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Royle KL, Meads D, Visser-Rogers JK, White IR, Cairns DA. How is overall survival assessed in randomised clinical trials in cancer and are subsequent treatment lines considered? A systematic review. Trials 2023; 24:708. [PMID: 37926806 PMCID: PMC10626781 DOI: 10.1186/s13063-023-07730-1] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/13/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Overall survival is the "gold standard" endpoint in cancer clinical trials. It plays a key role in determining the clinical- and cost-effectiveness of a new intervention and whether it is recommended for use in standard of care. The assessment of overall survival usually requires trial participants to be followed up for a long period of time. In this time, they may stop receiving the trial intervention and receive subsequent anti-cancer treatments, which also aim to extend survival, during trial follow-up. This can potentially change the interpretation of overall survival in the context of the clinical trial. This review aimed to determine how overall survival has been assessed in cancer clinical trials and whether subsequent anti-cancer treatments are considered. METHODS Two searches were conducted using MEDLINE within OVID© on the 9th of November 2021. The first sought to identify papers publishing overall survival results from randomised controlled trials in eight reputable journals and the second to identify papers mentioning or considering subsequent treatments. Papers published since 2010 were included if presenting or discussing overall survival in the context of treating cancer. RESULTS One hundred and thirty-four papers were included. The majority of these were presenting clinical trial results (98, 73%). Of these, 45 (46%) reported overall survival as a (co-) primary endpoint. A lower proportion of papers including overall survival as a (co-) primary endpoint compared to a secondary endpoint were published in recent years. The primary analysis of overall survival varied across the papers. Fifty-nine (60%) mentioned subsequent treatments. Seven papers performed additional analysis, primarily when patients in the control arm received the experimental treatment during trial follow-up (treatment switching). DISCUSSION Overall survival has steadily moved from being the primary to a secondary endpoint. However, it is still of interest with papers presenting overall survival results with the caveat of subsequent treatments, but little or no investigation into their effect. This review shows that there is a methodological gap for what researchers should do when trial participants receive anti-cancer treatment during trial follow-up. Future research will identify the stakeholder opinions, on how this methodological gap should be addressed.
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Affiliation(s)
- Kara-Louise Royle
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
| | - David Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | | | - David A Cairns
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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2
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Brown JE, Royle KL, Gregory W, Ralph C, Maraveyas A, Din O, Eisen T, Nathan P, Powles T, Griffiths R, Jones R, Vasudev N, Wheater M, Hamid A, Waddell T, McMenemin R, Patel P, Larkin J, Faust G, Martin A, Swain J, Bestall J, McCabe C, Meads D, Goh V, Min Wah T, Brown J, Hewison J, Selby P, Collinson F. Temporary treatment cessation versus continuation of first-line tyrosine kinase inhibitor in patients with advanced clear cell renal cell carcinoma (STAR): an open-label, non-inferiority, randomised, controlled, phase 2/3 trial. Lancet Oncol 2023; 24:213-227. [PMID: 36796394 DOI: 10.1016/s1470-2045(22)00793-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 02/17/2023]
Abstract
