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Yap C, Lee Aiyegbusi O, Alger E, Basch E, Bell J, Bhatnagar V, Cella D, Collis P, Dueck AC, Gilbert A, Gnanasakthy A, Greystoke A, Hansen AR, Kamudoni P, Kholmanskikh O, King-Kallimanis BL, Krumholz H, Minchom A, O'Connor D, Petrie J, Piccinin C, Rantell KR, Rauz S, Retzer A, Rizk S, Wagner L, Sasseville M, Seymour LK, Weber HA, Wilson R, Calvert M, Peipert JD. Advancing patient-centric care: integrating patient reported outcomes for tolerability assessment in early phase clinical trials - insights from an expert virtual roundtable. EClinicalMedicine 2024; 76:102838. [PMID: 39386161 PMCID: PMC11462221 DOI: 10.1016/j.eclinm.2024.102838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 09/04/2024] [Accepted: 09/04/2024] [Indexed: 10/12/2024] Open
Abstract
Early phase clinical trials provide an initial evaluation of therapies' risks and benefits to patients, including safety and tolerability, which typically relies on reporting outcomes by investigator and laboratory assessments. Use of patient-reported outcomes (PROs) to inform risks (tolerability) and benefits (improvement in disease symptoms) is more common in later than early phase trials. We convened a two-day expert roundtable covering: (1) the necessity and feasibility of a universal PRO core conceptual model for early phase trials; (2) the practical integration of PROs in early phase trials to inform tolerability assessment, guide dose decisions, or as real-time safety alerts to enhance investigator-reported adverse events. Participants (n = 22) included: patient advocates, regulators, clinicians, statisticians, pharmaceutical representatives, and PRO methodologists working across diverse clinical areas. In this manuscript, we report major recommendations resulting from the roundtable discussions corresponding to each theme. Additionally, we highlight priority areas necessitating further investigation.
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Affiliation(s)
- Christina Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Olalekan Lee Aiyegbusi
- Centre for Patient-Reported Outcomes Research (CPROR), Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre (BRC), University Hospital Birmingham and University of Birmingham, Birmingham, UK
- NIHR Applied Research Collaboration West Midlands, University of Birmingham, Birmingham, UK
- NIHR Blood and Transplant Research Unit in Precision Transplant and Cellular Therapeutics, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
| | - Emily Alger
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Ethan Basch
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC, 27514, USA
- Division of Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC, 27514, USA
| | - Jill Bell
- AstraZeneca, Oncology Research and Development, Gaithersburg, MD, USA
| | - Vishal Bhatnagar
- Oncology Center of Excellence, US Food and Drug Administration, Silver Spring, MD, USA
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Philip Collis
- Centre for Patient-Reported Outcomes Research (CPROR), Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Amylou C. Dueck
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA
| | - Alexandra Gilbert
- Leeds Institute for Medical Research, University of Leeds, St James's University Hospital, Leeds, UK
| | - Ari Gnanasakthy
- RTI Health Solutions, Patient Centered Outcomes Research, Research Triangle Park, NC, USA
| | | | - Aaron R. Hansen
- Princess Alexandra Hospital, Cancer Services, Brisbane, Queensland, Australia
- University of Queensland, Faculty of Medicine, Australia
| | | | - Olga Kholmanskikh
- Federal Agency for Medicines and Health Products (FAMHP), Brussels, Belgium
| | | | - Harlan Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
| | - Anna Minchom
- Drug Development Unit, Royal Marsden/Institute of Cancer Research, Sutton, UK
| | | | - Joan Petrie
- Canadian Cancer Trials Group (CCTG), Kingston, Ontario, Canada
| | - Claire Piccinin
- Quality of Life Department, European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | | | - Saaeha Rauz
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, UK
- Birmingham and Midland Eye Centre, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Ameeta Retzer
- Centre for Patient Reported Outcomes Research (CPROR), Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute of Health and Care Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Lynne Wagner
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | | | | | - Harald A. Weber
- Pfizer Oncology, Global Medical Affairs/Early-Stage Development, Zug, Switzerland
| | - Roger Wilson
- Cancer Research Advocates Forum UK, Sarcoma Patient Advocacy Global Network, UK
| | - Melanie Calvert
- Centre for Patient-Reported Outcomes Research (CPROR), Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre (BRC), University Hospital Birmingham and University of Birmingham, Birmingham, UK
- NIHR Applied Research Collaboration West Midlands, University of Birmingham, Birmingham, UK
- NIHR Blood and Transplant Research Unit in Precision Transplant and Cellular Therapeutics, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
| | - John Devin Peipert
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Westphalen CB, Martins-Branco D, Beal JR, Cardone C, Coleman N, Schram AM, Halabi S, Michiels S, Yap C, André F, Bibeau F, Curigliano G, Garralda E, Kummar S, Kurzrock R, Limaye S, Loges S, Marabelle A, Marchió C, Mateo J, Rodon J, Spanic T, Pentheroudakis G, Subbiah V. The ESMO Tumour-Agnostic Classifier and Screener (ETAC-S): a tool for assessing tumour-agnostic potential of molecularly guided therapies and for steering drug development. Ann Oncol 2024:S0923-7534(24)01519-9. [PMID: 39187421 DOI: 10.1016/j.annonc.2024.07.730] [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: 05/03/2024] [Revised: 07/19/2024] [Accepted: 07/29/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Advances in precision oncology led to approval of tumour-agnostic molecularly guided treatment options (MGTOs). The minimum requirements for claiming tumour-agnostic potential remain elusive. METHODS The European Society for Medical Oncology (ESMO) Precision Medicine Working Group (PMWG) coordinated a project to optimise tumour-agnostic drug development. International experts examined and summarised the publicly available data used for regulatory assessment of the tumour-agnostic indications approved by the US Food and Drug Administration and/or the European Medicines Agency as of December 2023. Different scenarios of minimum objective response rate (ORR), number of tumour types investigated, and number of evaluable patients per tumour type were assessed for developing a screening tool for tumour-agnostic potential. This tool was tested using the tumour-agnostic indications approved during the first half of 2024. A taxonomy for MGTOs and a framework for tumour-agnostic drug development were conceptualised. RESULTS Each tumour-agnostic indication had data establishing objective response in at least one out of five patients (ORR ≥ 20%) in two-thirds (≥4) of the investigated tumour types, with at least five evaluable patients in each tumour type. These minimum requirements were met by tested indications and may serve as a screening tool for tumour-agnostic potential, requiring further validation. We propose a conceptual taxonomy classifying MGTOs based on the therapeutic effect obtained by targeting a driver molecular aberration across tumours and its modulation by tumour-specific biology: tumour-agnostic, tumour-modulated, or tumour-restricted. The presence of biology-informed mechanistic rationale, early regulatory advice, and adequate trial design demonstrating signs of biology-driven tumour-agnostic activity, followed by confirmatory evidence, should be the principles for tumour-agnostic drug development. CONCLUSION The ESMO Tumour-Agnostic Classifier (ETAC) focuses on the interplay of targeted driver molecular aberration and tumour-specific biology modulating the therapeutic effect of MGTOs. We propose minimum requirements to screen for tumour-agnostic potential (ETAC-S) as part of tumour-agnostic drug development. Definition of ETAC cut-offs is warranted.
