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Pantoja K, Lanke S, Munafo A, Victor A, Habermehl C, Schueler A, Venkatakrishnan K, Girard P, Goteti K. Designing phase I oncology dose escalation using dose-exposure-toxicity models as a complementary approach to model-based dose-toxicity models. CPT Pharmacometrics Syst Pharmacol 2022; 11:1371-1381. [PMID: 35852048 PMCID: PMC9574748 DOI: 10.1002/psp4.12851] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 11/29/2022] Open
Abstract
One of the objectives of oncology phase I dose-escalation studies has been to determine the maximum tolerated dose (MTD). Although MTD is no longer set as the dose for further development in contemporary oncology drug development, MTD determination is still important for informing the therapeutic index. Bayesian adaptive model-based designs are becoming mainstream in oncology first-in-human trials. Herein, we illustrate via simulations the use of systemic exposure in Bayesian adaptive dose-toxicity models to estimate MTD. We extend traditional dose-toxicity models to incorporate pharmacokinetic exposure, which provides information on exposure-toxicity relationships. We pursue dose escalation until the maximum tolerated exposure (corresponding to the MTD) is reached. By leveraging pharmacokinetics, dose escalation considers exposure and interindividual variability on a continuous rather than discrete domain, offering additional information for dose-escalation decisions. To demonstrate this, we generated 1000 simulations (starting dose of 1/25th the reference dose and six dose levels) for several different scenarios. Both rule-based and model-based designs were compared using metrics of potential safety, accuracy, and reliability. The mean results over simulations and different toxicity scenarios showed that model-based designs were better than rule-based methods and that exposure-toxicity model-based methods have the potential to valuably complement dose-toxicity model-based methods. Exposure-toxicity model-based methods had decreased underdose risk accompanied by a relatively smaller increase in overdose risk, resulting in improved net reliability. MTD estimation accuracy was compromised when exposure variability was large, emphasizing the importance of appropriate control of pharmacokinetic variability in phase I dose-escalation studies.
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Affiliation(s)
- Kristyn Pantoja
- Department of StatisticsTexas A&M UniversityCollege StationTexasUSA,EMD Serono Research InstituteBillericaMassachusettsUSA
| | - Shankar Lanke
- EMD Serono Research InstituteBillericaMassachusettsUSA
| | - Alain Munafo
- Merck Institute for PharmacometricsLausanneSwitzerland
| | | | | | | | | | - Pascal Girard
- Merck Institute for PharmacometricsLausanneSwitzerland
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2
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Alshammari K, Aung KL, Zhang T, Razak ARA, Serra S, Stockley T, Wang L, Nguyen J, Spreafico A, Hansen AR, Zwir D, Siu LL, Bedard PL. Phase II Trial of Trametinib and Panitumumab in RAS/RAF Wild Type Metastatic Colorectal Cancer. Clin Colorectal Cancer 2021; 20:334-341. [PMID: 34417144 DOI: 10.1016/j.clcc.2021.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 01/02/2023]
Abstract
INTRODUCTION MEK inhibition may overcome resistance to EGFR inhibition in patients with RAS wildtype (wt) metastatic colorectal cancer (mCRC). We evaluated antitumor activity of trametinib (MEK1/2 inhibitor) with panitumumab (EGFR monoclonal antibody) in a phase II trial. METHODS Patients with KRAS, NRAS, and BRAF wt mCRC with prior 5-FU, irinotecan, oxaliplatin, +/- bevacizumab and no prior anti-EGFR therapy were treated with trametinib 1.5 mg oral daily and panitumumab 4.8 mg/kg IV every 2 weeks. Primary endpoint was clinical benefit rate (CB; CR, PR, or SD ≥24 weeks) by RECIST v1.1. A 2-stage minimax design was used. Serial plasma circulating free DNA (cfDNA) was collected and profiled using Oncomine Lung cfDNA assay. RESULTS Fourteen patients were enrolled from November 2015 to April 2019. CB rate was 38% (5/13) and median progression free survival (PFS) was 4.4 months (95% CI, 2.9-7.1). Confirmed overall response rate was 38% (5/13). Treatment-related AE (trAE) included acneiform rash (85%), diarrhea (62%), maculopapular rash (54%), mucositis (46%), and others. Dose modifications and interruptions of trametinib occurred in 69% and panitumumab in 54% of patients. The trial did not progress to stage II accrual due to tolerability and short duration of response. RAS or BRAF mutations cfDNA were detected in 3/13 patients (23%) before radiographic disease progression. CONCLUSION The addition of trametinib to panitumumab led to a high rate of tumor shrinkage in RAS/RAF wt metastatic colorectal cancer, with poor tolerability due to a high incidence of skin toxicity. Median PFS was similar to panitumumab alone in historical control data.
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Affiliation(s)
- Kanan Alshammari
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario
| | - Kyaw L Aung
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario
| | - Tong Zhang
- Department of Clinical Laboratory Genetics, University Health Network, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Albiruni R A Razak
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario
| | - Stefano Serra
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Tracy Stockley
- Department of Clinical Laboratory Genetics, University Health Network, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Lisa Wang
- Biostatistics Division, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Jessica Nguyen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Anna Spreafico
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario
| | - Aaron R Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario
| | - Dave Zwir
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Lillian L Siu
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario
| | - Philippe L Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario.
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Bitting RL, Tooze JA, Isom S, Petty WJ, Grant SC, Desnoyers RJ, Thomas A, Thomas CY, Alistar AT, Golden SL, Pleasant K, Chappell MC, Tallant EA, Gallagher PE, Klepin HD. Phase I Study of Muscadine Grape Extract for Patients With Advanced Cancer. Am J Clin Oncol 2021; 44:239-246. [PMID: 33867481 PMCID: PMC8141001 DOI: 10.1097/coc.0000000000000814] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Preclinical studies with muscadine grape extract (MGE) show antitumor activity and decreased systemic inflammation. This phase I study (NCT02583269) assessed safety and tolerability of a proprietary MGE preparation in patients with advanced solid tumors. METHODS Patients with metastatic or unresectable cancers who were progressing on standard therapies were assigned to MGE in a standard 3+3 design. Five dose levels were tested (320 to 1600 mg total phenolics/d). Safety and maximum-tolerated dose were assessed after 4 weeks. Patients were evaluated for response at 8 weeks and continued on MGE if clinically stable. Secondary outcomes were response, survival, adherence, fatigue, and quality of life (QOL). RESULTS In total, 23 patients (lung, n=7; gastrointestinal, n=7; genitourinary, n=6; other, n=3) received MGE capsules by mouth twice daily. The cohort [median age 72 years, 48% Eastern Cooperative Oncology Group (ECOG) 2] was heavily pretreated. After 4 weeks on MGE, possibly attributable adverse events grade 2 or higher were fatigue (n=1), decreased lymphocyte count (n=1), and constipation (n=2), including 1 dose-limiting toxicity for grade 3 constipation. Maximum-tolerated dose was not reached. No partial responses were observed. Median time on therapy was 8 weeks, with 29% of patients treated beyond 16 weeks and a median overall survival of 7.2 months. QOL and fatigue levels were stable from baseline to 8 weeks. Higher MGE dose was correlated with improvement in self-reported physical well-being QOL at 8 weeks (r=0.6; P=0.04). CONCLUSIONS MGE is safe and well-tolerated in heavily pretreated and older cancer patients. The potential anticancer properties and the effects of MGE on physical well-being and QOL metrics will be evaluated in future studies.