BACKGROUND Temporary drug treatment cessation might alleviate toxicity without substantially compromising efficacy in patients with cancer. We aimed to determine if a tyrosine kinase inhibitor drug-free interval strategy was non-inferior to a conventional continuation strategy for first-line treatment of advanced clear cell renal cell carcinoma. METHODS This open-label, non-inferiority, randomised, controlled, phase 2/3 trial was done at 60 hospital sites in the UK. Eligible patients (aged ≥18 years) had histologically confirmed clear cell renal cell carcinoma, inoperable loco-regional or metastatic disease, no previous systemic therapy for advanced disease, uni-dimensionally assessed Response Evaluation Criteria in Solid Tumours-defined measurable disease, and an Eastern Cooperative Oncology Group performance status of 0-1. Patients were randomly assigned (1:1) at baseline to a conventional continuation strategy or drug-free interval strategy using a central computer-generated minimisation programme incorporating a random element. Stratification factors were Memorial Sloan Kettering Cancer Center prognostic group risk factor, sex, trial site, age, disease status, tyrosine kinase inhibitor, and previous nephrectomy. All patients received standard dosing schedules of oral sunitinib (50 mg per day) or oral pazopanib (800 mg per day) for 24 weeks before moving into their randomly allocated group. Patients allocated to the drug-free interval strategy group then had a treatment break until disease progression, when treatment was re-instated. Patients in the conventional continuation strategy group continued treatment. Patients, treating clinicians, and the study team were aware of treatment allocation. The co-primary endpoints were overall survival and quality-adjusted life-years (QALYs); non-inferiority was shown if the lower limit of the two-sided 95% CI for the overall survival hazard ratio (HR) was 0·812 or higher and if the lower limit of the two-sided 95% CI of the marginal difference in mean QALYs was -0·156 or higher. The co-primary endpoints were assessed in the intention-to-treat (ITT) population, which included all randomly assigned patients, and the per-protocol population, which excluded patients in the ITT population with major protocol violations and who did not begin their randomisation allocation as per the protocol. Non-inferiority was to be concluded if it was met for both endpoints in both analysis populations. Safety was assessed in all participants who received a tyrosine kinase inhibitor. The trial was registered with ISRCTN, 06473203, and EudraCT, 2011-001098-16. FINDINGS Between Jan 13, 2012, and Sept 12, 2017, 2197 patients were screened for eligibility, of whom 920 were randomly assigned to the conventional continuation strategy (n=461) or the drug-free interval strategy (n=459; 668 [73%] male and 251 [27%] female; 885 [96%] White and 23 [3%] non-White). The median follow-up time was 58 months (IQR 46-73 months) in the ITT population and 58 months (46-72) in the per-protocol population. 488 patients continued on the trial after week 24. For overall survival, non-inferiority was demonstrated in the ITT population only (adjusted HR 0·97 [95% CI 0·83 to 1·12] in the ITT population; 0·94 [0·80 to 1·09] in the per-protocol population). Non-inferiority was demonstrated for QALYs in the ITT population (n=919) and per-protocol (n=871) population (marginal effect difference 0·06 [95% CI -0·11 to 0·23] for the ITT population; 0·04 [-0·14 to 0·21] for the per-protocol population). The most common grade 3 or worse adverse events were hypertension (124 [26%] of 485 patients in the conventional continuation strategy group vs 127 [29%] of 431 patients in the drug-free interval strategy group); hepatotoxicity (55 [11%] vs 48 [11%]); and fatigue (39 [8%] vs 63 [15%]). 192 (21%) of 920 participants had a serious adverse reaction. 12 treatment-related deaths were reported (three patients in the conventional continuation strategy group; nine patients in the drug-free interval strategy group) due to vascular (n=3), cardiac (n=3), hepatobiliary (n=3), gastrointestinal (n=1), or nervous system (n=1) disorders, and from infections and infestations (n=1). INTERPRETATION Overall, non-inferiority between groups could not be concluded. However, there seemed to be no clinically meaningful reduction in life expectancy between the drug-free interval strategy and conventional continuation strategy groups and treatment breaks might be a feasible and cost-effective option with lifestyle benefits for patients during tyrosine kinase inhibitor therapy in patients with renal cell carcinoma. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- Janet E Brown
- Department of Oncology and Metabolism, University of Sheffield, Weston Park Hospital, Sheffield.
