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Mogensen N, Kreicbergs U, Albertsen BK, Lähteenmäki P, Heyman M, Harila A. Parental experiences of the informed consent process in randomized clinical trials-A Nordic study. Pediatr Blood Cancer 2023; 70:e30684. [PMID: 37728014 DOI: 10.1002/pbc.30684] [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] [Received: 05/25/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Randomized clinical trials (RCTs) are an essential part of improving acute lymphoblastic leukemia (ALL) treatment. This population-based questionnaire study investigated parents' experiences of the informed consent process in the RCTs within the Nordic NOPHO (Nordic Society of Paediatric Haematology and Oncology) ALL2008 trial. PROCEDURE Parents in Sweden, Denmark, and Finland whose child was alive and in first remission after end of therapy and who were asked to participate in any RCT in the ALL2008 protocol, were asked to complete 15 questions/items regarding their experience of the RCT consent process. RESULTS A total of 483 parents of 279 children met the inclusion criteria and answered the study questionnaire. Most (91%) agreed/strongly agreed to having received sufficient information to make a well-informed decision, felt confidence in the study design (86%), and thought that the process was satisfactory (86%). Those who did not consent reported a generally more negative experience of the process. More than a third of all parents and over half of parents who had refused participation felt that it was burdensome to decide. Most parents (66%) in general, and one-third of those with children 8 years or older, reported that their child was not involved in the process. CONCLUSIONS Parents were in general satisfied with the informed consent process, although many parents, particularly those who refused participation, reported it as burdensome to make the decision concerning RCT. Fewer than expected of the school-aged children were involved in the decision process, which calls for attention on how children are included in the consent procedure in clinical trials.
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Affiliation(s)
- Nina Mogensen
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institute, Stockholm, Sweden
- Department of Pediatric Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrika Kreicbergs
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institute, Stockholm, Sweden
- Department of Health Care Sciences, Palliative Research Centre, Ersta Sköndal Bräcke University College, Stockholm, Sweden
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
- Institute of Clinical Medicine, Faculty of Health, University of Aarhus, Aarhus, Denmark
| | - Päivi Lähteenmäki
- Pediatric and Adolescent Hematology/Oncology, Turku University Hospital, Fican-West and Turku University, Turku, Finland
- Swedish Childhood Cancer Registry, Karolinska Institutet, Stockholm, Sweden
| | - Mats Heyman
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska Institute, Stockholm, Sweden
- Department of Pediatric Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Arja Harila
- Department of Women's and Children's Health, Uppsala University and Pediatric Oncology, Uppsala University Hospital, Uppsala, Sweden
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Wu LM, Huang IC, Su HL, Lee SL. Interventions to Support Adolescents With Cancer in Decision-Making: A Systematic Review and Meta-Analysis. Worldviews Evid Based Nurs 2021; 18:339-349. [PMID: 34291849 DOI: 10.1111/wvn.12522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Adolescents have autonomous views and participatory rights. There is increasing support for involving adolescents with cancer in the healthcare decision-making process. AIMS The purpose of this study was to synthesize current knowledge to identify major components and outcomes of interventions to enhance shared decision-making (SDM) by adolescents with cancer during and after treatment. METHODS Six electronic databases (PubMed, CINHAL, MEDLINE, Cochrane, EBSCO, and Web of Science) were searched from their inceptions to February 2020. Eligibility criteria were intervention studies, studies of interventions to support adolescents with cancer involved in SDM, and studies of patients diagnosed with cancer between 10 and 18 years of age. Data extraction and quality appraisal were conducted by using a standardized data extraction form. Quality appraisal was based on the Cochrane Risk of Bias Tool. RESULTS Of 331 citations, five studies with a total of 648 participants aged between 13 and 21 years met inclusion criteria. Interventions included structured sessions held one to three times per week. SDM engagement strategies incorporated weekly assignments, live action videos, brochures, Five Wishes© advance directives, and follow-up counseling. Treatment preference congruence in adolescent and parent dyads was higher in intervention groups. Meta-analysis was performed on two studies and demonstrated statistically significant improvements in decision quality at 6 months (z = 3.37, p = .001; 95% CI = .174-.657) and 12 months (z = 3.17, p = .002; 95% CI = .150-.633) after SDM interventions in adolescent cancer survivors. No adverse events among patients were found, although anxiety scores increased in families in an intervention group. LINKING EVIDENCE TO ACTION This review identified essential components of SDM interventions. Our findings may guide the future design of interventions to support high-quality decision-making by adolescents with cancer. Coaching can educate adolescent cancer survivors on quality decision-making methods and can improve the quality of consequent decisions. More research is needed to determine outcomes of SDM interventions.
