Endpoints for clinical trials and revised assessment in neuro-oncology
Purpose of review:
Recent advances in survival for patients with newly diagnosed and recurrent brain tumors, combined with the development of an ever-increasing number of potential treatments, has led to significant growth in the number of clinical trials for patients with brain tumors. Suitable clinical trial design and endpoints are vital for successfully evaluating these new treatments that may continue to improve outcome. However, inadequacies of clinical trial endpoints have challenged how best to evaluate promising new therapeutics.
Pseudoprogression and pseudoresponse confound imaging-based endpoints, including overall radiographic response and progression-free survival. Overall survival is still regarded as the definitive endpoint, but recently identified active salvage agents such as bevacizumab may diminish the association between presalvage therapy and overall survival, making interpretation of clinical trial results difficult. Novel imaging and the assessment of patient function, quality of life (QOL), and cognition are more frequently employed as endpoints.
An awareness of the benefits and imperfections of clinical trial endpoints will lead to improved clinical trial design and results. Validated endpoints of patient function, QOL, and cognition are available and increasingly valued as secondary endpoints.
Available from: Nick Dervisis
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ABSTRACT: The evaluation of therapeutic response using cross-sectional imaging techniques, particularly gadolinium-enhanced MRI, is an integral part of the clinical management of brain tumors in veterinary patients. Spontaneous canine brain tumors are increasingly recognized and utilized as a translational model for the study of human brain tumors. However, no standardized neuroimaging response assessment criteria have been formulated for use in veterinary clinical trials. Previous studies have found that the pathophysiologic features inherent to brain tumors and the surrounding brain complicate the use of the response evaluation criteria in solid tumors (RECIST) assessment system. Objectives of this review are to describe strengths and limitations of published imaging-based brain tumor response criteria and propose a system for use in veterinary patients. The widely used human Macdonald and response assessment in neuro-oncology (RANO) criteria are reviewed and described as to how they can be applied to veterinary brain tumors. Discussion points will include current challenges associated with the interpretation of brain tumor therapeutic responses such as imaging pseudophenomena and treatment-induced necrosis, and how advancements in perfusion imaging, positron emission tomography, and magnetic resonance spectroscopy have shown promise in differentiating tumor progression from therapy-induced changes. Finally, although objective endpoints such as MR imaging and survival estimates will likely continue to comprise the foundations for outcome measures in veterinary brain tumor clinical trials, we propose that in order to provide a more relevant therapeutic response metric for veterinary patients, composite response systems should be formulated and validated that combine imaging and clinical assessment criteria.
Available from: Florien Boele
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ABSTRACT: Background. Glioma patients are not only confronted with the diagnosis and treatment of a brain tumor, but also with changes in cognitive and neurological functioning that can profoundly affect their daily lives. At present, little is known about the relationship between cognitive functioning and health-related quality of life (HRQOL) during the disease trajectory. We studied this association in low-grade glioma (LGG) patients with stable disease at an average of 6 years after diagnosis.
Methods. Patients and healthy controls underwent neuropsychological testing and completed self-report measures of generic (MOS SF36) and disease-specific (EORTC BN20) HRQOL. Associations were determined with Pearson correlations, and corrections for multiple testing were made.
Results.We analyzed data gathered from 190 LGG patients. Performance in all cognitive domains was positively associated with physical health (SF36 Physical Component Summary). Executive functioning, processing speed, working memory, and information processing were positively associated with mental health (SF36 Mental Component Summary). We found negative associations between a wide range of cognitive domains and disease-specific HRQOL scales.
Conclusions. In stable LGG patients, poorer cognitive functioning is related to lower generic and disease-specific HRQOL. This confirms that cognitive assessment of LGG patients should not be done in isolation from assessment of its impact on HRQOL, both in clinical and in research settings.
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