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Lu X, Shan G. Two-stage response adaptive randomization designs for multi-arm trials with binary outcome. J Biopharm Stat 2024; 34:526-538. [PMID: 37452825 PMCID: PMC10788381 DOI: 10.1080/10543406.2023.2234028] [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: 03/02/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023]
Abstract
In recent years, adaptive randomization methods have gained significant popularity in clinical research and trial design due to their ability to provide both efficiency and flexibility in adjusting the statistical procedures of ongoing clinical trials. For a study to compare multiple treatments, a multi-arm two-stage design could be utilized to select the best treatment from the first stage and further compare that treatment with control in the second stage. The traditional design used equal randomization in both stages. To better utilize the interim results from the first stage, we propose to develop response adaptive randomization two-stage designs for a multi-arm clinical trial with binary outcome. Two allocation methods are considered: (1) an optimal allocation based on a sequential design; (2) the play-the-winner rule. Optimal multi-arm two-stage designs are obtained under three criteria: minimizing the expected number of failures, minimizing the average expected sample size, and minimizing the expected sample size under the null hypothesis. Simulation studies show that the proposed adaptive design based on the play-the-winner rule has good performance. A phase II trial for patients with pancreas adenocarcinoma and a germline BRCA/ PALB2 mutation was used to illustrate the application of the proposed response adaptive randomization designs.
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Affiliation(s)
- Xinlin Lu
- Department of Biostatistics, University of Florida, Gainesville FL, 32611
| | - Guogen Shan
- Department of Biostatistics, University of Florida, Gainesville FL, 32611
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2
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Polley MYC, Schwartz D, Karrison T, Dignam JJ. Leveraging external control data in the design and analysis of neuro-oncology trials: Pearls and perils. Neuro Oncol 2024; 26:796-810. [PMID: 38254183 PMCID: PMC11066907 DOI: 10.1093/neuonc/noae005] [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: 07/13/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Randomized controlled trials have been the gold standard for evaluating medical treatments for many decades but they are often criticized for requiring large sample sizes. Given the urgent need for better therapies for glioblastoma, it has been argued that data collected from patients treated with the standard regimen can provide high-quality external control data to supplement or replace concurrent control arm in future glioblastoma trials. METHODS In this article, we provide an in-depth appraisal of the use of external control data in the context of neuro-oncology trials. We describe several clinical trial designs with particular attention to how external information is utilized and address common fallacies that may lead to inappropriate adoptions of external control data. RESULTS Using 2 completed glioblastoma trials, we illustrate the use of an assessment tool that lays out a blueprint for assembling a high-quality external control data set. Using statistical simulations, we draw caution from scenarios where these approaches can fall short on controlling the type I error rate. CONCLUSIONS While this approach may hold promise in generating informative data in certain settings, this sense of optimism should be tampered with a healthy dose of skepticism due to a myriad of design and analysis challenges articulated in this review. Importantly, careful planning is key to its successful implementation.
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Affiliation(s)
- Mei-Yin C Polley
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania, USA
| | - Daniel Schwartz
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Theodore Karrison
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania, USA
| | - James J Dignam
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania, USA
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Schwartz DE, Essaouabi H, Trippa L. Clinical trials that leverage external data: Do we need more transparent protocols and statistical plans? Eur J Cancer 2024; 196:113443. [PMID: 38008030 DOI: 10.1016/j.ejca.2023.113443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 11/28/2023]
Affiliation(s)
- Daniel Evan Schwartz
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States; Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, United States.
| | | | - Lorenzo Trippa
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States; Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, United States
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Viklicky O, Zahradka I, Bold G, Bestard O, Hruba P, Otto NM, Stein M, Sefrin A, Modos I, Meneghini M, Crespo E, Grinyo J, Volk HD, Christakoudi S, Reinke P. Tacrolimus After rATG and Infliximab Induction Immunosuppression-RIMINI Trial. Transplantation 2024; 108:242-251. [PMID: 37525369 DOI: 10.1097/tp.0000000000004736] [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: 08/02/2023]
Abstract
BACKGROUND Infliximab selectively targets recently activated effector cells and, as an induction agent, might enable the safe elimination of mycophenolate from maintenance immunosuppression in kidney transplantation. METHODS This is a phase II international multicenter open-label single-arm confidence interval (CI)-based clinical trial of the BIO-DrIM EU consortium aimed at assessing the efficacy and safety of rabbit antithymocyte globulin and infliximab induction in kidney transplantation. Sixty-seven primary kidney transplant recipients at low risk (panel-reactive antibodies <20%, no donor-specific antibodies [DSA]) received rabbit antithymocyte globulin (2 × 1.5 mg/kg, postoperative days 0 and 1) and infliximab (5 mg/kg, postoperative day 2), followed by mycophenolate-free tacrolimus-based immunosuppression for 12 mo. The primary endpoint was efficacy failure, defined as a composite of acute rejection, graft loss, or poor graft function (estimated glomerular filtration rate <40 mL/min) at 12 mo and was based on the endpoint of the comparator study. Additionally, a historical propensity-matched control cohort was established. RESULTS Primary endpoint occurred in 22 of 67 patients (32.84%), with upper bound of an exact 1-sided 95% CI of 43.47%, which met the predefined criteria (efficacy failure of <40% and upper-bound 95% CI of <50%) and was similar in the historical matched cohort. By 12 mo, 79.1% of patients remained on the study protocol. Lower rates of BK replication (6% versus 22.4%; P = 0.013) but higher rates of de novo DSAs (11.9% versus 1.5%; P = 0.039) were observed in the study cohort. CONCLUSIONS A similar efficacy of the study immunosuppression regimen to the comparator study and the historical matched cohort was found. However, a higher de novo DSA emergence points to an increased risk of antibody-mediated rejection (NCT04114188).
