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Crotty P, Kari K, Hughes GK, Ladd C, McIntire R, Gardner B, Peña AM, Ferrell S, Tuia J, Cohn J, Haslam A, Prasad V, Vassar M. Assessing Patient Risk, Benefit, and Outcomes in Drug Development: A Decade of Lenvatinib Clinical Trials: A Systematic Review. Target Oncol 2024; 19:161-173. [PMID: 38466535 DOI: 10.1007/s11523-024-01040-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2024] [Indexed: 03/13/2024]
Abstract
IMPORTANCE Chemotherapy agents are typically initially tested in their most promising indications; however, following initial US FDA approval, new clinical trials are often initiated in less promising indications where patients experience a worse burden-benefit ratio. The current literature on the burden-benefit profile of lenvatinib in non-FDA-approved indications is lacking. OBJECTIVE This study aimed to evaluate published clinical trials of lenvatinib in order to determine the burden-benefit profile for patients over time. EVIDENCE REVIEW On 25 May 2023, we searched the Pubmed/MEDLINE, Embase, Cochrane CENTRAL, and ClinicalTrials.gov databases for clinical trials of lenvatinib used to treat solid cancers. Eligible articles were clinical trials, containing adult participants, published in English, and involving solid tumors. Screening and data collection took place in a masked, duplicate fashion. For each eligible study, we collected adverse event data, trial characteristics, progression-free survival (PFS), overall survival (OS), and objective response rate (ORR). Trials were classified as positive when meeting their primary endpoint and safety, negative (not meeting either criteria), or indeterminate (lacking prespecified primary endpoint). FINDINGS Expansion of clinical trial testing beyond lenvatinib's initial FDA indication demonstrated a consistent rise in cumulative adverse events, along with a decline in drug efficacy. Lenvatinib was tested in 16 cancer indications, receiving FDA approval in 4. A total of 5390 Grade 3-5 adverse events were experienced across 6225 clinical trial participants. Expanded indication testing further demonstrated widely variable ORR (11-69%), OS (6.2-32 months), and PFS (3.6-15.7 months) across all indications. After initial FDA approval, clinical trial results in expanded indications were less likely to meet their primary endpoints, particularly among non-randomized clinical trials. CONCLUSION AND RELEVANCE Our paper evaluated the effectiveness of lenvatinib for its FDA-approved indications; however, expansion of clinical trials into novel indications was characterized by diminished efficacy, while patients experienced a high burden of adverse events consistent with lenvatinib's established safety profile. Furthermore, clinical trials testing in novel indications was marked by repeated phase I and II clinical trials along with a failure to progress to phase III clinical trials. Future clinical trials using lenvatinib as an intervention should carefully evaluate the potential benefits and burden patients may experience.
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Affiliation(s)
- Patrick Crotty
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17th St., Tulsa, OK, 74107, USA.
| | - Karim Kari
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17th St., Tulsa, OK, 74107, USA
| | - Griffin K Hughes
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17th St., Tulsa, OK, 74107, USA
| | - Chase Ladd
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17th St., Tulsa, OK, 74107, USA
| | - Ryan McIntire
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17th St., Tulsa, OK, 74107, USA
| | - Brooke Gardner
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17th St., Tulsa, OK, 74107, USA
| | - Andriana M Peña
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17th St., Tulsa, OK, 74107, USA
| | - Sydney Ferrell
- Department of Internal Medicine, University of Vermont Medical Center, Burlington, VT, USA
| | - Jordan Tuia
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Jacob Cohn
- Department of Internal Medicine, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Alyson Haslam
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, 1111 W 17th St., Tulsa, OK, 74107, USA
- Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
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2
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Hutchinson N, Bicer S, Feldhake E, Carlisle BG, Gonen M, Del Paggio J, Kimmelman J. Probability of Regulatory Approval Over Time: A Cohort Study of Cancer Therapies. JCO Oncol Pract 2024; 20:247-253. [PMID: 38109682 DOI: 10.1200/op.23.00363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/04/2023] [Accepted: 10/23/2023] [Indexed: 12/20/2023] Open
Abstract
PURPOSE New cancer therapies are frequently evaluated in multiple disease indications. We evaluated whether the probability of achieving US Food and Drug Administration (FDA) approval for a new cancer therapy changes with time. METHODS We identified a cohort of anticancer drugs with a first registered efficacy trial from 2007 to 2011 on ClinicalTrials.gov. We downloaded all clinical trials for each included drug from the initiation of efficacy testing to January 11, 2021. Each trial was categorized by cancer indication and assigned to investigational trajectories on the basis of unique drug-indication pairings. We performed a univariate Cox's proportional hazards regression to assess the probability of a trajectory leading to regulatory approval over time since initiation of the first efficacy trial for a given drug. RESULTS We included 213 drugs in our cohort, of which 37 (17.4%) received FDA approval in at least one oncology indication. In our primary analysis, we found a 15% decrease in the probability of approval for every year since initiation of the first efficacy trial (hazard ratio [HR], 0.85 [95% CI, 0.73 to 0.99]; P = .032). We found a 45% increase in the probability of approval for the first trajectory launched for a given drug in comparison with all others (HR, 0.55 [95% CI, 0.33 to 0.91]; P = .021). CONCLUSION Drug-indication pairings pursued years after initial testing for efficacy have lowered probability of affecting care. Clinical trial investigators, sponsors, and regulatory bodies may benefit from awareness of this trend when considering both early and late trajectory trials in a drug's development.
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Affiliation(s)
- Nora Hutchinson
- Division of Hospital Medicine, University of California, San Francisco, CA
| | - Selin Bicer
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, QC, Canada
| | - Emma Feldhake
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, QC, Canada
| | - Benjamin G Carlisle
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, QC, Canada
| | - Mithat Gonen
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joseph Del Paggio
- Department of Medical Oncology, Thunder Bay Regional Health Sciences Centre and NOSM University, Thunder Bay, ON, Canada
| | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, QC, Canada
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Haslberger M, Schorr SG, Strech D, Haven T. Preclinical efficacy in investigator's brochures: Stakeholders' views on measures to improve completeness and robustness. Br J Clin Pharmacol 2023; 89:340-350. [PMID: 35986927 DOI: 10.1111/bcp.15503] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 07/25/2022] [Accepted: 08/08/2022] [Indexed: 11/29/2022] Open
Abstract
AIMS Research ethics committees and regulatory agencies assess whether the benefits of a proposed early-stage clinical trial outweigh the risks based on preclinical studies reported in investigator's brochures (IBs). Recent studies have indicated that the reporting of preclinical evidence presented in IBs does not enable proper risk-benefit assessment. We interviewed different stakeholders (regulators, research ethics committee members, preclinical and clinical researchers, ethicists, and metaresearchers) about their views on measures to increase the completeness and robustness of preclinical evidence reporting in IBs. METHODS This study was preregistered (https://osf.io/nvzwy/). We used purposive sampling and invited stakeholders to participate in an online semistructured interview between March and June 2021. Themes were derived using inductive content analysis. We used a strengths, weaknesses, opportunities and threats matrix to categorize our findings. RESULTS Twenty-seven international stakeholders participated. The interviewees pointed to several strengths and opportunities to improve completeness and robustness, mainly more transparent and systematic justifications for the included studies. However, weaknesses and threats were mentioned that could undermine efforts to enable a more thorough assessment: The interviewees stressed that current review practices are sufficient to ensure the safe conduct of first-in-human trials. They feared that changes to the IB structure or review process could overburden stakeholders and slow drug development. CONCLUSION In principle, more robust decision-making processes align with the interests of all stakeholders and with many current initiatives to increase the translatability of preclinical research and limit uninformative or ill-justified trials early in the development process. Further research should investigate measures that could be implemented to benefit all stakeholders.
