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Gelinas L, Lynch HF, Bierer B, Cohen IG. Institutions as an ethical locus of research prioritisation. JOURNAL OF MEDICAL ETHICS 2017; 43:816-818. [PMID: 28385733 DOI: 10.1136/medethics-2017-104165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/16/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Luke Gelinas
- Petrie-Flom Center at Harvard Law School, Cambridge, USA
| | | | - Barbara Bierer
- Multi-Regional Clinical Trials Center at Harvard University, Cambridge, Massachusetts, USA
| | - I Glenn Cohen
- Harvard Law School Ringgold standard institution, Cambridge, Massachusetts, USA
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202
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Rüegger CM, Dawson JA, Donath SM, Owen LS, Davis PG. Nonpublication and discontinuation of randomised controlled trials in newborns. Acta Paediatr 2017; 106:1940-1944. [PMID: 28871629 DOI: 10.1111/apa.14062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 08/31/2017] [Indexed: 12/24/2022]
Abstract
AIM To determine the rate of nonpublication and discontinuation of randomised controlled trials (RCTs) in newborns. METHODS This was a retrospective, cross-sectional study of RCTs registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR) between 2008 and 2012. RESULTS Fifty trials were identified, of which 23 (46%) were retrospectively registered. Thirty trials (60%) were published. After a median follow-up of 8.0 (range 4.6-17.4) years from Research Ethics Committee approval, 15 of 41 completed trials (37%) remained unpublished, representing 5422 neonatal trial participants. Nine trials (18%) were discontinued, including four that were published. The most frequent reason for discontinuation was poor recruitment (n = 4). Sample size discrepancies between registration and publication were found in 17 (65%) of the 26 completed, published trials. In nine (35%) of these trials, the calculated sample size in the method section of the published article differed from the planned sample size in the trial registry (relative difference -20% to +33%). CONCLUSION Nonpublication and discontinuation of RCTs conducted in newborns is common. Additional efforts are needed to minimise the number of neonatal trial participants that are exposed to interventions without subsequent publication.
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Affiliation(s)
- Christoph M. Rüegger
- Newborn Research Centre and Neonatal Services; The Royal Women's Hospital; Parkville VIC Australia
- Newborn Research; Department of Neonatology; University Hospital and University of Zürich; Zürich Switzerland
| | - Jennifer A. Dawson
- Newborn Research Centre and Neonatal Services; The Royal Women's Hospital; Parkville VIC Australia
- Murdoch Childrens Research Institute; Melbourne VIC Australia
- University of Melbourne; Melbourne VIC Australia
| | - Susan M. Donath
- Murdoch Childrens Research Institute; Melbourne VIC Australia
- University of Melbourne; Melbourne VIC Australia
| | - Louise S. Owen
- Newborn Research Centre and Neonatal Services; The Royal Women's Hospital; Parkville VIC Australia
- Murdoch Childrens Research Institute; Melbourne VIC Australia
- University of Melbourne; Melbourne VIC Australia
| | - Peter G. Davis
- Newborn Research Centre and Neonatal Services; The Royal Women's Hospital; Parkville VIC Australia
- Murdoch Childrens Research Institute; Melbourne VIC Australia
- University of Melbourne; Melbourne VIC Australia
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203
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van den Bogert CA, Souverein PC, Brekelmans CT, Janssen SW, Koëter GH, Leufkens HG, Bouter LM. Recruitment failure and futility were the most common reasons for discontinuation of clinical drug trials. Results of a nationwide inception cohort study in the Netherlands. J Clin Epidemiol 2017; 88:140-147. [PMID: 28487159 DOI: 10.1016/j.jclinepi.2017.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 03/16/2017] [Accepted: 05/02/2017] [Indexed: 01/11/2023]
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204
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Largent EA, Lynch HF. Paying Research Participants: The Outsized Influence of "Undue Influence". IRB 2017; 39:1-9. [PMID: 29038611 PMCID: PMC5640154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Emily A Largent
- Research Associate, Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard Law School; Regulatory Foundation, Ethics, and Law Program, Harvard Catalyst | The Harvard Clinical and Translational Science Center
| | - Holly Fernandez Lynch
- Executive Director, Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, Harvard Law School; Faculty, Center for Bioethics, Harvard Medical School; Regulatory Foundations, Ethics, and Law Program, Harvard Catalyst | The Harvard Clinical and Translational Science Center
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205