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Affiliation(s)
- C B Westphalen
- Comprehensive Cancer Center Munich & Department of Medicine III, University Hospital, LMU Munich, Munich; German Cancer Consortium (DKTK), partner site Munich, German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - D Martins-Branco
- Scientific and Medical Division, European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - J R Beal
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - C Cardone
- Experimental Clinical Abdominal Oncology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Naples, Italy
| | - N Coleman
- School of Medicine, Trinity College Dublin, Dublin; Medical Oncology Department, St. James's Hospital, Dublin; Trinity St. James's Cancer Institute, Dublin, Ireland
| | - A M Schram
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City; Weill Cornell Medical College, New York City
| | - S Halabi
- Department of Biostatistics and Bioinformatics, Duke University, Durham; Duke Cancer Institute, Duke University, Durham, USA
| | - S Michiels
- Oncostat U1018, Inserm, Université Paris-Saclay, labeled Ligue Contre le Cancer, Villejuif; Service de Biostatistique et Epidémiologie, Gustave Roussy, Villejuif, France
| | - C Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - F André
- INSERM U981, Gustave Roussy, Villejuif; Department of Cancer Medicine, Gustave Roussy, Villejuif; Faculty of Medicine, Université Paris-Saclay, Kremlin Bicêtre
| | - F Bibeau
- Service d'Anatomie Pathologique, CHU Besançon, Université de Bourgogne Franche-Comté, Besançon, France
| | - G Curigliano
- Istituto Europeo di Oncologia, IRCCS, Milan; Department of Oncology and Hemato-Oncology, University of Milano, Milan, Italy
| | - E Garralda
- Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - S Kummar
- Division of Hematology and Medical Oncology, Department of Medicine, Knight Cancer Institute, Oregon Health and Science University, Portland
| | - R Kurzrock
- Department of Medicine, Medical College of Wisconsin Cancer Center, Milwaukee, USA
| | - S Limaye
- Medical & Precision Oncology, Sir H. N. Reliance Foundation Hospital & Research Centre, Mumbai, India
| | - S Loges
- DKFZ-Hector Cancer Institute at the University Medical Center Mannheim, Department of Personalized Oncology, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim; Division of Personalized Medical Oncology (A420), German Cancer Research Center (DKFZ), German Center for Lung Research (DZL), German Cancer Consortium (DKTK), Heidelberg, Germany
| | - A Marabelle
- Drug Development Department (DITEP) and Laboratory for Translational Research in Immunotherapy (LRTI), Gustave Roussy, INSERM U1015 & CIC1428, Université Paris-Saclay, Villejuif, France
| | - C Marchió
- Department of Medical Sciences, University of Turin, Turin; Division of Pathology, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Italy
| | - J Mateo
- Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - J Rodon
- Department of Investigational Cancer Therapeutics, UT MD Anderson, Houston, USA
| | - T Spanic
- Europa Donna Slovenia, Ljubljana, Slovenia
| | - G Pentheroudakis
- Scientific and Medical Division, European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - V Subbiah
- Early-Phase Drug Development, Sarah Cannon Research Institute (SCRI), Nashville, USA
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Graber N, Canova N, Bryant‐Lukosius D, Robert G, Navarro‐Rodrigo B, Trueb L, Coukos G, Eicher M, Corbière T, Colomer‐Lahiguera S. Reflections on the opportunities and challenges of applying experience-based co-design (EBCD) to phase 1 clinical trials in oncology. Health Expect 2024; 27:e14068. [PMID: 38937953 PMCID: PMC11211206 DOI: 10.1111/hex.14068] [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: 12/21/2023] [Revised: 04/16/2024] [Accepted: 04/24/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Experience-Based Co-Design (EBCD) is a multi-stage participatory action research process which was developed originally to increase patient involvement in service improvement initiatives. This viewpoint article serves as a reflection on the researchers' experiences, focusing on the application and feasibility of participatory approaches, particularly co-design, in the specific context of early-phase clinical trials. METHODS We reflect on the opportunities and challenges of applying EBCD in a new context of early-phase clinical trials in oncology where experimental treatments are increasingly perceived as a therapeutic option and, in certain instances, their efficacy may lead to accelerated approval facilitating a swifter integration into standard care. RESULTS We propose that the opportunity of applying EBCD in such trials lies in improving the delivery of person-centered care, care coordination, and support during the transition from experimental to standard care. Three potential challenges when applying EBCD in early-phase clinical trials are discussed related to: the need for standardization in trial processes; planning EBCD in a context of high uncertainty; and vulnerability of patient populations. CONCLUSION Integrating EBCD into early-phase oncology trials presents an opportunity to enhance person-centered care and can lead to simultaneous improvements in care processes and therapeutic development. PATIENT OR PUBLIC CONTRIBUTION This article has been developed with the collaboration of a patient partner who serves on the advisory board of our ongoing EBCD study in early clinical trials.