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Affiliation(s)
- Rhonda L. Bitting
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem NC
- Departments of Internal Medicine, Wake Forest University, Winston-Salem NC
| | - Janet A. Tooze
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem NC
- Biostatistics and Data Science, Wake Forest University, Winston-Salem NC
| | - Scott Isom
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem NC
- Biostatistics and Data Science, Wake Forest University, Winston-Salem NC
| | - W. Jeffrey Petty
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem NC
- Departments of Internal Medicine, Wake Forest University, Winston-Salem NC
| | - Stefan C. Grant
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem NC
- Departments of Internal Medicine, Wake Forest University, Winston-Salem NC
| | - Rodwige J. Desnoyers
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem NC
- Departments of Internal Medicine, Wake Forest University, Winston-Salem NC
| | - Alexandra Thomas
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem NC
- Departments of Internal Medicine, Wake Forest University, Winston-Salem NC
| | - Christopher Y. Thomas
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem NC
- Departments of Internal Medicine, Wake Forest University, Winston-Salem NC
| | - Angela T. Alistar
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem NC
- Departments of Internal Medicine, Wake Forest University, Winston-Salem NC
| | | | | | | | - E. Ann Tallant
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem NC
- Surgery/Hypertension, Wake Forest University, Winston-Salem NC
| | - Patricia E. Gallagher
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem NC
- Surgery/Hypertension, Wake Forest University, Winston-Salem NC
| | - Heidi D. Klepin
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem NC
- Departments of Internal Medicine, Wake Forest University, Winston-Salem NC
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Tao DL, Kartika T, Tran A, Prasad V. Phase I trials and therapeutic intent in the age of precision oncology: What is a patient's chance of response? Eur J Cancer 2020; 139:20-26. [PMID: 32957010 DOI: 10.1016/j.ejca.2020.04.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 01/25/2023]
Abstract
The advancement of therapeutic strategies in oncology such as precision oncology has generated significant interest in better estimating the response of modern phase I cancer clinical trials. These estimates have varied widely. In this commentary, we provide an umbrella review of phase I response rates and discuss methodological reasons for variation in prior estimates which include limited use of unpublished data, the inclusion of expansion cohorts that artificially raise response rates of cumulative response rates, varying enrolment of haematologic malignancies, and increased next in class drugs.
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Affiliation(s)
- Derrick L Tao
- Division of Internal Medicine, Oregon Health & Science University, USA
| | - Thomas Kartika
- Division of Internal Medicine, Oregon Health & Science University, USA
| | - Audrey Tran
- School of Medicine, Oregon Health & Science University, USA
| | - Vinay Prasad
- Department of Epidemiology & Biostatistics, University of California, San Francisco, USA.
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Tateishi R. The Era of the Hepatic Oncologist. Liver Cancer 2020; 9:378-381. [PMID: 32999865 PMCID: PMC7506212 DOI: 10.1159/000508342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/24/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Ryosuke Tateishi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Teneggi V, Novotny‐Diermayr V, Lee LH, Yasin M, Yeo P, Ethirajulu K, Gan SBH, Blanchard SE, Nellore R, Umrani DN, Gomeni R, Teck DLW, Li G, Lu QS, Cao Y, Matter A. First-in-Human, Healthy Volunteers Integrated Protocol of ETC-206, an Oral Mnk 1/2 Kinase Inhibitor Oncology Drug. Clin Transl Sci 2020; 13:57-66. [PMID: 31343094 PMCID: PMC6951458 DOI: 10.1111/cts.12678] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 06/26/2019] [Indexed: 01/02/2023] Open
Abstract
In the last decade, drug development has tackled substantial challenges to improve efficiency and facilitate access to innovative medicines. Integrated clinical protocols and the investigation of targeted oncology drugs in healthy volunteers (HVs) have emerged as modalities with an increase in scope and complexity of early clinical studies and first-in-human (FIH) studies in particular. However, limited work has been done to explore the impact of these two modalities, alone or in combination, on the scientific value and on the implementation of such articulated studies. We conducted an FIH study in HVs with an oncology targeted drug, an Mnk 1/2 small molecule inhibitor. In this article, we describe results, advantages, and limitations of an integrated clinical protocol with an oncology drug. We further discuss and indicate points to consider when designing and conducting similar scientifically and operationally demanding FIH studies.
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Affiliation(s)
| | | | - Lay Hoon Lee
- D3 (Drug Discovery and Development)A*STARSingaporeSingapore
| | - Maryam Yasin
- D3 (Drug Discovery and Development)A*STARSingaporeSingapore
| | - Pauline Yeo
- D3 (Drug Discovery and Development)A*STARSingaporeSingapore
| | | | | | | | | | | | | | - Darren Lim Wan Teck
- SingHealth Investigational Medicine UnitSingapore Health ServicesSingaporeSingapore
| | - Greg Li
- SingHealth Investigational Medicine UnitSingapore Health ServicesSingaporeSingapore
| | - Qing Shu Lu
- Singapore Clinical Research InstituteSingaporeSingapore
| | - Yang Cao
- Singapore Clinical Research InstituteSingaporeSingapore
| | - Alex Matter
- D3 (Drug Discovery and Development)A*STARSingaporeSingapore
- Experimental Therapeutics CentreA*STARSingaporeSingapore
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7
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Rossoni C, Bardet A, Geoerger B, Paoletti X. Sequential or combined designs for Phase I/II clinical trials? A simulation study. Clin Trials 2019; 16:635-644. [DOI: 10.1177/1740774519872702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Phase I and Phase II clinical trials aim at identifying a dose that is safe and active. Both phases are increasingly combined. For Phase I/II trials, two main types of designs are debated: a dose-escalation stage to select the maximum tolerated dose, followed by an expansion cohort to investigate its activity (dose-escalation followed by an expansion cohort), or a joint modelling to identify the best trade-off between toxicity and activity (efficacy–toxicity). We explore this question in the context of a paediatric Phase I/II platform trial. Methods: In series of simulations, we assessed the operating characteristics of dose-escalation followed by an expansion cohort (DE-EC) designs without and with reassessment of the maximum tolerated dose during the expansion cohort (DE-ECext) and of the efficacy–toxicity (EffTox) design. We investigated the probability to identify an active and tolerable agent, that is, the percentage of correct decision, for various dose-toxicity activity scenarios. Results: For a large therapeutic index, the percentage of correct decision reached 96.0% for efficacy–toxicity versus 76.1% for dose-escalation followed by an expansion cohort versus 79.6% for DE-ECext. Conversely, when all doses were deemed not active, the percentage of correct decision was 47% versus 55.9% versus 69.2%, respectively, for efficacy–toxicity, dose-escalation followed by an expansion cohort and DE-ECext. Finally, in the case of a narrow therapeutic index, the percentage of correct decision was 48.0% versus 64.3% versus 67.2%, respectively, efficacy–toxicity, dose-escalation followed by an expansion cohort and DE-ECext. Conclusion: As narrow indexes are common in oncology, according to the present results, the sequential dose-escalation followed by an expansion cohort is recommended. The importance to re-estimate the maximum tolerated dose during the expansion cohort is confirmed. However, despite their theoretical advantages, Phase I/II designs are challenged by the variations in populations between the Phase I and the Phase II parts and by the lagtime in the evaluation of toxicity and activity.
