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30. November 2015Clinical Trial Design for Precision Medicine
Clinical Trial Design for Precision Medicine
Martin SchumacherInstitute for Medical Biometry and Statistics,
University of Freiburg – Medical Center
Targeted Therapies – Individualisierte Tumortherapieals evidenzbasierte Medizin
30. November 2015
Clinical Trial Design for Precision Medicine 30. November 2015Martin Schumacher
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Contents
• Problems of clinical trial design for targeted therapies
• Designs for predictive biomarker validation
• Designs with intraindividual comparisons
• Molecularly targeted therapy independent of tumor type
• Multi-arm, multi-stage (MAMS) trials
• Examples of recent trials
• Infrastructure for clinical trials
• Conclusions
Clinical Trial Design for Precision Medicine 30. November 2015Martin Schumacher
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Problems of clinical trial design for targeted therapies• “Personalized medicine”, often also called “precision medicine” is a form
of medicine that uses information about a person’s genes, proteins and environment to prevent, diagnose and treat disease. (Definition according to the National Cancer Institute)
• Traditionally, the site of tumor origin, together with histology, was used to make treatment decisions. This approach has been changed to include molecular tumor characteristics.
• Markers presently used to guide decisions for precision medicine treatment with targeted agents are either protein based or based on the detection of genetic aberrations.
• With multiple targets based on multiple markers we are often close to the situation that we are faced with in rare diseases.
Jürgensmeier et al. Clin Cancer Res 2014;20:4425-4435
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Design for predictive biomarker validation
• Marker-Interaction or Enrichment-Design?
• Marker-based Strategy Design
• Reverse Marker-based Strategy Design
Aim: Validate a given predictive biomarker
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Eng KH, Stat Med 2014
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Eng KH, Stat Med 2014
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Eng KH, Stat Med 2014
Clinical Trial Design for Precision Medicine 30. November 2015Martin Schumacher
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Eng KH, Stat Med 2014
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Eng KH, Stat Med 2014
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Design for predictive biomarker validation
• Marker-Interaction or Enrichment-Design?
• Marker-based Strategy Design
• Reverse Marker-based Strategy Design
• Various proposals for adaptive designs
• Various proposals for statistical analysis strategy
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Designs with intraindividual comparisons
• Idea: Compare progression-free survival (PFS) under current, biomarker-guided therapy with PFS under prior therapy (PFS = time to treatment failure (TTF))
• Determine proportion of patients with PFS ratio PFS on current therapy PFS on prior therapy⁄ 1.3
• Pilot study on patients with refractory metastatic cancer(von Hoff et al. J Clin Oncol 2010)
• Aim: (Proportion with PFS ratio 1.3 15%
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Von Hoff et al. J Clin Oncol 2010;28:4887-4883
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Von Hoff et al. J Clin Oncol 2010;28:4887-4883
18 66 27%;95%–CI:17%–38%⁄
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Problems with intraindividual comparisons
• Comparison of patients who match to targeted therapy with those who do not is problematic
• Need to have pre-baseline tumor assessment
• PFS on prior therapy is often not assessed according to validated criteria and might therefore be not accurate
• Cut-off for PFS ratio is somewhat arbitrary
• PFS ratio is only valid if there is a strong correlation between the endpoints (Recall: PFS on prior therapy = TTF)
Le Tourneau et al. Targeted Oncology 2012;7:253-265
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Buyse et al. J Clin Oncol 2011;29:e451-e452
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Molecularly targeted therapy independent of tumor type (“all-tumor trials”)
• Example: von Hoff study (breast, colorectal, ovarian, miscellaneous)
• WINTHER trial:
Patients with all types of metastatic solid tumors resistant to last line of treatment
“Complete biological analysis” of matched tumor and normal biopsies.
Therapeutic decision based on an estimated drug efficacy scoring bioinformatics tool
Aim: PFS ratio > 1.5 in 50% of patients
Implementation of trial much more difficult than expected
It took 19 to more than 36 months to activate study sites; only few patients enrolled so far
Rodon et al., Annals of Oncology 2015;26:1791-1798
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Le Tourneau et al., The Lancet Oncology 2015;16:1324-1334
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Le Tourneau et al. Targeted Oncology 2012;7:253-265
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Le Tourneau et al., The Lancet Oncology 2015;16:1324-1334
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Le Tourneau et al., The Lancet Oncology 2015;16:1324-1334
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Le Tourneau et al., The Lancet Oncology 2015;16:1324-1334
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Le Tourneau et al., The Lancet Oncology 2015;16:1324-1334
Hormone receptor pathway
P13k/AKT/mTOR pathway
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Le Tourneau et al., The Lancet Oncology 2015;16:1324-1334
RAF/MEK pathway
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Schwaederle M: JCO 2015; 33: 3817-3825
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Schwaederle M: J Clin Oncol 2015; 33: 3817-3825
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Multi-arm, multi-stage (MAMS) trials
• Multi-arm trials are more efficient in investigating a number of treatments than a series of two-arm studies (Example 2 2-factorial design)
• Multi-arm, multi-stage designs allow adaptive focusing of recruitment away from insufficiently active treatments, preferably on an early, intermediate outcome measure
• Formalisation of idea: P. Royston and M. Parmar (Stat Med 2003;22:2239-2256)
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MAMS-Design
Jaki T. Developments in Statistical Evaluation of Clinical Trials. Springer 2014
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Kaplan R et al. J Clin Oncol 2013;31:4562-4568
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FOCUS4 Issue3, August 2015
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News. Nature Biotechnology 2015; 33: 790
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http://ecog-acrin.org/trials/nci-match-eay131
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Infrastructure for clinical trials
• About 20% of adult cancer clinical trials fail to complete (Stensland et al. J Nat Cancer Inst 2014)
• Only 25% to 42% of superiority trials in oncology report success of the experimental treatment (Djulbegovic et al. PLOS ONE 2013)
• Concentrating on isolated trials done by single investigators will not lead to faster and more efficient developments
• While the steps towards multi-center trials and the creation of entity-specific, national and international study groups have been made in the past, professional coordination of all trial activities comprising all tumor entities is now warranted. This can best be achieved within a Comprehensive Cancer Center!
