Presentation on theme: "Patient Selection Markers in Drug Development Programs"— Presentation transcript:
1Patient Selection Markers in Drug Development Programs Michael OstlandGenentechFDA/Industry Statistics Workshop:Washington D.C., September 14 – 16, 2005
2Outline Background Seven Questions from a Drug Development POV Concluding Remarks
3BackgroundMost drugs benefit far less than 100% of the patients who are treated.Patients who get no efficacy from a drug:Still run the risk of toxicity or side effectsMay miss out on a benefit they would have received had they been treated with another drug insteadAdd costs to the health care systemDilute efficacy estimates in clinical trials
4Background (cont’d) In drug development patient selection may: Enrich a population for patients who benefit, thereby allowing a drug’s efficacy to be detected in a smaller phase III trial. (see Maitournam and Simon)Enrich a population for patients with a favorable toxicity profile, thereby improving the benefit/risk ratio.Maitournam and Simon, Statist. Med. 2005; 24:329–339
5Background (cont’d)By “marker” we typically have a biomarker in mind. Namely,a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention (Biomarkers Definitions Working Group 2001)In principle, any objectively measured baseline characteristic (or completely specified combination of multiple characteristics) could form the basis for selecting patients to be candidates to receive treatment.
6Seven Basic Questions What strategic imperative for patient selection? What is the desired outcome from the development program (“Target Product Profile”)?What could phase III look like?What should phase II look like?How do results from phase II lead to decisions about the design in phase III?How many patients are needed in phase II to ensure adequate decision making?What marker and what threshold for “positive”?
7Strategy for Patient Selection Patient selection for clinical drug development canproceed with one of several strategic imperatives:Efficacy:Include patients most likely to benefitExclude patients least likely to benefitSafety:Include patients least likely to experience toxicityExclude patients most likely to experience toxicity
8Target Product Profile Establish relationship between target efficacy/safetyand proportion of patients selected for treatment.e.g., How much more effective does a drug need to be if only 40% of the population can be treated?Other useful metrics possible.
9Phase III Designs with Patient Selection Option 1Standard design, except only enroll patientsfrom marker selected population.QuestionWhat are the scientific and regulatoryimplications of not performing a definitiveassessment of efficacy on unselected patients?
10Phase III Designs (cont’d) Option 2Enroll all patients and assay for marker. Performtwo primary efficacy analyses while controllingoverall type I error rate:(1) Efficacy among all patients(2) Efficacy on marker selected patientsQuestionHow does efficacy on marker unselected patients impact inference when (1) is positive?
11Phase II Design Usually best to consider a randomized trial: Allows assessment of whether the marker is truly predictive of increased treatment benefit, rather than simply prognostic for good outcome.Assessment of safety with contemporaneous control arm.Ideally, one tests the marker prior to randomization and stratifies, but this may not be possible for logistic reasons.
12Phase II Design (cont’d) A randomized design with retrospective testingPositiveAassayNegativeBTreatmentIndeterminateCEnrolled PatientsrandomizeControlassayPositiveNegativeIndeterminateDEFWhether patients who test “indeterminate” ultimately get treated depends on the selection strategy: exclude only those least likely to benefit (yes), or only include only those most likely to benefit (no).
13Phase II to III Decision Making Broadly speaking, there are four possibledecisions after a phase II trial with a patientselection marker:Proceed to Ph III in marker+ subset onlyProceed to Ph III in all patients and perform two tests: in all patients and in marker+ ptsProceed to Ph III in all patients and ignore markerDo not proceed to Ph III at this time
14Decision making (Cont’d) Key efficacy comparisons:A vs. D: Treatment effect among known marker positiveB vs. E: Trt. effect among known marker negative(A+B+C) vs. (D+E+F): Overall treatment effect(A vs. D) vs. (B vs. E): Treatment effect by marker interactionPositiveATreatmentNegativeBIndeterminateCPositiveDControlNegativeEIndeterminateF
15Decision making (Cont’d) Present the key efficacy and safety comparisons along with reasonable estimates of uncertaintyInterpret results using Target Product ProfileTake into accountAsymmetry of the decision-making loss functionBiologic plausibilityHard and fast rules for all possibilities are hard (impossible?) to come by.
16Size of Phase II An area of great opportunity for statisticians Power is too rigid to be very usefulExpected CI widths are hard to evaluate when several parameters are of simultaneous interestProbably want to approach it from a decision-theory point of view. But this is not trivial:The fore-mentioned lack of strictly defined decision rules makes analysis impossibleQuickly approach the sort of mind-numbing complexity that confirms clinicians worst prejudices about statisticians.
17Marker SelectionBest to have 1 – 3 candidate markers based on biologic MOA and preclinical evidence. Then a short phase II program can be used to prospectively assess.Sometimes need to use part of phase II to screen for candidate markers, and then a subsequent clinical study (prospective or retrospective?) to validate. This is lengthier and requires care (multiplicity, cross-validation at proper level, etc.). Fortunately, a lot of smart statisticians have made good progress on these matters.Similar points apply to establishing “positive” threshold
18Concluding RemarksPhase II is a critical part of clinical development when patient selection markers are consideredKnowledge of the assay is helpfulA clear Target Product Profile is criticalStatisticians have an important role in planning and decision making in this complex, uncertain environmentPlanning for phase II in a way that can be usefully communicated to decision makers is an open question.
19Acknowledgements Alex Bajamonde Cheryl Jones Lee Kaiser Gracie LiebermanBen LyonsHoward MackeyJames ReimannJulia VarshavskyXiaolin Wang