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El-Sayed MM, Bianco JR, Li Y, Fabian Z. Tumor-Agnostic Therapy-The Final Step Forward in the Cure for Human Neoplasms? Cells 2024; 13:1071. [PMID: 38920700 PMCID: PMC11201516 DOI: 10.3390/cells13121071] [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: 05/01/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 06/27/2024] Open
Abstract
Cancer accounted for 10 million deaths in 2020, nearly one in every six deaths annually. Despite advancements, the contemporary clinical management of human neoplasms faces a number of challenges. Surgical removal of tumor tissues is often not possible technically, while radiation and chemotherapy pose the risk of damaging healthy cells, tissues, and organs, presenting complex clinical challenges. These require a paradigm shift in developing new therapeutic modalities moving towards a more personalized and targeted approach. The tumor-agnostic philosophy, one of these new modalities, focuses on characteristic molecular signatures of transformed cells independently of their traditional histopathological classification. These include commonly occurring DNA aberrations in cancer cells, shared metabolic features of their homeostasis or immune evasion measures of the tumor tissues. The first dedicated, FDA-approved tumor-agnostic agent's profound progression-free survival of 78% in mismatch repair-deficient colorectal cancer paved the way for the accelerated FDA approvals of novel tumor-agnostic therapeutic compounds. Here, we review the historical background, current status, and future perspectives of this new era of clinical oncology.
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Affiliation(s)
| | | | | | - Zsolt Fabian
- School of Medicine and Dentistry, Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston PR1 2HE, UK; (M.M.E.-S.); (J.R.B.); (Y.L.)
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2
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Stewart DJ, Bradford JP, Sehdev S, Ramsay T, Navani V, Rawson NSB, Jiang DM, Gotfrit J, Wheatley-Price P, Liu G, Kaplan A, Spadafora S, Goodman SG, Auer RAC, Batist G. New Anticancer Drugs: Reliably Assessing "Value" While Addressing High Prices. Curr Oncol 2024; 31:2453-2480. [PMID: 38785465 PMCID: PMC11119944 DOI: 10.3390/curroncol31050184] [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: 02/27/2024] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/25/2024] Open
Abstract
Countries face challenges in paying for new drugs. High prices are driven in part by exploding drug development costs, which, in turn, are driven by essential but excessive regulation. Burdensome regulation also delays drug development, and this can translate into thousands of life-years lost. We need system-wide reform that will enable less expensive, faster drug development. The speed with which COVID-19 vaccines and AIDS therapies were developed indicates this is possible if governments prioritize it. Countries also differ in how they value drugs, and generally, those willing to pay more have better, faster access. Canada is used as an example to illustrate how "incremental cost-effectiveness ratios" (ICERs) based on measures such as gains in "quality-adjusted life-years" (QALYs) may be used to determine a drug's value but are often problematic, imprecise assessments. Generally, ICER/QALY estimates inadequately consider the impact of patient crossover or long post-progression survival, therapy benefits in distinct subpopulations, positive impacts of the therapy on other healthcare or societal costs, how much governments willingly might pay for other things, etc. Furthermore, a QALY value should be higher for a lethal or uncommon disease than for a common, nonlethal disease. Compared to international comparators, Canada is particularly ineffective in initiating public funding for essential new medications. Addressing these disparities demands urgent reform.
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Affiliation(s)
- David J. Stewart
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - John-Peter Bradford
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Sandeep Sehdev
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
| | - Vishal Navani
- Division of Medical Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Nigel S. B. Rawson
- Canadian Health Policy Institute, Toronto, ON M5V 0A4, Canada;
- Macdonald-Laurier Institute, Ottawa, ON K1N 7Z2, Canada
| | - Di Maria Jiang
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Princess Margaret Cancer Center, Toronto, ON M5G 2M9, Canada
| | - Joanna Gotfrit
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
| | - Paul Wheatley-Price
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Geoffrey Liu
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Princess Margaret Cancer Center, Toronto, ON M5G 2M9, Canada
| | - Alan Kaplan
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Family Physicians Airway Group of Canada, Markham, ON L3R 9X9, Canada
| | - Silvana Spadafora
- Algoma District Cancer Program, Sault Ste Marie, ON P6B 0A8, Canada;
| | - Shaun G. Goodman
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- St. Michael’s Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, Toronto, ON M5B 1W8, Canada
| | - Rebecca A. C. Auer
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Department of Surgery, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada
| | - Gerald Batist
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
- Centre for Translational Research, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
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3
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Fountzilas E, Tsimberidou AM, Hiep Vo H, Kurzrock R. Tumor-agnostic baskets to N-of-1 platform trials and real-world data: Transforming precision oncology clinical trial design. Cancer Treat Rev 2024; 125:102703. [PMID: 38484408 DOI: 10.1016/j.ctrv.2024.102703] [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: 01/08/2024] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 04/06/2024]
Abstract
Choosing the right drug(s) for the right patient via advanced genomic sequencing and multi-omic interrogation is the sine qua non of precision cancer medicine. Traditional cancer clinical trial designs follow well-defined protocols to evaluate the efficacy of new therapies in patient groups, usually identified by their histology/tissue of origin of their malignancy. In contrast, precision medicine seeks to optimize benefit in individual patients, i.e., to define who benefits rather than determine whether the overall group benefits. Since cancer is a disease driven by molecular alterations, innovative trial designs, including biomarker-defined tumor-agnostic basket trials, are driving ground-breaking regulatory approvals and deployment of gene- and immune-targeted drugs. Molecular interrogation further reveals the disruptive reality that advanced cancers are extraordinarily complex and individually distinct. Therefore, optimized treatment often requires drug combinations and N-of-1 customization, addressed by a new generation of N-of-1 trials. Real-world data and structured master registry trials are also providing massive datasets that are further fueling a transformation in oncology. Finally, machine learning is facilitating rapid discovery, and it is plausible that high-throughput computing, in silico modeling, and 3-dimensional printing may be exploitable in the near future to discover and design customized drugs in real time.
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Affiliation(s)
- Elena Fountzilas
- Department of Medical Oncology, St Luke's Clinic, Thessaloniki, Greece; European University Cyprus, German Oncology Center, Nicosia, Cyprus
| | - Apostolia-Maria Tsimberidou
- The University of Texas MD Anderson Cancer Center, Department of Investigational Cancer Therapeutics, Houston, TX, USA.
| | - Henry Hiep Vo
- The University of Texas MD Anderson Cancer Center, Department of Investigational Cancer Therapeutics, Houston, TX, USA
| | - Razelle Kurzrock
- WIN Consortium for Precision Medicine, France; Medical College of Wisconsin, USA
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Van Gool SW, Van de Vliet P, Kampers LFC, Kosmal J, Sprenger T, Reich E, Schirrmacher V, Stuecker W. Methods behind oncolytic virus-based DC vaccines in cancer: Toward a multiphase combined treatment strategy for Glioblastoma (GBM) patients. Methods Cell Biol 2023; 183:51-113. [PMID: 38548421 DOI: 10.1016/bs.mcb.2023.06.001] [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] [Indexed: 04/02/2024]
Abstract
Glioblastoma (GBM) remains an orphan cancer disease with poor outcome. Novel treatment strategies are needed. Immunotherapy has several modes of action. The addition of active specific immunotherapy with dendritic cell vaccines resulted in improved overall survival of patients. Integration of DC vaccination within the first-line combined treatment became a challenge, and immunogenic cell death immunotherapy during chemotherapy was introduced. We used a retrospective analysis using real world data to evaluate the complex combined treatment, which included individualized multimodal immunotherapy during and after standard of care, and which required adaptations during treatment, and found a further improvement of overall survival. We also discuss the use of real world data as evidence. Novel strategies to move the field of individualized multimodal immunotherapy forward for GBM patients are reviewed.
