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Moorthy V, Abubakar I, Qadri F, Ogutu B, Zhang W, Reeder J, Farrar J. The future of the global clinical trial ecosystem: a vision from the first WHO Global Clinical Trials Forum. Lancet 2024; 403:124-126. [PMID: 38128557 DOI: 10.1016/s0140-6736(23)02798-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Vasee Moorthy
- Science Division, World Health Organization, 1211 Geneva, Switzerland.
| | | | - Firdausi Qadri
- icddr,b (International Centre for Diarrhoeal Disease Research), Dhaka, Bangladesh
| | | | - Wei Zhang
- Science Division, World Health Organization, 1211 Geneva, Switzerland
| | - John Reeder
- Science Division, World Health Organization, 1211 Geneva, Switzerland
| | - Jeremy Farrar
- Science Division, World Health Organization, 1211 Geneva, Switzerland
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2
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Pickles A, Edwards D, Horvath L, Emsley R. Research Reviews: Advances in methods for evaluating child and adolescent mental health interventions. J Child Psychol Psychiatry 2023; 64:1765-1775. [PMID: 37793673 DOI: 10.1111/jcpp.13892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/06/2023]
Abstract
BACKROUND The evidence base for interventions for child mental health and neurodevelopment is weak and the current capacity for rigorous evaluation limited. We describe some of the challenges that make this field particularly difficult and expensive for evaluation studies. METHODS We describe and review the use of novel study designs and analysis methodology for their potential to improve this situation. RESULTS While several novel designs appeared ill-suited to our field, systematic review found others that offered potential but had yet to be widely adopted, some not at all. CONCLUSIONS While funding is inevitably a constraint, we argue that improvements in the evidence base of both current and new treatments will only be achieved by the adoption of a number of these new technologies and study designs, the consistent application of rigorous constructive but demanding standards, and the engagement of the public, patients, clinical and research services to build a design, recruitment, and analysis infrastructure.
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Affiliation(s)
- Andrew Pickles
- Department of Biostatistics and Health Informatics, King's College London, London, UK
| | - Danielle Edwards
- Department of Biostatistics and Health Informatics, King's College London, London, UK
| | - Levente Horvath
- Department of Biostatistics and Health Informatics, King's College London, London, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, King's College London, London, UK
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3
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Broglio K, Niewczas J, Wathen K. Who wants to go first? A simulation study of accrual in a stand-alone trial versus starting a platform trial. Contemp Clin Trials 2022; 123:107000. [PMID: 36372160 DOI: 10.1016/j.cct.2022.107000] [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: 09/03/2022] [Revised: 10/31/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
Others have quantified the efficiency of the platform approach as compared to a sequence of independent two-arm trials and have shown the platform approach more efficiently evaluates a set of candidate therapies. However, a practical barrier to initiating a platform trial is incentivizing the first candidate therapies to enter the platform. A platform trial is more complex and will take longer to design and operationalize than a traditional trial. For the first therapy, this additional up-front planning time must be considered along with the ability to enroll. There is a common concern that accrual in a platform setting would take longer than for a single stand-alone trial because intuition suggests that a two-arm trial with a smaller total sample size should complete accrual more quickly than a multi-armed trial. We focus on the accrual duration for the first therapy as a particular barrier to initiating a platform trial strategy. We simulate accrual into a platform trial versus a stand-alone trial in the setting of a large clinical trial network. Accrual duration in the platform strategy dominates that of a single stand-alone trial if the platform leverages a large enough fraction of the site network. Patient preference for a particular stand-alone trial has little impact on the ability of a stand-alone trial to enroll more quickly.
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Affiliation(s)
- Kristine Broglio
- AstraZeneca, Oncology Statistical Innovation, Gaithersburg, MD, USA.
| | - Julia Niewczas
- Janssen, Statistical Modeling and Methodology, Gothenburg, Sweden.
| | - Kyle Wathen
- Cytel, Scientific Strategy and Innovation, Waltham, MA, USA.
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4
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Love SB, Cafferty F, Snowdon C, Carty K, Savage J, Pallmann P, McParland L, Brown L, Masters L, Schiavone F, Hague D, Townsend S, Amos C, South A, Sturgeon K, Langley R, Maughan T, James N, Hall E, Kernaghan S, Bliss J, Turner N, Tutt A, Yap C, Firth C, Kong A, Mehanna H, Watts C, Hills R, Thomas I, Copland M, Bell S, Sebag-Montefiore D, Jones R, Parmar MKB, Sydes MR. Practical guidance for running late-phase platform protocols for clinical trials: lessons from experienced UK clinical trials units. Trials 2022; 23:757. [PMID: 36068599 PMCID: PMC9449272 DOI: 10.1186/s13063-022-06680-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 08/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Late-phase platform protocols (including basket, umbrella, multi-arm multi-stage (MAMS), and master protocols) are generally agreed to be more efficient than traditional two-arm clinical trial designs but are not extensively used. We have gathered the experience of running a number of successful platform protocols together to present some operational recommendations. METHODS Representatives of six UK clinical trials units with experience in running late-phase platform protocols attended a 1-day meeting structured to discuss various practical aspects of running these trials. We report and give guidance on operational aspects which are either harder to implement compared to a traditional late-phase trial or are specific to platform protocols. RESULTS We present a list of practical recommendations for trialists intending to design and conduct late-phase platform protocols. Our recommendations cover the entire life cycle of a platform trial: from protocol development, obtaining funding, and trial set-up, to a wide range of operational and regulatory aspects such as staffing, oversight, data handling, and data management, to the reporting of results, with a particular focus on communication with trial participants and stakeholders as well as public and patient involvement. DISCUSSION Platform protocols enable many questions to be answered efficiently to the benefit of patients. Our practical lessons from running platform trials will support trial teams in learning how to run these trials more effectively and efficiently.
