1
|
Vogelbaum MA, Li G, Heimberger AB, Lang FF, Fueyo J, Gomez-Manzano C, Sanai N. A Window of Opportunity to Overcome Therapeutic Failure in Neuro-Oncology. Am Soc Clin Oncol Educ Book 2022; 42:1-8. [PMID: 35580289 DOI: 10.1200/edbk_349175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Glioblastoma is the most common primary malignant brain neoplasm and it remains one of the most difficult-to-treat human cancers despite decades of discovery and translational and clinical research. Many advances have been made in our understanding of the genetics and epigenetics of gliomas in general; yet, there remains an urgent need to develop novel agents that will improve the survival of patients with this deadly disease. What sets glioblastoma apart from all other cancers is that it develops and spreads within an organ that renders tumor cells inaccessible to most systemically administered agents because of the presence of the blood-brain barrier. Inadequate drug penetration into the central nervous system is often cited as the most common cause of trial failure in neuro-oncology, and even so-called brain-penetrant therapeutics may not reach biologically relevant concentrations in tumor cells. Evaluation of the pharmacokinetics and pharmacodynamics of a novel therapy is a cornerstone of drug development, but few trials for glioma therapeutics have incorporated these basic elements in an organ-specific manner. Window-of-opportunity clinical trial designs can provide early insight into the biological plausibility of a novel therapeutic strategy in the clinical setting. A variety of window-of-opportunity trial designs, which take into account the limited access to treated tissue and the challenges with obtaining pretreatment control tissues, have been used for the initial development of traditional and targeted small-molecule drugs and biologic therapies, including immunotherapies and oncolytic viral therapies. Early-stage development of glioma therapeutics should include a window-of-opportunity component whenever feasible.
Collapse
Affiliation(s)
- Michael A Vogelbaum
- Department of NeuroOncology and NeuroOncology Program, Moffitt Cancer Center, Tampa, FL
| | - Gongbo Li
- Department of Neurosurgery, Northwestern University School of Medicine, Chicago, IL
| | - Amy B Heimberger
- Department of Neurosurgery, Northwestern University School of Medicine, Chicago, IL
| | - Frederick F Lang
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Juan Fueyo
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Nader Sanai
- Department of Neurosurgery, Barrow Neurologic Institute, Phoenix, AZ
| |
Collapse
|
2
|
Vogelbaum MA, Krivosheya D, Borghei-Razavi H, Sanai N, Weller M, Wick W, Soffietti R, Reardon DA, Aghi MK, Galanis E, Wen PY, van den Bent M, Chang S. Phase 0 and window of opportunity clinical trial design in neuro-oncology: a RANO review. Neuro Oncol 2021; 22:1568-1579. [PMID: 32598442 DOI: 10.1093/neuonc/noaa149] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Glioblastoma is a devastating disease with poor prognosis. Few effective chemotherapeutics are currently available, and much effort has been expended to identify new drugs capable of slowing tumor progression. The phase 0 trial design was developed to facilitate early identification of promising agents for cancer that should undergo accelerated approval. This design features an early in-human study that enrolls a small number of patients who receive subtherapeutic doses of medication with the goals of describing pharmacokinetics through drug blood level measurements and determining intratumoral concentrations of the investigational compound as well as pharmacodynamics by studying the biochemical and physiological effects of drugs. In neuro-oncology, however, the presence of the blood-brain barrier and difficulty in obtaining brain tumor tissue warrant a separate set of considerations. In this paper, we critically reviewed the protocols used in all brain tumor related in-human phase 0 and phase 0-like ("window of opportunity") studies between 1993 and 2018, as well as ongoing clinical trials, and identified major challenges in trial design as applied to central nervous system tumors that include surgical specimen collection and storage, brain tumor drug level analysis, and confirmation of drug action. We therefore propose that phase 0 trials in neuro-oncology should include (i) only patients in whom a resection of the tumor is planned, (ii) use of clinical doses of an investigational agent, (iii) tissue sampling from enhancing and non-enhancing portions of the tumor, and (iv) assessment of drug-specific target effects. Standardization of clinical protocols for phase 0/window of opportunity studies can help accelerate the development of effective treatments for glioblastoma.
Collapse
Affiliation(s)
| | - Daria Krivosheya
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Nader Sanai
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Wolfgang Wick
- Department of Neurology Heidelberg University Hospital and German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany
| | - Riccardo Soffietti
- Department of Neuro-Oncology, University and City of Health and Science, Turin, Italy
| | - David A Reardon
- Center For Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Manish K Aghi
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | | | - Patrick Y Wen
- Center For Neuro-Oncology, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Martin van den Bent
- The Brain Tumor Center at Erasmus MC Cancer Institute, University Medical Center Rotterdam
| | - Susan Chang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
3
|
Sanai N. Phase 0 Clinical Trial Strategies for the Neurosurgical Oncologist. Neurosurgery 2020; 85:E967-E974. [PMID: 31245813 PMCID: PMC6855937 DOI: 10.1093/neuros/nyz218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 03/08/2019] [Indexed: 12/04/2022] Open
Abstract
In an era of escalating drug discovery costs, shifting priorities within the pharmaceutical industry, and longstanding challenges in central nervous system drug delivery, surgical trials offer an avenue to identify promising agents with demonstrable tumor penetration and molecular effects. The rise of pharmacodynamic- and pharmacokinetic-driven clinical trials, including phase 0 study designs, creates an opportunity for the neurosurgical oncologist to engage drug development for brain tumor patients directly. Here, we review the phase 0 clinical trial mechanism as well as its current and future applications within neurosurgical oncology.
Collapse
Affiliation(s)
- Nader Sanai
- Ivy Brain Tumor Center, Barrow Neurological Institute, Phoenix, Arizona
| |
Collapse
|
4
|
Window of opportunity clinical trial designs to study cancer metabolism. Br J Cancer 2019; 122:45-51. [PMID: 31819180 PMCID: PMC6964681 DOI: 10.1038/s41416-019-0621-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 10/16/2019] [Accepted: 10/18/2019] [Indexed: 02/06/2023] Open
Abstract
Window of opportunity trials exploit the ‘window’ of time after cancer diagnosis, typically prior to initiation of cancer therapy. In recent years this study design has become a more regular feature of drug development, as this ‘window’ provides an opportunity to carry out a thorough pharmacodynamic assessment of a therapy of interest in tumours that are unperturbed by prior treatment. Many of the first window trials interrogated the bioactivity of drugs being repurposed for cancer treatment, in particular the anti-mitochondrial agent, metformin. In this review, we describe examples of window study designs that have been used to assess drugs that target cancer metabolism with a focus on metformin. In addition, we discuss how window studies may aid the development of molecular metabolic cancer imaging.
Collapse
|
5
|
Holbeck SL, Camalier R, Crowell JA, Govindharajulu JP, Hollingshead M, Anderson LW, Polley E, Rubinstein L, Srivastava A, Wilsker D, Collins JM, Doroshow JH. The National Cancer Institute ALMANAC: A Comprehensive Screening Resource for the Detection of Anticancer Drug Pairs with Enhanced Therapeutic Activity. Cancer Res 2017; 77:3564-3576. [PMID: 28446463 PMCID: PMC5499996 DOI: 10.1158/0008-5472.can-17-0489] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/13/2017] [Accepted: 04/24/2017] [Indexed: 12/22/2022]
Abstract
To date, over 100 small-molecule oncology drugs have been approved by the FDA. Because of the inherent heterogeneity of tumors, these small molecules are often administered in combination to prevent emergence of resistant cell subpopulations. Therefore, new combination strategies to overcome drug resistance in patients with advanced cancer are needed. In this study, we performed a systematic evaluation of the therapeutic activity of over 5,000 pairs of FDA-approved cancer drugs against a panel of 60 well-characterized human tumor cell lines (NCI-60) to uncover combinations with greater than additive growth-inhibitory activity. Screening results were compiled into a database, termed the NCI-ALMANAC (A Large Matrix of Anti-Neoplastic Agent Combinations), publicly available at https://dtp.cancer.gov/ncialmanac Subsequent in vivo experiments in mouse xenograft models of human cancer confirmed combinations with greater than single-agent efficacy. Concomitant detection of mechanistic biomarkers for these combinations in vivo supported the initiation of two phase I clinical trials at the NCI to evaluate clofarabine with bortezomib and nilotinib with paclitaxel in patients with advanced cancer. Consequently, the hypothesis-generating NCI-ALMANAC web-based resource has demonstrated value in identifying promising combinations of approved drugs with potent anticancer activity for further mechanistic study and translation to clinical trials. Cancer Res; 77(13); 3564-76. ©2017 AACR.
