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Lee SY. Using Bayesian statistics in confirmatory clinical trials in the regulatory setting: a tutorial review. BMC Med Res Methodol 2024; 24:110. [PMID: 38714936 PMCID: PMC11077897 DOI: 10.1186/s12874-024-02235-0] [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: 12/01/2023] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
Bayesian statistics plays a pivotal role in advancing medical science by enabling healthcare companies, regulators, and stakeholders to assess the safety and efficacy of new treatments, interventions, and medical procedures. The Bayesian framework offers a unique advantage over the classical framework, especially when incorporating prior information into a new trial with quality external data, such as historical data or another source of co-data. In recent years, there has been a significant increase in regulatory submissions using Bayesian statistics due to its flexibility and ability to provide valuable insights for decision-making, addressing the modern complexity of clinical trials where frequentist trials are inadequate. For regulatory submissions, companies often need to consider the frequentist operating characteristics of the Bayesian analysis strategy, regardless of the design complexity. In particular, the focus is on the frequentist type I error rate and power for all realistic alternatives. This tutorial review aims to provide a comprehensive overview of the use of Bayesian statistics in sample size determination, control of type I error rate, multiplicity adjustments, external data borrowing, etc., in the regulatory environment of clinical trials. Fundamental concepts of Bayesian sample size determination and illustrative examples are provided to serve as a valuable resource for researchers, clinicians, and statisticians seeking to develop more complex and innovative designs.
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Affiliation(s)
- Se Yoon Lee
- Department of Statistics, Texas A &M University, 3143 TAMU, College Station, TX, 77843, USA.
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Barnes C, Jones J, Wolfenden L, Robertson K, Seidler AL, Norman J, Budgen P, Mattingly M, Piliskic C, Moorhouse L, Mozina J, Plaskett J, McDermott S, Darney S, Vuong C, Douglass N, McDonnell K, Sutherland R. A collaborative network trial to evaluate the effectiveness of implementation strategies to maximize adoption of a school-based healthy lunchbox program: a study protocol. Front Public Health 2024; 12:1367017. [PMID: 38601495 PMCID: PMC11004312 DOI: 10.3389/fpubh.2024.1367017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/12/2024] [Indexed: 04/12/2024] Open
Abstract
Introduction An important impediment to the large-scale adoption of evidence-based school nutrition interventions is the lack of evidence on effective strategies to implement them. This paper describes the protocol for a "Collaborative Network Trial" to support the simultaneous testing of different strategies undertaken by New South Wales Local Health Districts to facilitate the adoption of an effective school-based healthy lunchbox program ('SWAP IT'). The primary objective of this study is to assess the effectiveness of different implementation strategies to increase school adoption of the SWAP across New South Wales Local Health Districts. Methods Within a Master Protocol framework, a collaborative network trial will be undertaken. Independent randomized controlled trials to test implementation strategies to increase school adoption of SWAP IT within primary schools in 10 different New South Wales Local Health Districts will occur. Schools will be randomly allocated to either the intervention or control condition. Schools allocated to the intervention group will receive a combination of implementation strategies. Across the 10 participating Local Health Districts, six broad strategies were developed and combinations of these strategies will be executed over a 6 month period. In six districts an active comparison group (containing one or more implementation strategies) was selected. The primary outcome of the trial will be adoption of SWAP IT, assessed via electronic registration records captured automatically following online school registration to the program. The primary outcome will be assessed using logistic regression analyses for each trial. Individual participant data component network meta-analysis, under a Bayesian framework, will be used to explore strategy-covariate interactions; to model additive main effects (separate effects for each component of an implementation strategy); two way interactions (synergistic/antagonistic effects of components), and full interactions. Discussion The study will provide rigorous evidence of the effects of a variety of implementation strategies, employed in different contexts, on the adoption of a school-based healthy lunchbox program at scale. Importantly, it will also provide evidence as to whether health service-centered, collaborative research models can rapidly generate new knowledge and yield health service improvements. Clinical trial registration This trial is registered prospectively with the Australian New Zealand Clinical Trials Registry (ACTRN12623000558628).
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Affiliation(s)
- Courtney Barnes
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- National Centre of Implementation Science, University of Newcastle, Callaghan, NSW, Australia
| | - Jannah Jones
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- National Centre of Implementation Science, University of Newcastle, Callaghan, NSW, Australia
| | - Luke Wolfenden
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- National Centre of Implementation Science, University of Newcastle, Callaghan, NSW, Australia
| | - Katie Robertson
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- National Centre of Implementation Science, University of Newcastle, Callaghan, NSW, Australia
| | - Anna Lene Seidler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Jennifer Norman
- Health Promotion Service, Illawarra Shoalhaven Local Health District, Warrawong, NSW, Australia
- School of Health and Society, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW, Australia
| | - Pip Budgen
- Health Promotion Service, Illawarra Shoalhaven Local Health District, Warrawong, NSW, Australia
| | - Megan Mattingly
- Health Promotion, Murrumbidgee Local Health District, Albury, NSW, Australia
| | - Carla Piliskic
- Health Promotion Unit, Population Health, Nepean Blue Mountains Local Health District, Penrith, NSW, Australia
| | - Lisa Moorhouse
- Health Equity, Promotion and Prevention Service, South Eastern Sydney Local Health District, Darlinghurst, NSW, Australia
| | - Jennifer Mozina
- Population Health, Southern NSW Local Health District, Queanbeyan, NSW, Australia
| | - Jennifer Plaskett
- Centre for Population Health, Western Sydney Local Health District, North Parramatta, NSW, Australia
| | - Sarah McDermott
- Centre for Population Health, Western Sydney Local Health District, North Parramatta, NSW, Australia
| | - Sara Darney
- Western NSW Health Promotion, Western NSW Local Health District, Dubbo, NSW, Australia
| | - Cecilia Vuong
- Health Promotion Service, South Western Sydney Local Health District, Liverpool, NSW, Australia
| | - Nina Douglass
- Health Promotion Service, Central Coast Local Health District, Gosford, NSW, Australia
| | - Kara McDonnell
- Population Health Promotion, Northern Sydney Local Health District, Brookvale, NSW, Australia
| | - Rachel Sutherland
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- National Centre of Implementation Science, University of Newcastle, Callaghan, NSW, Australia
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Gagg H, Williams ST, Conroy S, Myers KN, McGarrity-Cottrell C, Jones C, Helleday T, Rantala J, Rominiyi O, Danson SJ, Collis SJ, Wells G. Ex-vivo drug screening of surgically resected glioma stem cells to replace murine avatars and provide personalise cancer therapy for glioblastoma patients. F1000Res 2024; 12:954. [PMID: 37799492 PMCID: PMC10548111 DOI: 10.12688/f1000research.135809.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 10/07/2023] Open
Abstract
With diminishing returns and high clinical failure rates from traditional preclinical and animal-based drug discovery strategies, more emphasis is being placed on alternative drug discovery platforms. Ex vivo approaches represent a departure from both more traditional preclinical animal-based models and clinical-based strategies and aim to address intra-tumoural and inter-patient variability at an earlier stage of drug discovery. Additionally, these approaches could also offer precise treatment stratification for patients within a week of tumour resection in order to direct tailored therapy. One tumour group that could significantly benefit from such ex vivo approaches are high-grade gliomas, which exhibit extensive heterogeneity, cellular plasticity and therapy-resistant glioma stem cell (GSC) niches. Historic use of murine-based preclinical models for these tumours has largely failed to generate new therapies, resulting in relatively stagnant and unacceptable survival rates of around 12-15 months post-diagnosis over the last 50 years. The near universal use of DNA damaging chemoradiotherapy after surgical resection within standard-of-care (SoC) therapy regimens provides an opportunity to improve current treatments if we can identify efficient drug combinations in preclinical models that better reflect the complex inter-/intra-tumour heterogeneity, GSC plasticity and inherent DNA damage resistance mechanisms. We have therefore developed and optimised a high-throughput ex vivo drug screening platform; GliExP, which maintains GSC populations using immediately dissociated fresh surgical tissue. As a proof-of-concept for GliExP, we have optimised SoC therapy responses and screened 30+ small molecule therapeutics and preclinical compounds against tumours from 18 different patients, including multi-region spatial heterogeneity sampling from several individual tumours. Our data therefore provides a strong basis to build upon GliExP to incorporate combination-based oncology therapeutics in tandem with SoC therapies as an important preclinical alternative to murine models (reduction and replacement) to triage experimental therapeutics for clinical translation and deliver rapid identification of effective treatment strategies for individual gliomas.
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Affiliation(s)
- Hannah Gagg
- Oncology & Metabolism, The University of Sheffield, Sheffield, England, S10 2RX, UK
| | - Sophie T. Williams
- Oncology & Metabolism, The University of Sheffield, Sheffield, England, S10 2RX, UK
- Neurosurgery, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Samantha Conroy
- Oncology & Metabolism, The University of Sheffield, Sheffield, England, S10 2RX, UK
- Urology, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Katie N. Myers
- Oncology & Metabolism, The University of Sheffield, Sheffield, England, S10 2RX, UK
| | | | - Callum Jones
- Oncology & Metabolism, The University of Sheffield, Sheffield, England, S10 2RX, UK
| | - Thomas Helleday
- Oncology & Metabolism, The University of Sheffield, Sheffield, England, S10 2RX, UK
- Karolinska Institut, Solnavägen, Solna, 171 77, Sweden
| | - Juha Rantala
- Oncology & Metabolism, The University of Sheffield, Sheffield, England, S10 2RX, UK
- Misvik Biology Ltd, Karjakatu, Turku, FI-20520, Finland
| | - Ola Rominiyi
- Oncology & Metabolism, The University of Sheffield, Sheffield, England, S10 2RX, UK
- Neurosurgery, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Sarah J. Danson
- Oncology & Metabolism, The University of Sheffield, Sheffield, England, S10 2RX, UK
- Weston Park Hospital, Sheffield, S10 2SJ, UK
| | - Spencer J. Collis
- Oncology & Metabolism, The University of Sheffield, Sheffield, England, S10 2RX, UK
| | - Greg Wells
- Oncology & Metabolism, The University of Sheffield, Sheffield, England, S10 2RX, UK
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Duan XP, Qin BD, Jiao XD, Liu K, Wang Z, Zang YS. New clinical trial design in precision medicine: discovery, development and direction. Signal Transduct Target Ther 2024; 9:57. [PMID: 38438349 PMCID: PMC10912713 DOI: 10.1038/s41392-024-01760-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 03/06/2024] Open
Abstract
In the era of precision medicine, it has been increasingly recognized that individuals with a certain disease are complex and different from each other. Due to the underestimation of the significant heterogeneity across participants in traditional "one-size-fits-all" trials, patient-centered trials that could provide optimal therapy customization to individuals with specific biomarkers were developed including the basket, umbrella, and platform trial designs under the master protocol framework. In recent years, the successive FDA approval of indications based on biomarker-guided master protocol designs has demonstrated that these new clinical trials are ushering in tremendous opportunities. Despite the rapid increase in the number of basket, umbrella, and platform trials, the current clinical and research understanding of these new trial designs, as compared with traditional trial designs, remains limited. The majority of the research focuses on methodologies, and there is a lack of in-depth insight concerning the underlying biological logic of these new clinical trial designs. Therefore, we provide this comprehensive review of the discovery and development of basket, umbrella, and platform trials and their underlying logic from the perspective of precision medicine. Meanwhile, we discuss future directions on the potential development of these new clinical design in view of the "Precision Pro", "Dynamic Precision", and "Intelligent Precision". This review would assist trial-related researchers to enhance the innovation and feasibility of clinical trial designs by expounding the underlying logic, which be essential to accelerate the progression of precision medicine.
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Affiliation(s)
- Xiao-Peng Duan
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Bao-Dong Qin
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Xiao-Dong Jiao
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Ke Liu
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zhan Wang
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yuan-Sheng Zang
- Department of Medical Oncology, Changzheng Hospital, Naval Medical University, Shanghai, China.
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5
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Smith EJ, Naik A, Goel M, Wen PY, Lim M, Chang SM, Germano IM. Adult neuro-oncology trials in the United States over 5 decades: Analysis of trials completion rate to guide the path forward. Neurooncol Adv 2024; 6:vdad169. [PMID: 38312230 PMCID: PMC10838133 DOI: 10.1093/noajnl/vdad169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background Clinical trials are important to close the gap between therapeutic unmet needs and scientific advances in neuro-oncology. This study analyzes the landscape of neuro-oncology trials to identify completion rates and guide strategies for the path forward. Methods US-registered adult neuro-oncology clinical trials were extracted from www.clinicaltrials.gov (1966-2019), including funding source, trial type, scope, phase, and subjects' demographics. Completed trials defined as those that had completed participants' examinations or intervention administration for the purpose of the final collection of data for the primary outcome were dichotomized against those that failed to reach completion. Univariate and multivariate analyses were used to detect differences across factors comparing the last 2 decades (2000-2009, 2010-2019). Results Our search yielded 4522 trials, of which 1257 are eligible for this study. In 25 US states, neuro-oncology trial availability is <0.85/100,000 population. Comparing the past 2 decades, trial completion rate decreased from 88% to 64% (P < .001) and National Institutes of Health funding decreased from 47% to 24% (P < .001). Inclusion of subjects >65-year-old and women increased, while inclusion of Hispanic subjects decreased (P < .001). The top 2 reasons for lack of completion included accrual and operational difficulties. A larger proportion of women, non-Hispanic subjects, and older adults were enrolled in completed trials than in those that failed completion. Conclusions Our study is the first report on the neuro-oncology clinical trial landscape in the United States and supports the development of strategies to further improve access to these trials. Additionally, attention is needed to identify and modify other factors contributing to lack of completion.