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Affiliation(s)
| | | | | | | | | | - Ella Reich
- Immun-onkologisches Zentrum Köln, Cologne, Germany
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5
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Van de Vliet P, Sprenger T, Kampers LFC, Makalowski J, Schirrmacher V, Stücker W, Van Gool SW. The Application of Evidence-Based Medicine in Individualized Medicine. Biomedicines 2023; 11:1793. [PMID: 37509433 PMCID: PMC10376974 DOI: 10.3390/biomedicines11071793] [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: 05/26/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/30/2023] Open
Abstract
The fundamental aim of healthcare is to improve overall health of the population by providing state-of-the-art healthcare for individuals at an affordable cost. The foundation for this system is largely referred to as "evidence-based medicine". Too often, evidence-based medicine is based solely on so-called "best research evidence", collected through randomized controlled trials while disregarding clinical expertise and patient expectations. As healthcare gravitates towards personalized and individualized medicine, such external clinical (research) evidence can inform, but never replace, individual clinical expertise. This applies in particular to orphan diseases, for which clinical trials are methodologically particularly problematic, and evidence derived from them is often questionable. Evidence-based medicine constitutes a complex process to allow doctors and patients to select the best possible solutions for each individual based on rapidly developing new therapeutic directions. This requires a revisit of the foundations of evidence-based medicine. A proposition as to how to manage evidence-based data in individualized immune-oncology is presented here.
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Affiliation(s)
| | - Tobias Sprenger
- Immune-Oncological Centre Cologne (IOZK), D-50674 Cologne, Germany
| | | | | | | | - Wilfried Stücker
- Immune-Oncological Centre Cologne (IOZK), D-50674 Cologne, Germany
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6
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Tateo V, Marchese PV, Mollica V, Massari F, Kurzrock R, Adashek JJ. Agnostic Approvals in Oncology: Getting the Right Drug to the Right Patient with the Right Genomics. Pharmaceuticals (Basel) 2023; 16:ph16040614. [PMID: 37111371 PMCID: PMC10144220 DOI: 10.3390/ph16040614] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
(1) Background: The oncology field has drastically changed with the advent of precision medicine, led by the discovery of druggable genes or immune targets assessed through next-generation sequencing. Biomarker-based treatments are increasingly emerging, and currently, six tissue-agnostic therapies are FDA-approved. (2) Methods: We performed a review of the literature and reported the trials that led to the approval of tissue-agnostic treatments and ongoing clinical trials currently investigating novel biomarker-based approaches. (3) Results: We discussed the approval of agnostic treatments: pembrolizumab and dostarlimab for MMRd/MSI-H, pembrolizumab for TMB-H, larotrectinib and entrectinib for NTRK-fusions, dabrafenib plus trametinib for BRAF V600E mutation, and selpercatinib for RET fusions. In addition, we reported novel clinical trials of biomarker-based approaches, including ALK, HER2, FGFR, and NRG1. (4) Conclusions: Precision medicine is constantly evolving, and with the improvement of diagnostic tools that allow a wider genomic definition of the tumor, tissue-agnostic targeted therapies are a promising treatment strategy tailored to the specific tumor genomic profile, leading to improved survival outcomes.
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Affiliation(s)
- Valentina Tateo
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Paola Valeria Marchese
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Veronica Mollica
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Francesco Massari
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, 40127 Bologna, Italy
| | - Razelle Kurzrock
- MCW Cancer Center, Milwaukee, WI 53226, USA
- WIN Consortium, San Diego, CA 92093, USA
- Department of Oncology, University of Nebraska, Omaha, NE 68198, USA
| | - Jacob J Adashek
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Hospital, Baltimore, MD 21287, USA
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7
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Raoof S, Kurzrock R. For insights into the real world, consider real-world data. Sci Transl Med 2022; 14:eabn6911. [DOI: 10.1126/scitranslmed.abn6911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Randomized control trials (RCTs) are required before drug and device approvals and have contributed to patient safety, but they have also increased the cost and time of regulatory assessments. We propose that using real-world evidence to complement or, in some settings, to replace RCTs will accelerate delivery of new drugs to patients.
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Affiliation(s)
- Sana Raoof
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Razelle Kurzrock
- Worldwide Innovative Network Consortium, Villejuif, France
- Medical College of Wisconsin, Milwaukee, WI, USA
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8
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Stewart DJ, Bradford JP, Batist G. Treatment Access, Health Economics, and the Wave of a Magic Wand. Curr Oncol 2022; 29:1176-1189. [PMID: 35200599 PMCID: PMC8870945 DOI: 10.3390/curroncol29020100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 11/17/2022] Open
Abstract
New drugs are expensive, in part due to excessive drug development costs. Governments are trying to reduce drug prices. This can delay access to effective agents. A country’s access to new drugs correlates with prices they agree to pay. After Health Canada approves a drug, the Canadian Agency for Drug and Technologies in Health (CADTH) assesses it. CADTH’s approval is usually contingent on it costing ≤CAD 50,000 per quality adjusted life year (QALY) gained. This value (unchanged from the 1970s) is inappropriately low. An inflation-adjusted CAD 50,000 1975 QALY should translate into a CAD 250,000 2021 QALY. CADTH’s target also does not consider that drug development costs have risen much faster than inflation or that new precision therapies may only be used in small populations. In a separate process, proposals from the Patented Medicines Price Review Board (PMPRB) would decrease initial Canadian drug prices by 20%, but prices would fall further as sales increased, with ultimate price reductions of up to 80%. PMPRB claims its proposal would not reduce drug access, but multiple analyses strongly suggest otherwise. Government price controls target the symptom (high prices), not the disease. They translate into shortages without solving the problem. CADTH and PMPRB approaches both threaten access to effective drugs.
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Affiliation(s)
- David J. Stewart
- Department of Medicine, Faculty of Medicine, The Ottawa Hospital, University of Ottawa, 501 Smyth Rd., Ottawa, ON K1H 8L6, Canada
- Life Saving Therapies Network, 173 Heath St., Ottawa, ON K1H 5E6, Canada;
- Correspondence: ; Tel.: +613-737-7700
| | | | - Gerald Batist
- Segal Cancer Centre, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada;
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Stewart DJ, Wheatley-Price P. Randomized Clinical Trials in the Era of Precision Oncology-The Role of End Points, Industry Funding, and Medical Writing Integrity. JAMA Oncol 2021; 7:1577-1578. [PMID: 34436567 DOI: 10.1001/jamaoncol.2021.3338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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10
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Lim SJ, Gurusamy K, O'Connor D, Shaaban AM, Brierley D, Lewis I, Harrison D, Kendall TJ, Robinson M. Recommendations for cellular and molecular pathology input into clinical trials: a systematic review and meta-aggregation. J Pathol Clin Res 2021; 7:191-202. [PMID: 33635586 PMCID: PMC8073003 DOI: 10.1002/cjp2.199] [Citation(s) in RCA: 4] [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: 10/27/2020] [Revised: 12/11/2020] [Accepted: 01/03/2021] [Indexed: 01/10/2023]
Abstract
The SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) 2013 Statement was developed to provide guidance for inclusion of key methodological components in clinical trial protocols. However, these standards do not include guidance specific to pathology input in clinical trials. This systematic review aims to synthesise existing recommendations specific to pathology practice in clinical trials for implementation in trial protocol design. Articles were identified from database searches and deemed eligible for inclusion if they contained: (1) guidance and/or a checklist, which was (2) pathology-related, with (3) content relevant to clinical trial protocols or could influence a clinical trial protocol design from a pathology perspective and (4) were published in 1996 or later. The quality of individual papers was assessed using the AGREE-GRS (Appraisal of Guidelines for REsearch & Evaluation - Global Rating Scale) tool, and the confidence in cumulative evidence was evaluated using the GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in Evidence from Reviews of Qualitative research) approach. Extracted recommendations were synthesised using the best fit framework method, which includes thematic analysis followed by a meta-aggregative approach to synthesis within the framework. Of the 10 184 records screened and 199 full-text articles reviewed, only 40 guidance resources met the eligibility criteria for inclusion. Recommendations extracted from 22 guidance documents were generalisable enough for data synthesis. Seven recommendation statements were synthesised as follows: (1) multidisciplinary collaboration in trial design with early involvement of pathologists, particularly with respect to the use of biospecimens and associated biomarker/analytical assays and in the evaluation of pathology-related parameters; (2) funding and training for personnel undertaking trial work; (3) selection of an accredited laboratory with suitable facilities to undertake scheduled work; (4) quality assurance of pathology-related parameters; (5) transparent reporting of pathology-related parameters; (6) policies regarding informatics and tracking biospecimens across trial sites; and (7) informed consent for specimen collection and retention for future research.