| | - Kara-Louise Royle
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Walter Gregory
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Christy Ralph
- Leeds Institute of Medical Research at St James's, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Anthony Maraveyas
- Queens Centre for Oncology and Haematology, Faculty of Health Sciences, Hull York Medical School, Hull, UK
| | - Omar Din
- Department of Clinical Oncology, Cancer Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Timothy Eisen
- Department of Oncology, University of Cambridge, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Paul Nathan
- Mount Vernon Cancer Centre, East and North Hertfordshire NHS Trust, Northwood, UK
| | - Tom Powles
- Barts Cancer Institute, Queen Mary University, London, UK
| | | | - Robert Jones
- University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Naveen Vasudev
- Leeds Institute of Medical Research at St James's, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Matthew Wheater
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Abdel Hamid
- Broomfield Hospital, Mid and South Essex NHS Foundation Trust, Chelmsford, UK
| | - Tom Waddell
- Christie NHS Foundation Trust, Manchester, UK
| | - Rhona McMenemin
- Northern Centre for Cancer Care, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Poulam Patel
- Academic Unit of Translational Medical Sciences, University of Nottingham, Nottingham, UK
| | | | - Guy Faust
- Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Adam Martin
- Academic Unit of Health Economics, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Jayne Swain
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Janine Bestall
- Leeds Institute of Health Sciences, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | | | - David Meads
- Academic Unit of Health Economics, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Vicky Goh
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Tze Min Wah
- Department of Radiology, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Julia Brown
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jenny Hewison
- Leeds Institute of Health Sciences, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Peter Selby
- Leeds Institute of Medical Research at St James's, Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Fiona Collinson
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Royle KL, Coulson AB, Ramasamy K, Cairns DA, Hockaday A, Quezada S, Drayson M, Kaiser M, Owen R, Auner HW, Cook G, Meads D, Olivier C, Barnard L, Lambkin R, Paterson A, Dawkins B, Chapman M, Pratt G, Popat R, Jackson G, Bygrave C, Sive J, de Tute R, Chantry A, Parrish C, Cook M, Asher S, Yong K. Risk and response adapted therapy following autologous stem cell transplant in patients with newly diagnosed multiple myeloma (RADAR (UK-MRA Myeloma XV Trial): study protocol for a phase II/III randomised controlled trial. BMJ Open 2022; 12:e063037. [PMID: 36396306 PMCID: PMC9677008 DOI: 10.1136/bmjopen-2022-063037] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Multiple myeloma is a plasma cell malignancy that accounts for 1%-2% of newly diagnosed cancers.At diagnosis, approximately 20% of patients can be identified, using cytogenetics, to have inferior survival (high-risk). Additionally, standard-risk patients, with detectable disease (minimal residual disease (MRD)-positive) postautologus stem cell transplant (ASCT), fare worse compared with those who do not (MRD-negative). Research is required to determine whether a risk-adapted approach post-ASCT could further improve patient outcomes. METHODS RADAR is a UK, multicentre, risk-adapted, response-guided, open-label, randomised controlled trial for transplant-eligible newly diagnosed multiple myeloma patients, using combinations of lenalidomide (R), cyclophosphamide (Cy), bortezomib (Bor), dexamethasone (D) and isatuximab (Isa).Participants receive RCyBorD(x4) induction therapy, followed by high-dose melphalan and ASCT. Post-ASCT, there are three pathways as follows:A phase III discontinuation design to assess de-escalating therapy in standard-risk MRD-negative patients. Participants receive 12 cycles of Isa maintenance. Those who remain MRD-negative are randomised to either continue or stop treatment.A phase II/III multiarm multistage design to test treatment strategies for treatment escalation in standard-risk MRD-positive patients. Participants are randomised to either; R, RBorD(x4) +R, RIsa, or RBorIsaD(x4) + RIsa.A phase II design to assess the activity of intensive treatment strategies in high-risk patients. Participants are randomised to RBorD(x4) +R or RBorIsaD(x4) + RIsa.1400 participants will be registered to allow for 500, 450 and 172 participants in each pathway. Randomisations are equal and treatment is given until disease progression or intolerance. ETHICS AND DISSEMINATION Ethical approval was granted by the London-Central Research Ethics Committee (20/LO/0238) and capacity and capability confirmed by the appropriate local research and development department for each participating centre prior to opening recruitment. Participant informed consent is required before trial registration and reconfirmed post-ASCT. Results will be disseminated by conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER ISCRTN46841867.