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Affiliation(s)
- Ondrej Viklicky
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ivan Zahradka
- Department of Nephrology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Gantuja Bold
- Department of Nephrology and Intensive Care, Charité Universitätsmedizin Berlin, Berlin Center for Advanced Therapies (BeCAT), Berlin Institut of Health Center of Regenerative Therapies (BCRT), Berlin Institute of Health, Berlin, Germany
| | - Oriol Bestard
- Department of Nephrology and Kidney Transplantation, Vall d'Hebron University Hospital, Barcelona Hospital Campus, Barcelona, Spain
- Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona, Spain
| | - Petra Hruba
- Transplant Laboratory, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Natalie M Otto
- Department of Nephrology and Intensive Care, Charité Universitätsmedizin Berlin, Berlin Center for Advanced Therapies (BeCAT), Berlin Institut of Health Center of Regenerative Therapies (BCRT), Berlin Institute of Health, Berlin, Germany
| | - Maik Stein
- Department of Nephrology and Intensive Care, Charité Universitätsmedizin Berlin, Berlin Center for Advanced Therapies (BeCAT), Berlin Institut of Health Center of Regenerative Therapies (BCRT), Berlin Institute of Health, Berlin, Germany
| | - Anett Sefrin
- Department of Nephrology and Intensive Care, Charité Universitätsmedizin Berlin, Berlin Center for Advanced Therapies (BeCAT), Berlin Institut of Health Center of Regenerative Therapies (BCRT), Berlin Institute of Health, Berlin, Germany
| | - Istvan Modos
- Information Technology Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Maria Meneghini
- Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona, Spain
| | - Elena Crespo
- Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona, Spain
| | - Josep Grinyo
- Department of Medicine, Barcelona University, Barcelona, Spain
| | - Hans-Dieter Volk
- Berlin Center for Advanced Therapies (BeCAT) and Institute of Medical Immunology, Charité Universitätsmedizin Berlin, Berlin Institut of Health Center of Regenerative Therapies (BCRT), Berlin Institute of Health, Berlin, Germany
| | - Sofia Christakoudi
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, St. Mary's Campus, Norfolk Place, London, United Kingdom
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | - Petra Reinke
- Department of Nephrology and Intensive Care, Charité Universitätsmedizin Berlin, Berlin Center for Advanced Therapies (BeCAT), Berlin Institut of Health Center of Regenerative Therapies (BCRT), Berlin Institute of Health, Berlin, Germany
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Rahman R, Trippa L, Lee EQ, Arrillaga-Romany I, Fell G, Touat M, McCluskey C, Wiley J, Gaffey S, Drappatz J, Welch MR, Galanis E, Ahluwalia MS, Colman H, Nabors LB, Hepel J, Elinzano H, Schiff D, Chukwueke UN, Beroukhim R, Nayak L, McFaline-Figueroa JR, Batchelor TT, Rinne ML, Kaley TJ, Lu-Emerson C, Mellinghoff IK, Bi WL, Arnaout O, Peruzzi PP, Haas-Kogan D, Tanguturi S, Cagney D, Aizer A, Doherty L, Lavallee M, Fisher-Longden B, Dowling S, Geduldig J, Watkinson F, Pisano W, Malinowski S, Ramkissoon S, Santagata S, Meredith DM, Chiocca EA, Reardon DA, Alexander BM, Ligon KL, Wen PY. Inaugural Results of the Individualized Screening Trial of Innovative Glioblastoma Therapy: A Phase II Platform Trial for Newly Diagnosed Glioblastoma Using Bayesian Adaptive Randomization. J Clin Oncol 2023; 41:5524-5535. [PMID: 37722087 DOI: 10.1200/jco.23.00493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/17/2023] [Accepted: 07/24/2023] [Indexed: 09/20/2023] Open
Abstract
PURPOSE The Individualized Screening Trial of Innovative Glioblastoma Therapy (INSIGhT) is a phase II platform trial that uses response adaptive randomization and genomic profiling to efficiently identify novel therapies for phase III testing. Three initial experimental arms (abemaciclib [a cyclin-dependent kinase [CDK]4/6 inhibitor], neratinib [an epidermal growth factor receptor [EGFR]/human epidermal growth factor receptor 2 inhibitor], and CC-115 [a deoxyribonucleic acid-dependent protein kinase/mammalian target of rapamycin inhibitor]) were simultaneously evaluated against a common control arm. We report the results for each arm and examine the feasibility and conduct of the adaptive platform design. PATIENTS AND METHODS Patients with newly diagnosed O6-methylguanine-DNA methyltransferase-unmethylated glioblastoma were eligible if they had tumor genotyping to identify prespecified biomarker subpopulations of dominant glioblastoma signaling pathways (EGFR, phosphatidylinositol 3-kinase, and CDK). Initial random assignment was 1:1:1:1 between control (radiation therapy and temozolomide) and the experimental arms. Subsequent Bayesian adaptive randomization was incorporated on the basis of biomarker-specific progression-free survival (PFS) data. The primary end point was overall survival (OS), and one-sided P values are reported. The trial is registered with ClinicalTrials.gov (identifier: NCT02977780). RESULTS Two hundred thirty-seven patients were treated (71 control; 73 abemaciclib; 81 neratinib; 12 CC-115) in years 2017-2021. Abemaciclib and neratinib were well tolerated, but CC-115 was associated with ≥ grade 3 treatment-related toxicity in 58% of patients. PFS was significantly longer with abemaciclib (hazard ratio [HR], 0.72; 95% CI, 0.49 to 1.06; one-sided P = .046) and neratinib (HR, 0.72; 95% CI, 0.50 to 1.02; one-sided P = .033) relative to the control arm but there was no PFS benefit with CC-115 (one-sided P = .523). None of the experimental therapies demonstrated a significant OS benefit (P > .05). CONCLUSION The INSIGhT design enabled efficient simultaneous testing of three experimental agents using a shared control arm and adaptive randomization. Two investigational arms had superior PFS compared with the control arm, but none demonstrated an OS benefit. The INSIGhT design may promote improved and more efficient therapeutic discovery in glioblastoma. New arms have been added to the trial.
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Affiliation(s)
- Rifaquat Rahman
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Eudocia Q Lee
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | - Mehdi Touat
- Brigham and Women's Hospital, Boston, MA
- Sorbonne Universite, Hôpitaux Universitaires La Pitié Salpêtrière, Paris, France
| | | | | | | | | | - Mary R Welch
- Division of Neuro-Oncology, Department of Neurology and Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian, New York, NY
| | | | | | - Howard Colman
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | | | | | | | - Ugonma N Chukwueke
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Rameen Beroukhim
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Lakshmi Nayak
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Tracy T Batchelor
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | - Wenya Linda Bi
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | - Daphne Haas-Kogan
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Shyam Tanguturi
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Ayal Aizer
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | | | | | - David A Reardon
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Brian M Alexander
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Keith L Ligon
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Patrick Y Wen
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
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Kim Y, Armstrong TS, Gilbert MR, Celiku O. A critical analysis of neuro-oncology clinical trials. Neuro Oncol 2023; 25:1658-1671. [PMID: 36757281 PMCID: PMC10484169 DOI: 10.1093/neuonc/noad036] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Limitations in trial design, accrual, and data reporting impact efficient and reliable drug evaluation in cancer clinical trials. These concerns have been recognized in neuro-oncology but have not been comprehensively evaluated. We conducted a semi-automated survey of adult interventional neuro-oncology trials, examining design, interventions, outcomes, and data availability trends. METHODS Trials were selected programmatically from ClinicalTrials.gov using primary malignant central nervous system tumor classification terms. Regression analyses assessed design and accrual trends; effect size analysis utilized survival rates among trials investigating survival. RESULTS Of 3038 reviewed trials, most trials reporting relevant information were nonblinded (92%), single group (65%), nonrandomized (51%), and studied glioblastomas (47%) or other gliomas. Basic design elements were reported by most trials, with reporting increasing over time (OR = 1.24, P < .00001). Trials assessing survival outcomes were estimated to assume large effect sizes of interventions when powering their designs. Forty-two percent of trials were completed; of these, 38% failed to meet their enrollment target, with worse accrual over time (R = -0.94, P < .00001) and for US versus non-US based trials (OR = 0.5, P < .00001). Twenty-eight percent of completed trials reported partial results, with greater reporting for US (34.6%) versus non-US based trials (9.3%, P < .00001). Efficacy signals were detected by 15%-23% of completed trials reporting survival outcomes. CONCLUSION Low randomization rates, underutilization of controls, and overestimation of effect size, particularly pronounced in early-phase trials, impede generalizability of results. Suboptimal designs may be driven by accrual challenges, underscoring the need for cooperative efforts and novel designs. The limited results reporting highlights the need to incentivize data reporting and harmonization.
