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Purshouse K, Bulbeck HJ, Rooney AG, Noble KE, Carruthers RD, Thompson G, Hamerlik P, Yap C, Kurian KM, Jefferies SJ, Lopez JS, Jenkinson MD, Hanemann CO, Stead LF. Adult brain tumour research in 2024: Status, challenges and recommendations. Neuropathol Appl Neurobiol 2024; 50:e12979. [PMID: 38605644 DOI: 10.1111/nan.12979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/13/2024]
Abstract
In 2015, a groundswell of brain tumour patient, carer and charity activism compelled the UK Minister for Life Sciences to form a brain tumour research task and finish group. This resulted, in 2018, with the UK government pledging £20m of funding, to be paralleled with £25m from Cancer Research UK, specifically for neuro-oncology research over the subsequent 5 years. Herein, we review if and how the adult brain tumour research landscape in the United Kingdom has changed over that time and what challenges and bottlenecks remain. We have identified seven universal brain tumour research priorities and three cross-cutting themes, which span the research spectrum from bench to bedside and back again. We discuss the status, challenges and recommendations for each one, specific to the United Kingdom.
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Affiliation(s)
- Karin Purshouse
- Institute of Genetics and Cancer, The University of Edinburgh, Edinburgh, UK
| | | | - Alasdair G Rooney
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | | | | | - Gerard Thompson
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK
| | - Petra Hamerlik
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | | | - Kathreena M Kurian
- Bristol Brain Tumour Research Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Juanita S Lopez
- Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, Sutton, UK
| | | | | | - Lucy F Stead
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
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2
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Chatters R, Dimairo M, Cooper C, Ditta S, Woodward J, Biggs K, Ogunleye D, Thistlethwaite F, Yap C, Rothman A. Exploring the barriers to, and importance of, participant diversity in early-phase clinical trials: an interview-based qualitative study of professionals and patient and public representatives. BMJ Open 2024; 14:e075547. [PMID: 38508621 PMCID: PMC10952868 DOI: 10.1136/bmjopen-2023-075547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES To explore the importance of, and barriers to achieving, diversity in early-phase clinical trials. DESIGN Qualitative interviews analysed using thematic analysis. SETTING AND PARTICIPANTS Five professionals (clinical researchers and methodologists) and three patient and public representatives (those with experience of early-phase clinical trials and/or those from ethnic minority backgrounds) were interviewed between June and August 2022. Participants were identified via their institutional web page, existing contacts or social media (eg, X, formerly known as Twitter). RESULTS Professionals viewed that diversity is not currently considered in all early-phase clinical trials but felt that it should always be taken into account. Such trials are primarily undertaken at a small number of centres, thus limiting the populations they can access. Referrals from clinicians based in the community may increase diversity; however, those referred are often not from underserved groups. Referrals may be hindered by the extra resources required to approach and recruit underserved groups and participants often having to undertake 'self-driven' referrals. Patient and public representatives stated that diversity is important in research staff and that potential participants should be informed of the need for diversity. Those from underserved groups may require clarification regarding the potential harms of a treatment, even if these are unknown. Education may improve awareness and perception of early-phase clinical trials. We provide 14 recommendations to improve diversity in early-phase clinical trials. CONCLUSIONS Diversity should be considered in all early-phase trials. Consideration is required regarding the extent of diversity and how it is addressed. The increased resources needed to recruit those from underserved groups may warrant funders to increase the funds to support the recruitment of such participants. The potential harms and societal benefits of the research should be presented to potential participants in a balanced but accurate way to increase transparency.
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Affiliation(s)
- Robin Chatters
- Sheffield Clinical Trials Research Unit (CTRU), Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Munyaradzi Dimairo
- Sheffield Clinical Trials Research Unit (CTRU), Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Cindy Cooper
- Sheffield Clinical Trials Research Unit (CTRU), Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Shamila Ditta
- Sheffield Clinical Trials Research Unit (CTRU), Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Jonathan Woodward
- Sheffield Clinical Trials Research Unit (CTRU), Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Katie Biggs
- Sheffield Clinical Trials Research Unit (CTRU), Sheffield Centre for Health and Related Research, The University of Sheffield, Sheffield, UK
| | | | - Fiona Thistlethwaite
- The Christie Hospital NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Christina Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, UK
| | - Alexander Rothman
- Department of Infection, Immunity, and Cardiovascular Disease, The University of Sheffield and Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Lederhofer J, Tsybovsky Y, Nguyen L, Raab JE, Creanga A, Stephens T, Gillespie RA, Syeda HZ, Fisher BE, Skertic M, Yap C, Schaub AJ, Rawi R, Kwong PD, Graham BS, McDermott AB, Andrews SF, King NP, Kanekiyo M. Protective human monoclonal antibodies target conserved sites of vulnerability on the underside of influenza virus neuraminidase. Immunity 2024; 57:574-586.e7. [PMID: 38430907 PMCID: PMC10962683 DOI: 10.1016/j.immuni.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 12/02/2023] [Accepted: 02/06/2024] [Indexed: 03/05/2024]
Abstract
Continuously evolving influenza viruses cause seasonal epidemics and pose global pandemic threats. Although viral neuraminidase (NA) is an effective drug and vaccine target, our understanding of the NA antigenic landscape still remains incomplete. Here, we describe NA-specific human antibodies that target the underside of the NA globular head domain, inhibit viral propagation of a wide range of human H3N2, swine-origin variant H3N2, and H2N2 viruses, and confer both pre- and post-exposure protection against lethal H3N2 infection in mice. Cryo-EM structures of two such antibodies in complex with NA reveal non-overlapping epitopes covering the underside of the NA head. These sites are highly conserved among N2 NAs yet inaccessible unless the NA head tilts or dissociates. Our findings help guide the development of effective countermeasures against ever-changing influenza viruses by identifying hidden conserved sites of vulnerability on the NA underside.
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Affiliation(s)
- Julia Lederhofer
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Yaroslav Tsybovsky
- Vaccine Research Center Electron Microscopy Unit, Cancer Research Technology Program, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick, MD 21702, USA
| | - Lam Nguyen
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Julie E Raab
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Adrian Creanga
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Tyler Stephens
- Vaccine Research Center Electron Microscopy Unit, Cancer Research Technology Program, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick, MD 21702, USA
| | - Rebecca A Gillespie
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Hubza Z Syeda
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Brian E Fisher
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Michelle Skertic
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Christina Yap
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Andrew J Schaub
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Reda Rawi
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Peter D Kwong
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Barney S Graham
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Adrian B McDermott
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Sarah F Andrews
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Neil P King
- Department of Biochemistry, University of Washington, Seattle, WA 98195, USA; Institute for Protein Design, University of Washington, Seattle, WA 98195, USA
| | - Masaru Kanekiyo
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA.
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Mergental H, Laing RW, Kirkham AJ, Clarke G, Boteon YL, Barton D, Neil DAH, Isaac JR, Roberts KJ, Abradelo M, Schlegel A, Dasari BVM, Ferguson JW, Cilliers H, Morris C, Friend PJ, Yap C, Afford SC, Perera MTPR, Mirza DF. Discarded livers tested by normothermic machine perfusion in the VITTAL trial: Secondary end points and 5-year outcomes. Liver Transpl 2024; 30:30-45. [PMID: 38109282 DOI: 10.1097/lvt.0000000000000270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/27/2023] [Indexed: 12/20/2023]
Abstract
Normothermic machine perfusion (NMP) enables pretransplant assessment of high-risk donor livers. The VITTAL trial demonstrated that 71% of the currently discarded organs could be transplanted with 100% 90-day patient and graft survivals. Here, we report secondary end points and 5-year outcomes of this prospective, open-label, phase 2 adaptive single-arm study. The patient and graft survivals at 60 months were 82% and 72%, respectively. Four patients lost their graft due to nonanastomotic biliary strictures, one caused by hepatic artery thrombosis in a liver donated following brain death, and 3 in elderly livers donated after circulatory death (DCD), which all clinically manifested within 6 months after transplantation. There were no late graft losses for other reasons. All the 4 patients who died during the study follow-up had functioning grafts. Nonanastomotic biliary strictures developed in donated after circulatory death livers that failed to produce bile with pH >7.65 and bicarbonate levels >25 mmol/L. Histological assessment in these livers revealed high bile duct injury scores characterized by arterial medial necrosis. The quality of life at 6 months significantly improved in all but 4 patients suffering from nonanastomotic biliary strictures. This first report of long-term outcomes of high-risk livers assessed by normothermic machine perfusion demonstrated excellent 5-year survival without adverse effects in all organs functioning beyond 1 year (ClinicalTrials.gov number NCT02740608).
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Affiliation(s)
- Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Richard W Laing
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- Hepato-pancreato Biliary Unit, Royal Stoke University Hospital, Stoke on Trent, UK
| | - Amanda J Kirkham
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - George Clarke
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Yuri L Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- Liver Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Darren Barton
- D3B team, Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Desley A H Neil
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
- Department of Cellular Pathology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | - John R Isaac
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | - Keith J Roberts
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Manuel Abradelo
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- HPB and Abdominal Organ Transplantation Department, 12 de Octubre University Hospital, Madrid, Spain
| | - Andrea Schlegel
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, Milan, Italy
| | - Bobby V M Dasari
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | - James W Ferguson
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
| | - Hentie Cilliers
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | | | - Peter J Friend
- OrganOx Limited, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
- Clinical Trials and Statistics Unit, The Institute for Cancer Research, London
| | - Simon C Afford
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
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5
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Yin Z, Mander AP, de Bono JS, Zheng H, Yap C. Handling Incomplete or Late-Onset Toxicities in Early-Phase Dose-Finding Clinical Trials: Current Practice and Future Prospects. JCO Precis Oncol 2024; 8:e2300441. [PMID: 38181316 DOI: 10.1200/po.23.00441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/28/2023] [Accepted: 10/12/2023] [Indexed: 01/07/2024] Open
Abstract
PURPOSE The way late-onset toxicities are managed can affect trial outcomes and participant safety. Specifically, participants often might not have completed their entire follow-up period to observe any toxicities before new participants would be recruited. We conducted a methodological review of published early-phase dose-finding clinical trials that used designs accounting for partial and complete toxicity information, aiming to understand (1) how such designs were implemented and reported and (2) if sufficient information was provided to enable the replicability of trial results. METHODS Until March 26, 2023, we identified 141 trials using the rolling 6 design, the time-to-event continuous reassessment method (TITE-CRM), the TITE-CRM with cycle information, the TITE Bayesian optimal interval design, the TITE cumulative cohort design, and the rapid enrollment design. Clinical settings, design parameters, practical considerations, and dose-limiting toxicity (DLT) information were extracted from these published trials. RESULTS The TITE-CRM (61, 43.3%) and the rolling 6 design (76, 53.9%) were most frequently implemented in practice. Trials using the TITE-CRM had longer DLT assessment windows beyond the first cycle compared with the rolling 6 design (52.5% v 6.6%). Most trials implementing the TITE-CRM (91.8%, 56 of 61) failed to describe essential parameters in the protocols or the study result papers. Only five TITE-CRM trials (8.2%, 5 of 61) reported sufficient information to enable replication of the final analysis. CONCLUSION When compared with trials using the rolling 6 design, those implementing the TITE-CRM design exhibited notable deficiencies in reporting essential details necessary for reproducibility. Inadequate reporting quality of advanced model-based trial designs hinders their credibility. We provide recommendations that can improve transparency, reproducibility, and accurate interpretation of the results for such designs.
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Affiliation(s)
- Zhulin Yin
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, United Kingdom
| | - Adrian P Mander
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Johann S de Bono
- Drug Development Unit, The Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Haiyan Zheng
- Department of Mathematical Sciences, University of Bath, Bath, United Kingdom
| | - Christina Yap
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, United Kingdom
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6
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Rannikko JH, Verlingue L, de Miguel M, Pasanen A, Robbrecht D, Skytta T, Iivanainen S, Shetty S, Ma YT, Graham DM, Arora SP, Jaakkola P, Yap C, Xiang Y, Mandelin J, Karvonen MK, Jalkanen J, Karaman S, Koivunen JP, Minchom A, Hollmén M, Bono P. Bexmarilimab-induced macrophage activation leads to treatment benefit in solid tumors: The phase I/II first-in-human MATINS trial. Cell Rep Med 2023; 4:101307. [PMID: 38056464 PMCID: PMC10772343 DOI: 10.1016/j.xcrm.2023.101307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/04/2023] [Accepted: 11/07/2023] [Indexed: 12/08/2023]
Abstract
Macrophage Clever-1 contributes to impaired antigen presentation and suppression of anti-tumor immunity. This first-in-human trial investigates the safety and tolerability of Clever-1 blockade with bexmarilimab in patients with treatment-refractory solid tumors and assesses preliminary anti-tumor efficacy, pharmacodynamics, and immunologic correlates. Bexmarilimab shows no dose-limiting toxicities in part I (n = 30) and no additional safety signals in part II (n = 108). Disease control (DC) rates of 25%-40% are observed in cutaneous melanoma, gastric, hepatocellular, estrogen receptor-positive breast, and biliary tract cancers. DC associates with improved survival in a landmark analysis and correlates with high pre-treatment intratumoral Clever-1 positivity and increasing on-treatment serum interferon γ (IFNγ) levels. Spatial transcriptomics profiling of DC and non-DC tumors demonstrates bexmarilimab-induced macrophage activation and stimulation of IFNγ and T cell receptor signaling selectively in DC patients. These data suggest that bexmarilimab therapy is well tolerated and show that macrophage targeting can promote immune activation and tumor control in late-stage cancer.
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Affiliation(s)
- Jenna H Rannikko
- MediCity Research Laboratory and InFLAMES Flagship, University of Turku, Turku, Finland; Turku Doctoral Program of Molecular Medicine, University of Turku, Turku, Finland
| | - Loic Verlingue
- Institut Gustave Roussy, Paris and Centre Leon Berard in Lyon, Lyon, France
| | | | - Annika Pasanen
- Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
| | - Debbie Robbrecht
- Erasmus Medical Center/Cancer Institute, Rotterdam, the Netherlands
| | | | | | - Shishir Shetty
- University of Birmingham/University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Yuk Ting Ma
- University of Birmingham/University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Panu Jaakkola
- Department of Oncology, Turku University Hospital and University of Turku, Turku, Finland
| | - Christina Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Yujuan Xiang
- INDIVIDRUG Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | | | | | - Sinem Karaman
- INDIVIDRUG Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Wihuri Research Institute, Helsinki, Finland
| | - Jussi P Koivunen
- Oulu University Hospital, University of Oulu, Oulu, Finland; Faron Pharmaceuticals Ltd, Turku, Finland
| | - Anna Minchom
- Drug Development Unit, Royal Marsden Hospital/Institute of Cancer Research, Sutton, UK
| | - Maija Hollmén
- MediCity Research Laboratory and InFLAMES Flagship, University of Turku, Turku, Finland; Faron Pharmaceuticals Ltd, Turku, Finland.
| | - Petri Bono
- Terveystalo Finland and University of Helsinki, Helsinki, Finland.
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7
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Yap C. Let's make poor reporting of early phase dose finding clinical trials a thing of the past. BMJ 2023; 383:2865. [PMID: 38049170 DOI: 10.1136/bmj.p2865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Affiliation(s)
- Christina Yap
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, UK
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8
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Law M, Couturier DL, Choodari-Oskooei B, Crout P, Gamble C, Jacko P, Pallmann P, Pilling M, Robertson DS, Robling M, Sydes MR, Villar SS, Wason J, Wheeler G, Williamson SF, Yap C, Jaki T. Correction: Medicines and Healthcare products Regulatory Agency's "Consultation on proposals for legislative changes for clinical trials": a response from the Trials Methodology Research Partnership Adaptive Designs Working Group, with a focus on data sharing. Trials 2023; 24:744. [PMID: 37990330 PMCID: PMC10664262 DOI: 10.1186/s13063-023-07763-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023] Open
Affiliation(s)
- Martin Law
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.
| | - Dominique-Laurent Couturier
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | | | - Phillip Crout
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Peter Jacko
- Lancaster University Management School, Lancaster University, Lancaster, UK
- Berry Consultants, Abingdon, UK
| | | | - Mark Pilling
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - David S Robertson
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Matthew R Sydes
- University College London, London, UK
- British Heart Foundation Data Science Centre, Health Data Research UK, London, UK
| | - Sofía S Villar
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - James Wason
- Bio- Statistics Research Group, Population Health Sciences Institute, Newcastle Uni-Versity, Newcastle Upon Tyne, UK
| | - Graham Wheeler
- Imperial Clinical Trials Unit, Imperial College London, London, W12 7RH, UK
| | - S Faye Williamson
- Bio- Statistics Research Group, Population Health Sciences Institute, Newcastle Uni-Versity, Newcastle Upon Tyne, UK
| | - Christina Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Thomas Jaki
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Faculty for Informatics and Data Science, University of Regensburg, Regensburg, Germany
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9
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Guo C, Sharp A, Gurel B, Crespo M, Figueiredo I, Jain S, Vogl U, Rekowski J, Rouhifard M, Gallagher L, Yuan W, Carreira S, Chandran K, Paschalis A, Colombo I, Stathis A, Bertan C, Seed G, Goodall J, Raynaud F, Ruddle R, Swales KE, Malia J, Bogdan D, Tiu C, Caldwell R, Aversa C, Ferreira A, Neeb A, Tunariu N, Westaby D, Carmichael J, Fenor de la Maza MD, Yap C, Matthews R, Badham H, Prout T, Turner A, Parmar M, Tovey H, Riisnaes R, Flohr P, Gil J, Waugh D, Decordova S, Schlag A, Calì B, Alimonti A, de Bono JS. Targeting myeloid chemotaxis to reverse prostate cancer therapy resistance. Nature 2023; 623:1053-1061. [PMID: 37844613 PMCID: PMC10686834 DOI: 10.1038/s41586-023-06696-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/28/2023] [Indexed: 10/18/2023]
Abstract
Inflammation is a hallmark of cancer1. In patients with cancer, peripheral blood myeloid expansion, indicated by a high neutrophil-to-lymphocyte ratio, associates with shorter survival and treatment resistance across malignancies and therapeutic modalities2-5. Whether myeloid inflammation drives progression of prostate cancer in humans remain unclear. Here we show that inhibition of myeloid chemotaxis can reduce tumour-elicited myeloid inflammation and reverse therapy resistance in a subset of patients with metastatic castration-resistant prostate cancer (CRPC). We show that a higher blood neutrophil-to-lymphocyte ratio reflects tumour myeloid infiltration and tumour expression of senescence-associated mRNA species, including those that encode myeloid-chemoattracting CXCR2 ligands. To determine whether myeloid cells fuel resistance to androgen receptor signalling inhibitors, and whether inhibiting CXCR2 to block myeloid chemotaxis reverses this, we conducted an investigator-initiated, proof-of-concept clinical trial of a CXCR2 inhibitor (AZD5069) plus enzalutamide in patients with metastatic CRPC that is resistant to androgen receptor signalling inhibitors. This combination was well tolerated without dose-limiting toxicity and it decreased circulating neutrophil levels, reduced intratumour CD11b+HLA-DRloCD15+CD14- myeloid cell infiltration and imparted durable clinical benefit with biochemical and radiological responses in a subset of patients with metastatic CRPC. This study provides clinical evidence that senescence-associated myeloid inflammation can fuel metastatic CRPC progression and resistance to androgen receptor blockade. Targeting myeloid chemotaxis merits broader evaluation in other cancers.
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Affiliation(s)
- Christina Guo
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Adam Sharp
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Bora Gurel
- The Institute of Cancer Research, London, UK
| | | | | | - Suneil Jain
- Northern Ireland Cancer Centre, Belfast, UK
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
| | - Ursula Vogl
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | | | | | | | - Wei Yuan
- The Institute of Cancer Research, London, UK
| | | | - Khobe Chandran
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Alec Paschalis
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Ilaria Colombo
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - Anastasios Stathis
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
| | | | - George Seed
- The Institute of Cancer Research, London, UK
| | | | | | - Ruth Ruddle
- The Institute of Cancer Research, London, UK
| | | | - Jason Malia
- The Institute of Cancer Research, London, UK
| | | | - Crescens Tiu
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | | | - Antje Neeb
- The Institute of Cancer Research, London, UK
| | - Nina Tunariu
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Daniel Westaby
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Juliet Carmichael
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | | | | | - Toby Prout
- The Institute of Cancer Research, London, UK
| | | | - Mona Parmar
- The Institute of Cancer Research, London, UK
| | - Holly Tovey
- The Institute of Cancer Research, London, UK
| | | | - Penny Flohr
- The Institute of Cancer Research, London, UK
| | - Jesus Gil
- MRC London Institute of Medical Sciences (LMS), London, UK
- Institute of Clinical Sciences (ICS), Faculty of Medicine, Imperial College London, London, UK
| | - David Waugh
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
- Centre for Cancer Biology, University of South Australia, Adelaide, South Australia, Australia
| | | | - Anna Schlag
- The Institute of Cancer Research, London, UK
| | - Bianca Calì
- Institute of Oncology Research, Bellinzona, Switzerland
| | - Andrea Alimonti
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
- Institute of Oncology Research, Bellinzona, Switzerland
- Department of Health Sciences and Technology, Eidgenössische Technische Hochschule Zürich (ETH), Zurich, Switzerland
- Department of Medicine, Veneto Institute of Molecular Medicine, University of Padova, Padua, Italy
| | - Johann S de Bono
- The Institute of Cancer Research, London, UK.
- The Royal Marsden NHS Foundation Trust, London, UK.
