Small-cell lung cancer: patients included in clinical trials are not representative of the patient population as a whole

The SEER Program's evolution: supporting clinically meaningful population-level research

Although the Surveillance, Epidemiology, and End Results (SEER) Program has maintained high standards of quality and completeness, the traditional data captured through population-based cancer surveillance are no longer sufficient to understand the impact of cancer and its outcomes. Therefore, in recent years, the SEER Program has expanded the population it covers and enhanced the types of data that are being collected. Traditionally, surveillance systems collected data characterizing the patient and their cancer at the time of diagnosis, as well as limited information on the initial course of therapy. SEER performs active follow-up on cancer patients from diagnosis until death, ascertaining critical information on mortality and survival over time. With the growth of precision oncology and rapid development and dissemination of new diagnostics and treatments, the limited data that registries have traditionally captured around the time of diagnosis-although useful for characterizing the cancer-are insufficient for understanding why similar patients may have different outcomes. The molecular composition of the tumor and genetic factors such as BRCA status affect the patient's treatment response and outcomes. Capturing and stratifying by these critical risk factors are essential if we are to understand differences in outcomes among patients who may be demographically similar, have the same cancer, be diagnosed at the same stage, and receive the same treatment. In addition to the tumor characteristics, it is essential to understand all the therapies that a patient receives over time, not only for the initial treatment period but also if the cancer recurs or progresses. Capturing this subsequent therapy is critical not only for research but also to help patients understand their risk at the time of therapeutic decision making. This article serves as an introduction and foundation for a JNCI Monograph with specific articles focusing on innovative new methods and processes implemented or under development for the SEER Program. The following sections describe the need to evaluate the SEER Program and provide a summary or introduction of those key enhancements that have been or are in the process of being implemented for SEER.

Assessing patient burden and benefit: A decade of cabozantinib clinical trials

Drug development is complex and costly. Clinical trial participants take on risks, making it essential to maximize trial efficiency and maintain participant safety. Identifying periods of excessive burden during drug development can inform trial design, ensure patient benefit and prevent harm. This study aims to examine all published clinical trials for cabozantinib to assess patient benefit and burden over time. We conducted a retrospective cross-sectional review of interventional clinical trials of cabozantinib for solid cancer treatment. We searched PubMed/MEDLINE, Embase, Cochrane (CENTRAL) and ClinicalTrials.gov. We extracted adverse event rates, median progression-free survival (PFS), median overall survival and objective response rate (ORR) for each included trial. We calculated frequencies of trial characteristics, cumulative grade 3-5 adverse event rates and cumulative ORRs. Out of 1735 studies, 54 publications were included that involved 6372 participants and 21 cancers. Of the 54 studies in our sample, 31 (57.41%) were single-arm trials and 23 (42.60%) had negative results. Trials among and within various indications had conflicting results over time. Cumulative risk to participants increased over time, and clinical benefit decreased. The findings suggest that the risk profile of cabozantinib increased from 2011 to 2016 and has remained elevated but stable while benefit has decreased over time. The use of non-randomized and single-arm trials is concerning, and more methodologically rigorous trials are needed. The results of trials for different indications are inconsistent, and empirical administration may reduce the drug's efficacy.

Identifying and handling unbalanced baseline characteristics in a non-randomized, controlled, multicenter social care nurse intervention study for patients in advanced stages of cancer

Purpose

Given the psychosocial burdens patients in advanced stages of cancer face, innovative care concepts are needed. At the same time, such vulnerable patient groups are difficult to reach for participation in intervention studies and randomized patient inclusion may not be feasible. This article aims to identify systematic biases respectively selection effects occurring during the recruitment phase and to discuss their potential causes based on a non-randomized, multicenter intervention study with patients in advanced stages of cancer.

Methods

Patients diagnosed with at least one of 16 predefined cancers were recruited at four hospitals in three German cities. The effect of social care nurses’ continuous involvement in acute oncology wards was measured by health-related quality of life (EORTC QLQ-C30), information and participation preferences, decisional conflicts, doctor-patient communication, health literacy and symptom perception. Absolute standardized mean difference was calculated as a standardized effect size to test baseline characteristics balance between the intervention and control groups.

Results

The study enrolled 362 patients, 150 in the intervention and 212 in the control group. Except for gender, both groups differed in relevant socio-demographic characteristics, e.g. regarding age and educational background. With respect to the distribution of diagnoses, the intervention group showed a higher symptom burden than the control group. Moreover, the control group reported better quality of life at baseline compared to the intervention group (52.6 points (SD 21.7); 47.8 points (SD 22.0), ASMD = 0.218, p = 0.044).

Conclusion

Overall, the intervention group showed more social and health vulnerability than the control group. Among other factors, the wide range of diagnoses included and structural variation between the recruiting clinics increased the risk for bias. We recommend a close, continuous monitoring of relevant social and health-related characteristics during the recruitment phase as well as the use of appropriate statistical analysis strategies for adjustment, such as propensity score methods.

Trial registration: German Clinical Trials Register (DRKS-ID: DRKS00013640); registered on 29th December 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09646-6.

European Society of Gynaecological Oncology quality indicators for the surgical treatment of endometrial carcinoma

BACKGROUND

Quality of surgical care as a crucial component of a comprehensive multi-disciplinary management improves outcomes in patients with endometrial carcinoma, notably helping to avoid suboptimal surgical treatment. Quality indicators (QIs) enable healthcare professionals to measure their clinical management with regard to ideal standards of care.

