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Zhu X, Liu B. Review time of oncology drugs and its underlying factors: an exploration in China. Front Pharmacol 2023; 14:1151784. [PMID: 38027001 PMCID: PMC10654631 DOI: 10.3389/fphar.2023.1151784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction: How the launch delay of drugs and other factors of interest can influence the length of the review period by drug agencies is still unknown, and understanding this can help better strike the trade-off related to review speed. Methods: We included all new oncology drug applications submitted to China's National Medical Product Administration (NMPA) between 1 January 2018 and 31 December 2021, and ultimately succeeded in achieving marketing approval. For each drug, the length of the NMPA review process and other major characteristics were collected, including the registration class, approval class, priority review designation, and launch delay relative to the United States, as well as the number of patients enrolled, comparator, and primary endpoint of the pivotal trials supporting the approval. Linear regression model was employed to analyze the effects of factors of interest on the NMPA review time. Results: From 2018 to 2021, NMPA received 137 oncology applications that were ultimately approved. Half of the approvals [76 (55.5%)] were first licensed in the US, leaving a median launch delay of 2.71 years (IQR, 1.03-5.59) in China. In the pivotal studies, the median enrollment was 361 participants (IQR, 131-682), and the use of control groups [90 (65.7%)] and surrogate endpoints [101 (73.7%)] was prevalent. The median review time was 304 days (IQR, 253-376). Multivariate analysis for log-transformed review time showed that larger enrollment (> 92) was associated with a drop of 20.55% in review time (coefficient = -0.230; 95% CI, -0.404 to -0.055; p = 0.010); and a short delay (0 < delay ≤ 1.95 years) was associated with a drop of 17.63% in review time (coefficient = -0.194; 95% CI, -0.325 to -0.062; p = 0.004). Discussion: The short launch delay relative to the US was one important driver to the review speed of NMPA, which might suggest its latent regulatory reliance on the other global regulator during the post-marketing period when new information on the drug's clinical benefit was still lacking.
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Affiliation(s)
- Xingyue Zhu
- Department of Pharmacy Administration, School of Medicine and Health Management, Guizhou Medical University, Guiyang, China
| | - Bao Liu
- Department of Health Economics, School of Public Health, Fudan University, Shanghai, China
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Chen LN, Wei AZ, Shu CA. Neoadjuvant immunotherapy in resectable non-small-cell lung cancer. Ther Adv Med Oncol 2023; 15:17588359231163798. [PMID: 37007633 PMCID: PMC10052589 DOI: 10.1177/17588359231163798] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/24/2023] [Indexed: 03/30/2023] Open
Abstract
The advent of immune checkpoint inhibition has pushed the treatment paradigm for resectable non-small-cell lung cancer (NSCLC) toward neoadjuvant therapy. A growing number of promising trials have examined the utility of neoadjuvant immunotherapy, both alone and in combination with other modalities such as radiation therapy (RT) and chemotherapy. The phase II LCMC3 and NEOSTAR trials demonstrated a role for neoadjuvant immunotherapy in inducing meaningful pathologic responses, and another phase II trial established the feasibility of combining neoadjuvant durvalumab with RT. Significant interest in neoadjuvant chemoimmunotherapy resulted in the conduct of multiple successful phase II trials including the Columbia trial, NADIM, SAKK 16/14, and NADIM II. Across these trials, neoadjuvant chemoimmunotherapy led to high rates of pathologic response and improved surgical outcomes without compromising surgical timing or feasibility. CheckMate-816, which was a randomized phase III trial studying neoadjuvant nivolumab in addition to chemotherapy, definitively established a benefit for neoadjuvant chemoimmunotherapy compared to chemotherapy alone for resectable NSCLC. Despite the growing literature and success of these trials, several outstanding questions remain, including the relationship between pathologic response and patient survival, the role of biomarkers such as programmed death ligand 1 and circulating tumor DNA in determining patient selection and treatment course, and the utility of additional adjuvant therapies. Longer follow-up of CheckMate-816 and other ongoing phase III trials may help address these questions. Ultimately, the complexity of managing resectable NSCLC highlights the importance of a multidisciplinary approach to patient care.
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Randomized Controlled Trials in Lung, Gastrointestinal, and Breast Cancers: An Overview of Global Research Activity. Curr Oncol 2022; 29:2530-2538. [PMID: 35448181 PMCID: PMC9026406 DOI: 10.3390/curroncol29040207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/25/2022] [Accepted: 04/05/2022] [Indexed: 11/25/2022] Open
Abstract
Background: In this study, we compared and contrasted design characteristics, results, and publications of randomized controlled trials (RCTs) in gastrointestinal (GI), lung, and breast cancer. Methods: A PUBMED search identified phase III RCTs of anticancer therapy in GI, lung, and breast cancer published globally during the period 2014−2017. Descriptive statistics, chi-square tests, and the Kruskal−Wallis test were used to compare RCT design, results, and output across the cancer sites. Results: A total of 352 RCTs were conducted on GI (36%), lung (29%), and breast (35%) cancer. Surrogate endpoints were used in 55% of trials; this was most common in breast trials (72%) compared to GI (47%) and lung trials (43%, p < 0.001). Breast trials more often met their primary endpoint (54%) than GI (41%) and lung trials (41%) (p = 0.024). When graded with the ESMO-MCBS, lung cancer trials (50%, 15/30) were more likely to meet the threshold for substantial benefit. GI trials were published in journals with a substantially lower impact factor (IF; median IF 13) than lung (median IF 21) and breast cancer trials (median IF 21) (p = 0.038). Conclusions: Important differences in RCT design and output exist between the three major cancer sites. Use of surrogate endpoints and the magnitude of benefit associated with new treatments vary substantially across cancer sites.
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Ren S, Xu A, Lin Y, Camidge DR, Di Maio M, Califano R, Hida T, Rossi A, Guibert N, Zhu C, Shen J. A narrative review of primary research endpoints of neoadjuvant therapy for lung cancer: past, present and future. Transl Lung Cancer Res 2021; 10:3264-3275. [PMID: 34430363 PMCID: PMC8350086 DOI: 10.21037/tlcr-21-259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 05/28/2021] [Indexed: 12/25/2022]
Abstract
Objective This review summarizes the current status of neoadjuvant therapy and discusses the choice of new clinical research endpoints for non-small cell lung cancer. Background Neoadjuvant chemotherapy is a recognized practice in patients with resectable and locally advanced lung cancer. With the introduction of molecular targeted drugs and immune checkpoint inhibitors (ICIs), the overall survival (OS) of patients with lung cancer has been significantly improved, and the original traditional clinical research endpoints are no longer suitable for existing clinical research. In order to accelerate the process of clinical trials and the development and approval of drugs, it is necessary to find suitable alternative indicators as the main indicators of clinical research. Methods Therefore, this article focuses on clinical trials using disease-free survival (DFS), progression free survival, and pathological evaluation indicators, pathologic complete response and major pathologic response, as surrogate endpoints. We search related literature through PubMed database and clinical trials through clinicaltrials.gov. Conclusions Pathologic complete response and major pathologic response are recommended as surrogate endpoints in the era of neoadjuvant immunotherapy, and secondary endpoints are listed for the prediction of pathological results. In addition, the definitions of major pathological response (MPR) and PCR should be standardized, and a new pathological evaluation standard should be developed, which is applicable to all current treatment methods. Keywords Neoadjuvant therapy; resectable lung cancer; clinical research endpoint; pathological response.
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Affiliation(s)
- Sijia Ren
- Taizhou Hospital, Zhejiang University, Taizhou, China
| | - Anyi Xu
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
| | - Yilian Lin
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Taizhou, China
| | - D Ross Camidge
- Division of Medical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Massimo Di Maio
- Department of Oncology, University of Turin/Division of Medical Oncology, Ordine Mauriziano Hospital, Turin, Italy
| | - Raffaele Califano
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK.,Division of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Toyoaki Hida
- Department of Thoracic Oncology, Aichi Cancer Center Hospital, Aichi, Japan
| | - Antonio Rossi
- Oncology Center of Excellence, Therapeutic Science & Strategy Unit, IQVIA, Milan, Italy
| | - Nicolas Guibert
- Thoracic Oncology Department, Larrey Hospital, University Hospital of Toulouse, Toulouse, France
| | - Chengchu Zhu
- Taizhou Hospital, Zhejiang University, Taizhou, China
| | - Jianfei Shen
- Taizhou Hospital, Zhejiang University, Taizhou, China
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Leighl NB, Nirmalakumar S, Ezeife DA, Gyawali B. An Arm and a Leg: The Rising Cost of Cancer Drugs and Impact on Access. Am Soc Clin Oncol Educ Book 2021; 41:1-12. [PMID: 33956494 DOI: 10.1200/edbk_100028] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Increasing cancer drug prices present global challenges to treatment access and cancer outcomes. Substantial variability exists in drug pricing across countries. In countries without universal health care, patients are responsible for treatment costs. Low- or middle-income countries are heavily impacted, with limited patient access to novel cancer treatments. Financial toxicity is seen across cancer types, countries, and health care systems. Those at highest risk include younger patients, new immigrants, visible minority groups, and those without private health coverage. Currently, cancer drug pricing does not correlate with value or clinical benefit. Value-based pricing of oncology drugs may incentivize development of higher-value medicines and eliminate excess spending on drugs that yield little benefit. Generics and biosimilars in oncology can also improve affordability and patient access, offering dramatic reductions in drug spending while maintaining patient benefit. Oncologists can promote value-based care by following evidence-based clinical guidelines that avoid low-value treatments. Researchers can also engage in value-based research that critically explores optimal cancer drug dosing, schedules, and treatment duration and defines patient populations most likely to benefit (e.g., through biomarker selection). Cancer Groundshot proposes that we improve outcomes for today's patients with cancer, including broader global access for high-value treatments, promotion of affordable cancer control strategies, and reduction of cancer morbidity and mortality through low-cost prevention and screening initiatives. Moving forward, major oncology societies recommend promoting uniform global access to essential cancer medicines and avoiding financial harm for patients as key principles in addressing the affordability of cancer drugs.
