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Jacobs F, Molinelli C, Martins-Branco D, Marta GN, Salmon M, Ameye L, Piccart M, Lambertini M, Agostinetto E, de Azambuja E. Progression-free survival assessment by local investigators versus blinded independent central review in randomized clinical trials in metastatic breast cancer: A systematic review and meta-analysis. Eur J Cancer 2024; 197:113478. [PMID: 38103328 DOI: 10.1016/j.ejca.2023.113478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/02/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION In randomized clinical trials (RCTs), blinded independent central review (BICR) is used to minimize heterogeneity and bias associated with radiological response evaluation by local investigators. However, BICR adds costs and complexity to the trial management. We assessed the discrepancy index between progression-free survival (PFS) assessment by local investigators and by BICR in RCTs conducted in patients with metastatic breast cancer (MBC). METHODS A systematic search of PubMed, Embase, Cochrane databases and conference proceedings (ASCO, SABCS, ESMO) was performed up to January 4, 2023 (PROSPERO: CRD42021229865). All RCTs published from 2000 to 2022, including MBC patients treated in first- or second-line, and reporting PFS assessed by local investigators and BICR were included. A discrepancy index between BICR-assessed and investigator-assessed HR was calculated for each trial and an overall combined DI was obtained using a fixed-effects model. The agreement between hazard ratios (HR) of PFS assessed by local investigators and BICR was measured using intraclass correlation coefficient (ICC). RESULTS We analyzed 24 studies including 13,168 patients. Among them, 19 (79%) were in first-line, 18 (75%) were phase III trials and 23 (96%) had PFS as primary endpoint. The overall combined discrepancy index was 0.97 (95%CI 0.85-1.10; ICC 0.831, p < 0.001) suggesting no statistically significant difference in PFS assessment between local investigators and BICR. This result was consistent across all analyzed subgroups. CONCLUSIONS The good concordance between local investigator and BICR assessments supports the reliability of local investigator-assessed PFS as primary endpoint for RCTs in MBC and questions the practical utility of implementing BICR in all RCTs.
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Affiliation(s)
- Flavia Jacobs
- Université Libre de Bruxelles (U.L.B), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Academic Trials Promoting Team (ATPT), Brussels, Belgium; Humanitas Clinical and Research Center - IRCCS, Humanitas Cancer Center, via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Chiara Molinelli
- Université Libre de Bruxelles (U.L.B), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Academic Trials Promoting Team (ATPT), Brussels, Belgium; Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genoa, Italy
| | - Diogo Martins-Branco
- Université Libre de Bruxelles (U.L.B), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Academic Trials Promoting Team (ATPT), Brussels, Belgium
| | - Guilherme Nader Marta
- Université Libre de Bruxelles (U.L.B), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Academic Trials Promoting Team (ATPT), Brussels, Belgium
| | - Maurine Salmon
- Université Libre de Bruxelles (U.L.B), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Data Center, Brussels, Belgium
| | - Lieveke Ameye
- Université Libre de Bruxelles (U.L.B), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Data Center, Brussels, Belgium
| | - Martine Piccart
- Université Libre de Bruxelles (U.L.B), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Medical Oncology Department, Brussels, Belgium
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genoa, Italy; Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Elisa Agostinetto
- Université Libre de Bruxelles (U.L.B), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Academic Trials Promoting Team (ATPT), Brussels, Belgium.
| | - Evandro de Azambuja
- Université Libre de Bruxelles (U.L.B), Hôpital Universitaire de Bruxelles (HUB), Institut Jules Bordet, Academic Trials Promoting Team (ATPT), Brussels, Belgium.
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Funada S, Luo Y, Kataoka Y, Yoshioka T, Fujita Y, Yoshida S, Katsura M, Tada M, Nishioka N, Nakamura Y, Ueno K, Uozumi R, Furukawa TA. Detection bias in open-label trials of anticancer drugs: a meta-epidemiological study. BMJ Evid Based Med 2023; 28:372-382. [PMID: 37586872 DOI: 10.1136/bmjebm-2023-112332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES In anticancer clinical trials, particularly open-label trials, central reviewers are recommended to evaluate progression-free survival (PFS) and objective response rate (ORR) to avoid detection bias of local investigators. However, it is not clear whether the bias has been adequately identified, or to what extent it consistently distorts the results. Therefore, the objective of this study was to evaluate the detection bias in oncological open-label trials by confirming whether local investigators overestimate the PFS and ORR compared with the findings of central reviewers. DESIGN Meta-epidemiological study. DATA SOURCES MEDLINE via PubMed from 1 January 2010 to 30 June 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Open-label, parallel-group superiority, randomised trials of anticancer drugs that adjudicated PFS or ORR by both central reviewers and local investigators. REVIEW METHODS We assessed the values for the same outcome (PFS and ORR) adjudicated by both central reviewers and local investigators. A random-effects model was used to estimate the ratio of HR (RHR) for PFS and the ratio of OR (ROR) for ORR between central reviewers and local investigators. An RHR lower than 1 and an ROR higher than 1 indicated an overestimation of the effect estimated by local investigators. RESULTS We retrieved 1197 records of oncological open-label trials after full-text screening. We identified 171 records (PFS: 149 records, ORR: 136 records) in which both central reviewers and local investigators were used, and included 114 records (PFS: 92 records, ORR: 74 records) for meta-analyses. While the RHR for PFS was 0.95 (95% CI 0.91 to 0.98), the ROR of ORR was 1.00 (95% CI 0.91 to 1.09). The results remained unchanged in the prespecified sensitivity analysis. CONCLUSIONS This meta-epidemiological study found that overestimation of local investigators has a small impact on evaluating PFS and ORR in oncological open-label trials. However, a limitation of this study is that it did not include data from all trials; hence, the results may not fully evaluate detection bias. The necessity of central reviewers in oncological open-label trials needs to be assessed by further studies that overcome this limitation. TRIAL REGISTRATION NUMBER CTR-UMIN000044623.
