Dose optimization in cancer drug development: Review and outcome of a multi-stakeholder workshop

Poor dose optimization of oncology therapies may result in reduced efficacy, greater toxicity, worse adherence, and reduced clinical benefit. The traditional approach to dose-finding for cytotoxic cancer drugs - based on determining the maximum tolerated dose in the first course of treatment - is no longer appropriate for modern targeted therapies and immunotherapies. Dose finding is instead moving towards defining an optimal biological dose, and regulatory authorities have begun to adopt applicable recommendations. Based on the findings of a multi-stakeholder workshop held by the Cancer Drug Development Forum, we recommend that dose optimization should commence in the pre-clinical development phase with particular consideration for preclinical models and the specific therapeutic target, and with appropriate modelling based on preclinical testing. Clinical trials should characterize the dose-response curve and identify a range of possible doses early in development. Ideally, selected doses should be assessed in a subsequent dose-selection study (or sub-study), preferably in a randomized fashion if more than one dose is being considered. Dose selection should be informed and justified by all available and relevant clinical and nonclinical evidence. Successful adoption of a new dose-finding paradigm will require multi-stakeholder engagement and exchange but will bring benefits to patients, sponsors, and healthcare providers.