1
|
O'Connell NS, Wages NA, Garrett-Mayer E. Quasi-partial order continual reassessment method: Applying toxicity scores to cancer dose-finding drug combination trials. Contemp Clin Trials 2023; 125:107050. [PMID: 36529437 DOI: 10.1016/j.cct.2022.107050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
The primary endpoint of most dose-finding cancer trials is patient toxicity, and the primary goal is to identify the maximum tolerated dose (MTD), that is, the highest dose that falls below or within a pre-specified toxicity tolerability threshold. Conventionally, dose-finding methods have utilized a binary toxicity endpoint based on whether or not a patient experiences a dose limiting-toxicity (DLT). Improving upon this, in recent years several methods have been developed for modeling toxicity scores, a novel continuous endpoint designed to more precisely estimate patient toxicity burden. Separately, drug-combination trials have become increasingly prevalent, and due to added complexities regarding estimating 'true' dose ordering and potential for more complex patient toxicity profiles, provide an ideal setting which may benefit from the improved precision of toxicity scores. In this paper, we merge two frameworks based on the Continual Reassessment Method (CRM) - the Quasi-CRM and the Partial Order CRM (POCRM) - to propose a novel approach for modeling toxicity scores in a combination-trial setting. We demonstrate that utilizing toxicity scores has the potential to greatly improve correct dose-selection over a variety of trial scenarios. We further present a simple adaptation to the toxicity-score model to control for potential over-dosing issues such that it adheres to the conventional DLT definition and will, at worst, perform equivalently to that of the traditional binary DLT framework. We demonstrate that extending toxicity scores to the combination-trial setting offers potential for improvement over the conventional binary endpoint models.
Collapse
Affiliation(s)
- Nathaniel S O'Connell
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston Salem, NC, USA.
| | - Nolan A Wages
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Elizabeth Garrett-Mayer
- Center for Research and Analytics, American Society for Clinical Oncology, Alexandria, VA, USA
| |
Collapse
|
2
|
Menon S, Davies A, Frentzas S, Hawkins CA, Segelov E, Day D, Markman B. Recruitment, outcomes, and toxicity trends in phase I oncology trials: Six-year experience in a large institution. Cancer Rep (Hoboken) 2021; 5:e1465. [PMID: 34245134 PMCID: PMC8842700 DOI: 10.1002/cnr2.1465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 11/15/2022] Open
Abstract
Background With the rapid influx of novel anti‐cancer agents, phase I clinical trials in oncology are evolving. Historically, response rates on early phase trials have been modest with the clinical benefit and ethics of enrolment debated. However, there is a paucity of real‐world data in this setting. Aim To better understand the changing landscape of phase I oncology trials, we performed a retrospective review at our institution to examine patient and trial characteristics, screening outcomes, and treatment outcomes. Methods and results We analyzed all consecutive adult patients with advanced solid organ malignancies who were screened across phase I trials from January 2013 to December 2018 at a single institution. During this period, 242 patients were assessed for 28 different trials. Median age was 64 years (range 30–89) with an equal sex distribution. Among 257 screening visits, the overall screen failure rate was 18%, resulting in 212 patients being enrolled onto a study. Twenty‐six trials (93%) involved immunotherapeutic agents or molecular targeted agents either alone or in combination, with only two trials of cytotoxic agents (7%). Twenty‐two (13.4%) of the 209 treated patients experienced a total of 33 grade 3 or higher treatment‐related adverse events. There was one treatment‐related death (0.5%). Of 190 response‐evaluable patients, 7 (4%) had a complete response, 34 (18%) a partial response, and 59 (31%) experienced stable disease for a disease control rate of 53%. The median overall survival for our cohort was 8.0 (95% CI: 6.8–9.2) months. Conclusion The profile of phase I trials at our institution are consistent with the changing early drug development landscape. Response rates and overall survival in our cohort are superior to historically reported rates and comparable to contemporaneous studies. Severe treatment‐related toxicity was relatively uncommon, and treatment‐related mortality was rare.
Collapse
Affiliation(s)
- Siddharth Menon
- Monash Health, Melbourne, Australia.,Olivia Newton-John Cancer Research Institute, Melbourne, Australia.,La Trobe University, Melbourne, Australia
| | | | - Sophia Frentzas
- Monash Health, Melbourne, Australia.,Monash University, Melbourne, Australia
| | | | - Eva Segelov
- Monash Health, Melbourne, Australia.,Monash University, Melbourne, Australia
| | - Daphne Day
- Monash Health, Melbourne, Australia.,Monash University, Melbourne, Australia
| | - Ben Markman
- Monash Health, Melbourne, Australia.,The Alfred Hospital, Melbourne, Australia
| |
Collapse
|
3
|
Ye L, Ariyapperuma M, Jacques A, Meniawy T, Millward M. Hospitalizations in solid tumor phase I clinical trial patients: Incidence, pattern and clinical outcomes at an Australian phase I clinical trial unit. Asia Pac J Clin Oncol 2021; 18:287-294. [PMID: 34180591 DOI: 10.1111/ajco.13622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 05/30/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Participation in early-phase clinical trials has become a prominent part of medical oncology patient management. We examined the incidence and pattern of hospitalizations in early-phase clinical trial patients and the associated clinical outcomes. METHOD We conducted a retrospective review of 194 patients with solid tumors treated on phase I clinical trials between July 2014 and October 2018 at a phase I trial unit. Unplanned hospitalizations occurring during the study period were characterized and correlated with treatment response and duration of trial participation. RESULTS Among 194 patients, 104 hospitalizations were recorded involving 62 patients (31%). Nineteen percent of patients were hospitalized for cancer-related complications and 8% for treatment toxicity. No significant correlation was seen between the hospitalization and age, sex, tumor type, or trial drug. Best response to trial therapy was complete response, partial response, stable disease, and progressive disease in 5%, 11%, 37%, and 47% of patients, respectively. Median duration on trial was 86 days (range 0-1,412). Twenty-two patients (11%) remained on trial for more than 12 months. Overall, hospitalization did not impact treatment response or trial duration. However, cancer-related hospitalization was associated with significantly lower response (p < 0.001) and early patient attrition (p < 0.001). Resolution of the hospitalization event was associated with improved response (p = 0.002) and longer duration on trial (p < 0.001). The treatment related mortality was 0.5% (n = 1). CONCLUSION Approximately one third of patients required hospitalization, most commonly for cancer-related complications which correlated with poorer clinical outcomes. Hospitalizations related to treatment toxicity were infrequent. A significant proportion of patients derived significant therapeutic benefit. Phase I clinical trials provide a valuable treatment option for patients with cancer.