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Affiliation(s)
- Satoshi Funada
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine and Faculty of Medicine / School of Public Health, Kyoto, Japan
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Yan Luo
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine and Faculty of Medicine / School of Public Health, Kyoto, Japan
| | - Yuki Kataoka
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine and Faculty of Medicine, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Faculty of Medicine / School of Public Health, Kyoto, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Takashi Yoshioka
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Yusuke Fujita
- Department of Surgery, Kyoto University Graduate School of Medicine and Faculty of Medicine, Kyoto, Japan
| | - Shinya Yoshida
- Department of Surgery, Osaka Red Cross Hospital, Osaka, Japan
| | - Morihiro Katsura
- Department of Surgery, Okinawa Chubu Hospital, Okinawa, Japan
- Human Health Science, Kyoto University Graduate School of Medicine and Faculty of Medicine, Kyoto, Japan
| | - Masafumi Tada
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine and Faculty of Medicine / School of Public Health, Kyoto, Japan
- Department of Neurology, Emergency Medicine, Nagoya City University East Medical Center, Nagoya, Japan
| | - Norihiro Nishioka
- Department of Preventive Services, Kyoto University Graduate School of Medicine and Faculty of Medicine / School of Public Health, Kyoto, Japan
| | - Yoshiaki Nakamura
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center-Hospital East, Kashiwa, Japan
- Translational Research Support Section, National Cancer Center Hospital East, Kashiwa, Japan
| | - Kentaro Ueno
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine and Faculty of Medicine, Kyoto, Japan
| | - Ryuji Uozumi
- Department of Industrial Engineering and Economics, Tokyo Institute of Technology, Tokyo, Japan
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine and Faculty of Medicine / School of Public Health, Kyoto, Japan
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Herzog TJ, Wahab SA, Mirza MR, Pothuri B, Vergote I, Graybill WS, Malinowska IA, York W, Hurteau JA, Gupta D, González-Martin A, Monk BJ. Optimizing disease progression assessment using blinded central independent review and comparing it with investigator assessment in the PRIMA/ENGOT-ov26/GOG-3012 trial: challenges and solutions. Int J Gynecol Cancer 2023; 33:1733-1742. [PMID: 37931976 PMCID: PMC10646892 DOI: 10.1136/ijgc-2023-004605] [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: 05/17/2023] [Accepted: 09/26/2023] [Indexed: 11/08/2023] Open
Abstract
OBJECTIVE Progression-free survival is an established clinically meaningful endpoint in ovarian cancer trials, but it may be susceptible to bias; therefore, blinded independent centralized radiological review is often included in trial designs. We compared blinded independent centralized review and investigator-assessed progressive disease performance in the PRIMA/ENGOT-ov26/GOG-3012 trial examining niraparib monotherapy. METHODS PRIMA/ENGOT-ov26/GOG-3012 was a randomized, double-blind phase 3 trial; patients with newly diagnosed stage III/IV ovarian cancer received niraparib or placebo. The primary endpoint was progression-free survival (per Response Evaluation Criteria in Solid Tumors [RECIST] v1.1), determined by two independent radiologists, an arbiter if required, and by blinded central clinician review. Discordance rates between blinded independent centralized review and investigator assessment of progressive disease and non-progressive disease were routinely assessed. To optimize disease assessment, a training intervention was developed for blinded independent centralized radiological reviewers, and RECIST refresher training was provided for investigators. Discordance rates were determined post-intervention. RESULTS There was a 39% discordance rate between blinded independent centralized review and investigator-assessed progressive disease/non-progressive disease in an initial patient subset (n=80); peritoneal carcinomatosis was the most common source of discordance. All reviewers underwent training, and as a result, changes were implemented, including removal of two original reviewers and identification of 10 best practices for reading imaging data. Post-hoc analysis indicated final discordance rates between blinded independent centralized review and investigator improved to 12% in the overall population. Median progression-free survival and hazard ratios were similar between blinded independent centralized review and investigators in the overall population and across subgroups. CONCLUSION PRIMA/ENGOT-ov26/GOG-3012 highlights the need to optimize blinded independent centralized review and investigator concordance using early, specialized, ovarian-cancer-specific radiology training to maximize validity of outcome data.
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Affiliation(s)
- Thomas J Herzog
- Department of Obstetrics and Gynecology, University of Cincinnati Cancer Center, Cincinnati, Ohio, USA
| | - Shaun A Wahab
- Department of Radiology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Mansoor R Mirza
- Department of Oncology, Nordic Society of Gynaecological Oncology Clinical Trial Unit (NSGO-CTU) and Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
| | - Bhavana Pothuri
- Department of Obstetrics and Gynecology, NYU Langone Health Perlmutter Cancer Center, New York, New York, USA
| | - Ignace Vergote
- Department of Obstetrics and Gynecology, Leuven Cancer Institute, Catholic University Leuven, Leuven, Belgium
| | - Whitney S Graybill
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Whitney York
- Oncology Statistics, GSK, Upper Providence, Pennsylvania, USA
| | - Jean A Hurteau
- Synthetic Lethality & Immuno-oncology, GSK, Waltham, Massachusetts, USA
| | - Divya Gupta
- Synthetic Lethality, GSK, Waltham, Massachusetts, USA
| | - Antonio González-Martin
- Department of Medical Oncology, Grupo Español de Investigación en Cáncer de Ovario (GEICO), Program in Solid Tumors, Center for Applied Medical Research (CIMA), Madrid, Spain
| | - Bradley J Monk
- Department of Obstetrics and Gynecology, HonorHealth Research Institute, University of Arizona College of Medicine, Phoenix, Arizona, USA
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Lin TA, Sherry AD, Ludmir EB. Challenges, Complexities, and Considerations in the Design and Interpretation of Late-Phase Oncology Trials. Semin Radiat Oncol 2023; 33:429-437. [PMID: 37684072 PMCID: PMC10917127 DOI: 10.1016/j.semradonc.2023.06.007] [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] [Indexed: 09/10/2023]
Abstract
Optimal management of cancer patients relies heavily on late-phase oncology randomized controlled trials. A comprehensive understanding of the key considerations in designing and interpreting late-phase trials is crucial for improving subsequent trial design, execution, and clinical decision-making. In this review, we explore important aspects of late-phase oncology trial design. We begin by examining the selection of primary endpoints, including the advantages and disadvantages of using surrogate endpoints. We address the challenges involved in assessing tumor progression and discuss strategies to mitigate bias. We define informative censoring bias and its impact on trial results, including illustrative examples of scenarios that may lead to informative censoring. We highlight the traditional roles of the log-rank test and hazard ratio in survival analyses, along with their limitations in the presence of nonproportional hazards as well as an introduction to alternative survival estimands, such as restricted mean survival time or MaxCombo. We emphasize the distinctions between the design and interpretation of superiority and noninferiority trials, and compare Bayesian and frequentist statistical approaches. Finally, we discuss appropriate utilization of phase II and phase III trial results in shaping clinical management recommendations and evaluate the inherent risks and benefits associated with relying on phase II data for treatment decisions.