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Affiliation(s)
- Nils Graber
- Institute of Higher Education and Research in Healthcare (IUFRS), Faculty of Biology and MedicineUniversity of Lausanne (UNIL)LausanneSwitzerland
| | - Nina Canova
- Institute of Higher Education and Research in Healthcare (IUFRS), Faculty of Biology and MedicineUniversity of Lausanne (UNIL)LausanneSwitzerland
| | | | - Glenn Robert
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative CareKing's College LondonLondonUK
| | | | - Lionel Trueb
- Department of OncologyLausanne University Hospital (CHUV)LausanneSwitzerland
| | - George Coukos
- Department of OncologyLausanne University Hospital (CHUV)LausanneSwitzerland
| | - Manuela Eicher
- Institute of Higher Education and Research in Healthcare (IUFRS), Faculty of Biology and MedicineUniversity of Lausanne (UNIL)LausanneSwitzerland
- Department of OncologyLausanne University Hospital (CHUV)LausanneSwitzerland
| | - Tourane Corbière
- Institute of Higher Education and Research in Healthcare (IUFRS), Faculty of Biology and MedicineUniversity of Lausanne (UNIL)LausanneSwitzerland
| | - Sara Colomer‐Lahiguera
- Institute of Higher Education and Research in Healthcare (IUFRS), Faculty of Biology and MedicineUniversity of Lausanne (UNIL)LausanneSwitzerland
- Department of OncologyLausanne University Hospital (CHUV)LausanneSwitzerland
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Hong JSW, Ostinelli EG, Kamvar R, Smith KA, Walsh AEL, Kabir T, Tomlinson A, Cipriani A. An online evidence-based dictionary of common adverse events of antidepressants: a new tool to empower patients and clinicians in their shared decision-making process. BMC Psychiatry 2024; 24:532. [PMID: 39049079 PMCID: PMC11270875 DOI: 10.1186/s12888-024-05950-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Adverse events (AEs) are commonly reported in clinical studies using the Medical Dictionary for Regulatory Activities (MedDRA), an international standard for drug safety monitoring. However, the technical language of MedDRA makes it challenging for patients and clinicians to share understanding and therefore to make shared decisions about medical interventions. In this project, people with lived experience of depression and antidepressant treatment worked with clinicians and researchers to co-design an online dictionary of AEs associated with antidepressants, taking into account its ease of use and applicability to real-world settings. METHODS Through a pre-defined literature search, we identified MedDRA-coded AEs from randomised controlled trials of antidepressants used in the treatment of depression. In collaboration with the McPin Foundation, four co-design workshops with a lived experience advisory panel (LEAP) and one independent focus group (FG) were conducted to produce user-friendly translations of AE terms. Guiding principles for translation were co-designed with McPin/LEAP members and defined before the finalisation of Clinical Codes (CCs, or non-technical terms to represent specific AE concepts). FG results were thematically analysed using the Framework Method. RESULTS Starting from 522 trials identified by the search, 736 MedDRA-coded AE terms were translated into 187 CCs, which balanced key factors identified as important to the LEAP and FG (namely, breadth, specificity, generalisability, patient-understandability and acceptability). Work with the LEAP showed that a user-friendly language of AEs should aim to mitigate stigma, acknowledge the multiple levels of comprehension in 'lay' language and balance the need for semantic accuracy with user-friendliness. Guided by these principles, an online dictionary of AEs was co-designed and made freely available ( https://thesymptomglossary.com ). The digital tool was perceived by the LEAP and FG as a resource which could feasibly improve antidepressant treatment by facilitating the accurate, meaningful expression of preferences about potential harms through a shared decision-making process. CONCLUSIONS This dictionary was developed in English around AEs from antidepressants in depression but it can be adapted to different languages and cultural contexts, and can also become a model for other interventions and disorders (i.e., antipsychotics in schizophrenia). Co-designed digital resources may improve the patient experience by helping to deliver personalised information on potential benefits and harms in an evidence-based, preference-sensitive way.
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Affiliation(s)
- James S W Hong
- Department of Psychiatry, University of Oxford, Oxford, UK.
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK.
| | - Edoardo G Ostinelli
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | | | - Katharine A Smith
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | | | - Thomas Kabir
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Anneka Tomlinson
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
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Alger E, Van Zyl M, Aiyegbusi OL, Chuter D, Dean L, Minchom A, Yap C. Patient and public involvement and engagement in the development of innovative patient-centric early phase dose-finding trial designs. RESEARCH INVOLVEMENT AND ENGAGEMENT 2024; 10:63. [PMID: 38898479 PMCID: PMC11186095 DOI: 10.1186/s40900-024-00599-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/13/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND In light of the FDA's Project Optimus initiative, there is fresh interest in leveraging Patient-reported Outcome (PRO) data to enhance the assessment of tolerability for investigational therapies within early phase dose-finding oncology trials. Typically, dose escalation in most trial designs is solely reliant on clinician assessed adverse events. Research has shown a disparity between patients and clinicians when assessing whether an investigational therapy is tolerable, leading to the recommendation of potentially intolerable doses for further investigation in subsequent trials. It is also increasingly recognized that patient and public involvement and engagement (PPIE) plays a pivotal role in enriching trial design and conduct. However, to our knowledge, no PPIE has explored the optimal integration of PROs in the development of advanced statistical trial designs within early phase dose-finding oncology trials. METHODS A virtual PPIE session was held with nine participants on 18th October 2023 to discuss the incorporation of PROs within a dose-finding trial design. This cross disciplinary session was developed and led by a team of statisticians, clinical specialists, qualitative experts, and trial methodologists. Following the session, in-depth perspectives were provided by two patient advocates who actively engaged in the PPIE session. We discuss the importance of PPIE in shaping advanced dose-finding trial designs, share insights from patients on integrating PROs to inform treatment tolerability, and present a template for meaningful patient involvement in trial design development. RESULTS Participants generally supported the introduction of PROs within dose-finding trials but showed some apprehensiveness as to how PROs may reduce the size of the recommended dose (and potentially efficacious effect). Some participants shared that they may be reluctant to record the real severity of their symptoms via PROs if it would mean that they would have to discontinue treatment. They discussed that PROs could be used to assess tolerability rather than toxicity of a dose. CONCLUSIONS Amplifying patient voice in the development of patient-centric dose-finding trial designs is now essential. This paper offers an exemplary illustration of how trialists and methodologists can effectively incorporate patient voice in the future development of advanced dose-finding trial designs.
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Affiliation(s)
- Emily Alger
- Clinical Trial and Statistics Unit, Institute of Cancer Research, London, UK
| | - Mary Van Zyl
- Drug Development Unit, Royal Marsden/Institute of Cancer Research, Sutton, London, UK
| | - Olalekan Lee Aiyegbusi
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Dave Chuter
- Advocate Forum, NCRI - National Cancer Research Institute, London, UK
| | - Lizzie Dean
- Advocate Forum, NCRI - National Cancer Research Institute, London, UK
| | - Anna Minchom
- Drug Development Unit, Royal Marsden/Institute of Cancer Research, Sutton, London, UK
| | - Christina Yap
- Clinical Trial and Statistics Unit, Institute of Cancer Research, London, UK.
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Spencer K, Butenschoen H, Alger E, Bachini M, Cook N. Amplifying the Patient's Voice in Oncology Early-Phase Clinical Trials: Solutions to Burdens and Barriers. Am Soc Clin Oncol Educ Book 2024; 44:e433648. [PMID: 38857456 DOI: 10.1200/edbk_433648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Dose-finding oncology trials (DFOTs) provide early access to novel compounds of potential therapeutic benefit in addition to providing critical safety and dosing information. While access to trials for which a patient is eligible remains the largest barrier to enrollment on clinical trials, additional direct and indirect barriers unique to enrollment on DFOTs are often overlooked but worthy of consideration. Direct barriers including financial costs of care, travel and time investments, and logical challenges including correlative study designs are important to bear in mind when developing strategies to facilitate the patient experience on DFOTs. Indirect barriers such as strict eligibility criteria, washout periods, and concomitant medication restrictions should be accounted for during DFOT design to maintain the fidelity of the trial without being overly exclusionary. Involving patients and advocates and incorporating patient-reported outcomes (PROs) throughout the process, from initial DFOT design, through patient recruitment and participation, is critical to informing strategies to minimize identified barriers to offer the benefit of DFOTs to all patients.
