Phase I dose-escalation trials must be guided by a safety model in order to avoid exposing patients to unacceptably high risk of toxicities. Traditionally, these trials are based on one type of schedule. In more recent practice, however, there is often a need to consider more than one schedule, which means that in addition to the dose itself, the schedule needs to be varied in the trial. Hence, the aim is finding an acceptable dose-schedule combination. However, most established methods for dose-escalation trials are designed to escalate the dose only and ad-hoc choices must be made to adapt these to the more complicated setting of finding an acceptable dose-schedule combination. In this paper, we introduce a Bayesian time-to-event model which takes explicitly the dose amount and schedule into account through the use of pharmacokinetic principles. The model uses a time-varying exposure measure to account for the risk of a dose-limiting toxicity over time. The dose-schedule decisions are informed by an escalation with overdose control criterion. The model is formulated using interpretable parameters which facilitates the specification of priors. In a simulation study, we compared the proposed method with an existing method. The simulation study demonstrates that the proposed method yields similar or better results compared to an existing method in terms of recommending acceptable dose-schedule combinations, yet reduces the number of patients enrolled in most of scenarios. The \texttt{R} and \texttt{Stan} code to implement the proposed method is publicly available from Github (\url{https://github.com/gunhanb/TITEPK_code}).
The primary object of a phase I clinical trial is to determine the maximum tolerated dose (MTD). Typically, the MTD is identified using a dose-escalation study, where initial subjects are treated at the lowest dose level and subsequent subjects are treated at progressively higher dose levels until the MTD is identified. The continual reassessment method (CRM) is a popular model-based dose-escalation design, which utilizes a formal model for the relationship between dose and toxicity to guide dose-finding. Recently, it was shown that the CRM has a tendency to get "stuck" on a dose-level, with l…
Traditionally, the major objective in phase I trials is to identify a working-dose for subsequent studies, whereas the major endpoint in phase II and III trials is treatment efficacy. The dose sought is typically referred to as the maximum tolerated dose (MTD). Several statistical methodologies have been proposed to select the MTD in cancer phase I trials. In this manuscript, we focus on a Bayesian adaptive design, known as escalation with overdose control (EWOC). Several aspects of this design are discussed, including large sample properties of the sequence of doses selected in the trial, cho…
Phase I dose-escalation trials constitute the first step in investigating the safety of potentially promising drugs in humans. Conventional methods for phase I dose-escalation trials are based on a single treatment schedule only. More recently, however, multiple schedules are more frequently investigated in the same trial. Here, we consider sequential phase I trials, where the trial proceeds with a new schedule (e.g. daily or weekly dosing) once the dose escalation with another schedule has been completed. The aim is to utilize the information from both the completed and the ongoing dose-escal…
Dose-finding clinical trials in oncology aim to determine the maximum tolerated dose (MTD) of a new drug, generally defined by the proportion of patients with short-term dose-limiting toxicities (DLTs). Model-based approaches for such phase I oncology trials have been widely designed and are mostly restricted to the DLTs occurring during the first cycle of treatment, although patients continue to receive treatment for multiple cycles. We aim to estimate the probability of DLTs over sequences of treatment cycles via a Bayesian cumulative modeling approach, where the probability of DLT is modele…
This paper proposes a novel criterion for the allocation of patients in Phase~I dose-escalation clinical trials aiming to find the maximum tolerated dose (MTD). Conventionally, using a model-based approach the next patient is allocated to the dose with the toxicity estimate closest (in terms of the absolute or squared distance) to the maximum acceptable toxicity. This approach, however, ignores the uncertainty in point estimates and ethical concerns of assigning a lot of patients to overly toxic doses. Motivated by recent discussions in the theory of estimation in restricted parameter spaces, …
In parametric Bayesian designs of early phase cancer clinical trials with drug combinations exploring a discrete set of partially ordered doses, several authors claimed that there is no added value in including an interaction term to model synergism between the two drugs. In this paper, we investigate these claims in the setting of continuous dose levels of the two agents. Parametric models will be used to describe the relationship between the doses of the two agents and the probability of dose limiting toxicity and efficacy. Trial design proceeds by treating cohorts of two patients simultaneo…