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Baldi I, Lanera C, Berchialla P, Gregori D. Early termination of cardiovascular trials as a consequence of poor accrual: analysis of ClinicalTrials.gov 2006-2015. BMJ Open 2017; 7:e013482. [PMID: 28619765 PMCID: PMC5577897 DOI: 10.1136/bmjopen-2016-013482] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To present a snapshot of experimental cardiovascular research with a focus on geographical and temporal patterns of early termination due to poor accrual. SETTING The Aggregate Analysis of ClinicalTrials.gov (AACT) database, reflecting ClinicalTrials.gov as of 27 March 2016. DESIGN The AACT database was searched for all cardiovascular clinical trials that started from January 2006 up to December 2015. RESULTS Thirteen thousand and seven hundred twenty-nine cardiovascular trials were identified. Of these, 8900 (65%) were classified as closed studies. Globally, 11% of closed trials were terminated. This proportion varied from 9.6% to 14% for trials recruiting from Europe and Americas, respectively, with a slightly decreasing trend (p=0.02) over the study period. The most common reason for trials failing to complete was poor accrual (41%). Intercontinental trials exhibited lower figures of poor accrual as the reason for their early stopping, as compared with trials recruiting in a single continent (28% vs 44%, p=0.002). CONCLUSIONS Poor accrual significantly challenges the successful completion of cardiovascular clinical trials. Findings are suggestive of a positive effect of globalisation of cardiovascular clinical research on the achievement of enrolment goals within a reasonable time frame.
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Affiliation(s)
- Ileana Baldi
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Corrado Lanera
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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Abstract
Duchenne muscular dystrophy (DMD) is an X-linked disease caused by mutations in the DMD gene and loss of the protein dystrophin. The absence of dystrophin leads to myofiber membrane fragility and necrosis, with eventual muscle atrophy and contractures. Affected boys typically die in their second or third decade due to either respiratory failure or cardiomyopathy. Despite extensive attempts to develop definitive therapies for DMD, the standard of care remains prednisone, which has only palliative benefits. Animal models, mainly the mdx mouse and golden retriever muscular dystrophy (GRMD) dog, have played a key role in studies of DMD pathogenesis and treatment development. Because the GRMD clinical syndrome is more severe than in mice, better aligning with the progressive course of DMD, canine studies may translate better to humans. The original founder dog for all GRMD colonies worldwide was identified in the early 1980s before the discovery of the DMD gene and dystrophin. Accordingly, analogies to DMD were initially drawn based on similar clinical features, ranging from the X-linked pattern of inheritance to overlapping histopathologic lesions. Confirmation of genetic homology between DMD and GRMD came with identification of the underlying GRMD mutation, a single nucleotide change that leads to exon skipping and an out-of-frame DMD transcript. GRMD colonies have subsequently been established to conduct pathogenetic and preclinical treatment studies. Simultaneous with the onset of GRMD treatment trials, phenotypic biomarkers were developed, allowing definitive characterization of treatment effect. Importantly, GRMD studies have not always substantiated findings from mdx mice and have sometimes identified serious treatment side effects. While the GRMD model may be more clinically relevant than the mdx mouse, usage has been limited by practical considerations related to expense and the number of dogs available. This further complicates ongoing broader concerns about the poor rate of translation of animal model preclinical studies to humans with analogous diseases. Accordingly, in performing GRMD trials, special attention must be paid to experimental design to align with the approach used in DMD clinical trials. This review provides context for the GRMD model, beginning with its original description and extending to its use in preclinical trials.
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Affiliation(s)
- Joe N Kornegay
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, Mail Stop 4458, College Station, TX, 77843-4458, USA.
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207
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Morgan CJ. Statistical issues associated with terminating a clinical trial due to slow enrollment. J Nucl Cardiol 2017; 24:525-526. [PMID: 27804066 DOI: 10.1007/s12350-016-0702-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 09/26/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Charity J Morgan
- Department of Biostatistics, University of Alabama at Birmingham, 1720 Second Avenue South, Birmingham, AL, 35294-0022, UK.