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Affiliation(s)
- Kara-Louise Royle
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Insitute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Amy Beth Coulson
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Insitute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Karthik Ramasamy
- Radcliffe Department of Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David A Cairns
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Insitute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Anna Hockaday
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Insitute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sergio Quezada
- Department of Haematology, UCL Cancer Institute, London, UK
| | - Mark Drayson
- Clinical Immunology Service, Institute of Immunology and Immunotherapy, Medical School, University of Birmingham, Birmingham, UK
| | - Martin Kaiser
- Centre for Myeloma Research, Division of Molecular Pathology, Institute of Cancer Research, London, UK
| | - Roger Owen
- HMDS, St James's University Hospital, Leeds, UK
| | - Holger W Auner
- Department of Immunology and Inflammation, Imperial College London, London, UK
- Langmuir Centre for Myeloma Research, Imperial College London, London, UK
| | - Gordon Cook
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Insitute of Clinical Trials Research, University of Leeds, Leeds, UK
- Leeds Cancer Centre, St James's University Hospital, Leeds, UK
| | - David Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Catherine Olivier
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Insitute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Lorna Barnard
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Insitute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Rhiannon Lambkin
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Insitute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Andrea Paterson
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Insitute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Bryony Dawkins
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Mike Chapman
- Department of Haematology, University of Cambridge, Cambridge, UK
| | - Guy Pratt
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Rakesh Popat
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Graham Jackson
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle-Upon-Tyne, UK
| | - Ceri Bygrave
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | - Jonathan Sive
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Andrew Chantry
- Department of Haematology, Royal Hallamshire Hospital, Sheffield, UK
| | | | - Mark Cook
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Bristol Myers Squibb, Boundry, Switzerland
| | - Samir Asher
- Department of Haematology, UCL Cancer Institute, London, UK
| | - Kwee Yong
- Department of Haematology, UCL Cancer Institute, London, UK
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Coulson AB, Royle KL, Pawlyn C, Cairns DA, Hockaday A, Bird J, Bowcock S, Kaiser M, de Tute R, Rabin N, Boyd K, Jones J, Parrish C, Gardner H, Meads D, Dawkins B, Olivier C, Henderson R, Best P, Owen R, Jenner M, Kishore B, Drayson M, Jackson G, Cook G. Frailty-adjusted therapy in Transplant Non- Eligible patient s with newly diagno sed Multiple Myeloma (FiTNEss (UK-MRA Myeloma XIV Trial)): a study protocol for a randomised phase III trial. BMJ Open 2022; 12:e056147. [PMID: 35654466 PMCID: PMC9163533 DOI: 10.1136/bmjopen-2021-056147] [Citation(s) in RCA: 1] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 03/24/2022] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Multiple myeloma is a bone marrow cancer, which predominantly affects older people. The incidence is increasing in an ageing population.Over the last 10 years, patient outcomes have improved. However, this is less apparent in older, less fit patients, who are ineligible for stem cell transplant. Research is required in this patient group, taking into account frailty and aiming to improve: treatment tolerability, clinical outcomes and quality of life. METHODS AND ANALYSIS Frailty-adjusted therapy in Transplant Non-Eligible patients with newly diagnosed Multiple Myeloma is a national, phase III, multicentre, randomised controlled trial comparing standard (reactive) and frailty-adjusted (adaptive) induction therapy delivery with ixazomib, lenalidomide and dexamethasone (IRD), and to compare maintenance lenalidomide to lenalidomide+ixazomib, in patients with newly diagnosed multiple myeloma not suitable for stem cell transplant. Overall, 740 participants will be registered into the trial to allow 720 and 478 to be randomised at induction and maintenance, respectively.All participants will receive IRD induction with the dosing strategy randomised (1:1) at trial entry. Patients randomised to the standard, reactive arm will commence at the full dose followed by toxicity dependent reactive modifications. Patients randomised to the adaptive arm will commence at a dose level determined by their International Myeloma Working Group frailty score. Following 12 cycles of induction treatment, participants alive and progression free will undergo a second (double-blind) randomisation on a 1:1 basis to maintenance treatment with lenalidomide+placebo versus lenalidomide+ixazomib until disease progression or intolerance. ETHICS AND DISSEMINATION Ethical approval has been obtained from the North East-Tyne & Wear South Research Ethics Committee (19/NE/0125) and capacity and capability confirmed by local research and development departments for each participating centre prior to opening to recruitment. Participants are required to provide written informed consent prior to trial registration. Trial results will be disseminated by conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER ISRCTN17973108, NCT03720041.
