The NHLBI model: a 25 year history

Monitoring Multiple U.S. Government-Supported Covid-19 Vaccine Trials

Monitoring U.S. Government-Supported Covid-19 Vaccine TrialsOperation Warp Speed was a partnership created to accelerate the development of Covid-19 vaccines. The National Institutes of Health oversaw one data and safety monitoring board to review/monitor all Operation Warp Speed trials. This article describes the challenges faced in monitoring these trials and provides ideas for future similar endeavors.

The independent statistician model: How well is it working?

With the initiation in the late 1960s of the data and safety monitoring board or equivalently the data monitoring committee in randomized clinical trials came the need for interim statistical reports for these committees to review for study conduct and early evidence of harm or overwhelming evidence of benefit, perhaps leading to early trial termination. Initially, the statistical team was part of the data coordinating center for the trial. Later, starting in the early 1990s in many industry-sponsored trials, this statistical unit was separated organizationally from the team that collected and managed the data. This unit, often referred to as the statistical data analysis center, prepares reports for the data monitoring committee, which cover study conduct, data quality and completeness, primary and secondary outcomes, and safety measures by study arm in an unblinded fashion. The role of the statistical data analysis center is critical to any well-functioning data monitoring committee. With the proliferation of data monitoring committees has grown the need for many more well-trained and experienced statistical data analysis centers. In my experience, some such units perform their tasks extremely well but many do not. There is a tremendous need and opportunity to provide training for statistical data analysis centers, and what sponsors and data monitoring committees should expect from statistical data analysis centers.

Systematic qualitative review of the literature on data monitoring committees for randomized controlled trials

Aims To systematically review the published literature on data monitoring committees (DMCs) for randomized controlled trials (RCT) and summarize information and opinions on best practice. This was part of the DAMOCLES project. Methods A systematic and comprehensive search of five online bibliographic databases was performed, identifying 4007 potentially relevant articles. These were assessed in two stages by the authors. The 84 most relevant articles were agreed and were supplemented with extracts from 16 books: ultimately, 100 sources were reviewed. A series of 23 questions plus subquestions were developed to structure the data extraction and interpretation process.

Results Much has been written about DMCs but by a rather small community of authors. The papers included some results of surveys, but were mainly opinion pieces based on the authors' beliefs, practices and experiences. There is a lack of empirical evidence for many aspects of DMCs. There was a great range of detail in the literature relating to the prespecified questions. It was generally agreed that interim monitoring of accumulating data was necessary in some form for most trials. Questions such as membership of the DMC featured widely in the literature with opinions and practice ranging from 3–20 members, of whom between none and all should be independent. There was a consensus that formal statistical methods should be used as tools to guide decision making rather than as hard rules. Conversely, topics such as the training and experience required for DMC membership were discussed in very few papers.

Conclusions There is a consensus in the published literature in a number of areas, although there are many different models for structure and functions of a DMC. While uncertainty remains about some issues, it is strongly recommended that an explicit set of guidelines (Charter) is prepared for each DMC prior to the start of the trial specifying clearly how it will operate.

Prophylactic antibiotic regimens in tumour surgery (PARITY): protocol for a multicentre randomised controlled study

INTRODUCTION

Limb salvage with endoprosthetic reconstruction is the standard of care for the management of lower-extremity bone tumours in skeletally mature patients. The risk of deep postoperative infection in these procedures is high and the outcomes can be devastating. The most effective prophylactic antibiotic regimen remains unknown, and current clinical practice is highly varied. This trial will evaluate the effect of varying postoperative prophylactic antibiotic regimens on the incidence of deep infection following surgical excision and endoprosthetic reconstruction of lower-extremity bone tumours.

METHODS AND ANALYSIS

This is a multicentre, blinded, randomised controlled trial, using a parallel two-arm design. 920 patients 15 years of age or older from 12 tertiary care centres across Canada and the USA who are undergoing surgical excision and endoprosthetic reconstruction of a primary bone tumour will receive either short (24 h) or long (5 days) duration postoperative antibiotics. Exclusion criteria include prior surgery or infection within the planned operative field, known colonisation with methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus at enrolment, or allergy to the study antibiotics. The primary outcome will be rates of deep postoperative infections in each arm. Secondary outcomes will include type and frequency of antibiotic-related adverse events, patient functional outcomes and quality-of-life scores, reoperation and mortality. Randomisation will be blocked, with block sizes known only to the methods centre responsible for randomisation, and stratified by location of tumour and study centre. Patients, care givers and a Central Adjudication Committee will be blinded to treatment allocation. The analysis to compare groups will be performed using Cox regression and log-rank tests to compare survival functions at α=0.05.

