Bettie M. Steinberg, PhDChief Scientific Officer

The Feinstein Institute for Medical ResearchDean, Elmezzi Graduate School of Molecular MedicineProfessor and Chair, Department of Molecular Medicine

Hofstra North Shore-LIJ School of Medicine

“Designing and Preparing a Grant Application for Clinical Studies;

Initial Results of a Funded Study"

Disclosure Statement

• The Presenter, Dr. Bettie Steinberg, has the following conflict:

Receives a grant from Pfizer, Inc. for celecoxib and matched placebo for clinical trial

Learning Objectives

• Hypothesis – Definition – Types

• Using the medical literature – identifying a clear, structured, searchable clinical

question to be addressed

• Applying research to clinical care/grantsmanship– Planning and presenting assessment of study design,

performance & analysis

Choosing Your Project:Long-term and Short-term views

• Long term– Pick area where you wish to become the expert

• Based on clinical interest or research you have already done

• Chose topic with high impact• Select area with gaps no one is filling

– Create 10 year plan for research goals – Divide into 3-4 sections

• Short term– Actual study will address first section of plan– Identify immediate pressing problem – important and

unique– Write one sentence on project, impact and hypothesis

Hypothesis• Two types of studies:

– Hypothesis Testing: study tests idea to see if probably correct

– Hypothesis Generating: study collects data, look for patterns that might generate a hypothesis

• Hypothesis: Explanation or “educated guess” that is proposed in order to explain certain events or observations, to provide guidance for further investigation

– A hypothesis must be capable of being tested

• Two types– Null hypothesis: treatment will not differ from control– Alternative hypothesis: treatment will be effective

Generating a Hypothesis

• Can be based on your own observations

• Can be based on reading literature

• Or (usually is) combination of both

Your expertise – pediatric nephrology

• Epidemiology studies show that high sodium diets correlate with elevated blood pressure in adults, although the efficacy of sodium restriction for hypertension is not clear cut.

• Can you create a hypothesis to test in a study of kids?

When You Have Your Hypothesis• Define exactly what you propose to do• Think of all problems/complications you can

– There will be plenty you did not think of

• Get statistical help early – especially when a clinical study

• Identify funds to do study– Best source outside grant

• Write grant application, get funds• Conduct study• Analyze data• Write paper(s)• Write next grant

Writing A Good Grant Is Not Magic

The Grant – Based on A Good Idea

• The IDEA must be: Novel/Original/Creative/Significant

– Want a leap of concept, not just obvious next step

– Reviewer should think “I wish I had thought of that!”

– Potential results should move field forward

What You Need to Write a Successful Grant

• Communication skills– Must write clearly, simply, organized

– Tell a story

– “Good writing cannot make a good grant out of a bad idea, but bad writing will make a bad grant out of a good idea” – no spelling or grammar errors!

– Get help if writing is not your strength

• Persistence, persistence, and more persistence

Four Basic Elements To Writing The Grant

• What you want to study? – What is the question or problem to be studied?

• What need do you plan to fill?– Why does it matter?

• Why you should get the money – Not somebody else

• How you’re going to do it – Approach, study design

“Over-ambitious” is Common Major Error

Don’t propose more than is reasonable to do in time allotted

Very rare for grant to be criticized because it does not propose enough – common to be criticized as over-ambitious or unfocused, even if it includes exciting ideas

You As the Investigator

• Can study be done? by you? here?

– Have you or someone else published methods or preliminary data?

– Do you have the facilities, patients, etc.?

– Include collaborators for strength

• don’t try to be an expert at everything

Scientific Parts Of Most Grants• Description (abstract) – must fit in allotted space on form• Specific Aims• Research Strategy

– Significance, Innovation, and Approach• Resources/facilities – no limit, but normally 1-2 pages

– Descriptive

• Appropriate safeguards – human subjects, animal welfare

• Consortium/contractual arrangements, letters of support, etc.

• References• Appendix (if permitted)

– questionnaires, informed consent forms, etc.

NIH Review Criteria -Write All Grants to Address These Points

• Significance: Important problem? How will scientific knowledge or clinical practice be improved?

• Innovation: Novel concepts, approaches, methods?– Challenge or shift research or practice paradigms?

• Approach: Strategy, methodology and analyses appropriate for study? Potential problems presented and managed? Protection of human subjects, inclusion of children and minority plans OK?

• Investigators: Well suited? Sufficient experience and training? Collaborators?