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Affiliation(s)
- Martin Haslberger
- QUEST Center for Responsible Research, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Susanne Gabriele Schorr
- QUEST Center for Responsible Research, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Strech
- QUEST Center for Responsible Research, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tamarinde Haven
- QUEST Center for Responsible Research, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
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Strzebonska K, Wasylewski MT, Zaborowska L, Polak M, Slugocka E, Stras J, Blukacz M, Gyawali B, Waligora M. Risk and Benefit for Targeted Therapy Agents in Pediatric Phase II Trials in Oncology: A Systematic Review with a Meta-Analysis. Target Oncol 2021; 16:415-424. [PMID: 34110559 PMCID: PMC8266705 DOI: 10.1007/s11523-021-00822-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND For research with human participants to be ethical, risk must be in a favorable balance with potential benefits. Little is known about the risk/benefit ratio for pediatric cancer phase II trials testing targeted therapies. OBJECTIVE Our aim was to conduct a systematic review of preliminary efficacy and safety profiles of phase II targeted therapy clinical trials in pediatric oncology. METHODS Our protocol was prospectively registered in PROSPERO (CRD42020146491). We searched EMBASE and PubMed for phase II pediatric cancer trials testing targeted agents. We included solid and hematological malignancy studies published between 1 January, 2015 and 27 February, 2020. We measured risk using drug-related grade 3 or higher adverse events, and benefit by response rates. When possible, data were meta-analyzed. All statistical tests were two-sided. RESULTS We identified 34 clinical trials (1202 patients) that met our eligibility criteria. The pooled overall response rate was 24.4% (95% confidence interval [CI] 14.5-34.2) and was lower in solid tumors, 6.4% (95% CI 3.2-9.6), compared with hematological malignancies, 55.1% (95% CI 35.9-74.3); p < 0.001. The overall fatal drug-related (grade 5) adverse event rate was 1.6% (95% CI 0.6-2.5), and the average drug-related grade 3/4 adverse event rate per person was 0.66 (95% CI 0.55-0.78). CONCLUSIONS We provide an estimate for the risks and benefits of participation in pediatric phase II cancer trials. These data may be used as an empirical basis for informed communication about benefits and burdens in pediatric oncology research.
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Affiliation(s)
- Karolina Strzebonska
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, ul. Kopernika 40, 31-501, Kraków, Poland
| | - Mateusz T Wasylewski
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, ul. Kopernika 40, 31-501, Kraków, Poland
| | - Lucja Zaborowska
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, ul. Kopernika 40, 31-501, Kraków, Poland
| | - Maciej Polak
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, ul. Kopernika 40, 31-501, Kraków, Poland
- Chair of Epidemiology and Population Studies, Jagiellonian University Medical College, Kraków, Poland
| | - Emilia Slugocka
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, ul. Kopernika 40, 31-501, Kraków, Poland
| | - Jakub Stras
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, ul. Kopernika 40, 31-501, Kraków, Poland
| | - Mateusz Blukacz
- Institute of Psychology, University of Silesia, Katowice, Poland
| | - Bishal Gyawali
- Department of Oncology and the Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Marcin Waligora
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, ul. Kopernika 40, 31-501, Kraków, Poland.
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Sarvas H, Carlisle B, Dolter S, Vinarov E, Kimmelman J. Impact of Precision Medicine on Efficiencies of Novel Drug Development in Cancer. J Natl Cancer Inst 2021; 112:859-862. [PMID: 31722417 DOI: 10.1093/jnci/djz212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/13/2019] [Accepted: 10/24/2019] [Indexed: 11/14/2022] Open
Abstract
Precision medicine (PM) offers opportunities for reducing the costs, burdens, and time associated with drug development. We examined time, number of trials, indications tested, and patient burden needed to achieve first U.S. Food and Drug Administration license for all five novel anticancer PM drugs and all 10 novel non-PM drugs receiving U.S. Food and Drug Administration approval during 2010-2014. The 15 drug portfolios encompassed 242 trials: 87 for PM drugs and 155 for non-PM drugs. Embase and MEDLINE databases were searched for all prelicensure clinical trials, and data on time, patient numbers, indications tested, and total treatment-emergent grade 3-5 adverse events were measured from the first trial of each drug. We did not find patterns suggesting greater efficiencies in PM compared with non-PM. Gains in efficiency for PM drug development may be offset by challenges with recruitment.
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Affiliation(s)
- Holly Sarvas
- Studies of Translation, Ethics, and Medicine, McGill University Biomedical Ethics Unit, Montreal, Quebec, Canada
| | - Benjamin Carlisle
- Studies of Translation, Ethics, and Medicine, McGill University Biomedical Ethics Unit, Montreal, Quebec, Canada
| | - Samantha Dolter
- Studies of Translation, Ethics, and Medicine, McGill University Biomedical Ethics Unit, Montreal, Quebec, Canada
| | - Esther Vinarov
- Studies of Translation, Ethics, and Medicine, McGill University Biomedical Ethics Unit, Montreal, Quebec, Canada
| | - Jonathan Kimmelman
- Studies of Translation, Ethics, and Medicine, McGill University Biomedical Ethics Unit, Montreal, Quebec, Canada
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6
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Cai J, Lin K, Cai W, Lin Y, Liu X, Guo L, Zhang J, Xu W, Lin Z, Wong CW, Sander M, Hu J, Yan G, Zhu W, Liang J. Tumors driven by RAS signaling harbor a natural vulnerability to oncolytic virus M1. Mol Oncol 2020; 14:3153-3168. [PMID: 33037696 PMCID: PMC7718955 DOI: 10.1002/1878-0261.12820] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 09/18/2020] [Accepted: 10/07/2020] [Indexed: 12/11/2022] Open
Abstract
Oncolytic viruses are potent anticancer agents that replicate within and kill cancer cells rather than normal cells, and their selectivity is largely determined by oncogenic mutations. M1, a novel oncolytic virus strain, has been shown to target cancer cells, but the relationship between its cancer selectivity and oncogenic signaling pathways is poorly understood. Here, we report that RAS mutation promotes the replication and oncolytic effect of M1 in cancer, and we further provide evidence that the inhibition of the RAS/RAF/MEK signaling axis suppresses M1 infection and the subsequent cytopathic effects. Transcriptome analysis revealed that the inhibition of RAS signaling upregulates the type I interferon antiviral response, and further RNA interference screen identified CDKN1A as a key downstream factor that inhibits viral infection. Gain- and loss-of-function experiments confirmed that CDKN1A inhibited the replication and oncolytic effect of M1 virus. Subsequent TCGA data mining and tissue microarray (TMA) analysis revealed that CDKN1A is commonly deficient in human cancers, suggesting extensive clinical application prospects for M1. Our report indicates that virotherapy is feasible for treating undruggable RAS-driven cancers and provides reliable biomarkers for personalized cancer therapy.
