse tumor line as well, by determination of IC50. The in vivo toxicity was determined by measuring the LD50 in BALB/c mice by the sequential method and the in vivo antitumor potential was measured by the tumours growth test. The antitumor mechanism was investigated by complexation studies of zinc and magnesium ions characteristic to the farnesyltransferase enzyme, by studies of self-aggregation in the cells proximity and by investigation of the antitumor properties of the acid species resulted by enzymatic cleavage of the PEGylated derivatives. Results The two compounds showed antitumor activity, with IC50 against mouse colon carcinoma cell line comparable with that of the traditional antitumor drugs 5-Fluorouracil and doxorubicin. The phenothiazine PEGylation resulted in a significant toxicity diminishing, the LD50 in BALB/c mice increasing from 952.38 up to 1450 mg/kg, in phenothiazine equivalents. Both compounds inflicted a 92% inhibition of the tumour growth for doses much smaller than LD50. The investigation of the possible tumour inhibition mechanism suggested the nanoaggregate formation and the cleavage of ester bonds as key factors for the inhibition of cancer cell proliferation and biocompatibility improvement. Conclusion Phenothiazine and PEG building blocks have a synergetic effect working for both tumour growth inhibition and biocompatibility improvement. All these findings recommend the PEGylated phenothiazine derivatives as a valuable workbench for a next generation of antitumor drugs.
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Pattarawat P, Hunt JT, Poloway J, Archibald CJ, Wang HCR. A triple combination gemcitabine + romidepsin + cisplatin to effectively control triple-negative breast cancer tumor development, recurrence, and metastasis. Cancer Chemother Pharmacol 2021; 88:415-425. [PMID: 34043046 DOI: 10.1007/s00280-021-04298-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 05/15/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE Triple-negative breast cancer (TNBC) is an aggressive, lethal, heterogeneous type of breast cancer (BC). TNBC tends to have a lower response rate to chemotherapy and a lower 5-year survival rate than other types of BC due to recurrence and metastasis. Our previous study revealed that a combination of gemcitabine, romidepsin, and cisplatin was efficacious in controlling TNBC tumor development. In this study, we extended our investigation of gemcitabine + romidepsin + cisplatin in controlling TNBC tumor recurrence and metastasis. METHODS We investigated the ability of gemcitabine + romidepsin + cisplatin to control cell survival and invasiveness using cell viability, soft agar colony formation, and transwell invasion assays. We determined the efficacy of gemcitabine + romidepsin + cisplatin in controlling tumor recurrence and metastasis using cell-derived xenograft animal models. We used immunoblotting to study signaling modulators regulated by gemcitabine + romidepsin + cisplatin in TNBC cells and tumor tissues. RESULTS Treatment with gemcitabine + romidepsin + cisplatin reduced the TNBC MDA-MB231 and MDA-MB468 cell survival to ~ 50% and ~ 15%, as well as invasiveness to ~ 31% and ~ 13%, respectively. Gemcitabine + romidepsin + cisplatin suppressed modulators involved in epithelial-mesenchymal transition in an ROS-dependent manner. Controlling tumor recurrence, the Gem plus Rom + Cis regimen (~ 112%) was more efficacious than the Gem plus Cis regimen (~ 21%) in tumor growth inhibition. The Gem plus Rom + Cis regimen efficaciously reduced the development of metastatic nodules to 20% in animals. CONCLUSION The gemcitabine plus romidepsin + cisplatin regimen was highly efficacious in controlling TNBC tumor development, recurrence, and metastasis in animals. The combination regimen should be poised for efficient translation into clinical trials for controlling the recurrence and metastasis, ultimately contributing to reducing mortality and improving TNBC patients' quality of life.
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Affiliation(s)
- Pawat Pattarawat
- Department of Biomedical and Diagnostic Sciences, College of Veterinary Medicine, University of Tennessee, 2407 River Drive, Knoxville, TN, 37996, USA
| | - Jessica T Hunt
- Animal Resource Laboratory, College of Veterinary Medicine, University of Tennessee, 2407 River Drive, Knoxville, TN, 37996, USA
| | - Jacob Poloway
- Department of Biomedical and Diagnostic Sciences, College of Veterinary Medicine, University of Tennessee, 2407 River Drive, Knoxville, TN, 37996, USA
| | - Collin J Archibald
- Department of Biomedical and Diagnostic Sciences, College of Veterinary Medicine, University of Tennessee, 2407 River Drive, Knoxville, TN, 37996, USA
| | - Hwa-Chain Robert Wang
- Department of Biomedical and Diagnostic Sciences, College of Veterinary Medicine, University of Tennessee, 2407 River Drive, Knoxville, TN, 37996, USA.
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8
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Pre-clinical animal models are poor predictors of human toxicities in phase 1 oncology clinical trials. Br J Cancer 2020; 123:1496-1501. [PMID: 32868897 PMCID: PMC7652903 DOI: 10.1038/s41416-020-01033-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 07/23/2020] [Accepted: 08/06/2020] [Indexed: 12/13/2022] Open
Abstract
Background Our objective was to determine the correlation between preclinical toxicity found in animal models (mouse, rat, dog and monkey) and clinical toxicity reported in patients participating in Phase 1 oncology clinical trials. Methods We obtained from two major early-Phase clinical trial centres, preclinical toxicities from investigational brochures and clinical toxicities from published Phase 1 trials for 108 drugs, including small molecules, biologics and conjugates. Toxicities were categorised according to Common Terminology Criteria for Adverse Events version 4.0. Human toxicities were also categorised based on their reported clinical grade (severity). Positive predictive values (PPV) and negative predictive values (NPV) were calculated to determine the probability that clinical studies would/would not show a particular toxicity category given that it was seen in preclinical toxicology analysis. Statistical analyses also included kappa statistics, and Matthews (MCC) and Spearman correlation coefficients. Results Overall, animal toxicity did not show strong correlation with human toxicity, with a median PPV of 0.65 and NPV of 0.50. Similar results were obtained based on kappa statistics and MCC. Conclusions There is an urgent need to assess more novel approaches to the type and conduct of preclinical toxicity studies in an effort to provide better predictive value for human investigation.
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Pattarawat P, Wallace S, Pfisterer B, Odoi A, Wang HCR. Formulation of a triple combination gemcitabine plus romidepsin + cisplatin regimen to efficaciously and safely control triple-negative breast cancer tumor development. Cancer Chemother Pharmacol 2019; 85:141-152. [PMID: 31865420 DOI: 10.1007/s00280-019-04013-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 12/13/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE Triple-negative breast cancer (TNBC) is an aggressive, lethal, and heterogeneous subtype of breast cancers, tending to have lower 5-year survival rates than other BC subtypes in response to conventional chemotherapies. This study's aim was to identify advanced regimens to effectively control TNBC tumor development. METHODS We investigated the combination of the DNA synthesis inhibitor gemcitabine, the DNA-damaging agent cisplatin, and the histone deacetylase inhibitor romidepsin to control a variety of breast cells in vitro. We studied the toxicity of drug doses and administration schedules to determine tolerable combination regimens in immune-deficient nude and -competent BALB/c mice. We then studied the efficacy of tolerable regimens in controlling TNBC cell-derived xenograft development in nude mice. By reducing clinically equivalent doses of each agent in combination, we formulated tolerable regimens in animals. We verified that the tolerable triple combination gemcitabine plus romidepsin + cisplatin regimen more efficacious than double combination regimens in controlling xenograft tumor development in nude mice. RESULTS A triple combination of gemcitabine + romidepsin + cisplatin synergistically induced death of the TNBC M.D. Anderson-Metastatic Breast cancer (MDA-MB) 231 and MDA-MB468, as well as Michigan Cancer Foundation (MCF) 7, MCF10A, and MCF10A-Ras cells. Cell death induced by gemcitabine + romidepsin + cisplatin was in a reactive oxygen species-dependent manner. CONCLUSION Considering the high costs for developing a new anticancer agent, we used the FDA-approved drugs gemcitabine, romidepsin (is approved for T-cell lymphoma and is under clinical trial for TNBC), and cisplatin to economically formulate an efficacious and safe combination regimen. The highly efficacious gemcitabine plus romidepsin + cisplatin regimen should be poised for efficient translation into clinical trials, ultimately contributing to reduced mortality and improved quality of life for TNBC patients.
