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Watanabe S, Nonaka T, Maeda M, Yamada M, Sugii N, Hashimoto K, Takano S, Koyanagi T, Arakawa Y, Ishikawa E. Recent Status of Phase I Clinical Trials for Brain Tumors: A Regulatory Science Study of Exploratory Efficacy Endpoints. Ther Innov Regul Sci 2024; 58:655-662. [PMID: 38530629 PMCID: PMC11169007 DOI: 10.1007/s43441-024-00644-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/15/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Appropriate exploratory efficacy data from Phase I trials are vital for subsequent phases. Owing to the uniqueness of brain tumors (BTs), use of different strategies to evaluate efficacy is warranted. We studied exploratory efficacy evaluation in Phase I trials involving BTs. METHODS Using Clarivate's Cortellis™, 42 Phase I trials of BT interventions conducted from 2020 to 2022 were analyzed for efficacy endpoints, which were set as primary endpoints (PEs) or secondary endpoints (SEs). Additionally, these metrics were compared in two subgroups: trials including only BTs (Group-A) and those including BTs among mixed solid tumors (Group-B). RESULTS Selected studies included a median of 1.5 PEs (range, 1-6) and 5 SEs (range, 0-19). Efficacy endpoints were included as PEs and SEs in 2 (5%) and 31 (78%) trials, respectively. Among the latter 31 trials that included 94 efficacy endpoints, 24, 22, 20, 9, and 8 reflected overall response rate (ORR), progression-free survival (PFS), overall survival (OS), duration of response (DOR), and disease control rate (DCR), respectively. ORR for BT was determined using various methods; however, the Response Evaluation Criteria in Solid Tumors (RECIST) was used less frequently in Group-A than in Group-B (p = 0.0039). CONCLUSIONS Recent Phase I trials included efficacy endpoints as SEs, with ORR, PFS, or OS included in ~ 50% trials and DOR or DCR in ~ 25%. No established criteria exist for imaging evaluation of BTs. Phase I trials involving mixed solid tumor cohorts revealed challenges in designing methods to assess the exploratory efficacy of BTs.
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Affiliation(s)
- Shinya Watanabe
- Department of Neurosurgery, Mito Kyodo General Hospital, Tsukuba University Hospital Mito Area Medical Education Center, 3-2-7 Miyamachi, Mito, 310-0015, Ibaraki, Japan.
- Department of Neurosurgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan.
| | - Takahiro Nonaka
- Department of Health and Medical Innovation, Graduate School of Medicine, Osaka Metropolitan University School, Osaka, Japan
| | - Makoto Maeda
- Department of, Pharmacy, National Cancer Center Hospital, Tokyo, Japan
| | - Masanobu Yamada
- Tsukuba Clinical Research and Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Narushi Sugii
- Department of Neurosurgery, University of Tsukuba Hospital, Tsukuba, Japan
| | - Koichi Hashimoto
- Tsukuba Clinical Research and Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Shingo Takano
- Department of Neurosurgery, University of Tsukuba Hospital, Tsukuba, Japan
- Tsukuba Clinical Research and Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Tomoyoshi Koyanagi
- Tsukuba Clinical Research and Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Yoshihiro Arakawa
- Tsukuba Clinical Research and Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
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Tu Y, Renfro LA. Biomarker-driven basket trial designs: origins and new methodological developments. J Biopharm Stat 2024:1-13. [PMID: 38832723 DOI: 10.1080/10543406.2024.2358806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 05/12/2024] [Indexed: 06/05/2024]
Abstract
Due to increased use of gene sequencing techniques, understanding of cancer on a molecular level has evolved, in terms of both diagnosis and evaluation in response to initial therapies. In parallel, clinical trials meant to evaluate molecularly-driven interventions through assessment of both treatment effects and putative predictive biomarker effects are being employed to advance the goals of precision medicine. Basket trials investigate one or more biomarker-targeted therapies across multiple cancer types in a tumor location agnostic fashion. The review article offers an overview of the traditional forms of such designs, the practical challenges facing each type of design, and then review novel adaptations proposed in the last few years, categorized into Bayesian and Classical Frequentist perspectives. The review article concludes by summarizing potential advantages and limitations of the new trial design solutions.