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Affiliation(s)
- Jing Cai
- Department of PharmacologyZhongshan School of MedicineSun Yat‐sen UniversityGuangzhouChina
| | - Kaiying Lin
- Department of PharmacologyZhongshan School of MedicineSun Yat‐sen UniversityGuangzhouChina
| | - Wei Cai
- Department of PharmacologyZhongshan School of MedicineSun Yat‐sen UniversityGuangzhouChina
| | - Yuan Lin
- Department of PharmacologyZhongshan School of MedicineSun Yat‐sen UniversityGuangzhouChina
| | - Xincheng Liu
- Department of PharmacologyZhongshan School of MedicineSun Yat‐sen UniversityGuangzhouChina
| | - Li Guo
- Department of PharmacologyZhongshan School of MedicineSun Yat‐sen UniversityGuangzhouChina
| | - Jifu Zhang
- Guangzhou Virotech Pharmaceutical Co., Ltd.GuangzhouChina
| | - Wencang Xu
- Guangzhou Virotech Pharmaceutical Co., Ltd.GuangzhouChina
| | - Ziqing Lin
- Guangzhou Virotech Pharmaceutical Co., Ltd.GuangzhouChina
| | - Chun Wa Wong
- Department of PharmacologyZhongshan School of MedicineSun Yat‐sen UniversityGuangzhouChina
| | - Max Sander
- Guangzhou Virotech Pharmaceutical Co., Ltd.GuangzhouChina
| | - Jun Hu
- Department of PharmacologyZhongshan School of MedicineSun Yat‐sen UniversityGuangzhouChina
| | - Guangmei Yan
- Department of PharmacologyZhongshan School of MedicineSun Yat‐sen UniversityGuangzhouChina
| | - Wenbo Zhu
- Department of PharmacologyZhongshan School of MedicineSun Yat‐sen UniversityGuangzhouChina
| | - Jiankai Liang
- Department of PharmacologyZhongshan School of MedicineSun Yat‐sen UniversityGuangzhouChina
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Kahrass H, Bossert S, Schürmann C, Strech D. Details of risk-benefit communication in informed consent documents for phase I/II trials. Clin Trials 2020; 18:71-80. [PMID: 33231107 PMCID: PMC7876653 DOI: 10.1177/1740774520971770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Informed consent documents for clinical studies should disclose all reasonably foreseeable risks and benefits. Little guidance exists on how to navigate the complexities of risk-benefit communication, especially in early clinical research. Practice-oriented development of such guidance should be informed by evidence on what and how details of risks and benefits are currently communicated. METHOD We surveyed the responsible parties of phase I/II trials registered in ClinicalTrials.gov that started 2007 or later and completed between 2012 and 2016 to sample informed consent documents from a broad spectrum of early phase clinical trials. Based on an assessment matrix, we qualitatively and quantitatively assessed the informed consent documents for details of risk-benefit communication. RESULTS The risk-benefit communication in the 172 informed consent documents differed substantially in several regards. The outcome, extent, and likelihood of health risks, for example, were described in 83%, 32%, and 63% of the informed consent documents. Only 45% of informed consent documents specified the outcome of mentioned health benefits, and the extent and likelihood of health benefits were never specified. From those informed consent documents reporting risk likelihoods, only 57% added frequency numbers to words such as "common" or "rare," and even in these cases, we found strong variations for presented frequency ranges. Substantial heterogeneity also exists for how informed consent documents communicate other risk and benefit types and related safeguards. CONCLUSION Our study points to several shortcomings and heterogeneities in how informed consent documents communicate risks and benefits to potential research participants. Health risks, for example, should be specified with frequency numbers, and health benefits should be specified at least by mentioning their outcomes. Further demand for research and policy development is needed to harmonize risk-benefit communication and to clarify ways to specify the likelihood of health benefits.
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Affiliation(s)
- Hannes Kahrass
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Sabine Bossert
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany.,Forschungszentrum Jülich, Jülich, Germany
| | - Christopher Schürmann
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Daniel Strech
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany.,QUEST Center, Berlin Institute of Health (BIH), Berlin, Germany.,Charité-Universitätsmedizin-Berlin, Berlin, Germany
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8
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Chen JN, Li T, Cheng L, Qin TS, Sun YX, Chen CT, He YZ, Liu G, Yao D, Wei Y, Li QY, Zhang GJ. Synthesis and in vitro anti-bladder cancer activity evaluation of quinazolinyl-arylurea derivatives. Eur J Med Chem 2020; 205:112661. [PMID: 32827851 DOI: 10.1016/j.ejmech.2020.112661] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/01/2020] [Accepted: 07/12/2020] [Indexed: 12/11/2022]
Abstract
Based on the structural modification of molecular-targeted agent sorafenib, a series of quinazolinyl-arylurea derivatives were synthesized and evaluated for their anti-proliferative activities against six human cancer cell lines. Compared with other cell lines tested, T24 was more sensitive to most compounds. Compound 7j exhibited the best profile with lower IC50 value and favorable selectivity. In this study, we focused on 7j-induced death forms of T24 cells and tried to elucidate the reason for its potent proliferative inhibitory activity. Compound 7j treatment could trigger three different cell death forms including apoptosis, ferroptosis, and autophagy; which form would occur depended on the concentrations and incubation time of 7j: (1) Lower concentrations within the initial 8 h of 7j treatment led to apoptosis-dependent death. (2) Ferroptosis and autophagy occurred in the case of higher concentrations combining with extended incubation time through effectively regulating the Sxc-/GPx4/ROS and PI3K/Akt/mTOR/ULK1 pathways, respectively. (3) The above death forms were closely associated with intracellular ROS generation and decreased mitochondrial membrane potential induced by 7j. In molecular docking and structure-activity relationship analyses, 7j could bind well to the active site of the corresponding receptor glutathione peroxidase 4 (GPx4). Compound 7j could be a promising lead for molecular-targeted anti-bladder cancer agents' discovery.
