Evolution of the randomized controlled trial in oncology over three decades

Diagnosis and treatment of malignant tumors using integrated traditional and western medicine: progress, challenges and reflections

Malignant tumors are one of the leading causes of death in the world. Considerable progresses have been made on the treatment of tumors in recent decades, especially in the prevention, early diagnosis and the model changing of therapeutics. But we are still facing tough challenges, including the increasing treatment burden and limited improvement of efficacy. In China, Chinese medicine (CM) provides a powerful arsenal to fight against tumors. CM can be well applied to the onset and progression of tumors in China, bearing the characteristics of multi-target, multi-phase and multi-effect. But there are also many problems demanding urgent attention in the use of CM. Some most debated problems in this field were summarized. We should upgrade our concepts in using CM, find its position scientifically, and establish evidence of its effect by high quality clinical research.

Delivering affordable cancer care in high-income countries

The burden of cancer is growing, and the disease is becoming a major economic expenditure for all developed countries. In 2008, the worldwide cost of cancer due to premature death and disability (not including direct medical costs) was estimated to be US$895 billion. This is not simply due to an increase in absolute numbers, but also the rate of increase of expenditure on cancer. What are the drivers and solutions to the so-called cancer-cost curve in developed countries? How are we going to afford to deliver high quality and equitable care? Here, expert opinion from health-care professionals, policy makers, and cancer survivors has been gathered to address the barriers and solutions to delivering affordable cancer care. Although many of the drivers and themes are specific to a particular field-eg, the huge development costs for cancer medicines-there is strong concordance running through each contribution. Several drivers of cost, such as over-use, rapid expansion, and shortening life cycles of cancer technologies (such as medicines and imaging modalities), and the lack of suitable clinical research and integrated health economic studies, have converged with more defensive medical practice, a less informed regulatory system, a lack of evidence-based sociopolitical debate, and a declining degree of fairness for all patients with cancer. Urgent solutions range from re-engineering of the macroeconomic basis of cancer costs (eg, value-based approaches to bend the cost curve and allow cost-saving technologies), greater education of policy makers, and an informed and transparent regulatory system. A radical shift in cancer policy is also required. Political toleration of unfairness in access to affordable cancer treatment is unacceptable. The cancer profession and industry should take responsibility and not accept a substandard evidence base and an ethos of very small benefit at whatever cost; rather, we need delivery of fair prices and real value from new technologies.

Randomized controlled trials in the era of molecular oncology: methodology, biomarkers, and end points

BACKGROUND

We previously reported metrics of systemic therapy randomized controlled trials (RCTs) in breast cancer, colorectal cancer (CRC), and non-small-cell lung cancer (NSCLC) published 1975-2004. To evaluate trends in the era of targeted therapies (TT), we have repeated a similar analysis of RCTs published 2005-2009.

METHODS

A search for phase III RCTs of systemic agents published in five major journals 2005-2009 was carried out. Trials were classified as TT if they involved any non-hormonal targeted agent. We extracted data regarding biomarker use. Integral biomarkers were defined as tests used to determine eligibility, stratification, or allocation. Descriptive statistics were used to analyze trends over time.

RESULTS

One hundred and thirty-seven eligible RCTs were evaluated. Compared with 1995-2004, the number (17-27 RCTs/year) and size (median sample size 446-722, P < 0.001) of RCTs increased. The proportion of RCTs evaluating TT increased from 4% (7/167) to 29% (40/137) (P < 0.001). There was an increase in the proportion of trials with financial support from industry [57% (95/167) to 78% (107/137), P = 0.001]. Biomarkers were included in 58% (80/137) of RCTs; integral biomarkers were included in 36% (49/137) of trials. Among the 49 RCTs using integral biomarkers, 40 (82%) used HER2 and/or ER/PR status in studies of breast cancer.

CONCLUSIONS

RCTs published in 2005-2009 are larger, more likely to evaluate TT, and be supported by industry. Biomarkers may be increasingly used, but the most common use relates to traditional use of ER/PR and evolving use of HER2 in breast cancer RCTs.

Randomised controlled trials in oncology closed early for benefit: trends in methodology, results, and interpretation

PURPOSE

To assess methodology, results and interpretation of oncology randomised controlled trials closed early for benefit (RCTCEB).