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Affiliation(s)
- Yeonju Kim
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Terri S Armstrong
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mark R Gilbert
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Orieta Celiku
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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7
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Grossman SA. Using historical objective response rates to design single-arm phase II trials in patients with recurrent glioblastoma. Neuro Oncol 2023; 25:1029-1030. [PMID: 36881776 PMCID: PMC10237396 DOI: 10.1093/neuonc/noad046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Indexed: 03/09/2023] Open
Affiliation(s)
- Stuart A Grossman
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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Müller P, Chandra NK, Sarkar A. Bayesian approaches to include real-world data in clinical studies. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2023; 381:20220158. [PMID: 36970825 DOI: 10.1098/rsta.2022.0158] [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: 08/06/2022] [Accepted: 09/27/2022] [Indexed: 06/18/2023]
Abstract
Randomized clinical trials have been the mainstay of clinical research, but are prohibitively expensive and subject to increasingly difficult patient recruitment. Recently, there is a movement to use real-world data (RWD) from electronic health records, patient registries, claims data and other sources in lieu of or supplementing controlled clinical trials. This process of combining information from diverse sources calls for inference under a Bayesian paradigm. We review some of the currently used methods and a novel non-parametric Bayesian (BNP) method. Carrying out the desired adjustment for differences in patient populations is naturally done with BNP priors that facilitate understanding of and adjustment for population heterogeneities across different data sources. We discuss the particular problem of using RWD to create a synthetic control arm to supplement single-arm treatment only studies. At the core of the proposed approach is the model-based adjustment to achieve equivalent patient populations in the current study and the (adjusted) RWD. This is implemented using common atoms mixture models. The structure of such models greatly simplifies inference. The adjustment for differences in the populations can be reduced to ratios of weights in such mixtures. This article is part of the theme issue 'Bayesian inference: challenges, perspectives, and prospects'.
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Affiliation(s)
- P Müller
- Department of Statistics and Data Sciences, The University of Texas at Austin, 2317 Speedway D9800, Austin, TX 78712-1823, USA
| | - N K Chandra
- Department of Mathematical Sciences, The University of Texas at Dallas, 800 W Campbell Road, Richardson, TX 75080-3021, USA
| | - A Sarkar
- Department of Statistics and Data Sciences, The University of Texas at Austin, 2317 Speedway D9800, Austin, TX 78712-1823, USA
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9
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Rahman R, Polley MYC, Alder L, Brastianos PK, Anders CK, Tawbi HA, Mehta M, Wen PY, Geyer S, de Groot J, Zadeh G, Piantadosi S, Galanis E, Khasraw M. Current drug development and trial designs in neuro-oncology: report from the first American Society of Clinical Oncology and Society for Neuro-Oncology Clinical Trials Conference. Lancet Oncol 2023; 24:e161-e171. [PMID: 36990614 PMCID: PMC10401610 DOI: 10.1016/s1470-2045(23)00005-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/11/2022] [Accepted: 01/05/2023] [Indexed: 03/29/2023]
Abstract
Successful drug development for people with cancers of the CNS has been challenging. There are multiple barriers to successful drug development including biological factors, rarity of the disease, and ineffective use of clinical trials. Based upon a series of presentations at the First Central Nervous System Clinical Trials Conference hosted by the American Society of Clinical Oncology and the Society for Neuro-Oncology, we provide an overview on drug development and novel trial designs in neuro-oncology. This Review discusses the challenges of therapeutic development in neuro-oncology and proposes strategies to improve the drug discovery process by enriching the pipeline of promising therapies, optimising trial design, incorporating biomarkers, using external data, and maximising efficacy and reproducibility of clinical trials.
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Affiliation(s)
- Rifaquat Rahman
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Mei-Yin C Polley
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | - Laura Alder
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Priscilla K Brastianos
- Massachusetts General Hospital, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Carey K Anders
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | | | - Minesh Mehta
- Miami Cancer Institute, Baptist Hospital, Miami, FL, USA
| | - Patrick Y Wen
- Centre for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Susan Geyer
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - John de Groot
- University of California San Francisco Brain Tumor Center, San Francisco, CA, USA
| | - Gelareh Zadeh
- Department of Neurological Surgery University of Toronto, Toronto, ON, Canada
| | - Steven Piantadosi
- Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Evanthia Galanis
- Department of Oncology, Mayo Clinic Comprehensive Cancer Center, Mayo Clinic, Rochester, MN, USA
| | - Mustafa Khasraw
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
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Overbey JR, Cheung YK, Bagiella E. Integrating non-concurrent controls in the analyses of late-entry experimental arms in multi-arm trials with a shared control group in the presence of parameter drift. Contemp Clin Trials 2022; 123:106972. [PMID: 36307007 DOI: 10.1016/j.cct.2022.106972] [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: 02/11/2022] [Revised: 10/14/2022] [Accepted: 10/20/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Under a master protocol, open platform trials allow new experimental treatments to enter an existing clinical trial. Whether late-entry experimental treatments should be compared to all available or concurrently randomized controls is not well established. Using all available data can increase power and precision; however, drift in population parameters can yield biased estimates and impact type I error rate. METHODS We explored the application of methods developed to incorporate historical controls in two-arm trials to the analysis of a late-entry arm in a simulated open platform trial under varying scenarios of parameter drift. Methods explored include test-then-pool, fixed power prior, dynamic power prior, and multi-source exchangeability model approaches. RESULTS/CONCLUSIONS Simulated trial results confirm that in the presence of no drift, naively pooling all controls increases power and produces more precise, unbiased estimates when compared to using concurrent controls only. However, under drift, pooling can result in type I error rate inflation or deflation and biased estimates. In the presence of parameter drift, methods that partially borrow non-concurrent data, either through a static weighting mechanism or through methods that allow the heterogeneity between non-concurrent and concurrent data to determine the degree of borrowing, are superior to naively pooling the data. However, compared to using concurrent controls only, these approaches cannot guarantee type I error control or unbiased estimates. Thus, concurrent controls should be used as comparators in confirmatory studies.
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Affiliation(s)
- Jessica R Overbey
- Center for Biostatistics, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Ying Kuen Cheung
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Emilia Bagiella
- Center for Biostatistics, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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11
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Saraf A, Trippa L, Rahman R. Novel Clinical Trial Designs in Neuro-Oncology. Neurotherapeutics 2022; 19:1844-1854. [PMID: 35969361 PMCID: PMC9723049 DOI: 10.1007/s13311-022-01284-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2022] [Indexed: 12/13/2022] Open
Abstract
Scientific and technologic advances have led to a boon of candidate therapeutics for patients with malignancies of the central nervous system. The path from drug development to clinical use has generally followed a regimented order of sequential clinical trial phases. The recent increase in novel therapies, however, has strained the regulatory process and unearthed limitations of the current system, including significant cost, prolonged development time, and difficulties in testing therapies for rarer tumors. Novel clinical trial designs have emerged to increase efficiencies in clinical trial conduct to better evaluate and bring impactful drugs to patients in a timely manner. In order to better capture meaningful benefits for brain tumor patients, new endpoints to complement or replace traditional endpoints are also an increasingly important consideration. This review will explore the current challenges in the current clinical trial landscape and discuss novel clinical trial concepts, including consideration of limitations and risks of novel trial designs, within the context of neuro-oncology.
