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Abstract
PURPOSE OF REVIEW The purpose is to recall some of the key immunological elements that are at the crossroad and need to be combined for developing a potent therapeutic HIV-1 vaccine. RECENT FINDINGS Therapeutic vaccines and cytokines have been commonly used to enhance and/or recall preexisting HIV-1 specific cell-mediated immune responses aiming to suppress virus replication. While the vaccine is important to stimulate HIV-1 specific T-cell responses, the cytokine may support the expansion of the stimulated virus-specific T cells. Moreover, the current success of immune checkpoint blockers in cancer therapy render them very attractive to use in HIV-1 infected individuals, with the objective to preserve the function of HIV-specific T cells from exhaustion and target directly HIV-1 cell reservoir. More recently, the development of passive immunotherapy using broad neutralizing HIV antibodies (bNAbs) and their potential capacity to elicit innate or adaptive HIV-cellular responses, beyond their neutralizing activity, offers a new opportunity to improve the efficiency of therapeutic vaccine. These major advances provide the scientific basis for developing potent combinatorial interventions in HIV-1 infected patients. SUMMARY Major advances in our immunological understanding resulting from basic science and clinical trials studies have paved the way and established a solid platform to jump over the stumbling blocks that prevent the field from developing a therapeutic HIV-1 vaccine. It is time for immuno-modulation and combinatorial strategies towards HIV-1 eradication.
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Marron JM, Cronin AM, DuBois SG, Glade-Bender J, Kim A, Crompton BD, Meyer SC, Janeway KA, Mack JW. Duality of purpose: Participant and parent understanding of the purpose of genomic tumor profiling research among children and young adults with solid tumors. JCO Precis Oncol 2019; 3. [PMID: 31240271 DOI: 10.1200/po.18.00176] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Increasing use of genomic tumor profiling may blur the line between research and clinical care. We aimed to describe research participants' perspectives on the purpose of genomic tumor profiling research in pediatric oncology. METHODS We surveyed 45 participants (response rate 85%) in a pilot study of genomic profiling in pediatric solid tumors at four academic cancer centers following return of sequencing results. We defined understanding according to a one-item ("basic") definition (recognizing that the primary purpose was not to improve the patient's treatment) and a four-item ("comprehensive") definition (primary purpose was not to improve patient's treatment; primary purpose was to improve treatment of future patients; there may not be direct medical benefit; most likely result of participation was not increased likelihood of cure). RESULTS Sixty-eight percent of respondents (30/44) demonstrated basic understanding of the study purpose; 55% (24/44) demonstrated comprehensive understanding. Understanding was more frequently seen in those with higher education and greater genetic knowledge according to basic (81% vs 50%, p=0.05; and 82% vs 46%, p=0.03, respectively) and comprehensive definitions (73% vs 28%, p=0.01; 71% vs 23%, p=0.01). Ninety-three percent of respondents who believed the primary purpose was to improve the patient's care simultaneously stated that the research also aimed to benefit future patients. CONCLUSIONS Most participants in pediatric tumor profiling research understand that the primary goal of this research is to improve care for future patients, but many express dual goals when participating in sequencing research. Some populations demonstrate increased rates of misunderstanding. Nuanced participant views suggest further work is needed to assess and improve participant understanding, particularly as tumor sequencing moves beyond research into clinical practice.
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Affiliation(s)
- Jonathan M Marron
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts.,Office of Ethics, Boston Children's Hospital, Boston, Massachusetts.,Center for Bioethics, Harvard Medical School, Boston, Massachusetts
| | - Angel M Cronin
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Steven G DuBois
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Julia Glade-Bender
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplantation, Columbia University Medical Center, New York, New York
| | - AeRang Kim
- Department of Pediatric Oncology, Children's National Medical Center, Washington, District of Columbia
| | - Brian D Crompton
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Stephanie C Meyer
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Katherine A Janeway
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
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53
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Affiliation(s)
| | - Marcin Waligora
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Krakow, Poland
| | - Holly Fernandez Lynch
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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54
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Increasing complexity in oncology phase I clinical trials. Invest New Drugs 2018; 37:519-523. [PMID: 30443782 DOI: 10.1007/s10637-018-0699-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
Abstract
Clinical trials in oncology have become increasingly complex because of incorporation of predictive biomarkers and patient selection based on molecular profiling of tumors. We have examined the change in procedures and work intensity in phase 1 oncology trials over the years with several parameters used as surrogates of complexity. Categories that were included as events were clinical evaluations, pharmacokinetic (PK) laboratory tests, non-PK laboratory tests, specific molecular or histological characteristics, questionnaires and subjective assessments, routine clinical and physical examinations, imaging, invasive procedures and others. The information was extracted using a standardized form including study type, tumor type, information on agent, participant characteristics and study mandated events during the first 3 cycles of each protocol. A total of 102 phase I oncology and hematology study protocols that were active at a single institution in 1996, 2006 and 2016 were evaluated. In 2016, there were significantly more (P < 0.05) median number of procedures, outpatient tests, subjective assessments, PK's, molecular profiling, biopsies and medication dispensing times. There were higher median numbers of procedures in studies in hematologic malignancies, testing immunotherapies and those with over 15 inclusion or exclusion criteria. These values also differed significantly (P < .005) when the median values were compared in nonparametric tests. Our results suggest that study related procedures in cancer phase I trials have substantially increased over the last two decades. The successful conduct of early-phase oncology clinical trials in future will require additional research resources.
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Winkfield KM, Phillips JK, Joffe S, Halpern MT, Wollins DS, Moy B. Addressing Financial Barriers to Patient Participation in Clinical Trials: ASCO Policy Statement. J Clin Oncol 2018; 36:JCO1801132. [PMID: 30212297 DOI: 10.1200/jco.18.01132] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
Research conducted through clinical trials is essential for evaluating new treatment modalities, establishing new standards of cancer care, and ultimately improving and prolonging the lives of patients with cancer. However, participation in trials has been low, and this is attributable to various factors including patient financial barriers. Such financial barriers include the rising cost of cancer care; a lack of transparency in coverage policy; and the perception of ethical, compliance, or institutional impediments to patient financial support. ASCO convened a roundtable discussion with a variety of stakeholders to define the scope of the problem, as well as to identify clinical practice and policy solutions applicable at the institutional and system-wide levels. This statement summarizes key discussions from the ASCO Roundtable, as well as findings from the literature, and provides ASCO's recommendations for overcoming financial barriers that may otherwise prevent participation in clinical trials. These recommendations broadly address the following key areas: (1) improving the policy environment for coverage of clinical trials; (2) facilitating transparency among providers, patients, and payers for trial-related out-of-pocket costs; (3) refuting the specter of inducement to enable targeted financial support for patients; and (4) improving the available data on costs of cancer clinical trials.
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Affiliation(s)
- Karen M Winkfield
- Karen M. Winkfield, Wake Forest Baptist Medical Center, Winston-Salem, NC; Jonathan K. Phillips and Dana S. Wollins, American Society of Clinical Oncology, Alexandria, VA; Steven Joffe, University of Pennsylvania Perelman School of Medicine; Michael T. Halpern, Temple University, Philadelphia, PA; and Beverly Moy, Massachusetts General Hospital, Boston, MA
| | - Jonathan K Phillips
- Karen M. Winkfield, Wake Forest Baptist Medical Center, Winston-Salem, NC; Jonathan K. Phillips and Dana S. Wollins, American Society of Clinical Oncology, Alexandria, VA; Steven Joffe, University of Pennsylvania Perelman School of Medicine; Michael T. Halpern, Temple University, Philadelphia, PA; and Beverly Moy, Massachusetts General Hospital, Boston, MA
| | - Steven Joffe
- Karen M. Winkfield, Wake Forest Baptist Medical Center, Winston-Salem, NC; Jonathan K. Phillips and Dana S. Wollins, American Society of Clinical Oncology, Alexandria, VA; Steven Joffe, University of Pennsylvania Perelman School of Medicine; Michael T. Halpern, Temple University, Philadelphia, PA; and Beverly Moy, Massachusetts General Hospital, Boston, MA
| | - Michael T Halpern
- Karen M. Winkfield, Wake Forest Baptist Medical Center, Winston-Salem, NC; Jonathan K. Phillips and Dana S. Wollins, American Society of Clinical Oncology, Alexandria, VA; Steven Joffe, University of Pennsylvania Perelman School of Medicine; Michael T. Halpern, Temple University, Philadelphia, PA; and Beverly Moy, Massachusetts General Hospital, Boston, MA
| | - Dana S Wollins
- Karen M. Winkfield, Wake Forest Baptist Medical Center, Winston-Salem, NC; Jonathan K. Phillips and Dana S. Wollins, American Society of Clinical Oncology, Alexandria, VA; Steven Joffe, University of Pennsylvania Perelman School of Medicine; Michael T. Halpern, Temple University, Philadelphia, PA; and Beverly Moy, Massachusetts General Hospital, Boston, MA
| | - Beverly Moy
- Karen M. Winkfield, Wake Forest Baptist Medical Center, Winston-Salem, NC; Jonathan K. Phillips and Dana S. Wollins, American Society of Clinical Oncology, Alexandria, VA; Steven Joffe, University of Pennsylvania Perelman School of Medicine; Michael T. Halpern, Temple University, Philadelphia, PA; and Beverly Moy, Massachusetts General Hospital, Boston, MA
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Global trends in the distribution of cancer types among patients in oncology phase I trials, 1991-2015. Invest New Drugs 2018; 37:166-174. [PMID: 30083961 DOI: 10.1007/s10637-018-0654-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 07/31/2018] [Indexed: 12/26/2022]
Abstract
Background Systematic analyses regarding cancer types of patients enrolled in oncology phase I trials are scarce. The global distribution, time-dependent change, and regional differences were evaluated. Methods A systematic search of the PubMed database, in which all single-agent phase I trials permitting the enrollment of all-comer patients with any type of solid tumor published between January 1991 and December 2015 were specified, was performed. Trials expected to enroll specific patient populations were excluded according to predefined criteria. Results Eight hundred and sixty-six eligible trials, which had enrolled 29,112 advanced solid tumor patients, were identified. Colorectal (n = 7510; 25.8%) and lung cancer (n = 3212; 11.0%) were the most prevalent solid tumors, followed by sarcoma (n = 1756; 6.0%), breast cancer (n = 1623; 5.6%), and renal cancer (n = 1589; 5.5%). The proportion of patients with either colorectal or lung cancer tended to decrease over time. The proportion of trials, in which patients with either of these two cancers accounted for ≥50.0% of the total number of patients in each trial, also decreased: 33 of 67 trials (31/67) (46.3%) in 1991-1995, 58/142 (40.8%) in 1996-2000, 59/223 (26.5%) in 2001-2005, 38/189 (20.1%) in 2006-2010, and 41/245 (16.7%) in 2011-2015. Instead, the proportion of patients with various types of cancer increased, leading to diversification of enrolled patients. Conclusions The distribution of cancer types among patients in phase I trials has changed. The comprehensive review of the distribution of solid tumor types could contribute to flexible trial designs and optimal patient recruitment.