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Affiliation(s)
- Caroline Rossoni
- Biostatistics and Epidemiology Department, Gustave Roussy, Villejuif, France
- INSERM U1018, CESP OncoStat, Université Paris-Saclay, UVSQ, Villejuif, France
| | - Aurélie Bardet
- Biostatistics and Epidemiology Department, Gustave Roussy, Villejuif, France
- INSERM U1018, CESP OncoStat, Université Paris-Saclay, UVSQ, Villejuif, France
| | - Birgit Geoerger
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Xavier Paoletti
- Biostatistics and Epidemiology Department, Gustave Roussy, Villejuif, France
- INSERM U1018, CESP OncoStat, Université Paris-Saclay, UVSQ, Villejuif, France
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Adashek JJ, LoRusso PM, Hong DS, Kurzrock R. Phase I trials as valid therapeutic options for patients with cancer. Nat Rev Clin Oncol 2019; 16:773-778. [PMID: 31477881 DOI: 10.1038/s41571-019-0262-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2019] [Indexed: 12/17/2022]
Abstract
For many years, oncology phase I trials have been referred to as 'toxicity trials' and have been believed to have low clinical utility other than that of establishing the adverse event profile of novel therapeutic agents. The traditional distinction of clinical trials into three phases has been challenged in the past few years by the introduction of targeted therapies and immunotherapies into the routine management of patients with cancer. This transformation has especially affected early phase trials, leading to the current situation in which response rates are increasingly reported from phase I trials. In this Perspectives, we highlight key elements of phase I trials and discuss how each one of them contributes to a new paradigm whereby preliminary measurements of the clinical benefit from a novel treatment can be obtained in current phase I trials, which can therefore be considered to have a therapeutic intent.
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Affiliation(s)
- Jacob J Adashek
- Department of Internal Medicine, University of South Florida, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - David S Hong
- Department of Investigational Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy, Department of Medicine, University of California San Diego Moores Cancer Center, La Jolla, CA, USA.
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Affiliation(s)
- I F Tannock
- Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre and University of Toronto, Toronto, Canada.
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10
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Owonikoko TK, Busari AK, Kim S, Chen Z, Akintayo A, Lewis C, Carthon BC, Alese OB, El-Rayes BF, Ramalingam SS, Harvey RD. Race-, Age-, and Gender-Based Characteristics and Toxicities of Targeted Therapies on Phase I Trials. Oncology 2018; 95:138-146. [PMID: 29913438 PMCID: PMC6113074 DOI: 10.1159/000488763] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 03/12/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The impact of age-, gender-, and race-based differences on safety and efficacy in phase I clinical trials has not been well studied. METHODS We analyzed data from phase I clinical trials evaluating targeted biologic agents in patients with advanced solid malignancies. Race and gender distribution of enrolled patients was compared to the referral population demographics at the city, metro, and state levels. The association between age, gender, and race with type, frequency, and severity of treatment-emergent toxicities and clinical benefit was assessed using univariate and multivariable models. RESULTS Data from 117 eligible patients - Blacks/Caucasians/Others (27/85/5); male/female (66/51) - were obtained. Blacks were younger than Caucasian patients (median age of 56 vs. 62 years, p = 0.004). Nausea/vomiting was more frequent in female patients (43 vs. 24%, p = 0.03), while hematologic toxicity was more likely in Whites. While median time on treatment was comparable (113 vs. 91; p = 0.840), the median overall survival was significantly shorter for Blacks versus Caucasians (7.4 vs. 11.4 months; p = 0.0227). Black race (HR 2.11; 95% CI 1.24-3.60; p = 0.006) and older age (HR 1.03; 95% CI 1.00-1.06; p = 0.029) were associated with an increased risk of death. CONCLUSIONS Age-, gender-, and race-based disparities were observed with specific toxicity and survival outcomes on phase I clinical trials of anticancer agents.
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Affiliation(s)
- Taofeek K. Owonikoko
- Department of Hematology & Medical Oncology, Emory University School of Medicine, Atlanta GA
- Winship Cancer Institute of Emory University, Atlanta, GA
| | | | - Sungjin Kim
- Winship Cancer Institute of Emory University, Atlanta, GA
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Zhengjia Chen
- Winship Cancer Institute of Emory University, Atlanta, GA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta GA, USA
| | | | - Colleen Lewis
- Winship Cancer Institute of Emory University, Atlanta, GA
| | - Bradley C. Carthon
- Department of Hematology & Medical Oncology, Emory University School of Medicine, Atlanta GA
| | - Olatunji B. Alese
- Department of Hematology & Medical Oncology, Emory University School of Medicine, Atlanta GA
| | - Bassel F. El-Rayes
- Department of Hematology & Medical Oncology, Emory University School of Medicine, Atlanta GA
- Winship Cancer Institute of Emory University, Atlanta, GA
| | - Suresh S. Ramalingam
- Department of Hematology & Medical Oncology, Emory University School of Medicine, Atlanta GA
- Winship Cancer Institute of Emory University, Atlanta, GA
| | - R. Donald Harvey
- Department of Hematology & Medical Oncology, Emory University School of Medicine, Atlanta GA
- Winship Cancer Institute of Emory University, Atlanta, GA
- Department of Pharmacology, Emory University School of Medicine, Atlanta GA
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Waligora M, Bala MM, Koperny M, Wasylewski MT, Strzebonska K, Jaeschke RR, Wozniak A, Piasecki J, Sliwka A, Mitus JW, Polak M, Nowis D, Fergusson D, Kimmelman J. Risk and surrogate benefit for pediatric Phase I trials in oncology: A systematic review with meta-analysis. PLoS Med 2018; 15:e1002505. [PMID: 29462168 PMCID: PMC5819765 DOI: 10.1371/journal.pmed.1002505] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 01/12/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Pediatric Phase I cancer trials are critical for establishing the safety and dosing of anti-cancer treatments in children. Their implementation, however, must contend with the rarity of many pediatric cancers and limits on allowable risk in minors. The aim of this study is to describe the risk and benefit for pediatric cancer Phase I trials. METHODS AND FINDINGS Our protocol was prospectively registered in PROSPERO (CRD42015015961). We systematically searched Embase and PubMed for solid and hematological malignancy Phase I pediatric trials published between 1 January 2004 and 1 March 2015. We included pediatric cancer Phase I studies, defined as "small sample size, non‑randomized, dose escalation studies that defined the recommended dose for subsequent study of a new drug in each schedule tested." We measured risk using grade 3, 4, and 5 (fatal) drug-related adverse events (AEs) and benefit using objective response rates. When possible, data were meta-analyzed. We identified 170 studies meeting our eligibility criteria, accounting for 4,604 patients. The pooled overall objective response rate was 10.29% (95% CI 8.33% to 12.25%), and was lower in solid tumors, 3.17% (95% CI 2.62% to 3.72%), compared with hematological malignancies, 27.90% (95% CI 20.53% to 35.27%); p < 0.001. The overall fatal (grade 5) AE rate was 2.09% (95% CI 1.45% to 2.72%). Across the 4,604 evaluated patients, there were 4,675 grade 3 and 4 drug-related AEs, with an average grade 3/4 AE rate per person equal to 1.32. Our study had the following limitations: trials included in our review were heterogeneous (to minimize heterogeneity, we separated types of therapy and cancer types), and we relied on published data only and encountered challenges with the quality of reporting. CONCLUSIONS Our meta-analysis suggests that, on the whole, AE and response rates in pediatric Phase I trials are similar to those in adult Phase I trials. Our findings provide an empirical basis for the refinement and review of pediatric Phase I trials, and for communication about their risk and benefit.