OBJECTIVE

In order to complete its set of QIs for the surgical management of gynecological cancers, the European Society of Gynaecological Oncology (ESGO) initiated the development of QIs for the surgical treatment of endometrial carcinoma.

METHODS

QIs were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for the identification of potential QIs and documentation of the scientific evidence, two consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians and patient representatives. QIs were defined using a structured format comprising metrics specifications, and targets. A scoring system was then developed to ensure applicability and feasibility of a future ESGO accreditation process based on these QIs for endometrial carcinoma surgery and support any institutional or governmental quality assurance programs.

RESULTS

Twenty-nine structural, process and outcome indicators were defined. QIs 1-5 are general indicators related to center case load, training, experience of the surgeon, structured multi-disciplinarity of the team and active participation in clinical research. QIs 6 and 7 are related to the adequate pre-operative investigations. QIs 8-22 are related to peri-operative standards of care. QI 23 is related to molecular markers for endometrial carcinoma diagnosis and as determinants for treatment decisions. QI 24 addresses the compliance of management of patients after primary surgical treatment with the standards of care. QIs 25-29 highlight the need for a systematic assessment of surgical morbidity and oncologic outcome as well as standardized and comprehensive documentation of surgical and pathological elements. Each QI was associated with a score. An assessment form including a scoring system was built as basis for ESGO accreditation of centers for endometrial cancer surgery.

Single-agent carboplatin in extensive disease small-cell lung cancer patient with liver failure: a case report within the experience of a single institution

Until recently, platinum-based chemotherapy has represented the benchmark for the treatment of extensive disease small-cell lung cancer (ED-SCLC). ED-SCLC patients are often diagnosed with poor performance status (PS ≥2) and/or compromised organ functions. In fact, up to 63% of ED-SCLC has extensive liver involvement at diagnosis, which correlates with a poor prognosis. Whether to treat patients with tumor-related organ failure is still debated and the selection of those who could benefit from chemotherapy is crucial. Moreover, severe liver impairment contraindicates the administration of etoposide. Among 74 consecutive ED-SCLC patients followed at our institution from January 2017 to November 2019, three patients received single-agent carboplatin as a first-line treatment due to liver failure. We provide a brief description of a former heavy smoker 70-year-old man who was diagnosed with ED-SCLC and severe liver involvement leading to liver failure. The patient received a first-line treatment with single-agent carboplatin, obtaining a partial response, clinical benefit and the normalization of laboratory test, which documented the complete recovery of liver function. The intent of our work is to highlight the feasibility of single-agent carboplatin in ED-SCLC patients with tumor-related hepatic failure but preserved Eastern Cooperative Oncology Group PS, suggesting that this therapeutic option should not be discouraged a priori. Indeed, the identification of specific tools guiding physicians in the selection of patients who might benefit from the treatment is remarkably needed; meanwhile, the use of available prognostic score (e.g. Manchester score) might be of great value and should be considered in clinical practice.

Impact of Clinical Trial Participation on Survival of Patients with Metastatic Non-Small Cell Lung Cancer

INTRODUCTION

The impact of clinical trial participation on overall survival is unclear. We hypothesized that enrollment in a therapeutic drug clinical trial is associated with longer overall survival in patients with metastatic non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

We linked electronic medical record and Washington State cancer registry data to identify patients with metastatic NSCLC diagnosed between January 1, 2007, and December 31, 2015 who received treatment at a National Cancer Institute-designated cancer center. The exposure was trial enrollment. The primary outcome was overall survival, defined as the date of second-line treatment initiation to date of death or last follow-up. We used a conditional landmark analysis starting at the date of second-line treatment initiation and propensity scores with inverse probability of treatment weighting to estimate the association between trial enrollment and survival.

RESULTS

Of 215 patients, 40 (19%) participated in a second-line trial. Trial participants were more likely to be never smokers (45% vs 27%), have a good performance status (88% vs 77%) and have EGFR (48% vs 14%) and ALK mutations (8% vs 5%) than nonparticipants. Trial participants had similar overall survival to nonparticipants (HR 1.05; 95% CI, 0.72, 1.53; p = 0.81) after adjusting for sociodemographic and disease characteristics.

CONCLUSION

Accounting for the immortal time bias and selection bias, trial participation does not appear detrimental to survival. This finding may be reassuring to patients and supports programs and policies to improve clinical trial access.

Real world data of durvalumab consolidation after chemoradiotherapy in stage III non-small-cell lung cancer

OBJECTIVES

The PACIFIC study demonstrated the benefits of durvalumab consolidation on progression-free survival (PFS) and overall survival (OS) among patients with unresectable locally advanced non-small-cell lung cancer (LA-NSCLC). However, in real-world practice, patients with unresectable LA-NSCLC are heterogeneous with diverse tumor burdens and clinical factors; thus, it is important to examine the effectiveness and side effects of durvalumab when used in real clinical practice.

MATERIALS AND METHODS

We investigated the efficacy of durvalumab consolidation and the incidence of radiation pneumonitis in patients who received concurrent chemo-radiotherapy (CCRT) for unresectable LA-NSCLC in a single institute.

RESULTS

Overall, 55.3 % of patients did not meet the criteria of the PACIFIC study; however, they still received consolidation durvalumab in real-world practice. Durvalumab consolidation was associated with favorable PFS in the total population as well as in the subgroup of patients who did not meet the criteria of the PACIFIC study. However, radiation pneumonitis occurred more frequently in the durvalumab group, especially within 3-6 months after CCRT. The incidence of grade 3 radiation pneumonitis was 14.3 % in the durvalumab group versus 2.5 % in the observation group.