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Affiliation(s)
- Shujing Jane Lim
- Department of Cellular PathologyNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle Upon TyneUK
- Division of Surgery and Interventional SciencesUniversity College LondonLondonUK
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional SciencesUniversity College LondonLondonUK
| | - Daniel O'Connor
- The Medicines and Healthcare Products Regulatory AgencyLondonUK
| | - Abeer M Shaaban
- Department of HistopathologyQueen Elizabeth Hospital BirminghamBirminghamUK
- Institute of Cancer and Genomic SciencesUniversity of BirminghamBirminghamUK
| | - Daniel Brierley
- Unit of Oral and Maxillofacial PathologyUniversity of SheffieldSheffieldUK
| | - Ian Lewis
- National Cancer Research InstituteLondonUK
| | | | - Timothy James Kendall
- University of Edinburgh Centre for Inflammation Research, University of EdinburghEdinburghUK
| | - Max Robinson
- Department of Cellular PathologyNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle Upon TyneUK
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Freidlin B, Allegra CJ, Korn EL. Moving Molecular Profiling to Routine Clinical Practice: A Way Forward? J Natl Cancer Inst 2021; 112:773-778. [PMID: 31868907 DOI: 10.1093/jnci/djz240] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/09/2019] [Accepted: 12/18/2019] [Indexed: 01/09/2023] Open
Abstract
Molecular profiling of a patient's tumor to guide targeted treatment selection offers the potential to advance patient care by improving outcomes and minimizing toxicity (by avoiding ineffective treatments). However, current development of molecular profile (MP) panels is often based on applying institution-specific or subjective algorithms to nonrandomized patient cohorts. Consequently, obtaining reliable evidence that molecular profiling is offering clinical benefit and is ready for routine clinical practice is challenging. In particular, we discuss here the problems with interpreting for clinical utility nonrandomized studies that compare outcomes in patients treated based on their MP vs those treated with standard of care, studies that compare the progression-free survival (PFS) seen on a MP-directed treatment to the PFS seen for the same patient on a previous standard treatment (PFS ratio), and multibasket trials that evaluate the response rates of targeted therapies in specific molecularly defined subpopulations (regardless of histology). We also consider some limitations of randomized trial designs. A two-step strategy is proposed in which multiple mutation-agent pairs are tested for activity in one or more multibasket trials in the first step. The results of the first step are then used to identify promising mutation-agent pairs that are combined in a molecular panel that is then tested in the step-two strategy-design randomized clinical trial (the molecular panel-guided treatment for the selected mutations vs standard of care). This two-step strategy should allow rigorous evidence-driven identification of mutation-agent pairs that can be moved into routine clinical practice.
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Affiliation(s)
- Boris Freidlin
- Biometric Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, 9609 Medical Center Dr, Bethesda, MD 20892, USA
| | - Carmen J Allegra
- Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, 9609 Medical Center Dr, Bethesda, MD 20892, USA.,Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL 32608, USA
| | - Edward L Korn
- Biometric Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, 9609 Medical Center Dr, Bethesda, MD 20892, USA
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Maeda H, Takeda K, Urushihara H, Kurokawa T. Searching for potential surrogate endpoints of overall survival in clinical trials for patients with prostate cancer. Cancer Rep (Hoboken) 2021; 4:e1334. [PMID: 33455091 PMCID: PMC8222553 DOI: 10.1002/cnr2.1334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/11/2020] [Accepted: 12/14/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The purpose of this study was to investigate the correlation between overall survival (OS) and other clinical outcomes in patients with prostate cancer. Further, we conducted subgroup analysis in the correlation of OS. AIM This study intended to investigate potential surrogate endpoints of OS for prostate cancer by examining the correlation between OS and the other endpoints. METHODS We performed a systematic review through a literature search by computer-based searches of the Medline database (January 1965 and May 2014). RESULTS The contents of 115 studies with endpoint as OS were analyzed in our study. Our results showed that 47.8% (55/115) of the studies used progression-free survival as an endpoint besides OS, followed by time to progression (43.5% [50/115]) and PSA response (40.9% [47/115]). Also, the relationship between OS and each surrogate endpoint was examined using the hazard ratio (HR) by a Bayesian hybrid model for random effect multivariate meta-analysis. Our results showed that the endpoint that had the highest correlation with OS was progression-free survival (PFS) with an estimated marginal correlation of 0.939 (95%CI: 0.900, 0.967). Furthermore, our stratified analysis identified PFS in castration-resistant prostate cancer patients (0.937), in sensitive patients (0.932), in none of chemotherapy patients (0.929), in first line of the chemotherapy (0.948), in patients who received no Docetaxel previously (0.942), in both symptomatic and asymptomatic patients (0.950), in patients who received only chemotherapy (0.956), and in phase III (0.960), time to progression (TTP) in castration-resistant prostate cancer (CRPC) patients (0.942), in metastasis patients (0.948), in both symptomatic and asymptomatic patients (0.953), in patients who received only chemotherapy (0.938), and in Phase III (0.927) as endpoints, which showed a lower limit for 95% CI of estimated marginal correlation ≥0.850 with overall survival. CONCLUSIONS Our study suggests that PFS is a potential surrogate endpoint of OS in clinical trials for patients with prostate cancer. It also suggests potential surrogate endpoints for CRPC and locally advanced prostate cancer.
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Affiliation(s)
- Hideki Maeda
- Department of Regulatory Science, Faculty of Pharmacy, Meiji Pharmaceutical University, Kiyose-city, Tokyo, Japan
| | - Kentaro Takeda
- Biostatistics Group, Data Science Department, Astellas Pharma Global Development, Inc, Northbrook, Illinois, USA
| | - Hisashi Urushihara
- Division of Drug Development & Regulatory Science, Faculty of Pharmacy, Keio University, Minato-ku, Tokyo, Japan
| | - Tatsuo Kurokawa
- Division of Drug Development & Regulatory Science, Faculty of Pharmacy, Keio University, Minato-ku, Tokyo, Japan
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13
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Adashek JJ, Subbiah V, Kurzrock R. From Tissue-Agnostic to N-of-One Therapies: (R)Evolution of the Precision Paradigm. Trends Cancer 2021; 7:15-28. [DOI: 10.1016/j.trecan.2020.08.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/29/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022]
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14
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Keefe DMK, Bateman EH. Potential Successes and Challenges of Targeted Cancer Therapies. J Natl Cancer Inst Monogr 2020; 2019:5551349. [PMID: 31425592 DOI: 10.1093/jncimonographs/lgz008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/29/2019] [Accepted: 04/19/2019] [Indexed: 01/15/2023] Open
Abstract
The concept and realization of targeted anticancer therapy (TAT) have existed for at least two decades and continue to expand rapidly. It has become clear that there is no "magic bullet" to cure cancer and that even TATs are unlikely to be successful as single agents, necessitating combination with chemotherapy, radiotherapy, or even other targeting agents. The other promise that has not been fulfilled by TAT is that of reduced toxicity. It was thought that by targeting receptors on or within cells, rather than particular phases of the cell cycle, TATs would not be toxic. However, it turns out that the targets also exist on or within normal cells and that there is even cross-reactivity between receptors on nontarget tissues. All of this results in toxicity, the mechanism of which are the same as the mechanism of action of the drugs, making toxicity reduction or prevention very difficult. This leads to new toxicities with new targeted treatments. Nevertheless, all of the above should not detract from the obvious successes of targeted agents, which have turned several acutely fatal cancers into chronic diseases and rendered some hitherto untreatable cancers into treatable diseases.