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Affiliation(s)
- Jia-Nian Chen
- State Key Laboratory for Chemistry and Molecular Engineering of Medicinal Resources, Guangxi Normal University, Yucai Road 15, Guilin, 541004, Guangxi, PR China.
| | - Ting Li
- State Key Laboratory for Chemistry and Molecular Engineering of Medicinal Resources, Guangxi Normal University, Yucai Road 15, Guilin, 541004, Guangxi, PR China.
| | - Li Cheng
- State Key Laboratory for Chemistry and Molecular Engineering of Medicinal Resources, Guangxi Normal University, Yucai Road 15, Guilin, 541004, Guangxi, PR China.
| | - Tai-Sheng Qin
- State Key Laboratory for Chemistry and Molecular Engineering of Medicinal Resources, Guangxi Normal University, Yucai Road 15, Guilin, 541004, Guangxi, PR China.
| | - Ye-Xiang Sun
- State Key Laboratory for Chemistry and Molecular Engineering of Medicinal Resources, Guangxi Normal University, Yucai Road 15, Guilin, 541004, Guangxi, PR China.
| | - Chu-Ting Chen
- State Key Laboratory for Chemistry and Molecular Engineering of Medicinal Resources, Guangxi Normal University, Yucai Road 15, Guilin, 541004, Guangxi, PR China.
| | - Yue-Zhen He
- State Key Laboratory for Chemistry and Molecular Engineering of Medicinal Resources, Guangxi Normal University, Yucai Road 15, Guilin, 541004, Guangxi, PR China.
| | - Guang Liu
- State Key Laboratory for Chemistry and Molecular Engineering of Medicinal Resources, Guangxi Normal University, Yucai Road 15, Guilin, 541004, Guangxi, PR China.
| | - Di Yao
- State Key Laboratory for Chemistry and Molecular Engineering of Medicinal Resources, Guangxi Normal University, Yucai Road 15, Guilin, 541004, Guangxi, PR China.
| | - Ying Wei
- State Key Laboratory for Chemistry and Molecular Engineering of Medicinal Resources, Guangxi Normal University, Yucai Road 15, Guilin, 541004, Guangxi, PR China.
| | - Qiu-Yin Li
- State Key Laboratory for Chemistry and Molecular Engineering of Medicinal Resources, Guangxi Normal University, Yucai Road 15, Guilin, 541004, Guangxi, PR China.
| | - Guang-Ji Zhang
- State Key Laboratory for Chemistry and Molecular Engineering of Medicinal Resources, Guangxi Normal University, Yucai Road 15, Guilin, 541004, Guangxi, PR China.
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9
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Gumnit E, Feustel AC, Wong S, Bosan R, Hutchinson N, Kimmelman J. The proportion of North American cancer trials that evaluate novel targets. Invest New Drugs 2020; 39:256-259. [PMID: 32681475 DOI: 10.1007/s10637-020-00971-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
Abstract
Major advances in cancer care often emerge from the development of novel targets. We randomly sampled 10% of cancer trials on clinicaltrials.gov with start dates 2013-2016 to determine the proportion of trials and research subjects directed at evaluating novel targets. We found that 87 of 378 trials (23.0%) enrolling 9225 of 44,525 patients (20.7%) tested interventions that are directed towards novel targets. 146 of 378 trials (38.6%) enrolling 19,132 of 44,525 patients (43.0%) investigated treatments that were not FDA approved but utilized a previously studied target for treating cancer. Combined, 233 of 378 trials (61.6%) enrolling 28,357 of 44,525 patients (63.9%) investigated treatments that were not FDA approved. Furthermore, 36 of 378 trials (9.5%) enrolling 6592 of 44,525 patients (14.8%) investigated FDA approved anticancer drugs in their approved indication and combination while 109 of 378 trials (28.8%) enrolling 9576 of 44,525 patients (21.5%) investigated FDA approved anticancer drugs outside of their approved indication or combination. Logistic regression found that phase 1 trials were significantly more likely to test novel target interventions than phase 2 and 3 trials (p value = 0.00197 and 0.00130 respectively). Industry sponsored trials were also significantly more likely to involve novel target interventions than non-industry trials (p value <0.001). In conclusion, most cancer trials involve unapproved treatments, but a majority of these treatments are well-characterized or involve a previously studied target to treat cancer.
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Affiliation(s)
- Eli Gumnit
- Biomedical Ethics Unit/Social Studies of Medicine, McGill University, 3647 Peel Street, Montreal, QC, H3A 1X1, Canada
| | - Aden C Feustel
- Biomedical Ethics Unit/Social Studies of Medicine, McGill University, 3647 Peel Street, Montreal, QC, H3A 1X1, Canada
| | - Sandy Wong
- Biomedical Ethics Unit/Social Studies of Medicine, McGill University, 3647 Peel Street, Montreal, QC, H3A 1X1, Canada
| | - Rafia Bosan
- Biomedical Ethics Unit/Social Studies of Medicine, McGill University, 3647 Peel Street, Montreal, QC, H3A 1X1, Canada
| | - Nora Hutchinson
- Biomedical Ethics Unit/Social Studies of Medicine, McGill University, 3647 Peel Street, Montreal, QC, H3A 1X1, Canada
| | - Jonathan Kimmelman
- Division of Ethics and Policy/School of Population and Global Health, McGill University, 3647 Peel Street, Montreal, QC, H3A 1X1, Canada.
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10
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Sisk BA, Dubois J, Hobbs BP, Kodish E. Reprioritizing Risk and Benefit: The Future of Study Design in Early-Phase Cancer Research. Ethics Hum Res 2020; 41:2-11. [PMID: 31743629 DOI: 10.1002/eahr.500033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The scientific purpose of phase I trials is to determine the maximum tolerated dose and/or optimal biological dose of experimental agents. Yet most participants in phase I oncology trials enroll hoping for direct medical benefit. The most common phase I trial designs use low starting doses and escalate cautiously in a "risk-escalation" model focused on minimizing risk for each participant. This approach ensures that a proportion of subjects will likely not receive any benefit, even if the intervention proves to be successful at appropriate doses. In this article, we propose that trial designs should employ dosing strategies that increase chances of providing benefit if the investigational agent should prove to be successful while limiting risk to reasonable levels. We then describe how adaptive trial designs can facilitate refined dose optimization based on both therapeutic benefit and toxicity, which can simultaneously decrease the risk of harm while increasing the chances of benefit.