METHODS

Structured literature search (1950-2008) to identify all published oncology RCTCEB. We then searched for related follow-up articles and conference abstracts to evaluate whether study results and conclusions changed with longer follow-up. A standardised data abstraction process captured information related to statistical methodology, details of interim analyses, results and conclusions. Original articles and follow-up reports were compared for results of primary end-point and author conclusions.

RESULTS

We identified 71 RCTCEB. In 16 articles (23%) the study primary end-point was not explicitly stated. Most trials were open to accrual (47/71, 66%) at the time of closure. Formal interim analysis was performed in 65 (92%) trials of which 72% (47/65) was reported as planned; 82% (53/65) reported stopping rules. Trials on average accrued 75% of the planned sample size. Amongst the 23 (32%) RCTCEB with follow-up reports, in only one case did the study results or conclusions change substantially.

CONCLUSIONS

While the majority of oncology RCTCEB follows rigourous methodological principles, an important percentage includes limitations in design and/or analysis. Amongst the 23 studies with subsequent follow-up reports, initial results were confirmed in 22 (96%).

Association between pharmaceutical support and basic science research on erythropoiesis-stimulating agents

BACKGROUND

To our knowledge, no prior research has evaluated the association between pharmaceutical industry funding and basic science research results. When erythropoiesis-stimulating agents (ESAs) were licensed to treat chemotherapy-associated anemia, basic science concerns related to potential cancer stimulation were raised. We evaluated associations between pharmaceutical industry support and reported findings evaluating ESA effects on cancer cells.

METHODS

Articles identified in MEDLINE and EMBASE databases (1988-2008) investigating basic science findings related to ESA administration in the solid tumor setting were reviewed. Outcomes included information on erythropoietin receptors (EpoRs), Epo-induced signaling events, cellular function, and qualitative conclusions. Information on study funding (academic investigators with no reported funding from ESA manufacturers [64 studies], academic investigators with grant funding from ESA manufacturers [7 studies], and investigators employed by the ESA manufacturers [3 studies]) was evaluated. Some studies did not include information on each outcome.

RESULTS

Investigators without funding from ESA manufacturers were more likely than academic investigators with such funding or investigators employed by ESA manufacturers to identify EpoRs on solid tumor cells (100%, 60%, and 67%, respectively; P = .009), Epo-induced signaling events (94%, 0%, and 0%, respectively; P = .001), or changes in cellular function (57%, 0%, and 0%, respectively; P = .007) and to conclude that ESAs had potentially harmful effects on cancer cells (57%, 0%, and 0%, respectively; P = .008).

CONCLUSIONS

Researchers who do not have pharmaceutical industry support are more likely than those with pharmaceutical support to identify detrimental in vitro effects of ESAs. The potential for conflicts of interest to affect basic science research should be considered.

The financing of drug trials by pharmaceutical companies and its consequences: part 2: a qualitative, systematic review of the literature on possible influences on authorship, access to trial data, and trial registration and publication

BACKGROUND

In recent years, a number of studies have shown that clinical drug trials financed by pharmaceutical companies yield favorable results for company products more often than independent trials do. Moreover, pharmaceutical companies have been found to influence drug trials in various ways. This overview of current, systematic studies on this topic is intended to identify and characterize the particular aspects of the performance of a drug trial that can be affected by financial support from a pharmaceutical company.

METHODS

Publications retrieved from a systematic Medline search on this topic from 1 November 2002 to 16 December 2009 were independently evaluated and selected by two of the authors. These publications were supplemented by further ones found in their references sections.

RESULTS

57 publications were included for evaluation in Parts 1 and 2 of this article. A number of studies revealed that many trials financed by pharmaceutical companies-in some cases, as many as half of all such trials-are never published. Moreover, multiple publications of the same findings were found, and some reports were found to include selectively published data. Further studies revealed evidence of other problems including incomplete trial registration, constraints on publishing rights, withheld knowledge of adverse drug reactions, and the use of ghostwriters who were supplied by the pharmaceutical companies.

CONCLUSION

Financial support from a pharmaceutical company influences multiple aspects of the performance of drug trials and often leads to a favorable result for the corporate sponsor of the trial. Public access to trial protocols and results must be ensured. Moreover, more effort should be made to carry out drug trials independently, without the financial support of pharmaceutical companies.