Collapse
Affiliation(s)
- Linda Ye
- Linear Clinical Research, Nedlands, Western Australia, Australia.,The University of Western Australia, Faculty of Health and Medical Science, Nedlands, Western Australia, Australia
| | | | - Angela Jacques
- Institute for Health Research, University of Notre Dame, Perth, Western Australia, Australia.,Department of Research, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Tarek Meniawy
- Linear Clinical Research, Nedlands, Western Australia, Australia
| | - Michael Millward
- Linear Clinical Research, Nedlands, Western Australia, Australia.,The University of Western Australia, Faculty of Health and Medical Science, Nedlands, Western Australia, Australia
| |
Collapse
|
4
|
Geary B, Peat E, Dransfield S, Cook N, Thistlethwaite F, Graham D, Carter L, Hughes A, Krebs MG, Whetton AD. Discovery and Evaluation of Protein Biomarkers as a Signature of Wellness in Late-Stage Cancer Patients in Early Phase Clinical Trials. Cancers (Basel) 2021; 13:cancers13102443. [PMID: 34069985 PMCID: PMC8157875 DOI: 10.3390/cancers13102443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/07/2021] [Accepted: 05/12/2021] [Indexed: 12/22/2022] Open
Abstract
TARGET (tumour characterisation to guide experimental targeted therapy) is a cancer precision medicine programme focused on molecular characterisation of patients entering early phase clinical trials. Performance status (PS) measures a patient's ability to perform a variety of activities. However, the quality of present algorithms to assess PS is limited and based on qualitative clinician assessment. Plasma samples from patients enrolled into TARGET were analysed using the mass spectrometry (MS) technique: sequential window acquisition of all theoretical fragment ion spectra (SWATH)-MS. SWATH-MS was used on a discovery cohort of 55 patients to differentiate patients into either a good or poor prognosis by creation of a Wellness Score (WS) that showed stronger prediction of overall survival (p = 0.000551) compared to PS (p = 0.001). WS was then tested against a validation cohort of 77 patients showing significant (p = 0.000451) prediction of overall survival. WS in both sets had receiver operating characteristic curve area under the curve (AUC) values of 0.76 (p = 0.002) and 0.67 (p = 0.011): AUC of PS was 0.70 (p = 0.117) and 0.55 (p = 0.548). These signatures can now be evaluated further in larger patient populations to assess their utility in a clinical setting.
Collapse
Affiliation(s)
- Bethany Geary
- Stoller Biomarker Discovery Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9NQ, UK;
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (F.T.); (L.C.); (A.H.)
| | - Erin Peat
- The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; (E.P.); (S.D.); (N.C.); (D.G.)
| | - Sarah Dransfield
- The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; (E.P.); (S.D.); (N.C.); (D.G.)
| | - Natalie Cook
- The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; (E.P.); (S.D.); (N.C.); (D.G.)
| | - Fiona Thistlethwaite
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (F.T.); (L.C.); (A.H.)
- The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; (E.P.); (S.D.); (N.C.); (D.G.)
| | - Donna Graham
- The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; (E.P.); (S.D.); (N.C.); (D.G.)
| | - Louise Carter
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (F.T.); (L.C.); (A.H.)
- The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; (E.P.); (S.D.); (N.C.); (D.G.)
| | - Andrew Hughes
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (F.T.); (L.C.); (A.H.)
| | - Matthew G. Krebs
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (F.T.); (L.C.); (A.H.)
- The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M20 4BX, UK; (E.P.); (S.D.); (N.C.); (D.G.)
- Correspondence: (M.G.K.); (A.D.W.); Tel.: +44-(0)161-275-6267 (A.D.W.)
| | - Anthony D. Whetton
- Stoller Biomarker Discovery Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9NQ, UK;
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (F.T.); (L.C.); (A.H.)
- Manchester National Institute for Health Research Biomedical Research Centre, Manchester M13 9WL, UK
- Correspondence: (M.G.K.); (A.D.W.); Tel.: +44-(0)161-275-6267 (A.D.W.)
| |
Collapse
|
5
|
Kunnumakkara AB, Bordoloi D, Sailo BL, Roy NK, Thakur KK, Banik K, Shakibaei M, Gupta SC, Aggarwal BB. Cancer drug development: The missing links. Exp Biol Med (Maywood) 2019; 244:663-689. [PMID: 30961357 DOI: 10.1177/1535370219839163] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPACT STATEMENT The success rate for cancer drugs which enter into phase 1 clinical trials is utterly less. Why the vast majority of drugs fail is not understood but suggests that pre-clinical studies are not adequate for human diseases. In 1975, as per the Tufts Center for the Study of Drug Development, pharmaceutical industries expended 100 million dollars for research and development of the average FDA approved drug. By 2005, this figure had more than quadrupled, to $1.3 billion. In order to recover their high and risky investment cost, pharmaceutical companies charge more for their products. However, there exists no correlation between drug development cost and actual sale of the drug. This high drug development cost could be due to the reason that all patients might not respond to the drug. Hence, a given drug has to be tested in large number of patients to show drug benefits and obtain significant results.
Collapse
Affiliation(s)
- Ajaikumar B Kunnumakkara
- 1 Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Devivasha Bordoloi
- 1 Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Bethsebie Lalduhsaki Sailo
- 1 Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Nand Kishor Roy
- 1 Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Krishan Kumar Thakur
- 1 Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Kishore Banik
- 1 Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Mehdi Shakibaei
- 2 Faculty of Medicine, Institute of Anatomy, Ludwig Maximilian University of Munich, Munich D-80336, Germany
| | - Subash C Gupta
- 3 Department of Biochemistry, Institute of Science, Banaras Hindu University, Varanasi 221005, India
| | | |
Collapse
|
6
|
Ingles Garces AH, Ang JE, Ameratunga M, Chénard-Poirier M, Dolling D, Diamantis N, Seeramreddi S, Sundar R, de Bono J, Lopez J, Banerji U. A study of 1088 consecutive cases of electrolyte abnormalities in oncology phase I trials. Eur J Cancer 2018; 104:32-38. [PMID: 30316017 PMCID: PMC6259582 DOI: 10.1016/j.ejca.2018.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 08/28/2018] [Indexed: 11/19/2022]
Abstract
Background The incidence and clinical significance of electrolyte abnormalities (EAs) in phase I clinical trials are unknown. The objective of this study is to evaluate the incidence and severity of EAs, graded according to CTCAE, v4.03, to identify variables associated with EAs and their prognostic significance in a phase I population. Methods A retrospective chart review was performed of 1088 cases in 82 phase I clinical trials consecutively treated from 2011 to 2015 at the Drug Development Unit of the Royal Marsden Hospital. Cox regression analysis was performed to examine the relationship between overall survival (OS) and baseline characteristics, treating the occurrence of grade III/IV EAs as a time-varying covariate. Results The most common emergent EAs (all grades) were as follows: hyponatraemia 62%, hypokalaemia 40%, hypophosphataemia 32%, hypomagnesaemia 17% and hypocalcaemia 12%. Grade III/IV EAs occurred in 19% of cases. Grade III/IV EAs occurred during the dose-limiting toxicity window in 8.46% of cases. Diarrhoea was associated with hypomagnesaemia at all grades (p < 0.001), hyponatraemia at all grades (p = 0.006) and with G3/G4 hypokalaemia (p = 0.02). Baseline hypoalbuminaemia and hyponatraemia were associated with a higher risk of developing other EAs during the trial in the univariate analysis. Patients who developed grade III/IV EAs during follow-up had an inferior median OS (26 weeks vs 37 weeks, hazard ratio = 1.61; p < 0.001). Conclusion This is the first study to demonstrate the clinical significance of baseline hypoalbuminaemia and hyponatraemia, which are predictors of development of other EAs in phase I patients. Grade III/IV EAs are adverse prognostic factors of OS independent of serum albumin levels. Patients who develop grade III/IV electrolyte abnormalities have poorer overall survival. Hyponatraemia is linked to higher risk of developing other electrolyte abnormalities. Hypoalbuminaemia is linked to higher risk of developing electrolyte abnormalities.