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Affiliation(s)
- Natasha B Leighl
- Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Sharon Nirmalakumar
- Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Doreen A Ezeife
- Department of Medical Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Bishal Gyawali
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
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6
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Wells JC, Sharma S, Del Paggio JC, Hopman WM, Gyawali B, Mukherji D, Hammad N, Pramesh CS, Aggarwal A, Sullivan R, Booth CM. An Analysis of Contemporary Oncology Randomized Clinical Trials From Low/Middle-Income vs High-Income Countries. JAMA Oncol 2021; 7:379-385. [PMID: 33507236 DOI: 10.1001/jamaoncol.2020.7478] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance The burden of cancer falls disproportionally on low-middle-income countries (LMICs). It is not well known how novel therapies are tested in current clinical trials and the extent to which they match global disease burden. Objectives To describe the design, results, and publication of oncology randomized clinical trials (RCTs) and examine the extent to which trials match global disease burden and how trial methods and results differ across economic settings. Design, Setting, and Participants In this retrospective cohort study, a literature search identified all phase 3 RCTs evaluating anticancer therapies published from 2014 to 2017. Randomized clinical trials were classified based on World Bank economic classification. Descriptive statistics were used to compare RCT design and results from high-income countries (HICs) and low/middle-income countries (LMICs). Statistical analysis was conducted in January 2020. Main Outcomes and Measures Differences in the design, results, and output of RCTs between HICs and LMICs. Results The study cohort included 694 RCTs: 636 (92%) led by HICs and 58 (8%) led by LMICs. A total of 601 RCTs (87%) tested systemic therapy and 88 RCTs (13%) tested radiotherapy or surgery. The proportion of RCTs relative to global deaths was higher for breast cancer (121 RCTs [17%] and 7% of deaths) but lower for gastroesophageal cancer (38 RCTs [6%] and 14% of deaths), liver cancer (14 RCTs [2%] and 8% of deaths), pancreas cancer (14 RCTs [2%] and 5% of deaths), and cervical cancer (9 RCTs [1%] and 3% of deaths). Randomized clinical trials in HICs were more likely than those in LMICs to be funded by industry (464 [73%] vs 24 [41%]; P < .001). Studies in LMICs were smaller than those in HICs (median, 219 [interquartile range, 137-363] vs 474 [interquartile range, 262-743] participants; P < .001) and more likely to meet their primary end points (39 of 58 [67%] vs 286 of 636 [45%]; P = .001). The observed median effect size among superiority trials was larger in LMICs compared with HICs (hazard ratio, 0.62 [interquartile range, 0.54-0.76] vs 0.84 [interquartile range, 0.67-0.97]; P < .001). Studies from LMICs were published in journals with lower median impact factors than studies from HICs (7 [interquartile range, 4-21] vs 21 [interquartile range, 7-34]; P < .001). Publication bias persisted when adjusted for whether a trial was positive or negative (median impact factor: LMIC negative trial, 5 [interquartile range, 4-6] vs HIC negative trial, 18 [interquartile range, 6-26]; LMIC positive trial, 9 [interquartile range, 5-25] vs HIC positive trial, 25 [interquartile range, 10-48]; P < .001). Conclusions and Relevance This study suggests that oncology RCTs are conducted predominantly by HICs and do not match the global burden of cancer. Randomized clinical trials from LMICs are more likely to identify effective therapies and have a larger effect size than RCTs from HICs. This study suggests that there is a funding and publication bias against RCTs led by LMICs. Policy makers, research funders, and journals need to address this issue with a range of measures including building capacity and capability in RCTs.
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Affiliation(s)
- J Connor Wells
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Shubham Sharma
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Joseph C Del Paggio
- Department of Oncology, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Wilma M Hopman
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Deborah Mukherji
- Department of Hematology/Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nazik Hammad
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - C S Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Ajay Aggarwal
- Institute of Cancer Policy, King's College London, London, United Kingdom.,Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Sullivan
- Institute of Cancer Policy, King's College London, London, United Kingdom
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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Rubinstein SM, Sigworth EA, Etemad S, Martin RL, Chen Q, Warner JL. Indication of Measures of Uncertainty for Statistical Significance in Abstracts of Published Oncology Trials: A Systematic Review and Meta-analysis. JAMA Netw Open 2019; 2:e1917530. [PMID: 31834396 PMCID: PMC6991218 DOI: 10.1001/jamanetworkopen.2019.17530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
IMPORTANCE There is growing consensus that reliance on P values, particularly a cutoff level of .05 for statistical significance, is a factor in the challenges in scientific reproducibility. Despite this consensus, publications describing clinical trial results with P values near .05 anecdotally use declarative statements that do not express uncertainty. OBJECTIVES To quantify uncertainty expression in abstracts describing the results of cancer randomized clinical trials (RCTs) with P values between .01 and .10 and examine whether trial features are associated with uncertainty expression. DATA SOURCES A total of 5777 prospective trials indexed on HemOnc.org, as of September 15, 2019. STUDY SELECTION Two-arm RCTs with a superiority end point with P values between .01 and .10. DATA EXTRACTION AND SYNTHESIS Abstracts were evaluated based on an uncertainty expression algorithm. Ordinal logistic regression modeling with multiple imputation was performed to identify whether characteristics of study design, results, trial authors, and context P values were normalized by dividing by prespecified α value. MAIN OUTCOMES AND MEASURES Uncertainty expression in abstracts as determined by the algorithm and its association with trial and publication characteristics. RESULTS Of 5777 trials screened, 556 met analysis criteria. Of these, 222 trials (39.9%) did not express uncertainty, 161 trials (29.0%) expressed some uncertainty, and 173 trials (31.1%) expressed full uncertainty. In ordinal logistic regression with multiple imputation, trial features with statistically significant associations with uncertainty expression included later year of publication (odds ratio [OR], 1.70; 95% CI, 1.24-2.32; P < .001), normalized P value (OR, 1.36; 95% CI, 1.11-1.67; P = .003), noncooperative group studies (OR, 1.72; 95% CI, 1.12-2.63; P = .01), and reporting an end point other than overall survival (OR, 1.41; 95% CI, 1.01-1.96; P = .047). Funding source, number of authors, journal impact tier, author nationality, study of unapproved drugs, abstract word count, whether the marginal end point was a primary or coprimary end point, and effect size (in subgroup analysis) did not have statistically significant associations with uncertainty expression. CONCLUSIONS AND RELEVANCE Published oncology articles with marginally significant results may often incompletely convey uncertainty. Although it appears that more uncertainty is expressed in recent abstracts, full uncertainty expression remains uncommon, and seemingly is less common when reporting overall survival, results with P values lower than α levels, and cooperative group studies.
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Affiliation(s)
- Samuel M. Rubinstein
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | | | - Shervin Etemad
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Richard L. Martin
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Qingxia Chen
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee
| | - Jeremy L. Warner
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee
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8
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Fernández-López C, Calleja-Hernández MÁ, Balbino JE, Cabeza-Barrera J, Expósito-Hernández J. Trends in endpoint selection and result interpretation in advanced non-small cell lung cancer clinical trials published between 2000 and 2012: A retrospective cohort study. Thorac Cancer 2019; 10:904-908. [PMID: 30868737 PMCID: PMC6449273 DOI: 10.1111/1759-7714.13024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 01/31/2019] [Accepted: 02/01/2019] [Indexed: 11/30/2022] Open
Abstract
Background The objective of this review was to investigate trends in clinical trial design, specifically, the primary outcomes used, interpretation of results, and the magnitude of the benefits described in phase III controlled clinical trials in the first‐line treatment of patients with advanced non‐small cell lung cancer (NSCLC). Methods Seventy‐six trials published between 2000 and 2012 were selected from a total of 122 identified in a structured search. Results Overall survival (OS) was evaluated as the primary study endpoint in 50 (65.8%) trials, followed by progression‐free survival (PFS) in 15 (19.7%), and other variables, such as toxicity, quality of life (QoL), and response rate in 11 (14.5%). Ten (66.7%) out of 15 clinical trials using PFS as the primary endpoint were published between 2010 and 2012. Median overall survival (mOS) was 9.90 months (interquartile range: 3.5) with an increase of 0.384 months per year of publication (P < 0.001). A statistically significant improvement in mOS was obtained in only 13 (18.8%) trials. A total of 41 (53.9%) studies concluded that the result was positive. Of these, only 16 (39.1%) showed a statistically significant benefit in OS. QoL was assessed in 46 trials (60.5%) and of these, 10 (21.7%) reported significant improvements. Conclusions These findings raise important questions about how clinical benefits are measured in clinical trials in advanced NSCLC. Appropriate clinically relevant outcome variables should be established and validated, and post‐marketing studies should be requested by regulatory authorities to ensure meaningful clinical benefits in OS and QoL.
