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Jaki T, Barnett H, Titman A, Mozgunov P. A seamless Phase I/II platform design with a time-to-event efficacy endpoint for potential COVID-19 therapies. Stat Methods Med Res 2024:9622802241288348. [PMID: 39397762 DOI: 10.1177/09622802241288348] [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: 10/15/2024]
Abstract
In the search for effective treatments for COVID-19, the initial emphasis has been on re-purposed treatments. To maximize the chances of finding successful treatments, novel treatments that have been developed for this disease in particular, are needed. In this article, we describe and evaluate the statistical design of the AGILE platform, an adaptive randomized seamless Phase I/II trial platform that seeks to quickly establish a safe range of doses and investigates treatments for potential efficacy. The bespoke Bayesian design (i) utilizes randomization during dose-finding, (ii) shares control arm information across the platform, and (iii) uses a time-to-event endpoint with a formal testing structure and error control for evaluation of potential efficacy. Both single-agent and combination treatments are considered. We find that the design can identify potential treatments that are safe and efficacious reliably with small to moderate sample sizes.
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Affiliation(s)
- Thomas Jaki
- Faculty for Informatics and Data Science, University Regensburg, Germany
- MRC Biostatistics Unit, University of Cambridge, UK
| | - Helen Barnett
- School of Mathematical Sciences, Lancaster University, UK
| | - Andrew Titman
- School of Mathematical Sciences, Lancaster University, UK
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2
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Liu R, Yuan Y, Sen S, Yang X, Jiang Q, Li X(N, Lu C(C, Göneng M, Tian H, Zhou H, Lin R, Marchenko O. Accuracy and Safety of Novel Designs for Phase I Drug-Combination Oncology Trials*. Stat Biopharm Res 2022. [PMID: 37275462 PMCID: PMC10237505 DOI: 10.1080/19466315.2022.2081602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Despite numerous innovative designs having been published for phase I drug-combination dose finding trials, their use in real applications is rather limited. As a working group under the American Statistical Association Biopharmaceutical Section, our goal is to identify the unique challenges associated with drug combination, share industry's experiences with combination trials, and investigate the pros and cons of the existing designs. Toward this goal, we review seven existing designs and distinguish them based on the criterion of whether their primary objectives are to find a single maximum tolerated dose (MTD) or the MTD contour (i.e., multiple MTDs). Numerical studies, based on either industry-specified fixed scenarios or randomly generated scenarios, are performed to assess their relative accuracy, safety, and ease of implementation. We show that the algorithm-based 3+3 design has poor performance and often fails to find the MTD. The performance of model-based combination trial designs is mixed: some demonstrate high accuracy of finding the MTD but poor safety, while others are safe but with compromised identification accuracy. In comparison, the model-assisted designs, such as BOIN and waterfall designs, have competitive and balanced performance in the accuracy of MTD identification and patient safety, and are also simple to implement, thus offering an attractive approach to designing phase I drug-combination trials. By taking into consideration the design's operating characteristics, ease of implementation and regulation, the need for advanced infrastructures, as well as the risk of regulatory acceptance, our paper offers practical guidance on the selection of a suitable dose-finding approach for designing future combination trials.