Collapse
Affiliation(s)
- Alvaro H Ingles Garces
- The Royal Marsden NHS Foundation Trust, Downs Rd, Sutton, SM2 5PT, London, UK; The Institute of Cancer Research, 15 Cotswold Road, Sutton, SM2 5NG, London, UK
| | - Joo Ern Ang
- The Royal Marsden NHS Foundation Trust, Downs Rd, Sutton, SM2 5PT, London, UK; The Institute of Cancer Research, 15 Cotswold Road, Sutton, SM2 5NG, London, UK
| | - Malaka Ameratunga
- The Royal Marsden NHS Foundation Trust, Downs Rd, Sutton, SM2 5PT, London, UK; The Institute of Cancer Research, 15 Cotswold Road, Sutton, SM2 5NG, London, UK
| | - Maxime Chénard-Poirier
- The Royal Marsden NHS Foundation Trust, Downs Rd, Sutton, SM2 5PT, London, UK; The Institute of Cancer Research, 15 Cotswold Road, Sutton, SM2 5NG, London, UK
| | - David Dolling
- The Institute of Cancer Research, 15 Cotswold Road, Sutton, SM2 5NG, London, UK
| | - Nikolaos Diamantis
- The Royal Marsden NHS Foundation Trust, Downs Rd, Sutton, SM2 5PT, London, UK; The Institute of Cancer Research, 15 Cotswold Road, Sutton, SM2 5NG, London, UK
| | - Satyanarayana Seeramreddi
- The Royal Marsden NHS Foundation Trust, Downs Rd, Sutton, SM2 5PT, London, UK; The Institute of Cancer Research, 15 Cotswold Road, Sutton, SM2 5NG, London, UK
| | - Raghav Sundar
- The Royal Marsden NHS Foundation Trust, Downs Rd, Sutton, SM2 5PT, London, UK; The Institute of Cancer Research, 15 Cotswold Road, Sutton, SM2 5NG, London, UK
| | - Johann de Bono
- The Royal Marsden NHS Foundation Trust, Downs Rd, Sutton, SM2 5PT, London, UK; The Institute of Cancer Research, 15 Cotswold Road, Sutton, SM2 5NG, London, UK
| | - Juanita Lopez
- The Royal Marsden NHS Foundation Trust, Downs Rd, Sutton, SM2 5PT, London, UK; The Institute of Cancer Research, 15 Cotswold Road, Sutton, SM2 5NG, London, UK
| | - Udai Banerji
- The Royal Marsden NHS Foundation Trust, Downs Rd, Sutton, SM2 5PT, London, UK; The Institute of Cancer Research, 15 Cotswold Road, Sutton, SM2 5NG, London, UK.
| |
Collapse
|
7
|
Jordan EJ, Spicer J, Sarker D. Delayed adverse events in phase I trials of molecularly targeted and cytotoxic agents. Oncotarget 2018; 9:33961-33971. [PMID: 30338038 PMCID: PMC6188052 DOI: 10.18632/oncotarget.26104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 08/27/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Grade 3 and 4 adverse events (AEs) during cycle 1 are traditionally used for dose escalation decisions in Phase I oncology trials. With molecularly targeted agents (MTAs), assessment of lower grade AEs and those in later cycles is considered increasingly relevant. METHODS We conducted a retrospective analysis of AEs in patients enrolled onto relevant phase I trials of MTAs and cytotoxic combinations (CCs) at our UK centre between 2006 and 2016. All AEs in the first six cycles deemed at least 'possibly related' were recorded. RESULTS A total of 912 AEs were identified in 127 patients across 15 trials. Mean AE totals for CCs or MTAs respectively was 4.7 versus 3.0 in cycle 1, 3.8 versus 2.8 in cycles 2-6. Patients on CCs had higher mean AEs in six cycles compared to those on MTAs (8.5 vs. 5.7, p = 0.0005). For patients experiencing grade 3 AEs, 58% (CCs) and 60% (MTAs) occurred for the first time after cycle 1. CONCLUSION Overall AE incidence was lower in MTAs than CCs across six cycles. For MTAs, more frequent incidence of first grade 3/4 AEs after cycle 1 supports incorporation of delayed AEs into recommendations for Phase 2 dosing.