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Yap C, Solovyeva O, de Bono J, Rekowski J, Patel D, Jaki T, Mander A, Evans TRJ, Peck R, Hayward KS, Hopewell S, Ursino M, Rantell KR, Calvert M, Lee S, Kightley A, Ashby D, Chan AW, Garrett-Mayer E, Isaacs JD, Golub R, Kholmanskikh O, Richards D, Boix O, Matcham J, Seymour L, Ivy SP, Marshall LV, Hommais A, Liu R, Tanaka Y, Berlin J, Espinasse A, Dimairo M, Weir CJ. Enhancing reporting quality and impact of early phase dose-finding clinical trials: CONSORT Dose-finding Extension (CONSORT-DEFINE) guidance. BMJ 2023; 383:e076387. [PMID: 37863501 PMCID: PMC10583500 DOI: 10.1136/bmj-2023-076387] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2023] [Indexed: 10/22/2023]
Affiliation(s)
| | | | - Johann de Bono
- Institute of Cancer Research, London SM2 5NG, UK
- Royal Marsden NHS Foundation Trust, London, UK
| | - Jan Rekowski
- Institute of Cancer Research, London SM2 5NG, UK
| | | | - Thomas Jaki
- MRC Biostatistics Unit, Cambridge University, Cambridge, UK
- Computational Statistics Group, University of Regensburg, Regensburg, Germany
| | - Adrian Mander
- Centre For Trials Research, Cardiff University, Heath Park, Cardiff, UK
| | - Thomas R Jeffry Evans
- Institute of Cancer Sciences, CR-UK Beatson Institute, University of Glasgow, Glasgow, UK
| | - Richard Peck
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Hoffmann-La Roche, Basel, Switzerland
| | - Kathryn S Hayward
- Departments of Physiotherapy, and Medicine (Royal Melbourne Hospital), University of Melbourne, VIC, Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Sally Hopewell
- Oxford Clinical Research Unit, NDORMS, University of Oxford, Oxford, UK
| | - Moreno Ursino
- ReCAP/F CRIN, INSERM, Paris, France
- Unit of Clinical Epidemiology, CHU Robert Debré, APHP, URC, INSERM CIC-EC 1426, Reims, France
- INSERM Centre de Recherche des Cordeliers, Sorbonne University, Paris Cité University, Paris, France
- Health data and model driven approaches for Knowledge Acquisition team, Centre Inria, Paris, France
| | | | - Melanie Calvert
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Applied Research Collaboration West Midlands, University of Birmingham, Birmingham, UK
- NIHR Research Blood and Transplant Research Unit in Precision Transplant and Cellular Therapeutics, University of Birmingham, Edgbaston, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, Institute of Translational Medicine, University Hospital NHS Foundation Trust, Birmingham, UK
| | - Shing Lee
- Columbia University Mailman School of Public Health, New York, NY, USA
| | | | - Deborah Ashby
- School of Public Health, Imperial College London, London, UK
| | - An-Wen Chan
- Department of Medicine, Women's College Research Institute, University of Toronto, Toronto, ON, Canada
| | - Elizabeth Garrett-Mayer
- Center for Research and Analytics, American Society of Clinical Oncology, Alexandria, VA, USA
| | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Robert Golub
- Department of Medicine, Northwestern University Feinberg School of Medicine, 633 Clark Street, Evanston, IL, USA
| | - Olga Kholmanskikh
- Federal Agency for Medicines and Health Products, Brussels, Belgium
- European Medicines Agency, Amsterdam, Netherlands
| | - Dawn Richards
- Clinical Trials Ontario, MaRS Centre, Toronto, ON, Canada
| | | | - James Matcham
- Strategic Consulting, Cytel (Australia), Perth, WA, Australia
| | - Lesley Seymour
- Investigational New Drug Programme, Canadian Cancer Trials Group, Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - S Percy Ivy
- Investigational Drug Branch, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Institute of Health, Bethesda, MD, USA
| | - Lynley V Marshall
- Institute of Cancer Research, London SM2 5NG, UK
- Royal Marsden NHS Foundation Trust, London, UK
| | - Antoine Hommais
- Department of Clinical Research, National Cancer Institute, Boulogne-Billancourt, France
| | - Rong Liu
- Bristol Myers Squibb, New York, NY, USA
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | | | - Munyaradzi Dimairo
- Division of Population Health, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
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11
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Yap C, Rekowski J, Ursino M, Solovyeva O, Patel D, Dimairo M, Weir CJ, Chan AW, Jaki T, Mander A, Evans TRJ, Peck R, Hayward KS, Calvert M, Rantell KR, Lee S, Kightley A, Hopewell S, Ashby D, Garrett-Mayer E, Isaacs J, Golub R, Kholmanskikh O, Richards DP, Boix O, Matcham J, Seymour L, Ivy SP, Marshall LV, Hommais A, Liu R, Tanaka Y, Berlin J, Espinasse A, de Bono J. Enhancing quality and impact of early phase dose-finding clinical trial protocols: SPIRIT Dose-finding Extension (SPIRIT-DEFINE) guidance. BMJ 2023; 383:e076386. [PMID: 37863491 DOI: 10.1136/bmj-2023-076386] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Affiliation(s)
| | - Jan Rekowski
- Institute of Cancer Research, London SM2 5NG, UK
| | - Moreno Ursino
- ReCAP/F CRIN, INSERM, Paris, France
- Unit of Clinical Epidemiology, University Hospital Centre Robert Debré, Reims, France
- INSERM Centre de Recherche des Cordeliers, Sorbonne University, Paris, France
- Health data and model driven approaches for Knowledge Acquisition team, Centre Inria, Paris, France
| | | | | | - Munyaradzi Dimairo
- Division of Population Health, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - An-Wen Chan
- Department of Medicine, Women's College Research Institute, University of Toronto, Toronto, Canada
| | - Thomas Jaki
- MRC Biostatistics Unit, Cambridge University, Cambridge, UK
- Computational Statistics Group, University of Regensburg, Regensburg, Germany
| | - Adrian Mander
- Centre For Trials Research, Cardiff University, Cardiff, UK
| | - Thomas R Jeffry Evans
- Institute of Cancer Sciences, CR-UK Beatson Institute, University of Glasgow, Glasgow, UK
| | - Richard Peck
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Hoffmann-La Roche, Basel, Switzerland
| | - Kathryn S Hayward
- Departments of Physiotherapy, and Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, VIC, Australia
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, VIC, Australia
| | - Melanie Calvert
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research Applied Research Collaboration West Midlands, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Precision Transplant and Cellular Therapeutics, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research Birmingham Biomedical Research Centre, NIHR Birmingham Biomedical Research Centre, Institute of Translational Medicine, University Hospital NHS Foundation Trust, Birmingham, UK
| | | | - Shing Lee
- Columbia University Mailman School of Public Health, New York, NY, USA
| | | | - Sally Hopewell
- Oxford Clinical Research Unit, NDORMS, University of Oxford, Oxford, UK
| | - Deborah Ashby
- School of Public Health, Imperial College London, St Mary's Hospital, London, UK
| | - Elizabeth Garrett-Mayer
- Center for Research and Analytics, American Society of Clinical Oncology, Alexandria, VA, USA
| | - John Isaacs
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Musculoskeletal Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Robert Golub
- Department of Medicine, Northwestern University Feinberg School of Medicine, Evanston, IL, USA
| | | | | | | | - James Matcham
- Strategic Consulting, Cytel (Australia), Perth, WA, Australia
| | - Lesley Seymour
- Investigational New Drug Programme, Canadian Cancer Trials Group, Cancer Research Institute, Queen's University, Kingston, ON, Canada
| | - S Percy Ivy
- Investigational Drug Branch, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Institute of Health, Bethesda, MD, USA
| | - Lynley V Marshall
- Institute of Cancer Research, London SM2 5NG, UK
- Royal Marsden NHS Foundation Trust, London, UK
| | - Antoine Hommais
- Department of Clinical Research, National Cancer Institute, Boulogne-Billancourt, France
| | - Rong Liu
- Bristol Myers Squibb, New York, NY, USA
| | - Yoshiya Tanaka
- First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | | | | | - Johann de Bono
- Institute of Cancer Research, London SM2 5NG, UK
- Royal Marsden NHS Foundation Trust, London, UK
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12
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Law M, Couturier DL, Choodari-Oskooei B, Crout P, Gamble C, Jacko P, Pallmann P, Pilling M, Robertson DS, Robling M, Sydes MR, Villar SS, Wason J, Wheeler G, Williamson SF, Yap C, Jaki T. Medicines and Healthcare products Regulatory Agency's "Consultation on proposals for legislative changes for clinical trials": a response from the Trials Methodology Research Partnership Adaptive Designs Working Group, with a focus on data sharing. Trials 2023; 24:640. [PMID: 37798805 PMCID: PMC10552399 DOI: 10.1186/s13063-023-07576-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 08/04/2023] [Indexed: 10/07/2023] Open
Abstract
In the UK, the Medicines and Healthcare products Regulatory Agency consulted on proposals "to improve and strengthen the UK clinical trials legislation to help us make the UK the best place to research and develop safe and innovative medicines". The purpose of the consultation was to help finalise the proposals and contribute to the drafting of secondary legislation. We discussed these proposals as members of the Trials Methodology Research Partnership Adaptive Designs Working Group, which is jointly funded by the Medical Research Council and the National Institute for Health and Care Research. Two topics arose frequently in the discussion: the emphasis on legislation, and the absence of questions on data sharing. It is our opinion that the proposals rely heavily on legislation to change practice. However, clinical trials are heterogeneous, and as a result some trials will struggle to comply with all of the proposed legislation. Furthermore, adaptive design clinical trials are even more heterogeneous than their non-adaptive counterparts, and face more challenges. Consequently, it is possible that increased legislation could have a greater negative impact on adaptive designs than non-adaptive designs. Overall, we are sceptical that the introduction of legislation will achieve the desired outcomes, with some exceptions. Meanwhile the topic of data sharing - making anonymised individual-level clinical trial data available to other investigators for further use - is entirely absent from the proposals and the consultation in general. However, as an aspect of the wider concept of open science and reproducible research, data sharing is an increasingly important aspect of clinical trials. The benefits of data sharing include faster innovation, improved surveillance of drug safety and effectiveness and decreasing participant exposure to unnecessary risk. There are already a number of UK-focused documents that discuss and encourage data sharing, for example, the Concordat on Open Research Data and the Medical Research Council's Data Sharing Policy. We strongly suggest that data sharing should be the norm rather than the exception, and hope that the forthcoming proposals on clinical trials invite discussion on this important topic.
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Affiliation(s)
- Martin Law
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.
| | - Dominique-Laurent Couturier
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | | | - Phillip Crout
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Peter Jacko
- Lancaster University Management School, Lancaster University, Lancaster, UK
- Berry Consultants, Abingdon, UK
| | | | - Mark Pilling
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - David S Robertson
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Matthew R Sydes
- University College London, London, UK
- British Heart Foundation Data Science Centre, Health Data Research UK, London, UK
| | - Sofía S Villar
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - James Wason
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Graham Wheeler
- Imperial Clinical Trials Unit, Imperial College London, London, W12 7RH, UK
| | - S Faye Williamson
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christina Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Thomas Jaki
- Medical Research Council Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Faculty for Informatics and Data Science, University of Regensburg, Regensburg, Germany
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13
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Alger E, Minchom A, Lee Aiyegbusi O, Schipper M, Yap C. Statistical methods and data visualisation of patient-reported outcomes in early phase dose-finding oncology trials: a methodological review. EClinicalMedicine 2023; 64:102228. [PMID: 37781154 PMCID: PMC10541462 DOI: 10.1016/j.eclinm.2023.102228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 10/03/2023] Open
Abstract
Background Traditionally, within dose-finding clinical trials, treatment toxicity and tolerability are assessed by clinicians. Research has shown that clinician reporting may have inadequate inter-rater reliability, poor correlation with patient reported outcomes, and under capture the true toxicity burden. The introduction of patient-reported outcomes (PROs), where the patient can assess their own symptomatic adverse events or quality of life, has potential to complement current practice to aid dose optimisation. There are no international recommendations offering guidance for the inclusion of PROs in dose-finding trial design and analysis. Our review aimed to identify and describe current statistical methods and data visualisation techniques employed to analyse and visualise PRO data in published early phase dose-finding oncology trials (DFOTs). Methods DFOTs published from June 2016-December 2022, which presented PRO analysis methods, were included in this methodological review. We extracted 35 eligible papers indexed in PubMed. Study characteristics extracted included: PRO objectives, PRO measures, statistical analysis and visualisation techniques, and whether the PRO was involved in interim and final dose selection decisions. Findings Most papers (30, 85.7%) did not include clear PRO objectives. 20 (57.1%) papers used inferential statistical techniques to analyse PROs, including survival analysis and mixed-effect models. One trial used PROs to classify a clinicians' assessed dose-limiting toxicities (DLTs). Three (8.6%) trials used PROs to confirm the tolerability of the recommended dose. 25 trial reports visually presented PRO data within a figure or table within their publication, of which 12 papers presented PRO score longitudinally. Interpretation This review highlighted that the statistical methods and reporting of PRO analysis in DFOTs are often poorly described and inconsistent. Many trials had PRO objectives which were not clearly described, making it challenging to evaluate the appropriateness of the statistical techniques used. Drawing conclusions based on DFOTs which are not powered for PROs may be misleading. With no guidance and standardisation of analysis methods for PROs in early phase DFOTs, it is challenging to compare study findings across trials. Therefore, there is a crucial need to establish international guidance to enhance statistical methods and graphical presentation for PRO analysis in the dose-finding setting. Funding EA has been supported to undertake this work as part of a PhD studentship from the Institute of Cancer Research within the MRC/NIHR Trials Methodology Research Partnership. AM is supported by the National Institute for Health Research (NIHR) Biomedical Research Centre at the Royal Marsden NHS Foundation Trust, the Institute of Cancer Research and Imperial College.
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Affiliation(s)
- Emily Alger
- Clinical Trial and Statistics Unit, Institute of Cancer Research, London, UK
| | - Anna Minchom
- Drug Development Unit, Royal Marsden/Institute of Cancer Research, London, UK
| | - Olalekan Lee Aiyegbusi
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Matthew Schipper
- Departments of Radiation Oncology and Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Christina Yap
- Clinical Trial and Statistics Unit, Institute of Cancer Research, London, UK
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Alger E, Zhang Y, Yap C. Reporting quality of CONSORT flow diagrams in published early phase dose-finding clinical trial reports: Improvement is needed. Contemp Clin Trials 2023; 131:107277. [PMID: 37393003 DOI: 10.1016/j.cct.2023.107277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/15/2023] [Accepted: 06/28/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND This project aims to: (1) assess the completeness of information in flow diagrams of published early phase dose-finding (EPDF) trials based on CONSORT recommendations, and if additional features on dose (de-)escalation were presented; (2) propose new flow diagrams presenting how doses were (de-)escalated throughout the trial. METHODS Flow diagrams were extracted from a random sample of 259 EPDF trials, published from 2011 to 2020 indexed in PubMed. Diagrams were scored out of 15 following CONSORT recommendations with an additional score for presence of (de-)escalation. New templates were proposed for features that were deficient and presented to 39 methodologists and 11 clinical trialists in October and December 2022. RESULTS 98 (38%) papers included a flow diagram. Flow diagrams were most deficient in the reporting of reasons for lost to follow up (2%) and reasons for not receiving allocated intervention (14%). Few (39%) presented sequential dose-decision stages. Of voting methodologists, 33/38 (87%) agreed or strongly agreed that for participants recruited in cohorts, presenting the (de-)escalation steps in the flow diagram is a useful feature, also expressed by the trial investigators. Most workshop attendees (35/39, 90%) preferred a larger dose to be displayed higher up within the flow diagram than a smaller dose. CONCLUSION Most published trials do not provide a flow diagram, and for those that do, essential information is often omitted. EPDF flow diagrams capturing information on participant flow in the trial's journey, encapsulated within one figure, are highly recommended to promote transparency and interpretability of trial results.
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Affiliation(s)
- Emily Alger
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, United Kingdom.
| | - Yuqi Zhang
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, United Kingdom.
| | - Christina Yap
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, United Kingdom.
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15
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Solovyeva O, Dimairo M, Weir CJ, Hee SW, Espinasse A, Ursino M, Patel D, Kightley A, Hughes S, Jaki T, Mander A, Evans TRJ, Lee S, Hopewell S, Rantell KR, Chan AW, Bedding A, Stephens R, Richards D, Roberts L, Kirkpatrick J, de Bono J, Yap C. Development of consensus-driven SPIRIT and CONSORT extensions for early phase dose-finding trials: the DEFINE study. BMC Med 2023; 21:246. [PMID: 37408015 PMCID: PMC10324137 DOI: 10.1186/s12916-023-02937-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/12/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Early phase dose-finding (EPDF) trials are crucial for the development of a new intervention and influence whether it should be investigated in further trials. Guidance exists for clinical trial protocols and completed trial reports in the SPIRIT and CONSORT guidelines, respectively. However, both guidelines and their extensions do not adequately address the characteristics of EPDF trials. Building on the SPIRIT and CONSORT checklists, the DEFINE study aims to develop international consensus-driven guidelines for EPDF trial protocols (SPIRIT-DEFINE) and reports (CONSORT-DEFINE). METHODS The initial generation of candidate items was informed by reviewing published EPDF trial reports. The early draft items were refined further through a review of the published and grey literature, analysis of real-world examples, citation and reference searches, and expert recommendations, followed by a two-round modified Delphi process. Patient and public involvement and engagement (PPIE) was pursued concurrently with the quantitative and thematic analysis of Delphi participants' feedback. RESULTS The Delphi survey included 79 new or modified SPIRIT-DEFINE (n = 36) and CONSORT-DEFINE (n = 43) extension candidate items. In Round One, 206 interdisciplinary stakeholders from 24 countries voted and 151 stakeholders voted in Round Two. Following Round One feedback, one item for CONSORT-DEFINE was added in Round Two. Of the 80 items, 60 met the threshold for inclusion (≥ 70% of respondents voted critical: 26 SPIRIT-DEFINE, 34 CONSORT-DEFINE), with the remaining 20 items to be further discussed at the consensus meeting. The parallel PPIE work resulted in the development of an EPDF lay summary toolkit consisting of a template with guidance notes and an exemplar. CONCLUSIONS By detailing the development journey of the DEFINE study and the decisions undertaken, we envision that this will enhance understanding and help researchers in the development of future guidelines. The SPIRIT-DEFINE and CONSORT-DEFINE guidelines will allow investigators to effectively address essential items that should be present in EPDF trial protocols and reports, thereby promoting transparency, comprehensiveness, and reproducibility. TRIAL REGISTRATION SPIRIT-DEFINE and CONSORT-DEFINE are registered with the EQUATOR Network ( https://www.equator-network.org/ ).
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Affiliation(s)
| | - Munyaradzi Dimairo
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Siew Wan Hee
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
- University of Warwick, Coventry, UK
| | | | - Moreno Ursino
- Inserm, Centre de Recherche Des Cordeliers, Sorbonne UniversitéUniversité Paris Cité, 75006, Paris, France
- HeKA, Inria Paris, 75015, Paris, France
- Unit of Clinical Epidemiology, AP-HP, CHU Robert Debré, CIC-EC 1426, Paris, France
- RECaP/F-CRIN, Inserm, 5400, Nancy, France
| | | | - Andrew Kightley
- Patient and Public Involvement and Engagement (PPIE) Lead, Lichfield, UK
| | | | - Thomas Jaki
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- University of Regensburg, Regensburg, Germany
| | | | | | - Shing Lee
- Columbia University, Mailman School of Public Health, New York, USA
| | - Sally Hopewell
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | | | - An-Wen Chan
- Department of Medicine, Women's College Research Institute, University of Toronto, Toronto, Canada
| | | | | | | | | | | | - Johann de Bono
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
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16
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Harrison CN, Nangalia J, Boucher R, Jackson A, Yap C, O'Sullivan J, Fox S, Ailts I, Dueck AC, Geyer HL, Mesa RA, Dunn WG, Nadezhdin E, Curto-Garcia N, Green A, Wilkins B, Coppell J, Laurie J, Garg M, Ewing J, Knapper S, Crowe J, Chen F, Koutsavlis I, Godfrey A, Arami S, Drummond M, Byrne J, Clark F, Mead-Harvey C, Baxter EJ, McMullin MF, Mead AJ. Ruxolitinib Versus Best Available Therapy for Polycythemia Vera Intolerant or Resistant to Hydroxycarbamide in a Randomized Trial. J Clin Oncol 2023; 41:3534-3544. [PMID: 37126762 PMCID: PMC10306428 DOI: 10.1200/jco.22.01935] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/20/2023] [Accepted: 03/21/2023] [Indexed: 05/03/2023] Open
Abstract
PURPOSE Polycythemia vera (PV) is characterized by JAK/STAT activation, thrombotic/hemorrhagic events, systemic symptoms, and disease transformation. In high-risk PV, ruxolitinib controls blood counts and improves symptoms. PATIENTS AND METHODS MAJIC-PV is a randomized phase II trial of ruxolitinib versus best available therapy (BAT) in patients resistant/intolerant to hydroxycarbamide (HC-INT/RES). Primary outcome was complete response (CR) within 1 year. Secondary outcomes included duration of response, event-free survival (EFS), symptom, and molecular response. RESULTS One hundred eighty patients were randomly assigned. CR was achieved in 40 (43%) patients on ruxolitinib versus 23 (26%) on BAT (odds ratio, 2.12; 90% CI, 1.25 to 3.60; P = .02). Duration of CR was superior for ruxolitinib (hazard ratio [HR], 0.38; 95% CI, 0.24 to 0.61; P < .001). Symptom responses were better with ruxolitinib and durable. EFS (major thrombosis, hemorrhage, transformation, and death) was superior for patients attaining CR within 1 year (HR, 0.41; 95% CI, 0.21 to 0.78; P = .01); and those on ruxolitinib (HR, 0.58; 95% CI, 0.35 to 0.94; P = .03). Serial analysis of JAK2V617F variant allele fraction revealed molecular response was more frequent with ruxolitinib and was associated with improved outcomes (progression-free survival [PFS] P = .001, EFS P = .001, overall survival P = .01) and clearance of JAK2V617F stem/progenitor cells. ASXL1 mutations predicted for adverse EFS (HR, 3.02; 95% CI, 1.47 to 6.17; P = .003). The safety profile of ruxolitinib was as previously reported. CONCLUSION The MAJIC-PV study demonstrates ruxolitinib treatment benefits HC-INT/RES PV patients with superior CR, and EFS as well as molecular response; importantly also demonstrating for the first time, to our knowledge, that molecular response is linked to EFS, PFS, and OS.
