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Beltran-Bless AA, Clemons M, Vandermeer L, El Emam K, Ng TL, McGee S, Awan AA, Pond G, Renaud J, Barton G, Hutton B, Savard MF. The REthinking Clinical Trials Program Retreat 2023: Creating Partnerships to Optimize Quality Cancer Care. Curr Oncol 2024; 31:1376-1388. [PMID: 38534937 PMCID: PMC10969202 DOI: 10.3390/curroncol31030104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 04/13/2024] Open
Abstract
Patients, families, healthcare providers and funders face multiple comparable treatment options without knowing which provides the best quality of care. As a step towards improving this, the REthinking Clinical Trials (REaCT) pragmatic trials program started in 2014 to break down many of the traditional barriers to performing clinical trials. However, until other innovative methodologies become widely used, the impact of this program will remain limited. These innovations include the incorporation of near equivalence analyses and the incorporation of artificial intelligence (AI) into clinical trial design. Near equivalence analyses allow for the comparison of different treatments (drug and non-drug) using quality of life, toxicity, cost-effectiveness, and pharmacokinetic/pharmacodynamic data. AI offers unique opportunities to maximize the information gleaned from clinical trials, reduces sample size estimates, and can potentially "rescue" poorly accruing trials. On 2 May 2023, the first REaCT international symposium took place to connect clinicians and scientists, set goals and identify future avenues for investigator-led clinical trials. Here, we summarize the topics presented at this meeting to promote sharing and support other similarly motivated groups to learn and share their experiences.
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Affiliation(s)
- Ana-Alicia Beltran-Bless
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1H 8L6, Canada; (A.-A.B.-B.); (M.C.); (T.L.N.); (S.M.); (A.A.A.)
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada;
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1H 8L6, Canada; (A.-A.B.-B.); (M.C.); (T.L.N.); (S.M.); (A.A.A.)
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada;
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada;
| | | | - Terry L. Ng
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1H 8L6, Canada; (A.-A.B.-B.); (M.C.); (T.L.N.); (S.M.); (A.A.A.)
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada;
| | - Sharon McGee
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1H 8L6, Canada; (A.-A.B.-B.); (M.C.); (T.L.N.); (S.M.); (A.A.A.)
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada;
| | - Arif Ali Awan
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1H 8L6, Canada; (A.-A.B.-B.); (M.C.); (T.L.N.); (S.M.); (A.A.A.)
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada;
| | - Gregory Pond
- Department of Oncology, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Julie Renaud
- Champlain Regional Cancer Program, Ottawa, ON K1H 8L6, Canada;
| | - Gwen Barton
- Psychosocial Oncology, Patient Engagement/Experience, Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada;
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada;
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON K1N 6N, Canada
| | - Marie-France Savard
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1H 8L6, Canada; (A.-A.B.-B.); (M.C.); (T.L.N.); (S.M.); (A.A.A.)
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada;
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Tannock IF, Bouche G, Goldstein DA, Goto Y, Lichter AS, Prabhash K, Ranganathan P, Saltz LB, Sonke GS, Strohbehn GW, von Moos R, Ratain MJ. Patient-centred, self-funding dose optimisation trials as a route to reduce toxicity, lower cost and improve access to cancer therapy. Ann Oncol 2023:S0923-7534(23)00687-7. [PMID: 37230253 DOI: 10.1016/j.annonc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/27/2023] Open
Affiliation(s)
- Ian F Tannock
- Division of Medical Oncology, Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada; Optimal Cancer Care Alliance, Ann Arbor, MI, USA.
| | - Gauthier Bouche
- Anticancer Fund, Meise, Belgium; Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Daniel A Goldstein
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yasushi Goto
- Department of Thoracic Oncology, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | | | - Kumar Prabhash
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Leonard B Saltz
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gabe S Sonke
- Department of Medical Oncology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, & University of Amsterdam, Amsterdam, The Netherlands
| | - Garth W Strohbehn
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Rogel Cancer Center, University of Michigan; Section of Hematology Oncology, Veterans Affairs Ann Arbor Healthcare System; Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Roger von Moos
- Department of Oncology/Hematology, Kantonsspital Graubünden, Chur, Switzerland & SAKK Competence Center, Bern
| | - Mark J Ratain
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Section of Hematology/Oncology, Department of Medicine, The University of Chicago, Chicago, IL, USA
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Kulasekararaj A, Glasmacher A, Liu P, Szer J, Araten D, Rauch G, Gwaltney C, Sierra JR, Lee JW. Composite endpoint to evaluate complement inhibition therapy in patients with paroxysmal nocturnal hemoglobinuria. Eur J Haematol Suppl 2022; 108:391-402. [PMID: 35100459 PMCID: PMC9311164 DOI: 10.1111/ejh.13746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 12/16/2022]
Abstract
This study developed and explored a novel composite endpoint to assess the overall impact that treatment can have on patients living with paroxysmal nocturnal hemoglobinuria (PNH). Candidate composite endpoint variables were selected by a group of experts and included: lactate dehydrogenase levels as a measure of intravascular hemolysis; complete terminal complement inhibition; absence of major adverse vascular events, including thrombosis; absence of any adverse events leading to death or discontinuation of study treatment; transfusion avoidance; and improvements in fatigue‐related quality of life as determined by the Functional Assessment of Chronic Illness Therapy (FACIT)‐Fatigue score. From these variables, a novel composite endpoint was constructed and explored using data collected in the ravulizumab PNH Study 301 (NCT02946463). Thresholds were defined and reported for each candidate variable. Five of the six candidate variables were included in the final composite endpoint; the FACIT‐Fatigue score was excluded. Composite endpoint criterion was defined as patients meeting all five selected individual component thresholds. All patients in the ravulizumab arm achieved complete terminal complement inhibition and a reduction in lactate dehydrogenase levels; 51.2% and 41.3% of patients in the ravulizumab arm and eculizumab arm, respectively, achieved all composite endpoint component thresholds (treatment difference: 9.4%; 95% confidence interval: −3.0, 21.5). The composite endpoint provided a single and simultaneous measurement of overall benefit for patients receiving treatment for PNH. Use of the composite endpoint in future PNH research is recommended to determine clinical benefit, and its use in health technology assessments should be evaluated.