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Affiliation(s)
- Rong Liu
- Bristol-Myers Squibb, Berkeley Heights, NJ 07922
| | - Ying Yuan
- The University of Texas MD Anderson Cancer Center, Houston, TX 77030
| | | | - Xin Yang
- Novartis, East Hanover, NJ 07936
| | - Qi Jiang
- Seattle Genetics, Bothell, WA 98021
| | | | | | - Mithat Göneng
- Memorial Sloan Kettering Cancer Center, New York, NY 10022
| | | | - Heng Zhou
- Merck & Co., Inc., Kenilworth, NJ 07033
| | - Ruitao Lin
- The University of Texas MD Anderson Cancer Center, Houston, TX 77030
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3
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Ewings S, Saunders G, Jaki T, Mozgunov P. Practical recommendations for implementing a Bayesian adaptive phase I design during a pandemic. BMC Med Res Methodol 2022; 22:25. [PMID: 35057758 PMCID: PMC8771176 DOI: 10.1186/s12874-022-01512-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/06/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Modern designs for dose-finding studies (e.g., model-based designs such as continual reassessment method) have been shown to substantially improve the ability to determine a suitable dose for efficacy testing when compared to traditional designs such as the 3 + 3 design. However, implementing such designs requires time and specialist knowledge. METHODS We present a practical approach to developing a model-based design to help support uptake of these methods; in particular, we lay out how to derive the necessary parameters and who should input, and when, to these decisions. Designing a model-based, dose-finding trial is demonstrated using a treatment within the AGILE platform trial, a phase I/II adaptive design for novel COVID-19 treatments. RESULTS We present discussion of the practical delivery of AGILE, covering what information was found to support principled decision making by the Safety Review Committee, and what could be contained within a statistical analysis plan. We also discuss additional challenges we encountered in the study and discuss more generally what (unplanned) adaptations may be acceptable (or not) in studies using model-based designs. CONCLUSIONS This example demonstrates both how to design and deliver an adaptive dose-finding trial in order to support uptake of these methods.
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Affiliation(s)
- Sean Ewings
- Southampton Clinical Trials Unit, University of Southampton, Mailpoint 131, Southampton General Hospital, Tremona Road, Southampton, SO16, UK.
| | - Geoff Saunders
- Southampton Clinical Trials Unit, University of Southampton, Mailpoint 131, Southampton General Hospital, Tremona Road, Southampton, SO16, UK
| | - Thomas Jaki
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Department of Mathematics and Statistics, Lancaster University, University of Lancaster, Lancaster, UK
| | - Pavel Mozgunov
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
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Mozgunov P, Cro S, Lingford-Hughes A, Paterson LM, Jaki T. A dose-finding design for dual-agent trials with patient-specific doses for one agent with application to an opiate detoxification trial. Pharm Stat 2021; 21:476-495. [PMID: 34891221 PMCID: PMC7612599 DOI: 10.1002/pst.2181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 08/31/2021] [Accepted: 11/21/2021] [Indexed: 11/08/2022]
Abstract
There is a growing interest in early phase dose-finding clinical trials studying combinations of several treatments. While the majority of dose finding designs for such setting were proposed for oncology trials, the corresponding designs are also essential in other therapeutic areas. Furthermore, there is increased recognition of recommending the patient-specific doses/combinations, rather than a single target one that would be recommended to all patients in later phases regardless of their characteristics. In this paper, we propose a dose-finding design for a dual-agent combination trial motivated by an opiate detoxification trial. The distinguishing feature of the trial is that the (continuous) dose of one compound is defined externally by the clinicians and is individual for every patient. The objective of the trial is to define the dosing function that for each patient would recommend the optimal dosage of the second compound. Via a simulation study, we have found that the proposed design results in high accuracy of individual dose recommendation and is robust to the model misspecification and assumptions on the distribution of externally defined doses.