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Affiliation(s)
| | | | - Jaime Espín Balbino
- Andalusian School of Public Health (EASP), Granada, Spain.,Health Research Institute of Granada (ibs.GRANADA), University Hospitals of Granada/University of Granada, Granada, Spain
| | - José Cabeza-Barrera
- Department of Pharmacy, Biosanitary Research Institute of Granada, San Cecilio University Hospital, Granada, Spain
| | - José Expósito-Hernández
- Department of Oncology, University Hospitals of Granada, Health Research Institute of Granada (ibs.GRANADA), Spain
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Lawrence NJ, Roncolato F, Martin A, Simes RJ, Stockler MR. Effect Sizes Hypothesized and Observed in Contemporary Phase III Trials of Targeted and Immunological Therapies for Advanced Cancer. JNCI Cancer Spectr 2018; 2:pky037. [PMID: 31360867 PMCID: PMC6649714 DOI: 10.1093/jncics/pky037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 05/05/2018] [Accepted: 07/13/2018] [Indexed: 12/22/2022] Open
Abstract
Background We sought to compare the effect sizes hypothesized in the trial design, observed in the trial results, and considered clinically meaningful by the American Society of Clinical Oncology (ASCO) 2014 recommendations, in phase III trials of targeted and immunological therapies. Methods We studied phase III, superiority trials of targeted and immunological therapies in advanced cancers published from 2005 to 2015. We recorded the characteristics, design parameters, and observed results for the primary endpoint of each trial. The effect sizes hypothesized in the trial design were compared with the ASCO 2014 recommendation that phase III trials be designed to detect overall survival (OS) benefits that are clinically meaningful (hazard ratio ≤0.8). Results All critical elements of the trial design (effect sizes hypothesized, estimated survival in the control group, power, and significance level) were identified in 165 of 213 included trials (77%). Of trials with a statistically significant result for the primary endpoint, 16 of 30 (53%) with a primary endpoint of OS and 20 of 53 (38%) with a primary endpoint of progression free survival (PFS) had an observed effect size less extreme than hypothesized; and 7 of 30 trials (23%) reported an observed effect size for OS that was statistically significant but not clinically meaningful (HR > 0.80) according to the ASCO 2014 recommendations. Conclusion Many trials were designed such that an observed benefit in OS or PFS that was not clinically meaningful would be statistically significant. Phase III trials should be designed to provide results that are statistically significant for observed effects that are clinically meaningful but not for observed results that are of dubious clinical importance.
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Affiliation(s)
- Nicola Jane Lawrence
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Felicia Roncolato
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia.,Macarthur Cancer Therapy Centre, Campbelltown, New South Wales, Australia
| | - Andrew Martin
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Robert John Simes
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Martin R Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia.,Concord Cancer Centre, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
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10
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Tagliamento M, Genova C, Rijavec E, Rossi G, Biello F, Dal Bello MG, Alama A, Coco S, Boccardo S, Grossi F. Afatinib and Erlotinib in the treatment of squamous-cell lung cancer. Expert Opin Pharmacother 2018; 19:2055-2062. [DOI: 10.1080/14656566.2018.1540591] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
| | - Carlo Genova
- Lung Cancer Unit, Ospedale Policlinico San Martino , Genoa, Italy
- Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa , Genoa, Italy
| | - Erika Rijavec
- Lung Cancer Unit, Ospedale Policlinico San Martino , Genoa, Italy
| | - Giovanni Rossi
- Lung Cancer Unit, Ospedale Policlinico San Martino , Genoa, Italy
| | - Federica Biello
- Lung Cancer Unit, Ospedale Policlinico San Martino , Genoa, Italy
| | | | - Angela Alama
- Lung Cancer Unit, Ospedale Policlinico San Martino , Genoa, Italy
| | - Simona Coco
- Lung Cancer Unit, Ospedale Policlinico San Martino , Genoa, Italy
| | - Simona Boccardo
- Lung Cancer Unit, Ospedale Policlinico San Martino , Genoa, Italy
| | - Francesco Grossi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Medical Oncology , Milan, Italy
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11
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Liang F, Zhang S, Wang Q, Li W. Evolution of randomized controlled trials and surrogacy of progression-free survival in advanced/metastatic urothelial cancer. Crit Rev Oncol Hematol 2018; 130:36-43. [PMID: 30196910 DOI: 10.1016/j.critrevonc.2018.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/22/2018] [Accepted: 07/30/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Clinical trials in advanced/metastatic urothelial cancer have been difficult to perform. We review the current characteristics of randomized controlled trials (RCTs) and evaluate whether PFS could be a potential surrogate endpoint for overall survival (OS) in advanced/metastatic urothelial cancer. METHODS We identified trials by a systematic review of Medline, Embase, and the Cochrane Central Register of Controlled Trials from inception to April 2017. We included RCTs of patients with locally advanced/metastatic urothelial cancer that involved systemic therapy as an intervention, and those with reported hazards ratios (HRs) and corresponding 95% confidence intervals (CIs) for both OS and PFS, or provided Kaplan-Meier curves from which HRs and 95% CI could be calculated. The correlation coefficient between log of HRs for OS and PFS was calculated using linear regression weighted by sample size. RESULTS Forty eight trials that enrolled 7019 patients were included in the review and 24 RCTs were included in the surrogacy analysis. 27(56.3%) of identified 48 RCTs were phase II trials, and the median sample size was 107(range, 30-626) for all RCTs. The correlation coefficient between log HR for PFS and log HR for OS was 0.79 (95% CI, 0.58-0.91). The correlation coefficient increased to 0.87 (95% CI, 0.72-0.94) after excluding the only trial with immune checkpoint inhibitor. Multiple sensitivity analyses did not change the results..aph."/> CONCLUSIONS: PFS is strongly correlated with OS in trials of advanced/metastatic urothelial cancer assessing the treatment benefit of new drugs And PFS warrants further exploration as a surrogate endpoint in clinical trial datasets.
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Affiliation(s)
- Fei Liang
- Shanghai Cancer Center and Shanghai Medical College, Fudan University, Shanghai, China
| | - Sheng Zhang
- Shanghai Cancer Center and Shanghai Medical College, Fudan University, Shanghai, China.
| | - Qing Wang
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wenfeng Li
- The Affiliated Hospital of Qingdao University, Qingdao, China
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Wardak Z, Iyengar P. The Objective of Local Therapy in Oligometastatic Cancer Is a Moving Target-Reply. JAMA Oncol 2018; 4:1296-1297. [PMID: 29955791 DOI: 10.1001/jamaoncol.2018.1228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Zabi Wardak
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Puneeth Iyengar
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
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Cripe LD, Rand KL, Perkins SM, Tong Y, Schmidt KK, Hedrick DG, Rawl SM. Ambulatory Advanced Cancer Patients' and Oncologists' Estimates of Life Expectancy Are Associated with Patient Psychological Characteristics But Not Chemotherapy Use. J Palliat Med 2018; 21:1107-1113. [PMID: 29905496 DOI: 10.1089/jpm.2017.0686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Patients with advanced cancer often face distressing decisions about chemotherapy. There are conflicting data on the relationships among perceived prognosis, psychological characteristics, and chemotherapy use, which impair the refinement of decision support interventions. OBJECTIVE Clarify the relationships among patient and oncologist estimates of life expectancy for 6 and 12 months, chemotherapy use, and patient psychological characteristics. DESIGN Secondary analysis of data from two cross-sectional studies. SETTING/SUBJECTS One hundred sixty-six patients with advanced stage cancer recruited from ambulatory cancer clinics. MEASUREMENTS All data were obtained at study enrollment. Patients completed the Adult Hope Scale, Hospital Anxiety and Depression Scale, and Life Orientation Test-Revised. Patients and their oncologists provided estimates of surviving beyond 6 and 12 months. Chemotherapy use was determined by chart review. RESULTS There were no significant associations between life-expectancy estimates and chemotherapy use nor patient anxiety, depression, hope, or optimism and chemotherapy use. Patients' life expectancy estimates for 12 months and oncologists' for 6 months were associated with higher patient anxiety and depression. Finally, both oncologist and patient estimates of life expectancy for 6 and 12 months were associated with increased levels of trait hope. CONCLUSION Advanced cancer patients who provide less optimistic estimates of life expectancy have increased anxiety and depression, but do not use chemotherapy more often. Increased patient trait hope is associated with more favorable oncologist estimates. These findings highlight the need for interventions to support both patients and oncologists as they clarify prognostic expectations and patients cope with the psychological distress of a limited life expectancy.