CONCLUSIONS

Durvalumab consolidation was associated with favorable PFS in patients with LA-NSCLC in clinical practice. However, careful selection of candidates for durvalumab treatment and active surveillance and appropriate management for radiation pneumonitis are needed.

Evaluation of the representativeness and generalizability of Japanese clinical trials for localized rectal/colon cancer: Comparing participants in the Japan Clinical Oncology Group study with patients in Japanese registries

INTRODUCTION

It is unclear if clinical trial results including patients who meet trial eligibility criteria, are applicable to actual patients in daily practice (generalizability). Moreover, the extent to which are trial participants different from patients seen in daily practice (representativeness) is also unclear. The aim of this study was to evaluate the representativeness of the patients registered in randomized clinical trials to patients in daily practice and examine the generalizability of trial results to daily practice.

METHODS

We compared the results of surgical trials conducted by the Japan Clinical Oncology Group with data from two Japanese cancer registries, representing patients seen in daily practice. We compared overall survival (OS) between trial participants and registry patients to evaluate representativeness of trial participants. We then compared the OS of registry patients who received open surgery (OP) and laparoscopic surgery (LAP) to evaluate the generalizability of trial results.

RESULTS

We analyzed 3051 patients (701 in JCOG0212, 2350 registry patients) with rectal cancer and 3116 patients (1057 in JCOG0404, 2059 registry patients) with colon cancer. Trial participants tended to possess lower clinical stages. Multivariable analyses revealed registry patients with significantly worse survival compared with trial participants. The hazard ratio of LAP to OP among registry patients was 0.305 (95% CI; 0.048-2.188), which did not meet the prespecified generalizability criteria of 0.9.

CONCLUSIONS

Our results failed to ensure either the representativeness or generalizability of clinical trial results, compared to daily practice. Careful considerations are required when applying trial results to patients in daily practice.

Are clinical trial eligibility criteria an accurate reflection of a real-world population of advanced non-small-cell lung cancer patients?

Background

Advanced non-small-cell lung cancer (nsclc) represents a major health issue globally. Systemic treatment decisions are informed by clinical trials, which, over years, have improved the survival of patients with advanced nsclc. The applicability of clinical trial results to the broad lung cancer population is unclear because strict eligibility criteria in trials generally select for optimal patients.

Methods

We performed a retrospective chart review of all consecutive patients with advanced nsclc seen in outpatient consultation at our academic institution between September 2009 and September 2012, collecting data about patient demographics and cancer characteristics, treatment, and survival from hospital and pharmacy records. Two sets of arbitrary trial eligibility criteria were applied to the cohort. Scenario A stipulated Eastern Cooperative Oncology Group performance status (ecog ps) 0-1, no brain metastasis, creatinine less than 120 μmol/L, and no second malignancy. Less-strict scenario B stipulated ecog ps 0-2 and creatinine less than 120 μmol/L. We then used the two scenarios to analyze treatment and survival of patients by trial eligibility status.

Results

The 528 included patients had a median age of 67 years, with 55% being men and 58% having adenocarcinoma. Of those 528 patients, 291 received at least 1 line of palliative systemic therapy. Using the scenario A eligibility criteria, 73% were trial-ineligible. However, 46% of "ineligible" patients actually received therapy and experienced survival similar to that of the "eligible" treated patients (10.2 months vs. 11.6 months, p = 0.10). Using the scenario B criteria, only 35% were ineligible, but again, the survival of treated patients was similar in the ineligible and eligible groups (10.1 months vs. 10.9 months, p = 0.57).

Conclusions

Current trial eligibility criteria are often strict and limit the enrolment of patients in clinical trials. Our results suggest that, depending on the chosen drug, its toxicities and tolerability, eligibility criteria could be carefully reviewed and relaxed.

Willingness of breast cancer patients to undergo biopsy and breast cancer clinicians' practices around seeking biopsy at the time of breast cancer relapse

PURPOSE

The practice of seeking a biopsy to confirm a metastatic relapse of a prior breast cancer is individualized. Tumor samples have well-recognized importance in clinical and translational research, but also an increasing role in routine care. We sought to determine the attitudes of patients and breast cancer clinicians about biopsy at breast cancer relapses.

METHODS

Consenting breast cancer patients and clinicians completed questionnaires with scenarios of decreasing personal benefit and increasing discomfort or inconvenience associated with biopsy at relapse of a prior breast cancer. For each scenario, patients were asked whether they would, would not, or were unsure about agreeing to a biopsy. Clinicians provided information about their practice, research activities, and usual biopsy habits. They were asked to estimate how often patients would agree to a biopsy under each of the conditions presented to patient participants.

RESULTS

The majority of patients expressed a willingness to undergo a biopsy procedure of modest inconvenience and discomfort to establish an uncertain diagnosis, guide treatment, to participate in a trial, or for research purposes only. About 50% of patients indicated that they would undergo an invasive biopsy procedure requiring IV sedation or general anesthetic for purely altruistic reasons. In spite of being a largely academic group, clinician respondents underestimated patient willingness to have a biopsy in all scenarios, particularly when there was no attached personal benefit.

CONCLUSION

Breast cancer patients were very willing to undergo biopsy at breast cancer relapse for their routine care, clinical trials, or for research only. Clinicians act as the intermediary between patients and tumor tissue repositories, and clinician perceptions and practices should shift to match the altruistic attitudes of breast cancer patients.

The Effect of Receiving Treatment Within a Clinical Trial Setting on Survival and Quality of Care Perception in Advanced Stage Non-Small Cell Lung Cancer

OBJECTIVES

Treatment outcomes of advanced stage (IIIB and IV) non-small cell lung cancer (NSCLC) are poor. In this study, we explore the survival outcomes and the perception of the quality of care delivered in stage IIIB and IV NSCLC patients treated within versus outside a clinical trial.