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Affiliation(s)
- Anurag Saraf
- Harvard Radiation Oncology Program, Boston, MA, USA
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Lorenzo Trippa
- Department of Data Sciences, Dana-Farber Cancer Institute, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Rifaquat Rahman
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
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12
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Cao TQ, Wainwright DA, Lee-Chang C, Miska J, Sonabend AM, Heimberger AB, Lukas RV. Next Steps for Immunotherapy in Glioblastoma. Cancers (Basel) 2022; 14:4023. [PMID: 36011015 PMCID: PMC9406905 DOI: 10.3390/cancers14164023] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/12/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
Outcomes for glioblastoma (GBM) patients undergoing standard of care treatment remain poor. Here we discuss the portfolio of previously investigated immunotherapies for glioblastoma, including vaccine therapy and checkpoint inhibitors, as well as novel emerging therapeutic approaches. In addition, we explore the factors that potentially influence response to immunotherapy, which should be considered in future research aimed at improving immunotherapy efficacy.
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Affiliation(s)
- Toni Q. Cao
- Department of Neurology, Northwestern University, Chicago, IL 60611, USA
| | - Derek A. Wainwright
- Department of Neurological Surgery, Northwestern University, Chicago, IL 60611, USA
- Lou & Jean Malnati Brain Tumor Institute, Chicago, IL 60611, USA
- Department of Medicine, Division of Hematology/Oncology, Northwestern University, Chicago, IL 60611, USA
- Department of Neuroscience, Northwestern University, Chicago, IL 60611, USA
- Department of Microbiology-Immunology, Northwestern University, Chicago, IL 60611, USA
| | - Catalina Lee-Chang
- Department of Neurological Surgery, Northwestern University, Chicago, IL 60611, USA
- Lou & Jean Malnati Brain Tumor Institute, Chicago, IL 60611, USA
| | - Jason Miska
- Department of Neurological Surgery, Northwestern University, Chicago, IL 60611, USA
- Lou & Jean Malnati Brain Tumor Institute, Chicago, IL 60611, USA
| | - Adam M. Sonabend
- Department of Neurological Surgery, Northwestern University, Chicago, IL 60611, USA
- Lou & Jean Malnati Brain Tumor Institute, Chicago, IL 60611, USA
| | - Amy B. Heimberger
- Department of Neurological Surgery, Northwestern University, Chicago, IL 60611, USA
- Lou & Jean Malnati Brain Tumor Institute, Chicago, IL 60611, USA
| | - Rimas V. Lukas
- Department of Neurology, Northwestern University, Chicago, IL 60611, USA
- Lou & Jean Malnati Brain Tumor Institute, Chicago, IL 60611, USA
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13
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Bagley SJ, Kothari S, Rahman R, Lee EQ, Dunn GP, Galanis E, Chang SM, Burt Nabors L, Ahluwalia MS, Stupp R, Mehta MP, Reardon DA, Grossman SA, Sulman EP, Sampson JH, Khagi S, Weller M, Cloughesy TF, Wen PY, Khasraw M. Glioblastoma Clinical Trials: Current Landscape and Opportunities for Improvement. Clin Cancer Res 2022; 28:594-602. [PMID: 34561269 PMCID: PMC9044253 DOI: 10.1158/1078-0432.ccr-21-2750] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/29/2021] [Accepted: 09/14/2021] [Indexed: 11/16/2022]
Abstract
Therapeutic advances for glioblastoma have been minimal over the past 2 decades. In light of the multitude of recent phase III trials that have failed to meet their primary endpoints following promising preclinical and early-phase programs, a Society for Neuro-Oncology Think Tank was held in November 2020 to prioritize areas for improvement in the conduct of glioblastoma clinical trials. Here, we review the literature, identify challenges related to clinical trial eligibility criteria and trial design in glioblastoma, and provide recommendations from the Think Tank. In addition, we provide a data-driven context with which to frame this discussion by analyzing key study design features of adult glioblastoma clinical trials listed on ClinicalTrials.gov as "recruiting" or "not yet recruiting" as of February 2021.
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Affiliation(s)
- Stephen J. Bagley
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Shawn Kothari
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rifaquat Rahman
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Eudocia Q. Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gavin P. Dunn
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri
| | | | - Susan M. Chang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Louis Burt Nabors
- Division of Neuro-oncology, Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Manmeet S. Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Roger Stupp
- Department of Medicine, Northwestern University, Chicago, Illinois
| | - Minesh P. Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - David A. Reardon
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Stuart A. Grossman
- Department of Oncology, Johns Hopkins Kimmel Cancer Center, Baltimore, Maryland
| | - Erik P. Sulman
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, New York
| | - John H. Sampson
- Preston Robert Tisch Brain Tumor Center, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Simon Khagi
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michael Weller
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Timothy F. Cloughesy
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Patrick Y. Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mustafa Khasraw
- Preston Robert Tisch Brain Tumor Center, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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14
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Ye X, Schreck KC, Ozer BH, Grossman SA. High-grade glioma therapy: adding flexibility in trial design to improve patient outcomes. Expert Rev Anticancer Ther 2022; 22:275-287. [PMID: 35130447 DOI: 10.1080/14737140.2022.2038138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Outcomes for patients with high grade gliomas have changed little over the past thirty years. This realization prompted renewed efforts to increase flexibility in the design and conduct of clinical brain tumor trials. AREAS COVERED This manuscript reviews the development of clinical trial methods, challenges and considerations of flexible clinical trial designs, approaches to improve identification and testing of active agents for high grade gliomas, and evaluation of their delivery to the central nervous system. EXPERT OPINION Flexibility can be introduced in clinical trials in several ways. Flexible designs tout smaller sample sizes, adaptive modifications, fewer control arms, and inclusion of multiple arms in one study. Unfortunately, modifications in study designs cannot address two challenges that are largely responsible for the lack of progress in treating high grade gliomas: 1) the identification of active pharmaceutical agents and 2) the delivery of these agents to brain tumor tissue in therapeutic concentrations. To improve the outcomes of patients with high grade gliomas efforts must be focused on the pre-clinical screening of drugs for activity, the ability of these agents to achieve therapeutic concentrations in non-enhancing tumors, and a willingness to introduce novel compounds in minimally pre-treated patient populations.
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Affiliation(s)
- Xiaobu Ye
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore MD, USA
| | - Karisa C Schreck
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore MD, USA
| | - Byram H Ozer
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore MD, USA
| | - Stuart A Grossman
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore MD, USA
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15
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An Overview of Phase 2 Clinical Trial Designs. Int J Radiat Oncol Biol Phys 2022; 112:22-29. [PMID: 34363901 PMCID: PMC8688307 DOI: 10.1016/j.ijrobp.2021.07.1700] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/22/2021] [Indexed: 01/03/2023]
Abstract
Clinical trials are studies to test new treatments in humans. Typically, these treatments are evaluated over several phases to assess their safety and efficacy. Phase 1 trials are designed to evaluate the safety and tolerability of a new treatment, typically with a small number of patients (eg, 20-80), generally spread across several dose levels. Phase 2 trials are designed to determine whether the new treatment has sufficiently promising efficacy to warrant further investigation in a large-scale randomized phase 3 trial, as well as to further assess safety. These studies usually involve a few hundred patients. This article provides an overview of some of the most commonly used phase 2 designs for clinical trials and emphasizes their critical elements and considerations. Key references to some of the most commonly used phase 2 designs are given to allow the reader to explore in more detail the critical aspects when planning a phase 2 trial. A comparison of 3 potential designs in the context of the NRG-HN002 trial is presented to complement the discussion about phase 2 trials.
