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van Sasse van IJsselt MEA, van der Biessen DAJ, van Puffelen AJ, Robbrecht DGJ, Oldenmenger WH. "If only I had", patients' experiences during early oncology trials. Support Care Cancer 2023; 31:290. [PMID: 37084141 PMCID: PMC10121491 DOI: 10.1007/s00520-023-07738-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/05/2023] [Indexed: 04/22/2023]
Abstract
PURPOSE Until today, it is not clear why patients decide to continue with early clinical trial (ECT) participation. Therefore, the aim of this study is to explore to which extent the self-determination theory of Ryan and Deci, according to the ECT enrollment phase, corresponds to the motivations of participants during ECT's. METHODS This study has a qualitative design. Data were collected using semistructured interviews and were deductively analyzed in Nvivo12 using the thematic analysis approach of Braun and Clarke. RESULTS As a result of the deductive analysis performed, six themes and twenty subthemes emerged which matched the three personal needs: competence, relatedness, and autonomy (n = 11). "Competence" included the following themes: mixed future expectations, treatment expectations, and control of the outcome. "Relatedness" included the theme altruistic motivation. "Autonomy" included the themes; to live and act in harmony as well as mental and physical burden. CONCLUSION Participants felt they tried everything and that they were treated to the limit. This not only gives the motivation to continue participating but also a sense of altruism. Despite different burdens, side-effects, and the feeling of being a test subject, the participants will not easily choose to stop participation in order to prevent saying afterwards: "If only I had".
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Affiliation(s)
| | - Diane A J van der Biessen
- Erasmus MC Cancer Institute, Department of Medical Oncology, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Andrea J van Puffelen
- Erasmus MC Cancer Institute, Department of Medical Oncology, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Debbie G J Robbrecht
- Erasmus MC Cancer Institute, Department of Medical Oncology, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Wendy H Oldenmenger
- Erasmus MC Cancer Institute, Department of Medical Oncology, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
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Yang GM, Ong WY, Tan J, Ding J, Ho S, Tan D, Neo P. Motivations and experiences of patients with advanced cancer participating in Phase 1 clinical trials: A qualitative study. Palliat Med 2023; 37:257-264. [PMID: 36476098 DOI: 10.1177/02692163221137105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Persons with advanced cancer may participate in Phase 1 clinical trials - first-in-human trials that are conducted with the main objectives of safety and dosing. The motivations for participation are not well understood and may include hope for cure. AIM To explore the perspectives of persons with advanced cancer in order to understand the motivations for participating in Phase 1 clinical trials, experiences while being on trial and views on palliative care provision. DESIGN Qualitative study with a constructivist stance, using thematic analysis based upon the grounded theory approach. SETTING/PARTICIPANTS 20 persons with advanced cancer who were participating in a Phase 1 clinical trial. RESULTS Many participants described how Phase 1 clinical trial participation was their last hope, as they were cognisant of their advanced disease. Information-seeking needs differed - some needed comprehensive information while others relied on the doctor's recommendation. Participants experienced varied negative and positive physical and psycho-emotional concerns, and needed to draw on multiple sources of support such as family, friends and healthcare professionals. Some could list potential benefits of palliative care but felt they did not require it yet. The overarching theme was hope and positive thinking as a way of coping. CONCLUSIONS The concepts of hope as a way of coping and the supportive presence of healthcare professionals could be weaved into a future model of palliative care to improve the illness journey for patients considering Phase 1 clinical trial participation and other persons with advanced cancer.
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Affiliation(s)
- Grace Meijuan Yang
- Division of Supportive and Palliative care, National Cancer Centre Singapore, Singapore.,Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Wah Ying Ong
- Division of Supportive and Palliative care, National Cancer Centre Singapore, Singapore
| | - Jasmine Tan
- Division of Supportive and Palliative care, National Cancer Centre Singapore, Singapore
| | | | - Shirlynn Ho
- Division of Supportive and Palliative care, National Cancer Centre Singapore, Singapore
| | - Daniel Tan
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - Patricia Neo
- Division of Supportive and Palliative care, National Cancer Centre Singapore, Singapore
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Chou WYS, Falisi AL, Castro K, Ferrer RA, Gaysynsky A, Huang GC, Mollica MA, Peterson EB, Kent EE. Cancer clinical trial providers' perspectives on communicating goals of care: A key informant study. PEC INNOVATION 2022; 1:100041. [PMID: 37213723 PMCID: PMC10194320 DOI: 10.1016/j.pecinn.2022.100041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 04/15/2022] [Accepted: 04/16/2022] [Indexed: 05/23/2023]
Abstract
Objectives There has been limited research to date exploring provider communication in the context of cancer clinical trials. To elucidate multidisciplinary care providers' experiences, this qualitative study sought to understand their perspectives and communication patterns around goals of care discussions with patients enrolled in cancer clinical trials. Methods Semi-structured key informant interviews were conducted with a purposive sample of physicians, nurse practitioners, social workers, chaplains, nurses, and administrative staff in a cancer research hospital (N=19). Data were analyzed and interpreted using thematic analysis. Results Providers hold varied perspectives on goals of care in cancer clinical trials, highlighting the tension and potential for misalignment between scientific and clinical (patient-centered) goals. Inherent institutional hierarchies may impede some team members from initiating goal discussions. Care transitions (e.g., stopping treatment or initiating hospice) offer critical opportunities for goals of care discussions. Conclusion Conflicting perspectives among team members, perceptions of provider roles, and communication patterns could help explain some of the communication challenges previously documented in advanced cancer and clinical trial care. Innovation This qualitative study contributes to the literature on healthcare team communication in the clinical trial context and highlights tangible opportunities to better leverage providers' diverse experience and improve patient-centered care.