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Affiliation(s)
- Claire N. Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jyoti Nangalia
- Wellcome-MRC Cambridge Stem Cell Institute, University of Cambridge, Cambridge, United Kingdom
- Wellcome Sanger Institute Hinxton, Cambridgeshire, United Kingdom
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Rebecca Boucher
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Aimee Jackson
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, United Kingdom
| | - Jennifer O'Sullivan
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Medical Research Council (MRC) Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, NIHR, Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Sonia Fox
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Isaak Ailts
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ
| | - Amylou C. Dueck
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ
| | - Holly L. Geyer
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ
| | - Ruben A. Mesa
- Mays Cancer Center at UT Health San Antonio MD Anderson, San Antonio, TX
| | - William G. Dunn
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Eugene Nadezhdin
- Wellcome Sanger Institute Hinxton, Cambridgeshire, United Kingdom
| | - Natalia Curto-Garcia
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Anna Green
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Bridget Wilkins
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jason Coppell
- Royal Devon & Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - John Laurie
- Worthing Hospital, Western Sussex NHS Foundation Trust, Worthing, United Kingdom
| | - Mamta Garg
- University Hospital of Leicester, Leicester, United Kingdom
| | - Joanne Ewing
- Birmingham Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Steven Knapper
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | | | | | - Ioannis Koutsavlis
- Western General Hospital, Lothian Health Board, Edinburgh, United Kingdom
| | - Anna Godfrey
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Siamak Arami
- London North West Healthcare NHS Trust, London, United Kingdom
| | - Mark Drummond
- The Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Jennifer Byrne
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Fiona Clark
- Queen Elizabeth Hospital, Birmingham, United Kingdom
| | | | - Elizabeth Joanna Baxter
- Haematology, Cambridge Blood and Stem Cell Biobank NHS-BT Cambridge Centre, Cambridge, United Kingdom
| | | | - Adam J. Mead
- Medical Research Council (MRC) Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, NIHR, Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
- Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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17
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Villacampa G, Patel D, Zheng H, McAleese J, Rekowski J, Solovyeva O, Yin Z, Yap C. Assessing the reporting quality of early phase dose-finding trial protocols: a methodological review. EClinicalMedicine 2023; 60:102020. [PMID: 37261325 PMCID: PMC10227378 DOI: 10.1016/j.eclinm.2023.102020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/09/2023] [Accepted: 05/09/2023] [Indexed: 06/02/2023] Open
Abstract
Background The paradigm of early phase dose-finding trials has evolved in recent years. Innovative dose-finding designs and protocols which combine phases I and II are becoming more popular in health research. However, the quality of these trial protocols is unknown due to a lack of specific reporting guidelines. Here, we evaluated the reporting quality of dose-finding trial protocols. Methods We conducted a cross-sectional study of oncology and non-oncology early phase dose-finding trial protocols posted on ClinicalTrials.gov in 2017-2023. A checklist of items comprising: 1) the original 33-items from the SPIRIT 2013 Statement and 2) additional items unique to dose-finding trials were used to assess reporting quality. The primary endpoint was the overall proportion of adequately reported items. This study was registered with PROSPERO (no: CRD42022314572). Finding A total of 106 trial protocols were included in the study with the rule-based 3 + 3 being the most used trial design (39.6%). Eleven model-based and model-assisted designs were identified in oncology trials only (11/58, 19.0%). The overall proportion of adequately reported items was 65.1% (95%CI: 63.9-66.3%). However, the reporting quality of each individual item varied substantially (range 9.4%-100%). Oncology study protocols showed lower reporting quality than non-oncology. In the multivariable analysis, trials with larger sample sizes and industry funding were associated with higher proportions of adequately reported items (all p-values <0.05). Interpretation The overall reporting quality of early phase dose-finding trial protocols is suboptimal (65.1%). There is a need for improved completeness and transparency in early phase dose-finding trial protocols to facilitate rigorous trial conduct, reproducibility and external review. Funding None.
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Affiliation(s)
- Guillermo Villacampa
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), United Kingdom
| | - Dhrusti Patel
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), United Kingdom
| | - Haiyan Zheng
- MRC Biostatistics Unit, University of Cambridge, United Kingdom
| | - Jessica McAleese
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), United Kingdom
| | - Jan Rekowski
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), United Kingdom
| | - Olga Solovyeva
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), United Kingdom
| | - Zhulin Yin
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), United Kingdom
| | - Christina Yap
- Clinical Trials and Statistics Unit at The Institute of Cancer Research (ICR-CTSU), United Kingdom
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18
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Tsu BV, Agarwal R, Gokhale NS, Kulsuptrakul J, Ryan AP, Fay EJ, Castro LK, Beierschmitt C, Yap C, Turcotte EA, Delgado-Rodriguez SE, Vance RE, Hyde JL, Savan R, Mitchell PS, Daugherty MD. Host-specific sensing of coronaviruses and picornaviruses by the CARD8 inflammasome. PLoS Biol 2023; 21:e3002144. [PMID: 37289745 PMCID: PMC10249858 DOI: 10.1371/journal.pbio.3002144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 05/02/2023] [Indexed: 06/10/2023] Open
Abstract
Hosts have evolved diverse strategies to respond to microbial infections, including the detection of pathogen-encoded proteases by inflammasome-forming sensors such as NLRP1 and CARD8. Here, we find that the 3CL protease (3CLpro) encoded by diverse coronaviruses, including Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), cleaves a rapidly evolving region of human CARD8 and activates a robust inflammasome response. CARD8 is required for cell death and the release of pro-inflammatory cytokines during SARS-CoV-2 infection. We further find that natural variation alters CARD8 sensing of 3CLpro, including 3CLpro-mediated antagonism rather than activation of megabat CARD8. Likewise, we find that a single nucleotide polymorphism (SNP) in humans reduces CARD8's ability to sense coronavirus 3CLpros and, instead, enables sensing of 3C proteases (3Cpro) from select picornaviruses. Our findings demonstrate that CARD8 is a broad sensor of viral protease activities and suggests that CARD8 diversity contributes to inter- and intraspecies variation in inflammasome-mediated viral sensing and immunopathology.
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Affiliation(s)
- Brian V. Tsu
- Department of Molecular Biology, University of California, San Diego, La Jolla, California, United States of America
| | - Rimjhim Agarwal
- Department of Molecular Biology, University of California, San Diego, La Jolla, California, United States of America
| | - Nandan S. Gokhale
- Department of Immunology, University of Washington; Seattle, Washington, United States of America
| | - Jessie Kulsuptrakul
- Molecular and Cellular Biology Graduate Program, University of Washington; Seattle, Washington, United States of America
| | - Andrew P. Ryan
- Department of Molecular Biology, University of California, San Diego, La Jolla, California, United States of America
| | - Elizabeth J. Fay
- Department of Molecular Biology, University of California, San Diego, La Jolla, California, United States of America
| | - Lennice K. Castro
- Department of Molecular Biology, University of California, San Diego, La Jolla, California, United States of America
| | - Christopher Beierschmitt
- Department of Molecular Biology, University of California, San Diego, La Jolla, California, United States of America
| | - Christina Yap
- Department of Microbiology, University of Washington; Seattle, Washington, United States of America
| | - Elizabeth A. Turcotte
- Division of Immunology and Pathogenesis, University of California, Berkeley, Berkeley, California, United States of America
| | - Sofia E. Delgado-Rodriguez
- Department of Molecular Biology, University of California, San Diego, La Jolla, California, United States of America
| | - Russell E. Vance
- Division of Immunology and Pathogenesis, University of California, Berkeley, Berkeley, California, United States of America
- Howard Hughes Medical Institute, University of California, Berkeley, Berkeley, California, United States of America
| | - Jennifer L. Hyde
- Department of Microbiology, University of Washington; Seattle, Washington, United States of America
| | - Ram Savan
- Department of Immunology, University of Washington; Seattle, Washington, United States of America
| | - Patrick S. Mitchell
- Department of Microbiology, University of Washington; Seattle, Washington, United States of America
| | - Matthew D. Daugherty
- Department of Molecular Biology, University of California, San Diego, La Jolla, California, United States of America
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19
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Tedjawirja VN, Mieremet A, Rombouts KB, Yap C, Neele AE, Northoff BH, Chen HJ, Vos M, Klaver D, Yeung KK, Balm R, de Waard V. Exploring the expression and potential function of follicle stimulating hormone receptor in extragonadal cells related to abdominal aortic aneurysm. PLoS One 2023; 18:e0285607. [PMID: 37228156 DOI: 10.1371/journal.pone.0285607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/26/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Follicle stimulating hormone (FSH) is identified to play a role in postmenopausal disease and hypothesized to affect abdominal aortic aneurysm (AAA) onset/progression in postmenopausal women. We aimed to detect FSHR gene expression in AAA tissue and cell types involved in AAA formation. METHODS FSH stimulation of human umbilical cord endothelial cells (HUVECs), smooth muscle cells (HUCs) and PMA-differentiated macrophages to assess gene expression of FSHR and various markers. Human macrophages activated with various stimuli were assessed for FSHR gene expression. AAA dataset, AAA tissue samples and AAA-derived smooth muscle cells (SMC) obtained from elderly female donors were assessed for FSHR gene expression. AAA-SMCs were stimulated with FSH to assess its effect on gene expression. Lastly, oxidized low-density-lipoprotein (ox-LDL) uptake and abundance of cell surface protein markers were assessed by flow cytometry after FSH stimulation of human monocytes. RESULTS FSH stimulation showed similar levels of gene expression in HUVECs and HUCs. Only ACTA2 was downregulated in HUCs. In PMA-differentiated macrophages, gene expression of inflammation markers was unchanged after FSH stimulation. FSHR gene expression was found to be low in the AAA datasets. Female AAA-SMCs show occasional FSHR gene expression at a very low level, yet stimulation with FSH did not affect gene expression of SMC- or inflammation markers. FSH stimulation did not impact ox-LDL uptake or alter cell surface protein expression in monocytes. While FSHR gene expression was detected in human testis tissue, it was below quantification level in all other investigated cell types, even upon activation of macrophages with various stimuli. CONCLUSION Despite previous reports, we did not detect FSHR gene expression in various extragonadal cell types, except in occasional female AAA-SMCs. No clear effect on cell activation was observed upon FSH stimulation in any cell type. Our data suggest that a direct effect of FSH in AAA-related extragonadal cells is unlikely to influence AAA.
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Affiliation(s)
- V N Tedjawirja
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - A Mieremet
- Department of Medical Biochemistry, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - K B Rombouts
- Department of Surgery and Physiology, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - C Yap
- Department of Medical Biochemistry, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - A E Neele
- Department of Medical Biochemistry, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - B H Northoff
- Institute of Laboratory Medicine, Ludwig Maximilians University Munich, Munich, Germany
| | - H J Chen
- Department of Medical Biochemistry, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - M Vos
- Department of Medical Biochemistry, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - D Klaver
- Department of Medical Biochemistry, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - K K Yeung
- Department of Surgery and Physiology, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - R Balm
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - V de Waard
- Department of Medical Biochemistry, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Espinasse A, Solovyeva O, Dimairo M, Weir C, Jaki T, Mander A, Kightley A, Evans J, Lee S, Bedding A, Hopewell S, Rantell K, Liu R, Chan AW, De Bono J, Yap C. SPIRIT and CONSORT extensions for early phase dose-finding clinical trials: the DEFINE (DosE-FIndiNg Extensions) study protocol. BMJ Open 2023; 13:e068173. [PMID: 36990492 PMCID: PMC10069529 DOI: 10.1136/bmjopen-2022-068173] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/13/2023] [Indexed: 03/31/2023] Open
Abstract
INTRODUCTION Early phase dose-finding (EPDF) studies are critical for the development of new treatments, directly influencing whether compounds or interventions can be investigated in further trials to confirm their safety and efficacy. There exists guidance for clinical trial protocols and reporting of completed trials in the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 and CONsolidated Standards Of Reporting Randomised Trials (CONSORT) 2010 statements. However, neither the original statements nor their extensions adequately cover the specific features of EPDF trials. The DEFINE (DosE-FIndiNg Extensions) study aims to enhance transparency, completeness, reproducibility and interpretation of EPDF trial protocols (SPIRIT-DEFINE) and their reports once completed (CONSORT-DEFINE), across all disease areas, building on the original SPIRIT 2013 and CONSORT 2010 statements. METHODS AND ANALYSIS A methodological review of published EPDF trials will be conducted to identify features and deficiencies in reporting and inform the initial generation of the candidate items. The early draft checklists will be enriched through a review of published and grey literature, real-world examples analysis, citation and reference searches and consultation with international experts, including regulators and journal editors. Development of CONSORT-DEFINE commenced in March 2021, followed by SPIRIT-DEFINE from January 2022. A modified Delphi process, involving worldwide, multidisciplinary and cross-sector key stakeholders, will be run to refine the checklists. An international consensus meeting in autumn 2022 will finalise the list of items to be included in both guidance extensions. ETHICS AND DISSEMINATION This project was approved by ICR's Committee for Clinical Research. The Health Research Authority confirmed Research Ethics Approval is not required. The dissemination strategy aims to maximise guideline awareness and uptake, including but not limited to dissemination in stakeholder meetings, conferences, peer-reviewed publications and on the EQUATOR Network and DEFINE study websites. REGISTRATION DETAILS SPIRIT-DEFINE and CONSORT-DEFINE are registered with the EQUATOR Network.
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Affiliation(s)
- Aude Espinasse
- Clinical Trial and Statistical Unit, Institute of Cancer Research Sutton, London, UK
| | - Olga Solovyeva
- Clinical Trial and Statistical Unit, Institute of Cancer Research Sutton, London, UK
| | - Munyaradzi Dimairo
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, University of Edinburgh, Usher Institute, Edinburgh, UK
| | - Thomas Jaki
- Computational Statistics Group, Department of Informatics and Data Science, University of Regensburg, Regensburg, Germany
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Adrian Mander
- Cardiff University Centre for Trials Research, Cardiff, UK
| | | | - Jeffry Evans
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Shing Lee
- Columbia University, New York, New York, USA
| | - Alun Bedding
- Data and Statistical Sciences Department, Roche Products Ltd, Welwyn Garden City, UK
| | - Sally Hopewell
- Centre for Statistics in Medicine, Oxford Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Khadija Rantell
- Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Rong Liu
- Biostatistics Department, Bristol-Myers Squibb Co, New York, New York, USA
| | - An-Wen Chan
- Department of Medicine, Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Johann De Bono
- Institute of Cancer Research, London, UK
- Royal Marsden Hospital, London, UK
| | - Christina Yap
- Clinical Trial and Statistical Unit, Institute of Cancer Research Sutton, London, UK
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21
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Solovyeva O, Dimairo M, Weir C, de Bono J, Bedding A, Chan AW, Espinasse A, Evans T, Hee S, Hopewell S, Hughes S, Jaki T, Kightley A, Lee S, Mander A, Patel D, Rantell K, Rekowski J, Ursino M, Yap C. 79MO Developing international consensus-driven SPIRIT and CONSORT extensions for early phase dose-finding clinical trials: The DEFINE (DosE FIndiNg Extensions) study. ESMO Open 2023. [DOI: 10.1016/j.esmoop.2023.100937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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22
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Yap C, Yin Z, Lee S, Cheung K. 37P Dose transition pathways for time-to-event continual reassessment method (TITE-CRM): Will imposing a waiting time result in better performance? ESMO Open 2023. [DOI: 10.1016/j.esmoop.2023.101003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
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23
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Araujo D, Greystoke A, Bates S, Bayle A, Calvo E, Castelo-Branco L, de Bono J, Drilon A, Garralda E, Ivy P, Kholmanskikh O, Melero I, Pentheroudakis G, Petrie J, Plummer R, Ponce S, Postel-Vinay S, Siu L, Spreafico A, Stathis A, Steeghs N, Yap C, Yap TA, Ratain M, Seymour L. Oncology phase I trial design and conduct: time for a change - MDICT Guidelines 2022. Ann Oncol 2023; 34:48-60. [PMID: 36182023 DOI: 10.1016/j.annonc.2022.09.158] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/18/2022] [Indexed: 02/03/2023] Open
Abstract
In 2021, the Food and Drug Administration Oncology Center of Excellence announced Project Optimus focusing on dose optimization for oncology drugs. The Methodology for the Development of Innovative Cancer Therapies (MDICT) Taskforce met to review and discuss the optimization of dosage for oncology trials and to develop a practical guide for oncology phase I trials. Defining a single recommended phase II dose based on toxicity may define doses that are neither the most effective nor the best tolerated. MDICT recommendations address the need for robust non-clinical data which are needed to inform trial design, as well as an expert team including statisticians and pharmacologists. The protocol must be flexible and adaptive, with clear definition of all endpoints. Health authorities should be consulted early and regularly. Strategies such as randomization, intrapatient dose escalation, and real-world eligibility criteria are encouraged whereas serial tumor sampling is discouraged in the absence of a strong rationale and appropriately validated assay. Endpoints should include consideration of all longitudinal toxicity. The phase I dose escalation trial should define the recommended dose range for later testing in randomized phase II trials, rather than a single recommended phase II dose, and consider scenarios where different populations may require different dosages. The adoption of these recommendations will improve dosage selection in early clinical trials of new anticancer treatments and ultimately, outcomes for patients.
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Affiliation(s)
- D Araujo
- Hospital de Base, Sao Jose do Rio Preto, Brazil
| | - A Greystoke
- Northern Centre for Cancer Care, Newcastle, UK
| | - S Bates
- Division of Hematology and Oncology, Department of Medicine, Columbia University, New York, USA
| | - A Bayle
- Institut Gustave Roussy, Paris, France
| | - E Calvo
- START Madrid-CIOCC, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - L Castelo-Branco
- European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - J de Bono
- Institute of Cancer Research, University of London, London; The Royal Marsden Hospital, London, UK
| | - A Drilon
- Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, USA
| | - E Garralda
- Vall d'Hebron Institute of Oncology, Barcelona, Spain
| | - P Ivy
- National Cancer Institute, USA Cancer Therapy Evaluation Program Investigational Drug Branch (NCI/CTEP/IDB), Bethesda, USA
| | - O Kholmanskikh
- European Medicines Agency, Amsterdam, Netherlands; Federal Agency for Medicines and Health Products, Brussels, Belgium
| | - I Melero
- CUN and CIMA, University of Navarra, Pamplona, Spain
| | - G Pentheroudakis
- European Society for Medical Oncology (ESMO), Lugano, Switzerland
| | - J Petrie
- Canadian Cancer Trials Group, Queen's University, Kingston
| | - R Plummer
- Northern Centre for Cancer Care, Newcastle, UK
| | - S Ponce
- Institut Gustave Roussy, Paris, France
| | | | - L Siu
- Princess Margaret Cancer Centre, Toronto, Canada
| | - A Spreafico
- Princess Margaret Cancer Centre, Toronto, Canada
| | - A Stathis
- Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
| | - N Steeghs
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - C Yap
- Institute of Cancer Research, University of London, London
| | - T A Yap
- Department of Investigational Cancer Therapeutics, University of Texas, MD Anderson Cancer Center, Houston
| | - M Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, USA
| | - L Seymour
- Canadian Cancer Trials Group, Queen's University, Kingston.
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Fenor de la Maza MD, Chandran K, Rekowski J, Shui IM, Gurel B, Cross E, Carreira S, Yuan W, Westaby D, Miranda S, Ferreira A, Seed G, Crespo M, Figueiredo I, Bertan C, Gil V, Riisnaes R, Sharp A, Rodrigues DN, Rescigno P, Tunariu N, Liu XQ, Cristescu R, Schloss C, Yap C, de Bono JS. Immune Biomarkers in Metastatic Castration-resistant Prostate Cancer. Eur Urol Oncol 2022; 5:659-667. [PMID: 35491356 DOI: 10.1016/j.euo.2022.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/15/2022] [Accepted: 04/13/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Metastatic castration-resistant prostate cancer (mCRPC) is a heterogeneous disease in which molecular stratification is needed to improve clinical outcomes. The identification of predictive biomarkers can have a major impact on the care of these patients, but the availability of metastatic tissue samples for research in this setting is limited. OBJECTIVE To study the prevalence of immune biomarkers of potential clinical utility to immunotherapy in mCRPC and to determine their association with overall survival (OS). DESIGN, SETTING, AND PARTICIPANTS From 100 patients, mCRPC biopsies were assayed by whole exome sequencing, targeted next-generation sequencing, RNA sequencing, tumor mutational burden, T-cell-inflamed gene expression profile (TcellinfGEP) score (Nanostring), and immunohistochemistry for programmed cell death 1 ligand 1 (PD-L1), ataxia-telangiectasia mutated (ATM), phosphatase and tensin homolog (PTEN), SRY homology box 2 (SOX2), and the presence of neuroendocrine features. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The phi coefficient determined correlations between biomarkers of interest. OS was assessed using Kaplan-Meier curves and adjusted hazard ratios (aHRs) from Cox regression. RESULTS AND LIMITATIONS PD-L1 and SOX2 protein expression was detected by immunohistochemistry (combined positive score ≥1 and >5% cells, respectively) in 24 (33%) and 27 (27%) mCRPC biopsies, respectively; 23 (26%) mCRPC biopsies had high TcellinfGEP scores (>-0.318). PD-L1 protein expression and TcellinfGEP scores were positively correlated (phi 0.63 [0.45; 0.76]). PD-L1 protein expression (aHR: 1.90 [1.05; 3.45]), high TcellinfGEP score (aHR: 1.86 [1.04; 3.31]), and SOX2 expression (aHR: 2.09 [1.20; 3.64]) were associated with worse OS. CONCLUSIONS PD-L1, TcellinfGEP score, and SOX2 are prognostic of outcome from the mCRPC setting. If validated, predictive biomarker studies incorporating survival endpoints need to take these findings into consideration. PATIENT SUMMARY This study presents an analysis of immune biomarkers in biopsies from patients with metastatic prostate cancer. We describe tumor alterations that predict prognosis that can impact future studies.
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Affiliation(s)
| | - Khobe Chandran
- The Institute of Cancer Research, London, UK; The Royal Marsden Hospital, London, UK
| | | | | | - Bora Gurel
- The Institute of Cancer Research, London, UK
| | - Emily Cross
- The Institute of Cancer Research, London, UK
| | | | - Wei Yuan
- The Institute of Cancer Research, London, UK
| | - Daniel Westaby
- The Institute of Cancer Research, London, UK; The Royal Marsden Hospital, London, UK
| | - Susana Miranda
- The Institute of Cancer Research, London, UK; The Royal Marsden Hospital, London, UK
| | | | - George Seed
- The Institute of Cancer Research, London, UK
| | | | | | | | | | | | - Adam Sharp
- The Institute of Cancer Research, London, UK; The Royal Marsden Hospital, London, UK
| | | | | | - Nina Tunariu
- The Institute of Cancer Research, London, UK; The Royal Marsden Hospital, London, UK
| | | | | | | | | | - Johann S de Bono
- The Institute of Cancer Research, London, UK; The Royal Marsden Hospital, London, UK.
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Pal A, Daly R, Mohamedkhan S, Grochot R, Stapleton S, Yap C, Magkos D, Baikady BR, Minchom A, Banerji U, De Bono J, Karikios D, Boyle F, Lopez J. CONSENT - A Randomised Controlled Trial of Enhanced Informed Consent Compared to Standard Informed Consent to Improve Patient Understanding of Early Phase Oncology Clinical Trials – GBM Cohort (Nonrandomised) Analysis. Neuro Oncol 2022. [DOI: 10.1093/neuonc/noac200.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
AIMS
Early phase cancer clinical trials have become more complicated and patients often misunderstand their nature and purpose. CONSENT (NCT04407676) is a randomised controlled trial testing whether enhanced informed consent for patient education can improve comprehension – since patients with glioblastoma multiforme (GBM) have a higher rate of baseline cognitive impairment, we studied this group separately.