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Lin R, Yin G. Uniformly most powerful Bayesian interval design for phase I dose-finding trials. Pharm Stat 2018; 17:710-724. [PMID: 30066466 DOI: 10.1002/pst.1889] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 05/08/2018] [Accepted: 06/09/2018] [Indexed: 11/10/2022]
Abstract
Interval designs have recently attracted much attention in phase I clinical trials because of their simplicity and desirable finite-sample performance. However, existing interval designs typically cannot converge to the optimal dose level since their intervals do not shrink to the target toxicity probability as the sample size increases. The uniformly most powerful Bayesian test (UMPBT) is an objective Bayesian hypothesis testing procedure, which results in the largest probability that the Bayes factor against null hypothesis exceeds the evidence threshold for all possible values of the data generating parameter. On the basis of the rejection region of UMPBT, we develop the uniformly most powerful Bayesian interval (UMPBI) design for phase I dose-finding trials. The proposed UMPBI design enjoys convergence properties because the induced interval indeed shrinks to the toxicity target and the recommended dose converges to the true maximum tolerated dose as the sample size increases. Moreover, it possesses an optimality property that the probability of incorrect decisions is minimized. We conduct simulation studies to demonstrate the competitive finite-sample operating characteristics of the UMPBI in comparison with other existing interval designs. As an illustration, we apply the UMPBI design to a panitumumab and standard gemcitabine-based chemoradiation combination trial.
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Affiliation(s)
- Ruitao Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Key Laboratory for Applied Statistics of MOE, Northeast Normal University, Changchun, Jilin, China
| | - Guosheng Yin
- Department of Statistics and Actuarial Science, The University of Hong Kong, Hong Kong
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Willingness to participate in HIV research at the end of life (EOL). PLoS One 2018; 13:e0199670. [PMID: 30036365 PMCID: PMC6056048 DOI: 10.1371/journal.pone.0199670] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 06/12/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Animal models have been vital for scientific discovery but have limitations, especially in infectious disease research. It is essential to develop a means to study these diseases in human models. We hypothesized that altruistic people would willingly participate in research near the end-of-life (EOL), for the benefit of science and to provide one last gift to society. METHODOLOGY Two surveys were administered to 377 self-reported HIV-negative and 96 HIV-positive individuals. Hypothetical questions assessed their willingness to participate in altruistic research in the last 6 months of life, which might result in a shortened lifespan or physical discomforts. The self-reported HIV-negative group was also asked about willingness to be exposed to infectious pathogens for the sake of research. RESULTS Almost all responders expressed willingness to participate in research at the EOL, regardless of HIV-status. The majority of participants were willing to endure physical discomfort for the sake of research. 'Blood draws' was identified as the most tolerable physical discomfort (>70% in both groups). In both groups, >60% were willing to shorten their lifespans for the sake of research. A third of the self-reported HIV-negative group expressed willingness to be exposed to at least one infectious agent to participate in EOL research. CONCLUSIONS Our exploratory study demonstrates that people would welcome the opportunity to participate in altruistic research near the EOL. Such research could greatly impact the way infectious disease research is conducted. This study is limited however by its hypothetical nature. Further research is necessary to confirm this interest in those with terminal illness before any further clinical research effort at the EOL can be performed.
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Hlubocky FJ, Sachs GA, Larson ER, Nimeiri HS, Cella D, Wroblewski KE, Ratain MJ, Peppercorn JM, Daugherty CK. Do Patients With Advanced Cancer Have the Ability to Make Informed Decisions for Participation in Phase I Clinical Trials? J Clin Oncol 2018; 36:2483-2491. [PMID: 29985748 DOI: 10.1200/jco.2017.73.3592] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Purpose Patients with advanced cancer (ACPs) participating in phase I clinical trials inadequately understand many elements of informed consent (IC); however, the prevalence and impact of cognitive impairment has not been described. Patients and Methods ACPs enrolled onto phase I trials underwent neuropsychological assessment to evaluate cognitive functioning (CF) covering the following domains: memory (Hopkins Verbal Learning Test), executive functioning (Trail Making Test B), language (Boston Naming Test-Short Version and Controlled Oral Word Association Test), attention (Trail Making Test A and Wechsler Adult Intelligenence Scale-IV Digit Span), comprehension (Wechsler Adult Intelligence Scale-IV), and quality of life (Functional Assessment of Cancer Therapy-Cognitive Function). Structured interviews evaluated IC and decisional capacity. Psychological measures included distress (Hospital Anxiety Depression Scale) and depression (Beck Depression Inventory-II). Results One hundred eighteen ACPs on phase I trials were evaluated, with CF ranging from mild impairment to superior performance. Only 45% of ACPs recalled physician disclosure of the phase I trial purpose. The 50% of ACPs who correctly identified the phase I research purpose had greater CF compared with ACPs who did not, as revealed by the mean T scores for memory (37.2 ± 5.6 v 32.5 ± 5.1, respectively; P = .001), attention (29 ± 2.7 v 26.9 ± 2.4, respectively; P < .001), visual attention (35.2 ± 6.6 v 31.5 ± 6.2, respectively; P = .001), and executive function (38.9 ± 7.5 v 34 ± 7.1, respectively; P < .001). Older ACPs (≥ 60 years) were less likely to recall physician disclosure of phase I purpose than younger ACPs (30% v 70%, respectively; P = .02) and had measurable deficits in total memory (34.2 ± 5.0 v 37.3 ± 5.6, respectively; P = .002), attention (24.5 ± 2.6 v 28 ± 2.8, respectively; P < .001), and executive function (32.8 ± 7.3 v 36.4 ± 7.6, respectively; P = .01). Older ACPs, compared with younger ACPs, also had greater depression scores (10.6 ± 9.2 v 8.1 ± 5.2, respectively; P = .03) and lower quality-of-life scores (152 ± 29.6 v 167 ± 20, respectively; P = .03). After adjustment by age, no psychological or neuropsychological variable was further significantly associated with likelihood of purpose identification. Conclusion CF seems to play a role in ACP recall and comprehension of IC for early-phase clinical trials, especially among older ACPs.