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Affiliation(s)
- Li-Min Wu
- School of Nursing, Kaohsiung Medical University, Kaohsiung City, Taiwan.,Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
| | - I-Chin Huang
- School of Nursing, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Hsiu-Lan Su
- School of Nursing, Kaohsiung Medical University, Kaohsiung City, Taiwan.,Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shu-Li Lee
- School of Nursing, Kaohsiung Medical University, Kaohsiung City, Taiwan
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Albertsen BK, Grell K, Abrahamsson J, Lund B, Vettenranta K, Jónsson ÓG, Frandsen TL, Wolthers BO, Heyman M, Schmiegelow K. Intermittent Versus Continuous PEG-Asparaginase to Reduce Asparaginase-Associated Toxicities: A NOPHO ALL2008 Randomized Study. J Clin Oncol 2019; 37:1638-1646. [DOI: 10.1200/jco.18.01877] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Asparaginase is an essential drug in childhood acute lymphoblastic leukemia (ALL) therapy and is frequently given for months to obtain continuous asparagine depletion. We randomly assigned patients to continuous versus intermittent pegylated-asparaginase (PEG-asp) treatment, hypothesizing there would be decreased toxicity with unchanged efficacy. METHODS Children (median age, 4.2 years) treated for non–high-risk ALL according to the Nordic Society for Pediatric Hematology and Oncology ALL2008 protocol received five intramuscular PEG-asp injections (1,000 IU/m2) every two weeks and were then randomly assigned to additional three doses (6-week intervals [experimental arm], n = 309) versus 10 doses (2-week intervals [standard arm], n = 316). The primary end point was noninferior (6% margin) disease-free survival. Toxicity reduction was a secondary end point. Occurrence of asparaginase-associated hypersensitivity, pancreatitis, osteonecrosis, and thromboembolism were prospectively registered. RESULTS After a median follow-up of 4.1 years, the 5-year disease-free survival was 92.2% (95% CI, 88.6 to 95.8) and 90.8% (95% CI, 87.0 to 94.6) in the experimental and standard arms, respectively. The 3-year cumulative incidence of any first asparaginase-associated toxicity (hypersensitivity [n = 13]; osteonecrosis [n = 29]; pancreatitis [n = 24]; thromboembolism [n = 17]) was 9.3% in the experimental arm and 18.1% in the standard arm ( P = .001). Asparaginase-associated toxicity reduction was confirmed in sex- and risk-group–adjusted Cox regression analysis stratified by age (≥ 10 and < 10 years; hazard ratio, 0.48; P = .001). The experimental arm had the lowest incidences of all four toxicities, reaching significance for pancreatitis (6-month risk, 5.8% v 1.3%; P = .002). CONCLUSION The excellent cure rates and reduced toxicity risk support the use of intermittent PEG-asp therapy after the first 10 weeks in future childhood ALL trials that apply prolonged PEG-asp therapy.
