Adaptive, Group Sequential Designs that Balance the Benefits and Risks of Wider Inclusion Criteria

We propose a new class of adaptive randomized trial designs aimed at gaining the advantages of wider generalizability and faster recruitment, while mitigating the risks of including a population for which there is greater a priori uncertainty. Our designs use adaptive enrichment, i.e., they have preplanned decision rules for modifying enrollment criteria based on data accrued at interim analyses. For example, enrollment can be restricted if the participants from predefined subpopulations are not benefiting from the new treatment. To the best of our knowledge, our designs are the first adaptive enrichment designs to have all of the following features: the multiple testing procedure fully leverages the correlation among statistics for different populations; the familywise Type I error rate is strongly controlled; for outcomes that are binary, normally distributed, or Poisson distributed, the decision rule and multiple testing procedure are functions of the data only through minimal sufficient statistics. The advantage of relying solely on minimal sufficient statistics is that not doing so can lead to losses in power. Our designs incorporate standard group sequential boundaries for each population of interest; this may be helpful in communicating our designs, since many clinical investigators are familiar with such boundaries, which can be summarized succinctly in a single table or graph. We demonstrate these adaptive designs in the context of a Phase III trial of a new treatment for stroke, and provide user-friendly, free software implementing these designs

Mismatch repair deficiency predicts response of solid tumors to PD-1 blockade.

The genomes of cancers deficient in mismatch repair contain exceptionally high numbers of somatic mutations. In a proof-of-concept study, we previously showed that colorectal cancers with mismatch repair deficiency were sensitive to immune checkpoint blockade with antibodies to programmed death receptor-1 (PD-1). We have now expanded this study to evaluate the efficacy of PD-1 blockade in patients with advanced mismatch repair-deficient cancers across 12 different tumor types. Objective radiographic responses were observed in 53% of patients, and complete responses were achieved in 21% of patients. Responses were durable, with median progression-free survival and overall survival still not reached. Functional analysis in a responding patient demonstrated rapid in vivo expansion of neoantigen-specific T cell clones that were reactive to mutant neopeptides found in the tumor. These data support the hypothesis that the large proportion of mutant neoantigens in mismatch repair-deficient cancers make them sensitive to immune checkpoint blockade, regardless of the cancers\u27 tissue of origin

TRIAL DESIGNS THAT SIMULTANEOUSLY OPTIMIZE THE POPULATION ENROLLED AND THE TREATMENT ALLOCATION PROBABILITIES

Standard randomized trials may have lower than desired power when the treatment effect is only strong in certain subpopulations. This may occur, for example, in populations with varying disease severities or when subpopulations carry distinct biomarkers and only those who are biomarker positive respond to treatment. To address such situations, we develop a new trial design that combines two types of preplanned rules for updating how the trial is conducted based on data accrued during the trial. The aim is a design with greater overall power and that can better determine subpopulation specific treatment effects, while maintaining strong control of the familywise Type I error rate. The first component of our design involves response-adaptive randomization, in which the probability of being assigned to the treatment or control arm is updated during the trial to target an optimal allocation. The second component of our design involves enrichment, where the criteria for patient enrollment may be modified to help learn which subpopulations benefit from the treatment. We do a simulation study to compare the power of our design, which we call a response-adaptive enrichment design, to three simpler designs: a standard randomized trial design, a response-adaptive design, and an enrichment design. Our simulation study compares these designs in scenarios that arise from the problem of testing the effectiveness of a hypothetical new antidepressant

From validity to clinical utility: the influence of circulating tumor DNA on melanoma patient management in a real‐world setting

Melanoma currently lacks a reliable blood‐based biomarker of disease activity, although circulating tumor DNA (ctDNA) may fill this role. We investigated the clinical utility (i.e., impact on clinical outcomes and interpretation of radiographic data) of measuring ctDNA in patients with metastatic or high‐risk resected melanoma. Patients were prospectively accrued into ≥ 1 of three cohorts, as follows. Cohort A: patients with radiographically measurable metastatic melanoma who underwent comparison of ctDNA measured by a BEAMing digital PCR assay to tissue mutational status and total tumor burden; when appropriate, determinations about initiation of targeted therapy were based on ctDNA data. Cohorts B and C: patients with BRAF‐ or NRAS‐mutant melanoma who had either undergone surgical resection of high‐risk disease (cohort B) or were receiving or had received medical therapy for advanced disease (cohort C). Patients were followed longitudinally with serial ctDNA measurements with contemporaneous radiographic imaging to ascertain times to detection of disease activity and progressive disease, respectively. The sensitivity and specificity of the ctDNA assay were 86.8% and 100%, respectively. Higher tumor burden and visceral metastases were found to be associated with detectable ctDNA. In two patients in cohort A, ctDNA test results revealed a targetable mutation where tumor testing had not; both patients experienced a partial response to targeted therapy. In four of 30 patients with advanced melanoma, ctDNA assessments indicated evidence of melanoma activity that predicted radiographic evidence of disease progression by 8, 14, 25, and 38 weeks, respectively. CtDNA was detectable in three of these four patients coincident with radiographic evaluations that alone were interpreted as showing no evidence of neoplastic disease. Our findings provide evidence for the clinical utility of integrating ctDNA data in managing patients with melanoma in a real‐world setting