Flexible seamless 2-in-1 design with sample size adaptation

The 2-in-1 design is becoming popular in oncology drug development, with the flexibility in using different endpoints at different decision time. Based on the observed interim data, sponsors can choose to seamlessly advance a small phase 2 trial to a full-scale confirmatory phase 3 trial with a pre-determined maximum sample size or remain in a phase 2 trial. While this approach may increase efficiency in drug development, it is rigid and requires a pre-specified fixed sample size. In this paper, we propose a flexible 2-in-1 design with sample size adaptation, while retaining the advantage of allowing an intermediate endpoint for interim decision-making. The proposed design reflects the needs of the recent FDA's Project FrontRunner initiative, which encourages the use of an earlier surrogate endpoint to potentially support accelerated approval with conversion to standard approval with long-term endpoints from the same randomized study. Additionally, we identify the interim decision cut-off to allow a conventional test procedure at the final analysis. Extensive simulation studies showed that the proposed design requires much a smaller sample size and shorter timeline than the simple 2-in-1 design, while achieving similar power. We present a case study in multiple myeloma to demonstrate the benefits of the proposed design.