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Affiliation(s)
- Timothy A Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexander D Sherry
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ethan B Ludmir
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.; Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX..
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Inadequate reporting of adjudicators in open-label trials of anticancer drugs between 2017 and 2021: a methodological review. J Clin Epidemiol 2022; 150:80-89. [DOI: 10.1016/j.jclinepi.2022.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/23/2022] [Accepted: 06/28/2022] [Indexed: 11/18/2022]
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Dello Russo C, Navarra P. Local Investigators Significantly Overestimate Overall Response Rates Compared to Blinded Independent Central Reviews in Uncontrolled Oncology Trials: A Comprehensive Review of the Literature. Front Pharmacol 2022; 13:858354. [PMID: 35652050 PMCID: PMC9149259 DOI: 10.3389/fphar.2022.858354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/11/2022] [Indexed: 11/26/2022] Open
Abstract
Several drugs gained market authorization based on the demonstration of improved progression-free survival (PFS), adopted as a primary endpoint in Phase 3 clinical trials. In addition, an increasing number of drugs have been granted accelerated approval, and sometimes regular approval, by the main regulatory agencies based on the evaluation of the overall response rate in Phase 1 and 2 clinical trials. However, while the overall survival is an unbiased measure of drug efficacy, these outcomes rely on the assessment of radiological images and patients’ categorization using standardized response criteria. The evaluation of these outcomes may be influenced by subjective factors, particularly when the analysis is performed locally. In fact, blinding of treatment is not always possible in modern oncology trials. Therefore, a blinded independent central review is often adopted to overcome the problem of expectation bias associated with local investigator assessments. In this regard, we have recently observed that local investigators tend to overestimate the overall response rate in comparison to central reviewers in Phase 2 clinical trials, whereas we did not find any significant evaluation bias between local investigators and central reviews when considering progression-free survival in both Phase 2 and 3 trials. In the present article, we have tried to understand the reasons behind this discrepancy by reviewing the available evidence in the literature. In addition, a further analysis of Phase 2 and 3 clinical trials that included the evaluation of both endpoints showed that local investigators significantly overestimate overall response rates compared to blinded independent central reviews in uncontrolled oncology trials.
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Affiliation(s)
- Cinzia Dello Russo
- Section of Pharmacology, Department of Healthcare Surveillance and Bioethics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy.,MRC Centre for Drug Safety Science and Wolfson Centre for Personalized Medicine, Institute of Systems Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, United Kingdom
| | - Pierluigi Navarra
- Section of Pharmacology, Department of Healthcare Surveillance and Bioethics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Del Sacro Cuore, Rome, Italy
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Tomasik B, Bieńkowski M, Braun M, Popat S, Dziadziuszko R. Effectiveness and safety of immunotherapy in NSCLC patients with ECOG PS score ≥2 - Systematic review and meta-analysis. Lung Cancer 2021; 158:97-106. [PMID: 34144405 DOI: 10.1016/j.lungcan.2021.06.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/08/2021] [Accepted: 06/03/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are standard of care in advanced non-small cell lung cancer (NSCLC), however their status in patients with poor performance status (PS) is poorly defined. We aimed to evaluate the efficacy and safety of ICIs in NSCLC patients with PS ≥ 2. METHODS We conducted a systematic review and meta-analysis of interventional and observational studies, which reported efficacy and safety data on ICIs in PS ≥ 2 comparing to PS ≤ 1 NSCLC patients. Efficacy endpoints included: Objective Response Rate (ORR), Disease-Control Rate (DCR), Overall Survival (OS), Progression-Free Survival (PFS). Safety endpoint was the incidence of severe (grade≥3) Adverse Events (AE). Random-effects model was applied for meta-analysis. Heterogeneity was assessed using I2. The review is registered on PROSPERO (CRD42020162668). FINDINGS Sixty-seven studies (n = 26,442 patients) were included. In PS ≥ 2 vs. PS ≤ 1 patients, the pooled odds ratios were: for ORR 0.46 (95 %CI: 0.39-0.54, I2:0 %); for DCR 0.39 (95 %CI: 0.33-0.48, I2:50 %) and for AEs 1.12 (95 %CI: 0.84-1.48, I2:39 %). The pooled hazard ratio for PFS was 2.17 (95 %CI: 1.96-2.39, I2:65 %) and for OS was 2.76 (95 %CI: 2.43-3.14, I2:76 %). The safety profile was comparable regardless of the PS status. INTERPRETATION Patients with impaired PS status are, on average, twice less likely to achieve a response when exposed to ICIs when compared with representative PS ≤ 1 population. For lung cancer patients treated with ICIs, the impaired PS is not only prognostic, but also predictive for response, while the safety profile is not affected. Prospective randomized studies are indispensable to determine whether poor PS patients derive benefit from ICIs.
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Affiliation(s)
- Bartłomiej Tomasik
- Department of Biostatistics and Translational Medicine, Medical University of Łódź, 15 Mazowiecka Street, 92-215 Łódź, Poland; Department of Radiation Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
| | - Michał Bieńkowski
- Department of Pathomorphology, Medical University of Gdańsk, 17 Smoluchowskiego Street, 80-214 Gdańsk, Poland
| | - Marcin Braun
- Department of Pathology, Chair of Oncology, Medical University of Łódź, Pomorska 251 Street, 92-213 Łódź, Poland
| | - Sanjay Popat
- Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK; The Institute of Cancer Research, 123 Old Brompton Road, London SW7 3RP, UK; National Hearth and Lung Institute, Imperial College London, Dovehouse Street, London SW3 6LY, UK
| | - Rafał Dziadziuszko
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, 7 Debinki Street, 80-211 Gdańsk, Poland.