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Affiliation(s)
| | - Kathrine Grell
- University of Copenhagen, Copenhagen, Denmark,
- Rigshospitalet, Copenhagen, Denmark
| | | | - Bendik Lund
- Trondheim University Hospital, Trondheim, Norway
| | | | | | | | | | - Mats Heyman
- Karolinska University Hospital, Stockholm, Sweden
| | - Kjeld Schmiegelow
- University of Copenhagen, Copenhagen, Denmark,
- Rigshospitalet, Copenhagen, Denmark
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4
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Tulstrup M, Frandsen TL, Abrahamsson J, Lund B, Vettenranta K, Jonsson OG, Marquart HVH, Albertsen BK, Heyman M, Schmiegelow K. Individualized 6-mercaptopurine increments in consolidation treatment of childhood acute lymphoblastic leukemia: A NOPHO randomized controlled trial. Eur J Haematol 2017; 100:53-60. [DOI: 10.1111/ejh.12979] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Morten Tulstrup
- Department of Pediatrics and Adolescent Medicine; University Hospital Rigshospitalet; Copenhagen Denmark
| | - Thomas L. Frandsen
- Department of Pediatrics and Adolescent Medicine; University Hospital Rigshospitalet; Copenhagen Denmark
| | - Jonas Abrahamsson
- Department of Pediatrics; Institution for Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - Bendik Lund
- Department of Pediatrics; St. Olavs Hospital; Trondheim University Hospital; Trondheim Norway
- Department of Laboratory Medicine; Faculty of Medicine and Health sciences; Children's and Women's Health; Norwegian University of Science and Technology; Trondheim Norway
| | - Kim Vettenranta
- Department of Paediatrics; University of Tampere; Tampere Finland
| | | | | | | | - Mats Heyman
- Department of Pediatrics; Astrid Lindgrens Hospital; Stockholm Sweden
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine; University Hospital Rigshospitalet; Copenhagen Denmark
- Institute of Clinical Medicine; University of Copenhagen; Copenhagen Denmark
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Maggi M, Mittelman SD, Parmentier JH, Colombo G, Meli M, Whitmire JM, Merrell DS, Whitelegge J, Scotti C. A protease-resistant Escherichia coli asparaginase with outstanding stability and enhanced anti-leukaemic activity in vitro. Sci Rep 2017; 7:14479. [PMID: 29101342 PMCID: PMC5670125 DOI: 10.1038/s41598-017-15075-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 10/20/2017] [Indexed: 11/30/2022] Open
Abstract
L-Asparaginases (ASNases) have been used as first line drugs for paediatric Acute Lymphoblastic Leukaemia (ALL) treatment for more than 40 years. Both the Escherichia coli (EcAII) and Erwinia chrysanthemi (ErAII) type II ASNases currently used in the clinics are characterized by high in vivo instability, short half-life and the requirement of several administrations to obtain a pharmacologically active concentration. Moreover, they are sensitive to proteases (cathepsin B and asparagine endopeptidase) that are over-expressed by resistant leukaemia lymphoblasts, thereby impairing drug activity and pharmacokinetics. Herein, we present the biochemical, structural and in vitro antiproliferative characterization of a new EcAII variant, N24S. The mutant shows completely preserved asparaginase and glutaminase activities, long-term storage stability, improved thermal parameters, and outstanding resistance to proteases derived from leukaemia cells. Structural analysis demonstrates a modification in the hydrogen bond network related to residue 24, while Normal Mode-based geometric Simulation and Molecular Dynamics predict a general rigidification of the monomer as compared to wild-type. These improved features render N24S a potential alternative treatment to reduce the number of drug administrations in vivo and to successfully address one of the major current challenges of ALL treatment: spontaneous, protease-dependent and immunological inactivation of ASNase.
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Affiliation(s)
- Maristella Maggi
- Department of Molecular Medicine, Unit of Immunology and General Pathology, University of Pavia, Pavia, Italy
| | - Steven D Mittelman
- Center for Endocrinology, Diabetes & Metabolism, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jean Hugues Parmentier
- Center for Endocrinology, Diabetes & Metabolism, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Giorgio Colombo
- Biomolecular Simulations & Computational Chemistry Group, Istituto di Chimica del Riconoscimento Molecolare, CNR, Milan, Italy
| | - Massimiliano Meli
- Biomolecular Simulations & Computational Chemistry Group, Istituto di Chimica del Riconoscimento Molecolare, CNR, Milan, Italy
| | - Jeannette Marie Whitmire
- Department of Microbiology and Immunology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - D Scott Merrell
- Department of Microbiology and Immunology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Julian Whitelegge
- Julian Whitelegge, The Pasarow Mass Spectrometry Laboratory, The NPI-Semel Institute & Jonsson Comprehensive Cancer Center, David Geffen School of Medicine, UCLA, USA
| | - Claudia Scotti
- Department of Molecular Medicine, Unit of Immunology and General Pathology, University of Pavia, Pavia, Italy.
