THE FUTURE OF CLINICAL
TRIALS:
NEW MODEL TO ENHANCE
EFFICIENCY
Jeff Allen, PhD
Executive Director
Friends of Cancer Research
Current Challenges
• Each potential new therapy is typically tested independently
from other therapies seeking to treat the same condition
• For every new trial, the protocol must be reviewed by a number
of oversight entities
• new phase III trials requires an average of 36 administrative or
regulatory approvals and averages more than 2 years
• Approximately 4% of adult cancer patients enroll in clinical
trials
• inability to meet accrual goals is a frequent factor causing trials to
close, wasting time, money, and limited patient resources
• New therapies molecularly targeted against specific mutations
may be present in only a fraction of the patient population
Design of a Disease-Specific Master Protocol
2012 Conference on Clinical Cancer Research
http://www.focr.org/events/design-lung-cancer-master-protocol
Major elements
• Setting: Squamous cell carcinoma (SCCA), advanced
stage, 2nd line therapy
• Agents: Candidate drugs must demonstrate biologic
activity against a measurable target with a proposed
predictive biomarker
• Study design: Multi-arm randomized, controlled phase
II/III master registration protocol. Each arm able to open
and close independent of other arms
Screening
• Archival FFPE tumor-common broad testing analytically
validated platform suitable for registration purposes
• Molecule–specific tests, to include IHC, fresh core needle
biopsy as appropriate
• Protocol arm powered for central test+ cases, with subsequent
bridging studies as per FDA clearance.
• Goal is to develop each molecule with a companion
diagnostic to support clinical use
Trial Structure
• Primary Endpoint: Each arm independently powered for
OS; interim analysis for PFS. Positive results at “rolling”
interim analysis (no temporary closure) determine if a
protocol arm proceeds to phase III portion.
• Goal: minimum of 4 arms open at any time, to ascertain a
reasonable chance for patients to be “biomarker positive”.
• Marker-negative patients enter common control group
treated with SoC (vs anti-PD1 agent) to establish
annotated repository
Trial operations
• Operations Management: Neutral 3rd party - FNIH in
collaboration with NCI Cooperative Groups
• Independent Drug Selection Committee: evaluates
each drug-marker pair for suitability
• Oversight Committee: Comprised of leaders from NCI,
Academia, FDA, industry, advocates, to ensure
operational efficacy
MASTER PROTOCOL
CNB/CLIA Biomarker
Profiling
Biomarker A
TT A
CT*
Endpoint
(Interim PFS)
OS
Biomarker Β
TT B
CT*
Endpoint
(Interim PFS)
OS
Biomarker C
TT C+CT
CT*
Endpoint
(Interim PFS)
OS
CT*
Unkn-Neg
biomarker
Anti
PD1
Biomarker D
TT D+E
E*
Endpoint
(Interim PFS)
OS
TT=Targeted therapy, CT=chemotherapy (docetaxel or gemcitabine), E=erlotinib
Courtesy of: Vali Papadimitrakopoulou
Study Design Within Each Biomarkerdefined Subgroup
R
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Phase II
Analysis
56 PFS
events
Phase III
Interim Analyses
Based on OS
Futility established
Complete
Accrual
Final Analysis
210 OS events
12 months follow-up
Stop
Courtesy of: Mary Redman
Master Protocol over time
Additional drug/biomarker combinations dropped and added to study
Trial Start
Patient Accrual/
Patient Screening
for initial
biomarkers
Marker/Drug A
treatment arm
starts
A – HR=.84,
Trial continues
A -- 100%?
eventsOS analysis
A -- 30% eventsInterim analysis
for OS
Master Protocol Trial Timeline
Marker/Drug B
treatment arm
starts
Marker/Drug C
apply to trial
Marker/Drug C
reviewed by steering
committee
Marker/Drug C
added to trial
B -- 30%
eventsInterim
analysis
for OS
Marker/Drug
C treatment
arm starts
B– HR= .87Trial continues
C--30% eventsInterim analysis
for OS
Benefits of a Master Protocol
• Enrollment Efficiency: Grouping these studies under a single trial
reduces the overall screen failure rate
• Operational Efficiency: single master protocol can be amended as
needed as drugs enter and exit the study
• Consistency: every drug entered into the trial would be tested in the
identical manner
• Predictability: If pre-specified efficacy and safety criteria are met, the
drug and accompanying companion diagnostic will be approved
• Patient Benefit: offers the advantage of bringing safe and effective
drugs to patients sooner than they might otherwise be available.
Expert Working Group
• Roy Herbst – Yale University
• David Gandara – UC Davis
• Vali Papadimitrakopoulou – MD Anderson
• Fred Hirsch – University of Colorado
• Mary Redman - Fred Hutchinson Cancer Center
• Jeff Abrams – National Cancer Institute
• Jack Welch – National Cancer Institute
• Shakun Malik – Food and Drug Administration
• David Wholley – Foundation for the NIH
• Vince Miller – Foundation Medicine
• Eric Rubin - Merck