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Affiliation(s)
- Emily J Smith
- Carle Illinois College of Medicine, Urbana, Illinois, USA
| | - Anant Naik
- Carle Illinois College of Medicine, Urbana, Illinois, USA
| | - Mahima Goel
- Carle Illinois College of Medicine, Urbana, Illinois, USA
| | - Patrick Y Wen
- Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Lim
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Susan M Chang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | - Isabelle M Germano
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Rahman R, Trippa L, Lee EQ, Arrillaga-Romany I, Fell G, Touat M, McCluskey C, Wiley J, Gaffey S, Drappatz J, Welch MR, Galanis E, Ahluwalia MS, Colman H, Nabors LB, Hepel J, Elinzano H, Schiff D, Chukwueke UN, Beroukhim R, Nayak L, McFaline-Figueroa JR, Batchelor TT, Rinne ML, Kaley TJ, Lu-Emerson C, Mellinghoff IK, Bi WL, Arnaout O, Peruzzi PP, Haas-Kogan D, Tanguturi S, Cagney D, Aizer A, Doherty L, Lavallee M, Fisher-Longden B, Dowling S, Geduldig J, Watkinson F, Pisano W, Malinowski S, Ramkissoon S, Santagata S, Meredith DM, Chiocca EA, Reardon DA, Alexander BM, Ligon KL, Wen PY. Inaugural Results of the Individualized Screening Trial of Innovative Glioblastoma Therapy: A Phase II Platform Trial for Newly Diagnosed Glioblastoma Using Bayesian Adaptive Randomization. J Clin Oncol 2023; 41:5524-5535. [PMID: 37722087 DOI: 10.1200/jco.23.00493] [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: 03/03/2023] [Revised: 05/17/2023] [Accepted: 07/24/2023] [Indexed: 09/20/2023] Open
Abstract
PURPOSE The Individualized Screening Trial of Innovative Glioblastoma Therapy (INSIGhT) is a phase II platform trial that uses response adaptive randomization and genomic profiling to efficiently identify novel therapies for phase III testing. Three initial experimental arms (abemaciclib [a cyclin-dependent kinase [CDK]4/6 inhibitor], neratinib [an epidermal growth factor receptor [EGFR]/human epidermal growth factor receptor 2 inhibitor], and CC-115 [a deoxyribonucleic acid-dependent protein kinase/mammalian target of rapamycin inhibitor]) were simultaneously evaluated against a common control arm. We report the results for each arm and examine the feasibility and conduct of the adaptive platform design. PATIENTS AND METHODS Patients with newly diagnosed O6-methylguanine-DNA methyltransferase-unmethylated glioblastoma were eligible if they had tumor genotyping to identify prespecified biomarker subpopulations of dominant glioblastoma signaling pathways (EGFR, phosphatidylinositol 3-kinase, and CDK). Initial random assignment was 1:1:1:1 between control (radiation therapy and temozolomide) and the experimental arms. Subsequent Bayesian adaptive randomization was incorporated on the basis of biomarker-specific progression-free survival (PFS) data. The primary end point was overall survival (OS), and one-sided P values are reported. The trial is registered with ClinicalTrials.gov (identifier: NCT02977780). RESULTS Two hundred thirty-seven patients were treated (71 control; 73 abemaciclib; 81 neratinib; 12 CC-115) in years 2017-2021. Abemaciclib and neratinib were well tolerated, but CC-115 was associated with ≥ grade 3 treatment-related toxicity in 58% of patients. PFS was significantly longer with abemaciclib (hazard ratio [HR], 0.72; 95% CI, 0.49 to 1.06; one-sided P = .046) and neratinib (HR, 0.72; 95% CI, 0.50 to 1.02; one-sided P = .033) relative to the control arm but there was no PFS benefit with CC-115 (one-sided P = .523). None of the experimental therapies demonstrated a significant OS benefit (P > .05). CONCLUSION The INSIGhT design enabled efficient simultaneous testing of three experimental agents using a shared control arm and adaptive randomization. Two investigational arms had superior PFS compared with the control arm, but none demonstrated an OS benefit. The INSIGhT design may promote improved and more efficient therapeutic discovery in glioblastoma. New arms have been added to the trial.
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Affiliation(s)
- Rifaquat Rahman
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Eudocia Q Lee
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | - Mehdi Touat
- Brigham and Women's Hospital, Boston, MA
- Sorbonne Universite, Hôpitaux Universitaires La Pitié Salpêtrière, Paris, France
| | | | | | | | | | - Mary R Welch
- Division of Neuro-Oncology, Department of Neurology and Herbert Irving Comprehensive Cancer Center, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian, New York, NY
| | | | | | - Howard Colman
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | | | | | | | - Ugonma N Chukwueke
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Rameen Beroukhim
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Lakshmi Nayak
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Tracy T Batchelor
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | - Wenya Linda Bi
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | - Daphne Haas-Kogan
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Shyam Tanguturi
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | - Ayal Aizer
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | | | | | - David A Reardon
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Brian M Alexander
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Keith L Ligon
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Patrick Y Wen
- Dana-Farber Cancer Institute, Boston, MA
- Brigham and Women's Hospital, Boston, MA
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Vanderlinden A, Jones CG, Myers KN, Rominiyi O, Collis SJ. DNA damage response inhibitors enhance tumour treating fields (TTFields) potency in glioma stem-like cells. Br J Cancer 2023; 129:1829-1840. [PMID: 37777579 PMCID: PMC10667536 DOI: 10.1038/s41416-023-02454-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/19/2023] [Accepted: 09/22/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND High-grade gliomas are primary brain cancers with unacceptably low and persistent survival rates of 10-16 months for WHO grade 4 gliomas over the last 40 years, despite surgical resection and DNA-damaging chemo-radiotherapy. More recently, tumour-treating fields therapy (TTFields) has demonstrated modest survival benefit and been clinically approved in several countries. TTFields is thought to mediate anti-cancer activity by primarily disrupting mitosis. However, recent data suggest that TTFields may also attenuate DNA damage repair and replication fork dynamics, providing a potential platform for therapeutic combinations incorporating standard-of-care treatments and targeted DNA damage response inhibitors (DDRi). METHODS We have used patient-derived, typically resistant, glioma stem-like cells (GSCs) in combination with the previously validated preclinical Inovitro™ TTFields system together with a number of therapeutic DDRi. RESULTS We show that TTFields robustly activates PARP- and ATR-mediated DNA repair (including PARylation and CHK1 phosphorylation, respectively), whilst combining TTFields with PARP1 or ATR inhibitor treatment leads to significantly reduced clonogenic survival. The potency of each of these strategies is further enhanced by radiation treatment, leading to increased amounts of DNA damage with profound delay in DNA damage resolution. CONCLUSION To our knowledge, our findings represent the first report of TTFields applied with clinically approved or in-trial DDRi in GSC models and provides a basis for translational studies toward multimodal DDRi/TTFields-based therapeutic strategies for patients with these currently incurable tumours.
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Affiliation(s)
- Aurelie Vanderlinden
- Division of Clinical Medicine, The University of Sheffield, School of Medicine and Population Health, Sheffield, S10 2RX, UK
| | - Callum G Jones
- Division of Clinical Medicine, The University of Sheffield, School of Medicine and Population Health, Sheffield, S10 2RX, UK
| | - Katie N Myers
- Division of Clinical Medicine, The University of Sheffield, School of Medicine and Population Health, Sheffield, S10 2RX, UK
| | - Ola Rominiyi
- Division of Clinical Medicine, The University of Sheffield, School of Medicine and Population Health, Sheffield, S10 2RX, UK.
- Division of Neuroscience, The University of Sheffield, School of Medicine and Population Health, Sheffield, S10 2RX, UK.
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, S10 2JF, UK.
| | - Spencer J Collis
- Division of Clinical Medicine, The University of Sheffield, School of Medicine and Population Health, Sheffield, S10 2RX, UK.
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Hirsch G, Velentgas P, Curtis JR, Larholt K, Park JJH, Pashos CL, Trinquart L. Extending the vision of adaptive point-of-care platform trials to improve targeted use of drug therapy regimens: An agile approach in the learning healthcare system toolkit. Contemp Clin Trials 2023; 133:107327. [PMID: 37652359 DOI: 10.1016/j.cct.2023.107327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/24/2023] [Accepted: 08/28/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVES Improving the targeted use of drug regimens requires robust real-world evidence (RWE) to address the uncertainties that remain regarding their real-world performance following market entry. However, challenges in the current state of RWE production limit its impact on clinical decisions, as well as its operational scalability and sustainability. We propose an adaptive point-of-care (APoC) platform trial as an approach to RWE production that improves both clinical and operational efficiencies. METHODS AND FINDINGS We explored design innovations, operational challenges, and infrastructure needs within a multi-stakeholder consortium to evaluate the potential of an APoC platform trial for studying chronic disease treatment regimens using rheumatoid arthritis as a case study. The concept integrates elements from adaptive clinical trials (dynamic treatment regimen strategies) and point-of-care trials (research embedded into routine clinical care) under a perpetual platform infrastructure. The necessary components to implement an APoC platform trial within outpatient settings exist, and present an opportunity for a cross-disciplinary, multi-stakeholder approach. Effective engagement of key stakeholders involved in and impacted by the platform is critical to success. Our collaborative design process identified three high-impact stakeholder-engagement areas: (1) focus on research question(s), (2) design and implementation planning such that it is feasible and fit-for-purpose, and (3) measurement, or meaningful metrics for both clinical (patient outcomes) and system (operational efficiencies) impact. CONCLUSIONS An APoC platform trial for rheumatoid arthritis integrating innovative design elements in a scalable infrastructure has the potential to reduce important uncertainties about the real-world performance of biomedical innovations and improve clinical decisions.
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Affiliation(s)
- Gigi Hirsch
- Center for Biomedical System Design & NEWDIGS, Tufts Medical Center, Boston, MA, USA.
| | | | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Illumination Health, Hoover, AL, USA
| | - Kay Larholt
- Center for Biomedical System Design & NEWDIGS, Tufts Medical Center, Boston, MA, USA
| | - Jay J H Park
- Core Clinical Sciences Inc, Vancouver, BC, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Ludovic Trinquart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
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Agarwal A, Marion J, Nagy P, Robinson M, Walkey A, Sevransky J. How Electronic Medical Record Integration Can Support More Efficient Critical Care Clinical Trials. Crit Care Clin 2023; 39:733-749. [PMID: 37704337 DOI: 10.1016/j.ccc.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Large volumes of data are collected on critically ill patients, and using data science to extract information from the electronic medical record (EMR) and to inform the design of clinical trials represents a new opportunity in critical care research. Using improved methods of phenotyping critical illnesses, subject identification and enrollment, and targeted treatment group assignment alongside newer trial designs such as adaptive platform trials can increase efficiency while lowering costs. Some tools such as the EMR to automate data collection are already in use. Refinement of data science approaches in critical illness research will allow for better clinical trials and, ultimately, improved patient outcomes.
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Affiliation(s)
- Ankita Agarwal
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
| | | | - Paul Nagy
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew Robinson
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan Walkey
- Department of Medicine - Section of Pulmonary, Allergy, Critical Care and Sleep Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jonathan Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA.
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Kim Y, Armstrong TS, Gilbert MR, Celiku O. A critical analysis of neuro-oncology clinical trials. Neuro Oncol 2023; 25:1658-1671. [PMID: 36757281 PMCID: PMC10484169 DOI: 10.1093/neuonc/noad036] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Limitations in trial design, accrual, and data reporting impact efficient and reliable drug evaluation in cancer clinical trials. These concerns have been recognized in neuro-oncology but have not been comprehensively evaluated. We conducted a semi-automated survey of adult interventional neuro-oncology trials, examining design, interventions, outcomes, and data availability trends. METHODS Trials were selected programmatically from ClinicalTrials.gov using primary malignant central nervous system tumor classification terms. Regression analyses assessed design and accrual trends; effect size analysis utilized survival rates among trials investigating survival. RESULTS Of 3038 reviewed trials, most trials reporting relevant information were nonblinded (92%), single group (65%), nonrandomized (51%), and studied glioblastomas (47%) or other gliomas. Basic design elements were reported by most trials, with reporting increasing over time (OR = 1.24, P < .00001). Trials assessing survival outcomes were estimated to assume large effect sizes of interventions when powering their designs. Forty-two percent of trials were completed; of these, 38% failed to meet their enrollment target, with worse accrual over time (R = -0.94, P < .00001) and for US versus non-US based trials (OR = 0.5, P < .00001). Twenty-eight percent of completed trials reported partial results, with greater reporting for US (34.6%) versus non-US based trials (9.3%, P < .00001). Efficacy signals were detected by 15%-23% of completed trials reporting survival outcomes. CONCLUSION Low randomization rates, underutilization of controls, and overestimation of effect size, particularly pronounced in early-phase trials, impede generalizability of results. Suboptimal designs may be driven by accrual challenges, underscoring the need for cooperative efforts and novel designs. The limited results reporting highlights the need to incentivize data reporting and harmonization.
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Affiliation(s)
- Yeonju Kim
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Terri S Armstrong
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mark R Gilbert
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Orieta Celiku
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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11
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Quintana M, Saville BR, Vestrucci M, Detry MA, Chibnik L, Shefner J, Berry JD, Chase M, Andrews J, Sherman AV, Yu H, Drake K, Cudkowicz M, Paganoni S, Macklin EA. Design and Statistical Innovations in a Platform Trial for Amyotrophic Lateral Sclerosis. Ann Neurol 2023; 94:547-560. [PMID: 37245090 DOI: 10.1002/ana.26714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Abstract
Platform trials allow efficient evaluation of multiple interventions for a specific disease. The HEALEY ALS Platform Trial is testing multiple investigational products in parallel and sequentially in persons with amyotrophic lateral sclerosis (ALS) with the goal of rapidly identifying novel treatments to slow disease progression. Platform trials have considerable operational and statistical efficiencies compared with typical randomized controlled trials due to their use of shared infrastructure and shared control data. We describe the statistical approaches required to achieve the objectives of a platform trial in the context of ALS. This includes following regulatory guidance for the disease area of interest and accounting for potential differences in outcomes of participants within the shared control (potentially due to differences in time of randomization, mode of administration, and eligibility criteria). Within the HEALEY ALS Platform Trial, the complex statistical objectives are met using a Bayesian shared parameter analysis of function and survival. This analysis serves to provide a common integrated estimate of treatment benefit, overall slowing in disease progression, as measured by function and survival while accounting for potential differences in the shared control group using Bayesian hierarchical modeling. Clinical trial simulation is used to provide a better understanding of this novel analysis method and complex design. ANN NEUROL 2023;94:547-560.
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Affiliation(s)
| | - Benjamin R Saville
- Berry Consultants, Austin, Texas, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Lori Chibnik
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy Shefner
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - James D Berry
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Marianne Chase
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Jinsy Andrews
- Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Alexander V Sherman
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Hong Yu
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristin Drake
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Merit Cudkowicz
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Sabrina Paganoni
- Sean M. Healey & AMG Center for ALS at Mass General, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
| | - Eric A Macklin
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona, USA
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12
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Cho NS, Wong WK, Nghiemphu PL, Cloughesy TF, Ellingson BM. The Future Glioblastoma Clinical Trials Landscape: Early Phase 0, Window of Opportunity, and Adaptive Phase I-III Studies. Curr Oncol Rep 2023; 25:1047-1055. [PMID: 37402043 PMCID: PMC10474988 DOI: 10.1007/s11912-023-01433-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 07/05/2023]
Abstract
PURPOSE OF REVIEW Innovative clinical trial designs for glioblastoma (GBM) are needed to expedite drug discovery. Phase 0, window of opportunity, and adaptive designs have been proposed, but their advanced methodologies and underlying biostatistics are not widely known. This review summarizes phase 0, window of opportunity, and adaptive phase I-III clinical trial designs in GBM tailored to physicians. RECENT FINDINGS Phase 0, window of opportunity, and adaptive trials are now being implemented for GBM. These trials can remove ineffective therapies earlier during drug development and improve trial efficiency. There are two ongoing adaptive platform trials: GBM Adaptive Global Innovative Learning Environment (GBM AGILE) and the INdividualized Screening trial of Innovative GBM Therapy (INSIGhT). The future clinical trials landscape in GBM will increasingly involve phase 0, window of opportunity, and adaptive phase I-III studies. Continued collaboration between physicians and biostatisticians will be critical for implementing these trial designs.