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Affiliation(s)
- Wen-Ying Sylvia Chou
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
- Corresponding author at: Health Communication and Informatics Research Branch, National Cancer Institute, 9609 Medical Center Dr. 3E614, MSC – 9761, Rockville, MD 20850, USA.
| | - Angela L. Falisi
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
| | - Kathleen Castro
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
| | - Rebecca A. Ferrer
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
| | - Anna Gaysynsky
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
- ICF, 530 Gaither Road, Rockville, MD 20850, USA
| | - Grace C. Huang
- Westat, 1600 Research Boulevard, Rockville, MD 20850, USA
| | - Michelle A. Mollica
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
| | - Emily B. Peterson
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
| | - Erin E. Kent
- National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
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Dooms M, Saesen R, Steemans I, Lansens J, Huys I. Characteristics of Early Phase Clinical Trials for Rare Cancers: Insights From Interviews With Stakeholders. Front Pharmacol 2022; 13:775217. [PMID: 35586057 PMCID: PMC9108391 DOI: 10.3389/fphar.2022.775217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Rare cancers occur with an incidence of no more than six cases per 100,000 people according to the definition used by the Surveillance of Rare Cancers in Europe project. For a variety of reasons (low prevalence, cytotoxicity), it is challenging to perform the necessary clinical studies to investigate the safety and efficacy of investigational medicines against such rare malignancies, reformulating even at the earliest stages of the drug development process. This article investigates the differences between phase I rare cancer trials performed in commercial (companies) and non-commercial settings (academic hospitals).Materials and Methods: The differences were explored through the conduct of semi-structured interviews with three different stakeholder groups: representatives from academia (n = 7), representatives from companies (n = 4) and representatives from patient organizations (n = 4). All the interviews were transcribed verbatim and analyzed in NVivo using the framework method.Results: According to the interviewees, the academic and commercial stakeholders collaborate in the majority of phase I rare cancer trials. In general, the commercial partner finances the trial, whereas academia is responsible for the execution of the study procedures. The average cost of undertaking these trials is difficult to estimate because it depends on what is specifically requested during the trial. The 3 + 3 study design remains the most widely used design and the use of expansion cohorts is controversial. With regard to the regulatory aspects of phase I rare cancer trials, it was expressed that a good regulatory framework facilitates the conduct of these studies, but that increased regulation and oversight also has drawbacks, e.g., differences in standards between different ethics committees, over interpretation of the rules, insufficient availability of qualified personnel and higher workloads. The patient organization representatives claimed that patients experience no differences in terms of accommodation, compensation and paperwork between the academic and commercial settings or the degree of follow-up. They also believed that the direct input of patients can bring added value to such studies not only with regard to the recruitment process and the feasibility of the study but also the legibility of the informed consent forms.Conclusion: The growing need for first-in-man trials in rare malignancies needs to be highlighted, as difficult as they are to undertake and to co-develop, not only because rare cancer patients deserve an appropriate treatment, but also because these medicines represent the future of cancer therapy in the precision medicine era. Cooperation of commercial and academic sites are needed. Patient organizations need to be educated to take part in this process.
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Laryionava K, Schildmann J, Wensing M, Wedding U, Surmann B, Woydack L, Krug K, Winkler E. Development and Evaluation of a Decision Aid to Support Patients' Participatory Decision-Making for Tumor-Specific and Palliative Therapy for Advanced Cancer: Protocol for a Pre-Post Study. JMIR Res Protoc 2021; 10:e24954. [PMID: 34533464 PMCID: PMC8486990 DOI: 10.2196/24954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 11/21/2022] Open
Abstract
Background To support advanced cancer patients and their oncologists in therapeutic decisions, we aim to develop a decision aid (DA) in a multiphased, bicentric study. The DA aims to help patients to better understand risks and benefits of the available treatment options including the options of standard palliative care or cancer-specific treatment (ie, off-label drug use within an individual treatment plan). Objective This study protocol outlines the development and testing of the DA in a pre-post study targeting a heterogeneous population of advanced cancer patients. Methods In the first step, we will assess patients’ information and decisional needs as well as the views of the health care providers regarding the content and implementation of the DA. Through a scoping review, we aim to analyze specific characteristics of the decision-making process and to specify the treatment options, outcomes, and probabilities. An interdisciplinary research group of experts will develop and review the DA. In the second step, testing of the DA (design and field testing) with patients and oncologists will be conducted. As a last step, we will run a pre-post design study with 70 doctor-patient encounters to assess improvements on the primary study outcome: patients’ level of decisional conflict. In addition, the user acceptance of all involved parties will be tested. Results Interviews with cancer patients, oncologists, and health care providers (ie, nurses, nutritionists) as well as a literature review from phase I have been completed. The field testing is scheduled for April 2021 to August 2021, with the final revision scheduled for September 2021. The pre-post study of the DA and acceptance testing are scheduled to start in October 2021 and shall be finished in September 2022. Conclusions A unique feature of this study is the development of a DA for patients with different types of advanced cancer, which covers a wide range of topics relevant for patients near the end of life such as forgoing cancer-specific therapy and switching to best supportive care. Trial Registration ClinicalTrials.gov NCT04606238; https://clinicaltrials.gov/ct2/show/NCT04606238. International Registered Report Identifier (IRRID) DERR1-10.2196/24954