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Affiliation(s)
- Fay J Hlubocky
- Fay J. Hlubocky, Kristen E. Wroblewski, Mark J. Ratain, and Christopher K. Daugherty, The University of Chicago, Chicago; Halla S. Nimeiri and David Cella, Northwestern University, Evanston, IL; Greg A. Sachs, Indiana University and Regenstrief Institute, Indianapolis, IN; Eric R. Larson, Department of Veterans Affairs, Milwaukee, WI; and Jeffery M. Peppercorn, Massachusetts General Hospital, Dana-Farber Partners/Harvard Health System, Boston, MA
| | - Greg A Sachs
- Fay J. Hlubocky, Kristen E. Wroblewski, Mark J. Ratain, and Christopher K. Daugherty, The University of Chicago, Chicago; Halla S. Nimeiri and David Cella, Northwestern University, Evanston, IL; Greg A. Sachs, Indiana University and Regenstrief Institute, Indianapolis, IN; Eric R. Larson, Department of Veterans Affairs, Milwaukee, WI; and Jeffery M. Peppercorn, Massachusetts General Hospital, Dana-Farber Partners/Harvard Health System, Boston, MA
| | - Eric R Larson
- Fay J. Hlubocky, Kristen E. Wroblewski, Mark J. Ratain, and Christopher K. Daugherty, The University of Chicago, Chicago; Halla S. Nimeiri and David Cella, Northwestern University, Evanston, IL; Greg A. Sachs, Indiana University and Regenstrief Institute, Indianapolis, IN; Eric R. Larson, Department of Veterans Affairs, Milwaukee, WI; and Jeffery M. Peppercorn, Massachusetts General Hospital, Dana-Farber Partners/Harvard Health System, Boston, MA
| | - Halla S Nimeiri
- Fay J. Hlubocky, Kristen E. Wroblewski, Mark J. Ratain, and Christopher K. Daugherty, The University of Chicago, Chicago; Halla S. Nimeiri and David Cella, Northwestern University, Evanston, IL; Greg A. Sachs, Indiana University and Regenstrief Institute, Indianapolis, IN; Eric R. Larson, Department of Veterans Affairs, Milwaukee, WI; and Jeffery M. Peppercorn, Massachusetts General Hospital, Dana-Farber Partners/Harvard Health System, Boston, MA
| | - David Cella
- Fay J. Hlubocky, Kristen E. Wroblewski, Mark J. Ratain, and Christopher K. Daugherty, The University of Chicago, Chicago; Halla S. Nimeiri and David Cella, Northwestern University, Evanston, IL; Greg A. Sachs, Indiana University and Regenstrief Institute, Indianapolis, IN; Eric R. Larson, Department of Veterans Affairs, Milwaukee, WI; and Jeffery M. Peppercorn, Massachusetts General Hospital, Dana-Farber Partners/Harvard Health System, Boston, MA
| | - Kristen E Wroblewski
- Fay J. Hlubocky, Kristen E. Wroblewski, Mark J. Ratain, and Christopher K. Daugherty, The University of Chicago, Chicago; Halla S. Nimeiri and David Cella, Northwestern University, Evanston, IL; Greg A. Sachs, Indiana University and Regenstrief Institute, Indianapolis, IN; Eric R. Larson, Department of Veterans Affairs, Milwaukee, WI; and Jeffery M. Peppercorn, Massachusetts General Hospital, Dana-Farber Partners/Harvard Health System, Boston, MA
| | - Mark J Ratain
- Fay J. Hlubocky, Kristen E. Wroblewski, Mark J. Ratain, and Christopher K. Daugherty, The University of Chicago, Chicago; Halla S. Nimeiri and David Cella, Northwestern University, Evanston, IL; Greg A. Sachs, Indiana University and Regenstrief Institute, Indianapolis, IN; Eric R. Larson, Department of Veterans Affairs, Milwaukee, WI; and Jeffery M. Peppercorn, Massachusetts General Hospital, Dana-Farber Partners/Harvard Health System, Boston, MA
| | - Jeffery M Peppercorn
- Fay J. Hlubocky, Kristen E. Wroblewski, Mark J. Ratain, and Christopher K. Daugherty, The University of Chicago, Chicago; Halla S. Nimeiri and David Cella, Northwestern University, Evanston, IL; Greg A. Sachs, Indiana University and Regenstrief Institute, Indianapolis, IN; Eric R. Larson, Department of Veterans Affairs, Milwaukee, WI; and Jeffery M. Peppercorn, Massachusetts General Hospital, Dana-Farber Partners/Harvard Health System, Boston, MA
| | - Christopher K Daugherty
- Fay J. Hlubocky, Kristen E. Wroblewski, Mark J. Ratain, and Christopher K. Daugherty, The University of Chicago, Chicago; Halla S. Nimeiri and David Cella, Northwestern University, Evanston, IL; Greg A. Sachs, Indiana University and Regenstrief Institute, Indianapolis, IN; Eric R. Larson, Department of Veterans Affairs, Milwaukee, WI; and Jeffery M. Peppercorn, Massachusetts General Hospital, Dana-Farber Partners/Harvard Health System, Boston, MA
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60
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Affiliation(s)
- Alex John London
- Department of Philosophy, Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Jonathan Kimmelman
- Studies of Translation, Ethics, and Medicine, Biomedical Ethics Unit, McGill University, Montréal, Quebec, Canada
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Besle S, Schultz E, Hollebecque A, Varga A, Baldini C, Martin P, Postel-Vinay S, Bahleda R, Gazzah A, Michot JM, Marabelle A, Angevin E, Armand JP, Ribrag V, Soria JC, Massard C. Organisational factors influencing early clinical trials enrollment: Gustave Roussy experience. Eur J Cancer 2018; 98:17-22. [PMID: 29859337 DOI: 10.1016/j.ejca.2018.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 04/19/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE Enrolment process influences the likelihood of patients' inclusion in early clinical trials (ECT) through social, medical and organisational factors. PATIENTS AND METHODS All patients referred from 2008 to 2016 to the Drug Development Department (DITEP) of Gustave Roussy (GR) were reviewed. Referring physician, organisational factors, medical and socioeconomic characteristics for patients were analysed. Multivariate analysis was performed with regard to those factors. A telephone survey was conducted on a sample of referring physicians located outside GR (N = 142). RESULTS Between 2008 and 2016, 8694 requests were received with 49% from external physicians. Here, 4517 were male patients with a median age of 58 [49-66] years (range 18-85). Tumour types were gastrointestinal (28%), lung (19%), breast (9%) and gynaecologic (8%). Mean enrolment rate was 37% (ranging from 24 to 45%). From 2008 to 2016, the enrolment rate decreases from 39% to 24%. In the meantime, DITEP trials portfolio evolves with the part of precision medicine trials increase from 12% to 40%. Factors that were significantly associated with a lower likelihood of being enrolled were referral from an external physician (OR 0.15 s.16-0.21]) compared to a physician from DITEP and year of the request (2.74 [1.8-2.9] 2008 versus 2016). The enrolment rate and the number of patients addressed have a high variability regarding referring physicians, which is little explained by characteristics as training, previous experience or attitude regarding ECT. CONCLUSION Beyond patients' individual characteristics, we show that organisational and professional factors have a major impact on likelihood of enrolment in ECT.
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Affiliation(s)
- Sylvain Besle
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France; Aix Marseille Univ, INSERM, IRD, SESSTIM, 232 Bd Ste Marguerite BP 156 13273 Marseille Cedex 9 France.
| | - Emilien Schultz
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France; Aix Marseille Univ, INSERM, IRD, SESSTIM, 232 Bd Ste Marguerite BP 156 13273 Marseille Cedex 9 France
| | - Antoine Hollebecque
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
| | - Andreea Varga
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
| | - Capucine Baldini
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
| | - Patricia Martin
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
| | - Sophie Postel-Vinay
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
| | - Rastislav Bahleda
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
| | - Anas Gazzah
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
| | - Jean-Marie Michot
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
| | - Aurélien Marabelle
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
| | - Eric Angevin
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
| | - Jean-Pierre Armand
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
| | - Vincent Ribrag
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
| | - Jean-Charles Soria
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
| | - Christophe Massard
- Gustave Roussy, Université Paris-Saclay, Drug Development Department (DITEP), Villejuif, F-94805, France
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Hlubocky FJ, Kass NE, Roter D, Larson S, Wroblewski KE, Sugarman J, Daugherty CK. Investigator Disclosure and Advanced Cancer Patient Understanding of Informed Consent and Prognosis in Phase I Clinical Trials. J Oncol Pract 2018; 14:e357-e367. [PMID: 29787333 DOI: 10.1200/jop.18.00028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE Advanced cancer patients (ACPs) who participate in phase I clinical trials often report a less-than-ideal understanding of the required elements of informed consent (IC) and unrealistic expectations for anticancer benefit and prognosis. We examined phase I clinical trial enrollment discussions and their associations with subsequent ACP understanding. METHODS Clinical encounters about enrollment in phase I trials between 101 ACPs and 29 oncologists (principal investigators [PIs] and fellows) at three US academic medical institutions were recorded. The Roter Interaction Analysis System was used for analysis. ACPs completed follow-up questionnaires to assess IC recall. RESULTS PIs disclosed the following phase I IC elements to ACPs in encounters: trial purpose in 40%; specific physical risks in 60%; potential specific medical benefits gained by trial participation (eg, disease stabilization) in 48.2%; and alternatives to phase I trial participation in 47.1%, with 1.1% of encounters containing palliative and 2.3% hospice information. PIs provided ACP-specific prognoses in 29.0% of encounters but used precise terms of death in only 4.7% and terminal in 1.2%. A significant association existed between PI disclosure of the trial purpose as dosage/toxicity, and ACPs subsequently correctly recalled trial purpose versus PIs who did not disclose it (85% v 13%; P < .05). CONCLUSION Many oncologists provide incomplete disclosures about phase I trials to ACPs. When disclosure of certain elements of IC occurs, it seems to be associated with better recall, especially with regard to the research purpose of phase I trials.