Collapse
Affiliation(s)
- Susan L Holbeck
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, NIH, Bethesda, Maryland
| | - Richard Camalier
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, NIH, Bethesda, Maryland
| | - James A Crowell
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, NIH, Bethesda, Maryland
| | - Jeevan Prasaad Govindharajulu
- Clinical Pharmacodynamics Program, Applied/Developmental Research Directorate, Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Melinda Hollingshead
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, NIH, Bethesda, Maryland
| | - Lawrence W Anderson
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, NIH, Bethesda, Maryland
| | - Eric Polley
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, NIH, Bethesda, Maryland
| | - Larry Rubinstein
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, NIH, Bethesda, Maryland
| | - Apurva Srivastava
- Clinical Pharmacodynamics Program, Applied/Developmental Research Directorate, Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Deborah Wilsker
- Clinical Pharmacodynamics Program, Applied/Developmental Research Directorate, Leidos Biomedical Research Inc., Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - Jerry M Collins
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, NIH, Bethesda, Maryland
| | - James H Doroshow
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, NIH, Bethesda, Maryland.
- Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland
| |
Collapse
|
6
|
Citrin DE, Prasanna PGS, Walker AJ, Freeman ML, Eke I, Barcellos-Hoff MH, Arankalayil MJ, Cohen EP, Wilkins RC, Ahmed MM, Anscher MS, Movsas B, Buchsbaum JC, Mendonca MS, Wynn TA, Coleman CN. Radiation-Induced Fibrosis: Mechanisms and Opportunities to Mitigate. Report of an NCI Workshop, September 19, 2016. Radiat Res 2017; 188:1-20. [PMID: 28489488 PMCID: PMC5558616 DOI: 10.1667/rr14784.1] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
A workshop entitled "Radiation-Induced Fibrosis: Mechanisms and Opportunities to Mitigate" (held in Rockville, MD, September 19, 2016) was organized by the Radiation Research Program and Radiation Oncology Branch of the Center for Cancer Research (CCR) of the National Cancer Institute (NCI), to identify critical research areas and directions that will advance the understanding of radiation-induced fibrosis (RIF) and accelerate the development of strategies to mitigate or treat it. Experts in radiation biology, radiation oncology and related fields met to identify and prioritize the key areas for future research and clinical translation. The consensus was that several known and newly identified targets can prevent or mitigate RIF in pre-clinical models. Further, basic and translational research and focused clinical trials are needed to identify optimal agents and strategies for therapeutic use. It was felt that optimally designed preclinical models are needed to better study biomarkers that predict for development of RIF, as well as to understand when effective therapies need to be initiated in relationship to manifestation of injury. Integrating appropriate endpoints and defining efficacy in clinical trials testing treatment of RIF were felt to be critical to demonstrating efficacy. The objective of this meeting report is to (a) highlight the significance of RIF in a global context, (b) summarize recent advances in our understanding of mechanisms of RIF,
Collapse
Affiliation(s)
- Deborah E. Citrin
- Radiation Oncology Branch, Center for Cancer Research, Bethesda, Maryland
| | - Pataje G. S. Prasanna
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, Maryland
| | - Amanda J. Walker
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Michael L. Freeman
- Department of Radiation Oncology, Vanderbilt School of Medicine, Nashville, Tennessee
| | - Iris Eke
- Radiation Oncology Branch, Center for Cancer Research, Bethesda, Maryland
| | - Mary Helen Barcellos-Hoff
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | | | - Eric P. Cohen
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ruth C. Wilkins
- Radiobiology Division, Consumer and Clinical Radiation Protection Bureau, Health Canada, Ottawa, Ontario
| | - Mansoor M. Ahmed
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, Maryland
| | - Mitchell S. Anscher
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Benjamin Movsas
- Department of Radiation Oncology, Henry Ford Hospital, Detroit, Michigan
| | - Jeffrey C. Buchsbaum
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, Maryland
| | - Marc S. Mendonca
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Thomas A. Wynn
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - C. Norman Coleman
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, Maryland
| |
Collapse
|
7
|
Hierro C, Azaro A, Argilés G, Elez E, Gómez P, Carles J, Rodon J. Unveiling changes in the landscape of patient populations in cancer early drug development. Oncotarget 2017; 8:14158-14172. [PMID: 27835915 PMCID: PMC5355170 DOI: 10.18632/oncotarget.13258] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 10/26/2016] [Indexed: 01/25/2023] Open
Abstract
The introduction of new Molecularly Targeted Agents (MTA) has changed the landscape in Early Drug Development (EDD) over the last two decades, leading to an improvement in clinical trial design. Previous Phase 1 (Ph1) studies with cytotoxics focused on safety objectives, only recruiting heavily pre-treated cancer patients, have been left behind. In this review, we will illustrate the slow although unstoppable change that has increasingly been observed in those populations candidate to participate in EDD trials with the advent of MTA. As more evidence regarding oncogene addiction becomes available, molecular-biomarker driven selection has been implemented among Molecularly-Selected Population (MSP) studies. New Window-Of-Opportunity (WOO) and Phase 0 (Ph0) studies have been developed in order to assess whether a MTA produces the hypothetical proposed biological effect. The rising need of getting early pharmacokinetics and pharmacodynamics data has led to the conduction of Healthy Volunteer (HV) studies, in part favoured for the particular and different toxicity profile of these MTA. However, several challenges will need to be addressed in order to boost the implementation of these new clinical trial designs in the forthcoming years. Among the problems to overcome, we would highlight a better coordination effort between centers for ensuring adequate patient accrual among small patient populations and a deepening into the ethics implied in enrolling patients in studies with no therapeutic intent. However, these tribulations will be certainly compensated by the possibility of opening a new horizon of treatment for diseases with dismal prognosis.
Collapse
Affiliation(s)
- Cinta Hierro
- Department of Medical Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Analía Azaro
- Department of Medical Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Guillem Argilés
- Department of Medical Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Elena Elez
- Department of Medical Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Patricia Gómez
- Department of Medical Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Joan Carles
- Department of Medical Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - Jordi Rodon
- Department of Medical Oncology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Barcelona, Spain
| |
Collapse
|
8
|
Abstract
The phosphoinositide 3-kinase (PI3K) pathway plays an integral role in many cellular processes and is frequently altered in cancer, contributing to tumor growth and survival. Small molecule inhibitors have been developed that target the three major nodes of this pathway: PI3K, AKT, and mammalian target of rapamycin. However, because oncogenic PI3K pathway activation is achieved in diverse, potentially redundant ways, the clinical efficacy of these inhibitors as monotherapies has, so far, been limited, despite demonstrating promising preclinical activity. Moreover, pathway activation is associated with resistance to other therapies; thus, in combination, PI3K pathway inhibitors could restore therapeutic sensitivity to these agents. To maximize therapeutic benefit, drug combinations and schedules must be explored to identify those with the highest efficacy and lowest toxicity overlap. In addition, defining appropriate patient subpopulations, for both monotherapy and drug combinations, will be important. However, identifying predictive biomarkers remains a challenge.
