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Loeser A, Kim JS, Peppercorn J, Burkard ME, Niemierko A, Juric D, Kalinsky K, Rugo H, Glenn L, Hodgdon C, Maues J, Johnson S, Padron N, Parekh K, Lustberg M, Bardia A. The Right Dose: Results of a Patient Advocate-Led Survey of Individuals With Metastatic Breast Cancer Regarding Treatment-Related Side Effects and Views About Dosage Assessment to Optimize Quality of Life. JCO Oncol Pract 2024; 20:972-983. [PMID: 38518184 DOI: 10.1200/op.23.00539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/29/2023] [Accepted: 02/07/2024] [Indexed: 03/24/2024] Open
Abstract
PURPOSE Although patients with metastatic breast cancer (MBC) have been living longer with the advent of more effective treatments such as targeted therapy and immunotherapy, the disease remains incurable, and most patients will undergo therapy indefinitely. When beginning therapy, patients are typically prescribed dose often based upon the maximum tolerated dose identified in phase I clinical trials. However, patients' perspectives about tolerability and willingness to discuss individualized dosing of drugs upon initiation of a new regimen and throughout the course of treatment have not been comprehensively evaluated. METHODS Patient advocates and medical oncologists from the Patient-Centered Dosing Initiative (PCDI) developed a survey to ascertain the prevalence and severity of MBC patients' treatment-related side effects, the level of patient-physician communication, mitigation strategies, perception about the relative efficacy of higher versus lower doses, and willingness to discuss alternative dosing. The PCDI distributed the anonymous confidential online survey in August 2020 to individuals with self-reported MBC. RESULTS One thousand and two hundred twenty-one patients with MBC completed the survey. 86.1% (n = 1,051) reported experiencing at least one significant treatment-related side effect, and of these, 20.3% (n = 213) visited the emergency room/hospital and 43.2% (n = 454) missed at least one treatment. Nearly all patients with side effects (97.6%, n = 1,026) informed their doctor and 81.7% (n = 838) received assistance. Of the 556 patients given a dose reduction for side-effect mitigation, 82.6% (n = 459) reported relief. Notably, majority of patients (53.3%, n = 651) do not believe that higher dose is always more effective than lower dose, and 92.3% (n = 1,127) would be willing to discuss flexible dosing options with their physicians based upon personal characteristics to optimize quality of life. CONCLUSION Given that the majority of patients with MBC experienced at least one substantial treatment-related side effect and most patients given a dose reduction reported improvement, innovative dosage-related strategies are warranted to sustain and improve patients' well-being. Patient-physician discussions in which the patient's unique attributes and circumstances are assessed upon initiation of new treatment and throughout the course of therapy may facilitate the identification of the most favorable dose for each patient, and the majority of patients would be receptive to this approach.
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Affiliation(s)
- Anne Loeser
- Patient-Centered Dosing Initiative, New York, NY
- Yale School of Medicine, New Haven, CT
| | | | | | | | | | | | | | - Hope Rugo
- University of California, San Francisco, San Francisco, CA
| | - Lesley Glenn
- Patient-Centered Dosing Initiative, New York, NY
| | | | - Julia Maues
- Patient-Centered Dosing Initiative, New York, NY
| | | | | | | | | | - Aditya Bardia
- UCLA Health Jonsson Comprehensive Cancer Center, Los Angeles, CA
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Kulesza A, Couty C, Lemarre P, Thalhauser CJ, Cao Y. Advancing cancer drug development with mechanistic mathematical modeling: bridging the gap between theory and practice. J Pharmacokinet Pharmacodyn 2024:10.1007/s10928-024-09930-x. [PMID: 38904912 DOI: 10.1007/s10928-024-09930-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 06/07/2024] [Indexed: 06/22/2024]
Abstract
Quantitative predictive modeling of cancer growth, progression, and individual response to therapy is a rapidly growing field. Researchers from mathematical modeling, systems biology, pharmaceutical industry, and regulatory bodies, are collaboratively working on predictive models that could be applied for drug development and, ultimately, the clinical management of cancer patients. A plethora of modeling paradigms and approaches have emerged, making it challenging to compile a comprehensive review across all subdisciplines. It is therefore critical to gauge fundamental design aspects against requirements, and weigh opportunities and limitations of the different model types. In this review, we discuss three fundamental types of cancer models: space-structured models, ecological models, and immune system focused models. For each type, it is our goal to illustrate which mechanisms contribute to variability and heterogeneity in cancer growth and response, so that the appropriate architecture and complexity of a new model becomes clearer. We present the main features addressed by each of the three exemplary modeling types through a subjective collection of literature and illustrative exercises to facilitate inspiration and exchange, with a focus on providing a didactic rather than exhaustive overview. We close by imagining a future multi-scale model design to impact critical decisions in oncology drug development.
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Affiliation(s)
| | - Claire Couty
- Novadiscovery, 1 Place Giovanni Verrazzano, 69009, Lyon, France
| | - Paul Lemarre
- Novadiscovery, 1 Place Giovanni Verrazzano, 69009, Lyon, France
| | - Craig J Thalhauser
- Genmab US, Inc., 777 Scudders Mill Rd Bldg 2 4th Floor, Plainsboro, NJ, 08536, USA
| | - Yanguang Cao
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
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Jagannath S, Delimpasi S, Grosicki S, Van Domelen DR, Bentur OS, Špička I, Dimopoulos MA. Association of Selinexor Dose Reductions With Clinical Outcomes in the BOSTON Study. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:917-923.e3. [PMID: 37743180 DOI: 10.1016/j.clml.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/24/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Dose modifications in response to adverse events (AEs) can maintain tumor response and improve therapy tolerability. We conducted a post-hoc analysis of the efficacy and safety of reduced selinexor doses in the BOSTON trial (NCT03110562). PATIENTS AND METHODS Efficacy, safety, and quality of life (QoL) in 195 patients with relapsed/refractory multiple myeloma randomized to once-weekly (QW) selinexor (100 mg), QW subcutaneous bortezomib (1.3 mg/m2), and twice-weekly dexamethasone (20 mg) were compared between patients with dose reductions and those without. RESULTS In total, 126 patients (65%) had selinexor dose reductions (median dose 71.4 mg/wk). In patients with dose reductions versus those without median progression-free survival was 16.6 months (95% CI 12.9-not evaluable [NE]) versus 9.2 months [95% CI 6.8-15.5]), overall response rate was 81.7% (95% CI 73.9-88.1%) versus 66.7% (95% CI 54.3-77.6%), ≥very good partial response was (51.6% [95% CI 42.5-60.6%] vs. 31.9% [95% CI 21.2-44.2]), median duration of response was not reached (95% CI 13.8-NE) versus 12.0 months (95% CI 8.3-NE), and time to next treatment was 22.6 months (95% CI 14.6-NE) versus 10.5 months (95% CI 6.3-18.2). Mean best change from baseline on the EORTC QLQ-C30 Global Health Status/QoL scale was 10.0 ± 20.5 versus 4.0 ± 20.9. Duration-adjusted AE rates that were lower after selinexor dose reduction included thrombocytopenia (62.5% before vs. 47.6% after), nausea (31.6% vs. 7.3%), fatigue (28.1% vs. 9.9%), decreased appetite (21.5% vs. 6.4%), anemia (17.9% vs. 10.3%), and diarrhea (12.9% vs. 5.2%). CONCLUSION Appropriate dose reductions in response to AEs of the 100 mg selinexor starting dose in the BOSTON study were associated with improved efficacy, reduced AE rates and improved QoL.
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Affiliation(s)
- Sundar Jagannath
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
| | | | | | | | | | - Ivan Špička
- Charles University and General Hospital, Prague, Czech Republic
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Nikanjam M, Kato S, Sicklick JK, Kurzrock R. At the right dose: personalised (N-of-1) dosing for precision oncology. Eur J Cancer 2023; 194:113359. [PMID: 37832506 DOI: 10.1016/j.ejca.2023.113359] [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: 08/02/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023]
Abstract
The objective of oncology therapeutics, especially in the age of precision medicine, is to give the right drug(s) to the right patient at the right time. Yet, a major challenge is finding the right dose for each patient. Determining safe and efficacious doses of oncology treatments, especially for novel combination therapies, can be challenging. Moreover, traditionally, dosing cancer drugs is based on giving each patient the same dose (a flat dose) or a dose based on surface area/weight. But patients' ability to tolerate drugs is influenced by additional factors including, but not limited to age, gender, race, comorbidities, organ function, and metabolism. Herein, we present evidence that, in the era of targeted drugs, individualised drug dosing determined by starting at reduced doses and using intrapatient dose escalation can yield safe and effective personalised dosing of novel combinations of approved drugs that have not previously undergone formal phase I trials and can also optimise dosing of tested drug regimens.
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Affiliation(s)
- Mina Nikanjam
- Division of Hematology-Oncology, University of California San Diego, La Jolla, CA, USA.
| | - Shumei Kato
- Division of Hematology-Oncology, University of California San Diego, La Jolla, CA, USA
| | - Jason K Sicklick
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, 3855 Health Sciences Drive, La Jolla, CA, USA; Department of Pharmacology, University of California San Diego, 3855 Health Sciences Drive, La Jolla, CA, USA
| | - Razelle Kurzrock
- Division of Hematology and Oncology, Medical College of Wisconsin Cancer Center, Milwaukee, WI, USA; WIN Consortium, Paris, France
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Yates JWT, Mistry HB. Skipping a pillar does not make for strong foundations: Pharmacokinetic-pharmacodynamic reasoning behind the shape of dose-response relationships in oncology. CPT Pharmacometrics Syst Pharmacol 2023; 12:1591-1601. [PMID: 37771203 PMCID: PMC10681527 DOI: 10.1002/psp4.13020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/17/2023] [Accepted: 07/20/2023] [Indexed: 09/30/2023] Open
Abstract
Dose-response analysis is often applied to the quantification of drug-effect especially for slowly responding disease end points where a comparison is made across dose levels after a particular period of treatment. It has long been recognized that exposure - response is more appropriate than dose-response. However, trials necessarily are designed as dose-response experiments. Second, a wide range of functional forms are used to express relationships between dose and response. These considerations are also important for clinical development because pharmacokinetic (PK; and variability) plus pharmacokinetic-pharmacodynamic modeling may allow one to anticipate the shape of the dose-response curve and so the trial design. Here, we describe how the location and steepness of the dose response is determined by the PKs of the compound being tested and its exposure-response relationship in terms of potency (location), efficacy (maximum effect) and Hill coefficient (steepness). Thus, the location (50% effective dose [ED50 ]) is dependent not only on the potency (half-maximal effective concentration) but also the compound's PKs. Similarly, the steepness of the dose response is shown to be a function of the half-life of the drug. It is also shown that the shape of relationship varies dependent on the assumed time course of the disease. This is important in the context of drug-discovery where the in vivo potencies of compounds are compared as well as when considering an analysis of summary data (for example, model-based meta-analysis) for clinical decision making.