MATERIALS AND METHODS

Data were obtained from the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS). Baseline characteristics according to clinical trial participation were determined. The association between clinical trial enrollment and survival was assessed using a Cox proportional hazard model after adjusting for age, income, primary data collection and research site, comorbidities, self-reported performance status, presence of brain metastasis, stage IIIB versus IV, and cancer histology.

RESULTS

Of 815 stage IIIB and IV NSCLC patients, 56 (7%) were enrolled in clinical trials. Median survival for the patients treated within versus outside a clinical trial was 20.5 versus 16.7 months, respectively (P=0.21). Using a multivariate survival model, clinical trial enrollment did not correlate with longer survival (P=0.81). Comparing patients according to clinical trial enrollment, patients treated within a clinical trial setting perceived a better overall quality of care (P<0.01).

CONCLUSIONS

Management of stage IIIB and IV NSCLC patients within a clinical trial setting conveyed a perception of superior care that did not translate into survival benefit. These findings suggest that providing cancer care within a clinical trial should not imply a survival benefit when counseling stage IIIB and IV NSCLC patients about entering clinical trials.

Psycho-oncology

Psycho-oncologic care for glioma patients has two important aspects. First, clinical decision making regarding treatment of the tumor should reflect a sound balance between quality and quantity of life. Second, supportive care should be targeted at the symptoms that are most detrimental to perceived quality of life (QOL) of glioma patients, and of their informal caregivers. In this chapter we will first focus on the definition of QOL and the ways of measuring this adequately in clinical trials, and then discuss the impact of the disease itself, and of established and experimental treatment modalities on perceived QOL. Subsequently, we will discuss frequently occurring symptoms that have an impact on the perceived QOL of glioma patients and their caregivers. This will include what is known about the efficacy of symptomatic treatment and maintaining or improving QOL in both patients and caregivers, followed by recommendations for future directions of clinical care and research.

Factors influencing inclusion in digestive cancer clinical trials: A population-based study

BACKGROUND

Inclusion in a randomized therapeutic trial represents an optimal therapeutic strategy.

AIMS

To determine the influence of demographic characteristics and deprivation on the enrolment of patients in digestive cancer clinical trials.

METHODS

Between 2004 and 2010, 4632 patients were recorded by the Burgundy Digestive Cancer Registry. According to a balancing score, the 136 patients included in a clinical trial were matched with 272 patients who met the eligibility criteria for trials. Deprivation was measured by the ecological European deprivation index. A conditional multivariate logistic regression was performed.

RESULTS

Patients aged over 75 years were significantly less likely to be included in clinical trials than younger patients (odds ratio 0.33; [0.13-0.87]). Patients treated in private institutions were also less likely to be enrolled than those treated in public institutions (odds ratio 0.04; [0.01-0.16]; p<0.001). A relationship between type of institution and the European deprivation index was observed (p=0.017). Deprived patients were less likely to be included in clinical trials when they were managed in private institutions (odds ratio 0.706; [0.524-0.952]; p=0.022). The European deprivation index had no impact when patients were managed in other institutions.

CONCLUSION

The relationship between type of institution and deprivation underlines the necessity for improving patients' chance of being recruited in digestive cancer clinical trials.

Competing events and costs of clinical trials: Analysis of a randomized trial in prostate cancer

BACKGROUND

Clinical trial costs may be reduced by identifying enriched subpopulations of patients with favorable risk profiles for the events of interest. However, increased selectivity affects accrual rates, with uncertain impact on clinical trial cost.

METHODS

We conducted a secondary analysis of Southwest Oncology Group (SWOG) 8794 randomized trial of adjuvant radiotherapy for high-risk prostate cancer. The primary endpoint was metastasis-free survival (MFS), defined as time to metastasis or death from any cause (competing mortality). We used competing risks regression models to identify an enriched subgroup at high risk for metastasis and low risk for competing mortality. We applied a cost model to estimate the impact of enrichment on trial cost and duration.

RESULTS

The treatment effect on metastasis was similar in the enriched subgroup (HR, 0.42; 95% CI, 0.23-0.76) compared to the whole cohort (HR, 0.50; 95% CI, 0.30-0.81) while the effect on competing mortality was not significant in the subgroup or the whole cohort (HR 0.70; 95% CI 0.39-1.23, vs. HR 0.94; 95% CI, 0.68-1.31). Due to the higher incidence of metastasis relative to competing mortality in the enriched subgroup, the treatment effect on MFS was greater in the subgroup compared to the whole cohort (HR 0.55; 95% CI 0.36-0.82, vs. HR 0.77; 95% CI, 0.58-1.01). Trial cost was 75% less in the subgroup compared to the whole cohort ($1.7 million vs. $6.8 million), and the trial duration was 30% shorter (8.4 vs. 12.0 years).

CONCLUSION

Competing event enrichment can reduce clinical trial cost and duration, without sacrificing generalizability.

Factors influencing participation in a randomized controlled resistance exercise intervention study in breast cancer patients during radiotherapy

Background

Over the past years knowledge about benefits of physical activity after cancer is evolving from randomized exercise intervention trials. However, it has been argued that results may be biased by selective participation. Therefore, we investigated factors influencing participation in a randomized exercise intervention trial for breast cancer patients.