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Affiliation(s)
- Larry D Cripe
- 1 Department of Medicine, Indiana University School of Medicine , Indianapolis, Indiana
| | - Kevin L Rand
- 2 Department of Psychology, Indiana University-Purdue University Indianapolis , Indianapolis, Indiana
| | - Susan M Perkins
- 1 Department of Medicine, Indiana University School of Medicine , Indianapolis, Indiana
| | - Yan Tong
- 1 Department of Medicine, Indiana University School of Medicine , Indianapolis, Indiana
| | - Karen Krall Schmidt
- 1 Department of Medicine, Indiana University School of Medicine , Indianapolis, Indiana
| | - David G Hedrick
- 1 Department of Medicine, Indiana University School of Medicine , Indianapolis, Indiana
| | - Susan M Rawl
- 3 Indiana University School of Nursing , Indianapolis, Indiana
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Lee CK, Novello S, Rydén A, Mann H, Mok T. Patient-Reported Symptoms and Impact of Treatment With Osimertinib Versus Chemotherapy in Advanced Non-Small-Cell Lung Cancer: The AURA3 Trial. J Clin Oncol 2018; 36:1853-1860. [PMID: 29733770 DOI: 10.1200/jco.2017.77.2293] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Capturing patient-reported outcome data is important for evaluating the overall clinical benefits of new cancer therapeutics. We assessed self-reported symptoms of advanced non-small-cell lung cancer in patients treated with osimertinib or chemotherapy in the AURA3 phase III trial. Patients and Methods Patients completed the European Organisation for Research and Treatment of Cancer 13-item Quality of Life Questionnaire-Lung Cancer Module (EORTC QLQ-LC13) questionnaire on disease-specific symptoms and the EORTC 30-item Core Quality of Life Questionnaire (EORTC QLC-C30) on general cancer symptoms, functioning, global health status/quality of life. We assessed differences between treatments in time to deterioration of individual symptoms and odds of improvement (a deterioration or improvement was defined as a change in score from baseline of ≥ 10). Hazard ratios (HRs) were calculated using a log-rank test stratified by ethnicity; odds ratios (ORs) were assessed using logistic regression adjusted for ethnicity. Results At baseline, the questionnaires were completed by 82% to 88% of patients, and 30% to 70% had individual key symptoms. Time to deterioration was longer with osimertinib than with chemotherapy for cough (HR, 0.74; 95% CI, 0.53 to 1.05), chest pain (HR, 0.52; 95% CI, 0.37 to 0.73), and dyspnea (HR, 0.42; 95% CI, 0.31 to 0.58). The proportion of symptomatic patients with improvement in global health status/quality of life was higher with osimertinib (80 [37%] of 215) than with chemotherapy (23 [22%] of 105; OR, 2.11; 95% CI, 1.24 to 3.67; P = .007). Proportions were also higher for appetite loss (OR, 2.50; 95% CI, 1.31 to 4.84) and fatigue (OR, 1.96; 95% CI, 1.20 to 3.22). Conclusion Time to deterioration of key symptoms was longer with osimertinib than with chemotherapy, and a higher proportion of patients had improvement in global health status/quality of life, demonstrating improved patient outcomes with osimertinib.
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Affiliation(s)
- Chee Khoon Lee
- Chee Khoon Lee, St George Hospital, Kogarah, New South Wales, Australia; Silvia Novello, University of Turin, Turin, Italy; Anna Rydén, AstraZeneca Gothenburg, Mölndal, Sweden; Helen Mann, AstraZeneca R&D, Cambridge, United Kingdom; and Tony Mok, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, Special Administrative Region, People's Republic of China
| | - Silvia Novello
- Chee Khoon Lee, St George Hospital, Kogarah, New South Wales, Australia; Silvia Novello, University of Turin, Turin, Italy; Anna Rydén, AstraZeneca Gothenburg, Mölndal, Sweden; Helen Mann, AstraZeneca R&D, Cambridge, United Kingdom; and Tony Mok, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, Special Administrative Region, People's Republic of China
| | - Anna Rydén
- Chee Khoon Lee, St George Hospital, Kogarah, New South Wales, Australia; Silvia Novello, University of Turin, Turin, Italy; Anna Rydén, AstraZeneca Gothenburg, Mölndal, Sweden; Helen Mann, AstraZeneca R&D, Cambridge, United Kingdom; and Tony Mok, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, Special Administrative Region, People's Republic of China
| | - Helen Mann
- Chee Khoon Lee, St George Hospital, Kogarah, New South Wales, Australia; Silvia Novello, University of Turin, Turin, Italy; Anna Rydén, AstraZeneca Gothenburg, Mölndal, Sweden; Helen Mann, AstraZeneca R&D, Cambridge, United Kingdom; and Tony Mok, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, Special Administrative Region, People's Republic of China
| | - Tony Mok
- Chee Khoon Lee, St George Hospital, Kogarah, New South Wales, Australia; Silvia Novello, University of Turin, Turin, Italy; Anna Rydén, AstraZeneca Gothenburg, Mölndal, Sweden; Helen Mann, AstraZeneca R&D, Cambridge, United Kingdom; and Tony Mok, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, Special Administrative Region, People's Republic of China
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15
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Evolution of Symptom Burden of Advanced Lung Cancer Over a Decade. Clin Lung Cancer 2017; 18:274-280.e6. [DOI: 10.1016/j.cllc.2016.12.010] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 11/29/2016] [Accepted: 12/13/2016] [Indexed: 01/17/2023]
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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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Zhou Q, Yang JJ, Chen ZH, Zhang XC, Yan HH, Xu CR, Su J, Chen HJ, Tu HY, Zhong WZ, Yang XN, Wu YL. Serial cfDNA assessment of response and resistance to EGFR-TKI for patients with EGFR-L858R mutant lung cancer from a prospective clinical trial. J Hematol Oncol 2016; 9:86. [PMID: 27619632 PMCID: PMC5020532 DOI: 10.1186/s13045-016-0316-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 09/03/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Detecting epidermal growth factor receptor (EGFR) activating mutations in plasma could guide EGFR-tyrosine kinase inhibitor (EGFR-TKI) treatment for advanced non-small cell lung cancer (NSCLC). However, dynamic quantitative changes of plasma EGFR mutations during the whole course of EGFR-TKI treatment and its correlation with clinical outcomes were not determined. The aim of this study was to measure changes of plasma EGFR L858R mutation during EGFR-TKI treatment and to determine its correlation with the response and resistance to EGFR-TKI. METHODS This study was a pre-planned exploratory analysis of a randomized phase III trial conducted from 2009 to 2014 comparing erlotinib with gefitinib in advanced NSCLC harboring EGFR mutations in tumor (CTONG0901). Totally, 256 patients were enrolled in CTONG0901 and randomized to receive erlotinib or gefitinib. One hundred and eight patients harbored L858R mutation in their tumors and 80 patients provided serial blood samples as pre-planned scheduled. Serial plasma L858R was detected using quantitative polymerase chain reaction. Dynamic types of plasma L858R were analyzed using Ward's hierarchical clustering method. Progression-free survival (PFS) and overall survival (OS) were compared between different types. RESULTS As a whole, the quantity of L858R decreased and reached the lowest level at the time of best response to EGFR-TKI. After the analysis of Ward's hierarchical clustering method, two dynamic types were found. In 61 patients, L858R increased to its highest level when disease progressed (ascend type), while in 19 patients, L858R maintained a stable level when disease progressed (stable type). Median PFS was 11.1 months (95 % CI, 6.6-15.6) and 7.5 months (95 % CI, 1.4-13.6) in patients with ascend and stable types, respectively (P = 0.023). Median OS was 19.7 months (95 % CI, 16.5-22.9) and 16.0 months (95 % CI, 13.4-18.5), respectively (P = 0.050). CONCLUSIONS This is the first report finding two different dynamic types of plasma L858R mutation during EGFR-TKI treatment based on a prospective randomized study. Different dynamic types were correlated with benefits from EGFR-TKI. The impact of plasma L858R levels at disease progression on subsequent treatment strategy needs further exploration. TRIAL REGISTRATION ClinicalTrials.gov, NCT01024413.
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Affiliation(s)
- Qing Zhou
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Jin-Ji Yang
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Zhi-Hong Chen
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Xu-Chao Zhang
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Hong-Hong Yan
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Chong-Rui Xu
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Jian Su
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Hua-Jun Chen
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Hai-Yan Tu
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Wen-Zhao Zhong
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Xue-Ning Yang
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, China.