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Kim Y, Gilbert MR, Armstrong TS, Celiku O. Clinical outcome assessment trends in clinical trials-Contrasting oncology and non-oncology trials. Cancer Med 2023; 12:16945-16957. [PMID: 37421295 PMCID: PMC10501237 DOI: 10.1002/cam4.6325] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Clinical outcome assessments (COAs) are key to patient-centered evaluation of novel interventions and supportive care. COAs are particularly informative in oncology where a focus on how patients feel and function is paramount, but their incorporation in trial outcomes have lagged that of traditional survival and tumor responses. To understand the trends of COA use in oncology and the impact of landmark efforts to promote COA use, we computationally surveyed oncology clinical trials in ClinicalTrials.gov comparing them to the rest of the clinical research landscape. METHODS Oncology trials were identified using medical subject heading neoplasm terms. Trials were searched for COA instrument names obtained from PROQOLID. Regression analyses assessed chronological and design-related trends. RESULTS Eighteen percent of oncology interventional trials initiated 1985-2020 (N = 35,415) reported using one or more of 655 COA instruments. Eighty-four percent of the COA-using trials utilized patient-reported outcomes, with other COA categories used in 4-27% of these trials. Likelihood of COA use increased with progressing trial phase (OR = 1.30, p < 0.001), randomization (OR = 2.32, p < 0.001), use of data monitoring committees (OR = 1.26, p < 0.001), study of non-FDA-regulated interventions (OR = 1.23, p = 0.001), and in supportive care versus treatment-focused trials (OR = 2.94, p < 0.001). Twenty-six percent of non-oncology trials initiated 1985-2020 (N = 244,440) reported COA use; they had similar COA-use predictive factors as oncology trials. COA use increased linearly over time (R = 0.98, p < 0.001), with significant increases following several individual regulatory events. CONCLUSION While COA use across clinical research has increased over time, there remains a need to further promote COA use particularly in early phase and treatment-focused oncology trials.
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Affiliation(s)
- Yeonju Kim
- Neuro‐Oncology BranchNational Cancer Institute, National Institutes of HealthBethesdaMarylandUSA
| | - Mark R. Gilbert
- Neuro‐Oncology BranchNational Cancer Institute, National Institutes of HealthBethesdaMarylandUSA
| | - Terri S. Armstrong
- Neuro‐Oncology BranchNational Cancer Institute, National Institutes of HealthBethesdaMarylandUSA
| | - Orieta Celiku
- Neuro‐Oncology BranchNational Cancer Institute, National Institutes of HealthBethesdaMarylandUSA
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Patient-centered dosing: oncologists' perspectives about treatment-related side effects and individualized dosing for patients with metastatic breast cancer (MBC). Breast Cancer Res Treat 2022; 196:549-563. [PMID: 36198984 DOI: 10.1007/s10549-022-06755-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/18/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Although metastatic breast cancer (MBC) is treatable, it is not curable and most patients remain on treatment indefinitely. While oncologists commonly prescribe the recommended starting dose (RSD) from the FDA-approved label, patient tolerance may differ from that seen in clinical trials. We report on a survey of medical oncologists' perspectives about treatment-related toxicity and willingness to discuss flexible dosing with patients. METHODS We disseminated a confidential survey via social media/email in Spring 2021. Eligible respondents needed to be US-based medical oncologists with experience treating patients with MBC. RESULTS Of 131 responses, 119 were eligible. Physicians estimated that 47% of their patients reported distressing treatment-related side effects; of these, 15% visited the Emergency Room/hospital and 37% missed treatment. 74% (n = 87) of doctors reported improvement of patient symptoms after dose reduction. 87% (n = 104) indicated that they had ever, if appropriate, initiated treatment at lower doses. Most (85%, n = 101) respondents did not believe that the RSD is always more effective than a lower dose and 97% (n = 115) were willing to discuss individualized dosing with patients. CONCLUSION Treatment-related side effects are prevalent among patients with MBC, resulting in missed treatments and acute care visits. To help patients tolerate treatment, oncologists may decrease initial and/or subsequent doses. The majority of oncologists reject the premise that a higher dose is always superior and are willing to discuss individualized dosing with patients. Given potential improvements regarding quality of life and clinical care, dose modifications should be part of routine shared decision-making between patients and oncologists.
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Embracing Project Optimus: Can we Leverage Evolutionary Theory to Optimize Dosing in Oncology? Pharm Res 2022; 39:3259-3265. [PMID: 36056271 PMCID: PMC9789176 DOI: 10.1007/s11095-022-03380-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 08/25/2022] [Indexed: 12/27/2022]
Abstract
Project Optimus is a US Food and Drug Administration (FDA) initiative to reform dose selection in oncology drug development. Here, we focus on tumor evolution, a broadly observed phenomenon that invariably leads to therapeutic failure and disease relapse, and its effect on the exposure-response (E-R) relationships of oncology drugs. We propose a greater emphasis on tumor evolution during clinical development to facilitate the selection of optimal doses for molecularly targeted therapies and immunotherapies in oncology.
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Jimenez RB, Schenkel C, Levit LA, Hu B, Lei XJ, Harvey RD, Morrison VA, Pollastro T, Waterhouse D, Weekes C, Williams GR, Bruinooge S, Garrett-Mayer E, Peppercorn J. Oncologists' Perspectives on Individualizing Dose Selection for Patients With Metastatic Cancer. JCO Oncol Pract 2022; 18:e1807-e1817. [PMID: 36126244 DOI: 10.1200/op.22.00427] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Treatment goals for patients with metastatic cancer include prolongation and maintenance of quality of life. Patients and oncologists have questioned the current paradigm of initial dose selection for systemic therapy; however, data on oncologists' dose selection strategies and beliefs are lacking. METHODS We conducted an electronic international survey of medical oncologists who treat patients with breast and/or gastrointestinal cancers. Survey questions addressed experiences with, and attitudes toward, dose reduction at initiation (DRI) of a new systemic therapy for patients with metastatic cancer. RESULTS Among 3,099 eligible oncologists, 367 responded (response rate 12%). Most (52%) reported using DRI at least 10% of the time to minimize toxicities. Gastrointestinal specialists were more likely to report DRI ≥ 10% of the time (72% v 50% of generalists and 51% of breast specialists, P < .005). Of those who dose reduced ≥ 10% of the time, 89% reported discussing potential tradeoffs between efficacy and toxicity with patients. Overall, 65% agreed it is acceptable to lower starting doses to reduce side effects even if it compromises efficacy; younger clinicians were more likely to agree (P < .005). There was strong support (89%) for future trials to determine optimal effective, rather than maximum tolerated, dose. CONCLUSION Oncology practice varies with regard to discussion and individualized selection of starting doses in the metastatic setting. This study demonstrates a need for consideration of shared decision making regarding initial dose selection and strong support among oncologists for clinical studies to define optimal dosing and best practices for individualizing care.
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Affiliation(s)
| | | | - Laura A Levit
- American Society of Clinical Oncology (ASCO), Alexandria, VA
| | - Bonnie Hu
- Massachusetts General Hospital, Boston, MA
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Determining drug dose in the era of targeted therapies: playing it (un)safe? Blood Cancer J 2022; 12:123. [PMID: 35999205 PMCID: PMC9399108 DOI: 10.1038/s41408-022-00720-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/15/2022] [Accepted: 08/11/2022] [Indexed: 11/26/2022] Open
Abstract
Targeted therapies against phosphatidylinositol 3-kinase (PI3K), Bruton’s tyrosine kinase (BTK), and B-cell lymphoma-2 (BCL-2) are approved for chronic lymphocytic leukemia (CLL). Since approval of the first-in-class drugs, next-generation agents have become available and are continuously under development. While these therapies act on well-characterized molecular targets, this knowledge is only to some extent taken into consideration when determining their dose in phase I trials. For example, BTK occupancy has been assessed in dose-finding studies of various BTK inhibitors, but the minimum doses that result in full BTK occupancy were not determined. Although targeted agents have a different dose–response relationship than cytotoxic agents, which are more effective near the maximum tolerated dose, the traditional 3 + 3 toxicity-driven trial design remains heavily used in the era of targeted therapies. If pharmacodynamic biomarkers were more stringently used to guide dose selection, the recommended phase II dose would likely be lower as compared to the toxicity-driven selection. Reduced drug doses may lower toxicity, which in some cases is severe for these agents, and are supported by retrospective studies demonstrating non-inferior outcomes for patients with clinically indicated dose reductions. Here, we review strategies that were used for dose selection in phase I studies of currently approved and select investigational targeted therapies in CLL, and discuss how our initial clinical experience with targeted therapies have pointed to dose reductions, intermittent dosing, and drug combinations as strategies to overcome treatment intolerance and resistance.
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11
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Basu A, Budhraja A, Juwayria, Abhilash D, Gupta I. Novel omics technology driving translational research in precision oncology. ADVANCES IN GENETICS 2021; 108:81-145. [PMID: 34844717 DOI: 10.1016/bs.adgen.2021.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In this review, we summarize the current challenges faced by cancer researchers and motivate the use of novel genomics solutions. We follow this up with a comprehensive overview of three recent genomics technologies: liquid biopsy, single-cell RNA sequencing and spatial transcriptomics. We discuss a few representative protocols/assays for each technology along with their strengths, weaknesses, optimal use-cases, and their current stage of clinical deployment by summarizing trial data. We focus on how these technologies help us develop a better understanding of cancer as a rapidly evolving heterogeneous genetic disease that modulates its immediate microenvironment leading to systemic macro-level changes in the patient body. We summarize the review with a flowchart that integrates these three technologies in the existing workflows of clinicians and researchers toward robust detection, accurate diagnosis, and precision oncology.
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Affiliation(s)
- Anubhav Basu
- Department of Biochemical Engineering and Biotechnology, Indian Institute of Technology, Delhi, Hauz Khas, New Delhi, India
| | - Anshul Budhraja
- Department of Biochemical Engineering and Biotechnology, Indian Institute of Technology, Delhi, Hauz Khas, New Delhi, India
| | - Juwayria
- Department of Biochemical Engineering and Biotechnology, Indian Institute of Technology, Delhi, Hauz Khas, New Delhi, India
| | - Dasari Abhilash
- Department of Biochemical Engineering and Biotechnology, Indian Institute of Technology, Delhi, Hauz Khas, New Delhi, India
| | - Ishaan Gupta
- Department of Biochemical Engineering and Biotechnology, Indian Institute of Technology, Delhi, Hauz Khas, New Delhi, India.