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Affiliation(s)
- Yue Tu
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Lindsay A Renfro
- Department of Population and Public Health Sciences, University of Southern California and Children's Oncology Group, Los Angeles, California, USA
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Lee CK, Park S, Nam CM, Chung HC, Rha SY. Reply to B. Freidlin et al. J Clin Oncol 2024; 42:1455-1456. [PMID: 38437615 DOI: 10.1200/jco.24.00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/05/2024] [Indexed: 03/06/2024] Open
Affiliation(s)
- Choong-Kun Lee
- Choong-kun Lee, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; Sejung Park, PhD, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; Chung Mo Nam, PhD, Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea; Hyun Cheol Chung, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; and Sun Young Rha, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Sejung Park
- Choong-kun Lee, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; Sejung Park, PhD, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; Chung Mo Nam, PhD, Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea; Hyun Cheol Chung, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; and Sun Young Rha, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Chung Mo Nam
- Choong-kun Lee, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; Sejung Park, PhD, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; Chung Mo Nam, PhD, Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea; Hyun Cheol Chung, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; and Sun Young Rha, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Cheol Chung
- Choong-kun Lee, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; Sejung Park, PhD, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; Chung Mo Nam, PhD, Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea; Hyun Cheol Chung, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; and Sun Young Rha, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Young Rha
- Choong-kun Lee, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; Sejung Park, PhD, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; Chung Mo Nam, PhD, Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea; Hyun Cheol Chung, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea; and Sun Young Rha, MD, PhD, Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea, Songdang Institute for Cancer Research, Yonsei University College of Medicine, Seoul, Korea, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
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Chen J, Li XN, Lu CC, Yuan S, Yung G, Ye J, Tian H, Lin J. Considerations for master protocols using external controls. J Biopharm Stat 2024:1-23. [PMID: 38363805 DOI: 10.1080/10543406.2024.2311248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 01/24/2024] [Indexed: 02/18/2024]
Abstract
There has been an increasing use of master protocols in oncology clinical trials because of its efficiency to accelerate cancer drug development and flexibility to accommodate multiple substudies. Depending on the study objective and design, a master protocol trial can be a basket trial, an umbrella trial, a platform trial, or any other form of trials in which multiple investigational products and/or subpopulations are studied under a single protocol. Master protocols can use external data and evidence (e.g. external controls) for treatment effect estimation, which can further improve efficiency of master protocol trials. This paper provides an overview of different types of external controls and their unique features when used in master protocols. Some key considerations in master protocols with external controls are discussed including construction of estimands, assessment of fit-for-use real-world data, and considerations for different types of master protocols. Similarities and differences between regular randomized controlled trials and master protocols when using external controls are discussed. A targeted learning-based causal roadmap is presented which constitutes three key steps: (1) define a target statistical estimand that aligns with the causal estimand for the study objective, (2) use an efficient estimator to estimate the target statistical estimand and its uncertainty, and (3) evaluate the impact of causal assumptions on the study conclusion by performing sensitivity analyses. Two illustrative examples for master protocols using external controls are discussed for their merits and possible improvement in causal effect estimation.
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Affiliation(s)
- Jie Chen
- Data Sciences, ECR Global, Shanghai, China
| | | | | | - Sammy Yuan
- Oncology Statistics, GlaxoSmithKline, Collegeville, Pennsylvania, USA
| | - Godwin Yung
- Product Development Data and Statistical Sciences, Genentech/Roche, South San Francisco, Cambridge, USA
| | - Jingjing Ye
- Global Statistics and Data Sciences, BeiGene, Fulton, Maryland, USA
| | - Hong Tian
- Global Statistics, BeiGene, Ridgefield Park, New Jersy, USA
| | - Jianchang Lin
- Statistical & Quantitative Sciences, Takeda, Cambridge, Massachusetts, USA
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Parashar D. Unlocking multidimensional cancer therapeutics using geometric data science. Sci Rep 2023; 13:8255. [PMID: 37217528 DOI: 10.1038/s41598-023-34853-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 05/09/2023] [Indexed: 05/24/2023] Open
Abstract
Personalised approaches to cancer therapeutics primarily involve identification of patient sub-populations most likely to benefit from targeted drugs. Such a stratification has led to plethora of designs of clinical trials that are often too complex due to the need for incorporating biomarkers and tissue types. Many statistical methods have been developed to address these issues; however, by the time such methodology is available research in cancer has moved on to new challenges and therefore in order to avoid playing catch-up it is necessary to develop new analytic tools alongside. One of the challenges facing cancer therapy is to effectively and appropriately target multiple therapies for sensitive patient population based on a panel of biomarkers across multiple cancer types, and matched future trial designs. We present novel geometric methods (mathematical theory of hypersurfaces) to visualise complex cancer therapeutics data as multidimensional, as well as geometric representation of oncology trial design space in higher dimensions. The hypersurfaces are used to describe master protocols, with application to a specific example of a basket trial design for melanoma, and thus setup a framework for further incorporating multi-omics data as multidimensional therapeutics.
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Affiliation(s)
- Deepak Parashar
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK.
- Warwick Cancer Research Centre, University of Warwick, Coventry, UK.
- The Alan Turing Institute for Data Science and Artificial Intelligence, The British Library, London, UK.
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6
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Aqib A, Lebouché B, Engler K, Schuster T. Feasibility of a Platform Trial Design for the Development of Mobile Health Applications: A Review. Telemed J E Health 2022; 29:501-509. [PMID: 35951018 DOI: 10.1089/tmj.2021.0620] [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: 11/13/2022] Open
Abstract
Background: A novel adaptive trial design called platform trials (PTs) may offer an effective, efficient, and unbiased approach to evaluate different developer versions of mobile health (m-health) apps. However, the feasibility of their use for this purpose is yet to be explored. Objective: This literature review aims to explore the reported challenges associated with the adaptive PT design to assess its feasibility for the development of m-health apps. Methods: A descriptive literature review using two databases (MEDLINE and Embase) was conducted. Documents published in English between 1947 and September 20, 2020, were eligible for inclusion. Results: The titles and abstracts of 758 records were screened after which 179 full-text articles were assessed for eligibility. A total of 41 articles were included in the synthesis, all published after the year 2000. The synthesis yielded eight distinct categories of challenging issues with PTs relevant to their application in m-health app development, along with potential solutions. These categories are ethical issues (e.g., related to informed consent, equipoise, justice) (with 19 articles contributing content), biases (7 articles), temporal drift (4 articles), miscellaneous statistical issues (3 articles), logistical issues (e.g., cost and human resources, frequent amendments; 6 articles), sample size and power conflict (2 articles), generalizability of the results (2 articles), and operational challenges (1 article). Conclusion: Although PT designs are relatively new, they have promising feasibility for the seamless evaluation of interventions that undergo continuous development, including m-health apps; however, various challenges may hinder their successful implementation.