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Fernández-López C, Expósito-Hernández J, Arrebola-Moreno JP, Calleja-Hernández MÁ, Expósito-Ruíz M, Guerrero-Tejada R, Linares I, Cabeza-Barrera J. Trends in phase III randomized controlled clinical trials on the treatment of advanced non-small-cell lung cancer. Cancer Med 2016; 5:2190-7. [PMID: 27449070 PMCID: PMC5055155 DOI: 10.1002/cam4.782] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 04/29/2016] [Accepted: 05/02/2016] [Indexed: 12/02/2022] Open
Abstract
The objective of this review was to analyze trends in outcomes and in the quality of phase III randomized controlled trials on advanced NSCLC published between 2000 and 2012, selecting 76 trials from a total of 122 retrieved in a structured search. Over the study period, the number of randomized patients per trial increased by 14 per year (P = 0.178). The sample size significantly increased between 2000 and 2012 in trials of targeted agents (460.1 vs. 740.8 patients, P = 0.009), trials of >1 drug (360.4 vs. 584.8, P = 0.014), and those including patients with good performance status (675.3 vs. 425.6; P = 0.003). Quality of life was assessed in 46 trials (60.5%), and significant improvements were reported in 10 of these (21.7%). Platinum-based regimens were the most frequently investigated (86.8% of trials). Molecular-targeted agents were studied in 25.0% of chemotherapy arms, and the percentage of trials including these agents increased each year. The median (interquartile range) overall survival (MOS) was 9.90 (3.5) months with an increase of 0.384 months per year of publication (P < 0.001). A statistically significant improvement in MOS was obtained in only 13 (18.8%) trials. The median progression-free survival was 4.9 (1.9) months, with a nonsignificant increase of 0.026 months per year (P > 0.05). There has been a continuous but modest improvement in the survival of patients with advanced NSCLC over the past 12 years. Nevertheless, the quality of clinical trials and the benefit in outcomes should be carefully considered before the incorporation of novel approaches into clinical practice.
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Affiliation(s)
- Cristina Fernández-López
- Department of Pharmacy, Biosanitary Institute of Granada (ibs.GRANADA), University Hospitals of Granada/University of Granada, Granada, Spain.
| | | | | | - Miguel Ángel Calleja-Hernández
- Department of Pharmacy, Biosanitary Institute of Granada (ibs.GRANADA), University Hospitals of Granada/University of Granada, Granada, Spain
| | - Manuela Expósito-Ruíz
- Unit Research Support, Biosanitary Institute of Granada (ibs.GRANADA), University Hospitals of Granada/University of Granada, Granada, Spain
| | - Rosa Guerrero-Tejada
- Department of Oncology, Virgen de las Nieves Universitary Hospital, Granada, Spain
| | - Isabel Linares
- Department of Oncology, Virgen de las Nieves Universitary Hospital, Granada, Spain
| | - José Cabeza-Barrera
- Department of Pharmacy, Biosanitary Institute of Granada (ibs.GRANADA), University Hospitals of Granada/University of Granada, Granada, Spain
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Gyawali B, Prasad V. Negative trials in ovarian cancer: is there such a thing as too much optimism? Ecancermedicalscience 2016; 10:ed58. [PMID: 27594913 PMCID: PMC4990052 DOI: 10.3332/ecancer.2016.ed58] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Indexed: 02/01/2023] Open
Abstract
Recently, two clinical trials of novel agents in metastatic ovarian cancer were published: a phase 3 study of nintedanib and a phase 2 study of volasertib. There seemed to be discordance between the results and conclusions in the publication of both these trials. Despite not very optimistic results, the studies concluded optimistically in favor of the new agents under study. Using these examples, we point out the discrepancies and the risks of concluding optimistically based on statistical significance when the actual benefit is minimal. We also appeal against conducting large phase 3 trials that require significant resources without good phase 2 evidence for doing so.
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Affiliation(s)
- Bishal Gyawali
- Department of Hemato-Oncology, Nobel Hospital, Sinamangal, Kathmandu 21034, Nepal
| | - Vinay Prasad
- Division of Hematology Oncology, Knight Cancer Institute, Oregon Health and Science University, USA; Department of Public Health and Preventive Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, Oregon, USA; Center for Health Care Ethics, Oregon Health and Science University, Portland, Oregon 97239, USA
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20
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Kim C, Prasad V. Strength of Validation for Surrogate End Points Used in the US Food and Drug Administration's Approval of Oncology Drugs. Mayo Clin Proc 2016; 91:S0025-6196(16)00125-7. [PMID: 27236424 PMCID: PMC5104665 DOI: 10.1016/j.mayocp.2016.02.012] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 01/21/2016] [Accepted: 02/09/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To determine the strength of the surrogate-survival correlation for cancer drug approvals based on a surrogate. PARTICIPANTS AND METHODS We performed a retrospective study of the US Food and Drug Administration (FDA) database, with focused searches of MEDLINE and Google Scholar. Among cancer drugs approved based on a surrogate end point, we examined previous publications assessing the strength of the surrogate-survival correlation. Specifically, we identified the percentage of surrogate approvals lacking any formal analysis of the strength of the surrogate-survival correlation, and when conducted, the strength of such correlations. RESULTS Between January 1, 2009, and December 31, 2014, the FDA approved marketing applications for 55 indications based on a surrogate, of which 25 were accelerated approvals and 30 were traditional approvals. We could not find any formal analyses of the strength of the surrogate-survival correlation in 14 out of 25 accelerated approvals (56%) and 11 out of 30 traditional approvals (37%). For accelerated approvals, just 4 approvals (16%) were made where a level 1 analysis (the most robust way to validate a surrogate) had been performed, with all 4 studies reporting low correlation (r≤0.7). For traditional approvals, a level 1 analysis had been performed for 15 approvals (50%): 8 (53%) reported low correlation (r≤0.7), 4 (27%) medium correlation (r>0.7 to r<0.85), and 3 (20%) high correlation (r≥0.85) with survival. CONCLUSIONS The use of surrogate end points for drug approval often lacks formal empirical verification of the strength of the surrogate-survival association.
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Affiliation(s)
- Chul Kim
- Medical Oncology Service, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Vinay Prasad
- Department of Medicine, Division of Hematology Oncology/Knight Cancer Institute, Oregon Health & Science University, Portland.
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Zer A, Prince RM, Amir E, Abdul Razak A. Evolution of Randomized Trials in Advanced/Metastatic Soft Tissue Sarcoma: End Point Selection, Surrogacy, and Quality of Reporting. J Clin Oncol 2016; 34:1469-75. [PMID: 26951308 DOI: 10.1200/jco.2015.64.3437] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Randomized controlled trials (RCTs) in soft tissue sarcoma (STS) have used varying end points. The surrogacy of intermediate end points, such as progression-free survival (PFS), response rate (RR), and 3-month and 6-month PFS (3moPFS and 6moPFS) with overall survival (OS), remains unknown. The quality of efficacy and toxicity reporting in these studies is also uncertain. METHODS A systematic review of systemic therapy RCTs in STS was performed. Surrogacy between intermediate end points and OS was explored using weighted linear regression for the hazard ratio for OS with the hazard ratio for PFS or the odds ratio for RR, 3moPFS, and 6moPFS. The quality of reporting for efficacy and toxicity was also evaluated. RESULTS Fifty-two RCTs published between 1974 and 2014, comprising 9,762 patients, met the inclusion criteria. There were significant correlations between PFS and OS (R = 0.61) and between RR and OS (R = 0.51). Conversely, there were nonsignificant correlations between 3moPFS and 6moPFS with OS. A reduction in the use of RR as the primary end point was observed over time, favoring time-based events (P for trend = .02). In 14% of RCTs, the primary end point was not met, but the study was reported as being positive. Toxicity was comprehensively reported in 47% of RCTs, whereas 14% inadequately reported toxicity. CONCLUSION In advanced STS, PFS and RR seem to be appropriate surrogates for OS. There is poor correlation between OS and both 3moPFS and 6moPFS. As such, caution is urged with the use of these as primary end points in randomized STS trials. The quality of toxicity reporting and interpretation of results is suboptimal.
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Affiliation(s)
- Alona Zer
- All authors: Princess Margaret Cancer Centre, and University of Toronto, Toronto, Ontario, Canada.
| | - Rebecca M Prince
- All authors: Princess Margaret Cancer Centre, and University of Toronto, Toronto, Ontario, Canada
| | - Eitan Amir
- All authors: Princess Margaret Cancer Centre, and University of Toronto, Toronto, Ontario, Canada
| | - Albiruni Abdul Razak
- All authors: Princess Margaret Cancer Centre, and University of Toronto, Toronto, Ontario, Canada
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Cortinovis D, Abbate M, Bidoli P, Pelizzoni D, Canova S. Interpretation of lung cancer study outcomes. J Thorac Dis 2015; 7:E541-7. [PMID: 26716052 DOI: 10.3978/j.issn.2072-1439.2015.11.26] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Lung cancer is the leading cause of cancer death in developed countries. However, in the last few years we observed an important acceleration in drug development due to oncogenic driver tumors discovery. Sharing and putting together preclinical data from benchmark and data from clinical research is the scientific paradigm that allows real breakthrough in clinical practice in this field, but only a few targeted agents are worthy and practice changing. The clinical research and proper use of statistical methodology are the pillars to continue to achieve important goals like improvement of overall survival. A good medical oncologist should be able to critically read a scientific paper and move from the observed outcomes into clinical perspective. Despite clinical improvements, sometimes the union of promising targeted agents and optimistic expectations misrepresent the reality and the value of clinical research. In this article, we try to analyze the meaning of statistical assumptions from clinical trials, especially in lung cancer, through a critical review of the concept of value-based medicine. We also attempt to give the reader some practical tools to weigh scientific value of literature reports.