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Affiliation(s)
- Amy Beth Coulson
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | - Kara-Louise Royle
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | | | - David A Cairns
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | - Anna Hockaday
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | - Jennifer Bird
- Department of Haematology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Stella Bowcock
- Department of Haematology, Kings College Hospital NHS Foundation Trust, Princess Royal Hospital, Hull, UK
| | - Martin Kaiser
- Institute of Cancer Research, London, UK
- The Department of Haemato-oncology, Royal Marsden Hospital NHS Trust, London, UK
| | - Ruth de Tute
- Haematology Malignancy Diagnostic Service (HMDS), St James's University Hospital, Leeds, West Yorkshire, UK
| | - Neil Rabin
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Kevin Boyd
- The Department of Haemato-oncology, Royal Marsden Hospital NHS Trust, London, UK
| | - John Jones
- King's College Hospital, London, UK
- Brighton and Sussex Medical School, Brighton, UK
| | | | - Hayley Gardner
- Department of Haematology and Stem Cell Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Meads
- Academic Unit of Health Economics, University of Leeds, Leeds Institute of Health Sciences, Leeds, West Yorkshire, UK
| | - Bryony Dawkins
- Academic Unit of Health Economics, University of Leeds, Leeds Institute of Health Sciences, Leeds, West Yorkshire, UK
| | - Catherine Olivier
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | - Rowena Henderson
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | - Phillip Best
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | - Roger Owen
- Haematology Malignancy Diagnostic Service (HMDS), St James's University Hospital, Leeds, West Yorkshire, UK
| | | | - Bhuvan Kishore
- Department of Haematology and Stem Cell Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark Drayson
- Institute of Immunology and Immunotherapy, Department of Haematology, University of Birmingham, Birmingham, UK
| | - Graham Jackson
- Department of Haematology, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Gordon Cook
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
- Leeds Cancer Centre, St James's University Hospital, Leeds, West Yorkshire, UK
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Royle KL, Cairns DA. The development and validation of prognostic models for overall survival in the presence of missing data in the training dataset: a strategy with a detailed example. Diagn Progn Res 2021; 5:14. [PMID: 34344484 PMCID: PMC8335879 DOI: 10.1186/s41512-021-00103-9] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 06/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The United Kingdom Myeloma Research Alliance (UK-MRA) Myeloma Risk Profile is a prognostic model for overall survival. It was trained and tested on clinical trial data, aiming to improve the stratification of transplant ineligible (TNE) patients with newly diagnosed multiple myeloma. Missing data is a common problem which affects the development and validation of prognostic models, where decisions on how to address missingness have implications on the choice of methodology. METHODS Model building The training and test datasets were the TNE pathways from two large randomised multicentre, phase III clinical trials. Potential prognostic factors were identified by expert opinion. Missing data in the training dataset was imputed using multiple imputation by chained equations. Univariate analysis fitted Cox proportional hazards models in each imputed dataset with the estimates combined by Rubin's rules. Multivariable analysis applied penalised Cox regression models, with a fixed penalty term across the imputed datasets. The estimates from each imputed dataset and bootstrap standard errors were combined by Rubin's rules to define the prognostic model. Model assessment Calibration was assessed by visualising the observed and predicted probabilities across the imputed datasets. Discrimination was assessed by combining the prognostic separation D-statistic from each imputed dataset by Rubin's rules. Model validation The D-statistic was applied in a bootstrap internal validation process in the training dataset and an external validation process in the test dataset, where acceptable performance was pre-specified. Development of risk groups Risk groups were defined using the tertiles of the combined prognostic index, obtained by combining the prognostic index from each imputed dataset by Rubin's rules. RESULTS The training dataset included 1852 patients, 1268 (68.47%) with complete case data. Ten imputed datasets were generated. Five hundred twenty patients were included in the test dataset. The D-statistic for the prognostic model was 0.840 (95% CI 0.716-0.964) in the training dataset and 0.654 (95% CI 0.497-0.811) in the test dataset and the corrected D-Statistic was 0.801. CONCLUSION The decision to impute missing covariate data in the training dataset influenced the methods implemented to train and test the model. To extend current literature and aid future researchers, we have presented a detailed example of one approach. Whilst our example is not without limitations, a benefit is that all of the patient information available in the training dataset was utilised to develop the model. TRIAL REGISTRATION Both trials were registered; Myeloma IX- ISRCTN68454111 , registered 21 September 2000. Myeloma XI- ISRCTN49407852 , registered 24 June 2009.