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Affiliation(s)
- Katsiaryna Laryionava
- Institute for History and Ethics of Medicine, Centre for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Schildmann
- Institute for History and Ethics of Medicine, Centre for Health Sciences, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Michael Wensing
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Ullrich Wedding
- Palliative Care, Department of Internal Medicine II, University of Jena, Jena, Germany
| | - Bastian Surmann
- Health Economics and Health Care Management, Bielefeld University, Bielefeld, Germany
| | - Lena Woydack
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | - Katja Krug
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Eva Winkler
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
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Pal A, Stapleton S, Yap C, Lai-Kwon J, Daly R, Magkos D, Baikady BR, Minchom A, Banerji U, De Bono J, Karikios D, Boyle F, Lopez J. Study protocol for a randomised controlled trial of enhanced informed consent compared to standard informed consent to improve patient understanding of early phase oncology clinical trials (CONSENT). BMJ Open 2021; 11:e049217. [PMID: 34489282 PMCID: PMC8422487 DOI: 10.1136/bmjopen-2021-049217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 08/11/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Early phase cancer clinical trials have become increasingly complicated in terms of patient selection and trial procedures-this is reflected in the increasing length of participant information sheets (PIS). Informed consent for early phase clinical trials has been contentious due to the potential ethical issues associated with performing experimental research on a terminally ill population which has exhausted standard treatment options. Empirical studies have demonstrated significant gaps in patient understanding regarding the nature and intent of these trials. This study aims to test whether enhanced informed consent for patient education can improve patient scores on a validated questionnaire testing clinical trial comprehension. METHODS AND ANALYSIS This is a randomised controlled trial that will allocate patients who are eligible to participate in one of four investigator-initiated clinical trials at the Royal Marsden Drug Development Unit to either a standard arm or an experimental arm, stratified by age and educational level. The standard arm will involve the full length trial PIS, followed by electronic or paper administration of the Quality of Informed Consent Questionnaire Parts A and B (QuIC-A and QuIC-B). The experimental arm will involve the full length trial PIS, exposure to a two-page study aid and 10 online educational videos, followed by administration of the QuIC-A and QuIC-B. The primary endpoint will be the difference (using a one-sided two-sample t-test) in the QuIC-A score, which measures objective understanding, between the standard and experimental arm. Accrual target is at least 17 patients per arm to detect an 8 point difference (80% power, alpha 0.05). ETHICS AND DISSEMINATION Ethics approval was granted by the National Health Service Health Research Authority on 15 June 2020-IRAS Project ID 277065, Protocol Number CCR5165, REC Reference 20/EE/0155. Results will be disseminated via publication in a relevant journal. TRIAL REGISTRATION NUMBER NCT04407676; Pre-results.
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Affiliation(s)
- Abhijit Pal
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
- The University of Sydney, Sydney, New South Wales, Australia
| | - Sarah Stapleton
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
- Clinical Trials and Statistics Unit, Institute of Cancer Research, London, UK
| | - Julia Lai-Kwon
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Robert Daly
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Dimitrios Magkos
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Bindumalini Rao Baikady
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Anna Minchom
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Udai Banerji
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Johann De Bono
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
| | - Deme Karikios
- The University of Sydney, Sydney, New South Wales, Australia
| | - Frances Boyle
- The University of Sydney, Sydney, New South Wales, Australia
| | - Juanita Lopez
- Institute of Cancer Research, London, UK
- Drug Development Unit, Royal Marsden Hospital Sutton, London, UK
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Long JE, Jankovic M, Maddalo D. Drug discovery oncology in a mouse: concepts, models and limitations. Future Sci OA 2021; 7:FSO737. [PMID: 34295539 PMCID: PMC8288236 DOI: 10.2144/fsoa-2021-0019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/27/2021] [Indexed: 02/08/2023] Open
Abstract
The utilization of suitable mouse models is a critical step in the drug discovery oncology workflow as their generation and use are important for target identification and validation as well as toxicity and efficacy assessments. Current murine models have been instrumental in furthering insights into the mode of action of drugs before transitioning into the clinic. Recent advancements in genome editing with the development of the CRISPR/Cas9 system and the possibility of applying such technology directly in vivo have expanded the toolkit of preclinical models available. In this review, a brief presentation of the current models used in drug discovery will be provided with a particular emphasis on the novel CRISPR/Cas9 models.
