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Hansen A.R.,University Health Network | Hansen A.R.,University of Toronto | Graham D.M.,University Health Network | Graham D.M.,University of Toronto | And 4 more authors.
Cancer Control | Year: 2014

Background: Concerns have been recognized about the operating characteristics of the standard 3 + 3 dose-escalation design. Various innovative phase 1 trial designs have been proposed to address the issues and new challenges posed by molecularly targeted agents. However, in spite of these proposals, the conventional design is still the most widely utilized. Methods: A review of the literature of phase 1 trials and relevant statistical studies was performed. Results: Beyond statistical simulations, sparse clinical data exist to support or refute many of the shortcomings ascribed to the 3 + 3 rule method. Data from phase 1 trials demonstrate that traditional designs identified the correct dose and relevant toxicities with an acceptable level of precision in some instances; however, no single escalation method was proven superior in all circumstances. Conclusions: Design selection should be guided by the principle of slow escalation in the face of toxicity and rapid dose increases in the setting of minimal or no adverse events. When the toxicity of a drug is uncertain or a narrow therapeutic window is suggested from preclinical testing, then a conservative 3 + 3 method is generally appropriate. However, if the therapeutic window is wide and the expected toxicity is low, then rapid escalation with a novel rule- or model-based design should be employed. Source


You B.,University of Toronto | You B.,Center Hospitalier Lyon Sud | Pond G.,Ontario Clinical Oncology Group | Siu L.L.,University of Toronto | And 3 more authors.
Annals of Oncology | Year: 2012

Background: To prevent potential drug-drug interaction, lists of cautioned or prohibited (C/P) drugs are commonly included in protocols of phases I and II cancer trials. Heterogeneity among lists may affect patient eligibility and comparability of results. Methods: Protocols of phase I/II trials conducted at an academic cancer centre between 2004 and 2009 were reviewed. All C/P drugs were collected and compared among trials. Results: Of 100 protocols reviewed, 77 protocols include lists of C/P drugs to prevent CYP3A4-, 2C9- and 2C19-related interactions and/or QT interval prolongation. Sixty-five protocols evaluating 38 unique study drugs include lists of CYP3A4-related C/P drugs. These lists contain 0-137 inhibitors [coefficient of variation (CV): 123%], 0-20 inducers (CV: 57%) and 10-157 substrates (CV: 76%). There is a high degree of inconsistency among protocols of the same study drug or from the same originator. Heterogeneity is also common for lists of C/P CYP2C9 and 2C19 drugs and for QT interval prolongation drugs. Approximately 20% protocols contain potential sources of confusion in their drug lists. Conclusions: There is high degree of heterogeneity among lists of drugs C/P in protocols of oncology phase I/II trials. There is an urgent need to standardize these lists. © The Author 2011. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. Source


Levin L.,Kings College | Goeree R.,McMaster University | Goeree R.,Programs for Assessment of Technologies in Health PATH Research Institute | Levine M.,McMaster University | And 9 more authors.
International Journal of Technology Assessment in Health Care | Year: 2011

Background: For non-drug technologies, there is often residual uncertainty following systematic review, mainly due to inadequate evidence of efficacy. The unwillingness to make decisions in the presence of uncertainty may lead to passive diffusion and intuitive decision making with or without public pressure. This may affect health system sustainability. There is increasing interest in post-market evaluation through processes that include coverage with evidence development (CED) to address residual uncertainty regarding effectiveness and cost-effectiveness. Global experience of CED has been slow to develop despite their potential contribution to decision making. Methods: Ontario's field evaluation program to better inform decision making represents a collaboration between physicians, policy decision makers and academic centers. We report results of the first ten CEDs from this program to assess whether they achieved their objective of influencing policy by addressing residual uncertainty following systematic review. Results: Since 2003, nineteen field evaluation studies to resolve residual uncertainty following systematic review have been completed, ten of which met the criteria of CED and are the focus of this report. There was more than one patient subgroup or intervention in three of the CEDs. This provided the basis for evaluating thirteen outcomes. In each case, the CED addressed the uncertainty and led to a decision based on the systematic review and CED result. The CEDs led to adoption of the technology in six instances, modified adoption in three instances and withdrawal in four instances. Conclusions: CED makes an important contribution to translating evidence to decision making. Methodologies are needed to increase the scope and reduce timelines for CEDs, such as the use of linked comprehensive and robust data sets and collaborative studies with other jurisdictions. CED before making long-term funding decisions, especially where there is uncertainty of effectiveness, safety or cost-effectiveness, should be increasingly funded by health systems. © 2011 Cambridge University Press. Source


