1
|
Crowley F, Sheppard R, Lehrman S, Easton E, Marron TU, Doroshow D, Afezolli D. Optimizing care in early phase cancer trials: The role of palliative care. Cancer Treat Rev 2024; 128:102767. [PMID: 38776612 DOI: 10.1016/j.ctrv.2024.102767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
Advancements in cancer treatment have led to improved survival rates, with early phase clinical trials (EPCTs) serving as important initial steps in evaluating novel therapies. Recent studies have shown that response rates in these trials have doubled in the last twenty years. Patients who enroll on EPCTs have advanced cancer and heightened symptomatology yet maintain a robust performance status that qualifies them for clinical trial participation. It is well established that many of these patients have needs that can be addressed by palliative care, including symptom management, value assessments, advance care planning, and psychosocial and spiritual support. Several small studies have aimed to identify the most beneficial palliative care intervention for this cohort of patients, ranging from formal clinic-based multidisciplinary palliative care interventions to home-based interventions. While outcomes have trended towards benefit for patients, especially pertaining to psychological well-being, most studies were not powered to detect additional benefits for improved physical symptom management, reduction in care utilization or increased length of time on trial. In this review, we discuss the unique palliative care needs of this population and what we can learn from results of past interventional studies. We advocate for a tailored palliative care approach that acknowledges the time toxicity experienced by patients enrolled in EPCTs and address challenges posed by shortages within the palliative care workforce.
Collapse
Affiliation(s)
- Fionnuala Crowley
- Department of Hematology Oncology, Icahn School of Medicine at Mount Sinai, New York, USA; Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Richard Sheppard
- Department of Hematology Oncology, Icahn School of Medicine at Mount Sinai, New York, USA
| | | | - Eve Easton
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Thomas U Marron
- Department of Hematology Oncology, Icahn School of Medicine at Mount Sinai, New York, USA; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Early Phase Trials Unit, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deborah Doroshow
- Department of Hematology Oncology, Icahn School of Medicine at Mount Sinai, New York, USA; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Early Phase Trials Unit, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Debora Afezolli
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| |
Collapse
|
2
|
Kim J, Kim MG, Lim KM. Participation in and withdrawal from cancer clinical trials: A survey of clinical research coordinators. Asia Pac J Oncol Nurs 2022; 9:197-201. [PMID: 35571627 PMCID: PMC9096735 DOI: 10.1016/j.apjon.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/22/2021] [Indexed: 11/17/2022] Open
Abstract
Objective Poor accrual and withdrawal are the main reasons for the failure of cancer clinical trials. As clinical research coordinators (CRCs) work at the frontlines of clinical trials, CRCs can best identify the main factors that influence patient participation and dropout and suggest potential remedial measures. This study aimed to investigate participation and withdrawal in cancer clinical trials through a survey of CRCs. Furthermore, we collected suggestions of CRCs to increase patient participation and reduce withdrawal from cancer clinical trials. Methods This cross-sectional survey among 100 CRC nurses currently coordinating cancer clinical trials and having more than six months of experience was conducted at four hospitals in South Korea between March and August 2021. We designed a questionnaire based on prior studies, and the key items included characteristics of respondents, characteristics of clinical trials, clinical trial participation, and withdrawal. Results Patients refused to participate due to concern about adverse events (46.5%) and negative perception of clinical trials (44.4%). The main reasons for study withdrawal were disease progression (71.5%), adverse events (10.6%), and withdrawal of consent due to personal issues (5.5%). The provision of sufficient explanation was suggested as a remedial measure for increasing consent to participate (67.4%) and reducing withdrawal (21.8%). Conclusions A survey of CRCs revealed the reasons governing patient participation and withdrawal in cancer clinical trials, thereby providing a novel insight into strategies for promoting subject enrollment and reducing withdrawal from cancer clinical trials.
Collapse
|
3
|
Treasure M, Daly B, Cao S, Fu P, Hong A, Weinstein E, Surdam J, Meropol NJ, Dowlati A. A randomized controlled trial of structured palliative care versus standard supportive care for patients enrolled in phase 1 clinical trials. Cancer Med 2021; 10:4312-4321. [PMID: 34033228 PMCID: PMC8267138 DOI: 10.1002/cam4.3971] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/13/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose Patients enrolled in Phase 1 clinical trials have typically exhausted standard therapies and often are choosing between a clinical trial and hospice care. Significant symptom burden can result in early trial discontinuation and confound trial outcomes. This study aimed to examine differences in study duration, symptom burden, adverse events (AE), and quality of life (QOL) between those receiving structured palliative care versus usual supportive care. Patients and methods Sixty‐eight patients enrolled in phase 1 clinical trials and 39 of their CGs were randomly assigned to receive structured palliative care or usual supportive care. Patient QOL was measured monthly using the Functional Assessment of Cancer Therapy and Memorial Symptom Assessment Scale. The Quality of Life in Life‐Threatening Illness–Family Care Version and Caregiver Reaction Assessment were used for CGs. AEs and use of palliative care resources were compared between arms. Results Mean duration of the phase 1 study was 142 days in the palliative care arm versus 116 days in the usual care arm (p = 0.55). Although not statistically significant, patients in the palliative care arm experienced fewer AEs and better QOL, as did their CGs, compared to those receiving usual care. Conclusions Phase 1 patients and their CGs have physical and psychosocial needs warranting palliative care services. Results suggest that structured palliative care is associated with the increased duration of the study and improved patient and CG QOL. Phase 1 patients and their caregivers have physical and psychosocial needs warranting palliative care services. Providing structured palliative care servies to this population was associated with increased duration on phase 1 study and improved patient and caregiver QOL.
