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Executive Summary
The determination of the maximum tolerated dose (MTD)
level is a critical step in oncology drug development.
High doses are needed to improve the efficacy of the
drug, but can result in an increased number and severity
of undesired drug limiting toxic (DLT) reactions. Phase
I oncology trials aim to determine the MTD using dose
escalation strategies, resulting in the recommendation
of a dose or drug combination for Phase II efficacy
testing. The selection of the dose escalation strategy
has an impact on the recommended dose level and
inadequate dose escalation schemes may put the
whole drug development program at risk.
Oncology Phase I trials differ from most general Phase
I trials in that the medication is examined in the target
population of diseased patients. Patients included into
these trials often suffer from advanced cancer, and
have often exhausted the standard treatment options.
Therefore in addition to the appropriate detection of the
MTD, dose escalation designs should enroll the majority
of patients to therapeutic levels of the drug,
while controlling the numbers of DLT events. These
competing objectives for dose escalation designs
make it unlikely that one design will be the best in
all circumstances.
Although the determination of the MTD is of such
critical importance in oncology, in the vast majority
of dose escalation trials a simple common method
has been used. The 3+3 design is a simple rule-based
escalation scheme, and has been used in approximately
95% of the published Phase I oncology trials over the
last two decades.1 During the same period, a number
of innovative rule-based and model-based dose
escalation designs have been developed and studied,
for example the Continual Reassessment Method (CRM)
or interval-based escalation schemes. These innovative
approaches allow tailored escalation towards the dose
level providing the specified maximal tolerable rate of
toxic events.
3+3 Design
Approximately 95% of all published Phase I oncology
dose escalation trials have used a 3+3 design.
The 3+3 design (Figure 1) can be described as follows.
Under-dosing:
Target toxicity:
Excessive toxicity
Unacceptable toxicity
(0,0.2]
(0.2,0.35]
(0.35,0.6]
(0.6,1.00]
Conclusion
The accurate estimation of the MTD is of critical
importance in the drug development process. This white
paper discusses innovative dose escalation designs and
their implementation in ADDPLAN DF.
The aim of the software is to support the process of
decision making in the design and analysis of dose
Finding trials using these innovative methods.
Uncertainty in the true underlying dose-toxicity profile
needs to be taken into account when designing efficient
and effective dose escalation trials.
ADDPLAN DF enables drug developers to study the
operating characteristics of standard and innovative
dose escalation methods under different scenarios,
allowing the selection of the appropriate methods for
successful Phase I dose escalation trials.
References