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208
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Krischer J, Cronholm PF, Burroughs C, McAlear CA, Borchin R, Easley E, Davis T, Kullman J, Carette S, Khalidi N, Koening C, Langford CA, Monach P, Moreland L, Pagnoux C, Specks U, Sreih AG, Ytterberg S, Merkel PA. Experience With Direct-to-Patient Recruitment for Enrollment Into a Clinical Trial in a Rare Disease: A Web-Based Study. J Med Internet Res 2017; 19:e50. [PMID: 28246067 PMCID: PMC5350442 DOI: 10.2196/jmir.6798] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 01/18/2017] [Accepted: 01/21/2017] [Indexed: 12/28/2022] Open
Abstract
Background The target sample size for clinical trials often necessitates a multicenter (center of excellence, CoE) approach with associated added complexity, cost, and regulatory requirements. Alternative recruitment strategies need to be tested against this standard model. Objectives The aim of our study was to test whether a Web-based direct recruitment approach (patient-centric, PC) using social marketing strategies provides a viable option to the CoE recruitment method. Methods PC recruitment and Web-based informed consent was compared with CoE recruitment for a randomized controlled trial (RCT) of continuing versus stopping low-dose prednisone for maintenance of remission of patients with granulomatosis with polyangiitis (GPA). Results The PC approach was not as successful as the CoE approach. Enrollment of those confirmed eligible by their physician was 10 of 13 (77%) and 49 of 51 (96%) in the PC and CoE arms, respectively (P=.05). The two approaches were not significantly different in terms of eligibility with 34% of potential participants in the CoE found to be ineligible as compared with 22% in the PC arm (P=.11) nor in provider acceptance, 22% versus 26% (P=.78). There was no difference in the understanding of the trial as reflected in the knowledge surveys of individuals in the PC and CoE arms. Conclusions PC recruitment was substantially less successful than that achieved by the CoE approach. However, the PC approach was good at confirming eligibility and was as acceptable to providers and as understandable to patients as the CoE approach. The PC approach should be evaluated in other clinical settings to get a better sense of its potential.
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Affiliation(s)
- Jeffrey Krischer
- Rare Diseases Clinical Research Network Data Coordinating Center, Health Informatics Institute, University of South Florida, Tampa, FL, United States
| | | | - Cristina Burroughs
- Rare Diseases Clinical Research Network Data Coordinating Center, Health Informatics Institute, University of South Florida, Tampa, FL, United States
| | | | - Renee Borchin
- Rare Diseases Clinical Research Network Data Coordinating Center, Health Informatics Institute, University of South Florida, Tampa, FL, United States
| | - Ebony Easley
- University of Pennsylvania, Philadelphia, PA, United States
| | - Trocon Davis
- University of Pennsylvania, Philadelphia, PA, United States
| | - Joyce Kullman
- Vasculitis Foundation, Kansas City, MO, United States
| | | | - Nader Khalidi
- St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Curry Koening
- University of Utah, Salt Lake City, UT, United States
| | | | - Paul Monach
- Boston University School of Medicine, Boston, MA, United States
| | | | | | | | | | | | - Peter A Merkel
- University of Pennsylvania, Philadelphia, PA, United States
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- Vasculitis Clinical Research Consortium, Philadelphia, PA, United States
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209
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Mattina J, Carlisle B, Hachem Y, Fergusson D, Kimmelman J. Inefficiencies and Patient Burdens in the Development of the Targeted Cancer Drug Sorafenib: A Systematic Review. PLoS Biol 2017; 15:e2000487. [PMID: 28158308 PMCID: PMC5291369 DOI: 10.1371/journal.pbio.2000487] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 01/06/2017] [Indexed: 02/06/2023] Open
Abstract
Failure in cancer drug development exacts heavy burdens on patients and research systems. To investigate inefficiencies and burdens in targeted drug development in cancer, we conducted a systematic review of all prelicensure trials for the anticancer drug, sorafenib (Bayer/Onyx Pharmaceuticals). We searched Embase and MEDLINE databases on October 14, 2014, for prelicensure clinical trials testing sorafenib against cancers. We measured risk by serious adverse event rates, benefit by objective response rates and survival, and trial success by prespecified primary endpoint attainment with acceptable toxicity. The first two clinically useful applications of sorafenib were discovered in the first 2 efficacy trials, after five drug-related deaths (4.6% of 108 total) and 93 total patient-years of involvement (2.4% of 3,928 total). Thereafter, sorafenib was tested in 26 indications and 67 drug combinations, leading to one additional licensure. Drug developers tested 5 indications in over 5 trials each, comprising 56 drug-related deaths (51.8% of 108 total) and 1,155 patient-years (29.4% of 3,928 total) of burden in unsuccessful attempts to discover utility against these malignancies. Overall, 32 Phase II trials (26% of Phase II activity) were duplicative, lacked appropriate follow-up, or were uninformative because of accrual failure, constituting 1,773 patients (15.6% of 11,355 total) participating in prelicensure sorafenib trials. The clinical utility of sorafenib was established early in development, with low burden on patients and resources. However, these early successes were followed by rapid and exhaustive testing against various malignancies and combination regimens, leading to excess patient burden. Our evaluation of sorafenib development suggests many opportunities for reducing costs and unnecessary patient burden in cancer drug development.