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Affiliation(s)
- Sharon B. Love
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Fay Cafferty
- The Institute of Cancer Research, London, SW7 3RP UK
| | | | - Karen Carty
- Cancer Research UK Clinical Trials Unit, Level 0 The Beatson West of Scotland Cancer Centre, 1053 Great Western Road, Glasgow, G12 0YN UK
| | - Joshua Savage
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
| | - Philip Pallmann
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | | | - Louise Brown
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Lindsey Masters
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | | | - Dominic Hague
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Stephen Townsend
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Claire Amos
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Annabelle South
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Kate Sturgeon
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Ruth Langley
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | | | | | - Emma Hall
- The Institute of Cancer Research, London, SW7 3RP UK
| | | | - Judith Bliss
- The Institute of Cancer Research, London, SW7 3RP UK
| | - Nick Turner
- The Institute of Cancer Research, London, SW7 3RP UK
| | - Andrew Tutt
- The Institute of Cancer Research, London, SW3 6JB UK
| | - Christina Yap
- The Institute of Cancer Research, London, SW7 3RP UK
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - Charlotte Firth
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - Anthony Kong
- Comprehensive Cancer Centre, King’s College London, Guy’s Campus, New Hunt’s House, Room 2.36b, London, SE1 1UL UK
| | - Hisham Mehanna
- Institute for Head and Neck Studies and Education, University of Birmingham, Birmingham, B15 2TT UK
| | - Colin Watts
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - Robert Hills
- Doll Building, CTSU, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF UK
| | - Ian Thomas
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park Way, Cardiff, CF14 4YS UK
| | - Mhairi Copland
- Paul O’Gorman Research Centre, Gartnavel General Hospital, Glasgow, G12 0YN UK
| | - Sue Bell
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | | | - Robert Jones
- Beatson West of Scotland Cancer Centre, Glasgow, UK
| | | | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
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Aqib A, Lebouché B, Engler K, Schuster T. Feasibility of a Platform Trial Design for the Development of Mobile Health Applications: A Review. Telemed J E Health 2022; 29:501-509. [PMID: 35951018 DOI: 10.1089/tmj.2021.0620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: A novel adaptive trial design called platform trials (PTs) may offer an effective, efficient, and unbiased approach to evaluate different developer versions of mobile health (m-health) apps. However, the feasibility of their use for this purpose is yet to be explored. Objective: This literature review aims to explore the reported challenges associated with the adaptive PT design to assess its feasibility for the development of m-health apps. Methods: A descriptive literature review using two databases (MEDLINE and Embase) was conducted. Documents published in English between 1947 and September 20, 2020, were eligible for inclusion. Results: The titles and abstracts of 758 records were screened after which 179 full-text articles were assessed for eligibility. A total of 41 articles were included in the synthesis, all published after the year 2000. The synthesis yielded eight distinct categories of challenging issues with PTs relevant to their application in m-health app development, along with potential solutions. These categories are ethical issues (e.g., related to informed consent, equipoise, justice) (with 19 articles contributing content), biases (7 articles), temporal drift (4 articles), miscellaneous statistical issues (3 articles), logistical issues (e.g., cost and human resources, frequent amendments; 6 articles), sample size and power conflict (2 articles), generalizability of the results (2 articles), and operational challenges (1 article). Conclusion: Although PT designs are relatively new, they have promising feasibility for the seamless evaluation of interventions that undergo continuous development, including m-health apps; however, various challenges may hinder their successful implementation.
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Affiliation(s)
- Asma Aqib
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada.,Department of Internal Medicine, University of Alabama, Montgomery, Alabama, USA
| | - Bertrand Lebouché
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada.,Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, Canada.,Chronic Viral Illness Service, Royal Victoria Hospital, McGill University Health Centre, Montreal, Canada
| | - Kim Engler
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, Canada
| | - Tibor Schuster
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
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Park JJH, Sharif B, Harari O, Dron L, Heath A, Meade M, Zarychanski R, Lee R, Tremblay G, Mills EJ, Jemiai Y, Mehta C, Wathen JK. Economic Evaluation of Cost and Time Required for a Platform Trial vs Conventional Trials. JAMA Netw Open 2022; 5:e2221140. [PMID: 35819785 PMCID: PMC9277502 DOI: 10.1001/jamanetworkopen.2022.21140] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Platform trial design allows the introduction of new interventions after the trial is initiated and offers efficiencies to clinical research. However, limited guidance exists on the economic resources required to establish and maintain platform trials. OBJECTIVE To compare cost (US dollars) and time requirements of conducting a platform trial vs a series of conventional (nonplatform) trials using a real-life example. DESIGN, SETTING, AND PARTICIPANTS For this economic evaluation, an online survey was administered to a group of international experts (146 participants) with publication records of platform trials to elicit their opinions on cost and time to set up and conduct platform, multigroup, and 2-group trials. Using the reported entry dates of 10 interventions into Systemic Therapy in Advancing Metastatic Prostate Cancer: Evaluation of Drug Efficacy, the longest ongoing platform trial, 3 scenarios were designed involving a single platform trial (scenario 1), 1 multigroup followed by 5 2-group trials (scenario 2), and a series of 10 2-group trials (scenario 3). All scenarios started with 5 interventions, then 5 more interventions were either added to the platform or evaluated independently. Simulations with the survey results as inputs were used to compare the platform vs conventional trial designs. Data were analyzed from July to September 2021. EXPOSURE Platform trial design. MAIN OUTCOMES AND MEASURES Total trial setup and conduct cost and cumulative duration. RESULTS Although setup time and cost requirements of a single trial were highest for the platform trial, cumulative requirements of setting up a series of multiple trials in scenarios 2 and 3 were larger. Compared with the platform trial, there was a median (IQR) increase of 216.7% (202.2%-242.5%) in cumulative setup costs for scenario 2 and 391.1% (365.3%-437.9%) for scenario 3. In terms of total cost, there was a median (IQR) increase of 17.4% (12.1%-22.5%) for scenario 2 and 57.5% (43.1%-69.9%) for scenario 3. There was a median (IQR) increase in cumulative trial duration of 171.1% (158.3%-184.3%) for scenario 2 and 311.9% (282.0%-349.1%) for scenario 3. Cost and time reductions in the platform trial were observed in both the initial and subsequently evaluated interventions. CONCLUSIONS AND RELEVANCE Although setting up platform trials can take longer and be costly, the findings of this study suggest that having a single infrastructure can improve efficiencies with respect to costs and efforts.