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Affiliation(s)
- Kristen Spencer
- Department of Medicine at NYU Grossman School of Medicine, NYU Langone Perlmutter Cancer Center, New York, NY
| | - Henry Butenschoen
- Department of Medicine at NYU Grossman School of Medicine, NYU Langone Perlmutter Cancer Center, New York, NY
| | - Emily Alger
- The Alan Turing Institute, London, United Kingdom
| | | | - Natalie Cook
- University of Manchester and the Christie NHS Foundation Trust, Manchester, United Kingdom
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Yap C, Solovyeva O, de Bono J, Rekowski J, Patel D, Jaki T, Mander A, Evans TRJ, Peck R, Hayward KS, Hopewell S, Ursino M, Rantell KR, Calvert M, Lee S, Kightley A, Ashby D, Chan AW, Garrett-Mayer E, Isaacs JD, Golub R, Kholmanskikh O, Richards D, Boix O, Matcham J, Seymour L, Ivy SP, Marshall LV, Hommais A, Liu R, Tanaka Y, Berlin J, Espinasse A, Dimairo M, Weir CJ. Enhancing reporting quality and impact of early phase dose-finding clinical trials: CONSORT Dose-finding Extension (CONSORT-DEFINE) guidance. BMJ 2023; 383:e076387. [PMID: 37863501 PMCID: PMC10583500 DOI: 10.1136/bmj-2023-076387] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2023] [Indexed: 10/22/2023]
Affiliation(s)
| | | | - Johann de Bono
- Institute of Cancer Research, London SM2 5NG, UK
- Royal Marsden NHS Foundation Trust, London, UK
| | - Jan Rekowski
- Institute of Cancer Research, London SM2 5NG, UK
| | | | - Thomas Jaki
- MRC Biostatistics Unit, Cambridge University, Cambridge, UK
- Computational Statistics Group, University of Regensburg, Regensburg, Germany
| | - Adrian Mander
- Centre For Trials Research, Cardiff University, Heath Park, Cardiff, UK
| | - Thomas R Jeffry Evans
- Institute of Cancer Sciences, CR-UK Beatson Institute, University of Glasgow, Glasgow, UK
| | - Richard Peck
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Hoffmann-La Roche, Basel, Switzerland
| | - Kathryn S Hayward
- Departments of Physiotherapy, and Medicine (Royal Melbourne Hospital), University of Melbourne, VIC, Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Sally Hopewell
- Oxford Clinical Research Unit, NDORMS, University of Oxford, Oxford, UK
| | - Moreno Ursino
- ReCAP/F CRIN, INSERM, Paris, France
- Unit of Clinical Epidemiology, CHU Robert Debré, APHP, URC, INSERM CIC-EC 1426, Reims, France
- INSERM Centre de Recherche des Cordeliers, Sorbonne University, Paris Cité University, Paris, France
- Health data and model driven approaches for Knowledge Acquisition team, Centre Inria, Paris, France
| | | | - Melanie Calvert
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Applied Research Collaboration West Midlands, University of Birmingham, Birmingham, UK
- NIHR Research Blood and Transplant Research Unit in Precision Transplant and Cellular Therapeutics, University of Birmingham, Edgbaston, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Institute of Translational Medicine, University Hospital NHS Foundation Trust, Birmingham, UK
| | - Shing Lee
- Columbia University Mailman School of Public Health, New York, NY, USA
| | | | - Deborah Ashby
- School of Public Health, Imperial College London, London, UK
| | - An-Wen Chan
- Department of Medicine, Women's College Research Institute, University of Toronto, Toronto, ON, Canada
| | - Elizabeth Garrett-Mayer
- Center for Research and Analytics, American Society of Clinical Oncology, Alexandria, VA, USA
| | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Robert Golub
- Department of Medicine, Northwestern University Feinberg School of Medicine, 633 Clark Street, Evanston, IL, USA
| | - Olga Kholmanskikh
- Federal Agency for Medicines and Health Products, Brussels, Belgium
- European Medicines Agency, Amsterdam, Netherlands
| | - Dawn Richards
- Clinical Trials Ontario, MaRS Centre, Toronto, ON, Canada
| | | | - James Matcham
- Strategic Consulting, Cytel (Australia), Perth, WA, Australia
| | - Lesley Seymour
- Investigational New Drug Programme, Canadian Cancer Trials Group, Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - S Percy Ivy
- Investigational Drug Branch, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Institute of Health, Bethesda, MD, USA
| | - Lynley V Marshall
- Institute of Cancer Research, London SM2 5NG, UK
- Royal Marsden NHS Foundation Trust, London, UK
| | - Antoine Hommais
- Department of Clinical Research, National Cancer Institute, Boulogne-Billancourt, France
| | - Rong Liu
- Bristol Myers Squibb, New York, NY, USA
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | | | - Munyaradzi Dimairo
- Division of Population Health, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
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Yap C, Rekowski J, Ursino M, Solovyeva O, Patel D, Dimairo M, Weir CJ, Chan AW, Jaki T, Mander A, Evans TRJ, Peck R, Hayward KS, Calvert M, Rantell KR, Lee S, Kightley A, Hopewell S, Ashby D, Garrett-Mayer E, Isaacs J, Golub R, Kholmanskikh O, Richards DP, Boix O, Matcham J, Seymour L, Ivy SP, Marshall LV, Hommais A, Liu R, Tanaka Y, Berlin J, Espinasse A, de Bono J. Enhancing quality and impact of early phase dose-finding clinical trial protocols: SPIRIT Dose-finding Extension (SPIRIT-DEFINE) guidance. BMJ 2023; 383:e076386. [PMID: 37863491 DOI: 10.1136/bmj-2023-076386] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Affiliation(s)
| | - Jan Rekowski
- Institute of Cancer Research, London SM2 5NG, UK
| | - Moreno Ursino
- ReCAP/F CRIN, INSERM, Paris, France
- Unit of Clinical Epidemiology, University Hospital Centre Robert Debré, Reims, France
- INSERM Centre de Recherche des Cordeliers, Sorbonne University, Paris, France
- Health data and model driven approaches for Knowledge Acquisition team, Centre Inria, Paris, France
| | | | | | - Munyaradzi Dimairo
- Division of Population Health, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - An-Wen Chan
- Department of Medicine, Women's College Research Institute, University of Toronto, Toronto, Canada
| | - Thomas Jaki
- MRC Biostatistics Unit, Cambridge University, Cambridge, UK
- Computational Statistics Group, University of Regensburg, Regensburg, Germany
| | - Adrian Mander
- Centre For Trials Research, Cardiff University, Cardiff, UK
| | - Thomas R Jeffry Evans
- Institute of Cancer Sciences, CR-UK Beatson Institute, University of Glasgow, Glasgow, UK
| | - Richard Peck
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Hoffmann-La Roche, Basel, Switzerland
| | - Kathryn S Hayward
- Departments of Physiotherapy, and Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Melanie Calvert
