Academic physician specialists' views toward the unproven stem cell intervention industry: areas of common ground and divergence

What is known about healthcare professional-patient communication when discussing stem cell therapies? A scoping review

OBJECTIVES

When therapeutic options are limited, patients may invest hope in therapies proposed by healthcare professional, or those they find online. This review aims to explore how healthcare professional-patient communication is realised when discussing stem cell therapies.

METHOD

Four electronic databases were systematically searched for relevant studies. Twenty-six studies met the inclusion criteria. Descriptive analyses and a thematic analysis guided by a functions of medical communication framework were performed on extracted data.

RESULTS

Most included studies addressed communication in contexts of conventional stem cell therapies, such as bone marrow transplants for blood cancers. Few studies investigated communication in contexts of experimental stem cell therapies yet to receive regulatory approval. Two themes were identified as informational and relational aspects of communication, and a third theme being a mismatch in orientations.

CONCLUSIONS

Communication between healthcare professionals and patients about stem cell therapies is practised using a combination of communication approaches that do not always align with patients' needs, hopes or expectations.

PRACTICE IMPLICATIONS

The context of healthcare settings and health conditions are important when communicating about stem cell therapies. Acknowledging healthcare professionals' environmental and personal determinants can inform strategies to navigate complex discussions about stem cell therapies with patients.

Periodontists and stem cell-based therapy for alveolar bone regeneration: A national survey

BACKGROUND

Stem cell-based therapy for bone regeneration has received attention in medical settings but has not yet been used in clinical practice for treating alveolar bone defects. The objectives of this study were to explore whether periodontists had heard about this approach, and if so how, how interested they were to learn about it, which attitudes and behavioral intentions they had related to using stem cell-based grafting, and what they would like to know before using this approach.

METHODS

Anonymous survey data were collected from 481 members of the American Academy of Periodontology (response rate: 19.41%).

RESULTS

Responses showed 35.3% had heard about stem cell-based therapy, mostly from publications (9.6%) and meetings (8.3%); 76.1% wanted to learn about it through in-person continuing education (CE) courses, 68.6% in online CE courses, and 57.1% from manuals; 73% considered this approach promising; and 54.9% preferred it to traditional approaches. It was important to them that it would result in more bone volume (93%), better bone quality (90.4%), and accelerated healing (83.2%). Also, 60.1% considered it likely/very likely that they would adopt this approach, 54% that patients would prefer it, and 62.1% that it would benefit their practice. When asked what they would like to know about this approach, information about short- and long-term outcomes, cost, and logistical considerations were most frequently named.

CONCLUSIONS

These findings provide the basis to develop educational interventions for periodontists about this novel approach and inform future research activities aimed to translate this approach to clinical practice.

Time to Total Knee Arthroplasty (TKA) Post Intra-Articular Injection

Background: Disease-modifying treatments are not currently developed to target the underlying causes of knee osteoarthritis (KOA). Corticosteroids (CS), hyaluronic acid (HA), and platelet-rich plasma (PRP) intra-articular (IA) injections are commonly used for patients that do not respond to non-pharmacological treatments, oral nonsteroidal anti-inflammatory, or pain medications to address solely KOA symptoms. Utilizing TKA as an endpoint in the KOA disease progression provides a basis to determine efficacy of this treatment pathway. The primary objective is to evaluate a large national database to determine the time between first injection and total knee arthroplasty in patients solely administered intra-articular IA, CS, and HA. Methods: A retrospective query was performed on a national, all-payer claims database (PearlDiver, Colorado Springs, CO, USA), a composite of over 160 million Health Insurance Portability and Accountability Act compliant orthopedic records across all states and territories of the United States spanning 2016 to 2022. The database was queried to produce three distinct cohorts for analysis (PRP, HA, and CS). A 4:1 case match was conducted to compare cohorts receiving a subsequent TKA. Kaplan-Meier survival analysis analyzed the TKA-free survival of patients within each group at 6 months and 1 to 4 years. The log-rank test was performed for comparisons between survival cohorts. Results: The PRP cohort had a total population of 3240 patients, of which 71 (2.2%) received a subsequent TKA. The corticosteroid cohort had a total population of 1,382,572, of which 81,271 (5.9%) received a subsequent TKA. The HA cohort had a total population of 164,000, of which 13,044 (8.0%) received a subsequent TKA. Due to the low population within the PRP group, this group was excluded from comparison. The mean time to TKA from first injection in the HA group was 377.8 days, while in the corticosteroid group it was 370.0 days. The proportions of TKA-free survival for CS and HA when compared at 4 years post-injection was similar between groups (p = 0.05). Discussion and Conclusion: Patients that received only IA-corticosteroids or IA-hyaluronic acid had a similar length of time between the first injection and the total knee arthroplasty associated with the injected joint. This evidence provides information for clinicians and patients alike when contemplating these non-surgical injection modalities for KOA. The similarity observed between these treatments supports the need for future research to determine whether there is any potential for reduction in healthcare costs for KOA treatment prior to TKA.