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Affiliation(s)
- Nicholas S Cho
- UCLA Brain Tumor Imaging Laboratory, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, 924 Westwood Blvd., Suite 615, Los Angeles, CA, 90024, USA
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Bioengineering, Henry Samueli School of Engineering and Applied Science, University of California Los Angeles, Los Angeles, CA, USA
- Medical Scientist Training Program, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Weng Kee Wong
- Department of Biostatistics, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Phioanh L Nghiemphu
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Timothy F Cloughesy
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory, Center for Computer Vision and Imaging Biomarkers, Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, 924 Westwood Blvd., Suite 615, Los Angeles, CA, 90024, USA.
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Bioengineering, Henry Samueli School of Engineering and Applied Science, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
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13
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Schoenmakers DH, Leferink PS, Vanderver A, Bonkowsky JL, Krägeloh-Mann I, Bernard G, Bertini E, Fatemi A, Fogel BL, Wolf NI, Skwirut D, Buck A, Holberg B, Saunier-Vivar EF, Rauner R, Dekker H, van Bokhoven P, Stellingwerff MD, Berkhof J, van der Knaap MS. Core protocol development for phase 2/3 clinical trials in the leukodystrophy vanishing white matter: a consensus statement by the VWM consortium and patient advocates. BMC Neurol 2023; 23:305. [PMID: 37592248 PMCID: PMC10433679 DOI: 10.1186/s12883-023-03354-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 08/02/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The leukodystrophy "Vanishing White Matter" (VWM) is an orphan disease with neurological decline and high mortality. Currently, VWM has no approved treatments, but advances in understanding pathophysiology have led to identification of promising therapies. Several investigational medicinal products are either in or about to enter clinical trial phase. Clinical trials in VWM pose serious challenges, as VWM has an episodic disease course; disease phenotype is highly heterogeneous and predictable only for early onset; and study power is limited by the small patient numbers. To address these challenges and accelerate therapy delivery, the VWM Consortium, a group of academic clinicians with expertise in VWM, decided to develop a core protocol to function as a template for trials, to improve trial design and facilitate sharing of control data, while permitting flexibility regarding other trial details. Overall aims of the core protocol are to collect safety, tolerability, and efficacy data for treatment assessment and marketing authorization. METHODS To develop the core protocol, the VWM Consortium designated a committee, including clinician members of the VWM Consortium, family and patient group advocates, and experts in statistics, clinical trial design and alliancing with industries. We drafted three age-specific protocols, to stratify into more homogeneous patient groups, of ages ≥ 18 years, ≥ 6 to < 18 years and < 6 years. We chose double-blind, randomized, placebo-controlled design for patients aged ≥ 6 years; and open-label non-randomized natural-history-controlled design for patients < 6 years. The protocol describes study populations, age-specific endpoints, inclusion and exclusion criteria, study schedules, sample size determinations, and statistical considerations. DISCUSSION The core protocol provides a shared uniformity across trials, enables a pool of shared controls, and reduces the total number of patients necessary per trial, limiting the number of patients on placebo. All VWM clinical trials are suggested to adhere to the core protocol. Other trial components such as choice of primary outcome, pharmacokinetics, pharmacodynamics, and biomarkers are flexible and unconstrained by the core protocol. Each sponsor is responsible for their trial execution, while the control data are handled by a shared research organization. This core protocol benefits the efficiency of parallel and consecutive trials in VWM, and we hope accelerates time to availability of treatments for VWM. TRIAL REGISTRATION NA. From a scientific and ethical perspective, it is strongly recommended that all interventional trials using this core protocol are registered in a clinical trial register.
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Affiliation(s)
- Daphne H Schoenmakers
- Department of Child Neurology, Emma's Children's Hospital, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam Leukodystrophy Center, Amsterdam Neuroscience, Cellular & Molecular Mechanisms, Amsterdam, The Netherlands
- Department of Endocrinology and Metabolism, Platform "Medicine for Society", Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Prisca S Leferink
- IXA Neuroscience, Amsterdam Neuroscience, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Adeline Vanderver
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Joshua L Bonkowsky
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Ingeborg Krägeloh-Mann
- Department of Developmental and Child Neurology, Social Pediatrics, University Children's Hospital Tübingen, Tübingen, Germany
| | - Geneviève Bernard
- Departments of Neurology and Neurosurgery, Pediatrics and Human Genetics, McGill University; Department Specialized Medicine, Division of Medical Genetics, McGill University Health Center, Montreal, Canada
- Child Health and Human Development Program, Research Institute of the McGill University Health Center, Montreal, Canada
| | - Enrico Bertini
- Research Unit of Neuromuscular and Neurodegenerative Diseases, Translational Pediatrics and Clinical Genetics Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
| | - Ali Fatemi
- Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Brent L Fogel
- Los Angeles David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Nicole I Wolf
- Department of Child Neurology, Emma's Children's Hospital, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam Leukodystrophy Center, Amsterdam Neuroscience, Cellular & Molecular Mechanisms, Amsterdam, The Netherlands
| | - Donna Skwirut
- United Leukodystrophy Foundation, DeKalb Illinois, USA
- VWM Families Foundation, Greenwhich, CT, USA
| | | | | | - Elise F Saunier-Vivar
- Research Department, European Leukodystrophies Association International and European Leukodystrophies Association France, Paris, France
| | - Robert Rauner
- United Leukodystrophy Foundation, DeKalb Illinois, USA
| | - Hanka Dekker
- Vereniging Volwassenen, Kinderen en Stofwisselingsziekten, Zwolle, The Netherlands
| | - Pieter van Bokhoven
- IXA Neuroscience, Amsterdam Neuroscience, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Menno D Stellingwerff
- Department of Child Neurology, Emma's Children's Hospital, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam Leukodystrophy Center, Amsterdam Neuroscience, Cellular & Molecular Mechanisms, Amsterdam, The Netherlands
| | - Johannes Berkhof
- Department of Epidemiology and Data Science, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Marjo S van der Knaap
- Department of Child Neurology, Emma's Children's Hospital, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands.
- Amsterdam Leukodystrophy Center, Amsterdam Neuroscience, Cellular & Molecular Mechanisms, Amsterdam, The Netherlands.
- Department of Integrative Neurophysiology, Center for Neurogenomics and Cognitive Research, Vrije Universiteit, Amsterdam, The Netherlands.
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14
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Yu Z, Wu L, Bunn V, Li Q, Lin J. Evolution of Phase II Oncology Trial Design: from Single Arm to Master Protocol. Ther Innov Regul Sci 2023; 57:823-838. [PMID: 36871111 DOI: 10.1007/s43441-023-00500-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 02/10/2023] [Indexed: 03/06/2023]
Abstract
The recent development of novel anticancer treatments with diverse mechanisms of action has accelerated the detection of treatment candidates tremendously. The rapidly changing drug development landscapes and the high failure rates in Phase III trials both underscore the importance of more efficient and robust phase II designs. The goals of phase II oncology studies are to explore the preliminary efficacy and toxicity of the investigational product and to inform future drug development strategies such as go/no-go decisions for phase III development, or dose/indication selection. These complex purposes of phase II oncology designs call for efficient, flexible, and easy-to-implement clinical trial designs. Therefore, innovative adaptive study designs with the potential of improving the efficiency of the study, protecting patients, and improving the quality of information gained from trials have been commonly used in Phase II oncology studies. Although the value of adaptive clinical trial methods in early phase drug development is generally well accepted, there is no comprehensive review and guidance on adaptive design methods and their best practice for phase II oncology trials. In this paper, we review the recent development and evolution of phase II oncology design, including frequentist multistage design, Bayesian continuous monitoring, master protocol design, and innovative design methods for randomized phase II studies. The practical considerations and the implementation of these complex design methods are also discussed.
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Affiliation(s)
- Ziji Yu
- , 95 Hayden Ave, Lexington, MA, 02421, USA.
- Takeda Pharmaceuticals, Lexington, USA.
| | - Liwen Wu
- Takeda Pharmaceuticals, Lexington, USA
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15
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Ellingson BM, Wen PY, Chang SM, van den Bent M, Vogelbaum MA, Li G, Li S, Kim J, Youssef G, Wick W, Lassman AB, Gilbert MR, de Groot JF, Weller M, Galanis E, Cloughesy TF. Objective response rate targets for recurrent glioblastoma clinical trials based on the historic association between objective response rate and median overall survival. Neuro Oncol 2023; 25:1017-1028. [PMID: 36617262 PMCID: PMC10237425 DOI: 10.1093/neuonc/noad002] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Indexed: 01/09/2023] Open
Abstract
Durable objective response rate (ORR) remains a meaningful endpoint in recurrent cancer; however, the target ORR for single-arm recurrent glioblastoma trials has not been based on historic information or tied to patient outcomes. The current study reviewed 68 treatment arms comprising 4793 patients in past trials in recurrent glioblastoma in order to judiciously define target ORRs for use in recurrent glioblastoma trials. ORR was estimated at 6.1% [95% CI 4.23; 8.76%] for cytotoxic chemothera + pies (ORR = 7.59% for lomustine, 7.57% for temozolomide, 0.64% for irinotecan, and 5.32% for other agents), 3.37% for biologic agents, 7.97% for (select) immunotherapies, and 26.8% for anti-angiogenic agents. ORRs were significantly correlated with median overall survival (mOS) across chemotherapy (R2= 0.4078, P < .0001), biologics (R2= 0.4003, P = .0003), and immunotherapy trials (R2= 0.8994, P < .0001), but not anti-angiogenic agents (R2= 0, P = .8937). Pooling data from chemotherapy, biologics, and immunotherapy trials, a meta-analysis indicated a strong correlation between ORR and mOS (R2= 0.3900, P < .0001; mOS [weeks] = 1.4xORR + 24.8). Assuming an ineffective cytotoxic (control) therapy has ORR = 7.6%, the average ORR for lomustine and temozolomide trials, a sample size of ≥40 patients with target ORR>25% is needed to demonstrate statistical significance compared to control with a high level of confidence (P < .01) and adequate power (>80%). Given this historic data and potential biases in patient selection, we recommend that well-controlled, single-arm phase II studies in recurrent glioblastoma should have a target ORR >25% (which translates to a median OS of approximately 15 months) and a sample size of ≥40 patients, in order to convincingly demonstrate antitumor activity. Crucially, this response needs to have sufficient durability, which was not addressed in the current study.
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Affiliation(s)
- Benjamin M Ellingson
- UCLA Brain Tumor Imaging Laboratory, Center for Computer Vision and Imaging Biomarkers, Los Angeles, California, USA
- UCLA Neuro-Oncology Program, Los Angeles, California, USA
- Department of Radiological Sciences, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, Los Angeles, California, USA
- Department of Neurosurgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Susan M Chang
- Division of Neuro-Oncology, University of California San Francisco, San Francisco, California, USA
| | - Martin van den Bent
- Brain Tumor Center at Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Gang Li
- Department of Biostatistics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Shanpeng Li
- Department of Biostatistics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Jiyoon Kim
- Department of Biostatistics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Gilbert Youssef
- Center for Neuro-Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Wolfgang Wick
- Neurology Clinic, University of Heidelberg and Clinical Cooperation Unit Neuro-oncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Andrew B Lassman
- Division of Neuro-Oncology, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, Herbert Irving Comprehensive Cancer Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Mark R Gilbert
- Neuro-Oncology Branch, National Cancer Institute, Bethesda, Maryland, USA
| | - John F de Groot
- Division of Neuro-Oncology, University of California San Francisco, San Francisco, California, USA
| | - Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Evanthia Galanis
- Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Timothy F Cloughesy
- UCLA Neuro-Oncology Program, Los Angeles, California, USA
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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16
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Sim HW, Lorrey S, Khasraw M. Advances in Treatment of Isocitrate Dehydrogenase (IDH)-Wildtype Glioblastomas. Curr Neurol Neurosci Rep 2023; 23:263-276. [PMID: 37154886 DOI: 10.1007/s11910-023-01268-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE OF REVIEW The management of isocitrate dehydrogenase (IDH)-wildtype glioblastomas is an area of unmet need. Despite multimodal therapy incorporating maximal safe resection, radiotherapy, and temozolomide, clinical outcomes remain poor. At disease progression or relapse, available systemic agents such as temozolomide, lomustine, and bevacizumab have limited efficacy. We review the recent advances in the treatment of IDH-wildtype glioblastomas. RECENT FINDINGS A broad repertoire of systemic agents is in the early stages of development, encompassing the areas of precision medicine, immunotherapy, and repurposed medications. The use of medical devices may present opportunities to bypass the blood-brain barrier. Novel clinical trial designs aim to efficiently test treatment options to advance the field. There are a number of emerging treatment options for IDH-wildtype glioblastomas which are undergoing evaluation in clinical trials. Advances in our scientific understanding of IDH-wildtype glioblastomas offer hope and the prospect of incremental improvements in clinical outcomes.
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Affiliation(s)
- Hao-Wen Sim
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, 2050, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, 2010, Australia
- Department of Medical Oncology, The Kinghorn Cancer Centre, Sydney, NSW, 2010, Australia
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, NSW, 2050, Australia
| | - Selena Lorrey
- Department of Immunology, Duke University Medical Center, Durham, NC, 27710, USA
- Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, 27710, USA
| | - Mustafa Khasraw
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, 2050, Australia.
- Brain Tumor Immunotherapy Program, Department of Neurosurgery, Duke University Medical Center, Durham, NC, 27710, USA.
- Duke University School of Medicine, Duke University Medical Center, Box 3624, Durham, NC, 27710, USA.
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17
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Barker AD, Alba MM, Mallick P, Agus DB, Lee JSH. An Inflection Point in Cancer Protein Biomarkers: What Was and What's Next. Mol Cell Proteomics 2023:100569. [PMID: 37196763 PMCID: PMC10388583 DOI: 10.1016/j.mcpro.2023.100569] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 05/19/2023] Open
Abstract
Biomarkers remain the highest value proposition in cancer medicine today - especially protein biomarkers. Yet despite decades of evolving regulatory frameworks to facilitate the review of emerging technologies, biomarkers have been mostly about promise with very little to show for improvements in human health. Cancer is an emergent property of a complex system and deconvoluting the integrative and dynamic nature of the overall system through biomarkers is a daunting proposition. The last two decades have seen an explosion of multi-omics profiling and a range of advanced technologies for precision medicine, including the emergence of liquid biopsy, exciting advances in single cell analysis, artificial intelligence (machine and deep learning) for data analysis and many other advanced technologies that promise to transform biomarker discovery. Combining multiple omics modalities to acquire a more comprehensive landscape of the disease state, we are increasingly developing biomarkers to support therapy selection and patient monitoring. Furthering precision medicine, especially in oncology, necessitates moving away from the lens of reductionist thinking towards viewing and understanding that complex diseases are, in fact, complex adaptive systems. As such, we believe it is necessary to re-define biomarkers as representations of biological system states at different hierarchical levels of biological order. This definition could include traditional molecular, histologic, radiographic, or physiological characteristics, as well as emerging classes of digital markers and complex algorithms. To succeed in the future, we must move past purely observational individual studies and instead start building a mechanistic framework to enable integrative analysis of new studies within the context of prior studies. Identifying information in complex systems and applying theoretical constructs, such as information theory, to study cancer as a disease of dysregulated communication could prove to be "game changing" for the clinical outcome of cancer patients.