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Affiliation(s)
- Pavel Mozgunov
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Suzie Cro
- Imperial Clinical Trials Unit, School of Public Health, Imperial College, London, UK
| | - Anne Lingford-Hughes
- Division of Psychiatry, Department of Brain Sciences, Imperial College, London, UK
| | - Louise M Paterson
- Division of Psychiatry, Department of Brain Sciences, Imperial College, London, UK
| | - Thomas Jaki
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK.,Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
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5
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Zimmer L, Livingstone E, Krackhardt A, Schultz ES, Göppner D, Assaf C, Trebing D, Stelter K, Windemuth-Kieselbach C, Ugurel S, Schadendorf D. Encorafenib, binimetinib plus pembrolizumab triplet therapy in patients with advanced BRAF V600 mutant melanoma: safety and tolerability results from the phase I IMMU-TARGET trial. Eur J Cancer 2021; 158:72-84. [PMID: 34655839 DOI: 10.1016/j.ejca.2021.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Combination of immune checkpoint inhibitors and mitogen-activated protein kinase (MAPK) pathway inhibitors (MAPKi) has been proposed to enhance the durability of anti-tumour responses induced by MAPKi. Here, we present phase I safety results from an open-label, phase I/II study of pembrolizumab (PEM), encorafenib (ENC) and binimetinib (BIN) triplet therapy in advanced, B-Raf proto-oncogene serine/threonine kinase (BRAF)V600-mutated melanoma (IMMU-TARGET, NCT02902042). METHODS The dose finding phase I part used a 3 + 3 design, starting with the approved doses of PEM (200 mg every three weeks), ENC (450 mg once daily [QD]) and BIN (45 mg twice daily [BID]) as dose level (DL) 0. Reduction of the ENC and BIN doses (300 mg QD and 30 mg BID at DL-1 and 200 mg QD and 30 mg BID at DL-2) was preplanned in case of ≥2 dose-limiting toxicities (DLTs). Primary objectives were to estimate the recommended phase II dose of the triplet combination, DLT and safety. As per the sponsor's decision, the study was terminated after the phase I part, as the clinical efficacy of the combination is currently being investigated in a pivotal, placebo-controlled (PEM mono), double-blinded phase III trial (STARBOARD,NCT04657991). RESULTS Fifteen patients were enrolled. DLTs of DL0 were creatine phosphokinase (CPK) elevation plus cytokine release syndrome (n = 1) and gamma glutamyl transferase (GGT) increase (n = 1). No DLT was observed in further 3 + 3 patients at DL-1. One (isolated GGT elevations) DLT of DL0 was questionable, as the patient had further episodes of isolated GGT elevations after treatment discontinuation. Hence, further 6 patients were enrolled at DL0: here, no DLT occurred. In total, 13 of 15 patients (87%) experienced a treatment-related adverse event (TRAE) and 8 patients (53%), a grade ≥III TRAE; there were no TRAE-related deaths. Increases in aspartate aminotransferases, GGT (6/15 patients) and CPK elevations (4/15) were the most common grade III-IV TRAE. In median, patients received triplet therapy for 24 weeks (interquartile range [IQR], 12-45). Of the 14 patients evaluable for efficacy, the overall response rate was 64% (95% confidence interval [CI], 35-87). At a median follow-up of 25 months (IQR, 9-28), progression-free survival at 12 months was 41% (95% CI, 13-68). CONCLUSIONS Triplet therapy with PEM, ENC and BIN as used in the study was feasible and safe and led to clinically meaningful disease control.
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Affiliation(s)
- Lisa Zimmer
- Department of Dermatology, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site Essen, Germany.
| | - Elisabeth Livingstone
- Department of Dermatology, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site Essen, Germany.
| | - Angela Krackhardt
- Technische Universität München, School of Medicine, Klinik und Poliklinik Für Innere Medizin III, Klinikum Rechts der Isar, Ismaningerstr. 22, Munich 81675, Germany; German Cancer Consortium (DKTK), Technische Universität München, Partner Site Munich, Germany.
| | - Erwin S Schultz
- Department of Dermatology, University Hospital of the Paracelsus Medical Private University, Nuremberg, Germany.
| | - Daniela Göppner
- Clinic for Dermatology and Allergology, Justus-Liebig-University, Gießen, Germany.
| | - Chalid Assaf
- Department of Dermatology, Helios-Klinikum Krefeld, Germany.
| | - Dietrich Trebing
- Department of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane, Dessau, Germany.
| | - Kai Stelter
- Department of Biostatistics, Alcedis GmbH, Giessen, Germany.
| | | | - Selma Ugurel
- Department of Dermatology, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site Essen, Germany.
| | - Dirk Schadendorf
- Department of Dermatology, University Hospital Essen, Essen, Germany; German Cancer Consortium (DKTK), Partner Site Essen, Germany.