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Affiliation(s)
- James Mattina
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, Quebec, Canada
| | - Benjamin Carlisle
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, Quebec, Canada
| | - Yasmina Hachem
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, Quebec, Canada
| | - Dean Fergusson
- Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Biomedical Ethics Unit, McGill University, Montréal, Quebec, Canada
- * E-mail:
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210
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Kahan BC. Using re-randomization to increase the recruitment rate in clinical trials - an assessment of three clinical areas. Trials 2016; 17:595. [PMID: 27964743 PMCID: PMC5154140 DOI: 10.1186/s13063-016-1736-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 11/23/2016] [Indexed: 11/17/2022] Open
Abstract
Background Patient recruitment in clinical trials is often challenging, and as a result, many trials are stopped early due to insufficient recruitment. The re-randomization design allows patients to be re-enrolled and re-randomized for each new treatment episode that they experience. Because it allows multiple enrollments for each patient, this design has been proposed as a way to increase the recruitment rate in clinical trials. However, it is unknown to what extent recruitment could be increased in practice. Methods We modelled the expected recruitment rate for parallel-group and re-randomization trials in different settings based on estimates from real trials and datasets. We considered three clinical areas: in vitro fertilization, severe asthma exacerbations, and acute sickle cell pain crises. We compared the two designs in terms of the expected time to complete recruitment, and the sample size recruited over a fixed recruitment period. Results Across the different scenarios we considered, we estimated that re-randomization could reduce the expected time to complete recruitment by between 4 and 22 months (relative reductions of 19% and 45%), or increase the sample size recruited over a fixed recruitment period by between 29% and 171%. Re-randomization can increase recruitment most for trials with a short follow-up period, a long trial recruitment duration, and patients with high rates of treatment episodes. Conclusions Re-randomization has the potential to increase the recruitment rate in certain settings, and could lead to quicker and more efficient trials in these scenarios.
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Affiliation(s)
- Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, 58 Turner St, London, E1 2AB, UK.
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211
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Mileham KF, Kim ES. Who's Eligible Anyway? Risk Modeling for Clinical Trial Accrual. Clin Cancer Res 2016; 22:5397-5399. [PMID: 27601589 DOI: 10.1158/1078-0432.ccr-16-1710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/05/2016] [Indexed: 11/16/2022]
Abstract
Accrual continues to be a challenge for oncology clinical trials. Interventions to enhance accrual after study activation exist, including corrective action plans for NCI-sponsored trials. Clinical trials would benefit from a proactive approach rather than a reactive approach. Accrual strategy planning early in trial development is suggested. Clin Cancer Res; 22(22); 5397-9. ©2016 AACRSee related article by Massett et al., p. 5408.
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Affiliation(s)
- Kathryn F Mileham
- Department of Solid Tumor Oncology and Investigational Therapeutics, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Edward S Kim
- Department of Solid Tumor Oncology and Investigational Therapeutics, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, North Carolina.