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Affiliation(s)
- Jay J. H. Park
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University Health Sciences Centre, Hamilton, Ontario, Canada
| | | | | | | | - Anna Heath
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Statistical Science, University College London, London, United Kingdom
| | - Maureen Meade
- Department of Health Research Methods, Evidence, and Impact, McMaster University Health Sciences Centre, Hamilton, Ontario, Canada
- Interdepartmental Division of Critical Care, Hamilton Health Sciences, Critical Care, Hamilton, Ontario, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Section of Critical Care, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Internal Medicine, Section of Hematology/Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | - Edward J. Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University Health Sciences Centre, Hamilton, Ontario, Canada
| | | | - Cyrus Mehta
- Cytel, Inc, Waltham, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Cambridge, Massachusetts
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7
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White IR, Choodari-Oskooei B, Sydes MR, Kahan BC, McCabe L, Turkova A, Esmail H, Gibb DM, Ford D. Combining factorial and multi-arm multi-stage platform designs to evaluate multiple interventions efficiently. Clin Trials 2022; 19:432-441. [PMID: 35579066 PMCID: PMC9373200 DOI: 10.1177/17407745221093577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Factorial-MAMS design platform designs have many advantages, but the practical advantages and disadvantages of combining the two designs have not been explored. METHODS We propose practical methods for a combined design within the platform trial paradigm where some interventions are not expected to interact and could be given together. RESULTS We describe the combined design and suggest diagrams that can be used to represent it. Many properties are common both to standard factorial designs, including the need to consider interactions between interventions and the impact of intervention efficacy on power of other comparisons, and to standard multi-arm multi-stage designs, including the need to pre-specify procedures for starting and stopping intervention comparisons. We also identify some specific features of the factorial-MAMS design: timing of interim and final analyses should be determined by calendar time or total observed events; some non-factorial modifications may be useful; eligibility criteria should be broad enough to include any patient eligible for any part of the randomisation; stratified randomisation may conveniently be performed sequentially; and analysis requires special care to use only concurrent controls. CONCLUSION A combined factorial-MAMS design can combine the efficiencies of factorial trials and multi-arm multi-stage platform trials. It allows us to address multiple research questions under one protocol and to test multiple new treatment options, which is particularly important when facing a new emergent infection such as COVID-19.
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8
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Brown LC, Graham J, Fisher D, Adams R, Seligmann J, Seymour M, Kaplan R, Yates E, Parmar M, Richman SD, Quirke P, Butler R, Shiu K, Middleton G, Samuel L, Wilson RH, Maughan TS. Experiences of running a stratified medicine adaptive platform trial: Challenges and lessons learned from 10 years of the FOCUS4 trial in metastatic colorectal cancer. Clin Trials 2022; 19:146-157. [PMID: 35083924 PMCID: PMC9036145 DOI: 10.1177/17407745211069879] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Complex innovative design trials are becoming increasingly common and offer potential for improving patient outcomes in a faster time frame. FOCUS4 was the first molecularly stratified trial in metastatic colorectal cancer and it remains one of the first umbrella trial designs to be launched globally. Here, we aim to describe lessons learned from delivery of the trial over the last 10 years. METHODS FOCUS4 was a Phase II/III molecularly stratified umbrella trial testing the safety and efficacy of targeted therapies in metastatic colorectal cancer. It used adaptive statistical methodology to decide which sub-trial should close early, and new therapies were added as protocol amendments. Patients with newly diagnosed metastatic colorectal cancer were registered, and central laboratory testing was used to stratify their tumour into molecular subtypes. Following 16 weeks of first-line therapy, patients with stable or responding disease were eligible for randomisation into either a molecularly stratified sub-trial (FOCUS4-B, C or D) or non-stratified FOCUS4-N. The primary outcome for all studies was progression-free survival comparing the intervention with active monitoring/placebo. At the close of the trial, feedback was elicited from all investigators through surveys and interviews and consolidated into a series of recommendations and lessons learned for the delivery of similar future trials. RESULTS Between January 2014 and October 2020, 1434 patients were registered from 88 UK hospitals. Of the 20 drug combinations that were explored for inclusion in the platform trial, three molecularly targeted sub-trials were activated: FOCUS4-D (February 2014-March 2016) evaluated AZD8931 in the BRAF-PIK3CA-RAS wildtype subgroup; FOCUS4-B (February 2016-July 2018) evaluated aspirin in the PIK3CA mutant subgroup and FOCUS4-C (June 2017-October 2020) evaluated adavosertib in the RAS+TP53 double mutant subgroup. FOCUS4-N was active throughout and evaluated capecitabine monotherapy versus a treatment break. A total of 361 (25%) registered patients were randomised into a sub-trial. Feedback on the experiences of delivery of FOCUS4 could be grouped into three main areas of challenge: funding/infrastructure, biomarker testing procedures and trial design efficiencies within which 20 recommendations are summarised. CONCLUSION Adaptive stratified medicine platform studies are feasible in common cancers but present challenges. Our stakeholder feedback has helped to inform how these trial designs can succeed and answer multiple questions efficiently, providing resource is adequate.
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Affiliation(s)
| | - Janet Graham
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | | | - Richard Adams
- Centre for Trials Research, Cardiff University and Velindre NHS Trust, Cardiff, UK
| | - Jenny Seligmann
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
| | - Matthew Seymour
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
| | | | - Emma Yates
- MRC Clinical Trials Unit at UCL, London, UK
| | | | - Susan D Richman
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
| | - Philip Quirke
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
| | | | | | | | | | - Richard H Wilson
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Timothy S Maughan
- MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
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9
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Noor NM, Love SB, Isaacs T, Kaplan R, Parmar MKB, Sydes MR. Uptake of the multi-arm multi-stage (MAMS) adaptive platform approach: a trial-registry review of late-phase randomised clinical trials. BMJ Open 2022; 12:e055615. [PMID: 35273052 PMCID: PMC8915371 DOI: 10.1136/bmjopen-2021-055615] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND For medical conditions with numerous interventions worthy of investigation, there are many advantages of a multi-arm multi-stage (MAMS) platform trial approach. However, there is currently limited knowledge on uptake of the MAMS design, especially in the late-phase setting. We sought to examine uptake and characteristics of late-phase MAMS platform trials, to enable better planning for teams considering future use of this approach. DESIGN We examined uptake of registered, late-phase MAMS platforms in the EU clinical trials register, Australian New Zealand Clinical Trials Registry, International Standard Randomised Controlled Trial Number registry, Pan African Clinical Trials Registry, WHO International Clinical Trial Registry Platform and databases: PubMed, Medline, Cochrane Library, Global Health Library and EMBASE. Searching was performed and review data frozen on 1 April 2021. MAMS platforms were defined as requiring two or more comparison arms, with two or more trial stages, with an interim analysis allowing for stopping of recruitment to arms and typically the ability to add new intervention arms. RESULTS 62 late-phase clinical trials using an MAMS approach were included. Overall, the number of late-phase trials using the MAMS design has been increasing since 2001 and been accelerated by COVID-19. The majority of current MAMS platforms were either targeting infectious diseases (52%) or cancers (29%) and all identified trials were for treatment interventions. 89% (55/62) of MAMS platforms were evaluating medications, with 45% (28/62) of the MAMS platforms having at least one or more repurposed medication as a comparison arm. CONCLUSIONS Historically, late-phase trials have adhered to long-established standard (two-arm) designs. However, the number of late-phase MAMS platform trials is increasing, across a range of different disease areas. This study highlights the potential scope of MAMS platform trials and may assist research teams considering use of this approach in the late-phase randomised clinical trial setting. PROSPERO REGISTRATION NUMBER CRD42019153910.