METHOD
GBM patients (from the ICE-CAP Phase 1 study - NCT03673787), underwent the schedule for the standard CONSENT arm - full length trial PIS, Quality of Informed Consent Questionnaire Parts A and B (QuIC-A and QuIC-B), experimental intervention (2 page study aid and 10 educational videos), and a repeat QuIC-A and QuIC-B. The primary endpoint for this subgroup was the difference in QuIC-A scores before and after the intervention using a paired t-test.
RESULTS
6 patients with GBM were recruited - 3 did not complete any study questionnaires. The three pre intervention QuIC-A scores were 70, 81, 88, with a mean of 75 (unit reference 76). The three pre intervention QuIC-B scores were 69, 62, 75 with a mean of 69 (unit reference is 91). Only one patient completed the post intervention questionnaire - their QuIC-A score moved from 88 to 100.
CONCLUSION
This study demonstrates the significant difficulties in studying comprehension in patients with GBM considering early phase trials. There is a need for creative multi-modality solutions to provide information to GBM patients considering clinical trials, and novel tools to assess the effectiveness of these solutions.
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Affiliation(s)
- Abhijit Pal
- Drug Development Unit, Royal Marsden Hospital , Sutton
| | - Robert Daly
- Drug Development Unit, Royal Marsden Hospital , Sutton
| | | | | | | | - Christina Yap
- Drug Development Unit, Royal Marsden Hospital , Sutton
| | | | | | - Anna Minchom
- Drug Development Unit, Royal Marsden Hospital , Sutton
| | - Udai Banerji
- Drug Development Unit, Royal Marsden Hospital , Sutton
| | | | | | | | - Juanita Lopez
- Drug Development Unit, Royal Marsden Hospital , Sutton
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26
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Williamson SF, Grayling MJ, Mander AP, Noor NM, Savage JS, Yap C, Wason JMS. Subgroup analyses in randomized controlled trials frequently categorized continuous subgroup information. J Clin Epidemiol 2022; 150:72-79. [PMID: 35788399 DOI: 10.1016/j.jclinepi.2022.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/15/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND OBJECTIVES To investigate how subgroup analyses of published Randomized Controlled Trials (RCTs) are performed when subgroups are created from continuous variables. METHODS We carried out a review of RCTs published in 2016-2021 that included subgroup analyses. Information was extracted on whether any of the subgroups were based on continuous variables and, if so, how they were analyzed. RESULTS Out of 428 reviewed papers, 258 (60.4%) reported RCTs with a subgroup analysis. Of these, 178/258 (69%) had at least one subgroup formed from a continuous variable and 14/258 (5.4%) were unclear. The vast majority (169/178, 94.9%) dichotomized the continuous variable and treated the subgroup as categorical. The most common way of dichotomizing was using a pre-specified cutpoint (129/169, 76.3%), followed by a data-driven cutpoint (26/169, 15.4%), such as the median. CONCLUSION It is common for subgroup analyses to use continuous variables to define subgroups. The vast majority dichotomize the continuous variable and, consequently, may lose substantial amounts of statistical information (equivalent to reducing the sample size by at least a third). More advanced methods that can improve efficiency, through optimally choosing cutpoints or directly using the continuous information, are rarely used.
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Affiliation(s)
- S Faye Williamson
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Michael J Grayling
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Nurulamin M Noor
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), London, UK
| | - Joshua S Savage
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Christina Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - James M S Wason
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.
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27
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Suls JM, Alfano C, Yap C. Personalized (N-of-1) Trials for Patient-Centered Treatments of Multimorbidity. Harv Data Sci Rev 2022; 4:10.1162/99608f92.d99e6ff5. [PMID: 38009131 PMCID: PMC10673634 DOI: 10.1162/99608f92.d99e6ff5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023] Open
Abstract
Treatment of patients who suffer from concurrent health conditions is not well served by (1) evidence-based clinical guidelines that mainly specify treatment of single conditions and (2) conventional randomized controlled trials (RCTs) that identify treatments as safe and effective on average. Clinical decision-making based on the average patient effect may be inappropriate for treatment of those with multimorbidity who experience burdens and obstacles that may be unique to their personal situation. We describe how the personalized (N-of-1) trials can be integrated with an automatic platform and virtual/remote technologies to improve patient-centered care for those living with multimorbidity. To illustrate, we present a hypothetical clinical scenario-survivors of both coronavirus disease 2019 (COVID-19) and cancer who chronically suffer from sleeplessness and fatigue. Then, we will describe how the four standard phases of conventional RCT development can be modified for personalized trials and applied to the multimorbidity clinical scenario, outline how personalized trials can be adapted and extended to compare the benefits of personalized trials versus between-subject trial design, and explain how personalized trials can address special problems associated with multimorbidity for which conventional trials are poorly suited.
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Affiliation(s)
- Jerry M Suls
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health; Manhasset, NY, USA
| | - Catherine Alfano
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health; Manhasset, NY, USA
- Northwell Health Cancer Institute; Manhasset, NY, USA
| | - Christina Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research; London, UK
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28
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Love SB, Cafferty F, Snowdon C, Carty K, Savage J, Pallmann P, McParland L, Brown L, Masters L, Schiavone F, Hague D, Townsend S, Amos C, South A, Sturgeon K, Langley R, Maughan T, James N, Hall E, Kernaghan S, Bliss J, Turner N, Tutt A, Yap C, Firth C, Kong A, Mehanna H, Watts C, Hills R, Thomas I, Copland M, Bell S, Sebag-Montefiore D, Jones R, Parmar MKB, Sydes MR. Practical guidance for running late-phase platform protocols for clinical trials: lessons from experienced UK clinical trials units. Trials 2022; 23:757. [PMID: 36068599 PMCID: PMC9449272 DOI: 10.1186/s13063-022-06680-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 08/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Late-phase platform protocols (including basket, umbrella, multi-arm multi-stage (MAMS), and master protocols) are generally agreed to be more efficient than traditional two-arm clinical trial designs but are not extensively used. We have gathered the experience of running a number of successful platform protocols together to present some operational recommendations. METHODS Representatives of six UK clinical trials units with experience in running late-phase platform protocols attended a 1-day meeting structured to discuss various practical aspects of running these trials. We report and give guidance on operational aspects which are either harder to implement compared to a traditional late-phase trial or are specific to platform protocols. RESULTS We present a list of practical recommendations for trialists intending to design and conduct late-phase platform protocols. Our recommendations cover the entire life cycle of a platform trial: from protocol development, obtaining funding, and trial set-up, to a wide range of operational and regulatory aspects such as staffing, oversight, data handling, and data management, to the reporting of results, with a particular focus on communication with trial participants and stakeholders as well as public and patient involvement. DISCUSSION Platform protocols enable many questions to be answered efficiently to the benefit of patients. Our practical lessons from running platform trials will support trial teams in learning how to run these trials more effectively and efficiently.
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Affiliation(s)
- Sharon B. Love
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Fay Cafferty
- The Institute of Cancer Research, London, SW7 3RP UK
| | | | - Karen Carty
- Cancer Research UK Clinical Trials Unit, Level 0 The Beatson West of Scotland Cancer Centre, 1053 Great Western Road, Glasgow, G12 0YN UK
| | - Joshua Savage
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
| | - Philip Pallmann
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | | | - Louise Brown
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Lindsey Masters
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | | | - Dominic Hague
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Stephen Townsend
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Claire Amos
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Annabelle South
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Kate Sturgeon
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Ruth Langley
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | | | | | - Emma Hall
- The Institute of Cancer Research, London, SW7 3RP UK
| | | | - Judith Bliss
- The Institute of Cancer Research, London, SW7 3RP UK
| | - Nick Turner
- The Institute of Cancer Research, London, SW7 3RP UK
| | - Andrew Tutt
- The Institute of Cancer Research, London, SW3 6JB UK
| | - Christina Yap
- The Institute of Cancer Research, London, SW7 3RP UK
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - Charlotte Firth
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - Anthony Kong
- Comprehensive Cancer Centre, King’s College London, Guy’s Campus, New Hunt’s House, Room 2.36b, London, SE1 1UL UK
| | - Hisham Mehanna
- Institute for Head and Neck Studies and Education, University of Birmingham, Birmingham, B15 2TT UK
| | - Colin Watts
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - Robert Hills
- Doll Building, CTSU, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF UK
| | - Ian Thomas
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park Way, Cardiff, CF14 4YS UK
| | - Mhairi Copland
- Paul O’Gorman Research Centre, Gartnavel General Hospital, Glasgow, G12 0YN UK
| | - Sue Bell
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | | | - Robert Jones
- Beatson West of Scotland Cancer Centre, Glasgow, UK
| | | | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
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de Bono J, Lord S, Yap C, Rowinsky E, Gandhi N, Thakkar D, Ingram P, Padmanabhan N, Chandran K, Paschalis A, McGuigan L, Neal P, Paisley D, Walter H, Kelly F, Craigan J, Westwood N, Halbert G, Boyd-Kirkup J, Halford S. 493TiP A CRUK phase I/IIA, first in human dose-escalation and expansion trial of HMBD-001 (an anti-HER-3 antibody) in patients with advanced HER3-positive solid tumours. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.07.621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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30
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Wason JMS, Dimairo M, Biggs K, Bowden S, Brown J, Flight L, Hall J, Jaki T, Lowe R, Pallmann P, Pilling MA, Snowdon C, Sydes MR, Villar SS, Weir CJ, Wilson N, Yap C, Hancock H, Maier R. Practical guidance for planning resources required to support publicly-funded adaptive clinical trials. BMC Med 2022; 20:254. [PMID: 35945610 PMCID: PMC9364623 DOI: 10.1186/s12916-022-02445-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/20/2022] [Indexed: 11/15/2022] Open
Abstract
Adaptive designs are a class of methods for improving efficiency and patient benefit of clinical trials. Although their use has increased in recent years, research suggests they are not used in many situations where they have potential to bring benefit. One barrier to their more widespread use is a lack of understanding about how the choice to use an adaptive design, rather than a traditional design, affects resources (staff and non-staff) required to set-up, conduct and report a trial. The Costing Adaptive Trials project investigated this issue using quantitative and qualitative research amongst UK Clinical Trials Units. Here, we present guidance that is informed by our research, on considering the appropriate resourcing of adaptive trials. We outline a five-step process to estimate the resources required and provide an accompanying costing tool. The process involves understanding the tasks required to undertake a trial, and how the adaptive design affects them. We identify barriers in the publicly funded landscape and provide recommendations to trial funders that would address them. Although our guidance and recommendations are most relevant to UK non-commercial trials, many aspects are relevant more widely.
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Affiliation(s)
- James M S Wason
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.
| | - Munyaradzi Dimairo
- School of Health and Related Research, Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Katie Biggs
- School of Health and Related Research, Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Sarah Bowden
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - Julia Brown
- Cancer Research UK CTU, University of Leeds, Leeds, UK
| | - Laura Flight
- School of Health and Related Research, Health Economics and Decision Science, University of Sheffield, Sheffield, UK
| | - Jamie Hall
- School of Health and Related Research, Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Thomas Jaki
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Rachel Lowe
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Mark A Pilling
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Claire Snowdon
- The Institute of Cancer Research Clinical Trials & Statistics Unit, London, UK
| | | | - Sofía S Villar
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Nina Wilson
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christina Yap
- The Institute of Cancer Research Clinical Trials & Statistics Unit, London, UK
| | - Helen Hancock
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Maier
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
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31
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Kouli O, Murray V, Bhatia S, Cambridge WA, Kawka M, Shafi S, Knight SR, Kamarajah SK, McLean KA, Glasbey JC, Khaw RA, Ahmed W, Akhbari M, Baker D, Borakati A, Mills E, Thavayogan R, Yasin I, Raubenheimer K, Ridley W, Sarrami M, Zhang G, Egoroff N, Pockney P, Richards T, Bhangu A, Creagh-Brown B, Edwards M, Harrison EM, Lee M, Nepogodiev D, Pinkney T, Pearse R, Smart N, Vohra R, Sohrabi C, Jamieson A, Nguyen M, Rahman A, English C, Tincknell L, Kakodkar P, Kwek I, Punjabi N, Burns J, Varghese S, Erotocritou M, McGuckin S, Vayalapra S, Dominguez E, Moneim J, Salehi M, Tan HL, Yoong A, Zhu L, Seale B, Nowinka Z, Patel N, Chrisp B, Harris J, Maleyko I, Muneeb F, Gough M, James CE, Skan O, Chowdhury A, Rebuffa N, Khan H, Down B, Fatimah Hussain Q, Adams M, Bailey A, Cullen G, Fu YXJ, McClement B, Taylor A, Aitken S, Bachelet B, Brousse de Gersigny J, Chang C, Khehra B, Lahoud N, Lee Solano M, Louca M, Rozenbroek P, Rozitis E, Agbinya N, Anderson E, Arwi G, Barry I, Batchelor C, Chong T, Choo LY, Clark L, Daniels M, Goh J, Handa A, Hanna J, Huynh L, Jeon A, Kanbour A, Lee A, Lee J, Lee T, Leigh J, Ly D, McGregor F, Moss J, Nejatian M, O'Loughlin E, Ramos I, Sanchez B, Shrivathsa A, Sincari A, Sobhi S, Swart R, Trimboli J, Wignall P, Bourke E, Chong A, Clayton S, Dawson A, Hardy E, Iqbal R, Le L, Mao S, Marinelli I, Metcalfe H, Panicker D, R HH, Ridgway S, Tan HH, Thong S, Van M, Woon S, Woon-Shoo-Tong XS, Yu S, Ali K, Chee J, Chiu C, Chow YW, Duller A, Nagappan P, Ng S, Selvanathan M, Sheridan C, Temple M, Do JE, Dudi-Venkata NN, Humphries E, Li L, Mansour LT, Massy-Westropp C, Fang B, Farbood K, Hong H, Huang Y, Joan M, Koh C, Liu YHA, Mahajan T, Muller E, Park R, Tanudisastro M, Wu JJG, Chopra P, Giang S, Radcliffe S, Thach P, Wallace D, Wilkes A, Chinta SH, Li J, Phan J, Rahman F, Segaran A, Shannon J, Zhang M, Adams N, Bonte A, Choudhry A, Colterjohn N, Croyle JA, Donohue J, Feighery A, Keane A, McNamara D, Munir K, Roche D, Sabnani R, Seligman D, Sharma S, Stickney Z, Suchy H, Tan R, Yordi S, Ahmed I, Aranha M, El Sabawy D, Garwood P, Harnett M, Holohan R, Howard R, Kayyal Y, Krakoski N, Lupo M, McGilberry W, Nepon H, Scoleri Y, Urbina C, Ahmad Fuad MF, Ahmed O, Jaswantlal D, Kelly E, Khan MHT, Naidu D, Neo WX, O'Neill R, Sugrue M, Abbas JD, Abdul-Fattah S, Azlan A, Barry K, Idris NS, Kaka N, Mc Dermott D, Mohammad Nasir MN, Mozo M, Rehal A, Shaikh Yousef M, Wong RH, Curran E, Gardner M, Hogan A, Julka R, Lasser G, Ní Chorráin N, Ting J, Browne R, George S, Janjua Z, Leung Shing V, Megally M, Murphy S, Ravenscroft L, Vedadi A, Vyas V, Bryan A, Sheikh A, Ubhi J, Vannelli K, Vawda A, Adeusi L, Doherty C, Fitzgerald C, Gallagher H, Gill P, Hamza H, Hogan M, Kelly S, Larry J, Lynch P, Mazeni NA, O'Connell R, O'Loghlin R, Singh K, Abbas Syed R, Ali A, Alkandari B, Arnold A, Arora E, Azam R, Breathnach C, Cheema J, Compton M, Curran S, Elliott JA, Jayasamraj O, Mohammed N, Noone A, Pal A, Pandey S, Quinn P, Sheridan R, Siew L, Tan EP, Tio SW, Toh VTR, Walsh M, Yap C, Yassa J, Young T, Agarwal N, Almoosawy SA, Bowen K, Bruce D, Connachan R, Cook A, Daniell A, Elliott M, Fung HKF, Irving A, Laurie S, Lee YJ, Lim ZX, Maddineni S, McClenaghan RE, Muthuganesan V, Ravichandran P, Roberts N, Shaji S, Solt S, Toshney E, Arnold C, Baker O, Belais F, Bojanic C, Byrne M, Chau CYC, De Soysa S, Eldridge M, Fairey M, Fearnhead N, Guéroult A, Ho JSY, Joshi K, Kadiyala N, Khalid S, Khan F, Kumar K, Lewis E, Magee J, Manetta-Jones D, Mann S, McKeown L, Mitrofan C, Mohamed T, Monnickendam A, Ng AYKC, Ortu A, Patel M, Pope T, Pressling S, Purohit K, Saji S, Shah Foridi J, Shah R, Siddiqui SS, Surman K, Utukuri M, Varghese A, Williams CYK, Yang JJ, Billson E, Cheah E, Holmes P, Hussain S, Murdock D, Nicholls A, Patel P, Ramana G, Saleki M, Spence H, Thomas D, Yu C, Abousamra M, Brown C, Conti I, Donnelly A, Durand M, French N, Goan R, O'Kane E, Rubinchik P, Gardiner H, Kempf B, Lai YL, Matthews H, Minford E, Rafferty C, Reid C, Sheridan N, Al Bahri T, Bhoombla N, Rao BM, Titu L, Chatha S, Field C, Gandhi T, Gulati R, Jha R, Jones Sam MT, Karim S, Patel R, Saunders M, Sharma K, Abid S, Heath E, Kurup D, Patel A, Ali M, Cresswell B, Felstead D, Jennings K, Kaluarachchi T, Lazzereschi L, Mayson H, Miah JE, Reinders B, Rosser A, Thomas C, Williams H, Al-Hamid Z, Alsadoun L, Chlubek M, Fernando P, Gaunt E, Gercek Y, Maniar R, Ma R, Matson M, Moore S, Morris A, Nagappan PG, Ratnayake M, Rockall L, Shallcross O, Sinha A, Tan KE, Virdee S, Wenlock R, Donnelly HA, Ghazal R, Hughes I, Liu X, McFadden