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Affiliation(s)
- Fay J Hlubocky
- University of Chicago, Chicago, IL; and Johns Hopkins University, Baltimore, MD
| | - Nancy E Kass
- University of Chicago, Chicago, IL; and Johns Hopkins University, Baltimore, MD
| | - Debra Roter
- University of Chicago, Chicago, IL; and Johns Hopkins University, Baltimore, MD
| | - Susan Larson
- University of Chicago, Chicago, IL; and Johns Hopkins University, Baltimore, MD
| | | | - Jeremy Sugarman
- University of Chicago, Chicago, IL; and Johns Hopkins University, Baltimore, MD
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Waligora M, Bala MM, Koperny M, Wasylewski MT, Strzebonska K, Jaeschke RR, Wozniak A, Piasecki J, Sliwka A, Mitus JW, Polak M, Nowis D, Fergusson D, Kimmelman J. Risk and surrogate benefit for pediatric Phase I trials in oncology: A systematic review with meta-analysis. PLoS Med 2018; 15:e1002505. [PMID: 29462168 PMCID: PMC5819765 DOI: 10.1371/journal.pmed.1002505] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 01/12/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Pediatric Phase I cancer trials are critical for establishing the safety and dosing of anti-cancer treatments in children. Their implementation, however, must contend with the rarity of many pediatric cancers and limits on allowable risk in minors. The aim of this study is to describe the risk and benefit for pediatric cancer Phase I trials. METHODS AND FINDINGS Our protocol was prospectively registered in PROSPERO (CRD42015015961). We systematically searched Embase and PubMed for solid and hematological malignancy Phase I pediatric trials published between 1 January 2004 and 1 March 2015. We included pediatric cancer Phase I studies, defined as "small sample size, non‑randomized, dose escalation studies that defined the recommended dose for subsequent study of a new drug in each schedule tested." We measured risk using grade 3, 4, and 5 (fatal) drug-related adverse events (AEs) and benefit using objective response rates. When possible, data were meta-analyzed. We identified 170 studies meeting our eligibility criteria, accounting for 4,604 patients. The pooled overall objective response rate was 10.29% (95% CI 8.33% to 12.25%), and was lower in solid tumors, 3.17% (95% CI 2.62% to 3.72%), compared with hematological malignancies, 27.90% (95% CI 20.53% to 35.27%); p < 0.001. The overall fatal (grade 5) AE rate was 2.09% (95% CI 1.45% to 2.72%). Across the 4,604 evaluated patients, there were 4,675 grade 3 and 4 drug-related AEs, with an average grade 3/4 AE rate per person equal to 1.32. Our study had the following limitations: trials included in our review were heterogeneous (to minimize heterogeneity, we separated types of therapy and cancer types), and we relied on published data only and encountered challenges with the quality of reporting. CONCLUSIONS Our meta-analysis suggests that, on the whole, AE and response rates in pediatric Phase I trials are similar to those in adult Phase I trials. Our findings provide an empirical basis for the refinement and review of pediatric Phase I trials, and for communication about their risk and benefit.
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Affiliation(s)
- Marcin Waligora
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
| | - Malgorzata M. Bala
- Department of Hygiene and Dietetics, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Kraków, Poland
- * E-mail: (MMB); (JK)
| | - Magdalena Koperny
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
- Department of Public Health and Health Promotion, Regional Sanitary-Epidemiological Station in Kraków, Poland
| | - Mateusz T. Wasylewski
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
| | - Karolina Strzebonska
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
| | - Rafał R. Jaeschke
- Section of Affective Disorders, Department of Psychiatry, Jagiellonian University Medical College, Kraków, Poland
| | - Agnieszka Wozniak
- Agency for Health Technology Assessment and Tariff System, Warsaw, Poland
| | - Jan Piasecki
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
| | - Agnieszka Sliwka
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
- Department of Rehabilitation in Internal Diseases, Jagiellonian University Medical College, Kraków, Poland
| | - Jerzy W. Mitus
- Department of Surgical Oncology, Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Kraków, Poland
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Maciej Polak
- Research Ethics in Medicine Study Group (REMEDY), Department of Philosophy and Bioethics, Jagiellonian University Medical College, Kraków, Poland
- Chair of Epidemiology and Population Studies, Jagiellonian University Medical College, Kraków, Poland
| | - Dominika Nowis
- Department of Immunology, Medical University of Warsaw, Warsaw, Poland
- Genomic Medicine, Medical University of Warsaw, Warsaw, Poland
- Laboratory of Experimental Medicine, Centre of New Technologies, University of Warsaw, Warsaw, Poland
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montreal, Canada
- * E-mail: (MMB); (JK)
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Ananth P, Monsereenusorn C, Ma C, Al-Sayegh H, Wolfe J, Rodriguez-Galindo C. Influence of early phase clinical trial enrollment on patterns of end-of-life care for children with advanced cancer. Pediatr Blood Cancer 2018; 65. [PMID: 28771913 DOI: 10.1002/pbc.26748] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/05/2017] [Accepted: 07/07/2017] [Indexed: 11/06/2022]
Abstract
We conducted a retrospective cohort study of 125 pediatric oncology patients who died in 2010-2014 to explore how healthcare utilization, pediatric palliative care (PPC) receipt, and end-of-life care (EOLC) differed between patients enrolled in early phase clinical trials (EP) and those not enrolled (NEP). Baseline characteristics and healthcare utilization did not significantly differ between groups. EP patients received PPC consultation closer to death than NEP patients (median days before death = 58 [interquartile range = 16-84] vs. 85 [32-173]; P = 0.04). Our findings suggest that early phase trial enrollment does not substantially alter EOLC for children with advanced cancer but may contribute to later PPC engagement. Future studies should definitively assess the relationship between trial enrollment and PPC timing.
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Affiliation(s)
- Prasanna Ananth
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Chalinee Monsereenusorn
- Department of Pediatrics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Clement Ma
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Hasan Al-Sayegh
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Joanne Wolfe
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
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Harrington JA, Hernandez-Guerrero TC, Basu B. Early Phase Clinical Trial Designs - State of Play and Adapting for the Future. Clin Oncol (R Coll Radiol) 2017; 29:770-777. [PMID: 29108786 DOI: 10.1016/j.clon.2017.10.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 09/20/2017] [Indexed: 11/25/2022]
Abstract
The process of anti-cancer drug development is complex, with high attrition rates. Factors that may optimise this process include well-constructed and relevant pre-clinical testing and use of biomarkers for patient selection. However, the design of early phase clinical trials will probably play a vital role in both the robust clinical investigation of new targeted therapies and in streamlining drug development. In this overview, we assess current concepts in phase I clinical trials, highlighting issues and opportunities to improve their meaningfulness. The particular challenge of how to design combination trials is addressed, with focus on the potential of new adaptive and model-based designs.
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Affiliation(s)
- J A Harrington
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - T C Hernandez-Guerrero
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - B Basu
- Department of Oncology, University of Cambridge, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK.
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Dunn LB, Wiley J, Garrett S, Hlubocky F, Daugherty C, Trupin L, Munster P, Dohan D. Interest in initiating an early phase clinical trial: results of a longitudinal study of advanced cancer patients. Psychooncology 2017; 26:1604-1610. [PMID: 27233054 DOI: 10.1002/pon.4179] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 04/14/2016] [Accepted: 05/22/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Enhanced recruitment of patients with advanced cancer (ACP) to early phase (EP) trials is needed. However, selective recruitment may affect the kinds of patients who are recruited. To address whether ACP who initiate EP trial enrollment differ from those who do not, we prospectively surveyed ACP well in advance of potential trial recruitment and followed them over time to identify those who initiated the recruitment process. METHODS EP trial initiation was defined as a patient being referred for screening to an active EP trial. Depression and anxiety were assessed with the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Scale (GAD-7), respectively. Demographic and disease characteristics, functional status, and patient preferences regarding decision making were examined as possible predictors of EP trial initiation. RESULTS Of the 78 advanced cancer patients in the cohort studied, 21 (27%) initiated EP trial participation, while 57 (73%) did not. Of those who initiated this process, 14 (67%) went on to enroll in an EP study. Level of depression severity was associated with EP trial initiation, with rates of initiation nearly three times higher (35% vs. 12%, p = 0.054) among patients with minimal to mild levels of depression compared to those with moderate or higher levels of depression. EP trial initiation was not associated with demographic or socioeconomic variables, cancer type, functional status, quality of life, or decision-making variables. CONCLUSIONS The presence of elevated depressive symptoms may be associated with the EP trial recruitment and enrollment processes. This possible relationship warrants further study. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Laura B Dunn
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Jim Wiley
- Department of Family and Community Medicine and Institute for Health Policy Studies, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Sarah Garrett
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Fay Hlubocky
- Department of Medicine, Section of Hematology/Oncology, Maclean Center for Clinical Medical Ethics, The University of Chicago Medicine, Chicago, IL, USA
| | - Christopher Daugherty
- Department of Medicine, Section of Hematology/Oncology, Maclean Center for Clinical Medical Ethics, The University of Chicago Medicine, Chicago, IL, USA
| | - Laura Trupin
- Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Pamela Munster
- Department of Medicine (Hematology/Oncology), and UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Daniel Dohan
- Philip R. Lee Institute for Health Policy Studies and the Department of Anthropology, History, and Social Medicine, University of California, San Francisco (UCSF), CA, USA
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Qualitative analysis of clinical research coordinators' role in phase I cancer clinical trials. Contemp Clin Trials Commun 2017; 8:156-161. [PMID: 29696205 PMCID: PMC5898507 DOI: 10.1016/j.conctc.2017.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 09/15/2017] [Accepted: 09/26/2017] [Indexed: 12/03/2022] Open
Abstract
Background Clinical research coordinators play a pivotal role in phase I cancer clinical trials. Purpose We clarified the care coordination and practice for patients provided by clinical research coordinators in phase I cancer clinical trials in Japan and elucidated clinical research coordinators' perspective on patients' expectations and understanding of these trials. Method Fifteen clinical research coordinators participated in semi-structured interviews regarding clinical practices; perceptions of patients' expectations; and the challenges that occur before, during, and after phase I cancer clinical trials. Discussion Qualitative content analysis showed that most clinical research coordinators observed that patients have high expectations from the trials. Most listened to patients to confirm patients' understanding and reflected on responses to maintain hope, but to avoid excessive expectations; clinical research coordinators considered avoiding unplanned endings; and they aimed to establish good relationships between patients, medical staff, and among the professional team. Conclusions Clinical research coordinators were insightful about the needs of patients and took a meticulous approach to the phase I cancer clinical trial process, allowing time to connect with patients and to coordinate the inter-professional research team. Additionally, education in advanced oncology care was valuable for comforting participants in cancer clinical trials.