• Environment: Will it enhance likelihood of success?

Ways to Kill A Grant

• Major ethical or design problem

• Central scientific question not important

• Ideas not original, important or exciting

• PI and/or research team lacks the experience or ability to carry out proposed work

• Preliminary data weak or absent – no justification for the hypothesis

• Proverbial house of cards

• Scope too ambitious, or with multiple hypotheses

• Don’t follow instructions

• Write over weekend

Description (Abstract)

• Summary of the whole grant– Only part that is public knowledge on NIH Grants

• Critical First Page– First thing reviewer reads

• I leave to the end, after the whole grant is finished• If do first, and then change grant, must rewrite

Structure of Specific Aims Page• Narrative Paragraph

– Define problem and significance– State long and short term goals, how address problem– Summarize expected outcome(s) – State hypothesis (can put in bold or italic to emphasize)

• Specific Aims– Each should test part of hypothesis – otherwise why do– Each should be linked but independent of other aims –

don’t set up house of cards– Aims should address mechanism, not correlations

• Keep grant narrow, keep it focused and keep the number of aims small (3-4 aims for 4-5 years work)

Research StrategySignificance and Innovation

• This is where you set up the rationale and novelty for your proposal

• Explain importance of problem or critical barrier to progress that you will address

• Describe how concepts, methods, technologies or treatments in field will be changed if proposed aims are achieved– Need a conceptual leap, not just a “better mousetrap”

• Explain how project will improve scientific knowledge, technical capability, and/or clinical practice– Review of current literature is part of this

• –All this in about 1-2 pages for most grants

Preliminary Data• Do you need?

• Very helpful, even for exploratory and small grants– Supports your idea

– Proves you (your mentor/collaborator) can do what you propose

– Amount of preliminary results depends on grant type

• Preliminary data must be very high (publication) quality - don’t include poor quality data– “There are no preliminary results, just unpublished

ones”

• Organize so reviewer can see your points

Sample Preliminary Data

“We first asked whether COX-2 was expressed in papilloma tissues” (gives flow and thought process) 

COX-2

Negative control

Normal PapillomaA

A: Paraffin embedded tissues were incubated with anti-COX-2 (Santa Cruz) or PBS (control), briefly counterstained with hematoxylin and detected using DAB stain. B: Extracts from normal and papilloma tissues were analyzed by western blot. Membranes were reprobed for β-actin to confirm equal loading and transfer, and intensity determined by densitometry. Graph shows data from 6 papillomas and 7 normal tissues. * p=<0.01 by Student t-test. COX-1 levels were extremely low, and comparable in both types of tissue (not shown).

Rel

ativ

e C

OX-

2 le

velsB.

0123456

Normal

Papilloma

*

0123456

0123456

Normal

Papilloma

*

Research Strategy

• Describe overall strategy, methodology, and analyses to accomplish specific aims

• Discuss potential problems, alternative strategies, and benchmarks for success

• If in the early stages of development, describe any strategy to establish feasibility

– Address management of any high risk aspects

• Point out anything that may be hazardous and precautions to be taken

Overall Strategy, Methodology, Analyses Clinical Study

• Several essential sections – I put in a small table of contents for this section

– Research question pg __– Study Design/Approach pg __– Patient Sample pg __– Attrition pg __– Detailed Treatment Plan (for efficacy studies) pg __– Data Management pg __– Time Periods for Study pg __– Biostatistical Considerations pg __– Sample Size Determination pg __

• Include Case Report Forms (CRFs), Consent form, Data Safety Monitoring Plan (DSMP), etc. in appendix

•Research Question – one short paragraph, clearly stated

•Study Design – use a diagram! If you cannot draw one, you have a problem

Overall Strategy

CelebrexCelebrexPlacebo

PlaceboPre Treat

-6 -3 0 3 6 9 12 15 18 21 24

Months on Study Drug

Arm 1

Arm 2

(Endoscopy, biopsies, blood sample collection at each 3-month time point)

Overall Strategy, con.• Patient sample

– inclusion, exclusion criteria; how recruit; enrollment procedure

– accrual plan – what if problem?• Attrition - must address, predict rate• Detailed treatment plan

– narrative - who will do what, when– maybe a table with all lab tests, evaluations, etc

• Time periods for study– figure showing first enrollment and last, interim data

analysis, etc• Biostatistical analyses – work with an expert• Sample size calculations – critical for feasibility