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Affiliation(s)
| | | | - Talia Isaacs
- Institute of Education, University College London, London, UK
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10
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Wong C, Stavrou M, Elliott E, Gregory JM, Leigh N, Pinto AA, Williams TL, Chataway J, Swingler R, Parmar MKB, Stallard N, Weir CJ, Parker RA, Chaouch A, Hamdalla H, Ealing J, Gorrie G, Morrison I, Duncan C, Connelly P, Carod-Artal FJ, Davenport R, Reitboeck PG, Radunovic A, Srinivasan V, Preston J, Mehta AR, Leighton D, Glasmacher S, Beswick E, Williamson J, Stenson A, Weaver C, Newton J, Lyle D, Dakin R, Macleod M, Pal S, Chandran S. Clinical trials in amyotrophic lateral sclerosis: a systematic review and perspective. Brain Commun 2021; 3:fcab242. [PMID: 34901853 PMCID: PMC8659356 DOI: 10.1093/braincomms/fcab242] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 09/07/2021] [Accepted: 09/13/2021] [Indexed: 12/15/2022] Open
Abstract
Amyotrophic lateral sclerosis is a progressive and devastating neurodegenerative disease. Despite decades of clinical trials, effective disease-modifying drugs remain scarce. To understand the challenges of trial design and delivery, we performed a systematic review of Phase II, Phase II/III and Phase III amyotrophic lateral sclerosis clinical drug trials on trial registries and PubMed between 2008 and 2019. We identified 125 trials, investigating 76 drugs and recruiting more than 15 000 people with amyotrophic lateral sclerosis. About 90% of trials used traditional fixed designs. The limitations in understanding of disease biology, outcome measures, resources and barriers to trial participation in a rapidly progressive, disabling and heterogenous disease hindered timely and definitive evaluation of drugs in two-arm trials. Innovative trial designs, especially adaptive platform trials may offer significant efficiency gains to this end. We propose a flexible and scalable multi-arm, multi-stage trial platform where opportunities to participate in a clinical trial can become the default for people with amyotrophic lateral sclerosis.
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Affiliation(s)
- Charis Wong
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Maria Stavrou
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.,UK Dementia Research Institute, Chancellor's Building, The University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Elizabeth Elliott
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.,UK Dementia Research Institute, Chancellor's Building, The University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Jenna M Gregory
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.,UK Dementia Research Institute, Chancellor's Building, The University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Nigel Leigh
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, BN1 9PX, UK
| | - Ashwin A Pinto
- Neurology Department, Wessex Neurosciences Centre, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - Timothy L Williams
- Department of Neurology, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London WC1B 5EH, UK.,National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, W1T 7DN, UK.,MRC CTU at UCL, Institute of Clinical Trials and Methodology, University College London, London, WC1V 6LJ, UK
| | - Robert Swingler
- Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Mahesh K B Parmar
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, University College London, London, WC1V 6LJ, UK
| | - Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, Level 2, NINE Edinburgh BioQuarter, 9 Little France Road, Edinburgh EH16 4UX, UK
| | - Richard A Parker
- Edinburgh Clinical Trials Unit, Usher Institute, Level 2, NINE Edinburgh BioQuarter, 9 Little France Road, Edinburgh EH16 4UX, UK
| | - Amina Chaouch
- Motor Neurone Disease Care Centre, Manchester Centre for Clinical Neurosciences, Salford, M6 8HD, UK
| | - Hisham Hamdalla
- Motor Neurone Disease Care Centre, Manchester Centre for Clinical Neurosciences, Salford, M6 8HD, UK
| | - John Ealing
- Motor Neurone Disease Care Centre, Manchester Centre for Clinical Neurosciences, Salford, M6 8HD, UK
| | - George Gorrie
- Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, G51 4TF, UK
| | - Ian Morrison
- Department of Neurology, NHS Tayside, Dundee, DD2 1UB, UK
| | - Callum Duncan
- Department of Neurology, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZN, UK
| | - Peter Connelly
- NHS Research Scotland Neuroprogressive Disorders and Dementia Network, Ninewells Hospital, Dundee, DD1 9SY, UK
| | | | - Richard Davenport
- Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Department of Clinical Neurosciences, NHS Lothian, Edinburgh, EH16 4SA, UK
| | - Pablo Garcia Reitboeck
- Atkinson Morley Regional Neurosciences Centre, St. George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | | | | | - Jenny Preston
- Department of Neurology, NHS Ayrshire & Arran, KA12 8SS, UK
| | - Arpan R Mehta
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.,UK Dementia Research Institute, Chancellor's Building, The University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Danielle Leighton
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Stella Glasmacher
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Emily Beswick
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Jill Williamson
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Amy Stenson
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Christine Weaver
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Judith Newton
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Dawn Lyle
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Rachel Dakin
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Malcolm Macleod
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Suvankar Pal
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Siddharthan Chandran
- Centre for Clinical Brain Sciences, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Anne Rowling Regenerative Neurology Clinic, Chancellor's Building, 49 Little France Crescent, The University of Edinburgh, Edinburgh, EH16 4SB, UK.,Euan MacDonald Centre for MND Research, University of Edinburgh, FU303F, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.,UK Dementia Research Institute, Chancellor's Building, The University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
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11
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Randomised clinical trials in critical care: past, present and future. Intensive Care Med 2021; 48:164-178. [PMID: 34853905 PMCID: PMC8636283 DOI: 10.1007/s00134-021-06587-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/17/2021] [Indexed: 12/15/2022]
Abstract
Randomised clinical trials (RCTs) are the gold standard for providing unbiased evidence of intervention effects. Here, we provide an overview of the history of RCTs and discuss the major challenges and limitations of current critical care RCTs, including overly optimistic effect sizes; unnuanced conclusions based on dichotomization of results; limited focus on patient-centred outcomes other than mortality; lack of flexibility and ability to adapt, increasing the risk of inconclusive results and limiting knowledge gains before trial completion; and inefficiency due to lack of re-use of trial infrastructure. We discuss recent developments in critical care RCTs and novel methods that may provide solutions to some of these challenges, including a research programme approach (consecutive, complementary studies of multiple types rather than individual, independent studies), and novel design and analysis methods. These include standardization of trial protocols; alternative outcome choices and use of core outcome sets; increased acceptance of uncertainty, probabilistic interpretations and use of Bayesian statistics; novel approaches to assessing heterogeneity of treatment effects; adaptation and platform trials; and increased integration between clinical trials and clinical practice. We outline the advantages and discuss the potential methodological and practical disadvantages with these approaches. With this review, we aim to inform clinicians and researchers about conventional and novel RCTs, including the rationale for choosing one or the other methodological approach based on a thorough discussion of pros and cons. Importantly, the most central feature remains the randomisation, which provides unparalleled restriction of confounding compared to non-randomised designs by reducing confounding to chance.
