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Gao W, Liu J, Shtylla B, Venkatakrishnan K, Yin D, Shah M, Nicholas T, Cao Y. Realizing the promise of Project Optimus: Challenges and emerging opportunities for dose optimization in oncology drug development. CPT Pharmacometrics Syst Pharmacol 2024; 13:691-709. [PMID: 37969061 PMCID: PMC11098159 DOI: 10.1002/psp4.13079] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/20/2023] [Accepted: 10/30/2023] [Indexed: 11/17/2023] Open
Abstract
Project Optimus is a US Food and Drug Administration Oncology Center of Excellence initiative aimed at reforming the dose selection and optimization paradigm in oncology drug development. This project seeks to bring together pharmaceutical companies, international regulatory agencies, academic institutions, patient advocates, and other stakeholders. Although there is much promise in this initiative, there are several challenges that need to be addressed, including multidimensionality of the dose optimization problem in oncology, the heterogeneity of cancer and patients, importance of evaluating long-term tolerability beyond dose-limiting toxicities, and the lack of reliable biomarkers for long-term efficacy. Through the lens of Totality of Evidence and with the mindset of model-informed drug development, we offer insights into dose optimization by building a quantitative knowledge base integrating diverse sources of data and leveraging quantitative modeling tools to build evidence for drug dosage considering exposure, disease biology, efficacy, toxicity, and patient factors. We believe that rational dose optimization can be achieved in oncology drug development, improving patient outcomes by maximizing therapeutic benefit while minimizing toxicity.
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Affiliation(s)
- Wei Gao
- Quantitative PharmacologyEMD Serono Research & Development Institute, Inc.BillericaMassachusettsUSA
| | - Jiang Liu
- Food and Drug AdministrationSilver SpringMarylandUSA
| | - Blerta Shtylla
- Quantitative Systems PharmacologyPfizerSan DiegoCaliforniaUSA
| | - Karthik Venkatakrishnan
- Quantitative PharmacologyEMD Serono Research & Development Institute, Inc.BillericaMassachusettsUSA
| | - Donghua Yin
- Clinical PharmacologyPfizerSan DiegoCaliforniaUSA
| | - Mirat Shah
- Food and Drug AdministrationSilver SpringMarylandUSA
| | | | - Yanguang Cao
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of PharmacyUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Liu H, Milenković‐Grišić A, Krishnan SM, Jönsson S, Friberg LE, Girard P, Venkatakrishnan K, Vugmeyster Y, Khandelwal A, Karlsson MO. A multistate modeling and simulation framework to learn dose-response of oncology drugs: Application to bintrafusp alfa in non-small cell lung cancer. CPT Pharmacometrics Syst Pharmacol 2023; 12:1738-1750. [PMID: 37165943 PMCID: PMC10681430 DOI: 10.1002/psp4.12976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/06/2023] [Accepted: 04/14/2023] [Indexed: 05/12/2023] Open
Abstract
The dose/exposure-efficacy analyses are often conducted separately for oncology end points like best overall response, progression-free survival (PFS) and overall survival (OS). Multistate models offer to bridge these dose-end point relationships by describing transitions and transition times from enrollment to response, progression, and death, and evaluating transition-specific dose effects. This study aims to apply the multistate pharmacometric modeling and simulation framework in a dose optimization setting of bintrafusp alfa, a fusion protein targeting TGF-β and PD-L1. A multistate model with six states (stable disease [SD], response, progression, unknown, dropout, and death) was developed to describe the totality of endpoints data (time to response, PFS, and OS) of 80 patients with non-small cell lung cancer receiving 500 or 1200 mg of bintrafusp alfa. Besides dose, evaluated predictor of transitions include time, demographics, premedication, disease factors, individual clearance derived from a pharmacokinetic model, and tumor dynamic metrics observed or derived from tumor size model. We found that probabilities of progression and death upon progression decreased over time since enrollment. Patients with metastasis at baseline had a higher probability to progress than patients without metastasis had. Despite dose failed to be statistically significant for any individual transition, the combined effect quantified through a model with dose-specific transition estimates was still informative. Simulations predicted a 69.2% probability of at least 1 month longer, and, 55.6% probability of at least 2-months longer median OS from the 1200 mg compared to the 500 mg dose, supporting the selection of 1200 mg for future studies.