Collapse
|
9
|
Parchment RE, Doroshow JH. Pharmacodynamic endpoints as clinical trial objectives to answer important questions in oncology drug development. Semin Oncol 2016; 43:514-25. [PMID: 27663483 PMCID: PMC5117459 DOI: 10.1053/j.seminoncol.2016.07.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Analyzing the molecular interplay between malignancies and therapeutic agents is rarely a straightforward process, but we hope that this special issue of Seminars has highlighted the clinical value of such endeavors as well as the relevant theoretical and practical considerations. Here, we conclude with both an overview of the various high-value applications of clinical pharmacodynamics (PD) in developmental therapeutics and an outline of the framework for incorporating PD analyses into the design of clinical trials. Given the increasingly recognized importance of determining and administering the biologically effective dose (BED) and schedule of targeted agents, we explain how clinical PD biomarkers specific to the agent mechanism of action (MOA) can be used for the development of pharmacodynamics-guided biologically effective dosage regimens (PD-BEDR) to maximize the efficacy and minimize the toxicity of targeted therapies. In addition, we discuss how MOA-based PD biomarker analyses can be used both as patient selection diagnostic tools and for designing novel drug combinations targeting the specific mutational signature of a given malignancy. We also describe the role of PD analyses in clinical trials, including for MOA confirmation and dosage regimen optimization during phase 0 trials as well as for correlating molecular changes with clinical efficacy when establishing proof-of-concept in phase I/II trials. Finally, we outline the critical technological developments that are needed to enhance the quality and quantity of future clinical PD data collection, broaden the types of molecular questions that can be answered in the clinic, and, ultimately, improve patient outcomes.
Collapse
Affiliation(s)
- Ralph E Parchment
- Clinical Pharmacodynamics Program, Applied/Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - James H Doroshow
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD.
| |
Collapse
|
10
|
Abstract
The clinical development of molecularly targeted cancer therapies is enhanced by proof of mechanism of action as well as proof of concept, which relate molecular pharmacodynamics to efficacy via changes in cancer cell biology and physiology resulting from drug action on its intended target. Here, we present an introduction to the field of clinical pharmacodynamics, its medical and laboratory aspects, and its practical incorporation into clinical trials. We also describe key success factors that are useful for judging the quality of clinical pharmacodynamic studies, including biopsy quality and suitability, specimen handling, assay fitness-for-purpose, and reagent quality control. This introduction provides not only context for the following articles in this issue, but also an appreciation of the role of well-conducted clinical pharmacodynamic studies in oncology drug development.
Collapse
Affiliation(s)
- Ralph E Parchment
- Clinical Pharmacodynamics Program, Applied/Developmental Research Directorate, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD.
| | - James H Doroshow
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| |
Collapse
|
11
|
Ferry-Galow KV, Makhlouf HR, Wilsker DF, Lawrence SM, Pfister TD, Marrero AM, Bigelow KM, Yutzy WH, Ji JJ, Butcher DO, Gouker BA, Kummar S, Chen AP, Kinders RJ, Parchment RE, Doroshow JH. The root causes of pharmacodynamic assay failure. Semin Oncol 2016; 43:484-91. [PMID: 27663480 DOI: 10.1053/j.seminoncol.2016.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Robust pharmacodynamic assay results are valuable for informing go/no-go decisions about continued development of new anti-cancer agents and for identifying combinations of targeted agents, but often pharmacodynamic results are too incomplete or variable to fulfill this role. Our experience suggests that variable reagent and specimen quality are two major contributors to this problem. Minimizing all potential sources of variability in procedures for specimen collection, processing, and assay measurements is essential for meaningful comparison of pharmacodynamic biomarkers across sample time points. This is especially true in the evaluation of pre- and post-dose tumor biopsies, which suffer from high levels of tumor insufficiency due to variations in biopsy collection techniques and significant specimen heterogeneity within and across patients. Developing methods to assess heterogeneous biopsies is necessary in order to evaluate a majority of tumor biopsies collected for pharmacodynamic biomarker studies. Improved collection devices and standardization of methods are being sought in order to improve the tumor content and quality of tumor biopsies. In terms of reagent variability, we have found that stringent initial reagent qualification and quality control of R&D-grade reagents is critical to minimize lot-to-lot variability and prevent assay failures, especially for clinical pharmacodynamic questions, which often demand assay performance that meets or exceeds clinical diagnostic assay standards. Rigorous reagent specifications and use of appropriate assay quality control methodologies help to ensure consistency between assay runs, laboratories and trials to provide much needed pharmacodynamic insights into the activity of investigational agents.
Collapse
Affiliation(s)
- Katherine V Ferry-Galow
- Applied/Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD.
| | - Hala R Makhlouf
- Cancer Diagnosis Program, Division of Cancer Treatment and Diagnosis, Rockville, MD
| | - Deborah F Wilsker
- Applied/Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Scott M Lawrence
- Applied/Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Thomas D Pfister
- Applied/Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD
| | | | - Kristina M Bigelow
- Johns Hopkins School of Medicine, Department of Pharmacology and Molecular Sciences, Baltimore, MD
| | - William H Yutzy
- Applied/Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Jiuping J Ji
- Applied/Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Donna O Butcher
- Pathology/Histotechnology Laboratory, Animal Sciences Program, Leidos Biomedical Research, Frederick National Laboratories, Frederick, MD
| | - Brad A Gouker
- Pathology/Histotechnology Laboratory, Animal Sciences Program, Leidos Biomedical Research, Frederick National Laboratories, Frederick, MD
| | - Shivaani Kummar
- Stanford University School of Medicine, Department of Oncology, Stanford, CA
| | - Alice P Chen
- NCI/DCTD-Early Clinical Trials Development Program, Bethesda, MD
| | - Robert J Kinders
- Applied/Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - Ralph E Parchment
- Applied/Developmental Research Directorate, Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, MD
| | - James H Doroshow
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD
| |
Collapse
|
12
|
Kinders R, Ferry-Galow K, Wang L, Srivastava AK, Ji JJ, Parchment RE. Implementation of validated pharmacodynamic assays in multiple laboratories: challenges, successes, and limitations. Clin Cancer Res 2015; 20:2578-86. [PMID: 24831280 DOI: 10.1158/1078-0432.ccr-14-0476] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is a "life cycle" of pharmacodynamic (PD) biomarker assays that guides the development and clinical implementation in our laboratories. The well-recognized elements of analytical assay validation and demonstration of fitness-for-purpose of the biomarker, specimen collection, handling, and assay methods are only a part of the required activities. Assay transfer across laboratories and testing on actual human clinical specimens are vital for understanding assay performance and robustness. In our experience, this patient specimen-centered approach has required assay method modifications, some unexpected, but which were critical to successful implementation in clinical trials. In addition, dispersing assays throughout the National Cancer Institute's clinical trials network has required the development of calibrator and control materials as well as formal training courses for smooth implementation. One measure of success of this approach has been that a number of the assays developed at NCI's Frederick National Laboratory have ultimately reached the stage of commercialization, enabling wide accessibility of the PD biomarker assays by the research community. See all articles in this ccr focus section, "Progress in pharmacodynamic endpoints."
Collapse
Affiliation(s)
- Robert Kinders
- Authors' Affiliations: Laboratory of Human Toxicology and Pharmacology; National Cancer Target Validation Laboratory, Applied/Developmental Research Directorate, Frederick National Laboratory for Cancer Research and Leidos Biomedical Research, Inc., Frederick, Maryland
| | - Kate Ferry-Galow
- Authors' Affiliations: Laboratory of Human Toxicology and Pharmacology; National Cancer Target Validation Laboratory, Applied/Developmental Research Directorate, Frederick National Laboratory for Cancer Research and Leidos Biomedical Research, Inc., Frederick, Maryland
| | - Lihua Wang
- Authors' Affiliations: Laboratory of Human Toxicology and Pharmacology; National Cancer Target Validation Laboratory, Applied/Developmental Research Directorate, Frederick National Laboratory for Cancer Research and Leidos Biomedical Research, Inc., Frederick, Maryland
| | - Apurva K Srivastava
- Authors' Affiliations: Laboratory of Human Toxicology and Pharmacology; National Cancer Target Validation Laboratory, Applied/Developmental Research Directorate, Frederick National Laboratory for Cancer Research and Leidos Biomedical Research, Inc., Frederick, Maryland
| | - Jiuping Jay Ji
- Authors' Affiliations: Laboratory of Human Toxicology and Pharmacology; National Cancer Target Validation Laboratory, Applied/Developmental Research Directorate, Frederick National Laboratory for Cancer Research and Leidos Biomedical Research, Inc., Frederick, Maryland
| | - Ralph E Parchment
- Authors' Affiliations: Laboratory of Human Toxicology and Pharmacology; National Cancer Target Validation Laboratory, Applied/Developmental Research Directorate, Frederick National Laboratory for Cancer Research and Leidos Biomedical Research, Inc., Frederick, Maryland
| |
Collapse
|
13
|
Doroshow JH, Kummar S. Translational research in oncology--10 years of progress and future prospects. Nat Rev Clin Oncol 2014; 11:649-62. [PMID: 25286976 DOI: 10.1038/nrclinonc.2014.158] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
International efforts to sequence the genomes of various human cancers have been broadly deployed in drug discovery programmes. Diagnostic tests that predict the value of the molecularly targeted anticancer agents used in such programmes are conceived and validated in parallel with new small-molecule treatments and immunotherapies. This approach has been aided by better preclinical cancer models; an enhanced appreciation of the complex interactions that exist between tumour cells and their microenvironment; the elucidation of interactions between many of the genetic drivers of cancer, including oncogenes and tumour suppressors; and recent insights into the genetic heterogeneity of human tumours made possible by extraordinary improvements in DNA-sequencing techniques. These advances are being employed in the first generation of genomic clinical trials that will examine the feasibility of matching a broad range of systemic therapies to specific molecular tumour characteristics. More-extensive molecular characterization of tumours and their supporting matrices are anticipated to become standard aspects of oncological practice, permitting continuous molecular re-evaluations of human malignancies on a patient-by-patient and treatment-by-treatment basis. We review selected developments in translational cancer biology, diagnostics, and therapeutics that have occurred over the past decade and offer our thoughts on future prospects for the next few years.