The commonplace description of phase 1 clinical trials in oncology as "primarily concerned with safety" is belied by their near universal adoption of dose-escalation practices which are inherently unsafe. In contrast with dose titration, cohort-wise dose escalation regards patients as exchangeable, an indefensible assumption in the face of widely appreciated inter-individual heterogeneity in pharmacokinetics and pharmacodynamics (PKPD). I have previously advanced this argument in terms of a precautionary coherence principle that brings the well-known coherence notion of Cheung (2005) into cont…
A key objective in two phase 2b AMP clinical trials of VRC01 is to evaluate whether drug concentration over time, as estimated by non-linear mixed effects pharmacokinetics (PK) models, is associated with HIV infection rate. We conducted a simulation study of marker sampling designs, and evaluated the effect of study adherence and sub-cohort sample size on PK model estimates in multiple-dose studies. With m=120, even under low adherence (about half of study visits missing per participant), reasonably unbiased and consistent estimates of most fixed and random effect terms were obtained. Coarsene…
BACKGROUND:Levobupivacaine is commonly used during transversus abdominis plane block in pediatric patients. However, the dosing regimen is still empirical, and the pharmacokinetic properties of levobupivacaine are not considered. Here, the pharmacokinetics of levobupivacaine during an ultrasound-guided transversus abdominis plane block were evaluated to optimize dosing regimen, with regard to the between-subject variability and the volume of levobupivacaine injected.METHOD:The clinical trial (prospective, randomized, double-blind study protocol) was conducted in 40 children aged 1 to 5 years, …
Two useful strategies to speed up drug development are to increase the patient accrual rate and use novel adaptive designs. Unfortunately, these two strategies often conflict when the evaluation of the outcome cannot keep pace with the patient accrual rate and thus the interim data cannot be observed in time to make adaptive decisions. A similar logistic difficulty arises when the outcome is of late onset. Based on a novel formulation and approximation of the likelihood of the observed data, we propose a general methodology for model-assisted designs to handle toxicity data that are pending du…
Phase I-II cancer clinical trial designs are intended to accelerate drug development. In cases where efficacy cannot be ascertained in a short period of time, it is common to divide the study in two stages: i) a first stage in which dose is escalated based only on toxicity data and we look for the maximum tolerated dose (MTD) set and ii) a second stage in which we search for the most efficacious dose within the MTD set. Current available approaches in the area of continuous dose levels involve fixing the MTD after stage I and discarding all collected stage I efficacy data. However, this method…
Incorporating historical data or real-world evidence has a great potential to improve the efficiency of phase I clinical trials and to accelerate drug development. For model-based designs, such as the continuous reassessment method (CRM), this can be conveniently carried out by specifying a "skeleton," i.e., the prior estimate of dose limiting toxicity (DLT) probability at each dose. In contrast, little work has been done to incorporate historical data or real-world evidence into model-assisted designs, such as the Bayesian optimal interval (BOIN), keyboard, and modified toxicity probability i…
Phase I dose-finding trials in oncology seek to find the maximum tolerated dose (MTD) of a drug under a specific schedule. Evaluating drug-schedules aims at improving treatment safety while maintaining efficacy. However, while we can reasonably assume that toxicity increases with the dose for cytotoxic drugs, the relationship between toxicity and multiple schedules remains elusive. We proposed a Bayesian dose-regimen assessment method (DRtox) using pharmacokinetics/pharmacodynamics (PK/PD) information to estimate the maximum tolerated dose-regimen (MTD-regimen), at the end of the dose-escalati…
Although there is an extensive statistical literature showing the disadvantages of discretizing continuous variables, categorization is a common practice in clinical research which results in substantial loss of information. A large collection of methods in cancer phase I clinical trial design establishes dose of a new agent as a discrete variable. A noteworthy exception is the Escalation With Overdose Control (EWOC) design, where doses can be defined either as continuous or as a grid of discrete doses. A Monte Carlo simulation study was performed to compare the operating characteristics of co…
Drug combination trials are increasingly common nowadays in clinical research. However, very few methods have been developed to consider toxicity attributions in the dose escalation process. We are motivated by a trial in which the clinician is able to identify certain toxicities that can be attributed to one of the agents. We present a Bayesian adaptive design in which toxicity attributions are modeled via Copula regression and the maximum tolerated dose (MTD) curve is estimated as a function of model parameters. The dose escalation algorithm uses cohorts of two patients, following the contin…
If explicit, formal consideration of clinical pharmacology at all informs the design and conduct of modern oncology dose-finding trials, the designs themselves hardly attest to this. Yet in conducting a trial, investigators affirm that they hold reasonable expectations of participant safety - expectations that necessarily depend on beliefs about how certain pharmacologic parameters are distributed in the study population. Thus, these beliefs are implicit in a trial's presumed conformance to a community standard of safety, and may therefore to some extent be reverse-engineered from trial design…