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Jürgensmeier et al. Clin Cancer Res 2014;20:4425-4435
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Conclusions• For targeted therapies in oncology based on molecular
characteristics, there are certainly parallels to the situation in rare diseases.
• There are developments in clinical trial design and statistical analysis strategies to meet the special needs (however, there is no special statistical methodology for this situation!).
• The most important prerequisite for the efficient conduct of studies is a comprehensive approach based on appropriate precision medicine infrastructure.
• Utility of molecular profiling for monitoring of disease and resistance e.g. by repeated (liquid) biopsies has to be further investigated.
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Nationale Akademie der Wissenschaften Leopoldina e.V. Individualisierte Medizin, December 2014
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References• Brower V. NCI-MATCH pairs tumor mutations with matching drugs. NEWS Nature Biotechnology
2015;33:790-791
• Buyse M, Quinaux E, Hendlisz A et al. Progression-free survival ratio as end point for phase II trials in advanced solid. tumors. J Clin Oncol 2011 ;29:451–452.
• Djulbegovic B, Kumar A, Miladinovic B. Treatment Success in Cancer: Industry Compared to Publicly Sponsored Randomized Controlled Trials. PLoS ONE 2013;8:e58711.
• Eng KH. Randomized reverse marker strategy design for prospective biomarker validation. Statist Med 2014, 33 3089–3099.
• Jaki T. Designing Multi-arm Multi-stage Clinical Studies (Chapter 3). In: Developments in Statistical Evaluation of Clinical Trials. Ed.: van Montfort K, Oud J, Ghidey W. Springer-Verlag Berlin Heidelberg 2014
• Jürgensmeier JM, Eder JP, Herbst RS. New Strategies in Personalized Medicine for Solid Tumors: Molecular Markers and Clinical Trial Designs. Clin Cancer Res 2014;20:4425-4435.
• Kaplan R, Maughan T, Crook A, Fisher D, Wilson R, Brown L, Parmar M. Evaluating Many Treatments and Biomarkers in Oncology: A New Design. J Clin Oncol 2013;31:4562-4568.
• Individualisierte Medizin. Voraussetzungen und Konsequenzen. Nationale Akademie der Wissenschaften Leopoldina, acatech – Deutsche Akademie der Technikwissenschaften, Union der deutschen Akademien der Wissenschaften (Hrsg.) (2014).
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References• Le Tourneau C, Delord J-P, Gonçalves A et al. Molecularly targeted therapy based on tumour
molecular profiling versus conventional therapy for advanced cancer (SHIVA): a multicentre, open-label, proof-of-concept, randomised, controlled phase 2 trial. Lancet Oncol 2015;16:1324-1334.
• Le Tourneau C, Kamal M, Trédan O et al. Designs and challenges for personalized medicine studies in oncology: focus on the SHIVA trial. Targ Oncol 2012;7:253–265.
• Parmar MKB, Carpenter J, Sydes MR. More multiarm randomised trials of superiority are needed. The Lancet 2014;384:283-284.
• Rodon J, Soria JC, Berger R et al. Challenges in initiating and conducting personalized cancer therapy trials: perspectives from WINTHER, a Worldwide Innovative Network (WIN) Consortium trial. Ann Oncol 2015; 26:1791-1798.
• Schwaederle M, Zhao M, Lee JJ et al. Impact of Precision Medicine in Diverse Cancers: A Meta-Analysis of Phase II Clinical Trials. J Clin Oncol 2015;33:3817-3825.
• Stensland KD, McBride RB, Latif A et al. Adult Cancer Clinical Trials That Fail to Complete: An Epidemic? Natl Cancer Inst 2014;106(9).
• Von Hoff DD, Stephenson JJ, Rosen P et al. Pilot Study Using Molecular Profiling of Patients’ Tumors to Find Potential Targets and Select Treatments for Their Refractory Cancers. J Clin Oncol2010;28:4877-4883.
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