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Loreen A, Polen-De C, Monk BJ, Jackson AL, Billingsley CC, Herzog TJ. The role of blinded independent radiologic review in ovarian cancer clinical trials: Discerning the value. Gynecol Oncol 2021; 161:491-495. [PMID: 33722416 DOI: 10.1016/j.ygyno.2021.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/21/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Amy Loreen
- University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH 45219, United States of America
| | - Clarissa Polen-De
- University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH 45219, United States of America
| | - Bradley J Monk
- Biltmore Cancer Center, 2222 E Highland Ave #400, Phoenix, AR 85016, United States of America
| | - Amanda L Jackson
- University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH 45219, United States of America
| | - Caroline C Billingsley
- University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH 45219, United States of America
| | - Thomas J Herzog
- University of Cincinnati Medical Center, 234 Goodman St, Cincinnati, OH 45219, United States of America.
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Dello Russo C, Cappoli N, Pilunni D, Navarra P. Local Investigators Significantly Overestimate Overall Response Rates Compared to Blinded Independent Central Reviews in Phase 2 Oncology Trials. J Clin Pharmacol 2020; 61:810-819. [PMID: 33244770 DOI: 10.1002/jcph.1790] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/18/2020] [Indexed: 11/11/2022]
Abstract
The overall response rate (ORR) is a largely adopted outcome measure in early-phase oncology trials. ORR is highly relevant in cancer drug development at the time of deciding whether to move to confirmatory phase 3 trials; moreover, ORR is gaining increasing relevance in fast-track registration procedures. No systematic analysis has been conducted so far to investigate whether a discrepancy exists between ORR assessed by local investigators and those assessed by blinded reviewers in phase 2 oncology trials. In this study, we carried out a search in the clinicaltrials.gov and EudraCT databases, looking at the trials reporting the results of both investigator-assessed and independently-assessed ORR. A discrepancy index was obtained by calculating the ratio of each investigator-assessed ORR on the corresponding independently assessed ORR, so that a discrepancy index >1 indicates that the investigator was "more optimistic," whereas a discrepancy index <1 indicates the opposite. We also analyzed different subgroups (by tumor type, by drug type, by year). Twenty trials met the search criteria; in some cases, >1 comparison was conducted in the trial, so that the total number of comparisons analyzed was 33. The estimated mean discrepancy index was 1.175 (95% confidence interval, 1.083-1.264; n = 33). In conclusion, local investigators significantly overestimate ORR compared to paired blinded reviewers in phase 2 oncology trials. This may represent a risk in drug development, when deciding whether to move to confirmatory, more expensive phase 3 trials. Blinded independent central review should be used in ORR assessment if a more conservative estimate of treatment efficacy is required, as in the case of fast-track drug developments leading to accelerated approvals of cancer therapies.
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Affiliation(s)
- Cinzia Dello Russo
- Department of Healthcare Surveillance and Bioethics, Section of Pharmacology, Università Cattolica del Sacro Cuore-Fondazione Policlinico Universitario A. , Gemelli IRCCS, Rome, Italy
| | - Natalia Cappoli
- Department of Healthcare Surveillance and Bioethics, Section of Pharmacology, Università Cattolica del Sacro Cuore-Fondazione Policlinico Universitario A. , Gemelli IRCCS, Rome, Italy
| | - Daniela Pilunni
- Postgraduate School of Hospital Pharmacy, Sapienza University, Rome, Italy
| | - Pierluigi Navarra
- Department of Healthcare Surveillance and Bioethics, Section of Pharmacology, Università Cattolica del Sacro Cuore-Fondazione Policlinico Universitario A. , Gemelli IRCCS, Rome, Italy
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Pasalic D, McGinnis GJ, Fuller CD, Grossberg AJ, Verma V, Mainwaring W, Miller AB, Lin TA, Jethanandani A, Espinoza AF, Diefenhardt M, Das P, Subbiah V, Subbiah IM, Jagsi R, Garden AS, Fokas E, Rödel C, Thomas CR, Minsky BD, Ludmir EB. Progression-free survival is a suboptimal predictor for overall survival among metastatic solid tumour clinical trials. Eur J Cancer 2020; 136:176-185. [PMID: 32702645 DOI: 10.1016/j.ejca.2020.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/01/2020] [Accepted: 06/11/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND The use of overall survival (OS) as the gold standard primary end-point (PEP) in metastatic oncologic randomised controlled trials (RCTs) has declined in favour of progression-free survival (PFS) without a complete understanding of the degree to which PFS reliably predicts for OS. METHODS Using ClinicalTrials.gov, we identified 1239 phase III oncologic RCTs, 260 of which were metastatic solid tumour trials with a superiority-design investigating a therapeutic intervention by using either a PFS or OS PEP. Each individual trial was reviewed to quantify RCT design factors and disease-related outcomes. RESULTS A total of 172,133 patients were enrolled from the year 1999 to 2015 in RCTs that used PFS (56.2%, 146/260) or OS (43.8%, 114/260) as the PEP. PFS trials were more likely to restrict patient eligibility by using molecular criteria (15.1% versus 4.4%, p = 0.005) use targeted therapy (80.1% versus 67.5%, p = 0.048), accrue fewer patients (median 495 versus 619, p = 0.03), and successfully meet the trial PEP (66.9% versus 33.3%, p < 0.0001). On multiple binary logistic regression analysis, factors that predicted for PFS or OS PEP trial success included choice of PFS PEP (p < 0.0001), molecular profile restriction (p = 0.02) and single agent therapy (p = 0.02). Notably, there was only a 38% (31/82) conversion rate of positive PFS-to-OS benefit; lack of industry sponsorship predicted for PFS-to-OS signal conversion (80.0% without industry sponsorship versus 35.1% with industry sponsorship, p = 0.045). CONCLUSIONS A PFS PEP has suboptimal positive predictive value for OS among phase III metastatic solid tumour RCTs. Regulatory agency decisions should be judicious in using PFS results as the primary basis for approval.