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12
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Yang S, Wu H. The Performance Impact of New Ventures in Working Environment and Innovation Behavior From the Perspective of Personality Psychology. Front Psychol 2021; 12:734014. [PMID: 34803812 PMCID: PMC8595093 DOI: 10.3389/fpsyg.2021.734014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/01/2021] [Indexed: 11/30/2022] Open
Abstract
A new venture barely makes a profit in its initial stage, and its success depends on innovation. Innovation is related to the work environment, and the innovation behavior of employees is of great significance to the performance improvement of new venture. Based on the previous research, in this study, hypotheses on the correlation between work environment, employee innovation behavior, and corporate performance are put forward first. Then, with team cooperation, organizational incentive, leadership support, sufficient resources, and work pressure as the factors of the work environment, the bosses, middle and senior managers involved in entrepreneurship, and the main members of the entrepreneurial team of 202 newly established enterprises in developed regions are surveyed online or in scene. Multivariate hierarchical regression analysis is performed to analyze the data collected from the questionnaire. The results show that the effective recovery rate of the questionnaire is 86.4%; the number of traditional enterprises is 108 (53.47%), and that of R&D enterprises is 68 (33.66%); teamwork, leadership support, and work pressure are all correlated with employees’ innovative behavior (P < 0.05), while organizational motivation and sufficient resources are not correlated with employees’ innovative behavior (P > 0.05); employee innovation behavior is positively correlated with enterprise performance (β = 0.375, P ≤ 0.01); the working environment and employee innovation behavior promote enterprise performance (β = 0.433, P ≤ 0.01); and the working environment affects the relationship between employee innovation behavior and enterprise performance (β = 0.399, P ≤ 0.05). The study theoretically enriches the research on the relationship between innovation behavior, work environment, and enterprise performance of new ventures. In practice, it is suggested that start-up enterprises provide good working environment for employees and attach importance to innovation activities at the individual level of employees, which provides useful guidance and reference for the development of Chinese start-up enterprises.
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Affiliation(s)
- Shufang Yang
- School of Business, Changshu Institute of Technology, Suzhou, China
| | - Hainan Wu
- School of Finance and Public Administration, Anhui University of Finance and Economics, Bengbu, China
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13
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Park JJH, Dron L, Mills EJ. Moving forward in clinical research with master protocols. Contemp Clin Trials 2021; 106:106438. [PMID: 34000408 PMCID: PMC8120789 DOI: 10.1016/j.cct.2021.106438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 12/15/2022]
Abstract
With billions of dollars in research and development (R&D) funding continuing to be invested, the novel coronavirus disease 2019 (COVID-19) has become into a singular focus for the scientific community. However, the collective response from the scientific communities have seen poor return on investment, particularly for therapeutic research for COVID-19, revealing the existing weaknesses and inefficiencies of the clinical trial enterprise. In this article, we argue for the importance of structural changes to existing research programs for clinical trials in light of the lessons learned from COVID-19.
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Affiliation(s)
- Jay J H Park
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Louis Dron
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Edward J Mills
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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14
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Latimer NR, Pollard D, Towse A, Henshall C, Sansom L, Ward RL, Bruce A, Deakin C. Challenges in valuing and paying for combination regimens in oncology: reporting the perspectives of a multi-stakeholder, international workshop. BMC Health Serv Res 2021; 21:412. [PMID: 33941174 PMCID: PMC8091555 DOI: 10.1186/s12913-021-06425-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/21/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND It is increasingly common for two or more treatments for cancer to be combined as a single regimen. Determining value and appropriate payment for such regimens can be challenging. This study discusses these challenges, and possible solutions. METHODS Stakeholders from around the world attended a 2-day workshop, supported by a background paper. This study captures key outcomes from the discussion, but is not a consensus statement. RESULTS Workshop attendees agreed that combining on-patent treatments can result in affordability and value for money challenges that delay or deny patient access to clinically effective treatments in many health systems. Options for addressing these challenges include: (i) Increasing the value of combination therapies through improved clinical development; (ii) Willingness to pay more for combinations than for single drugs offering similar benefit, or; (iii) Aligning the cost of constituent therapies with their value within a regimen. Workshop attendees felt that (i) and (iii) merited further discussion, whereas (ii) was unlikely to be justifiable. Views differed on the feasibility of (i). Key to (iii) would be systems allowing different prices to apply to different uses of a drug. CONCLUSIONS Common ground was identified on immediate actions to improve access to combination regimens. These include an exploration of the legal challenges associated with price negotiations, and ensuring that pricing systems can support implementation of negotiated prices for specific uses. Improvements to clinical development and trial design should be pursued in the medium and longer term.
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Affiliation(s)
- Nicholas R Latimer
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, S1 4DA, Sheffield, UK.
| | - Daniel Pollard
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, S1 4DA, Sheffield, UK
| | | | | | - Lloyd Sansom
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Robyn L Ward
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | | | - Carla Deakin
- National Institute for Health and Care Excellence, Manchester, UK
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15
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Collignon O, Burman CF, Posch M, Schiel A. Collaborative Platform Trials to Fight COVID-19: Methodological and Regulatory Considerations for a Better Societal Outcome. Clin Pharmacol Ther 2021; 110:311-320. [PMID: 33506495 PMCID: PMC8014457 DOI: 10.1002/cpt.2183] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/19/2021] [Indexed: 12/19/2022]
Abstract
For the development of coronavirus disease 2019 (COVID‐19) drugs during the ongoing pandemic, speed is of essence whereas quality of evidence is of paramount importance. Although thousands of COVID‐19 trials were rapidly started, many are unlikely to provide robust statistical evidence and meet regulatory standards (e.g., because of lack of randomization or insufficient power). This has led to an inefficient use of time and resources. With more coordination, the sheer number of patients in these trials might have generated convincing data for several investigational treatments. Collaborative platform trials, comparing several drugs to a shared control arm, are an attractive solution. Those trials can utilize a variety of adaptive design features in order to accelerate the finding of life‐saving treatments. In this paper, we discuss several possible designs, illustrate them via simulations, and also discuss challenges, such as the heterogeneity of the target population, time‐varying standard of care, and the potentially high number of false hypothesis rejections in phase II and phase III trials. We provide corresponding regulatory perspectives on approval and reimbursement, and note that the optimal design of a platform trial will differ with our societal objective and by stakeholder. Hasty approvals may delay the development of better alternatives, whereas searching relentlessly for the single most efficacious treatment may indirectly diminish the number of lives saved as time is lost. We point out the need for incentivizing developers to participate in collaborative evidence‐generation initiatives when a positive return on investment is not met.