Collapse
Affiliation(s)
- Michelle Treasure
- Department of Medicine, University Hospitals Cleveland Medical Center, Seidman Cancer Center and Case Western Reserve University, Cleveland, OH, USA
| | - Barbara Daly
- Frances Payne School of Nursing, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Shufen Cao
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Pingfu Fu
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Augustine Hong
- Department of Medicine, University Hospitals Cleveland Medical Center, Seidman Cancer Center and Case Western Reserve University, Cleveland, OH, USA
| | - Elizabeth Weinstein
- Department of Medicine, University Hospitals Cleveland Medical Center, Seidman Cancer Center and Case Western Reserve University, Cleveland, OH, USA
| | - Jessica Surdam
- University Hospitals Cleveland Medical Center, Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Neal J Meropol
- Department of Medicine, University Hospitals Cleveland Medical Center, Seidman Cancer Center and Case Western Reserve University, Cleveland, OH, USA
| | - Afshin Dowlati
- Department of Medicine, University Hospitals Cleveland Medical Center, Seidman Cancer Center and Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|
4
|
Kennedy F, Shearsmith L, Ayres M, Lindner OC, Marston L, Pass A, Danson S, Velikova G. Online monitoring of patient self-reported adverse events in early phase clinical trials: Views from patients, clinicians, and trial staff. Clin Trials 2020; 18:168-179. [PMID: 33231103 PMCID: PMC8010887 DOI: 10.1177/1740774520972125] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND/AIMS New classes of cancer drugs bring a range of unknown and undesirable adverse events. Adverse event monitoring is essential in phase I trials to assess toxicity and safety. In phase II, the focus is also on efficacy but robust data on adverse events continue to inform the safety and the adverse event profile. Standard, clinician-led monitoring has been shown to underestimate patients' symptoms. Hence, patient-reported adverse event monitoring has been argued to complement and improve the information on adverse events in early phase clinical trials. With advances in information technology, real-time patient self-reported adverse events in trials are feasible. This study explored the experiences and procedures for reporting adverse events in early phase trials among patients, clinical staff, and trial staff, and their views on using an electronic patient-reported outcome adverse event system in this setting. METHODS Qualitative interviews were conducted with patients, purposively sampled across ages, gender, and different phases of trials, and with clinical and trial-related staff involved in early phase trials (e.g. consultants, research nurses, hospital-based trial assistants/data managers, trial unit management staff). Interviews explored patient experiences and views on current adverse event reporting processes and electronic patient-reported outcome adverse event reporting. Framework analysis techniques were used to analyse the data. RESULTS Interviewees were from two hospital trusts with early phase portfolios in England and a trial unit, and included sixteen patients, five consultants, four research nurses, five hospital-based trial staff, and two trial unit staff. Interviews identified three key themes (patient experiences, data flow, and views on electronic patient-reported outcome adverse event reporting). Stakeholders emphasised the intensity of trials for patients and the importance of extensive information provision within the uncertainty of early phase trial drugs. Regular face-to-face appointments for patients supplemented by telephone contact aimed to capture any adverse events. Delayed or under-reporting of mild- or low-severity symptoms was evident among patients. Hospital-based staff highlighted the challenges of current data collection including intense timescales, monitoring by trial sponsors, and high workload. Positive views on electronic patient-reported outcome adverse events highlighted that this could provide a more comprehensive and accurate view on the side effects of new drugs. Clinical staff emphasised patient safety and the need for clear responsibilities for monitoring. The need for careful decision-making about data flow and symptom attribution was highlighted; with trial unit staff emphasising the need for clinician review. CONCLUSION Technology advances mean it is timely to explore the benefits and challenges of electronic patient-reported outcome adverse event reporting. This is a complex area warranting further consideration within the trial community. We have developed an online patient self-reporting tool and a small pilot with early phase trial patients is underway.