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Affiliation(s)
- Dario Pasalic
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - C David Fuller
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Vivek Verma
- Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | | | - Austin B Miller
- The University of Texas Health Science Center, McGovern Medical School, Houston, TX, USA
| | - Timothy A Lin
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Markus Diefenhardt
- University of Frankfurt, Frankfurt, Germany; Frankfurt Cancer Institute, Frankfurt, Germany
| | - Prajnan Das
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vivek Subbiah
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Adam S Garden
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Emmanouil Fokas
- University of Frankfurt, Frankfurt, Germany; Frankfurt Cancer Institute, Frankfurt, Germany; German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, Frankfurt, Germany
| | - Claus Rödel
- University of Frankfurt, Frankfurt, Germany; Frankfurt Cancer Institute, Frankfurt, Germany; German Cancer Research Center, Heidelberg, Germany; German Cancer Consortium, Frankfurt, Germany
| | | | - Bruce D Minsky
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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11
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Rischin D, Migden MR, Lim AM, Schmults CD, Khushalani NI, Hughes BGM, Schadendorf D, Dunn LA, Hernandez-Aya L, Chang ALS, Modi B, Hauschild A, Ulrich C, Eigentler T, Stein B, Pavlick AC, Geiger JL, Gutzmer R, Alam M, Okoye E, Mathias M, Jankovic V, Stankevich E, Booth J, Li S, Lowy I, Fury MG, Guminski A. Phase 2 study of cemiplimab in patients with metastatic cutaneous squamous cell carcinoma: primary analysis of fixed-dosing, long-term outcome of weight-based dosing. J Immunother Cancer 2020; 8:e000775. [PMID: 32554615 PMCID: PMC7304829 DOI: 10.1136/jitc-2020-000775] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Cemiplimab, a high-affinity, potent human immunoglobulin G4 monoclonal antibody to programmed cell death-1 demonstrated antitumor activity in a Phase 1 advanced cutaneous squamous cell carcinoma (CSCC) expansion cohort (NCT02383212) and the pivotal Phase 2 study (NCT02760498). Here we report the primary analysis of fixed dose cemiplimab 350 mg intravenously every 3 weeks (Q3W) (Group 3) and provide a longer-term update after the primary analysis of weight-based cemiplimab 3 mg/kg intravenously every 2 weeks (Q2W) (Group 1) among metastatic CSCC (mCSCC) patients in the pivotal study (NCT02760498). METHODS The primary objective for each group was objective response rate (ORR) per independent central review (ICR). Secondary endpoints included ORR by investigator review (INV), duration of response (DOR) per ICR and INV, and safety and tolerability. RESULTS For Group 3 (n=56) and Group 1 (n=59), median follow-up was 8.1 (range, 0.6 to 14.1) and 16.5 (range, 1.1 to 26.6) months, respectively. ORR per ICR was 41.1% (95% CI, 28.1% to 55.0%) in Group 3, 49.2% (95% CI, 35.9% to 62.5%) in Group 1, and 45.2% (95% CI, 35.9% to 54.8%) in both groups combined. Per ICR, Kaplan-Meier estimate for DOR at 8 months was 95.0% (95% CI, 69.5% to 99. 3%) in responding patients in Group 3, and at 12 months was 88.9% (95% CI, 69.3% to 96.3%) in responding patients in Group 1. Per INV, ORR was 51.8% (95% CI, 38.0% to 65.3%) in Group 3, 49.2% (95% CI, 35.9% to 62.5%) in Group 1, and 50.4% (95% CI, 41.0% to 59.9%) in both groups combined. Overall, the most common adverse events regardless of attribution were fatigue (27.0%) and diarrhea (23.5%). CONCLUSION In patients with mCSCC, cemiplimab 350 mg intravenously Q3W produced substantial antitumor activity with durable response and an acceptable safety profile. Follow-up data of cemiplimab 3 mg/kg intravenously Q2W demonstrate ongoing durability of responses. TRIAL REGISTRATION NUMBER Clinicaltrials.gov, NCT02760498. Registered May 3, 2016, https://clinicaltrials.gov/ct2/show/NCT02760498.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Body Weight
- Carcinoma, Squamous Cell/drug therapy
- Carcinoma, Squamous Cell/immunology
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/secondary
- Dose-Response Relationship, Drug
- Drug Administration Schedule
- Drug Dosage Calculations
- Female
- Follow-Up Studies
- Humans
- Immune Checkpoint Inhibitors/administration & dosage
- Immune Checkpoint Inhibitors/adverse effects
- Infusions, Intravenous
- Kaplan-Meier Estimate
- Male
- Middle Aged
- Programmed Cell Death 1 Receptor/antagonists & inhibitors
- Programmed Cell Death 1 Receptor/immunology
- Progression-Free Survival
- Skin Neoplasms/drug therapy
- Skin Neoplasms/immunology
- Skin Neoplasms/mortality
- Skin Neoplasms/pathology
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Affiliation(s)
- Danny Rischin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Michael R Migden
- Departments of Dermatology and Head and Neck Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Annette M Lim
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Chrysalyne D Schmults
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhil I Khushalani
- Department of Cutaneous Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Brett G M Hughes
- Royal Brisbane and Women's Hospital and the University of Queensland, Brisbane, Queensland, Australia
| | - Dirk Schadendorf
- University Hospital Essen, Essen and German Cancer Consortium, Essen, Germany
| | - Lara A Dunn
- Department of Medicine, Head and Neck Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Leonel Hernandez-Aya
- Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Anne Lynn S Chang
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California, USA
| | - Badri Modi
- Division of Dermatology, City of Hope, Duarte, California, USA
| | - Axel Hauschild
- Department of Dermatology, University Hospital (UKSH), Kiel, Germany
| | - Claas Ulrich
- Skin Cancer Centre, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Eigentler
- Department of Dermatology, Center for Dermatooncology, University Medical Center Tübingen, Tübingen, Germany
| | - Brian Stein
- Adelaide Cancer Centre, Adelaide, South Australia, Australia
| | - Anna C Pavlick
- Department of Medical Oncology, New York University Langone Medical Center, New York, New York, USA
| | - Jessica L Geiger
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio, USA
| | - Ralf Gutzmer
- Department of Dermatology and Allergy, Skin Cancer Center Hannover, Hannover Medical School, Hannover, Germany
| | - Murad Alam
- Department of Dermatology, Northwestern University, Chicago, Illinois, USA
| | | | | | | | | | - Jocelyn Booth
- Regeneron Pharmaceuticals, Inc, Basking Ridge, New Jersey, USA