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Affiliation(s)
| | - Carl-Fredrik Burman
- Statistical Innovation, Data Science, and Artificial Intelligence, AstraZeneca R&D, Gothenburg, Sweden
| | - Martin Posch
- Section for Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
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16
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Lee KM, Brown LC, Jaki T, Stallard N, Wason J. Statistical consideration when adding new arms to ongoing clinical trials: the potentials and the caveats. Trials 2021; 22:203. [PMID: 33691748 PMCID: PMC7944243 DOI: 10.1186/s13063-021-05150-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 02/24/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Platform trials improve the efficiency of the drug development process through flexible features such as adding and dropping arms as evidence emerges. The benefits and practical challenges of implementing novel trial designs have been discussed widely in the literature, yet less consideration has been given to the statistical implications of adding arms. MAIN: We explain different statistical considerations that arise from allowing new research interventions to be added in for ongoing studies. We present recent methodology development on addressing these issues and illustrate design and analysis approaches that might be enhanced to provide robust inference from platform trials. We also discuss the implication of changing the control arm, how patient eligibility for different arms may complicate the trial design and analysis, and how operational bias may arise when revealing some results of the trials. Lastly, we comment on the appropriateness and the application of platform trials in phase II and phase III settings, as well as publicly versus industry-funded trials. CONCLUSION Platform trials provide great opportunities for improving the efficiency of evaluating interventions. Although several statistical issues are present, there are a range of methods available that allow robust and efficient design and analysis of these trials.
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Affiliation(s)
- Kim May Lee
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SR, UK.
- Pragmatic Clinical Trials Unit, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK.
| | - Louise C Brown
- MRC Clinical Trials Unit, University College London, 90 High Holborn 2nd Floor, London, WC1V 6LJ, UK
| | - Thomas Jaki
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SR, UK
- Medical and Pharmaceutical Statistics Research Unit, Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - James Wason
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SR, UK
- Population Health Sciences Institute, Baddiley-Clark Building, Newcastle University, Richardson Road, Newcastle upon Tyne, UK
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17
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Nooka AK, Weisel K, van de Donk NW, Routledge D, Otero PR, Song K, Quach H, Callander N, Minnema MC, Trudel S, Jackson NA, Ahlers CM, Im E, Cheng S, Smith L, Hareth N, Ferron-Brady G, Brouch M, Montes de Oca R, Paul S, Holkova B, Gupta I, Kremer BE, Richardson P. Belantamab mafodotin in combination with novel agents in relapsed/refractory multiple myeloma: DREAMM-5 study design. Future Oncol 2021; 17:1987-2003. [PMID: 33682447 DOI: 10.2217/fon-2020-1269] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Belantamab mafodotin (belamaf) is a BCMA-targeted antibody-drug conjugate recently approved as monotherapy for adults with relapsed/refractory multiple myeloma who have received ≥4 prior therapies. Belamaf binds to BCMA and eliminates myeloma cells by multimodal mechanisms of action. The cytotoxic and potential immunomodulatory properties of belamaf have led to novel combination studies with other anticancer therapies. Here, we describe the rationale and design of DREAMM-5, an ongoing Phase I/II platform study evaluating the safety and efficacy of belamaf combined with novel agents, including GSK3174998 (OX40 agonist), feladilimab (an ICOS; GSK3359609), nirogacestat (a gamma-secretase inhibitor; PF-03084014) and dostarlimab (a PD-1 blocker) versus belamaf monotherapy for patients with relapsed/refractory multiple myeloma. Clinical trial registration: NCT04126200 (ClinicalTrials.gov).
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Affiliation(s)
- Ajay K Nooka
- Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Katja Weisel
- Department of Oncology, Hematology & Bone Marrow Transplantation, University Medical Center of Hamburg-Eppendorf, Hamburg, 20246, Germany
| | - Niels Wcj van de Donk
- Department of Hematology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, 1081 HV, The Netherlands
| | - David Routledge
- Peter MacCallum Cancer Centre & Royal Melbourne Hospital, Melbourne, VIC 3000, Australia
| | - Paula Rodriguez Otero
- Centro de Investigación Médica Aplicada, Clínica Universidad de Navarra-Pamplona, Navarra, 31008, Spain
| | - Kevin Song
- Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Hang Quach
- Department of Haematology, University of Melbourne, St. Vincent's Hospital Melbourne, Melbourne, VIC 3065, Australia
| | - Natalie Callander
- Carbone Cancer Center, University of Wisconsin, Madison, WI WI 53705, USA
| | - Monique C Minnema
- Department of Hematology, University Medical Center Utrecht, Utrecht, 3584 CX, The Netherlands
| | - Suzanne Trudel
- Department of Medicine, Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada
| | | | | | - Ellie Im
- GlaxoSmithKline, Waltham, MA 02451, USA
| | - Shinta Cheng
- SpringWorks Therapeutics, Stamford, CT 06902, USA
| | - L Smith
- SpringWorks Therapeutics, Stamford, CT 06902, USA
| | - Nahi Hareth
- Department of Medicine, Karolinska University Hospital, Stockholm, SE 171 76, Sweden
| | | | - Maria Brouch
- GlaxoSmithKline, Upper Providence, PA 19426, USA
| | | | - Sofia Paul
- GlaxoSmithKline, Upper Providence, PA 19426, USA
| | | | - Ira Gupta
- GlaxoSmithKline, Upper Providence, PA 19426, USA
| | | | - Paul Richardson
- Department of Medical Oncology, Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA 02215, USA
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18
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Implementation of the Randomized Embedded Multifactorial Adaptive Platform for COVID-19 (REMAP-COVID) trial in a US health system-lessons learned and recommendations. Trials 2021; 22:100. [PMID: 33509275 PMCID: PMC7841377 DOI: 10.1186/s13063-020-04997-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 12/22/2020] [Indexed: 12/18/2022] Open
Abstract
Background The Randomized Embedded Multifactorial Adaptive Platform for COVID-19 (REMAP-COVID) trial is a global adaptive platform trial of hospitalized patients with COVID-19. We describe implementation at the first US site, the UPMC health system, and offer recommendations for implementation at other sites. Methods To implement REMAP-COVID, we focused on six major areas: engaging leadership, trial embedment, remote consent and enrollment, regulatory compliance, modification of traditional trial management procedures, and alignment with other COVID-19 studies. Results We recommend aligning institutional and trial goals and sharing a vision of REMAP-COVID implementation as groundwork for learning health system development. Embedment of trial procedures into routine care processes, existing institutional structures, and the electronic health record promotes efficiency and integration of clinical care and clinical research. Remote consent and enrollment can be facilitated by engaging bedside providers and leveraging institutional videoconferencing tools. Coordination with the central institutional review board will expedite the approval process. Protocol adherence, adverse event monitoring, and data collection and export can be facilitated by building electronic health record processes, though implementation can start using traditional clinical trial tools. Lastly, establishment of a centralized institutional process optimizes coordination of COVID-19 studies. Conclusions Implementation of the REMAP-COVID trial within a large US healthcare system is feasible and facilitated by multidisciplinary collaboration. This investment establishes important groundwork for future learning health system endeavors. Trial registration NCT02735707. Registered on 13 April 2016.