Methods

Non-metastatic breast cancer patients were systematically screened for a randomized exercise intervention trial on cancer-related fatigue. Participants and nonparticipants were compared concerning sociodemographic characteristics (age, marital status, living status, travel time to the training facility), clinical data (body-mass-index, tumor stage, tumor size and lymph node status, comorbidities, chemotherapy), fatigue, and physical activity. Reasons for participation or declination were recorded.

Results

117 patients (52 participants, 65 nonparticipants) were evaluable for analysis. Multiple regression analyses revealed significantly higher odds to decline participation among patients with longer travel time (p = 0.0012), living alone (p = 0.039), with more comorbidities (0.031), previous chemotherapy (p = 0.0066), of age ≥ 70 years (p = 0.025), or being free of fatigue (p = 0.0007). No associations were found with BMI or physical activity. By far the most frequently reported reason for declination of participation was too long commuting time to the training facility.

Conclusions

Willingness of breast cancer patients to participate in a randomized exercise intervention study differed by sociodemographic factors and health status. Neither current physical activity level nor BMI appeared to be selective for participation. Reduction of personal inconveniences and time effort, e.g. by decentralized training facilities or flexible training schedules, seem most promising for enhancing participation in exercise intervention trials.

Trial registration

Registered at ClinicalTrials.gov: NCT01468766 (October 2011).

Evaluation of eligibility and recruitment in breast cancer clinical trials

Objectives of the study were to measure recruitment rates in clinical trials and to identify patients, physicians or trials characteristics associated with higher recruitment rates. Among patients who had a clinical trial available for their cancer, 83.5% (345/413) met the eligibility criteria to at least one clinical trial. At least one trial was proposed to 33.1% (113/341) of the eligible patients and 19.7% (68/345) were recruited. Overall recruitment was 16.5% (68/413). In multivariate analyses, trial proposal and enrollment were lower for elderly patients and higher in high cancer stages. Trials from pharmaceutical industry had higher recruitment rates and trials testing hormonal therapy enrolled more patients. Breast cancer patients' accrual to a clinical trial could be improved by trying to systematically identify all eligible patients and propose a trial to those eligible and to whom the treatment is planned to be equivalent to the standard arm of the trial.

Comparison of survival outcomes among cancer patients treated in and out of clinical trials

BACKGROUND

Clinical trials test the efficacy of a treatment in a select patient population. We examined whether cancer clinical trial patients were similar to nontrial, "real-world" patients with respect to presenting characteristics and survival.

METHODS

We reviewed the SWOG national clinical trials consortium database to identify candidate trials. Demographic factors, stage, and overall survival for patients in the standard arms were compared with nontrial control subjects selected from the Surveillance, Epidemiology, and End Results program. Multivariable survival analyses using Cox regression were conducted. The survival functions from aggregate data across all studies were compared separately by prognosis (≥50% vs <50% average 2-year survival). All statistical tests were two-sided.

RESULTS

We analyzed 21 SWOG studies (11 good prognosis and 10 poor prognosis) comprising 5190 patients enrolled from 1987 to 2007. Trial patients were younger than nontrial patients (P < .001). In multivariable analysis, trial participation was not associated with improved overall survival for all 11 good-prognosis studies but was associated with better survival for nine of 10 poor-prognosis studies (P < .001). The impact of trial participation on overall survival endured for only 1 year.

CONCLUSIONS

Trial participation was associated with better survival in the first year after diagnosis, likely because of eligibility criteria that excluded higher comorbidity patients from trials. Similar survival patterns between trial and nontrial patients after the first year suggest that trial standard arm outcomes are generalizable over the long term and may improve confidence that trial treatment effects will translate to the real-world setting. Reducing eligibility criteria would improve access to clinical trials.

Impact of chemotherapy-induced peripheral neuropathy on treatment delivery in nonmetastatic breast cancer

PURPOSE

To determine the incidence of dose-limiting (DL) chemotherapy-induced peripheral neuropathy (CIPN) events in clinical practice.

PATIENTS AND METHODS

This retrospective cohort study included 488 women who received docetaxel or paclitaxel. The primary outcome was a DL event (dose delay, dose reduction, or treatment discontinuation) attributed to CIPN (DL CIPN). The paired t test was used to test the difference in received cumulative dose and planned cumulative dose by dose reduction and treatment discontinuation status.

RESULTS

A total of 150 unique DL events occurred in 120 women (24.6%). More than one third (37.3%; n=56) of the events were attributed to CIPN. The 56 DL CIPN events occurred in 50 women (10.2%). DL CIPN incidence differed significantly by agent (docetaxel, 2.4%; n=five of 209; paclitaxel, 16.1%; n=45 of 279; P<.001). DL CIPN occurred in 24.5% and 14.4% of women who received paclitaxel 80 mg/m2 weekly for 12 cycles and 175 mg/m2 biweekly for four cycles, respectively (adjusted odds ratio, 2.11; 95% CI, 0.97 to 4.60; P=.06). The cumulative dose actually received was significantly lower than the planned cumulative dose among women who had a dose reduction or treatment termination attributed to CIPN (9.4% less; P<.001 and 28.4% less; P<.001, respectively).

CONCLUSION

Oncologists limited the dosing of chemotherapy because of CIPN in a significant proportion of paclitaxel recipients, most frequently in those who received a weekly regimen. Patients who had their dose reduced or discontinued received significantly less cumulative chemotherapy than planned. The implications of these DL CIPN events on treatment outcomes must be investigated.

Characteristics of advanced cancer patients with cancer-related fatigue enrolled in clinical trials and patients referred to outpatient palliative care clinics

CONTEXT

Limited published data exist on whether characteristics of patients with advanced cancer enrolled in cancer-related fatigue clinical trials (CCTs) differ from patients in outpatient palliative care clinics (OPCs).

