Cancer clinical trials in the community setting: a 20 year retrospective

During the past two decades clinical cancer research in the United States has grown dramatically and has been significantly enhanced by the participation of community hospitals, practicing oncologists, and the creation of community cancer clinical trials organizations. More than 102,000 patients have been enrolled by these community based groups to important clinical trials which have answered questions that have improved cancer treatment in this country and worldwide (Figure 3, Table 8). Practicing oncologists are now well trained in the practice of clinical research and efforts should be directed to ensure that their participation in clinical research continues to increase. There are many obstacles to performing clinical cancer research, but none is greater than the issue of cost. We are currently facing the daunting prospect that health care reform may dramatically curtail or bias future cancer clinical trials. Consumers, providers, politicians, and the general public must be educated to protect and expand the cancer clinical research structure so that we can continue the pursuit of optimal cancer management.

The future direction of clinical trials

BACKGROUND

A milestone in the acquisition of medical information was the development of the concept of clinical trials, which has permitted the documentation and codification of treatment results. This has led to significant advances in clinical medicine during the past few decades.

METHOD

This article addresses the future of clinical trials from several perspectives. What forces are present in the clinical world that would affect the continuation of clinical trials? What are the influences of cost and participants' attitudes on clinical trials? What developments in basic science may alter the direction of clinical trials?

RESULTS

The role of volunteers in the conduct of clinical trials is explored. The entry of gene transfer therapy into clinical trials is discussed.

CONCLUSIONS

Clinical trials hold the key to treatment decisions in medicine. Health care planners will look at clinical trial results for the basis of reimbursement or financing. Therefore, as medical professionals, we must be vigilant of the conduct and results of clinical trials. We must be sure of the validity of their results and ensure their applicability to the proper management of patients.

["State of the art" of adjuvant chemo-endocrine therapy for breast cancer in Japan]

Breast cancer is a solid tumor moderately responsive to chemotherapy and/or endocrine therapy. Based upon meta-analysis covering 233 prospective randomized clinical trials, a consensus about adjuvant chemo and endocrine therapy has been reached according to prognostic factors, including nodal status, tumor size, estrogen receptor and histological grade. The preventive effect of tamoxifen against recurrence has been also proven in Japanese ACETBC (adjuvant chemoendocrine therapy for breast cancer) trials and KEIO BR1 trial. Several other prospective randomized trials have been run in Japan, and the results will be obtained within several years. The features of breast cancer in Japan are low incidence and good prognosis. In these circumstances, the accrual of a vast number of patients and multi-institutional collaboration are essential. The issues under investigation include best chemotherapy dosage and duration, identification of risk factors and the role of preoperative chemotherapy.

[Current status of clinical trials on pre- and postoperative chemotherapy for head and neck cancer]

The purpose of this paper is to discuss the current status and issues of clinical trials in pre- and post-operative chemotherapy for head and neck cancer, focusing on 1) neo-adjuvant chemotherapy, 2) concurrent radiotherapy and chemotherapy, and 3) adjuvant chemotherapy. Although neo-adjuvant chemotherapy did not increase survival, it produced a higher rate of organ preservation in some sites such as the larynx and maxilla. Concurrent radiotherapy and chemotherapy is the most promising primary chemotherapy approach to prolong survival of patients with locally advanced resectable and unresectable disease. It is the only systemic approach consistently shown to improve local-regional control and survival in randomized trials. No survival benefit is evident in trials of adjuvant chemotherapy, the third major treatment category, but some randomized trials produced a significant reduction in distant relapse rate. Based on the results obtained so far, future clinical trials should be continued to search for more effective programs in the systemic control of advanced head and neck cancer.