Collapse
Affiliation(s)
- Emma J. Jordan
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - James Spicer
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK
| | - Debashis Sarker
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK
| |
Collapse
|
8
|
Coleman N, Michalarea V, Alken S, Rihawi K, Lopez RP, Tunariu N, Petruckevitch A, Molife LR, Banerji U, De Bono JS, Welsh L, Saran F, Lopez J. Safety, efficacy and survival of patients with primary malignant brain tumours (PMBT) in phase I (Ph1) trials: the 12-year Royal Marsden experience. J Neurooncol 2018; 139:107-116. [PMID: 29637509 DOI: 10.1007/s11060-018-2847-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/25/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Primary malignant brain tumours (PMBT) constitute less than 2% of all malignancies and carry a dismal prognosis. Treatment options at relapse are limited. First-in-human solid tumour studies have historically excluded patients with PMBT due to the poor prognosis, concomitant drug interactions and concerns regarding toxicities. METHODS Retrospective data were collected on clinical and tumour characteristics of patients referred for consideration of Ph1 trials in the Royal Marsden Hospital between June 2004 and August 2016. Survival analyses were performed using the Kaplan-Meier method, Cox proportional hazards model. Chi squared test was used to measure bivariate associations between categorical variables. RESULTS 100pts with advanced PMBT were referred. At initial consultation, patients had a median ECOG PS 1, median age 48 years (range 18-70); 69% were men, 76% had glioblastoma; 68% were on AEDs, 63% required steroid therapy; median number of prior treatments was two. Median OS for patients treated on a Ph1 trials was 9.3 months (95% CI 5.9-12.9) versus 5.3 months (95% CI 4.1-6.1) for patients that did not proceed with a Ph1 trial, p = 0.0094. Steroid use, poor PS, neutrophil-to-lymphocyte ratio and treatment on a Ph1 trial were shown to independently influence OS. CONCLUSIONS We report a survival benefit for patients with PMBT treated on Ph1 trials. Toxicity and efficacy outcomes were comparable to the general Ph1 population. In the absence of an internationally recognized standard second line treatment for patients with recurrent PMBT, more Ph1 trials should allow enrolment of patients with refractory PMBT and Ph1 trial participation should be considered at an earlier stage.
Collapse
Affiliation(s)
- Niamh Coleman
- Drug Development Unit, The Royal Marsden Hospital Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - Vasiliki Michalarea
- Drug Development Unit, The Royal Marsden Hospital Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - Scheryll Alken
- Drug Development Unit, The Royal Marsden Hospital Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - Karim Rihawi
- Drug Development Unit, The Royal Marsden Hospital Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - Raquel Perez Lopez
- Radiology Department, The Royal Marsden Hospital Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - Nina Tunariu
- Radiology Department, The Royal Marsden Hospital Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - Ann Petruckevitch
- Drug Development Unit, The Royal Marsden Hospital Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - L R Molife
- Drug Development Unit, The Royal Marsden Hospital Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - Udai Banerji
- Drug Development Unit, The Royal Marsden Hospital Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - Johann S De Bono
- Drug Development Unit, The Royal Marsden Hospital Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - Liam Welsh
- Neuro-oncology Department, The Royal Marsden Hospital Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - Frank Saran
- Neuro-oncology Department, The Royal Marsden Hospital Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK
| | - Juanita Lopez
- Drug Development Unit, The Royal Marsden Hospital Trust and Institute of Cancer Research, 15 Cotswold Road, Sutton, London, SM2 5NG, UK.
| |
Collapse
|
9
|
Shankaran H, Cronin A, Barnes J, Sharma P, Tolsma J, Jasper P, Mettetal JT. Systems Pharmacology Model of Gastrointestinal Damage Predicts Species Differences and Optimizes Clinical Dosing Schedules. CPT Pharmacometrics Syst Pharmacol 2017; 7:26-33. [PMID: 28941225 PMCID: PMC5784737 DOI: 10.1002/psp4.12255] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 08/08/2017] [Accepted: 09/18/2017] [Indexed: 12/14/2022]
Abstract
Gastrointestinal (GI) adverse events (AEs) are frequently dose limiting for oncology agents, requiring extensive clinical testing of alternative schedules to identify optimal dosing regimens. Here, we develop a translational mathematical model to predict these clinical AEs starting from preclinical GI toxicity data. The model structure incorporates known biology and includes stem cells, daughter cells, and enterocytes. Published data, including cellular numbers and division times, informed the system parameters for humans and rats. The drug‐specific parameters were informed with preclinical histopathology data from rats treated with irinotecan. The model fit the rodent irinotecan‐induced pathology changes well. The predicted time course of enterocyte loss in patients treated with weekly doses matched observed AE profiles. The model also correctly predicts a lower level of AEs for every 3 weeks (Q3W), as compared to the weekly schedule.
Collapse
Affiliation(s)
- Harish Shankaran
- Drug Safety and MetabolismIMED Biotech Unit, AstraZenecaWalthamMassachusettsUSA
| | - Anna Cronin
- Drug Safety and MetabolismIMED Biotech UnityAstraZenecaCambridgeUK
| | - Jen Barnes
- Drug Safety and MetabolismIMED Biotech UnityAstraZenecaCambridgeUK
| | - Pradeep Sharma
- Drug Safety and MetabolismIMED Biotech UnityAstraZenecaCambridgeUK
| | | | | | - Jerome T. Mettetal
- Drug Safety and MetabolismIMED Biotech Unit, AstraZenecaWalthamMassachusettsUSA
| |
Collapse
|
10
|
Abstract
Background. Absent adaptive, individualized dose-finding in early-phase oncology trials, subsequent 'confirmatory' Phase III trials risk suboptimal dosing, with resulting loss of statistical power and reduced probability of technical success for the investigational therapy. While progress has been made toward explicitly adaptive dose-finding and quantitative modeling of dose-response relationships, most such work continues to be organized around a concept of 'the' maximum tolerated dose (MTD). The purpose of this paper is to demonstrate concretely how the aim of early-phase trials might be conceived, not as 'dose-finding', but as dose titration algorithm (DTA)-finding. Methods. A Phase I dosing study is simulated, for a notional cytotoxic chemotherapy drug, with neutropenia constituting the critical dose-limiting toxicity. The drug's population pharmacokinetics and myelosuppression dynamics are simulated using published parameter estimates for docetaxel. The amenability of this model to linearization is explored empirically. The properties of a simple DTA targeting neutrophil nadir of 500 cells/mm 3 using a Newton-Raphson heuristic are explored through simulation in 25 simulated study subjects. Results. Individual-level myelosuppression dynamics in the simulation model approximately linearize under simple transformations of neutrophil concentration and drug dose. The simulated dose titration exhibits largely satisfactory convergence, with great variance in individualized optimal dosing. Some titration courses exhibit overshooting. Conclusions. The large inter-individual variability in simulated optimal dosing underscores the need to replace 'the' MTD with an individualized concept of MTD i . To illustrate this principle, the simplest possible DTA capable of realizing such a concept is demonstrated. Qualitative phenomena observed in this demonstration support discussion of the notion of tuning such algorithms. Although here illustrated specifically in relation to cytotoxic chemotherapy, the DTAT principle appears similarly applicable to Phase I studies of cancer immunotherapy and molecularly targeted agents.