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Affiliation(s)
- Asma Aqib
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada.,Department of Internal Medicine, University of Alabama, Montgomery, Alabama, USA
| | - Bertrand Lebouché
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada.,Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, Canada.,Chronic Viral Illness Service, Royal Victoria Hospital, McGill University Health Centre, Montreal, Canada
| | - Kim Engler
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, Canada
| | - Tibor Schuster
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
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7
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Strzebonska K, Blukacz M, Wasylewski MT, Polak M, Gyawali B, Waligora M. Risk and benefit for umbrella trials in oncology: a systematic review and meta-analysis. BMC Med 2022; 20:219. [PMID: 35799149 PMCID: PMC9264503 DOI: 10.1186/s12916-022-02420-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 05/30/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Umbrella clinical trials in precision oncology are designed to tailor therapies to the specific genetic changes within a tumor. Little is known about the risk/benefit ratio for umbrella clinical trials. The aim of our systematic review with meta-analysis was to evaluate the efficacy and safety profiles in cancer umbrella trials testing targeted drugs or a combination of targeted therapy with chemotherapy. METHODS Our study was prospectively registered in PROSPERO (CRD42020171494). We searched Embase and PubMed for cancer umbrella trials testing targeted agents or a combination of targeted therapies with chemotherapy. We included solid tumor studies published between 1 January 2006 and 7 October 2019. We measured the risk using drug-related grade 3 or higher adverse events (AEs), and the benefit by objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). When possible, data were meta-analyzed. RESULTS Of the 6207 records identified, we included 31 sub-trials or arms of nine umbrella trials (N = 1637). The pooled overall ORR was 17.7% (95% confidence interval [CI] 9.5-25.9). The ORR for targeted therapies in the experimental arms was significantly lower than the ORR for a combination of targeted therapy drugs with chemotherapy: 13.3% vs 39.0%; p = 0.005. The median PFS was 2.4 months (95% CI 1.9-2.9), and the median OS was 7.1 months (95% CI 6.1-8.4). The overall drug-related death rate (drug-related grade 5 AEs rate) was 0.8% (95% CI 0.3-1.4), and the average drug-related grade 3/4 AE rate per person was 0.45 (95% CI 0.40-0.50). CONCLUSIONS Our findings suggest that, on average, one in five cancer patients in umbrella trials published between 1 January 2006 and 7 October 2019 responded to a given therapy, while one in 125 died due to drug toxicity. Our findings do not support the expectation of increased patient benefit in cancer umbrella trials. Further studies should investigate whether umbrella trial design and the precision oncology approach improve patient outcomes.
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Affiliation(s)
- Karolina Strzebonska
- Research Ethics in Medicine Study Group (REMEDY), Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Mateusz Blukacz
- Institute of Psychology, University of Silesia, Katowice, Poland
- Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Mateusz T. Wasylewski
- Research Ethics in Medicine Study Group (REMEDY), Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Maciej Polak
- Research Ethics in Medicine Study Group (REMEDY), Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
- Department of Epidemiology and Population Studies, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Bishal Gyawali
- Department of Oncology and the Department of Public Health Sciences, Queen’s University, Kingston, Ontario Canada
| | - Marcin Waligora
- Research Ethics in Medicine Study Group (REMEDY), Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
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Murphy P, Glynn D, Dias S, Hodgson R, Claxton L, Beresford L, Cooper K, Tappenden P, Ennis K, Grosso A, Wright K, Cantrell A, Stevenson M, Palmer S. Modelling approaches for histology-independent cancer drugs to inform NICE appraisals: a systematic review and decision-framework. Health Technol Assess 2022; 25:1-228. [PMID: 34990339 DOI: 10.3310/hta25760] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The first histology-independent marketing authorisation in Europe was granted in 2019. This was the first time that a cancer treatment was approved based on a common biomarker rather than the location in the body at which the tumour originated. This research aims to explore the implications for National Institute for Health and Care Excellence appraisals. METHODS Targeted reviews were undertaken to determine the type of evidence that is likely to be available at the point of marketing authorisation and the analyses required to support National Institute for Health and Care Excellence appraisals. Several challenges were identified concerning the design and conduct of trials for histology-independent products, the greater levels of heterogeneity within the licensed population and the use of surrogate end points. We identified approaches to address these challenges by reviewing key statistical literature that focuses on the design and analysis of histology-independent trials and by undertaking a systematic review to evaluate the use of response end points as surrogate outcomes for survival end points. We developed a decision framework to help to inform approval and research policies for histology-independent products. The framework explored the uncertainties and risks associated with different approval policies, including the role of further data collection, pricing schemes and stratified decision-making. RESULTS We found that the potential for heterogeneity in treatment effects, across tumour types or other characteristics, is likely to be a central issue for National Institute for Health and Care Excellence appraisals. Bayesian hierarchical methods may serve as a useful vehicle to assess the level of heterogeneity across tumours and to estimate the pooled treatment effects for each tumour, which can inform whether or not the assumption of homogeneity is reasonable. Our review suggests that response end points may not be reliable surrogates for survival end points. However, a surrogate-based modelling approach, which captures all relevant uncertainty, may be preferable to the use of immature survival data. Several additional sources of heterogeneity were identified as presenting potential challenges to National Institute for Health and Care Excellence appraisal, including the cost of testing, baseline risk, quality of life and routine management costs. We concluded that a range of alternative approaches will be required to address different sources of heterogeneity to support National Institute for Health and Care Excellence appraisals. An exemplar case study was developed to illustrate the nature of the assessments that may be required. CONCLUSIONS Adequately designed and analysed basket studies that assess the homogeneity of outcomes and allow borrowing of information across baskets, where appropriate, are recommended. Where there is evidence of heterogeneity in treatment effects and estimates of cost-effectiveness, consideration should be given to optimised recommendations. Routine presentation of the scale of the consequences of heterogeneity and decision uncertainty may provide an important additional approach to the assessments specified in the current National Institute for Health and Care Excellence methods guide. FURTHER RESEARCH Further exploration of Bayesian hierarchical methods could help to inform decision-makers on whether or not there is sufficient evidence of homogeneity to support pooled analyses. Further research is also required to determine the appropriate basis for apportioning genomic testing costs where there are multiple targets and to address the challenges of uncontrolled Phase II studies, including the role and use of surrogate end points. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 76. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Peter Murphy
