The Futility of Futility Analyses in Adjuvant Trials in Hormone Receptor Positive Breast Cancer

An interim analysis is commonly used in phase III superiority trials to compare treatment arms, with the goal of terminating exposure of patients to ineffective or unsafe drugs, or to identify highly effective therapies for earlier public disclosure. Traditionally, interim analyses have been designed to identify early evidence of extremely large benefit of the experimental approach, potentially leading to early dissemination of effective treatments. Increasingly, interim analysis has also involved analysis of futility which may lead to early termination of a trial that will not yield additional useful information This presents an important challenge in early-stage hormone receptor positive breast cancer, where recurrence often occurs late, with a steady annual event rate up to 20 years. Early analysis of events may miss late treatment effects that can be observed only with longer follow-up. We discuss approaches to futility analysis in adjuvant clinical trials in hormone receptor positive breast cancer, the role of the Data Safety Monitoring Committee in such analyses, considerations of the potential harms versus benefits of treatment, and the risks of continuing versus early stopping of a trial.

Evaluation of Selective Outcome Reporting Bias in Efficacy Endpoints in Print and Television Advertisements for Oncology Drugs

IMPORTANCE

Selective outcome reporting bias in oncology drug advertisements may encourage misconceptions about a drug's efficacy profile.

OBJECTIVE

We sought to determine the rates of selective outcome reporting in published cancer clinical trials and in television and print advertisements for anticancer medications. We also quantified the number of advertisements that did not include or cite any studies with mature overall survival (OS) data (i.e., data with all required patient events for final analysis).

DESIGN/SETTING/PARTICIPANTS

We conducted a cross-sectional investigation of advertisements uploaded to the AdPharm Database (repository of pharmaceutical advertisements); the clinical trials supporting the ads; and the trial registrations associated with the trials. Data were extracted by two investigators who were blinded to each other's data.

MAIN OUTCOME MEASURES

The first co-primary objective was to investigate selective outcome reporting between trial registrations and published trials. The second co-primary objective was to investigate selective outcome reporting between the same published trials and drug advertisements.

RESULTS

We included 74 advertisements and 48 clinical trials. Print ads were the most common (n = 66), and most print advertisements were targeted to health care providers (n = 55, 83.3%). Overall, 41/48 (85.4%) trials were registered prior to study enrollment, and 41/48 (85.4%) did not deviate from the registered primary endpoints. Across all advertisements (n = 74), statistically significant endpoints were more often reported (unadjusted risk ratio [uRR] 1.26; 95% confidence interval [CI] (1.14-1.40)) and 22/55 (40.0%) advertisements cited trials with immature overall survival data (i.e., data without the required number of events for final analysis).

CONCLUSIONS

In our sample, statistically significant endpoints were more commonly reported than nonsignificant endpoints. Immature endpoints (those analyzed before the required number of accrued patient events) were often reported. By reporting only significant endpoints and those that are immature, advertisers may encourage misconceptions about a drug's efficacy profile.

Comparison of FDA accelerated vs regular pathway approvals for lung cancer treatments between 2006 and 2018

Regulatory agencies around the world have been using flexible requirements for approval of new drugs, especially for cancer drugs. The US Food and Drug Administration (FDA) is mostly the first agency to approve new drugs worldwide, mainly due to the faster terms of the accelerated pathway and breakthrough therapy designation. Surrogate endpoints and preliminary data (e.g. single-arm and phase 2 studies) are used for these new approvals, however larger effect sizes are expected. We aim to compare FDA Accelerated vs Regular Pathway approvals and Breakthrough therapy designations (BTD) for lung cancer treatments between 2006 and 2018 regarding study design, sample size, outcome measures and effect size. We assessed the FDA database to collect data from studies that formed the basis of approvals of new drugs or indications for lung cancer spanning from 2006 to 2018. We found that accelerated pathway approvals are based on significantly more single-arm studies with small sample sizes and surrogate primary endpoints. However, effect size was not different between the pathways. A large proportion of studies used to support regular pathway approvals also showed these characteristics that are related to low quality and uncertain evidence. Compared to other approvals, BTD were more frequently based on single-arm studies. There was no significant difference in use of surrogate endpoints or sample size. 44% of BTD were based on studies demonstrating large effect sizes, proportionally more than approvals not receiving this designation. In conclusion, based on the indicators of evidence quality we extracted, criteria’s for granting accelerated approval and breakthrough therapy designation seen not clear. Faster approvals are in the majority full of uncertainties which should be viewed with caution and the patient have to be communicated to allow shared decision making. Post-marketing validation is essential.

Clinical trials with sequential analysis that were early-stopped: How to interpret them?

Sequential analysis of clinical trials allows researchers a continuous monitoring of emerging data and greater security to avoid subjecting the trial participants to a less effective therapy before the inferiority is evident, while controlling the overall error rate. Although it has been widely used since its development, sequential analysis is not problem-free. Among them main issues to be mentioned are the balance between safety and efficacy, overestimation of the effect size of interventions and conditional bias. In this review, we develop different aspects of this methodology and the impact of including early-stopped clinical trials in systematic reviews with meta-analysis.