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Affiliation(s)
- Jason E Long
- Department of Translational Oncology, Genentech, Inc., South San Francisco, CA 94080, USA
| | - Maja Jankovic
- Department of Medicine, Division of Experimental Medicine, McGill University, Montréal, QC, H4A 3J1, Canada
- Lady Davis Institute for Medical Research, Montréal, QC, H4A 3J1, Canada
| | - Danilo Maddalo
- Department of Translational Oncology, Genentech, Inc., South San Francisco, CA 94080, USA
- Pharmaceutical Research & Early Development, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, Basel, 4070, Switzerland
- Author for correspondence:
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Hlubocky FJ, Sher TG, Cella D, Wroblewski KE, Peppercorn J, Daugherty CK. Anxiety Shapes Expectations of Therapeutic Benefit in Phase I Trials for Patients With Advanced Cancer and Spousal Caregivers. JCO Oncol Pract 2021; 17:e101-e110. [PMID: 33567241 DOI: 10.1200/op.20.00646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Advanced cancer patients (ACP) hope to receive significant therapeutic benefit from phase I trials despite terminal disease and presumed symptom burdens. We examined associations between symptom burdens and expectations of therapeutic benefit for ACP and spousal caregivers (SC) during phase I trials. PATIENTS AND METHODS A prospective cohort of ACP-SC enrolled in phase I trials was assessed at baseline and one month using symptom burden measures evaluating depression, state-trait anxiety, quality of life, global health, post-traumatic coping, and marital adjustment. Interviews evaluated expectations of benefit. RESULTS Fifty-two phase I ACP and 52 SC (N = 104) were separately assessed and interviewed at baseline and one month. Total population demographics included the following: median age 61 years (28-78), 50% male, 100% married, 90% White, and 46% ≥ college education. At T1, ACP reported symptoms of mild state anxiety, mild trait anxiety, poor global health, and quality of life. SC reported moderate state and mild trait anxiety and good global health with little disability at baseline. State anxiety was a significant predictor of ACP expectations for phase I producing the following therapeutic benefits: stabilization (P = .01), shrinkage (P < .01), and remission (P = .04). Regression analyses also revealed negative associations between SC expectation for stabilization and SC anxiety: state (P = .01) and trait (P = .02). ACP quality of life was also negatively associated with SC expectations for stabilization (P = .02) and shrinkage (P = .01). CONCLUSION Anxiety, both state and trait, impacts couples' beliefs regarding the likelihood of therapeutic benefit from phase I trial participation.
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Affiliation(s)
- Fay J Hlubocky
- Department of Medicine, Hematology/Oncology, MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
| | - Tamara G Sher
- Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - David Cella
- Departments of Medical Social Sciences, Psychiatry Behavioral Sciences, Northwestern University, Chicago, IL
| | | | - Jeffery Peppercorn
- Division of Medicine, Hematology & Oncology, Massachusetts General Hospital, Dana Farber Partners, Boston, MA
| | - Christopher K Daugherty
- Department of Medicine, Hematology/Oncology, MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
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Martin ML, Correll J, Walding A, Rydén A. How patients being treated for non-small cell lung cancer value treatment benefit despite side effects. Qual Life Res 2021; 31:135-146. [PMID: 34056687 PMCID: PMC8800875 DOI: 10.1007/s11136-021-02882-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2021] [Indexed: 10/28/2022]
Abstract
PURPOSE To describe symptoms and side effects experienced by patients with advanced non-small cell lung cancer (NSCLC), assess how patients allocate sensations (i.e. symptoms or side effects) to either the disease or its treatment, and evaluate how patients balance side effects with treatment benefits. METHODS Qualitative sub-studies were conducted as part of two clinical trials in patients treated for advanced NSCLC (AURA [NCT01802632]; ARCTIC [NCT02352948]). RESULTS Interviews were conducted with 23 patients and 19 patients in the AURA and ARCTIC sub-studies, respectively. The most commonly experienced symptoms/side effects were respiratory (81% of patients), digestive (76%), pain and discomfort (76%), energy-related (71%), and sensory (62%). Patients identified a sensation as a treatment side effect if they had not experienced it before, if there was a temporal link between the sensation and receipt of treatment, and/or if their doctors consistently told or asked them about it in relation to side effects. Themes that emerged when patients talked about their cancer treatment and its side effects related to the serious nature of their advanced disease and their treatment expectations. Patients focused on treatment benefits, wanting a better quality of life, being hopeful, not really having a choice, and not thinking about side effects. CONCLUSIONS In these two qualitative sub-studies, patients with advanced NSCLC valued the benefits of their treatment regardless of side effects that they experienced. Patients weighed their options against the seriousness of their disease and expressed their willingness to tolerate their side effects in return for receiving continued treatment benefits.
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Castillo G, Lalu M, Asad S, Foster M, Kekre N, Fergusson D, Hawrysh T, Atkins H, Thavorn K, Montroy J, Schwartz S, Holt R, Broady R, Presseau J. Hematologists' barriers and enablers to screening and recruiting patients to a chimeric antigen receptor (CAR) T cell therapy trial: a theory-informed interview study. Trials 2021; 22:230. [PMID: 33766105 PMCID: PMC7995587 DOI: 10.1186/s13063-021-05121-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 02/11/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Novel therapies often fail to reach the bedside due to low trial recruitment rates. Prior to conducting one of the first chimeric antigen receptor (CAR) T cell therapy trials in Canada, we used the Theoretical Domains Framework, a novel tool for identifying barriers and enablers to behavior change, to identify physician-related barriers and enablers to screening and recruiting patients for an early phase immunotherapy trial. METHODS We conducted interviews with hematologists across Canada and used a directed content analysis to identify relevant domains reflecting the key factors that may affect screening and recruitment. RESULTS In total, we interviewed 15 hematologists. Physicians expressed "cautious hope"; while expressing safety, feasibility, and screening criteria concerns, 14 out of 15 hematologists intended to screen for the trial (domains: knowledge, goals, beliefs about consequences, intentions). Physicians underscored the "challenging contexts," identifying resources, workload, forgetting, and patient wait times to receive CAR T cells as key practical barriers to screening (domains: environmental context and resources, memory, attention and decision-making, behavioral regulation). They also highlighted "variability in roles and procedures" that may lead to missed trial candidates (domain: social and professional role). Left unaddressed, these barriers may undermine trial recruitment. CONCLUSIONS This study is among the first to use the Theoretical Domains Framework from the physician perspective to identify recruitment challenges to early phase trials and demonstrates the value of this approach for identifying barriers to screening and recruitment that may not otherwise have been elicited. This approach can optimize trial procedures and may serve to inform future promising early phase cancer therapy trials. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03765177 . Registered on December 5, 2018.