Collapse
Affiliation(s)
- James H Doroshow
- 1] Division of Cancer Treatment and Diagnosis, Room 3A-44, Building 31, 31 Center Drive, National Cancer Institute, NIH, Bethesda, MD 20892, USA. [2] Developmental Therapeutics Branch of the Center for Cancer Research, Room 3A-44, Building 31, 31 Center Drive, National Cancer Institute, NIH, Bethesda, MD 20892, USA
| | - Shivaani Kummar
- Division of Cancer Treatment and Diagnosis, Room 3A-44, Building 31, 31 Center Drive, National Cancer Institute, NIH, Bethesda, MD 20892, USA
| |
Collapse
|
14
|
Park SR, Kinders RJ, Khin S, Hollingshead M, Antony S, Parchment RE, Tomaszewski JE, Kummar S, Doroshow JH. Validation of a hypoxia-inducible factor-1 alpha specimen collection procedure and quantitative enzyme-linked immunosorbent assay in solid tumor tissues. Anal Biochem 2014; 459:1-11. [PMID: 24799347 PMCID: PMC4810780 DOI: 10.1016/j.ab.2014.04.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 04/15/2014] [Accepted: 04/18/2014] [Indexed: 01/23/2023]
Abstract
Hypoxia-inducible factor-1 alpha (HIF-1α) is an important marker of hypoxia in human tumors and has been implicated in tumor progression. Drugs targeting HIF-1α are being developed, but the ability to measure drug-induced changes in HIF-1α is limited by the lability of the protein in normoxia. Our goal was to devise methods for specimen collection and processing that preserve HIF-1α in solid tumor tissues and to develop and validate a two-site chemiluminescent quantitative enzyme-linked immunosorbent assay (ELISA) for HIF-1α. We tested various strategies for HIF-1α stabilization in solid tumors, including nitrogen gas-purged lysis buffer, the addition of proteasome inhibitors or the prolyl hydroxylase inhibitor 2-hydroxyglutarate, and bead homogenization. Degassing and the addition of 2-hydroxyglutarate to the collection buffer significantly increased HIF-1α recovery, whereas bead homogenization in sealed tubes improved HIF-1α recovery and reduced sample variability. Validation of the ELISA demonstrated intra- and inter-assay variability of less than 15% and accuracy of 99.8±8.3% as assessed by spike recovery. Inter-laboratory reproducibility was also demonstrated (R(2)=0.999). Careful sample handling techniques allow us to quantitatively detect HIF-1α in samples as small as 2.5μg of total protein extract, and this method is currently being applied to analyze tumor biopsy specimens in early-phase clinical trials.
Collapse
Affiliation(s)
- Sook Ryun Park
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD 20892, USA
| | - Robert J Kinders
- Laboratory of Human Toxicology and Pharmacology, Applied/Developmental Research Directorate, Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA.
| | - Sonny Khin
- Laboratory of Human Toxicology and Pharmacology, Applied/Developmental Research Directorate, Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Melinda Hollingshead
- Biological Testing Branch, Developmental Therapeutics Program, Frederick National Laboratory for Cancer Research, Frederick, MD 20892, USA
| | - Smitha Antony
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD 20892, USA
| | - Ralph E Parchment
- Laboratory of Human Toxicology and Pharmacology, Applied/Developmental Research Directorate, Leidos Biomedical Research, Frederick National Laboratory for Cancer Research, Frederick, MD 21702, USA
| | - Joseph E Tomaszewski
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD 20892, USA
| | - Shivaani Kummar
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD 20892, USA
| | - James H Doroshow
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD 20892, USA; Center for Cancer Research, National Cancer Institute, Bethesda, MD 20892, USA
| |
Collapse
|
15
|
Wlodkowic D, Cooper JM. Microfluidic cell arrays in tumor analysis: new prospects for integrated cytomics. Expert Rev Mol Diagn 2014; 10:521-30. [DOI: 10.1586/erm.10.28] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
16
|
Doroshow JH. Timely completion of scientifically rigorous cancer clinical trials: an unfulfilled priority. J Clin Oncol 2013; 31:3312-4. [PMID: 23960175 DOI: 10.1200/jco.2013.51.3192] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- James H Doroshow
- National Cancer Institute, National Institutes of Health, Bethesda, MD
| |
Collapse
|
17
|
Arron JR, Scheerens H, Matthews JG. Redefining approaches to asthma: developing targeted biologic therapies. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2013; 66:1-49. [PMID: 23433454 DOI: 10.1016/b978-0-12-404717-4.00001-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Asthma is a chronic respiratory disorder canonically associated with type 2 airway inflammation as characterized by elevated levels of eosinophils, immunoglobulin E, and cytokines including interleukin (IL) 4, IL5, IL9, and IL13 and tumor necrosis factor (TNF) α. However, mounting evidence has shown that considerable heterogeneity exists in human asthma in terms of the nature and intensity of airway inflammation. While many asthma patients achieve acceptable control of symptoms with standard-of-care therapies such as β₂-adrenergic agonists and inhaled corticosteroids, a minority remains symptomatic despite maximal standard-of-care therapy and constitutes a significant unmet medical need. A growing number of investigational therapeutics under clinical development for asthma are biologic therapies that specifically target mediators of type 2 airway inflammation. In this chapter, we consider the biological functions of therapeutic targets in asthma and data from clinical trials of biologic agents directed against these targets. We discuss recent clinical trial results in terms of four key components of drug development: target selection, molecule selection, outcome selection, and patient selection, with particular attention paid to the emerging role of biomarkers in clinical development for asthma.
Collapse
|
18
|
Saucedo-Zeni N, Mewes S, Niestroj R, Gasiorowski L, Murawa D, Nowaczyk P, Tomasi T, Weber E, Dworacki G, Morgenthaler NG, Jansen H, Propping C, Sterzynska K, Dyszkiewicz W, Zabel M, Kiechle M, Reuning U, Schmitt M, Lücke K. A novel method for the in vivo isolation of circulating tumor cells from peripheral blood of cancer patients using a functionalized and structured medical wire. Int J Oncol 2012; 41:1241-50. [PMID: 22825490 PMCID: PMC3583719 DOI: 10.3892/ijo.2012.1557] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 04/03/2012] [Indexed: 12/25/2022] Open
Abstract
The isolation of circulating tumor cells (CTCs) from the blood of patients afflicted with solid malignant tumors becomes increasingly important as it may serve as a 'liquid biopsy' with the potential of monitoring the course of the cancer disease and its response to cancer therapy, with subsequent molecular characterization. For this purpose, we functionalized a structured medical Seldinger guidewire (FSMW), normally used to obtain safe access to blood vessels and other organ cavities, with a chimeric monoclonal antibody directed to the cell surface expressed epithelial cell surface adhesion molecule (EpCAM). This medical device was optimized in vitro and its biocompatibility was tested according to the regulations for medical devices and found to be safe with no noteworthy side effects. Suitability, specificity and sensitivity of the FSMW to catch and enrich CTCs in vivo from circulating peripheral blood were tested in 24 breast cancer or non-small cell lung cancer (NSCLC) patients and in 29 healthy volunteers. For this, the FSMW was inserted through a standard venous cannula into the cubital veins of healthy volunteers or cancer patients for the duration of 30 min. After removal, CTCs were identified by immuno-cytochemical staining of EpCAM and/or cytokeratins and staining of their nuclei and counted. The FSMW successfully enriched EpCAM-positive CTCs from 22 of the 24 patients, with a median of 5.5 (0-50) CTCs in breast cancer (n=12) and 16 (2-515) CTCs in NSCLC (n=12). CTCs could be isolated across all tumor stages, including early stage cancer, in which distant metastases were not yet diagnosed, while no CTCs could be detected in healthy volunteers. In this observatory study, no adverse effects were noted. Evidently, the FSMW has the potential to become an important device to enrich CTCs in vivo for monitoring the course of the cancer disease and the efficacy of anticancer treatment.