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212
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Blümle A, Schandelmaier S, Oeller P, Kasenda B, Briel M, von Elm E. Premature Discontinuation of Prospective Clinical Studies Approved by a Research Ethics Committee - A Comparison of Randomised and Non-Randomised Studies. PLoS One 2016; 11:e0165605. [PMID: 27792749 PMCID: PMC5085068 DOI: 10.1371/journal.pone.0165605] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 10/15/2016] [Indexed: 11/22/2022] Open
Abstract
Background Premature discontinuation of clinical studies affects about 25% of randomised controlled trials (RCTs) which raises concerns about waste of scarce resources for research. The risk of discontinuation of non-randomised prospective studies (NPSs) is yet unclear. Objectives To compare the proportion of discontinued studies between NPSs and RCTs that received ethical approval. Methods We systematically surveyed prospective longitudinal clinical studies that were approved by a single REC in Freiburg, Germany between 2000 and 2002. We collected study characteristics, identified subsequent publications, and surveyed investigators to elucidate whether a study was discontinued and, if so, why. Results Of 917 approved studies, 547 were prospective longitudinal studies (306 RCTs and 241 NPSs). NPSs were on average smaller than RCTs, more frequently single centre and pilot studies, and less frequently funded by industry. NPSs were less frequently discontinued than RCTs: 32/221 (14%) versus 78/288 (27%, p<0.001, missing data excluded). Poor recruitment was the most frequent reason for discontinuation in both NPSs (36%) and RCTs (37%). Conclusions Compared to RCTs, NPSs were at lower risk for discontinuation. Measures to reliably predict, sustain, and stimulate recruitment could prevent discontinuation of many RCTs but also of some NPSs.
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Affiliation(s)
- Anette Blümle
- Cochrane Germany, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- * E-mail:
| | - Stefan Schandelmaier
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Patrick Oeller
- Cochrane Germany, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benjamin Kasenda
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Matthias Briel
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Erik von Elm
- Cochrane Switzerland, Institute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland
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213
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Hughes-Morley A, Young B, Hempel RJ, Russell IT, Waheed W, Bower P. What can we learn from trial decliners about improving recruitment? Qualitative study. Trials 2016; 17:494. [PMID: 27733181 PMCID: PMC5062905 DOI: 10.1186/s13063-016-1626-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/28/2016] [Indexed: 11/10/2022] Open
Abstract
Background Trials increasingly experience problems in recruiting participants. Understanding the causes of poor recruitment is critical to developing solutions. We interviewed people who had declined a trial of an innovative psychological therapy for depression (REFRAMED) about their response to the trial invitation, in order to understand their decision and identify ways to improve recruitment. Methods Of 214 people who declined the trial, 35 (16 %) gave permission to be contacted about a qualitative study to explore their decision. Analysis of transcripts of semi-structured interviews was informed by grounded theory. Results We interviewed 20 informants: 14 women and six men, aged 18 to 77 years. Many interviewees had prior experience of research participation and positive views of the trial. Interviewees’ decision making resembled a four-stage sequential process; in each stage they either decided not to participate in the trial or progressed to the next stage. In stage 1, interviewees assessed the invitation in the context of their experiences and attitudes; we term those who opted out at this stage ‘prior decliners’ as they had an established position of declining trials. In stage 2, interviewees assessed their own eligibility; those who judged themselves ineligible and opted out at this stage are termed ‘self-excluders’. In stage 3, interviewees assessed their need for the trial therapy and potential to benefit; we term those who decided they did not need the trial therapy and opted out at this stage ‘treatment decliners’. In stage 4, interviewees deliberated the benefits and costs of trial participation; those who opted out after judging that disadvantages outweighed advantages are termed ‘trial decliners’. Across all stages, most individuals declined because they judged themselves ineligible or not in need of the trial therapy. While ‘prior decliners’ are unlikely to respond to any trial recruitment initiative, the factors leading others to decline are amenable to amelioration as they do not arise from a rejection of trials or a personal stance. Conclusions To improve recruitment in similar trials, the most successful interventions are likely to address patients’ assessments of their eligibility and their potential to benefit from the trial treatment, rather than reducing trial burden. Trial registration International Standard Randomised Controlled Trial Number: ISRCTN85784627. Registration date 10 August 2011. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1626-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adwoa Hughes-Morley
- MRC North West Hub for Trials Methodology Research, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, M13 9PT, UK. .,York Trials Unit, Department of Health Sciences, University of York, York, YO10 5DD, UK.