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Affiliation(s)
- Pawat Pattarawat
- Department of Biomedical and Diagnostic Sciences, College of Veterinary Medicine, University of Tennessee, 2407 River Drive, Knoxville, TN, 37996, USA.,UT-ORNL Graduate School of Genome Science and Technology, University of Tennessee, Knoxville, TN, 37996, USA
| | - Shelby Wallace
- Department of Biomedical and Diagnostic Sciences, College of Veterinary Medicine, University of Tennessee, 2407 River Drive, Knoxville, TN, 37996, USA
| | - Bianca Pfisterer
- Department of Biomedical and Diagnostic Sciences, College of Veterinary Medicine, University of Tennessee, 2407 River Drive, Knoxville, TN, 37996, USA
| | - Agricola Odoi
- Department of Biomedical and Diagnostic Sciences, College of Veterinary Medicine, University of Tennessee, 2407 River Drive, Knoxville, TN, 37996, USA
| | - Hwa-Chain Robert Wang
- Department of Biomedical and Diagnostic Sciences, College of Veterinary Medicine, University of Tennessee, 2407 River Drive, Knoxville, TN, 37996, USA. .,UT-ORNL Graduate School of Genome Science and Technology, University of Tennessee, Knoxville, TN, 37996, USA.
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Imam A, Sulaiman NA, Oyewole AL, Chengetanai S, Williams V, Ajibola MI, Folarin RO, Muhammad AS, Shittu STT, Ajao MS. Chlorpyrifos- and Dichlorvos-Induced Oxidative and Neurogenic Damage Elicits Neuro-Cognitive Deficits and Increases Anxiety-Like Behavior in Wild-Type Rats. TOXICS 2018; 6:toxics6040071. [PMID: 30513797 PMCID: PMC6316642 DOI: 10.3390/toxics6040071] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/21/2018] [Accepted: 11/27/2018] [Indexed: 11/16/2022]
Abstract
The execution of agricultural activities on an industrial scale has led to indiscriminate deposition of toxic xenobiotics, including organophosphates, in the biome. This has led to intoxication characterized by deleterious oxidative and neuronal changes. This study investigated the consequences of oxidative and neurogenic disruptions that follow exposure to a combination of two organophosphates, chlorpyrifos (CPF) and dichlorvos (DDVP), on neuro-cognitive performance and anxiety-like behaviors in rats. Thirty-two adult male Wistar rats (150–170 g) were randomly divided into four groups, orally exposed to normal saline (NS), DDVP (8.8 mg/kg), CPF (14.9 mg/kg), and DDVP + CPF for 14 consecutive days. On day 10 of exposure, anxiety-like behavior and amygdala-dependent fear learning were assessed using open field and elevated plus maze paradigms, respectively, while spatial working memory was assessed on day 14 in the Morris water maze paradigm, following three training trials on days 11, 12, and 13. On day 15, the rats were euthanized, and their brains excised, with the hippocampus and amygdala removed. Five of these samples were homogenized and centrifuged to analyze nitric oxide (NO) metabolites, total reactive oxygen species (ROS), and acetylcholinesterase (AChE) activity, and the other three were processed for histology (cresyl violet stain) and proliferative markers (Ki67 immunohistochemistry). Marked (p ≤0.05) loss in body weight, AChE depletion, and overproduction of both NO and ROS were observed after repeated exposure to individual and combined doses of CPF and DDVP. Insults from DDVP exposure appeared more severe owing to the observed greater losses in the body weights of exposed rats. There was also a significant (p ≤0.05) effect on the cognitive behaviors recorded from the exposed rats, and these deficits were related to the oxidative damage and neurogenic cell loss in the hippocampus and the amygdala of the exposed rats. Taken together, these results provided an insight that oxidative and neurogenic damage are central to the severity of neuro-cognitive dysfunction and increased anxiety-like behaviors that follow organophosphate poisoning.
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Affiliation(s)
- Aminu Imam
- Neuroscience Unit, Department of Anatomy, College of Health Sciences, University of Ilorin, P.M.B 1515, Ilorin 240003, Nigeria.
- Comparative Neurobiology Unit, School of Anatomical sciences, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown 2193, Johannesburg, South Africa.
| | - Nafeesah Abdulkareem Sulaiman
- Neuroscience Unit, Department of Anatomy, College of Health Sciences, University of Ilorin, P.M.B 1515, Ilorin 240003, Nigeria.
| | - Aboyeji Lukuman Oyewole
- Neurophysiology Unit, Department of Physiology, College of Health Sciences, University of Ilorin, P.M.B 1515, Ilorin 240003, Nigeria.
| | - Samson Chengetanai
- Comparative Neurobiology Unit, School of Anatomical sciences, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown 2193, Johannesburg, South Africa.
- Department of Anatomy and Physiology, Faculty of Medicine, National University of Science and Technology, Bulawayo 0000, Zimbabwe.
| | - Victoria Williams
- Comparative Neurobiology Unit, School of Anatomical sciences, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown 2193, Johannesburg, South Africa.
| | - Musa Iyiola Ajibola
- Institute of Neuroscience, National Yang-Ming University, Shih-Pai, Taipei 11221, Taiwan.
| | | | - Asma'u Shehu Muhammad
- Department of Human Anatomy, Faculty of Basic Medical Sciences, Federal University of Dutse, PMB 7156, Dutse, Jigawa State, Nigeria.
| | - Sheu-Tijani Toyin Shittu
- Endocrinology and metabolism Research Unit, Department of Physiology, College of Medicine, University of Ibadan, Ibadan, Oyo state, Nigeria.
| | - Moyosore Salihu Ajao
- Neuroscience Unit, Department of Anatomy, College of Health Sciences, University of Ilorin, P.M.B 1515, Ilorin 240003, Nigeria.
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11
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Stewart DJ, Stewart AA, Wheatley-Price P, Batist G, Kantarjian HM, Schiller J, Clemons M, Bradford JP, Gillespie L, Kurzrock R. The importance of greater speed in drug development for advanced malignancies. Cancer Med 2018; 7:1824-1836. [PMID: 29601671 PMCID: PMC5943431 DOI: 10.1002/cam4.1454] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/10/2018] [Accepted: 02/09/2018] [Indexed: 12/13/2022] Open
Abstract
It takes on average 6-12 years to develop new anticancer drugs from discovery to approval. Effective new agents prolong survival. To demonstrate the importance of rapid drug approval, we calculated life-years potentially saved if selected agents were approved more rapidly. As illustrative examples, we used 27 trials documenting improvements in survival. We multiplied improvement in median survival by numbers of patients dying annually and multiplied this by number of years from drug discovery until approval. For every year by which time to drug approval could have been shortened, there would have been a median number of life-years potentially saved of 79,920 worldwide per drug. Median number of life-years lost between time of drug discovery and approval was 1,020,900 per example. If we were able to use available opportunities to decrease the time required to take a drug from discovery to approval to 5 years, the median number of life-years saved per example would have been 523,890 worldwide. Various publications have identified opportunities to speed drug development without sacrificing patient safety. While many investigational drugs prove to be ineffective, some significantly prolong survival and/or reduce suffering. These illustrative examples suggest that a substantial number of life-years could potentially be saved by increasing the efficiency of development of new drugs for advanced malignancies.