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Affiliation(s)
- Bryan Anthony Sisk
- Clinical fellow in pediatric hematology/oncology in the Department of Pediatrics at Washington University School of Medicine
| | - James Dubois
- Professor in the Department of Medicine at Washington University School of Medicine
| | - Brian P Hobbs
- Associate staff member in the Department of Quantitative Health Sciences in the Lerner Research Institute at the Cleveland Clinic
| | - Eric Kodish
- Professor of pediatrics, oncology, and bioethics at Case Western Reserve and Cleveland Clinic Lerner College of Medicine
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11
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Carlisle BG, Doussau A, Kimmelman J. Patient burden and clinical advances associated with postapproval monotherapy cancer drug trials: a retrospective cohort study. BMJ Open 2020; 10:e034306. [PMID: 32071183 PMCID: PMC7044865 DOI: 10.1136/bmjopen-2019-034306] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES After regulatory approval, drug companies, public funding agencies and academic researchers often pursue trials aimed at extending the uses of a new drug by testing it in new non-approved indications. Patient burden and clinical impact of such research are not well understood. DESIGN AND SETTING We conducted a retrospective cohort study of postapproval clinical trials launched within 5 years after the drug's first approval, testing anticancer drugs in monotherapy in indications that were first pursued after a drug's first Food and Drug Administration (FDA) license, for all 12 anticancer drugs approved between 2005 and 2007. FDA, Medline and Embase search date 2019 February 12. PRIMARY AND SECONDARY OUTCOME MEASURES Our primary objective was to measure burden and clinical impact for patients enrolling in these trials. Each trial was sorted into a 'trajectory' defined by the drug and cancer indication. The risk was operationalised by proportions of grade 3-4 severe adverse events and deaths. The clinical impact was measured by estimating the proportion of patients participating in trajectories that resulted in FDA approval, uptake into National Comprehensive Cancer Network (NCCN) clinical practice guidelines or advancement to randomised controlled trials within 8 years. RESULTS Our search captured 104 published trials exploring monotherapy, including 69 unique trajectories. In total, trials in our sample enrolled 4699 patients. Grade 3-4 adverse events were experienced by 19.6% of patients; grade 5 events were experienced by 2.8% of patients. None of the trajectories launched after initial drug approval received FDA approval. Five trajectories were recommended by the NCCN within 8 years of the first trial within that trajectory. Eleven trajectories were advanced to randomised controlled testing. CONCLUSIONS The challenges associated with unlocking new applications for drugs that first received approval from 2005 to 2007 were similar to those for developing new drugs altogether. Our findings can help inform priority setting in research and provide a basis for calibrating expectations when considering enrolment in label-extending trials.
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Affiliation(s)
| | | | - Jonathan Kimmelman
- Biomedical Ethics Unit / SSOM, McGill University, Montreal, Quebec, Canada
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12
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Abstract
This study reviews publications and the level of evidence for US Food and Drug Administration–approved and off-label indications for eculizumab.
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Affiliation(s)
- Myung S Kim
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland
| | - Vinay Prasad
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland.,Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland.,Center for Health Care Ethics, Oregon Health and Science University, Portland
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13
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Bin Y, Ding Y, Xiao W, Liao A. RASSF1A: A promising target for the diagnosis and treatment of cancer. Clin Chim Acta 2020; 504:98-108. [PMID: 31981586 DOI: 10.1016/j.cca.2020.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/16/2020] [Accepted: 01/16/2020] [Indexed: 02/07/2023]
Abstract
The Ras association domain family 1 isoform A (RASSF1A), a tumor suppressor, regulates several tumor-related signaling pathways and interferes with diverse cellular processes. RASSF1A is frequently demonstrated to be inactivated by hypermethylation in numerous types of solid cancers. It is also associated with lymph node metastasis, vascular invasion, and chemo-resistance. Therefore, reactivation of RASSF1A may be a viable strategy to block tumor progress and reverse drug resistance. In this review, we have summarized the clinical value of RASSF1A for screening, staging, and therapeutic management of human malignancies. We also highlighted the potential mechanism of RASSF1A in chemo-resistance, which may help identify novel drugs in the future.
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Affiliation(s)
- Yuling Bin
- Digestive System Department, the First Affiliated Hospital of University of South China, Hengyang, Hunan 421001, China
| | - Yong Ding
- Department of Vascular Surgery, Zhongshan Hospital, Institue of Vascular Surgery, Fudan University, Shanghai 200032, China
| | - Weisheng Xiao
- Digestive System Department, the First Affiliated Hospital of University of South China, Hengyang, Hunan 421001, China
| | - Aijun Liao
- Digestive System Department, the First Affiliated Hospital of University of South China, Hengyang, Hunan 421001, China.
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14
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The oxidation and hypoglycaemic effect of sorafenib in streptozotocin-induced diabetic rats. Pharmacol Rep 2020; 72:254-259. [PMID: 32016844 PMCID: PMC8187206 DOI: 10.1007/s43440-019-00021-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/11/2019] [Accepted: 08/25/2019] [Indexed: 12/18/2022]
Abstract
Background Diabetes reduces the activity of CYP3A4 and may increase the exposure for the drugs metabolized by the isoenzyme. Sorafenib is a multi-targeted tyrosine kinase inhibitor (TKI), used for the treatment of advanced renal cell carcinoma, hepatocellular carcinoma and radioactive iodine resistant thyroid carcinoma. The TKI undergoes CYP3A4-dependent oxidative transformation, which may be influenced by hyperglycaemia. The aim of the study was to compare the oxidation for sorafenib between healthy and streptozotocin-induced diabetic rats. Additionally, the effect of sorafenib on glucose levels was investigated. Methods The rats were assigned to the groups: streptozotocin-induced diabetic (DG, n = 8) or healthy (HG, n = 8). The rats received sorafenib orally as a single dose of 100 mg/kg. The plasma concentrations of sorafenib and its metabolite N-oxide were measured with the validated high-performance liquid chromatography with ultraviolet detection. Results The difference between groups in Cmax and AUC0−t values for sorafenib were significant (p = 0.0004, p = 0.0104), and similarly for the metabolite (p = 0.0008, p = 0.0011). Greater exposure for the parent drug and analysed metabolite was achieved in diabetic group. However, the Cmax, AUC0−t, and AUC0−∞ ratios between the metabolite and sorafenib were similar in both groups. The significant reduction of glycaemia was observed only in the diabetic animals. Conclusion The findings of the study provide evidence that diabetes significantly influence on the exposition for sorafenib and its metabolite, but similar ratios N-oxide/sorafenib for AUC and Cmax in healthy and diabetic animals suggest that oxidation of the TKI is rather unchanged. Additionally, sorafenib-associated hypoglycaemia was confirmed in diabetic animals.
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15
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Bucy T, Zoscak JM, Mori M, Borate U. Patients with FLT3-mutant AML needed to enroll on FLT3-targeted therapeutic clinical trials. Blood Adv 2019; 3:4055-4064. [PMID: 31816063 PMCID: PMC6963255 DOI: 10.1182/bloodadvances.2019000532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 10/30/2019] [Indexed: 12/21/2022] Open
Abstract
We sought to identify the total number of therapeutic trials targeting FLT3-mutant acute myeloid leukemia (AML) to estimate the number of patients needed to satisfy recruitment when compared with the incidence of this mutation in the US AML population. A systematic review of all therapeutic clinical trials focusing on adult FLT3-mutated AML was conducted from 2000 to 2017. An updated search was performed using ClinicalTrials.gov for trials added between October 2017 and December 2018. Analysis was performed for ClinicalTrials.gov search results from 2000 to 2017 to provide descriptive estimates of discrepancies between anticipated clinical trial enrollment using consistently cited rates of adult participation of 1%, 3%, and 5%, as well as 10% participation identified by the American Society of Clinical Oncology in 2008. Twenty-five pharmaceutical or biological agents aimed at treating FLT3-mutant AML were identified. Pharmaceutical vs cooperative group/nonprofit support was 2.3:1, with 30 different pharmaceutical collaborators and 13 cooperative group/nonprofit collaborators. The number of patients needed to satisfy study enrollment begins to surpass the upper bound of estimated participation in 2010, noticeably surpassing projected participation rates between 2015 and 2016. The number of patients needed to satisfy study enrollment surpasses 3% and 5% rates of historical participation for US-only trials in 2017. We estimate that 15% of all US patients with FLT3-mutant AML would have to enroll in US and internationally accruing trials to satisfy requirements in 2017, or approximately 3 times the upper level of historical participation rates in the United States. The current clinical trial agenda in this space requires high percentage enrollment for sustainability.
