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This focus on empiric "most dose with acceptable risk" may be misguided for mechanism-targeting new agents, and this could lead to unnecessary delays, increased costs and even higher risk of missing important signals of activity and benefit.
Specifically, the investigator specifies desirable and undesirable values for RR and TTP only, so that both potential manifestations of drug activity can be observed as signals of activity.
Signals of activity were reported in patients with breast cancer, cholangiocellular carcinoma, renal cell carcinoma and other cancer types (Arnold et al, 2009; Schmid et al, 2010).
Similarly, endothelin receptor (END1) targeting agents, atrasentan and zibotentan, also failed in phase III studies (Carducci et al, 2007; Nelson et al, 2012), despite biologic and preclinical proof-of-principle as well as signals of activity in phase II studies.
Alongside, these therapeutic advances have been a change in the regulatory landscape; the provisional registration of crizotinib was based on high signals of activity in non-randomized, single-arm studies [ 3].
Although randomized trials make it possible to tease out the predictive and prognostic effects of putative biomarkers for therapies, we are looking here for robust signals of activity such as one would expect from a bona fide targeted therapy.
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Whilst occasional PCa patients have been enrolled in the phase I trials of these compounds, there has been no particular signal of activity in CRPC to date.
Randomized studies would be necessary to determine if this signal of activity with TMZ + HCQ is actually attributable to the addition of HCQ.
The aim is to determine whether there is sufficient signal of activity in any drug biomarker combination to warrant further investigation.
The high rate of stable disease coupled with the median progression-free survival of 3.5 mo observed in this clinical trial is a signal of activity that warrants further study in a melanoma population.
The pace of advances in stratified medicine in lung cancer is such that signal of activity programmes must be nimble, flexible and able to respond promptly to new biomarkers drug combinations being considered.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com