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16
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Molinaro AM. External Controls to Improve on Glioblastoma Clinical Trials. Neuro Oncol 2021; 24:257-258. [PMID: 34718780 DOI: 10.1093/neuonc/noab251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Annette M Molinaro
- Department of Neurological Surgery, UCSF, San Francisco CA.,Department of Epidemiology and Biostatistics, UCSF, CA
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17
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Rahman R, Ventz S, McDunn J, Louv B, Reyes-Rivera I, Polley MYC, Merchant F, Abrey LE, Allen JE, Aguilar LK, Aguilar-Cordova E, Arons D, Tanner K, Bagley S, Khasraw M, Cloughesy T, Wen PY, Alexander BM, Trippa L. Leveraging external data in the design and analysis of clinical trials in neuro-oncology. Lancet Oncol 2021; 22:e456-e465. [PMID: 34592195 PMCID: PMC8893120 DOI: 10.1016/s1470-2045(21)00488-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 01/20/2023]
Abstract
Integration of external control data, with patient-level information, in clinical trials has the potential to accelerate the development of new treatments in neuro-oncology by contextualising single-arm studies and improving decision making (eg, early stopping decisions). Based on a series of presentations at the 2020 Clinical Trials Think Tank hosted by the Society of Neuro-Oncology, we provide an overview on the use of external control data representative of the standard of care in the design and analysis of clinical trials. High-quality patient-level records, rigorous methods, and validation analyses are necessary to effectively leverage external data. We review study designs, statistical methods, risks, and potential distortions in using external data from completed trials and real-world data, as well as data sources, data sharing models, ongoing work, and applications in glioblastoma.
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Affiliation(s)
- Rifaquat Rahman
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA.
| | - Steffen Ventz
- Department of Data Sciences, Dana-Farber Cancer Institute, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Jon McDunn
- Project Data Sphere, Morrisville, NC, USA
| | - Bill Louv
- Project Data Sphere, Morrisville, NC, USA
| | | | - Mei-Yin C Polley
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | | | | | | | | | | | - David Arons
- National Brain Tumor Society, Newton, MA, USA
| | - Kirk Tanner
- National Brain Tumor Society, Newton, MA, USA
| | - Stephen Bagley
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mustafa Khasraw
- Department of Neurosurgery, Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, NC, USA
| | - Timothy Cloughesy
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Brian M Alexander
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA; Foundation Medicine, Cambridge, MA, USA
| | - Lorenzo Trippa
- Department of Data Sciences, Dana-Farber Cancer Institute, Harvard T H Chan School of Public Health, Boston, MA, USA
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18
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Toward the Next Generation of High-Grade Glioma Clinical Trials in the Era of Precision Medicine. Cancer J 2021; 27:410-415. [PMID: 34570456 DOI: 10.1097/ppo.0000000000000549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABSTRACT In the era of precision medicine, there is a desire to harness our improved understanding of genomic and molecular underpinnings of gliomas to develop therapies that can be tailored to individual patients and tumors. With the rapid development of novel therapies, there has been a growing need to develop smart clinical trials that are designed to efficiently test promising agents, identify therapies likely to benefit patients, and discard ineffective therapies. We review clinical trial design in gliomas and developments designed to address the unique challenges of precision medicine. To provide an overview of this topic, we examine considerations for endpoints and response assessment, biomarkers, and novel clinical trial designs such as adaptive platform trials in the testing of new therapies for glioma patients.
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19
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Wang Y, Chen W, Shi Y, Yan C, Kong Z, Wang Y, Wang Y, Ma W. Imposing Phase II and Phase III Clinical Trials of Targeted Drugs for Glioblastoma: Current Status and Progress. Front Oncol 2021; 11:719623. [PMID: 34568049 PMCID: PMC8458950 DOI: 10.3389/fonc.2021.719623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/24/2021] [Indexed: 12/21/2022] Open
Abstract
The most common primary intracranial tumor is glioma, among which glioblastoma (GBM) has the worst prognosis. Because of the high degree of malignancy of GBM and frequent recurrence after surgery, postoperative therapy, including chemotherapy, radiotherapy, targeted therapy, and immunotherapy, is particularly important. A wide variety of targeted drugs have undergone phase III clinical trials for patients with GBM, but these drugs do not work for all patients, and few patients in these trials have prolonged overall survival. In this review, some imposing phase III clinical trials of targeted drugs for glioma are introduced, and some prospective phase II clinical trials that have been completed or are in progress are summarized. In addition, the mechanisms of these drugs are briefly introduced, and deficiencies of these clinical trials are analyzed. This review aims to provide a comprehensive overview of current research on targeted drugs for glioma to clarify future research directions.
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Affiliation(s)
- Yaning Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wanqi Chen
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yixin Shi
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chengrui Yan
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Ziren Kong
- Department of Head and Neck Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuekun Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenbin Ma
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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20
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Balasubramanian A, Gunjur A, Hafeez U, Menon S, Cher LM, Parakh S, Gan HK. Inefficiencies in phase II to phase III transition impeding successful drug development in glioblastoma. Neurooncol Adv 2021; 3:vdaa171. [PMID: 33543145 PMCID: PMC7850118 DOI: 10.1093/noajnl/vdaa171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Improving outcomes of patients with glioblastoma (GBM) represents a significant challenge in neuro-oncology. We undertook a systematic review of key parameters of phase II and III trials in GBM to identify and quantify the impact of trial design on this phenomenon. Methods Studies between 2005 and 2019 inclusive were identified though MEDLINE search and manual bibliography searches. Phase II studies (P2T) were restricted to those referenced by the corresponding phase III trials (P3T). Clinical and statistical characteristics were extracted. For each P3T, corresponding P2T data was “optimally matched,” where same drug was used in similar schedule and similar population; “suboptimally matched” if dis-similar schedule and/or treatment setting; or “lacking.” Phase II/III transition data were compared by Pearson Correlation, Fisher’s exact or chi-square testing. Results Of 20 P3Ts identified, 6 (30%) lacked phase II data. Of the remaining 14 P3T, 9 had 1 prior P2T, 4 had 2 P2T, and 1 had 3 P2T, for a total of 20 P3T-P2T pairs (called dyads). The 13 “optimally matched” dyads showed strong concordance for mPFS (r2 = 0.95, P < .01) and mOS (r2 = 0.84, P < .01), while 7 “suboptimally matched” dyads did not (P > .05). Overall, 7 P3Ts underwent an ideal transition from P2T to P3T. “Newly diagnosed” P2Ts with mPFS < 14 months and/or mOS< 22 months had subsequent negative P3Ts. “Recurrent” P2Ts with mPFS < 6 months and mOS< 12 months also had negative P3Ts. Conclusion Our findings highlight the critical role of optimally designed phase II trials in informing drug development for GBM.