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Affiliation(s)
- Kara-Louise Royle
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
| | - David A Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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6
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Cook G, Royle KL, Pawlyn C, Hockaday A, Shah V, Kaiser MF, Brown SR, Gregory WM, Child JA, Davies FE, Morgan GJ, Cairns DA, Jackson GH. A clinical prediction model for outcome and therapy delivery in transplant-ineligible patients with myeloma (UK Myeloma Research Alliance Risk Profile): a development and validation study. Lancet Haematol 2019; 6:e154-e166. [PMID: 30738834 PMCID: PMC6391517 DOI: 10.1016/s2352-3026(18)30220-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/30/2018] [Accepted: 11/30/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Tolerability of treatments for multiple myeloma can depend on the characteristics of the patient being treated. We aimed to develop and validate a risk profile, using routinely collected data, that could predict overall survival in patients with multiple myeloma who were ineligible for stem-cell transplantation. METHODS We used patient data from two randomised controlled trials done in patients with newly diagnosed multiple myeloma who were ineligible for stem-cell transplantation (the NCRI Myeloma XI study [NCRI-XI, n=1852] and the MRC Myeloma IX study [MRC-IX, n=520]), to develop the UK Myeloma Research Alliance Risk Profile (MRP) for overall survival. We used multivariable Cox regression with a least absolute shrinkage and selection operator penalty term. Multiple imputation by chained equations was used to account for missing data in the development and internal validation of the model. The MRP was internally validated in NCRI-XI and externally validated in MRC-IX. The D-statistic was estimated in the developed model and used to internally and externally validate the model according to prespecified criteria. FINDINGS The MRP included WHO performance status, International Staging System, age, and C-reactive protein concentration as prognostic variables. The MRP was prognostic of overall survival and was successfully internally validated in NCRI-XI and externally validated in MRC-IX (D-statistic NCRI-XI: 0·840 [95% CI 0·718-0·963] and MRC-IX: 0·654 [0·497-0·811]). The MRP groups defining low-risk, medium-risk, and high-risk patients were associated with progression-free survival and early mortality. A decrease in the percentage of protocol dose delivered and quality of life at baseline were associated with increased risk. The MRP groups remained prognostic in patients exposed to different therapeutic combinations and in patients with genetic high-risk disease defined according to both the UK and International Myeloma Working Group definitions. INTERPRETATION We have developed and externally validated a risk profile for overall survival containing widely available clinical parameters. This risk profile could aid decision making in patients with multiple myeloma ineligible for stem-cell transplantation, but further external validation is required. FUNDING Medical Research Council, Novartis, Schering Health Care, Chugai, Pharmion, Celgene, Ortho Biotech, Cancer Research UK, Celgene, Merck Sharp & Dohme, and Amgen.