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Affiliation(s)
- Anna D Barker
- Lawrence J. Ellison Institute for Transformative Medicine, Los Angeles, CA; Complex Adaptive Systems Initiative and School of Life Sciences, Arizona State University, Tempe, Arizona
| | - Mario M Alba
- Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Southern California, Los Angeles, CA
| | - Parag Mallick
- Canary Center at Stanford for Cancer Early Detection, Stanford University, Stanford, CA; Department of Radiology, Stanford University, Stanford, CA
| | - David B Agus
- Lawrence J. Ellison Institute for Transformative Medicine, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Viterbi School of Engineering, University of Southern California, Los Angeles, CA
| | - Jerry S H Lee
- Lawrence J. Ellison Institute for Transformative Medicine, Los Angeles, CA; Keck School of Medicine, University of Southern California, Los Angeles, CA; Viterbi School of Engineering, University of Southern California, Los Angeles, CA
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18
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Rahman R, Polley MYC, Alder L, Brastianos PK, Anders CK, Tawbi HA, Mehta M, Wen PY, Geyer S, de Groot J, Zadeh G, Piantadosi S, Galanis E, Khasraw M. Current drug development and trial designs in neuro-oncology: report from the first American Society of Clinical Oncology and Society for Neuro-Oncology Clinical Trials Conference. Lancet Oncol 2023; 24:e161-e171. [PMID: 36990614 PMCID: PMC10401610 DOI: 10.1016/s1470-2045(23)00005-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/11/2022] [Accepted: 01/05/2023] [Indexed: 03/29/2023]
Abstract
Successful drug development for people with cancers of the CNS has been challenging. There are multiple barriers to successful drug development including biological factors, rarity of the disease, and ineffective use of clinical trials. Based upon a series of presentations at the First Central Nervous System Clinical Trials Conference hosted by the American Society of Clinical Oncology and the Society for Neuro-Oncology, we provide an overview on drug development and novel trial designs in neuro-oncology. This Review discusses the challenges of therapeutic development in neuro-oncology and proposes strategies to improve the drug discovery process by enriching the pipeline of promising therapies, optimising trial design, incorporating biomarkers, using external data, and maximising efficacy and reproducibility of clinical trials.
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Affiliation(s)
- Rifaquat Rahman
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Mei-Yin C Polley
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
| | - Laura Alder
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Priscilla K Brastianos
- Massachusetts General Hospital, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Carey K Anders
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | | | - Minesh Mehta
- Miami Cancer Institute, Baptist Hospital, Miami, FL, USA
| | - Patrick Y Wen
- Centre for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Susan Geyer
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - John de Groot
- University of California San Francisco Brain Tumor Center, San Francisco, CA, USA
| | - Gelareh Zadeh
- Department of Neurological Surgery University of Toronto, Toronto, ON, Canada
| | - Steven Piantadosi
- Department of Surgery, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Evanthia Galanis
- Department of Oncology, Mayo Clinic Comprehensive Cancer Center, Mayo Clinic, Rochester, MN, USA
| | - Mustafa Khasraw
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
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19
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Wathen JK, Jagannatha S, Ness S, Bangerter A, Pandina G. A platform trial approach to proof-of-concept (POC) studies in autism spectrum disorder: Autism spectrum POC initiative (ASPI). Contemp Clin Trials Commun 2023; 32:101061. [PMID: 36949847 PMCID: PMC10025278 DOI: 10.1016/j.conctc.2023.101061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/29/2022] [Accepted: 01/14/2023] [Indexed: 01/18/2023] Open
Abstract
Background Over the past decade, autism spectrum disorder (ASD) research has blossomed, and multiple clinical trials have tested potential interventions, with varying results and no clear demonstration of efficacy. Lack of clarity concerning appropriate biological mechanisms to target and lack of sensitive, objective tools to identify subgroups and measure symptom changes have hampered the efforts to develop treatments. A platform trial for proof-of-concept studies in ASD could help address these issues. A major goal of a platform trial is to find the best treatment in the most expeditious manner, by simultaneously investigating multiple treatments, using specialized statistical tools for allocation and analysis. We describe the setup of a platform trial and perform simulations to evaluate the operating characteristics under several scenarios. We use the Autism Behavior Inventory (ABI), a psychometrically validated web-based rating scale to measure the change in ASD core and associated symptoms. Methods Detailed description of the setup, conduct, and decision-making rules of a platform trial are explained. Simulations of a virtual platform trial for several scenarios are performed to compare operating characteristics. The success and futility criteria for treatments are based on a Bayesian posterior probability model. Results Overall, simulation results show the potential gain in terms of statistical properties especially for improved decision-making ability, while careful planning is needed due to the complexities of a platform trial. Conclusions Autism research, shaped particularly by its heterogeneity, may benefit from the platform trial approach for POC clinical studies.
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Affiliation(s)
| | - Shyla Jagannatha
- Corresponding author. Janssen Research & Development, LLC 1125 Trenton-Harbourton Road Titusville NJ 08560, USA.
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20
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Wu H, Guo C, Wang C, Xu J, Zheng S, Duan J, Li Y, Bai H, Xu Q, Ning F, Wang F, Yang Q. Single-cell RNA sequencing reveals tumor heterogeneity, microenvironment, and drug-resistance mechanisms of recurrent glioblastoma. Cancer Sci 2023. [PMID: 36853018 DOI: 10.1111/cas.15773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 02/02/2023] [Accepted: 02/20/2023] [Indexed: 03/01/2023] Open
Abstract
Glioblastomas are highly heterogeneous brain tumors. Despite the availability of standard treatment for glioblastoma multiforme (GBM), i.e., Stupp protocol, which involves surgical resection followed by radiotherapy and chemotherapy, glioblastoma remains refractory to treatment and recurrence is inevitable. Moreover, the biology of recurrent glioblastoma remains unclear. Increasing evidence has shown that intratumoral heterogeneity and the tumor microenvironment contribute to therapeutic resistance. However, the interaction between intracellular heterogeneity and drug resistance in recurrent GBMs remains controversial. The aim of this study was to map the transcriptome landscape of cancer cells and the tumor heterogeneity and tumor microenvironment in recurrent and drug-resistant GBMs at a single-cell resolution and further explore the mechanism of drug resistance of GBMs. We analyzed six tumor tissue samples from three patients with primary GBM and three patients with recurrent GBM in which recurrence and drug resistance developed after treatment with the standard Stupp protocol using single-cell RNA sequencing. Using unbiased clustering, nine major cell clusters were identified. Upregulation of the expression of stemness-related and cell-cycle-related genes was observed in recurrent GBM cells. Compared with the initial GBM tissues, recurrent GBM tissues showed a decreased proportion of microglia, consistent with previous reports. Finally, vascular endothelial growth factor A expression and the blood-brain barrier permeability were high, and the O6 -methylguanine DNA methyltransferase-related signaling pathway was activated in recurrent GBM. Our results delineate the single-cell map of recurrent glioblastoma, tumor heterogeneity, tumor microenvironment, and drug-resistance mechanisms, providing new insights into treatment strategies for recurrent glioblastomas.
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Affiliation(s)
- Haibin Wu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chengcheng Guo
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chaoye Wang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China.,Department of Biometric Information, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jiang Xu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Suyue Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jian Duan
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yiyun Li
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hongming Bai
- Department of Neurosurgery, General Hospital of Southern Theatre Command of PLA, Guangzhou, China
| | - Qiuyan Xu
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Fangling Ning
- Department of Medical Oncology, Binzhou Medical University Hospital, Binzhou, China
| | - Feng Wang
- Department of Medical Oncology, Binzhou Medical University Hospital, Binzhou, China
| | - Qunying Yang
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
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21
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D'Alessandris QG, Martini M, Cenci T, DI Bonaventura R, Lauretti L, Stumpo V, Olivi A, Larocca LM, Pallini R, Montano N. Tailored therapy for recurrent glioblastoma: report of a personalized molecular approach. J Neurosurg Sci 2023; 67:103-107. [PMID: 32550606 DOI: 10.23736/s0390-5616.20.04943-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Failure of clinical trials with targeted therapies in glioblastoma (GBM) is probably related to the enrollment of molecularly unselected patients. In this study we report the results of a precision medicine protocol in recurrent GBM. METHODS We prospectively evaluated 34 patients with recurrent GBM. We determined the expression of vascular endothelial growth factor (VEGF), epidermal growth factor receptor variant III (EGFRvIII), and phosphatase and tensin homolog (PTEN). According to the molecular pattern we administered bevacizumab alone in patients with VEGF overexpression, absence of EGFRvIII, and normal PTEN (group A; N.=16); bevacizumab + erlotinib in patients with VEGF overexpression, expression of EGFRvIII, and normal PTEN (group B; N.=14); and bevacizumab + sirolimus in patients with VEGF overexpression and loss of PTEN, irrespective of the EGFRvIII status (group C; N.=4). We evaluated the response rate, the clinical benefit rate, the 6-month progression-free survival (PFS-6), the 12-month PFS (PFS-12) and the safety profile of the treatment. Moreover, we compared our results with the ones of EORTC 26101 trial. RESULTS Response rate was 50% in the whole cohort with the highest rate in group C (75%). Clinical benefit rate was 71% with the highest rate in group C (75%). PFS-6 was 56% in the whole cohort with the highest rate in group B (64%). PFS-12 was 21% in the whole cohort with the highest rate in group B (29%). When comparing our results with those from the combination arm of the EORTC 26101 trial we found a significantly higher PFS-6 and PFS-12 in our cohort. CONCLUSIONS The precision medicine protocol for recurrent GBM is feasible and leads to improved results if compared with studies lacking molecular selection.
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Affiliation(s)
- Quintino G D'Alessandris
- Department of Neurosurgery, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Maurizio Martini
- Department of Pathology, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Tonia Cenci
- Department of Pathology, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Rina DI Bonaventura
- Department of Neurosurgery, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Liverana Lauretti
- Department of Neurosurgery, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Vittorio Stumpo
- Department of Neurosurgery, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Luigi M Larocca
- Department of Pathology, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Roberto Pallini
- Department of Neurosurgery, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Nicola Montano
- Department of Neurosurgery, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy -
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22
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Pineda E, Domenech M, Hernández A, Comas S, Balaña C. Recurrent Glioblastoma: Ongoing Clinical Challenges and Future Prospects. Onco Targets Ther 2023; 16:71-86. [PMID: 36721854 PMCID: PMC9884437 DOI: 10.2147/ott.s366371] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/19/2023] [Indexed: 01/26/2023] Open
Abstract
Virtually all glioblastomas treated in the first-line setting will recur in a short period of time, and the search for alternative effective treatments has so far been unsuccessful. Various obstacles remain unresolved, and no effective salvage therapy for recurrent glioblastoma can be envisaged in the short term. One of the main impediments to progress is the low incidence of the disease itself in comparison with other pathologies, which will be made even lower by the recent WHO classification of gliomas, which includes molecular alterations. This new classification helps refine patient prognosis but does not clarify the most appropriate treatment. Other impediments are related to clinical trials: glioblastoma patients are often excluded from trials due to their advanced age and limiting neurological symptoms; there is also the question of how best to measure treatment efficacy, which conditions the design of trials and can affect the acceptance of results by oncologists and medicine agencies. Other obstacles are related to the drugs themselves: most treatments cannot cross the blood-brain-barrier or the brain-to-tumor barrier to reach therapeutic drug levels in the tumor without producing toxicity; the drugs under study may have adverse metabolic interactions with those required for symptom control; identifying the target of the drug can be a complex issue. Additionally, the optimal method of treatment - local vs systemic therapy, the choice of chemotherapy, irradiation, targeted therapy, immunotherapy, or a combination thereof - is not yet clear in glioblastoma in comparison with other cancers. Finally, in addition to curing or stabilizing the disease, glioblastoma therapy should aim at maintaining the neurological status of the patients to enable them to return to their previous lifestyle. Here we review currently available treatments, obstacles in the search for new treatments, and novel lines of research that show promise for the future.
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Affiliation(s)
- Estela Pineda
- Medical Oncology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Marta Domenech
- Medical Oncology, Institut Catala d’Oncologia (ICO) Badalona, Barcelona, Spain
| | - Ainhoa Hernández
- Medical Oncology, Institut Catala d’Oncologia (ICO) Badalona, Barcelona, Spain
| | - Silvia Comas
- Radiation Oncology, Institut Catala d’Oncologia (ICO) Badalona, Badalona, Spain
| | - Carmen Balaña
- Medical Oncology, Institut Catala d’Oncologia (ICO) Badalona, Barcelona, Spain,Correspondence: Carmen Balaña, Institut Catala d’Oncologia (ICO) Badalona, Carretera Canyet s/n, Badalona, 08916, Spain, Tel +34 497 89 25, Fax +34 497 89 50, Email
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23
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Li Y, Yang Z, Jalil AT, Saleh MM, Wu B. In Vivo and In Vitro Biocompatibility Study of CuS Nanoparticles: Photosensitizer for Glioblastoma Photothermal Therapy. Appl Biochem Biotechnol 2023:10.1007/s12010-023-04313-3. [PMID: 36652089 DOI: 10.1007/s12010-023-04313-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 01/19/2023]
Abstract
Although photothermal treatment (PTT) has made significant progress in the fight against cancer, certain types of malignant tumors are still difficult to eradicate. PTT uses photothermal transforming agents to absorb NIR light and convert it to thermal energy, causing cancer cell death. In this study, we synthesized alginate (Alg)-coated CuS nanoparticles (CuS@Alg) as photothermal transforming agents to kill glioblastoma cancer cells. Nanoparticles were synthesized via a facile method, then, were characterized with different techniques such as ultraviolet-visible spectroscopy (UV-Vis), Fourier transform infrared (FTIR), X-ray diffraction analysis (XRD), transmission electron microscopy (TEM), and dynamic light scattering (DLS). Nanoparticles show high stability, and are monodisperse. CuS@Alg was discovered to have a spherical shape, a hydrodynamic size of about 19.93 nm, and a zeta potential of - 9.74 mV. CuS@Alg is able to increase temperature of medium under NIR light. Importantly, in vitro investigations show that PTT based on CuS@Alg has a strong theraputic impact, resulting in much high effectiveness. The LD50 and histopathology assays were used to confirm the NPs' non-toxicity in vivo. Results from an in vivo subacute toxicity investigation showed that the fabricated NPs were perfectly safe to biomedical usage.