Collapse
|
11
|
Abstract
Background. Absent adaptive, individualized dose-finding in early-phase oncology trials, subsequent 'confirmatory' Phase III trials risk suboptimal dosing, with resulting loss of statistical power and reduced probability of technical success for the investigational therapy. While progress has been made toward explicitly adaptive dose-finding and quantitative modeling of dose-response relationships, most such work continues to be organized around a concept of 'the' maximum tolerated dose (MTD). The purpose of this paper is to demonstrate concretely how the aim of early-phase trials might be conceived, not as 'dose-finding', but as dose titration algorithm (DTA)-finding. Methods. A Phase I dosing study is simulated, for a notional cytotoxic chemotherapy drug, with neutropenia constituting the critical dose-limiting toxicity. The drug's population pharmacokinetics and myelosuppression dynamics are simulated using published parameter estimates for docetaxel. The amenability of this model to linearization is explored empirically. The properties of a simple DTA targeting neutrophil nadir of 500 cells/mm 3 using a Newton-Raphson heuristic are explored through simulation in 25 simulated study subjects. Results. Individual-level myelosuppression dynamics in the simulation model approximately linearize under simple transformations of neutrophil concentration and drug dose. The simulated dose titration exhibits largely satisfactory convergence, with great variance in individualized optimal dosing. Some titration courses exhibit overshooting. Conclusions. The large inter-individual variability in simulated optimal dosing underscores the need to replace 'the' MTD with an individualized concept of MTD i . To illustrate this principle, the simplest possible DTA capable of realizing such a concept is demonstrated. Qualitative phenomena observed in this demonstration support discussion of the notion of tuning such algorithms. Although here illustrated specifically in relation to cytotoxic chemotherapy, the DTAT principle appears similarly applicable to Phase I studies of cancer immunotherapy and molecularly targeted agents.
Collapse
|
12
|
Anwar S, Tan W, Hong CC, Admane S, Dozier A, Siedlecki F, Whitworth A, DiRaddo AM, DePaolo D, Jacob SM, Ma WW, Miller A, Adjei AA, Dy GK. Quality-of-Life (QOL) during Screening for Phase 1 Trial Studies in Patients with Advanced Solid Tumors and Its Impact on Risk for Serious Adverse Events. Cancers (Basel) 2017; 9:E73. [PMID: 28672850 PMCID: PMC5532609 DOI: 10.3390/cancers9070073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/21/2017] [Accepted: 06/21/2017] [Indexed: 11/19/2022] Open
Abstract
Background: Serious adverse events (SAEs) and subject replacements occur frequently in phase 1 oncology clinical trials. Whether baseline quality-of-life (QOL) or social support can predict risk for SAEs or subject replacement among these patients is not known. Methods: Between 2011-2013, 92 patients undergoing screening for enrollment into one of 22 phase 1 solid tumor clinical trials at Roswell Park Cancer Institute were included in this study. QOL Questionnaires (EORTC QLQ-C30 and FACT-G), Medical Outcomes Study Social Support Survey (MOSSSS), Charlson comorbidity scores (CCS) and Royal Marsden scores (RMS) were obtained at baseline. Frequency of dose limiting toxicities (DLTs), subject replacement and SAEs that occurred within the first 4 cycles of treatment were recorded. Fisher's exact test and Mann-Whitney-Wilcoxon test were used to study the association between categorical and continuous variables, respectively. A linear transformation was used to standardize QOL scores. p-value ≤ 0.05 was considered statistically significant. Results: Baseline QOL, MOSSSS, CCS and RMS were not associated with subject replacement nor DLTs. Baseline EORTC QLQ-C30 scores were significantly lower among patients who encountered SAEs within the first 4 cycles (p = 0.04). Conclusions: Lower (worse) EORTC QLQ-C30 score at baseline is associated with SAE occurrence during phase 1 oncology trials.
Collapse
Affiliation(s)
- Sidra Anwar
- State University of New York at Buffalo, 12 Capen Hall, Buffalo, NY 14260, USA.
| | - Wei Tan
- Roswell Park Cancer Institute, Elm and Carlton Street, Buffalo, NY 14263, USA.
| | - Chi-Chen Hong
- Roswell Park Cancer Institute, Elm and Carlton Street, Buffalo, NY 14263, USA.
| | | | - Askia Dozier
- Roswell Park Cancer Institute, Elm and Carlton Street, Buffalo, NY 14263, USA.
| | - Francine Siedlecki
- Roswell Park Cancer Institute, Elm and Carlton Street, Buffalo, NY 14263, USA.
| | - Amy Whitworth
- Roswell Park Cancer Institute, Elm and Carlton Street, Buffalo, NY 14263, USA.
| | - Ann Marie DiRaddo
- Roswell Park Cancer Institute, Elm and Carlton Street, Buffalo, NY 14263, USA.
| | - Dawn DePaolo
- Roswell Park Cancer Institute, Elm and Carlton Street, Buffalo, NY 14263, USA.
| | - Sandra M Jacob
- Roswell Park Cancer Institute, Elm and Carlton Street, Buffalo, NY 14263, USA.
| | - Wen Wee Ma
- Mayo Clinic, 200 1st St. SW, Rochester, MN 55905, USA.
| | - Austin Miller
- Roswell Park Cancer Institute, Elm and Carlton Street, Buffalo, NY 14263, USA.
| | - Alex A Adjei
- Mayo Clinic, 200 1st St. SW, Rochester, MN 55905, USA.
| | - Grace K Dy
- Roswell Park Cancer Institute, Elm and Carlton Street, Buffalo, NY 14263, USA.
| |
Collapse
|
13
|
Papadatos-Pastos D, Roda D, De Miguel Luken MJ, Petruckevitch A, Jalil A, Capelan M, Michalarea V, Lima J, Diamantis N, Bhosle J, Molife LR, Banerji U, de Bono JS, Popat S, O'Brien MER, Yap TA. Clinical outcomes and prognostic factors of patients with advanced mesothelioma treated in a phase I clinical trials unit. Eur J Cancer 2017; 75:56-62. [PMID: 28214659 DOI: 10.1016/j.ejca.2016.12.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 12/04/2016] [Accepted: 12/22/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND We have previously reported a prognostic score for patients in phase I trials in the Drug Development Unit, treated at the Royal Marsden Hospital (RPS). The RPS is an objective tool used in patient selection for phase I trials based on albumin, number of disease sites and LDH. Patients with mesothelioma are often selected for phase I trials as the disease remains localised for long periods of time. We have now reviewed the clinical outcomes of patients with relapsed malignant mesothelioma (MM) and propose a specific mesothelioma prognostic score (m-RPS) that can help identify patients who are most likely to benefit from early referral. METHODS Patients who participated in 38 phase I trials between September 2003 and November 2015 were included in the analysis. Efficacy was assessed by response rate, median overall survival (OS) and progression-free survival (PFS). Univariate (UVA) and multivariate analyses (MVA) were carried out to develop the m-RPS. RESULTS A total of 65 patients with advanced MM were included in this retrospective study. The PFS was 2.5 months (95% confidence interval [CI] 2.0-3.1 months) and OS was 8 months (95% CI 5.6-9.8 months). A total of four (6%) patients had RECIST partial responses, whereas 26 (40%) patients had RECIST stable disease >3 months. The m-RPS was developed comprising of three different prognostic factors: a neutrophil: lymphocyte ratio greater than 3, the presence of more than two disease sites (including lymph nodes as a single site of disease) and albumin levels less than 35 from the MVA. Patients each received a score of 1 for the presence of each factor. Patients in group A (m-RPS 0-1; n = 35) had a median OS of 13.4 months (95% CI 8.5-21.6), whereas those in group B (m-RPS 2-3; n = 30) had a median OS of 4.0 months (95% CI 2.9-7.1, P < 0.0001). A total of 56 (86%) patients experienced G1-2 toxicities, whereas reversible G3-4 toxicities were observed in 18 (28%) patients. Only 10 (15%) patients discontinued phase I trials due to toxicity. CONCLUSIONS Phase I clinical trial therapies were well tolerated with early signals of antitumour activity in advanced MM patients. The m-RPS is a useful tool to assess MM patient suitability for phase I trials and should now be prospectively validated.