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Affiliation(s)
- Adithya Balasubramanian
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Ashray Gunjur
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Umbreen Hafeez
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia.,Olivia Newton-John Cancer Research Institute and La Trobe University School of Cancer Medicine, Heidelberg, Victoria, Australia
| | - Siddharth Menon
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia.,Olivia Newton-John Cancer Research Institute and La Trobe University School of Cancer Medicine, Heidelberg, Victoria, Australia
| | - Lawrence M Cher
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Sagun Parakh
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia.,Olivia Newton-John Cancer Research Institute and La Trobe University School of Cancer Medicine, Heidelberg, Victoria, Australia
| | - Hui Kong Gan
- Medical Oncology Department, Olivia Newton-John Cancer Wellness and Research Centre, Austin Hospital, Heidelberg, Victoria, Australia.,Olivia Newton-John Cancer Research Institute and La Trobe University School of Cancer Medicine, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia
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21
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Yom SS, Torres-Saavedra P, Caudell JJ, Waldron JN, Gillison ML, Xia P, Truong MT, Kong C, Jordan R, Subramaniam RM, Yao M, Chung CH, Geiger JL, Chan JW, O'Sullivan B, Blakaj DM, Mell LK, Thorstad WL, Jones CU, Banerjee RN, Lominska C, Le QT. Reduced-Dose Radiation Therapy for HPV-Associated Oropharyngeal Carcinoma (NRG Oncology HN002). J Clin Oncol 2021; 39:956-965. [PMID: 33507809 PMCID: PMC8078254 DOI: 10.1200/jco.20.03128] [Citation(s) in RCA: 194] [Impact Index Per Article: 64.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Reducing radiation treatment dose could improve the quality of life (QOL) of patients with good-risk human papillomavirus–associated oropharyngeal squamous cell carcinoma (OPSCC). Whether reduced-dose radiation produces disease control and QOL equivalent to standard chemoradiation is not proven.
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Affiliation(s)
- Sue S Yom
- University of California San Francisco, San Francisco, CA
| | | | | | - John N Waldron
- University Health Network-Princess Margaret Hospital, Toronto, ON, Canada
| | | | | | | | | | - Richard Jordan
- University of California San Francisco, San Francisco, CA
| | | | - Min Yao
- University Hospitals Cleveland, Cleveland, OH
| | | | | | - Jason W Chan
- University of California San Francisco, San Francisco, CA
| | - Brian O'Sullivan
- University Health Network-Princess Margaret Hospital, Toronto, ON, Canada
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22
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Grayling MJ, Dimairo M, Mander AP, Jaki TF. A Review of Perspectives on the Use of Randomization in Phase II Oncology Trials. J Natl Cancer Inst 2019; 111:1255-1262. [PMID: 31218346 PMCID: PMC6910171 DOI: 10.1093/jnci/djz126] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/05/2019] [Accepted: 06/12/2019] [Indexed: 12/21/2022] Open
Abstract
Historically, phase II oncology trials assessed a treatment's efficacy by examining its tumor response rate in a single-arm trial. Then, approximately 25 years ago, certain statistical and pharmacological considerations ignited a debate around whether randomized designs should be used instead. Here, based on an extensive literature review, we review the arguments on either side of this debate. In particular, we describe the numerous factors that relate to the reliance of single-arm trials on historical control data and detail the trial scenarios in which there was general agreement on preferential utilization of single-arm or randomized design frameworks, such as the use of single-arm designs when investigating treatments for rare cancers. We then summarize the latest figures on phase II oncology trial design, contrasting current design choices against historical recommendations on best practice. Ultimately, we find several ways in which the design of recently completed phase II trials does not appear to align with said recommendations. For example, despite advice to the contrary, only 66.2% of the assessed trials that employed progression-free survival as a primary or coprimary outcome used a randomized comparative design. In addition, we identify that just 28.2% of the considered randomized comparative trials came to a positive conclusion as opposed to 72.7% of the single-arm trials. We conclude by describing a selection of important issues influencing contemporary design, framing this discourse in light of current trends in phase II, such as the increased use of biomarkers and recent interest in novel adaptive designs.
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Affiliation(s)
- Michael J Grayling
- Correspondence to: Michael J. Grayling, Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Rd, Newcastle upon Tyne NE2 4AX, UK (e-mail: )
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23
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Vanderbeek AM, Ventz S, Rahman R, Fell G, Cloughesy TF, Wen PY, Trippa L, Alexander BM. To randomize, or not to randomize, that is the question: using data from prior clinical trials to guide future designs. Neuro Oncol 2019; 21:1239-1249. [PMID: 31155679 PMCID: PMC6784282 DOI: 10.1093/neuonc/noz097] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Understanding the value of randomization is critical in designing clinical trials. Here, we introduce a simple and interpretable quantitative method to compare randomized designs versus single-arm designs using indication-specific parameters derived from the literature. We demonstrate the approach through application to phase II trials in newly diagnosed glioblastoma (ndGBM). METHODS We abstracted data from prior ndGBM trials and derived relevant parameters to compare phase II randomized controlled trials (RCTs) and single-arm designs within a quantitative framework. Parameters included in our model were (i) the variability of the primary endpoint distributions across studies, (ii) potential for incorrectly specifying the single-arm trial's benchmark, and (iii) the hypothesized effect size. Strengths and weaknesses of RCT and single-arm designs were quantified by various metrics, including power and false positive error rates. RESULTS We applied our method to show that RCTs should be preferred to single-arm trials for evaluating overall survival in ndGBM patients based on parameters estimated from prior trials. More generally, for a given effect size, the utility of randomization compared with single-arm designs is highly dependent on (i) interstudy variability of the outcome distributions and (ii) potential errors in selecting standard of care efficacy estimates for single-arm studies. CONCLUSIONS A quantitative framework using historical data is useful in understanding the utility of randomization in designing prospective trials. For typical phase II ndGBM trials using overall survival as the primary endpoint, randomization should be preferred over single-arm designs.
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Affiliation(s)
- Alyssa M Vanderbeek
- Program in Regulatory Science, Boston, Massachusetts
- Department of Biostatistics and Computational Biology, Boston, Massachusetts
| | - Steffen Ventz
- Program in Regulatory Science, Boston, Massachusetts
- Department of Biostatistics and Computational Biology, Boston, Massachusetts
| | - Rifaquat Rahman
- Department of Radiation Oncology, Boston, Massachusetts
- Center for Neuro-Oncology, Boston, Massachusetts, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Radiation Oncology Program, Boston, Massachusetts
| | - Geoffrey Fell
- Program in Regulatory Science, Boston, Massachusetts
- Department of Biostatistics and Computational Biology, Boston, Massachusetts
| | - Timothy F Cloughesy
- UCLA Neuro-Oncology Program and Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Patrick Y Wen
- Center for Neuro-Oncology, Boston, Massachusetts, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lorenzo Trippa
- Program in Regulatory Science, Boston, Massachusetts
- Department of Biostatistics and Computational Biology, Boston, Massachusetts
| | - Brian M Alexander
- Program in Regulatory Science, Boston, Massachusetts
- Department of Radiation Oncology, Boston, Massachusetts
- Center for Neuro-Oncology, Boston, Massachusetts, Dana-Farber Cancer Institute, Boston, Massachusetts
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24
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Sheikh S, Radivoyevitch T, Barnholtz-Sloan JS, Vogelbaum M. Long-term trends in glioblastoma survival: implications for historical control groups in clinical trials. Neurooncol Pract 2019; 7:158-163. [PMID: 32626584 DOI: 10.1093/nop/npz046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Historical controls continue to be used in early-phase brain tumor trials. We aim to show that historical changes in survival trends for glioblastoma (GBM) call into question the use of noncontemporary controls. Methods We analyzed data from 46 106 primary GBM cases from the SEER database (1998-2016). We performed trend analysis on survival outcomes (2-year survival probability, median survival, and hazard ratios) and patient characteristics (age, sex, resection extent, and treatment type). Results In 2005-2016 (ie, the post-Stupp protocol era), fitting a parameter independently to each year, there was a demonstrable increase in median survival (R2 = 0.81, P < .001) and 2-year survival probability (R2 = 0.55, P = .006) for GBM. Trend analysis of the hazard ratio showed a significant time-dependent downward trend (R2 = 0.62, P = .002). When controlling, via multivariable Cox regression modeling, for age, sex, resection extent, and treatment type, there was a persistent downward trend in hazard ratios with increases in calendar time, especially in the most recent data. Conclusion Contemporary GBM patients face a different overall hazard profile from their historical counterparts, which is evident in changes in measures of patient survival and parametric hazard modeling. Though there was a plateau in these measures before 2005 (pre-Stupp protocol), there is no evidence of a new plateau in recent years even when controlling for known prognostic factors (age, sex, resection extent, and treatment type), suggesting that it may be insufficient to match contemporary patients and noncontemporary controls on the basis of these factors.
