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Presentation at PhUSE 2007
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PhUSELisbon, Portugal – 8-10 October 2007
Web-TriageAn Application for patient registration in phase I dose escalation studies
Microsoft Tools Stream (MT02)
Angelo TinazziData Management and Programming Unit
SENDO Tech S.r.l. – Milan (ITALY)co-authors
Alessandro CattaneoSENDO Tech S.r.l.Paolo Ferroni, Lucio FerraresiEventi Telematici – Milan (ITALY)
Early Drug Development Early Drug Development In OncologyIn Oncology
2Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
SENDO (Southern Europe New Drug Organisation )
� Non profit Academic Research Organisation (ARO)� Early Drug Development in Oncology� Coordinating a Network of oncology-hospitals
� 5 phase I (2 in Italy, 3 in Switzerland)� ~ 30 phase II (Italy, Switzerland, Spain)� Pre-clinical Laboratory (PK, PD)� Head Quarter based in Milan
� Clinical Development� Clinical Operations� Data-Management� Biostatistics� Medical Writing
3Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
INT, Milano Luca Gianni
HGVdH BarcelonaJosè Baselga
IOSI, Bellinzona,Cristiana Sessa
IEO, MilanFilippo deBraud
and also .... CHUV Lausanne, KSSG S Gallen, Istituto Mario Negri Milano
Head quartersMilano
Via Visconti di Modrone, 12
18 people
Core activitiesTrial design
Selected Screening & MoAClinical trials
PharmacokineticsPharmacodynamics
HQ-ActivitiesClinical development
Clinical OperationData Center RegulatoryMonitoring
Logistic
SENDO (Southern Europe New Drug Organisation) - Partner s
4Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
Drug Development Process – Study Phases
Classic Clinical DevelopmentClassic Clinical Development
Phase I
Tolerability
Phase II
Activity
Phase III
Efficacy
Phase IV
Surveillance
Approval
FDA/EMEA/…
5Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
Phase I Dose Escalation studies in Oncology
� Conducted in humans
� Conducted in cancer patients� Usually with advanced disease� Failing previous ‘standard’ therapies� Good Performance Status
� Dose escalation� Pre-defined dose-levels (Fibonacci series)
�The starting dose is usually 1/10 the median lethaldose in mouse or other animals (LD10)�Maximum Tolerated Dose (MTD), the dose where 2/3 or 2/6 DLTs are experienced�Recommended Dose (RD), the dose before MTD where no more than 1/6 DLTs are experienced
6Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
Examples of Dose Limiting Toxicities (DLT)
� Drug Related Toxicities, such as� Absolute granulocyte count <0.5 x10^9/L lasting
>= 5 days
� Platelets <50 x10^9/L� Failure to deliver therapy in day 8 due to drug
related toxicity
7Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
Example of a Dose Escalation Protocol
2.0833%9
1.5733%8
1.1833%7
0.8933%6
0.6733%5
0.5050%4
0.3367%3
0.20100%2
0.10Starting dose1
Dose (mg/m 2)
Doseincrement
Dose level (cohort)
Dose Limiting Toxicities
321
654 987
121110
151413 …1716
191817
x3x2x1 Patient Cohort (patient nr. x1, x2, x3, …)
RD
MTD
8Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
Ethical Issues in Phase I in Oncology
� Maximising patients exposure to potentiallytherapeutic doses
� Minimising patients treated at ineffectivedoses
� Minimising patients treated at toxic doses� Historically low probability of response in
phase I trials� Unknown toxicity and benefit of new agent� Informed Consent
9Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
Accrual Issues in Phase I in Oncology
� Better selection of patients� Appropriate education of referring physicians� Apply fewer restrictions in eligibility criteria� The window of opportunity of starting a phase
I trial may be limited because the clinicalcourse of these end-stage patients isunpredictable
� No more than 2-3 investigator sites per trial� Concurrent trials
10Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
Patient Triage
The french word ‘triage’ means ‘picking out’ (sorting) and it was used in World War I, when a ‘system’ was adopted for the sorting of wounded soldiers into specific groups requiring differential medical interventions according to the severity of their injuries
In phase I trials, patients have to be selected as soon as possible so that investigators can be prepared to treat a new patient
…a similar approach is used in emergency unitunit to ration limited medical resources and in Phase I studies in oncology…..
11Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
� Defining Study Characteristics� Dose Levels� Data to be Collected, including pre-registration data� Library for Study items (i.e. chemotherapy regimens)
� Opening or Close dose-levels according to dose-escalation rules
� Manage concurrent dose-escalation trials� The Investigators can review study status (dose-level
cohorts) and propose candidates� The Study Project Managers need to be alerted as
soon as a candidate is proposed� Review and approve|reject patient candidate� Manage dose-levels (close, open and re-open)
The Web-Triage Application : User Requirements
12Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
The Web-Triage Application : Take a tour (1)
� Study Information: The Dose Levels
13Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
The Web-Triage Application : Take a tour (2)
� Investigator Login: List of enabled open Trials
14Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
The Web-Triage Application : Take a tour (3)
� The Investigator Propose a Candidate
� The first dose-escalation (7.5+40), is going to be closed, no DLT criteria reached� The 15+40 Opened dose-level, has slots available
� EPTD, it is the planned administration starting date for next patients
15Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
The Web-Triage Application : Take a tour (3)
� Data-entry functionality
Prior ChemotherapyDictionary
Online DataValidation
16Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
The Web-Triage Application : Take a tour (4)
� Study Project Manager Reviews the Study Status
The candidate is eligible and accepted for registration
The candidate is not fully eligible and accepted for registration
The candidate is not eligible and not suitable for study registration
17Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
Automatic Communication
� Via email� Once a candidate is proposed (from Inv � HQ)� Once a candidate is accepted/rejected (from HQ � Inv)� Once a candidate is confirmed for registration (from HQ � Inv)
18Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
The Web-Triage Application : System Design
� ASP.NETunified software development model that includes theservices necessary to build enterprise-class Web
applications
� MS SQL Server 2005� IIS (version 6.0) Web Server� HTTPS SSL 128/256 bit for data-encryption
19Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
The Web-Triage Application : N-Tier Concept
� N-Tier SystemA Client-Server Architecture, where each module is developed separately� Presentation Layer
� Workflow Layer� Business Rule Layer� Data Layer
� Data Store
20Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
Triage Network Architecture
21Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
The Web-Triage Application : Technical References
� HTTP://MSDN2.MICROSOFT.COM/EN-US/LIBRARY/MS973279.ASPX
� HTTP://WWW.MICROSOFT.COM/BELUX/MSDN/NL/COMMUNITY/COLUMNS/HYATT/NTIER1.MSPX
� HTTP://MSDN2.MICROSOFT.COM/IT-IT/NETFRAMEWORK/DEFAULT.ASPX
22Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
Conclusions
� Conducting phase I oncology studies has major potential pitfalls
� Fast accrual is required in phase I oncology studies for both ethical and economical issues
� The Accrual is a crucial step in succeeding and a tool such as Web-Triage may improve timeline and quality
23Tinazzi A Cattaneo A Ferraresi L Ferroni P WEB-Triag e: an applicaition for patient Registration in Phase I dose-escalation studies PhUSE 2007, MT02 (Lisbon, Portugal – 8-10 October 2007)
Questions