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Kehl KL, Fullmer CP, Fu S, George GC, Hess KR, Janku F, Karp DD, Kato S, Kizer CK, Kurzrock R, Naing A, Pant S, Piha-Paul SA, Subbiah V, Tsimberidou AM, Hong DS. Insurance Clearance for Early-Phase Oncology Clinical Trials Following the Affordable Care Act. Clin Cancer Res 2017; 23:4155-4162. [PMID: 28729355 DOI: 10.1158/1078-0432.ccr-16-3027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/02/2017] [Accepted: 05/03/2017] [Indexed: 11/16/2022]
Abstract
Purpose: The Affordable Care Act (ACA) required that private insurance plans allow clinical trial participation and cover standard-of-care costs, but the impact of this provision has not been well-characterized. We assessed rates of insurance clearance for trial participation within our large early-phase clinical trials program, before and after implementation of the requirement.Experimental Design: We analyzed the departmental database for the Clinical Center for Targeted Therapy (CCTT) at MD Anderson Cancer Center (Houston, TX). Among patients referred for sponsored trials, we described rates of insurance clearance and prolonged time to clearance (at least 14 days) from July 2012 to June 2013 (baseline), July 2013-December 2013 (following CCTT staffing changes in July 2103), and January 2014-June 2015 (following implementation of the ACA). We used multivariable logistic regression models to compare rates across these time periods.Results: We identified 2,404 referrals for insurance clearance. Among privately insured patients, insurance clearance rates were higher for those referred from January 2014 to June 2015 than for those referred from July 2012 to June 2013 (OR, 4.72; 95% CI, 2.96-7.51). There was no association between referral period and clearance rates for Medicare/Medicaid patients (P = 0.25). Referral from January 2014 to June 2015 was associated with lower rates of prolonged clearance among both privately insured (OR 0.57; 95% CI, 0.38-0.86) and Medicare/Medicaid patients (OR 0.39; 95% CI, 0.19-0.83).Conclusions: Within our large early-phase clinical trials program, insurance clearance rates among privately insured patients improved following implementation of the ACA's requirement for coverage of standard-of-care costs. Clin Cancer Res; 23(15); 4155-62. ©2017 AACR.
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Affiliation(s)
- Kenneth L Kehl
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cheryl P Fullmer
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Siqing Fu
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Goldy C George
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kenneth R Hess
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Filip Janku
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel D Karp
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shumei Kato
- The Center for Personalized Cancer Therapy and Clinical Trials, University of California, San Diego, California
| | - Cynthia K Kizer
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Razelle Kurzrock
- The Center for Personalized Cancer Therapy and Clinical Trials, University of California, San Diego, California
| | - Aung Naing
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shubham Pant
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarina A Piha-Paul
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Vivek Subbiah
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Apostolia M Tsimberidou
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David S Hong
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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van der Biessen DA, van der Helm PG, Klein D, van der Burg S, Mathijssen RH, Lolkema MP, de Jonge MJ. Understanding how coping strategies and quality of life maintain hope in patients deliberating phase I trial participation. Psychooncology 2017; 27:163-170. [PMID: 28665008 DOI: 10.1002/pon.4487] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/31/2017] [Accepted: 06/22/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study aimed to understand how hope and motivation of patients considering phase I trial participation are affected by psychological factors such as coping strategies and locus of control (LoC) and general well-being as measured by the quality of life (QoL). METHODS An exploratory cross-sectional study was performed in patients with incurable cancer (N = 135) referred to our phase I unit for the first time. Patients were potentially eligible for phase I trial participation and participated in our study while deliberating phase I trial participation. We used questionnaires on hope, motivation to participate, coping, LoC, and QoL. To investigate the nature and magnitude of the relationships between the scales, a structural equation modeling (SEM) was fitted to the data. RESULTS Hope significantly predicted the motivation to participate in phase I trials. Predictors of hope were a combination of flexible and tenacious goal pursuit (both P < .01), internal LoC (P < .01), and QoL (P < .01). The SEM showed an exact fit to the data, using a null hypothesis significance test: chi-square (8) = 9.30, P = .32. CONCLUSIONS Patients considering phase I trial participation seem to use a pact of tenacious and flexible coping and control to stay hopeful. Furthermore, hope and QoL positively affected each other. The psychological pact may promote an adaptation enabling them to adjust to difficult circumstances by unconsciously ignoring information, called dissonance reduction. This mechanism may impair their ability to provide a valid informed consent. We suggest including a systematic exploration of patients' social context and values before proposing a phase I trial.
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Affiliation(s)
| | | | - Dennis Klein
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Simone van der Burg
- Scientific Institute for Quality of Healthcare, Radboud UMC, Nijmegen, the Netherlands
| | - Ron H Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Martijn P Lolkema
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Maja J de Jonge
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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Ferrell BR, Paterson CL, Hughes MT, Chung V, Koczywas M, Smith TJ. Characteristics of Participants Enrolled onto a Randomized Controlled Trial of Palliative Care for Patients on Phase I Studies. J Palliat Med 2017; 20:1338-1344. [PMID: 28609257 DOI: 10.1089/jpm.2017.0158] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Advanced cancer patients participating in phase 1 clinical trials experience considerable symptom burden. Palliative care (PC) may benefit these individuals by providing supportive care during clinical research participation. This study investigates integration of a PC intervention among phase 1 trial participants with advanced cancer. METHODS AND MATERIALS This study is a multisite randomized clinical trial testing a concurrent PC intervention among phase 1 trial participants. Baseline demographic and clinical characteristics and descriptive baseline assessment findings were examined for all participants to date. Self-report assessments included quality of life (QOL) using the Functional Assessment of Cancer Therapy-General, spirituality using the Functional Assessment of Chronic Illness Therapy-Spirituality, and overall distress using the Distress Thermometer. Clinical trial retention and healthcare utilization were assessed through chart audit at study completion. RESULTS The study has enrolled 178 participants to date. The average age is 60.3 years, the majority was Caucasian (57.9%), and participants had an average of 1.7 comorbidities. Overall QOL was 77.6 (±15.1). Responses were most favorable for social/family well-being (22.6 ± 4.6), lowest for emotional well-being (14.9 ± 5.1), and average overall distress was 3.6 (±2.7). Healthcare utilization at study completion (n = 134) identified low rates of supportive care referrals, with approximately half of participants referred to social work (50.8%), and fewer referred for pain (43%), resource centers (44%), and physical therapy (18%). CONCLUSION Phase 1 clinical trial participants experience unmet QOL needs at baseline and levels of distress that merit clinical intervention. Although this study is in progress, initial findings support the potential benefits of PC among this population.