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Ehling TJ, Klein MK, Smith L, Prescott D, Haney S, Looper J, LaDue T, Brawner W, Fidel J, Shiomitsu K, Green E, Saba C, Turek M, Farrelly J. A prospective, multi-centre, Veterinary Radiation Therapy Oncology Group study reveals potential efficacy of toceranib phosphate (Palladia) as a primary or adjuvant agent in the treatment of canine nasal carcinoma. Vet Comp Oncol 2021; 20:293-303. [PMID: 34655275 DOI: 10.1111/vco.12776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/04/2021] [Indexed: 01/28/2023]
Abstract
Radiation is the standard of care for dogs with nasal tumours. The addition of another therapy that could improve outcome without increasing toxicity is attractive. Medical therapy that could offer better outcome than maximally tolerated dose chemotherapy when radiation therapy (RT) is not possible or is declined is also attractive. This article reports the findings from a prospective, multi-centre, non-randomized, Veterinary Radiation Therapy Oncology Group clinical trial designed to evaluate whether toceranib phosphate (toceranib) has primary activity and if the addition of toceranib to RT could positively impact outcome. Owner's discretion determined enrolment in toceranib alone or toceranib + RT arm. Historical controls for radiation alone were selected from patients treated with identical RT and imaging protocols. Responses were evaluated with pre-treatment and week-16 CT scans. RT total dose of 42 Gy was completed in 10 fractions. Sixty-three dogs enrolled from 10 study sites. Overall response rates (CR + PR) were significantly improved in the toceranib + RT (79.4%) and RT alone (68.9%) arms over toceranib alone (22%) (p = .011). Clinical benefit rates (CR + PR + SD) were significantly improved in the toceranib + RT arm over the RT alone arm at 97.3% and 79.2% respectively (p = .036). Treatment with toceranib alone, toceranib + RT and RT alone resulted in median survival times of 298, 615 and 368 days respectively, but were not statistically significantly different (p = .0502). Adverse events associated with toceranib administration did not potentiate the RT side effect profile. Toceranib appears to have primary activity against nasal carcinoma.
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Affiliation(s)
- Tara Jean Ehling
- Veterinary Health Center of Wentzville, Department of Veterinary Medicine and Surgery, University of Missouri, Wentzville, Missouri, USA.,Southwest Veterinary Oncology, Tucson, Arizona, USA
| | | | - Lauren Smith
- Southwest Veterinary Oncology, Tucson, Arizona, USA
| | | | - Siobhan Haney
- Hope Veterinary Specialists, Malvern, Pennsylvania, USA
| | - Jayme Looper
- Chicago Veterinary Internal Medicine & Oncology, Chicago, Illinois, USA
| | - Tracey LaDue
- Southeast Veterinary Oncology, Orange Park, Florida, USA
| | - William Brawner
- Department of Clinical Sciences at the College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA
| | - Janean Fidel
- Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA
| | - Keijiro Shiomitsu
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA
| | - Eric Green
- Veterinary Clinical Sciences, Ohio State University, Columbus, Ohio, USA
| | - Corey Saba
- Department of Small Animal Medicine & Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Michelle Turek
- Department of Small Animal Medicine & Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
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de Las Heras B, Bouyoucef-Cherchalli D, Reeve L, Reichl A, Mandarino D, Flach S, Vidal L, van Brummelen EMJ, Steeghs N. Healthy volunteers in first-in-human oncology drug development for small molecules. Br J Clin Pharmacol 2021; 88:1773-1784. [PMID: 34558113 DOI: 10.1111/bcp.15092] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/03/2021] [Accepted: 09/14/2021] [Indexed: 12/20/2022] Open
Abstract
This review provides tools to consider the inclusion of healthy volunteers (HVs) in first-in-human (FIH) oncology clinical trials with small molecules, including targeted and immunomodulatory agents, a strategy that was not envisioned with classic chemotherapy. To enable an FIH oncology trial in HVs compared to cancer patients (CPs), a robust nonclinical package must be generated, which includes toxicokinetic and pharmacokinetic studies, as well as more extensive safety pharmacology, toxicology and genotoxicity studies. This strategy could provide an early clinical characterization of the pharmacokinetic parameters and clinical safety profile in the absence of comorbidities and concomitant medication. It also avoids the ethical issue of administrating subtherapeutic doses to CPs, and could potentially help to accelerate the timelines of clinical drug development for patient care. That being said, stakeholders involved in these studies need to proceed with caution, fully understand the regulatory guidance and thoroughly evaluate the benefits and risks. This paper serves to address the regulatory guidance and other considerations needed when using healthy volunteers in early oncology trials.
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Affiliation(s)
- Begoña de Las Heras
- Labcorp Drug Development Inc., headquarters in Burlington, North Carolina, USA.,Madrid Medical Doctors Association, Madrid, Spain
| | | | - Lesley Reeve
- Labcorp Drug Development Inc., headquarters in Burlington, North Carolina, USA
| | - Andreas Reichl
- Labcorp Drug Development Inc., headquarters in Burlington, North Carolina, USA
| | - Debra Mandarino
- Labcorp Drug Development Inc., headquarters in Burlington, North Carolina, USA
| | - Stephen Flach
- Labcorp Drug Development Inc., headquarters in Burlington, North Carolina, USA
| | - Laura Vidal
- Labcorp Drug Development Inc., headquarters in Burlington, North Carolina, USA
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14
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New strategies for targeting kinase networks in cancer. J Biol Chem 2021; 297:101128. [PMID: 34461089 PMCID: PMC8449055 DOI: 10.1016/j.jbc.2021.101128] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 12/18/2022] Open
Abstract
Targeted strategies against specific driver molecules of cancer have brought about many advances in cancer treatment since the early success of the first small-molecule inhibitor Gleevec. Today, there are a multitude of targeted therapies approved by the Food and Drug Administration for the treatment of cancer. However, the initial efficacy of virtually every targeted treatment is often reversed by tumor resistance to the inhibitor through acquisition of new mutations in the target molecule, or reprogramming of the epigenome, transcriptome, or kinome of the tumor cells. At the core of this clinical problem lies the assumption that targeted treatments will only be efficacious if the inhibitors are used at their maximum tolerated doses. Such aggressive regimens create strong selective pressure on the evolutionary progression of the tumor, resulting in resistant cells. High-dose single agent treatments activate alternative mechanisms that bypass the inhibitor, while high-dose combinatorial treatments suffer from increased toxicity resulting in treatment cessation. Although there is an arsenal of targeted agents being tested clinically and preclinically, identifying the most effective combination treatment plan remains a challenge. In this review, we discuss novel targeted strategies with an emphasis on the recent cross-disciplinary studies demonstrating that it is possible to achieve antitumor efficacy without increasing toxicity by adopting low-dose multitarget approaches to treatment of cancer and metastasis.
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15
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Alshammari K, Aung KL, Zhang T, Razak ARA, Serra S, Stockley T, Wang L, Nguyen J, Spreafico A, Hansen AR, Zwir D, Siu LL, Bedard PL. Phase II Trial of Trametinib and Panitumumab in RAS/RAF Wild Type Metastatic Colorectal Cancer. Clin Colorectal Cancer 2021; 20:334-341. [PMID: 34417144 DOI: 10.1016/j.clcc.2021.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 01/02/2023]
Abstract
INTRODUCTION MEK inhibition may overcome resistance to EGFR inhibition in patients with RAS wildtype (wt) metastatic colorectal cancer (mCRC). We evaluated antitumor activity of trametinib (MEK1/2 inhibitor) with panitumumab (EGFR monoclonal antibody) in a phase II trial. METHODS Patients with KRAS, NRAS, and BRAF wt mCRC with prior 5-FU, irinotecan, oxaliplatin, +/- bevacizumab and no prior anti-EGFR therapy were treated with trametinib 1.5 mg oral daily and panitumumab 4.8 mg/kg IV every 2 weeks. Primary endpoint was clinical benefit rate (CB; CR, PR, or SD ≥24 weeks) by RECIST v1.1. A 2-stage minimax design was used. Serial plasma circulating free DNA (cfDNA) was collected and profiled using Oncomine Lung cfDNA assay. RESULTS Fourteen patients were enrolled from November 2015 to April 2019. CB rate was 38% (5/13) and median progression free survival (PFS) was 4.4 months (95% CI, 2.9-7.1). Confirmed overall response rate was 38% (5/13). Treatment-related AE (trAE) included acneiform rash (85%), diarrhea (62%), maculopapular rash (54%), mucositis (46%), and others. Dose modifications and interruptions of trametinib occurred in 69% and panitumumab in 54% of patients. The trial did not progress to stage II accrual due to tolerability and short duration of response. RAS or BRAF mutations cfDNA were detected in 3/13 patients (23%) before radiographic disease progression. CONCLUSION The addition of trametinib to panitumumab led to a high rate of tumor shrinkage in RAS/RAF wt metastatic colorectal cancer, with poor tolerability due to a high incidence of skin toxicity. Median PFS was similar to panitumumab alone in historical control data.
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Affiliation(s)
- Kanan Alshammari
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario
| | - Kyaw L Aung
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario
| | - Tong Zhang
- Department of Clinical Laboratory Genetics, University Health Network, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Albiruni R A Razak
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario
| | - Stefano Serra
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Tracy Stockley
- Department of Clinical Laboratory Genetics, University Health Network, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Lisa Wang
- Biostatistics Division, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Jessica Nguyen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Anna Spreafico
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario
| | - Aaron R Hansen
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario
| | - Dave Zwir
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Lillian L Siu
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario
| | - Philippe L Bedard
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Ontario.
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16
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Mu R, Xu G, Liu G, Pan H. A two-stage Bayesian adaptive design for minimum effective dose (MinED)-based dosing-finding trials. Contemp Clin Trials 2021; 108:106504. [PMID: 34303862 DOI: 10.1016/j.cct.2021.106504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/02/2021] [Accepted: 07/08/2021] [Indexed: 12/01/2022]
Abstract
Conventional phase I designs for finding a phase II recommended dose (P2RD) based on toxicity alone is problematic because the maximum tolerated dose (MTD) is not necessarily the optimal dose. Instead, recently attention has been given to find the minimum effective dose (MinED) - defined as the lowest effective dose. Traditional paradigms for the MinED studies are conducted as dose-ranging or dose-response trials which involve several doses and randomize patients among doses to find the MinED. An alternative approach for the MinED study is the so-called MinED-based dose-finding study, in which instead of conducting hypothesis testings and without power analysis, this kind of trial conduct dose escalation/de-escalation to target a pre-set MinED target. In this study, we propose a new Bayesian two-stage adaptive design schema based on framework of the interval-based phase I method. The proposed method is model-free without curve pre-specifications, which is suitable for various dose-efficacy relationships. The proposed method shows desirable theoretical finite property of semi-coherence and large sample property of consistency. A random scenario generative algorithm for the MinED has also been proposed for extensive simulation studies, which demonstrated desirable performances of the proposed method. An R package "MinEDfind" and a Shiny app have been developed for implementing the method.
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Affiliation(s)
- Rongji Mu
- Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Guoying Xu
- Jiangsu Hengrui Medicine Co., Ltd, Shanghai 201203, China
| | - Guanfu Liu
- School of Statistics and Information, Shanghai University of International Business and Economics, Shanghai 201620, China
| | - Haitao Pan
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
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17
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Cammarota A, D'Alessio A, Pressiani T, Rimassa L, Personeni N. Systemic Treatment for Older Patients with Unresectable Hepatocellular Carcinoma. Drugs Aging 2021; 38:579-591. [PMID: 34152589 DOI: 10.1007/s40266-021-00871-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2021] [Indexed: 12/25/2022]
Abstract
The incidence rate of hepatocellular carcinoma is growing and age at diagnosis is increasing; however, despite the unprecedented wealth of therapeutic options for advanced HCC, its optimal management in some categories, such as older adults, is yet to be defined. Even though age is not an exclusion criterion per se, most of the landmark trials enrolled a limited number of senior patients, raising some concerns on the potential benefit of active treatments in this group. The identification of more vulnerable patients remains a crucial issue in clinical practice. In fact, the suitability assessment for systemic therapy through performance status metrics might underestimate or conversely overestimate the fitness of older patients, failing to detect other relevant impairments. Thus, the assessment of frailty through geriatric screening scales is largely necessary. In addition, most of the available data relate to the use of sorafenib, while very little is known about the most recent therapeutic agents. Age subgroup analyses provided by many of the pivotal trials did not find significant efficacy or safety differences across ages; however, the most widely used cut-off age of 65 years may not be very informative for the current older population. Regarding immunotherapy, the clinical benefit reported with immune checkpoint inhibitors reassures their safe use in senior patients and supports further investigations to assess their efficacy in this population.
