eugm 2014 | bekele | adaptive dose finding using toxicity probability intervals
TRANSCRIPT
Adaptive Dose Finding Using Toxicity Probability IntervalsProbability Intervals
Neby Bekele, PhDy ,Senior DirectorGil d S iGilead Sciences
1Phase I & TPI. Oct, 2014.
Outline of TalkOutline of Talk Phase I Clinical Trials in Oncologygy
Overview of common methods– 3+3 Design3 3 Design– Model Based Alternatives
Overview of the TPI method Overview of the TPI method
Implementation and Software Demonstration
Concluding Remarks
2Phase I & TPI. Oct, 2014.
Phase I Clinical Trials in OncologyPhase I Clinical Trials in Oncology
Given a set of doses of a new agent find a dose with an “acceptable” level of toxicityy
Underlying Assumptions: – We explicitly assume that the probability of toxicityWe explicitly assume that the probability of toxicity
increases with dose– While implicitly assuming that the probability of
response increases with dose
3Phase I & TPI. Oct, 2014.
Phase I Clinical Trials in OncologyPhase I Clinical Trials in Oncology
Implications of underlying assumptions:A higher dose is worse because it is more likely toA higher dose is worse, because it is more likely to cause toxicity while also being better because it is more likely to have an anti-tumor effect y
Goal: Finding the dose that balances benefit relative to risk (i.e., the MTD)( )
4Phase I & TPI. Oct, 2014.
Practical Considerations for Phase I Oncology Clinical TrialsClinical Trials
For ethical reasons doses must be selected For ethical reasons, doses must be selected sequentially, for small cohorts of patients
It may be the case that no dose is safe It may be the case that no dose is safe
The maximum sample size is usually very small
Patient heterogeneity is usually ignored
Little is known about the dose-toxicity curvey
Evaluating toxicity usually takes weeks
Whil t i iti f i t d
5Phase I & TPI. Oct, 2014.
While toxicities are of various types and severities, this is usually ignored
Practical Considerations for Phase I Oncology Clinical TrialsClinical Trials
For ethical reasons doses must be selected For ethical reasons, doses must be selected sequentially, for small cohorts of patients
Phase I is often ethical only for patients with Phase I is often ethical only for patients with little or no therapeutic alternative
– Patients typically are pre-treated, with advanced or a e s yp ca y a e p e ea ed, ad a ced oresistant disease, little chance of response
– Dose-finding typically is done in terms of toxicity only to find a “maximum tolerated dose”only, to find a maximum tolerated dose
6Phase I & TPI. Oct, 2014.
Typical Phase I Oncology Clinical Trial SetupTypical Phase I Oncology Clinical Trial Setup The investigator chooses the starting level g g
based on clinical judgment, & possibly animal or in vitro data
Treat patients in cohorts of 1, 2, or 3
Escalate & de-escalate using reasonable rules & g
If the lowest dose is too toxic, stop the trial, or add lower dose levelsadd o e dose e e s
7Phase I & TPI. Oct, 2014.
The 3+3 DesignThe 3+3 Design Example of an Up-and-Down Designp p g
Algorithm based – “If I see this then I do this”If I see this then I do this
Up-and-down designs based on 1948 paper by Mood and Dixon (applications dealt withMood and Dixon (applications dealt with explosives and lethal toxicities!)
Easy to understand Easy to understand
Easy to implement
8Phase I & TPI. Oct, 2014.
Example 3+3 Decision Rules (Approach I)Example 3+3 Decision Rules (Approach I)# Patients with DLT Decision
0/3 Escalate one level
1/3 Treat 3 more1/3 Treat 3 more at the same level
2/3 or 3/3 Stop & choose previous level p pas the MTD
1/3 + {0/3} Escalate one level
1/3 + {1/3} Stop & choose previous level as the MTD
9Phase I & TPI. Oct, 2014.
1/3 + { 2/3 or 3/3 } Stop & choose previous level as the MTD
Example 3+3 Decision Rules (Approach II)Example 3+3 Decision Rules (Approach II)
Step 1: Enroll 3Step 1: Enroll 3 patients at the kth Dose
More than 3 patients
>1 toxicities1 toxicity0 toxicities
Let k=k+1 and go to Step 1.Step 1B: Enroll 3 more patientsat the kAth Dose.
