Abstract
Simple SummaryClinical trials in pediatric oncology and personalized medicine are challenging due to the rarity of the disease, the low prevalence, and the ever-improving treatment outcomes. Many of the methods designed for small numbers and approaches used in classical population studies are not suitable for personalized pediatric oncology. There has been a change of perspective on the whole issue of rare diseases and personalized medicine. For example, a shift from a population to an individual perspective, generalizing from the individual to the population, using repeated measures and a within-subject design instead of parallel groups, exploring the variability instead of suppressing it, etc. N-of-1 should be understood as a whole range of approaches that fit the new inferential, evidential and analytical paradigms of modern medicine.Pediatric oncology is a critical area where the more efficient development of new treatments is urgently needed. The speed of approval of new drugs is still limited by regulatory requirements and a lack of innovative designs appropriate for trials in children. Childhood cancers meet the criteria of rare diseases. Personalized medicine brings it even closer to the horizon of individual cases. Thus, not all the traditional research tools, such as large-scale RCTs, are always suitable or even applicable, mainly due to limited sample sizes. Small samples and traditional versus subject-specific evidence are both distinctive issues in personalized pediatric oncology. Modern analytical approaches and adaptations of the paradigms of evidence are warranted. We have reviewed innovative trial designs and analytical methods developed for small populations, together with individualized approaches, given their applicability to pediatric oncology. We discuss traditional population-based and individualized perspectives of inferences and evidence, and explain the possibilities of using various methods in pediatric personalized oncology. We find that specific derivatives of the original N-of-1 trial design adapted for pediatric personalized oncology may represent an optimal analytical tool for this area of medicine. We conclude that no particular N-of-1 strategy can provide a solution. Rather, a whole range of approaches is needed to satisfy the new inferential and analytical paradigms of modern medicine. We reveal a new view of cancer as continuum model and discuss the “evidence puzzle”.
Highlights
The treatment of children with cancer requires the integration of clinical expertise and external evidence [1]
One of the most important reasons is that cancer in children meets the criteria of a rare disease, and all methodological consequences related to small populations are applicable [7]
For the following discussion of the applicability of N-of-1 studies in pediatric oncology, we have divided them into two categories: (1) N-of-1 trials as a tool to find the best treatment for the individual patient without any ambition to generalize the outcomes, and
Summary
The treatment of children with cancer requires the integration of clinical expertise and external evidence [1]. Different sources of evidence are available for pediatric oncologists with regard to drug efficacy and safety. This ranges from individual expert opinions to the most valuable meta-analyses of randomized controlled clinical trials [2]. One of the most important sources of evidence are population-based randomized clinical trials (RCTs) [5,6]. One of the most important reasons is that cancer in children meets the criteria of a rare disease, and all methodological consequences related to small populations are applicable [7]. Limited progress has been made in the development of new treatments for children in oncology, necessitating the development of a new platform to speed up drug development [15]
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