New clinical trial designs in the era of precision medicine: An overview of definitions, strengths, weaknesses, and current use in oncology

With expanding knowledge in tumor biology and biomarkers, oncology therapies are increasingly moving away from the one-size-fits-all rationale onto biomarker-driven therapies tailored according to patient-specific characteristics, most commonly the tumor's molecular profile. The advent of precision medicine in oncology has been accompanied by the introduction of novel clinical trial designs that aim to identify biomarker-matched subgroups of patients that will benefit the most from targeted therapies. This innovation comes with the promise of answering more treatment questions, more efficiently and in less time. In this article, we give an overview of the different biomarker-based designs, comparing the features of enrichment, randomize-all, umbrella, and basket trials, and highlighting their advantages and disadvantages. We focus more on the novel designs known as master protocols, which include umbrella and basket trials. We have also conducted a search in ClinicalTrials. gov for registered oncology-related protocols of ongoing or completed trials labeled as umbrella or basket trials for solid tumors; we also included additional relevant trials retrieved from other reviews. We present and discuss the key features of the 30 eligible basket trials and 27 eligible umbrella trials. Only a minority of them are randomized (2 and 9, respectively), including three trials with adaptive randomization. Five of these trials have been completed as of July 2018. Precision medicine trial designs fuel new hopes for identifying best treatments, but there is also the potential for hype. The benefits and challenges associated with their use will need continued monitoring.