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Affiliation(s)
- Gordon Cook
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
| | - Kara-Louise Royle
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Anna Hockaday
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | | | - Sarah R Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Walter M Gregory
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - J Anthony Child
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Faith E Davies
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gareth J Morgan
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - David A Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Graham H Jackson
- Department of Haematology, Newcastle University, Newcastle-upon-Tyne, UK
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7
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Cook G, Royle KL, O'Connor S, Cairns DA, Ashcroft AJ, Williams CD, Hockaday A, Cavenagh JD, Snowden JA, Ademokun D, Tholouli E, Andrews VE, Jenner M, Parrish C, Yong K, Cavet J, Hunter H, Bird JM, Pratt G, Drayson MT, Brown JM, Morris TCM. The impact of cytogenetics on duration of response and overall survival in patients with relapsed multiple myeloma (long-term follow-up results from BSBMT/UKMF Myeloma X Relapse [Intensive]): a randomised, open-label, phase 3 trial. Br J Haematol 2019; 185:450-467. [PMID: 30729512 PMCID: PMC6519200 DOI: 10.1111/bjh.15782] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 10/09/2018] [Accepted: 12/11/2018] [Indexed: 12/04/2022]
Abstract
The Myeloma X trial (ISCRTN60123120) registered patients with relapsed multiple myeloma. Participants were randomised between salvage autologous stem cell transplantation (ASCT) or weekly cyclophosphamide following re‐induction therapy. Cytogenetic analysis performed at trial registration defined t(4;14), t(14;16) and del(17p) as high‐risk. The effect of cytogenetics on time to progression (TTP) and overall survival was investigated. At 76 months median follow‐up, ASCT improved TTP compared to cyclophosphamide (19 months (95% confidence interval [95% CI] 16–26) vs. 11 months (9–12), hazard ratio [HR]: 0·40, 95% CI: 0·29–0·56, P < 0·001), on which the presence of any single high‐risk lesion had a detrimental impact [likelihood ratio test (LRT): P = 0·011]. ASCT also improved OS [67 months (95% CI 59‐not reached) vs. 55 months (44–67), HR: 0·64, 95% CI: 0·42–0·99, P = 0·0435], with evidence of a detrimental impact with MYC rearrangement (LRT: P = 0·021). Twenty‐one (24·7%) cyclophosphamide patients received an ASCT post‐trial, median OS was not reached (95% CI: 39‐not reached) for these participants compared to 31 months (22–39), in those who did not receive a post‐trial ASCT. The analysis further supports the benefit of salvage ASCT, which may still be beneficial after second relapse in surviving patients. There is evidence that this benefit reduces in cytogenetic high‐risk patients, highlighting the need for targeted study in this patient group.
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Affiliation(s)
- Gordon Cook
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK.,Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Kara-Louise Royle
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - David A Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Cathy D Williams
- Department of Haematology, Centre for Clinical Haematology, Nottingham City Hospitals, Nottingham, UK
| | - Anna Hockaday
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jamie D Cavenagh
- Department of Haematology, Barts & The London NHS Trust, London, UK
| | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Eleni Tholouli
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | | | - Matthew Jenner
- University Hospital Southampton NHS Foundation, Southampton, UK
| | | | - Kwee Yong
- Department of Haematology, University College Hospital, London, UK
| | - Jim Cavet
- Department of Haematology, The Christie NHS Foundation Trust, Manchester, UK
| | - Hannah Hunter
- Department of Haematology, Plymouth Hospitals Trust, Plymouth, UK
| | - Jenny M Bird
- Department of Haematology, University Hospitals Bristol NHS Trust, Bristol, UK
| | - Guy Pratt
- Department of Haematology, Heart of England NHS Trust, Birmingham, UK
| | | | - Julia M Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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8
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Royle KL, Gregory WM, Cairns DA, Bell SE, Cook G, Owen RG, Drayson MT, Davies FE, Jackson GH, Morgan GJ, Child JA. Quality of life during and following sequential treatment of previously untreated patients with multiple myeloma: findings of the Medical Research Council Myeloma IX randomised study. Br J Haematol 2018; 182:816-829. [PMID: 29984830 PMCID: PMC6175065 DOI: 10.1111/bjh.15459] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 03/27/2018] [Accepted: 05/25/2018] [Indexed: 12/30/2022]
Abstract
In the Medical Research Council (MRC) Myeloma IX trial (ISRCTN684564111) patients were randomised to sodium clodronate or zoledronic acid and induction treatment: cyclophosphamide, vincristine, doxorubicin and dexamethasone (CVAD) or cyclophosphamide, thalidomide and dexamethasone (CTD) followed by autologous stem cell transplant (ASCT) in the intensive pathway; attenuated CTD or melphalan and prednisolone (MP) in the non-intensive pathway. Subsequent randomisation allocated patients to either thalidomide or observation. The European Organisation for Research and Treatment of Cancer (EORTC) quality of life (QoL) questionnaires, QLQ-C30 and QLQ-MY24, were administered at baseline, 3, 6 and 12 months and annually thereafter, enabling the effect of sequential treatment on patient-reported health-related QoL (HR-QoL) to be investigated. The protocol specified four subscales of interest: Pain, Fatigue, Global Health Status/Quality of Life and Physical Functioning at 3, 6 and 12 months that were compared using linear models. The intensive pathway showed significant differences in favour of CTD for Fatigue at 3 months and Physical Functioning at 12 months. The non-intensive pathway and maintenance phase reported significant differences at 3 months; Pain (improved with attenuated CTD) and Global Health status/Quality of Life (improved with observation). The improved outcomes in MRC Myeloma IX were accompanied by some beneficial and few detrimental effects on HR-QoL.