Collapse
Affiliation(s)
| | - Desam Roda
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom
| | | | - Ann Petruckevitch
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom
| | - Awais Jalil
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom
| | - Marta Capelan
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom
| | - Vasiliki Michalarea
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom
| | - Joao Lima
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom
| | - Nikolaos Diamantis
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom
| | - Jaishree Bhosle
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom
| | - L Rhoda Molife
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom
| | - Udai Banerji
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom
| | - Johann S de Bono
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom
| | - Sanjay Popat
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom
| | - Mary E R O'Brien
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom
| | - Timothy A Yap
- Royal Marsden NHS Foundation Trust, The Institute of Cancer Research, London, United Kingdom.
| |
Collapse
|
14
|
Geuna E, Roda D, Rafii S, Jimenez B, Capelan M, Rihawi K, Montemurro F, Yap TA, Kaye SB, De Bono JS, Molife LR, Banerji U. Complications of hyperglycaemia with PI3K-AKT-mTOR inhibitors in patients with advanced solid tumours on Phase I clinical trials. Br J Cancer 2015; 113:1541-7. [PMID: 26554652 DOI: 10.1038/bjc.2015.373] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/16/2015] [Accepted: 10/05/2015] [Indexed: 01/17/2023] Open
Abstract
Background: PI3K–AKT–mTOR inhibitors (PAMi) are promising anticancer treatments. Hyperglycaemia is a mechanism-based toxicity of these agents and is becoming increasingly important with their use in larger numbers of patients. Methods: Retrospective case-control study comparing incidence and severity of hyperglycaemia (all grades) between a case group of 387 patients treated on 18 phase I clinical trials with PAMi (78 patients with PI3Ki, 138 with mTORi, 144 with AKTi and 27 with PI3K/mTORi) and a control group of 109 patients treated on 10 phase I clinical trials with agents not directly targeting the PAM pathway. Diabetic patients were excluded in both groups. Results: The incidence of hyperglycaemia was not significantly different between cases and controls (86.6% vs 80.7%, respectively, P=0.129). However, high grade (grade 3–4) hyperglycaemia was more frequent in the PAMi group than in controls (6.7% vs 0%, respectively, P=0.005). The incidence of grade 3–4 hyperglycaemia was greater with AKT and multikinase inhibitors compared with other PAMi (P<0.001). All patients with high-grade hyperglycaemia received antihyperglycemic treatment and none developed severe metabolic complications (diabetic ketoacidosis or hyperosmolar hyperglycemic nonketotic state). High-grade hyperglycaemia was the cause of permanent PAMi discontinuation in nine patients. Conclusions: PI3K–AKT–mTOR inhibitors are associated with small (6.7%) but statistically significant increased risk of high-grade hyperglycaemia compared with non-PAM targeting agents. However, PAMi-induced hyperglycaemia was not found to be associated with severe metabolic complications in this non-diabetic population of patients with advanced cancers.
Collapse
|
15
|
Gounder MM, Nayak L, Sahebjam S, Muzikansky A, Sanchez AJ, Desideri S, Ye X, Ivy SP, Nabors LB, Prados M, Grossman S, DeAngelis LM, Wen PY. Evaluation of the Safety and Benefit of Phase I Oncology Trials for Patients With Primary CNS Tumors. J Clin Oncol 2015; 33:3186-92. [PMID: 26282642 DOI: 10.1200/jco.2015.61.1525] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
PURPOSE Patients with high-grade gliomas (HGG) are frequently excluded from first-in-human solid tumor trials because of perceived poor prognosis, excessive toxicities, concomitant drug interactions, and poor efficacy. We conducted an analysis of outcomes from select, single-agent phase I studies in patients with HGG. We compared outcomes to pooled analysis of published studies in solid tumors with various molecular and cytotoxic drugs evaluated as single agents or as combinations. PATIENT AND METHODS Individual records of patients with recurrent HGG enrolled onto Adult Brain Tumor Consortium trials of single-agent, cytotoxic or molecular agents from 2000 to 2008 were analyzed for baseline characteristics, toxicities, responses, and survival. RESULTS Our analysis included 327 patients with advanced, refractory HGG who were enrolled onto eight trials involving targeted molecular (n=5) and cytotoxic (n=3) therapies. At enrollment, patients had a median Karnofsky performance score of 90 and median age of 52 years; 62% were men, 63% had glioblastoma, and the median number of prior systemic chemotherapies was one. Baseline laboratory values were in an acceptable range to meet eligibility criteria. Patients were on the study for a median of two cycles (range, <one to 56 cycles), and 96% were evaluable for primary end points. During cycle 1, grade≥3 nonhematologic and grade≥4 hematologic toxicities were 5% (28 of 565 adverse events) and 0.9% (five of 565 adverse events), respectively, and 66% of these occurred at the highest dose level. There was one death attributed to drug. Overall response rate (complete and partial response) was 5.5%. Median progression-free and overall survival times were 1.8 and 6 months, respectively. CONCLUSION Patients with HGG who meet standard eligibility criteria may be good candidates for solid tumor phase I studies with single-agent molecular or cytotoxic drugs with favorable preclinical rationale and pharmacokinetic properties in this population.