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Affiliation(s)
- Betty R Ferrell
- 1 Division of Nursing Research and Education , Department of Population Sciences, City of Hope, Duarte, California
| | - Carly L Paterson
- 2 National Cancer Institute, National Institutes of Health , Rockville, Maryland
| | - Mark T Hughes
- 3 Sidney Kimmel Comprehensive Cancer Center of Johns Hopkins Medical Institutions , Baltimore, Maryland
| | - Vincent Chung
- 1 Division of Nursing Research and Education , Department of Population Sciences, City of Hope, Duarte, California
| | - Marianna Koczywas
- 1 Division of Nursing Research and Education , Department of Population Sciences, City of Hope, Duarte, California
| | - Thomas J Smith
- 3 Sidney Kimmel Comprehensive Cancer Center of Johns Hopkins Medical Institutions , Baltimore, Maryland
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Saad ED, Paoletti X, Burzykowski T, Buyse M. Precision medicine needs randomized clinical trials. Nat Rev Clin Oncol 2017; 14:317-323. [DOI: 10.1038/nrclinonc.2017.8] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Ridgeway JL, Asiedu GB, Carroll K, Tenney M, Jatoi A, Radecki Breitkopf C. Patient and family member perspectives on searching for cancer clinical trials: A qualitative interview study. PATIENT EDUCATION AND COUNSELING 2017; 100:349-354. [PMID: 27578272 PMCID: PMC5318255 DOI: 10.1016/j.pec.2016.08.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 07/29/2016] [Accepted: 08/20/2016] [Indexed: 05/05/2023]
Abstract
OBJECTIVE Clinical trials are vital in the context of ovarian cancer and may offer further treatment options during disease recurrence, yet enrollment remains low. Understanding patient and family member experiences with identifying trials can inform engagement and education efforts. METHODS Interviews were conducted with 33 patients who had experience with clinical trial conversations and 39 nominated family members. Thematic analysis examined experiences and generated findings for clinical practice. RESULTS Trial conversations with providers at diagnosis were uncommon and often overwhelming. Most participants delayed engagement until later in the disease course. With hindsight, though, some wished they considered trials earlier. Difficulty identifying appropriate trials led some to defer searching to providers, but then they worried about missed opportunities. Most family members felt unqualified to search. CONCLUSION Trial conversations during clinical encounters should start early and include specifying search responsibilities of providers, patients, and family. Patients and family members can be engaged in searches but need guidance. PRACTICE IMPLICATIONS Trials should be discussed throughout the disease course, even if patients are not ready to participate or are not making a treatment decision. Education should focus on identifying trials that meet search criteria. Transparency regarding each individual's role in identifying trials is critical.
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Affiliation(s)
- Jennifer L Ridgeway
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery and the Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - Gladys B Asiedu
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery and the Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - Katherine Carroll
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery and the Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - Meaghan Tenney
- Department of Obstetrics and Gynecology, The University of Chicago Medicine, Chicago, USA
| | - Aminah Jatoi
- Department of Oncology, Mayo Clinic, Rochester, USA
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Pancholi N, Maheshwari E, Jauregui J, Maheshwari AV. Clinical Trials for Sarcomas. Sarcoma 2017. [DOI: 10.1007/978-3-319-43121-5_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Alkhateeb SS, Alkhateeb JM, Alrashidi EA. Increasing trends in kidney cancer over the last 2 decades in Saudi Arabia. Saudi Med J 2016; 36:698-703. [PMID: 25987112 PMCID: PMC4454904 DOI: 10.15537/smj.2015.6.10841] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objectives: To examine the trends of kidney cancer over the last 2 decades in a subset of a Saudi Arabian population. Methods: We conducted a retrospective study in a tertiary care center including all adult patients with primary kidney cancer who presented and were managed between 1990 and 2010. The time period was split into 4 quartiles, and variables tested and compared using chi-square, T-test, and Kaplan-Meier curves for survival. Results: The total was 215 patients with a mean age of 57.8 years. There was an increase in the number of kidney cancer cases over the last 2 decades. There was no significant difference in the mode of presentation or stage distribution between quartiles. A significant change was observed in the management towards minimally invasive and nephron-sparing surgeries (p<0.001). There was no change in recurrence-free and disease-specific survival over the last 20 years. Conclusions: There have been an increasing number of kidney cancer patients over the last 2 decades with no observed migration towards more incidental and low stage tumors as compared with developed countries.
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Affiliation(s)
- Sultan S Alkhateeb
- Division of Urology, Department of Surgery, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia. E-mail.
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Weber JS, Levit LA, Adamson PC, Bruinooge SS, Burris HA, Carducci MA, Dicker AP, Gönen M, Keefe SM, Postow MA, Thompson MA, Waterhouse DM, Weiner SL, Schuchter LM. Reaffirming and Clarifying the American Society of Clinical Oncology's Policy Statement on the Critical Role of Phase I Trials in Cancer Research and Treatment. J Clin Oncol 2016; 35:139-140. [PMID: 27893329 PMCID: PMC5559890 DOI: 10.1200/jco.2016.70.4692] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Jeffrey S Weber
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
| | - Laura A Levit
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
| | - Peter C Adamson
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
| | - Suanna S Bruinooge
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
| | - Howard A Burris
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
| | - Michael A Carducci
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
| | - Adam P Dicker
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
| | - Mithat Gönen
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
| | - Stephen M Keefe
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
| | - Michael A Postow
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
| | - Michael A Thompson
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
| | - David M Waterhouse
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
| | - Susan L Weiner
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
| | - Lynn M Schuchter
- Jeffrey S. Weber, New York University Langone Medical Center, New York, NY; Laura A. Levit, American Society of Clinical Oncology, Alexandria, VA; Peter C. Adamson, The Children's Hospital of Philadelphia, Philadelphia, PA; Suanna S. Bruinooge, American Society of Clinical Oncology, Alexandria, VA; Howard A. Burris III, Sarah Cannon Research Institute, Nashville, TN; Michael A. Carducci, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Adam P. Dicker, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Mithat Gönen, Memorial Sloan Kettering Cancer Center, New York, NY; Stephen M. Keefe, University of Pennsylvania, Philadelphia, PA; Michael A. Postow, Memorial Sloan Kettering Cancer Center, New York, NY; Michael A. Thompson, Aurora Health Care, Milwaukee, WI; David M. Waterhouse, Oncology Hematology Care, Cincinnati, OH; Susan L. Weiner, Children's Cause for Cancer Advocacy, Washington, DC; and Lynn M. Schuchter, University of Pennsylvania, Philadelphia, PA
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Lin R, Yin G. Nonparametric overdose control with late-onset toxicity in phase I clinical trials. Biostatistics 2016; 18:180-194. [DOI: 10.1093/biostatistics/kxw038] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 07/08/2016] [Accepted: 07/11/2016] [Indexed: 11/12/2022] Open
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Nooka AK, Behera M, Lonial S, Dixon MD, Ramalingam SS, Pentz RD. Access to Children's Oncology Group and Pediatric Brain Tumor Consortium phase 1 clinical trials: Racial/ethnic dissimilarities in participation. Cancer 2016; 122:3207-3214. [PMID: 27404488 DOI: 10.1002/cncr.30090] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 03/31/2016] [Accepted: 04/14/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Phase 1 clinical trials introduce new therapies to humans with the goal of establishing their safety. A prior Children's Oncology Group (COG) study analyzed the proportional enrollment of patients by race, ethnicity, sex, and age for all trial phases. The current study evaluated the representation of patients by race, ethnicity, sex, and age in phase 1 clinical trials. METHODS This study evaluated 1348 children with 128 diagnoses enrolled in COG and Pediatric Brain Tumor Consortium phase 1 clinical trials in the United States from February 28, 2000 to December 29, 2008. Observed and expected proportions were calculated according to an established methodology with a representative population from Surveillance, Epidemiology, and End Results data, which included 27,766 children with the same International Classification of Diseases for Oncology (third edition) diagnostic codes. RESULTS Underrepresentation in phase 1 trials was seen for lymphohematopoietic (LH) tumors (9.3% observed vs 37% expected) versus solid tumors (90.6% observed vs 63% expected). Although representation was fairly proportional, Hispanics (12.6% observed vs 27% expected), particularly Hispanic females (6% observed vs 18% expected), were significantly underrepresented. The 0- to 4-year age group was underrepresented (11.7% observed vs 36.5% expected). By tumor type, the most significantly underrepresented groups were 0- to 4-year-old children and Hispanics for both solid cancers (11% observed vs 34.4% expected for 0- to 4-year-old children and 12% observed vs 24% expected for Hispanics) and LH cancers (16% observed vs 40% expected for 0- to 4-year-old children and 19.4% observed vs 33% expected for Hispanics). CONCLUSIONS Although sex and racial/ethnic groups are mostly proportionally represented in phase 1 trials, some specific subgroups such as Hispanic children are underrepresented and may benefit from focused accrual. Cancer 2016;122:3207-14. © 2016 American Cancer Society.