| | - Bridget Young
- MRC North West Hub for Trials Methodology Research, Department of Psychology, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Roelie J Hempel
- School of Psychology, University of Southampton, Southampton, SO17 1BJ, UK
| | - Ian T Russell
- Swansea University Medical School, Swansea University, Swansea, SA2 8PP, UK
| | - Waquas Waheed
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, The University of Manchester, Williamson Building, Manchester, M13 9PT, UK
| | - Peter Bower
- MRC North West Hub for Trials Methodology Research, Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester, M13 9PT, UK.,NIHR School for Primary Care Research, Manchester Academic Health Science Centre, The University of Manchester, Williamson Building, Manchester, M13 9PT, UK
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214
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Pica N, Bourgeois F. Discontinuation and Nonpublication of Randomized Clinical Trials Conducted in Children. Pediatrics 2016; 138:peds.2016-0223. [PMID: 27492817 PMCID: PMC5005019 DOI: 10.1542/peds.2016-0223] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Trial discontinuation and nonpublication represent potential waste in research resources and lead to compromises in medical evidence. Pediatric trials may be particularly vulnerable to these outcomes given the challenges encountered in conducting trials in children. We aimed to determine the prevalence of discontinuation and nonpublication of randomized clinical trials (RCTs) conducted in pediatric populations. METHODS Retrospective, cross-sectional study of pediatric RCTs registered in ClinicalTrials.gov from 2008 to 2010. Data were collected from the registry and associated publications identified (final search on September 1, 2015). RESULTS Of 559 trials, 104 (19%) were discontinued early, accounting for an estimated 8369 pediatric participants. Difficulty with patient accrual (37%) was the most commonly cited reason for discontinuation. Trials were less likely to be discontinued if they were funded by industry compared with academic institutions (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.27-0.77). Of the 455 completed trials, 136 (30%) were not published, representing 69 165 pediatric participants. Forty-two unpublished trials posted results on ClinicalTrials.gov. Trials funded by industry were more than twice as likely to result in nonpublication at 24 and 36 months (OR 2.21, 95% CI 1.35-3.64; OR 3.12, 95% CI 1.6-6.08, respectively) and had a longer mean time to publication compared with trials sponsored by academia (33 vs 24 months, P < .001). CONCLUSIONS In this sample of pediatric RCTs, discontinuation and nonpublication were common, with thousands of children exposed to interventions that did not lead to informative or published findings. Trial funding source was an important determinant of these outcomes, with both academic and industry sponsors contributing to inefficiencies.
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Affiliation(s)
- Natalie Pica
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;,Boston Combined Residency Program, Boston Children's Hospital and Boston Medical Center, Boston, Massachusetts; and
| | - Florence Bourgeois
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; Division of Emergency Medicine and Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts
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215
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Bates SE, Berry DA, Balasubramaniam S, Bailey S, LoRusso PM, Rubin EH. Advancing Clinical Trials to Streamline Drug Development. Clin Cancer Res 2016; 21:4527-35. [PMID: 26473188 DOI: 10.1158/1078-0432.ccr-15-0039] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The last decade in oncology has been marked by the identification of numerous new potential cancer targets and even more agents designed to inhibit them. The matrix of new targets, new agents, and the companion diagnostics required to identify the right patient for the right drug has created a major challenge for the clinical trial process. This has been compounded by the addition of new immunomodulators targeting the host immune system rather than the tumor. Recognizing the need for new approaches, industry, investigators, and regulators have responded to this challenge. New clinical trial designs are being evaluated to incorporate the genomic sequence data being obtained almost routinely after cancer diagnosis. New dose-finding approaches are being proposed to identify the maximum effective dose rather than the maximum tolerated dose. The FDA is involved in the drug approval process from points early in development and has accepted registration quality data from expansion cohorts in support of drug approval. Despite progress on several fronts, many challenges remain, including the lack of predictability of preclinical data for clinical results and phase II data for phase III results, an infrastructure that can be an obstacle to clinical trial development and implementation, and the increasing use of contracted clinical research organizations that limit a fit-for-purpose approach to clinical trial execution. Perhaps most challenging and important of all are the difficulties with clinical trial accrual that can prevent study completion. Both the innovations and the challenges highlight the important role of process in progress in clinical oncology.