Survey of genetic counselors identifies a knowledge gap discerning properly regulated cell and gene therapy trials

BACKGROUND AND AIMS

As cell and gene therapy (CGT) has grown in availability and scope, more unapproved regenerative medicine is being marketed to the public. It is essential that health care providers have sufficient knowledge and comfort to determine whether treatments are properly regulated and address these topics with patients. Due to the applicability of CGT to genetic disease, genetic counselors could be key in providing education and answering patients' questions about these topics. However, previous studies have focused only on physicians' knowledge and comfort with CGT and unapproved regenerative medicine. The purpose of this study was to assess genetic counselors' self-reported knowledge and comfort discussing these topics with patients and to explore what factors predict increased knowledge and comfort.

METHODS

The authors designed an online survey distributed to genetic counselors who were part of the National Society of Genetic Counselors Student Research Program e-mail list. The survey addressed genetic counselors' demographics, practice experience with CGT, education about CGT, knowledge and comfort.

RESULTS

The survey was completed by 144 genetic counselors. The best predictor of increased knowledge and comfort was experience discussing CGT in practice. In addition, those who worked at an institution at which CGT trials were offered had greater knowledge and comfort. However, most genetic counselors reported their knowledge was not sufficient to address questions from patients, and most had little-to-no knowledge or comfort determining whether a trial was properly regulated. There was no correlation between education and either knowledge or comfort; however, most participants desired more education about these topics.

CONCLUSIONS

This study suggests that genetic counselors who (i) have experience with CGT in practice or (ii) work at institutions at which CGT trials are offered may have better knowledge regarding CGT. These results may help identify individuals and/or institutions in whom increasing knowledge regarding CGT could be beneficial. This is crucial as CGT becomes mainstream, leading to more widely marketed unapproved regenerative medicine. Several gaps in knowledge and comfort were identified, including participants' ability to determine whether a treatment is properly regulated. Further research is needed to better characterize the educational needs of genetic counselors surrounding these topics to address these gaps.

From the Integrity of Potency Assays to Safe Clinical Intervention: Legal Perspectives

Potency assays associated with the efficacy of investigational pharmaceutical products are one of the critical quality attributes that need to be carefully monitored during advanced therapy medicinal product (ATMP) development projects. Ensuring integrity of relevant potency assays for stem cell-based ATMPs is of paramount importance for safety and efficacy of clinical interventions. Yet, due to the complex and heterogeneous nature of stem cell-based ATMPs, creation of an appropriate set of potency assays is associated with a number of specific challenges ranging from intrinsic and operational to legal and regulatory ones. This chapter provides an overview of the EU regulatory landscape for advanced therapies, highlighting important aspects that need to be taken into consideration when preparing a strategic plan to meet the EU regulatory requirements.

The two-bucket problem of unproven stem cell interventions

The two-bucket problem of unproven stem cell interventions (SCIs) continues to bifurcate good (ethical) from bad (unethical) practices in the translation of stem cell medicine in ways that divert attention from other salient and challenging questions. It causes scholars to focus narrowly on reprimanding bad actors through legal and regulatory approaches and distracts from other important considerations such as how best to balance evidence with unmet patient needs and address misinformation about unproven stem cell interventions potentially changing patient behavior. The stem cell science community needs to consider a range of ethical practices and aim to address important questions that have yet not received sufficient consideration.

The Direct to Consumer Stem Cell Market and the Role of Primary Care Providers in Correcting Misinformation

INTRODUCTION

Direct to consumer stem cell and regenerative interventions (SCRIs) for various medical conditions have increased in popularity due to unmet medical needs and the promise of SCRIs to meet those needs. These interventions may have varying levels of safety and efficacy data and many lack sufficient scientific data to be marketed. The direct to consumer SCRI industry has received significant attention due to potential physical, economic, and emotional harms to patients. Patients may seek the counsel of their primary care providers when considering stem cell therapy for their condition.