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Massett HA, Mishkin G, Rubinstein L, Ivy SP, Denicoff A, Godwin E, DiPiazza K, Bolognese J, Zwiebel JA, Abrams JS. Challenges Facing Early Phase Trials Sponsored by the National Cancer Institute: An Analysis of Corrective Action Plans to Improve Accrual. Clin Cancer Res 2016; 22:5408-5416. [PMID: 27401246 DOI: 10.1158/1078-0432.ccr-16-0338] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 06/28/2016] [Accepted: 06/29/2016] [Indexed: 11/16/2022]
Abstract
Accruing patients in a timely manner represents a significant challenge to early phase cancer clinical trials. The NCI Cancer Therapy Evaluation Program analyzed 19 months of corrective action plans (CAP) received for slow-accruing phase I and II trials to identify slow accrual reasons, evaluate whether proposed corrective actions matched these reasons, and assess the CAP impact on trial accrual, duration, and likelihood of meeting primary scientific objectives. Of the 135 CAPs analyzed, 69 were for phase I trials and 66 for phase II trials. Primary reasons cited for slow accrual were safety/toxicity (phase I: 48%), design/protocol concerns (phase I: 42%, phase II: 33%), and eligibility criteria (phase I: 41%, phase II: 35%). The most commonly proposed corrective actions were adding institutions (phase I: 43%, phase II: 85%) and amending the trial to change eligibility or design (phase I: 55%, phase II: 44%). Only 40% of CAPs provided proposed corrective actions that matched the reasons given for slow accrual. Seventy percent of trials were closed to accrual at time of analysis (phase I = 48; phase II = 46). Of these, 67% of phase I and 70% of phase II trials met their primary objectives, but they were active three times longer than projected. Among closed trials, 24% had an accrual rate increase associated with a greater likelihood of meeting their primary scientific objectives. Ultimately, trials receiving CAPs saw improved accrual rates. Future trials may benefit from implementing CAPs early in trial life cycles, but it may be more beneficial to invest in earlier accrual planning. Clin Cancer Res; 22(22); 5408-16. ©2016 AACRSee related commentary by Mileham and Kim, p. 5397.
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Affiliation(s)
| | | | | | - S Percy Ivy
- National Cancer Institute, Bethesda, Maryland
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Kummar S, Do K, Coyne GO, Chen A, Ji J, Rubinstein L, Doroshow JH. Establishing proof of mechanism: Assessing target modulation in early-phase clinical trials. Semin Oncol 2016; 43:446-52. [PMID: 27663476 DOI: 10.1053/j.seminoncol.2016.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Since modulation of the putative target and the observed anti-tumor effects form the basis for the clinical development of a molecularly targeted therapy, early-phase clinical trials should be designed to demonstrate proof-of-mechanism in tissues of interest. In addition to establishing safety and the maximum tolerated dose, first-in-human clinical trials should be designed to demonstrate target modulation, define the proposed mechanism of action, and evaluate pharmacokinetic-pharmacodynamic relationships of a new anti-cancer agent. Assessing target modulation in paired tumor biopsies in patients with solid tumors presents multiple challenges, including procedural issues such as patient safety, ethical considerations, and logistics of sample handling and processing. In addition, the availability of qualified biomarker assay technologies, resources to conduct such studies, and real-time analysis of samples to detect inter-species differences that may affect the determination of optimal sampling time points must be taken into account. This article provides a discussion of the challenges that confront the practical application of pharmacodynamic studies in early-phase clinical trials of anti-cancer agents.
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Affiliation(s)
- Shivaani Kummar
- National Cancer Institute, National Institutes of Health, Bethesda, MD.
| | - Khanh Do
- National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | - Alice Chen
- National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Jiuping Ji
- Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD 21702
| | - Larry Rubinstein
- National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - James H Doroshow
- National Cancer Institute, National Institutes of Health, Bethesda, MD
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Shih J, Bashir B, Gustafson KS, Andrake M, Dunbrack RL, Goldstein LJ, Boumber Y. Cancer Signature Investigation: ERBB2 (HER2)-Activating Mutation and Amplification-Positive Breast Carcinoma Mimicking Lung Primary. J Natl Compr Canc Netw 2016; 13:947-52. [PMID: 26285240 DOI: 10.6004/jnccn.2015.0115] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Next-generation sequencing of primary and metachronous metastatic cancer lesions may impact patient care. We present a case of relapsed metastatic breast cancer with a dominant pulmonary lesion originally identified as lung adenocarcinoma. A 72-year-old, never-smoker woman with a protracted cough was found to have a large lung mass and regional lymphadenopathy on a chest CT. Lung mass biopsy showed adenocarcinoma with focal TTF-1 (thyroid transcription factor 1) positivity, favoring a lung primary. In addition to stereotactic brain radiation for cerebral metastases, she was started on carboplatin/pemetrexed. As part of the workup, the tumor was analyzed by a 50-gene targeted mutation panel, which detected 3 somatic mutations: ERBB2 (HER2) D769H activating missense mutation, TP53 Y126 inactivating truncating mutation, and SMARCB1 R374Q missense mutation. Of note, the patient had a history of stage IIA triple-negative grade 3 invasive ductal carcinoma of the left breast 1.5 years ago and received neoadjuvant chemotherapy and adjuvant radiation, and underwent a lumpectomy. Further analysis of her primary breast tumor showed a mutational profile identical to that of the lung tumor. Fluorescence in situ hybridization revealed HER2 amplification in the lung tumor, with a HER2/CEP17 ratio of 3.9. The patient was diagnosed with recurrent HER2-positive metastatic breast carcinoma with a coexisting ERBB2 (HER2) activating mutation. Chemotherapy was adjusted to include dual HER2-targeted therapy containing trastuzumab and pertuzumab, resulting in an ongoing partial response. This case demonstrates that a unique genetic mutational profile can clarify whether a tumor represents a metastatic lesion or new malignancy when conventional morphological and immunohistochemical methods are indeterminate, and can directly impact treatment decisions.
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Affiliation(s)
- Jennifer Shih
- From Fox Chase Cancer Center, Temple University Heath System, Philadelphia; Abington Memorial Hospital, Abington; and Molecular Therapeutics Research Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Babar Bashir
- From Fox Chase Cancer Center, Temple University Heath System, Philadelphia; Abington Memorial Hospital, Abington; and Molecular Therapeutics Research Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Karen S Gustafson
- From Fox Chase Cancer Center, Temple University Heath System, Philadelphia; Abington Memorial Hospital, Abington; and Molecular Therapeutics Research Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Mark Andrake
- From Fox Chase Cancer Center, Temple University Heath System, Philadelphia; Abington Memorial Hospital, Abington; and Molecular Therapeutics Research Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Roland L Dunbrack
- From Fox Chase Cancer Center, Temple University Heath System, Philadelphia; Abington Memorial Hospital, Abington; and Molecular Therapeutics Research Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Lori J Goldstein
- From Fox Chase Cancer Center, Temple University Heath System, Philadelphia; Abington Memorial Hospital, Abington; and Molecular Therapeutics Research Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Yanis Boumber
- From Fox Chase Cancer Center, Temple University Heath System, Philadelphia; Abington Memorial Hospital, Abington; and Molecular Therapeutics Research Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania. From Fox Chase Cancer Center, Temple University Heath System, Philadelphia; Abington Memorial Hospital, Abington; and Molecular Therapeutics Research Program, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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Claringbold PG, Turner JH. NeuroEndocrine Tumor Therapy with Lutetium-177-octreotate and Everolimus (NETTLE): A Phase I Study. Cancer Biother Radiopharm 2016; 30:261-9. [PMID: 26181854 DOI: 10.1089/cbr.2015.1876] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To establish the optimal safe dose of everolimus in combination with (177)Lu-octreotate peptide receptor radionuclide therapy (PRRT) of advanced progressive gastro-entero pancreatic neuroendocrine tumors (GEP-NETs) and to define dose-limiting toxicity. PATIENTS AND METHODS Patients with advanced unresectable progressive well-differentiated GEP-NETS avid for (68)Ga-octreotate on positron emission tomography-computed tomography imaging underwent PRRT with four cycles of 7.8 GBq (177)Lu-octreotate at 8 week intervals. Successive cohorts of 3 patients received escalating doses of everolimus comprising 5, 7.5, and 10 mg daily for 24 weeks. RESULTS Sixteen patients comprised 4 at 5 mg, 9 at 7.5 mg, and 3 at 10 mg everolimus. Patient cohorts at 5 and 7.5 mg received 83% and 80% of the total planned dose of everolimus over 24 weeks. All patients required dose reduction or complete cessation of everolimus at the 10 mg level, which induced neutropenia and thrombocytopenia, and reduced creatinine clearance. The overall response rate was 44% (7 of 16 patients), and no patient progressed over the 6 month period of treatment. Four of 5 pancreatic NET patients achieved PR 80%. No patient progressed on study. CONCLUSION In combination, PRRT with (177)Lu-octreotate, the maximum tolerated dose of everolimus is 7.5 mg daily.