Collapse
|
19
|
Effects of lapatinib monotherapy: results of a randomised phase II study in therapy-naive patients with locally advanced squamous cell carcinoma of the head and neck. Br J Cancer 2011; 105:618-27. [PMID: 21829197 PMCID: PMC3188940 DOI: 10.1038/bjc.2011.237] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Lapatinib is a dual inhibitor of epidermal growth factor receptor (EGFR) and human EGFR-2 (HER-2) tyrosine kinases. This study investigated the pharmacodynamic and clinical effects of lapatinib in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN). METHODS In total, 107 therapy-naive patients with locally advanced SCCHN were randomised (2 : 1) to receive lapatinib or placebo for 2-6 weeks before chemoradiation therapy (CRT). Endpoints included apoptosis and proliferation rates, clinical response, and toxicity. RESULTS Versus placebo, lapatinib monotherapy did not significantly increase apoptosis detected by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end labelling or caspase-3 assays. A statistically significant decrease in proliferation using Ki67 assay was observed (P=0.030). In a subset of 40 patients that received 4 weeks of lapatinib or placebo, objective response rate (ORR) was 17% (n=4/24) vs 0% (n=0/16). In the lapatinib single-agent responders, all had EGFR overexpression, 50% had EGFR amplification, and 50% had HER2 expression by immunohistochemistry (including one patient with HER2 amplification). However, these patients showed variable modulation of apoptosis, proliferation, and phosphorylated EGFR on drug treatment. Following CRT, there was a statistically non-significant difference in ORR between lapatinib (70%) and placebo (53%). There was no clear correlation between changes in apoptosis or proliferation and response to chemoradiation. Mucosal inflammation, asthenia, odynophagia, and dysphagia were the most commonly reported adverse events with lapatinib. CONCLUSION Short-term lapatinib monotherapy did not demonstrate apoptotic changes, but provided evidence of clinical activity in locally advanced SCCHN, and warrants further investigation in this disease.
Collapse
|
20
|
Abstract
Currently in oncology a novel agent entering development has only 5% chance of making it to commercial use. One of the ways to mitigate this problem would be to conduct exploratory or 'phase 0' clinical trials, conducted before phase 1 dose-escalation safety and tolerance studies. These phase 0 studies are a first administration of the novel agent to humans, at limited doses, on a small number of patients and over a short period. The objectives are to validate preclinical development and to acquire pharmacokinetic and pharmacodynamic data in order to better justify the scientific rational. In this article, we focus on phase 0 trials and their usefulness for the development of new drugs in oncology. We performed a literature review of questions related to phase 0 trials in articles published during 2006 to 2009. Thirty articles on phase 0 clinical trials have been published. The affected fields are oncology and pharmacology. Phase 0 clinical trials are discussed in the literature in terms of theoretical issues and from academic, pharmaceutical industry and patient point of views. If phase 0 clinical trials are a future prospect for drug development against cancer, the clinical applications of these trials need to be specified.
Collapse
|
21
|
New considerations in the design of clinical trials for the treatment of acute leukemia. ACTA ACUST UNITED AC 2011; 1:509-517. [PMID: 23459118 DOI: 10.4155/cli.11.24] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
There is great need for improved therapy for patients with acute leukemia. The current systems of clinical drug development and delivery of leukemia care are imperfectly adapted to the optimal identification and testing of future regimens. Novel clinical trial design with increased enrolment and appropriate end point selection would facilitate more efficient validation of candidate therapies. Clinical outcomes registries and biological sample storage would allow patient and leukemic factor substratification for the development of the next generation of targeted personalized therapy. We believe that the standard of care for patients in the USA diagnosed with acute leukemia, if treated with curative intent, is referral to a specialized center where an appropriate clinical trial can be offered.
Collapse
|
22
|
Abstract
Microdosing provides a tool to enhance drug development by initiating human studies prior to Phase I studies. The purpose is to assist in the go versus no-go decision-making process and to eliminate early ineffective compounds from the drug pipeline. Selection of multiple potential leads can be performed at the clinical stage instead of in preclinical studies. The microdosing approach can be easily used for a molecularly targeted potential drug compound with a known mechanism of action. It provides useful data regarding accessibility and biodistribution that can be used in many estimations benefiting the development of the molecule. In addition, steady state and genetic investigations are becoming possible. Microdosing has a sparing effect on timelines and costs, however, the real importance is not yet known because, although it is known to be widely performed, only a few original reports have been published.
Collapse
|
23
|
Gupta UC, Bhatia S, Garg A, Sharma A, Choudhary V. Phase 0 clinical trials in oncology new drug development. Perspect Clin Res 2011; 2:13-22. [PMID: 21584177 PMCID: PMC3088951 DOI: 10.4103/2229-3485.76285] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Research focus of pharmaceutical industry has expanded to a larger extent in last few decades putting many more new molecules, particularly targeted agents, for the clinical development. On the other hand, researchers are facing serious challenges due to high failure rates of new molecules in clinical studies. The United States Food and Drug Administration (FDA) in combination with academia and industry experts identified many factors responsible for failures of new molecules, and with a vision of taking traditional drug development model toward an innovative paradigm shift, issued regulatory guidance on conduct of exploratory investigational new drug (exploratory IND) studies, often called as phase 0 clinical trials, requiring reduced preclinical testing, which has special relevance to life-threatening diseases such as cancer. Phase 0 trials, utilizing much lower drug doses, provide an opportunity to explore the clinical behavior of new molecules very early in the drug development pathway, helping to identify the promising candidates and eliminating non-promising molecules, thus improving the efficiency of overall drug development with significant savings of resources. Being non-therapeutic in nature, these studies, however, pose certain ethical challenges requiring careful study designing and informed consent process. This article reviews the insights and perspectives for the feasibility, utility, planning, designing and conduct of phase 0 clinical trials, in addition to ethical issues and industrial perspective focused at oncology new drug development.
Collapse
Affiliation(s)
- Umesh Chandra Gupta
- Clinical Research and Medical Services, Fresenius Kabi Oncology Ltd., Gurgaon, Delhi
| | | | - Amit Garg
- Medical Services, Merck Serono, Mumbai, Maharashtra
| | - Amit Sharma
- Clinical Research and Medical Services, Fresenius Kabi Oncology Ltd., Gurgaon, Delhi
| | - Vaibhav Choudhary
- Clinical Research and Medical Services, Fresenius Kabi Oncology Ltd., Gurgaon, Delhi
| |
Collapse
|
24
|
Utilizing targeted cancer therapeutic agents in combination: novel approaches and urgent requirements. Nat Rev Drug Discov 2010; 9:843-56. [PMID: 21031001 DOI: 10.1038/nrd3216] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The rapid development of new therapeutic agents that target specific molecular pathways involved in tumour cell proliferation provides an unprecedented opportunity to achieve a much higher degree of biochemical specificity than previously possible with traditional chemotherapeutic anticancer agents. However, the lack of specificity of these established chemotherapeutic drugs allowed a relatively straightforward approach to their use in combination therapies. Developing a paradigm for combining new, molecularly targeted agents, on the other hand, is substantially more complex. The abundance of molecular data makes it possible, at least in theory, to predict how such agents might interact across crucial growth control networks. Initial strategies to examine molecularly targeted agent combinations have produced a small number of successes in the clinic. However, for most of these combination strategies, both in preclinical models and in patients, it is not clear whether the agents being combined actually hit their targets to induce growth inhibition. Here, we consider the initial approach of the US National Cancer Institute (NCI) to the evaluation of combinations of molecularly targeted anticancer agents in patients and provide a description of several new approaches that the NCI has initiated to improve the effectiveness of combination-targeted therapy for cancer.