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Affiliation(s)
- Antonella Cammarota
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy.,Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Antonio D'Alessio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy.,Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Tiziana Pressiani
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy. .,Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy.
| | - Nicola Personeni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy.,Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089, Milan, Italy
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18
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Kurzrock R, Lin CC, Wu TC, Hobbs BP, Pestana RC, Hong DS. Moving Beyond 3+3: The Future of Clinical Trial Design. Am Soc Clin Oncol Educ Book 2021; 41:e133-e144. [PMID: 34061563 DOI: 10.1200/edbk_319783] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Misgivings have been raised about the operating characteristics of the canonical 3+3 dose-escalation phase I clinical trial design. Yet, the traditional 3+3 design is still the most commonly used. Although it has been implied that adhering to this design is due to a stubborn reluctance to adopt change despite other designs performing better in hypothetical computer-generated simulation models, the continued adherence to 3+3 dose-escalation phase I strategies is more likely because these designs perform the best in the real world, pinpointing the correct dose and important side effects with an acceptable degree of precision. Beyond statistical simulations, there are little data to refute the supposed shortcomings ascribed to the 3+3 method. Even so, to address the unique nuances of gene- and immune-targeted compounds, a variety of inventive phase 1 trial designs have been suggested. Strategies for developing these therapies have launched first-in-human studies devised to acquire a breadth of patient data that far exceed the size of a typical phase I design and blur the distinction between dose selection and efficacy evaluation. Recent phase I trials of promising cancer therapies assessed objective tumor response and durability at various doses and schedules as well as incorporated multiple expansion cohorts spanning a variety of histology or biomarker-defined tumor subtypes, sometimes resulting in U.S. Food and Drug Administration approval after phase I. This article reviews recent innovations in phase I design from the perspective of multiple stakeholders and provides recommendations for future trials.
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Affiliation(s)
- Razelle Kurzrock
- Center for Personalized Cancer Therapy, University of California San Diego, Moores Cancer Center, La Jolla, CA
| | - Chia-Chi Lin
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung-Che Wu
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Brian P Hobbs
- Department of Population Health, Dell Medical School, University of Texas at Austin, Austin, TX
| | - Roberto Carmagnani Pestana
- Centro de Oncologia e Hematologia Einstein Familia Dayan-Daycoval, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - David S Hong
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX
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19
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Coleman RL, Beck JT, Baranda JC, Jacobs I, Smoyer KE, Lee LJ, Askerova Z, McGinnis J, Ganti AK. The Use of Patient-Reported Outcome Measures in Phase I Oncology Clinical Trials. Oncology 2021; 99:444-453. [PMID: 33823518 DOI: 10.1159/000514874] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/18/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate patient-reported outcome (PRO) usage in phase I oncology clinical trials, including types of PRO measures and changes over time. METHODS We analyzed ClinicalTrials.gov records of phase I oncology clinical trials completed by December 2019. RESULTS Of all eligible trials, 2.3% (129/5,515) reported ≥1 PRO, totaling 181 instances of PRO usage. PRO usage increased over time, from 0.6% (trials initiated before 2000) to 3.4% (trials starting between 2015 and 2019). The most common PRO measures were unspecified (29%), tumor-specific (24%), and generic cancer (19%). CONCLUSION Although uncommon in phase I oncology clinical trials, PRO usage is increasing over time. PRO measures were often unspecified on ClinicalTrials.gov, suggesting that more precise reporting and standardization are needed.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Apar Kishor Ganti
- VA Nebraska Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska, USA
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20
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Systemic treatment of HCC in special populations. J Hepatol 2021; 74:931-943. [PMID: 33248171 DOI: 10.1016/j.jhep.2020.11.026] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/05/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
Recent years have seen significant progress in the systemic treatment of hepatocellular carcinoma (HCC), including the advent of immunotherapy. While several large phase III trials have provided the evidence for a multi-line treatment paradigm, they have focused on a highly selected group of patients by excluding potentially confounding comorbidities. As a result, high quality evidence for the systemic treatment of HCC in patients with various comorbidities is missing. This review summarises current knowledge on the use of approved medicines in patients with HIV, autoimmune disease, cardiovascular disease, diabetes, fibrolamellar HCC, mixed HCC-cholangiocarcinoma, decompensated cirrhosis (Child-Pugh B and C), a significant bleeding history, vascular invasion or portal vein thrombosis, as well as the elderly, those on haemodialysis, and those after solid organ transplantation. The article highlights relevant knowledge gaps and current clinical challenges. To improve the safety and efficacy of HCC treatment in these subgroups, future trials should be designed to specifically include patients with comorbidities.
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21
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Tannock IF, Ratain MJ, Goldstein DA, Lichter AS, Rosner GL, Saltz LB. Near-Equivalence: Generating Evidence to Support Alternative Cost-Effective Treatments. J Clin Oncol 2021; 39:950-955. [DOI: 10.1200/jco.20.02768] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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22
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van Bijsterveldt L, Durley SC, Maughan TS, Humphrey TC. The Challenge of Combining Chemo- and Radiotherapy with Checkpoint Kinase Inhibitors. Clin Cancer Res 2021; 27:937-962. [PMID: 33257428 DOI: 10.1158/1078-0432.ccr-20-3358] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/10/2020] [Accepted: 11/20/2020] [Indexed: 11/16/2022]
Abstract
Preclinical models of cancer have demonstrated enhanced efficacy of cell-cycle checkpoint kinase inhibitors when used in combination with genotoxic agents. This combination therapy is predicted to be exquisitely toxic to cells with a deficient G1-S checkpoint or cells with a genetic predisposition leading to intrinsic DNA replication stress, as these cancer cells become fully dependent on the intra-S and G2-M checkpoints for DNA repair and cellular survival. Therefore, abolishing remaining cell-cycle checkpoints after damage leads to increased cell death in a tumor cell-specific fashion. However, the preclinical success of these drug combinations is not consistently replicated in clinical trials. Here, we provide a perspective on the translation of preclinical studies into rationally designed clinical studies. We will discuss successes and failures of current treatment combinations and drug regimens and provide a detailed overview of all clinical trials using ATR, CHK1, or WEE1 inhibitors in combination with genotoxic agents. This highlights the need for revised patient stratification and the use of appropriate pharmacodynamic biomarkers to improve the success rate of clinical trials.
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Affiliation(s)
- Linda van Bijsterveldt
- MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Samuel C Durley
- MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Tim S Maughan
- MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom
| | - Timothy C Humphrey
- MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, United Kingdom.
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23
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Zoetemelk M, Ramzy GM, Rausch M, Koessler T, van Beijnum JR, Weiss A, Mieville V, Piersma SR, de Haas RR, Delucinge-Vivier C, Andres A, Toso C, Henneman AA, Ragusa S, Petrova TV, Docquier M, McKee TA, Jimenez CR, Daali Y, Griffioen AW, Rubbia-Brandt L, Dietrich PY, Nowak-Sliwinska P. Optimized low-dose combinatorial drug treatment boosts selectivity and efficacy of colorectal carcinoma treatment. Mol Oncol 2020; 14:2894-2919. [PMID: 33021054 PMCID: PMC7607171 DOI: 10.1002/1878-0261.12797] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/24/2020] [Accepted: 08/11/2020] [Indexed: 12/19/2022] Open
Abstract
The current standard of care for colorectal cancer (CRC) is a combination of chemotherapeutics, often supplemented with targeted biological drugs. An urgent need exists for improved drug efficacy and minimized side effects, especially at late‐stage disease. We employed the phenotypically driven therapeutically guided multidrug optimization (TGMO) technology to identify optimized drug combinations (ODCs) in CRC. We identified low‐dose synergistic and selective ODCs for a panel of six human CRC cell lines also active in heterotypic 3D co‐culture models. Transcriptome sequencing and phosphoproteome analyses showed that the mechanisms of action of these ODCs converged toward MAP kinase signaling and cell cycle inhibition. Two cell‐specific ODCs were translated to in vivo mouse models. The ODCs reduced tumor growth by ~80%, outperforming standard chemotherapy (FOLFOX). No toxicity was observed for the ODCs, while significant side effects were induced in the group treated with FOLFOX therapy. Identified ODCs demonstrated significantly enhanced bioavailability of the individual components. Finally, ODCs were also active in primary cells from CRC patient tumor tissues. Taken together, we show that the TGMO technology efficiently identifies selective and potent low‐dose drug combinations, optimized regardless of tumor mutation status, outperforming conventional chemotherapy.
