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Biard L, Andrillon A, Silva RB, Lee SM. Dose optimization for cancer treatments with considerations for late-onset toxicities. Clin Trials 2024; 21:322-330. [PMID: 38591582 PMCID: PMC11132952 DOI: 10.1177/17407745231221152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Given that novel anticancer therapies have different toxicity profiles and mechanisms of action, it is important to reconsider the current approaches for dose selection. In an effort to move away from considering the maximum tolerated dose as the optimal dose, the Food and Drug Administration Project Optimus points to the need of incorporating long-term toxicity evaluation, given that many of these novel agents lead to late-onset or cumulative toxicities and there are no guidelines on how to handle them. Numerous methods have been proposed to handle late-onset toxicities in dose-finding clinical trials. A summary and comparison of these methods are provided. Moreover, using PI3K inhibitors as a case study, we show how late-onset toxicity can be integrated into the dose-optimization strategy using current available approaches. We illustrate a re-design of this trial to compare the approach to those that only consider early toxicity outcomes and disregard late-onset toxicities. We also provide proposals going forward for dose optimization in early development of novel anticancer agents with considerations for late-onset toxicities.
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Affiliation(s)
- Lucie Biard
- INSERM U1153 Team ECSTRRA, Université Paris Cité, Paris, France
| | - Anaïs Andrillon
- INSERM U1153 Team ECSTRRA, Université Paris Cité, Paris, France
- Department of Statistical Methodology, Saryga, Tournus, France
| | - Rebecca B Silva
- Columbia University, Mailman School of Public Health, Department of Biostatistics, New York, USA
| | - Shing M Lee
- Columbia University, Mailman School of Public Health, Department of Biostatistics, New York, USA
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Brown SR, Hinsley S, Hall E, Hurt C, Baird RD, Forster M, Scarsbrook AF, Adams RA. A Road Map for Designing Phase I Clinical Trials of Radiotherapy-Novel Agent Combinations. Clin Cancer Res 2022; 28:3639-3651. [PMID: 35552622 PMCID: PMC9433953 DOI: 10.1158/1078-0432.ccr-21-4087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/26/2022] [Accepted: 04/28/2022] [Indexed: 01/07/2023]
Abstract
Radiotherapy has proven efficacy in a wide range of cancers. There is growing interest in evaluating radiotherapy-novel agent combinations and a drive to initiate this earlier in the clinical development of the novel agent, where the scientific rationale and preclinical evidence for a radiotherapy combination approach are high. Optimal design, delivery, and interpretation of studies are essential. In particular, the design of phase I studies to determine safety and dosing is critical to an efficient development strategy. There is significant interest in early-phase research among scientific and clinical communities over recent years, at a time when the scrutiny of the trial methodology has significantly increased. To enhance trial design, optimize safety, and promote efficient trial conduct, this position paper reviews the current phase I trial design landscape. Key design characteristics extracted from 37 methodology papers were used to define a road map and a design selection process for phase I radiotherapy-novel agent trials. Design selection is based on single- or dual-therapy dose escalation, dose-limiting toxicity categorization, maximum tolerated dose determination, subgroup evaluation, software availability, and design performance. Fifteen of the 37 designs were identified as being immediately accessible and relevant to radiotherapy-novel agent phase I trials. Applied examples of using the road map are presented. Developing these studies is intensive, highlighting the need for funding and statistical input early in the trial development to ensure appropriate design and implementation from the outset. The application of this road map will improve the design of phase I radiotherapy-novel agent combination trials, enabling a more efficient development pathway.
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Affiliation(s)
- Sarah R. Brown
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Samantha Hinsley
- Clinical Trials Unit Glasgow, University of Glasgow, Glasgow, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Chris Hurt
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | | | | | - Andrew F. Scarsbrook
- Radiotherapy Research Group, Leeds Institute of Medical Research at St James's, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Richard A. Adams
- Centre for Trials Research, Cardiff University and Velindre Cancer Centre, Cardiff, United Kingdom
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Altzerinakou MA, Paoletti X. Change-point joint model for identification of plateau of activity in early phase trials. Stat Med 2021; 40:2113-2138. [PMID: 33561898 DOI: 10.1002/sim.8889] [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: 01/25/2020] [Revised: 12/19/2020] [Accepted: 01/06/2021] [Indexed: 11/10/2022]
Abstract
This article presents a phase I/II trial design for targeted therapies and immunotherapies, with the objective of identifying the optimal dose (OD). We employ a joint modeling technique for discrete time-to-event toxicity data and repeated and continuous biomarker measurements. For the biomarker measurements, we implement a change point linear mixed effects skeleton model. This model can accommodate both plateauing and nonplateauing dose-activity relationships. For each new cohort of patients, we estimate the maximum tolerated dose (MTD) taking toxicity as a cumulative endpoint, over six treatment cycles. Then, we select the OD using two different criteria. The OD is a dose that is equally active to the MTD or a dose located on the beginning of the plateau of the dose-activity relationship. Joint modeling allows us to take into account informative censoring due to toxicities or lack of activity and we also consider consent withdrawal and intermittent missing responses. Model estimation relies on likelihood inference.