Collapse
|
25
|
Circulating tumor cells, enumeration and beyond. Cancers (Basel) 2010; 2:1236-50. [PMID: 24281115 PMCID: PMC3835128 DOI: 10.3390/cancers2021236] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 05/21/2010] [Accepted: 05/26/2010] [Indexed: 12/20/2022] Open
Abstract
The detection and enumeration of circulating tumor cells (CTCs) has shown significant clinical utility with respect to prognosis in breast, colorectal and prostate cancers. Emerging studies show that CTCs can provide pharmacodynamic information to aid therapy decision making. CTCs as a ‘virtual and real-time biopsy’ have clear potential to facilitate exploration of tumor biology, and in particular, the process of metastasis. The challenge of profiling CTC molecular characteristics and generating CTC signatures using current technologies is that they enrich rather than purify CTCs from whole blood; we face the problem of looking for the proverbial ‘needle in the haystack’. This review summarizes the current methods for CTC detection and enumeration, focuses on molecular characterization of CTCs, unveils some aspects of CTC heterogeneity, describes attempts to purify CTCs and scans the horizon for approaches leading to comprehensive dissection of CTC biology.
Collapse
|
26
|
Wlodkowic D, Cooper JM. Microfabricated analytical systems for integrated cancer cytomics. Anal Bioanal Chem 2010; 398:193-209. [DOI: 10.1007/s00216-010-3722-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Revised: 03/29/2010] [Accepted: 04/03/2010] [Indexed: 01/09/2023]
|
27
|
LoRusso PM, Boerner SA, Seymour L. An overview of the optimal planning, design, and conduct of phase I studies of new therapeutics. Clin Cancer Res 2010; 16:1710-8. [PMID: 20215546 DOI: 10.1158/1078-0432.ccr-09-1993] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Phase I clinical trials represent the first step in bringing promising new treatments from the laboratory to the clinic. Although the importance of phase I clinical trials is widely recognized, there is currently no consensus among the scientific, medical, and statistical communities on how best to do these studies in humans. With the advent of targeted therapies, it has become evident that we need to tailor the design of phase I studies for the particular drug class under investigation and any endpoints that are being defined. The National Cancer Institute (NCI) Investigational Drug Steering Committee (IDSC) provides broad external scientific and clinical input on the design and prioritization of early-phase clinical trials with agents for which the NCI Cancer Therapy Evaluation Program (CTEP) holds an Investigational New Drug (IND) application through the U.S. Food and Drug Administration (FDA). The IDSC has formed a number of task forces and working groups, including the Clinical Trial Design Task Force and the Biomarker Working Group, many with membership from within the IDSC as well as external experts, including participants from academia, the pharmaceutical industry, and regulatory authorities. The Clinical Trials Design Taskforce sponsored a Phase I Workshop with the primary goal being to develop consensus recommendations for the optimal design of phase I studies. The primary focus included (1) efficient trial designs, (2) phase I drug combinations, and (3) appropriate statistical and correlative endpoints. In this CCR Focus series, articles summarize key aspects and recommendations on phase I studies (including combination trials), such as design, use of biomarkers, the European Union and Japanese perspectives on design, requirements for first-in-human and other phase I studies, and ensuring regulatory and International Conference on Harmonization (ICH) compliance. A final article summarizes recommendations for the design and conduct of phase II studies.
Collapse
Affiliation(s)
- Patricia M LoRusso
- Karmanos Cancer Institute, Wayne State University, Detroit, Michigan 48201, USA.
| | | | | |
Collapse
|
28
|
Rodon J, Perez J, Kurzrock R. Combining targeted therapies: practical issues to consider at the bench and bedside. Oncologist 2010; 15:37-50. [PMID: 20080862 DOI: 10.1634/theoncologist.2009-0117] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Numerous practical issues must be considered when combining targeted therapies in early clinical drug development. These include tumor resistance mechanisms, the existence of multiple, redundant signaling pathways, and the failure of single-agent therapies to achieve cures. The strategies adopted to examine combinatorial therapy include the goal of hitting more than one target by specifically inhibiting signal transduction cascades and suppressing specific mechanisms of action with the use of multitargeted kinase inhibitors made possible by high-throughput screening techniques, combinatorial chemistry, and chemoinformatics. Two complex considerations are: which agents to combine given the heterogeneity of tumors and their various underlying perturbations, including secondary mutations and feedback loops, and how to translate findings from the bench to the bedside or directly from the bedside. Another consideration is: When is there enough information to provide a rationale for instituting a phase I trial? Various strategies have been used in combining molecules, including targeting diverse pathways, inhibiting upstream and downstream signals, and adopting a synthetic lethality paradigm. Other issues are: determining appropriate target populations for treatment, how to combine therapeutics with diagnostics, and the frequency of targets in patients referred to clinical trials. Here, we review these issues and we propose various novel trial designs that are logical for determining the efficacy of a drug or drug combination for personalized treatment. A difficult issue that must be answered is how many and which drugs to combine. Recent technologies, such as multiplexed assay platforms and bioinformatics, will shape the future of clinical trials and help answer these questions surrounding combinatorial treatment.
Collapse
Affiliation(s)
- Jordi Rodon
- Servei d'Oncologia Medica, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Oncology (V.H.I.O), Passatge Vall d'Hebron 119, 08035 Barcelona, Spain.
| | | | | |
Collapse
|
29
|
Smith BD, Karp JE. What are the endpoints of therapy for acute leukemias? Old definitions and new challenges. ACTA ACUST UNITED AC 2010; 9 Suppl 3:S296-301. [PMID: 19778856 DOI: 10.3816/clm.2009.s.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Acute leukemias are complex diseases on multiple levels, and laboratory efforts over the past 3 decades have focused on better understanding of the molecular underpinnings and their stem cell biology. We now have a panoply of technologic advances that allow us to characterize individual leukemias by molecular profiles that relate directly to clinical behavior, to detect minimal residual disease, and to begin to develop "targeted" therapeutic strategies based on molecular considerations. There are a number of challenges surrounding this task: first, how to combine these agents with traditional chemotherapeutics and/or with each other to maximize leukemic cell kill and increase the cure rate; second, how to use these targeted agents in the minimal residual disease with potential curative intent; third, for patients unable to tolerate or unlikely to benefit from aggressive approaches, how to use one or more of these agents to reduce tumor bulk and either permit some restoration of normal marrow function or induce morphologic and functional differentiation of the leukemic clone to overcome the leukemia-associated bone marrow failure; and lastly, how to measure the effects of these agents on the molecular and cellular biologic levels in ways that correlate with and might even predict overall clinical outcome. These challenges are further complicated by the inherent heterogeneity in host biology; disease etiology and biology; and interactions among host, disease, and treatment that ultimately determine individual clinical outcomes. Toward this end, we will discuss selected issues surrounding new clinical trial designs and the development of clinically relevant molecular endpoints that might facilitate the development of new treatment approaches that will improve the outlook for adults with acute leukemias.
Collapse
Affiliation(s)
- B Douglas Smith
- Division of Hematologic Malignancies, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD 21231-1000, USA
| | | |
Collapse
|
30
|
Abstract
Phase 0 trials can provide proof of concept that an agent modulates its intended target without exposing patients to the drug-tolerability testing that precedes efficacy evaluation. Drugs that do not modulate their targets can be discarded, focusing development resources on the most clinically promising agents. However, wider uptake of Phase 0 trials may be hindered by ethical concerns over their lack of therapeutic intent, the substantial resources required to develop and validate target assays or skepticism that such trials save development time.