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research Applied Research Collaboration West Midlands, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Precision Transplant and Cellular Therapeutics, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research Birmingham Biomedical Research Centre, NIHR Birmingham Biomedical Research Centre, Institute of Translational Medicine, University Hospital NHS Foundation Trust, Birmingham, UK
| | | | - Shing Lee
- Columbia University Mailman School of Public Health, New York, NY, USA
| | | | - Sally Hopewell
- Oxford Clinical Research Unit, NDORMS, University of Oxford, Oxford, UK
| | - Deborah Ashby
- School of Public Health, Imperial College London, St Mary's Hospital, London, UK
| | - Elizabeth Garrett-Mayer
- Center for Research and Analytics, American Society of Clinical Oncology, Alexandria, VA, USA
| | - John Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Robert Golub
- Department of Medicine, Northwestern University Feinberg School of Medicine, Evanston, IL, USA
| | | | | | | | - James Matcham
- Strategic Consulting, Cytel (Australia), Perth, WA, Australia
| | - Lesley Seymour
- Investigational New Drug Programme, Canadian Cancer Trials Group, Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - S Percy Ivy
- Investigational Drug Branch, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Institute of Health, Bethesda, MD, USA
| | - Lynley V Marshall
- Institute of Cancer Research, London SM2 5NG, UK
- Royal Marsden NHS Foundation Trust, London, UK
| | - Antoine Hommais
- Department of Clinical Research, National Cancer Institute, Boulogne-Billancourt, France
| | - Rong Liu
- Bristol Myers Squibb, New York, NY, USA
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | | | - Johann de Bono
- Institute of Cancer Research, London SM2 5NG, UK
- Royal Marsden NHS Foundation Trust, London, UK
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9
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Alger E, Minchom A, Lee Aiyegbusi O, Schipper M, Yap C. Statistical methods and data visualisation of patient-reported outcomes in early phase dose-finding oncology trials: a methodological review. EClinicalMedicine 2023; 64:102228. [PMID: 37781154 PMCID: PMC10541462 DOI: 10.1016/j.eclinm.2023.102228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 10/03/2023] Open
Abstract
Background Traditionally, within dose-finding clinical trials, treatment toxicity and tolerability are assessed by clinicians. Research has shown that clinician reporting may have inadequate inter-rater reliability, poor correlation with patient reported outcomes, and under capture the true toxicity burden. The introduction of patient-reported outcomes (PROs), where the patient can assess their own symptomatic adverse events or quality of life, has potential to complement current practice to aid dose optimisation. There are no international recommendations offering guidance for the inclusion of PROs in dose-finding trial design and analysis. Our review aimed to identify and describe current statistical methods and data visualisation techniques employed to analyse and visualise PRO data in published early phase dose-finding oncology trials (DFOTs). Methods DFOTs published from June 2016-December 2022, which presented PRO analysis methods, were included in this methodological review. We extracted 35 eligible papers indexed in PubMed. Study characteristics extracted included: PRO objectives, PRO measures, statistical analysis and visualisation techniques, and whether the PRO was involved in interim and final dose selection decisions. Findings Most papers (30, 85.7%) did not include clear PRO objectives. 20 (57.1%) papers used inferential statistical techniques to analyse PROs, including survival analysis and mixed-effect models. One trial used PROs to classify a clinicians' assessed dose-limiting toxicities (DLTs). Three (8.6%) trials used PROs to confirm the tolerability of the recommended dose. 25 trial reports visually presented PRO data within a figure or table within their publication, of which 12 papers presented PRO score longitudinally. Interpretation This review highlighted that the statistical methods and reporting of PRO analysis in DFOTs are often poorly described and inconsistent. Many trials had PRO objectives which were not clearly described, making it challenging to evaluate the appropriateness of the statistical techniques used. Drawing conclusions based on DFOTs which are not powered for PROs may be misleading. With no guidance and standardisation of analysis methods for PROs in early phase DFOTs, it is challenging to compare study findings across trials. Therefore, there is a crucial need to establish international guidance to enhance statistical methods and graphical presentation for PRO analysis in the dose-finding setting. Funding EA has been supported to undertake this work as part of a PhD studentship from the Institute of Cancer Research within the MRC/NIHR Trials Methodology Research Partnership. AM is supported by the National Institute for Health Research (NIHR) Biomedical Research Centre at the Royal Marsden NHS Foundation Trust, the Institute of Cancer Research and Imperial College.
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Affiliation(s)
- Emily Alger
- Clinical Trial and Statistics Unit, Institute of Cancer Research, London, UK
| | - Anna Minchom
- Drug Development Unit, Royal Marsden/Institute of Cancer Research, London, UK
| | - Olalekan Lee Aiyegbusi
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Matthew Schipper
- Departments of Radiation Oncology and Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Christina Yap
- Clinical Trial and Statistics Unit, Institute of Cancer Research, London, UK
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10
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Gnanasakthy A, Norcross L, Fitzgerald K. Assessment of Patient-Reported Outcomes in Industry-Sponsored Phase I Oncology Studies: Considerations for Translating Theory Into Practice. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1440-1443. [PMID: 37353056 DOI: 10.1016/j.jval.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 05/04/2023] [Accepted: 06/09/2023] [Indexed: 06/25/2023]
Abstract
An increasing interest in the identification of optimal dosage for oncology therapies has prompted key opinion leaders and regulators to encourage the integration of patient-reported outcome (PRO) assessments in phase I oncology clinical trials. Although the potential benefits of assessing PROs in early-phase studies have been acknowledged, the difficulties that arise from such a radical shift have been largely overlooked in the public discussion. In this commentary, the authors provide insight into the challenges that industry sponsors face in integrating PRO assessments into phase I oncology trials, with the ultimate goal of facilitating conversations that may help to resolve some of these issues.