| | - Siyu Li
- Regeneron Pharmaceuticals, Inc, Basking Ridge, New Jersey, USA
| | - Israel Lowy
- Regeneron Pharmaceuticals, Inc, Tarrytown, New York, USA
| | - Matthew G Fury
- Regeneron Pharmaceuticals, Inc, Tarrytown, New York, USA
| | - Alexander Guminski
- Department of Medical Oncology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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12
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Dello Russo C, Cappoli N, Navarra P. A comparison between the assessments of progression-free survival by local investigators versus blinded independent central reviews in phase III oncology trials. Eur J Clin Pharmacol 2020; 76:1083-1092. [PMID: 32447437 DOI: 10.1007/s00228-020-02895-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/08/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE In this study, we compared the assessments of progression-free survival (PFS) carried out by the local investigator or by a blinded independent central review in the framework of phase III registration randomized controlled trials (RCT) in oncology. METHODS We carried out a search in the clinicatrials.gov database, looking at the RCTs reporting the results of both independently assessed and investigator-assessed PFS. The hazard ratios (HRs) of investigator-assessed PFS and independently assessed PFS were recorded, and a discrepancy index was obtained by calculating the ratio of their respective HRs. Moreover, we investigated possible factors of discrepancy by analyzing the trials in different groups (by year, by tumor type, by drug type, by study design). RESULTS We analyzed 28 RCTs meeting the search criteria. The estimated mean discrepancy index was 0.98 (confidence interval 0.927-1.032 (n = 32)). Subgroup analysis showed that the confidence intervals in all cases included the value 1, except in the subgroup of studies started in the period 2003-2006. CONCLUSION In phase III oncology trials, we found no significant differences between the hazard ratios estimated by local investigators and those estimated by blinded independent central reviews. A relatively higher variability, in terms of large CI, was found in trials with biological agents.
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Affiliation(s)
- Cinzia Dello Russo
- Institute of Pharmacology, Catholic University Medical School, Largo F. Vito 1, 00168, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Natalia Cappoli
- Institute of Pharmacology, Catholic University Medical School, Largo F. Vito 1, 00168, Rome, Italy
| | - Pierluigi Navarra
- Institute of Pharmacology, Catholic University Medical School, Largo F. Vito 1, 00168, Rome, Italy. .,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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13
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Noronha V, Patil VM, Joshi A, Menon N, Chougule A, Prabhash K. Reply to T. Tanaka et al and F. Liang. J Clin Oncol 2020; 38:844-846. [PMID: 31895609 DOI: 10.1200/jco.19.02974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Vanita Noronha
- Vanita Noronha, MBBS, MD, DM; Vijay M. Patil, MBBS, MD, DM; Amit Joshi, MBBS, MD, DM; Nandini Menon, MBBS, MD, DNB; Anuradha Chougule, PhD; and Kumar Prabhash, MBBS, MD, DM, Homi Bhabha National Institute (HBNI); and Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
| | - Vijay M Patil
- Vanita Noronha, MBBS, MD, DM; Vijay M. Patil, MBBS, MD, DM; Amit Joshi, MBBS, MD, DM; Nandini Menon, MBBS, MD, DNB; Anuradha Chougule, PhD; and Kumar Prabhash, MBBS, MD, DM, Homi Bhabha National Institute (HBNI); and Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
| | - Amit Joshi
- Vanita Noronha, MBBS, MD, DM; Vijay M. Patil, MBBS, MD, DM; Amit Joshi, MBBS, MD, DM; Nandini Menon, MBBS, MD, DNB; Anuradha Chougule, PhD; and Kumar Prabhash, MBBS, MD, DM, Homi Bhabha National Institute (HBNI); and Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
| | - Nandini Menon
- Vanita Noronha, MBBS, MD, DM; Vijay M. Patil, MBBS, MD, DM; Amit Joshi, MBBS, MD, DM; Nandini Menon, MBBS, MD, DNB; Anuradha Chougule, PhD; and Kumar Prabhash, MBBS, MD, DM, Homi Bhabha National Institute (HBNI); and Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
| | - Anuradha Chougule
- Vanita Noronha, MBBS, MD, DM; Vijay M. Patil, MBBS, MD, DM; Amit Joshi, MBBS, MD, DM; Nandini Menon, MBBS, MD, DNB; Anuradha Chougule, PhD; and Kumar Prabhash, MBBS, MD, DM, Homi Bhabha National Institute (HBNI); and Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
| | - Kumar Prabhash
- Vanita Noronha, MBBS, MD, DM; Vijay M. Patil, MBBS, MD, DM; Amit Joshi, MBBS, MD, DM; Nandini Menon, MBBS, MD, DNB; Anuradha Chougule, PhD; and Kumar Prabhash, MBBS, MD, DM, Homi Bhabha National Institute (HBNI); and Department of Medical Oncology, Tata Memorial Hospital, Tata Memorial Center, Mumbai, India
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14
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Parmar A, Chaves-Porras J, Saluja R, Perry K, Rahmadian AP, Santos SD, Ko YJ, Berry S, Doherty M, Chan KKW. Adjuvant treatment for resected pancreatic adenocarcinoma: A systematic review and network meta-analysis. Crit Rev Oncol Hematol 2019; 145:102817. [PMID: 31955005 DOI: 10.1016/j.critrevonc.2019.102817] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 09/30/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023] Open
Abstract
Adjuvant chemotherapy has significantly improved outcomes following surgical resection for pancreatic adenocarcinoma; however, the optimal adjuvant strategy remains unclear. This systematic review and network meta-analysis was conducted to provide indirect comparative evidence across adjuvant chemotherapies. Electronic searches of EMBASE, MEDLINE, Cochrane and ASCO databases were conducted to identify eligible randomized controlled trials (RCT). Direct pairwise meta-analysis was conducted for disease-free survival (DFS), overall-survival (OS) and adverse events (AE). Network meta-analysis of DFS and OS was conducted to evaluate indirect comparisons. Ten publications of eleven RCT met eligibility criteria. Indirect DFS comparison demonstrated superiority of mFOLFIRINOX versus gemcitabine-capecitabine, gemcitabine-erlotinib and gemcitabine-nab-paclitaxel. S-1 demonstrated a DFS benefit versus gemcitabine-capecitabine, gemcitabine-erlotinib, gemcitabine-nab-paclitaxel. OS benefits were demonstrated for mFOLFIRINOX verus gemcitabine-erlotinib and for S-1 versus gemcitabine-based combination with erlotinib, capecitabine and nab-paclitaxel. In conclusion, mFOLFIRINOX is the preferred approach for adjuvant therapy. For mFOLFIRINOX-ineligible patients no additional benefit is seen with gemcitabine-nab-paclitaxel.