Collapse
Affiliation(s)
- Fiona Kennedy
- Patient Reported Outcomes Group, Section of Patient-Centred Outcomes Research, Leeds Institute of Medical Research (LIMR) at St James's, University of Leeds, Leeds, UK
| | - Leanne Shearsmith
- Patient Reported Outcomes Group, Section of Patient-Centred Outcomes Research, Leeds Institute of Medical Research (LIMR) at St James's, University of Leeds, Leeds, UK
| | - Michael Ayres
- Patient Reported Outcomes Group, Section of Patient-Centred Outcomes Research, Leeds Institute of Medical Research (LIMR) at St James's, University of Leeds, Leeds, UK
| | - Oana C Lindner
- Patient Reported Outcomes Group, Section of Patient-Centred Outcomes Research, Leeds Institute of Medical Research (LIMR) at St James's, University of Leeds, Leeds, UK
| | - Lewis Marston
- Patient Reported Outcomes Group, Section of Patient-Centred Outcomes Research, Leeds Institute of Medical Research (LIMR) at St James's, University of Leeds, Leeds, UK
| | - Alison Pass
- Sheffield Experimental Cancer Medicine Centre, University of Sheffield & Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Sarah Danson
- Sheffield Experimental Cancer Medicine Centre, University of Sheffield & Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Galina Velikova
- Patient Reported Outcomes Group, Section of Patient-Centred Outcomes Research, Leeds Institute of Medical Research (LIMR) at St James's, University of Leeds, Leeds, UK
| |
Collapse
|
5
|
Berman R, Davies A, Cooksley T, Gralla R, Carter L, Darlington E, Scotté F, Higham C. Supportive Care: An Indispensable Component of Modern Oncology. Clin Oncol (R Coll Radiol) 2020; 32:781-788. [PMID: 32814649 PMCID: PMC7428722 DOI: 10.1016/j.clon.2020.07.020] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/14/2020] [Accepted: 07/29/2020] [Indexed: 12/15/2022]
Abstract
The advent of new cancer therapies, alongside expected growth and ageing of the population, better survival rates and associated costs of care, is uncovering a need to more clearly define and integrate supportive care services across the whole spectrum of the disease. The current focus of cancer care is on initial diagnosis and treatment, and end of life care. The Multinational Association of Supportive Care in Cancer defines supportive care as 'the prevention and management of the adverse effects of cancer and its treatment'. This encompasses the entire cancer journey, and necessitates involvement and integration of most clinical specialties. Optimal supportive care can assist in accurate diagnosis and management, and ultimately improve outcomes. A national strategy to implement supportive care is needed to acknowledge evolving oncology practice, changing disease patterns and the changing patient demographic.
Collapse
Affiliation(s)
- R Berman
- The Christie NHS Foundation Trust, Manchester, UK.
| | - A Davies
- Royal Surrey NHS Foundation Trust, Guildford, UK
| | - T Cooksley
- The Christie NHS Foundation Trust, Manchester, UK
| | - R Gralla
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - L Carter
- The Christie NHS Foundation Trust, Manchester, UK
| | - E Darlington
- The Christie NHS Foundation Trust, Manchester, UK
| | - F Scotté
- Gustave Roussy Cancer Institute, Interdisciplinary Cancer Course Department (DIOPP), Villejuif, France
| | - C Higham
- The Christie NHS Foundation Trust, Manchester, UK
| |
Collapse
|
6
|
Ferrell B, Chung V, Hughes MT, Koczywas M, Azad NS, Ruel NH, Knight L, Cooper RS, Smith TJ. A Palliative Care Intervention for Patients on Phase 1 Studies. J Palliat Med 2020; 24:846-856. [PMID: 33103938 DOI: 10.1089/jpm.2020.0597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Phase 1 clinical trials remain vital for oncology care. Patients on these trials require supportive care for quality-of-life (QOL) concerns. Objective: To test a Palliative Care Intervention (PCI) for patients with solid tumors enrolled in Phase I therapeutic trials with a priori hypothesis that psychological distress, QOL, satisfaction, symptoms, and resource utilization would be improved in the PCI group. Design: This unblinded randomized trial compared the PCI with usual care in patients accrued to Phase I Clinical Trials. Subjects (n = 479) were followed for 24 weeks, with 12 weeks as the primary outcome. Setting: Two Comprehensive Cancer Centers in the United States. Subjects: A consecutive sample, 21 years or older, English fluency, with solid tumors initiating a Phase 1 trial. Measurements: Psychological Distress (Distress Thermometer), QOL total and subscales (FACT-G), satisfaction (FAM-CARE), survival, and resource utilization (chart audit). Results: PCI subjects showed improved Psychological Distress (-0.47, p = 0.015) and Emotional Well-Being (0.81, p = 0.045), with differences on variables of QOL and distress between sites. High rates of symptom-management admissions (41.3%) and low rates of Advance Directive completion (39.0%), and hospice enrollment (30.7%), despite a median survival in both groups of 10.1 months from initiating a Phase 1 study. Conclusions: A nurse-delivered PCI can improve some QOL outcomes and distress for patients participating in Phase 1 trials. Greater integration of PC is needed to provide quality care to these patients and to support transitions from treatment to supportive care, especially at the end of life. ClinicalTrials.gov Identifier: NCT01612598.