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Affiliation(s)
- Marloes Zoetemelk
- Molecular Pharmacology Group, School of Pharmaceutical Sciences, University of Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland.,Translational Research Center in Oncohaematology, Geneva, Switzerland
| | - George M Ramzy
- Molecular Pharmacology Group, School of Pharmaceutical Sciences, University of Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland.,Translational Research Center in Oncohaematology, Geneva, Switzerland
| | - Magdalena Rausch
- Molecular Pharmacology Group, School of Pharmaceutical Sciences, University of Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland.,Translational Research Center in Oncohaematology, Geneva, Switzerland
| | - Thibaud Koessler
- Department of Oncology, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Judy R van Beijnum
- Angiogenesis Laboratory, Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC-location VUmc, VU University Amsterdam, The Netherlands
| | - Andrea Weiss
- Molecular Pharmacology Group, School of Pharmaceutical Sciences, University of Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland
| | - Valentin Mieville
- Molecular Pharmacology Group, School of Pharmaceutical Sciences, University of Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland
| | - Sander R Piersma
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands.,OncoProteomics Laboratory, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands
| | - Richard R de Haas
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands.,OncoProteomics Laboratory, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands
| | | | - Axel Andres
- Translational Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Switzerland.,Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Christian Toso
- Translational Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Switzerland.,Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Alexander A Henneman
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands.,OncoProteomics Laboratory, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands
| | - Simone Ragusa
- Department of Oncology, University of Lausanne, Switzerland.,Ludwig Institute for Cancer Research Lausanne, Switzerland
| | - Tatiana V Petrova
- Department of Oncology, University of Lausanne, Switzerland.,Ludwig Institute for Cancer Research Lausanne, Switzerland
| | - Mylène Docquier
- iGE3 Genomics Platform, University of Geneva, Switzerland.,Department of Genetics & Evolution, University of Geneva, Switzerland
| | - Thomas A McKee
- Division of Clinical Pathology, Diagnostic Department, University Hospitals of Geneva (HUG), Switzerland
| | - Connie R Jimenez
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands.,OncoProteomics Laboratory, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology, Department of Anaesthesiology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Pharmacology, Switzerland
| | - Arjan W Griffioen
- Angiogenesis Laboratory, Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC-location VUmc, VU University Amsterdam, The Netherlands
| | - Laura Rubbia-Brandt
- Division of Clinical Pathology, Diagnostic Department, University Hospitals of Geneva (HUG), Switzerland
| | - Pierre-Yves Dietrich
- Translational Research Center in Oncohaematology, Geneva, Switzerland.,Department of Oncology, Geneva University Hospitals and Faculty of Medicine, Switzerland
| | - Patrycja Nowak-Sliwinska
- Molecular Pharmacology Group, School of Pharmaceutical Sciences, University of Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland.,Translational Research Center in Oncohaematology, Geneva, Switzerland
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24
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Schperberg AV, Boichard A, Tsigelny IF, Richard SB, Kurzrock R. Machine learning model to predict oncologic outcomes for drugs in randomized clinical trials. Int J Cancer 2020; 147:2537-2549. [PMID: 32745254 DOI: 10.1002/ijc.33240] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 11/12/2022]
Abstract
Predicting oncologic outcome is challenging due to the diversity of cancer histologies and the complex network of underlying biological factors. In this study, we determine whether machine learning (ML) can extract meaningful associations between oncologic outcome and clinical trial, drug-related biomarker and molecular profile information. We analyzed therapeutic clinical trials corresponding to 1102 oncologic outcomes from 104 758 cancer patients with advanced colorectal adenocarcinoma, pancreatic adenocarcinoma, melanoma and nonsmall-cell lung cancer. For each intervention arm, a dataset with the following attributes was curated: line of treatment, the number of cytotoxic chemotherapies, small-molecule inhibitors, or monoclonal antibody agents, drug class, molecular alteration status of the clinical arm's population, cancer type, probability of drug sensitivity (PDS) (integrating the status of genomic, transcriptomic and proteomic biomarkers in the population of interest) and outcome. A total of 467 progression-free survival (PFS) and 369 overall survival (OS) data points were used as training sets to build our ML (random forest) model. Cross-validation sets were used for PFS and OS, obtaining correlation coefficients (r) of 0.82 and 0.70, respectively (outcome vs model's parameters). A total of 156 PFS and 110 OS data points were used as test sets. The Spearman correlation (rs ) between predicted and actual outcomes was statistically significant (PFS: rs = 0.879, OS: rs = 0.878, P < .0001). The better outcome arm was predicted in 81% (PFS: N = 59/73, z = 5.24, P < .0001) and 71% (OS: N = 37/52, z = 2.91, P = .004) of randomized trials. The success of our algorithm to predict clinical outcome may be exploitable as a model to optimize clinical trial design with pharmaceutical agents.
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Affiliation(s)
- Alexander V Schperberg
- CureMatch, Inc., San Diego, California, USA.,Department of Mechanical and Aerospace Engineering, University of California Los Angeles, Los Angeles, California, USA
| | - Amélie Boichard
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, University of California San Diego Moores Cancer Center, La Jolla, California, USA
| | - Igor F Tsigelny
- CureMatch, Inc., San Diego, California, USA.,San Diego Supercomputer Center, University of California San Diego, La Jolla, California, USA.,Department of Neurosciences, University of California San Diego, La Jolla, California, USA
| | - Stéphane B Richard
- CureMatch, Inc., San Diego, California, USA.,Oncodesign, Inc., New York, New York, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, University of California San Diego Moores Cancer Center, La Jolla, California, USA
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25
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Rational Cancer Treatment Combinations: An Urgent Clinical Need. Mol Cell 2020; 78:1002-1018. [DOI: 10.1016/j.molcel.2020.05.031] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 02/07/2023]
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26
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Comprehensive analyses of safety and efficacy toward individualizing imatinib dosage in patients with chronic myeloid leukemia. Int J Hematol 2019; 111:417-426. [DOI: 10.1007/s12185-019-02805-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
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27
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Adashek JJ, LoRusso PM, Hong DS, Kurzrock R. Phase I trials as valid therapeutic options for patients with cancer. Nat Rev Clin Oncol 2019; 16:773-778. [PMID: 31477881 DOI: 10.1038/s41571-019-0262-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2019] [Indexed: 12/17/2022]
Abstract
For many years, oncology phase I trials have been referred to as 'toxicity trials' and have been believed to have low clinical utility other than that of establishing the adverse event profile of novel therapeutic agents. The traditional distinction of clinical trials into three phases has been challenged in the past few years by the introduction of targeted therapies and immunotherapies into the routine management of patients with cancer. This transformation has especially affected early phase trials, leading to the current situation in which response rates are increasingly reported from phase I trials. In this Perspectives, we highlight key elements of phase I trials and discuss how each one of them contributes to a new paradigm whereby preliminary measurements of the clinical benefit from a novel treatment can be obtained in current phase I trials, which can therefore be considered to have a therapeutic intent.
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Affiliation(s)
- Jacob J Adashek
- Department of Internal Medicine, University of South Florida, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - David S Hong
- Department of Investigational Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy, Department of Medicine, University of California San Diego Moores Cancer Center, La Jolla, CA, USA.
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La réévaluation de dose : une réponse au coût élevé des médicaments utilisés en oncologie ? Bull Cancer 2019; 106:719-724. [DOI: 10.1016/j.bulcan.2019.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/25/2019] [Accepted: 04/22/2019] [Indexed: 11/30/2022]
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Sun H, Wu YL. Dacomitinib in non-small-cell lung cancer: a comprehensive review for clinical application. Future Oncol 2019; 15:2769-2777. [PMID: 31401844 DOI: 10.2217/fon-2018-0535] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Dacomitinib is a second-generation EGFR tyrosine kinase inhibitor (TKI) that irreversibly binds to and inhibits EGFR/Her1, Her2 and Her4 subtypes with an efficacy comparable to other TKIs. In the ARCHER 1050 trial, progression-free survival was improved by dacomitinib compared with gefitinib, supporting dacomitinib as a first-line treatment option for advanced non-small-cell lung cancer with sensitive EGFR mutation. Regarding to the higher adverse events rate, dose reductions did not reduce the efficacy of dacomitinib and could effectively decreased the incidence and severity of adverse events. Considering the evolving landscape of EGFR-mutant non-small-cell lung cancer, future head to head comparison between dacomitinib and osimertinib could provide key information to determine the optimal TKI treatment schedule.
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Affiliation(s)
- Hao Sun
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital, First Affiliated Hospital of South China University of Technology, Guangzhou 510080, PR China
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou 510080, PR China
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Yan D, Tait C, Wages NA, Kindwall-Keller T, Dressler EV. Generalization of the time-to-event continual reassessment method to bivariate outcomes. J Biopharm Stat 2019; 29:635-647. [PMID: 31264936 DOI: 10.1080/10543406.2019.1634087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This article considers the problem of designing Phase I-II clinical trials with delayed toxicity and efficacy outcomes. The proposed design is motivated by a Phase I-II study evaluating all-trans retinoic acid (ATRA) in combination with a fixed dose of daratumumab in the treatment of relapsed or refractory multiple myeloma. The primary objective of the study is to identify a dose that maximizes efficacy and has an acceptable level of toxicity. The toxicity endpoint is observed in one cycle of therapy (i.e., 4 weeks) while the efficacy endpoint is assessed after 8 weeks of treatment. The difference in endpoint observation windows causes logistical challenges in conducting the trial, since it is not practical to wait until both outcomes for each patient have been fully observed before sequentially assigning the dose of a newly eligible patient. In order to avoid delays in treatment for newly enrolled patients and to accelerate trial progress, we generalize the time-to-event continual reassessment method (TITE-CRM) to bivariate outcomes. Simulation studies are conducted to evaluate the proposed method, and we found that the proposed design is able to accurately select doses that maximize efficacy and have acceptable toxicity, while using all available information in allocating patients at the time of dose assignment. We compare the proposed methodology to two existing methods in the area.
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Affiliation(s)
- Donglin Yan
- a Department of Biostatistics, College of Public Health, University of Kentucky , Lexington , Kentucky , USA
| | - Christopher Tait
- b Department of Biostatistics, PRA Health Sciences , Charlottesville , Virginia , USA
| | - Nolan A Wages
- c Department of Public Health Sciences, University of Virginia , Charlottesville , Virginia , USA
| | - Tamila Kindwall-Keller
- d Division of Hematology/Oncology, University of Virginia Health System , Charlottesville , Virginia , USA
| | - Emily V Dressler
- e Department of Biostatistical Sciences, Wake Forest School of Medicine , Winston-Salem , North Carolina , USA
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Prabhash K, Patil V, Noronha V, Joshi A, Abhyankar A, Menon N, Banavali S, Gupta S. Low doses in immunotherapy: Are they effective? CANCER RESEARCH, STATISTICS, AND TREATMENT 2019. [DOI: 10.4103/crst.crst_29_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Muenz DG, Taylor JMG, Braun TM. Phase I–II trial design for biologic agents using conditional auto‐regressive models for toxicity and efficacy. J R Stat Soc Ser C Appl Stat 2018. [DOI: 10.1111/rssc.12314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Tuxen IV, Rohrberg KS, Oestrup O, Ahlborn LB, Schmidt AY, Spanggaard I, Hasselby JP, Santoni-Rugiu E, Yde CW, Mau-Sørensen M, Nielsen FC, Lassen U. Copenhagen Prospective Personalized Oncology (CoPPO)-Clinical Utility of Using Molecular Profiling to Select Patients to Phase I Trials. Clin Cancer Res 2018; 25:1239-1247. [PMID: 30274980 DOI: 10.1158/1078-0432.ccr-18-1780] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/21/2018] [Accepted: 09/27/2018] [Indexed: 11/16/2022]
Abstract
PURPOSE We evaluated the clinical benefit of tumor molecular profiling to select treatment in the phase I setting. EXPERIMENTAL DESIGN Patients with advanced solid cancers and exhausted treatment options referred to a phase I unit were included in a prospective, single-center, single-arm open-label study (NCT02290522). Tumor biopsies were obtained for comprehensive genomic analysis including whole-exome sequencing and RNA sequencing. When possible, patients were treated with regimen matched to the genomic profile. Primary endpoint was progression-free survival (PFS). RESULTS From May 2013 to January 2017, a total of 591 patients were enrolled, with 500 patients undergoing biopsy. Genomic profiles were obtained in 460 patients and a potential actionable target was identified in 352 (70%) of 500 biopsied patients. A total of 101 patients (20%) received matched treatment based on either gene mutations or RNA expression levels of targets available in early clinical trials or off-label treatment. Objective response according to RECIST1.1 was observed in 15 of 101 patients (0% complete response, 15% partial response), with a median PFS of 12 weeks (95% confidence interval, 9.9-14.4). CONCLUSIONS Our study supports the feasibility of genomic profiling to select patients in the phase I setting and suggests that genomic matching can be beneficial for a minor subset of patients with no other treatment options. Randomized studies may validate this assumption.See related commentary by Ratain, p. 1136.