Swaminath A.,McMaster University | Swaminath A.,Hamilton Health Sciences | Wright J.R.,McMaster University | Wright J.R.,Hamilton Health Sciences | And 14 more authors.
Clinical Lung Cancer | Year: 2015

Background: The downstream signaling pathways of the epidermal growth factor receptor might influence radiation resistance. Data from preclinical work support the hypothesis that erlotinib concurrent with radiation therapy (RT) might increase cancer cell killing. The present trial was designed to examine the efficacy and toxicity of combined erlotinib and palliative chest thoracic RT in non-small-cell lung cancer (NSCLC). Materials and Methods: Patients with newly diagnosed stage III-IV (American Joint Committee on Cancer, version 6) or recurrent NSCLC received 3 weeks of erlotinib at a dose of 150 mg daily, starting 1 week before palliative thoracic RT to 30 Gy in 10 fractions within 2 weeks. The primary outcome was a change in the quality of life, as measured by the Lung Cancer Symptom Scale (LCSS) question on the "symptoms of lung cancer" from baseline to 4 weeks after treatment. Results: A total of 40 patients were recruited from 2 institutions. Of the 40 patients, 22 (55%) were men, with an average age of 71 years, and 60% had stage IV disease. A total of 26 patients (65%) completed the full course of erlotinib, and 35 (88%) completed the planned RT. Twenty-five patients (62.5%) reported LCSS scores at 4 weeks after treatment, with an average change (improvement) of -12.5 U (95% confidence interval, -23.0 to -1.9; 2P = .023). This was less than the a priori hypothesis of a change of -17.5 U. The median overall and progression-free survival was 5.2 and 3.2 months, respectively. Conclusion: The present single-arm, phase II trial did not demonstrate additional symptomatic benefit from concurrent erlotinib therapy with standard palliative thoracic RT for patients with locally advanced or metastatic NSCLC. © 2015 Elsevier Inc. Source


Grunfeld E.,Ontario Cancer Institute | Grunfeld E.,University of Toronto | Julian J.A.,Ontario Clinical Oncology Group | Julian J.A.,McMaster University | And 23 more authors.
Journal of Clinical Oncology | Year: 2011

Purpose: An Institute of Medicine report recommends that patients with cancer receive a survivorship care plan (SCP). The trial objective was to determine if an SCP for breast cancer survivors improves patient-reported outcomes. Patients and Methods: Women with early-stage breast cancer who completed primary treatment at least 3 months previously were eligible. Consenting patients were allocated within two strata: less than 24 months and ≥ 24 months since diagnosis. All patients were transferred to their own primary care physician (PCP) for follow-up. In addition to a discharge visit, the intervention group received an SCP, which was reviewed during a 30-minute educational session with a nurse, and their PCP received the SCP and guideline on follow-up. The primary outcome was cancer-related distress at 12 months, assessed by the Impact of Event Scale (IES). Secondary outcomes included quality of life, patient satisfaction, continuity/coordination of care, and health service measures. Results: Overall, 408 survivors were enrolled through nine tertiary cancer centers. There were no differences between groups on cancer-related distress or on any of the patient-reported secondary outcomes, and there were no differences when the two strata were analyzed separately. More patients in the intervention than control group correctly identify their PCP as primarily responsible for follow-up (98.7% v 89.1%; difference, 9.6%; 95% CI, 3.9 to 15.9; P = .005). Conclusion: The results do not support the hypothesis that SCPs are beneficial for improving patient-reported outcomes. Transferring follow-up to PCPs is considered an important strategy to meet the demand for scarce oncology resources. SCPs were no better than a standard discharge visit with the oncologist to facilitate transfer. © 2011 by American Society of Clinical Oncology. Source

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