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Affiliation(s)
- Yin Li
- Department of Neurosurgery, Zhen'an Hospital, Shangluo, 711500, China
| | - Zhangkai Yang
- Department of Neurosurgery, Xi'an Children's Hospital, Xi'an, 710000, China
| | - Abduladheem Turki Jalil
- Medical Laboratory Techniques Department, Al-Mustaqbal University College, Babylon, Hilla, 51001, Iraq
| | - Marwan Mahmood Saleh
- Department of Biophysics, College of Applied Sciences, University of Anbar, Ramadi, Iraq
- Medical Laboratory Technology Department, College of Medical Technology, The Islamic University, Najaf, Iraq
| | - Bin Wu
- Department of Outpatient Comprehensive Surgery, Xi'an Children's Hospital, Xi'an, 710000, China.
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24
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Schaumberg D, Larholt K, Apgar E, Pashos CL, Hirsch G. Examining Endpoint Concordance in Clinical Trials and Real-World Clinical Practice to Advance Real-World Evidence Utilization. Ther Innov Regul Sci 2023; 57:472-475. [PMID: 36624361 DOI: 10.1007/s43441-022-00492-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 12/24/2022] [Indexed: 01/11/2023]
Abstract
Real-world evidence (RWE) is increasingly contributing to more informed decisions regarding the optimal access to and use of therapeutics to improve patient outcomes. However, in many cases, a disconnect between evidence derived from clinical trials and the RWE that follows market approval impedes the potential value and widespread adoption of RWE to optimize patient care. Collaborators with the Learning Ecosystems Accelerator for Patient-centered, Sustainable innovation (LEAPS), a major project of the Tufts Medical Center [formally Massachusetts Institute of Technology (MIT)] NEW Drug Development ParadIGmS (NEWDIGS) initiative, propose assessing the relationship between efficacy endpoints used in randomized controlled trials (RCTs) and effectiveness measures that inform treatment decisions within real-world clinical settings as one way to bridge this divide and further leverage RWE to improve care and patient outcomes. This commentary outlines elements of an endpoint concordance study using Rheumatoid Arthritis as a case study. The authors describe the ways in which better understanding of the relationship between effectiveness and RCT endpoints could improve the confidence in and adoption of RWE by both contextualizing existing RWE as well as identifying ways in which to improve the value of RWE in improving care and outcomes.
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Affiliation(s)
| | - Kay Larholt
- Center for Biomedical System Design & NEWDIGS, Institute for Clinical Research & Health Policy Studies, Tufts Medical Center, 800 Washington Street, #1013, Boston, MA, 02111, USA
| | - Elizabeth Apgar
- Center for Biomedical System Design & NEWDIGS, Institute for Clinical Research & Health Policy Studies, Tufts Medical Center, 800 Washington Street, #1013, Boston, MA, 02111, USA
| | | | - Gigi Hirsch
- Center for Biomedical System Design & NEWDIGS, Institute for Clinical Research & Health Policy Studies, Tufts Medical Center, 800 Washington Street, #1013, Boston, MA, 02111, USA.
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25
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McFaline-Figueroa JR, Wen PY. Negative trials over and over again: How can we do better? Neuro Oncol 2023; 25:1-3. [PMID: 36254884 PMCID: PMC9825326 DOI: 10.1093/neuonc/noac226] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Indexed: 01/12/2023] Open
Affiliation(s)
- J Ricardo McFaline-Figueroa
- Center For Neuro-Oncology, Dana-Farber Cancer Institute, Boston, USA
- Division of Neuro-Oncology, Department of Neurology, Brigham and Women’s Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - Patrick Y Wen
- Center For Neuro-Oncology, Dana-Farber Cancer Institute, Boston, USA
- Division of Neuro-Oncology, Department of Neurology, Brigham and Women’s Hospital, Boston, USA
- Harvard Medical School, Boston, USA
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26
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Liau LM, Ashkan K, Brem S, Campian JL, Trusheim JE, Iwamoto FM, Tran DD, Ansstas G, Cobbs CS, Heth JA, Salacz ME, D’Andre S, Aiken RD, Moshel YA, Nam JY, Pillainayagam CP, Wagner SA, Walter KA, Chaudhary R, Goldlust SA, Lee IY, Bota DA, Elinzano H, Grewal J, Lillehei K, Mikkelsen T, Walbert T, Abram S, Brenner AJ, Ewend MG, Khagi S, Lovick DS, Portnow J, Kim L, Loudon WG, Martinez NL, Thompson RC, Avigan DE, Fink KL, Geoffroy FJ, Giglio P, Gligich O, Krex D, Lindhorst SM, Lutzky J, Meisel HJ, Nadji-Ohl M, Sanchin L, Sloan A, Taylor LP, Wu JK, Dunbar EM, Etame AB, Kesari S, Mathieu D, Piccioni DE, Baskin DS, Lacroix M, May SA, New PZ, Pluard TJ, Toms SA, Tse V, Peak S, Villano JL, Battiste JD, Mulholland PJ, Pearlman ML, Petrecca K, Schulder M, Prins RM, Boynton AL, Bosch ML. Association of Autologous Tumor Lysate-Loaded Dendritic Cell Vaccination With Extension of Survival Among Patients With Newly Diagnosed and Recurrent Glioblastoma: A Phase 3 Prospective Externally Controlled Cohort Trial. JAMA Oncol 2023; 9:112-121. [PMID: 36394838 PMCID: PMC9673026 DOI: 10.1001/jamaoncol.2022.5370] [Citation(s) in RCA: 123] [Impact Index Per Article: 123.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/27/2022] [Indexed: 11/19/2022]
Abstract
Importance Glioblastoma is the most lethal primary brain cancer. Clinical outcomes for glioblastoma remain poor, and new treatments are needed. Objective To investigate whether adding autologous tumor lysate-loaded dendritic cell vaccine (DCVax-L) to standard of care (SOC) extends survival among patients with glioblastoma. Design, Setting, and Participants This phase 3, prospective, externally controlled nonrandomized trial compared overall survival (OS) in patients with newly diagnosed glioblastoma (nGBM) and recurrent glioblastoma (rGBM) treated with DCVax-L plus SOC vs contemporaneous matched external control patients treated with SOC. This international, multicenter trial was conducted at 94 sites in 4 countries from August 2007 to November 2015. Data analysis was conducted from October 2020 to September 2021. Interventions The active treatment was DCVax-L plus SOC temozolomide. The nGBM external control patients received SOC temozolomide and placebo; the rGBM external controls received approved rGBM therapies. Main Outcomes and Measures The primary and secondary end points compared overall survival (OS) in nGBM and rGBM, respectively, with contemporaneous matched external control populations from the control groups of other formal randomized clinical trials. Results A total of 331 patients were enrolled in the trial, with 232 randomized to the DCVax-L group and 99 to the placebo group. Median OS (mOS) for the 232 patients with nGBM receiving DCVax-L was 19.3 (95% CI, 17.5-21.3) months from randomization (22.4 months from surgery) vs 16.5 (95% CI, 16.0-17.5) months from randomization in control patients (HR = 0.80; 98% CI, 0.00-0.94; P = .002). Survival at 48 months from randomization was 15.7% vs 9.9%, and at 60 months, it was 13.0% vs 5.7%. For 64 patients with rGBM receiving DCVax-L, mOS was 13.2 (95% CI, 9.7-16.8) months from relapse vs 7.8 (95% CI, 7.2-8.2) months among control patients (HR, 0.58; 98% CI, 0.00-0.76; P < .001). Survival at 24 and 30 months after recurrence was 20.7% vs 9.6% and 11.1% vs 5.1%, respectively. Survival was improved in patients with nGBM with methylated MGMT receiving DCVax-L compared with external control patients (HR, 0.74; 98% CI, 0.55-1.00; P = .03). Conclusions and Relevance In this study, adding DCVax-L to SOC resulted in clinically meaningful and statistically significant extension of survival for patients with both nGBM and rGBM compared with contemporaneous, matched external controls who received SOC alone. Trial Registration ClinicalTrials.gov Identifier: NCT00045968.
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Affiliation(s)
- Linda M. Liau
- Department of Neurosurgery, University of California, Los Angeles
| | | | - Steven Brem
- Department of Neurosurgery, Penn Brain Tumor Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jian L. Campian
- Division of Neurology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - John E. Trusheim
- Givens Brain Tumor Center, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Fabio M. Iwamoto
- Columbia University Irving Medical Center, New York, New York
- New York-Presbyterian Hospital, New York, New York
| | - David D. Tran
- Preston A. Wells, Jr. Center for Brain Tumor Therapy, Division of Neuro-Oncology, Lillian S. Wells Department of Neurosurgery, University of Florida College of Medicine, Gainesville
| | - George Ansstas
- Department of Neurological Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Charles S. Cobbs
- Ben and Catherine Ivy Center for Advanced Brain Tumor Treatment, Swedish Medical Center, Seattle, Washington
| | - Jason A. Heth
- Taubman Medical Center, University of Michigan, Ann Arbor
| | - Michael E. Salacz
- Neuro-Oncology Program, Rutgers Cancer Institute of New Jersey, New Brunswick
| | | | - Robert D. Aiken
- Glasser Brain Tumor Center, Atlantic Healthcare, Summit, New Jersey
| | - Yaron A. Moshel
- Glasser Brain Tumor Center, Atlantic Healthcare, Summit, New Jersey
| | - Joo Y. Nam
- Department of Neurological Sciences, Rush Medical College, Chicago, Illinois
| | | | | | | | | | - Samuel A. Goldlust
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey
| | - Ian Y. Lee
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
| | - Daniela A. Bota
- Department of Neurology and Chao Family Comprehensive Cancer Center, University of California, Irvine
| | | | - Jai Grewal
- Long Island Brain Tumor Center at NSPC, Lake Success, New York
| | - Kevin Lillehei
- Department of Neurosurgery, University of Colorado Health Sciences Center, Boulder
| | - Tom Mikkelsen
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
| | - Tobias Walbert
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan
| | - Steven Abram
- Ascension St Thomas Brain and Spine Tumor Center, Howell Allen Clinic, Nashville, Tennessee
| | | | - Matthew G. Ewend
- Department of Neurosurgery, UNC School of Medicine and UNC Health, Chapel Hill, North Carolina
| | - Simon Khagi
- The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | - Jana Portnow
- Department of Medical Oncology & Therapeutics Research, City of Hope, Duarte, California
| | - Lyndon Kim
- Division of Neuro-Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Nina L. Martinez
- Jefferson Hospital for Neurosciences, Jefferson University, Philadelphia, Pennsylvania
| | - Reid C. Thompson
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David E. Avigan
- Beth Israel Deaconess Medical Center, Harvard Medical School, Cambridge, Massachusetts
| | - Karen L. Fink
- Baylor Scott & White Neuro-Oncology Associates, Dallas, Texas
| | | | - Pierre Giglio
- Medical University of South Carolina Neurosciences, Charleston
| | - Oleg Gligich
- Mount Sinai Medical Center, Miami Beach, Florida
| | | | - Scott M. Lindhorst
- Hollings Cancer Center, Medical University of South Carolina, Charleston
| | - Jose Lutzky
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | | | - Minou Nadji-Ohl
- Neurochirurgie Katharinenhospital, Klinikum der Landeshauptstadt Stuttgart, Stuttgart, Germany
| | | | - Andrew Sloan
- Seidman Cancer Center, University Hospitals–Cleveland Medical Center, Cleveland, Ohio
| | - Lynne P. Taylor
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts
| | - Julian K. Wu
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts
| | - Erin M. Dunbar
- Piedmont Physicians Neuro-Oncology, Piedmont Brain Tumor Center, Atlanta, Georgia
| | | | - Santosh Kesari
- Pacific Neurosciences Institute and Saint John’s Cancer Institute, Santa Monica, California
| | - David Mathieu
- Centre de Recherche du CHUS, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - David S. Baskin
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas
| | - Michel Lacroix
- Geisinger Neuroscience Institute, Danville, Pennsylvania
| | | | | | | | - Steven A. Toms
- Departments of Neurosurgery and Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Victor Tse
- Kaiser Permanente, Redwood City, California
| | - Scott Peak
- Kaiser Permanente, Redwood City, California
| | - John L. Villano
- University of Kentucky Markey Cancer Center, Department of Medicine, Neurosurgery, and Neurology, University of Kentucky, Lexington
| | | | | | | | - Kevin Petrecca
- Department of Neurology and Neurosurgery, Montreal Neurological Institute-Hospital, McGill University, Montreal, Quebec, Canada
| | - Michael Schulder
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Uniondale, New York
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27
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New therapeutic strategies based on molecularly targeted therapy in glioblastoma – a case report and review of the literature. CURRENT ISSUES IN PHARMACY AND MEDICAL SCIENCES 2022. [DOI: 10.2478/cipms-2022-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Abstract
Glioblastomas are the most common and most lethal forms of malignant primary brain tumor. We present a case report of a patient with III-grade glioma who achieved stable disease (SD) and clinical improvement after trametinib administration. We also report a review of the literature to Current Treatment Guidelines of Glioblastoma and new therapeutic strategies based on molecularly targeted therapy. Traditional treatments, including surgery, radiotherapy, and chemotherapy, have many limitations concerning the prognosis of patients with glioblastomas. Unfortunately, these tumors’recur after primary resection in the majority of cases. There is no standard therapy for recurrence of GBM. Targeted therapy offers a promising new treatment strategy. Regardless of those outstanding results much more can be done in the field of therapeutic options. Most urgent concerns include potent combining molecular targeted therapy with other types of treatments, selecting a group of patients for whom they turn out to be the most beneficial, and addressing adverse events of these molecules.
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28
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Bronson A, Chase MK, Fisher K, Millar D, Perlmutter J, Richardson N. Mobilizing the clinical trial ecosystem to drive adoption of master protocols. Clin Trials 2022; 19:690-696. [PMID: 36086812 PMCID: PMC9679560 DOI: 10.1177/17407745221110199] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Master protocol studies typically use an overarching protocol to answer several questions by guiding a variety of sub-studies. These sub-studies can incorporate multiple diseases, therapies, or both. Although this innovative approach offers many benefits, including the ability to deliver clinical research that is more patient-centric and efficient, several common barriers curtail widespread adoption. The Clinical Trials Transformation Initiative (CTTI) convened industry representatives, regulatory agencies, patient groups, and academic institutions to identify emerging best practices and develop resources designed to help sponsors and other stakeholders overcome these challenges. We first identify some broad changes needed in the clinical trials ecosystem to facilitate mainstream adoption of master protocol studies, and we subsequently summarize CTTI's resources designed to support this effort.
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Affiliation(s)
- Abby Bronson
- Parent Project Muscular Dystrophy,
Washington, DC, USA,Edgewise Therapeutics, Boulder, CO,
USA
| | - Marianne K Chase
- Sean M. Healey & AMG Center,
Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | - Nicholas Richardson
- Office of Oncologic Diseases, Center
for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring,
MD, USA,Nicholas Richardson, US Food and Drug
Administration, 10903 New Hampshire Ave, White Oak Building 22, Silver Spring,
MD 20993, USA.