3 patients enrolled atdose k-1?
No Yes
>2 toxicities for all patients at k dose
Declare the previous dose the MTD
Enroll 3 more patients at previous dose. Let k = k-1Go to Step 1
0 toxicity for current cohort
10Phase I & TPI. Oct, 2014.
High Level Process for Implementing a 3+3 MethodMethod
Decision RuleData
Decision Framework for
Toxicity Data making dosing decisions
Toxicity Data
11Phase I & TPI. Oct, 2014.
Problems with the 3+3 DesignProblems with the 3+3 Design
Ignores most of the data
St th t i l l ti l i kl Stops the trial relatively quickly
Unreliable and increases the risk of choosing an i ff ti dineffective dose
Is not flexible in that it does not allow the h t h th t t d t i it ilresearcher to change the targeted toxicity easily.
12Phase I & TPI. Oct, 2014.
Model Based AlternativesModel Based Alternatives
Much more reliable than 3+3 algorithms
M d l b d th d iti t Model based methods are sensitive to underlying assumptions about the dose-toxicity relationshipp
Minimally, requires expertise in the implementation of model based methodsp e e tat o o ode based et ods
May requires specialized software for trial conduct (including web-based software)
13Phase I & TPI. Oct, 2014.
co duct ( c ud g eb based so t a e)
Adaptive Dose findingAdaptive Dose-finding
Write Down a Probability Model
D fi t f t ti ti i d l d Define a set of statistics using your model and a set of decision rules to choose doses adaptively
At th d f th t d th d l t d l At the end of the study use the model to declare an MTD
W it ft f d t f T i l d f Write software for conduct of Trial and perform a simulation study to ensure the method can find appropriate doses.
14Phase I & TPI. Oct, 2014.
app op ate doses
Bayesian Models (Commonly Used in Phase I Dose Finding)(Commonly Used in Phase I Dose-Finding)
All Bayesian inferences follow from Bayes’ Theorem:
posterior prior • likelihood
The posterior is a product of our prior e poste o s a p oduct o ou p oknowledge (and subjective beliefs) and a summary of the observed data
15Phase I & TPI. Oct, 2014.
Bayesian Models (Commonly Used in Phase I Dose Finding)(Commonly Used in Phase I Dose-Finding)
1) Specify statistical model to estimate the ) p yToxicity probabilities
p1 < p2 < … < pkp1 p2 pk
corresponding to the k dose levels
2) S if t t T i it b bilit *2) Specify a target Toxicity probability, pTOX*
3) Prob(Toxicity | dose j) = pj , j=1,…,k,
*O’Quigley, Pepe, Fisher. (Biometrics, 1990)
16Phase I & TPI. Oct, 2014.
Bayesian Models (Commonly Used in Phase I Dose Finding)(Commonly Used in Phase I Dose-Finding)
4) Treat each successive cohort at the dose j* for ) jwhich pj* is closest to pTOX*.
5) The dose satisfying (4) at the end of the trial is the selected to be the MTDthe selected to be the MTD
17Phase I & TPI. Oct, 2014.
Pros and Cons of the Two Model Based ApproachesApproaches
3+3 Design Model Based Approaches
Pros:1. Easy to Implement
Pros:1. More reliable
2. Easy to understand3. Stops the trial relativelyquickly
Cons:1. Requires specializedquickly
Cons:1 Ignores most of the data
1. Requires specialized software for both trial setup and conduct
2 May be sensitive to prior1. Ignores most of the data2. Stops the trial relativelyquickly
2. May be sensitive to prior assumptions
18Phase I & TPI. Oct, 2014.
Adaptive Models Adaptive Models
Assume you decide to use an Adaptive Model
Which model should you use? Keeping up with ll th h i b bit i d b liall the choices can be a bit mind-boggling
How should the model interface with the user?
19Phase I & TPI. Oct, 2014.
High Level Process for Implementing a Model Based Method: Statistician as InterfaceBased Method: Statistician as Interface
ModelData Statistician
Statistician as User Statistical
Framework for Toxicity Data Interface Model making dosing
decisions
Toxicity Data
20Phase I & TPI. Oct, 2014.
