Preventive ethics for including women of childbearing potential in clinical trials

Representation of women, older patients, ethnic, and racial minorities in trials of atrial fibrillation

BACKGROUND

Representation trends of women, older adults, and ethnic/racial minorities in randomized controlled trials (RCTs) of atrial fibrillation (AF) are uncertain.

METHODS

We systematically reviewed 134 AF related RCTs (phase II and III) encompassing 149,162 participants using Medline and ClinicalTrials.gov through April 2019 to determine representation trends of women, older patients (≥75 years), and ethnic/racial minorities. Weighted data on the prevalence of AF from epidemiological studies were used to compare the representation of the studied groups of interest in AF RCTs to their expected burden of the disease.

RESULTS

Only 18.7% of the RCTs reported proportion of older patients, and 12.7% RCTs reported ethnic/racial minorities. The proportions of women in RCTs versus general population were 35.2% and 35.1%, of Hispanics were 11.9% and 5.2%, of Blacks were 1.2% and 5.7%, of American Indian/Alaskans were 0.2% and 0.2%, of Asians were 14.2% and 2.4%, of native Hawaiian/Pacific Islanders were 0.05% and 0.1% and of non-Whites were 19.5% and 22.5%, respectively. The weighted mean age (SD) across the trials was 65.3 (3.2) years which was less than the corresponding weighted mean age of 71.1 (4.5) years in the comparative epidemiological data.

CONCLUSION

The reporting of older patients and ethnic/racial minorities was poor in RCTs of AF. The representation of women and American Indian/Alaskan natives matched their expected population share of disease burden. Hispanics and Asians were over-represented and Blacks, native Hawaiian/Pacific Islanders and non-Whites were under-represented in RCTs of AF.

Women's involvement in clinical trials: historical perspective and future implications

The importance of considering the differences between the male and female sex in clinical decision-making is crucial. However, it has been acknowledged in recent decades that clinical trials have not always adequately enrolled women or analyzed sex-specific differences in the data. As these deficiencies have hindered the progress of understanding women's response to medications, agencies in the United States have worked towards the inclusion of women in clinical trials and appropriate analysis of sex-specific data from clinical trials. This review outlines the history and progress of women's inclusion in clinical trials for prescription drugs and presents considerations for researchers, clinicians, and academicians on this issue.

Women and contraception in research: a pilot study

BACKGROUND

There are no data on women's willingness to participate in clinical trials as a function of real or perceived reproductive risk. Further, it is unknown whether the requirement for contraception or the common practice of limiting women's contraceptive choices influences their willingness to participate in research. The uncertainty about women's preferences on these matters remains a barrier for recruiting women to and retaining women as subjects in clinical trials.

METHODS

We developed a pilot study to determine women's willingness to participate in research with contraceptive requirements by looking at the three most common types of reversible contraceptives: hormonal contraception, barrier contraception, and intrauterine contraception. This study tested the hypotheses that restrictions on contraceptive choice impact women's willingness to participate in research and that the impact of contraceptive choice differs depending on women's perception of risk.

RESULTS

Women's willingness to participate in the proposed study decreased overall as reproductive risk increased. In addition, requirements for specific contraceptive methods negatively impacted women's reported willingness to participate in the research studies in our survey.

CONCLUSIONS

Results suggest that requirements for specific contraceptive methods negatively impacted women's reported willingness to participate in research. If confirmed in a larger sample, the negative effect of contraceptive limitations on women's willingness to participate in research would be of importance to clinical investigators and to institutional review boards (IRBs), as most adult biomedical research has as an explicit goal the equitable recruitment of women of childbearing potential.

Ethics of fetal surgery

This article provides a comprehensive approach to the ethics of clinical investigation of fetal surgery. Investigators should address the initiation and assessment of clinical trials to determine whether they establish a standard of care and use an appropriate informed consent process to recruit and enroll subjects, consider whether selection criteria should include the abortion preferences of the pregnant woman, and consider whether physicians have an obligation to offer referral to such investigation. This approach is comprehensive because it takes account of the physician's obligations to the fetal patient, the pregnant woman, and future fetal and pregnant patients. The comprehensive approach to the ethics of fetal surgery is applied to the example of in utero surgical management of spina bifida.

Ethical considerations in clinical investigation: exploring relevance in haemophilia research

Painful controversy has so far been largely absent from the history of haemophilia-related clinical research. However, the investigative methods now needed to realize evidence-based clinical practice, therapeutic advance, and a progressive standard of care for patients worldwide will be accompanied by the potential for ethical dilemma and transgression. From the current vantage point, three primary ethical issues merit special consideration: (i) the therapeutic misconception inherent to all clinical research and the randomized trial in particular; (ii) high risk and potentially non-beneficial novel technology research in children; and (iii) a collaborative partnership approach to research in the developing world. This study will focus on a discussion of each of these, drawing from the research ethics literature to offer a potential template for future deliberations in clinical trial design.

Ethics of maternal-fetal surgery

The transition from innovation to standard of care for maternal-fetal surgery should be guided by ethical as well as scientific considerations. This chapter provides an ethical framework that identifies criteria for the investigation of maternal-fetal surgery. Using this framework, physicians should address the initiation and assessment of clinical trials to determine whether they establish a standard of care, use an appropriately informed consent process to recruit and enroll subjects, consider whether selection criteria should include the abortion preferences of the pregnant woman, and consider whether physicians have an obligation to offer referral to such investigation. This ethical framework, in a clinically comprehensive fashion, takes account of the physician's obligations to the fetal patient, the pregnant woman, and future fetal and pregnant patients. The ethical framework is illustrated by the example of fetal surgery for spina bifida.