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29
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Myles PS, Yeung J, Beattie WS, Ryan EG, Heritier S, McArthur CJ. Platform trials for anaesthesia and perioperative medicine: a narrative review. Br J Anaesth 2022; 130:677-686. [PMID: 36456249 DOI: 10.1016/j.bja.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 11/29/2022] Open
Abstract
Large randomised trials provide the most reliable evidence of effectiveness of new treatments in clinical practice. However, the time and resources required to complete such trials can be daunting. An overarching clinical trial platform focused on a single condition or type of surgery, aiming to compare several treatments, with an option to stop any or add in new treatment options, can provide greater efficiency. This has the potential to accelerate knowledge acquisition and identify effective, ineffective, or harmful treatments faster. The master protocol of the platform defines the study population(s) and standardised procedures. Ineffective or harmful treatments can be discarded or study drug dose modified during the life cycle of the trial. Other adaptive elements that can be modified include eligibility criteria, required sample size for any comparison(s), randomisation assignment ratio, and the addition of other promising treatment options. There are excellent opportunities for anaesthetists to establish platform trials in perioperative medicine. Platform trials are highly efficient, with the potential to provide quicker answers to important clinical questions that lead to improved patient care.
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30
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Rudà R, Bruno F, Pellerino A, Pronello E, Palmiero R, Bertero L, Crasto S, Polo V, Vitaliani R, Trincia E, Internò V, Porta C, Soffietti R. Observational real-life study on regorafenib in recurrent glioblastoma: does dose reduction reduce toxicity while maintaining the efficacy? J Neurooncol 2022; 160:389-402. [DOI: 10.1007/s11060-022-04155-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/30/2022] [Indexed: 11/24/2022]
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31
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Mellinghoff IK, Cloughesy TF. Balancing Risk and Efficiency in Drug Development for Rare and Challenging Tumors: A New Paradigm for Glioma. J Clin Oncol 2022; 40:3510-3519. [PMID: 35201903 PMCID: PMC10166355 DOI: 10.1200/jco.21.02166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/15/2021] [Accepted: 01/26/2022] [Indexed: 12/14/2022] Open
Abstract
The process of developing cancer therapies is well established and has enabled the incorporation of many new drugs and classes of agents into the standard of care for common cancers. Clinical drug development is fundamentally different for rare and difficult-to-treat solid tumors, such as glioma or pancreatic cancer. The failure to develop effective new agents for the latter diseases has discouraged the development of therapeutics for these cancers. Using glioma as an example, we describe a process toward obtaining more reliable early-stage signals of drug activity and a process toward translating those signals into clinical benefits with more efficient late-stage development. If linked together, these processes should increase the likelihood of benefit in late-stage settings at a lower cost and encourage more drug development for patients with rare and difficult-to-treat cancers.
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Affiliation(s)
- Ingo K. Mellinghoff
- Department of Neurology and Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Timothy F. Cloughesy
- Department of Neurology, Ronald Reagan UCLA Medical Center, University of California, Los Angeles, CA
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32
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Abstract
Glioblastoma is the most aggressive primary brain tumor with a poor prognosis. The 2021 WHO CNS5 classification has further stressed the importance of molecular signatures in diagnosis although therapeutic breakthroughs are still lacking. In this review article, updates on the current and novel therapies in IDH-wildtype GBM will be discussed.
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Affiliation(s)
- Jawad M Melhem
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Jay Detsky
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Mary Jane Lim-Fat
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - James R Perry
- Division of Neurology, Department of Medicine, Faculty of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.
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33
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Saraf A, Trippa L, Rahman R. Novel Clinical Trial Designs in Neuro-Oncology. Neurotherapeutics 2022; 19:1844-1854. [PMID: 35969361 PMCID: PMC9723049 DOI: 10.1007/s13311-022-01284-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2022] [Indexed: 12/13/2022] Open
Abstract
Scientific and technologic advances have led to a boon of candidate therapeutics for patients with malignancies of the central nervous system. The path from drug development to clinical use has generally followed a regimented order of sequential clinical trial phases. The recent increase in novel therapies, however, has strained the regulatory process and unearthed limitations of the current system, including significant cost, prolonged development time, and difficulties in testing therapies for rarer tumors. Novel clinical trial designs have emerged to increase efficiencies in clinical trial conduct to better evaluate and bring impactful drugs to patients in a timely manner. In order to better capture meaningful benefits for brain tumor patients, new endpoints to complement or replace traditional endpoints are also an increasingly important consideration. This review will explore the current challenges in the current clinical trial landscape and discuss novel clinical trial concepts, including consideration of limitations and risks of novel trial designs, within the context of neuro-oncology.
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Affiliation(s)
- Anurag Saraf
- Harvard Radiation Oncology Program, Boston, MA, USA
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Lorenzo Trippa
- Department of Data Sciences, Dana-Farber Cancer Institute, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Rifaquat Rahman
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
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34
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Gao G, Gajewski BJ, Wick J, Beall J, Saver JL, Meinzer C. Optimizing a Bayesian hierarchical adaptive platform trial design for stroke patients. Trials 2022; 23:754. [PMID: 36068547 PMCID: PMC9446515 DOI: 10.1186/s13063-022-06664-4] [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: 06/01/2021] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Platform trials are well-known for their ability to investigate multiple arms on heterogeneous patient populations and their flexibility to add/drop treatment arms due to efficacy/lack of efficacy. Because of their complexity, it is important to develop highly optimized, transparent, and rigorous designs that are cost-efficient, offer high statistical power, maximize patient benefit, and are robust to changes over time. METHODS To address these needs, we present a Bayesian platform trial design based on a beta-binomial model for binary outcomes that uses three key strategies: (1) hierarchical modeling of subgroups within treatment arms that allows for borrowing of information across subgroups, (2) utilization of response-adaptive randomization (RAR) schemes that seek a tradeoff between statistical power and patient benefit, and (3) adjustment for potential drift over time. Motivated by a proposed clinical trial that aims to find the appropriate treatment for different subgroup populations of ischemic stroke patients, extensive simulation studies were performed to validate the approach, compare different allocation rules, and study the model operating characteristics. RESULTS AND CONCLUSIONS Our proposed approach achieved high statistical power and good patient benefit and was also robust against population drift over time. Our design provided a good balance between the strengths of both the traditional RAR scheme and fixed 1:1 allocation and may be a promising choice for dichotomous outcomes trials investigating multiple subgroups.
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Affiliation(s)
- Guangyi Gao
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, 66160, USA.
| | - Byron J Gajewski
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Jo Wick
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, CA, 90095, USA
| | - Caitlyn Meinzer
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, 29425, USA
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35
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Śledzińska P, Bebyn M, Furtak J, Koper A, Koper K. Current and promising treatment strategies in glioma. Rev Neurosci 2022:revneuro-2022-0060. [PMID: 36062548 DOI: 10.1515/revneuro-2022-0060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/30/2022] [Indexed: 12/14/2022]
Abstract
Gliomas are the most common primary central nervous system tumors; despite recent advances in diagnosis and treatment, glioma patients generally have a poor prognosis. Hence there is a clear need for improved therapeutic options. In recent years, significant effort has been made to investigate immunotherapy and precision oncology approaches. The review covers well-established strategies such as surgery, temozolomide, PCV, and mTOR inhibitors. Furthermore, it summarizes promising therapies: tumor treating fields, immune therapies, tyrosine kinases inhibitors, IDH(Isocitrate dehydrogenase)-targeted approaches, and others. While there are many promising treatment strategies, none fundamentally changed the management of glioma patients. However, we are still awaiting the outcome of ongoing trials, which have the potential to revolutionize the treatment of glioma.
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Affiliation(s)
- Paulina Śledzińska
- Molecular Oncology and Genetics Department, Innovative Medical Forum, The F. Lukaszczyk Oncology Center, 85-796 Bydgoszcz, Poland
| | - Marek Bebyn
- Molecular Oncology and Genetics Department, Innovative Medical Forum, The F. Lukaszczyk Oncology Center, 85-796 Bydgoszcz, Poland
| | - Jacek Furtak
- Department of Neurosurgery, 10th Military Research Hospital and Polyclinic, 85-681 Bydgoszcz, Poland.,Department of Neurooncology and Radiosurgery, The F. Lukaszczyk Oncology Center, 85-796 Bydgoszcz, Poland
| | - Agnieszka Koper
- Department of Oncology, Nicolaus Copernicus University in Torun, Ludwik Rydygier Collegium Medicum, 85-067 Bydgoszcz, Poland.,Department of Oncology, Franciszek Lukaszczyk Oncology Centre, 85-796 Bydgoszcz, Poland
| | - Krzysztof Koper
- Department of Oncology, Franciszek Lukaszczyk Oncology Centre, 85-796 Bydgoszcz, Poland.,Department of Clinical Oncology, and Nursing, Departament of Oncological Surgery, Nicolaus Copernicus University in Torun, Ludwik Rydygier Collegium Medicum, 85-067 Bydgoszcz, Poland
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36
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Fountzilas E, Tsimberidou AM, Vo HH, Kurzrock R. Clinical trial design in the era of precision medicine. Genome Med 2022; 14:101. [PMID: 36045401 PMCID: PMC9428375 DOI: 10.1186/s13073-022-01102-1] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/09/2022] [Indexed: 12/24/2022] Open
Abstract
Recent rapid biotechnological breakthroughs have led to the identification of complex and unique molecular features that drive malignancies. Precision medicine has exploited next-generation sequencing and matched targeted therapy/immunotherapy deployment to successfully transform the outlook for several fatal cancers. Tumor and liquid biopsy genomic profiling and transcriptomic, immunomic, and proteomic interrogation can now all be leveraged to optimize therapy. Multiple new trial designs, including basket and umbrella trials, master platform trials, and N-of-1 patient-centric studies, are beginning to supplant standard phase I, II, and III protocols, allowing for accelerated drug evaluation and approval and molecular-based individualized treatment. Furthermore, real-world data, as well as exploitation of digital apps and structured observational registries, and the utilization of machine learning and/or artificial intelligence, may further accelerate knowledge acquisition. Overall, clinical trials have evolved, shifting from tumor type-centered to gene-directed and histology-agnostic trials, with innovative adaptive designs and personalized combination treatment strategies tailored to individual biomarker profiles. Some, but not all, novel trials now demonstrate that matched therapy correlates with superior outcomes compared to non-matched therapy across tumor types and in specific cancers. To further improve the precision medicine paradigm, the strategy of matching drugs to patients based on molecular features should be implemented earlier in the disease course, and cancers should have comprehensive multi-omic (genomics, transcriptomics, proteomics, immunomic) tumor profiling. To overcome cancer complexity, moving from drug-centric to patient-centric individualized combination therapy is critical. This review focuses on the design, advantages, limitations, and challenges of a spectrum of clinical trial designs in the era of precision oncology.
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Affiliation(s)
- Elena Fountzilas
- Department of Medical Oncology, St. Lukes's Hospital, Thessaloniki, Greece.,European University Cyprus, Limassol, Cyprus
| | - Apostolia M Tsimberidou
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henry Hiep Vo
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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37
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Saville BR, Berry DA, Berry NS, Viele K, Berry SM. The Bayesian Time Machine: Accounting for temporal drift in multi-arm platform trials. Clin Trials 2022; 19:490-501. [PMID: 35993547 DOI: 10.1177/17407745221112013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multi-arm platform trials investigate multiple agents simultaneously, typically with staggered entry and exit of experimental treatment arms versus a shared control arm. In such settings, there is considerable debate whether to limit analyses for a treatment arm to concurrent randomized control subjects or to allow comparisons to both concurrent and non-concurrent (pooled) control subjects. The potential bias from temporal drift over time is at the core of this debate. METHODS We propose time-adjusted analyses, including a "Bayesian Time Machine," to model potential temporal drift in the entire study population, such that primary analyses can incorporate all randomized control subjects from the platform trial. We conduct a simulation study to assess performance relative to utilizing concurrent or pooled controls. RESULTS In multi-arm platform trials with staggered entry, analyses adjusting for temporal drift (either Bayesian or frequentist) have superior estimation of treatment effects and favorable testing properties compared to analyses using either concurrent or pooled controls. The Bayesian Time Machine generally provides estimates with greater precision and smaller mean square error than alternative approaches, at the risk of small bias and small Type I error inflation. CONCLUSIONS The Bayesian Time Machine provides a compromise between bias and precision by smoothing estimates across time and leveraging all available data for the estimation of treatment effects. Prior distributions controlling the behavior of dynamic smoothing across time must be pre-specified and carefully calibrated to the unique context of each trial, appropriately accounting for the population, disease, and endpoints.
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Affiliation(s)
- Benjamin R Saville
- Berry Consultants, LLC, Austin, TX, USA.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Donald A Berry
- Berry Consultants, LLC, Austin, TX, USA.,Department of Biostatistics, University of Texas MD Anderson Cancer Center, TX, USA
| | | | - Kert Viele
- Berry Consultants, LLC, Austin, TX, USA.,Department of Biostatistics, University of Kentucky, Lexington, KY, USA
| | - Scott M Berry
- Berry Consultants, LLC, Austin, TX, USA.,Department of Biostatistics, University of Kansas Medical Center, Kansas City, KS, USA
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38
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Engineered biomimetic nanoparticles achieve targeted delivery and efficient metabolism-based synergistic therapy against glioblastoma. Nat Commun 2022; 13:4214. [PMID: 35864093 PMCID: PMC9304377 DOI: 10.1038/s41467-022-31799-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 06/29/2022] [Indexed: 02/07/2023] Open
Abstract
Glioblastoma multiforme (GBM) is an aggressive brain cancer with a poor prognosis and few treatment options. Here, building on the observation of elevated lactate (LA) in resected GBM, we develop biomimetic therapeutic nanoparticles (NPs) that deliver agents for LA metabolism-based synergistic therapy. Because our self-assembling NPs are encapsulated in membranes derived from glioma cells, they readily penetrate the blood-brain barrier and target GBM through homotypic recognition. After reaching the tumors, lactate oxidase in the NPs converts LA into pyruvic acid (PA) and hydrogen peroxide (H2O2). The PA inhibits cancer cell growth by blocking histones expression and inducing cell-cycle arrest. In parallel, the H2O2 reacts with the delivered bis[2,4,5-trichloro-6-(pentyloxycarbonyl)phenyl] oxalate to release energy, which is used by the co-delivered photosensitizer chlorin e6 for the generation of cytotoxic singlet oxygen to kill glioma cells. Such a synergism ensures strong therapeutic effects against both glioma cell-line derived and patient-derived xenograft models. Targeting cancer-associated metabolism is evolving as a promising approach for cancer therapy. Here, the authors generate cancer cell-membrane encapsulated nanoparticles to induce cell cycle arrest and cytotoxicity in lactate-high cancer cells, reducing tumourigensis in glioblastoma cell-line and patient-derived models.