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Khoo SH, Fitzgerald R, Fletcher T, Ewings S, Jaki T, Lyon R, Downs N, Walker L, Tansley-Hancock O, Greenhalf W, Woods C, Reynolds H, Marwood E, Mozgunov P, Adams E, Bullock K, Holman W, Bula MD, Gibney JL, Saunders G, Corkhill A, Hale C, Thorne K, Chiong J, Condie S, Pertinez H, Painter W, Wrixon E, Johnson L, Yeats S, Mallard K, Radford M, Fines K, Shaw V, Owen A, Lalloo DG, Jacobs M, Griffiths G. Optimal dose and safety of molnupiravir in patients with early SARS-CoV-2: a Phase I, open-label, dose-escalating, randomized controlled study. J Antimicrob Chemother 2021; 76:3286-3295. [PMID: 34450619 PMCID: PMC8598307 DOI: 10.1093/jac/dkab318] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/04/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES AGILE is a Phase Ib/IIa platform for rapidly evaluating COVID-19 treatments. In this trial (NCT04746183) we evaluated the safety and optimal dose of molnupiravir in participants with early symptomatic infection. METHODS We undertook a dose-escalating, open-label, randomized-controlled (standard-of-care) Bayesian adaptive Phase I trial at the Royal Liverpool and Broadgreen Clinical Research Facility. Participants (adult outpatients with PCR-confirmed SARS-CoV-2 infection within 5 days of symptom onset) were randomized 2:1 in groups of 6 participants to 300, 600 and 800 mg doses of molnupiravir orally, twice daily for 5 days or control. A dose was judged unsafe if the probability of 30% or greater dose-limiting toxicity (the primary outcome) over controls was 25% or greater. Secondary outcomes included safety, clinical progression, pharmacokinetics and virological responses. RESULTS Of 103 participants screened, 18 participants were enrolled between 17 July and 30 October 2020. Molnupiravir was well tolerated at 300, 600 and 800 mg doses with no serious or severe adverse events. Overall, 4 of 4 (100%), 4 of 4 (100%) and 1 of 4 (25%) of the participants receiving 300, 600 and 800 mg molnupiravir, respectively, and 5 of 6 (83%) controls, had at least one adverse event, all of which were mild (≤grade 2). The probability of ≥30% excess toxicity over controls at 800 mg was estimated at 0.9%. CONCLUSIONS Molnupiravir was safe and well tolerated; a dose of 800 mg twice daily for 5 days was recommended for Phase II evaluation.
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Affiliation(s)
- Saye H Khoo
- University of Liverpool, 70 Pembroke Place, Liverpool, UK.,Liverpool University Hospital NHS Foundation Trust, Prescot Road, Liverpool, UK
| | - Richard Fitzgerald
- Liverpool University Hospital NHS Foundation Trust, Prescot Road, Liverpool, UK
| | - Thomas Fletcher
- Liverpool University Hospital NHS Foundation Trust, Prescot Road, Liverpool, UK.,Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Sean Ewings
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | - Thomas Jaki
- University of Lancaster, Bailrigg, Lancaster, UK.,MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Rebecca Lyon
- Liverpool University Hospital NHS Foundation Trust, Prescot Road, Liverpool, UK
| | - Nichola Downs
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | - Lauren Walker
- University of Liverpool, 70 Pembroke Place, Liverpool, UK.,Liverpool University Hospital NHS Foundation Trust, Prescot Road, Liverpool, UK
| | - Olana Tansley-Hancock
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | | | - Christie Woods
- Liverpool University Hospital NHS Foundation Trust, Prescot Road, Liverpool, UK
| | - Helen Reynolds
- University of Liverpool, 70 Pembroke Place, Liverpool, UK
| | - Ellice Marwood
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | | | - Emily Adams
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Katie Bullock
- University of Liverpool, 70 Pembroke Place, Liverpool, UK
| | - Wayne Holman
- Ridgeback Biotherapeutics, 3480 Main Highway, Miami, FL, USA
| | - Marcin D Bula
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | - Jennifer L Gibney
- Liverpool University Hospital NHS Foundation Trust, Prescot Road, Liverpool, UK
| | - Geoffrey Saunders
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | - Andrea Corkhill
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | - Colin Hale
- Liverpool University Hospital NHS Foundation Trust, Prescot Road, Liverpool, UK
| | - Kerensa Thorne
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | - Justin Chiong
- University of Liverpool, 70 Pembroke Place, Liverpool, UK
| | - Susannah Condie
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | - Henry Pertinez
- University of Liverpool, 70 Pembroke Place, Liverpool, UK
| | - Wendy Painter
- Ridgeback Biotherapeutics, 3480 Main Highway, Miami, FL, USA
| | - Emma Wrixon
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | - Lucy Johnson
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | - Sara Yeats
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | - Kim Mallard
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | - Mike Radford
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | - Keira Fines
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
| | - Victoria Shaw
- University of Liverpool, 70 Pembroke Place, Liverpool, UK
| | - Andrew Owen
- University of Liverpool, 70 Pembroke Place, Liverpool, UK
| | - David G Lalloo
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Michael Jacobs