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Affiliation(s)
- Susan E Bates
- Developmental Therapeutics Branch, National Cancer Institute, Bethesda, Maryland.
| | - Donald A Berry
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sanjeeve Balasubramaniam
- Office of Hematology and Oncology Products, Center for Drug Evaluation and Research, FDA, Silver Spring, Maryland
| | - Stuart Bailey
- Novartis Institutes for BioMedical Research, Cambridge, Massachusetts
| | | | - Eric H Rubin
- Merck Research Laboratories, North Wales, Pennsylvania
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216
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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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217
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Kahan BC, Forbes AB, Doré CJ, Morris TP. A re-randomisation design for clinical trials. BMC Med Res Methodol 2015; 15:96. [PMID: 26541982 PMCID: PMC4634916 DOI: 10.1186/s12874-015-0082-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 10/07/2015] [Indexed: 11/17/2022] Open
Abstract
Background Recruitment to clinical trials is often problematic, with many trials failing to recruit to their target sample size. As a result, patient care may be based on suboptimal evidence from underpowered trials or non-randomised studies. Methods For many conditions patients will require treatment on several occasions, for example, to treat symptoms of an underlying chronic condition (such as migraines, where treatment is required each time a new episode occurs), or until they achieve treatment success (such as fertility, where patients undergo treatment on multiple occasions until they become pregnant). We describe a re-randomisation design for these scenarios, which allows each patient to be independently randomised on multiple occasions. We discuss the circumstances in which this design can be used. Results The re-randomisation design will give asymptotically unbiased estimates of treatment effect and correct type I error rates under the following conditions: (a) patients are only re-randomised after the follow-up period from their previous randomisation is complete; (b) randomisations for the same patient are performed independently; and (c) the treatment effect is constant across all randomisations. Provided the analysis accounts for correlation between observations from the same patient, this design will typically have higher power than a parallel group trial with an equivalent number of observations. Conclusions If used appropriately, the re-randomisation design can increase the recruitment rate for clinical trials while still providing an unbiased estimate of treatment effect and correct type I error rates. In many situations, it can increase the power compared to a parallel group design with an equivalent number of observations. Electronic supplementary material The online version of this article (doi:10.1186/s12874-015-0082-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, E1 2AB, UK.
| | - Andrew B Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia.
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, University College London, London, WC1E 6BT, UK.
| | - Tim P Morris
- Hub for Trials Methodology Research, MRC Clinical Trials Unit at UCL, London, WC2B 6NH, UK.
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218
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Williams RJ, Tse T, DiPiazza K, Zarin DA. Terminated Trials in the ClinicalTrials.gov Results Database: Evaluation of Availability of Primary Outcome Data and Reasons for Termination. PLoS One 2015; 10:e0127242. [PMID: 26011295 PMCID: PMC4444136 DOI: 10.1371/journal.pone.0127242] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 04/13/2015] [Indexed: 11/18/2022] Open
Abstract
Background Clinical trials that end prematurely (or “terminate”) raise financial, ethical, and scientific concerns. The extent to which the results of such trials are disseminated and the reasons for termination have not been well characterized. Methods and Findings A cross-sectional, descriptive study of terminated clinical trials posted on the ClinicalTrials.gov results database as of February 2013 was conducted. The main outcomes were to characterize the availability of primary outcome data on ClinicalTrials.gov and in the published literature and to identify the reasons for trial termination. Approximately 12% of trials with results posted on the ClinicalTrials.gov results database (905/7,646) were terminated. Most trials were terminated for reasons other than accumulated data from the trial (68%; 619/905), with an insufficient rate of accrual being the lead reason for termination among these trials (57%; 350/619). Of the remaining trials, 21% (193/905) were terminated based on data from the trial (findings of efficacy or toxicity) and 10% (93/905) did not specify a reason. Overall, data for a primary outcome measure were available on ClinicalTrials.gov and in the published literature for 72% (648/905) and 22% (198/905) of trials, respectively. Primary outcome data were reported on the ClinicalTrials.gov results database and in the published literature more frequently (91% and 46%, respectively) when the decision to terminate was based on data from the trial. Conclusions Trials terminate for a variety of reasons, not all of which reflect failures in the process or an inability to achieve the intended goals. Primary outcome data were reported most often when termination was based on data from the trial. Further research is needed to identify best practices for disseminating the experience and data resulting from terminated trials in order to help ensure maximal societal benefit from the investments of trial participants and others involved with the study.
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Affiliation(s)
- Rebecca J. Williams
- National Library of Medicine (NLM), National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, Maryland, United States of America
- * E-mail:
| | - Tony Tse
- National Library of Medicine (NLM), National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, Maryland, United States of America
| | - Katelyn DiPiazza
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Deborah A. Zarin
- National Library of Medicine (NLM), National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Bethesda, Maryland, United States of America
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