Surrogate endpoint

Jump to navigation Jump to search

WikiDoc Resources for Surrogate endpoint

Articles

Most recent articles on Surrogate endpoint

Most cited articles on Surrogate endpoint

Review articles on Surrogate endpoint

Articles on Surrogate endpoint in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Surrogate endpoint

Images of Surrogate endpoint

Photos of Surrogate endpoint

Podcasts & MP3s on Surrogate endpoint

Videos on Surrogate endpoint

Evidence Based Medicine

Cochrane Collaboration on Surrogate endpoint

Bandolier on Surrogate endpoint

TRIP on Surrogate endpoint

Clinical Trials

Ongoing Trials on Surrogate endpoint at Clinical Trials.gov

Trial results on Surrogate endpoint

Clinical Trials on Surrogate endpoint at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Surrogate endpoint

NICE Guidance on Surrogate endpoint

NHS PRODIGY Guidance

FDA on Surrogate endpoint

CDC on Surrogate endpoint

Books

Books on Surrogate endpoint

News

Surrogate endpoint in the news

Be alerted to news on Surrogate endpoint

News trends on Surrogate endpoint

Commentary

Blogs on Surrogate endpoint

Definitions

Definitions of Surrogate endpoint

Patient Resources / Community

Patient resources on Surrogate endpoint

Discussion groups on Surrogate endpoint

Patient Handouts on Surrogate endpoint

Directions to Hospitals Treating Surrogate endpoint

Risk calculators and risk factors for Surrogate endpoint

Healthcare Provider Resources

Symptoms of Surrogate endpoint

Causes & Risk Factors for Surrogate endpoint

Diagnostic studies for Surrogate endpoint

Treatment of Surrogate endpoint

Continuing Medical Education (CME)

CME Programs on Surrogate endpoint

International

Surrogate endpoint en Espanol

Surrogate endpoint en Francais

Business

Surrogate endpoint in the Marketplace

Patents on Surrogate endpoint

Experimental / Informatics

List of terms related to Surrogate endpoint

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Slide set: File:-Surrogate Endpoints-.pdf

Overview

A surrogate marker (or surrogate end point) is a term used in medical research for a change to the human body that has been documented to be involved in the causal pathway and necessary for an eventual outcome or end point to occur.[1] In clinical trials, a surrogate endpoint is a measure of the effect (often what is known as a biomarker like cholesterol) of a certain treatment that is substituted in the evaluation of a new drug or device in place of a "hard endpoint" like death or heart attack. The National Institutes of Health (USA) defines surrogate endpoints as: "A biomarker intended to substitute for a clinical endpoint".[2] The use of a surrogate endpoint can lead to more rapid and efficient completion of clinical trials, but the use of a surrogate endpoint has been criticized as reductions of a substitute maker are not always predictive of improvements in clinical outcomes. The classic example of a failed surrogate marker is the use of PVC suppression as a substitute marker of anti-arrhythmia effectiveness. Class III anti-arrhythmias reduced PVCs or extra heart beats, but were associated with a higher risk of death in the Cardiac Arrhythmia Suppression Trial (CAST)[3]. Surrogate markers may be used when it is unethical to look for the end point (e.g., death) in the experiment, or when the number of end point events is very small, thus making it impractical to conduct an experiment to look for the end point. The measurement of surrogate markers provides a way to test the effectiveness of a treatment for a fatal disease without having to wait for a statistically significant number of deaths to occur. the FDA will often accept evidence from clinical trials that show a benefit to surrogate markers instead of to end points. As stated by Thomas Fleming: "The accelerated-approval regulatory process is intended to address this need by allowing marketing of interventions shown to have strong effects on measures of biological activity, if those measures are potential "surrogates" for true measures of tangible clinical benefit.[4]"

The advantages of a surrogate endpoint

The assessment of "hard" primary clinical endpoints (such as death and heart attack) often requires large long-term clinical trials which can be quite expensive. The use of surrogate endpoints can allow trials to evaluate the efficacy of a new drug or device more rapidly, more efficiently and more inexpensively.

The disadvantage of surrogate endpoints

There are several potential disadvantages of a surrogate endpoint.

1. The surrogate endpoint may intuitively be hypothesized to be related to a "hard endpoint" such as death or heart attack, but may not be.

2. While a surrogate endpoint may be related to a "hard endpoint" such as death or heart attack, it is not clear that a reduction in the surrogate endpoint will lead to an improvement in the "hard endpoint" in death or heart attack. Anti-diabetic agents have been shown to reduce long term glucose (Hemoglobin A1c or HbA1C). It was hypothesized that more intense glucose control (a reduction in HbA1C) would be associated with a lower rate of death and heart attack. However, despite lowering of HbA1C, rosiglitazone or Avandia was not associated with a reduction in death and MI, but with an increase in the RECORD trial [5] [6].

In another example, class III antiarrhythmic agents were associated with suppression of premature ventricular contractions or PVCs, but were associated with a higher rate of death.

3. While a surrogate endpoint may be related to a "hard endpoint, it may be an acausal association (the surrogate may not lie in the causal pathway to the "hard endpoint" and changing the surrogate endpoint may not change the "hard endpoint".)

