A flexible multi-stage design for phase II oncology trials

Phase II trials evaluate whether a new drug or a new therapy is worth further pursuing or certain treatments are feasible or not. A typical phase II is a single arm (open label) trial with a binary clinical endpoint (response to therapy). Although many oncology Phase II clinical trials are designed with a two-stage procedure, multi-stage design for phase II cancer clinical trials are now feasible due to increased capability of data capture. Such design adjusts for multiple analyses and variations in analysis time, and provides greater flexibility such as minimizing the number of patients treated on an ineffective therapy and identifying the minimum number of patients needed to evaluate whether the trial would warrant further development. In most of the NIH sponsored studies, the early stopping rule is determined so that the number of patients treated on an ineffective therapy is minimized. In pharmaceutical trials, it is also of importance to know as early as possible if the trial is highly promising and what is the likelihood the early conclusion can sustain. Although various methods are available to address these issues, practitioners often use disparate methods for addressing different issues and do not realize a single unified method exists. This article shows how to utilize a unified approach via a fully sequential procedure, the sequential conditional probability ratio test, to address the multiple needs of a phase II trial. We show the fully sequential program can be used to derive an optimized efficient multi-stage design for either a low activity or a high activity, to identify the minimum number of patients required to assess whether a new drug warrants further study and to adjust for unplanned interim analyses. In addition, we calculate a probability of discordance that the statistical test will conclude otherwise should the trial continue to the planned end that is usually at the sample size of a fixed sample design. This probability can be used to aid in decision making in a drug development program. All computations are based on exact binomial distribution.