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Affiliation(s)
- Marcin Waligora
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
| | - Malgorzata M. Bala
- Department of Hygiene and Dietetics, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Kraków, Poland
- * E-mail: (MMB); (JK)
| | - Magdalena Koperny
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
- Department of Public Health and Health Promotion, Regional Sanitary-Epidemiological Station in Kraków, Poland
| | - Mateusz T. Wasylewski
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
| | - Karolina Strzebonska
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
| | - Rafał R. Jaeschke
- Section of Affective Disorders, Department of Psychiatry, Jagiellonian University Medical College, Kraków, Poland
| | - Agnieszka Wozniak
- Agency for Health Technology Assessment and Tariff System, Warsaw, Poland
| | - Jan Piasecki
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
| | - Agnieszka Sliwka
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
- Department of Rehabilitation in Internal Diseases, Jagiellonian University Medical College, Kraków, Poland
| | - Jerzy W. Mitus
- Department of Surgical Oncology, Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Maciej Polak
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
- Chair of Epidemiology and Population Studies, Jagiellonian University Medical College, Kraków, Poland
| | - Dominika Nowis
- Department of Immunology, Medical University of Warsaw, Warsaw, Poland
- Genomic Medicine, Medical University of Warsaw, Warsaw, Poland
- Laboratory of Experimental Medicine, Centre of New Technologies, University of Warsaw, Warsaw, Poland
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montreal, Canada
- * E-mail: (MMB); (JK)
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Liu S, Nikanjam M, Kurzrock R. Dosing de novo combinations of two targeted drugs: Towards a customized precision medicine approach to advanced cancers. Oncotarget 2017; 7:11310-20. [PMID: 26824502 PMCID: PMC4905475 DOI: 10.18632/oncotarget.7023] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 01/15/2016] [Indexed: 02/07/2023] Open
Abstract
Metastatic cancers harbor complex genomic alterations. Thus, monotherapies are often suboptimal. Individualized combinations are needed in order to attenuate resistance. To help inform selection of safe starting doses for novel, two-agent, targeted drug combinations, we identified clinical trials in adult oncology patients who received targeted drug doublets (PubMed, January 1, 2010 through December 31, 2013). The dose percentage was calculated for each drug: (safe dose in combination divided by single agent full dose) X 100. Additive dose percentage represented the sum of the dose percentage for each drug. A total of 144 studies (N = 8568 patients; 95 combinations) were analyzed. In 51% of trials, each of the two drugs could be administered at 100% of their full dose. The lowest safe additive dose percentage was 60% if targets and/or class of drugs overlapped, or in the presence of mTor inhibitors, which sometimes compromised the combination dose. If neither class nor target overlapped and if mTor inhibitors were absent, the lowest safe additive dose percentage was 143%. The current observations contribute to the knowledge base that informs safe starting doses for new combinations of targeted drugs in the context of clinical trials or practice, hence facilitating customized combination therapies.
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Affiliation(s)
- Sariah Liu
- Department of Hematology-Oncology, Kaiser Permanente San Diego Medical Center, San Diego, CA, USA
| | - Mina Nikanjam
- Division of Hematology-Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, UC San Diego Moores Cancer Center, San Diego, CA, USA
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13
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Hirakawa A, Yonemori K, Kinoshita F, Kobayashi Y, Okuma HS, Kawachi A, Tamura K, Fujiwara Y, Rubinstein L, Harris PJ, Takebe N. Potential utility of a longitudinal relative dose intensity of molecularly targeted agents in phase 1 dose-finding trials. Cancer Sci 2017; 109:207-214. [PMID: 29114963 PMCID: PMC5765308 DOI: 10.1111/cas.13436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 10/16/2017] [Accepted: 10/31/2017] [Indexed: 11/30/2022] Open
Abstract
Phase 1 trials of molecularly targeted agents (MTA) often do not use toxicity data beyond the first cycle of treatment to determine a recommended phase 2 dose (RP2D). We investigated the potential utility of longitudinal relative dose intensity (RDI) that may be a better new way of determining a more accurate RP2D as a lower dose that is presumably more tolerable over the long term without compromising efficacy. All consecutive patients who were initially treated using a single MTA at the conventional RP2D or at one level lower dose (OLLD) of that RP2D in 9 phase 1 trials sponsored by the National Cancer Institute were included. The associations between longitudinal RDI, time to first progression, and response rate were analyzed. The RDI of the conventional RP2D group were maintained a rate of ≥70% throughout 10 cycles, and were higher than those of the OLLD group, although in both groups the RDI gradually decreased with additional treatment cycles. The RP2D group was similar to the OLLD group with respect to time to first progression and response rate. In both groups, however, the decreasing RDI over time was significantly associated with shorter time to first disease progression; therefore, the longitudinal RDI, which takes into account lower grade toxicity occurrences, may be useful in determining a more desirable dose to use in phase 2 and 3 studies.
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Affiliation(s)
- Akihiro Hirakawa
- Department of Biostatistics and Bioinformatics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kan Yonemori
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan.,Department of Experimental Therapeutics, National Cancer Center Hospital, Tokyo, Japan.,Investigational Drug Branch, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institute of Health, Rockville, MD, USA
| | - Fumie Kinoshita
- Statistical Analysis Section, Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Yumiko Kobayashi
- Statistical Analysis Section, Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Hitomi S Okuma
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Asuka Kawachi
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kenji Tamura
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuhiro Fujiwara
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Larry Rubinstein
- Biometric Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institute of Health, Rockville, MD, USA
| | - Pamela Jo Harris
- Investigational Drug Branch, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institute of Health, Rockville, MD, USA
| | - Naoko Takebe
- Investigational Drug Branch, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institute of Health, Rockville, MD, USA
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Moreno L, Pearson ADJ, Paoletti X, Jimenez I, Geoerger B, Kearns PR, Zwaan CM, Doz F, Baruchel A, Vormoor J, Casanova M, Pfister SM, Morland B, Vassal G. Early phase clinical trials of anticancer agents in children and adolescents - an ITCC perspective. Nat Rev Clin Oncol 2017; 14:497-507. [PMID: 28508875 DOI: 10.1038/nrclinonc.2017.59] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In the past decade, the landscape of drug development in oncology has evolved dramatically; however, this paradigm shift remains to be adopted in early phase clinical trial designs for studies of molecularly targeted agents and immunotherapeutic agents in paediatric malignancies. In drug development, prioritization of drugs on the basis of knowledge of tumour biology, molecular 'drivers' of disease and a drug's mechanism of action, and therapeutic unmet needs are key elements; these aspects are relevant to early phase paediatric trials, in which molecular profiling is strongly encouraged. Herein, we describe the strategy of the Innovative Therapies for Children with Cancer (ITCC) Consortium, which advocates for the adoption of trial designs that enable uninterrupted patient recruitment, the extrapolation from studies in adults when possible, and the inclusion of expansion cohorts. If a drug has neither serious dose-related toxicities nor a narrow therapeutic index, then studies should generally be started at the adult recommended phase II dose corrected for body surface area, and act as dose-confirmation studies. The use of adaptive trial designs will enable drugs with promising activity to progress rapidly to randomized studies and, therefore, will substantially accelerate drug development for children and adolescents with cancer.