TIDieR checklist evaluation of clinical trial intervention reporting for recent FDA-approved anticancer medications

IMPORTANCE

Clear and comprehensive descriptions of clinical trial interventions are necessary to translate new results into clinical practice. The TIDieR checklist was developed to be a minimum set of key items considered essential to high-quality reporting of clinical trial interventions.

OBJECTIVE

To determine the quality of reporting of recent Food and Drug Administration (FDA)-approved oncology interventions.

DESIGN

Cross-sectional investigation.

SETTING/PARTICIPANTS/INTERVENTION

Recent, FDA-approved haematology/oncology anticancer interventions.

MAIN OUTCOME MEASURE

Quality of reporting.

RESULTS

Across all included trials (n=96), a median of 8-9 (out of 12) TIDieR items were reported. Seven TIDieR items had >90% adherence, including individual-level and study-level modifications of drugs and dosing schedules. Three items were less often reported: intervention provider, including training and expertise (7/192, 3.6%); trial institution infrastructure (0/192, 0.0%); and how intervention compliance was assessed (59/192, 30.7%). Publication of a protocol improved intervention reporting (p<0.001).

CONCLUSIONS

In this analysis of clinical trials of recent, FDA-approved anticancer interventions, we found good adherence to the TIDieR checklist. These studies were homogeneous in their structure and included information; some TIDieR items were always or never/rarely reported. Clinical trial effect sizes may not translate to real-world practice for a number of reasons. Thus, to aid the translation of trial effect sizes to real-world practice, we recommend authors adhere to the TIDieR checklist and describe the infrastructure of trial centres and describe who provided the intervention, along with their expertise.

Endpoint surrogacy in oncological randomized controlled trials with immunotherapies: a systematic review of trial-level and arm-level meta-analyses

Few cancer drugs or their indications achieved survival benefit in subsequent trials during postmarket period after approval based on surrogate endpoints. This causes a concern of using surrogate endpoints instead of overall survival (OS) as the primary endpoint for trial design, implementation and regulation approval. We conducted a systematic review to summarize the findings from published meta-analyses which have evaluated endpoint surrogacy for OS in oncological randomized controlled trials (RCTs) with immunotherapies. After searching articles indexed in PubMed prior to 24 February 2019, we identified a total of 11 meta-analyses for advanced multiple tumors, non-small cell lung cancer (NSCLC), urothelial carcinoma, renal cell carcinoma, melanoma; most (91%; 10/11) focused on immune checkpoint inhibitors. Although the evaluation criteria adopted by these meta-analyses for validating endpoint surrogacy were not consistent (ranging from R² ≥0.60 to R² ≥0.80), the results were consistent. Few studies show an association between OS and progression-free survival (PFS)/objective response rate (ORR) that met the lowest evaluation criteria (R² ≥0.60), based on treatment effects (8%; 2/26 indications) or absolute results from experimental arm (0%; 0/11 indications). However, the association between OS and 1-year survival rate met the lowest criteria based on both the trial-level results (4/4 indications) and the arm-level results (5/5 indications). In lieu of this finding, we are supportive of an alternative endpoint, e.g., 1-year survival rate, rather than the more conventional choices PFS and ORR, as promising surrogate endpoint for OS in immunotherapy RCTs. We encourage further investigation on endpoint surrogacy based on the same or different settings, especially an assessment on survival rate at milestone time (e.g., 1-year), which has been demonstrated valuable for predicting OS in meta-analyses.

Reporting Interim Results Can Show the Feasibility of Practicing Outcome-Based Neurovascular Care Within Randomized Trials: An Opinion

BACKGROUND

Randomized trials of commonly performed surgical interventions are notoriously difficult to conduct. The trial methodology may nevertheless be the best way to offer outcome-based neurovascular care in the presence of uncertainty. One obstacle to promoting such trials is the conventional prohibition of publication and dissemination of interim results as the trial progresses.

METHODS

We review the scientific and statistical reasons against the publication of interim analyses as well as exceptions that can occur when 1 treatment is unexpectedly shown to be harmful or when the results of other trials have convincingly shown the comparative benefits of a new intervention. We also discuss the promotion of difficult surgical trials.

RESULTS

Reasons to support the conventional ban on publication of interim results include control of statistical errors, prevention of invalid conclusions, and dissemination of false claims of equivalence of rival interventions. In the early phases of a trial, usually 1 treatment cannot be shown superior to the other. We believe, contrary to the received view, that a transparent report of the early progress of certain trials can be justified, even when interim results are inconclusive, to promote the recruitment of participating centers and the practice of a novel way to offer neurovascular care in the presence of uncertainty in the best medical interest of patients.

CONCLUSIONS

In our opinion, the early publication of inconclusive interim results may increase awareness of the feasibility of surgical care trials.