METHODS

Here we describe strategies primary care providers can utilize when counseling patients.

RESULTS

Although we recommend constructing these discussions around individual patients' needs, one can utilize a general approach consisting of 4 parts. First, providers should recognize what information the patient is seeking and what is their understanding of stem cell and regenerative medicine. Next, providers should convey evidence-based information at the level of patients understanding so that they are aware of the risks, benefits, and descriptions of possible procedures. Throughout the conversations, attempts should be made to guide patients to a trusted resource that can provide additional information. Finally, providers should make an effort to address misinformation in a way that is nonjudgmental and patient-centered to make the patient feel safe and comfortable.

CONCLUSION

Effectively communicating risk information by primary care providers to patients is important given the harms reported from direct-to-consumer SCRIs. Correcting misinformation remains a priority when discussing SCRI's. Providers should strive to offer patients with additional resources such as the opportunity for consultation with a specialist or a consultation service dedicated to informing patients about regenerative medicine.

Perspectives on Challenges to Cell Therapy Development in Taiwan: Strengthening Evidential Standards and Ways Forward

Over the past years, the field of regenerative medicine and cell therapy has garnered much interest, extending beyond the bench to broader use, and commercialization. These therapies undergo stringent regulatory oversight as a result of their complexities and potential risk across different jurisdictions. Taiwan’s government, with the aim of developing the country as a hub for regenerative medicine in Asia, enacted a dual track act to promote the development of regenerative and cell therapy products. This qualitative study used purposive sampling to recruit sixteen experts (Twelve respondents from medical institutions and four respondents from the industry) to understand their perspectives on one of the regulatory tracks which governs the medical use of cell technologies and challenges regarding its implementation. Semi-structured interviews were conducted, transcribed, coded and thematically analyzed. Three major themes emerged from the analysis: 1) Perceptions of the “Special Regulation for Cell Therapy” 2) Emerging issues and controversies on the medical use of cell technologies in private clinics, and 3) Challenges impeding the clinical innovation of cell technologies. As reported by the experts, it was clear that the special regulation for cell therapy was aimed at legalizing the clinical use of cell therapy in a similar fashion to an evidence-based pathway, to promote clinical innovation, ensure manufacturing consistency, and improve oversight on cell-based therapies. Thus, the regulation addresses the issues of safety concerns, patient’s access and stem cell tourism. However, the limited approved cell techniques, quality control during cell processing, time, and criteria used in evaluating applications in addition to the need to develop evidential standards for clinical evidence are some of the difficulties faced. Thus, policy interventions on funding, educational resources, training, and regulatory clarity addressing these challenges may positively impact clinical innovation of cell therapy in Taiwan.

Academic Physician Specialists' Approaches to Counseling Patients Interested in Unproven Stem Cell and Regenerative Therapies-A Qualitative Analysis

OBJECTIVE

To explore the experiences, approaches, and challenges of physicians consulting patients about experimental stem cell and regenerative medicine interventions (SCRIs).

PARTICIPANTS AND METHODS

From August 21, 2018, through July 30, 2019, semistructured interviews of 25 specialists in cardiology, ophthalmology, orthopedics, pulmonology, and neurology were conducted and qualitatively analyzed using modified grounded theory.

RESULTS

All specialists used informational approaches to counsel patients, especially orthopedists. Informational approaches included explaining stem cell science, sharing risks, and providing principles. Several specialists also used relational counseling approaches including emphasizing that physicians want what is best for patients, acknowledging suffering, reassuring continued care, empathizing with patients and families, and underscoring that patients have the final decision. Many specialists reported being comfortable with the conversation, although some were less comfortable and several noted challenges in the consultation including wanting to support a patient's decision but worrying about harms from unproven SCRIs, navigating family pressure, and addressing stem cell hype and unrealistic expectations. Specialists also desired that additional resources be available for them and patients.

CONCLUSION

Physicians relied more heavily on providing patients with information about SCRIs than using relational counseling approaches. Efforts should be directed at helping physicians address the informational and relational needs of patients, including providing tools and resources that inform physicians about the unproven SCRI industry, building skills in empathic communication, and the creation and dissemination of evidence-based resources to offer patients.