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19
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Howard DR, Hockaday A, Brown JM, Gregory WM, Todd S, Munir T, Oughton JB, Dimbleby C, Hillmen P. A platform trial in practice: adding a new experimental research arm to the ongoing confirmatory FLAIR trial in chronic lymphocytic leukaemia. Trials 2021; 22:38. [PMID: 33419469 PMCID: PMC7792072 DOI: 10.1186/s13063-020-04971-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/14/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The FLAIR trial in chronic lymphocytic leukaemia has a randomised, controlled, open-label, confirmatory, platform design. FLAIR was successfully amended to include an emerging promising experimental therapy to expedite its assessment, greatly reducing the time to reach the primary outcome compared to running a separate trial and without compromising the validity of the research or the ability to recruit to the trial and report the outcomes. The methodological and practical issues are presented, describing how they were addressed to ensure the amendment was a success. METHODS FLAIR was designed as a two-arm trial requiring 754 patients. In stage 2, two new arms were added: a new experimental arm and a second control arm to protect the trial in case of a change in practice. In stage 3, the original experimental arm was closed as its planned recruitment target was reached. In total, 1516 participants will be randomised to the trial. RESULTS The changes to the protocol and randomisation to add and stop arms were made seamlessly without pausing recruitment. The statistical considerations to ensure the results for the original and new hypotheses are unbiased were approved following peer review by oversight committees, Cancer Research UK, ethical and regulatory committees and pharmaceutical partners. These included the use of concurrent comparators in case of any stage effect, appropriate control of the type I error rate and consideration of analysis methods across trial stages. The operational aspects of successfully implementing the amendments are described, including gaining approvals and additional funding, data management requirements and implementation at centres. CONCLUSIONS FLAIR is an exemplar of how an emerging experimental therapy can be assessed within an existing trial structure without compromising the conduct, reporting or validity of the trial. This strategy offered considerable resource savings and allowed the new experimental therapy to be assessed within a confirmatory trial in the UK years earlier than would have otherwise been possible. Despite the clear efficiencies, treatment arms are rarely added to ongoing trials in practice. This paper demonstrates how this strategy is acceptable, feasible and beneficial to patients and the wider research community. TRIAL REGISTRATION ISRCTN Registry ISRCTN01844152 . Registered on August 08, 2014.
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Affiliation(s)
- Dena R Howard
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
| | - Anna Hockaday
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Julia M Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Walter M Gregory
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Susan Todd
- Department of Mathematics and Statistics, University of Reading, Reading, UK
| | - Tahla Munir
- St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Jamie B Oughton
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Claire Dimbleby
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Peter Hillmen
- St James's Institute of Oncology, St James's University Hospital, Leeds, UK
- Section of Experimental Haematology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
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20
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Noor NM, Pett SL, Esmail H, Crook AM, Vale CL, Sydes MR, Parmar MK. Adaptive platform trials using multi-arm, multi-stage protocols: getting fast answers in pandemic settings. F1000Res 2020; 9:1109. [PMID: 33149899 PMCID: PMC7596806 DOI: 10.12688/f1000research.26253.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 12/15/2022] Open
Abstract
Global health pandemics, such as coronavirus disease 2019 (COVID-19), require efficient and well-conducted trials to determine effective interventions, such as treatments and vaccinations. Early work focused on rapid sequencing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), subsequent in-vitro and in-silico work, along with greater understanding of the different clinical phases of the infection, have helped identify a catalogue of potential therapeutic agents requiring assessment. In a pandemic, there is a need to quickly identify efficacious treatments, and reject those that are non-beneficial or even harmful, using randomised clinical trials. Whilst each potential treatment could be investigated across multiple, separate, competing two-arm trials, this is a very inefficient process. Despite the very large numbers of interventional trials for COVID-19, the vast majority have not used efficient trial designs. Well conducted, adaptive platform trials utilising a multi-arm multi-stage (MAMS) approach provide a solution to overcome limitations of traditional designs. The multi-arm element allows multiple different treatments to be investigated simultaneously against a shared, standard-of-care control arm. The multi-stage element uses interim analyses to assess accumulating data from the trial and ensure that only treatments showing promise continue to recruitment during the next stage of the trial. The ability to test many treatments at once and drop insufficiently active interventions significantly speeds up the rate at which answers can be achieved. This article provides an overview of the benefits of MAMS designs and successes of trials, which have used this approach to COVID-19. We also discuss international collaboration between trial teams, including prospective agreement to synthesise trial results, and identify the most effective interventions. We believe that international collaboration will help provide faster answers for patients, clinicians, and health care systems around the world, including for future waves of COVID-19, and enable preparedness for future global health pandemics.
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Affiliation(s)
- Nurulamin M. Noor
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
| | - Sarah L. Pett
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
| | - Hanif Esmail
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
| | - Angela M. Crook
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
| | - Claire L. Vale
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
| | - Matthew R. Sydes
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
| | - Mahesh K.B. Parmar
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
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21
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Noor NM, Pett SL, Esmail H, Crook AM, Vale CL, Sydes MR, Parmar MK. Adaptive platform trials using multi-arm, multi-stage protocols: getting fast answers in pandemic settings. F1000Res 2020; 9:1109. [PMID: 33149899 PMCID: PMC7596806 DOI: 10.12688/f1000research.26253.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2020] [Indexed: 12/15/2022] Open
Abstract
Global health pandemics, such as coronavirus disease 2019 (COVID-19), require efficient and well-conducted trials to determine effective interventions, such as treatments and vaccinations. Early work focused on rapid sequencing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), subsequent in-vitro and in-silico work, along with greater understanding of the different clinical phases of the infection, have helped identify a catalogue of potential therapeutic agents requiring assessment. In a pandemic, there is a need to quickly identify efficacious treatments, and reject those that are non-beneficial or even harmful, using randomised clinical trials. Whilst each potential treatment could be investigated across multiple, separate, competing two-arm trials, this is a very inefficient process. Despite the very large numbers of interventional trials for COVID-19, the vast majority have not used efficient trial designs. Well conducted, adaptive platform trials utilising a multi-arm multi-stage (MAMS) approach provide a solution to overcome limitations of traditional designs. The multi-arm element allows multiple different treatments to be investigated simultaneously against a shared, standard-of-care control arm. The multi-stage element uses interim analyses to assess accumulating data from the trial and ensure that only treatments showing promise continue to recruitment during the next stage of the trial. The ability to test many treatments at once and drop insufficiently active interventions significantly speeds up the rate at which answers can be achieved. This article provides an overview of the benefits of MAMS designs and successes of trials, which have used this approach to COVID-19. We also discuss international collaboration between trial teams, including prospective agreement to synthesise trial results, and identify the most effective interventions. We believe that international collaboration will help provide faster answers for patients, clinicians, and health care systems around the world, including for each further wave of COVID-19, and enable preparedness for future global health pandemics.