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Affiliation(s)
| | - Marida Abbate
- Medical Oncology Unit, S Gerardo Hospital, Monza, Italy
| | - Paolo Bidoli
- Medical Oncology Unit, S Gerardo Hospital, Monza, Italy
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Glass HE, DiFrancesco JJ, Glass LM, Tran P. Are Phase 3 Clinical Trials Really Becoming More Complex? Ther Innov Regul Sci 2015; 49:852-860. [PMID: 30222375 DOI: 10.1177/2168479015583725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study uses the data from many of the mandatory fields in ClinicalTrials.gov to examine changes, possibly leading to more complexity in the design and execution of commercially sponsored phase 3 clinical trials. METHODS In this analysis we compare baseline year 2008 data, when a broad number of the protocol/study design and execution variables became mandatory, with the data from the last full year of results, 2013. RESULTS There has been relatively little change in the protocol and study design over the years covered in this study. The most pronounced change is associated with single-patient duration: there is a significant increase in the period of time a patient is treated in the study protocol. The study also highlights an important methodological issue: many of the claims in print about complexity have yet been substantiated through the use of peer-reviewed data or in settings where others can interrogate the results. CONCLUSIONS In general, there is limited evidence for significant increases in the study and protocol design and execution of phase 3 clinical trials sponsored by pharmaceutical companies.
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Affiliation(s)
- Harold E Glass
- 1 Department of Health Policy and Public Policy, University of the Sciences in Philadelphia, Philadelphia, PA, USA
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Pantziarka P, Bouche G, Meheus L, Sukhatme V, Sukhatme VP. Repurposing drugs in your medicine cabinet: untapped opportunities for cancer therapy? Future Oncol 2015; 11:181-4. [PMID: 25591833 DOI: 10.2217/fon.14.244] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Pan Pantziarka
- Anticancer Fund, Brussels, 1853 Strombeek-Bever, Belgium
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Carrera PM, Ormond M. Current practice in and considerations for personalized medicine in lung cancer: From the patient's molecular biology to patient values and preferences. Maturitas 2015; 82:94-9. [DOI: 10.1016/j.maturitas.2015.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 04/10/2015] [Accepted: 04/13/2015] [Indexed: 11/26/2022]
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Lilenbaum R, Leighl NB, Neubauer M. Expectations in the care of lung cancer. Am Soc Clin Oncol Educ Book 2015:e420-4. [PMID: 25993205 DOI: 10.14694/edbook_am.2015.35.e420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
One of the main challenges oncologists face in the care of patients with lung cancer is the decision to incorporate new clinical trial data into routine clinical practice. Beyond the question of statistical significance, which is a more objective metric, are the results meaningful and applicable to a broader population? Furthermore, in an era of value care, do the results justify a potential increase in costs? This article discusses the main points that clinicians consider in their decision-making process and illustrates the arguments with real-life examples.
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Affiliation(s)
- Rogerio Lilenbaum
- From the Yale Cancer Center, New Haven, CT; Princess Margaret Cancer Center, Toronto, Canada; McKesson Specialty Health, The Woodlands, TX
| | - Natasha B Leighl
- From the Yale Cancer Center, New Haven, CT; Princess Margaret Cancer Center, Toronto, Canada; McKesson Specialty Health, The Woodlands, TX
| | - Marcus Neubauer
- From the Yale Cancer Center, New Haven, CT; Princess Margaret Cancer Center, Toronto, Canada; McKesson Specialty Health, The Woodlands, TX
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Komiya T, Perez RP, Erickson KD, Huang CH. Systematic analysis of design and stratification for phase III trials in first-line advanced non-small cell lung cancer. Thorac Cancer 2015; 7:66-71. [PMID: 26813229 PMCID: PMC4718121 DOI: 10.1111/1759-7714.12276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 04/12/2015] [Indexed: 11/29/2022] Open
Abstract
Background A recent study reviewed phase III trials of first‐line advanced non‐small cell lung cancer (NSCLC) conducted from 1981 to 2010, and provided trends in the study outcome. However, such trials have never been analyzed in detail for design and stratification factors. Methods Phase III studies of systemic treatment for first‐line advanced or metastatic NSCLC published in English literature between 1981 and 2010 were identified. Characteristics, including sample size, number of trials, region, rate of meeting accrual goal, primary endpoint, type of phase III, interim analysis, allocation method, and stratification factors, were determined for each decade. Results A total of 162 studies met the criteria. The number of studies and sample size increased over the three decades. The primary endpoint was reported more frequently in recent decades, and non‐overall survival endpoints were chosen in European and Asian studies. Interim analysis was conducted more commonly during the 2000s. Allocation method was rarely reported throughout the three decades. The number of stratification factors increased significantly from one in 1980s to three in 2000s. Performance status, stage, and institution were most frequently selected, and at least one of the three factors was used in most of the studies in the 2000s. However, there are many other stratification factors that were used infrequently. Conclusions Despite Consolidated Standards of Reporting Trials guidelines, allocation method has rarely been reported. The choice of stratification factor remains inconsistent across studies.
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Affiliation(s)
- Takefumi Komiya
- Division of Hematology/Oncology University of Kansas Medical Center Fairway Kansas USA
| | - Raymond P Perez
- Division of Hematology/Oncology University of Kansas Medical Center Fairway Kansas USA
| | - Kirsten D Erickson
- Clinical Trial Office University of Kansas Cancer Center Fairway Kansas USA
| | - Chao H Huang
- Division of Hematology/Oncology University of Kansas Medical Center Fairway Kansas USA
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Abstract
There is evidence from some countries of a trend towards increasingly aggressive pharmacological treatment of patients with advanced, incurable cancer. To what extent should this be understood as a progressive development in which technological innovations address previously unmet needs, or is a significant amount of this expansion explained by futile or even harmful treatment? In this article it is argued that while some of this growth may be consistent with a progressive account of medicines consumption, part of the expansion is constituted by the inappropriate and overly aggressive use of drugs. Such use is often explained in terms of individual patient consumerism and/or factors to do with physician behaviour. Whilst acknowledging the role of physicians and patients' expectations, this paper, drawing on empirical research conducted in the US, the EU and the UK, examines the extent to which upstream factors shape expectations and drive pharmaceuticalisation, and explores the value of this concept as an analytical tool.
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Affiliation(s)
- Courtney Davis
- Department of Social Science, Health and Medicine, School of Social Science and Public Policy, King's College London, Strand, London WC2R 2LS, UK.
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29
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Spitzer G, Socinski MA. Alternative strategy to achieve increased overall survival and better quality of life in patients with second-line advanced non-small-cell lung cancer. J Clin Oncol 2015; 33:522-3. [PMID: 25584003 DOI: 10.1200/jco.2014.58.1603] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Mark A Socinski
- University of Pittsburgh Schools of the Health Sciences, Pittsburgh, PA
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Kawaguchi T, Ando M, Kubo A. Reply to G. Spitzer and M.A. Socinski, F. Zhou et al, and B. Biswas. J Clin Oncol 2015; 33:526-7. [PMID: 25584006 DOI: 10.1200/jco.2014.58.5315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Tomoya Kawaguchi
- Osaka City University and National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka, Japan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Aichi, Japan
| | - Akihito Kubo
- Aichi Medical University School of Medicine and National Hospital Organization Nagoya Medical Center, Aichi, Japan
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31
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Paesmans M, Grigoriu B, Ocak S, Roelandts M, Lafitte JJ, Holbrechts S, Berghmans T, Meert AP, Moretti L, Danyi S, Pasleau F, Ameye L, Van Meerhaeghe A, Sculier JP. Systematic qualitative review of randomised trials conducted in nonsmall cell lung cancer with a noninferiority or equivalence design. Eur Respir J 2014; 45:511-24. [DOI: 10.1183/09031936.00092814] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The use of noninferiority randomised trials for patients with advanced non-small cell lung cancer has emerged during the past 10–15 years but has raised some issues related to their justification and methodology. The present systematic review aimed to assess trial characteristics and methodological aspects.All randomised clinical trials with a hypothesis of noninferiority/equivalence, published in English, were identified. Several readers extracted a priori defined methodological information. A qualitative analysis was then performed.We identified 20 randomised clinical trials (three phase II and 17 phase III), 11 of them being conducted in strong collaboration with industry. We highlighted some deficiencies in the reports like the lack of justification for both the noninferiority assumption and the definition of the noninferiority margin, as well as inconsistencies between the results and the authors' conclusions. CONSORT guidelines were better followed for general items than for specific items (p<0.001).Improvement in the reporting of the meth"odology of noninferiority/equivalence trials is needed to avoid misleading interpretation and to allow readers to be fully aware of the assumptions underlying the trial designs. They should be restricted to limited specific situations with a strong justification why a noninferiority hypothesis is acceptable.