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11
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Atkinson TM, Lensing S, Lee JY, Chang D, Kim SY, Li Y, Lynch KA, Webb A, Holland SM, Lubetkin EI, Goldstone S, Einstein MH, Stier EA, Wiley DJ, Mitsuyasu R, Rosa-Cunha I, Aboulafia DM, Dhanireddy S, Schouten JT, Levine R, Gardner E, Logan J, Dunleavy H, Barroso LF, Bucher G, Korman J, Stearn B, Wilkin TJ, Ellsworth G, Pugliese JC, Arons A, Burkhalter JE, Cella D, Berry-Lawhorn JM, Palefsky JM. Construct validity and responsiveness of a health-related symptom index for persons either treated or monitored for anal high-grade squamous intraepithelial lesions (HSIL): AMC-A01/-A03. Qual Life Res 2023; 32:2293-2304. [PMID: 37020153 PMCID: PMC10330891 DOI: 10.1007/s11136-023-03391-4] [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] [Accepted: 03/04/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE To determine whether treatment of anal high-grade squamous intraepithelial lesions (HSIL), vs active monitoring, is effective in reducing incidence of anal cancer in persons living with HIV, the US National Cancer Institute funded the Phase III ANal Cancer/HSIL Outcomes Research (ANCHOR) clinical trial. As no established patient-reported outcomes (PRO) tool exists for persons with anal HSIL, we sought to estimate the construct validity and responsiveness of the ANCHOR Health-Related Symptom Index (A-HRSI). METHODS The construct validity phase enrolled ANCHOR participants who were within two weeks of randomization to complete A-HRSI and legacy PRO questionnaires at a single time point. The responsiveness phase enrolled a separate cohort of ANCHOR participants who were not yet randomized to complete A-HRSI at three time points: prior to randomization (T1), 14-70 (T2), and 71-112 (T3) days following randomization. RESULTS Confirmatory factor analysis techniques established a three-factor model (i.e., physical symptoms, impact on physical functioning, impact on psychological functioning), with moderate evidence of convergent validity and strong evidence of discriminant validity in the construct validity phase (n = 303). We observed a significant moderate effect for changes in A-HRSI impact on physical functioning (standardized response mean = 0.52) and psychological symptoms (standardized response mean = 0.60) from T2 (n = 86) to T3 (n = 92), providing evidence of responsiveness. CONCLUSION A-HRSI is a brief PRO index that captures health-related symptoms and impacts related to anal HSIL. This instrument may have broad applicability in other contexts assessing individuals with anal HSIL, which may ultimately help improve clinical care and assist providers and patients with medical decision-making.
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Affiliation(s)
- Thomas M Atkinson
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA.
| | - Shelly Lensing
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeannette Y Lee
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Di Chang
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Soo Young Kim
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - Yuelin Li
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - Kathleen A Lynch
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
- School of Global Public Health, New York University, New York, NY, USA
| | - Andrew Webb
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - Susan M Holland
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | | | | | | | | | - Dorothy J Wiley
- University of California, Los Angeles School of Nursing, Los Angeles, CA, USA
| | - Ronald Mitsuyasu
- UCLA Center for Clinical AIDS Research and Education, Los Angeles, CA, USA
| | | | | | | | - Jeffrey T Schouten
- Virginia Mason Medical Center, Seattle, WA, USA
- Harborview Medical Center, Seattle, WA, USA
| | | | - Edward Gardner
- Public Health Institute at Denver Health, Denver, CO, USA
| | - Jeffrey Logan
- Public Health Institute at Denver Health, Denver, CO, USA
| | | | - Luis F Barroso
- Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Gary Bucher
- Anal Dysplasia Clinic MidWest, Chicago, IL, USA
| | - Jessica Korman
- Metropolitan Gastroenterology Group, Washington, DC, USA
| | | | | | | | - Julia C Pugliese
- ANCHOR Data Management Center of The Emmes Company, LLC, Rockville, MD, USA
| | - Abigail Arons
- ANCHOR Data Management Center of The Emmes Company, LLC, Rockville, MD, USA
| | - Jack E Burkhalter
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - David Cella
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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12
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Andrillon A, Biard L, Lee SM. Incorporating patient-reported outcomes in dose-finding clinical trials with continuous patient enrollment. J Biopharm Stat 2023:1-12. [PMID: 37496233 PMCID: PMC10811281 DOI: 10.1080/10543406.2023.2236216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 07/09/2023] [Indexed: 07/28/2023]
Abstract
Dose-finding clinical trials in oncology estimate the maximum tolerated dose (MTD), based on toxicity obtained from the clinician's perspective. While the collection of patient-reported outcomes (PROs) has been advocated to better inform treatment tolerability, there is a lack of guidance and methods on how to use PROs for dose assignments and recommendations. The PRO continual reassessment method (PRO-CRM) has been proposed to formally incorporate PROs into dose-finding trials. In this paper, we propose two extensions of the PRO-CRM, which allow continuous enrollment of patients and longer toxicity observation windows to capture late-onset or cumulative toxicities by using a weighted likelihood to include the partial toxicity follow-up information. The TITE-PRO-CRM uses both the PRO and the clinician's information during the trial for dose assignment decisions and at the end of the trial to estimate the MTD. The TITE-CRM + PRO uses clinician's information solely to inform dose assignments during the trial and incorporates PRO at the end of the trial for the estimation of the MTD. Simulation studies show that the TITE-PRO-CRM performs similarly to the PRO-CRM in terms of dose recommendation and assignments during the trial while almost halving trial duration in case of an accrual of two patients per observation window. The TITE-CRM + PRO slightly underperforms compared to the TITE-PRO-CRM, but similar performance can be attained by requiring larger sample sizes. We also show that the performance of the proposed methods is robust to higher accrual rates, different toxicity hazards, and correlated time-to-clinician toxicity and time-to-patient toxicity data.
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Affiliation(s)
- Anaïs Andrillon
- INSERM U1153 Team ECSTRRA, Université Paris Cité, Paris, France
- Department of Statistical Methodology, Saryga, Tournus, France
| | - Lucie Biard
- INSERM U1153 Team ECSTRRA, Université Paris Cité, Paris, France
| | - Shing M. Lee
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
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13
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Wages NA, Nelson B, Kharofa J, Meier T. Application of the patient-reported outcomes continual reassessment method to a phase I study of radiotherapy in endometrial cancer. Int J Biostat 2023; 19:163-176. [PMID: 36394530 PMCID: PMC10238853 DOI: 10.1515/ijb-2022-0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 06/29/2022] [Accepted: 08/07/2022] [Indexed: 07/28/2023]
Abstract
This article considers the concept of designing Phase I clinical trials using both clinician- and patient-reported outcomes to adaptively allocate study participants to tolerable doses and determine the maximum tolerated dose (MTD) at the study conclusion. We describe an application of a Bayesian form of the patient-reported outcomes continual reassessment method (PRO-CRMB) in an ongoing Phase I study of adjuvant hypofractionated whole pelvis radiation therapy (WPRT) in endometrial cancer (NCT04458402). The study's primary objective is to determine the MTD per fraction of WPRT, defined by acceptable clinician- and patient-reported DLT rates. We conduct simulation studies of the operating characteristics of the design and compared them to a rule-based approach. We illustrate that the PRO-CRMB makes appropriate dose assignments during the study to give investigators and reviewers an idea of how the method behaves. In simulation studies, the PRO-CRMB demonstrates superior performance to a 5 + 2 stepwise design in terms of recommending target treatment courses and allocating patients to these courses. The design is accompanied by an easy-to-use R shiny web application to simulate operating characteristics at the design stage and sequentially update dose assignments throughout the trial's conduct.