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Affiliation(s)
- Nurulamin M. Noor
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
| | - Sarah L. Pett
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
| | - Hanif Esmail
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
| | - Angela M. Crook
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
| | - Claire L. Vale
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
| | - Matthew R. Sydes
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
| | - Mahesh K.B. Parmar
- Medical Research Council Clinical Trials Unit, University College London, London, WC1V6LJ, UK
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22
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The Evolution of Master Protocol Clinical Trial Designs: A Systematic Literature Review. Clin Ther 2020; 42:1330-1360. [DOI: 10.1016/j.clinthera.2020.05.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/10/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023]
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23
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Pollesello P, Ben Gal T, Bettex D, Cerny V, Comin-Colet J, Eremenko AA, Farmakis D, Fedele F, Fonseca C, Harjola VP, Herpain A, Heringlake M, Heunks L, Husebye T, Ivancan V, Karason K, Kaul S, Kubica J, Mebazaa A, Mølgaard H, Parissis J, Parkhomenko A, Põder P, Pölzl G, Vrtovec B, Yilmaz MB, Papp Z. Short-Term Therapies for Treatment of Acute and Advanced Heart Failure-Why so Few Drugs Available in Clinical Use, Why Even Fewer in the Pipeline? J Clin Med 2019; 8:jcm8111834. [PMID: 31683969 PMCID: PMC6912236 DOI: 10.3390/jcm8111834] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 01/10/2023] Open
Abstract
Both acute and advanced heart failure are an increasing threat in term of survival, quality of life and socio-economical burdens. Paradoxically, the use of successful treatments for chronic heart failure can prolong life but-per definition-causes the rise in age of patients experiencing acute decompensations, since nothing at the moment helps avoiding an acute or final stage in the elderly population. To complicate the picture, acute heart failure syndromes are a collection of symptoms, signs and markers, with different aetiologies and different courses, also due to overlapping morbidities and to the plethora of chronic medications. The palette of cardio- and vasoactive drugs used in the hospitalization phase to stabilize the patient's hemodynamic is scarce and even scarcer is the evidence for the agents commonly used in the practice (e.g. catecholamines). The pipeline in this field is poor and the clinical development chronically unsuccessful. Recent set backs in expected clinical trials for new agents in acute heart failure (AHF) (omecamtiv, serelaxine, ularitide) left a field desolately empty, where only few drugs have been approved for clinical use, for example, levosimendan and nesiritide. In this consensus opinion paper, experts from 26 European countries (Austria, Belgium, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Israel, Italy, The Netherlands, Norway, Poland, Portugal, Russia, Slovenia, Spain, Sweden, Switzerland, Turkey, U.K. and Ukraine) analyse the situation in details also by help of artificial intelligence applied to bibliographic searches, try to distil some lesson-learned to avoid that future projects would make the same mistakes as in the past and recommend how to lead a successful development project in this field in dire need of new agents.
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Affiliation(s)
| | - Tuvia Ben Gal
- Heart Failure Unit, Rabin Medical Center, Tel Aviv University, Petah Tikva 4941492d, Israel.
| | - Dominique Bettex
- Institute of Anaesthesiology, University Hospital of Zurich, University of Zurich, 8091 Zurich, Switzerland.
| | - Vladimir Cerny
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, 400 96 Usti nad Labem, Czech Republic.
| | - Josep Comin-Colet
- Heart Diseases Institute, Hospital Universitari de Bellvitge, 08015 Barcelona, Spain.
| | - Alexandr A Eremenko
- Department of Cardiac Intensive Care, Petrovskii National Research Centre of Surgery, Sechenov University, 119146 Moscow, Russia.
| | - Dimitrios Farmakis
- Department of Cardiology, Medical School, University of Cyprus, 1678 Nicosia, Cyprus.
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, 'La Sapienza' University of Rome, 00185 Rome, Italy.
| | - Cândida Fonseca
- Heart Failure Clinic of S. Francisco Xavier Hospital, CHLO, 1449-005 Lisbon, Portugal.
| | - Veli-Pekka Harjola
- Emergency Medicine, Department of Emergency Medicine and Services, Helsinki University Hospital, University of Helsinki, 00014 Helsinki, Finland.
| | - Antoine Herpain
- Department of Intensive Care, Experimental Laboratory of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, 1050 Bruxelles, Belgium.
| | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, University of Lübeck, 23562 Lübeck, Germany.
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc 081 HV, The Netherlands.
| | - Trygve Husebye
- Department of Cardiology, Oslo University Hospital Ullevaal, 0372 Oslo, Norway.
| | - Visnja Ivancan
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital Centre, 10000 Zagreb, Croatia.
| | - Kristian Karason
- Transplant Institute, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden.
| | - Sundeep Kaul
- Intensive Care Unit, National Health Service, Leeds LS2 9JT, UK.
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, 87-100 Torun, Poland.
| | - Alexandre Mebazaa
- Department of Anaesthesiology and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, Université de Paris and INSERM UMR-S 942-MASCOT, 75010 Paris, France.
| | - Henning Mølgaard
- Department of Cardiology, Århus University Hospital, 8200 Århus, Denmark.
| | - John Parissis
- Emergency Department, Attikon University Hospital, National and Kapodistrian University of Athens, 157 72 Athens, Greece.
| | - Alexander Parkhomenko
- Emergency Cardiology Department, National Scientific Center M.D. Strazhesko Institute of Cardiology, 02000 Kiev, Ukraine.
| | - Pentti Põder
- Department of Cardiology, North Estonia Medical Center, 13419 Tallinn, Estonia.
| | - Gerhard Pölzl
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, 6020 Innsbruck, Austria.
| | - Bojan Vrtovec
- Advanced Heart Failure and Transplantation Center, Department of Cardiology, Ljubljana University Medical Center, SI-1000 Ljubljana, Slovenia.
| | - Mehmet B Yilmaz
- Department of Cardiology, Dokuz Eylul University Faculty of Medicine, 35340 Izmir, Turkey.
| | - Zoltan Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, H-4032 Debrecen, Hungary.
- HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, 4001 Debrecen, Hungary.
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