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32
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Neal JW, Gainor JF, Shaw AT. Developing biomarker-specific end points in lung cancer clinical trials. Nat Rev Clin Oncol 2014; 12:135-46. [PMID: 25533947 DOI: 10.1038/nrclinonc.2014.222] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In cancer-drug development, a number of different end points have been used to establish efficacy and support regulatory approval, such as overall survival, progression-free survival (PFS), and radiographic response rate. However, these traditional end points have important limitations. For example, in lung cancer clinical trials, evaluating overall survival end points is a protracted process and these end points are most reliable when crossover to the investigational therapy is not permitted. Furthermore, although radiographic surrogate end points, such as PFS and response rate, generally correlate with clinical benefit in the setting of cytotoxic chemotherapy and molecular targeted therapies, novel immunotherapies might have atypical response kinetics, which confounds radiographic interpretation. In this Review, we discuss the need to develop alternative or surrogate end points for lung cancer clinical trials, and focus on several new biomarkers that could serve as surrogate end points, including functional imaging biomarkers, circulating factors (tumour proteins, DNA, and cells), and pharmacodynamic tumour markers. By enabling the size, duration, and complexity of cancer trials to be reduced, biomarker end points hold the promise to accelerate drug development and improve patient outcomes.
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Affiliation(s)
- Joel W Neal
- Department of Medicine, Division of Oncology, Stanford Cancer Institute and Stanford University School of Medicine, Stanford University, 875 Blake Wilbur Drive, Stanford, CA 94305, USA
| | - Justin F Gainor
- Division of Hematology-Oncology, Massachusetts General Hospital Cancer Center, Massachusetts General Hospital, 32 Fruit Street, Boston, MA 02114, USA
| | - Alice T Shaw
- Division of Hematology-Oncology, Massachusetts General Hospital Cancer Center, Massachusetts General Hospital, 32 Fruit Street, Boston, MA 02114, USA
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Boutron I, Altman DG, Hopewell S, Vera-Badillo F, Tannock I, Ravaud P. Impact of spin in the abstracts of articles reporting results of randomized controlled trials in the field of cancer: the SPIIN randomized controlled trial. J Clin Oncol 2014; 32:4120-6. [PMID: 25403215 DOI: 10.1200/jco.2014.56.7503] [Citation(s) in RCA: 248] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We aimed to assess the impact of spin (ie, reporting to convince readers that the beneficial effect of the experimental treatment is greater than shown by the results) on the interpretation of results of abstracts of randomized controlled trials (RCTs) in the field of cancer. METHODS We performed a two-arm, parallel-group RCT. We selected a sample of published RCTs with statistically nonsignificant primary outcome and with spin in the abstract conclusion. Two versions of these abstracts were used-the original with spin and a rewritten version without spin. Participants were clinician corresponding authors of articles reporting RCTs, investigators of trials, and reviewers of French national grants. The primary outcome was clinicians' interpretation of the beneficial effect of the experimental treatment (0 to 10 scale). Participants were blinded to study hypothesis. RESULTS Three hundred clinicians were randomly assigned using a Web-based system; 150 clinicians assessed an abstract with spin and 150 assessed an abstract without spin. For abstracts with spin, the experimental treatment was rated as being more beneficial (mean difference, 0.71; 95% CI, 0.07 to 1.35; P = .030), the trial was rated as being less rigorous (mean difference, -0.59; 95% CI, -1.13 to 0.05; P = .034), and clinicians were more interested in reading the full-text article (mean difference, 0.77; 95% CI, 0.08 to 1.47; P = .029). There was no statistically significant difference in the clinicians' rating of the importance of the study or the need to run another trial. CONCLUSION Spin in abstracts can have an impact on clinicians' interpretation of the trial results.
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Affiliation(s)
- Isabelle Boutron
- Isabelle Boutron, Sally Hopewell, and Philippe Ravaud, Methods of Therapeutic Evaluation of Chronic Diseases Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Centre, Unite Mixte de Recherche 1153, L'Institut National de la Santé et de la Recherche Médicale; Isabelle Boutron and Philippe Ravaud, Assistance Publique des Hôpitaux de Paris, Hôpital Hôtel Dieu; Isabelle Boutron and Philippe Ravaud, Paris Descartes University, Sorbonne Paris Cité; Isabelle Boutron, Sally Hopewell, and Philippe Ravaud, French Cochrane Centre, Paris, France; Douglas G. Altman and Sally Hopewell, Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom; Francisco Vera-Badillo and Ian Tannock, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Philippe Ravaud, Columbia University Mailman School of Public Health, New York, NY.
| | - Douglas G Altman
- Isabelle Boutron, Sally Hopewell, and Philippe Ravaud, Methods of Therapeutic Evaluation of Chronic Diseases Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Centre, Unite Mixte de Recherche 1153, L'Institut National de la Santé et de la Recherche Médicale; Isabelle Boutron and Philippe Ravaud, Assistance Publique des Hôpitaux de Paris, Hôpital Hôtel Dieu; Isabelle Boutron and Philippe Ravaud, Paris Descartes University, Sorbonne Paris Cité; Isabelle Boutron, Sally Hopewell, and Philippe Ravaud, French Cochrane Centre, Paris, France; Douglas G. Altman and Sally Hopewell, Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom; Francisco Vera-Badillo and Ian Tannock, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Philippe Ravaud, Columbia University Mailman School of Public Health, New York, NY
| | - Sally Hopewell
- Isabelle Boutron, Sally Hopewell, and Philippe Ravaud, Methods of Therapeutic Evaluation of Chronic Diseases Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Centre, Unite Mixte de Recherche 1153, L'Institut National de la Santé et de la Recherche Médicale; Isabelle Boutron and Philippe Ravaud, Assistance Publique des Hôpitaux de Paris, Hôpital Hôtel Dieu; Isabelle Boutron and Philippe Ravaud, Paris Descartes University, Sorbonne Paris Cité; Isabelle Boutron, Sally Hopewell, and Philippe Ravaud, French Cochrane Centre, Paris, France; Douglas G. Altman and Sally Hopewell, Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom; Francisco Vera-Badillo and Ian Tannock, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Philippe Ravaud, Columbia University Mailman School of Public Health, New York, NY
| | - Francisco Vera-Badillo
- Isabelle Boutron, Sally Hopewell, and Philippe Ravaud, Methods of Therapeutic Evaluation of Chronic Diseases Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Centre, Unite Mixte de Recherche 1153, L'Institut National de la Santé et de la Recherche Médicale; Isabelle Boutron and Philippe Ravaud, Assistance Publique des Hôpitaux de Paris, Hôpital Hôtel Dieu; Isabelle Boutron and Philippe Ravaud, Paris Descartes University, Sorbonne Paris Cité; Isabelle Boutron, Sally Hopewell, and Philippe Ravaud, French Cochrane Centre, Paris, France; Douglas G. Altman and Sally Hopewell, Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom; Francisco Vera-Badillo and Ian Tannock, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Philippe Ravaud, Columbia University Mailman School of Public Health, New York, NY
| | - Ian Tannock
- Isabelle Boutron, Sally Hopewell, and Philippe Ravaud, Methods of Therapeutic Evaluation of Chronic Diseases Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Centre, Unite Mixte de Recherche 1153, L'Institut National de la Santé et de la Recherche Médicale; Isabelle Boutron and Philippe Ravaud, Assistance Publique des Hôpitaux de Paris, Hôpital Hôtel Dieu; Isabelle Boutron and Philippe Ravaud, Paris Descartes University, Sorbonne Paris Cité; Isabelle Boutron, Sally Hopewell, and Philippe Ravaud, French Cochrane Centre, Paris, France; Douglas G. Altman and Sally Hopewell, Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom; Francisco Vera-Badillo and Ian Tannock, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Philippe Ravaud, Columbia University Mailman School of Public Health, New York, NY
| | - Philippe Ravaud
- Isabelle Boutron, Sally Hopewell, and Philippe Ravaud, Methods of Therapeutic Evaluation of Chronic Diseases Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Centre, Unite Mixte de Recherche 1153, L'Institut National de la Santé et de la Recherche Médicale; Isabelle Boutron and Philippe Ravaud, Assistance Publique des Hôpitaux de Paris, Hôpital Hôtel Dieu; Isabelle Boutron and Philippe Ravaud, Paris Descartes University, Sorbonne Paris Cité; Isabelle Boutron, Sally Hopewell, and Philippe Ravaud, French Cochrane Centre, Paris, France; Douglas G. Altman and Sally Hopewell, Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom; Francisco Vera-Badillo and Ian Tannock, Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada; Philippe Ravaud, Columbia University Mailman School of Public Health, New York, NY
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Sobrero AF, Pastorino A, Sargent DJ, Bruzzi P. Raising the bar for antineoplastic agents: how to choose threshold values for superiority trials in advanced solid tumors. Clin Cancer Res 2014; 21:1036-43. [PMID: 25231398 DOI: 10.1158/1078-0432.ccr-14-1505] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To establish the concept of minimum clinically meaningful outcome (mCMO) of treatment in advanced solid tumors, to establish its threshold and evaluate how many superiority trials of new antineoplastic agents pass this threshold. EXPERIMENTAL DESIGN We chose overall survival as the primary indicator of patient benefit. Four conceptually different types of treatment effect can be identified in OS curves: HR, gains in median OS, proportional, and absolute increases at long-term OS. We postulated threshold levels for these four parameters defining the mCMO and set the bar at three different levels of required benefit: high, medium, and low. The postulated values were then studied by comparing our thresholds with the actual results of the pivotal superiority phase III trials on new drugs reporting on mature OS data. RESULTS Forty-three trials on 35,419 patients in 12 cancer types on 23 novel agents met these criteria. Only two trials reached the postulated "high" thresholds for HR and median OS. The number of "positive trials" increased to eight and 15 when the bar was lowered to the "medium" and "low" levels, respectively. The same analysis was done for proportional and absolute increases in long-term OS. No trial satisfied the criteria for long-term benefit, whereas only two and nine trials satisfied both parameters for the "medium and low" required benefit levels, respectively. CONCLUSIONS All four OS-related parameters contribute to define the mCMO. If the bar for the mCMO is raised too much, positive trials are exceptional.