- Centre for Reviews and Dissemination, University of York, York, UK
| | - David Glynn
- Centre for Health Economics, University of York, York, UK
| | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Robert Hodgson
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Lindsay Claxton
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Lucy Beresford
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Katy Cooper
- School of Health and Related Research (ScHARR) Technology Assessment Group, University of Sheffield, Sheffield, UK
| | - Paul Tappenden
- School of Health and Related Research (ScHARR) Technology Assessment Group, University of Sheffield, Sheffield, UK
| | - Kate Ennis
- School of Health and Related Research (ScHARR) Technology Assessment Group, University of Sheffield, Sheffield, UK
| | | | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR) Technology Assessment Group, University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR) Technology Assessment Group, University of Sheffield, Sheffield, UK
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, UK
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Zhao W, Ma W, Wang F, Hu F. Incorporating covariates information in adaptive clinical trials for precision medicine. Pharm Stat 2021; 21:176-195. [PMID: 34369053 DOI: 10.1002/pst.2160] [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: 06/23/2020] [Revised: 06/02/2021] [Accepted: 07/20/2021] [Indexed: 11/05/2022]
Abstract
Precision medicine is the systematic use of information that pertains to an individual patient to select or optimize that patient's preventative and therapeutic care. Recent studies have classified biomarkers into predictive and prognostic biomarkers based on their roles in clinical studies. To design a clinical trial for precision medicine, predictive biomarkers and prognostic biomarkers should both be included. In statistical analysis, biomarkers are mathematically treated as covariates. We first classify covariates into predictive and prognostic covariates according to their roles. We then provide a brief review of recent advances in adaptive designs that incorporate covariates. However, the literature includes no designs that incorporate both prognostic covariates and predictive covariates simultaneously. In this paper, we propose a new family of covariate-adjusted response-adaptive (CARA) designs that incorporate both prognostic and predictive covariates and the responses. It is important to note that the predictive biomarkers and prognostic biomarkers play different roles in the new designs. The advantages of the proposed methods are demonstrated via numerical studies, and some further statistical issues are also discussed.
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Affiliation(s)
- Wanying Zhao
- Department of Biostatistics, Incyte Corporation, Wilmington, Delaware, USA
| | - Wei Ma
- Institute of Statistics and Big Data, Renmin University of China, Beijing, China
| | - Fan Wang
- Department of Statistics, The George Washington University, Washington, District of Columbia, USA
| | - Feifang Hu
- Department of Statistics, The George Washington University, Washington, District of Columbia, USA
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Abstract
Innovative medicinal products are required to achieve progress in oncology; however, these are associated with high financial investments, extensive development times, and significant risk of potential failure in the pivotal clinical trials required for marketing authorization. With increasing budgetary constraints and requirements to demonstrate value, effective strategies to develop and commercialize innovative oncology products are more important than ever. Strategies that have proved successful in other industries require major revision for use in the oncology field, both during preclinical and clinical development as well as in the post approval value chain. This paper will examine how medicinal product strategy development differs from other industries. In particular, it will look at how the global trend toward value-based healthcare requires strategies that are based on an in-depth scientific understanding of the disease area and product-specific characteristics supported by clinical evidence. The findings are complemented by a review of the available literature and a survey of industry representatives.
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Murphy P, Claxton L, Hodgson R, Glynn D, Beresford L, Walton M, Llewellyn A, Palmer S, Dias S. Exploring Heterogeneity in Histology-Independent Technologies and the Implications for Cost-Effectiveness. Med Decis Making 2021; 41:165-178. [PMID: 33435846 PMCID: PMC7879234 DOI: 10.1177/0272989x20980327] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background The National Institute for Health and Care Excellence and a number of international health technology assessment agencies have recently undertaken appraisals of histology-independent technologies (HITs). A strong and untested assumption inherent in the submissions included identical clinical response across all tumour histologies, including new histologies unrepresented in the trial. Challenging this assumption and exploring the potential for heterogeneity has the potential to impact upon cost-effectiveness. Method Using published response data for a HIT, a Bayesian hierarchical model (BHM) was used to identify heterogeneity in response and to estimate the probability of response for each histology included in single-arm studies, which informed the submission for the HIT, larotrectinib. The probability of response for a new histology was estimated. Results were inputted into a simplified response-based economic model using hypothetical parameters. Histology-independent and histology-specific incremental cost-effectiveness ratios accounting for heterogeneity were generated. Results The results of the BHM show considerable heterogeneity in response rates across histologies. The predicted probability of response estimated by the BHM is 60.9% (95% credible interval 16.0; 91.8%), lower than the naively pooled probability of 74.5%. A mean response probability of 56.9% (0.2; 99.9%) is predicted for an unrepresented histology. Based on the economic analysis, the probability of the hypothetical HIT being cost-effective under the assumption of identical response is 78%. Allowing for heterogeneity, the probability of various approval decisions being cost-effective ranges from 93% to 11%. Conclusions Central to the challenge of reimbursement of HITs is the potential for heterogeneity. This study illustrates how heterogeneity in clinical effectiveness can result in highly variable and uncertain estimates of cost-effectiveness. This analysis can help improve understanding of the consequences of histology-independent versus histology-specific decisions.