The financing of drug trials by pharmaceutical companies and its consequences. Part 1: a qualitative, systematic review of the literature on possible influences on the findings, protocols, and quality of drug trials

BACKGROUND

In recent years, a number of studies have shown that clinical drug trials financed by pharmaceutical companies yield favorable results for company products more often than independent trials do. Moreover, pharmaceutical companies have been found to influence drug trials in various ways. This paper provides an overview of the findings of current, systematic studies on this topic.

METHODS

Publications retrieved from a systematic Medline search on this topic from 1 November 2002 to 16 December 2009 were independently evaluated and selected by two of the authors. These publications were supplemented by further ones found in their references sections.

RESULTS

57 publications were included for evaluation in Parts 1 and 2 of this article. Published drug trials that were financed by pharmaceutical companies, or whose authors declared a financial conflict of interest, were found to yield favorable results for the drug manufacturer more frequently than independently financed trials whose authors had no such conflicts. The results were also interpreted favorably more often than in independently financed trials. Furthermore, there was evidence that pharmaceutical companies influenced study protocols in a way that was favorable to themselves. The methodological quality of trials financed by pharmaceutical companies was not found to be any worse than that of trials financed in other ways.

CONCLUSION

Published drug trials that are financed by pharmaceutical companies may present a distorted picture. This cannot be explained by any difference in methodological quality between such trials and trials financed in other ways.

Relationships between authorship contributions and authors' industry financial ties among oncology clinical trials

PURPOSE To test the hypothesis that authors who play key scientific roles in oncology clinical trials, and who therefore have increased influence over the design, analysis, interpretation or reporting of trials, are more likely than those who do not play such roles to have financial ties to industry. METHODS Data were abstracted from all trials (n = 235) of drugs or biologic agents published in the Journal of Clinical Oncology between January 1, 2006 and June 30, 2007. Article-level data included sponsorship, age group (adult v pediatric), phase, single versus multicenter, country (United States v other), and number of authors. Author-level data (n = 2,927) included financial ties (eg, employment, consulting) and performance of key scientific roles (ie, conception/design, analysis/interpretation, or manuscript writing). Associations between performance of key roles and financial ties, adjusting for article-level covariates, were examined using generalized linear mixed models. Results One thousand eight hundred eighty-one authors (64%) reported performing at least one key role, and 842 authors (29%) reported at least one financial tie. Authors who reported performing a key role were more likely than other authors to report financial ties to industry (adjusted odds ratio [OR], 4.3; 99% CI, 3.0 to 6.0; P < .0001). The association was stronger among trials with, compared with those without, industry funding (OR, 5.0 [99% CI, 3.4 to 7.5] v OR, 2.5 [99% CI, 1.3 to 4.8]), but was present regardless of sponsorship. CONCLUSION Authors who perform key roles in the conception and design, analysis, and interpretation, or reporting of oncology clinical trials are more likely than authors who do not perform such roles to have financial ties to industry.

Ultimate fate of oncology drugs approved by the us food and drug administration without a randomized Trial

PURPOSE

To approve a new anticancer drug, the US Food and Drug Administration often requires randomized trials. However, several oncology drugs have been approved on the basis of objective end points without a randomized trial. We reviewed the long-term safety and efficacy of such agents.

METHODS

We searched the Web site of the US Food and Drug Administration's Center for Drug Evaluation and Research and MEDLINE for initial applications of investigational anticancer drugs from 1973 through 2006.

RESULTS

Overall, 68 oncology drugs, excluding hormone therapy and supportive care, were approved, including 31 without a randomized trial. For these 31 drugs, a median of two clinical trials (range, one to seven) and 79 patients (range, 40 to 413) were used per approval. Objective response was the most common end point used for approval; median response rate was 33% (range, 11% to 90%). Thirty drugs are still fully approved. United States marketing authorization for one drug, gefitinib (an epidermal growth factor receptor [EGFR] inhibitor), was rescinded after a randomized trial showed no survival improvement; however, this trial was performed in unselected patients, and it was subsequently demonstrated that patients with EGFR mutation are more likely to respond. Nineteen of the 31 drugs have additional uses (per National Comprehensive Cancer Network or National Cancer Institute Physician Data Query guidelines), and subsequent formal US Food and Drug Administration approvals were obtained for 11 of these (range, one to 18 new indications). No drug has demonstrated safety concerns.