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Affiliation(s)
- David J Stewart
- The University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Paul Wheatley-Price
- The University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Gerald Batist
- Segal Cancer Centre, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Joan Schiller
- The Inova Dwight and Martha Schar Cancer Institute, Fairfax, Virginia and Lung Cancer Research Foundation, New York, USA
| | - Mark Clemons
- The University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
| | - John-Peter Bradford
- Bradford Bachinski Limited and the Life Saving Therapies Network, Ottawa, Ontario, Canada
| | | | - Razelle Kurzrock
- University of California San Diego Moores Cancer Center, San Diego, California
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12
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Ivachtchenko AV, Lavrovsky Y, Okun I. AVN-101: A Multi-Target Drug Candidate for the Treatment of CNS Disorders. J Alzheimers Dis 2018; 53:583-620. [PMID: 27232215 PMCID: PMC4969713 DOI: 10.3233/jad-151146] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Lack of efficacy of many new highly selective and specific drug candidates in treating diseases with poorly understood or complex etiology, as are many of central nervous system (CNS) diseases, encouraged an idea of developing multi-modal (multi-targeted) drugs. In this manuscript, we describe molecular pharmacology, in vitro ADME, pharmacokinetics in animals and humans (part of the Phase I clinical studies), bio-distribution, bioavailability, in vivo efficacy, and safety profile of the multimodal drug candidate, AVN-101. We have carried out development of a next generation drug candidate with a multi-targeted mechanism of action, to treat CNS disorders. AVN-101 is a very potent 5-HT7 receptor antagonist (Ki = 153 pM), with slightly lesser potency toward 5-HT6, 5-HT2A, and 5HT-2C receptors (Ki = 1.2–2.0 nM). AVN-101 also exhibits a rather high affinity toward histamine H1 (Ki = 0.58 nM) and adrenergic α2A, α2B, and α2C (Ki = 0.41–3.6 nM) receptors. AVN-101 shows a good oral bioavailability and facilitated brain-blood barrier permeability, low toxicity, and reasonable efficacy in animal models of CNS diseases. The Phase I clinical study indicates the AVN-101 to be well tolerated when taken orally at doses of up to 20 mg daily. It does not dramatically influence plasma and urine biochemistry, nor does it prolong QT ECG interval, thus indicating low safety concerns. The primary therapeutic area for AVN-101 to be tested in clinical trials would be Alzheimer’s disease. However, due to its anxiolytic and anti-depressive activities, there is a strong rational for it to also be studied in such diseases as general anxiety disorders, depression, schizophrenia, and multiple sclerosis.
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Affiliation(s)
- Alexandre V Ivachtchenko
- Alla Chem LLC, Hallandale Beach, FL, USA.,Avineuro Pharmaceuticals Inc., Hallandale Beach, FL, USA
| | | | - Ilya Okun
- Avineuro Pharmaceuticals Inc., Hallandale Beach, FL, USA
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13
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Aston WJ, Hope DE, Nowak AK, Robinson BW, Lake RA, Lesterhuis WJ. A systematic investigation of the maximum tolerated dose of cytotoxic chemotherapy with and without supportive care in mice. BMC Cancer 2017; 17:684. [PMID: 29037232 PMCID: PMC5644108 DOI: 10.1186/s12885-017-3677-7] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 10/08/2017] [Indexed: 12/11/2022] Open
Abstract
Background Cytotoxic chemotherapeutics form the cornerstone of systemic treatment of many cancers. Patients are dosed at maximum tolerated dose (MTD), which is carefully determined in phase I studies. In contrast, in murine studies, dosages are often based on customary practice or small pilot studies, which often are not well documented. Consequently, research groups need to replicate experiments, resulting in an excess use of animals and highly variable dosages across the literature. In addition, while patients often receive supportive treatments in order to allow dose escalation, mice do not. These issues could affect experimental results and hence clinical translation. Methods To address this, we determined the single-dose MTD in BALB/c and C57BL/6 mice for a range of chemotherapeutics covering the canonical classes, with clinical score and weight as endpoints. Results We found that there was some variation in MTDs between strains and the tolerability of repeated cycles of chemotherapy at MTD was drug-dependent. We also demonstrate that dexamethasone reduces chemotherapy-induced weight loss in mice. Conclusion These data form a resource for future studies using chemotherapy in mice, increasing comparability between studies, reducing the number of mice needed for dose optimisation experiments and potentially improving translation to the clinic. Electronic supplementary material The online version of this article (10.1186/s12885-017-3677-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wayne J Aston
- National Centre for Asbestos Related Diseases, University of Western Australia, 5th Floor, QQ Block, 6 Verdun Street, Nedlands, WA, 6009, Australia.,Faculty of Health and Medical Science, The University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia
| | - Danika E Hope
- National Centre for Asbestos Related Diseases, University of Western Australia, 5th Floor, QQ Block, 6 Verdun Street, Nedlands, WA, 6009, Australia.,Faculty of Health and Medical Science, The University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia
| | - Anna K Nowak
- National Centre for Asbestos Related Diseases, University of Western Australia, 5th Floor, QQ Block, 6 Verdun Street, Nedlands, WA, 6009, Australia.,Faculty of Health and Medical Science, The University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia.,Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Bruce W Robinson
- National Centre for Asbestos Related Diseases, University of Western Australia, 5th Floor, QQ Block, 6 Verdun Street, Nedlands, WA, 6009, Australia.,Faculty of Health and Medical Science, The University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia
| | - Richard A Lake
- National Centre for Asbestos Related Diseases, University of Western Australia, 5th Floor, QQ Block, 6 Verdun Street, Nedlands, WA, 6009, Australia.,Faculty of Health and Medical Science, The University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia
| | - W Joost Lesterhuis
- National Centre for Asbestos Related Diseases, University of Western Australia, 5th Floor, QQ Block, 6 Verdun Street, Nedlands, WA, 6009, Australia. .,Faculty of Health and Medical Science, The University of Western Australia, 35 Stirling Highway, Crawley, WA, 6009, Australia.
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14
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Sewell F, Edwards J, Prior H, Robinson S. Opportunities to Apply the 3Rs in Safety Assessment Programs. ILAR J 2016; 57:234-245. [PMID: 28053076 PMCID: PMC5886346 DOI: 10.1093/ilar/ilw024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 08/01/2016] [Accepted: 09/01/2016] [Indexed: 12/16/2022] Open
Abstract
Before a potential new medicine can be administered to humans it is essential that its safety is adequately assessed. Safety assessment in animals forms an integral part of this process, from early drug discovery and initial candidate selection to the program of recommended regulatory tests in animals. The 3Rs (replacement, reduction, and refinement of animals in research) are integrated in the current regulatory requirements and expectations and, in the EU, provide a legal and ethical framework for in vivo research to ensure the scientific objectives are met whilst minimizing animal use and maintaining high animal welfare standards. Though the regulations are designed to uncover potential risks, they are intended to be flexible, so that the most appropriate approach can be taken for an individual product. This article outlines current and future opportunities to apply the 3Rs in safety assessment programs for pharmaceuticals, and the potential (scientific, financial, and ethical) benefits to the industry, across the drug discovery and development process. For example, improvements to, or the development of, novel, early screens (e.g., in vitro, in silico, or nonmammalian screens) designed to identify compounds with undesirable characteristics earlier in development have the potential to reduce late-stage attrition by improving the selection of compounds that require regulatory testing in animals. Opportunities also exist within the current regulatory framework to simultaneously reduce and/or refine animal use and improve scientific outcomes through improvements to technical procedures and/or adjustments to study designs. It is important that approaches to safety assessment are continuously reviewed and challenged to ensure they are science-driven and predictive of relevant effects in humans.