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Affiliation(s)
- Peter Murphy
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
| | - Lindsay Claxton
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
| | - Robert Hodgson
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
| | - David Glynn
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Lucy Beresford
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
| | - Matthew Walton
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
| | - Alexis Llewellyn
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, Yorkshire, UK
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12
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Palmer AC, Plana D, Sorger PK. Comparing the Efficacy of Cancer Therapies between Subgroups in Basket Trials. Cell Syst 2020; 11:449-460.e2. [PMID: 33220857 PMCID: PMC8022348 DOI: 10.1016/j.cels.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 07/27/2020] [Accepted: 09/12/2020] [Indexed: 11/15/2022]
Abstract
The need to test anticancer drugs in multiple indications has been addressed by basket trials, which are Phase I or II clinical trials involving multiple tumor subtypes and a single master protocol. Basket trials typically involve few patients per type, making it challenging to rigorously compare responses across types. We describe the use of permutation testing to test for differences among subgroups using empirical null distributions and the Benjamini-Hochberg procedure to control for false discovery. We apply the approach retrospectively to tumor-volume changes and progression-free survival in published basket trials for neratinib, larotrectinib, pembrolizumab, and imatinib and uncover examples of therapeutic benefit missed by conventional binomial testing. For example, we identify an overlooked opportunity for use of neratinib in lung cancers carrying ERBB2 Exon 20 mutations. Permutation testing can be used to design basket trials but is more conservatively introduced alongside established approaches to enrollment such as Simon’s two-stage design. Basket clinical trials simultaneously test a single drug in multiple tumor subtypes, but statistical challenges limit the comparison of responses across subtypes. We describe a rigorous approach to permutation testing using empirical null distributions that can identify previously overlooked opportunities for use of targeted therapy in genetically defined cancer subtypes.
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Affiliation(s)
- Adam C Palmer
- Laboratory of Systems Pharmacology, and the Department of Systems Biology, Harvard Medical School, Boston, MA 02115, USA
| | - Deborah Plana
- Laboratory of Systems Pharmacology, and the Department of Systems Biology, Harvard Medical School, Boston, MA 02115, USA; Harvard-MIT Division of Health Sciences and Technology, Cambridge, MA 02139, USA
| | - Peter K Sorger
- Laboratory of Systems Pharmacology, and the Department of Systems Biology, Harvard Medical School, Boston, MA 02115, USA.
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13
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Basket trials: From tumour gnostic to tumour agnostic drug development. Cancer Treat Rev 2020; 90:102082. [DOI: 10.1016/j.ctrv.2020.102082] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 12/14/2022]
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14
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Lai TL, Sklar M, Weissmueller NT. Novel Clinical Trial Designs and Statistical Methods in the Era of Precision Medicine. Stat Biopharm Res 2020. [DOI: 10.1080/19466315.2020.1814403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Tze Leung Lai
- Department of Statistics, Stanford University, Stanford, CA
- Center for Innovative Study Design, Stanford School of Medicine, Stanford, CA
| | - Michael Sklar
- Department of Statistics, Stanford University, Stanford, CA
| | - Nikolas Thomas Weissmueller
- Department of Statistics, Stanford University, Stanford, CA
- Center for Observational Research and Data Science, Bristol-Myers Squibb, Redwood City, CA
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15
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Rashid MBMA. Artificial Intelligence Effecting a Paradigm Shift in Drug Development. SLAS Technol 2020; 26:3-15. [PMID: 32940124 DOI: 10.1177/2472630320956931] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The inverse relationship between the cost of drug development and the successful integration of drugs into the market has resulted in the need for innovative solutions to overcome this burgeoning problem. This problem could be attributed to several factors, including the premature termination of clinical trials, regulatory factors, or decisions made in the earlier drug development processes. The introduction of artificial intelligence (AI) to accelerate and assist drug development has resulted in cheaper and more efficient processes, ultimately improving the success rates of clinical trials. This review aims to showcase and compare the different applications of AI technology that aid automation and improve success in drug development, particularly in novel drug target identification and design, drug repositioning, biomarker identification, and effective patient stratification, through exploration of different disease landscapes. In addition, it will also highlight how these technologies are translated into the clinic. This paradigm shift will lead to even greater advancements in the integration of AI in automating processes within drug development and discovery, enabling the probability and reality of attaining future precision and personalized medicine.