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Affiliation(s)
- Ida Viller Tuxen
- The Phase I Unit, Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | | | - Olga Oestrup
- Center for Genomic Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Lise Barlebo Ahlborn
- The Phase I Unit, Department of Oncology, Rigshospitalet, Copenhagen, Denmark
- Center for Genomic Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Ane Yde Schmidt
- Center for Genomic Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Iben Spanggaard
- The Phase I Unit, Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | - Jane P Hasselby
- Department of Pathology, Rigshospitalet, Copenhagen, Denmark
| | | | | | - Morten Mau-Sørensen
- The Phase I Unit, Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | | | - Ulrik Lassen
- The Phase I Unit, Department of Oncology, Rigshospitalet, Copenhagen, Denmark.
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Older adults in phase I clinical trials: a comparative analysis of participation and clinical benefit rate among older adults versus middle age and AYA patients on phase I clinical trials with VEGF/VEGFR inhibitors. Oncotarget 2018; 9:28842-28848. [PMID: 29989021 PMCID: PMC6034739 DOI: 10.18632/oncotarget.25571] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 05/24/2018] [Indexed: 12/27/2022] Open
Abstract
Background Older adults aged 65 years and above remain underrepresented in cancer clinical trials. We hypothesized that older participation in early phase trials with VEGF/VEGFR (VEGF/R) inhibitors was lower than cancer prevalence in this group and lower than other age groups (middle age, adolescent/young adults [AYA]). Results Of 1489 patients, 278 were older adults (18%, median age 68.9y), 220 AYA (15%, median age 32.6 y), 991 middle age (67%, median age 53.8 y). Common malignancies included gastrointestinal (n = 438, 29%), gynecologic (n = 234, 16%), and thoracic/head/neck (n = 216, 15%). Median time to treatment failure did not vary significantly between the 3 age-based cohorts (3m in older adults, 3.5 m middle age, 3.3 m AYA). OR of achieving clinical benefit in older adults vs middle age (OR 1.10, p 0.19 [two-tailed], p 0.09 [one-tailed]) and AYA vs middle age (OR 0.85, p 0.31 [proportions z-test, two tailed], p 0.15 [one-tailed]) showed no significant differences. Conclusions Older adults accounted for <20% of participants on phase I clinical trials with VEGF/R inhibitors but those who participated were just as likely to achieve a clinical benefit as AYA and middle age patients. These findings merit further exploration into patient selection for early phase trials. Methods We identified and separated patients treated on VEGF/R-inhibitor-based phase I trials from 12/1/2004–07/31/2013 into 3 age-based cohorts, AYA (15–39y), middle age (40–64 y), older adults (65 y+). We analyzed clinical/treatment characteristics and response outcomes, calculating the odds ratios (OR) of clinical benefit (defined as SD ≥ 6months, PR, CR) for older adults and AYAs versus middle age participants.
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Koh SB, Wallez Y, Dunlop CR, Bernaldo de Quirós Fernández S, Bapiro TE, Richards FM, Jodrell DI. Mechanistic Distinctions between CHK1 and WEE1 Inhibition Guide the Scheduling of Triple Therapy with Gemcitabine. Cancer Res 2018; 78:3054-3066. [PMID: 29735549 PMCID: PMC5985963 DOI: 10.1158/0008-5472.can-17-3932] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/14/2018] [Accepted: 04/04/2018] [Indexed: 12/31/2022]
Abstract
Combination of cytotoxic therapy with emerging DNA damage response inhibitors (DDRi) has been limited by tolerability issues. However, the goal of most combination trials has been to administer DDRi with standard-of-care doses of chemotherapy. We hypothesized that mechanism-guided treatment scheduling could reduce the incidence of dose-limiting toxicities and enable tolerable multitherapeutic regimens. Integrative analyses of mathematical modeling and single-cell assays distinguished the synergy kinetics of WEE1 inhibitor (WEE1i) from CHEK1 inhibitor (CHK1i) by potency, spatiotemporal perturbation, and mitotic effects when combined with gemcitabine. These divergent properties collectively supported a triple-agent strategy, whereby a pulse of gemcitabine and CHK1i followed by WEE1i durably suppressed tumor cell growth. In xenografts, CHK1i exaggerated replication stress without mitotic CDK hyperactivation, enriching a geminin-positive subpopulation and intratumoral gemcitabine metabolite. Without overt toxicity, addition of WEE1i to low-dose gemcitabine and CHK1i was most effective in tumor control compared with single and double agents. Overall, our work provides quantitative insights into the mechanisms of DDRi chemosensitization, leading to the rational development of a tolerable multitherapeutic regimen.Significance: Multiple lines of mechanistic insight regarding DNA damage response inhibitors rationally guide the preclinical development of a tolerable multitherapeutic regimen.Graphical Abstract: http://cancerres.aacrjournals.org/content/canres/78/11/3054/F1.large.jpg Cancer Res; 78(11); 3054-66. ©2018 AACR.
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Affiliation(s)
- Siang-Boon Koh
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, United Kingdom.
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Yann Wallez
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, United Kingdom
| | - Charles R Dunlop
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, United Kingdom
| | | | - Tashinga E Bapiro
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, United Kingdom
- Oncology, IMED Biotech Unit, AstraZeneca, Cambridge, United Kingdom
| | - Frances M Richards
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, United Kingdom
| | - Duncan I Jodrell
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, United Kingdom
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Noh H, Jung SY, Kwak J, Kim S, Oh SJ, Zang DY, Lee S, Park HL, Jo DJ, Shin JS, Do YR, Kim D, Lee JI. Determination of a radotinib dosage regimen based on dose-response relationships for the treatment of newly diagnosed patients with chronic myeloid leukemia. Cancer Med 2018; 7:1766-1773. [PMID: 29577681 PMCID: PMC5943471 DOI: 10.1002/cam4.1436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 02/13/2018] [Accepted: 02/17/2018] [Indexed: 01/14/2023] Open
Abstract
Radotinib is a second-generation BCR-ABL1 tyrosine kinase inhibitor approved for the treatment of chronic myeloid leukemia in chronic phase (CP-CML). Here, using the data from a Phase 3 study conducted in patients with newly diagnosed CP-CML, the dose-efficacy as well as dose-safety relationship analyses were performed to determine a safe and effective initial dosage regimen of radotinib. A significant positive association was detected between the starting dose of radotinib adjusted for body weight (Dose/BW) and the probability of dose-limiting toxicity (≥grade 3 hematologic and nonhematologic toxicity) (P = 0.003). In contrast, a significant inverse association was discovered between Dose/BW and the probability of major molecular response (BCR-ABL1/ABL1 ≤ 0.1%) when controlled for sex (P = 0.033). Moreover, frequent dose interruptions and reductions secondary to radotinib toxicities occurred in the Phase 3 study, resulting in nearly half (44%) of patients receiving a reduced dose at a 12-month follow-up. In conclusion, the results of this study demonstrate the need for initial radotinib dose attenuation to improve the long-term efficacy and safety of radotinib. Hence, the authors suggest a new upfront radotinib dose of 400 mg once daily be tested in patients with newly diagnosed CP-CML.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Benzamides/administration & dosage
- Benzamides/adverse effects
- Dose-Response Relationship, Drug
- Drug Dosage Calculations
- Female
- Fusion Proteins, bcr-abl/genetics
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Male
- Middle Aged
- Molecular Weight
- Pyrazines/administration & dosage
- Pyrazines/adverse effects
- Treatment Outcome
- Young Adult
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Affiliation(s)
- Hayeon Noh
- Department of PharmacyCollege of PharmacyYonsei UniversityIncheonKorea
| | - Su Young Jung
- Department of PharmacyCollege of PharmacySeoul National UniversitySeoulKorea
- Research Institute of Pharmaceutical SciencesSeoul National UniversitySeoulKorea
| | - Jae‐Yong Kwak
- Chonbuk National University Medical School & HospitalJeonjuKorea
| | - Sung‐Hyun Kim
- Department of Internal MedicineDong‐A University College of MedicineBusanKorea
| | - Suk Joong Oh
- Department of Internal MedicineKangbuk Samsung HospitalSungkyunkwan University School of MedicineSeoulKorea
| | - Dae Young Zang
- Department of Internal MedicineHallym University Sacred Heart HospitalAnyangKorea
| | - Suhyun Lee
- Department of PharmacyCollege of PharmacySeoul National UniversitySeoulKorea
- Research Institute of Pharmaceutical SciencesSeoul National UniversitySeoulKorea
| | - Hye Lin Park
- Central Research InstituteIL‐YANG Pharmaceutical Co., Ltd.YonginKorea
| | - Dae Jin Jo
- Central Research InstituteIL‐YANG Pharmaceutical Co., Ltd.YonginKorea
| | - Jae Soo Shin
- Central Research InstituteIL‐YANG Pharmaceutical Co., Ltd.YonginKorea
| | - Young Rok Do
- Department of MedicineDongsan Medical CenterKeimyung UniversityDaeguKorea
| | - Dong‐Wook Kim
- Seoul St. Mary's HospitalLeukemia Research InstituteThe Catholic University of KoreaSeoulKorea
| | - Jangik I. Lee
- Department of PharmacyCollege of PharmacySeoul National UniversitySeoulKorea
- Research Institute of Pharmaceutical SciencesSeoul National UniversitySeoulKorea
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Woodcock VK, Clive S, Wilson RH, Coyle VM, Stratford MRL, Folkes LK, Eastell R, Barton C, Jones P, Kazmi-Stokes S, Turner H, Halford S, Harris AL, Middleton MR. A first-in-human phase I study to determine the maximum tolerated dose of the oral Src/ABL inhibitor AZD0424. Br J Cancer 2018; 118:770-776. [PMID: 29438361 PMCID: PMC5877436 DOI: 10.1038/bjc.2017.484] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 12/09/2017] [Accepted: 12/12/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Src is involved in cancer invasion and metastasis. AZD0424, an oral inhibitor of Src and ABL1, has shown evidence of anti-tumour activity in pre-clinical studies. METHODS A phase Ia, dose escalation study was performed to assess the safety of continuous oral dosing with AZD0424 in advanced solid tumours. Secondary objectives included investigation of AZD0424 pharmacokinetics, effect on Src activity using markers of bone turnover, and anti-tumour activity. RESULTS 41 patients were treated; 34 received AZD0424 once-daily at doses ranging from 5 mg to 150 mg, and 7 received 40 mg bi-daily 41.5% of patients experienced at least one AZD0424-related adverse event that was Grade 3-5 in severity, with patients treated at doses above 60 mg per day experiencing multiple treatment-related toxicities. The most commonly observed AZD0424-related adverse events were nausea, fatigue, anorexia and alopecia. Cmax and AUC increased linearly with dose and the mean±standard deviation t1/2 was 8.4±2.8 h. Clear evidence of Src target inhibition was seen at doses ⩾20 mg per day. No responses were observed and 7 patients (17.1%) achieved stable disease lasting 6 weeks or more. CONCLUSIONS AZD0424 displayed no evidence of efficacy as monotherapy despite a clear pharmacodynamic effect. Further evaluation of AZD0424 monotherapy in patients with solid tumours is not recommended.