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Affiliation(s)
- Phillip G Claringbold
- 1 Department of Oncology, Fremantle Hospital, The University of Western Australia , Fremantle, Australia
| | - J Harvey Turner
- 2 Department of Nuclear Medicine, Fremantle Hospital, The University of Western Australia , Fremantle, Australia
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The State of Cancer Care in America, 2016: A Report by the American Society of Clinical Oncology. J Oncol Pract 2016; 12:339-83. [PMID: 26979926 PMCID: PMC5015451 DOI: 10.1200/jop.2015.010462] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Kim H, Dan TD, Palmer JD, Leiby BE, Lawrence YR, Dicker AP. Quality and Reporting Accuracy of Phase 1 Drug Radiation Clinical Trials. JAMA Oncol 2016; 2:390-1. [PMID: 26841256 DOI: 10.1001/jamaoncol.2015.4833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Hyun Kim
- Department of Radiation Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tu D Dan
- Department of Radiation Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joshua D Palmer
- Department of Radiation Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Benjamin E Leiby
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yaacov R Lawrence
- Department of Radiation Oncology, Sheba Medical Center, Tel HaShomer, Israel
| | - Adam P Dicker
- Department of Radiation Oncology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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Zeidner JF, Karp JE, Blackford AL, Foster MC, Dees EC, Smith G, Ivy SP, Harris P. Phase I Clinical Trials in Acute Myeloid Leukemia: 23-Year Experience From Cancer Therapy Evaluation Program of the National Cancer Institute. J Natl Cancer Inst 2015; 108:djv335. [PMID: 26553781 DOI: 10.1093/jnci/djv335] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 10/13/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Therapy for acute myeloid leukemia (AML) has largely remained unchanged, and outcomes are unsatisfactory. We sought to analyze outcomes of AML patients enrolled in phase I studies to determine whether overall response rates (ORR) and mortality rates have changed over time. METHODS A retrospective analysis was performed on 711 adult AML patients enrolling in 45 phase I clinical trials supported by the Cancer Therapy Evaluation Program of the National Cancer Institute from 1986 to 2009. Changes in ORR and mortality rates for patients enrolled in 1986 to 1990, 1991 to 1995, 1996 to 2000, 2001 to 2005, and 2006 to 2009 were estimated with multivariable logistic regression models. All statistical tests were two-sided. RESULTS There was a statistically significant increase in AML patients enrolling in phase I clinical trials over time (1986 to 1990: n = 61; 2006 to 2009: n = 256; P = .03). The ORR for the entire cohort was 15.4% (1986 to 1990: 8.9%, 1991 to 1995: 21.1%; 1996 to 2000: 7.0%; 2001 to 2005: 10.0%; 2006 to 2009: 22.6%), and it statistically significantly improved over time (P < .001). There was a statistically significant improvement in ORRs with novel agents in combination vs single agents (ORR = 22.8% vs 4.7%, respectively, odds ratio = 5.95, 95% confidence interval = 3.22 to 11.9, P < .001). The 60-day mortality rate for the entire cohort was 22.6%, but it statistically significantly improved over time (P = .009). CONCLUSIONS There has been an encouraging increase in AML patients enrolling in phase I clinical studies over time. The improvement in ORRs appears to be partly because of the increase in combination trials and the inclusion of previously untreated poor-risk AML. Continued enrollment of AML patients in early phase clinical trials is vital for drug development and improvement in therapeutic outcomes.
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Affiliation(s)
- Joshua F Zeidner
- Affiliations of authors: University of North Carolina, Lineberger Comprehensive Cancer Center , Chapel Hill, NC (JFZ, MCF, ECD); Johns Hopkins Sidney Kimmel Comprehensive Cancer Center , Baltimore, MD (JEK, ALB); Cancer Therapy Evaluation Program , National Cancer Institute , Rockville, MD (GS, SPI, PH)
| | - Judith E Karp
- Affiliations of authors: University of North Carolina, Lineberger Comprehensive Cancer Center , Chapel Hill, NC (JFZ, MCF, ECD); Johns Hopkins Sidney Kimmel Comprehensive Cancer Center , Baltimore, MD (JEK, ALB); Cancer Therapy Evaluation Program , National Cancer Institute , Rockville, MD (GS, SPI, PH)
| | - Amanda L Blackford
- Affiliations of authors: University of North Carolina, Lineberger Comprehensive Cancer Center , Chapel Hill, NC (JFZ, MCF, ECD); Johns Hopkins Sidney Kimmel Comprehensive Cancer Center , Baltimore, MD (JEK, ALB); Cancer Therapy Evaluation Program , National Cancer Institute , Rockville, MD (GS, SPI, PH)
| | - Matthew C Foster
- Affiliations of authors: University of North Carolina, Lineberger Comprehensive Cancer Center , Chapel Hill, NC (JFZ, MCF, ECD); Johns Hopkins Sidney Kimmel Comprehensive Cancer Center , Baltimore, MD (JEK, ALB); Cancer Therapy Evaluation Program , National Cancer Institute , Rockville, MD (GS, SPI, PH)
| | - E Claire Dees
- Affiliations of authors: University of North Carolina, Lineberger Comprehensive Cancer Center , Chapel Hill, NC (JFZ, MCF, ECD); Johns Hopkins Sidney Kimmel Comprehensive Cancer Center , Baltimore, MD (JEK, ALB); Cancer Therapy Evaluation Program , National Cancer Institute , Rockville, MD (GS, SPI, PH)
| | - Gary Smith
- Affiliations of authors: University of North Carolina, Lineberger Comprehensive Cancer Center , Chapel Hill, NC (JFZ, MCF, ECD); Johns Hopkins Sidney Kimmel Comprehensive Cancer Center , Baltimore, MD (JEK, ALB); Cancer Therapy Evaluation Program , National Cancer Institute , Rockville, MD (GS, SPI, PH)
| | - S Percy Ivy
- Affiliations of authors: University of North Carolina, Lineberger Comprehensive Cancer Center , Chapel Hill, NC (JFZ, MCF, ECD); Johns Hopkins Sidney Kimmel Comprehensive Cancer Center , Baltimore, MD (JEK, ALB); Cancer Therapy Evaluation Program , National Cancer Institute , Rockville, MD (GS, SPI, PH)
| | - Pamela Harris
- Affiliations of authors: University of North Carolina, Lineberger Comprehensive Cancer Center , Chapel Hill, NC (JFZ, MCF, ECD); Johns Hopkins Sidney Kimmel Comprehensive Cancer Center , Baltimore, MD (JEK, ALB); Cancer Therapy Evaluation Program , National Cancer Institute , Rockville, MD (GS, SPI, PH)
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First-in-human study of the toxicity, pharmacokinetics, and pharmacodynamics of CG200745, a pan-HDAC inhibitor, in patients with refractory solid malignancies. Invest New Drugs 2015; 33:1048-57. [PMID: 26076682 DOI: 10.1007/s10637-015-0262-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 06/09/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of the present study was to assess the safety, maximum tolerated dose (MTD), pharmacokinetics, pharmacodynamics, and efficacy of single and multiple doses of intravenous CG200745, a novel histone deacetylase (HDAC) inhibitor, in patients with advanced solid malignancies. EXPERIMENTAL DESIGN Two to six patients received intravenous CG200745 according to the 2 + 4 dose-escalating method. This first-in-human trial was comprised of two parts: Part 1 was a single ascending dose, and Part 2 was multiple ascending doses weekly for 3 weeks, and then 1 week off. For the first cycle, pharmacokinetic sampling for CG200745 and pharmacodynamic sampling for acetylated histone H4 in peripheral blood mononuclear cells (PBMCs) were performed on day 1 for Part 1 and on days 1 and 15 for Part 2. Examination of acetylated histone H4 in pre- and post-biopsy samples was performed in accessible patients. RESULTS In all, 28 patients were treated at 13 dose levels (1.8-250 mg/m(2)) and received a total of 71 cycles of CG200745. Hematologic toxicities included grade 3/4 neutropenia (22.2 %) that did not last a week and non-hematologic toxicities included fatigue (22.2 %) and anorexia (16.7 %) that did not exceed grade 2. No dose-limiting toxic effects were noted. Dose proportionality was observed for both the maximum concentration and area under the curve. The elimination half-life was 5.67 ± 2.69 h (mean ± standard deviation). An increase in PBMC acetylated histone H4 was observed at dose levels up to 51 mg/m(2), which plateaued at higher dose levels. At 24 h, 75 % of patients (6/8) showed higher relative acetylation in tumor tissue compared to PBMCs. Although there was no partial or complete response, 57.1 % of patients (16/28) had stable disease that lasted at least 6 weeks. CONCLUSIONS CG200745 can be safely administered at effective dose levels that inhibit HDAC in PBMCs and tumor tissue. Although MTD was not reached, further escalation was not performed because acetylated histone H4 plateaued at dose levels higher than 51 mg/m(2). Additional phase II trials are recommended at 250 mg/m(2).
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Dignam JJ, Karrison TG. Building firm foundations for therapy development. J Natl Cancer Inst 2015; 107:djv016. [PMID: 25710961 DOI: 10.1093/jnci/djv016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- James J Dignam
- Department of Public Health Sciences, University of Chicago (JJD, TGK).
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Abstract
The overall aging of the population has resulted in a marked increase in the number of older patients with cancer. These patients have specific needs that are different from those of the younger population. Cancer clinical trials have included an inadequate number of older patients, resulting in lack of meaningful data to make evidence-based decisions for this population. As a result, clinicians have to extrapolate data from younger and healthier patients. There are a number of reasons for this under-representation, including a design and implementation structure for clinical trials that does not meet the needs of this vulnerable population. Issues that need to be addressed include alterations in eligibility criteria to make them less restrictive by accounting for multiple comorbidities and prior malignancy and endpoints specific for older patients, such as quality of life, changes in function, and maintenance of independence. Other issues specific to the older population include alterations in dose-limiting toxicity, measures of treatment-related toxicity, and polypharmacy. Phase I trials can be appropriate for older patients but need to be tailored to their needs. Some form of geriatric assessment needs to be included to help with eligibility, assessment, and stratification. For future clinical trials to be truly meaningful they need to appropriately assess and incorporate the needs of the majority of the cancer population.
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