Multidimensional assessment of acute and long-term effects in antidepressant drug trials

Contrasting the findings from pharmacoepidemiological studies with the status of registration of new compounds and the legal process of reviewing the old compounds indicates a crisis of the preclinical and clinical investigations of "antidepressants". Within the last two decades, the development of more and more formalized guidelines and regulations for the performance of clinical drug trials could be observed. Certainly, this has resulted into an improved internal validity of the findings. On the other hand, there appears to be a broad consensus among practising psychiatrists that published findings of clinical trials often do not concur with the experiences of psychiatric practice indicating unsatisfactory external validity. With regard to the aim of optimizing the antidepressant therapy and to lower the costs for mental health care, it appears to be of particular importance to test the real effectiveness of an "antidepressant" as close as possible to its use in practice. (To avoid misunderstandings: This does not mean to ask for more so-called "naturalistic" study designs!) It is self-evident that also in the future controlled studies, particularly vs. placebo, cannot be dispensed with. However, more promising for a relevant assessment of old and new substances would be the use and development of suitable mathematical procedures, which might imply re-evaluations and re-classifications of already published findings; furthermore, it seems essential also to integrate the existing experiences of psychiatrists in hospitals and in private practice.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical hyperthermia in the 1990s: does the buck stop here?

Clinical hyperthermia in the USA is entering difficult times. To describe the present state of this art (1) all of the clinical manuscripts published in the International Journal of Hyperthermia and the International Journal of Radiation Oncology, Biology and Physics in the period from 1 January 1990 to 30 June 1993 were reviewed; (2) the Radiotherapy Research Division of the National Cancer Institute was queried as to existing extramural funding of clinical hyperthermia projects; and (3) individual institutions known to have active clinical research programmes in hyperthermia were surveyed as to the status of current studies. At the present time there are no hyperthermia trials being conducted by US cooperative groups. The majority of reports and active scientific protocols continue to deal with phase I and pilot studies. Many studies in several sites continue to suggest improvement in CR rate and local control over historical controls when hyperthermia is used as an adjunct to radiotherapy; however phase III proof of these hypotheses is still lacking. Extramural funding of clinical hyperthermia is limited and third party funding is decreasing. Details and future portents are discussed.

The next generation: new chemotherapy agents for the 1990s

The progress in cancer chemotherapy since the 1940s has been tremendous with over 40 cytotoxic agents, excluding hormones, that have undergone clinical trials and been approved by the Food and Drug Administration (FDA). Preclinical drug development and clinical trials have made this progress possible. Several new agents that are either undergoing clinical trials or have recently been approved by the FDA include idarubicin, ICRF-187, piroxantrone, all-trans-retinoic acid, fludarabine phosphate, taxol, and suramin.

Secular changes in published clinical trials of second-line agents in rheumatoid arthritis

The present investigation was undertaken to explore changes over time in the design and reporting of trials of second-line drugs in rheumatoid arthritis, in the characteristics of patients included in the trials, and in the sources of funding. We studied 105 trials of second-line agents for the treatment of rheumatoid arthritis, including placebo-controlled and comparative trials involving 8 different agents. Three time periods, 1945-1969, 1970-1979, and 1980-1989, were compared. We found little change in the standards for reporting on the design of trials or for reporting information on patient dropout and drug side effects, some increase in the complexity of the statistical methods used, but no increase in the use of power analysis (reported in only 13% of trials). The average age of patients in clinical trials has increased. In recent years, there has been a substantial shift from placebo-controlled to comparative trials, and it is increasingly common for trials to be financially supported by pharmaceutical companies. The possible effects of secular trends should be considered when combining or comparing results of trials conducted in different years.

The use of one-sided tests in drug trials: an FDA advisory committee member's perspective

The use of one-sided or two-sided tests in drug trials to evaluate new compounds is considered. For drugs that may be tested against placebos, with two positive trials required (as in the United States), it is argued that from both a regulatory and pharmaceutical industry perspective, one-sided tests at the 0.05 significance level are appropriate. In situations where only one trial against placebo may be done (for example, survival trials), one-sided tests at the 0.025 level are appropriate in many cases. For active control trials it is argued that two-sided tests are usually appropriate.

[Pharmacist drug dispensing in clinical trials]

Dispensing experimental drugs in part of a pharmacist's task in the hospital since the 20.12.1988 law. A 13 month critical evaluation dispensing drugs for clinical trials is presented. Drug management, distribution and control in 61 new studies included 1,165 patients need a full time pharmacist. This new organization is well accepted by sponsors and investigators. The hospital pharmacist's contributions to clinical trials are: protocol application in hospital practice, nurses information, efficient and safe storage and distribution to patients. The pharmacist facilitates good clinical practices and quality assurance. The problem is that in many french hospitals the pharmaceutical department is chiefly a wholesale dealer for pharmaceutical products. Our opinion is that the pharmacists should deliver drugs to improve patient compliance.