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Affiliation(s)
- Shehryar Sheikh
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, OH, USA
| | - Tom Radivoyevitch
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, OH, USA
| | - Jill S Barnholtz-Sloan
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Vanderbeek AM, Rahman R, Fell G, Ventz S, Chen T, Redd R, Parmigiani G, Cloughesy TF, Wen PY, Trippa L, Alexander BM. The clinical trials landscape for glioblastoma: is it adequate to develop new treatments? Neuro Oncol 2019. [PMID: 29518210 DOI: 10.1093/neuonc/noy027] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background There have been few treatment advances for patients with glioblastoma (GBM) despite increasing scientific understanding of the disease. While factors such as intrinsic tumor biology and drug delivery are challenges to developing efficacious therapies, it is unclear whether the current clinical trial landscape is optimally evaluating new therapies and biomarkers. Methods We queried ClinicalTrials.gov for interventional clinical trials for patients with GBM initiated between January 2005 and December 2016 and abstracted data regarding phase, status, start and end dates, testing locations, endpoints, experimental interventions, sample size, clinical presentation/indication, and design to better understand the clinical trials landscape. Results Only approximately 8%-11% of patients with newly diagnosed GBM enroll on clinical trials with a similar estimate for all patients with GBM. Trial duration was similar across phases with median time to completion between 3 and 4 years. While 93% of clinical trials were in phases I-II, 26% of the overall clinical trial patient population was enrolled on phase III studies. Of the 8 completed phase III trials, only 1 reported positive results. Although 58% of the phase III trials were supported by phase II data with a similar endpoint, only 25% of these phase II trials were randomized. Conclusions The clinical trials landscape for GBM is characterized by long development times, inadequate dissemination of information, suboptimal go/no-go decision making, and low patient participation.
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Affiliation(s)
- Alyssa M Vanderbeek
- Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts.,Dana-Farber Program in Regulatory Science, Harvard Medical School, Boston, Massachusetts
| | - Rifaquat Rahman
- Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts.,Dana-Farber Program in Regulatory Science, Harvard Medical School, Boston, Massachusetts
| | - Geoffrey Fell
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Dana-Farber Program in Regulatory Science, Harvard Medical School, Boston, Massachusetts
| | - Steffen Ventz
- Dana-Farber Program in Regulatory Science, Harvard Medical School, Boston, Massachusetts.,Department of Computer Science and Statistics, University of Rhode Island, Kingston, Rhode Island
| | - Tianqi Chen
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Dana-Farber Program in Regulatory Science, Harvard Medical School, Boston, Massachusetts
| | - Robert Redd
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Dana-Farber Program in Regulatory Science, Harvard Medical School, Boston, Massachusetts
| | - Giovanni Parmigiani
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Dana-Farber Program in Regulatory Science, Harvard Medical School, Boston, Massachusetts
| | | | - Patrick Y Wen
- Center for Neuro-Oncology, Harvard Medical School, Boston, Massachusetts
| | - Lorenzo Trippa
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Dana-Farber Program in Regulatory Science, Harvard Medical School, Boston, Massachusetts
| | - Brian M Alexander
- Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts.,Center for Neuro-Oncology, Harvard Medical School, Boston, Massachusetts.,Dana-Farber Program in Regulatory Science, Harvard Medical School, Boston, Massachusetts
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26
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Ventz S, Lai A, Cloughesy TF, Wen PY, Trippa L, Alexander BM. Design and Evaluation of an External Control Arm Using Prior Clinical Trials and Real-World Data. Clin Cancer Res 2019; 25:4993-5001. [PMID: 31175098 DOI: 10.1158/1078-0432.ccr-19-0820] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/28/2019] [Accepted: 06/04/2019] [Indexed: 01/04/2023]
Abstract
PURPOSE We discuss designs and interpretable metrics of bias and statistical efficiency of "externally controlled" trials (ECT) and compare ECT performance to randomized and single-arm designs. EXPERIMENTAL DESIGN We specify an ECT design that leverages information from real-world data (RWD) and prior clinical trials to reduce bias associated with interstudy variations of the enrolled populations. We then used a collection of clinical studies in glioblastoma (GBM) and RWD from patients treated with the current standard of care to evaluate ECTs. Validation is based on a "leave one out" scheme, with iterative selection of a single-arm from one of the studies, for which we estimate treatment effects using the remaining studies as external control. This produces interpretable and robust estimates on ECT bias and type I errors. RESULTS We developed a model-free approach to evaluate ECTs based on collections of clinical trials and RWD. For GBM, we verified that inflated false positive error rates of standard single-arm trials can be considerably reduced (up to 30%) by using external control data. CONCLUSIONS The use of ECT designs in GBM, with adjustments for the clinical profiles of the enrolled patients, should be preferred to single-arm studies with fixed efficacy thresholds extracted from published results on the current standard of care.
