Efficient dose-finding for drug combination studies involving a shift in study populations

This paper describes the design of an early phase, prospective trial evaluating the safety and tolerability of the combination of the histone deacetylase inhibitor, entinostat, in combination with capecitabine. The study consists of two parts; an initial phase evaluating the safety of the combination in participants with metastatic breast cancer, followed by a second phase assessing the safety of the combination in participants with residual disease after neo-adjuvant chemotherapy for breast cancer. We describe the adaptation of a model-based design for identifying the maximum tolerated dose combination that efficiently moves from the initial phase in an advanced disease population to the second phase in the target population. Operating characteristics demonstrate the ability of the method to accurately predict true maximum tolerated dose combinations in a high percentage of trials with reasonable sample sizes, while treating participants at and around desirable combinations. The proposed design is a practical, early-phase, adaptive method for use with drug combination dose finding in the presence of shifting patient populations. More challenging research questions are being investigated in early-phase trials, which has created the need to implement more flexible designs that can meet the objectives of current studies, such as those exploring drug combinations while addressing patient heterogeneity. Our goal is to facilitate acceptance and application of more novel designs in contemporary early-phase studies.