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Affiliation(s)
- Lucas Moreno
- Paediatric Phase I-II Clinical Trials Unit, Paediatric Haematology &Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Andrew D J Pearson
- Paediatric Drug Development, Children and Young People's Unit, The Royal Marsden NHS Foundation Trust, Sutton, UK; and at the Division of Clinical Studies and Cancer Therapeutics, The Institute of Cancer Research, Sutton, UK
| | - Xavier Paoletti
- Biostatistics and Epidemiology, INSERM U1018, Gustave Roussy, Paris, France
| | - Irene Jimenez
- Department of Paediatric, Adolescents and Young Adults Oncology, Institut Curie; and at the University Paris Descartes, Paris, France
| | - Birgit Geoerger
- Department of Paediatric and Adolescent Oncology, CNRS UMR 8203 Vectorology and Anticancer Treatments, Gustave Roussy, University Paris-Sud, Villejuif, France
| | - Pamela R Kearns
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - C Michel Zwaan
- Department of Paediatric Oncology/Haematology, Erasmus MC/Sophia Children's Hospital, Rotterdam, Netherlands
| | - Francois Doz
- Department of Paediatric, Adolescents and Young Adults Oncology, Institut Curie; and at the University Paris Descartes, Paris, France
| | - Andre Baruchel
- Department of Paediatric Haematology, Hôpital Robert Debré, AP-HP; and at the University Paris Diderot, Paris, France
| | - Josef Vormoor
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University; and at the Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Michela Casanova
- Paediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stefan M Pfister
- German Cancer Research Center (DKFZ); German Cancer Consortium (DKTK); and at the Heidelberg University Hospital, Heidelberg, Germany
| | - Bruce Morland
- Department of Paediatric Oncology, Birmingham Children's Hospital, Birmingham, UK
| | - Gilles Vassal
- Department of Clinical Research, Gustave Roussy, Paris-Sud University, Paris, France
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15
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Nikanjam M, Patel H, Kurzrock R. Dosing immunotherapy combinations: Analysis of 3,526 patients for toxicity and response patterns. Oncoimmunology 2017; 6:e1338997. [PMID: 28920006 DOI: 10.1080/2162402x.2017.1338997] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/31/2017] [Accepted: 06/01/2017] [Indexed: 01/08/2023] Open
Abstract
Immunotherapy combinations are used to improve outcomes in metastatic cancer, but evidence-based knowledge of appropriate starting doses for novel combinations is lacking. Phase I-III adult combination clinical trials (≥ 1 drug was immunotherapy; anti-PD-1, PD-L1, or CTLA-4) were reviewed (PubMed Jan 1, 2010 to Sep 1, 2016; ASCO 2014-2016, ASH/ESMO 2014-2015 abstracts). The safe dose for each drug used in each combination was divided by the single-agent recommended dose to calculate dose percentage. Additive dose percentage was the sum of each dose percentage. Overall, 84 studies (N = 3,526 patients, 59 combinations) were analyzed. In 50% of studies, all drugs could be administered at full dose; 63%, in the presence of anti-PD-1/PD-L1 and 36% with anti-CTLA-4. The lowest safe starting dose for a doublet combination including a second immunotherapy was 50% of each drug; 60%, for a targeted agent. Most doublet/triplets combining anti-PD-1/PD-L1 with cytotoxics were tolerable at full doses. Response rates (median [interquartile range]) were higher for 3-drug than 2-drug combinations (53% [33-63%] (N = 23 studies) vs. 23% [14-39%]) (N = 60 studies) (p < 0.0001) with similar rates seen for targeted, cytotoxic, biologic, or additional immunotherapy combinations (p = 0.35). In conclusion, anti-PD-1/PD-L1 checkpoint inhibitors can be safely given with a variety of other immunotherapy and targeted agents, albeit at about half dose. Doublet and triplet combinations with cytotoxics could mostly be given at full doses. Anti-CTLA-4 agents compromised dosing more than anti-PD-1/PD-L1 agents. Response rates were significantly higher for 3- versus 2-drug combinations.
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Affiliation(s)
- Mina Nikanjam
- Division of Hematology-Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Harsh Patel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, UC San Diego Moores Cancer Center, San Diego, CA, USA
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16
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Nikanjam M, Liu S, Yang J, Kurzrock R. Dosing Three-Drug Combinations That Include Targeted Anti-Cancer Agents: Analysis of 37,763 Patients. Oncologist 2017; 22:576-584. [PMID: 28424323 DOI: 10.1634/theoncologist.2016-0357] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 01/10/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Combining targeted and cytotoxic agents has the potential to improve efficacy and attenuate resistance for metastatic cancer. Information regarding safe starting doses for clinical trials of novel three-drug combinations is lacking. MATERIALS AND METHODS Published phase I-III adult oncology clinical trials of three-drug combinations involving a targeted agent were identified by PubMed search (January 1, 2010 to December 31, 2013). A dose percentage was calculated to compare the dose used in combination to the single agent recommended dose: (U.S. Food and Drug Administration-approved/recommended phase II dose/maximum tolerated dose). The additive dose percentage was the sum of the dose percentages for each drug in the combination. RESULTS A total of 37,763 subjects and 243 drug combinations were included. Only 28% of studies could give each of the three agents at 100%. For combinations involving two targeted agents and a cytotoxic agent, the lowest starting additive dose percentage was 133%, which increased to 250% if two antibodies were included. For combinations of one targeted agent and two cytotoxic agents, the lowest additive safe dose percentage was 137%. When both cytotoxic agents were held at 100%, as occurred in 56% of studies (which generally used cytotoxic doublets with known combination safety dosing), the lowest safe dose percentage was 225% (providing that a histone deacetylase inhibitor was not the targeted agent). CONCLUSION These findings serve as a safe starting point for dosing novel three-drug combinations involving a targeted agent in clinical trials and practice. The Oncologist 2017;22:576-584 IMPLICATIONS FOR PRACTICE: Targeted and cytotoxic drug combinations can improve efficacy and overcome resistance. More knowledge of safe starting doses would facilitate use of combinations in clinical trials and practice. Analysis of 37,763 subjects (243 combinations) showed three drugs could be safely administered, but less than 30% of combinations could include all three drugs at full dose. Dose reductions to 45% of the dose of each single agent may be required. Combinations involving two antibodies required fewer dose reductions, and the use of established cytotoxic doublets made initial dose assignment easier.