4. The agent may reduce the surrogate endpoint, but due to off target toxicity, may increase the risk of "hard endpoints" such as death or MI. Lower HDL is associated with a higher risk of adverse cardiac outcomes, Torcetrapib raises HDL and should therefore improve clinical outcomes, however, Torcetrapib administration was found to be associated with a higher rate of adverse clinical outcomes. It was felt that the potential benefit of Torcetrapib was reversed due to off target toxicity of a slight increase in blood pressure associated with Torcetrapib administration.

5. The relationship between the surrogate endpoint and the "hard endpoint" may be non-linear or may be a threshold effect. For example, in antiplatelet agent studies, it is unclear if ever greater levels of inhibition of platelet aggregation are associated with ever greater reductions in adverse outcomes, or if one must achieve just a certain "threshold" level of inhibition to improve outcomes.

There have been a number of instances when studies using surrogate markers have been used to show benefit from a particular treatment, but later, a repeat study looking at endpoints has not shown a benefit, or even a harm.[7]

Examples of Surrogate Endpoints

Examples of surrogate markers include:

TTP;

Evaluation of a Surrogate Endpoint

There are multiple criteria that have been proposed to evaluate surrogate endpoints.

Does the surrogate lie in the causal pathway of disease, or is it simply a prognostic marker?

Examples of this criteria include CEA in colon cancer and PSA in prostate cancer. As stated by Thomas Flemming "While CEA and PSA are not the mechanism through which the disease process induces increased risk of the clinical-efficacy outcomes, so it is questionable whether treatment-induced changes in these markers could be relied upon to accurately predict treatment-induced effects on the clinical endpoints.[4]"

Are there multiple causal pathways present?

If there are multiple causal pathways present, what is the relative strength of the proposed surrogate relative to that of other pathways. This may alternatively lead to an over or under estimate of the impact of the surrogate marker.

Is there "off target" toxicity associated with altering the surrogate endpoint?

It is possible that the intervention being test could be associated with other deleterious mechanisms of action that are independent of its intended therapeutic effects[4]. Very often, because such effects are unintended, they are unanticipated, unrecognized, and unrecorded.The classic example of this is the hypertension caused by torcetrapib, or the pro-arrhytmic effects of class III antiarrhythmia agents as demonstrated in the CAST trial[8].

Proposed criteria for a surrogate endpoint

One investigator, Ross Prentice, proposed that the following two conditions must be meant[9]:

  1. The biological marker must be correlated with the clinical endpoint; and
  2. The marker must fully capture the net effect of the intervention on the clinical-efficacy endpoint.

From the persepctive of C. Michael Gibson, author of this chapter, a surrogate may be clinically relevant if the following three criteria are satisfied:

  1. The drug or device improves the surrogate
  2. Improvement in the surrogate is related to an improvement in a hard clinical endpoint
  3. The same drug or device improves the hard clinical endpoint

In order for a surrogate to be validated, there must be at least one large clinical trial that satisfies these criteria. After this, other studies could rely upon the surrogate if it has been validated in a large study.

References

  1. Cohn JN (2004). "Introduction to Surrogate Markers". Circulation. American Heart Association. 109: IV20&ndash, 1. PMID 15226247. Retrieved 2007-01-10.
  2. Controlled Clinical Trials 22:485–502 (2001))
  3. Naccarelli GV, Dougherty AH, Wolbrette D, Wiggins S (1991). "A critical appraisal of the cardiac arrhythmia suppression trial (CAST)". Applied Cardiopulmonary Pathophysiology : ACP. 4 (1): 9–16. PMID 10147539. |access-date= requires |url= (help)
  4. 4.0 4.1 4.2 Fleming TR (2005). "Surrogate endpoints and FDA's accelerated approval process". Health Affairs (Project Hope). 24 (1): 67–78. doi:10.1377/hlthaff.24.1.67. PMID 15647217. Retrieved 2010-11-21.
  5. Home PD, Pocock SJ, Beck-Nielsen H, Curtis PS, Gomis R, Hanefeld M, Jones NP, Komajda M, McMurray JJ (2009). "Rosiglitazone evaluated for cardiovascular outcomes in oral agent combination therapy for type 2 diabetes (RECORD): a multicentre, randomised, open-label trial". Lancet. 373 (9681): 2125–35. doi:10.1016/S0140-6736(09)60953-3. PMID 19501900. Retrieved 2010-10-31. Unknown parameter |month= ignored (help)
  6. Nissen SE (2010). "Setting the RECORD Straight". JAMA : the Journal of the American Medical Association. 303 (12): 1194–5. doi:10.1001/jama.2010.333. PMID 20332408. Retrieved 2010-10-31. Unknown parameter |month= ignored (help)
  7. Psaty BM, Weiss NS, Furberg CD; et al. (1999). "Surrogate end points, health outcomes, and the drug approval process for the treatment of risk factors for cardiovascular disease". JAMA. 282: 786&ndash, 790.
  8. Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, Greene HL (1991). "Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial". The New England Journal of Medicine. 324 (12): 781–8. doi:10.1056/NEJM199103213241201. PMID 1900101. Retrieved 2010-11-21. Unknown parameter |month= ignored (help)
  9. Prentice RL (1989). "Surrogate endpoints in clinical trials: definition and operational criteria". Statistics in Medicine. 8 (4): 431–40. PMID 2727467. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)

Template:WH Template:WS