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Affiliation(s)
- Han Liu
- Department of PharmacyUppsala UniversityUppsalaSweden
| | | | | | - Siv Jönsson
- Department of PharmacyUppsala UniversityUppsalaSweden
| | | | - Pascal Girard
- Merck Institute of Pharmacometrics, an affiliate of Merck KGaALausanneSwitzerland
| | - Karthik Venkatakrishnan
- EMD Serono Research & Development Institute, Inc., an affiliate of Merck KGaABillericaMassachusettsUSA
| | - Yulia Vugmeyster
- EMD Serono Research & Development Institute, Inc., an affiliate of Merck KGaABillericaMassachusettsUSA
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Kerioui M, Bertrand J, Desmée S, Le Tourneau C, Mercier F, Bruno R, Guedj J. Assessing the Increased Variability in Individual Lesion Kinetics During Immunotherapy: Does It Exist, and Does It Matter? JCO Precis Oncol 2023; 7:e2200368. [PMID: 36848611 DOI: 10.1200/po.22.00368] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
PURPOSE Several studies have raised the hypothesis that immunotherapy may exacerbate the variability in individual lesions, increasing the risk of observing divergent kinetic profiles within the same patient. This questions the use of the sum of the longest diameter to follow the response to immunotherapy. Here, we aimed to study this hypothesis by developing a model that estimates the different sources of variability in lesion kinetics, and we used this model to evaluate the impact of this variability on survival. METHODS We relied on a semimechanistic model to follow the nonlinear kinetics of lesions and their impact on the risk of death, adjusted on organ location. The model incorporated two levels of random effects to characterize both between- and within-patient variability in response to treatment. The model was estimated on 900 patients from a phase III randomized trial evaluating programmed death-ligand 1 checkpoint inhibitor atezolizumab versus chemotherapy in patients with second-line metastatic urothelial carcinoma (IMvigor211). RESULTS The within-patient variability in the four parameters that characterize individual lesion kinetics represented between 12% and 78% of the total variability during chemotherapy. Similar results were obtained during atezolizumab, except for the durability of the treatment effects, for which the within-patient variability was markedly larger than during chemotherapy (40% v 12%, respectively). Accordingly, the occurrence of divergent profile consistently increased over time in patients treated with atezolizumab and was equal to about 20% after 1 year of treatment. Finally, we show that accounting for the within-patient variability provided a better prediction of most at-risk patients than a model relying solely on the sum of the longest diameter. CONCLUSION Within-patient variability provides valuable information for the assessment of treatment efficacy and the detection of at-risk patients.
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Affiliation(s)
- Marion Kerioui
- Université Paris Cité, INSERM, IAME, Paris, France.,Université de Tours, Université de Nantes, INSERM SPHERE, UMR 1246, Tours, France.,Institut Roche, Boulogne-Billancourt, France.,Clinical Pharmacolgy, Genentech/Roche, Paris, France
| | | | - Solène Desmée
- Université de Tours, Université de Nantes, INSERM SPHERE, UMR 1246, Tours, France
| | - Christophe Le Tourneau
- Department of Drug Development and Innovation (D3i), INSERM U900 Research Unit, Paris-Saclay University, Paris & Saint-Cloud, France
| | | | - René Bruno
- Clinical Pharmacology, Genentech Inc, Marseille, France
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Grisic A, Venkatakrishnan K, French J, Khandelwal A. Variable or variate? A conundrum in pharmacometrics exposure-response models. CPT Pharmacometrics Syst Pharmacol 2022; 12:144-147. [PMID: 36537836 PMCID: PMC9931432 DOI: 10.1002/psp4.12905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/15/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
Key elements of scientific writing-consistency and clarity-can be compromised in case of inaccurate use of methodological terms, especially in complex and multidisciplinary scientific fields. Such is the case in reports of pharmacometrics exposure-response analyses with the use of the terms univariate/multivariate and univariable/multivariable. This perspective outlines the issues in the use of these terms, clarifies their definitions, provides examples, and makes recommendations for authors, reviewers, and journals in the fields of clinical pharmacology and pharmacometrics.
