Modifying phase I methodology to facilitate enrolment of molecularly selected patients

The Use of Patient-Reported Outcome Measures in Phase I Oncology Clinical Trials

OBJECTIVE

To investigate patient-reported outcome (PRO) usage in phase I oncology clinical trials, including types of PRO measures and changes over time.

METHODS

We analyzed ClinicalTrials.gov records of phase I oncology clinical trials completed by December 2019.

RESULTS

Of all eligible trials, 2.3% (129/5,515) reported ≥1 PRO, totaling 181 instances of PRO usage. PRO usage increased over time, from 0.6% (trials initiated before 2000) to 3.4% (trials starting between 2015 and 2019). The most common PRO measures were unspecified (29%), tumor-specific (24%), and generic cancer (19%).

CONCLUSION

Although uncommon in phase I oncology clinical trials, PRO usage is increasing over time. PRO measures were often unspecified on ClinicalTrials.gov, suggesting that more precise reporting and standardization are needed.

Clinical research in small genomically stratified patient populations

The paradigm of early drug development in cancer is shifting from 'histology-oriented' to 'molecularly oriented' clinical trials. This change can be attributed to the vast amount of tumour biology knowledge generated by large international research initiatives such as The Cancer Genome Atlas (TCGA) and the use of next generation sequencing (NGS) techniques developed in recent years. However, targeting infrequent molecular alterations entails a series of special challenges. The optimal molecular profiling method, the lack of standardised biological thresholds, inter- and intra-tumor heterogeneity, availability of enough tumour material, correct clinical trials design, attrition rate, logistics or costs are only some of the issues that need to be taken into consideration in clinical research in small genomically stratified patient populations. This article examines the most relevant challenges inherent to clinical research in these populations. Moreover, perspectives from the Academia point of view are reviewed as well as initiatives to be taken in forthcoming years.

An analysis of common ethical justifications for compassionate use programs for experimental drugs

BACKGROUND

When a new intervention or drug is developed, this has to pass through various phases of clinical testing before it achieves market approval, which can take many years. This raises an issue for drugs which could benefit terminally ill patients. These patients might set their hopes on the experimental drug but are unable to wait since they are likely to pass away before the drug is available. As a means of nevertheless getting access to experimental drug, many seriously ill and terminally ill patients are therefore very willing to participate in randomised controlled trials. However, only very few terminally ill patients are able to actually participate, and those that do participate are at risk of participating solely as a way of getting experimental drugs. Currently, there are, however, ways of getting access to drugs that have not (yet) gained market approval. One such mean is via expanded access or compassionate use programs where terminally ill patients receive experimental new drugs that are not yet market approved. In this paper, I examine some of the common justifications for such programs.

MAIN BODY

The most frequently voiced justifications for compassionate use or expanded access programs could be put in one of three categories. First, there are justifications of justice, where compassionate use programs could be seen as a just or fair way to distribute experimental new drugs to patients who are denied access to RCT's through no fault of their own. Second, such programs could be justified by reference to the ethical principle of beneficence where it could be claimed that terminally ill patients stand to benefit greatly at very little risk (as they are already dying). Third, there are considerations of autonomy where, it is claimed, patients should be able to exercise their autonomy and have access to such drugs if that is there free choice and they are fully aware of the risks associated with that choice.

SHORT CONCLUSION

In this paper, I argue currently all justifications are potentially problematic. If they truly form the basis for justification, compassionate use programs should be designed to maximize justice, beneficence and autonomy.

A Case-Control Study Brings to Light the Causes of Screen Failures in Phase 1 Cancer Clinical Trials

Introduction

Enrolling cancer patients in phase I clinical trials (P1s) requires that they fulfill specific criteria. Between the time they sign the consent form and the 1^st administration of the experimental drug, some patients may be excluded and considered as screen failures (SFs). Our objective was to assess SF patients profiles and the reasons and risk factors for SFs.

Materials and Methods

All patients included in P1s at Gustave Roussy from 2008 to 2013 were reviewed retrospectively. SFs were matched with control P1 patients who were successfully enrolled. Patient and tumor characteristics, P1 types and the reasons for SF were analyzed.

Results

Among 1,293 patients, 192 (15%) were SF cases; 182 SF cases were matched with 182 controls: median age was 57 (48–64) and 55 (47–63), median home-cancer center distance was 69 vs 55 km, 45% vs 34% had more than 2 metastatic sites, median screening period was 14 vs 11 days, median progression-free survival during the previous line was 12 vs 14 weeks, 37% vs 29% of LDH values were above the upper limit of normal, 42% vs 36% of albumin values were < 35 g/L, respectively. Reasons for SFs were cancer progression (44%), sponsor decision unrelated to a clinical reason (25%), patient retrieval (13.5%), relevant comorbidity (13.5%). Multivariate analysis revealed that a high Royal Marsden Hospital (RMH) prognostic score was potentially associated with higher risk of SFs (OR = 2.3; 95% CI [1.0–5.7], p = 0.06).

Conclusion

Cancer progression led to half of the SFs in P1s. Physicians should pay attention to the RMH score at the time of patient inclusion to avoid further SFs.

Cancer genomics: the challenge of drug accessibility

PURPOSE OF REVIEW

Although significant strides have been made in genome sequencing technology, target-drug matching remains challenging. This article highlights the difficulties associated with patients accessing targeted drugs based on genomic information, and some proposed solutions.

RECENT FINDINGS

Although cancers are increasingly stratified according to molecular subgroups, challenges remain in improving patient outcome based on drug-target matching. Before a drug-target match is even proposed, significant expertise is required of the clinician to interpret genomic information. Once a potential match is made, barriers remain for patients to access treatment via clinical trials, as approved agents on-label or off-label, or through expanded access programs. Solutions to improve drug accessibility are actively being investigated. Several prospective trials using molecular characterization as an entry to access target-drug matching are underway. For those unable to access target-drug matching on trial, proposals for a facilitated access program and registry have been suggested.

SUMMARY

Although improvements have been made in the drug development and approval timelines, drug accessibility based on molecular characterization remains problematic. However, with the emergence of novel trial designs, and efforts to enhance drug access outside of clinical trial settings, opportunities for drug-target matching are improving.

The changing landscape of phase I trials in oncology

KEY POINTS

Several aspects of phase I trials have evolved in the current era of molecular targeted agents to adapt to the changing nature of anticancer therapy and to increase the efficiency of drug development.

Current phase I designs are increasingly integrating novel dose-escalation approaches and biomarker-driven selection of patients, as well as expanding study objectives to include the evaluation of efficacy and pharmacodynamics/pharmacokinetics in addition to safety.

Changes to the regulatory approval process have helped to expedite drug development, particularly for novel agents with a strong biologic rationale and proof of concept, validated predictive biomarker, and clear evidence of efficacy in early trials.

As a result of the substantial changes in phase I trial goals and conduct, there is a parallel shift toward multi-institutional trials and central study management by clinical research organizations.

The use of multi-institutional trials has a significant impact on the structure of phase I programs and the experience of investigators, particularly because of limited patient enrollment at each site.