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Affiliation(s)
- Dorothy M K Keefe
- Mucositis Research Group, Discipline of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - Emma H Bateman
- Mucositis Research Group, Discipline of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
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15
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Stewart DJ, Bossé D, Goss G, Hilton JF, Jonker D, Fung-Kee-Fung M. A novel, more reliable approach to use of progression-free survival as a predictor of gain in overall survival: The Ottawa PFS Predictive Model. Crit Rev Oncol Hematol 2020; 148:102896. [PMID: 32087510 DOI: 10.1016/j.critrevonc.2020.102896] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/16/2020] [Accepted: 01/29/2020] [Indexed: 02/09/2023] Open
Abstract
Progression-free survival (PFS) hazard ratios and gain in median PFS are suggested predictors of overall survival (OS) gain (with gain defined as experimental arm minus control arm values). We assessed use of half-lives (time to progression/death of half remaining patients). We reviewed randomized trials from Journal of Clinical Oncology and New England Journal of Medicine, 01/2012-06/12/2017 (discovery series) and 01/01/2007-12/31/2011 (first validation series). If PFS or OS gains were significant, we used PFS/OS curve nonlinear regression analysis to estimate half-lives and defined "half-life gain" as experimental minus control arm half-life. With low crossover and significant PFS differences, PFS half-life gains ≥1.5 months had positive-predictive-values for OS gains ≥2 months of 79 % and 86 % and PFS half-life gains <1.5 months had negative-predictive-values for OS gains <2 months of 95 % and 75 %, in discovery and validation series, respectively. PFS half-life gains more reliably predicted OS gains than PFS hazard ratios or gains in median PFS. Findings were confirmed in a second validation series.
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Affiliation(s)
- David J Stewart
- University of Ottawa and the Ottawa Hospital, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
| | - Dominick Bossé
- University of Ottawa and the Ottawa Hospital, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
| | - Glenwood Goss
- University of Ottawa and the Ottawa Hospital, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
| | - John F Hilton
- University of Ottawa and the Ottawa Hospital, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
| | - Derek Jonker
- University of Ottawa and the Ottawa Hospital, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
| | - Michael Fung-Kee-Fung
- University of Ottawa and the Ottawa Hospital, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
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16
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Grayling MJ, Dimairo M, Mander AP, Jaki TF. A Review of Perspectives on the Use of Randomization in Phase II Oncology Trials. J Natl Cancer Inst 2019; 111:1255-1262. [PMID: 31218346 PMCID: PMC6910171 DOI: 10.1093/jnci/djz126] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/05/2019] [Accepted: 06/12/2019] [Indexed: 12/21/2022] Open
Abstract
Historically, phase II oncology trials assessed a treatment's efficacy by examining its tumor response rate in a single-arm trial. Then, approximately 25 years ago, certain statistical and pharmacological considerations ignited a debate around whether randomized designs should be used instead. Here, based on an extensive literature review, we review the arguments on either side of this debate. In particular, we describe the numerous factors that relate to the reliance of single-arm trials on historical control data and detail the trial scenarios in which there was general agreement on preferential utilization of single-arm or randomized design frameworks, such as the use of single-arm designs when investigating treatments for rare cancers. We then summarize the latest figures on phase II oncology trial design, contrasting current design choices against historical recommendations on best practice. Ultimately, we find several ways in which the design of recently completed phase II trials does not appear to align with said recommendations. For example, despite advice to the contrary, only 66.2% of the assessed trials that employed progression-free survival as a primary or coprimary outcome used a randomized comparative design. In addition, we identify that just 28.2% of the considered randomized comparative trials came to a positive conclusion as opposed to 72.7% of the single-arm trials. We conclude by describing a selection of important issues influencing contemporary design, framing this discourse in light of current trends in phase II, such as the increased use of biomarkers and recent interest in novel adaptive designs.
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Affiliation(s)
- Michael J Grayling
- Correspondence to: Michael J. Grayling, Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Rd, Newcastle upon Tyne NE2 4AX, UK (e-mail: )
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17
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Stewart DJ, Macdonald DB, Awan AA, Thavorn K. Optimal frequency of scans for patients on cancer therapies: A population kinetics assessment. Cancer Med 2019; 8:6871-6886. [PMID: 31560842 PMCID: PMC6853816 DOI: 10.1002/cam4.2571] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/03/2019] [Accepted: 09/09/2019] [Indexed: 12/26/2022] Open
Abstract
Background Optimal frequency of follow‐up scans for patients receiving systemic therapies is poorly defined. Progression‐free survival (PFS) generally follows first‐order kinetics. We used exponential decay nonlinear regression analysis to calculate half‐lives for 887 published PFS curves. Method We used the Excel formula x = EXP(‐tn*0.693/t1/2) to calculate proportion of residual patients remaining progression‐free at different times, where tn is the interval in weeks between scans (eg, 6 weeks), * indicates multiplication, 0.693 is the natural logarithm of 2, and t1/2 is the PFS half‐life in weeks. Results Proportion of residual patients predicted to remain progression‐free at each subsequent scan varied with scan intervals and regimen PFS half‐life. For example, with a 4‐month half‐life (17.3 weeks) and scans every 6 weeks, 21% of patients would progress by the first scan, 21% of the remaining patients would progress by the second scan at 12 weeks, etc With 2, 6‐ and 12‐month half‐lives (for example), the proportion of remaining patients progressing at each subsequent scan if repeated every 3 weeks would be 21%, 8% and 4%, respectively, while with scans every 12 weeks it would be 62%, 27% and 15%, respectively. Furthermore, optimal scan frequency can be calculated for populations comprised of distinct rapidly and slowly progressing subpopulations, as well as with convex curves arising from treatment breaks, where optimal scan frequency may differ during therapy administration vs during more rapid progression after therapy interruption. Conclusions A population kinetics approach permits a regimen‐ and tumor‐specific determination of optimal scan frequency for patients on systemic therapies.
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18
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Kantarjian HM, Prat F, Steensma DP, Kurzrock R, Stewart DJ, Sekeres MA, Leveque J. Cancer research in the United States: A critical review of current status and proposal for alternative models. Cancer 2018; 124:2881-2889. [DOI: 10.1002/cncr.31522] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 02/27/2018] [Accepted: 03/28/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Hagop M. Kantarjian
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Ferran Prat
- Research Administration and Industry Ventures; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - David P. Steensma
- Department of Medical Oncology; Dana-Farber Cancer Institute, Harvard Medical School; Boston Massachusetts
| | - Razelle Kurzrock
- Division of Hematology/Oncology, Department of Medicine; University of California at San Diego; San Diego California
| | - David J. Stewart
- Department of Medicine; University of Ottawa; Ottawa Ontario Canada
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19
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Stewart DJ, Stewart AA, Wheatley-Price P, Batist G, Kantarjian HM, Schiller J, Clemons M, Bradford JP, Gillespie L, Kurzrock R. The importance of greater speed in drug development for advanced malignancies. Cancer Med 2018; 7:1824-1836. [PMID: 29601671 PMCID: PMC5943431 DOI: 10.1002/cam4.1454] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/10/2018] [Accepted: 02/09/2018] [Indexed: 12/13/2022] Open
Abstract
It takes on average 6-12 years to develop new anticancer drugs from discovery to approval. Effective new agents prolong survival. To demonstrate the importance of rapid drug approval, we calculated life-years potentially saved if selected agents were approved more rapidly. As illustrative examples, we used 27 trials documenting improvements in survival. We multiplied improvement in median survival by numbers of patients dying annually and multiplied this by number of years from drug discovery until approval. For every year by which time to drug approval could have been shortened, there would have been a median number of life-years potentially saved of 79,920 worldwide per drug. Median number of life-years lost between time of drug discovery and approval was 1,020,900 per example. If we were able to use available opportunities to decrease the time required to take a drug from discovery to approval to 5 years, the median number of life-years saved per example would have been 523,890 worldwide. Various publications have identified opportunities to speed drug development without sacrificing patient safety. While many investigational drugs prove to be ineffective, some significantly prolong survival and/or reduce suffering. These illustrative examples suggest that a substantial number of life-years could potentially be saved by increasing the efficiency of development of new drugs for advanced malignancies.