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16
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Clinical development of cell therapies for cancer: The regulators' perspective. Eur J Cancer 2020; 138:41-53. [PMID: 32836173 DOI: 10.1016/j.ejca.2020.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/04/2020] [Indexed: 11/21/2022]
Abstract
Novel cell therapies for haematological malignancies and solid tumours address pressing clinical need while offering potentially paradigm shifts in efficacy. However, innovative development risks outflanking information on statutory frameworks, regulatory guidelines and their working application. Meeting this challenge, regulators offer wide-ranging expertise and experience in confidential scientific and regulatory advice. We advocate early incorporation of regulatory perspectives to support strategic development of clinical programmes. We examine critical issues and key advances in clinical oncology trials to highlight practical approaches to optimising the clinical development of cell therapies. We recommend early consideration of collaborative networks, early-access schemes, reducing bias in single-arm trials, adaptive trials, clinical end-points supporting risk/benefit and cost/benefit analyses, companion diagnostics, real-world data and common technical issues. This symbiotic approach between developers and regulators should reduce development risk, safely expedite marketing authorisation, and promote early, wider availability of potentially transformative cell therapies for cancer.
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17
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The Evolution of Master Protocol Clinical Trial Designs: A Systematic Literature Review. Clin Ther 2020; 42:1330-1360. [DOI: 10.1016/j.clinthera.2020.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/10/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023]
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18
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Principles of Good Clinical Trial Design. J Thorac Oncol 2020; 15:1277-1280. [PMID: 32417343 DOI: 10.1016/j.jtho.2020.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/13/2020] [Accepted: 05/04/2020] [Indexed: 12/14/2022]
Abstract
Clinical trials are a fundamental component of medical research and serve as the main route to obtain evidence of the safety and efficacy of treatment before its approval. A trial's ability to provide the intended evidence hinges on appropriate design, background knowledge, trial rationale to sample size, and interim monitoring rules. In this article, we present some general design principles for investigators and their research teams to consider when planning to conduct a trial.
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19
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Zheng H, Wason JMS. Borrowing of information across patient subgroups in a basket trial based on distributional discrepancy. Biostatistics 2020; 23:120-135. [PMID: 32380518 PMCID: PMC8759447 DOI: 10.1093/biostatistics/kxaa019] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 03/20/2020] [Accepted: 03/25/2020] [Indexed: 12/02/2022] Open
Abstract
Basket trials have emerged as a new class of efficient approaches in oncology to evaluate a new treatment in several patient subgroups simultaneously. In this article, we extend the key ideas to disease areas outside of oncology, developing a robust Bayesian methodology for randomized, placebo-controlled basket trials with a continuous endpoint to enable borrowing of information across subtrials with similar treatment effects. After adjusting for covariates, information from a complementary subtrial can be represented into a commensurate prior for the parameter that underpins the subtrial under consideration. We propose using distributional discrepancy to characterize the commensurability between subtrials for appropriate borrowing of information through a spike-and-slab prior, which is placed on the prior precision factor. When the basket trial has at least three subtrials, commensurate priors for point-to-point borrowing are combined into a marginal predictive prior, according to the weights transformed from the pairwise discrepancy measures. In this way, only information from subtrial(s) with the most commensurate treatment effect is leveraged. The marginal predictive prior is updated to a robust posterior by the contemporary subtrial data to inform decision making. Operating characteristics of the proposed methodology are evaluated through simulations motivated by a real basket trial in chronic diseases. The proposed methodology has advantages compared to other selected Bayesian analysis models, for (i) identifying the most commensurate source of information and (ii) gauging the degree of borrowing from specific subtrials. Numerical results also suggest that our methodology can improve the precision of estimates and, potentially, the statistical power for hypothesis testing.
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Affiliation(s)
- Haiyan Zheng
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, UK
| | - James M S Wason
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, UK,MRC Biostatistics Unit, University of Cambridge, UK
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20
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Collignon O, Gartner C, Haidich A, James Hemmings R, Hofner B, Pétavy F, Posch M, Rantell K, Roes K, Schiel A. Current Statistical Considerations and Regulatory Perspectives on the Planning of Confirmatory Basket, Umbrella, and Platform Trials. Clin Pharmacol Ther 2020; 107:1059-1067. [DOI: 10.1002/cpt.1804] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/31/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Olivier Collignon
- Competence Centre in Methodology and Statistics Luxembourg Institute of Health Strassen Luxembourg
| | - Christian Gartner
- AGES – Österreichische Agentur für Gesundheit und Ernährungssicherheit/Austrian Agency for Health and Food Safety Vienna Austria
| | - Anna‐Bettina Haidich
- Department of Hygiene Social‐Preventive Medicine & Medical Statistics Medical School Aristotle University of Thessaloniki Thessaloniki Greece
| | - Robert James Hemmings
- Consilium Hemmings Unit 96, The Maltings Business Center The Maltings Stanstead Abbotts UK
| | - Benjamin Hofner
- Paul‐Ehrlich‐Institut Federal Institute for Vaccines and Biomedicines Langen Germany
| | - Frank Pétavy
- European Medicines Agency Amsterdam The Netherlands
| | - Martin Posch
- Section for Medical Statistics Center for Medical Statistics, Informatics, and Intelligent Systems Medical University of Vienna Vienna Austria
| | - Khadija Rantell
- Medicines and Healthcare Products Regulatory Agency London UK
| | - Kit Roes
- Julius Center for Health Sciences and Primary Care University Medical Center Utrecht Utrecht The Netherlands
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21
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Blagden SP, Billingham L, Brown LC, Buckland SW, Cooper AM, Ellis S, Fisher W, Hughes H, Keatley DA, Maignen FM, Morozov A, Navaie W, Pearson S, Shaaban A, Wydenbach K, Kearns PR. Effective delivery of Complex Innovative Design (CID) cancer trials-A consensus statement. Br J Cancer 2020; 122:473-482. [PMID: 31907370 PMCID: PMC7028941 DOI: 10.1038/s41416-019-0653-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 11/06/2019] [Accepted: 11/06/2019] [Indexed: 01/13/2023] Open
Abstract
The traditional cancer drug development pathway is increasingly being superseded by trials that address multiple clinical questions. These are collectively termed Complex Innovative Design (CID) trials. CID trials not only assess the safety and toxicity of novel anticancer medicines but also their efficacy in biomarker-selected patients, specific cancer cohorts or in combination with other agents. They can be adapted to include new cohorts and test additional agents within a single protocol. Whilst CID trials can speed up the traditional route to drug licencing, they can be challenging to design, conduct and interpret. The Experimental Cancer Medicine Centres (ECMC) network, funded by the National Institute for Health Research (NIHR), Cancer Research UK (CRUK) and the Health Boards of Wales, Northern Ireland and Scotland, formed a working group with relevant stakeholders from clinical trials units, the pharmaceutical industry, funding bodies, regulators and patients to identify the main challenges of CID trials. The working group generated ten consensus recommendations. These aim to improve the conduct, quality and acceptability of oncology CID trials in clinical research and, importantly, to expedite the process by which effective treatments can reach cancer patients.