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Affiliation(s)
- Victoria K Woodcock
- University of Oxford Department of Oncology, Churchill Hospital, Old Road, Oxford OX3 7LJ, UK
| | - Sally Clive
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh EH4 2XU, UK
| | - Richard H Wilson
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Lisburn Road, Belfast BT9 7AE, Northern Ireland, UK
| | - Vicky M Coyle
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Lisburn Road, Belfast BT9 7AE, Northern Ireland, UK
| | - Michael R L Stratford
- Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
| | - Lisa K Folkes
- Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford OX3 7DQ, UK
| | - Richard Eastell
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield S10 2TN, UK
| | - Claire Barton
- Cancer Research UK Centre for Drug Development, Cancer Research UK, Angel Building, 407 St. John Street, London EC1V 4AD, UK
| | - Paul Jones
- Cancer Research UK Centre for Drug Development, Cancer Research UK, Angel Building, 407 St. John Street, London EC1V 4AD, UK
| | - Shamim Kazmi-Stokes
- Cancer Research UK Centre for Drug Development, Cancer Research UK, Angel Building, 407 St. John Street, London EC1V 4AD, UK
| | - Helen Turner
- Cancer Research UK Centre for Drug Development, Cancer Research UK, Angel Building, 407 St. John Street, London EC1V 4AD, UK
| | - Sarah Halford
- Cancer Research UK Centre for Drug Development, Cancer Research UK, Angel Building, 407 St. John Street, London EC1V 4AD, UK
| | - Adrian L Harris
- University of Oxford Department of Oncology, Churchill Hospital, Old Road, Oxford OX3 7LJ, UK
| | - Mark R Middleton
- University of Oxford Department of Oncology, Churchill Hospital, Old Road, Oxford OX3 7LJ, UK
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford OX3 7LE, UK
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Zang Y, Lee JJ, Yuan Y. Adaptive designs for identifying optimal biological dose for molecularly targeted agents. Clin Trials 2018; 11:319-327. [PMID: 24844841 DOI: 10.1177/1740774514529848] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Traditionally, the purpose of a dose-finding design in cancer is to find the maximum tolerated dose based solely on toxicity. However, for molecularly targeted agents, little toxicity may arise within the therapeutic dose range and the dose-response curves may not be monotonic. This challenges the principle that more is better, which is widely accepted for conventional chemotherapy. Methods We propose three adaptive dose-finding designs for trials evaluating molecularly targeted agents, for which the dose-response curves are unimodal or plateaued. The goal of these designs is to find the optimal biological dose, which is defined as the lowest dose with the highest rate of efficacy while safe. The first proposed design is parametric and assumes a logistic dose-efficacy curve for dose finding, the second design is nonparametric and uses the isotonic regression to identify the optimal biological dose, and the third design has the spirit of a 'semiparametric' approach by assuming a logistic model only locally around the current dose. Results We conducted extensive simulation studies to investigate the operating characteristics of the proposed designs. Simulation studies show that the nonparametric and semiparametric designs have good operating characteristics for finding the optimal biological dose. Limitations The proposed designs assume a binary endpoint. Extension of the proposed designs to ordinal and time-to-event endpoints is worth further investigation. Conclusion Among the three proposed designs, the nonparametric and semiparametric designs yield consistently good operating characteristics and thus are recommended for practical use. The software to implement these two designs is available for free download at http://odin.mdacc.tmc.edu/~yyuan/ .
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Affiliation(s)
- Yong Zang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Liu S, Nikanjam M, Kurzrock R. Dosing de novo combinations of two targeted drugs: Towards a customized precision medicine approach to advanced cancers. Oncotarget 2017; 7:11310-20. [PMID: 26824502 PMCID: PMC4905475 DOI: 10.18632/oncotarget.7023] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 01/15/2016] [Indexed: 02/07/2023] Open
Abstract
Metastatic cancers harbor complex genomic alterations. Thus, monotherapies are often suboptimal. Individualized combinations are needed in order to attenuate resistance. To help inform selection of safe starting doses for novel, two-agent, targeted drug combinations, we identified clinical trials in adult oncology patients who received targeted drug doublets (PubMed, January 1, 2010 through December 31, 2013). The dose percentage was calculated for each drug: (safe dose in combination divided by single agent full dose) X 100. Additive dose percentage represented the sum of the dose percentage for each drug. A total of 144 studies (N = 8568 patients; 95 combinations) were analyzed. In 51% of trials, each of the two drugs could be administered at 100% of their full dose. The lowest safe additive dose percentage was 60% if targets and/or class of drugs overlapped, or in the presence of mTor inhibitors, which sometimes compromised the combination dose. If neither class nor target overlapped and if mTor inhibitors were absent, the lowest safe additive dose percentage was 143%. The current observations contribute to the knowledge base that informs safe starting doses for new combinations of targeted drugs in the context of clinical trials or practice, hence facilitating customized combination therapies.
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Affiliation(s)
- Sariah Liu
- Department of Hematology-Oncology, Kaiser Permanente San Diego Medical Center, San Diego, CA, USA
| | - Mina Nikanjam
- Division of Hematology-Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, UC San Diego Moores Cancer Center, San Diego, CA, USA
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Evolution of early phase clinical trials in oncology. J Mol Med (Berl) 2017; 96:31-38. [PMID: 29177698 DOI: 10.1007/s00109-017-1612-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/06/2017] [Accepted: 11/09/2017] [Indexed: 12/19/2022]
Abstract
The therapeutic armamentarium for the treatment of cancer has rapidly evolved with the advent of molecularly targeted and immuno-oncology agents. Dramatic and prolonged responses observed in patients with advanced cancers have created excitement and promise for expedited development of effective new treatments. However, this has also necessitated a rethinking of our early phase clinical trial designs and the process of optimally developing a novel agent. In this review, we discuss the current state and future directions of phase I clinical trials in oncology. Firstly, we cover the statistical methodologies behind rules and model-based dose escalation designs, and what the future holds for optimal dose selection beyond targeting the maximum tolerated dose. Next, we discuss the recent adoption of seamless expansion strategies to expedite drug development timelines, highlighted by the pembrolizumab KEYNOTE-001 trial, and potential pitfalls with this approach. Finally, we delve into the concepts behind genomic matching trials, including early success stories and the challenges that lie ahead.
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41
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Lin R, Yin G. STEIN: A simple toxicity and efficacy interval design for seamless phase I/II clinical trials. Stat Med 2017; 36:4106-4120. [DOI: 10.1002/sim.7428] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 07/03/2017] [Accepted: 07/06/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Ruitao Lin
- Department of Biostatistics; University of Washington; Seattle 98195 Washington U.S.A
| | - Guosheng Yin
- Department of Statistics and Actuarial Science; The University of Hong Kong; Pokfulam Road Hong Kong
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Nikanjam M, Patel H, Kurzrock R. Dosing immunotherapy combinations: Analysis of 3,526 patients for toxicity and response patterns. Oncoimmunology 2017; 6:e1338997. [PMID: 28920006 DOI: 10.1080/2162402x.2017.1338997] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/31/2017] [Accepted: 06/01/2017] [Indexed: 01/08/2023] Open
Abstract
Immunotherapy combinations are used to improve outcomes in metastatic cancer, but evidence-based knowledge of appropriate starting doses for novel combinations is lacking. Phase I-III adult combination clinical trials (≥ 1 drug was immunotherapy; anti-PD-1, PD-L1, or CTLA-4) were reviewed (PubMed Jan 1, 2010 to Sep 1, 2016; ASCO 2014-2016, ASH/ESMO 2014-2015 abstracts). The safe dose for each drug used in each combination was divided by the single-agent recommended dose to calculate dose percentage. Additive dose percentage was the sum of each dose percentage. Overall, 84 studies (N = 3,526 patients, 59 combinations) were analyzed. In 50% of studies, all drugs could be administered at full dose; 63%, in the presence of anti-PD-1/PD-L1 and 36% with anti-CTLA-4. The lowest safe starting dose for a doublet combination including a second immunotherapy was 50% of each drug; 60%, for a targeted agent. Most doublet/triplets combining anti-PD-1/PD-L1 with cytotoxics were tolerable at full doses. Response rates (median [interquartile range]) were higher for 3-drug than 2-drug combinations (53% [33-63%] (N = 23 studies) vs. 23% [14-39%]) (N = 60 studies) (p < 0.0001) with similar rates seen for targeted, cytotoxic, biologic, or additional immunotherapy combinations (p = 0.35). In conclusion, anti-PD-1/PD-L1 checkpoint inhibitors can be safely given with a variety of other immunotherapy and targeted agents, albeit at about half dose. Doublet and triplet combinations with cytotoxics could mostly be given at full doses. Anti-CTLA-4 agents compromised dosing more than anti-PD-1/PD-L1 agents. Response rates were significantly higher for 3- versus 2-drug combinations.
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Affiliation(s)
- Mina Nikanjam
- Division of Hematology-Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Harsh Patel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, UC San Diego Moores Cancer Center, San Diego, CA, USA
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Yin J, Shen S. Challenges and Innovations in Phase I Dose-Finding Designs for Molecularly Targeted Agents and Cancer Immunotherapies. JOURNAL OF BIOMETRICS & BIOSTATISTICS 2017; 7. [PMID: 28616356 PMCID: PMC5467542 DOI: 10.4172/2155-6180.1000324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Phase I oncology trials are designed to identify a safe dose with an acceptable toxicity profile. In traditional phase I dose-finding design, the dose is typically determined based on the probability of severe toxicity observed during the first treatment cycle. The recent development of molecularly targeted agents and cancer immunotherapies call for new innovations in phase I designs, because of prolonged treatment cycles often involved. Various phase I designs using toxicity and efficacy endpoints from multiple treatment cycles have been developed for these new treatment agents. Here, we will review the novel endpoints and designs for the phase I oncology clinical trials.
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Affiliation(s)
- Jun Yin
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA
| | - Shihao Shen
- Department of Microbiology, Immunology, & Molecular Genetics, UCLA, Los Angeles, CA 90024, USA
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Nikanjam M, Liu S, Yang J, Kurzrock R. Dosing Three-Drug Combinations That Include Targeted Anti-Cancer Agents: Analysis of 37,763 Patients. Oncologist 2017; 22:576-584. [PMID: 28424323 DOI: 10.1634/theoncologist.2016-0357] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 01/10/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Combining targeted and cytotoxic agents has the potential to improve efficacy and attenuate resistance for metastatic cancer. Information regarding safe starting doses for clinical trials of novel three-drug combinations is lacking. MATERIALS AND METHODS Published phase I-III adult oncology clinical trials of three-drug combinations involving a targeted agent were identified by PubMed search (January 1, 2010 to December 31, 2013). A dose percentage was calculated to compare the dose used in combination to the single agent recommended dose: (U.S. Food and Drug Administration-approved/recommended phase II dose/maximum tolerated dose). The additive dose percentage was the sum of the dose percentages for each drug in the combination. RESULTS A total of 37,763 subjects and 243 drug combinations were included. Only 28% of studies could give each of the three agents at 100%. For combinations involving two targeted agents and a cytotoxic agent, the lowest starting additive dose percentage was 133%, which increased to 250% if two antibodies were included. For combinations of one targeted agent and two cytotoxic agents, the lowest additive safe dose percentage was 137%. When both cytotoxic agents were held at 100%, as occurred in 56% of studies (which generally used cytotoxic doublets with known combination safety dosing), the lowest safe dose percentage was 225% (providing that a histone deacetylase inhibitor was not the targeted agent). CONCLUSION These findings serve as a safe starting point for dosing novel three-drug combinations involving a targeted agent in clinical trials and practice. The Oncologist 2017;22:576-584 IMPLICATIONS FOR PRACTICE: Targeted and cytotoxic drug combinations can improve efficacy and overcome resistance. More knowledge of safe starting doses would facilitate use of combinations in clinical trials and practice. Analysis of 37,763 subjects (243 combinations) showed three drugs could be safely administered, but less than 30% of combinations could include all three drugs at full dose. Dose reductions to 45% of the dose of each single agent may be required. Combinations involving two antibodies required fewer dose reductions, and the use of established cytotoxic doublets made initial dose assignment easier.