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Affiliation(s)
- Fiona Sewell
- Fiona Sewell, PhD, is a Programme Manager in Toxicology and Regulatory Sciences at the UK National Centre for the Replacement, Refinement and Reduction of Animals in Research (NC3Rs), London, UK.Joanna Edwards, PhD, is a Programme Manager in Technology Development at the NC3Rs, London, UK.Helen Prior, PhD, is a Programme Manager in Drug Development at the NC3Rs, London, UK.Sally Robinson, PhD, is Head of Laboratory Animal Sciences at AstraZeneca, Alderley Park, UK
| | - Joanna Edwards
- Fiona Sewell, PhD, is a Programme Manager in Toxicology and Regulatory Sciences at the UK National Centre for the Replacement, Refinement and Reduction of Animals in Research (NC3Rs), London, UK.Joanna Edwards, PhD, is a Programme Manager in Technology Development at the NC3Rs, London, UK.Helen Prior, PhD, is a Programme Manager in Drug Development at the NC3Rs, London, UK.Sally Robinson, PhD, is Head of Laboratory Animal Sciences at AstraZeneca, Alderley Park, UK
| | - Helen Prior
- Fiona Sewell, PhD, is a Programme Manager in Toxicology and Regulatory Sciences at the UK National Centre for the Replacement, Refinement and Reduction of Animals in Research (NC3Rs), London, UK.Joanna Edwards, PhD, is a Programme Manager in Technology Development at the NC3Rs, London, UK.Helen Prior, PhD, is a Programme Manager in Drug Development at the NC3Rs, London, UK.Sally Robinson, PhD, is Head of Laboratory Animal Sciences at AstraZeneca, Alderley Park, UK
| | - Sally Robinson
- Fiona Sewell, PhD, is a Programme Manager in Toxicology and Regulatory Sciences at the UK National Centre for the Replacement, Refinement and Reduction of Animals in Research (NC3Rs), London, UK.Joanna Edwards, PhD, is a Programme Manager in Technology Development at the NC3Rs, London, UK.Helen Prior, PhD, is a Programme Manager in Drug Development at the NC3Rs, London, UK.Sally Robinson, PhD, is Head of Laboratory Animal Sciences at AstraZeneca, Alderley Park, UK
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15
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Stewart DJ, Batist G, Kantarjian HM, Bradford JP, Schiller JH, Kurzrock R. The Urgent Need for Clinical Research Reform to Permit Faster, Less Expensive Access to New Therapies for Lethal Diseases. Clin Cancer Res 2016; 21:4561-8. [PMID: 26473192 DOI: 10.1158/1078-0432.ccr-14-3246] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High costs of complying with drug development regulations slow progress and contribute to high drug prices and, hence, mounting health care costs. If it is exorbitantly expensive to bring new therapies to approval, fewer agents can be developed with available resources, impeding the emergence of urgently needed treatments and escalating prices by limiting competition. Excessive regulation produces numerous speed bumps on the road to drug authorization. Although an explosion of knowledge could fuel rapid advances, progress has been slowed worldwide by inefficient regulatory and clinical research systems that limit access to therapies that prolong life and relieve suffering. We must replace current compliance-centered regulation (appropriate for nonlethal diseases like acne) with "progress-centered regulation" in lethal diseases, where the overarching objective must be rapid, inexpensive development of effective new therapies. We need to (i) reduce expensive, time-consuming preclinical toxicology and pharmacology assessments, which add little value; (ii) revamp the clinical trial approval process to make it fast and efficient; (iii) permit immediate multiple-site trial activation when an eligible patient is identified ("just-in-time" activation); (iv) reduce the requirement for excessive, low-value documentation; (v) replace this excessive documentation with sensible postmarketing surveillance; (vi) develop pragmatic investigator accreditation; (vii) where it is to the benefit of the patient, permit investigators latitude in deviating from protocols, without requiring approved amendments; (viii) confirm the value of predictive biomarkers before requiring the high costs of IDE/CLIA compliance; and (ix) approve agents based on high phase I-II response rates in defined subpopulations, rather than mandating expensive, time-consuming phase III trials.
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Affiliation(s)
- David J Stewart
- The University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Gerald Batist
- Segal Cancer Centre, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - John-Peter Bradford
- Bradford Bachinski Limited and the Life Saving Therapies Network, Ottawa, Ontario, Canada
| | - Joan H Schiller
- The University of Texas Southwestern, Dallas, TX and Free to Breathe
| | - Razelle Kurzrock
- University of California San Diego Moores Cancer Center, San Diego, California
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16
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Sheng CC, Amiri-Kordestani L, Palmby T, Force T, Hong CC, Wu JC, Croce K, Kim G, Moslehi J. 21st Century Cardio-Oncology: Identifying Cardiac Safety Signals in the Era of Personalized Medicine. JACC Basic Transl Sci 2016; 1:386-398. [PMID: 28713868 PMCID: PMC5508213 DOI: 10.1016/j.jacbts.2016.05.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/21/2016] [Accepted: 05/23/2016] [Indexed: 01/01/2023]
Abstract
Cardiotoxicity is a well-established complication of oncology therapies. Cardiomyopathy resulting from anthracyclines is a classic example. In the past decade, an explosion of novel cancer therapies, often targeted and more specific than traditional therapies, has revolutionized oncology therapy and dramatically changed cancer prognosis. However, some of these therapies have introduced an assortment of cardiovascular (CV) complications. At times, these devastating outcomes have only become apparent after drug approval and have limited the use of potent therapies. There is a growing need for better testing platforms, both for CV toxicity screening, as well as for elucidating mechanisms of cardiotoxicities of approved cancer therapies. This review discusses the utility of nonclinical models (in vitro, in vivo, & in silico) available and highlights recent advancements in modalities like human stem cell-derived cardiomyocytes for developing more comprehensive cardiotoxicity testing and new means of cardioprotection with targeted anticancer therapies.
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Affiliation(s)
- Calvin Chen Sheng
- Cardiovascular Division, Vanderbilt University School of Medicine, Nashville, Tennessee
- Cardio-Oncology Program, Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Laleh Amiri-Kordestani
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Todd Palmby
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Thomas Force
- Cardiovascular Division, Vanderbilt University School of Medicine, Nashville, Tennessee
- Cardio-Oncology Program, Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Charles C. Hong
- Cardiovascular Division, Vanderbilt University School of Medicine, Nashville, Tennessee
- Research Medicine, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
- Accelerating Drug Repurposing Incubator, Vanderbilt Institute for Clinical and Translational Research, Nashville, Tennessee
| | - Joseph C. Wu
- Cardiovascular Division, Department of Medicine, Stanford University School of Medicine, Stanford, California
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
| | - Kevin Croce
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Geoffrey Kim
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, White Oak, Maryland
| | - Javid Moslehi
- Cardiovascular Division, Vanderbilt University School of Medicine, Nashville, Tennessee
- Cardio-Oncology Program, Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
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17
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Grankvist H, Kimmelman J. How do researchers decide early clinical trials? MEDICINE, HEALTH CARE, AND PHILOSOPHY 2016; 19:191-198. [PMID: 26833467 DOI: 10.1007/s11019-016-9685-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Launch of clinical investigation represents a substantial escalation in commitment to a particular clinical translation trajectory; it also exposes human subjects to poorly understood interventions. Despite these high stakes, there is little to guide decision-makers on the scientific and ethical evaluation of early phase trials. In this article, we review policies and consensus statements on human protections, drug regulation, and research design surrounding trial launch, and conclude that decision-making is largely left to the discretion of research teams and sponsors. We then review what is currently understood about how research teams exercise this discretion, and close by laying out a research agenda for characterizing the way investigators, sponsors, and reviewers approach decision-making in early phase research.