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Affiliation(s)
- Steffen Ventz
- Department of Data Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts. .,Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts.,Dana-Farber Program in Regulatory Science, Harvard Medical School, Boston, Massachusetts
| | - Albert Lai
- Neuro-Oncology Program, University of California Los Angeles, Los Angeles, California
| | - Timothy F Cloughesy
- Neuro-Oncology Program, University of California Los Angeles, Los Angeles, California
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Lorenzo Trippa
- Department of Data Sciences, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts.,Dana-Farber Program in Regulatory Science, Harvard Medical School, Boston, Massachusetts
| | - Brian M Alexander
- Dana-Farber Program in Regulatory Science, Harvard Medical School, Boston, Massachusetts. .,Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
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27
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Alexander BM, Trippa L, Gaffey S, Arrillaga-Romany IC, Lee EQ, Rinne ML, Ahluwalia MS, Colman H, Fell G, Galanis E, de Groot J, Drappatz J, Lassman AB, Meredith DM, Nabors LB, Santagata S, Schiff D, Welch MR, Ligon KL, Wen PY. Individualized Screening Trial of Innovative Glioblastoma Therapy (INSIGhT): A Bayesian Adaptive Platform Trial to Develop Precision Medicines for Patients With Glioblastoma. JCO Precis Oncol 2019; 3:1800071. [PMID: 32914038 PMCID: PMC7448806 DOI: 10.1200/po.18.00071] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2018] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Adequately prioritizing the numerous therapies and biomarkers available in late-stage testing for patients with glioblastoma (GBM) requires an efficient clinical testing platform. We developed and implemented INSIGhT (Individualized Screening Trial of Innovative Glioblastoma Therapy) as a novel adaptive platform trial (APT) to develop precision medicine approaches in GBM. METHODS INSIGhT compares experimental arms with a common control of standard concurrent temozolomide and radiation therapy followed by adjuvant temozolomide. The primary end point is overall survival. Patients with newly diagnosed unmethylated GBM who are IDH R132H mutation negative and with genomic data available for biomarker grouping are eligible. At the initiation of INSIGhT, three experimental arms (neratinib, abemaciclib, and CC-115), each with a proposed genomic biomarker, are tested simultaneously. Initial randomization is equal across arms. As the trial progresses, randomization probabilities adapt on the basis of accumulating results using Bayesian estimation of the biomarker-specific probability of treatment impact on progression-free survival. Treatment arms may drop because of low probability of treatment impact on overall survival, and new arms may be added. Detailed information on the statistical model and randomization algorithm is provided to stimulate discussion on trial design choices more generally and provide an example for other investigators developing APTs. CONCLUSION INSIGhT (NCT02977780) is an ongoing novel biomarker-based, Bayesian APT for patients with newly diagnosed unmethylated GBM. Our goal is to dramatically shorten trial execution timelines while increasing scientific power of results and biomarker discovery using adaptive randomization. We anticipate that trial execution efficiency will also be improved by using the APT format, which allows for the collaborative addition of new experimental arms while retaining the overall trial structure.
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Affiliation(s)
- Brian M Alexander
- Dana-Farber Cancer Institute, Boston, MA.,Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | - Mikael L Rinne
- Brigham and Women's Hospital, Boston, MA.,Novartis Institutes for Biomedical Research, Boston, MA
| | | | | | | | | | | | - Jan Drappatz
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - David M Meredith
- Dana-Farber Cancer Institute, Boston, MA.,Brigham and Women's Hospital, Boston, MA
| | | | - Sandro Santagata
- Dana-Farber Cancer Institute, Boston, MA.,Brigham and Women's Hospital, Boston, MA
| | - David Schiff
- University of Virginia Health System, Charlottesville, VA
| | - Mary R Welch
- Columbia University Medical Center, New York, NY
| | - Keith L Ligon
- Dana-Farber Cancer Institute, Boston, MA.,Brigham and Women's Hospital, Boston, MA
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28
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Fares J, Kanojia D, Cordero A, Rashidi A, Miska J, Schwartz CW, Savchuk S, Ahmed AU, Balyasnikova IV, Cristofanilli M, Gradishar WJ, Lesniak MS. Current state of clinical trials in breast cancer brain metastases. Neurooncol Pract 2019; 6:392-401. [PMID: 31555454 DOI: 10.1093/nop/npz003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/05/2018] [Accepted: 01/10/2019] [Indexed: 12/13/2022] Open
Abstract
Background Breast cancer brain metastases (BCBM) are the final frontier in neuro-oncology for which more efficacious therapies are required. In this work, we explore clinical trials in BCBM, and determine the shortcomings in the development of new BCBM therapies to shed light on potential areas for enhancement. Methods On July 9, 2018, we searched ClinicalTrials.gov for all interventional and therapeutic clinical trials involving BCBM, without limiting for date or location. Information on trial characteristics, including phase, status, start and end dates, study design, primary endpoints, selection criteria, sample size, experimental interventions, results, and publications were collected and analyzed. Results Fifty-three trials fulfilled the selection criteria. Median trial duration across phases ranged between 3 and 6 years. More than half of the trials were conducted in the United States. Although 94% of the trials were in early phases (I-II), 20% of patients were in phase III trials. Two phase III trials were anteceded by phase II trials that were non-randomized; one reported positive results. Approximately one-third of the trials were completed, whereas 23% of trials were terminated early; mostly due to inadequate enrollment. Only 13% of all trials and 22% of completed trials had published results directly linked to their primary outcomes. Conclusions The low number of trials and accrual numbers, the lack of diversity, and the scarcity of published results represent the main troubles in clinical BCBM research. Optimization of BCBM trials is necessary to achieve effective therapies.
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Affiliation(s)
- Jawad Fares
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Deepak Kanojia
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alex Cordero
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Aida Rashidi
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jason Miska
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Charles W Schwartz
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Solomiia Savchuk
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Atique U Ahmed
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Irina V Balyasnikova
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Massimo Cristofanilli
- Lynn Sage Breast Cancer Program, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - William J Gradishar
- Lynn Sage Breast Cancer Program, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Maciej S Lesniak
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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29
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Alexander BM, Cloughesy TF. Platform trials arrive on time for glioblastoma. Neuro Oncol 2018; 20:723-725. [PMID: 29617844 DOI: 10.1093/neuonc/noy040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Brian M Alexander
- Radiation Oncology, Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center
| | - Timothy F Cloughesy
- UCLA Neuro-Oncology Program and Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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30
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Mandel JJ, Youssef M, Ludmir E, Yust-Katz S, Patel AJ, De Groot JF. Highlighting the need for reliable clinical trials in glioblastoma. Expert Rev Anticancer Ther 2018; 18:1031-1040. [PMID: 29973092 DOI: 10.1080/14737140.2018.1496824] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Several recent phase III studies have attempted to improve the dismal survival seen in glioblastoma patients, with disappointing results despite prior promising phase II data. Areas covered: A literature review of prior phase II and phase III studied in glioblastoma was performed to help identify possible areas of concern. Numerous issues in previous phase II trials for glioblastoma were found that may have contributed to these discouraging outcomes and discordant results. Expert commentary: These concerns include the improper selection of therapeutics warranting investigation in a phase III trial, suboptimal design of phase II studies (often lacking a control arm), absence of molecular data, the use of imaging criteria as a surrogate endpoint, and a lack of pharmacodynamic testing. Hopefully, by recognizing prior phase II trial limitations that contributed to failed phase III trials, we can adapt quickly to improve our ability to accurately discover survival-prolonging treatments for glioblastoma patients.
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Affiliation(s)
- Jacob J Mandel
- a Department of Neurology , Baylor College of Medicine , Houston , Texas , USA
| | - Michael Youssef
- a Department of Neurology , Baylor College of Medicine , Houston , Texas , USA
| | - Ethan Ludmir
- b Department of Radiation Oncology , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
| | - Shlomit Yust-Katz
- c Department of Neurosurgery , Rabin Medical Center , Petah Tikva , Israel
| | - Akash J Patel
- a Department of Neurology , Baylor College of Medicine , Houston , Texas , USA
| | - John F De Groot
- d Department of Neuro-Oncology , The University of Texas MD Anderson Cancer Center , Houston , Texas , USA
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31
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Wen PY, Jiang T, Schiff D. How can we develop therapies for glioblastoma more efficiently? Randomized versus single-arm studies. Neuro Oncol 2017; 19:459-460. [PMID: 28388714 PMCID: PMC5464309 DOI: 10.1093/neuonc/nox041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Tao Jiang
- Department of Neurosurgery, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - David Schiff
- Department of Neurology, University of Virginia, Charlottesville, Virginia, USA
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