CLINICAL PROTOCOL DEVELOPMENT

1. CLINICAL PROTOCOL DEVELOPMENT

2. What’s The Question? What is the study hypothesis?

3. What’s The Question? • What’s the outcome? • What’s the intervention? • When and for how long? • For whom? • How many participants are needed? • How can we optimize potential benefit (and what we learn) while minimizing potential harm?

4. Answering the Question • Response variable selection and measurement • Defining the intervention • Study design • Eligibility criteria • Sample size estimate • Patient management procedures • Monitoring for safety and benefit • Data analysis approaches

5. Response Variable Selection • “Dose ranging” • Biologic activity • Biomarker • Understand mechanism • Surrogate outcome • Toxicity • Condition/vector/gene interaction • Feasibility for larger study • Clinical outcome

6. Response Variable Criteria • Well defined • Stable • Reproducible • Unbiased • Ascertainable in all participants • Adequately address study hypothesis

7. Defining the Intervention • Dose/dosing schedule • Vector • Route of delivery • Method of preparation

8. Study Design • Uncontrolled • Controlled • Before/after • Historical • Concurrent, not randomized • Randomized

9. Comparing Treatments • Fundamental principle • Groups must be alike in all important aspects and only differ in the intervention each group receives • In practical terms, “comparable treatment groups” means“alike on the average” • Randomization • Each participant has the same chance of receiving any of theinterventions under study • Allocation is carried out using a chance mechanism so that neither the participant nor the investigator will know in advance which will be assigned • Blinding • Avoidance of conscious or subconscious influence • Fair evaluation of outcomes

10. Non-randomized Trials May Be Appropriate • Early studies of new and untried therapies • Uncontrolled early phase studies where the standard is relatively ineffective • Investigations which cannot be done within the current climate of controversy (no “clinical equipoise”) • Truly dramatic response

11. Advantages of Randomized Control Clinical Trial 1. Randomization "tends" to produce comparable groups 2. Randomization produces valid statistical tests

12. Disadvantages of Randomized Control Clinical Trial 1. Generalizable Results? • Participants studied may not represent general study population. 2. Recruitment • Hard 3. Acceptability of Randomization Process • Some physicians will refuse • Some participants will refuse 4. Administrative Complexity

13. Study Population Subset of the general population determined by the eligibility criteria General population Eligibility criteria Study population Enrollment Study sample Observed

14. Eligibility Criteria • State in advance • Consider • Potential for effect of intervention • Ability to detect that effect • Safety • Ability for true informed consent

15. Sample Size (1) • The study is an experiment in people • Need enough participants to answer the question • Should not enroll more than needed to answer the question • Sample size is an estimate, using guidelines and assumptions

16. Sample Size (2) • Approaches for early phase studies • Dose escalation schemes • Decision that intervention is unlikely to be effective in x% of participants • Decision that intervention could be effective in x% of participants • Standard ways of estimating for phase III

17. Sample Size (3) • Assumptions depend on • Nature of condition • Desired precision of answer • Availability of alternative treatments • Knowledge of intervention being studied • Availability of participants

18. Regular Follow-up • Routine Procedures (report forms) • Interviews • Examinations • Laboratory Tests • Adverse Event Detection/Reporting • Quality Assurance

19. Contingency Plans • Patient management • Evaluation and reporting to all relevant persons and groups • Data monitoring plans • Protocol amendment or study termination

20. Data Analysis (1) • Occurrence of event • Time to event • Mean level of response • Duration of response

21. Data Analysis (2) • Intention-to-treat • Explanatory • Subgroups • Adjusted vs. Unadjusted

22. Data Analysis (3) • Specify in advance • Primary • Secondary • Other • Statistical approach • Exploratory

23. Clinical Protocol (1) • Background/Justification --Where we are in the field --What the study will add that is important • Objectives --Primary hypothesis --Secondary hypotheses --Other

24. Clinical Protocol (2) • Study Design and Methods --Type of study, comparison --Inclusion and exclusion criteria --Description of intervention (what, how) --Concomitant therapy --Examination procedures (baseline, follow-up, outcome assessment) --Intervention assignment procedure

25. Clinical Protocol (3) • Monitoring and Management --Data and safety monitoring --Adverse event assessment, reporting --Contingency procedures --Withdrawal criteria

26. Clinical Protocol (4) • Statistics --Sample size --Stopping guidelines --Analysis plans • Participant protection issues

27. Summary • Protocol lays out who, what, why, when, where, how • Safeguards participants • Safeguards study integrity • Midcourse changes are often appropriate (even necessary)