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Affiliation(s)
- Hannah Grankvist
- Department of Thematic Studies - Technology and Social Change, Linköping University, 581 83, Linköping, Sweden.
| | - Jonathan Kimmelman
- Studies for Translation, Research Ethics, and Medicine (STREAM), Biomedical Ethics Unit/Social Studies of Medicine, McGill University, 3647 Peel St., Montreal, QC, H3A 1X1, Canada
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18
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Hansen AR, Cook N, Ricci MS, Razak A, Le Tourneau C, McKeever K, Roskos L, Dixit R, Siu LL, Hinrichs MJ. Choice of Starting Dose for Biopharmaceuticals in First-in-Human Phase I Cancer Clinical Trials. Oncologist 2015; 20:653-9. [PMID: 25964306 DOI: 10.1634/theoncologist.2015-0008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/03/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND First-in-human (FIH) trials of low-molecular-weight anticancer agents conventionally derive a safe start dose (SD) from one-tenth the severely toxic dose in 10% of rodents or one-sixth the highest nonseverely toxic dose (HNSTD) in nonrodent species. No consensus has been reached on whether this paradigm can be safely applied to biotechnology-derived products (BDPs). MATERIALS AND METHODS A comprehensive search was conducted to identify all BDPs (excluding immune checkpoint inhibitors and antibody drug conjugates) with sufficient nonclinical and clinical data to assess the safety of hypothetical use of one-sixth HNSTD in an advanced cancer FIH trial. RESULTS The search identified 23 BDPs, of which 21 were monoclonal antibodies. The median ratio of the maximum tolerated or maximum administered dose (MTD or MAD) to the actual FIH SD was 36 (range, 8-500). Only 2 BDPs reached the MTD. Hypothetical use of one-sixth HNSTD (allometrically scaled to humans) would not have exceeded the MTD or MAD for all 23 BDPs and would have reduced the median ratio of the MTD or MAD to a SD to 6.1 (range, 3.5-55.3). Pharmacodynamic (PD) markers were included in some animal toxicology studies and were useful to confirm the hypothetical SD of one-sixth HNSTD. CONCLUSION One-sixth HNSTD would not have resulted in unacceptable toxicities in the data available. Supporting its use could reduce the number of dose escalations needed to reach the recommended dose. A low incidence of toxicities in animals and humans underscores the need to identify the pharmacokinetic and PD parameters to guide SD selection of BDPs for FIH cancer trials. IMPLICATIONS FOR PRACTICE Start dose (SD) for biotechnology-derived products (BDPs) can be safely derived from one-sixth the highest nonseverely toxic dose in nonrodent species and may reduce the number of dose escalations needed to reach the recommended dose in first-in-human studies while limiting unnecessary exposure to high drug levels in humans. The use of this type of SD could improve the design of phase I studies of BDPs by making them more efficient. The role of preclinical pharmacodynamic markers was useful in confirming the hypothetical SD, and attempts should be explored in future animal studies to identify such parameters.
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Affiliation(s)
- Aaron R Hansen
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Natalie Cook
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - M Stacey Ricci
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Albiruni Razak
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Christophe Le Tourneau
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Kathleen McKeever
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Lorin Roskos
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Rakesh Dixit
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Lillian L Siu
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
| | - Mary Jane Hinrichs
- Drug Development Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Hematology and Oncology Toxicology, Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA; Department of Medical Oncology, Institut Curie, Paris and Saint-Cloud, France; INSERM U900, Institut Curie, Paris, France; Translational Sciences, MedImmune LLC, Gaithersburg, Maryland, USA
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Housing temperature-induced stress drives therapeutic resistance in murine tumour models through β2-adrenergic receptor activation. Nat Commun 2015; 6:6426. [PMID: 25756236 DOI: 10.1038/ncomms7426] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 01/28/2015] [Indexed: 01/04/2023] Open
Abstract
Cancer research relies heavily on murine models for evaluating the anti-tumour efficacy of therapies. Here we show that the sensitivity of several pancreatic tumour models to cytotoxic therapies is significantly increased when mice are housed at a thermoneutral ambient temperature of 30 °C compared with the standard temperature of 22 °C. Further, we find that baseline levels of norepinephrine as well as the levels of several anti-apoptotic molecules are elevated in tumours from mice housed at 22 °C. The sensitivity of tumours to cytotoxic therapies is also enhanced by administering a β-adrenergic receptor antagonist to mice housed at 22 °C. These data demonstrate that standard housing causes a degree of cold stress sufficient to impact the signalling pathways related to tumour-cell survival and affect the outcome of pre-clinical experiments. Furthermore, these data highlight the significant role of host physiological factors in regulating the sensitivity of tumours to therapy.
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Preclinical pharmacology and toxicology study of Ad-hTERT-E1a-Apoptin, a novel dual cancer-specific oncolytic adenovirus. Toxicol Appl Pharmacol 2014; 280:362-9. [DOI: 10.1016/j.taap.2014.08.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 08/05/2014] [Accepted: 08/12/2014] [Indexed: 11/17/2022]
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Rani I, Vaiphei K, Agnihotri N. Supplementation of fish oil augments efficacy and attenuates toxicity of 5-fluorouracil in 1,2-dimethylhydrazine dihydrochloride/dextran sulfate sodium-induced colon carcinogenesis. Cancer Chemother Pharmacol 2014; 74:309-22. [PMID: 24916547 DOI: 10.1007/s00280-014-2497-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 05/22/2014] [Indexed: 12/20/2022]
Abstract
PURPOSE 5-Fluorouracil (5-FU) is used for the treatment of colorectal cancer, but has low therapeutic response rate and severe side effects. Recently, fish oil (FO) rich in n-3 polyunsaturated fatty acids has been preferred to chemosensitize tumor cells to anticancer drugs. Therefore, the current study is designed to evaluate chemotherapeutic efficacy and toxicity profile of 5-FU in combination with FO in 1,2-dimethylhydrazine dihydrochloride/dextran sulfate sodium (DMH/DSS)-induced colon cancer model. METHODS The therapeutic efficacy of 5-FU along with FO was analyzed through assessment of survival rate, tumor burden, volume, serum sialic acid levels, cytokeratin 19 (CK19) expression and index of cell proliferation such as cell cycle progression. Toxicological aspects were evaluated by standard functional and structural parameters related to spleen, gastrointestinal, liver and kidney. RESULTS In the present study, 5-FU in combination with FO increased the survival rate in carcinogen-treated animals. Synergism of 5-FU and FO was also reflected in significant inhibition in tumor growth and serum sialic acid levels in DMH/DSS model. Moreover, the combination dosage significantly augmented the inhibition of cell cycle progression, as shown by CK19 expression. Additionally, FO ameliorated hematologic depression, gastrointestinal, hepatic and renal toxicity caused by 5-FU as substantiated by a marked improvement in structural and functional alterations of these organs. CONCLUSION The supplementation of FO is potentially a promising option for increasing the therapeutic potential and mitigating the side effects of 5-FU.