OBJECTIVES

The primary aim of this study was to compare the characteristics of two groups of patients with advanced cancer and moderate-to-severe fatigue: patients in CCTs and patients at an OPC.

METHODS

We retrospectively reviewed the records of 337 patients who were enrolled in one of five CCTs for advanced cancer patients at The University of Texas M. D. Anderson Cancer Center as well as the records of 1896 consecutive patients who were referred to our OPC from January 2003 through December 2010. Patients with fatigue scores of ≥4/10 (measured by the Edmonton Symptom Assessment System [ESAS]) were eligible (1252 OPC patients and 337 CCT patients). Patient characteristics, ESAS scores, and survival times were compared using Chi-square tests, Wilcoxon rank sum tests, and the Kaplan-Meier method.

RESULTS

Compared with the CCT patients, OPC patients were more likely to be older (58 vs. 59 years; P=0.009) and male (38% vs. 52%; P<0.001). The most common primary cancer type was breast cancer (22%) in the CCT patients and lung cancer (23%) in the OPC patients (P<0.001). The median ESAS scores in the OPC and CCT groups, respectively, were 6 and 4 for pain (P<0.001), 7 and 7 for fatigue (P=0.525), 3 and 2 for depression (P=0.004), 3 and 2 for anxiety (P<0.001), 3 and 2 for dyspnea (P<0.001), and 43 and 32 for the symptom distress score (P<0.001). The median overall survival times were 17.9 months (95% CI 13.5-22.3 months) in the CCT group and 3.8 months (95% CI 3.5-4.1 months) in the OPC group (P<0.001).

CONCLUSION

Baseline characteristics and overall survival times significantly differed between patients enrolled in the CCT and OPC groups. Therefore, we conclude that the results of CCTs cannot be generalized to patients being treated in OPCs.

Does enrollment in cancer trials improve survival?

BACKGROUND

Stakeholders derive many benefits from cancer clinical trials, including guidance for future oncologic treatment decisions. However, whether enrollment in cancer trials also improves patient survival independently of trial outcomes remains underinvestigated. We hypothesized that cancer trial enrollment is not associated with patient survival outcomes.

STUDY DESIGN

Using the 2002 to 2008 California Cancer Registry, we identified 555,469 patients with stage I to IV solid organ tumors. Baseline characteristics were compared by trial participation status. Logistic regression determined predictors of trial enrollment. Multivariate Cox proportional hazards regression examined the impact of trial participation on overall and cancer-specific mortality with adjustment for covariates.

RESULTS

Only 0.33% of our cohort was enrolled in clinical trials. Trial participants were likely to be younger than 65 (odds ratio [OR] 2.13; 95% CI 1.90 to 2.38), Hispanic rather than non-Hispanic white (OR 0.78; 95% CI 0.67 to 0.90), and have breast cancer (OR 3.14; 95% CI 2.62 to 3.77). Multivariate survival analyses demonstrated that enrollment in cancer trials predicted a lower hazard of death. However, when stratified by disease site, this survival benefit was observed only in lung, colon, and breast cancers. Sensitivity and interaction analyses confirmed these relationships.

CONCLUSIONS

In this first population-based study examining trial effect in solid organ cancers, enrollment into cancer trials predicted lower overall and cancer-specific mortality among common cancer sites. Although these findings may demonstrate a survival benefit due to trial enrollment, they likely also reflect the favorable attributes of trial enrollees. Once corroborated, stakeholders must consider broader cancer trial designs representative of the cancer burden treated in the real world.

Does enrollment in cancer trials improve survival?

BACKGROUND

Stakeholders derive many benefits from cancer clinical trials, including guidance for future oncologic treatment decisions. However, whether enrollment in cancer trials also improves patient survival independently of trial outcomes remains underinvestigated. We hypothesized that cancer trial enrollment is not associated with patient survival outcomes.

STUDY DESIGN

Using the 2002 to 2008 California Cancer Registry, we identified 555,469 patients with stage I to IV solid organ tumors. Baseline characteristics were compared by trial participation status. Logistic regression determined predictors of trial enrollment. Multivariate Cox proportional hazards regression examined the impact of trial participation on overall and cancer-specific mortality with adjustment for covariates.

RESULTS

Only 0.33% of our cohort was enrolled in clinical trials. Trial participants were likely to be younger than 65 (odds ratio [OR] 2.13; 95% CI 1.90 to 2.38), Hispanic rather than non-Hispanic white (OR 0.78; 95% CI 0.67 to 0.90), and have breast cancer (OR 3.14; 95% CI 2.62 to 3.77). Multivariate survival analyses demonstrated that enrollment in cancer trials predicted a lower hazard of death. However, when stratified by disease site, this survival benefit was observed only in lung, colon, and breast cancers. Sensitivity and interaction analyses confirmed these relationships.

CONCLUSIONS

In this first population-based study examining trial effect in solid organ cancers, enrollment into cancer trials predicted lower overall and cancer-specific mortality among common cancer sites. Although these findings may demonstrate a survival benefit due to trial enrollment, they likely also reflect the favorable attributes of trial enrollees. Once corroborated, stakeholders must consider broader cancer trial designs representative of the cancer burden treated in the real world.

Identifying barriers associated with enrollment of patients with lung cancer into clinical trials

BACKGROUND

Enrollment of patients with lung cancer into clinical trials is required to accelerate the pace of new therapy development and contribute to a better understanding of the biological characteristics of cancer.