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Affiliation(s)
- Taylor Bucy
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR; and
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR
| | - John M Zoscak
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR; and
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR
| | - Motomi Mori
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR; and
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR
| | - Uma Borate
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR; and
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16
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Fang JH, Xu L, Shang LR, Pan CZ, Ding J, Tang YQ, Liu H, Liu CX, Zheng JL, Zhang YJ, Zhou ZG, Xu J, Zheng L, Chen MS, Zhuang SM. Vessels That Encapsulate Tumor Clusters (VETC) Pattern Is a Predictor of Sorafenib Benefit in Patients with Hepatocellular Carcinoma. Hepatology 2019; 70:824-839. [PMID: 30506570 DOI: 10.1002/hep.30366] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/19/2018] [Indexed: 12/18/2022]
Abstract
Sorafenib is the most recommended first-line systemic therapy for advanced hepatocellular carcinoma (HCC). Yet there is no clinically applied biomarker for predicting sorafenib response. We have demonstrated that a vascular pattern, named VETC (Vessels that Encapsulate Tumor Clusters), facilitates the release of whole tumor clusters into the bloodstream; VETC-mediated metastasis relies on vascular pattern, but not on migration and invasion of cancer cells. In this study, we aimed to explore whether vascular pattern could predict sorafenib benefit. Two cohorts of patients were recruited from four academic hospitals. The survival benefit of sorafenib treatment for patients with or without the VETC pattern (VETC+ /VETC- ) was investigated. Kaplan-Meier analyses revealed that sorafenib treatment significantly reduced death risk and prolonged overall survival (OS; in cohort 1/2, P = 0.004/0.005; hazard ratio [HR] = 0.567/0.408) and postrecurrence survival (PRS; in cohort 1/2, P = 0.001/0.002; HR = 0.506/0.384) in VETC+ patients. However, sorafenib therapy was not beneficial for VETC- patients (OS in cohort 1/2, P = 0.204/0.549; HR = 0.761/1.221; PRS in cohort 1/2, P = 0.121/0.644; HR = 0.728/1.161). Univariate and multivariate analyses confirmed that sorafenib treatment significantly improved OS/PRS in VETC+ , but not VETC- , patients. Further mechanistic investigations showed that VETC+ and VETC- HCCs displayed similar levels of light chain 3 (LC3) and phosphorylated extracellular signal-regulated kinase (ERK) in tumor tissues (pERK) or endothelial cells (EC-pERK), and greater sorafenib benefit was consistently observed in VETC+ HCC patients than VETC- irrespective of levels of pERK/EC-pERK/LC3, suggesting that the different sorafenib benefit between VETC+ and VETC- HCCs may not result from activation of Raf/mitogen-activated protein kinase kinase (MEK)/ERK and vascular endothelial growth factor (VEGF)A/VEGF receptor 2 (VEGFR2)/ERK signaling or induction of autophagy. Conclusion: Sorafenib is effective in prolonging the survival of VETC+ , but not VETC- , patients. VETC pattern may act as a predictor of sorafenib benefit for HCC.
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Affiliation(s)
- Jian-Hong Fang
- MOE Key Laboratory of Gene Function and Regulation, School of Life Sciences, Sun Yat-sen University, Guangzhou, China
| | - Li Xu
- Department of Hepatobilliary & Pancreatic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Li-Ru Shang
- MOE Key Laboratory of Gene Function and Regulation, School of Life Sciences, Sun Yat-sen University, Guangzhou, China
| | - Chu-Zhi Pan
- Department of Hepatobiliary Surgery and Key Laboratory of Liver Disease of Guangdong Province, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jin Ding
- The International Cooperation Laboratory on Signal Transduction and The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Yun-Qiang Tang
- Department of Hepatobilliary Oncology, Cancer Center of Guangzhou Medical University, Guangzhou, China
| | - Hui Liu
- The International Cooperation Laboratory on Signal Transduction and The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Chu-Xing Liu
- MOE Key Laboratory of Gene Function and Regulation, School of Life Sciences, Sun Yat-sen University, Guangzhou, China
| | - Jia-Lin Zheng
- MOE Key Laboratory of Gene Function and Regulation, School of Life Sciences, Sun Yat-sen University, Guangzhou, China
| | - Yao-Jun Zhang
- Department of Hepatobilliary & Pancreatic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zhong-Guo Zhou
- Department of Hepatobilliary & Pancreatic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Jing Xu
- Department of Hepatobilliary & Pancreatic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Limin Zheng
- MOE Key Laboratory of Gene Function and Regulation, School of Life Sciences, Sun Yat-sen University, Guangzhou, China
| | - Min-Shan Chen
- Department of Hepatobilliary & Pancreatic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shi-Mei Zhuang
- MOE Key Laboratory of Gene Function and Regulation, School of Life Sciences, Sun Yat-sen University, Guangzhou, China.,Department of Hepatobilliary & Pancreatic Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Hepatobiliary Surgery and Key Laboratory of Liver Disease of Guangdong Province, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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17
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London AJ, Kimmelman J. Clinical Trial Portfolios: A Critical Oversight in Human Research Ethics, Drug Regulation, and Policy. Hastings Cent Rep 2019; 49:31-41. [DOI: 10.1002/hast.1034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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18
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Luo J, Nishikawa G, Prasad V. A systematic review of head-to-head trials of approved monoclonal antibodies used in cancer: an overview of the clinical trials agenda. J Cancer Res Clin Oncol 2019; 145:2303-2311. [DOI: 10.1007/s00432-019-02984-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/18/2019] [Indexed: 12/23/2022]
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19
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Wieschowski S, Riedel N, Wollmann K, Kahrass H, Müller-Ohlraun S, Schürmann C, Kelley S, Kszuk U, Siegerink B, Dirnagl U, Meerpohl J, Strech D. Result dissemination from clinical trials conducted at German university medical centers was delayed and incomplete. J Clin Epidemiol 2019; 115:37-45. [PMID: 31195110 DOI: 10.1016/j.jclinepi.2019.06.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 05/22/2019] [Accepted: 06/03/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Timely and comprehensive reporting of clinical trial results builds the backbone of evidence-based medicine and responsible research. The proportion of timely disseminated trial results can inform alternative national and international benchmarking of university medical centers (UMCs). STUDY DESIGN AND SETTING For all German UMCs, we tracked all registered trials completed between 2009 and 2013. The results and an interactive website benchmark German UMCs regarding their performance in result dissemination. RESULTS We identified and tracked 2,132 clinical trials. For 1,509 trials, one of the German UMCs took the academic lead. Of these 1,509 "lead trials," 39% published their results (mostly via journal publications) in a timely manner (<24 months after completion). More than 6 years after study completion, 26% of all eligible lead trials still had not disseminated results. CONCLUSION Despite substantial attention from many stakeholders to the topic, there is still a strong delay or even absence of result dissemination for many trials. German UMCs have several opportunities to improve this situation. Further research should evaluate whether and how a transparent benchmarking of UMC performance in result dissemination helps to increase value and reduce waste in medical research.