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Affiliation(s)
- Austin Kulasekararaj
- King's College Hospital, King's College London, and NIHR/Wellcome Trust King's Clinical Research Facility, London, UK
| | - Axel Glasmacher
- AG Life Science Consulting, Alfter, Germany.,Department of Medicine III, University of Bonn, Bonn, Germany
| | - Peng Liu
- Alexion Pharmaceuticals, Inc., Boston, Massachusetts, USA
| | - Jeff Szer
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
| | - David Araten
- New York University Grossman School of Medicine, New York, New York, USA
| | - Geraldine Rauch
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Chad Gwaltney
- Gwaltney Consulting, Westerly, Rhode Island, USA.,Brown University, Providence, Rhode Island, USA
| | | | - Jong Wook Lee
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Jatoi I, Pinsky PF. Breast Cancer Screening Trials: Endpoints and Overdiagnosis. J Natl Cancer Inst 2021; 113:1131-1135. [PMID: 32898241 PMCID: PMC8633447 DOI: 10.1093/jnci/djaa140] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/19/2020] [Accepted: 08/27/2020] [Indexed: 10/04/2023] Open
Abstract
Screening mammography was assessed in 9 randomized trials initiated between 1963 and 1990, with breast cancer-specific mortality as the primary endpoint. In contrast, breast cancer detection has been the primary endpoint in most screening trials initiated during the past decade. These trials have evaluated digital breast tomosynthesis, magnetic resonance imaging, and ultrasound, and novel screening strategies have been recommended solely on the basis of improvements in breast cancer detection rates. Yet, the assumption that increases in tumor detection produce reductions in cancer mortality has not been validated, and tumor-detection endpoints may exacerbate the problem of overdiagnosis. Indeed, the detection of greater numbers of early stage breast cancers in the absence of a subsequent decline in rates of metastatic cancers and cancer-related mortality is the hallmark of overdiagnosis. There is now evidence to suggest that both ductal carcinoma in situ and invasive cancers are overdiagnosed as a consequence of screening. For each patient who is overdiagnosed with breast cancer, the adverse consequences include unnecessary anxiety, financial hardships, and a small risk of morbidity and mortality from unnecessary treatments. Moreover, the overtreatment of breast cancer, as a consequence of overdiagnosis, is costly and contributes to waste in health-care spending. In this article, we argue that there is a need to establish better endpoints in breast cancer screening trials, including quality of life and composite endpoints. Tumor-detection endpoints should be abandoned, because they may lead to the implementation of screening strategies that increase the risk of overdiagnosis.
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Affiliation(s)
- Ismail Jatoi
- Division of Surgical Oncology and Endocrine Surgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Paul F Pinsky
- Division of Cancer Prevention, National Cancer Institute, Rockville, MD, USA
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Tannock IF, Ratain MJ, Goldstein DA, Lichter AS, Rosner GL, Saltz LB. Near-Equivalence: Generating Evidence to Support Alternative Cost-Effective Treatments. J Clin Oncol 2021; 39:950-955. [DOI: 10.1200/jco.20.02768] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Drago JZ, Gönen M, Thanarajasingam G, Sacks CA, Morris MJ, Kantoff PW, Stopsack KH. Inferences About Drug Safety in Phase III Trials in Oncology: Examples From Advanced Prostate Cancer. J Natl Cancer Inst 2020; 113:553-561. [PMID: 32857839 DOI: 10.1093/jnci/djaa134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/18/2020] [Accepted: 08/21/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Safety is a central consideration when choosing between multiple medications with similar efficacy. We aimed to evaluate whether adverse event (AE) profiles of 3 such drugs in advanced prostate cancer could be distinguished based on published literature. METHODS We assessed consistency in AE reporting, AE risk in placebo arms, and methodology used for risk estimates and quantification of statistical uncertainty in randomized placebo-controlled phase III trials of apalutamide, enzalutamide, and darolutamide in advanced prostate cancer. RESULTS Seven included clinical trials enrolled a total of 9215 participants (range = 1051-1715 per trial) across 3 prostate cancer disease states. Within disease states, baseline patient characteristics appeared similar between trials. Of 54 distinct AE types in total, only 3 (fatigue, hypertension, and seizure) were reported by all 7 trials. Absolute risks of AEs in the placebo arms differed systematically and more than twofold between trials, which was associated with visit frequency and resulted in different degrees of uncertainty in AE profiles between trials. No trial used inferential methodology to quantify statistical uncertainty in AE risks, but 6 of 7 trials drew overall conclusions. Two trials concluded that there was no elevated AE risk because of the intervention, including the trial of darolutamide, which had the greatest statistical uncertainty. CONCLUSIONS Rigorous comparison of drug safety was precluded by heterogeneity in AE reporting, variation in AE risks in the placebo arms, and lack of inferential statistical methodology, underscoring considerable opportunities to improve how AE data are collected, analyzed, and interpreted in oncology trials.
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Affiliation(s)
- Joshua Z Drago
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gita Thanarajasingam
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Chana A Sacks
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Michael J Morris
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Philip W Kantoff
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Konrad H Stopsack
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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