PKComb-BOIN12: A Pharmacokinetically Guided Bayesian Design for Dose Optimisation in Oncology Drug-Combination Trials
Global Statistical Sciences, Eli Lilly and Company（礼来公司全球统计科学部）；Department of Biostatistics, The University of Texas MD Anderson Cancer Center（德克萨斯大学安德森癌症中心生物统计学系）；Population Health Sciences Institute, Newcastle University（纽卡斯尔大学人口健康科学研究所）
It is increasingly common for therapies in oncology to be given in combination. In some cases, patients can benefit from the interaction between two drugs, although often at the risk of higher toxicity. A large number of designs to conduct phase I trials in this setting are available, where the objective is to select the maximum tolerated dose combination (MTC). Recently, a number of model-free (also called model-assisted) designs have provoked interest, providing several practical advantages over the more conventional approaches of rule-based or model-based designs. In this paper, we demonstr…
U-DESPE: a Bayesian Utility-based methodology for dosing regimen optimization in early-phase oncology trials based on Dose-Exposure, Safety, Pharmacodynamics, Efficacy
Adaptive designs for clinical trials permit alterations to a study in response to accumulating data in order to make trials more flexible, ethical and efficient. These benefits are achieved while preserving the integrity and validity of the trial, through the pre-specification and proper adjustment for the possible alterations during the course of the trial. Despite much research in the statistical literature highlighting the potential advantages of adaptive designs over traditional fixed designs, the uptake of such methods in clinical research has been slow. One major reason for this is that …
The use of drug combinations in clinical trials is increasingly common during the last years since a more favorable therapeutic response may be obtained by combining drugs. In phase I clinical trials, most of the existing methodology recommends a one unique dose combination as "optimal", which may result in a subsequent failed phase II clinical trial since other dose combinations may present higher treatment efficacy for the same level of toxicity. We are particularly interested in the setting where it is necessary to wait a few cycles of therapy to observe an efficacy outcome and the phase I …
A non-parametric optimal design algorithm for population pharmacokinetics
Oslo University Hospital, University of Oslo（奥斯陆大学医院，奥斯陆大学）；California State University Channel Islands（加州州立大学海峡群岛分校）；Children’s Hospital Los Angeles, University of Southern California（南加州大学洛杉矶儿童医院）；University of Southern California（南加州大学）；Children’s Hospital Los Angeles（洛杉矶儿童医院）
PK/PD-integrated Bayesian platform design for phase II dose regimen optimization
Inserm；Université Paris Cité（巴黎西岱大学）；Inria；HeKA；Centre d’Étude des Pathologies Respiratoires (CEPR)（呼吸疾病研究中心 (CEPR)）；UMR 1100；Université de Tours（图尔大学）；Service de Médecine Intensive Réanimation, CHRU de Tours（图尔大学医院重症医学科）；Université Sorbonne Paris Nord（巴黎北索邦大学）；IAME；Univ Rennes（雷恩大学）；EHESP；Irset；UMRS 1085
Leveraging preclinical animal data for a phase I first-in-man trial is appealing yet challenging. A prior based on animal data may place large probability mass on values of the dose-toxicity model parameter(s), which appear infeasible in light of data accrued from the ongoing phase I clinical trial. In this paper, we seek to use animal data to improve decision making in a model-based dose-escalation procedure for phase I oncology trials. Specifically, animal data are incorporated via a robust mixture prior for the parameters of the dose-toxicity relationship. This prior changes dynamically as …
In Oncology, trials evaluating drug combinations are becoming more common. While combination therapies bring the potential for greater efficacy, they also create unique challenges for ensuring drug safety. In Phase-I dose escalation trials of drug combinations, model-based approaches enable efficient use of information gathered, but the models need to account for trial complexities: appropriate modeling of interactions becomes increasingly important with growing numbers of drugs being tested simultaneously in a given trial. In principle, we can use data from multiple arms testing varying combi…
Adaptive Weighting for Time-to-Event Continual Reassessment Method: Improving Safety in Phase I Dose-Finding Through Data-Driven Delay Distribution Estimation
Optimal design of a Phase I cancer trial can be formulated as a stochastic optimization problem. By making use of recent advances in approximate dynamic programming to tackle the problem, we develop an approximation of the Bayesian optimal design. The resulting design is a convex combination of a "treatment" design, such as Babb et al.'s (1998) escalation with overdose control, and a "learning" design, such as Haines et al.'s (2003) $c$-optimal design, thus directly addressing the treatment versus experimentation dilemma inherent in Phase I trials and providing a simple and intuitive design fo…
Partial Ordering Bayesian Logistic Regression Model for Phase I Combination Trials and Computationally Efficient Approach to Operational Prior Specification
MRC Biostatistics Unit, University of Cambridge（剑桥大学医学研究委员会生物统计学单元）