- Royal Free London NHS Foundation Trust, Pond Street, London, UK
| | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Tremona Road, Southampton, UK
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Shah A, Grimberg D, Inman BA. Immunotherapy: From Discovery to Bedside. Bioanalysis 2021. [DOI: 10.1007/978-3-030-78338-9_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Stallard N, Hampson L, Benda N, Brannath W, Burnett T, Friede T, Kimani PK, Koenig F, Krisam J, Mozgunov P, Posch M, Wason J, Wassmer G, Whitehead J, Williamson SF, Zohar S, Jaki T. Efficient Adaptive Designs for Clinical Trials of Interventions for COVID-19. Stat Biopharm Res 2020; 12:483-497. [PMID: 34191981 PMCID: PMC8011600 DOI: 10.1080/19466315.2020.1790415] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 02/06/2023]
Abstract
The COVID-19 pandemic has led to an unprecedented response in terms of clinical research activity. An important part of this research has been focused on randomized controlled clinical trials to evaluate potential therapies for COVID-19. The results from this research need to be obtained as rapidly as possible. This presents a number of challenges associated with considerable uncertainty over the natural history of the disease and the number and characteristics of patients affected, and the emergence of new potential therapies. These challenges make adaptive designs for clinical trials a particularly attractive option. Such designs allow a trial to be modified on the basis of interim analysis data or stopped as soon as sufficiently strong evidence has been observed to answer the research question, without compromising the trial's scientific validity or integrity. In this article, we describe some of the adaptive design approaches that are available and discuss particular issues and challenges associated with their use in the pandemic setting. Our discussion is illustrated by details of four ongoing COVID-19 trials that have used adaptive designs.
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Affiliation(s)
- Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Lisa Hampson
- Advanced Methodology and Data Science, Novartis Pharma AG, Basel, Switzerland
| | - Norbert Benda
- The Federal Institute for Drugs and Medical Devices (BfArM), Bonn, Germany
| | - Werner Brannath
- Institute for Statistics, University of Bremen, Bremen, Germany
| | - Thomas Burnett
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Peter K. Kimani
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Franz Koenig
- Section for Medical Statistics, CeMSIIS, Medical University of Vienna, Vienna, Austria
| | - Johannes Krisam
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Pavel Mozgunov
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Martin Posch
- Section for Medical Statistics, CeMSIIS, Medical University of Vienna, Vienna, Austria
| | - James Wason
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | | | - John Whitehead
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - S. Faye Williamson
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Sarah Zohar
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
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9
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Mozgunov P, Jaki T. Improving safety of the continual reassessment method via a modified allocation rule. Stat Med 2020; 39:906-922. [PMID: 31859399 PMCID: PMC7064916 DOI: 10.1002/sim.8450] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/26/2019] [Accepted: 11/29/2019] [Indexed: 01/20/2023]
Abstract
This article proposes a novel criterion for the allocation of patients in phase I dose-escalation clinical trials, aiming to find the maximum tolerated dose (MTD). Conventionally, using a model-based approach, the next patient is allocated to the dose with the toxicity estimate closest (in terms of the absolute or squared distance) to the maximum acceptable toxicity. This approach, however, ignores the uncertainty in point estimates and ethical concerns of assigning a lot of patients to overly toxic doses. In fact, balancing the trade-off between how accurately the MTD can be estimated and how many patients would experience adverse events is one of the primary challenges in phase I studies. Motivated by recent discussions in the theory of estimation in restricted parameter spaces, we propose a criterion that allows to balance these explicitly. The criterion requires a specification of one additional parameter only that has a simple and intuitive interpretation. We incorporate the proposed criterion into the one-parameter Bayesian continual reassessment method and show, using simulations, that it can result in similar accuracy on average as the original design, but with fewer toxic responses on average. A comparison with other model-based dose-escalation designs, such as escalation with overdose control and its modifications, demonstrates that the proposed design can result in either the same mean accuracy as alternatives but fewer toxic responses or in a higher mean accuracy but the same number of toxic responses. Therefore, the proposed design can provide a better trade-off between the accuracy and the number of patients experiencing adverse events, making the design a more ethical alternative over some of the existing methods for phase I trials.