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Affiliation(s)
| | - Xavier Paoletti
- Université Versailles St Quentin, Université Paris Saclay, INSERM U900 STAMPM, Saint-Cloud, France.,Institut Curie, Paris, France
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Fraisse J, Dinart D, Tosi D, Bellera C, Mollevi C. Optimal biological dose: a systematic review in cancer phase I clinical trials. BMC Cancer 2021; 21:60. [PMID: 33441097 PMCID: PMC7805102 DOI: 10.1186/s12885-021-07782-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 01/01/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Classical phase 1 dose-finding designs based on a single toxicity endpoint to assess the maximum tolerated dose were initially developed in the context of cytotoxic drugs. With the emergence of molecular targeted agents and immunotherapies, the concept of optimal biological dose (OBD) was subsequently introduced to account for efficacy in addition to toxicity. The objective was therefore to provide an overview of published phase 1 cancer clinical trials relying on the concept of OBD. METHODS We performed a systematic review through a computerized search of the MEDLINE database to identify early phase cancer clinical trials that relied on OBD. Relevant publications were selected based on a two-step process by two independent readers. Relevant information (phase, type of therapeutic agents, objectives, endpoints and dose-finding design) were collected. RESULTS We retrieved 37 articles. OBD was clearly mentioned as a trial objective (primary or secondary) for 22 articles and was traditionally defined as the smallest dose maximizing an efficacy criterion such as biological target: biological response, immune cells count for immunotherapies, or biological cell count for targeted therapies. Most trials considered a binary toxicity endpoint defined in terms of the proportion of patients who experienced a dose-limiting toxicity. Only two articles relied on an adaptive dose escalation design. CONCLUSIONS In practice, OBD should be a primary objective for the assessment of the recommended phase 2 dose (RP2D) for a targeted therapy or immunotherapy phase I cancer trial. Dose escalation designs have to be adapted accordingly to account for both efficacy and toxicity.
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Affiliation(s)
- J Fraisse
- Unité de Biométrie, Institut du Cancer Montpellier (ICM), Université de Montpellier, 208 rue des Apothicaire, 34298, Montpellier Cedex 5, France
| | - D Dinart
- Inserm CIC1401, Module Epidémiologie clinique, Institut Bergonié, Bordeaux, France
| | - D Tosi
- Unité de Biométrie, Institut du Cancer Montpellier (ICM), Université de Montpellier, 208 rue des Apothicaire, 34298, Montpellier Cedex 5, France
| | - C Bellera
- Inserm CIC1401, Module Epidémiologie clinique, Institut Bergonié, Bordeaux, France
| | - C Mollevi
- Unité de Biométrie, Institut du Cancer Montpellier (ICM), Université de Montpellier, 208 rue des Apothicaire, 34298, Montpellier Cedex 5, France. .,Institut Desbrest d'Epidémiologie et de Santé Publique, UMR Inserm - Université de Montpellier, Montpellier, France.
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Mazzarella L, Morganti S, Marra A, Trapani D, Tini G, Pelicci P, Curigliano G. Master protocols in immuno-oncology: do novel drugs deserve novel designs? J Immunother Cancer 2020; 8:e000475. [PMID: 32238471 PMCID: PMC7174064 DOI: 10.1136/jitc-2019-000475] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2020] [Indexed: 12/31/2022] Open
Abstract
The rapid rise to fame of immuno-oncology (IO) drugs has generated unprecedented interest in the industry, patients and doctors, and has had a major impact in the treatment of most cancers. An interesting aspect in the clinical development of many IO agents is the increasing reliance on nonconventional trial design, including the so-called 'master protocols' that incorporate various adaptive features and often heavily rely on biomarkers to select patient populations most likely to benefit. These novel designs promise to maximize the clinical benefit that can be reaped from clinical research, but are not without costs. Their acceptance as solid evidence basis for use outside of the research context requires profound cultural changes by multiple stakeholders, including regulatory bodies, decision-makers, statisticians, researchers, doctors and, most importantly, patients. Here we review characteristics of recent and ongoing trials testing IO drugs with unconventional design, and we highlight trends and critical aspects.
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Affiliation(s)
- Luca Mazzarella
- Division of Early Drug Development for Innovative Therapies, IEO European Institute of Oncology IRCCS, Milan, Italy
- Experimental Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Stefania Morganti
- Division of Early Drug Development for Innovative Therapies, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Antonio Marra
- Division of Early Drug Development for Innovative Therapies, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Dario Trapani
- Division of Early Drug Development for Innovative Therapies, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Giulia Tini
- Experimental Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Piergiuseppe Pelicci
- Experimental Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, Universita degli Studi di Milano, Milan, Italy
| | - Giuseppe Curigliano
- Division of Early Drug Development for Innovative Therapies, IEO European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hematology, Universita degli Studi di Milano, Milan, Italy
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