A seamless dose-optimization design for monotherapy and combination therapy

The emergence of molecular-targeted agents and immune-oncology therapies has fundamentally transformed oncology drug development, necessitating evolution beyond traditional dose-finding approaches designed for cytotoxic agents. While conventional agents exhibit predictable monotonic dose-response relationships, novel anticancer agents often demonstrate plateau-effect patterns where higher doses may compromise therapeutic benefit, requiring identification of optimal biological doses that balance efficacy and tolerability. The FDA's Project Optimus initiative emphasizes comprehensive dose optimization through parallel randomized cohorts and patient backfilling to better understand pharmacological profiles across multiple dose levels. Contemporary drug development increasingly prioritizes combination therapy alongside monotherapy evaluation, yet existing designs typically assume equivalent roles for both agents, diverging from clinical practice where novel agents combine with established treatments having limited dose options. This article proposes a seamless dose-optimization design that adaptively evaluates both monotherapy and combination therapy based on efficacy and toxicity outcomes through adaptive subtrials with patient backfilling capabilities. The model-assisted framework employs predetermined Bayesian optimal boundaries, eliminating real-time model fitting while accommodating evaluation of both monotherapy and combination therapy and enabling sequential enrollment with strategic backfilling. Simulation studies demonstrate robust performance across diverse dose-response patterns relevant to contemporary oncology. The design addresses critical gaps between methodological assumptions and clinical reality, offering a practical approach that integrates monotherapy and combination therapy evaluation with efficacy-toxicity-based backfilling. This framework ensures straightforward implementation while maintaining flexibility for complex dose-response relationships characteristic of novel anticancer agents, providing significant advantages for clinical implementation in the era of targeted and immune-oncology therapeutics.