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Affiliation(s)
- David J Stewart
- The University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Paul Wheatley-Price
- The University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Gerald Batist
- Segal Cancer Centre, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Joan Schiller
- The Inova Dwight and Martha Schar Cancer Institute, Fairfax, Virginia and Lung Cancer Research Foundation, New York, USA
| | - Mark Clemons
- The University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
| | - John-Peter Bradford
- Bradford Bachinski Limited and the Life Saving Therapies Network, Ottawa, Ontario, Canada
| | | | - Razelle Kurzrock
- University of California San Diego Moores Cancer Center, San Diego, California
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20
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Subbiah V, Kurzrock R. Challenging Standard-of-Care Paradigms in the Precision Oncology Era. Trends Cancer 2018; 4:101-109. [PMID: 29458960 DOI: 10.1016/j.trecan.2017.12.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 12/11/2017] [Accepted: 12/12/2017] [Indexed: 12/30/2022]
Abstract
The pace of genomic and immunological breakthroughs in oncology is accelerating, making it likely that large randomized trials will increasingly become outdated before their completion. Traditional clinical research/practice paradigms must adapt to the reality unveiled by genomics, especially the need for customized drug combinations, rather than one-size-fits-all monotherapy. The raison-d'être of precision oncology is to offer 'the right drug for the right patient at the right time', a process enabled by transformative tissue and blood-based genomic technologies. Genomically targeted therapies are most suitable in early disease, when molecular heterogeneity is less pronounced, while immunotherapy is most effective against tumors with unstable genomes. Next-generation cancer research/practice models will need to overcome the tyranny of tradition and emphasize an innovative, precise and personalized patient-centric approach.
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Affiliation(s)
- Vivek Subbiah
- Department of Investigational Cancer Therapeutics, Division of Cancer Medicine, Unit 0455, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | - Razelle Kurzrock
- Division of Hematology & Oncology, Center for Personalized Therapy & Clinical Trials Office, UC San Diego - Moores Cancer Center, 3855 Health Sciences Drive, MC #0658, La Jolla, CA 92093-0658, USA
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21
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Vincent JL. In Pursuit of Precision Medicine in the Critically Ill. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2018 2018. [PMCID: PMC7121780 DOI: 10.1007/978-3-319-73670-9_48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jean-Louis Vincent
- Dept. of Intensive Care Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
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22
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Brooks N, Campone M, Paddock S, Shortenhaus S, Grainger D, Zummo J, Thomas S, Li R. Approving cancer treatments based on endpoints other than overall survival: an analysis of historical data using the PACE Continuous Innovation Indicators™ (CII). Drugs Context 2017; 6:212507. [PMID: 29167693 PMCID: PMC5699106 DOI: 10.7573/dic.212507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/28/2017] [Accepted: 09/29/2017] [Indexed: 02/06/2023] Open
Abstract
Background There is an active debate about the role that endpoints other than overall survival (OS) should play in the drug approval process. Yet the term ‘surrogate endpoint’ implies that OS is the only critical metric for regulatory approval of cancer treatments. We systematically analyzed the relationship between U.S. Food and Drug Administration (FDA) approval and publication of OS evidence to understand better the risks and benefits of delaying approval until OS evidence is available. Scope Using the PACE Continuous Innovation Indicators (CII) platform, we analyzed the effects of cancer type, treatment goal, and year of approval on the lag time between FDA approval and publication of first significant OS finding for 53 treatments approved between 1952 and 2016 for 10 cancer types (n = 71 approved indications). Findings Greater than 59% of treatments were approved before significant OS data for the approved indication were published. Of the drugs in the sample, 31% had lags between approval and first published OS evidence of 4 years or longer. The average number of years between approval and first OS evidence varied by cancer type and did not reliably predict the eventual amount of OS evidence accumulated. Conclusions Striking the right balance between early access and minimizing risk is a central challenge for regulators worldwide. We illustrate that endpoints other than OS have long helped to provide timely access to new medicines, including many current standards of care. We found that many critical drugs are approved many years before OS data are published, and that OS may not be the most appropriate endpoint in some treatment contexts. Our examination of approved treatments without significant OS data suggests contexts where OS may not be the most relevant endpoint and highlights the importance of using a wide variety of fit-for-purpose evidence types in the approval process.
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Affiliation(s)
- Neon Brooks
- Rose Li and Associates, Inc., Bethesda, MD, USA
| | | | | | | | | | | | | | - Rose Li
- Rose Li and Associates, Inc., Bethesda, MD, USA
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23
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Aggarwal C, Borghaei H. Treatment Paradigms for Advanced Non-Small Cell Lung Cancer at Academic Medical Centers: Involvement in Clinical Trial Endpoint Design. Oncologist 2017; 22:700-708. [PMID: 28408617 PMCID: PMC5469580 DOI: 10.1634/theoncologist.2016-0345] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 01/03/2017] [Indexed: 12/25/2022] Open
Abstract
Selection of appropriate clinical endpoints for examining the efficacy of investigational agents for non‐small cell lung cancer is of vital importance in clinical trial design. This review provides an overview of the study designs of clinical trials for approved agents in non‐small cell lung cancer and focuses on the validity of alternative endpoints for such trials. Based on the positive results of various clinical trials, treatment options for non‐small cell lung cancer (NSCLC) have expanded greatly over the last 25 years. While regulatory approvals of chemotherapeutic agents for NSCLC have largely been based on improvements in overall survival, recent approvals of many targeted agents for NSCLC (afatinib, crizotinib, ceritinib, osimertinib) have been based on surrogate endpoints such as progression‐free survival and objective response. As such, selection of appropriate clinical endpoints for examining the efficacy of investigational agents for NSCLC is of vital importance in clinical trial design. This review provides an overview of clinical trial endpoints previously utilized for approved agents for NSCLC and highlights the key efficacy results for these trials. Trends for more recent approvals in NSCLC, including those for the immunotherapeutic agents nivolumab and pembrolizumab, are also discussed. The results of a correlative analysis of endpoints from 18 clinical trials that supported approvals of investigational agents in clinical trials for NSCLC are also presented. Implications for Practice. While improving survival remains the ultimate goal of oncology clinical trials, overall survival may not always be the most feasible or appropriate endpoint to assess patient response. Recently, several investigational agents, both targeted agents and immunotherapies, have gained U.S. Food and Drug Administration approval in non‐small cell lung cancer based on alternate endpoints such as progression‐free survival or response rate. An understanding of the assessment of response and trial endpoint choice is important for future oncology clinical trial design.
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Affiliation(s)
- Charu Aggarwal
- Division of Hematology/Oncology, Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hossein Borghaei
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
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24
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Kurzrock R, Stewart DJ. Exploring the Benefit/Risk Associated with Antiangiogenic Agents for the Treatment of Non-Small Cell Lung Cancer Patients. Clin Cancer Res 2017; 23:1137-1148. [PMID: 27940520 DOI: 10.1158/1078-0432.ccr-16-1968] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/18/2016] [Accepted: 10/19/2016] [Indexed: 11/16/2022]
Abstract
Following the approval of bevacizumab, an antibody targeting VEGF-A, for advanced non-squamous non-small cell lung cancer (NSCLC) in 2006, intensive efforts were put into the clinical development of antiangiogenic agents for NSCLC. Currently, the other antiangiogenic agents approved for NSCLC are ramucirumab, a VEGF receptor-2 (VEGFR-2)-targeting antibody indicated for both squamous and non-squamous NSCLC in the United States, and nintedanib, an anti-VEGFR-1/2/3, platelet-derived growth factor receptor-α/β, fibroblast growth factor receptor-1/2/3 angiokinase inhibitor indicated for adenocarcinoma of the lung in the European Union. Many other antiangiogenic agents are being evaluated in phase III trials for NSCLC, including aflibercept, sunitinib, sorafenib, cediranib, and vandetanib. Although many of the same signaling pathways are targeted by these novel agents, mixed efficacy results have been observed in these trials. Moreover, safety issues have raised concerns about using antiangiogenic agents in this patient population, and fatal bleeding events have been reported. Importantly, although no biomarker has yet been validated for antiangiogenic agents in NSCLC, biomarkers that show potential include circulating levels of short VEGF-A isoforms, expression of neuropilin-1 and VEGFR-1 in tumors and plasma, genetic variants in VEGF-A and VEGFR, and tumor protein p53 mutations (with the latter having been shown to correlate with increased levels of VEGF-A transcripts). This review provides an overview of the clinical benefit and risk associated with the use of antiangiogenic agents for NSCLC, and summarizes the research to date on the identification of predictive biomarkers for antiangiogenic therapies. Clin Cancer Res; 23(5); 1137-48. ©2016 AACR.