Clinical trials in Europe and the development of new psychotropics as viewed by European manufacturers

A number of external and internal (industry-specific) difficulties and problems related to clinical trials and the development of new psychotropics in Europe, are reviewed. These can be classified into 3 interdependent categories of problems: 1. strategy-related; 2. implementation-related; 3. time-related. Apart from ethical and methodological issues, the external problems are: a) diversity of country-specific regulations and requirements for registration and drug approval; b) differences in culture, traditions, education and training background of investigators and patients; c) high competition for good trial centers; d) increasing pressure and negative attitude from public media with respect to clinical testing of drugs. In the strategic planning of the development of a new drug, resources and heavy/costly logistic commitments for each individual study have to be taken into consideration. For the manufacturers it is therefore imperative to fix the plans and the kind of the studies to be performed sometimes several years in advance. Conflict often arises with respect to the developmental changes, both in environmental conditions and in the state of the art. Implementation of the clinical, particularly multicenter/multinational trials poses problems of multilingual documentation, heavy logistics of drug supply, quality control and monitoring of the studies. Inherent to these European problems is a unproportional high time expenditure which has important consequences for scientific progress and economy. Possible solutions for these problems are discussed. The initial steps in this direction will be the establishment of European standards for clinical trials, and uniform requirements for drug registration and approval.

[Present and future of trial design]

Nowadays, clinical researchers can choose from a large variety of designs. These can be classified as observational or experimental, descriptive or comparative, longitudinal or cross-sectional, prospective or retrospective, "blind" or "unblind", prolective or retrolective. The randomized double-blind trial is still the most controlled design and, therefore, the least susceptible to bias. However, ethical, economical and generalizability reasons limit their use. Current tendencies are towards the use of poorly controlled studies that can provide weak evidence and could, ultimately, do more harm than good to our patients and our economy. There is, therefore, the need for designs that could I) provide high quality evidence, II) substitute an experiment when it cannot be done, and III) overcome the limitations of randomized clinical trials.

Research challenges, new drug development, preclinical and clinical trials in the ageing population

The aged are now viewed as a special population for the purposes of drug development. This has produced challenges for the investigator, in that separation of age- and disease-related changes in drug effect is only beginning to be defined. In addition, development of measurement tools for use in the elderly, particularly for central nervous system-active drugs, is an important ongoing process. As investigations proceed, we can look forward to an improved understanding of the physiology of normal ageing and the impact of disease processes and drugs on this physiological functioning. For the regulatory agency, evaluation of both efficacy and toxicity data in elderly patients for a drug-in-development is required; however, at present these data will be obtained in a 'young' elderly group, whereas much of the clinical use of the drug will be in the 'old' elderly. Extrapolation from one group to the other is required, although the relevance of this extrapolation is unknown. It is reassuring that, so far, few if any drug effects or toxicities have been identified which are truly unique to the elderly, though the magnitude of pharmacological or toxicological effects may differ.

The size of clinical trials in cancer research--what are the current needs? Medical Research Council Cancer Therapy Committee

Most randomised clinical trials of cancer treatment include a few hundred patients or less. Recent statistical papers advocate that sometimes thousands of patients should be entered. In this paper I show that for certain types of cancer trials the 'thousands policy' is not required while for others it is desirable but not feasible. In the latter case other strategies should be considered, such as two-stage phase III studies or parallel studies leading to overviews. There is, however, an important subset of trials for which application of the thousands policy is both necessary and feasible. The key to progress lies partly in the achievement of greater recruitment rates in trails of common cancers and partly in greater inter-group collaboration.