M, Misbert E, Mogey P, O'Hara A, Peace C, Rainey C, Raja P, Salem M, Salmon J, Tan CH, Alves D, Bahl S, Baker C, Coulthurst J, Koysombat K, Linn T, Rai P, Sharma A, Shergill A, Ahmed M, Ahmed S, Belk LH, Choudhry H, Cummings D, Dixon Y, Dobinson C, Edwards J, Flint J, Franco Da Silva C, Gallie R, Gardener M, Glover T, Greasley M, Hatab A, Howells R, Hussey T, Khan A, Mann A, Morrison H, Ng A, Osmond R, Padmakumar N, Pervaiz F, Prince R, Qureshi A, Sawhney R, Sigurdson B, Stephenson L, Vora K, Zacken A, Cope P, Di Traglia R, Ferarrio I, Hackett N, Healicon R, Horseman L, Lam LI, Meerdink M, Menham D, Murphy R, Nimmo I, Ramaesh A, Rees J, Soame R, Dilaver N, Adebambo D, Brown E, Burt J, Foster K, Kaliyappan L, Knight P, Politis A, Richardson E, Townsend J, Abdi M, Ball M, Easby S, Gill N, Ho E, Iqbal H, Matthews M, Nubi S, Nwokocha JO, Okafor I, Perry G, Sinartio B, Vanukuru N, Walkley D, Welch T, Yates J, Yeshitila N, Bryans K, Campbell B, Gray C, Keys R, Macartney M, Chamberlain G, Khatri A, Kucheria A, Lee STP, Reese G, Roy choudhury J, Tan WYR, Teh JJ, Ting A, Kazi S, Kontovounisios C, Vutipongsatorn K, Amarnath T, Balasubramanian N, Bassett E, Gurung P, Lim J, Panjikkaran A, Sanalla A, Alkoot M, Bacigalupo V, Eardley N, Horton M, Hurry A, Isti C, Maskell P, Nursiah K, Punn G, Salih H, Epanomeritakis E, Foulkes A, Henderson R, Johnston E, McCullough H, McLarnon M, Morrison E, Cheung A, Cho SH, Eriksson F, Hedges J, Low Z, May C, Musto L, Nagi S, Nur S, Salau E, Shabbir S, Thomas MC, Uthayanan L, Vig S, Zaheer M, Zeng G, Ashcroft-Quinn S, Brown R, Hayes J, McConville R, French R, Gilliam A, Sheetal S, Shehzad MU, Bani W, Christie I, Franklyn J, Khan M, Russell J, Smolarek S, Varadarassou R, Ahmed SK, Narayanaswamy S, Sealy J, Shah M, Dodhia V, Manukyan A, O'Hare R, Orbell J, Chung I, Forenc K, Gupta A, Agarwal A, Al Dabbagh A, Bennewith R, Bottomley J, Chu TSM, Chu YYA, Doherty W, Evans B, Hainsworth P, Hosfield T, Li CH, McCullagh I, Mehta A, Thaker A, Thompson B, Virdi A, Walker H, Wilkins E, Dixon C, Hassan MR, Lotca N, Tong KS, Batchelor-Parry H, Chaudhari S, Harris T, Hooper J, Johnson C, Mulvihill C, Nayler J, Olutobi O, Piramanayagam B, Stones K, Sussman M, Weaver C, Alam F, Al Rawi M, Andrew F, Arrayeh A, Azizan N, Hassan A, Iqbal Z, John I, Jones M, Kalake O, Keast M, Nicholas J, Patil A, Powell K, Roberts P, Sabri A, Segue AK, Shah A, Shaik Mohamed SA, Shehadeh A, Shenoy S, Tong A, Upcott M, Vijayasingam D, Anarfi S, Dauncey J, Devindaran A, Havalda P, Komninos G, Mwendwa E, Norman C, Richards J, Urquhart A, Allan J, Cahya E, Hunt H, McWhirter C, Norton R, Roxburgh C, Tan JY, Ali Butt S, Hansdot S, Haq I, Mootien A, Sanchez I, Vainas T, Deliyannis E, Tan M, Vipond M, Chittoor Satish NN, Dattani A, De Carvalho L, Gaston-Grubb M, Karunanithy L, Lowe B, Pace C, Raju K, Roope J, Taylor C, Youssef H, Munro T, Thorn C, Wong KHF, Yunus A, Chawla S, Datta A, Dinesh AA, Field D, Georgi T, Gwozdz A, Hamstead E, Howard N, Isleyen N, Jackson N, Kingdon J, Sagoo KS, Schizas A, Yin L, Aung E, Aung YY, Franklin S, Han SM, Kim WC, Martin Segura A, Rossi M, Ross T, Tirimanna R, Wang B, Zakieh O, Ben-Arzi H, Flach A, Jackson E, Magers S, Olu abara C, Rogers E, Sugden K, Tan H, Veliah S, Walton U, Asif A, Bharwada Y, Bowley D, Broekhuizen A, Cooper L, Evans N, Girdlestone H, Ling C, Mann H, Mehmood N, Mulvenna CL, Rainer N, Trout I, Gujjuri R, Jeyaraman D, Leong E, Singh D, Smith E, Anderton J, Barabas M, Goyal S, Howard D, Joshi A, Mitchell D, Weatherby T, Badminton R, Bird R, Burtle D, Choi NY, Devalia K, Farr E, Fischer F, Fish J, Gunn F, Jacobs D, Johnston P, Kalakoutas A, Lau E, Loo YNAF, Louden H, Makariou N, Mohammadi K, Nayab Y, Ruhomaun S, Ryliskyte R, Saeed M, Shinde P, Sudul M, Theodoropoulou K, Valadao-Spoorenberg J, Vlachou F, Arshad SR, Janmohamed AM, Noor M, Oyerinde O, Saha A, Syed Y, Watkinson W, Ahmadi H, Akintunde A, Alsaady A, Bradley J, Brothwood D, Burton M, Higgs M, Hoyle C, Katsura C, Lathan R, Louani A, Mandalia R, Prihartadi AS, Qaddoura B, Sandland-Taylor L, Thadani S, Thompson A, Walshaw J, Teo S, Ali S, Bawa JH, Fox S, Gargan K, Haider SA, Hanna N, Hatoum A, Khan Z, Krzak AM, Li T, Pitt J, Tan GJS, Ullah Z, Wilson E, Cleaver J, Colman J, Copeland L, Coulson A, Davis P, Faisal H, Hassan F, Hughes JT, Jabr Y, Mahmoud Ali F, Nahaboo Solim ZN, Sangheli A, Shaya S, Thompson R, Cornwall H, De Andres Crespo M, Fay E, Findlay J, Groves E, Jones O, Killen A, Millo J, Thomas S, Ward J, Wilkins M, Zaki F, Zilber E, Bhavra K, Bilolikar A, Charalambous M, Elawad A, Eleni A, Fawdon R, Gibbins A, Livingstone D, Mala D, Oke SE, Padmakumar D, Patsalides MA, Payne D, Ralphs C, Roney A, Sardar N, Stefanova K, Surti F, Timms R, Tosney G, Bannister J, Clement NS, Cullimore V, Kamal F, Lendor J, McKay J, Mcswiggan J, Minhas N, Seneviratne K, Simeen S, Valverde J, Watson N, Bloom I, Dinh TH, Hirniak J, Joseph R, Kansagra M, Lai CKN, Melamed N, Patel J, Randev J, Sedighi T, Shurovi B, Sodhi J, Vadgama N, Abdulla S, Adabavazeh B, Champion A, Chennupati R, Chu K, Devi S, Haji A, Schulz J, Testa F, Davies P, Gurung B, Howell S, Modi P, Pervaiz A, Zahid M, Abdolrazaghi S, Abi Aoun R, Anjum Z, Bawa G, Bhardwaj R, Brown S, Enver M, Gill D, Gopikrishna D, Gurung D, Kanwal A, Kaushal P, Khanna A, Lovell E, McEvoy C, Mirza M, Nabeel S, Naseem S, Pandya K, Perkins R, Pulakal R, Ray M, Reay C, Reilly S, Round A, Seehra J, Shakeel NM, Singh B, Vijay Sukhnani M, Brown L, Desai B, Elzanati H, Godhaniya J, Kavanagh E, Kent J, Kishor A, Liu A, Norwood M, Shaari N, Wood C, Wood M, Brown A, Chellapuri A, Ferriman A, Ghosh I, Kulkarni N, Noton T, Pinto A, Rajesh S, Varghese B, Wenban C, Aly R, Barciela C, Brookes T, Corrin E, Goldsworthy M, Mohamed Azhar MS, Moore J, Nakhuda S, Ng D, Pillay S, Port S, Abdullah M, Akinyemi J, Islam S, Kale A, Lewis A, Manjunath T, McCabe H, Misra S, Stubley T, Tam JP, Waraich N, Chaora T, Ford C, Osinkolu I, Pong G, Rai J, Risquet R, Ainsworth J, Ayandokun P, Barham E, Barrett G, Barry J, Bisson E, Bridges I, Burke D, Cann J, Cloney M, Coates S, Cripps P, Davies C, Francis N, Green S, Handley G, Hathaway D, Hurt L, Jenkins S, Johnston C, Khadka A, McGee U, Morris D, Murray R, Norbury C, Pierrepont Z, Richards C, Ross O, Ruddy A, Salmon C, Shield M, Soanes K, Spencer N, Taverner S, Williams C, Wills-Wood W, Woodward S, Chow J, Fan J, Guest O, Hunter I, Moon WY, Arthur-Quarm S, Edwards P, Hamlyn V, McEneaney L, N D G, Pranoy S, Ting M, Abada S, Alawattegama LH, Ashok A, Carey C, Gogna A, Haglund C, Hurley P, Leelo N, Liu B, Mannan F, Paramjothy K, Ramlogan K, Raymond-Hayling O, Shanmugarajah A, Solichan D, Wilkinson B, Ahmad NA, Allan D, Amin A, Bakina C, Burns F, Cameron F, Campbell A, Cavanagh S, Chan SMZ, Chapman S, Chong V, Edelsten E, Ekpete O, El Sheikh M, Ghose R, Hassane A, Henderson C, Hilton-Christie S, Husain M, Hussain H, Javid Z, Johnson-Ogbuneke J, Johnston A, Khalil M, Leung TCC, Makin I, Muralidharan V, Naeem M, Patil P, Ravichandran S, Saraeva D, Shankey-Smith W, Sharma N, Swan R, Waudby-West R, Wilkinson A, Wright K, Balasubramanian A, Bhatti S, Chalkley M, Chou WK, Dixon M, Evans L, Fisher K, Gandhi P, Ho S, Lau YB, Lowe S, Meechan C, Murali N, Musonda C, Njoku P, Ochieng L, Pervez MU, Seebah K, Shaikh I, Sikder MA, Vanker R, Alom J, Bajaj V, Coleman O, Finch G, Goss J, Jenkins C, Kontothanassis A, Liew MS, Ng K, Outram M, Shakeel MM, Tawn J, Zuhairy S, Chapple K, Cinnamond A, Coleman S, George HA, Goulder L, Hare N, Hawksley J, Kret A, Luesley A, Mecia L, Porter H, Puddy E, Richardson G, Sohail B, Srikaran V, Tadross D, Tobin J, Tokidis E, Young L, Ashdown T, Bratsos S, Koomson A, Kufuor A, Lim MQ, Shah S, Thorne EPC, Warusavitarne J, Xu S, Abigail S, Ahmed A, Ahmed J, Akmal A, Al-Khafaji M, Amini B, Arshad M, Bogie E, Brazkiewicz M, Carroll M, Chandegra A, Cirelli C, Deng A, Fairclough S, Fung YJ, Gornell C, Green RL, Green SV, Gulamhussein AHM, Isaac AG, Jan R, Jegatheeswaran L, Knee M, Kotecha J, Kotecha S, Maxwell-Armstrong C, McIntyre C, Mendis N, Naing TKP, Oberman J, Ong ZX, Ramalingam A, Saeed Adam A, Tan LL, Towell S, Yadav J, Anandampillai R, Chung S, Hounat A, Ibrahim B, Jeyakumar G, Khalil A, Khan UA, Nair G, Owusu-Ayim M, Wilson M, Kanani A, Kilkelly B, Ogunmwonyi I, Ong L, Samra B, Schomerus L, Shea J, Turner O, Yang Y, Amin M, Blott N, Clark A, Feather A, Forrest M, Hague S, Hamilton K, Higginbotham G, Hope E, Karimian S, Loveday K, Malik H, McKenna O, Noor A, Onsiong C, Patel B, Radcliffe N, Shah P, Tye L, Verma K, Walford R, Yusufi U, Zachariah M, Casey A, Doré C, Fludder V, Fortescue L, Kalapu SS, Karel E, Khera G, Smith C, Appleton B, Ashaye A, Boggon E, Evans A, Faris Mahmood H, Hinchcliffe Z, Marei O, Silva I, Spooner C, Thomas G, Timlin M, Wellington J, Yao SL, Abdelrazek M, Abdelrazik Y, Bee F, Joseph A, Mounce A, Parry G, Vignarajah N, Biddles D, Creissen A, Kolhe S, K T, Lea A, Ledda V, O'Loughlin P, Scanlon J, Shetty N, Weller C, Abdalla M, Adeoye A, Bhatti M, Chadda KR, Chu J, Elhakim H, Foster-Davies H, Rabie M, Tailor B, Webb S, Abdelrahim ASA, Choo SY, Jiwa A, Mangam S, Murray S, Shandramohan A, Aghanenu O, Budd W, Hayre J, Khanom S, Liew ZY, McKinney R, Moody N, Muhammad-Kamal H, Odogwu J, Patel D, Roy C, Sattar Z, Shahrokhi N, Sinha I, Thomson E, Wonga L, Bain J, Khan J, Ricardo D, Bevis R, Cherry C, Darkwa S, Drew W, Griffiths E, Konda N, Madani D, Mak JKC, Meda B, Odunukwe U, Preest G, Raheel F, Rajaseharan A, Ramgopal A, Risbrooke C, Selvaratnam K, Sethunath G, Tabassum R, Taylor J, Thakker A, Wijesingha N, Wybrew R, Yasin T, Ahmed Osman A, Alfadhel S, Carberry E, Chen JY, Drake I, Glen P, Jayasuriya N, Kawar L, Myatt R, Sinan LOH, Siu SSY, Tjen V, Adeboyejo O, Bacon H, Barnes R, Birnie C, D'Cunha Kamath A, Hughes E, Middleton S, Owen R, Schofield E, Short C, Smith R, Wang H, Willett M, Zimmerman M, Balfour J, Chadwick T, Coombe-Jones M, Do Le HP, Faulkner G, Hobson K, Shehata Z, Beattie M, Chmielewski G, Chong C, Donnelly B, Drusch B, Ellis J, Farrelly C, Feyi-Waboso J, Hibell I, Hoade L, Ho C, Jones H, Kodiatt B, Lidder P, Ni Cheallaigh L, Norman R, Patabendi I, Penfold H, Playfair M, Pomeroy S, Ralph C, Rottenburg H, Sebastian J, Sheehan M, Stanley V, Welchman J, Ajdarpasic D, Antypas A, Azouaghe O, Basi S, Bettoli G, Bhattarai S, Bommireddy L, Bourne K, Budding J, Cookey-Bresi R, Cummins T, Davies G, Fabelurin C, Gwilliam R, Hanley J, Hird A, Kruczynska A, Langhorne B, Lund J, Lutchman I, McGuinness R, Neary M, Pampapathi S, Pang E, Podbicanin S, Rai N, Redhouse White G, Sujith J, Thomas P, Walker I, Winterton R, Anderson P, Barrington M, Bhadra K, Clark G, Fowler G, Gibson C, Hudson S, Kaminskaite V, Lawday S, Longshaw A, MacKrill E, McLachlan F, Murdeshwar A, Nieuwoudt R, Parker P, Randall R, Rawlins E, Reeves SA, Rye D, Sirkis T, Sykes B, Ventress N, Wosinska N, Akram B, Burton L, Coombs A, Long R, Magowan D, Ong C, Sethi M, Williams G, Chan C, Chan LH, Fernando D, Gaba F, Khor Z, Les JW, Mak R, Moin S, Ng Kee Kwong KC, Paterson-Brown S, Tew YY, Bardon A, Burrell K, Coldwell C, Costa I, Dexter E, Hardy A, Khojani M, Mazurek J, Raymond T, Reddy V, Reynolds J, Soma A, Agiotakis S, Alsusa H, Desai N, Peristerakis I, Adcock A, Ayub H, Bennett T, Bibi F, Brenac S, Chapman T, Clarke G, Clark F, Galvin C, Gwyn-Jones A, Henry-Blake C, Kerner S, Kiandee M, Lovett A, Pilecka A, Ravindran R, Siddique H, Sikand T, Treadwell K, Akmal K, Apata A, Barton O, Broad G, Darling H, Dhuga Y, Emms L, Habib S, Jain R, Jeater J, Kan CYP, Kathiravelupillai A, Khatkar H, Kirmani S, Kulasabanathan K, Lacey H, Lal K, Manafa C, Mansoor M, McDonald S, Mittal A, Mustoe S, Nottrodt L, Oliver P, Papapetrou I, Pattinson F, Raja M, Reyhani H, Shahmiri A, Small O, Soni U, Aguirrezabala Armbruster B, Bunni J, Hakim MA, Hawkins-Hooker L, Howell KA, Hullait R, Jaskowska A, Ottewell L, Thomas-Jones I, Vasudev A, Clements B, Fenton J, Gill M, Haider S, Lim AJM, Maguire H, McMullan J, Nicoletti J, Samuel S, Unais MA, White N, Yao PC, Yow L, Boyle C, Brady R, Cheekoty P, Cheong J, Chew SJHL, Chow R, Ganewatta Kankanamge D, Mamer L, Mohammed B, Ng Chieng Hin J, Renji Chungath R, Royston A, Sharrad E, Sinclair R, Tingle S, Treherne K, Wyatt F, Maniarasu VS, Moug S, Appanna T, Bucknall T, Hussain F, Owen A, Parry M, Parry R, Sagua N, Spofforth K, Yuen ECT, Bosley N, Hardie W, Moore T, Regas C, Abdel-Khaleq S, Ali N, Bashiti H, Buxton-Hopley R, Constantinides M, D'Afflitto M, Deshpande A, Duque Golding J, Frisira E, Germani Batacchi M, Gomaa A, Hay D, Hutchison R, Iakovou A, Iakovou D, Ismail E, Jefferson S, Jones L, Khouli Y, Knowles C, Mason J, McCaughan R, Moffatt J, Morawala A, Nadir H, Neyroud F, Nikookam Y, Parmar A, Pinto L, Ramamoorthy R, Richards E, Thomson S, Trainer C, Valetopoulou A, Vassiliou A, Wantman A, Wilde S, Dickinson M, Rockall T, Senn D, Wcislo K, Zalmay P, Adelekan K, Allen K, Bajaj M, Gatumbu P, Hang S, Hashmi Y, Kaur T, Kawesha A, Kisiel A, Woodmass M, Adelowo T, Ahari D, Alhwaishel K, Atherton R, Clayton B, Cockroft A, Curtis Lopez C, Hilton M, Ismail N, Kouadria M, Lee L, MacConnachie A, Monks F, Mungroo S, Nikoletopoulou C, Pearce L, Sara X, Shahid A, Suresh G, Wilcha R, Atiyah A, Davies E, Dermanis A, Gibbons H, Hyde A, Lawson A, Lee C, Leung-Tack M, Li Saw Hee J, Mostafa O, Nair D, Pattani N, Plumbley-Jones J, Pufal K, Ramesh P, Sanghera J, Saram S, Scadding S, See S, Stringer H, Torrance A, Vardon H, Wyn-Griffiths F, Brew A, Kaur G, Soni D, Tickle A, Akbar Z, Appleyard T, Figg K, Jayawardena P, Johnson A, Kamran Siddiqui Z, Lacy-Colson J, Oatham R, Rowlands B, Sludden E, Turnbull C, Allin D, Ansar Z, Azeez Z, Dale VH, Garg J, Horner A, Jones S, Knight S, McGregor C, McKenna J, McLelland T, Packham-Smith A, Rowsell K, Spector-Hill I, Adeniken E, Baker J, Bartlett M, Chikomba L, Connell B, Deekonda P, Dhar M, Elmansouri A, Gamage K, Goodhew R, Hanna P, Knight J, Luca A, Maasoumi N, Mahamoud F, Manji S, Marwaha PK, Mason F, Oluboyede A, Pigott L, Razaq AM, Richardson M, Saddaoui I, Wijeyendram P, Yau S, Atkins W, Liang K, Miles N, Praveen B, Ashai S, Braganza J, Common J, Cundy A, Davies R, Guthrie J, Handa I, Iqbal M, Ismail R, Jones C, Jones I, Lee KS, Levene A, Okocha M, Olivier J, Smith A, Subramaniam E, Tandle S, Wang A, Watson A, Wilson C, Chan XHF, Khoo E, Montgomery C, Norris M, Pugalenthi PP, Common T, Cook E, Mistry H, Shinmar HS, Agarwal G, Bandyopadhyay S, Brazier B, Carroll L, Goede A, Harbourne A, Lakhani A, Lami M, Larwood J, Martin J, Merchant J, Pattenden S, Pradhan A, Raafat N, Rothwell E, Shammoon Y, Sudarshan R, Vickers E, Wingfield L, Ashworth I, Azizi S, Bhate R, Chowdhury T, Christou A, Davies L, Dwaraknath M, Farah Y, Garner J, Gureviciute E, Hart E, Jain A, Javid S, Kankam HK, Kaur Toor P, Kaz R, Kermali M, Khan I, Mattson A, McManus A, Murphy M, Nair K, Ngemoh D, Norton E, Olabiran A, Parry L, Payne T, Pillai K, Price S, Punjabi K, Raghunathan A, Ramwell A, Raza M, Ritehnia J, Simpson G, Smith W, Sodeinde S, Studd L, Subramaniam M, Thomas J, Towey S, Tsang E, Tuteja D, Vasani J, Vio M, Badran A, Adams J, Anthony Wilkinson J, Asvandi S, Austin T, Bald A, Bix E, Carrick M, Chander B, Chowdhury S, Cooper Drake B, Crosbie S, D Portela S, Francis D, Gallagher C, Gillespie R, Gravett H, Gupta P, Ilyas C, James G, Johny J, Jones A, Kinder F, MacLeod C, Macrow C, Maqsood-Shah A, Mather J, McCann L, McMahon R, Mitham E, Mohamed M, Munton E, Nightingale K, O'Neill K, Onyemuchara I, Senior R, Shanahan A, Sherlock J, Spyridoulias A, Stavrou C, Stokes D, Tamang R, Taylor E, Trafford C, Uden C, Waddington C, Yassin D, Zaman M, Bangi S, Cheng T, Chew D, Hussain N, Imani-Masouleh S, Mahasivam G, McKnight G, Ng HL, Ota HC, Pasha T, Ravindran W, Shah K, Vishnu K S, Zaman S, Carr W, Cope S, Eagles EJ, Howarth-Maddison M, Li CY, Reed J, Ridge A, Stubbs T, Teasdaled D, Umar R, Worthington J, Dhebri A, Kalenderov R, Alattas A, Arain Z, Bhudia R, Chia D, Daniel S, Dar T, Garland H, Girish M, Hampson A, Kyriacou H, Lehovsky K, Mullins W, Omorphos N, Vasdev N, Venkatesh A, Waldock W, Bhandari A, Brown G, Choa G, Eichenauer CE, Ezennia K, Kidwai Z, Lloyd-Thomas A, Macaskill Stewart A, Massardi C, Sinclair E, Skajaa N, Smith M, Tan I, Afsheen N, Anuar A, Azam Z, Bhatia P, Davies-kelly N, Dickinson S, Elkawafi M, Ganapathy M, Gupta S, Khoury EG, Licudi D, Mehta V, Neequaye S, Nita G, Tay VL, Zhao S, Botsa E, Cuthbert H, Elliott J, Furlepa M, Lehmann J, Mangtani A, Narayan A, Nazarian S, Parmar C, Shah D, Shaw C, Zhao Z, Beck C, Caldwell S, Clements JM, French B, Kenny R, Kirk S, Lindsay J, McClung A, McLaughlin N, Watson S, Whiteside E, Alyacoubi S, Arumugam V, Beg R, Dawas K, Garg S, Lloyd ER, Mahfouz Y, Manobharath N, Moonesinghe R, Morka N, Patel K, Prashar J, Yip S, Adeeko ES, Ajekigbe F, Bhat A, Evans C, Farrugia A, Gurung C, Long T, Malik B, Manirajan S, Newport D, Rayer J, Ridha A, Ross E, Saran T, Sinker A, Waruingi D, Allen R, Al Sadek Y, Alves do Canto Brum H, Asharaf H, Ashman M, Balakumar V, Barrington J, Baskaran R, Berry A, Bhachoo H, Bilal A, Boaden L, Chia WL, Covell G, Crook D, Dadnam F, Davis L, De Berker H, Doyle C, Fox C, Gruffydd-Davies M, Hafouda Y, Hill A, Hubbard E, Hunter A, Inpadhas V, Jamshaid M, Jandu G, Jeyanthi M, Jones T, Kantor C, Kwak SY, Malik N, Matt R, McNulty P, Miles C, Mohomed A, Myat P, Niharika J, Nixon A, O'Reilly D, Parmar K, Pengelly S, Price L, Ramsden M, Turnor R, Wales E, Waring H, Wu M, Yang T, Ye TTS, Zander A, Zeicu C, Bellam S, Francombe J, Kawamoto N, Rahman MR, Sathyanarayana A, Tang HT, Cheung J, Hollingshead J, Page V, Sugarman J, Wong E, Chiong J, Fung E, Kan SY, Kiang J, Kok J, Krahelski O, Liew MY, Lyell B, Sharif Z, Speake D, Alim L, Amakye NY, Chandrasekaran J, Chandratreya N, Drake J, Owoso T, Thu YM, Abou El Ela Bourquin B, Alberts J, Chapman D, Rehnnuma N, Ainsworth K, Carpenter H, Emmanuel T, Fisher T, Gabrel M, Guan Z, Hollows S, Hotouras A, Ip Fung Chun N, Jaffer S, Kallikas G, Kennedy N, Lewinsohn B, Liu FY, Mohammed S, Rutherfurd A, Situ T, Stammer A, Taylor F, Thin N, Urgesi E, Zhang N, Ahmad MA, Bishop A, Bowes A, Dixit A, Glasson R, Hatta S, Hatt K, Larcombe S, Preece J, Riordan E, Fegredo D, Haq MZ, Li C, McCann G, Stewart D, Baraza W, Bhullar D, Burt G, Coyle J, Deans J, Devine A, Hird R, Ikotun O, Manchip G, Ross C, Storey L, Tan WWL, Tse C, Warner C, Whitehead M, Wu F, Court EL, Crisp E, Huttman M, Mayes F, Robertson H, Rosen H, Sandberg C, Smith H, Al Bakry M, Ashwell W, Bajaj S, Bandyopadhyay D, Browlee O, Burway S, Chand CP, Elsayeh K, Elsharkawi A, Evans E, Ferrin S, Fort-Schaale A, Iacob M, I K, Impelliziere Licastro G, Mankoo AS, Olaniyan T, Otun J, Pereira R, Reddy R, Saeed D, Simmonds O, Singhal G, Tron K, Wickstone C, Williams R, Bradshaw E, De Kock Jewell V, Houlden C, Knight C, Metezai H, Mirza-Davies A, Seymour Z, Spink D, Wischhusen S. Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study. Lancet Digit Health 2022; 4:e520-e531. [PMID: 35750401 DOI: 10.1016/s2589-7500(22)00069-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/07/2022] [Accepted: 04/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications. METHODS We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC). FINDINGS In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]). INTERPRETATION In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required. FUNDING British Journal of Surgery Society.