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Affiliation(s)
| | - Lucinda Billingham
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Studies, University of Birmingham, Birmingham, UK
| | - Louise C Brown
- Medical Research Council (MRC) Clinical Trials Unit, University College London, London, UK
| | | | - Alison M Cooper
- The Association of the British Pharmaceutical Industry (ABPI), London, UK
| | | | | | - Helen Hughes
- Cardiff and Vale University Health Board, Cardiff, UK
| | - Debbie A Keatley
- Independent Cancer Patients' Voice, National Cancer Research Institute (NCRI), London, UK
| | | | | | | | - Sarah Pearson
- Oncology Clinical Trials Office, University of Oxford, Oxford, UK
| | - Abeer Shaaban
- Queen Elizabeth Hospital Birmingham and the University of Birmingham, Birmingham, UK
| | - Kirsty Wydenbach
- Medicines and Healthcare products Regulatory Agency (MHRA), London, UK
| | - Pamela R Kearns
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Studies, University of Birmingham, Birmingham, UK
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Cancer and Genomic Studies, University of Birmingham, Birmingham, UK
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22
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Ou FS, An MW, Ruppert AS, Mandrekar SJ. Discussion of Trial Designs for Biomarker Identification and Validation Through the Use of Case Studies. JCO Precis Oncol 2019; 3:PO.19.00051. [PMID: 32190807 PMCID: PMC7079723 DOI: 10.1200/po.19.00051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2019] [Indexed: 12/29/2022] Open
Abstract
With the launch of the National Cancer Institute's Precision Medicine Initiative in 2015, there has been a shift to trial designs that tailor health care solutions to individual patients by using a screening platform and by moving away from the one-trial/one-biomarker-at-a-time approach. To make precision medicine a reality, it is critical to identify and validate potential biomarkers to help select patients who will truly benefit from a targeted therapy. In this article, we discuss five trial designs: enrichment, umbrella, basket, subgroup, and window of opportunity. For each trial design, we describe the design characteristics, use ongoing or completed trials as case studies, provide any recent advances to the trial design, and discuss advantages and disadvantages of each design.
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23
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Strzebonska K, Waligora M. Umbrella and basket trials in oncology: ethical challenges. BMC Med Ethics 2019; 20:58. [PMID: 31443704 PMCID: PMC6708208 DOI: 10.1186/s12910-019-0395-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 08/13/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Novel precision oncology trial designs, such as basket and umbrella trials, are designed to test new anticancer agents in more effective and affordable ways. However, they present some ethical concerns referred to scientific validity, risk-benefit balance and informed consent. Our aim is to discuss these issues in basket and umbrella trials, giving examples of two ongoing cancer trials: NCI-MATCH (National Cancer Institute - Molecular Analysis for Therapy Choice) and Lung-MAP (Lung Cancer Master Protocol) study. MAIN BODY We discuss three ethical requirements for clinical trials which may be challenged in basket and umbrella trial designs. Firstly, we consider scientific validity. Thanks to the new trial designs, patients with rare malignancies have the opportunity to be enrolled and benefit from the trial, but due to insufficient accrual, the trial may generate clinically insignificant findings. Inadequate sample size in study arms and the use of surrogate endpoints may result in a drug approval without confirmed efficacy. Moreover, complexity, limited quality and availability of tumor samples may not only introduce bias and result in unreliable and unrepresentative findings, but also can potentially harm patients and assign them to an inappropriate therapy arm. Secondly, we refer to benefits and risks. Novel clinical trials can gain important knowledge on the variety of tumors, which can be used in future trials to develop effective therapies. However, they offer limited direct benefits to patients. All potential participants must wait about 2 weeks for the results of the genetic screening, which may be stressful and produce anxiety. The enrollment of patients whose tumors harbor multiple mutations in treatments matching a single mutation may be controversial. As to informed consent - the third requirement we discuss, the excessive use of phrases like "personalized medicine", "tailored therapy" or "precision oncology" might be misleading and cause personal convictions that the study protocol is designed to fulfill the individual health-related needs of participants. CONCLUSIONS We suggest that further approaches should be implemented to enhance scientific validity, reduce misunderstandings and risks, thus maximizing the benefits to society and to trial participants.