Clinical ProtocolProcedure -6

mo-3 mo

-4 wk

-7 day

0 3 mo 6 mo

9 mo 12 mo

history/physical*

A A A A A A A

chest x-ray A

CBC/diff.* A A A A A A A

liver function / creatine tests.*

A A A A A A A

s- Beta HCG** F F F F F F

randomize A

start drug X Y

directendoscopy

A A A A A A A

biopsies and blood

A A A A A A A

Finally, The Abstract Page

• Take key sentence(s) on significance of problem from Significance section

• Summarize in 1-2 sentences the essential background

• State or paraphrase the hypothesis or goal

• State the Specific Aims and the general approach you plan to use

• Must fit in space defined

Respiratory Papillomas –Caused by HPVs 6 and 11

Tracheal disease

Pulmonary disease

Moderate disease Severe diseaseMild disease

Respiratory Papillomas Express COX-2

COX-2

Negative control

Normal PapillomaA

Rel

ativ

e C

OX

-2

leve

ls

B.

0

1

2

3

4

5

6Normal

Papilloma

*

0

1

2

3

4

5

6

0

1

2

3

4

5

6Normal

Papilloma

*

Cyclooxygenase -2 (COX-2)Arachidonic Acid

PGG2

PGH2

PGD2 PGE2 PGF2a PGI2 TXA2

COX-2

COX-2

Inducible synthases

• Elevated in many premalignant and malignant tumors• If express in transgenic mouse skin, get tumors• Stimulates EGF Receptor• Stimulates tumor angiogenesis – induces VEGF• Inhibits apoptosis• Suppresses TH1 immune response

Inhibiting COX-2 Reduces Papilloma Cell Proliferation and Increases Apoptosis

R

elat

ive

Pro

lifer

atio

n

Celecoxib (µM)

*

0 2.5 5.0 7.5

*

0.0

0.2

0.4

0.6

0.8

1.0

1.2

Normal

Papilloma

Rel

ativ

e A

pop

tosi

s

*

*

* *

*

0 2.5 5 7.5

Celecoxib (µM)

*

* *

*

0

1

2

3

4

5

6

* p < 0.05** p < 0.01

COX-2 and PGE2 Regulate Expression of HPV In Vitro

0

0.5

1

1.5

2

2.5 *

*

**

HPV11 HPV16

control

PGE2

celecoxib

R

elat

ive

E6/

E7

mR

NA

-6 -3 0 3 6 9 12 15 18 21 24

Months on Study Drug

Arm 1

Arm 2

Scheduled surg.

12 months 18 months

Trachea, Subject 3

Months after randomization

0

0.02

0.04

0.06

0.08

0.1

0 3 9 12 15 18 21 24 30 41 69

G

row

th R

ate Subject 3

0

0.02

0.04

0.06

0.08

0.1

0 3 6 9 12 15 18 21 24 36 50 55 60

Months after randomization

G

row

th R

ate Subject 1

0

0.02

0.04

0.06

0.08

0.1

0 3 6 9 12 15 18 21 24 34 60 72

Months after randomization

G

row

th R

ate-

Subject 2

Celebrex

CelebrexPlacebo

Placebo Pre Treat

Clinical Celecoxib Study Design

Preliminary Results

Laryngeal Response – 28 patients Tracheal Response

Preliminary Results Summary• Enrolled to date: 50 subjects

• Patients with >6 months follow-up after randomization: 29

• 13 with clinical response – reduction in severity >50%

• 9 free of disease for > 6 months

– 5 free of disease for a year or more

• 4 free of disease for > 3 months, but not disease-free at two successive surgeries

– marked reduction in disease severity

• 16 with no significant remission of laryngeal disease

– One patient with persistent laryngeal disease now free of tracheal disease

Current Questions – In Progress• Is celecoxib an effective adjunct treatment for RRP?• Is improvement maintained when celecoxib therapy

stops?

• Do clinical characteristics (juvenile vs. adult onset, gender or HPV type) correlate with response?

• Are molecular markers consistent with a COX-2 dependent mechanism of response?

• Does celecoxib treatment reduce the prevalence of latent HPV DNA?

• How does COX-2/PGE2 impact on local immune response to HPV?

• Does COX-2/PGE2 also play a role in HPV+ tonsil cancers?

Thank You

Clinicians

Allan AbramsonMark ShikowitzGinny Mullooly

Physicians at participating sites

Laboratory Studies

Alexandra LucsRong WuRay PicaAli Afzal

All Participating RRP Patients