CONCLUSION

Nonrandomized clinical trials with definitive end points can yield US Food and Drug Administration approvals, and these drugs have a reassuring record of long-term safety and efficacy.

Presentation of Nonfinal Results of Randomized Controlled Trials at Major Oncology Meetings

Purpose

To assess the frequency, implications, and factors associated with reporting nonfinal analyses (NFAs) of randomized controlled trials (RCTs) as abstract publications.

Methods

We identified 138 consecutive reports of RCTs testing systemic therapy for lymphoma, breast, colorectal, or non–small-cell lung cancer published in six major journals between 2000 and 2004. We then searched proceedings of seven major cancer meetings, 1990 to 2004, for abstracts related to these publications which presented efficacy results. Articles and abstracts were compared for discordance in sample size, median follow-up, results, and conclusions. Abstracts were evaluated for statements explicitly noting or implying that results were not final. Factors associated with discordance were assessed by uni- and multivariate analyses.

Results

We identified 303 related abstracts; 197 were eligible. In 86 abstracts (44%), results were stated or implied to be NFA; this was explicitly stated in 41 (21%). The NFAs included 12 where accrual was ongoing. Discordance with article was found in 124 abstracts (63%) and was more common with NFAs (67 of 86 [78%] v 57 of 111 [51%]; P = .0001). When compared with articles, authors' conclusions were substantively different in 17 abstracts (10%). Factors most associated with data discordance were lymphoma trial (odds ratio [OR], 3.8; 95% CI, 1.5 to 10.8), cooperative group trial (OR, 2.8; 95% CI, 1.4 to 5.6), and presentation of a NFA (OR, 2.9; 95% CI, 1.5 to 5.8).

Conclusion

Meeting abstracts often include NFAs and are frequently discordant with subsequent article publication.

Clinical benefit in oncology trials: is this a patient-centred or tumour-centred end-point?

BACKGROUND

Clinical benefit (CB) was first successfully used as an end-point in 1997 in the pivotal study of gemcitabine in advanced pancreas cancer. In the trial by Burris et al. CB was a composite measure of pain, performance status and weight. Here we describe how CB has been used in oncology trials since that time.

METHODS

We performed an electronic search (www.jco.org) for reports of all clinical trials (phase I, II and III) published in the Journal of Clinical Oncology 1997-2008 citing 'clinical benefit'. Eligible trials were those reporting clinical benefit as an end-point. Details related to study methodology, sponsorship and end-points were abstracted. Use of CB was classified as patient centred if it referred to improvement in the clinical parameters used by Burris et al. or in other disease-related symptoms. CB was classified as tumour centred if it related to objective tumour criteria for partial/complete response and/or stable disease. Descriptive statistics were used to summarise findings and the chi-square test was used to compare proportions.

RESULTS

Seventy-one trials reporting CB as an end-point were identified: 37 in breast, 8 in pancreas and 26 in other cancers. The definition of CB was patient centred in 20 trials (28%) and tumour centred in 51 trials (72%). Only 20% (14/71) of trials (including all 8 pancreas studies) used the original Burris definition. Among the 71 trials reporting clinical benefit, in only 31 (44%) cases was the end-point defined as a primary or secondary study objective. Trials with a patient-centred definition of CB were considerably more likely to do so than trials with a tumour-centred definition (19/20, 95% versus 12/51, 24%, p<0.0001). Study variables associated with the use of a tumour-centred definition include: disease site (breast 35/37, 95%; all others 16/34, 47%, p<0.001) and intervention (hormone or targeted agent 38/40, 95%; chemotherapy 13/31, 42%, p<0.001). There has been a steady increase in the number of trials using CB as an end-point; in the second half of the study period the number of trials increased from 17 to 54, along with the proportion of trials with a tumour-centred definition (10/17, 59% to 41/54, 76%, p=0.09).

CONCLUSIONS

Despite its initial definition, clinical benefit is often used to describe objective tumour findings. Clinical trials should use end-points in a consistent manner to enable clear communication between investigators, clinicians and patients about the benefit of novel therapies.