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MESH Headings
- Angiogenesis Inhibitors/adverse effects
- Angiogenesis Inhibitors/therapeutic use
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Bevacizumab/therapeutic use
- Carcinoma, Non-Small-Cell Lung/drug therapy
- Carcinoma, Non-Small-Cell Lung/epidemiology
- Carcinoma, Non-Small-Cell Lung/pathology
- Humans
- Indoles/adverse effects
- Indoles/therapeutic use
- Neovascularization, Pathologic/drug therapy
- Neovascularization, Pathologic/epidemiology
- Neovascularization, Pathologic/pathology
- Pyrroles/adverse effects
- Pyrroles/therapeutic use
- Receptors, Vascular Endothelial Growth Factor/therapeutic use
- Recombinant Fusion Proteins/adverse effects
- Recombinant Fusion Proteins/therapeutic use
- Risk Assessment
- Sunitinib
- Vascular Endothelial Growth Factor A/antagonists & inhibitors
- Vascular Endothelial Growth Factor Receptor-1/antagonists & inhibitors
- Vascular Endothelial Growth Factor Receptor-2/antagonists & inhibitors
- Ramucirumab
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Affiliation(s)
- Razelle Kurzrock
- Center for Personalized Cancer Therapy and Division of Hematology & Oncology, University of California San Diego Moores Cancer Center, San Diego, California.
| | - David J Stewart
- Division of Medical Oncology, University of Ottawa, Ottawa, Canada
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25
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Khan M, Mansoor AER, Kadia TM. Future prospects of therapeutic clinical trials in acute myeloid leukemia. Future Oncol 2016; 13:523-535. [PMID: 27771959 DOI: 10.2217/fon-2016-0262] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Acute myeloid leukemia (AML) is a markedly heterogeneous hematological malignancy that is most commonly seen in elderly adults. The response to current therapies to AML is quite variable, and very few new drugs have been recently approved for use in AML. This review aims to discuss the issues with current trial design for AML therapies, including trial end points, patient enrollment, cost of drug discovery and patient heterogeneity. We also discuss the future directions in AML therapeutics, including intensification of conventional therapy and new drug delivery mechanisms; targeted agents, including epigenetic therapies, cell cycle regulators, hypomethylating agents and chimeric antigen receptor T-cell therapy; and detail of the possible agents that may be incorporated into the treatment of AML in the future.
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Affiliation(s)
- Maliha Khan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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26
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Stewart DJ, Batist G, Kantarjian HM, Bradford JP, Schiller JH, Kurzrock R. The Urgent Need for Clinical Research Reform to Permit Faster, Less Expensive Access to New Therapies for Lethal Diseases. Clin Cancer Res 2016; 21:4561-8. [PMID: 26473192 DOI: 10.1158/1078-0432.ccr-14-3246] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High costs of complying with drug development regulations slow progress and contribute to high drug prices and, hence, mounting health care costs. If it is exorbitantly expensive to bring new therapies to approval, fewer agents can be developed with available resources, impeding the emergence of urgently needed treatments and escalating prices by limiting competition. Excessive regulation produces numerous speed bumps on the road to drug authorization. Although an explosion of knowledge could fuel rapid advances, progress has been slowed worldwide by inefficient regulatory and clinical research systems that limit access to therapies that prolong life and relieve suffering. We must replace current compliance-centered regulation (appropriate for nonlethal diseases like acne) with "progress-centered regulation" in lethal diseases, where the overarching objective must be rapid, inexpensive development of effective new therapies. We need to (i) reduce expensive, time-consuming preclinical toxicology and pharmacology assessments, which add little value; (ii) revamp the clinical trial approval process to make it fast and efficient; (iii) permit immediate multiple-site trial activation when an eligible patient is identified ("just-in-time" activation); (iv) reduce the requirement for excessive, low-value documentation; (v) replace this excessive documentation with sensible postmarketing surveillance; (vi) develop pragmatic investigator accreditation; (vii) where it is to the benefit of the patient, permit investigators latitude in deviating from protocols, without requiring approved amendments; (viii) confirm the value of predictive biomarkers before requiring the high costs of IDE/CLIA compliance; and (ix) approve agents based on high phase I-II response rates in defined subpopulations, rather than mandating expensive, time-consuming phase III trials.
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Affiliation(s)
- David J Stewart
- The University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Gerald Batist
- Segal Cancer Centre, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - John-Peter Bradford
- Bradford Bachinski Limited and the Life Saving Therapies Network, Ottawa, Ontario, Canada
| | - Joan H Schiller
- The University of Texas Southwestern, Dallas, TX and Free to Breathe
| | - Razelle Kurzrock
- University of California San Diego Moores Cancer Center, San Diego, California
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27
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Abstract
There is now compelling evidence that the molecular heterogeneity of cancer is associated with disparate phenotypes with variable outcomes and therapeutic responsiveness to therapy in histologically indistinguishable cancers. This diversity may explain why conventional clinical trial designs have mostly failed to show efficacy when patients are enrolled in an unselected fashion. Knowledge of the molecular phenotype has the potential to improve therapeutic selection and hence the early delivery of the optimal therapeutic regimen. Resolution of the challenges associated with a more stratified approach to health care will ensure more precise diagnostics and enhance therapeutic selection, which will improve overall outcomes.
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Affiliation(s)
- Nigel B Jamieson
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Switchback Road, Bearsden, Glasgow G61 1BD, UK; Academic Unit of Surgery, School of Medicine, College of Medical, Veterinary and Life Sciences, Glasgow Royal Infirmary, University of Glasgow, Alexandra Parade, Glasgow G31 2ER, UK; West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Alexandra Parade, Glasgow G31 2ER, UK
| | - David K Chang
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Switchback Road, Bearsden, Glasgow G61 1BD, UK; The Kinghorn Cancer Centre, Garvan Institute of Medical Research, 370 Victoria Street, Darlinghurst, New South Wales 2010, Australia; Cancer Research Program, Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, Sydney, New South Wales 2010, Australia; Department of Surgery, Bankstown Hospital, Eldridge Road, Bankstown, Sydney, New South Wales 2200, Australia; Faculty of Medicine, South Western Sydney Clinical School, University of NSW, Goulburn St, Liverpool, New South Wales 2170, Australia
| | - Andrew V Biankin
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Switchback Road, Bearsden, Glasgow G61 1BD, UK; The Kinghorn Cancer Centre, Garvan Institute of Medical Research, 370 Victoria Street, Darlinghurst, New South Wales 2010, Australia; Cancer Research Program, Garvan Institute of Medical Research, 384 Victoria Street, Darlinghurst, Sydney, New South Wales 2010, Australia; Department of Surgery, Bankstown Hospital, Eldridge Road, Bankstown, Sydney, New South Wales 2200, Australia; Faculty of Medicine, South Western Sydney Clinical School, University of NSW, Goulburn St, Liverpool, New South Wales 2170, Australia.
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28
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Sheehan JP, Kavanagh BD, Asher A, Harbaugh RE. Inception of a national multidisciplinary registry for stereotactic radiosurgery. J Neurosurg 2015; 124:155-62. [PMID: 26252466 DOI: 10.3171/2015.1.jns142466] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Stereotactic radiosurgery (SRS) represents a multidisciplinary approach to the delivery of ionizing high-dose radiation to treat a wide variety of disorders. Much of the radiosurgical literature is based upon retrospective single-center studies along with a few randomized controlled clinical trials. More timely and effective evidence is needed to enhance the consistency and quality of and clinical outcomes achieved with SRS. The authors summarize the creation and implementation of a national SRS registry. The American Association of Neurological Surgeons (AANS) through NeuroPoint Alliance, Inc., started a successful registry effort with its lumbar spine initiative. Following a similar approach, the AANS and NeuroPoint Alliance collaborated with corporate partners and the American Society for Radiation Oncology to devise a data dictionary for an SRS registry. Through administrative and financial support from professional societies and corporate partners, a framework for implementation of the registry was created. Initial plans were devised for a 3-year effort encompassing 30 high-volume SRS centers across the country. Device-specific web-based data-extraction platforms were built by the corporate partners. Data uploaders were then used to port the data to a common repository managed by Quintiles, a national and international health care trials company. Audits of the data for completeness and veracity will be undertaken by Quintiles to ensure data fidelity. Data governance and analysis are overseen by an SRS board comprising equal numbers of representatives from the AANS and NeuroPoint Alliance. Over time, quality outcome assessments and post hoc research can be performed to advance the field of SRS. Stereotactic radiosurgery offers a high-technology approach to treating complex intracranial disorders. Improvements in the consistency and quality of care delivered to patients who undergo SRS should be afforded by the national registry effort that is underway.