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Affiliation(s)
- Alberto F Sobrero
- Medical Oncology and Epidemiology, IRCCS AOU San Martino IST, Genova, Italy.
| | | | - Daniel J Sargent
- Biostatistics and Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Paolo Bruzzi
- Medical Oncology and Epidemiology, IRCCS AOU San Martino IST, Genova, Italy
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35
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Gentzler RD, Yentz SE, Johnson ML, Rademaker AW, Patel JD. The changing landscape of phase II/III metastatic NSCLC clinical trials and the importance of biomarker selection criteria. Cancer 2014; 120:3853-8. [PMID: 25155290 DOI: 10.1002/cncr.28956] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 06/25/2014] [Accepted: 07/03/2014] [Indexed: 11/09/2022]
Abstract
Over the last decade, new cytotoxic treatments and targeted therapies have altered treatment paradigms for patients with metastatic non-small cell lung cancer (NSCLC). We sought to analyze the impact of histology and biomarker selection criteria on outcomes of clinical trials in metastatic NSCLC reported over the last decade at the American Society of Clinical Oncology (ASCO) Annual Meeting. Data were collected from ASCO abstracts of Phase II-IV clinical trials for patients with metastatic NSCLC from 2004-2014. 770 of 2,989 identified metastatic NSCLC category abstracts met selection criteria. Despite a decline in the number of abstracts from 107 to 46 abstracts annually over this period, the proportion of trials with positive progression free survival (PFS) and overall survival (OS) outcomes has increased significantly. Trials with histology selection (6%) or molecular biomarker (15%) criteria were more likely to result in an improvement in PFS than those without selection criteria (21% vs. 8%, p = 0.0001 and 31% vs. 10%, p < 0.0001, respectively). These data demonstrate profound changes in the clinical trial landscape over the last 10 years with significantly increasing proportion of trials with positive outcomes. These changes are likely attributed to the use of histology and biomarker selection criteria in clinical trial design.
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Affiliation(s)
- Ryan D Gentzler
- Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
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36
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Kandioler D, Schoppmann SF, Zwrtek R, Kappel S, Wolf B, Mittlböck M, Kührer I, Hejna M, Pluschnig U, Ba-Ssalamah A, Wrba F, Zacherl J. The biomarker TP53 divides patients with neoadjuvantly treated esophageal cancer into 2 subgroups with markedly different outcomes. A p53 Research Group study. J Thorac Cardiovasc Surg 2014; 148:2280-6. [PMID: 25135238 DOI: 10.1016/j.jtcvs.2014.06.079] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 04/14/2014] [Accepted: 06/12/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fluorouracil and cisplatin have been used most frequently as neoadjuvant therapy for esophageal cancer. Both drugs are believed to act via a p53-dependent apoptosis pathway. The TP53 gene is frequently mutated in esophageal cancer. OBJECTIVE To test the value of TP53 as a biomarker prognosing outcome in patients with neoadjuvantly treated esophageal cancer. PATIENTS AND METHODS The investigation included 36 patients with primary operable esophageal cancer who were treated neoadjuvantly with cisplatin and fluorouracil. The TP53 genotype was assessed from paraffin-embedded diagnostic tumor biopsies using a standardized gene-specific TP53 sequencing protocol (mark53 kit; mark53 Ltd, Vienna, Austria). RESULTS Mutations in the TP53 gene were present in 50% of tumors. Two-year overall survival rates were 55.6% in patients with a normal TP53 marker status, compared with 16.7% in those with a mutant TP53 gene. In patients with normal TP53, neoadjuvant treatment resulted in significant advantages in terms of tumor-associated survival (P=.0049) and overall survival (P=.0304) compared with those with mutant TP53. The median tumor-associated survival was 34.2 months for patients with normal TP53, compared with 8.9 months for those with mutant TP53. The latter had a 3-fold higher risk of dying (hazard ratio, 3.01; 95% confidence interval, 1.359-6.86). CONCLUSIONS The biomarker TP53 divides esophageal cancer patients into 2 categories with markedly different outcomes: patients with a normal TP53 marker status may experience notable benefits from neoadjuvant chemotherapy with cisplatin/fluorouracil, whereas those with a mutant TP53 marker status appear to be at risk for lack of response.
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Affiliation(s)
- Daniela Kandioler
- Department of Surgery, Medical University of Vienna, Vienna, Austria.
| | - Sebastian F Schoppmann
- Department of Surgery, Medical University of Vienna, Vienna, Austria; Comprehensive Cancer Center-GI Tumor Unit, Medical University of Vienna, Vienna, Austria
| | - Ronald Zwrtek
- Department of Surgery, Landesklinikum Sankt Poelten, Sankt Poelten, Austria
| | - Sonja Kappel
- Department of Surgery, Medical University of Vienna, Vienna, Austria; Surgical Research, Medical University of Vienna, Vienna, Austria
| | - Brigitte Wolf
- Department of Surgery, Medical University of Vienna, Vienna, Austria; Surgical Research, Medical University of Vienna, Vienna, Austria
| | - Martina Mittlböck
- Center for Medical Statistics, Informatics, and Intelligent Systems, Section for Clinical Biometrics, Medical University of Vienna, Vienna, Austria
| | - Irene Kührer
- Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Michael Hejna
- Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ursula Pluschnig
- Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ahmed Ba-Ssalamah
- Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Fritz Wrba
- Department of Clinical Pathology, Medical University of Vienna, Vienna, Austria
| | - Johannes Zacherl
- Department of Surgery, Medical University of Vienna, Vienna, Austria
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Pantziarka P, Bouche G, Meheus L, Sukhatme V, Sukhatme VP, Vikas P. The Repurposing Drugs in Oncology (ReDO) Project. Ecancermedicalscience 2014; 8:442. [PMID: 25075216 PMCID: PMC4096030 DOI: 10.3332/ecancer.2014.442] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Indexed: 12/13/2022] Open
Abstract
The Repurposing Drugs in Oncology (ReDO) Project seeks to repurpose well-known and well-characterised non-cancer drugs for new uses in oncology. The rationale for this project is presented, examining current issues in oncological drug development, challenges for health systems, and existing and future patient needs. In addition to discussing the advantages of repurposing, the paper also outlines some of the characteristics used in the selection of drug candidates by this project. Challenges in moving candidate drugs into clinical trial and subsequent practice are also discussed.
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Affiliation(s)
- Pan Pantziarka
- Anticancer Fund, Brussels, 1853 Strombeek-Bever, Belgium ; The George Pantziarka TP53 Trust, London KT1 2JP, UK
| | | | - Lydie Meheus
- Anticancer Fund, Brussels, 1853 Strombeek-Bever, Belgium
| | | | | | - P Vikas
- GlobalCures, Inc, Newton, MA 02459, USA ; Beth Israel Deaconess Medical Centre and Harvard Medical School, Boston, MA 02215, USA
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38
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Abstract
Over the past three decades, the interpretation of clinical trial outcomes in studies of advanced-stage non-small-cell lung cancer has changed. The robustness of findings from these trials has been called into question. We believe this change is a reflection of the improved understanding of molecular-based therapeutics and continued advances in this field.
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39
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Johnson DH. Setting the bar for therapeutic trials in non-small-cell lung cancer: how low can we go? J Clin Oncol 2014; 32:1389-91. [PMID: 24687823 DOI: 10.1200/jco.2014.55.1929] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- David H Johnson
- University of Texas Southwestern School of Medicine, Dallas, TX
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