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Lai-Kwon J, Vanderbeek AM, Minchom A, Lee Aiyegbusi O, Ogunleye D, Stephens R, Calvert M, Yap C. Using Patient-Reported Outcomes in Dose-Finding Oncology Trials: Surveys of Key Stakeholders and the National Cancer Research Institute Consumer Forum. Oncologist 2022; 27:768-777. [PMID: 35762393 PMCID: PMC9438918 DOI: 10.1093/oncolo/oyac117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background Patient-reported adverse events may be a useful adjunct for assessing a drug’s tolerability in dose-finding oncology trials (DFOT). We conducted surveys of international stakeholders and the National Cancer Research Institute (NCRI) Consumer Forum to understand attitudes about patient-reported outcome (PRO) use in DFOT. Methods A 35-question survey of clinicians, trial managers, statisticians, funders, and regulators of DFOT was distributed via professional bodies examining experience using PROs, benefits/barriers, and their potential role in defining tolerable doses. An 8-question survey of the NCRI Consumer Forum explored similar themes. Results International survey: 112 responses from 15 September–30 November 2020; 103 trialists [48 clinicians (42.9%), 38 statisticians (34.0%), 17 trial managers (15.2%)], 7 regulators (6.3%), 2 funders (1.8%)]. Most trialists had no experience designing (73, 70.9%), conducting (52, 50.5%), or reporting (88, 85.4%) PROs in DFOT. Most agreed that PROs could identify new toxicities (75, 67.0%) and provide data on the frequency (86, 76.8%) and duration (81, 72.3%) of toxicities. The top 3 barriers were lack of guidance regarding PRO selection (73/103, 70.9%), missing PRO data (71/103, 68.9%), and overburdening staff (68/103, 66.0%). NCRI survey: 57 responses on 21 March 2021. A total of 28 (49.1%) were willing to spend <15 min/day completing PROs. Most (55, 96.5%) preferred to complete PROs online. 61 (54.5%) trialists and 57 (100%) consumers agreed that patient-reported adverse events should be used to inform dose-escalation decisions. Conclusion Stakeholders reported minimal experience using PROs in DFOT but broadly supported their use. Guidelines are needed to standardize PRO selection, analysis, and reporting in DFOT.
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Affiliation(s)
- Julia Lai-Kwon
- Drug Development Unit, The Institute of Cancer Research and Royal Marsden Hospital, London, UK
| | - Alyssa M Vanderbeek
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, UK
| | - Anna Minchom
- Drug Development Unit, The Institute of Cancer Research and Royal Marsden Hospital, London, UK
| | - Olalekan Lee Aiyegbusi
- Centre for Patient-Reported Outcome Research, Institute of Applied Health Research, University of Birmingham, UK
| | | | | | - Melanie Calvert
- Centre for Patient-Reported Outcome Research, Institute of Applied Health Research, University of Birmingham, UK.,Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, UK.,National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, NIHR Surgical Reconstruction and Microbiology Research Centre and NIHR Applied Research Collaborative West Midlands, University of Birmingham, Birmingham, UK
| | - Christina Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, UK
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Stewart AR, Pickard L, Paranjape E, Perez VS, Chowdhury S, Lustgarten S, Coma S, Pachter JA, Carey MS, DiMattia G, Badham HC, Prout T, Parmar M, Mahmud M, Yap C, Krebs MG, Banerjee S, Banerji U. Abstract 3476: Mechanistic evaluation of VS-6766 (dual RAF/MEK inhibitor) and defactinib (FAK inhibitor) in low-grade serous ovarian cancer models with correlations to clinical response. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-3476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Low-grade serous ovarian cancer (LGSOC) constitutes up to 10% of all ovarian cancer and has clinical and molecular characteristics (resistance to chemotherapy, presence of RAS/RAF mutations, lack of TP53 mutations) distinct from high-grade serous ovarian cancer. Here, we characterized the effects of the dual RAF/MEK inhibitor VS-6766 and the FAK inhibitor defactinib on signal transduction and viability in LGSOC cell lines and patient-derived organoids. To correlate molecular characteristics with clinical response, we characterized genomic alterations in archival tumor samples from patients with LGSOC treated with the combination of VS-6766 and defactinib on a clinical trial (FRAME).
Material and Methods: We exposed 5 LGSOC cell lines to clinical Cmax concentrations adjusted for protein binding of VS-6766 and defactinib. We quantified phospho- and total proteins (n=66) with an antibody-bead based assay normalized to GAPDH. We also studied growth inhibitory effects of the combination on KRAS mutant (mt) LGSOC patient-derived organoids. We performed next generation sequencing on archival samples from LGSOC patients treated with VS-6766 in combination with defactinib.
Results: Signal transduction changes at 1 hr included reduction of p-FAK in 5/5 cell lines in response to defactinib. Cells exposed to VS-6766 showed a reduction in p-ERK and p-p90-RSK in 4/5 cell lines. Additionally, VS-6766 decreased p-cJUN and increased p-IκB in 4/5 cell lines, changes correlated with apoptosis. At 24 hrs, p-ERK and p-p90-RSK inhibition were maintained in 3/5 cell lines. Both drugs increased cleaved PARP in 4/5 cell lines and VS-6766 increased p-SMAD3 and BIM levels, indicating an increase in cell death/apoptosis. The combination of VS-6766 + defactinib showed synergistic growth inhibition in a KRAS mt LGSOC organoid model (combination index 0.51). The clinical combination of VS-6766 and defactinib (September 2021 cut-off) has shown an objective response rate (ORR) of 11/24 (46%) across all patients with LGSOC, and an ORR of 64% (7/11) for patients with KRAS mt LGSOC (n=11). In addition to mutations in KRAS, emerging data may suggest a correlation of U2AF1 and MED12 mutations with response.
Conclusions: VS-6766, the dual RAF/MEK inhibitor, induces significant inhibition of ERK pathway signaling in addition to perturbations in TNF/NFκB signaling. Both defactinib and VS-6766 induce apoptosis in LGSOC models. The results provide mechanistic insights into the encouraging response rates observed in patients with LGSOC treated with VS-6766 and defactinib (NCT03875820). These data support the ongoing randomized phase II ENGOTov60/GOG3052/RAMP201 study (NCT04625270).
Citation Format: Adam R. Stewart, Lisa Pickard, Ekta Paranjape, Victoria Sanchez Perez, Sanjib Chowdhury, Stephanie Lustgarten, Silvia Coma, Jonathan A. Pachter, Mark S. Carey, Gabriel DiMattia, Hannah C. Badham, Toby Prout, Mona Parmar, Muneeb Mahmud, Christina Yap, Matthew G. Krebs, Susana Banerjee, Udai Banerji. Mechanistic evaluation of VS-6766 (dual RAF/MEK inhibitor) and defactinib (FAK inhibitor) in low-grade serous ovarian cancer models with correlations to clinical response [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3476.
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Affiliation(s)
| | - Lisa Pickard
- 1The Institute of Cancer Research, London, United Kingdom
| | - Ekta Paranjape
- 1The Institute of Cancer Research, London, United Kingdom
| | | | | | | | | | | | - Mark S. Carey
- 4University of British Columbia, Canada, Vancouver, British Columbia, Canada
| | - Gabriel DiMattia
- 5University of Western Ontario, London, Canada, London, Ontario, Canada
| | | | - Toby Prout
- 1The Institute of Cancer Research, London, United Kingdom
| | - Mona Parmar
- 1The Institute of Cancer Research, London, United Kingdom
| | - Muneeb Mahmud
- 1The Institute of Cancer Research, London, United Kingdom
| | - Christina Yap
- 1The Institute of Cancer Research, London, United Kingdom
| | | | - Susana Banerjee
- 2The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
| | - Udai Banerji
- 7The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, United Kingdom
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Ma YT, Kirkham A, Curbishley S, Rowe A, Blahova M, Mehrzad H, Karkhanis S, Punia P, James M, Rao AR, Stern N, Palmer DH, Hull D, Lowe F, Douglas-Pugh J, Bathurst C, Wilkhu M, Yap C, Adams DH. A randomised phase II clinical trial of low-dose cyclophosphamide and transarterial chemoembolization (TACE) with or without vaccination with dendritic cells (DC) pulsed with HepG2 lysate ex vivo in patients with hepatocellular carcinoma (HCC): The ImmunoTACE trial. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.4012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
4012 Background: A previous study by our group using autologous monocyte-derived DC pulsed ex vivo with HepG2 cell lysate showed some clinical benefit with evidence of antigen-specific T-cell responses in patients with advanced HCC. The current trial reports the activity of this vaccine in combination with TACE in patients with HCC. All patients also received low-dose cyclophosphamide to deplete regulatory T cells and thereby enhance vaccination. Methods: Patients with intermediate stage HCC (performance status 0-2, Child Pugh A/B7) were randomised 1:1 to TACE plus low-dose cyclophosphamide (Group 1) or TACE plus low-dose cyclophosphamide plus dendritic cell vaccination (Group 2). Cyclophosphamide was administered on Day 1 and 29 followed by TACE on Day 31 (+/- DC infusion), with further cyclophosphamide on Days 60, 90 and 120 (+/- additional DC infusions on Days 62, 92 and 122). The primary endpoint was progression free survival (PFS) by RECIST v1.1. Secondary endpoints included radiological response by RECIST v1.1, PFS and radiological response according to modified (m) RECIST, overall survival (OS), immune response and toxicity. Target recruitment was 48 evaluable patients (24 patients in each arm) to detect a 20% increase in PFS rate at 1 year (30% vs 50%) with a relaxed one-sided statistical significance level of 20% and 80% power using a logrank test. Results: Between March 2016 and October 2019, 55 patients from 3 UK centres were randomised of whom 48 were evaluable (24 each arm). Median PFS by RECIST criteria was significantly longer in Group 2 compared to Group 1 (18.6 vs 10.4 months: hazard ratio (HR) 0.43, 80% CI -∞-0.59; one-sided p = 0.02). Median PFS using mRECIST criteria showed a similar magnitude of benefit (18.6 vs 10.8 months: HR 0.48, 95% CI 0.22-1.02). Median OS was 25.7 months in Group 2 vs 21.5 months in Group 1 (HR 0.61, 95% CI 0.27-1.38). Group 2 showed a higher overall response rate (complete and partial response) by RECIST (54% vs 29%) and mRECIST (75% vs 54%) and a higher disease control rate (complete and partial response and stable disease) by RECIST (92% vs 67%) and mRECIST (88% vs 67%). Treatment with DC infusions was well tolerated; the most common adverse events were chills (30%), fatigue (22%) and nausea (22%), all of which were low grade. Immune response analyses are currently ongoing. Conclusions: The addition of tumour lysate pulsed DC infusions to treatment with TACE plus low-dose cyclophosphamide significantly increased PFS in patients with HCC. To the best of our knowledge, this is the first randomised study to demonstrate efficacy using DC in HCC. Further investigation of the role of DC infusions in the treatment of HCC are warranted but will need to take into account the current evolving immunotherapy landscape. Clinical trial information: 11889464.
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Affiliation(s)
- Yuk Ting Ma
- University of Birmingham, Birmingham, United Kingdom
| | - Amanda Kirkham
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | | | - Anna Rowe
- University of Birmingham, Birmingham, United Kingdom
| | | | - Homoyon Mehrzad
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Salil Karkhanis
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Pankaj Punia
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Martin James
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Ankit Rohit Rao
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Nick Stern
- Aintree University Hospital, Liverpool, United Kingdom
| | | | - Diana Hull
- University of Birmingham, Birmingham, United Kingdom
| | - Faye Lowe
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Jessica Douglas-Pugh
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Camilla Bathurst
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Manpreet Wilkhu
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Christina Yap
- The Institute of Cancer Research, ICR-CTSU, Sutton, United Kingdom
| | - David H Adams
- University of Birmingham, Birmingham, United Kingdom
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Bono P, Pasanen A, Verlingue L, de Jonge MJ, de Miguel MJ, Skytta T, Iivanainen S, Shetty S, Ma YT, Graham DM, Arora SP, Jaakkola P, Yap C, Jalkanen S, Hollmen M, Koivunen J, Minchom AR. Promising clinical benefit rates in advanced cancers alongside potential biomarker correlation in a phase I/II trial investigating bexmarilimab, a novel macrophage-guided immunotherapy. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.2645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
2645 Background: Clever-1 is an immunosuppressive scavenger receptor expressed on tumor associated macrophages. High levels of Clever-1 are associated with poor survival and immunotherapy resistance. Bexmarilimab (FP-1305) is a novel humanized anti-CLEVER-1 IgG4-antibody capable of inducing a phenotypic M2 to M1 immune switch of tumor-associated macrophages. Methods: MATINS (Macrophage Antibody To INhibit immune Suppression) trial is a first-in-human phase I/II study (NCT03733990) to assess safety and preliminary efficacy of Bexmarilimab in patients with refractory advanced solid tumours. Part I has been completed with initial good safety profile of the IMP, preliminary signs of efficiency, and recommended dose of 1mg/kg Q3W for part II (ESMO 2020). In Part II (ESMO 2021), 10 distinct solid tumour types were enrolled to assess preliminary efficacy (overall survival (OS), progression free survival (PFS), and clinical benefit rate (CBR). Clever-1 IHC in pre-treatment biopsies with Ventana platform using a primary antibody 4G9 (Santa Cruz) was scored by % of positive cells compared to the viable tumor cells. Results: At the Jan 2022, a total of 193 patients have been enrolled to the study. In the completed cohorts, 138 patients have received 1-21 doses (median 3) of Bexmarilimab Q3W. Bexmarilimab was well tolerated, and no new safety signals were detected. Part I and Part II fully enrolled 11 cancer cohorts, the median PFS was 2.0 months (95% CI 1.9 – 2.0) and the median OS was 5.2 months (95% CI 4.3 – 6.4). CBR for Part II was 17.3% (19/110) at cycle 4 of treatment (by RECIST v.1.1). Notably, 30-40% CBR at cycle 4 was seen in cutaneous melanoma (30%), gastric cancer (30%), cholangiocarcinoma (30%), hepatocellular cancer (40%), and ER+ breast cancer (40%). Six-month survival rates (landmark analysis) were 70.1% for CBR compared to 34.7% for non-CBR patients, with a similar duration of prior therapy in both groups. Preliminary biomarker analysis (n = 77) demonstrated positive trend (p = 0.038) between CBR and higher intratumoral Clever-1 positivity (median of 15% positivity (range 0-25) in CBR and 3% (range 0-85) in non-CBR patients) Conclusions: Bexmarilimab continues to demonstrate promising anti-tumour activity as a monotherapy in several refractory solid tumours. Furthermore, preliminary biomarker analysis suggests a possibility for patient selection based on tumour Clever-1 expression. Further expansion of the study will investigate optimal dosing and biomarkers of efficacy. Clinical trial information: NCT03733990.
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Affiliation(s)
- Petri Bono
- Terveystalo Hospital and University of Helsinki, Helsinki, Finland
| | - Annika Pasanen
- Helsinki University Hospital Comprehensive Cancer Center, Helsinki, Finland
| | | | | | | | | | | | | | - Yuk Ting Ma
- University of Birmingham, Birmingham, United Kingdom
| | - Donna M. Graham
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | | | - Christina Yap
- The Institute of Cancer Research, ICR-CTSU, Sutton, United Kingdom
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Papadatos-Pastos D, Yuan W, Pal A, Crespo M, Ferreira A, Gurel B, Prout T, Ameratunga M, Chénard-Poirier M, Curcean A, Bertan C, Baker C, Miranda S, Masrour N, Chen W, Pereira R, Figueiredo I, Morilla R, Jenkins B, Zachariou A, Riisnaes R, Parmar M, Turner A, Carreira S, Yap C, Brown R, Tunariu N, Banerji U, Lopez J, de Bono J, Minchom A. Phase 1, dose-escalation study of guadecitabine (SGI-110) in combination with pembrolizumab in patients with solid tumors. J Immunother Cancer 2022; 10:jitc-2022-004495. [PMID: 35717027 PMCID: PMC9240883 DOI: 10.1136/jitc-2022-004495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2022] [Indexed: 12/14/2022] Open
Abstract
Background Data suggest that immunomodulation induced by DNA hypomethylating agents can sensitize tumors to immune checkpoint inhibitors. We conducted a phase 1 dose-escalation trial (NCT02998567) of guadecitabine and pembrolizumab in patients with advanced solid tumors. We hypothesized that guadecitabine will overcome pembrolizumab resistance. Methods Patients received guadecitabine (45 mg/m2 or 30 mg/m2, administered subcutaneously on days 1–4), with pembrolizumab (200 mg administered intravenously starting from cycle 2 onwards) every 3 weeks. Primary endpoints were safety, tolerability and maximum tolerated dose; secondary and exploratory endpoints included objective response rate (ORR), changes in methylome, transcriptome, immune contextures in pre-treatment and on-treatment tumor biopsies. Results Between January 2017 and January 2020, 34 patients were enrolled. The recommended phase II dose was guadecitabine 30 mg/m2, days 1–4, and pembrolizumab 200 mg on day 1 every 3 weeks. Two dose-limiting toxicities (neutropenia, febrile neutropenia) were reported at guadecitabine 45 mg/m2 with none reported at guadecitabine 30 mg/m2. The most common treatment-related adverse events (TRAEs) were neutropenia (58.8%), fatigue (17.6%), febrile neutropenia (11.8%) and nausea (11.8%). Common, grade 3+ TRAEs were neutropaenia (38.2%) and febrile neutropaenia (11.8%). There were no treatment-related deaths. Overall, 30 patients were evaluable for antitumor activity; ORR was 7% with 37% achieving disease control (progression-free survival) for ≥24 weeks. Of 12 evaluable patients with non-small cell lung cancer, 10 had been previously treated with immune checkpoint inhibitors with 5 (42%) having disease control ≥24 weeks (clinical benefit). Reduction in LINE-1 DNA methylation following treatment in blood (peripheral blood mononuclear cells) and tissue samples was demonstrated and methylation at transcriptional start site and 5’ untranslated region gene regions showed enriched negative correlation with gene expression. Increases in intra-tumoural effector T-cells were seen in some responding patients. Patients having clinical benefit had high baseline inflammatory signature on RNAseq analyses. Conclusions Guadecitabine in combination with pembrolizumab is tolerable with biological and anticancer activity. Reversal of previous resistance to immune checkpoint inhibitors is demonstrated.
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Affiliation(s)
| | - Wei Yuan
- Cancer Biomarkers Team, Institute of Cancer Research, Sutton, UK
| | - Abhijit Pal
- Drug Development Unit, Royal Marsden Hospital/Institute of Cancer Research, Sutton, UK
| | - Mateus Crespo
- Cancer Biomarkers Team, Institute of Cancer Research, Sutton, UK
| | - Ana Ferreira
- Cancer Biomarkers Team, Institute of Cancer Research, Sutton, UK
| | - Bora Gurel
- Cancer Biomarkers Team, Institute of Cancer Research, Sutton, UK
| | - Toby Prout
- Drug Development Unit - Investigator Initiated Trials Team, Institute of Cancer Research, Sutton, UK
| | - Malaka Ameratunga
- Drug Development Unit, Royal Marsden Hospital/Institute of Cancer Research, Sutton, UK
| | | | - Andra Curcean
- Drug Development Unit, Royal Marsden Hospital/Institute of Cancer Research, Sutton, UK
| | - Claudia Bertan
- Cancer Biomarkers Team, Institute of Cancer Research, Sutton, UK
| | - Chloe Baker
- Cancer Biomarkers Team, Institute of Cancer Research, Sutton, UK
| | - Susana Miranda
- Cancer Biomarkers Team, Institute of Cancer Research, Sutton, UK
| | - Nahal Masrour
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Wentin Chen
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Rita Pereira
- Cancer Biomarkers Team, Institute of Cancer Research, Sutton, UK
| | - Ines Figueiredo
- Cancer Biomarkers Team, Institute of Cancer Research, Sutton, UK
| | - Ricardo Morilla
- Drug Development Unit, Royal Marsden Hospital/Institute of Cancer Research, Sutton, UK
| | - Ben Jenkins
- Clinical Trials and Statistics Unit, Institute of Cancer Research, Sutton, UK
| | - Anna Zachariou
- Drug Development Unit - Investigator Initiated Trials Team, Institute of Cancer Research, Sutton, UK
| | - Ruth Riisnaes
- Cancer Biomarkers Team, Institute of Cancer Research, Sutton, UK
| | - Mona Parmar
- Drug Development Unit - Investigator Initiated Trials Team, Institute of Cancer Research, Sutton, UK
| | - Alison Turner
- Drug Development Unit - Investigator Initiated Trials Team, Institute of Cancer Research, Sutton, UK
| | - Suzanne Carreira
- Cancer Biomarkers Team, Institute of Cancer Research, Sutton, UK
| | - Christina Yap
- Clinical Trials and Statistics Unit, Institute of Cancer Research, Sutton, UK
| | - Robert Brown
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Nina Tunariu
- Drug Development Unit, Royal Marsden Hospital/Institute of Cancer Research, Sutton, UK
| | - Udai Banerji
- Drug Development Unit, Royal Marsden Hospital/Institute of Cancer Research, Sutton, UK
| | - Juanita Lopez
- Drug Development Unit, Royal Marsden Hospital/Institute of Cancer Research, Sutton, UK
| | - Johann de Bono
- Cancer Biomarkers Team, Institute of Cancer Research, Sutton, UK.,Drug Development Unit, Royal Marsden Hospital/Institute of Cancer Research, Sutton, UK
| | - Anna Minchom
- Drug Development Unit, Royal Marsden Hospital/Institute of Cancer Research, Sutton, UK
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Cruz Rivera S, Aiyegbusi OL, Ives J, Draper H, Mercieca-Bebber R, Ells C, Hunn A, Scott JA, Fernandez CV, Dickens AP, Anderson N, Bhatnagar V, Bottomley A, Campbell L, Collett C, Collis P, Craig K, Davies H, Golub R, Gosden L, Gnanasakthy A, Haf Davies E, von Hildebrand M, Lord JM, Mahendraratnam N, Miyaji T, Morel T, Monteiro J, Zwisler ADO, Peipert JD, Roydhouse J, Stover AM, Wilson R, Yap C, Calvert MJ. Ethical Considerations for the Inclusion of Patient-Reported Outcomes in Clinical Research: The PRO Ethics Guidelines. JAMA 2022; 327:1910-1919. [PMID: 35579638 DOI: 10.1001/jama.2022.6421] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Patient-reported outcomes (PROs) can inform health care decisions, regulatory decisions, and health care policy. They also can be used for audit/benchmarking and monitoring symptoms to provide timely care tailored to individual needs. However, several ethical issues have been raised in relation to PRO use. OBJECTIVE To develop international, consensus-based, PRO-specific ethical guidelines for clinical research. EVIDENCE REVIEW The PRO ethics guidelines were developed following the Enhancing the Quality and Transparency of Health Research (EQUATOR) Network's guideline development framework. This included a systematic review of the ethical implications of PROs in clinical research. The databases MEDLINE (Ovid), Embase, AMED, and CINAHL were searched from inception until March 2020. The keywords patient reported outcome* and ethic* were used to search the databases. Two reviewers independently conducted title and abstract screening before full-text screening to determine eligibility. The review was supplemented by the SPIRIT-PRO Extension recommendations for trial protocol. Subsequently, a 2-round international Delphi process (n = 96 participants; May and August 2021) and a consensus meeting (n = 25 international participants; October 2021) were held. Prior to voting, consensus meeting participants were provided with a summary of the Delphi process results and information on whether the items aligned with existing ethical guidance. FINDINGS Twenty-three items were considered in the first round of the Delphi process: 6 relevant candidate items from the systematic review and 17 additional items drawn from the SPIRIT-PRO Extension. Ninety-six international participants voted on the relevant importance of each item for inclusion in ethical guidelines and 12 additional items were recommended for inclusion in round 2 of the Delphi (35 items in total). Fourteen items were recommended for inclusion at the consensus meeting (n = 25 participants). The final wording of the PRO ethical guidelines was agreed on by consensus meeting participants with input from 6 additional individuals. Included items focused on PRO-specific ethical issues relating to research rationale, objectives, eligibility requirements, PRO concepts and domains, PRO assessment schedules, sample size, PRO data monitoring, barriers to PRO completion, participant acceptability and burden, administration of PRO questionnaires for participants who are unable to self-report PRO data, input on PRO strategy by patient partners or members of the public, avoiding missing data, and dissemination plans. CONCLUSIONS AND RELEVANCE The PRO ethics guidelines provide recommendations for ethical issues that should be addressed in PRO clinical research. Addressing ethical issues of PRO clinical research has the potential to ensure high-quality PRO data while minimizing participant risk, burden, and harm and protecting participant and researcher welfare.