Collapse
Affiliation(s)
- Betty Ferrell
- Division of Nursing Research and Education, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, USA
| | - Vincent Chung
- Department of Medical Oncology and Therapeutics Research, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, USA
| | - Mark T Hughes
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Marianna Koczywas
- Department of Medical Oncology and Therapeutics Research, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, USA
| | - Nilofer Saba Azad
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Nora H Ruel
- Department of Computational and Quantitative Medicine, Beckman Research Institute, City of Hope National Medical Center, Duarte, California, USA
| | - Louise Knight
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Rhonda S Cooper
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Thomas J Smith
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| |
Collapse
|
7
|
Ferrell B, Borneman T, Williams AC, Scardina A, Fischer P, Smith TJ. Integrating Palliative Care for Patients on Clinical Trials: Opportunities for Oncology Nurses. Asia Pac J Oncol Nurs 2020; 7:243-249. [PMID: 32642494 PMCID: PMC7325778 DOI: 10.4103/apjon.apjon_2_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/25/2020] [Indexed: 12/13/2022] Open
Abstract
The purpose of this article is to describe the lessons learned in the course of a 5-year research study on a palliative care intervention for persons on a Phase 1 clinical trial. Patients who are participating in Phase 1 trials and the families who care for them may be especially vulnerable and require special attention. The patients are generally experiencing the effects of advanced disease, and they also may soon experience unknown side effects, intense treatment regimens, and the emotional stress of an uncertain future as a result of clinical trial participation. Oncology nurses in all roles including clinical trials/research nurses, clinicians, educators, and advanced practice registered nurses play a critical role in addressing the quality-of-life concerns in this population. Palliative care can provide better symptom control and information on treatment options and facilitate a better understanding of patient/family goals. Attending to these factors can ultimately mean improved survival for the advanced cancer patient, and support for these patients can assist in advancing the field of oncology as these investigational therapies hold the promise for enhancing survival.
Collapse
Affiliation(s)
- Betty Ferrell
- Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA, USA
| | - Tami Borneman
- Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA, USA
| | - Anna Cathy Williams
- Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA, USA
| | - Angela Scardina
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Patricia Fischer
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Thomas J Smith
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| |
Collapse
|
8
|
van der Biessen DA, Oldenmenger WH, van der Helm PG, Klein D, Oomen-de Hoop E, Mathijssen RH, Lolkema MP, de Jonge MJ. Self-reported quality of life and hope in phase-I trial participants: An observational prospective cohort study. Eur J Cancer Care (Engl) 2018; 27:e12908. [PMID: 30179287 DOI: 10.1111/ecc.12908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/26/2018] [Accepted: 07/21/2018] [Indexed: 12/20/2022]
Abstract
For advanced cancer patients deliberating early clinical trial participation, adequate information about expected effect on quality of life (HRQoL) and hope, may support decision making. The aim was to assess the potential relation of HRQoL to eligibility for phase-I trial participation, and to observe the variations in patient-reported outcomes. Patients completed questionnaires at preconsent (n = 124), baseline (n = 96), and after first evaluation of a phase-I trial (n = 76). The Mann-Whitney U test was used to test differences between eligible and ineligible patients. Univariate logistic regression was performed for eligibility. Factorial repeated-measures ANOVA compared the outcomes of patients continuing vs. stopping participation after first evaluation over time. Eligibility is associated with significant better global health OR = 0.946, 95% CI [0.918, 0.975], p = 0.001, physical functioning OR = 0.959, 95% CI [0.933, 0.985], p = 0.002, role functioning OR = 0.974, 95% CI [0.957, 0.991] and better appetite OR = 1.114 95% CI [1.035, 1.192]. HRQoL outcomes like global health, social functioning and appetite decline in all patients and differ between patients continuing or having to end participation. Over time, hope and tenacity decline in all patients and coping strategies alter in patients stopping participation. Trial participation influences patient-reported outcomes. Global health may predict for eligibility and trial continuation. Informing patients could affect patients' decision making.
Collapse
Affiliation(s)
| | - Wendy H Oldenmenger
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Peer G van der Helm
- Faculty of Social Work and Applied Psychology, Leiden University of Applied Sciences, Leiden, The Netherlands
| | - Dennis Klein
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Esther Oomen-de Hoop
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, 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
| |
Collapse
|