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Venkatakrishnan K, van der Graaf PH. Toward Project Optimus for Oncology Precision Medicine: Multi-Dimensional Dose Optimization Enabled by Quantitative Clinical Pharmacology. Clin Pharmacol Ther 2022; 112:927-932. [PMID: 36264968 DOI: 10.1002/cpt.2742] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | - Piet H van der Graaf
- Certara QSP, Certara UK Ltd, Sheffield, UK.,Leiden University, Leiden, The Netherlands
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Vugmeyster Y, Grisic AM, Wilkins JJ, Loos AH, Hallwachs R, Osada M, Venkatakrishnan K, Khandelwal A. Model-informed approach for risk management of bleeding toxicities for bintrafusp alfa, a bifunctional fusion protein targeting TGF-β and PD-L1. Cancer Chemother Pharmacol 2022; 90:369-379. [PMID: 36066618 PMCID: PMC9474582 DOI: 10.1007/s00280-022-04468-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/17/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Bintrafusp alfa (BA) is a bifunctional fusion protein composed of the extracellular domain of the transforming growth factor-β (TGF-β) receptor II fused to a human immunoglobulin G1 antibody blocking programmed death ligand 1 (PD-L1). The recommended phase 2 dose (RP2D) was selected based on phase 1 efficacy, safety, and pharmacokinetic (PK)-pharmacodynamic data, assuming continuous inhibition of PD-L1 and TGF-β is required. Here, we describe a model-informed dose modification approach for risk management of BA-associated bleeding adverse events (AEs). METHODS The PK and AE data from studies NCT02517398, NCT02699515, NCT03840915, and NCT04246489 (n = 936) were used. Logistic regression analyses were conducted to evaluate potential relationships between bleeding AEs and BA time-averaged concentration (Cavg), derived using a population PK model. The percentage of patients with trough concentrations associated with PD-L1 or TGF-β inhibition across various dosing regimens was derived. RESULTS The probability of bleeding AEs increased with increasing Cavg; 50% dose reduction was chosen based on the integration of modeling and clinical considerations. The resulting AE management guidance to investigators regarding temporary or permanent treatment discontinuation was further refined with recommendations on restarting at RP2D or at 50% dose, depending on the grade and type of bleeding (tumoral versus nontumoral) and investigator assessment of risk of additional bleeding. CONCLUSION A pragmatic model-informed approach for management of bleeding AEs was implemented in ongoing clinical trials of BA. This approach is expected to improve benefit-risk profile; however, its effectiveness will need to be evaluated based on safety data generated after implementation.
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Affiliation(s)
- Yulia Vugmeyster
- EMD Serono Research and Development Institute, Inc., An Affiliate of Merck KGaA, 45 Middlesex Turnpike, Billerica, MA, 01821, USA.
| | - Ana-Marija Grisic
- Merck Healthcare KGaA, Frankfurter Str. 250, 64293, Darmstadt, Germany
| | | | - Anja H Loos
- Merck Healthcare KGaA, Frankfurter Str. 250, 64293, Darmstadt, Germany
| | - Roland Hallwachs
- Merck Healthcare KGaA, Frankfurter Str. 250, 64293, Darmstadt, Germany
| | - Motonobu Osada
- Merck Biopharma Co., Ltd., An Affiliate of Merck KGaA, Tokyo, Japan
| | - Karthik Venkatakrishnan
- EMD Serono Research and Development Institute, Inc., An Affiliate of Merck KGaA, 45 Middlesex Turnpike, Billerica, MA, 01821, USA
| | - Akash Khandelwal
- Merck Healthcare KGaA, Frankfurter Str. 250, 64293, Darmstadt, Germany.
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Holstein SA, Venkatakrishnan K, van der Graaf PH. Quantitative Clinical Pharmacology of CAR T-Cell Therapy. Clin Pharmacol Ther 2022; 112:11-15. [PMID: 35716389 DOI: 10.1002/cpt.2631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 04/29/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Sarah A Holstein
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Piet H van der Graaf
- Certera QSP, Certara UK Ltd., Sheffield, UK.,Leiden University, Leiden, The Netherlands
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