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Affiliation(s)
- Mina Nikanjam
- Division of Hematology-Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Sariah Liu
- Department of Hematology-Oncology, Kaiser Permanente San Diego Medical Center, San Diego, California, USA
| | - Jincheng Yang
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, California, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, UC San Diego Moores Cancer Center, San Diego, California, USA
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17
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Hansen AR, Cook N, Amir E, Siu LL, Abdul Razak AR. Determinants of the recommended phase 2 dose of molecular targeted agents. Cancer 2017; 123:1409-1415. [DOI: 10.1002/cncr.30579] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/02/2016] [Accepted: 11/04/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Aaron R. Hansen
- Princess Margaret Cancer Centre; Drug Development Program; Toronto Ontario Canada
| | - Natalie Cook
- Princess Margaret Cancer Centre; Drug Development Program; Toronto Ontario Canada
| | - Eitan Amir
- Princess Margaret Cancer Centre; Drug Development Program; Toronto Ontario Canada
- Institute of Health Policy Management and Evaluation; University of Toronto; Toronto Ontario Canada
| | - Lillian L. Siu
- Princess Margaret Cancer Centre; Drug Development Program; Toronto Ontario Canada
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19
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Cassel JB, Del Fabbro E, Arkenau T, Higginson IJ, Hurst S, Jansen LA, Poklepovic A, Rid A, Rodón J, Strasser F, Miller FG. Phase I Cancer Trials and Palliative Care: Antagonism, Irrelevance, or Synergy? J Pain Symptom Manage 2016; 52:437-45. [PMID: 27233136 DOI: 10.1016/j.jpainsymman.2016.02.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 02/06/2016] [Accepted: 02/26/2016] [Indexed: 12/19/2022]
Abstract
This article synthesizes the presentations and conclusions of an international symposium on Phase 1 oncology trials, palliative care, and ethics held in 2014. The purpose of the symposium was to discuss the intersection of three independent trends that unfolded in the past decade. First, large-scale reviews of hundreds of Phase I trials have indicated there is a relatively low risk of serious harm and some prospect of clinical benefit that can be meaningful to patients. Second, changes in the design and analysis of Phase I trials, the introduction of "targeted" investigational agents that are generally less toxic, and an increase in Phase I trials that combine two or more agents in a novel way have changed the conduct of these trials and decreased fears and apprehensions about participation. Third, the field of palliative care in cancer has expanded greatly, offering symptom management to late-stage cancer patients, and demonstrated that it is not mutually exclusive with disease-targeted therapies or clinical research. Opportunities for collaboration and further research at the intersection of Phase 1 oncology trials and palliative care are highlighted.
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Affiliation(s)
- J Brian Cassel
- Virginia Commonwealth University, Richmond, Virginia, USA.
| | | | - Tobias Arkenau
- Sarah Cannon Research Institute and University College London, London, United Kingdom
| | - Irene J Higginson
- Cicely Saunders Institute, King's College London, London, United Kingdom
| | - Samia Hurst
- Institut d'éthique biomedicale, Centre médical universitaire, Geneva, Switzerland
| | - Lynn A Jansen
- Oregon Health and Science University, Portland, Oregon, USA
| | | | - Annette Rid
- King's College London, London, United Kingdom
| | - Jordi Rodón
- Vall d'Hebron Institut d'Oncologia, Barcelona, Spain
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20
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Nikanjam M, Liu S, Kurzrock R. Dosing targeted and cytotoxic two-drug combinations: Lessons learned from analysis of 24,326 patients reported 2010 through 2013. Int J Cancer 2016; 139:2135-41. [PMID: 27389805 PMCID: PMC5096042 DOI: 10.1002/ijc.30262] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 06/26/2016] [Accepted: 06/30/2016] [Indexed: 02/05/2023]
Abstract
Combining agents has the potential to attenuate resistance in metastatic cancer. However, knowledge of appropriate starting doses for novel drug combinations in clinical trials and practice is lacking. Analysis of 372 published studies was used to ascertain safe starting doses for doublets involving a cytotoxic and targeted agent. Phase I–III adult oncology clinical trial publications (January 1, 2010 to December 31, 2013) were identified (PubMed). The dose of drug used in each combination was compared to the single agent recommended dose [FDA‐approved/recommended phase 2 dose (RP2D)/maximum tolerated dose (MTD)]. Dose percentages were calculated as: (safe dose of drug in combination/dose of drug as single agent at FDA/RP2D/MTD) × 100. Additive dose percentages were the sum of the dose percentage for each drug. A total of 24,326 patients (248 drug combinations) were analyzed. In 38% of studies, both drugs could be administered at 100% of their FDA‐approved/RP2D/MTD dose. The lowest safe additive dose percentage was 41% with poly‐ADP ribose polymerase (PARP) or histone deacetylase inhibitors as the targeted agents; 82%, in the absence of these agents; and 97%, with an antibody in the combination. If one drug was administered at 100% of the single agent dose, the lowest safe dose percentage for the second drug was 17% (cytotoxic at 100%) or 36% (targeted at 100%) of the FDA‐approved/RP2D/MTD dose. The current findings can help inform safe starting doses for novel two‐drug combinations (cytotoxic and targeted agents) in the context of clinical trials and practice. What's new? Cytotoxic and targeted cancer drugs act through distinct mechanisms, and when used in combination they can potentially augment therapeutic effectiveness while minimally impacting toxicity. However, whereas algorithms for safe starting doses for new single‐agent therapies are well established, there are few guidelines for combination therapies. Here, analyses of data from published Phase I–III clinical trials shows that about 38% of patients tolerated combinations in which both drugs were administered at full starting doses. In the majority of patients, significant dose reductions were required to guard against toxicity. Intrapatient dose escalation is possible, however, potentially allowing for increased efficacy.
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Affiliation(s)
- Mina Nikanjam
- Division of Hematology-Oncology, University of California Los Angeles, Los Angeles, CA
| | - Sariah Liu
- Department of Hematology-Oncology, Kaiser Permanente San Diego Medical Center, San Diego, CA
| | - Razelle Kurzrock
- Division of Hematology and Oncology, Center for Personalized Cancer Therapy, UC San Diego Moores Cancer Center, San Diego, CA
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22
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Paoletti X, Ezzalfani M, Le Tourneau C. Statistical controversies in clinical research: requiem for the 3 + 3 design for phase I trials. Ann Oncol 2015; 26:1808-1812. [PMID: 26088197 PMCID: PMC4551156 DOI: 10.1093/annonc/mdv266] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 05/18/2015] [Accepted: 06/02/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND More than 95% of published phase I trials have used the 3 + 3 design to identify the dose to be recommended for phase II trials. However, the statistical community agrees on the limitations of the 3 + 3 design compared with model-based approaches. Moreover, the mechanisms of action of targeted agents strongly challenge the hypothesis that the maximum tolerated dose constitutes the optimal dose, and more outcomes including clinical and biological activity increasingly need to be taken into account to identify the optimal dose. PATIENTS AND METHODS We review key elements from clinical publications and from the statistical literature to show that the 3 + 3 design lacks the necessary flexibility to address the challenges of targeted agents. RESULTS The design issues raised by expansion cohorts, new definitions of dose-limiting toxicity and trials of combinations are not easily addressed by the 3 + 3 design or its extensions. CONCLUSIONS Alternative statistical proposals have been developed to make a better use of the complex data generated by phase I trials. Their applications require a close collaboration between all actors of early phase clinical trials.