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Affiliation(s)
- Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Brian D Kavanagh
- Department of Radiation Oncology, University of Colorado at Denver, Aurora, Colorado
| | - Anthony Asher
- Carolina Neurosurgery & Spine, Charlotte, North Carolina; and
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Stewart DJ. Interview of David J Stewart, on the future of lung cancer management. Lung Cancer Manag 2015. [DOI: 10.2217/lmt.15.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
David J Stewart returned to Ottawa from the University of Texas MD Anderson Cancer Center (Houston, TX, USA) in 2011 to assume the position of Head of the Division of Medical Oncology at The Ottawa Hospital and the University of Ottawa. He received his MD degree from Queen's University, Kingston, followed by training in Internal Medicine at McGill University and in medical oncology in the Department of Developmental Therapeutics at the UT MD Anderson Cancer Center. He first moved from MD Anderson to the University of Ottawa and the Cancer Care Ontario Ottawa Regional Cancer Center in 1980, and served as Chief of Medical Oncology at the Ottawa Civic Hospital from 1989 to 1999. He returned to the Department of Thoracic/Head and Neck Medical Oncology at MD Anderson Cancer Center from 2003 to 2011 where he served as Chief of the Section of Experimental Therapeutics (2003–2005), Chair Ad Interim (2005), Deputy Chair (2006–2009) and Director of Translational Research (2009–2011). He was also the Principle Investigator of MD Anderson’ Phase II N01 contract with the National Cancer Institute, and was the clinical leader of a number of other federally funded translational research project. He has more than 300 peer-reviewed publications, with a research focus on Phase I and II trials of new anticancer agents, translational research and resistance to anticancer agents. He also has a major interest in and concern for issues impeding cancer clinical research, with publications that have included (among others): Cancer: the road to Amiens (J. Clin. Oncol. 27(3), 328–33 [2009]); Equipoise lost: ethics, costs and the regulation of cancer clinical research (J. Clin. Oncol. 28(17), 2925–35 [2010]); Fool's gold, lost treasures and the randomized clinical trial (BMC Cancer 13(1), 193 [2013]); and Redefining cancer: a new paradigm for better and faster treatment innovation (J. Popul. Ther. Clin. Pharmacol. 21(1), e56–e65 [2014]). His experience in both the American and Canadian healthcare systems has provided him a unique perspective on how common regulatory factors seriously impair access to effective new therapies and drive inordinately high clinical research costs in both countries.
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Membrane carbonic anhydrase IX expression and relapse risk in resected stage I-II non-small-cell lung cancer. J Thorac Oncol 2015; 9:675-84. [PMID: 24662455 DOI: 10.1097/jto.0000000000000148] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Adjuvant chemotherapy reduces recurrences of non-small-cell lung cancer (NSCLC). To determine which patients need adjuvant chemotherapy, we assessed factors associated with time to relapse (TTR). METHODS In 230 resected stage I-II NSCLCs, we correlated immunohistochemistry scores for factors associated with cell growth rate, growth regulation, hypoxia, cell survival, and cell death with TTR. RESULTS With a median follow-up of 82 months (1-158) for those alive and relapse free at last follow-up, median time to recurrence was not reached. The 2- and 5-year probabilities of maintaining freedom from recurrence were 80.7% (95% confidence interval, 75.3%, 86.4%) and 74.6% (95% confidence interval, 68.6%, 81.2%), respectively. TTR curves flattened at an apparent cure rate of 70%. In multicovariate Cox models, factors correlating with shorter TTR were membranous carbonic anhydrase IX (mCAIX) staining (any versus none, hazard ratio = 2.083, p = 0.023) and node stage (N1 versus N0, hazard ratio = 2.591, p = 0.002). mCAIX scores correlated positively with tumor size, grade, squamous histology, necrosis, mitoses, Ki67, p53, nuclear DNA methyltransferase 1, and cytoplasmic enhancer-of-split-and-hairy-related protein, and they correlated inversely with papillary histology, epidermal growth factor receptor mutation (trend), copper transporter-1, and cytoplasmic hypoxia-inducible factor-1α, vascular endothelial growth factor, DNA methyltransferase 1, and excision repair cross-complementing rodent repair deficiency, complementation group 1. CONCLUSION Nodal stage and mCAIX immunohistochemistry were the strongest independent predictors of shorter TTR in resected NSCLCs. mCAIX correlated with tumor size, markers of tumor proliferation and necrosis, and tumor genetic characteristics, and it paradoxically correlated inversely with the hypoxia markers, hypoxia-inducible factor-1α and vascular endothelial growth factor. Presence of mCAIX could help determine patients with high risk of recurrence who might require adjuvant chemotherapy.
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Wilson MK, Collyar D, Chingos DT, Friedlander M, Ho TW, Karakasis K, Kaye S, Parmar MKB, Sydes MR, Tannock IF, Oza AM. Outcomes and endpoints in cancer trials: bridging the divide. Lancet Oncol 2015; 16:e43-52. [PMID: 25638556 DOI: 10.1016/s1470-2045(14)70380-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cancer is not one disease. Outcomes and endpoints in trials should incorporate the therapeutic modality and cancer type because these factors affect clinician and patient expectations. In this Review, we discuss how to: define the importance of endpoints; make endpoints understandable to patients; improve the use of patient-reported outcomes; advance endpoints to parallel changes in trial design and therapeutic interventions; and integrate these improvements into trials and practice. Endpoints need to reflect benefit to patients, and show that changes in tumour size either in absolute terms (response and progression) or relative to control (progression) are clinically relevant. Improvements in trial design should be accompanied by improvements in available endpoints. Stakeholders need to come together to determine the best approach for research that ensures accountability and optimises the use of available resources.
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Affiliation(s)
- Michelle K Wilson
- University of Toronto Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | | | - Michael Friedlander
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Tony W Ho
- AstraZeneca, Wilmington DE 19850-5437, USA
| | | | - Stan Kaye
- Drug Development Unit and Gynaecology Unit, Royal Marsden Hospital and Institute of Cancer Research, London, UK
| | | | - Matthew R Sydes
- MRC Clinical Trials Unit, University College London, London, UK
| | - Ian F Tannock
- University of Toronto Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Amit M Oza
- University of Toronto Princess Margaret Cancer Centre, Toronto, ON, Canada.
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Wilson MK, Karakasis K, Oza AM. Outcomes and endpoints in trials of cancer treatment: the past, present, and future. Lancet Oncol 2014; 16:e32-42. [PMID: 25638553 DOI: 10.1016/s1470-2045(14)70375-4] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Cancer treatment should allow patients to live better or longer lives, and ideally, both. Trial endpoints should show clinically meaningful improvements in patient survival or quality of life. Alternative endpoints such as progression-free survival, disease-free survival, and objective response rate have been used to identify benefit earlier, but their true validity as surrogate endpoints is controversial. In this Review we discuss the measurement, assessment, and benefits and limitations of trial endpoints in use for cancer treatment. Many stakeholders are affected, including regulatory agencies, industry partners, clinicians, and most importantly, patients. In an accompanying Review, reflections from individual stakeholders are incorporated into a discussion of what the future holds for clinical trial endpoints and design.
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Affiliation(s)
| | | | - Amit M Oza
- Princess Margaret Cancer Centre, Toronto, Canada.