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Affiliation(s)
- Nolan A. Wages
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Bailey Nelson
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Jordan Kharofa
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Teresa Meier
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
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14
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Di Maio M. The value of patient-reported outcomes in single-arm cancer trials. Cancer Invest 2023:1-4. [PMID: 37083469 DOI: 10.1080/07357907.2023.2206497] [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: 04/22/2023]
Abstract
Recently, many cancer drugs have been approved by regulatory agencies based on single-arm studies, where analysis of quality of life (QoL) and patient reported outcomes (PROs) is not a direct comparison with the standard, but the simple description of changes versus baseline and trends over time. This analysis can be potentially biased by missing data: QoL level could be overestimated, and symptoms underestimated. Caution is needed to avoid that a methodologically weak evidence in PROs and QoL data is overrated, if not for the drug approval, for the interpretation of data by scientific community and the communication with patients. PROs experts should be involved in planning, conduction and interpretation of analyses.
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Affiliation(s)
- Massimo Di Maio
- Department of Oncology, University of Turin, at Ordine Mauriziano Hospital, Turin, Italy
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15
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Araujo D, Greystoke A, Bates S, Bayle A, Calvo E, Castelo-Branco L, de Bono J, Drilon A, Garralda E, Ivy P, Kholmanskikh O, Melero I, Pentheroudakis G, Petrie J, Plummer R, Ponce S, Postel-Vinay S, Siu L, Spreafico A, Stathis A, Steeghs N, Yap C, Yap TA, Ratain M, Seymour L. Oncology phase I trial design and conduct: time for a change - MDICT Guidelines 2022. Ann Oncol 2023; 34:48-60. [PMID: 36182023 DOI: 10.1016/j.annonc.2022.09.158] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/18/2022] [Indexed: 02/03/2023] Open
Abstract
In 2021, the Food and Drug Administration Oncology Center of Excellence announced Project Optimus focusing on dose optimization for oncology drugs. The Methodology for the Development of Innovative Cancer Therapies (MDICT) Taskforce met to review and discuss the optimization of dosage for oncology trials and to develop a practical guide for oncology phase I trials. Defining a single recommended phase II dose based on toxicity may define doses that are neither the most effective nor the best tolerated. MDICT recommendations address the need for robust non-clinical data which are needed to inform trial design, as well as an expert team including statisticians and pharmacologists. The protocol must be flexible and adaptive, with clear definition of all endpoints. Health authorities should be consulted early and regularly. Strategies such as randomization, intrapatient dose escalation, and real-world eligibility criteria are encouraged whereas serial tumor sampling is discouraged in the absence of a strong rationale and appropriately validated assay. Endpoints should include consideration of all longitudinal toxicity. The phase I dose escalation trial should define the recommended dose range for later testing in randomized phase II trials, rather than a single recommended phase II dose, and consider scenarios where different populations may require different dosages. The adoption of these recommendations will improve dosage selection in early clinical trials of new anticancer treatments and ultimately, outcomes for patients.
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Affiliation(s)
- D Araujo
- Hospital de Base, Sao Jose do Rio Preto, Brazil
| | - A Greystoke
- Northern Centre for Cancer Care, Newcastle, UK
| | - S Bates
- Division of Hematology and Oncology, Department of Medicine, Columbia University, New York, USA
| | - A Bayle
- Institut Gustave Roussy, Paris, France
| | - E Calvo
- START Madrid-CIOCC, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - L Castelo-Branco
- European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - J de Bono
- Institute of Cancer Research, University of London, London; The Royal Marsden Hospital, London, UK
| | - A Drilon
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, USA
| | - E Garralda
- Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - P Ivy
- National Cancer Institute, USA Cancer Therapy Evaluation Program Investigational Drug Branch (NCI/CTEP/IDB), Bethesda, USA
| | - O Kholmanskikh
- European Medicines Agency, Amsterdam, Netherlands; Federal Agency for Medicines and Health Products, Brussels, Belgium
| | - I Melero
- CUN and CIMA, University of Navarra, Pamplona, Spain
| | - G Pentheroudakis
- European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - J Petrie
- Canadian Cancer Trials Group, Queen's University, Kingston
| | - R Plummer
- Northern Centre for Cancer Care, Newcastle, UK
| | - S Ponce
- Institut Gustave Roussy, Paris, France
| | | | - L Siu
- Princess Margaret Cancer Centre, Toronto, Canada
| | - A Spreafico
- Princess Margaret Cancer Centre, Toronto, Canada
| | - A Stathis
- Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
| | - N Steeghs
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - C Yap
- Institute of Cancer Research, University of London, London
| | - T A Yap
- Department of Investigational Cancer Therapeutics, University of Texas, MD Anderson Cancer Center, Houston
| | - M Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, USA
| | - L Seymour
- Canadian Cancer Trials Group, Queen's University, Kingston.
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16
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Retzer A, Sivell S, Scott H, Nelson A, Bulbeck H, Seddon K, Grant R, Adams R, Watts C, Aiyegbusi OL, Kearns P, Cruz Rivera S, Dirven L, Baddeley E, Calvert M, Byrne A. Development of a core outcome set and identification of patient-reportable outcomes for primary brain tumour trials: protocol for the COBra study. BMJ Open 2022; 12:e057712. [PMID: 36180121 PMCID: PMC9528585 DOI: 10.1136/bmjopen-2021-057712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 07/18/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Primary brain tumours, specifically gliomas, are a rare disease group. The disease and treatment negatively impacts on patients and those close to them. The high rates of physical and cognitive morbidity differ from other cancers causing reduced health-related quality of life. Glioma trials using outcomes that allow holistic analysis of treatment benefits and risks enable informed care decisions. Currently, outcome assessment in glioma trials is inconsistent, hindering evidence synthesis. A core outcome set (COS) - an agreed minimum set of outcomes to be measured and reported - may address this. International initiatives focus on defining core outcomes assessments across brain tumour types. This protocol describes the development of a COS involving UK stakeholders for use in glioma trials, applicable across glioma types, with provision to identify subsets as required. Due to stakeholder interest in data reported from the patient perspective, outcomes from the COS that can be patient-reported will be identified. METHODS AND ANALYSIS Stage I: (1) trial registry review to identify outcomes collected in glioma trials and (2) systematic review of qualitative literature exploring glioma patient and key stakeholder research priorities. Stage II: semi-structured interviews with glioma patients and caregivers. Outcome lists will be generated from stages I and II. Stage III: study team will remove duplicate items from the outcome lists and ensure accessible terminology for inclusion in the Delphi survey. Stage IV: a two-round Delphi process whereby the outcomes will be rated by key stakeholders. Stage V: a consensus meeting where participants will finalise the COS. The study team will identify the COS outcomes that can be patient-reported. Further research is needed to match patient-reported outcomes to available measures. ETHICS AND DISSEMINATION Ethical approval was obtained (REF SMREC 21/59, Cardiff University School of Medicine Research Ethics Committee). Study findings will be disseminated widely through conferences and journal publication. The final COS will be adopted and promoted by patient and carer groups and its use by funders encouraged. PROSPERO REGISTRATION NUMBER CRD42021236979.