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Affiliation(s)
- X Paoletti
- Biostatistics and Epidemiology Department, Gustave Roussy, Villejuif; INSERM U1018, CESP, Paris-Sud University, Villejuif.
| | - M Ezzalfani
- INSERM/Institut Curie/Mines ParisTech U900, Paris
| | - C Le Tourneau
- INSERM/Institut Curie/Mines ParisTech U900, Paris; Department of Medical Oncology, Clinical Trial Unit, Institut Curie, Paris & Saint-Cloud, France
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23
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Gounder MM, Nayak L, Sahebjam S, Muzikansky A, Sanchez AJ, Desideri S, Ye X, Ivy SP, Nabors LB, Prados M, Grossman S, DeAngelis LM, Wen PY. Evaluation of the Safety and Benefit of Phase I Oncology Trials for Patients With Primary CNS Tumors. J Clin Oncol 2015; 33:3186-92. [PMID: 26282642 DOI: 10.1200/jco.2015.61.1525] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
PURPOSE Patients with high-grade gliomas (HGG) are frequently excluded from first-in-human solid tumor trials because of perceived poor prognosis, excessive toxicities, concomitant drug interactions, and poor efficacy. We conducted an analysis of outcomes from select, single-agent phase I studies in patients with HGG. We compared outcomes to pooled analysis of published studies in solid tumors with various molecular and cytotoxic drugs evaluated as single agents or as combinations. PATIENT AND METHODS Individual records of patients with recurrent HGG enrolled onto Adult Brain Tumor Consortium trials of single-agent, cytotoxic or molecular agents from 2000 to 2008 were analyzed for baseline characteristics, toxicities, responses, and survival. RESULTS Our analysis included 327 patients with advanced, refractory HGG who were enrolled onto eight trials involving targeted molecular (n=5) and cytotoxic (n=3) therapies. At enrollment, patients had a median Karnofsky performance score of 90 and median age of 52 years; 62% were men, 63% had glioblastoma, and the median number of prior systemic chemotherapies was one. Baseline laboratory values were in an acceptable range to meet eligibility criteria. Patients were on the study for a median of two cycles (range, <one to 56 cycles), and 96% were evaluable for primary end points. During cycle 1, grade≥3 nonhematologic and grade≥4 hematologic toxicities were 5% (28 of 565 adverse events) and 0.9% (five of 565 adverse events), respectively, and 66% of these occurred at the highest dose level. There was one death attributed to drug. Overall response rate (complete and partial response) was 5.5%. Median progression-free and overall survival times were 1.8 and 6 months, respectively. CONCLUSION Patients with HGG who meet standard eligibility criteria may be good candidates for solid tumor phase I studies with single-agent molecular or cytotoxic drugs with favorable preclinical rationale and pharmacokinetic properties in this population.
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Affiliation(s)
- Mrinal M Gounder
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA.
| | - Lakshmi Nayak
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Solmaz Sahebjam
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Alona Muzikansky
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Armando J Sanchez
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Serena Desideri
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Xiaobu Ye
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - S Percy Ivy
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - L Burt Nabors
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Michael Prados
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Stuart Grossman
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Lisa M DeAngelis
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Patrick Y Wen
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
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Paoletti X, Doussau A, Ezzalfani M, Rizzo E, Thiébaut R. Dose finding with longitudinal data: simpler models, richer outcomes. Stat Med 2015; 34:2983-98. [PMID: 26109523 DOI: 10.1002/sim.6552] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 05/17/2015] [Indexed: 01/29/2023]
Abstract
Phase I oncology clinical trials are designed to identify the optimal dose that will be recommended for phase II trials. This dose is typically defined as the dose associated with a certain probability of severe toxicity at cycle 1, although toxicity is repeatedly measured over cycles on an ordinal scale. Recently, a proportional odds mixed-effect model for ordinal outcomes has been proposed to (i) identify the optimal dose accounting for repeated events and (ii) to provide some framework to explore time trend. We compare this approach to a method based on repeated binary variables and to a method based on an under-parameterized model of the dose-time toxicity relationship. We show that repeated binary and ordinal outcomes both improve the accuracy of dose-finding trials in the same proportion; ordinal outcomes are, however, superior to detect time trend even in the presence of nonproportional odds models. Moreover, less parameterized models led to the best operating characteristics. These approaches are illustrated on two dose-finding phase I trials. Integration of repeated measurements is appealing in phase I dose-finding trials.
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Affiliation(s)
| | - Adélaïde Doussau
- INSERM U900, Institut Curie, Paris, France
- Centre de recherche INSERM U897, & INRIA SISTM & Université de Bordeaux, ISPED, France
| | | | - Elisa Rizzo
- European Organization for Research and Treatment of Cancer Headquarters, Brussels, Belgium
| | - Rodolphe Thiébaut
- Centre de recherche INSERM U897, & INRIA SISTM & Université de Bordeaux, ISPED, France
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Kawazoe A, Shitara K, Fukuoka S, Noguchi M, Kuboki Y, Bando H, Okamoto W, Kojima T, Fuse N, Yoshino T, Ohtsu A, Doi T. Clinical outcomes in 66 patients with advanced gastric cancer treated in phase I trials: the NCCHE experience. Invest New Drugs 2015; 33:664-70. [PMID: 25773493 DOI: 10.1007/s10637-015-0231-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 03/06/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Although patients with advanced gastric cancer (AGC) have a poor prognosis when conventional therapies fail, they are often candidates for phase I trials. However, there is no detailed report on clinical outcomes of patients with AGC treated in phase I trials. METHODS We retrospectively reviewed the medical records of 66 consecutive patients with AGC enrolled in phase I trials between March 2008 and July 2014 at our institution in Japan. RESULTS Median age was 66 years (range, 28-78 years) and median number of previous lines of conventional chemotherapy was 3 (range, 1-6). Five (8.6 %) and seven (12 %) patients showed objective response and stable disease >3 months, respectively. Although the time to treatment failure (TTF) of the best phase I treatment was shorter than that of the last line of conventional chemotherapy (median 1.5 vs. 2.3 months; P = 0.002), TTF of the best phase I treatment was longer than that of the last line of treatment in 21 patients (32 %). Severe adverse events and grade 3 or higher toxicities were reported in eight (12 %) and 13 patients (20 %), respectively. No treatment-related death was observed. Median survival time from the start of phase I treatment was 7.5 months, and four deaths (6 %) within 30 days after last administration were observed. CONCLUSION Phase I trials of patients with AGC was acceptably feasible with some efficacy signal. Our results suggest that phase I trials might be one treatment option for patients with AGC when conventional therapies fail.
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Affiliation(s)
- Akihito Kawazoe
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East (NCCHE), 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
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26
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Garrido-Laguna I, Tometich D, Hu N, Ying J, Geiersbach K, Whisenant J, Wang K, Ross JS, Sharma S. N of 1 case reports of exceptional responders accrued from pancreatic cancer patients enrolled in first-in-man studies from 2002 through 2012. Oncoscience 2015; 2:285-93. [PMID: 25897431 PMCID: PMC4394134 DOI: 10.18632/oncoscience.141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 03/04/2015] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To identify exceptional responders among patients with advanced pancreatic cancer enrolled in first-in-man (FIM) studies. METHODS A Scopus search identified 66 FIM studies that enrolled at least one patient with advanced pancreatic cancer between 2002-2012. Descriptive statistics were used to summarize categorical variables. We also screened CRKL amplifications in the FoundationOne™ pancreatic cancer database. RESULTS Most FIM studies included targeted therapies (76 vs. 24%). The most common targeted therapy involved cell cycle inhibitors (24%). Pharmacodynamic analyses were more frequently done in trials with targeted therapies (70 vs. 31%, p=0.006). Response rates were similar. Treatment-related death was 0.5%. Skin, cardiovascular and metabolic grade 3-4 toxicities were more frequent with targeted therapies. Four exceptional responses were identified including a complete response to bosutinib (Src Inhibitor) and partial responses to trametinib (MEK inhibitor) (2 patients) and CHR-3996 (histone deacetylase inhibitor). We found that CRKL amplifications, a potential biomarker for Src inhibitors, are present in 1% of PDA. CONCLUSIONS We retrospectively identified extraordinary responses among patients with advanced PDA enrolled in FIM studies with Src, HDAC and MEK inhibitors. We identified CRKL amplifications are present in 1% of PDA and need to be evaluated as predictive biomarker for Src inhibitors.