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Affiliation(s)
- Samantha Cruz Rivera
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, United Kingdom
- DEMAND Hub, University of Birmingham, Birmingham, United Kingdom
| | - Olalekan Lee Aiyegbusi
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health and Care Research (NIHR) Applied Research Centre West Midlands, Birmingham, United Kingdom
| | - Jonathan Ives
- Centre for Ethics in Medicine, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Heather Draper
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Rebecca Mercieca-Bebber
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Carolyn Ells
- School of Population and Global Health, McGill University, Montreal, Quebec, Canada
| | | | - Jane A Scott
- PRO Center of Excellence, Global Commercial Strategy Organization, Janssen Global Services, Warrington, United Kingdom
| | - Conrad V Fernandez
- Division of Pediatric Haematology-Oncology, IWK Health Care Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Andrew P Dickens
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Observational and Pragmatic Research Institute, Midview City, Singapore
| | - Nicola Anderson
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | | | - Andrew Bottomley
- European Organization for Research and Treatment of Cancer, Brussels, Belgium
| | - Lisa Campbell
- Medicines and Healthcare Products Regulatory Agency, London, United Kingdom
| | | | - Philip Collis
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Patient partner, University of Birmingham, Birmingham, United Kingdom
| | - Kathrine Craig
- Fast Track Research Ethics Committee, Health Research Authority, London, United Kingdom
| | - Hugh Davies
- Fast Track Research Ethics Committee, Health Research Authority, London, United Kingdom
| | | | - Lesley Gosden
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Patient partner, University of Birmingham, Birmingham, United Kingdom
| | | | | | - Maria von Hildebrand
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Patient partner, University of Birmingham, Birmingham, United Kingdom
| | - Janet M Lord
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- NIHR Birmingham Biomedical Research Centre, University Hospital Birmingham and University of Birmingham, Birmingham, United Kingdom
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospital Birmingham and University of Birmingham, Birmingham, United Kingdom
| | | | - Tempei Miyaji
- Department of Clinical Trial Data Management, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Thomas Morel
- Global Patient-Centred Outcomes Research & Policy, UCB, Belgium, Brussels
| | | | - Ann-Dorthe Olsen Zwisler
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - John Devin Peipert
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jessica Roydhouse
- Menzies Institute for Medical Research, University of Tasmania, Tasmania, Australia
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
| | | | - Roger Wilson
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Consumer Forum, National Cancer Research Institute, London, United Kingdom
- Patient Involvement Network, Health Research Authority, London, United Kingdom
| | - Christina Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Melanie J Calvert
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, United Kingdom
- DEMAND Hub, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health and Care Research (NIHR) Applied Research Centre West Midlands, Birmingham, United Kingdom
- NIHR Birmingham Biomedical Research Centre, University Hospital Birmingham and University of Birmingham, Birmingham, United Kingdom
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospital Birmingham and University of Birmingham, Birmingham, United Kingdom
- Health Data Research United Kingdom, London, United Kingdom
- UK SPINE, University of Birmingham, Birmingham, United Kingdom
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Ellis D, Lederhofer J, Acton OJ, Tsybovsky Y, Kephart S, Yap C, Gillespie RA, Creanga A, Olshefsky A, Stephens T, Pettie D, Murphy M, Sydeman C, Ahlrichs M, Chan S, Borst AJ, Park YJ, Lee KK, Graham BS, Veesler D, King NP, Kanekiyo M. Structure-based design of stabilized recombinant influenza neuraminidase tetramers. Nat Commun 2022; 13:1825. [PMID: 35383176 PMCID: PMC8983682 DOI: 10.1038/s41467-022-29416-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 03/14/2022] [Indexed: 11/21/2022] Open
Abstract
Influenza virus neuraminidase (NA) is a major antiviral drug target and has recently reemerged as a key target of antibody-mediated protective immunity. Here we show that recombinant NAs across non-bat subtypes adopt various tetrameric conformations, including an “open” state that may help explain poorly understood variations in NA stability across viral strains and subtypes. We use homology-directed protein design to uncover the structural principles underlying these distinct tetrameric conformations and stabilize multiple recombinant NAs in the “closed” state, yielding two near-atomic resolution structures of NA by cryo-EM. In addition to enhancing thermal stability, conformational stabilization improves affinity to protective antibodies elicited by viral infection, including antibodies targeting a quaternary epitope and the broadly conserved catalytic site. Stabilized NAs can also be integrated into viruses without affecting fitness. Our findings provide a deeper understanding of NA structure, stability, and antigenicity, and establish design strategies for reinforcing the conformational integrity of recombinant NA proteins. Influenza virus neuraminidase (NA) is a drug target and a potential vaccine antigen. Here, the authors provide a detailed analysis of the conformational stability of NA, and show how expression and stability of recombinant NA antigens can be strengthened through structure-based design.
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Affiliation(s)
- Daniel Ellis
- Institute for Protein Design, University of Washington, Seattle, WA, 98195, USA.,Department of Biochemistry, University of Washington, Seattle, WA, 98195, USA.,Graduate Program in Molecular and Cellular Biology, University of Washington, Seattle, WA, 98195, USA.,Icosavax Inc., Seattle, WA, 98102, USA
| | - Julia Lederhofer
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Oliver J Acton
- Department of Biochemistry, University of Washington, Seattle, WA, 98195, USA
| | - Yaroslav Tsybovsky
- Electron Microscopy Laboratory, Cancer Research Technology Program, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick, MD, 21702, USA
| | - Sally Kephart
- Department of Medicinal Chemistry, University of Washington, Seattle, WA, 98195, USA
| | - Christina Yap
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Rebecca A Gillespie
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Adrian Creanga
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Audrey Olshefsky
- Institute for Protein Design, University of Washington, Seattle, WA, 98195, USA.,Department of Bioengineering, University of Washington, Seattle, WA, 98195, USA
| | - Tyler Stephens
- Electron Microscopy Laboratory, Cancer Research Technology Program, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick, MD, 21702, USA
| | - Deleah Pettie
- Institute for Protein Design, University of Washington, Seattle, WA, 98195, USA.,Department of Biochemistry, University of Washington, Seattle, WA, 98195, USA
| | - Michael Murphy
- Institute for Protein Design, University of Washington, Seattle, WA, 98195, USA.,Department of Biochemistry, University of Washington, Seattle, WA, 98195, USA
| | - Claire Sydeman
- Institute for Protein Design, University of Washington, Seattle, WA, 98195, USA.,Department of Biochemistry, University of Washington, Seattle, WA, 98195, USA
| | - Maggie Ahlrichs
- Institute for Protein Design, University of Washington, Seattle, WA, 98195, USA.,Department of Biochemistry, University of Washington, Seattle, WA, 98195, USA
| | - Sidney Chan
- Institute for Protein Design, University of Washington, Seattle, WA, 98195, USA.,Department of Biochemistry, University of Washington, Seattle, WA, 98195, USA
| | - Andrew J Borst
- Institute for Protein Design, University of Washington, Seattle, WA, 98195, USA.,Department of Biochemistry, University of Washington, Seattle, WA, 98195, USA
| | - Young-Jun Park
- Department of Biochemistry, University of Washington, Seattle, WA, 98195, USA.,Howard Hughes Medical Institute, University of Washington, Seattle, WA, 98195, USA
| | - Kelly K Lee
- Department of Medicinal Chemistry, University of Washington, Seattle, WA, 98195, USA
| | - Barney S Graham
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - David Veesler
- Department of Biochemistry, University of Washington, Seattle, WA, 98195, USA.,Howard Hughes Medical Institute, University of Washington, Seattle, WA, 98195, USA
| | - Neil P King
- Institute for Protein Design, University of Washington, Seattle, WA, 98195, USA. .,Department of Biochemistry, University of Washington, Seattle, WA, 98195, USA.
| | - Masaru Kanekiyo
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, 20892, USA.
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Yap C, Solovyeva O, Yin Z, Martin J, Manickavasagar T, Weir C, Lee S, Dimairo M, Liu R, Kightley A, de Bono J. 53P Assessing the reporting quality of early phase dose-finding trials. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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40
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Fisher BA, Veenith T, Slade D, Gaskell C, Rowland M, Whitehouse T, Scriven J, Parekh D, Balasubramaniam MS, Cooke G, Morley N, Gabriel Z, Wise MP, Porter J, McShane H, Ho LP, Newsome PN, Rowe A, Sharpe R, Thickett DR, Bion J, Gates S, Richards D, Kearns P, Turner R, Libri V, Mussai F, Middleton G, Bowden S, Bangash M, Gao-Smith F, Patel J, Sapey E, Thomas M, Coles M, Watkinson P, Rahman N, Angus B, Mentzer AJ, Novak A, Feldman M, Richter A, Faustini S, Bathurst C, Van de Wiel J, Mee S, James K, Rahman B, Turner K, Hill A, Gordon A, Yap C, Matthay M, McAuley D, Hall A, Dark P, McMichael A. Namilumab or infliximab compared with standard of care in hospitalised patients with COVID-19 (CATALYST): a randomised, multicentre, multi-arm, multistage, open-label, adaptive, phase 2, proof-of-concept trial. Lancet Respir Med 2022; 10:255-266. [PMID: 34922649 PMCID: PMC8676420 DOI: 10.1016/s2213-2600(21)00460-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/08/2021] [Accepted: 10/12/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Dysregulated inflammation is associated with poor outcomes in COVID-19. We aimed to assess the efficacy of namilumab (a granulocyte-macrophage colony stimulating factor inhibitor) and infliximab (a tumour necrosis factor inhibitor) in hospitalised patients with COVID-19, to prioritise agents for phase 3 trials. METHODS In this randomised, multicentre, multi-arm, multistage, parallel-group, open-label, adaptive, phase 2, proof-of-concept trial (CATALYST), we recruited patients (aged ≥16 years) admitted to hospital with COVID-19 pneumonia and C-reactive protein (CRP) concentrations of 40 mg/L or greater, at nine hospitals in the UK. Participants were randomly assigned with equal probability to usual care or usual care plus a single intravenous dose of namilumab (150 mg) or infliximab (5 mg/kg). Randomisation was stratified by care location within the hospital (ward vs intensive care unit [ICU]). Patients and investigators were not masked to treatment allocation. The primary endpoint was improvement in inflammation, measured by CRP concentration over time, analysed using Bayesian multilevel models. This trial is now complete and is registered with ISRCTN, 40580903. FINDINGS Between June 15, 2020, and Feb 18, 2021, we screened 299 patients and 146 were enrolled and randomly assigned to usual care (n=54), namilumab (n=57), or infliximab (n=35). For the primary outcome, 45 patients in the usual care group were compared with 52 in the namilumab group, and 29 in the usual care group were compared with 28 in the infliximab group. The probabilities that the interventions were superior to usual care alone in reducing CRP concentration over time were 97% for namilumab and 15% for infliximab; the point estimates for treatment-time interactions were -0·09 (95% CI -0·19 to 0·00) for namilumab and 0·06 (-0·05 to 0·17) for infliximab. 134 adverse events occurred in 30 (55%) of 55 patients in the namilumab group compared with 145 in 29 (54%) of 54 in the usual care group. 102 adverse events occurred in 20 (69%) of 29 patients in the infliximab group compared with 112 in 17 (50%) of 34 in the usual care group. Death occurred in six (11%) patients in the namilumab group compared with ten (19%) in the usual care group, and in four (14%) in the infliximab group compared with five (15%) in the usual care group. INTERPRETATION Namilumab, but not infliximab, showed proof-of-concept evidence for reduction in inflammation-as measured by CRP concentration-in hospitalised patients with COVID-19 pneumonia. Namilumab should be prioritised for further investigation in COVID-19. FUNDING Medical Research Council.
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Affiliation(s)
- Benjamin A Fisher
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK,Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK,National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,Correspondence to: Dr Benjamin A Fisher, Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Tonny Veenith
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK,Department of Critical Care Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Daniel Slade
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Charlotte Gaskell
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Matthew Rowland
- Kadoorie Centre for Critical Care Research, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Tony Whitehouse
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK,Department of Critical Care Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James Scriven
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK,Department of Infectious Diseases, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Dhruv Parekh
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK,Department of Critical Care Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Graham Cooke
- Department of Infectious Disease, Imperial College London, London, UK
| | - Nick Morley
- Department of Haematology, Royal Hallamshire Hospital, Sheffield, UK
| | - Zoe Gabriel
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Matthew P Wise
- Department of Critical Care Medicine, University Hospital of Wales, Cardiff, UK
| | - Joanna Porter
- Department of Respiratory Medicine, University College Hospital, London, UK
| | | | - Ling-Pei Ho
- Medical Research Council Human Immunology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK,Oxford Interstitial Lung Disease Service, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Philip N Newsome
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anna Rowe
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK,National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rowena Sharpe
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - David R Thickett
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK,Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Julian Bion
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK,Department of Critical Care Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon Gates
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Duncan Richards
- Oxford Clinical Trials Research Unit, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Pamela Kearns
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK,National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Pettaway CA, Nicholson S, Spiess PE, Pagliaro LC, Watkin N, Barber J, Carducci MA, Trabulsi EJ, Crook JM, Rosen MA, Branney P, Oxley J, Billingham L, Burnett SM, Penegar S, Yap C, Hall E. The international penile advanced cancer trial (InPACT): The first phase III trial for squamous carcinoma of the penis with regional lymph node metastases. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.6_suppl.tps7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS7 Background: Penis cancer is a rare but potentially fatal disease. A limited body of evidence exists on which to base the majority of management decisions for patients with regional nodal metastases. Five-year survival for patients with a single involved inguinal lymph node treated with surgery alone is approximately 80%, whilst it ranges from 0 to 12% for patients with pelvic node involvement (N3). Additional strategies are required for the management regionally-advanced disease. InPACT (NCT02305654) aims to determine prospectively the relative benefits and sequencing of surgery, chemotherapy, and chemoradiotherapy in the management of patients with penis cancer who present with palpable or radiologically evident inguinal lymph node metastases. InPACT addresses the following questions: Is there a role for neoadjuvant therapy and, if so, which of the two options (chemotherapy or chemoradiotherapy) before surgery gives superior outcomes? Among patients whose inguinal node histology predicts a high risk of recurrence, does prophylactic pelvic lymph node dissection (PLND) plus chemoradiation to the inguinal and pelvic fields improve survival compared to chemoradiation alone? Methods: A Bayesian trial design aims to include a wide population of patients and incorporates two randomisations: InPACT-neoadjuvant and InPACT-pelvis. Participants are stratified by disease burden (extent of nodal involvement), by the presence or absence of high-risk radiological features, and by GFR. Participants with high disease burden where neoadjuvant treatment is thought to be indicated are randomised to neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy. Participants with intermediate disease burden are randomised to one of 3 arms: Surgery alone or neoadjuvant chemoradiotherapy followed by surgery, or neoadjuvant chemotherapy prior to surgery. Participants in the low-burden group proceed directly to surgery. Participants with postoperative inguinal node pathology that shows high-risk features may then proceed to InPACT-pelvis where randomisation is between adjuvant chemoradiotherapy ± PLND for those not previously treated with chemoradiotherapy & between PLND & observation for those previously treated with neoadjuvant chemoradiotherapy. The study aims to recruit 200 participants. The primary outcome measure is overall survival, with secondary outcome measures of disease-specific survival, disease-free survival, and freedom from locoregional recurrence and distant metastasis. Feasibility, toxicity, the type/extent of surgical complications, and quality of life will be assessed as secondary endpoints for all the InPACT treatment arms. To October 2021, 65 participants have been recruited with centres open in the UK, US and Canada. Clinical trial information: NCT02305654.
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Affiliation(s)
| | | | | | | | - Nick Watkin
- St. George’s University Hospitals, NHS Foundation Trust, London, United Kingdom
| | | | | | - Edouard John Trabulsi
- Department of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | | | | | | | - Jon Oxley
- North Bristol NHS Trust, Bristol, United Kingdom
| | | | - Stephanie M. Burnett
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, United Kingdom
| | | | - Christina Yap
- The Institute of Cancer Research, ICR-CTSU, Sutton, United Kingdom
| | - Emma Hall
- The Institute of Cancer Research, London, United Kingdom
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Homer V, Yap C, Bond S, Holmes J, Stocken D, Walker K, Robinson EJ, Wheeler G, Brown S, Hinsley S, Schipper M, Weir CJ, Rantell K, Prior T, Yu LM, Kirkpatrick J, Bedding A, Gamble C, Gaunt P. Early phase clinical trials extension to guidelines for the content of statistical analysis plans. BMJ 2022; 376:e068177. [PMID: 35131744 PMCID: PMC8819597 DOI: 10.1136/bmj-2021-068177] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Victoria Homer
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Christina Yap
- Clinical Trials and Statistics Unit, Institute for Cancer Research, London, UK
| | - Simon Bond
- Cambridge Clinical Trials Unit, Cambridge, UK
| | - Jane Holmes
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Katrina Walker
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Emily J Robinson
- Royal Marsden Clinical Trials Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Graham Wheeler
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Sarah Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Samantha Hinsley
- Cancer Research UK Glasgow Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Matthew Schipper
- Departments of Radiation Oncology and Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Khadija Rantell
- Medicines and Healthcare products Regulatory Agency, London, UK
| | - Thomas Prior
- Early Development Oncology Statistics Department, Janssen Research and Development, Spring House, PA, USA
| | - Ly-Mee Yu
- Primary Care Clinical Trials Unit, University of Oxford, Oxford, UK
| | | | | | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Piers Gaunt
- Cancer Research Clinical Trials Unit, University of Birmingham, Birmingham, UK
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43
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Copland M, Slade D, McIlroy G, Horne G, Byrne JL, Rothwell K, Brock K, De Lavallade H, Craddock C, Clark RE, Smith ML, Fletcher R, Bishop R, Milojkovic D, Yap C. Ponatinib with fludarabine, cytarabine, idarubicin, and granulocyte colony-stimulating factor chemotherapy for patients with blast-phase chronic myeloid leukaemia (MATCHPOINT): a single-arm, multicentre, phase 1/2 trial. Lancet Haematol 2022; 9:e121-e132. [PMID: 34906334 DOI: 10.1016/s2352-3026(21)00370-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Outcomes for patients with blast-phase chronic myeloid leukaemia are poor. Long-term survival depends on reaching a second chronic phase, followed by allogeneic haematopoietic stem-cell transplantation (HSCT). We investigated whether the novel combination of the tyrosine-kinase inhibitor ponatinib with fludarabine, cytarabine, granulocyte colony-stimulating factor, and idarubicin (FLAG-IDA) could improve response and optimise allogeneic HSCT outcomes in patients with blast-phase chronic myeloid leukaemia. The aim was to identify a dose of ponatinib, which combined with FLAG-IDA, showed clinically meaningful activity and tolerability. METHODS MATCHPOINT was a seamless, phase 1/2, multicentre trial done in eight UK Trials Acceleration Programme-funded centres. Eligible participants were adults (aged ≥16 years) with Philadelphia chromosome-positive or BCR-ABL1-positive blast-phase chronic myeloid leukaemia, suitable for intensive chemotherapy. Participants received up to two cycles of ponatinib with FLAG-IDA. Experimental doses of oral ponatinib (given from day 1 to day 28 of FLAG-IDA) were between 15 mg alternate days and 45 mg once daily and the starting dose was 30 mg once daily. Intravenous fludarabine (30 mg/m2 for 5 days), cytarabine (2 g/m2 for 5 days), and idarubicin (8 mg/m2 for 3 days), and subcutaneous granulocyte colony-stimulating factor (if used), were delivered according to local protocols. We used an innovative EffTox design to investigate the activity and tolerability of ponatinib-FLAG-IDA; the primary endpoints were the optimal ponatinib dose meeting prespecified thresholds of activity (inducement of second chronic phase defined as either haematological or minor cytogenetic response) and tolerability (dose-limiting toxicties). Analyses were planned on an intention-to-treat basis. MATCHPOINT was registered as an International Standard Randomised Controlled Trial, ISRCTN98986889, and has completed recruitment; the final results are presented. FINDINGS Between March 19, 2015, and April 26, 2018, 17 patients (12 men, five women) were recruited, 16 of whom were evaluable for the coprimary outcomes. Median follow-up was 41 months (IQR 36-48). The EffTox model simultaneously considered clinical responses and dose-limiting toxicities, and determined the optimal ponatinib dose as 30 mg daily, combined with FLAG-IDA. 11 (69%) of 16 patients were in the second chronic phase after one cycle of treatment. Four (25%) patients had a dose-limiting toxicity (comprising cardiomyopathy and grade 4 increased alanine aminotransferase, cerebral venous sinus thrombosis, grade 3 increased amylase, and grade 4 increased alanine aminotransferase), fulfilling the criteria for clinically relevant activity and toxicity. 12 (71%) of 17 patients proceeded to allogeneic HSCT. The most common grade 3-4 non-haematological adverse events were lung infection (n=4 [24%]), fever (n=3 [18%]), and hypocalcaemia (n=3 [18%]). There were 12 serious adverse events in 11 (65%) patients. Three (18%) patients died due to treatment-related events (due to cardiomyopathy, pulmonary haemorrhage, and bone marrow aplasia). INTERPRETATION Ponatinib-FLAG-IDA can induce second chronic phase in patients with blast-phase chronic myeloid leukaemia, representing an active salvage therapy to bridge to allogeneic HSCT. The number of treatment-related deaths is not in excess of what would be expected in this very high-risk group of patients receiving intensive chemotherapy. The efficient EffTox method is a model for investigating novel therapies in ultra-orphan cancers. FUNDING Blood Cancer UK and Incyte.