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Affiliation(s)
- Mina Nikanjam
- Division of Hematology-Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - Sariah Liu
- Department of Hematology-Oncology, Kaiser Permanente San Diego Medical Center, San Diego, California, USA
| | - Jincheng Yang
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, California, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, UC San Diego Moores Cancer Center, San Diego, California, USA
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Tolcher A. Dose determination for molecularly targeted therapies: Much Ado About Nothing. Cancer 2017; 123:1298-1300. [PMID: 28182254 DOI: 10.1002/cncr.30584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 12/28/2016] [Accepted: 01/04/2017] [Indexed: 11/07/2022]
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Hansen AR, Cook N, Amir E, Siu LL, Abdul Razak AR. Determinants of the recommended phase 2 dose of molecular targeted agents. Cancer 2017; 123:1409-1415. [DOI: 10.1002/cncr.30579] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/02/2016] [Accepted: 11/04/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Aaron R. Hansen
- Princess Margaret Cancer Centre; Drug Development Program; Toronto Ontario Canada
| | - Natalie Cook
- Princess Margaret Cancer Centre; Drug Development Program; Toronto Ontario Canada
| | - Eitan Amir
- Princess Margaret Cancer Centre; Drug Development Program; Toronto Ontario Canada
- Institute of Health Policy Management and Evaluation; University of Toronto; Toronto Ontario Canada
| | - Lillian L. Siu
- Princess Margaret Cancer Centre; Drug Development Program; Toronto Ontario Canada
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Saad ED, Paoletti X, Burzykowski T, Buyse M. Precision medicine needs randomized clinical trials. Nat Rev Clin Oncol 2017; 14:317-323. [DOI: 10.1038/nrclinonc.2017.8] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Sharma RA, Plummer R, Stock JK, Greenhalgh TA, Ataman O, Kelly S, Clay R, Adams RA, Baird RD, Billingham L, Brown SR, Buckland S, Bulbeck H, Chalmers AJ, Clack G, Cranston AN, Damstrup L, Ferraldeschi R, Forster MD, Golec J, Hagan RM, Hall E, Hanauske AR, Harrington KJ, Haswell T, Hawkins MA, Illidge T, Jones H, Kennedy AS, McDonald F, Melcher T, O'Connor JPB, Pollard JR, Saunders MP, Sebag-Montefiore D, Smitt M, Staffurth J, Stratford IJ, Wedge SR. Clinical development of new drug-radiotherapy combinations. Nat Rev Clin Oncol 2016; 13:627-42. [PMID: 27245279 DOI: 10.1038/nrclinonc.2016.79] [Citation(s) in RCA: 213] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In countries with the best cancer outcomes, approximately 60% of patients receive radiotherapy as part of their treatment, which is one of the most cost-effective cancer treatments. Notably, around 40% of cancer cures include the use of radiotherapy, either as a single modality or combined with other treatments. Radiotherapy can provide enormous benefit to patients with cancer. In the past decade, significant technical advances, such as image-guided radiotherapy, intensity-modulated radiotherapy, stereotactic radiotherapy, and proton therapy enable higher doses of radiotherapy to be delivered to the tumour with significantly lower doses to normal surrounding tissues. However, apart from the combination of traditional cytotoxic chemotherapy with radiotherapy, little progress has been made in identifying and defining optimal targeted therapy and radiotherapy combinations to improve the efficacy of cancer treatment. The National Cancer Research Institute Clinical and Translational Radiotherapy Research Working Group (CTRad) formed a Joint Working Group with representatives from academia, industry, patient groups and regulatory bodies to address this lack of progress and to publish recommendations for future clinical research. Herein, we highlight the Working Group's consensus recommendations to increase the number of novel drugs being successfully registered in combination with radiotherapy to improve clinical outcomes for patients with cancer.
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Affiliation(s)
- Ricky A Sharma
- UCL Cancer Institute, University College London, 72 Huntley Street, London WC1E 6DD, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Martin D Forster
- UCL Cancer Institute, University College London, 72 Huntley Street, London WC1E 6DD, UK
| | - Julian Golec
- Vertex Pharmaceuticals (Europe) Ltd, Abingdon, UK
| | | | - Emma Hall
- The Institute of Cancer Research/The Royal Marsden NIHR Biomedical Research Centre, London, UK
| | | | - Kevin J Harrington
- The Institute of Cancer Research/The Royal Marsden NIHR Biomedical Research Centre, London, UK
| | | | | | | | | | | | - Fiona McDonald
- The Institute of Cancer Research/The Royal Marsden NIHR Biomedical Research Centre, London, UK
| | | | | | | | | | | | | | - John Staffurth
- Cardiff University and Velindre Cancer Centre, Cardiff, UK
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Wong HH, Barton C, Acton G, McLeod R, Halford S. Trends in the characteristics, dose-limiting toxicities and efficacy of phase I oncology trials: The Cancer Research UK experience. Eur J Cancer 2016; 66:9-16. [PMID: 27514008 DOI: 10.1016/j.ejca.2016.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 06/28/2016] [Accepted: 07/04/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Phase I oncology trials have evolved over the years, and these changes could have implications for future studies and patients. METHODS Adult trials sponsored by Cancer Research UK Centre for Drug Development between 1995 and 2013 were analysed. Forty-nine trials were divided into two groups based on the starting date for recruitment: 1995-2003 (24 trials, n = 603) and 2004-2013 (25 trials, n = 750) for comparative purposes. RESULTS From 1995-2003 to 2004-2013, there was a shift towards studying non-cytotoxic agents that are administered orally. In later trials, patients tended to have better performance status, were older, had greater disease burden, and were more likely to have received prior treatment. In 2004-2013, wider variety of dose escalation designs were used, and studies were more likely to be multicentre, target/disease specific, conducted in first-/any-line setting and to require tumour biopsy. The overall incidence of dose-limiting toxicities (DLTs) was unchanged (10.9%; risk of death 0.4%), but DLTs such as neuropathy, stomatitis and thrombocytopaenia were less frequent in the more recent trials, while elevated liver enzymes were more frequent. Non-classical DLTs emerged in the later trials, including hypertension, hypophosphataemia, cardiac and ophthalmic toxicities. Disease control rate (DCR) increased from 27.9% (1995-2003) to 36.0% (2004-2013; P = 0.0033) due to higher rates of disease stabilisation. CONCLUSION Changes in trial designs, therapeutic agents, patient characteristics and DLTs were observed. Although the nature of DLTs changed, the incidence was similar in the two time periods and DCR improved, suggesting that the benefit-risk balance for patients participating in early-phase trials remains acceptable.
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Affiliation(s)
- Han Hsi Wong
- Cancer Research UK Centre for Drug Development, Angel Building, 407 St. John Street, London EC1V 4AD, UK; Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Box 193, Cambridge Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK.
| | - Claire Barton
- Cancer Research UK Centre for Drug Development, Angel Building, 407 St. John Street, London EC1V 4AD, UK
| | - Gary Acton
- Cancer Research UK Centre for Drug Development, Angel Building, 407 St. John Street, London EC1V 4AD, UK
| | - Robert McLeod
- Cancer Research UK Centre for Drug Development, Angel Building, 407 St. John Street, London EC1V 4AD, UK
| | - Sarah Halford
- Cancer Research UK Centre for Drug Development, Angel Building, 407 St. John Street, London EC1V 4AD, UK
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Nikanjam M, Liu S, Kurzrock R. Dosing targeted and cytotoxic two-drug combinations: Lessons learned from analysis of 24,326 patients reported 2010 through 2013. Int J Cancer 2016; 139:2135-41. [PMID: 27389805 PMCID: PMC5096042 DOI: 10.1002/ijc.30262] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 06/26/2016] [Accepted: 06/30/2016] [Indexed: 02/05/2023]
Abstract
Combining agents has the potential to attenuate resistance in metastatic cancer. However, knowledge of appropriate starting doses for novel drug combinations in clinical trials and practice is lacking. Analysis of 372 published studies was used to ascertain safe starting doses for doublets involving a cytotoxic and targeted agent. Phase I–III adult oncology clinical trial publications (January 1, 2010 to December 31, 2013) were identified (PubMed). The dose of drug used in each combination was compared to the single agent recommended dose [FDA‐approved/recommended phase 2 dose (RP2D)/maximum tolerated dose (MTD)]. Dose percentages were calculated as: (safe dose of drug in combination/dose of drug as single agent at FDA/RP2D/MTD) × 100. Additive dose percentages were the sum of the dose percentage for each drug. A total of 24,326 patients (248 drug combinations) were analyzed. In 38% of studies, both drugs could be administered at 100% of their FDA‐approved/RP2D/MTD dose. The lowest safe additive dose percentage was 41% with poly‐ADP ribose polymerase (PARP) or histone deacetylase inhibitors as the targeted agents; 82%, in the absence of these agents; and 97%, with an antibody in the combination. If one drug was administered at 100% of the single agent dose, the lowest safe dose percentage for the second drug was 17% (cytotoxic at 100%) or 36% (targeted at 100%) of the FDA‐approved/RP2D/MTD dose. The current findings can help inform safe starting doses for novel two‐drug combinations (cytotoxic and targeted agents) in the context of clinical trials and practice. What's new? Cytotoxic and targeted cancer drugs act through distinct mechanisms, and when used in combination they can potentially augment therapeutic effectiveness while minimally impacting toxicity. However, whereas algorithms for safe starting doses for new single‐agent therapies are well established, there are few guidelines for combination therapies. Here, analyses of data from published Phase I–III clinical trials shows that about 38% of patients tolerated combinations in which both drugs were administered at full starting doses. In the majority of patients, significant dose reductions were required to guard against toxicity. Intrapatient dose escalation is possible, however, potentially allowing for increased efficacy.
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Affiliation(s)
- Mina Nikanjam
- Division of Hematology-Oncology, University of California Los Angeles, Los Angeles, CA
| | - Sariah Liu
- Department of Hematology-Oncology, Kaiser Permanente San Diego Medical Center, San Diego, CA
| | - Razelle Kurzrock
- Division of Hematology and Oncology, Center for Personalized Cancer Therapy, UC San Diego Moores Cancer Center, San Diego, CA
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