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Affiliation(s)
- Ignacio Garrido-Laguna
- Departments of Internal Medicine (Division of Oncology), Huntsman Cancer Institute and University of Utah School of Medicine, Salt Lake City
- Center for Investigational Therapeutics, Huntsman Cancer Institute and University of Utah School of Medicine, Salt Lake City
| | - Danielle Tometich
- Departments of Internal Medicine (Division of Oncology), Huntsman Cancer Institute and University of Utah School of Medicine, Salt Lake City
| | - Nan Hu
- Oncological Sciences, Huntsman Cancer Institute and University of Utah School of Medicine, Salt Lake City
| | - Jian Ying
- Oncological Sciences, Huntsman Cancer Institute and University of Utah School of Medicine, Salt Lake City
| | - Katherine Geiersbach
- Department of Pathology at Huntsman Cancer Institute and University of Utah School of Medicine, Salt Lake City
| | | | - Kai Wang
- Foundation Medicine, Cambridge, Massachusetts
| | - Jeffrey S. Ross
- Foundation Medicine, Cambridge, Massachusetts
- Department of Pathology and Laboratory Medicine, Albany Medical College, Albany, New York, USA
| | - Sunil Sharma
- Departments of Internal Medicine (Division of Oncology), Huntsman Cancer Institute and University of Utah School of Medicine, Salt Lake City
- Center for Investigational Therapeutics, Huntsman Cancer Institute and University of Utah School of Medicine, Salt Lake City
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Moreno García V, Olmos D, Gomez-Roca C, Cassier PA, Morales-Barrera R, Del Conte G, Gallerani E, Brunetto AT, Schöffski P, Marsoni S, Schellens JH, Penel N, Voest E, Evans J, Plummer R, Wilson RH, Soria JC, Tabernero J, Verweij J, Kaye SB. Dose–Response Relationship in Phase I Clinical Trials: A European Drug Development Network (EDDN) Collaboration Study. Clin Cancer Res 2014; 20:5663-71. [DOI: 10.1158/1078-0432.ccr-14-0719] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Iasonos A, O'Quigley J. Adaptive dose-finding studies: a review of model-guided phase I clinical trials. J Clin Oncol 2014; 32:2505-11. [PMID: 24982451 DOI: 10.1200/jco.2013.54.6051] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE We provide a comprehensive review of adaptive phase I clinical trials in oncology that used a statistical model to guide dose escalation to identify the maximum-tolerated dose (MTD). We describe the clinical setting, practical implications, and safety of such applications, with the aim of understanding how these designs work in practice. METHODS We identified 53 phase I trials published between January 2003 and September 2013 that used the continual reassessment method (CRM), CRM using escalation with overdose control, or time-to-event CRM for late-onset toxicities. Study characteristics, design parameters, dose-limiting toxicity (DLT) definition, DLT rate, patient-dose allocation, overdose, underdose, sample size, and trial duration were abstracted from each study. In addition, we examined all studies in terms of safety, and we outlined the reasons why escalations occur and under what circumstances. RESULTS On average, trials accrued 25 to 35 patients over a 2-year period and tested five dose levels. The average DLT rate was 18%, which is lower than in previous reports, whereas all levels above the MTD had an average DLT rate of 36%. On average, 39% of patients were treated at the MTD, and 74% were treated at either the MTD or an adjacent level (one level above or below). CONCLUSION This review of completed phase I studies confirms the safety and generalizability of model-guided, adaptive dose-escalation designs, and it provides an approach for using, interpreting, and understanding such designs to guide dose escalation in phase I trials.
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Affiliation(s)
- Alexia Iasonos
- Alexia Iasonos, Memorial Sloan Kettering Cancer Center, New York, NY; and John O'Quigley, Université Paris VI, Paris, France.
| | - John O'Quigley
- Alexia Iasonos, Memorial Sloan Kettering Cancer Center, New York, NY; and John O'Quigley, Université Paris VI, Paris, France
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Ganesan P, Janku F, Naing A, Hong DS, Tsimberidou AM, Falchook GS, Wheler JJ, Piha-Paul SA, Fu S, Stepanek VM, Lee JJ, Luthra R, Overman MJ, Kopetz ES, Wolff RA, Kurzrock R. Target-based therapeutic matching in early-phase clinical trials in patients with advanced colorectal cancer and PIK3CA mutations. Mol Cancer Ther 2013; 12:2857-63. [PMID: 24092809 DOI: 10.1158/1535-7163.mct-13-0319-t] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Target-matched treatment with PI3K/AKT/mTOR pathway inhibitors in patients with diverse advanced cancers with PIK3CA mutations have shown promise. Tumors from patients with colorectal cancer were analyzed for PIK3CA, KRAS, and BRAF mutations. PIK3CA-mutated tumors were treated, whenever feasible, with agents targeting the PI3K/AKT/mTOR pathway. Of 194 patients analyzed, 31 (16%) had PIK3CA mutations and 189 (97%) were assessed for KRAS mutations. Patients with PIK3CA mutations had a higher prevalence of simultaneous KRAS mutations than patients with wild-type PIK3CA (71%, 22/31 vs. 43%, 68/158; P = 0.006). Of 31 patients with PIK3CA mutations, 17 (55%) were treated with protocols containing PI3K/AKT/mTOR pathway inhibitors [median age, 57 years; median number of prior therapies, 4; mTORC1 inhibitors (11), phosphoinositide 3-kinase (PI3K) inhibitors (5), or an AKT inhibitor (1)]. None (0/17) had a partial or complete response (PR/CR) and only 1 [6%, 95% confidence interval (CI), 0.01-0.27] had stable disease 6 months or more, which was not significantly different from a stable disease ≥6 month/PR/CR rate of 16% (11/67; 95% CI, 0.09-0.27) in patients with colorectal cancer without PIK3CA mutations treated with PI3K/AKT/mTOR pathway inhibitors (P = 0.44). Median progression-free survival was 1.9 months (95% CI, 1.5-2.3). In conclusion, our data provide preliminary evidence that in heavily pretreated patients with PIK3CA-mutant advanced colorectal cancer, protocols incorporating PI3K/AKT/mTOR inhibitors have minimal activity. PIK3CA mutations are associated with simultaneous KRAS mutations, possibly accounting for therapeutic resistance.
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Affiliation(s)
- Prasanth Ganesan
- Corresponding Author: Filip Janku, Department of Investigational Cancer Therapeutics (Phase I Clinical Trials Program), The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, FC8.2018, Box 0455, Houston, Texas 77030.
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Joffe S. RE: Meta-analysis of the Relationship Between Dose and Benefit in Phase I Targeted Agent Trials. J Natl Cancer Inst 2013; 105:993. [DOI: 10.1093/jnci/djt125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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31
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Jain RK, Lee JJ, Hong D, Kurzrock R. RE: Meta-analysis of the Relationship Between Dose and Benefit in Phase I Targeted Agent Trials. J Natl Cancer Inst 2013; 105:833. [DOI: 10.1093/jnci/djt100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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