Collapse
Affiliation(s)
- Mrinal M Gounder
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA.
| | - Lakshmi Nayak
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Solmaz Sahebjam
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Alona Muzikansky
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Armando J Sanchez
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Serena Desideri
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Xiaobu Ye
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - S Percy Ivy
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - L Burt Nabors
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Michael Prados
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Stuart Grossman
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Lisa M DeAngelis
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| | - Patrick Y Wen
- Mrinal M. Gounder, Armando J. Sanchez, and Lisa M. DeAngelis, Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical School, New York, NY; Lakshmi Nayak and Patrick Y. Wen, Dana-Farber/Brigham and Women's Cancer Center and Harvard Medical School; Alona Muzikansky, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Solmaz Sahebjam, Moffitt Cancer Center, University of South Florida, Tampa, FL; Serena Desideri, Xiaobu Ye, and Stuart Grossman, Johns Hopkins Sidney Kimmel Cancer Center, Baltimore; S. Percy Ivy, National Cancer Institute, Cancer Therapy Evaluation Program, Bethesda, MD; L. Burt Nabors, University of Alabama at Birmingham, Birmingham, AL; and Michael Prados, University of California at San Francisco, San Francisco, CA
| |
Collapse
|
16
|
Rafii S, Roda D, Geuna E, Jimenez B, Rihawi K, Capelan M, Yap TA, Molife LR, Kaye SB, de Bono JS, Banerji U. Higher Risk of Infections with PI3K-AKT-mTOR Pathway Inhibitors in Patients with Advanced Solid Tumors on Phase I Clinical Trials. Clin Cancer Res 2015; 21:1869-76. [PMID: 25649020 PMCID: PMC4401558 DOI: 10.1158/1078-0432.ccr-14-2424] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 01/28/2015] [Indexed: 01/20/2023]
Abstract
PURPOSE Novel antitumor therapies against the PI3K-AKT-mTOR pathway are increasingly used to treat cancer, either as single agents or in combination with chemotherapy or other targeted therapies. Although these agents are not known to be myelosuppressive, an increased risk of infection has been reported with rapamycin analogues. However, the risk of infection with new inhibitors of this pathway such as PI3K, AKT, mTORC 1/2, or multikinase inhibitors is unknown. EXPERIMENTAL DESIGN In this retrospective case-control study, we determined the incidence of infection in a group of 432 patients who were treated on 15 phase I clinical trials involving PI3K-AKT-mTOR pathway inhibitors (cases) versus a group of 100 patients on 10 phase I clinical trials of single agent non-PI3K-AKT-mTOR pathway inhibitors (controls) which did not involve conventional cytotoxic agents. We also collected data from 42 patients who were treated with phase I trials of combinations of PI3K-AKT-mTOR inhibitors and MEK inhibitors and 24 patients with combinations of PI3K-AKT-mTOR inhibitors and cytotoxic chemotherapies. RESULTS The incidence of all grade infection was significantly higher with all single-agent PI3K-AKT-mTOR inhibitors compared with the control group [27% vs. 8%, respectively, OR, 4.26; 95% confidence intervals (CI), 1.9-9.1, P = 0.0001]. The incidence of grade 3 and 4 infection was also significantly higher with PI3K-AKT-mTOR inhibitors compared with the control group (10.3% vs. 3%, OR, 3.74; 95% CI, 1.1-12.4; P = 0.02). Also, the combination of PI3K-AKT-mTOR inhibitors and chemotherapy was associated with a significantly higher incidence of all grade (OR, 4.79; 95% CI, 2.0-11.2; P = 0.0001) and high-grade (OR, 2.87; 95% CI, 1.0-7.6; P = 0.03) infection when compared with single-agent PI3K-AKT-mTOR inhibitors. CONCLUSIONS Inhibitors of the PI3K-AKT-mTOR pathway can be associated with a higher risk of infection. Combinations of PI3K-AKT-mTOR inhibitors and cytotoxic chemotherapy significantly increase the risk of infection. This should be taken into consideration during the design and conduct of trials involving PI3K-AKT-mTOR pathway inhibitors, particularly when combined with chemotherapy or myelosuppressive agents.
Collapse
Affiliation(s)
- Saeed Rafii
- Drug Development Unit, Division of Cancer Therapeutics and Division of Clinical Studies, The Institute of Cancer Research and The Royal Marsden, London, United Kingdom
| | - Desamparados Roda
- Drug Development Unit, Division of Cancer Therapeutics and Division of Clinical Studies, The Institute of Cancer Research and The Royal Marsden, London, United Kingdom
| | - Elena Geuna
- Drug Development Unit, Division of Cancer Therapeutics and Division of Clinical Studies, The Institute of Cancer Research and The Royal Marsden, London, United Kingdom
| | - Begona Jimenez
- Drug Development Unit, Division of Cancer Therapeutics and Division of Clinical Studies, The Institute of Cancer Research and The Royal Marsden, London, United Kingdom
| | - Karim Rihawi
- Drug Development Unit, Division of Cancer Therapeutics and Division of Clinical Studies, The Institute of Cancer Research and The Royal Marsden, London, United Kingdom
| | - Marta Capelan
- Drug Development Unit, Division of Cancer Therapeutics and Division of Clinical Studies, The Institute of Cancer Research and The Royal Marsden, London, United Kingdom
| | - Timothy A Yap
- Drug Development Unit, Division of Cancer Therapeutics and Division of Clinical Studies, The Institute of Cancer Research and The Royal Marsden, London, United Kingdom
| | - L Rhoda Molife
- Drug Development Unit, Division of Cancer Therapeutics and Division of Clinical Studies, The Institute of Cancer Research and The Royal Marsden, London, United Kingdom
| | - Stanley B Kaye
- Drug Development Unit, Division of Cancer Therapeutics and Division of Clinical Studies, The Institute of Cancer Research and The Royal Marsden, London, United Kingdom
| | - Johann S de Bono
- Drug Development Unit, Division of Cancer Therapeutics and Division of Clinical Studies, The Institute of Cancer Research and The Royal Marsden, London, United Kingdom
| | - Udai Banerji
- Drug Development Unit, Division of Cancer Therapeutics and Division of Clinical Studies, The Institute of Cancer Research and The Royal Marsden, London, United Kingdom.