METHODS

We conducted a retrospective chart review of all patients seen by the thoracic medical oncology team at the Vanderbilt Ingram Cancer Center (VICC) from November 2005 to November 2008 to determine the barriers associated with patient enrollment in to clinical trials.

RESULTS

One thousand forty-three patient charts were audited: 32% of patients were eligible for enrollment, and 14% enrolled in a study. There were no significant differences in protocol availability or eligibility by sex, smoking status, or age. Patients living further from the cancer center were significantly less likely to have a study protocol available (P = .009), but if a protocol was available they were more likely to be eligible for enrollment (P < .001). Significantly more protocols were available for patients with non-small-cell lung cancer (NSCLC) compared with those who had small-cell lung cancer (SCLC) (63% vs. 48%; P < .001). Patients with advanced disease were more likely to have a protocol available (P < .001) and enter a study (P = .031). The most common reasons for patients not being eligible for enrollment were poor performance status (32%) and presence of comorbid disease (27%). The most common reasons for potentially eligible patients not enrolling in a study included preference for treatment closer to home (49%) and patient refusal (43%).

CONCLUSION

Additional strategies are required to increase accrual of patients into lung cancer trials, including development of protocols for early-stage disease and modifying eligibility and performance status criteria for this unique patient population.

Obesity in cancer survival

Although obesity is a well-known risk factor for several cancers, its role on cancer survival is poorly understood. We conducted a systematic literature review to assess the current evidence evaluating the impact of body adiposity on the prognosis of the three most common obesity-related cancers: prostate, colorectal, and breast. We included 33 studies of breast cancer, six studies of prostate cancer, and eight studies of colo-rectal cancer. We note that the evidence overrepresents breast cancer survivorship research and is sparse for prostate and colorectal cancers. Overall, most studies support a relationship between body adiposity and site-specific mortality or cancer progression. However, most of the research was not specifically designed to study these outcomes and, therefore, several methodological issues should be considered before integrating their results to draw conclusions. Further research is urgently warranted to assess the long-term impact of obesity among the growing population of cancer survivors.

Generalizability of toxicity data from oncology clinical trials to clinical practice: toxicity of irinotecan-based regimens in patients with metastatic colorectal cancer

Background

The relevance of oncology trial results to clinical practice depends on whether the trial participants are similar to the actual population of patients receiving treatment for the malignancy and whether the patients are treated similarly in both circumstances. Chemotherapy treatments may be more toxic in patients of advanced age and poor performance status—patients typically excluded from clinical trials.

Methods

In a retrospective chart review that included all non-trial patients with metastatic colorectal cancer treated with irinotecan-based chemotherapy from January 2004 to September 2006 at our institution, we quantified and subsequently compared the toxicity rates of the irinotecan regimens in clinical practice with published toxicity rates from corresponding phase iii clinical trials. The primary endpoint was the incidence of grades 3 and 4 diarrhea.

Results

The study included 203 patients, and the irinotecan regimens considered included

folfiri [irinotecan, leucovorin, 5-fluorouracil (5fu)],

ifl (bevacizumab, irinotecan, 5fu, leucovorin),

xeliri (capecitabine, 3-weekly irinotecan), and

irinotecan monotherapy.

The rates of grades 3 and 4 diarrhea for folfiri, ifl, xeliri, and irinotecan monotherapy in clinical practice were 10%, 15%, 17%, and 21% as compared with 10%, 23%, 20%, and 31% respectively in clinical trials. When only patients meeting trial performance status and age criteria were analyzed, the rates of grades 3 and 4 diarrhea by regimen were 11%, 20%, 19%, and 26% respectively.

Conclusions

Overall, the toxicity rates for folfiri and irinotecan monotherapy in non-trial patients were not statistically different from the rates quoted in published clinical trials.

Clinicians' attitudes towards clinical trials of cancer therapy

Background:

Patient accrual into cancer clinical trials remains at low levels. This survey elicited attitudes and practices of cancer clinicians towards clinical trials.

Method:

The 43-item Clinicians Attitudes to Clinical Trials Questionnaire was completed by participants in an intervention study aimed at improving multi-disciplinary involvement in randomised trials. Responses from 13 items were summed to form a research-orientation score.

Results:

Eighty-seven clinicians (78%) returned questionnaires. Physicians, more often than surgeons, chose to prioritise prolonging a patient's life, recruited ⩾50% of patients into trials and attended more research-focussed conferences. Clinicians at specialist centres were more positive about trials with no-treatment arms than those at district general hospitals, more likely to believe clinician, rather than patient reluctance to participate was the greater obstacle to trial accrual, and preferred national and international to local recognition. Clinicians belonging to breast and colorectal teams were less disappointed about not enrolling patients in trials and more accepting of no-treatment arm trials. Research orientation was higher in physicians than surgeons and higher in specialist centres than district hospitals.

Conclusions:

This study provides greater understanding of clinicians’ attitudes to trials. Results have been used to inform training interventions for clinicians targeting the problem of low and selective accrual.

Comparison of treatment and outcome information between a clinical trial and the National Cancer Data Repository

BACKGROUND

Clinical trials are important but many factors limit their success, including the costs of long-term follow-up and participants often not being representative of the general population. The National Cancer Data Repository (NCDR) contains data about patients with cancer in England that may help overcome some of these problems. This study compared treatment and outcome information between the Medical Research Council Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC) trial and the NCDR.

METHODS

Participants in the CLASICC trial were identified in the NCDR, and management and outcome data were compared. Data on all surgically treated English patients with colorectal cancer were extracted from the NCDR and compared with those of CLASICC participants.