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Affiliation(s)
- Gisell Castillo
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Manoj Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Department of Anaesthesiology and Pain Medicine, University of Ottawa at the Ottawa Hospital General Campus, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Sarah Asad
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Madison Foster
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Natasha Kekre
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blood and Marrow Transplant Program, The Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario, K1G 5Z3, Canada
| | | | - Harold Atkins
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blood and Marrow Transplant Program, The Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario, K1G 5Z3, Canada
- Institute for Clinical and Evaluative Sciences (ICES), University of Ottawa, 1053 Carling Ave., Ottawa, Ontario, K1Y 4E9, Canada
| | - Joshua Montroy
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | | | - Robert Holt
- BC Cancer Genome Sciences Centre, 100-570 West 7th Avenue, Vancouver, British Columbia, V5Z 4S6, Canada
| | - Raewyn Broady
- Leukemia/BMT Program, Vancouver General Hospital, 2775 Laurel St - 10th floor, Vancouver, British Columbia, V5Z 1M9, Canada
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada.
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada.
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario, K1G 5Z3, Canada.
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11
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Castillo G, Lalu MM, Asad S, Foster M, Kekre N, Fergusson DA, Hawrysh T, Atkins H, Thavorn K, Montroy J, Schwartz S, Holt RA, Broady R, Presseau J. Navigating choice in the face of uncertainty: using a theory informed qualitative approach to identifying potential patient barriers and enablers to participating in an early phase chimeric antigen receptor T (CAR-T) cell therapy trial. BMJ Open 2021; 11:e043929. [PMID: 33741670 PMCID: PMC7986876 DOI: 10.1136/bmjopen-2020-043929] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 02/02/2021] [Accepted: 02/16/2021] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES Bench to bedside translation of groundbreaking treatments like chimeric antigen receptor T (CAR-T) cell therapy depends on patient participation in early phase trials. Unfortunately, many novel therapies fail to be adequately evaluated due to low recruitment rates, which slows patient access to emerging treatments. Using the Theoretical Domains Framework (TDF), we sought to identify potential patient barriers and enablers to participating in an early phase CAR-T cell therapy trial. DESIGN We used qualitative semistructured interviews to identify potential barriers and enablers to patients' hypothetical participation in an early phase CAR-T cell therapy trial. We used the TDF and directed content analysis to identify relevant domains based on frequency, relevance and the presence of conflicting beliefs. PARTICIPANTS Canadian adult patients diagnosed with haematological malignancies. RESULTS In total, we interviewed 13 participants (8 women, 5 men). Participants ranged in age from 18 to 73 (median=56) and had been living with haematological cancer from a few months to several years. We found participants were unfamiliar with CAR-T cell therapy but wished to know more about treatment safety, efficacy and trial logistics (domains: knowledge, beliefs about consequences). They were motivated by altruistic considerations, though many prioritised personal health benefits despite recognising the goals (ie, establishing safety) of early phase clinical trials (domains: goals, intentions). Every participant valued receiving medical advice from their haematologists and oncologists, though some preferred impartial medical experts to inform their decision making (domain: social influences). Finally, participants indicated that improving access to financial and social supports would improve their trial participation experience (domain: environmental context and resources). CONCLUSION Using the TDF allowed us to identify factors that might undermine participation to a CAR-T cell therapy trial and to optimise recruitment processes by considering patient perspectives to taking part in early phase trials.Trial regestration: NCT03765177; Pre-results.
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Affiliation(s)
- Gisell Castillo
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Manoj M Lalu
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Anaesthesiology and Pain Medicine, Ottawa Hospital General Campus, Ottawa, Ontario, Canada
| | - Sarah Asad
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Madison Foster
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Natasha Kekre
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Blood and Marrow Transplant Program, Ottawa Hospital General Campus, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Harold Atkins
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Blood and Marrow Transplant Program, Ottawa Hospital General Campus, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- ICES University of Ottawa, Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada
| | - Joshua Montroy
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Robert A Holt
- Genome Sciences Centre, BC Cancer, Vancouver, British Columbia, Canada
| | - Raewyn Broady
- Leukemia/BMT Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Justin Presseau
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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12
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Murphy M, McCaughan E, Carson MA, Donovan M, Wilson RH, Fitzsimons D. Nothing to lose: a grounded theory study of patients' and healthcare professionals' perspectives of being involved in the consent process for oncology trials with non-curative intent. BMC Palliat Care 2020; 19:166. [PMID: 33126874 PMCID: PMC7602307 DOI: 10.1186/s12904-020-00661-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/29/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Clinical cancer research trials may offer little or no direct clinical benefit to participants where a cure is no longer possible. As such, the decision-making and consent process for patient participation is often challenging. AIM To gain understanding of how patients make decisions regarding clinical trial participation, from the perspective of both the patient and healthcare professionals involved. METHODS In-depth, face to face interviews using a grounded theory approach. This study was conducted in a regional Cancer Centre in the United Kingdom. Of the 36 interviews, 16 were conducted with patients with cancer that had non-curative intent and 18 with healthcare professionals involved in the consent process. RESULTS 'Nothing to lose' was identified as the core category that underpinned all other data within the study. This highlighted the desperation articulated by participants, who asserted trial participation was the 'only hope in the room'. The decision regarding participation was taken within a 'trusting relationship' that was important to both patients and professionals. Both were united in their 'fight against cancer'. These two categories are critical in understanding the decision-making/consent process and are supported by other themes presented in the theoretical model. CONCLUSION This study presents an important insight into the complex and ethically contentious situation of consent in clinical trials that have non-curative intent. It confirms that patients with limited options trust their doctor and frequently hold unrealistic hopes for personal benefit. It highlights a need for further research to develop a more robust and context appropriate consent process.