The changing face of clinical trials

We have now seen 20 years of clinical trials testing the efficacy and safety of antihypertensive drugs, involving more than 40,000 patients internationally. Much has been learned and should be applied to future studies. First, patient selection: will selection of patients from different races and nationalities permit pooling of data? There should be a sufficient number of female patients and elderly patients above 80 years of age to draw unequivocal conclusions about the effectiveness of antihypertensive treatment in that population. Further, will the patient population reflect the population cared for by individual community practitioners? End-points must be carefully selected, and it will be important to prove not only that a specific drug can lower blood pressure, but also how far blood pressure should be lowered. Lowering of blood pressure per se is not enough, and end-points should involve all-cause mortality and specific mortalities. Data analysis may revolve around intention to treat analysis or on-treatment analysis. Regarding side effects of the study drug, consideration should be given to survival statistics. Finally, decision analysis is needed. After the trial, postmarketing surveillance is important, and patient selection is just as important in that instance as it was in the original trial. Once the trial has been completed, careful meta-analysis is needed to answer the question still unanswered: can small multiple-centre trials replace large, international trials? One should not consider a trial completed unless measures have been suggested or taken to inform the practising clinician of the inferential statistics applied to the data and the meaning of the data analysis for the clinician in managing the individual patient.

Interpreting age-related aspects of antihypertensive treatment: statistical defects and their remedy

Much of the literature concerning age-related effects in hypertension and its treatment suffers from serious deficiencies in statistical design and analysis. The problems include the measurement of response to treatment, the lack of a suitable control group, the way response is related to baseline blood pressure, the interpretation of post hoc analyses and the pooling of data from related but different studies. We discuss these problems and attempt to identify solutions which give a satisfactory balance between scientific validity and the practical issues of conducting clinical trials in hypertension.

Monoclonal antibodies in urologic oncology

The sensitivity and specificity of immune reactions have long been recognized. However, since the description of the monoclonal antibody technique certain technical hurdles have been overcome. Monoclonal antibody (mAb) technology allows far more precise understanding of the humoral immune response by allowing dissection of this response into its individual B-lymphocyte populations. Furthermore, the ability to select and expand a particular B-cell clone allows for production of unlimited amounts of a pure antibody "reagent." Each of these reagents may be readily used as a "probe" for its respective antigenic determinant. Panels of these reagents may be used to probe complex biologic structures (e.g., neoplastic cells) and thereby "dissect" them at a molecular level. Murine mAbs are produced by hyperimmunizing a mouse with the antigen of interest. The spleen provides a rich source of B-lymphocytes. These normal B-lymphocytes are incapable of surviving in culture. However, mouse B-lymphocyte tumor cell lines (myelomas) have been previously immortalized in tissue culture. A hybridoma is formed by fusing the normal immunized B-cells with myeloma cells. The hybridoma combines the best features of its parent cells. The immunoglobulin product of each resulting clone is screened against a panel of antigens. This allows selection of those clones producing antibody to the desired antigens. The mAb may be used to purify and/or characterize its respective antigen including definition of the chromosomal site of its gene and factors involved in the regulation of its expression. A large number of mAbs have been produced against renal, bladder, and prostate cancer antigens. These mAbs are allowing a more precise, molecular subclassification of these cancers and providing improved predictability of the natural history of each patient's cancer. Evidence in experimental animals demonstrates that mAbs accumulate at the site of tumor and can lead to the destruction of tumor cells. These encouraging results have prompted clinical trials in patients with metastatic cancer. Such a clinical trial in patients with metastatic renal cancer is currently underway at New York Hospital and Memorial Sloan-Kettering Cancer Center.

Interferons in oncology: current status and future directions

The European School of Oncology has formed a study group to consider the present status of interferons in oncology. This position paper summarizes the discussions and conclusions of the first meeting of this study group.

The role of fluorescein angiography in national collaborative studies

Over the past 20 years, fluorescein angiography has demonstrated its value in the diagnosis and management of most diseases of the retinal vessels and choroidal vessels, including diabetic retinopathy, aging macular degeneration, and venous occlusive disorders. Fluorescein angiography has become so important for diagnostic purposes and for laser management that it has become a standard technique in the authors' most carefully performed clinical research studies such as randomized clinical trials. These clinical trials demand fluorescein angiography not only for diagnosis and eligibility of patients, but also to document the adequacy of laser photocoagulation. The use of fluorescein angiography has encouraged the development of newer photographic techniques and has encouraged a commendable level of expertise among photographers. Experience with fluorescein angiography in clinical trials has led to the development of general guidelines for the use of angiography for the management of patients outside the confines of a clinical trial; we emphasize the importance of recent angiography as a general guideline for all patients with macular edema or choroidal neovascularization before consideration of laser photocoagulation.