ETHICS AND DISSEMINATION

This study has ethics approval from the McMaster University/Hamilton Health Sciences Research Ethics Board (REB# 12-009). Successful completion will significantly impact on clinical practice and enhance patients' lives. More broadly, this trial will develop a network of collaboration from which further high-quality trials in Orthopaedic Oncology will follow.

Release of data from an ongoing randomized clinical trial for sample size adjustment or planning

The determination of an appropriate sample size is a key issue in planning and designing randomized clinical trials. In settings with time-to-event or binary outcomes, the required sample size depends on the control-arm event (response) rate. An accurate estimate of this rate is not often available at the planning stage. Therefore, non-comparative control-arm or pooled-arm event rates from an ongoing trial are sometimes released for sample size adjustment or planning purposes. It is shown that such non-comparative data release may still contain information on the relative treatment benefit and may thus adversely affect the ongoing trial. A simple approach to minimizing the effect of the data release is suggested.

Role of the Data and Safety Monitoring Committee (DSMC)

The Data and Safety Monitoring Committee (DSMC) is a committee independent of both the Steering Committee (SC) and any sponsor. It advises these bodies on continuation or stopping based upon safety and efficacy considerations. The primary objective is to assure safety for the patients in the trial. Blinding of the DSMC regarding type of treatment is usually avoided. The DSMC is composed of three to five members and should include one or two clinicians knowledgeable in the field of the trial, one or two statisticians and in some situations a pharmacologist and an ethicist. It is important that the members have experience from other trials and have high integrity. Rules for the statistical analyses have to be set up in the beginning of the trial. However, the DSMC cannot rely only upon statistical rules. Information from other sources may cause stopping before the scheduled end of the trial. The DSMC has to check that the overall quality of the data is good. Of special importance is that the Endpoint Committee is current with classification of endpoints. Timing of the DSMC meetings is dependent on several factors: (i) the incidence of events; (ii) the power of the study design; (iii) the effectiveness of the intervention. Legal requirements to report serious adverse events to legal authorities may be taken over by the DSMC, which ideally is the only body that has access to unblinded data.

Independent data monitoring committees: rationale, operations and controversies

Data monitoring committees (DMCs) have become an increasingly common component of randomized clinical trials in recent years. As experience has accumulated, and more individuals and organizations have become involved in such activities, a variety of approaches to the operation of such committees has inevitably arisen. Because these committees play such a critical role in the process of new drug development, it is important to consider the implications of the different approaches that are being used. It is also timely to consider the present and possible future regulatory status of data monitoring committees. Published in 2001 by John Wiley & Sons, Ltd.

Electronic clinical trial protocol distribution via the World-Wide Web: a prototype for reducing costs and errors, improving accrual, and saving trees

Clinical trials today typically are inefficient, paper-based operations. Poor community physician awareness of available trials and difficult referral mechanisms also contribute to poor accrual. The Physicians Research Network (PRN) web was developed for more efficient trial protocol distribution and eligibility inquiries. The Medical University of South Carolina's Hollings Cancer Center trials program and two community oncology practices served as a testbed. In 581 man-hours over 18 months, 147 protocols were loaded into PRN. The trials program eliminated all protocol hardcopies except the masters, reduced photocopier use 59%, and saved 1.0 full-time equivalents (FTE), but 1.0 FTE was needed to manage PRN. There were no known security breaches, downtime, or content-related problems. Therefore, PRN is a paperless, user-preferred, reliable, secure method for distributing protocols and reducing distribution errors and delays because only a single copy of each protocol is maintained. Furthermore, PRN is being extended to serve other aspects of trial operations.

Data monitoring committees and problems of lower-than-expected accrual or events rates

Data monitoring committees for randomized clinical trials must frequently decide what action, if any, is required for trials whose accrual has been slower than expected, or whose event rates have been less than expected. We discuss in this article some of the practical issues concerning modifying or closing such trials, including what data and analyses could be helpful to the data monitoring committee in their deliberations.