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Affiliation(s)
- Isha Rani
- Department of Biochemistry, Panjab University, Chandigarh, 160014, India
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Danson SJ, Johnson P, Ward TH, Dawson M, Denneny O, Dickinson G, Aarons L, Watson A, Jowle D, Cummings J, Robson L, Halbert G, Dive C, Ranson M. Phase I pharmacokinetic and pharmacodynamic study of the bioreductive drug RH1. Ann Oncol 2011; 22:1653-1660. [PMID: 21378203 DOI: 10.1093/annonc/mdq638] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This trial describes a first-in-man evaluation of RH1, a novel bioreductive drug activated by DT-diaphorase (DTD), an enzyme overexpressed in many tumours. PATIENTS AND METHODS A dose-escalation phase I trial of RH1 was carried out. The primary objective was to establish the maximum tolerated dose (MTD) of RH1. Secondary objectives were assessment of toxicity, pharmacokinetic determination of RH1 and pharmacodynamic assessment of drug effect through measurement of DNA cross linking in peripheral blood mononuclear cells (PBMCs) and tumour, DTD activity in tumour and NAD(P)H:quinone oxidoreductase 1 (NQO1) polymorphism status. RESULTS Eighteen patients of World Health Organization performance status of zero to one with advanced refractory solid malignancies were enrolled. MTD was 1430 μg/m(2)/day with reversible bone marrow suppression being dose limiting. Plasma pharmacokinetic analysis showed RH1 is rapidly cleared from blood (t(1/2) = 12.3 min), with AUC increasing proportionately with dose. The comet-X assay demonstrated dose-related increases in DNA cross linking in PBMCs. DNA cross linking was demonstrated in tumours, even with low levels of DTD. Only one patient was homozygous for NQO1 polymorphism precluding any conclusion of its effect. CONCLUSIONS RH1 was well tolerated with predictable and manageable toxicity. The MTD of 1430 μg/m(2)/day is the dose recommended for phase II trials. The biomarkers of DNA cross linking, DTD activity and NQO1 status have been validated and clinically developed.
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Affiliation(s)
- S J Danson
- Department of Medical Oncology, University of Manchester, Christie Hospital NHS Foundation Trust, Manchester; Clinical and Experimental Pharmacology, Paterson Institute for Cancer Research.
| | - P Johnson
- Cancer Research UK Clinical Centre, Southampton General Hospital, Southampton
| | - T H Ward
- Clinical and Experimental Pharmacology, Paterson Institute for Cancer Research
| | - M Dawson
- Clinical and Experimental Pharmacology, Paterson Institute for Cancer Research
| | - O Denneny
- Clinical and Experimental Pharmacology, Paterson Institute for Cancer Research
| | - G Dickinson
- School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester
| | - L Aarons
- School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester
| | - A Watson
- Cancer Research UK Clinical Centre, Southampton General Hospital, Southampton
| | - D Jowle
- Department of Medical Oncology, University of Manchester, Christie Hospital NHS Foundation Trust, Manchester
| | - J Cummings
- Clinical and Experimental Pharmacology, Paterson Institute for Cancer Research
| | - L Robson
- Cancer Research UK Drug Development Office, Cancer Research UK, London
| | - G Halbert
- Cancer Research UK Formulation Unit, University of Strathclyde, Glasgow, UK
| | - C Dive
- Clinical and Experimental Pharmacology, Paterson Institute for Cancer Research
| | - M Ranson
- Department of Medical Oncology, University of Manchester, Christie Hospital NHS Foundation Trust, Manchester; Clinical and Experimental Pharmacology, Paterson Institute for Cancer Research
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Stewart DJ, Whitney SN, Kurzrock R. Equipoise Lost: Ethics, Costs, and the Regulation of Cancer Clinical Research. J Clin Oncol 2010; 28:2925-35. [PMID: 20406924 DOI: 10.1200/jco.2009.27.5404] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Cancer is the leading cause of death in Americans younger than 85 years of age and kills one American every 56 seconds. Advances in understanding of cancer biology have given us the potential to develop new, effective targeted therapies. However, progress is slowed by suboptimal/outdated clinical trial design paradigms and by regulatory complexity and rigidity. For instance, simulations suggest that restricting randomized trials to patients expressing drug target, instead of using unselected patient populations, could substantially reduce patient numbers required to demonstrate efficacy. High response rates that are achievable when patients and drugs are matched on the basis of molecular profiles may also make some randomized trials unnecessary or unjustifiable. Moreover, increasing the regulatory rigidity of clinical trials (regulatory fundamentalism) augments trial complexity and costs while slowing progress without demonstrating meaningful safety benefits. Time from drug discovery to marketing increased from 8 years in 1960 to 12 to 15 years currently. Toxic death rates on phase I trials have decreased from 0.8% in 1979 to 0.5% by 2002, but the estimated cost per life-year gained by tighter regulations is $2,700,000 (far higher than costs of other health measures), and simulations suggest that regulatory delays in development of effective therapies result in tens to hundreds of thousands of life-years lost, whereas stringent regulations save extremely few. Dysregulation is also a major disincentive to patient and clinician participation in clinical research. In summary, current approaches squander research resources and discourage research participation, and the marked imbalance between potential life-years lost versus saved renders the regulatory burden potentially unethical. We outline suggested solutions.
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Affiliation(s)
- David J. Stewart
- From The University of Texas M. D. Anderson Cancer Center and Baylor College of Medicine, Houston, TX
| | - Simon N. Whitney
- From The University of Texas M. D. Anderson Cancer Center and Baylor College of Medicine, Houston, TX
| | - Razelle Kurzrock
- From The University of Texas M. D. Anderson Cancer Center and Baylor College of Medicine, Houston, TX
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Le Tourneau C, Stathis A, Vidal L, Moore MJ, Siu LL. Choice of Starting Dose for Molecularly Targeted Agents Evaluated in First-in-Human Phase I Cancer Clinical Trials. J Clin Oncol 2010; 28:1401-7. [DOI: 10.1200/jco.2009.25.9606] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose One tenth of the lethal dose to 10% of mice is one of the conventional parameters used to derive a safe starting dose in phase I trials of cytotoxic agents. There is no consensus on which preclinical models and parameters should define the starting dose for molecularly targeted agents. Patients and Methods Reports of 81 first-in-human phase I trials evaluating 60 different molecularly targeted agents administered as monotherapy were reviewed. The maximum-tolerated dose (MTD) was defined as the highest safe dose administered to patients, whereas the maximum-administered dose (MAD) was recorded if the MTD was not reached. Results Fifty-seven of the 81 trials specified the animal model used to determine the starting dose, with 29 (51%) of 57 based on rodent data and 28 (49%) of 57 based on non-rodent data. A wide range of toxicologic parameters was used to select the starting dose. The starting dose exceeded the human MTD in three (3.7%) of 81 trials, and in all three trials, nonhematologic toxicity was dose limiting. The median number of dose levels to reach MTD or MAD from starting dose was five (range, one to 14 dose levels), and the median ratio of MTD or MAD to starting dose was 12 (range, < 1 to 300). Hypothetical doubling of the starting dose appeared to be safe, whereas tripling of the starting dose was unsafe. Conclusion The derivation of starting dose for first-in-human phase I trials of molecularly targeted agents in patients with cancer is safe but is based on diverse practices using a variety of preclinical toxicologic parameters.