High Level Process for Implementing a Model Based Method: Graphical InterfaceBased Method: Graphical Interface
Data Model User Interface
Graphical User Statistical
Framework for k dToxicity Data
Interface Modelmaking dosing decisions
Toxicity Data
21Phase I & TPI. Oct, 2014.
Pros and Cons of the Two Model Based ApproachesApproaches
Statistician as Interface Graphical User Interface
Pros:1. Relatively Easy to
Pros:1. Easy to Scale up
Implement
Cons:Cons:1. Requires expertise in bothCons:
1. Difficult to Scale up (may be difficult to use in a multicenter setting)
1. Requires expertise in both statistics (to build the model) and computer programming (to build the GUI and to havemulticenter setting)
2. Risk of data entry error(to build the GUI and to have the data communicate with the model)
22Phase I & TPI. Oct, 2014.
2. Risk of data entry error
Middle Ground: Toxicity Probability IntervalsMiddle Ground: Toxicity Probability Intervals
Combines model based methods with simple up-and-down rules similar to the 3+3 algorithmp g
A simple spreadsheet can be used to monitor Escalation Rules
23Phase I & TPI. Oct, 2014.
Toxicity Probability Intervals (mTPI)Toxicity Probability Intervals (mTPI)
A priori, assumes that pi follows a non-informative beta(0.0005,0.0005) distribution( , )
A t i i th d l th t f ll A posteriori, the model assumes that pi follows a beta(xi+.0005,ni-xi+0.0005) distribution
24Phase I & TPI. Oct, 2014.
Toxicity Probability Intervals (TPI)Toxicity Probability Intervals (TPI)K1 and K2 are constants and i is the posterior 1 2 i pstandard deviation of pi
Pe: Pr(0 < pi<K1i | data)
Ps: Pr( K1i <pi<K2i | data)
Pd: Pr( K2i <pi< 1 | data)
25Phase I & TPI. Oct, 2014.
Pstop: Pr(pi> | data)
Modified Toxicity Probability Intervals (mTPI)Modified Toxicity Probability Intervals (mTPI)
A priori, assumes that pi follows a uniform beta(1,1) distribution( , )
A t i i th d l th t f ll A posteriori, the model assumes that pi follows a beta(xi+1,ni-xi+1) distribution
26Phase I & TPI. Oct, 2014.
Modified Toxicity Probability Intervals (mTPI)Modified Toxicity Probability Intervals (mTPI)
Pe: Pr(0 < pi<1 | data)/(1)
Ps: Pr( 1<pi<2 | data)/(2 1)
Pd: Pr( 2<pi< 1 |data)/(1 2)
Pstop: Pr(pi> | data)
27Phase I & TPI. Oct, 2014.
Toxicity Probability Intervals (TPI): Decision RulesDecision Rules
If Pstop>.9 then do not allow additional patients to enroll stop pto the ith dose
If Pe is largest then escalate to the next dose
If Ps is largest then stay at the current dose
If Pd is largest then de-escalate
28Phase I & TPI. Oct, 2014.
Toxicity Probability Intervals (TPI): Decision RulesDecision Rules
Decision Rules lead to the exact same decisions as a Decision-Theoretic framework in which the loss functions are defined as:
29Phase I & TPI. Oct, 2014.
Toxicity Probability Intervals Limitations(?)Toxicity Probability Intervals Limitations(?)
Toxicity rates are modeled independently
Monotone dose-toxicity curve imposed at the d f th t dend of the study
Need to define 1 and 2
30Phase I & TPI. Oct, 2014.
mTPI: Example CalculationsmTPI: Example Calculations What do you need to Implement the method:y p
Software
Define max sample size
Define Pstop threshold
Define (target toxicity)
31Phase I & TPI. Oct, 2014.
Define 1 and 2
Concluding RemarksConcluding Remarks
mTPI is a middle ground between up-and-down designs and model based designsg g
mTPI is easy to implement
O ti ll t d t d Operationally easy to understand
Is flexible
Does not require software while trial is ongoing
Has good operating characteristics
33Phase I & TPI. Oct, 2014.
Has good operating characteristics