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Affiliation(s)
- Mary Murphy
- Resuscitation Services, Elliott Dynes Building, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Eilís McCaughan
- School of Nursing and Midwifery, Institute of Nursing and Health Research, Ulster University, Coleraine, UK
| | - Matthew A Carson
- School of Nursing and Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, UK
| | - Monica Donovan
- School of Nursing and Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, UK
| | - Richard H Wilson
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Donna Fitzsimons
- School of Nursing and Midwifery, Medical Biology Centre, Queen's University Belfast, Belfast, UK.
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13
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Sisk BA, Dubois J, Hobbs BP, Kodish E. Reprioritizing Risk and Benefit: The Future of Study Design in Early-Phase Cancer Research. Ethics Hum Res 2020; 41:2-11. [PMID: 31743629 DOI: 10.1002/eahr.500033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The scientific purpose of phase I trials is to determine the maximum tolerated dose and/or optimal biological dose of experimental agents. Yet most participants in phase I oncology trials enroll hoping for direct medical benefit. The most common phase I trial designs use low starting doses and escalate cautiously in a "risk-escalation" model focused on minimizing risk for each participant. This approach ensures that a proportion of subjects will likely not receive any benefit, even if the intervention proves to be successful at appropriate doses. In this article, we propose that trial designs should employ dosing strategies that increase chances of providing benefit if the investigational agent should prove to be successful while limiting risk to reasonable levels. We then describe how adaptive trial designs can facilitate refined dose optimization based on both therapeutic benefit and toxicity, which can simultaneously decrease the risk of harm while increasing the chances of benefit.
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Affiliation(s)
- Bryan Anthony Sisk
- Clinical fellow in pediatric hematology/oncology in the Department of Pediatrics at Washington University School of Medicine
| | - James Dubois
- Professor in the Department of Medicine at Washington University School of Medicine
| | - Brian P Hobbs
- Associate staff member in the Department of Quantitative Health Sciences in the Lerner Research Institute at the Cleveland Clinic
| | - Eric Kodish
- Professor of pediatrics, oncology, and bioethics at Case Western Reserve and Cleveland Clinic Lerner College of Medicine
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14
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Rezash V, Reed J, Gedeon B, Parsons E, Siedlecki S, Daniels B, Shepard DR. Who Needs What? Perceptions of Patients and Caregivers in Oncology Phase 1 Trials. J Patient Exp 2020; 7:27-33. [PMID: 32128368 PMCID: PMC7036678 DOI: 10.1177/2374373519830743] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: The study design and nature of oncology phase 1 clinical trials create a uniquely
vulnerable patient population yet little research has been conducted to identify the
added burden these trials create for both cancer patients and their caregiver(s). Objective: Examining the perceptions and needs of patients and their caregivers participating in
phase 1 oncology clinical trials, the investigators tested the hypothesis that the
caregiver will exhibit a higher level of burden and/or distress than the patient. Method: A mixed-methods exploratory process utilizing patient and caregiver interviews and
quality-of-life questionnaires was used to assess the psychosocial burdens associated
with oncology clinical trial participation. A qualitative and quantitative analysis of
the responses were 8 performed. Result: Both patients and caregivers reported similar themes identifying the burdens and
benefits related to phase 1 clinical trial participation. However, the caregivers’
expressed burden exceeded that of the patients’ validating the study’s hypothesis. Conclusion: The need for ongoing additional support services for not only the patient but also the
caregiver was identified.