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Affiliation(s)
- Ambica Parmar
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jorge Chaves-Porras
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Ronak Saluja
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kaitlyn Perry
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Amanda P Rahmadian
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Yoo-Joung Ko
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Scott Berry
- Kingston Health Sciences Centre, Queen's University, Kingston, ON, Canada
| | - Mark Doherty
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kelvin K W Chan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada.
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15
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Schmitt AM, Herbrand AK, Fox CP, Bakunina K, Bromberg JEC, Cwynarski K, Doorduijn JK, Ferreri AJM, Illerhaus G, Issa S, Schorb E, Zucca E, Hemkens LG, Schandelmaier S, Kasenda B. Rituximab in primary central nervous system lymphoma-A systematic review and meta-analysis. Hematol Oncol 2019; 37:548-557. [PMID: 31418878 DOI: 10.1002/hon.2666] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/09/2019] [Accepted: 08/10/2019] [Indexed: 01/17/2023]
Abstract
The CD-20 antibody rituximab is a standard component of treatment of non-Hodgkin B-cell lymphomas, including diffuse large B-cell lymphoma (DLBCL). Primary DLBCL of the central nervous system, also called primary central nervous system lymphoma (PCNSL), is a DLBCL confined to the central nervous system. There has been debate whether intravenous rituximab accumulates sufficiently in the central nervous system to exert an effect. In this systematic review, we assess the benefits and harms of rituximab in the treatment of immunocompetent patients with PCNSL. By searching MEDLINE, CENTRAL, and ClincialTrials.gov up to March 2019, we identified randomized controlled trials (RCTs) investigating the effect of rituximab in patients with PCNSL. We extracted study characteristics and results, assessed risk of bias, performed trial-level random-effects meta-analyses, and graded the certainty of evidence. The protocol was registered with PROSPERO (CRD42019121965). Main outcomes were overall survival (time to death), progression-free survival (time to progression or death), quality of life, grades 3 and 4 toxicity, and treatment-related mortality. We included two RCTs with a total of 343 participants. Overall survival was not statistically significantly improved (HR 0.76; 95% CI, 0.52-1.12; low certainty), with 187 fewer to 39 more deaths after 2 years in 1000 treated patients. Low certainty of evidence indicated that rituximab improved progression-free survival (HR 0.65; 95% CI, 0.45-0.95), which translated into 137 fewer progressions or deaths after 2 years in 1000 treated patients (231 to 18 fewer). None of the RCTs provided data on quality of life. We found no evidence that rituximab increased grades 3 and 4 toxicity or treatment-related mortality (RR 0.53; 95% CI, 0.20-1.37; low certainty). Overall, the available evidence suggests with low certainty that rituximab in combination with methotrexate-based chemotherapy may improve progression-free survival in immunocompetent patients with newly diagnosed PCNSL, the pooled effect estimates did not show evidence for improvement of overall survival.
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Affiliation(s)
- Andreas M Schmitt
- Department of Medical Oncology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Amanda K Herbrand
- Department of Medical Oncology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christopher P Fox
- Department of Clinical Haematology, Nottingham Hospitals NHS Trust, Nottingham, UK
| | - Katerina Bakunina
- HOVON Data Center, Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | | | - Kate Cwynarski
- Department of Haematology, University College London Hospital, London, UK
| | | | - Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Hematology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gerald Illerhaus
- Department of Hematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany
| | - Samar Issa
- Department of Hematology, Middlemore Hospital, Auckland, New Zealand
| | - Elisabeth Schorb
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Emanuele Zucca
- Istituto Oncologico Della Svizzera Italiana, Bellinzona, Switzerland
| | - Lars G Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Stefan Schandelmaier
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Benjamin Kasenda
- Department of Medical Oncology, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Hematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany
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16
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Naci H, Davis C, Savović J, Higgins JPT, Sterne JAC, Gyawali B, Romo-Sandoval X, Handley N, Booth CM. Design characteristics, risk of bias, and reporting of randomised controlled trials supporting approvals of cancer drugs by European Medicines Agency, 2014-16: cross sectional analysis. BMJ 2019; 366:l5221. [PMID: 31533922 PMCID: PMC6749182 DOI: 10.1136/bmj.l5221] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To examine the design characteristics, risk of bias, and reporting adequacy of pivotal randomised controlled trials of cancer drugs approved by the European Medicines Agency (EMA). DESIGN Cross sectional analysis. SETTING European regulatory documents, clinical trial registry records, protocols, journal publications, and supplementary appendices. ELIGIBILITY CRITERIA Pivotal randomised controlled trials of new cancer drugs approved by the EMA between 2014 and 2016. MAIN OUTCOME MEASURES Study design characteristics (randomisation, comparators, and endpoints); risk of bias using the revised Cochrane tool (bias arising from the randomisation process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result); and reporting adequacy (completeness and consistency of information in trial protocols, publications, supplementary appendices, clinical trial registry records, and regulatory documents). RESULTS Between 2014 and 2016, the EMA approved 32 new cancer drugs on the basis of 54 pivotal studies. Of these, 41 (76%) were randomised controlled trials and 13 (24%) were either non-randomised studies or single arm studies. 