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Affiliation(s)
- Susanne Wieschowski
- Institute for Ethics, History, and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Nico Riedel
- QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany
| | - Katharina Wollmann
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Cochrane Germany Foundation, Freiburg, Germany
| | - Hannes Kahrass
- Institute for Ethics, History, and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | | | - Christopher Schürmann
- Institute for Ethics, History, and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Sean Kelley
- Department of Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ute Kszuk
- Cochrane Germany Foundation, Freiburg, Germany
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrich Dirnagl
- QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany; Department of Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jörg Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Strech
- Institute for Ethics, History, and Philosophy of Medicine, Hannover Medical School, Hannover, Germany; QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany; Charité Universitätsmedizin Berlin, Berlin, Germany.
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20
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Pratte M, Ganeshamoorthy S, Carlisle B, Kimmelman J. How well are Phase 2 cancer trial publications supported by preclinical efficacy evidence? Int J Cancer 2019; 145:3370-3375. [DOI: 10.1002/ijc.32405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/12/2019] [Accepted: 04/30/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Michael Pratte
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics UnitMcGill University Québec Canada
| | - Sylviya Ganeshamoorthy
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics UnitMcGill University Québec Canada
| | - Benjamin Carlisle
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics UnitMcGill University Québec Canada
| | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics UnitMcGill University Québec Canada
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21
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Li Z, Wu T, Zheng B, Chen L. Individualized precision treatment: Targeting TAM in HCC. Cancer Lett 2019; 458:86-91. [PMID: 31129147 DOI: 10.1016/j.canlet.2019.05.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/28/2019] [Accepted: 05/15/2019] [Indexed: 12/24/2022]
Abstract
Tumor-associated macrophage (TAM) plays a prominent role in inflammatory microenvironment which contributes to hepatocellular carcinoma (HCC) progress by presenting M1 and M2 polarization. HCC, which is highly associated with inflammation, always leads to poor prognosis for recurrence and metastasis. TAMs with M2 polarization induce cellular proliferation, angiogenesis, epithelial-mesenchymal transition (EMT) in HCC. Furthermore, it also interacts with other immune cell clusters which leads to the resistance in targeted therapy and immunotherapy. This article reviews studies on the role of TAM to affect HCC treatment and provides insight into the potential individualized precision monotherapy or combination therapy in HCC.
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Affiliation(s)
- Zhixuan Li
- International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Institute, Second Military Medical University, Shanghai, 200438, PR China
| | - Tong Wu
- International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Institute, Second Military Medical University, Shanghai, 200438, PR China
| | - Bo Zheng
- International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Institute, Second Military Medical University, Shanghai, 200438, PR China
| | - Lei Chen
- International Cooperation Laboratory on Signal Transduction, Eastern Hepatobiliary Surgery Institute, Second Military Medical University, Shanghai, 200438, PR China.
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22
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Federico CA, Wang T, Doussau A, Mogil JS, Fergusson D, Kimmelman J. Assessment of Pregabalin Postapproval Trials and the Suggestion of Efficacy for New Indications: A Systematic Review. JAMA Intern Med 2019; 179:90-97. [PMID: 30477010 DOI: 10.1001/jamainternmed.2018.5705] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE After a drug receives regulatory approval, researchers often pursue small, underpowered trials, called exploratory trials, aimed at testing additional indications. If favorable early findings from exploratory trials are not promptly followed by confirmatory trials, then physicians, patients, and payers can be left uncertain about a drug's clinical value (clinical agnosticism). Such findings may encourage the off-label use of ineffective drugs. OBJECTIVE To characterize the relationship between exploratory and confirmatory postapproval trials for the blockbuster drug, pregabalin (Lyrica). EVIDENCE REVIEW Ovid MEDLINE and Embase databases were used to identify clinical trials published prior to January 2018 and that tested the efficacy of pregabalin for nonapproved indications. Indications, trial outcomes, publication dates, and trial design elements were recorded. Time elapsed was calculated between the generation of clinical agnosticism about pregabalin (ie, publications reporting positive or inconclusive evidence of efficacy on a primary endpoint) and it being addressed (publication of at least 1 confirmatory trial in the same indication, regardless of outcome). FINDINGS There were 238 trials identified that tested the efficacy of pregabalin in at least 33 indications; 5 indications eventually received European Medicines Agency and/or US Food and Drug Administration marketing approval. Sixty-seven percent (22 of 33) of first publications for new indications may have generated clinical agnosticism. Of those indications with at least 5 years of follow-up, 63% (17 of 27) may have generated agnosticism that was not addressed in confirmatory trials within 5 years. As pregabalin development expanded from indications that received regulatory approval to other indications, the linkage of exploratory to confirmatory trial publication diminished. CONCLUSIONS AND RELEVANCE After initial approval, exploratory evidence suggesting the value of pregabalin for new indications often went unconfirmed for extended periods of time. Poor coordination between exploratory and confirmatory testing may represent an important vehicle through which off-label prescription is recommended in clinical practice guidelines and encouraged in the absence of confirmatory trial evidence.
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Affiliation(s)
- Carole A Federico
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Taiji Wang
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada.,School of Public Health, University of California, Berkeley, Berkeley
| | - Adélaïde Doussau
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Jeffrey S Mogil
- Departments of Psychology and Anesthesia, Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jonathan Kimmelman
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
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23
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Langhof H, Chin WWL, Wieschowski S, Federico C, Kimmelman J, Strech D. Preclinical efficacy in therapeutic area guidelines from the U.S. Food and Drug Administration and the European Medicines Agency: a cross-sectional study. Br J Pharmacol 2018; 175:4229-4238. [PMID: 30153701 DOI: 10.1111/bph.14485] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/28/2018] [Accepted: 08/06/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND AND PURPOSE Therapeutic area guidelines (TAGs) published by the EMA and the FDA offer guidance in planning the launch of a trial in a certain indication. We assessed and compared the guidance on preclinical efficacy of all available TAGs from EMA and FDA. EXPERIMENTAL APPROACH EMA and FDA websites and databases were searched for all TAGs. A mixed deductive and inductive approach was applied to analyse and cluster content for preclinical efficacy. KEY RESULTS A total of 114 EMA and 120 FDA TAGs were identified, covering 126 indications. Our core finding is that 75% of EMA TAGs and 58% from the FDA TAGs do not offer any guidance on preclinical efficacy. TAGs varied widely on the extent, nature and detail of guidance. CONCLUSIONS AND IMPLICATIONS Guidance on preclinical efficacy in a consistent, comprehensive and explicit way that still allows for justified deviations is an important but neglected aspect of transparency for drug development. This transparency would help sponsors in designing preclinical studies and in negotiating more efficiently with regulators.