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Insel PA, Amara SG, Blaschke TF. Introduction to the theme "Precision medicine and prediction in pharmacology". Annu Rev Pharmacol Toxicol 2014; 55:11-4. [PMID: 25562643 DOI: 10.1146/annurev-pharmtox-101714-123102] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Paul A Insel
- Department of Pharmacology, University of California, San Diego School of Medicine, La Jolla, California 92093;
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Abstract
This article explores the philosophical implications of evidence-based medicine's (EBM's) epistemology in terms of the problem of underdetermination of theory by evidence as expounded by the Duhem-Quine thesis. EBM hierarchies of evidence privilege clinical research over basic science, exacerbating the problem of underdetermination. Because of severe underdetermination, EBM is unable to meaningfully test core medical beliefs that form the basis of our understanding of disease and therapeutics. As a result, EBM adopts an epistemic attitude that is sceptical of explanations from the basic biological sciences, and is relegated to a view of disease at a population level. EBM's epistemic attitude provides a limited research heuristic by preventing the development of a theoretical framework required for understanding disease mechanism and integrating knowledge to develop new therapies. Medical epistemology should remain pluralistic and include complementary approaches of basic science and clinical research, thus avoiding the limited epistemic attitude entailed by EBM hierarchies.
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Affiliation(s)
- Benjamin H Chin-Yee
- Faculty of Medicine, Institute for the History and Philosophy of Science and Technology, University of Toronto, Toronto, Ontario, Canada
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Kashyap R, Hofman MS, Michael M, Kong G, Akhurst T, Eu P, Zannino D, Hicks RJ. Favourable outcomes of (177)Lu-octreotate peptide receptor chemoradionuclide therapy in patients with FDG-avid neuroendocrine tumours. Eur J Nucl Med Mol Imaging 2014; 42:176-85. [PMID: 25209134 DOI: 10.1007/s00259-014-2906-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 08/25/2014] [Indexed: 12/21/2022]
Abstract
PURPOSE Increased glycolytic activity on FDG PET/CT defines a subgroup of patients with metastatic gastroenteropancreatic neuroendocrine tumour (NET) with a poor prognosis. A limited range of systemic treatment options exist for more aggressive NET. The role of peptide receptor chemoradionuclide therapy (PRCRT) in such patients is, however, unclear. This retrospective study assessed the outcomes of patients with FDG-avid NET treated with PRCRT. METHODS Clinical, biochemical and imaging response was assessed after completion of induction treatment of PRCRT with 5-fluorouracil in 52 patients selected for treatment on the basis of somatostatin-receptor imaging without spatially discordant FDG-avid disease. Of the cohort, 67% had received prior chemotherapy. Overall survival (OS) and progression-free survival (PFS) were also analysed. RESULTS PRCRT was well tolerated with negligible grade 3/4 toxicities. After a median follow-up period of 36 months, the median OS was not achieved with a median PFS of 48 months. At 3 months after completion of PRCRT 2% of patients showed a complete anatomical response, 28% a partial response, 68% stable disease, and only 2% progression. On FDG PET/CT, 27% achieved a complete metabolic response during the follow-up period. A biochemical response (>25% fall in chromogranin-A levels) was seen in 45%. CONCLUSION PRCRT is an effective treatment in patients with FDG-avid NET, even in patients who have failed conventional therapies. Given apparently higher response rates than with alternative therapeutic options and low toxicity, further research is needed to establish whether PRCRT should be used as a first-line treatment modality in this patient population.
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Affiliation(s)
- Raghava Kashyap
- Centre for Cancer Imaging, Peter MacCallum Cancer Center, St Andrews Place, 3002, Melbourne, Australia,
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Browman GP, Vollmann J, Virani A, Schildmann J. Improving the quality of 'personalized medicine' research and practice: through an ethical lens. Per Med 2014; 11:413-423. [PMID: 29783476 DOI: 10.2217/pme.14.17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The evolving vision for personalized medicine (PM) implies a systems approach to the re-organization of healthcare and how we define the boundary between care and research. Calls for scaling PM up to a systems level requires a broad definition of quality not restricted to how the different elements of the system perform (e.g., laboratory quality control, biomarker prediction, biobanking, information systems, data sharing and security, and clinical outcomes) but how these elements work together to optimize population relevant quality indicators - effectiveness, affordability, system sustainability, public confidence and accessibility. Examples of PM-associated information technologies and innovative clinical evaluation methods with a focus on cancer medicine are provided to demonstrate how quality and ethics are inextricably linked to a PM systems approach. While current, traditional ethical standards sometimes challenge the PM approach, PM is challenging us to review ethical standards and improve ethical frameworks to meet new and future realities.
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Affiliation(s)
- George P Browman
- British Columbia Cancer Agency, Vancouver Island Centre, Canada.,The School of Population & Public Health, University of British Columbia, Vancouver, Canada
| | - Jochen Vollmann
- Institute for Medical Ethics & History of Medicine, Ruhr-University Bochum, Bochum, Germany
| | - Alice Virani
- Centre for Applied Ethics, University of British Columbia BC Children's & Women's Hospitals, Vancouver, British Columbia, Canada
| | - Jan Schildmann
- Institute for Medical Ethics & History of Medicine, Ruhr-University Bochum, Bochum, Germany
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Kurzrock R, Stewart DJ. Equipoise abandoned? Randomization and clinical trials. Ann Oncol 2014; 24:2471-2474. [PMID: 24072520 DOI: 10.1093/annonc/mdt358] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- R Kurzrock
- Division of Hematology and Oncology, University of California Moores Cancer Center, San Diego, USA.
| | - D J Stewart
- Division of Medical Oncology, University of Ottawa, Ottawa, Canada
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Neumann RM, Garvey C, Kaufman S. Biospecimen Collection, Processing, and Analysis: New Challenges for Oncology Nurses. Semin Oncol Nurs 2014; 30:117-23. [DOI: 10.1016/j.soncn.2014.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
The National Cancer Institute of the United States recently announced a major new initiative in understanding the genomes or, more broadly, the molecular phenotypes of exceptional responders. What can we expect to learn from exceptional responders? What are the potential benefits, and how do we approach studying them?
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Affiliation(s)
- David K Chang
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Garsube Estate, Switchback Road, Bearsden Glasgow, Scotland G61 1BD, UK; The Kinghorn Cancer Centre, Cancer Division, Garvan Institute of Medical Research, 364 Victoria Street, Darlinghurst, Sydney, New South Wales 2010, Australia
| | - Sean M Grimmond
- Wolfson Wohl Cancer Research Centre, Insitute of Cancer Sciences, University of Glasgow, Garscube Estate, Switchback Road, Bearsden, Glasgow, Scotland G61 1BD, UK; Queensland Centre for Medical Genomics, Institute for Molecular Bioscience, The University of Queensland, St. Lucia, 4067 Brisbane, Queensland, Australia
| | - T R Jeffry Evans
- Wolfson Wohl Cancer Research Centre, Institute of Cancer Sciences, University of Glasgow, Garscube Estate, Switchback Road, Bearsden, Glasgow, Scotland G61 1BD, UK
| | - Andrew V Biankin
- Wolfson Wohl Cancer Research Centre, Insitute of Cancer Sciences, University of Glasgow, Garscube Estate, Switchback Road, Bearsden, Glasgow, Scotland G61 1BD, UK; The Kinghorn Cancer Centre, Cancer Division, Garvan Institute of Medical Research, 364 Victoria Street, Darlinghurst, Sydney, New South Wales 2010, Australia.
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Stephens R, Stewart D. The Randomised Clinical Trial and the Hazard Ratio - medical research's Emperor's New Clothes? BMC Cancer 2014; 14:260. [PMID: 24731512 PMCID: PMC4003285 DOI: 10.1186/1471-2407-14-260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 04/08/2014] [Indexed: 11/10/2022] Open
Abstract
As the enthusiasm for individualized treatment and targeted therapies continues to gain momentum, it seems timely to re-assess whether our current research tools are fit for purpose. Randomized Clinical Trials compare groups of patients, the Hazard Ratio is a ‘group summary statistic’, and modeling shows that the same Hazard Ratio score could result from a number of scenarios. Thus the current tools do not provide definitive information as to how to treat an individual patient. We therefore need to concentrate on the use of predictive factor analyses to identify the characteristics of subgroups of patients who respond to specific treatments.
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