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Affiliation(s)
- Victoria Rezash
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Janice Reed
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Barbara Gedeon
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eric Parsons
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sandra Siedlecki
- Office of Nursing Research and Innovation, Cleveland Clinic, Cleveland, OH, USA
| | - Bradley Daniels
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Dale R Shepard
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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15
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Garrett SB, Matthews TM, Abramson CM, Koenig CJ, Hlubocky FJ, Daugherty CK, Munster PN, Dohan D. Before Consent: Qualitative Analysis of Deliberations of Patients With Advanced Cancer About Early-Phase Clinical Trials. JCO Oncol Pract 2020; 16:e56-e63. [PMID: 31603726 PMCID: PMC6993554 DOI: 10.1200/jop.19.00256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2019] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients with advanced cancer and oncologists deliberate about early-phase (EP) trials as they consider whether to pursue EP trial enrollment. We have limited information about those deliberations and how they may facilitate or impede trial initiation. This study describes these deliberations and their relationship to trial initiation. PATIENTS AND METHODS We collected longitudinal, ethnographic data on deliberations of patients with advanced cancer at two academic medical centers. We used constant comparative and framework analyses to characterize the deliberative process and its relationship to trial initiation. RESULTS Of 96 patients with advanced cancer, 26% initiated EP enrollment and 19% joined a trial. Constant comparative analysis revealed two foci of deliberation. Setting the stage focused on patient and physician support for EP trial involvement, including patients' interest in research and oncologists' awareness of trials and assessment of patient fit. Securing a seat focused on eligibility for and entrance to a specific trial and involved trial availability, treatment history, disease progression, and enrollment timing. Patients enrolled in a trial only when both stages could be successfully navigated. CONCLUSION Ethnographic data revealed two foci of deliberation about EP trial enrollment among patients with advanced cancer. Physician support played a consequential role in both stages, but enrollment also reflected factors beyond the control of any specific individual. Insights from this study, combined with other recent studies of trial enrollment, advance our understanding of the complex process of EP trial accrual and may help identify strategies to improve rates of participation.
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Affiliation(s)
| | | | | | | | | | | | | | - Daniel Dohan
- University of California San Francisco, San Francisco, CA
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16
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Adashek JJ, LoRusso PM, Hong DS, Kurzrock R. Phase I trials as valid therapeutic options for patients with cancer. Nat Rev Clin Oncol 2019; 16:773-778. [PMID: 31477881 DOI: 10.1038/s41571-019-0262-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2019] [Indexed: 12/17/2022]
Abstract
For many years, oncology phase I trials have been referred to as 'toxicity trials' and have been believed to have low clinical utility other than that of establishing the adverse event profile of novel therapeutic agents. The traditional distinction of clinical trials into three phases has been challenged in the past few years by the introduction of targeted therapies and immunotherapies into the routine management of patients with cancer. This transformation has especially affected early phase trials, leading to the current situation in which response rates are increasingly reported from phase I trials. In this Perspectives, we highlight key elements of phase I trials and discuss how each one of them contributes to a new paradigm whereby preliminary measurements of the clinical benefit from a novel treatment can be obtained in current phase I trials, which can therefore be considered to have a therapeutic intent.
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Affiliation(s)
- Jacob J Adashek
- Department of Internal Medicine, University of South Florida, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - David S Hong
- Department of Investigational Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Razelle Kurzrock
- Center for Personalized Cancer Therapy, Department of Medicine, University of California San Diego Moores Cancer Center, La Jolla, CA, USA.
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17
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Gyawali B, Hwang TJ, Vokinger KN, Booth CM, Amir E, Tibau A. Patient-Centered Cancer Drug Development: Clinical Trials, Regulatory Approval, and Value Assessment. Am Soc Clin Oncol Educ Book 2019; 39:374-387. [PMID: 31099613 DOI: 10.1200/edbk_242229] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Historically, patient experience, including symptomatic toxicities, physical function, and disease-related symptoms during treatment or their perspectives on clinical trials, has played a secondary role in cancer drug development. Regulatory criteria for drug approval require that drugs are safe and effective, and almost all drug approvals have been based only on efficacy endpoints rather than on quality-of-life (QoL) assessments. In contrast to Europe, information regarding the impact of drugs on patients' QoL is rarely included in oncology drug labeling in the United States. Until recently, patient input and preferences have not been incorporated into the design and conduct of clinical trials. In recent years, a more in-depth understanding of cancer biology, as well as regulatory changes focused on expediting cancer drug development and approval, has allowed earlier access to novel therapeutic agents. Understanding the implications of these expedited programs is important for oncologists and patients, given the rapid expansion of these programs. In this article, we provide an overview of the role of QoL in the regulatory drug-approval process, key issues regarding trial participation from the patient perspective, and the implications of key expedited approval programs that are increasingly being used by regulatory bodies for cancer care.
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Affiliation(s)
- Bishal Gyawali
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Thomas J Hwang
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kerstin Noelle Vokinger
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,2 Institute for Primary Care and Health Outcomes Research, University of Zürich, Zürich, Switzerland
| | - Christopher M Booth
- 3 Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,4 Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Eitan Amir
- 5 Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Ariadna Tibau
- 6 Department of Oncology, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Spain
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18
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Sisk BA, Canavera K, Sharma A, Baker JN, Johnson LM. Ethical issues in the care of adolescent and young adult oncology patients. Pediatr Blood Cancer 2019; 66:e27608. [PMID: 30623573 DOI: 10.1002/pbc.27608] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 12/07/2018] [Accepted: 12/08/2018] [Indexed: 12/12/2022]
Abstract
The diagnosis and treatment of cancer leads to short-term and long-term challenges for every patient. This is especially true for adolescents and young adults (AYAs) with cancer who strive to gain independence, autonomy, confidence, and social status while developing into adulthood. In this article, we review prominent ethical issues in AYA oncology that are related to autonomy, shared decision-making, care refusal or abandonment, end-of-life care, truth telling, and fertility preservation. Clinicians should recognize that AYA patients develop at their own pace; the onus lies with clinicians to determine the patient's interests, values, maturity, and desire to participate in decision-making.