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Affiliation(s)
- Karolina Strzebonska
- REMEDY, Research Ethics in Medicine Study Group, Department of Philosophy and Bioethics, Jagiellonian University Medical College, ul. Michałowskiego 12, 31-126 Krakow, Poland
| | - Marcin Waligora
- REMEDY, Research Ethics in Medicine Study Group, Department of Philosophy and Bioethics, Jagiellonian University Medical College, ul. Michałowskiego 12, 31-126 Krakow, Poland
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24
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Sotelo-Rodríguez DC, Ruíz-Patiño A, Ricaurte L, Arrieta O, Zatarain-Barrón ZL, Cardona AF. Challenges and shifting paradigms in clinical trials in oncology: the case for immunological and targeted therapies. Ecancermedicalscience 2019; 13:936. [PMID: 31552109 PMCID: PMC6695130 DOI: 10.3332/ecancer.2019.936] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Indexed: 11/20/2022] Open
Abstract
The advent of immunotherapy has undoubtedly changed the current standard for cancer treatment. Immunotherapy offers the possibility of achieving excellent results—a new alternative for patients with advanced-stage or relapsed disease. Nowadays, the progress made in tumour biology has led to multiple advances in clinical and translational cancer research. Many oncogenic pathways responsible for tumour growth and metastases have been described and, consequently, multiple new cancer therapeutic agents have been developed and are under current investigation. Due to this rapid increase in knowledge and pharmaceutical development, traditional clinical trials designs have encountered major limitations. The pharmacological differences (in toxicity profiles and effectiveness patterns) between immunotherapy and chemotherapy have caused traditional clinical trials to evolve in order to meet this emerging need. This review focuses on the different options pertaining to clinical trial design that have arisen in the field of immuno-oncology, as well as the challenges of accurately interpreting traditional survival analyses within this novel area of cancer medicine.
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Affiliation(s)
| | | | - Luisa Ricaurte
- Foundation for Clinical and Applied Cancer Research-FICMAC, Bogotá 100110, Colombia
| | - Oscar Arrieta
- Thoracic Oncology Unit and Laboratory of Personalized Medicine, Instituto Nacional de Cancerología (INCan), México City 14080, Mexico
| | - Zyanya Lucia Zatarain-Barrón
- Thoracic Oncology Unit and Laboratory of Personalized Medicine, Instituto Nacional de Cancerología (INCan), México City 14080, Mexico
| | - Andrés F Cardona
- Foundation for Clinical and Applied Cancer Research-FICMAC, Bogotá 100110, Colombia.,Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá 100110, Colombia
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25
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Hirakawa A, Asano J, Sato H, Teramukai S. Master protocol trials in oncology: Review and new trial designs. Contemp Clin Trials Commun 2018; 12:1-8. [PMID: 30182068 PMCID: PMC6120722 DOI: 10.1016/j.conctc.2018.08.009] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 08/10/2018] [Accepted: 08/23/2018] [Indexed: 01/08/2023] Open
Abstract
In oncology, next generation sequencing and comprehensive genomic profiling have enabled the detailed classification of tumors using molecular biology. However, it is unrealistic to conduct phase I-III trials according to each sub-population based on patient molecular subtypes. Common protocols that assess the combination of several molecular markers and their targeted therapies by means of multiple sub-studies are required. These protocols are called "master protocols," and are drawing attention as a next-generation clinical trial design. Recently, several reviews of clinical trials based on the master protocol design have been published, but their definitions of these such trials, including basket, umbrella, and platform trials, were not consistent. Concurrently, the acceleration of the development of new statistical designs for master protocol trials has been underway. This article provides an overview of recent reviews for master protocols, including their statistical design methodologies in Oncology. We also introduce several examples of previous and on-going master protocol trials along with their classifications by some recent studies.
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Affiliation(s)
- Akihiro Hirakawa
- Department of Biostatistics and Bioinformatics, Graduate School of Medicine, The University of Tokyo, Tokyo, 113-8654, Japan
| | - Junichi Asano
- Biostatistics Group, Center for Product Evaluation, Pharmaceuticals and Medical Devices Agency, Tokyo, 100-0013, Japan
| | - Hiroyuki Sato
- Biostatistics Group, Center for Product Evaluation, Pharmaceuticals and Medical Devices Agency, Tokyo, 100-0013, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, 602-8566, Japan
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26
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Le-Rademacher J, Dahlberg S, Lee JJ, Adjei AA, Mandrekar SJ. Biomarker Clinical Trials in Lung Cancer: Design, Logistics, Challenges, and Practical Considerations. J Thorac Oncol 2018; 13:1625-1637. [PMID: 30194034 DOI: 10.1016/j.jtho.2018.08.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/10/2018] [Accepted: 08/15/2018] [Indexed: 10/28/2022]
Abstract
Treatment for lung cancer has evolved in the past 3 decades starting with platinum-based chemotherapy as the standard of care, regardless of histology, in the early 1990s to the current age of biomarker-driven therapy. Consequently, clinical trials in lung cancer have evolved in response to this new shift of paradigm, leading to novel approaches that simultaneously shorten the development process and allow evaluation of multiple patient cohorts. Herein, we provide an overview of the landscape of lung cancer clinical trials in the era of targeted therapies, precision medicine, and biomarkers. Specific trials are given as examples to illustrate the design paradigms. The paper is organized by drug development phases starting with early-phase biomarker discovery to proof-of-concept trials to definitive trials. We also present some thoughts on future directions.
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Affiliation(s)
| | | | - J Jack Lee
- MD Anderson Cancer Institute, Houston, Texas
| | - Alex A Adjei
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
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