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39
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Hu F, Ye X, Zhang LX. Multi-arm covariate-adaptive randomization. SCIENCE CHINA. MATHEMATICS 2022; 66:163-190. [PMID: 35912316 PMCID: PMC9326148 DOI: 10.1007/s11425-020-1954-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/21/2022] [Indexed: 06/15/2023]
Abstract
Simultaneously investigating multiple treatments in a single study achieves considerable efficiency in contrast to the traditional two-arm trials. Balancing treatment allocation for influential covariates has become increasingly important in today's clinical trials. The multi-arm covariate-adaptive randomized clinical trial is one of the most powerful tools to incorporate covariate information and multiple treatments in a single study. Pocock and Simon's procedure has been extended to the multi-arm case. However, the theoretical properties of multi-arm covariate-adaptive randomization have remained largely elusive for decades. In this paper, we propose a general framework for multi-arm covariate-adaptive designs which also includes the two-arm case, and establish the corresponding theory under widely satisfied conditions. The theoretical results provide new insights into the balance properties of covariate-adaptive randomization procedures and make foundations for most existing statistical inferences under two-arm covariate-adaptive randomization. Furthermore, these open a door to study the theoretical properties of statistical inferences for clinical trials based on multi-arm covariate-adaptive randomization procedures.
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Affiliation(s)
- Feifang Hu
- Department of Statistics, The George Washington University, Washington, DC, 20052 USA
| | - Xiaoqing Ye
- Institute of Statistics and Big Data, Renmin University of China, Beijing, 100872 China
| | - Li-Xin Zhang
- School of Mathematical Sciences, Zhejiang University, Hangzhou, 310058 China
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40
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Lim-Fat MJ, Youssef GC, Touat M, Iorgulescu JB, Whorral S, Allen M, Rahman R, Chukwueke U, McFaline-Figueroa JR, Nayak L, Lee EQ, Batchelor TT, Arnaout O, Peruzzi PP, Chiocca EA, Reardon DA, Meredith D, Santagata S, Beroukhim R, Bi WL, Ligon KL, Wen PY. Clinical utility of targeted next-generation sequencing assay in IDH-wildtype glioblastoma for therapy decision-making. Neuro Oncol 2022; 24:1140-1149. [PMID: 34878541 PMCID: PMC9248387 DOI: 10.1093/neuonc/noab282] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Targeted gene NGS testing is available through many academic institutions and commercial entities and is increasingly incorporated in practice guidelines for glioblastoma (GBM). This single-center retrospective study aimed to evaluate the clinical utility of incorporating NGS results in the management of GBM patients at a clinical trials-focused academic center. METHODS We identified 1011 consecutive adult patients with pathologically confirmed GBM (IDHwt or IDHmut) who had somatic tumor sequencing (Oncopanel, ~500 cancer gene panel) at DFCI from 2013-2019. Clinical records of all IDHwt GBM patients were reviewed to capture clinical trial enrollment and off-label targeted therapy use based on NGS results. RESULTS Of the 557 IDHwt GBM patients with sequencing, 182 entered clinical trials at diagnosis (32.7%) and 213 (38.2%) entered after recurrence. Sequencing results for 130 patients (23.3%) were utilized for clinical trial enrollment for either targeted therapy indications (6.9 % upfront and 27.7% at recurrent clinical trials and 3.1% for off-label targeted therapy) or exploratory studies (55.4% upfront and 6.9% recurrent clinical trials). Median overall survival was 20.1 months with no survival difference seen between patients enrolled in clinical trials compared to those who were not, in a posthoc analysis. CONCLUSIONS While NGS testing has become essential for improved molecular diagnostics, our study illustrates that targeted gene panels remain underutilized for selecting therapy in GBM-IDHwt. Targeted therapy and clinical trial design remain to be improved to help leverage the potential of NGS in clinical care.
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Affiliation(s)
- Mary Jane Lim-Fat
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Gilbert C Youssef
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mehdi Touat
- Sorbonne Université, Inserm, CNRS, UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, AP-HP, Hôpitaux Universitaires La Pitié Salpêtrière - Charles Foix, Service de Neurologie 2-Mazarin, Paris, France
| | - J Bryan Iorgulescu
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sydney Whorral
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Marie Allen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rifaquat Rahman
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ugonma Chukwueke
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - J Ricardo McFaline-Figueroa
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Eudocia Q Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tracy T Batchelor
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Omar Arnaout
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pier Paolo Peruzzi
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - E Antonio Chiocca
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David A Reardon
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David Meredith
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sandro Santagata
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rameen Beroukhim
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Keith L Ligon
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Oncologic Pathology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Werner JM, Wolf L, Tscherpel C, Bauer EK, Wollring M, Ceccon G, Deckert M, Brunn A, Pappesch R, Goldbrunner R, Fink GR, Galldiks N. Efficacy and tolerability of regorafenib in pretreated patients with progressive CNS grade 3 or 4 gliomas. J Neurooncol 2022; 159:309-317. [PMID: 35716310 PMCID: PMC9424167 DOI: 10.1007/s11060-022-04066-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/09/2022] [Indexed: 11/22/2022]
Abstract
Background The phase 2 REGOMA trial suggested an encouraging overall survival benefit in glioblastoma patients at first relapse treated with the multikinase inhibitor regorafenib. Here, we evaluated the efficacy and side effects of regorafenib in a real-life setting. Methods From 2018 to 2021, 30 patients with progressive WHO CNS grade 3 or 4 gliomas treated with regorafenib (160 mg/day; first 3 weeks of each 4-week cycle) with individual dose adjustment depending on toxicity were retrospectively identified. Side effects were evaluated according to the Common Terminology Criteria for Adverse Events (version 5.0). MRI was obtained at baseline and after every second cycle. Tumor progression was assessed according to RANO criteria. After regorafenib initiation, the median PFS and OS were calculated. Results The median number of treatment lines before regorafenib was 2 (range 1–4). Most patients (73%) had two or more pretreatment lines. At first relapse, 27% of patients received regorafenib. A total of 94 regorafenib cycles were administered (median 2 cycles; range 1–9 cycles). Grade 3 and 4 side effects were observed in 47% and 7% of patients, respectively, and were not significantly increased in patients with two or more pretreatments (P > 0.05). The most frequent grade 3 or 4 side effects were laboratory abnormalities (62%). PFS was 2.6 months (range 0.8–8.2 months), and the OS was 6.2 months (range 0.9–24 months). Conclusions In patients with progressive WHO grade 3 or 4 gliomas, predominantly with two pretreatment lines or more, regorafenib seems to be effective despite considerable grade 3 or 4 side effects.
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Affiliation(s)
- Jan-Michael Werner
- Deptartment of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener St. 62, 50937, Cologne, Germany
| | - Lena Wolf
- Deptartment of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener St. 62, 50937, Cologne, Germany
| | - Caroline Tscherpel
- Deptartment of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener St. 62, 50937, Cologne, Germany.,Institute of Neuroscience and Medicine (INM-3), Research Center Juelich, Leo-Brandt-St. 5, 52425, Juelich, Germany
| | - Elena K Bauer
- Deptartment of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener St. 62, 50937, Cologne, Germany
| | - Michael Wollring
- Deptartment of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener St. 62, 50937, Cologne, Germany.,Institute of Neuroscience and Medicine (INM-3), Research Center Juelich, Leo-Brandt-St. 5, 52425, Juelich, Germany
| | - Garry Ceccon
- Deptartment of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener St. 62, 50937, Cologne, Germany
| | - Martina Deckert
- Institute. of Neuropathology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, Cologne, Germany
| | - Anna Brunn
- Institute. of Neuropathology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Roberto Pappesch
- Institute of Pathology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, Cologne, Germany.,Deptartment of General Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gereon R Fink
- Deptartment of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener St. 62, 50937, Cologne, Germany.,Institute of Neuroscience and Medicine (INM-3), Research Center Juelich, Leo-Brandt-St. 5, 52425, Juelich, Germany
| | - Norbert Galldiks
- Deptartment of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener St. 62, 50937, Cologne, Germany. .,Institute of Neuroscience and Medicine (INM-3), Research Center Juelich, Leo-Brandt-St. 5, 52425, Juelich, Germany. .,Center of Integrated Oncology (CIO), Universities of Aachen, Bonn, Cologne, and Düsseldorf, Cologne, Germany.
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42
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Germano IM, Ziu M, Wen P, Ormond DR, Olson JJ. Congress of Neurological Surgeons systematic review and evidence-based guidelines update on the role of cytotoxic chemotherapy and other cytotoxic therapies in the management of progressive glioblastoma in adults. J Neurooncol 2022; 158:225-253. [PMID: 35195819 DOI: 10.1007/s11060-021-03900-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/12/2021] [Indexed: 11/29/2022]
Abstract
TARGET POPULATION These recommendations apply to adult patients diagnosed with progressive glioblastoma (pGBM). QUESTION (Q1): In adult patients with pGBM does the use of temozolomide (TMZ) with alternative dosing or the use of TMZ in combination with other cytotoxic treatments result in increased overall survival compared to other chemotherapy? RECOMMENDATION Level III: Adult patients with pGBM might derive benefit in treatment with TMZ, especially those who progress after more than 5 months of TMZ-treatment free interval. LEVEL III Combination of TMZ with other cytotoxic agents such as nitrosourea, cisplatin, electrohyperthermia, or tamoxifen is not suggested in adult patients with pGBM as a stand-alone therapy. There is insufficient data to make a recommendation about which alternative TMZ dosing provides the best benefits. QUESTION (Q2): In adult patients with pGBM does the use of systemic or in situ nitrosourea result in increased overall survival compared to other chemotherapy? RECOMMENDATION Level III: In the setting of pGBM, fotemustine is suggested in elderly patients with methylated MGMT promoter status. There is insufficient evidence to compare fotemustine to other nitrosoureas. There is insufficient evidence to make a recommendation about the use of in situ nitrosourea in patients with pGBM who underwent the Stupp regimen. QUESTION (Q3): In adult patients with pGBM does the use of platinum compounds and topoisomerase result in increased survival compared to other chemotherapy? RECOMMENDATION Level III: Other chemotherapy including platinum compounds and topoisomerase inhibitors are not suggested to be used in adult patients with pGBM. LEVEL III Other cytotoxic therapies like perillyl acohol or ketogenic diet are not suggested for use in adult patients with pGBM as a stand-alone therapy. QUESTION (Q4): In adult patients with pGBM does the use of tumor treating field (TTF) result in increased overall survival compared to chemotherapy? RECOMMENDATION Level III: The use of TTF with other chemotherapy may be considered when treating adult patients with pGBM. There is insufficient evidence to recommend TTF to increase overall survival in adult patients with pGBM. QUESTION (Q5): In adult patients with pGBM does the use of oncolytic virotherapy result in increased survival compared to chemotherapy? RECOMMENDATION Level III: Oncolytic virotherapy is not suggested in patients with pGBM.
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Affiliation(s)
- Isabelle M Germano
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Mateo Ziu
- Department of Neurosurgery, Inova Neurosciences, Fairfax, VA, USA
| | - Patrick Wen
- Center For Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - D Ryan Ormond
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
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43
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Menna G, Mattogno PP, Donzelli CM, Lisi L, Olivi A, Della Pepa GM. Glioma-Associated Microglia Characterization in the Glioblastoma Microenvironment through A ‘Seed-and Soil’ Approach: A Systematic Review. Brain Sci 2022; 12:brainsci12060718. [PMID: 35741603 PMCID: PMC9220868 DOI: 10.3390/brainsci12060718] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/25/2022] [Accepted: 05/28/2022] [Indexed: 12/04/2022] Open
Abstract
Background and aim: Ever since the discovery of tumor-associated immune cells, there has been growing interest in the understanding of the mechanisms underlying the crosstalk between these cells and tumor cells. A “seed and soil” approach has been recently introduced to describe the glioblastoma (GBM) landscape: tumor microenvironments act as fertile “soil” and interact with the “seed” (glial and stem cells compartment). In the following article, we provide a systematic review of the current evidence pertaining to the characterization of glioma-associated macrophages and microglia (GAMs) and microglia and macrophage cells in the glioma tumor microenvironment (TME). Methods: An online literature search was launched on PubMed Medline and Scopus using the following research string: “((Glioma associated macrophages OR GAM OR Microglia) AND (glioblastoma tumor microenvironment OR TME))”. The last search for articles pertinent to the topic was conducted in February 2022. Results: The search of the literature yielded a total of 349 results. A total of 235 studies were found to be relevant to our research question and were assessed for eligibility. Upon a full-text review, 58 articles were included in the review. The reviewed papers were further divided into three categories based on their focus: (1) Microglia maintenance of immunological homeostasis and protection against autoimmunity; (2) Microglia crosstalk with dedifferentiated and stem-like glioblastoma cells; (3) Microglia migratory behavior and its activation pattern. Conclusions: Aggressive growth, inevitable recurrence, and scarce response to immunotherapies are driving the necessity to focus on the GBM TME from a different perspective to possibly disentangle its role as a fertile ‘soil’ for tumor progression and identify within it feasible therapeutic targets. Against this background, our systematic review confirmed microglia to play a paramount role in promoting GBM progression and relapse after treatments. The correct and extensive understanding of microglia–glioma crosstalk could help in understanding the physiopathology of this complex disease, possibly opening scenarios for improvement of treatments.
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Affiliation(s)
- Grazia Menna
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.M.); (P.P.M.); (C.M.D.); (A.O.)
| | - Pier Paolo Mattogno
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.M.); (P.P.M.); (C.M.D.); (A.O.)
| | - Carlo Maria Donzelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.M.); (P.P.M.); (C.M.D.); (A.O.)
| | - Lucia Lisi
- Institute of Pharmacology, Catholic University of Rome, 00168 Rome, Italy;
| | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.M.); (P.P.M.); (C.M.D.); (A.O.)
| | - Giuseppe Maria Della Pepa
- Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (G.M.); (P.P.M.); (C.M.D.); (A.O.)
- Correspondence: ; Tel.: +39-0630154120
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Gatto L, Di Nunno V, Franceschi E, Tosoni A, Bartolini S, Brandes AA. Pharmacotherapeutic Treatment of Glioblastoma: Where Are We to Date? Drugs 2022; 82:491-510. [PMID: 35397073 DOI: 10.1007/s40265-022-01702-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 12/30/2022]
Abstract
The clinical management of glioblastoma (GBM) is still bereft of treatments able to significantly improve the poor prognosis of the disease. Despite the extreme clinical need for novel therapeutic drugs, only a small percentage of patients with GBM benefit from inclusion in a clinical trial. Moreover, often clinical studies do not lead to final interpretable conclusions. From the mistakes and negative results obtained in the last years, we are now able to plan a novel generation of clinical studies for patients with GBM, allowing the testing of multiple anticancer agents at the same time. This assumes critical importance, considering that, thanks to improved knowledge of altered molecular mechanisms related to the disease, we are now able to propose several potential effective compounds in patients with both newly diagnosed and recurrent GBM. Among the novel compounds assessed, the initially great enthusiasm toward trials employing immune checkpoint inhibitors (ICIs) was disappointing due to the negative results that emerged in three randomized phase III trials. However, novel biological insights into the disease suggest that immunotherapy can be a convincing and effective treatment in GBM even if ICIs failed to prolong the survival of these patients. In this regard, the most promising approach consists of engineered immune cells such as chimeric antigen receptor (CAR) T, CAR M, and CAR NK alone or in combination with other treatments. In this review, we discuss several issues related to systemic treatments in GBM patients. First, we assess critical issues toward the planning of clinical trials and the strategies employed to overcome these obstacles. We then move on to the most relevant interventional studies carried out on patients with previously untreated (newly diagnosed) GBM and those with recurrent and pretreated disease. Finally, we investigate novel immunotherapeutic approaches with special emphasis on preclinical and clinical data related to the administration of engineered immune cells in GBM.