39/41 randomised controlled trials had available publications and were included in our study. Only 10 randomised controlled trials (26%) measured overall survival as either a primary or coprimary endpoint, with the remaining trials evaluating surrogate measures such as progression free survival and response rates. Overall, 19 randomised controlled trials (49%) were judged to be at high risk of bias for their primary outcome. Concerns about missing outcome data (n=10) and measurement of the outcome (n=7) were the most common domains leading to high risk of bias judgments. Fewer randomised controlled trials that evaluated overall survival as the primary endpoint were at high risk of bias than those that evaluated surrogate efficacy endpoints (2/10 (20%) v 16/29 (55%), respectively). When information available in regulatory documents and the scientific literature was considered separately, overall risk of bias judgments differed for eight randomised controlled trials (21%), which reflects reporting inadequacies in both sources of information. Regulators identified additional deficits beyond the domains captured in risk of bias assessments for 10 drugs (31%). These deficits included magnitude of clinical benefit, inappropriate comparators, and non-preferred study endpoints, which were not disclosed as limitations in scientific publications. CONCLUSIONS Most pivotal studies forming the basis of EMA approval of new cancer drugs between 2014 and 2016 were randomised controlled trials. However, almost half of these were judged to be at high risk of bias based on their design, conduct, or analysis, some of which might be unavoidable because of the complexity of cancer trials. Regulatory documents and the scientific literature had gaps in their reporting. Journal publications did not acknowledge the key limitations of the available evidence identified in regulatory documents.
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Affiliation(s)
- Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London WC2A 2AE, UK
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Courtney Davis
- Department of Global Health and Social Medicine, King's College London, London, UK
| | - Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK
| | - Jonathan A C Sterne
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK
| | - Bishal Gyawali
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cancer Research Institute, Queen's University at Kingston, Kingston, Ontario, Canada
| | - Xochitl Romo-Sandoval
- Department of Health Policy, London School of Economics and Political Science, London WC2A 2AE, UK
| | - Nicola Handley
- Department of Global Health and Social Medicine, King's College London, London, UK
| | - Christopher M Booth
- Cancer Research Institute, Queen's University at Kingston, Kingston, Ontario, Canada
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17
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Radiology workflow for RECIST assessment in clinical trials: Can we reconcile time-efficiency and quality? Eur J Radiol 2019; 118:257-263. [DOI: 10.1016/j.ejrad.2019.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/10/2019] [Accepted: 07/23/2019] [Indexed: 01/01/2023]
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18
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Yang Y, Chang J, Huang C, Zhang Y, Wang J, Shu Y, Burillon JP, Riggi M, Petain A, Ferre P, Liang Y, Zhang L. A randomised, multicentre open-label phase II study to evaluate the efficacy, tolerability and pharmacokinetics of oral vinorelbine plus cisplatin versus intravenous vinorelbine plus cisplatin in Chinese patients with chemotherapy-naive unresectable or metastatic non-small cell lung cancer. J Thorac Dis 2019; 11:3347-3359. [PMID: 31559038 DOI: 10.21037/jtd.2019.08.22] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background A phase II study to evaluate the efficacy, tolerability and pharmacokinetics of oral or intravenous vinorelbine (VRL) plus cisplatin (CDDP) in Chinese patients with non-small cell lung cancer (NSCLC). Methods One hundred and thirty-one patients were randomised to oral VRL 60 mg/m2 (arm A) or intravenous VRL 25 mg/m2 (arm B) on days 1 and 8, plus CDDP 80 mg/m2 on day 1 (both arms). VRL was increased to 80 mg/m2 (arm A) or 30 mg/m2 (arm B) in cycles 2-4 in the absence of toxicity. Primary efficacy endpoint was objective response rate (ORR). VRL pharmacokinetics was evaluated for possible drug-drug interactions with CDDP. Results ORR was 25.8% in arm A and 23.1% in arm B. Disease control rate was 72.7% in arm A, 72.3% in arm B. Median overall survival was 16.1 months in arm A and 19.0 months in arm B. Median progression-free survival was 4.6 months in arm A and 4.9 months in arm B. Forty-three point nine percent and 86.2% of patients had grade 3/4 neutropenia in arms A and B, respectively; incidence of febrile neutropenia was low (6.1% and 9.2%, respectively). Frequency of grade 3/4 non-haematological adverse events was also low. VRL pharmacokinetics was not affected by co-administration of CDDP. Conclusions Oral and intravenous VRL in combination with CDDP is effective and well-tolerated in Chinese patients with advanced NSCLC. VRL pharmacokinetics is unaffected by CDDP co-administration. Oral VRL could be an effective alternative to intravenous VRL as a first-line treatment for NSCLC, as it optimises treatment convenience while maintaining high efficacy.
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Affiliation(s)
- Yunpeng Yang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Jianhua Chang
- Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Cheng Huang
- Fujian Provincial Tumor Hospital, Fuzhou 350014, China
| | - Yiping Zhang
- Zhejiang Cancer Hospital, Hangzhou 310022, China
| | - Jie Wang
- Beijing Cancer Hospital, Beijing 100035, China
| | - Yongqian Shu
- Jiangsu Provincial People's Hospital, Nanjing 210029, China
| | | | | | | | - Pierre Ferre
- Institut de Recherche Pierre Fabre, Toulouse, France
| | - Ying Liang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
| | - Li Zhang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
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Lavery JA, Panageas KS. Appropriate statistical methods are available to handle biases encountered in blinded, independent, central review (BICR) determined progression-free survival. JOURNAL OF HOSPITAL MANAGEMENT AND HEALTH POLICY 2019; 3:8. [PMID: 31304462 PMCID: PMC6625798 DOI: 10.21037/jhmhp.2019.04.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Jessica A Lavery
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katherine S Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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