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Affiliation(s)
- Ameeta Retzer
- Centre for Patient Reported Outcomes Research, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Applied Research Centre, West Midlands, Birmingham, UK
| | - Stephanie Sivell
- Marie Curie Palliative Care Research Centre, Division of Population Medicine, Cardiff University School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Hannah Scott
- Cambridge Public Health, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre, Division of Population Medicine, Cardiff University School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | | | | | - Robin Grant
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Richard Adams
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Colin Watts
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Olalekan Lee Aiyegbusi
- Centre for Patient Reported Outcomes Research, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Pamela Kearns
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Samantha Cruz Rivera
- Centre for Patient Reported Outcomes Research, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
| | - Linda Dirven
- Department of Neurology, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
- Department of Neurology, Medical Centre Haaglanden, Den Haag, The Netherlands
| | - Elin Baddeley
- Marie Curie Palliative Care Research Centre, Division of Population Medicine, Cardiff University School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Melanie Calvert
- Centre for Patient Reported Outcomes Research, Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Applied Research Centre, West Midlands, Birmingham, UK
| | - Anthony Byrne
- Marie Curie Palliative Care Research Centre, Division of Population Medicine, Cardiff University School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
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Lai-Kwon J, Vanderbeek AM, Minchom A, Lee Aiyegbusi O, Ogunleye D, Stephens R, Calvert M, Yap C. Using Patient-Reported Outcomes in Dose-Finding Oncology Trials: Surveys of Key Stakeholders and the National Cancer Research Institute Consumer Forum. Oncologist 2022; 27:768-777. [PMID: 35762393 PMCID: PMC9438918 DOI: 10.1093/oncolo/oyac117] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background Patient-reported adverse events may be a useful adjunct for assessing a drug’s tolerability in dose-finding oncology trials (DFOT). We conducted surveys of international stakeholders and the National Cancer Research Institute (NCRI) Consumer Forum to understand attitudes about patient-reported outcome (PRO) use in DFOT. Methods A 35-question survey of clinicians, trial managers, statisticians, funders, and regulators of DFOT was distributed via professional bodies examining experience using PROs, benefits/barriers, and their potential role in defining tolerable doses. An 8-question survey of the NCRI Consumer Forum explored similar themes. Results International survey: 112 responses from 15 September–30 November 2020; 103 trialists [48 clinicians (42.9%), 38 statisticians (34.0%), 17 trial managers (15.2%)], 7 regulators (6.3%), 2 funders (1.8%)]. Most trialists had no experience designing (73, 70.9%), conducting (52, 50.5%), or reporting (88, 85.4%) PROs in DFOT. Most agreed that PROs could identify new toxicities (75, 67.0%) and provide data on the frequency (86, 76.8%) and duration (81, 72.3%) of toxicities. The top 3 barriers were lack of guidance regarding PRO selection (73/103, 70.9%), missing PRO data (71/103, 68.9%), and overburdening staff (68/103, 66.0%). NCRI survey: 57 responses on 21 March 2021. A total of 28 (49.1%) were willing to spend <15 min/day completing PROs. Most (55, 96.5%) preferred to complete PROs online. 61 (54.5%) trialists and 57 (100%) consumers agreed that patient-reported adverse events should be used to inform dose-escalation decisions. Conclusion Stakeholders reported minimal experience using PROs in DFOT but broadly supported their use. Guidelines are needed to standardize PRO selection, analysis, and reporting in DFOT.
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Affiliation(s)
- Julia Lai-Kwon
- Drug Development Unit, The Institute of Cancer Research and Royal Marsden Hospital, London, UK
| | - Alyssa M Vanderbeek
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, UK
| | - Anna Minchom
- Drug Development Unit, The Institute of Cancer Research and Royal Marsden Hospital, London, UK
| | - Olalekan Lee Aiyegbusi
- Centre for Patient-Reported Outcome Research, Institute of Applied Health Research, University of Birmingham, UK
| | | | | | - Melanie Calvert
- Centre for Patient-Reported Outcome Research, Institute of Applied Health Research, University of Birmingham, UK.,Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, UK.,National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, NIHR Surgical Reconstruction and Microbiology Research Centre and NIHR Applied Research Collaborative West Midlands, University of Birmingham, Birmingham, UK
| | - Christina Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, UK
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Lai‐Kwon J, Yin Z, Minchom A, Yap C. Trends in patient-reported outcome use in early phase dose-finding oncology trials - an analysis of ClinicalTrials.gov. Cancer Med 2021; 10:7943-7957. [PMID: 34676991 PMCID: PMC8607259 DOI: 10.1002/cam4.4307] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/14/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patient-reported adverse events (AEs) may be a useful adjunct to clinician-assessed AEs for assessing tolerability in early phase, dose-finding oncology trials (DFOTs). We reviewed DFOTs on ClinicalTrials.gov to describe trends in patient-reported outcome (PRO) use. METHODS DFOTs commencing 01 January 2007 - 20 January 2020 with 'PROs' or 'quality of life' as an outcome were extracted and inclusion criteria confirmed. Study and PRO characteristics were extracted. Completed trials that reported PRO outcomes and published manuscripts on ClinicalTrials.gov were identified, and PRO reporting details were extracted. RESULTS 5.3% (548/10 372) DFOTs included PROs as an outcome. 231 (42.2%) were eligible: adult (224, 97%), solid tumour (175, 75.8%), and seamless phase 1/2 (108, 46.8%). PRO endpoints were identified in more trials (2.3 increase/year, 95% CI: 1.6-2.9) from an increasing variety of countries (0.7/year) (95% CI: 0.4-0.9) over time. PROs were typically secondary endpoints (207, 89.6%). 15/77 (19.5%) completed trials reported results on the ClinicalTrials.gov results database, and of those eight included their PRO results. Eighteen trials had published manuscripts available on ClinicalTrials.gov. Three (16.7%) used PROs to confirm the maximum tolerated dose. No trials identified who completed the PROs or how PROs were collected. CONCLUSIONS PRO use in DFOT has increased but remains limited. Future work should explore the role of PROs in DFOT and determine what guidelines are needed to standardise PRO use.
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Affiliation(s)
- Julia Lai‐Kwon
- Drug Development UnitThe Institute of Cancer Research and Royal Marsden HospitalLondonUK
| | - Zhulin Yin
- Clinical Trials and Statistics UnitThe Institute of Cancer ResearchSuttonUK
| | - Anna Minchom
- Drug Development UnitThe Institute of Cancer Research and Royal Marsden HospitalLondonUK
| | - Christina Yap
- Clinical Trials and Statistics UnitThe Institute of Cancer ResearchSuttonUK
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