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Affiliation(s)
- Lidia Gatto
- Department of Oncology, AUSL Bologna, Bologna, Italy
| | | | - Enrico Franceschi
- Nervous System Medical Oncology Department, IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura 3, Bologna, Italy.
| | - Alicia Tosoni
- Nervous System Medical Oncology Department, IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura 3, Bologna, Italy
| | - Stefania Bartolini
- Nervous System Medical Oncology Department, IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura 3, Bologna, Italy
| | - Alba Ariela Brandes
- Nervous System Medical Oncology Department, IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura 3, Bologna, Italy
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45
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Bruno F, Pellerino A, Palmiero R, Bertero L, Mantovani C, Garbossa D, Soffietti R, Rudà R. Glioblastoma in the Elderly: Review of Molecular and Therapeutic Aspects. Biomedicines 2022; 10:biomedicines10030644. [PMID: 35327445 PMCID: PMC8945166 DOI: 10.3390/biomedicines10030644] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 12/22/2022] Open
Abstract
Glioblastoma (GBM) is the most aggressive primary brain tumour. As GBM incidence is associated with age, elderly people represent a consistent subgroup of patients. Elderly people with GBM show dismal prognosis (about 6 months) and limited response to treatments. Age is a negative prognostic factor, which correlates with clinical frailty, poorer tolerability to surgery or adjuvant radio-chemotherapy, and higher occurrence of comorbidities and/or secondary complications. The aim of this paper is to review the clinical and molecular characteristics, current therapeutic options, and prognostic factors of elderly patients with GBM.
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Affiliation(s)
- Francesco Bruno
- Division of Neuro-Oncology, Department of Neuroscience, University and City of Health and Science, 10126 Turin, Italy; (A.P.); (R.P.); (R.S.); (R.R.)
- Correspondence:
| | - Alessia Pellerino
- Division of Neuro-Oncology, Department of Neuroscience, University and City of Health and Science, 10126 Turin, Italy; (A.P.); (R.P.); (R.S.); (R.R.)
| | - Rosa Palmiero
- Division of Neuro-Oncology, Department of Neuroscience, University and City of Health and Science, 10126 Turin, Italy; (A.P.); (R.P.); (R.S.); (R.R.)
| | - Luca Bertero
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy;
| | - Cristina Mantovani
- Division of Radiotherapy, Department of Oncology, University and City of Health and Science, 10126 Turin, Italy;
| | - Diego Garbossa
- Division of Neurosurgery, Department of Neuroscience, University and City of Health and Science, 10126 Turin, Italy;
| | - Riccardo Soffietti
- Division of Neuro-Oncology, Department of Neuroscience, University and City of Health and Science, 10126 Turin, Italy; (A.P.); (R.P.); (R.S.); (R.R.)
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience, University and City of Health and Science, 10126 Turin, Italy; (A.P.); (R.P.); (R.S.); (R.R.)
- Department of Neurology, Castelfranco and Treviso Hospitals, 31100 Treviso, Italy
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Bagley SJ, Kothari S, Rahman R, Lee EQ, Dunn GP, Galanis E, Chang SM, Burt Nabors L, Ahluwalia MS, Stupp R, Mehta MP, Reardon DA, Grossman SA, Sulman EP, Sampson JH, Khagi S, Weller M, Cloughesy TF, Wen PY, Khasraw M. Glioblastoma Clinical Trials: Current Landscape and Opportunities for Improvement. Clin Cancer Res 2022; 28:594-602. [PMID: 34561269 PMCID: PMC9044253 DOI: 10.1158/1078-0432.ccr-21-2750] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/29/2021] [Accepted: 09/14/2021] [Indexed: 11/16/2022]
Abstract
Therapeutic advances for glioblastoma have been minimal over the past 2 decades. In light of the multitude of recent phase III trials that have failed to meet their primary endpoints following promising preclinical and early-phase programs, a Society for Neuro-Oncology Think Tank was held in November 2020 to prioritize areas for improvement in the conduct of glioblastoma clinical trials. Here, we review the literature, identify challenges related to clinical trial eligibility criteria and trial design in glioblastoma, and provide recommendations from the Think Tank. In addition, we provide a data-driven context with which to frame this discussion by analyzing key study design features of adult glioblastoma clinical trials listed on ClinicalTrials.gov as "recruiting" or "not yet recruiting" as of February 2021.
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Affiliation(s)
- Stephen J. Bagley
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Shawn Kothari
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rifaquat Rahman
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Eudocia Q. Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gavin P. Dunn
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri
| | | | - Susan M. Chang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Louis Burt Nabors
- Division of Neuro-oncology, Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Manmeet S. Ahluwalia
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Roger Stupp
- Department of Medicine, Northwestern University, Chicago, Illinois
| | - Minesh P. Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - David A. Reardon
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Stuart A. Grossman
- Department of Oncology, Johns Hopkins Kimmel Cancer Center, Baltimore, Maryland
| | - Erik P. Sulman
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, New York
| | - John H. Sampson
- Preston Robert Tisch Brain Tumor Center, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Simon Khagi
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michael Weller
- Department of Neurology and Brain Tumor Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Timothy F. Cloughesy
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Patrick Y. Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mustafa Khasraw
- Preston Robert Tisch Brain Tumor Center, Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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Singh K, Batich KA, Wen PY, Tan AC, Bagley SJ, Lim M, Platten M, Colman H, Ashley DM, Chang SM, Rahman R, Galanis E, Mansouri A, Puduvalli VK, Reardon DA, Sahebjam S, Sampson JH, Simes J, Berry DA, Zadeh G, Cloughesy TF, Mehta MP, Piantadosi S, Weller M, Heimberger AB, Khasraw M. Designing Clinical Trials for Combination Immunotherapy: A Framework for Glioblastoma. Clin Cancer Res 2022; 28:585-593. [PMID: 34561270 PMCID: PMC9306329 DOI: 10.1158/1078-0432.ccr-21-2681] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/31/2021] [Accepted: 09/14/2021] [Indexed: 01/07/2023]
Abstract
Immunotherapy has revolutionized treatment for many hard-to-treat cancers but has yet to produce significant improvement in outcomes for patients with glioblastoma. This reflects the multiple and unique mechanisms of immune evasion and escape in this highly heterogeneous tumor. Glioblastoma engenders profound local and systemic immunosuppression and is remarkably effective at inducing T-cell dysfunction, posing a challenge to any immunotherapy-based approach. To overcome these mechanisms, multiple disparate modes of immune-oriented therapy will be required. However, designing trials that can evaluate these combinatorial approaches requires careful consideration. In this review, we explore the immunotherapy resistance mechanisms that have been encountered to date and how combinatorial approaches may address these. We also describe the unique aspects of trial design in both preclinical and clinical settings and consider endpoints and markers of response best suited for an intervention involving multiple agents.
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Affiliation(s)
| | | | | | | | | | | | - Michael Platten
- Medical Faculty Mannheim, MCTN, Heidelberg University and German Cancer Research Center, Heidelberg, Germany
| | | | | | - Susan M. Chang
- University of California, San Francisco (UCSF), San Francisco, California
| | | | | | | | | | | | - Solmaz Sahebjam
- Moffitt Cancer Center, University of South Florida, Tampa, Florida
| | | | - John Simes
- NHMRC Clinical Trials Centre, University of Sydney, NSW, Australia
| | | | | | | | | | | | - Michael Weller
- University Hospital and University of Zurich, Department of Neurology, Zürich, Switzerland
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Ye X, Schreck KC, Ozer BH, Grossman SA. High-grade glioma therapy: adding flexibility in trial design to improve patient outcomes. Expert Rev Anticancer Ther 2022; 22:275-287. [PMID: 35130447 DOI: 10.1080/14737140.2022.2038138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Outcomes for patients with high grade gliomas have changed little over the past thirty years. This realization prompted renewed efforts to increase flexibility in the design and conduct of clinical brain tumor trials. AREAS COVERED This manuscript reviews the development of clinical trial methods, challenges and considerations of flexible clinical trial designs, approaches to improve identification and testing of active agents for high grade gliomas, and evaluation of their delivery to the central nervous system. EXPERT OPINION Flexibility can be introduced in clinical trials in several ways. Flexible designs tout smaller sample sizes, adaptive modifications, fewer control arms, and inclusion of multiple arms in one study. Unfortunately, modifications in study designs cannot address two challenges that are largely responsible for the lack of progress in treating high grade gliomas: 1) the identification of active pharmaceutical agents and 2) the delivery of these agents to brain tumor tissue in therapeutic concentrations. To improve the outcomes of patients with high grade gliomas efforts must be focused on the pre-clinical screening of drugs for activity, the ability of these agents to achieve therapeutic concentrations in non-enhancing tumors, and a willingness to introduce novel compounds in minimally pre-treated patient populations.
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Affiliation(s)
- Xiaobu Ye
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore MD, USA
| | - Karisa C Schreck
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore MD, USA
| | - Byram H Ozer
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore MD, USA
| | - Stuart A Grossman
- The Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore MD, USA
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Lopez BGC, Kohale IN, Du Z, Korsunsky I, Abdelmoula WM, Dai Y, Stopka SA, Gaglia G, Randall EC, Regan MS, Basu SS, Clark AR, Marin BM, Mladek AC, Burgenske DM, Agar JN, Supko JG, Grossman SA, Nabors LB, Raychaudhuri S, Ligon KL, Wen PY, Alexander B, Lee EQ, Santagata S, Sarkaria J, White FM, Agar NYR. Multimodal platform for assessing drug distribution and response in clinical trials. Neuro Oncol 2022; 24:64-77. [PMID: 34383057 PMCID: PMC8730776 DOI: 10.1093/neuonc/noab197] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Response to targeted therapy varies between patients for largely unknown reasons. Here, we developed and applied an integrative platform using mass spectrometry imaging (MSI), phosphoproteomics, and multiplexed tissue imaging for mapping drug distribution, target engagement, and adaptive response to gain insights into heterogeneous response to therapy. METHODS Patient-derived xenograft (PDX) lines of glioblastoma were treated with adavosertib, a Wee1 inhibitor, and tissue drug distribution was measured with MALDI-MSI. Phosphoproteomics was measured in the same tumors to identify biomarkers of drug target engagement and cellular adaptive response. Multiplexed tissue imaging was performed on sister sections to evaluate spatial co-localization of drug and cellular response. The integrated platform was then applied on clinical specimens from glioblastoma patients enrolled in the phase 1 clinical trial. RESULTS PDX tumors exposed to different doses of adavosertib revealed intra- and inter-tumoral heterogeneity of drug distribution and integration of the heterogeneous drug distribution with phosphoproteomics and multiplexed tissue imaging revealed new markers of molecular response to adavosertib. Analysis of paired clinical specimens from patients enrolled in the phase 1 clinical trial informed the translational potential of the identified biomarkers in studying patient's response to adavosertib. CONCLUSIONS The multimodal platform identified a signature of drug efficacy and patient-specific adaptive responses applicable to preclinical and clinical drug development. The information generated by the approach may inform mechanisms of success and failure in future early phase clinical trials, providing information for optimizing clinical trial design and guiding future application into clinical practice.
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Affiliation(s)
- Begoña G C Lopez
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ishwar N Kohale
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Ziming Du
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ilya Korsunsky
- Center for Data Sciences, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Divisions of Genetics and Rheumatology, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Walid M Abdelmoula
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yang Dai
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sylwia A Stopka
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Giorgio Gaglia
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth C Randall
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael S Regan
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sankha S Basu
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amanda R Clark
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bianca-Maria Marin
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ann C Mladek
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jeffrey N Agar
- Department of Chemistry and Chemical Biology, Northeastern University, Boston, Massachusetts, USA
| | - Jeffrey G Supko
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Stuart A Grossman
- Brain Cancer Program, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Louis B Nabors
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Soumya Raychaudhuri
- Center for Data Sciences, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Divisions of Genetics and Rheumatology, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Keith L Ligon
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Brian Alexander
- Department of Radiation Oncology, Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Eudocia Q Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Sandro Santagata
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jann Sarkaria
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Forest M White
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
- Center for Precision Cancer Medicine, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Nathalie Y R Agar
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Cancer Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
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Fougner V, Hasselbalch B, Lassen U, Weischenfeldt J, Poulsen HS, Urup T. Implementing targeted therapies in the treatment of glioblastoma: Previous shortcomings, future promises, and a multimodal strategy recommendation. Neurooncol Adv 2022; 4:vdac157. [PMID: 36325372 PMCID: PMC9616055 DOI: 10.1093/noajnl/vdac157] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023] Open
Abstract
The introduction of targeted therapies to the field of oncology has prolonged the survival of several tumor types. Despite extensive research and numerous trials, similar outcomes have unfortunately not been realized for glioblastoma. For more than 15 years, the standard treatment of glioblastoma has been unchanged. This review walks through the elements that have challenged the success of previous trials and highlight some future promises. Concurrently, this review describes how institutions, through a multimodal and comprehensive strategy with 4 essential components, may increase the probability of finding a meaningful role for targeted therapies in the treatment of glioblastoma. These components are (1) prudent trial designs, (2) considered drug and target selection, (3) harnessed real-world clinical and molecular evidence, and (4) incorporation of translational research.
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Affiliation(s)
- Vincent Fougner
- Department for Cancer Treatment, DCCC—Brain Tumor Center, Rigshospitalet, Copenhagen, Capitol Region of Denmark, Denmark
| | - Benedikte Hasselbalch
- Department for Cancer Treatment, DCCC—Brain Tumor Center, Rigshospitalet, Copenhagen, Capitol Region of Denmark, Denmark
| | - Ulrik Lassen
- Department for Cancer Treatment, DCCC—Brain Tumor Center, Rigshospitalet, Copenhagen, Capitol Region of Denmark, Denmark
| | - Joachim Weischenfeldt
- BRIC - Biotech Research and Innovation Centre, University of Copenhagen, Copenhagen, Denmark
| | - Hans Skovgaard Poulsen
- Department for Cancer Treatment, DCCC—Brain Tumor Center, Rigshospitalet, Copenhagen, Capitol Region of Denmark, Denmark
| | - Thomas Urup
- Department for Cancer Treatment, DCCC—Brain Tumor Center, Rigshospitalet, Copenhagen, Capitol Region of Denmark, Denmark
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