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Affiliation(s)
- Bryan A Sisk
- Division of Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Kristin Canavera
- Division of Psychology, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Akshay Sharma
- Department of Bone Marrow Transplant and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Justin N Baker
- Division of Quality-of-Life and Palliative Care, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Liza-Marie Johnson
- Division of Quality-of-Life and Palliative Care, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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19
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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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20
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Gad KT, Lassen U, Mau-Søerensen M, Høybye MT, Johansen C. Patient information in phase 1 trials: A systematic review. Psychooncology 2017; 27:768-780. [DOI: 10.1002/pon.4559] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/13/2017] [Accepted: 09/14/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Katrine Toubro Gad
- Department of Oncology, Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Ulrik Lassen
- Department of Oncology, Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Morten Mau-Søerensen
- Department of Oncology, Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - Mette Terp Høybye
- Interdisciplinary Research Unit; Elective Surgery Center; Silkeborg Denmark
| | - Christoffer Johansen
- Department of Oncology, Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Unit of Survivorship; Danish Cancer Society Research Center; Copenhagen Denmark
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21
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Reeder-Hayes KE, Roberts MC, Henderson GE, Dees EC. Informed Consent and Decision Making Among Participants in Novel-Design Phase I Oncology Trials. J Oncol Pract 2017; 13:e863-e873. [PMID: 28837373 DOI: 10.1200/jop.2017.021303] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although phase I clinical trials are the gateway to progress in cancer therapies, this setting poses ethical challenges to ensure that patients provide consent free from misunderstandings of therapeutic intent or unrealistic expectations of benefit. The design of phase I oncology trials has evolved rapidly over time and today includes more targeted agents and combinations of experimental drugs with standard drugs, which may further complicate how patients understand phase I research participation. METHODS We conducted semistructured interviews regarding motivations, decision making, and understanding of trial purpose nested within a phase I clinical trial of a novel PI3kinase inhibitor combined with a standard oral chemotherapy in 18 participants. RESULTS Fewer than half of patients correctly identified the safety and dosing objectives. The inclusion of a targeted agent was attractive to participants and was perceived as an indicator of less toxic or more efficacious therapy, with less appreciation for added risks. The significance of a cellular drug target, without a known predictive biomarker of response, was unclear to patients. The inclusion of a standard drug in the regimen attracted patients with more treatment options than traditional first-in-human participants. Patients frequently expressed a realistic understanding of prognosis and uncertainty of benefit, but simultaneous hopes for extraordinary outcomes. CONCLUSION Novel phase I oncology trial designs may attract patients with less constrained treatment options, but the inclusion of targeted drugs and combinations including standard chemotherapies is likely to complicate understanding of safety and dosing objectives and likelihood of personal benefit for purposes of informed consent.
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Affiliation(s)
| | - Megan C Roberts
- University of North Carolina, Chapel Hill, NC; and National Cancer Institute, Washington, DC
| | - Gail E Henderson
- University of North Carolina, Chapel Hill, NC; and National Cancer Institute, Washington, DC
| | - Elizabeth C Dees
- University of North Carolina, Chapel Hill, NC; and National Cancer Institute, Washington, DC
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22
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Samuel GN, Dheensa S, Farsides B, Fenwick A, Lucassen A. Healthcare professionals' and patients' perspectives on consent to clinical genetic testing: moving towards a more relational approach. BMC Med Ethics 2017; 18:47. [PMID: 28789658 PMCID: PMC5549302 DOI: 10.1186/s12910-017-0207-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 07/24/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This paper proposes a refocusing of consent for clinical genetic testing, moving away from an emphasis on autonomy and information provision, towards an emphasis on the virtues of healthcare professionals seeking consent, and the relationships they construct with their patients. METHODS We draw on focus groups with UK healthcare professionals working in the field of clinical genetics, as well as in-depth interviews with patients who have sought genetic testing in the UK's National Health Service (data collected 2013-2015). We explore two aspects of consent: first, how healthcare professionals consider the act of 'consenting' patients; and second how these professional accounts, along with the accounts of patients, deepen our understanding of the consent process. RESULTS Our findings suggest that while healthcare professionals working in genetic medicine put much effort into ensuring patients' understanding about their impending genetic test, they acknowledge, and we show, that patients can still leave genetic consultations relatively uninformed. Moreover, we show how placing emphasis on the informational aspect of genetic testing is not always reflective of, or valuable to, patients' decision-making. Rather, decision-making is socially contextualised - also based on factors outside of information provision. CONCLUSIONS A more collaborative on-going consent process, grounded in virtue ethics and values of honesty, openness and trustworthiness, is proposed.
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Affiliation(s)
- Gabrielle Natalie Samuel
- Brighton and Sussex Medical School, Falmer, BN1 9PX, UK.,Department of Educational Research, Lancaster University, Lancaster, UK
| | - Sandi Dheensa
- Clinical Ethics and Law, University of Southampton, Southampton General Hospital, South Academic Block, Tremona Road, Southampton, SO16 6YD, UK.
| | | | - Angela Fenwick
- Clinical Ethics and Law, University of Southampton, Southampton General Hospital, South Academic Block, Tremona Road, Southampton, SO16 6YD, UK
| | - Anneke Lucassen
- Clinical Ethics and Law, University of Southampton, Southampton General Hospital, South Academic Block, Tremona Road, Southampton, SO16 6YD, UK.,Wessex Clinical Genetics Service, University Hospitals Southampton Trust, Southampton, UK
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23
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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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