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Affiliation(s)
- Christophe Le Tourneau
- From the Division of Medical Oncology and Hematology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Anastasios Stathis
- From the Division of Medical Oncology and Hematology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Laura Vidal
- From the Division of Medical Oncology and Hematology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Malcolm J. Moore
- From the Division of Medical Oncology and Hematology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Lillian L. Siu
- From the Division of Medical Oncology and Hematology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Canada
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Anderson JA, Kimmelman J. Extending clinical equipoise to phase 1 trials involving patients: unresolved problems. KENNEDY INSTITUTE OF ETHICS JOURNAL 2010; 20:75-98. [PMID: 20506695 PMCID: PMC4482670 DOI: 10.1353/ken.0.0307] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Notwithstanding requirements for scientific/social value and risk/benefit proportionality in major research ethics policies, there are no widely accepted standards for these judgments in Phase 1 trials. This paper examines whether the principle of clinical equipoise can be used as a standard for assessing the ratio of risk to direct-benefit presented by drugs administered in one category of Phase 1 study--first-in-human trials involving patients. On the basis of the supporting evidence for, and architecture of, Phase 1 studies, the articles offers two provisional conclusions: (1) the risks of drug administration in such trials cannot generally be justified on therapeutic grounds but by appeal to the social value of the research; and (2) a framework for adjudicating the ratio of risk/social-value must be developed.
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Affiliation(s)
- James A Anderson
- Biomedical Ethics Unit, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
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Rosenfeldt H, Kropp T, Benson K, Ricci MS, McGuinn WD, Verbois SL. Regulatory aspects of oncology drug safety evaluation: Past practice, current issues, and the challenge of new drugs. Toxicol Appl Pharmacol 2010; 243:125-33. [DOI: 10.1016/j.taap.2009.12.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 12/14/2009] [Accepted: 12/14/2009] [Indexed: 11/29/2022]
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Scaling the time-course of myelosuppression from rats to patients with a semi-physiological model. Invest New Drugs 2009; 28:744-53. [DOI: 10.1007/s10637-009-9308-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 08/11/2009] [Indexed: 11/26/2022]
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29
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Direct in vivo xenograft tumor model for predicting chemotherapeutic drug response in cancer patients. Clin Pharmacol Ther 2008; 85:217-21. [PMID: 19005462 DOI: 10.1038/clpt.2008.200] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Talmadge JE, Singh RK, Fidler IJ, Raz A. Murine models to evaluate novel and conventional therapeutic strategies for cancer. THE AMERICAN JOURNAL OF PATHOLOGY 2007; 170:793-804. [PMID: 17322365 PMCID: PMC1864878 DOI: 10.2353/ajpath.2007.060929] [Citation(s) in RCA: 333] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/12/2006] [Indexed: 12/20/2022]
Abstract
Animal models, by definition, are an approximation of reality, and their use in developing anti-cancer drugs is controversial. Positive retrospective clinical correlations have been identified with several animal models, in addition to limitations and a need for improvement. Model inadequacies include experimental designs that do not incorporate biological concepts, drug pharmacology, or toxicity. Ascites models have been found to identify drugs active against rapidly dividing tumors; however, neither ascitic nor transplantable subcutaneous tumors are predictive of activity for solid tumors. In contrast, primary human tumor xenografts have identified responsive tumor histiotypes if relevant pharmacodynamic and toxicological parameters were considered. Murine toxicology studies are also fundamental because they identify safe starting doses for phase I protocols. We recommend that future studies incorporate orthotopic and spontaneous metastasis models (syngeneic and xenogenic) because they incorporate microenvironmental interactions, in addition to confirmatory autochthonous models and/or genetically engineered models, for molecular therapeutics. Collectively, murine models are critical in drug development, but require a rational and hierarchical approach beginning with toxicology and pharmacology studies, progressing to human primary tumors to identify therapeutic targets and models of metastatic disease from resected orthotopic, primary tumors to compare drugs using rigorous, clinically relevant outcome parameters.
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Affiliation(s)
- James E Talmadge
- University of Nebraska Medical Center, 987660 Nebraska Medical Center, Omaha, NE 68198-7660, USA.
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31
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Kimmelman J. Ethics at phase 0: clarifying the issues. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2007; 35:727-514. [PMID: 18076522 DOI: 10.1111/j.1748-720x.2007.00194.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The Food and Drug Administration (FDA) and the European Agency for the Evaluation of Medicinal Products (EMEA) recently issued documents encouraging sponsors to consider microdose testing before launching Phase I trials, and many commentators predict that such methodologies will be applied more routinely in drug development. However, exploratory testing has provoked several ethical criticisms. Skeptics question the value and validity of microdose trials, and whether they present a reasonable balance of risks and benefits for subjects. Another major criticism is that such studies serve mainly commercial ends. The present article explores these and other ethical concerns for studies conducted in the oncology setting. It concludes that microdosing is not inconsistent with prevailing practices in Phase I research, and that in principle, such studies could strengthen the ethical basis for Phase I trials by providing them better evidentiary justification.
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Cummings J, Ward TH, Ranson M, Dive C. Apoptosis pathway-targeted drugs--from the bench to the clinic. Biochim Biophys Acta Rev Cancer 2005; 1705:53-66. [PMID: 15585173 DOI: 10.1016/j.bbcan.2004.09.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
It is an exciting time for cancer researchers in the field of apoptotic cell death. The avalanche of discoveries over the past decade or so regarding how apoptosis is regulated begins to be exploited for therapeutic benefit as the first apoptosis-targeted drugs enter early clinical trials. This chapter provides a selective review on the development of such drugs. We also outline issues regarding the regulation and design of early clinical trials of this type of molecularly targeted agent. Finally, we discuss the biomarkers and surrogate pharmacodynamic endpoint assays currently available to chart the efficacy of apoptosis-inducing anticancer therapy.
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Affiliation(s)
- Jeff Cummings
- Clinical and Experimental Pharmacology Group, Cancer Research UK Paterson Institute, Wilmslow Road, Manchester M20 4BX, UK
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Tomaszewski JE. Multi-species toxicology approaches for oncology drugs. Eur J Cancer 2004; 40:907-13. [PMID: 15120046 DOI: 10.1016/j.ejca.2003.11.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2003] [Accepted: 11/21/2003] [Indexed: 11/16/2022]
Abstract
The Toxicology and Pharmacology Branch (T&PB) of the National Cancer Institute (NCI) performs pharmacological and toxicological evaluations of new oncology agents according to an agent-directed paradigm in which all studies are tailored to each agent. The United States Food and Drug Administration (US FDA) requires that preclinical toxicology studies be conducted in two species, a rodent and a non-rodent for all small molecules, and T&PB has successfully used this formula. While pharmacokinetic (PK) studies are considered optional, T&PB routinely develops new methods for plasma/tissue drug analysis and employs this methodology throughout development to determine kinetics in various species and toxicokinetics in the toxicity studies. In the current era of molecular target-based development, the T&PB also develops or employs methodology to evaluate effects of the new chemical entity on appropriate biomarkers in tumour and normal tissues. In this comprehensive programme, T&PB is able to correlate safety and toxicity with both plasma drug levels and biomarker modulation in two species for a seamless entry into Phase I.
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Affiliation(s)
- Joseph E Tomaszewski
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Executive Plaza North, Room 8034, 6130 Executive Boulevard, Rockville, MD 20852, USA.