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Ingersgaard MV, Tulstrup M, Schmiegelow K, Larsen HB. A qualitative study of decision-making on Phase III randomized clinical trial participation in paediatric oncology: Adolescents' and parents' perspectives and preferences. J Adv Nurs 2017; 74:110-118. [PMID: 28771784 DOI: 10.1111/jan.13407] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2017] [Indexed: 01/07/2023]
Abstract
AIM To explore parents' and adolescents' motives for accepting/declining participation in the ALL2008 trials and adolescents' involvement in the decision-making process. BACKGROUND Children and adolescents with acute lymphoblastic leukaemia treated on the Nordic Society of Paediatric Haematology and Oncology ALL2008 protocol were eligible for two randomizations testing 6-mercaptopurine treatment intensifications to improve efficacy and Asparaginase de-escalation to reduce toxicity. We recently reported that while adolescents favoured treatment reduction, parents of young children favoured treatment intensification. DESIGN A qualitative, exploratory study. METHODS A maximum variation sampling strategy was used. Five adolescents aged 12-17 years, six parents of adolescents and five parents of children aged 1-12 years were interviewed in the period March-May 2015. Data were analysed using content analysis. FINDINGS Adolescents and parents emphasized the importance of adolescents' active participation in decisions regarding enrolment into clinical trials. A majority of adolescents were either final or collaborative decision-makers. Parents stated that in case of disagreement, they would overrule the adolescents' decision. There were no differences between motivations of preferences held by parents of children or adolescents, respectively. Decisions were based on subjective values attributed to cure contra toxicity and individual preferences for either standard or experimental treatment. The possibility of a negative outcome induced fear of decisional regret and distress by the parents, yet they invested considerable trust in the physician's expertise. CONCLUSION Our findings highlight the importance of adolescents' active involvement in consent conferences. Research on management of disagreements between adolescents and parents in trial decisions is needed.
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Affiliation(s)
- Marianne Vie Ingersgaard
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Morten Tulstrup
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Faculty of Health Sciences, University of Copenhagen and the Pediatric Clinic, Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hanne Baekgaard Larsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
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7
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Khakban A, Mohammadi T, Lynd LD, Mabbott D, Bouffet E, Gastonguay L, Zafari Z, Malkin D, Taylor M, Marra CA. Societal preferences in the treatment of pediatric medulloblastoma: Balancing risk of death and quality of life. Pediatr Blood Cancer 2017; 64. [PMID: 27917595 DOI: 10.1002/pbc.26340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 09/18/2016] [Accepted: 10/05/2016] [Indexed: 11/09/2022]
Abstract
PURPOSE Medulloblastoma is the most prevalent childhood brain cancer. Children with medulloblastoma typically receive a combination of surgery, radiation, and chemotherapy. The survival rate is high but survivors often have sequelae from radiotherapy of the entire developing brain and spinal cord. Ongoing genetic studies have suggested that decreasing the dose of radiation might be possible among children with favorable molecular variants; however, this may result in an increased disease recurrence. As such, there is a need to investigate the nature of trade-offs that individuals are willing to make regarding the treatment of medulloblastoma. METHOD We used best-worst scaling to estimate the importance of attributes affecting the general public's decision making around the treatment of medulloblastoma. After conducting focus groups, we selected three relevant attributes: (1) the accuracy of the genetic test; (2) the probability of serious adverse effects of the treatment(s); and (3) the survival rate. Using the paired method, we applied a conditional logit model to estimate preferences. RESULTS In total, 3,006 respondents (51.3% female) with an average age of 43 years answered the questionnaires. All coefficients were statistically significantly different from zero and the attribute levels of adverse effects and the survival rate had the most impact on individuals' stated decision making. CONCLUSION Overall, respondents showed high sensitivity to children experiencing disability particularly in the setting of a good prognosis. However, among children with poor prognostic molecular variants, participants showed tolerance about having a child with mild and partial disability compared to a low rate of survival.
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Affiliation(s)
- Amir Khakban
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, Canada
| | - Tima Mohammadi
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, Canada.,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Don Mabbott
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Eric Bouffet
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Louise Gastonguay
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, Canada
| | - Zafar Zafari
- Centre for Clinical Epidemiology and Evaluation, The University of British Columbia, Vancouver, Canada
| | - David Malkin
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Michael Taylor
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Carlo A Marra
- School of Pharmacy, Otago University, Dunedin, New Zealand
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