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Affiliation(s)
- Mhairi Copland
- Paul O'Gorman Leukaemia Research Centre, College of Medical, Veterinary and Life Sciences, Institute of Cancer Sciences, University of Glasgow, Gartnavel General Hospital, Glasgow, UK.
| | - Daniel Slade
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Graham McIlroy
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Gillian Horne
- Paul O'Gorman Leukaemia Research Centre, College of Medical, Veterinary and Life Sciences, Institute of Cancer Sciences, University of Glasgow, Gartnavel General Hospital, Glasgow, UK
| | - Jenny L Byrne
- Department of Clinical Haematology, Nottingham University Hospitals, Nottingham, UK
| | - Kate Rothwell
- Department of Clinical Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kristian Brock
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Richard E Clark
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Matthew L Smith
- Department of Haemato-Oncology, St Bartholomew's Hospital, London, UK
| | - Rachel Fletcher
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Rebecca Bishop
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Christina Yap
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK; Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
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Yap C, Bedding A, de Bono J, Dimairo M, Espinasse A, Evans J, Hopewell S, Jaki T, Kightley A, Lee S, Liu R, Mander A, Solovyeva O, Weir CJ. The need for reporting guidelines for early phase dose-finding trials: Dose-Finding CONSORT Extension. Nat Med 2022; 28:6-7. [PMID: 34992264 DOI: 10.1038/s41591-021-01594-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Christina Yap
- Clinical Trials and Statistics Unit, Institute of Cancer Research, Sutton, UK.
| | | | - Johann de Bono
- Clinical Trials and Statistics Unit, Institute of Cancer Research, Sutton, UK
| | - Munyaradzi Dimairo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Aude Espinasse
- Clinical Trials and Statistics Unit, Institute of Cancer Research, Sutton, UK
| | | | | | - Thomas Jaki
- Lancaster University, Lancaster, UK
- University of Cambridge, Cambridge, UK
| | - Andrew Kightley
- Patient and Public involvement partner, Lichfield, Staffordshire, UK
| | - Shing Lee
- Columbia University, New York, NY, USA
| | - Rong Liu
- Bristol Meyers Squibb, Berkeley Heights, New Jersey, USA
| | - Adrian Mander
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Olga Solovyeva
- Clinical Trials and Statistics Unit, Institute of Cancer Research, Sutton, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
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Vanderbeek AM, Bliss JM, Yin Z, Yap C. Implementation of platform trials in the COVID-19 pandemic: A rapid review. Contemp Clin Trials 2021; 112:106625. [PMID: 34793985 PMCID: PMC8591985 DOI: 10.1016/j.cct.2021.106625] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 10/17/2021] [Accepted: 11/11/2021] [Indexed: 11/26/2022]
Abstract
Motivation Platform designs - master protocols that allow for new treatment arms to be added over time - have gained considerable attention in recent years. Between 2001 and 2019, 16 platform trials were initiated globally. The COVID-19 pandemic seems to have provided a new motivation for these designs. We conducted a rapid review to quantify and describe platform trials used in COVID-19. Methods We cross-referenced PubMed, ClinicalTrials.gov, and the Cytel COVID-19 Clinical Trials Tracker to identify platform trials, defined by their stated ability to add future arms. Results We identified 58 COVID-19 platform trials globally registered between January 2020 and May 2021. According to trial registries, 16 trials have added new therapies (median 3, IQR 4) and 11 have dropped arms (median 3, IQR 2.5). About 50% of trials publicly share their protocol, and 31 trials (53%) intend to share trial data. Forty-nine trials (84%) explicitly report adaptive features, and 21 trials (36%) state Bayesian methods. Conclusions During the pandemic, there has been a surge in the number of platform trials compared to historical use. While transparency in statistical methods and clarity of data sharing policies needs improvement, platform trials appear particularly well-suited for rapid evidence generation. Trials secured funding quickly and many succeeded in adding new therapies in a short time period, thus demonstrating the potential for these trial designs to be implemented beyond the pandemic. The evidence gathered here may provide ample insight to further inform operational, statistical, and regulatory aspects of future platform trial conduct.
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Affiliation(s)
- Alyssa M Vanderbeek
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Judith M Bliss
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Zhulin Yin
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Christina Yap
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK.
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46
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Lai‐Kwon J, Yin Z, Minchom A, Yap C. Trends in patient-reported outcome use in early phase dose-finding oncology trials - an analysis of ClinicalTrials.gov. Cancer Med 2021; 10:7943-7957. [PMID: 34676991 PMCID: PMC8607259 DOI: 10.1002/cam4.4307] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/14/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patient-reported adverse events (AEs) may be a useful adjunct to clinician-assessed AEs for assessing tolerability in early phase, dose-finding oncology trials (DFOTs). We reviewed DFOTs on ClinicalTrials.gov to describe trends in patient-reported outcome (PRO) use. METHODS DFOTs commencing 01 January 2007 - 20 January 2020 with 'PROs' or 'quality of life' as an outcome were extracted and inclusion criteria confirmed. Study and PRO characteristics were extracted. Completed trials that reported PRO outcomes and published manuscripts on ClinicalTrials.gov were identified, and PRO reporting details were extracted. RESULTS 5.3% (548/10 372) DFOTs included PROs as an outcome. 231 (42.2%) were eligible: adult (224, 97%), solid tumour (175, 75.8%), and seamless phase 1/2 (108, 46.8%). PRO endpoints were identified in more trials (2.3 increase/year, 95% CI: 1.6-2.9) from an increasing variety of countries (0.7/year) (95% CI: 0.4-0.9) over time. PROs were typically secondary endpoints (207, 89.6%). 15/77 (19.5%) completed trials reported results on the ClinicalTrials.gov results database, and of those eight included their PRO results. Eighteen trials had published manuscripts available on ClinicalTrials.gov. Three (16.7%) used PROs to confirm the maximum tolerated dose. No trials identified who completed the PROs or how PROs were collected. CONCLUSIONS PRO use in DFOT has increased but remains limited. Future work should explore the role of PROs in DFOT and determine what guidelines are needed to standardise PRO use.
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Affiliation(s)
- Julia Lai‐Kwon
- Drug Development UnitThe Institute of Cancer Research and Royal Marsden HospitalLondonUK
| | - Zhulin Yin
- Clinical Trials and Statistics UnitThe Institute of Cancer ResearchSuttonUK
| | - Anna Minchom
- Drug Development UnitThe Institute of Cancer Research and Royal Marsden HospitalLondonUK
| | - Christina Yap
- Clinical Trials and Statistics UnitThe Institute of Cancer ResearchSuttonUK
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Chiu R, Tran T, Miranda-Taylor M, Bamdad S, Jia Y, Crabtree M, Cornford M, Yap C, Peng S. Biphasic Sarcomatoid Sweat Gland Carcinoma With Ductal Epithelial And Spindled Myoepithelial Cell Components (Malignant Mixed Tumor Of Skin). Am J Clin Pathol 2021. [DOI: 10.1093/ajcp/aqab191.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction/Objective
Sweat gland carcinomas are a group of malignant skin adnexal tumors that are difficult to diagnose due to their rarity, wide morphologic variation, and limited literature on diagnosis and classification. These tumors may appear bland and morphologically resemble benign skin adnexal tumors, or may appear poorly differentiated and mimic metastatic carcinoma especially from a breast primary. Biphasic sweat gland carcinomas are an even rarer entity, with only few cases reported in literature, and have been described to consist of a well- differentiated ductal epithelial component and a poorly differentiated, sarcomatoid, spindle cell component.
Methods/Case Report
Our case report describes a 53 year old female referred to our institution for diagnosis of an excised skin lesion of the right upper arm, which had been slowly growing for 8 years. The histology revealed a biphasic malignant neoplasm involving the dermis and subcutis. The tumor consisted of an epithelial cell component with glandular and squamoid morphology and positive for CK5/6, CK7, and CAM5.2, and a spindled myoepithelial cell component with sarcomatoid morphology and positive for S100, vimentin, and p63. Stains for CK20, ER, PR, PAX8, CEA, and TTF1 were negative. The histological and clinical findings favored a primary skin adnexal tumor, rather than a metastatic lesion.
The patient underwent wide local excision of the lesion given that margins of the original excision were indeterminate. The histology of this re-excision demonstrated the same biphasic tumor with ductal epithelial and sarcomatoid myoepithelial cell components positive for the same stains. Although margins were negative in this re-excision, 3-4 months later, the patient developed dyspnea with multiple new pulmonary and hilar masses discovered on imaging, and new-onset headache with a frontal lobe mass discovered on brain imaging. These masses were biopsied/resected, and revealed to be metastases of the original cutaneous tumor positive for the same markers.
Results (if a Case Study enter NA)
NA
Conclusion
This case report describes a rare, diagnostically challenging case of a biphasic sweat gland carcinoma with ductal epithelial and sarcomatoid myoepithelial cell components, which demonstrated aggressive behavior with distant metastasis. These tumors are a clinicopathological quandary given their rarity and the paucity of literature on their characterization.
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Affiliation(s)
- R Chiu
- Pathology, Harbor-UCLA Medical Center, Torrance, California, UNITED STATES
| | - T Tran
- Pathology, Harbor-UCLA Medical Center, Torrance, California, UNITED STATES
| | - M Miranda-Taylor
- Pathology, Harbor-UCLA Medical Center, Torrance, California, UNITED STATES
| | - S Bamdad
- Pathology, Harbor-UCLA Medical Center, Torrance, California, UNITED STATES
| | - Y Jia
- Pathology, Harbor-UCLA Medical Center, Torrance, California, UNITED STATES
| | - M Crabtree
- Pathology, Harbor-UCLA Medical Center, Torrance, California, UNITED STATES
| | - M Cornford
- Pathology, Harbor-UCLA Medical Center, Torrance, California, UNITED STATES
| | - C Yap
- Pathology, Harbor-UCLA Medical Center, Torrance, California, UNITED STATES
| | - S Peng
- Pathology, Harbor-UCLA Medical Center, Torrance, California, UNITED STATES
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Wilson N, Biggs K, Bowden S, Brown J, Dimairo M, Flight L, Hall J, Hockaday A, Jaki T, Lowe R, Murphy C, Pallmann P, Pilling MA, Snowdon C, Sydes MR, Villar SS, Weir CJ, Welburn J, Yap C, Maier R, Hancock H, Wason JMS. Costs and staffing resource requirements for adaptive clinical trials: quantitative and qualitative results from the Costing Adaptive Trials project. BMC Med 2021; 19:251. [PMID: 34696781 PMCID: PMC8545558 DOI: 10.1186/s12916-021-02124-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/13/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Adaptive designs offer great promise in improving the efficiency and patient-benefit of clinical trials. An important barrier to further increased use is a lack of understanding about which additional resources are required to conduct a high-quality adaptive clinical trial, compared to a traditional fixed design. The Costing Adaptive Trials (CAT) project investigated which additional resources may be required to support adaptive trials. METHODS We conducted a mock costing exercise amongst seven Clinical Trials Units (CTUs) in the UK. Five scenarios were developed, derived from funded clinical trials, where a non-adaptive version and an adaptive version were described. Each scenario represented a different type of adaptive design. CTU staff were asked to provide the costs and staff time they estimated would be needed to support the trial, categorised into specified areas (e.g. statistics, data management, trial management). This was calculated separately for the non-adaptive and adaptive version of the trial, allowing paired comparisons. Interviews with 10 CTU staff who had completed the costing exercise were conducted by qualitative researchers to explore reasons for similarities and differences. RESULTS Estimated resources associated with conducting an adaptive trial were always (moderately) higher than for the non-adaptive equivalent. The median increase was between 2 and 4% for all scenarios, except for sample size re-estimation which was 26.5% (as the adaptive design could lead to a lengthened study period). The highest increase was for statistical staff, with lower increases for data management and trial management staff. The percentage increase in resources varied across different CTUs. The interviews identified possible explanations for differences, including (1) experience in adaptive trials, (2) the complexity of the non-adaptive and adaptive design, and (3) the extent of non-trial specific core infrastructure funding the CTU had. CONCLUSIONS This work sheds light on additional resources required to adequately support a high-quality adaptive trial. The percentage increase in costs for supporting an adaptive trial was generally modest and should not be a barrier to adaptive designs being cost-effective to use in practice. Informed by the results of this research, guidance for investigators and funders will be developed on appropriately resourcing adaptive trials.
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Affiliation(s)
- Nina Wilson
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Katie Biggs
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Bowden
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - Julia Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Munyaradzi Dimairo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jamie Hall
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Hockaday
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Thomas Jaki
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Rachel Lowe
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Caroline Murphy
- King's College Trials Unit, King's College London, London, UK
| | | | - Mark A Pilling
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Claire Snowdon
- The Institute of Cancer Research Clinical Trials & Statistics Unit, London, UK
| | | | - Sofía S Villar
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Jessica Welburn
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Christina Yap
- The Institute of Cancer Research Clinical Trials & Statistics Unit, London, UK
| | - Rebecca Maier
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Hancock
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - James M S Wason
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
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Tiu C, Welsh L, Jones T, Zachariou A, Prout T, Turner A, Daly R, Tunariu N, Riisnaes R, Gurel B, Crespo M, Carreira S, Vivanco I, Jenkins B, Yap C, Minchom A, Banerji U, deBono J, Lopez J. Preliminary evidence of antitumour activity of Ipatasertib (Ipat) and Atezolizumab (ATZ) in glioblastoma patients (pts) with PTEN loss from the Phase 1 Ice-CAP trial (NCT03673787). Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab195.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
Despite improved understanding of effector T-cell trafficking into the central nervous system, initial trials with anti-PD1/PD-L1 immune checkpoint inhibitors (ICIs) have failed to meet their primary endpoints. PTEN loss of function is frequent in GBM and has been correlated with not only poor overall prognosis, but also impaired antitumour responses, including reduced T cell infiltration into tumour and reduced efficacy of ICIs.
Ipatasertib is a novel, potent, selective, small-molecule inhibitor of Akt. We have shown that Ipatasertib efficiently depletes FOXP3+ regulatory T cells from the tumour microenvironment (TME) resulting in increased infiltration of effector T cells in solid tumours (Lopez 2020, AACR).
We hypothesize that the use of AKT inhibition in PTEN glioblastomas may deplete the TME of suppressive immune cells, and render malignant brain tumours more responsive to ICIs. We present updated data for the combination of Ipat+ATZ in patients with glioblastoma.
Method
Patients with relapsed WHO grade IV GBM with stable neurological symptoms ≥5 days prior to enrolment, requiring <3mg Dexamethasone were recruited into two cohorts of this early phase, open-label, single-centre trial studying the combination of Ipatasertib (Ipat) and Atezolizumab (ATZ): a dose finding cohort (A2; n=9) and an expansion cohort (B3; n=7, recruitment ongoing).
The Ice-CAP A2 cohort assessed safety, pharmacodynamic, and preliminary clinical activity of Ipat (200mg or 400mg OD) + ATZ (1200mg Q3W) in pts with potentially resectable relapsed WHO Grade IV GBM. Pts had a 14-21-day run-in phase of Ipat then surgical tumour resection. Combination Ipat+ATZ commenced post surgery. Patients who declined surgery or who were deemed high risk for surgery proceeded directly to combination.
Patients in the expansion cohort B3 commenced directly on Ipat+ATZ at the RP2D of 400mg Ipat with ATZ.
Results
16 evaluable recurrent GBM pts were enrolled across two cohorts. Median age 56 yrs (25-71 yrs). Median ECOG PS 1. Median lines of prior therapy 1 (range 1-4). 10 pts had PTEN loss by IHC (H<30) and/or PTEN mutations on next generation sequencing.
No DLTs, treatment-related (TR) serious adverse events (AEs), or immune-related AEs were observed. Most common TR AEs were G1 diarrhoea (44%), mucositis (17%), rash (28%).
Clinical benefit rate (CR, PR and SD> 6 cycles) at clinical cutoff date (23/02/21) in patients with PTEN aberration was 30% (3/10). A 58-year-old man with PTEN loss had MRI at Cycle 5 showing worsening enhancement suggestive of disease progression. Resection of the lesion showed intense lymphocyte infiltration and pathological CR. He is currently on Cycle 22 with no evidence of disease. Two other patients with PTEN loss with radiological stable disease per RANO criteria remain well on study for >6 cycles.
Conclusion
Combination Ipat+ATZ appears safe and tolerable in GBM pts, with 400mg Ipatasertib OD + 1200mg ATZ Q3W declared as RP2D. Early efficacy signals were detected with PTEN loss being a promising predictive biomarker for response to combination. An expansion cohort enriched with pts with PTEN loss is ongoing.
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Affiliation(s)
- Crescens Tiu
- Royal Marsden Hospital
- Institute of Cancer Research, Royal Marsden Hospital
| | | | - Timothy Jones
- St George’s University Hospital NHS Foundation Trust
| | | | - Toby Prout
- Institute of Cancer Research, Royal Marsden Hospital
| | - Alison Turner
- Institute of Cancer Research, Royal Marsden Hospital
| | - Rob Daly
- Institute of Cancer Research, Royal Marsden Hospital
| | - Nina Tunariu
- Royal Marsden Hospital
- Institute of Cancer Research, Royal Marsden Hospital
| | - Ruth Riisnaes
- Institute of Cancer Research, Royal Marsden Hospital
| | - Bora Gurel
- Institute of Cancer Research, Royal Marsden Hospital
| | - Mateus Crespo
- Institute of Cancer Research, Royal Marsden Hospital
| | | | - Igor Vivanco
- Institute of Cancer Research, Royal Marsden Hospital
| | - Ben Jenkins
- Institute of Cancer Research, Royal Marsden Hospital
| | - Christina Yap
- Institute of Cancer Research, Royal Marsden Hospital
| | - Anna Minchom
- Royal Marsden Hospital
- Institute of Cancer Research, Royal Marsden Hospital
| | - Udai Banerji
- Royal Marsden Hospital
- Institute of Cancer Research, Royal Marsden Hospital
| | - Johann deBono
- Royal Marsden Hospital
- Institute of Cancer Research, Royal Marsden Hospital
| | - Juanita Lopez
- Royal Marsden Hospital
- Institute of Cancer Research, Royal Marsden Hospital
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50
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Pal A, Stapleton S, Yap C, Lai-Kwon J, Daly R, Magkos D, Baikady BR, Minchom A, Banerji U, De Bono J, Karikios D, Boyle F, Lopez J. Study protocol for a randomised controlled trial of enhanced informed consent compared to standard informed consent to improve patient understanding of early phase oncology clinical trials (CONSENT). BMJ Open 2021; 11:e049217. [PMID: 34489282 PMCID: PMC8422487 DOI: 10.1136/bmjopen-2021-049217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 08/11/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Early phase cancer clinical trials have become increasingly complicated in terms of patient selection and trial procedures-this is reflected in the increasing length of participant information sheets (PIS). Informed consent for early phase clinical trials has been contentious due to the potential ethical issues associated with performing experimental research on a terminally ill population which has exhausted standard treatment options. Empirical studies have demonstrated significant gaps in patient understanding regarding the nature and intent of these trials. This study aims to test whether enhanced informed consent for patient education can improve patient scores on a validated questionnaire testing clinical trial comprehension. METHODS AND ANALYSIS This is a randomised controlled trial that will allocate patients who are eligible to participate in one of four investigator-initiated clinical trials at the Royal Marsden Drug Development Unit to either a standard arm or an experimental arm, stratified by age and educational level. The standard arm will involve the full length trial PIS, followed by electronic or paper administration of the Quality of Informed Consent Questionnaire Parts A and B (QuIC-A and QuIC-B). The experimental arm will involve the full length trial PIS, exposure to a two-page study aid and 10 online educational videos, followed by administration of the QuIC-A and QuIC-B. The primary endpoint will be the difference (using a one-sided two-sample t-test) in the QuIC-A score, which measures objective understanding, between the standard and experimental arm. Accrual target is at least 17 patients per arm to detect an 8 point difference (80% power, alpha 0.05). ETHICS AND DISSEMINATION Ethics approval was granted by the National Health Service Health Research Authority on 15 June 2020-IRAS Project ID 277065, Protocol Number CCR5165, REC Reference 20/EE/0155. Results will be disseminated via publication in a relevant journal. TRIAL REGISTRATION NUMBER NCT04407676; Pre-results.
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Affiliation(s)
- Abhijit Pal
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
- The University of Sydney, Sydney, New South Wales, Australia
| | - Sarah Stapleton
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, UK
| | - Julia Lai-Kwon
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Robert Daly
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Dimitrios Magkos
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Bindumalini Rao Baikady
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Anna Minchom
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Udai Banerji
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Johann De Bono
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Deme Karikios
- The University of Sydney, Sydney, New South Wales, Australia
| | - Frances Boyle
- The University of Sydney, Sydney, New South Wales, Australia
| | - Juanita Lopez
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| |
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