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Newell DR, Searle KM, Westwood NB, Burtles SS. Professor Tom Connors and the development of novel cancer therapies by the Phase I/II Clinical Trials Committee of Cancer Research UK. Br J Cancer 2003; 89:437-54. [PMID: 12888809 PMCID: PMC2394365 DOI: 10.1038/sj.bjc.6601106] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- D R Newell
- Northern Institute for Cancer Research, University of Newcastle upon Tyne, Framlington Place, Newcastle upon Tyne NE2 4HH, UK
| | - K M Searle
- Drug Development Office, Cancer Research UK, PO Box 123, 61 Lincoln's Inn Fields, London WC2A 3PX, UK
| | - N B Westwood
- Drug Development Office, Cancer Research UK, PO Box 123, 61 Lincoln's Inn Fields, London WC2A 3PX, UK
| | - S S Burtles
- Drug Development Office, Cancer Research UK, PO Box 123, 61 Lincoln's Inn Fields, London WC2A 3PX, UK
- Drug Development Office, Cancer Research UK, PO Box 123, 61 Lincoln's Inn Fields, London WC2A 3PX, UK. E-mail:
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Professor Tom Connors and the development of novel cancer therapies by the Phase I/II Clinical Trials Committee of Cancer Research UK. Br J Cancer 2003. [PMID: 12888809 DOI: 10.1038/sj.bjc.6601106+[doi]] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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36
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Newell DR, Searle KM, Westwood NB, Burtles SS. Professor Tom Connors and the development of novel cancer therapies by the Phase I/II Clinical Trials Committee of Cancer Research UK. Br J Cancer 2003. [DOI: 10.1038/sj.bjc.6601106 [doi]] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Califf RM, Morse MA, Wittes J, Goodman SN, Nelson DK, DeMets DL, Iafrate RP, Sugarman J. Toward protecting the safety of participants in clinical trials. CONTROLLED CLINICAL TRIALS 2003; 24:256-71. [PMID: 12757992 DOI: 10.1016/s0197-2456(03)00005-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It is a widely held belief that the current system of oversight of clinical research, particularly the means of assessing risks and minimizing harms to participants in clinical trials, could be improved. In particular, the system is inefficient with overemphasis on the monitoring ability of some groups such as research ethics review boards and investigators, underemphasis on others such as data monitoring committees (DMCs) and sponsors, confusion about responsibilities for safety and imperfect communication between these different groups. Research ethics review boards are not able to perform safety monitoring by review of individual adverse events and are often burdened by duplicative reviews of large multicenter studies. There are no standards for DMCs to ensure they can reliably identify safety issues. Sponsors may be overreliant on data audits and slow to disseminate safety data in a coherent summary. Investigators, their staffs and clinical sites may not fully appreciate all the nuances of good clinical practice or may be inattentive to the daily conduct of studies. Regulators, particularly those in the United States, have failed to completely harmonize their policies with each other or with international regulatory agencies. We recommend well-designed monitoring plans for all studies that are appropriate to their scope and risk, more centralized review of large multisite studies and closer local scrutiny of single-institution studies. In addition, sponsors should pay greater attention to monitoring adverse events and keeping up-to-date databases or investigator's brochures emphasizing safety issues. A minimal standard of education or expertise in good clinical practice should be established for investigators, their staffs and research ethics review board members. DMC composition and functions should be standardized and regulations should be harmonized nationally and internationally. Finally, there should be a concerted effort to study the efficacy of various components of the system.
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Affiliation(s)
- Robert M Califf
- Duke Clinical Research Institute, Duke University Medical Center, PO Box 17969, Durham, NC 27715, USA.
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Double J, Barrass N, Barnard ND, Navaratnam V. Toxicity testing in the development of anticancer drugs. Lancet Oncol 2002; 3:438-42. [PMID: 12142174 DOI: 10.1016/s1470-2045(02)00791-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- John Double
- Cancer Research Unit, The Tom Connors Cancer Research Centre, University of Bradford, Bradford, UK
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Burger AM, Hartung G, Stehle G, Sinn H, Fiebig HH. Pre-clinical evaluation of a methotrexate-albumin conjugate (MTX-HSA) in human tumor xenografts in vivo. Int J Cancer 2001; 92:718-24. [PMID: 11340578 DOI: 10.1002/1097-0215(20010601)92:5<718::aid-ijc1257>3.0.co;2-d] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Methotrexate covalently bound to human serum albumin in a 1:1 molar ratio (MTX-HSA) is a new macromolecular drug which is currently being studied in phase I clinical trials by the German Association for Medical Oncology (AIO) Phase I/II study group. Previous studies have shown that MTX-HSA differs favorably from unbound MTX in terms of plasma half-life time, tumor accumulation of albumin and uptake mechanisms into cancer cells. To achieve optimal drug efficacy, repeated treatment cycles were necessary. To evaluate the anti-tumor activity of MTX-HSA and MTX in pre-clinical in vivo models, we selected 7 solid human tumor xenografts growing s.c. in nude mice and administered drug either i.p. or i.v. weekly for 3 weeks. The maximal tolerated dose (MTD) of MTX-HSA in nude mice was 12.5 mg/kg given i.p. on days 1, 8 and 15, whereas the MTD for free MTX was 100 mg/kg given i.v. MTX-HSA was significantly more active (p > 0.01) than MTX in 3 models. In the soft tissue sarcoma SXF 1301, MTX-HSA effected complete remission/cure after a single injection, whereas free MTX resulted in short-lasting, partial tumor regression. In the prostate-cancer model PRXF PC3M, MTX-HSA produced growth inhibition of 92.8% of control or an optimal test/control (T/C) of 7.2% compared to a T/C of 20.8% for MTX (p = 0.05). In the osteosarcoma model SXF 1410, optimal T/C values were 10.2% and 14.5%, respectively (p = 0.025). In lung cancers LXFE 409 and LXFL 529, bladder cancer BXF 1258 and breast cancer MAXF 449, both compounds were inactive. The improved therapeutic effects seen in 3 xenograft models under MTX-HSA treatment are promising and might be due to specific accumulation of the compound in solid tumors owing to their enhanced permeability and retention effect. Thus, clinical development of MTX-HSA will continue and sarcomas as well as prostate cancers will be included as potential target tumors for upcoming clinical phase II trials.
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Affiliation(s)
- A M Burger
- Tumor Biology Center at the University of Freiburg, Breisacherstr. 117, D-79106 Freiburg, Germany
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Abstract
Current preclinical safety evaluation programs use a combination of computational methods, mechanistic in vitro screening and - primarily - in vivo experimentation to predict human toxicity. The rapid transition of pharmaceutical R&D into electronic R&D (e-R&D) makes it imperative that predictive safety testing also develops into an information-rich, knowledge-based process in the near future. Accordingly, enhanced databases and computational tools are expected to change the way the pharmaceutical industry assesses drug toxicity during discovery and early development. Expert use of prediction tools should lead to lower failure rates in drug development and decrease the cost and time involved in successful drug approval.
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Abstract
There is enormous potential for the discovery of innovative cancer drugs with improved efficacy and selectivity for the third millennium. In this review we show how novel mechanism-based agents are being discovered by focusing on the molecular targets and pathways that are causally involved in cancer formation, maintenance and progression. We also show how new technologies, from genomics through high through-put bioscience, combinatorial chemistry, rational drug design and molecular pharmacodynamic and imaging techniques, are accelerating the pace of cancer drug discovery. The process of contemporary small molecule drug discovery is described and progress and current issues are reviewed. New and potential targets and pathways for therapeutic intervention are illustrated. The first examples of a new generation of molecular therapeutics are now entering hypothesis-testing clinical trials and showing activity. The early years of the new millennium will see a range of exciting new agents moving from bench to bedside and beginning to impact on the management and cure of cancer.
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Affiliation(s)
- M D Garrett
- CRC Centre for Cancer Therapeutics, The Institute of Cancer Research, Sutton, Surrey, U.K
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