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Affiliation(s)
- Holger Langhof
- Charité - University Medicine Berlin, QUEST - Center for Transforming Biomedical Research, Berlin Institute of Health (BIH), Berlin, Germany.,Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School (MHH), Hannover, Germany
| | - William Wei Lim Chin
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School (MHH), Hannover, Germany
| | - Susanne Wieschowski
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School (MHH), Hannover, Germany
| | - Carole Federico
- STREAM (Studies of Translation, Ethics and Medicine), Biomedical Ethics Unit, McGill University, Montreal, QC, Canada
| | - Jonathan Kimmelman
- STREAM (Studies of Translation, Ethics and Medicine), Biomedical Ethics Unit, McGill University, Montreal, QC, Canada
| | - Daniel Strech
- Charité - University Medicine Berlin, QUEST - Center for Transforming Biomedical Research, Berlin Institute of Health (BIH), Berlin, Germany.,Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School (MHH), Hannover, Germany
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Kang J, Rancati T, Lee S, Oh JH, Kerns SL, Scott JG, Schwartz R, Kim S, Rosenstein BS. Machine Learning and Radiogenomics: Lessons Learned and Future Directions. Front Oncol 2018; 8:228. [PMID: 29977864 PMCID: PMC6021505 DOI: 10.3389/fonc.2018.00228] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 06/04/2018] [Indexed: 12/25/2022] Open
Abstract
Due to the rapid increase in the availability of patient data, there is significant interest in precision medicine that could facilitate the development of a personalized treatment plan for each patient on an individual basis. Radiation oncology is particularly suited for predictive machine learning (ML) models due to the enormous amount of diagnostic data used as input and therapeutic data generated as output. An emerging field in precision radiation oncology that can take advantage of ML approaches is radiogenomics, which is the study of the impact of genomic variations on the sensitivity of normal and tumor tissue to radiation. Currently, patients undergoing radiotherapy are treated using uniform dose constraints specific to the tumor and surrounding normal tissues. This is suboptimal in many ways. First, the dose that can be delivered to the target volume may be insufficient for control but is constrained by the surrounding normal tissue, as dose escalation can lead to significant morbidity and rare. Second, two patients with nearly identical dose distributions can have substantially different acute and late toxicities, resulting in lengthy treatment breaks and suboptimal control, or chronic morbidities leading to poor quality of life. Despite significant advances in radiogenomics, the magnitude of the genetic contribution to radiation response far exceeds our current understanding of individual risk variants. In the field of genomics, ML methods are being used to extract harder-to-detect knowledge, but these methods have yet to fully penetrate radiogenomics. Hence, the goal of this publication is to provide an overview of ML as it applies to radiogenomics. We begin with a brief history of radiogenomics and its relationship to precision medicine. We then introduce ML and compare it to statistical hypothesis testing to reflect on shared lessons and to avoid common pitfalls. Current ML approaches to genome-wide association studies are examined. The application of ML specifically to radiogenomics is next presented. We end with important lessons for the proper integration of ML into radiogenomics.
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Affiliation(s)
- John Kang
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY, United States
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sangkyu Lee
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Jung Hun Oh
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Sarah L. Kerns
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY, United States
| | - Jacob G. Scott
- Department of Translational Hematology and Oncology Research, Cleveland Clinic, Cleveland, OH, United States
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, United States
| | - Russell Schwartz
- Computational Biology Department, Carnegie Mellon School of Computer Science, Pittsburgh, PA, United States
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, United States
| | - Seyoung Kim
- Computational Biology Department, Carnegie Mellon School of Computer Science, Pittsburgh, PA, United States
| | - Barry S. Rosenstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Affiliation(s)
- Alex John London
- Department of Philosophy, Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Jonathan Kimmelman
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montréal, Quebec, Canada
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Wieschowski S, Chin WWL, Federico C, Sievers S, Kimmelman J, Strech D. Preclinical efficacy studies in investigator brochures: Do they enable risk-benefit assessment? PLoS Biol 2018; 16:e2004879. [PMID: 29621228 PMCID: PMC5886385 DOI: 10.1371/journal.pbio.2004879] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/28/2018] [Indexed: 12/11/2022] Open
Abstract
Human protection policies require favorable risk–benefit judgments prior to launch of clinical trials. For phase I and II trials, evidence for such judgment often stems from preclinical efficacy studies (PCESs). We undertook a systematic investigation of application materials (investigator brochures [IBs]) presented for ethics review for phase I and II trials to assess the content and properties of PCESs contained in them. Using a sample of 109 IBs most recently approved at 3 institutional review boards based at German Medical Faculties between the years 2010–2016, we identified 708 unique PCESs. We then rated all identified PCESs for their reporting on study elements that help to address validity threats, whether they referenced published reports, and the direction of their results. Altogether, the 109 IBs reported on 708 PCESs. Less than 5% of all PCESs described elements essential for reducing validity threats such as randomization, sample size calculation, and blinded outcome assessment. For most PCESs (89%), no reference to a published report was provided. Only 6% of all PCESs reported an outcome demonstrating no effect. For the majority of IBs (82%), all PCESs were described as reporting positive findings. Our results show that most IBs for phase I/II studies did not allow evaluators to systematically appraise the strength of the supporting preclinical findings. The very rare reporting of PCESs that demonstrated no effect raises concerns about potential design or reporting biases. Poor PCES design and reporting thwart risk–benefit evaluation during ethical review of phase I/II studies. To make a clinical trial ethical, regulatory agencies and institutional review boards have to judge whether the trial-related benefits (the knowledge gain) outweigh the trial-inherent risks. For early-phase human research, these risk–benefit assessments are often based on evidence from preclinical animal studies reported in so-called “investigator brochures.” However, our analysis shows that the vast majority of such investigator brochures lack sufficient information to systematically appraise the strength of the supporting preclinical findings. Furthermore, the very rare reporting of preclinical efficacy studies that demonstrated no effect raises concerns about potential design and/or reporting biases. The poor preclinical study design and reporting thwarts risk–benefit evaluation during ethical review of early human research. Regulators should develop standards for the design and reporting of preclinical efficacy studies in order to support the conduct of ethical clinical trials.
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Affiliation(s)
- Susanne Wieschowski
- Institute for Ethics, History, and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - William Wei Lim Chin
- Institute for Ethics, History, and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Carole Federico
- Studies of Translation, Ethics, and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montreal, Québec, Canada
| | - Sören Sievers
- Institute for Ethics, History, and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Jonathan Kimmelman
- Studies of Translation, Ethics, and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montreal, Québec, Canada
| | - Daniel Strech
- Institute for Ethics, History, and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
- * E-mail:
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Affiliation(s)
- Vinay Prasad
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland.,Department of Preventive Medicine and Public Health, Oregon Health and Science University, Portland.,Center for Health Care Ethics, Oregon Health and Science University, Portland
| | - Sham Mailankody
- Myeloma Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, New York
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