| |
Collapse
|
17
|
Tunariu N. Lung, CNS and musculo-skeletal targeted therapy-induced toxicity: imaging features. Cancer Imaging 2014; 14:O38. [DOI: 10.1186/1470-7330-14-s1-o38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
18
|
Paoletti X, Le Tourneau C, Verweij J, Siu LL, Seymour L, Postel-Vinay S, Collette L, Rizzo E, Ivy P, Olmos D, Massard C, Lacombe D, Kaye SB, Soria JC. Defining dose-limiting toxicity for phase 1 trials of molecularly targeted agents: Results of a DLT-TARGETT international survey. Eur J Cancer 2014; 50:2050-6. [DOI: 10.1016/j.ejca.2014.04.030] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 04/04/2014] [Indexed: 10/25/2022]
|
19
|
Schwandt A, Harris PJ, Hunsberger S, Deleporte A, Smith GL, Vulih D, Anderson BD, Ivy SP. The role of age on dose-limiting toxicities in phase I dose-escalation trials. Clin Cancer Res 2014; 20:4768-75. [PMID: 25028396 DOI: 10.1158/1078-0432.ccr-14-0866] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Elderly oncology patients are not enrolled in early-phase trials in proportion to the numbers of geriatric patients with cancer. There may be concern that elderly patients will not tolerate investigational agents as well as younger patients, resulting in a disproportionate number of dose-limiting toxicities (DLT). Recent single-institution studies provide conflicting data on the relationship between age and DLT. EXPERIMENTAL DESIGN We retrospectively reviewed data about patients treated on single-agent, dose-escalation, phase I clinical trials sponsored by the Cancer Therapy Evaluation Program (CTEP) of the National Cancer Institute. Patients' dose levels were described as a percentage of maximum tolerated dose, the highest dose level at which <33% of patients had a DLT, or recommended phase II dose (RP2D). Mixed-effect logistic regression models were used to analyze relationships between the probability of a DLT and age and other explanatory variables. RESULTS Increasing dose, increasing age, and worsening performance status (PS) were significantly related to an increased probability of a DLT in this model (P < 0.05). There was no association between dose level administered and age (P = 0.57). CONCLUSIONS This analysis of phase I dose-escalation trials, involving more than 500 patients older than 70 years of age, is the largest reported. As age and dose level increased and PS worsened, the probability of a DLT increased. Although increasing age was associated with occurrence of DLT, this risk remained within accepted thresholds of risk for phase I trials. There was no evidence of age bias on enrollment of patients on low or high dose levels.
Collapse
Affiliation(s)
- A Schwandt
- Case Western Reserve School of Medicine, Cleveland, Ohio
| | - P J Harris
- National Cancer Institute, Bethesda, Maryland
| | | | | | - G L Smith
- National Cancer Institute, Bethesda, Maryland
| | - D Vulih
- Theradex Systems, Inc, Princeton, New Jersey
| | | | - S P Ivy
- National Cancer Institute, Bethesda, Maryland.
| |
Collapse
|
20
|
Hyman DM, Eaton AA, Gounder MM, Smith GL, Pamer EG, Hensley ML, Spriggs DR, Ivy P, Iasonos A. Nomogram to predict cycle-one serious drug-related toxicity in phase I oncology trials. J Clin Oncol 2014; 32:519-26. [PMID: 24419130 DOI: 10.1200/jco.2013.49.8808] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
PURPOSE All patients in phase I trials do not have equivalent susceptibility to serious drug-related toxicity (SDRT). Our goal was to develop a nomogram to predict the risk of cycle-one SDRT to better select appropriate patients for phase I trials. PATIENTS AND METHODS The prospectively maintained database of patients with solid tumor enrolled onto Cancer Therapeutics Evaluation Program-sponsored phase I trials activated between 2000 and 2010 was used. SDRT was defined as a grade ≥ 4 hematologic or grade ≥ 3 nonhematologic toxicity attributed, at least possibly, to study drug(s). Logistic regression was used to test the association of candidate factors to cycle-one SDRT. A final model, or nomogram, was chosen based on both clinical and statistical significance and validated internally using a bootstrapping technique and externally in an independent data set. RESULTS Data from 3,104 patients enrolled onto 127 trials were analyzed to build the nomogram. In a model with multiple covariates, Eastern Cooperative Oncology Group performance status, WBC count, creatinine clearance, albumin, AST, number of study drugs, biologic study drug (yes v no), and dose (relative to maximum administered) were significant predictors of cycle-one SDRT. All significant factors except dose were included in the final nomogram. The model was validated both internally (bootstrap-adjusted concordance index, 0.60) and externally (concordance index, 0.64). CONCLUSION This nomogram can be used to accurately predict a patient's risk for SDRT at the time of enrollment. Excluding patients at high risk for SDRT should improve the safety and efficiency of phase I trials.
Collapse
Affiliation(s)
- David M Hyman
- David M. Hyman, Anne A. Eaton, Mrinal M. Gounder, Erika G. Pamer, Martee L. Hensley, David R. Spriggs, and Alexia Iasonos, Memorial Sloan-Kettering Cancer Center; David M. Hyman, Mrinal M. Gounder, Martee L. Hensley, David R. Spriggs, and Alexia Iasonos, Weill Cornell Medical College, New York, NY; and Gary L. Smith and Percy Ivy, National Cancer Institute, Bethesda, MD
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
|
22
|
Basu B, Vitfell-Pedersen J, Moreno Garcia V, Puglisi M, Tjokrowidjaja A, Shah K, Malvankar S, Anghan B, de Bono JS, Kaye SB, Molife LR, Banerji U. Creatinine clearance is associated with toxicity from molecularly targeted agents in phase I trials. Oncology 2012; 83:177-82. [PMID: 22889980 PMCID: PMC5079100 DOI: 10.1159/000341152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 06/18/2012] [Indexed: 11/19/2022]
Abstract
Objectives This study aimed to evaluate any correlations between baseline creatinine clearance and the development of grade 3/4 toxicities during treatment within oncology phase I trials of molecularly targeted agents where entry criteria mandate a serum creatinine of ≤1.5 × the upper limit of normal. Methods Documented toxicity and creatinine clearance (calculated by the Cockcroft-Gault formula) from all patients treated with molecularly targeted agents in the context of phase I trials within our centre over a 5-year period were analyzed. Results Data from 722 patients were analyzed; 116 (16%) developed at least one episode of grade 3/4 toxicity. Patients who developed a late-onset (>1 cycle) grade 3/4 toxicity had a lower creatinine clearance than those who did not (82.69 ml/min vs. 98.97 ml/min; p = < 0.001). Conclusion Creatinine clearance (even when within normal limits) should be studied as a potential factor influencing late toxicities in the clinical trials of molecularly targeted anti-cancer drugs.
Collapse
Affiliation(s)
- B Basu
- Drug Development Unit, Division of Clinical Studies, The Institute of Cancer Research/The Royal Marsden NHS Foundation Trust, Sutton, UK
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Affiliation(s)
- A Greystoke
- Drug Development Unit, Christie NHS Trust, Manchester, UK.
| | - M Ranson
- Drug Development Unit, Christie NHS Trust, Manchester, UK
| |
Collapse
|