Collapse
|
31
|
|
32
|
Kinsella TJ. Understanding DNA damage response and DNA repair pathways: applications to more targeted cancer therapeutics. Semin Oncol 2009; 36:S42-51. [PMID: 19393835 DOI: 10.1053/j.seminoncol.2009.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Radiation therapy and many of the commonly used cancer chemotherapeutic drugs target DNA for cytotoxicity. Indeed, the subsequent DNA damage response (DDR) to these cancer treatments in both malignant and normal cells/tissues determines the therapeutic index (TI) of the treatment. The DDR is a complex set of cell processes involving multiple DNA repair, cell cycle regulation, and cell death/survival pathways (or networks) with both damage specificity and coordination of the DDR to different types of DNA damage. Over the last decade, significant progress has been made in elucidating these complex cellular and molecular networks involved in the DDR in human tumor and normal tissues. Based on what has been learned about these processes using experimental in vitro and in vivo models, DDR and DNA pathways are now potential targets for cancer therapy. This article presents an overview of our current understanding of the DDR, including the key DNA repair pathways involved in determining the cytotoxicity to several classes of chemotherapy drugs (CT) as well as ionizing radiation (IR). Since many different types of human cancers can arise from genetic or epigenetic changes in the DDR and DNA repair pathways, this article also covers recent developments in cancer therapeutics that attempt to target these specific tumor-related DDR/DNA repair defects as monotherapy or, more commonly, when combined with conventional cancer treatments.
Collapse
Affiliation(s)
- Timothy J Kinsella
- Stony Brook University Cancer Center, Stony Brook University School of Medicine, Stony Brook, NY, USA.
| |
Collapse
|
33
|
Wittig A, Collette L, Appelman K, Bührmann S, Jäckel MC, Jöckel KH, Schmid KW, Ortmann U, Moss R, Sauerwein WAG. EORTC trial 11001: distribution of two 10B-compounds in patients with squamous cell carcinoma of head and neck, a translational research/phase 1 trial. J Cell Mol Med 2009; 13:1653-1665. [PMID: 19602035 DOI: 10.1111/j.1582-4934.2009.00856.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Boron neutron capture therapy (BNCT) provides highly targeted delivery of radiation through the limited spatial distribution of its effects. This translational research/phase I clinical trial investigates whether BNCT might be developed as a treatment option for squamous cell carcinoma of head and neck (SCCHN) relying upon preferential uptake of the two compounds, sodium mercaptoundecahydro-closo-dodecaborate (BSH) or L-para-boronophenylalanine (BPA) in the tumour. Before planned tumour resection, three patients received BSH and three patients received BPA. The (10)B-concentration in tissues and blood was measured with prompt gamma ray spectroscopy. Adverse effects from compounds did not occur. After BPA infusion the (10)B-concentration ratio of tumour/blood was 4.0 +/- 1.7. (10)B-concentration ratios of tumour/normal tissue were 1.3 +/- 0.5 for skin, 2.1 +/- 1.2 for muscle and 1.4 +/- 0.01 for mucosa. After BSH infusion the (10)B-concentration ratio of tumour/blood was 1.2 +/- 0.4. (10)B-concentration ratios of tumour/normal tissue were 3.6 +/- 0.6 for muscle, 2.5 +/- 1.0 for lymph nodes, 1.4 +/- 0.5 for skin and 1.0 +/- 0.3 for mucosa. BPA and BSH deliver (10)B to SCCHN to an extent that might allow effective BNCT treatment. Mucosa and skin are the most relevant organs at risk.
Collapse
Affiliation(s)
- Andrea Wittig
- Department of Radiation Oncology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Laurence Collette
- Statistics Department, European Organisation for Research and Treatment of Cancer (EORTC), Brussels, Belgium
| | - Klaas Appelman
- Nuclear Research and consultancy Group (NRG), Petten, The Netherlands
| | - Sandra Bührmann
- Pharmacy of the University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Martin C Jäckel
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Karl-Heinz Jöckel
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Kurt Werner Schmid
- Institute of Pathology and Neuropathology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Uta Ortmann
- Department of Radiation Oncology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Raymond Moss
- HFR Unit, Institute for Energy, Joint Research Centre, European Commission, Petten, The Netherlands
| | - Wolfgang A G Sauerwein
- Department of Radiation Oncology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| |
Collapse
|
34
|
Abstract
Throughout history, humankind has won the battle against deadly diseases, including small pox and polio, by defeating them through prevention. Cancer prevention is a global priority, but studying history suggests that the journey towards achieving this goal is difficult and full of detours and roadblocks. Epidemiology and clinical evidence clearly indicate that specific genetic, environmental and behavioural factors are associated with an increased risk for cancer development. What can we learn from the past that is applicable to the reality of successful cancer prevention?
Collapse
Affiliation(s)
- Ann M Bode
- The Hormel Institute, University of Minnesota, 801 16th Ave NE, Austin, Minnesota 55912, USA
| | | |
Collapse
|
35
|
Francillon A, Pickering G, Belorgey C, Abiteboul M, Bégaud B, Behier JM, Belorgey C, Chauvin B, Cournot A, Defrance R, Demarez JP, Devilliers É, Diebolt V, Diquet B, Donazzolo Y, Echemann M, Francillon A, Funck-Brentano C, Genissel P, Houedé N, Husson JM, Lefevre P, Macquin-Mavier I, Marchenay B, Marey C, Negres-Pages L, Pickering G, Pitel S, Plattner V, Roy C, Sibille M, Simon N, Thalamas C, Tremblay D, Waegemans T. Exploratory Clinical Trials: Implementation Modes & Guidelines, Scope and Regulatory Framework. Therapie 2009; 64:149-59. [DOI: 10.2515/therapie/2009022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2008] [Indexed: 11/20/2022]
|
36
|
Francillon A, Pickering G, Belorgey C, Abiteboul M, Bégaud B, Behier JM, Belorgey C, Chauvin B, Cournot A, Defrance R, Demarez JP, Devilliers É, Diebolt V, Diquet B, Donazzolo Y, Echemann M, Francillon A, Funck-Brentano C, Genissel P, Houedé N, Husson JM, Lefevre P, Macquin-Mavier I, Marchenay B, Marey C, Negres-Pages L, Pickering G, Pitel S, Plattner V, Roy C, Sibille M, Simon N, Thalamas C, Tremblay D, Waegemans T. Essais cliniques exploratoires : quelles modalités de mise en œuvre, recommandations de mise en œuvre, champ d’application, cadre réglementaire ? Therapie 2009. [DOI: 10.2515/therapie/2009018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
37
|
Kummar S, Doroshow JH, Tomaszewski JE, Calvert AH, Lobbezoo M, Giaccone G. Phase 0 clinical trials: recommendations from the Task Force on Methodology for the Development of Innovative Cancer Therapies. Eur J Cancer 2009; 45:741-6. [PMID: 19091546 PMCID: PMC2902269 DOI: 10.1016/j.ejca.2008.10.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 10/24/2008] [Accepted: 10/29/2008] [Indexed: 01/07/2023]
Abstract
The Methodology for the Development of Innovative Cancer Therapies (MDICT) task force has been established as an expert forum to develop practical guidance on the development of innovative anticancer agents, in particular targeted agents. The task force recently addressed the utility, design and application of Phase 0 clinical trials in anticancer drug development. It was concluded that the role of non-therapeutic Phase 0 trials is controversial for several reasons, including the lack of clinical benefit for participating patients. However, it was recognised that Phase 0 trials provide an opportunity to generate essential human pharmacokinetic and pharmacodynamic data earlier in the drug development process, which could be a major advantage in the design and decision making concerning further clinical development of an agent. Construction of a 'decision chart' was highly recommended to assist investigators and sponsors in determining whether an agent is suitable for evaluation in a Phase 0 trial.
Collapse
Affiliation(s)
- Shivaani Kummar
- Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, 20892
| | - James H. Doroshow
- Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, 20892
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, Maryland, 20892
| | - Joseph E. Tomaszewski
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, Maryland, 20892
| | - A. Hilary Calvert
- Northern Institute for Cancer Research, Medical School, Newcastle upon Tyne, UK
| | | | - Giuseppe Giaccone
- Medical Oncology Branch, National Cancer Institute, Bethesda, Maryland, 20892
| | | |
Collapse
|
38
|
Abstract
Environmental and life-style aspects are major contributors to human carcinogenesis and, therefore, many human cancers may be preventable. Cancer is the end result of defects in cellular signaling processes that play a key role in the control of cell growth, survival, division, and differentiation. Therefore, identifying molecular and cellular targets critical in cancer development and prevention is an area of intensive research, driving the development of highly specific small-molecule inhibitors. A major idea today is that cancer may be prevented or treated by targeting the products of specific cancer-related genes, frequently encoding signaling proteins or transcription factors. Participants in these joint conferences discussed their latest findings in the identification of promising molecular targets and the development of agents directed against these targets with the goal of effectively transitioning these into the clinical setting.