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Affiliation(s)
| | | | | | | | | | | | - Mark T Drayson
- Clinical Immunology Service, University of Birmingham, Birmingham, UK
| | | | - Graham H Jackson
- Northern Cancer Centre, Newcastle University, Newcastle-upon-Tyne, UK
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Whittle R, Royle KL, Jordan KP, Riley RD, Mallen CD, Peat G. Prognosis research ideally should measure time-varying predictors at their intended moment of use. Diagn Progn Res 2017; 1:1. [PMID: 31093533 PMCID: PMC6457137 DOI: 10.1186/s41512-016-0006-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 10/21/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Prognosis research studies (e.g. those deriving prognostic models or examining potential predictors of outcome) often collect information on time-varying predictors after their intended moment of use, sometimes using a measurement method different to that which would be used. We aimed to illustrate how estimates of predictor-outcome associations and prognostic model performance obtained from such studies may differ to those at the earlier, intended moment of use. METHODS We analysed data from two primary care cohorts of patients consulting for non-inflammatory musculoskeletal conditions: the Prognostic Research Study (PROG-RES: n = 296, aged >50 years) and the Primary care Osteoarthritis Screening Trial (POST: n = 756, >45 years). Both cohorts had collected comparable information on a potentially important time-varying predictor (current pain intensity: 0-10 numerical rating scale), other predictors (age, gender, practice) and outcome (patient-perceived non-recovery at 6 months). Using logistic regression models, we compared the direction and magnitude of predictor-outcome associations and model performance measures under two scenarios: (i) current pain intensity ascertained by the treating general practitioner in the consultation (the intended moment of use) and (ii) current pain intensity ascertained by a questionnaire mailed several days after the consultation. RESULTS In both cohorts, the predictor-outcome association was substantially weaker for pain measured at the consultation (OR (95% CI): PROG-RES 1.06 (0.95, 1.18); POST 1.04 (0.96, 1.12)) than for pain measured in the questionnaire (PROG-RES 1.34 (1.20, 1.48); POST 1.26 (1.18, 1.34)). The c-statistic of the multivariable model was lower when pain was measured at the consultation (c-statistic (95% CI): PROG-RES 0.57 (0.51, 0.64); POST 0.66 (0.62, 0.70)) than when pain was measured in the questionnaire (PROG-RES 0.69 (0.63, 0.75); POST 0.72 (0.68, 0.76)), reflecting the lower OR for pain at the consultation. CONCLUSIONS Prognostic research studies ideally should measure time-varying predictors at their intended moment of use and using the intended measurement method. Otherwise, they may produce substantially different estimates of predictor-outcome associations and model performance. Researchers should report when, how and where predictors were measured and identify any significant departures from their intended use that may limit the applicability of findings in practice. TRIAL REGISTRATION The protocol for the PROG-RES cohort data collection and primary analysis has been published in an open-access journal (Mallen et al., BMC Musculoskelet Disord 7:84, 2006). The POST trial was registered (ISRCTN40721988; date of registration: 21 June 2011; date of enrolment of the first participant: 3 October 2011) and had a pre-specified protocol covering primary analysis. There was no published protocol for the current secondary analyses presented in this manuscript.
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Affiliation(s)
- Rebecca Whittle
- grid.9757.c0000000404156205Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Kara-Louise Royle
- grid.9757.c0000000404156205Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Kelvin P. Jordan
- grid.9757.c0000000404156205Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Richard D. Riley
- grid.9757.c0000000404156205Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - Christian D. Mallen
- grid.9757.c0000000404156205Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
| | - George Peat
- grid.9757.c0000000404156205Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
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