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Affiliation(s)
- Pavel Mozgunov
- Department of Mathematics and StatisticsLancaster UniversityLancasterUK
| | - Thomas Jaki
- Department of Mathematics and StatisticsLancaster UniversityLancasterUK
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10
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Grayling MJ, Dimairo M, Mander AP, Jaki TF. A Review of Perspectives on the Use of Randomization in Phase II Oncology Trials. J Natl Cancer Inst 2019; 111:1255-1262. [PMID: 31218346 PMCID: PMC6910171 DOI: 10.1093/jnci/djz126] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/05/2019] [Accepted: 06/12/2019] [Indexed: 12/21/2022] Open
Abstract
Historically, phase II oncology trials assessed a treatment's efficacy by examining its tumor response rate in a single-arm trial. Then, approximately 25 years ago, certain statistical and pharmacological considerations ignited a debate around whether randomized designs should be used instead. Here, based on an extensive literature review, we review the arguments on either side of this debate. In particular, we describe the numerous factors that relate to the reliance of single-arm trials on historical control data and detail the trial scenarios in which there was general agreement on preferential utilization of single-arm or randomized design frameworks, such as the use of single-arm designs when investigating treatments for rare cancers. We then summarize the latest figures on phase II oncology trial design, contrasting current design choices against historical recommendations on best practice. Ultimately, we find several ways in which the design of recently completed phase II trials does not appear to align with said recommendations. For example, despite advice to the contrary, only 66.2% of the assessed trials that employed progression-free survival as a primary or coprimary outcome used a randomized comparative design. In addition, we identify that just 28.2% of the considered randomized comparative trials came to a positive conclusion as opposed to 72.7% of the single-arm trials. We conclude by describing a selection of important issues influencing contemporary design, framing this discourse in light of current trends in phase II, such as the increased use of biomarkers and recent interest in novel adaptive designs.
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Affiliation(s)
- Michael J Grayling
- Correspondence to: Michael J. Grayling, Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Rd, Newcastle upon Tyne NE2 4AX, UK (e-mail: )
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11
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Delou JMA, Souza ASO, Souza LCM, Borges HL. Highlights in Resistance Mechanism Pathways for Combination Therapy. Cells 2019; 8:E1013. [PMID: 31480389 PMCID: PMC6770082 DOI: 10.3390/cells8091013] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/15/2019] [Accepted: 08/20/2019] [Indexed: 12/14/2022] Open
Abstract
Combination chemotherapy has been a mainstay in cancer treatment for the last 60 years. Although the mechanisms of action and signaling pathways affected by most treatments with single antineoplastic agents might be relatively well understood, most combinations remain poorly understood. This review presents the most common alterations of signaling pathways in response to cytotoxic and targeted anticancer drug treatments, with a discussion of how the knowledge of signaling pathways might support and orient the development of innovative strategies for anticancer combination therapy. The ultimate goal is to highlight possible strategies of chemotherapy combinations based on the signaling pathways associated with the resistance mechanisms against anticancer drugs to maximize the selective induction of cancer cell death. We consider this review an extensive compilation of updated known information on chemotherapy resistance mechanisms to promote new combination therapies to be to discussed and tested.
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Affiliation(s)
- João M A Delou
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
| | - Alana S O Souza
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
| | - Leonel C M Souza
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
| | - Helena L Borges
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro 21941-902, Brazil.
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