Collapse
Affiliation(s)
- Ann M Bode
- The Hormel Institute, University of Minnesota, 801 16th Avenue NE, Austin, MN 55912, USA.
| | | |
Collapse
|
39
|
Kinsella TJ. Coordination of DNA mismatch repair and base excision repair processing of chemotherapy and radiation damage for targeting resistant cancers. Clin Cancer Res 2009; 15:1853-9. [PMID: 19240165 DOI: 10.1158/1078-0432.ccr-08-1307] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
DNA damage processing by mismatch repair (MMR) and/or base excision repair (BER) can determine the therapeutic index following treatment of human cancers using radiation therapy and several classes of chemotherapy drugs. Over the last decade, basic and translational cancer research in DNA repair has led to an increased understanding of how these two DNA repair pathways can modify cytotoxicity to chemotherapy and/or ionizing radiation treatments in both normal and malignant tissues. This Molecular Pathways article provides an overview of the current understanding of mechanisms involved in MMR and BER damage processing, including insights into possible coordination of these two DNA repair pathways after chemotherapy and/or ionizing radiation damage. It also introduces principles of systems biology that have been applied to better understand the complexities and coordination of MMR and BER in processing these DNA damages. Finally, it highlights novel therapeutic approaches to target resistant (or DNA damage tolerant) human cancers using chemical and molecular modifiers of chemotherapy and/or ionizing radiation including poly (ADP-ribose) polymerase inhibitors, methoxyamine and iododeoxyuridine (and the prodrug, 5-iodo-2-pyrimidinone-2'-deoxyribose).
Collapse
Affiliation(s)
- Timothy J Kinsella
- Case Integrative Cancer Biology Program, Case Western Reserve University, Cleveland, OH, USA.
| |
Collapse
|
40
|
Camporesi S. Phase 0 Workshop at the 20th EORTC-NCI-AACR Symposium, Geneva. Ecancermedicalscience 2008; 2:107. [PMID: 22275983 PMCID: PMC3234041 DOI: 10.3332/ecancer.2008.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Indexed: 11/06/2022] Open
Affiliation(s)
- S Camporesi
- European School of Molecular Medicine, IFOM-IEO Campus, Via Adamello, 16, 20139 Milan, Italy.
| |
Collapse
|
41
|
Calvert AH, Plummer R. The development of phase I cancer trial methodologies: the use of pharmacokinetic and pharmacodynamic end points sets the scene for phase 0 cancer clinical trials. Clin Cancer Res 2008; 14:3664-9. [PMID: 18559580 DOI: 10.1158/1078-0432.ccr-07-4559] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although the concept of a phase 0 trial is a relatively new one, there has been a slowly increasing trend toward basing early clinical trial designs on pharmacokinetic and pharmacodynamic end points that has been developing over many years. This article will review the early cancer trial methodologies and the various techniques that have been used to refine them. Several illustrative examples will be presented showing their relevance to trial designs using pharmacodynamic end points and targeted agents. Some criteria for characterizing suitable phase 0 end points are suggested. Four trial designs that are essentially developed for cytotoxic agents using the maximal tolerated dose as an end point are described. Although these trials were not designed with the use of more sophisticated pharmacodynamic end points (such as the measurement of the effect of a targeted agent on its target), they have been developed to optimize the speed with which a dose needed to achieve a particular effect can be determined and are, to this extent, relevant to the design of studies with pharmacodynamic end points.
Collapse
|
42
|
Jacobson-Kram D, Mills G. Leveraging exploratory investigational new drug studies to accelerate drug development. Clin Cancer Res 2008; 14:3670-4. [PMID: 18559581 DOI: 10.1158/1078-0432.ccr-07-4558] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In 2006, the U.S. Food and Drug Administration published its guide on exploratory investigational new drug (IND) studies with the goal of making the approach to early-stage, pilot clinical trials more flexible within the context of current regulations. The exploratory IND allows sponsors to initiate clinical trials of limited scale with reduced preclinical requirements. These studies may be important vehicles for the conduct of proof-of-principle pharmacodynamic investigations of highly potent molecules, for bioavailability studies that require only a single drug dose to be administered, and for imaging trials that permit critical dosimetry and biodistribution investigations of new molecules. These trials were done with no therapeutic intent and must be followed by traditional dose-escalation investigations that are supported by standard preclinical toxicologic and pharmacologic studies. To the extent that they allow early evaluations of essential drug characteristics that can only be obtained in humans, exploratory IND trials have the potential to limit the cost and improve the development times of new agents.
Collapse
Affiliation(s)
- David Jacobson-Kram
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland 20993, USA.
| | | |
Collapse
|
43
|
Abstract
Recent guidance from the Food and Drug Administration supports the conduct of a new type of exploratory clinical trial, commonly called phase 0 clinical trials. Proponents argue that phase 0 clinical trials have the potential to expedite the development of new oncology drugs while exposing fewer research subjects to the risks of experimental treatments. At the same time, phase 0 oncology trials raise important ethical concerns that have received little attention. In particular, there is a question of whether it is ethical to enroll individuals in research that offers them no potential for clinical benefit. Further concern focuses on the inclusion of terminally ill and consequently vulnerable cancer patients in these trials. To evaluate these concerns, this article considers relevant empirical data from phase 1 oncology trials and develops several recommendations regarding the conduct of phase 0 clinical trials in oncology.
Collapse
Affiliation(s)
- Emily Abdoler
- Department of Bioethics, NIH Clinical Center, Bethesda Maryland, USA
| | | | | |
Collapse
|
44
|
Affiliation(s)
- Martin Gutierrez
- Center for Cancer Research, National Cancer Institute, Bethesda, Maryland 20892, USA.
| | | |
Collapse
|
45
|
Eliopoulos H, Giranda V, Carr R, Tiehen R, Leahy T, Gordon G. Phase 0 Trials: An Industry Perspective. Clin Cancer Res 2008; 14:3683-8. [DOI: 10.1158/1078-0432.ccr-07-4586] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
46
|
Murgo AJ, Kummar S, Rubinstein L, Gutierrez M, Collins J, Kinders R, Parchment RE, Ji J, Steinberg SM, Yang SX, Hollingshead M, Chen A, Helman L, Wiltrout R, Tomaszewski JE, Doroshow JH. Designing phase 0 cancer clinical trials. Clin Cancer Res 2008; 14:3675-82. [PMID: 18559582 PMCID: PMC2435428 DOI: 10.1158/1078-0432.ccr-07-4560] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Phase 0 trials are designed primarily to evaluate the pharmacodynamic and/or pharmacokinetic properties of selected investigational agents before initiating more traditional phase I testing. One of the major objectives of phase 0 trials is to interrogate and refine a target or biomarker assay for drug effect in human samples implementing procedures developed and validated in preclinical models. Thus, close collaboration between laboratory scientists and clinical investigators is essential to the design and conduct of phase 0 trials. Given the relatively small number of patients and tissue samples, showing a significant drug effect in phase 0 trials requires precise and reproducible assay procedures and innovative statistical methodology. Furthermore, phase 0 trials involving limited exposure of a study agent administered at low doses and/or for a short period allow them to be initiated under the Food and Drug Administration exploratory investigational new drug guidance with less preclinical toxicity data than usually required for traditional first-in-human studies. Because of the very limited drug exposure, phase 0 trials offer no chance of therapeutic benefit, which can impede patient enrollment, particularly if invasive tumor biopsies are required. The challenges to accrual are not insurmountable, however, and well-designed and executed phase 0 trials are feasible and have great potential for improving the efficiency and success of subsequent trials, particularly those evaluating molecularly targeted agents.
Collapse
Affiliation(s)
- Anthony J Murgo
- Division of Cancer Treatment and Diagnosis and Center for Cancer Research, National Cancer Institute, Bethesda, Maryland 20892-2440, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|