RESULTS

Survival and treatment data for those in the CLASICC trial were available in the NCDR for 98·9 and 95·8 per cent of patients respectively. There was agreement in operation type for 86·1 per cent of patients but surgical approach coding was poor, with only 58·4 per cent of laparoscopic procedures coded in the NCDR. There was no significant difference in survival calculated from either data set. Surgical information was available in the NCDR for 19 of 20 trial participants with missing data. The trial population was younger (P < 0·001), of better socioeconomic status (P = 0·001) and with earlier disease (P < 0·001) than the general surgically treated colorectal cancer population. Rectal cancer survival was similar, but 5-year survival after treatment of colonic cancer was significantly better in the trial than in the national data: 57·1 (95 per cent confidence interval 51·5 to 62·3) versus 49·8 (49·3 to 50·2) per cent respectively.

CONCLUSION

The National Cancer Data Repository demonstrates potential for informing clinical trials, but limitations prevent full intention-to-treat analyses.

Are patients in clinical trials representative of the general population? Dose intensity and toxicities associated with FE100C-D chemotherapy in a non-trial population of node positive breast cancer patients compared with PACS-01 trial group

PURPOSE

In our institution, adjuvant taxanes are currently offered to fit, node positive breast cancer patients who are either Her2 positive (any ER/PR) or triple negative (ER/PR/Her2 negative). The FE(100)C-D (FE(100)C × 3→docetaxel 100mg/m(2) × 3) regime, based on the PACS 01 trial [Roche H, Fumoleau P, Spielmann M, et al. Sequential Adjuvant Epirubicin-Based and Docetaxel Chemotherapy for node positive Breast Cancer Patients: The FNCLCC PACS 01 Trial. J Clin Oncol 2006;24:5664-5671] is used. We retrospectively audited our experience with FE(100)C-D at The Beatson West of Scotland Cancer Centre and one representative district general hospital (DGH), Falkirk and District Royal Infirmary (FDRI).

PATIENTS AND METHODS

Over a two year period, 101 patients commenced adjuvant FE(100)C-D chemotherapy. Data was matched with the FE(100)C-D arm of the PACS 01 trial.

RESULTS

Median age was 54 years. Twenty-six patients (26%) had ≥ 1 episode of febrile neutropaenia (FN), including one fatal episode. Twenty-nine percent of patients required treatment interruption ≥ 1 week. Thirty percent of patients had dose reductions. Thirty percent of patients received <90% dose intensity of docetaxel.

CONCLUSION

The FN rate was substantially higher and docetaxel dose intensity substantially lower in our unselected sample of patients than in the reference study.(1) This 'real-life' data illustrates the problems of applying clinical trial data to the more generalised patient population.

Long-term cohort study of women at intermediate risk of familial breast cancer: experiences of living at risk

AIMS

To identify how women adjusted to living at intermediate risk of breast cancer six years following risk assessment, and what factors contributed to health service usage.

METHOD

Two studies are reported. Both report data from a cohort of women found at intermediate risk of breast cancer six years previously. In the first, 30 women with a range of Cancer Worry Scale (Lerman et al. Health Psychol 1991;10:259-267) scores were interviewed about how they lived with their risk of cancer and their use of health resources. The generalisability of these findings was tested in a sample of 387 women from the same cohort using psychometrically appropriate measures.

FINDINGS

In study 1, women scoring above the median baseline BCWS scale score were most likely to perceive their family history as a burden, exaggerate their susceptibility to breast cancer, not be reassured by genetic counselling, be focussed on the need for mammographic screening, and have a low reliance on breast self-examination. Key findings of the second study were that over a quarter of the cohort were experiencing at least moderate levels of intrusive worries. Worries were associated with perceptions of high personal vulnerability to and severity of cancer and breast cancer being highly salient. Women aged over 50 years with high levels of worry-related distress were most likely to request a mammogram.

CONCLUSION

The high levels of distress in this cohort reinforce the need to provide appropriate interventions for vulnerable women following risk assessment.

Differences in clinical trial patient attributes and outcomes according to enrollment setting

PURPOSE

During the last 25 years, National Cancer Institute (NCI) cooperative trial groups have extended trial networks from academic centers to include certain community and Veterans Health Administration (VHA) centers. We compared trial patients' attributes and outcomes by these enrollment settings.

PATIENTS AND METHODS

Studying 2,708 patients on one of 10 cooperative group, randomized lung trials at 272 institutions, we compared patient attributes by enrollment setting (ie, academic, community, and VHA affiliates). We used adjusted Cox regression to evaluate for survival differences by setting.

RESULTS

Main member institutions enrolled 44% of patients; community affiliates enrolled 44%; and VHAs enrolled 12%. Patient attributes (ie, case-mix) of age, ethnicity, sex, and performance status varied by enrollment setting. After analysis was adjusted for patient case-mix, no mortality differences by enrollment setting were noted.

CONCLUSION

Although trial patients with primarily advanced-stage lung cancer from nonacademic centers were older and had worse performance statuses than those from academic centers, survival did not differ by enrollment setting after analysis accounted for patient heterogeneity. An answer for whether long-term outcomes for patients at community and VHA centers affiliated with cooperative trial groups are equivalent to those at academic centers when care is delivered through NCI trials requires additional research among patients with longer survival horizons.

Patterns of recruitment into acute myeloid leukaemia (AML) 15 and outcome for young patients with AML at a single referral centre

This study assessed the recruitment to an acute myeloid leukaemia (AML) trial (AML15) in a single centre, evaluated whether outcome was influenced by trial entry and whether the trial population could be considered representative of all AML patients by retrospective comparison of patient characteristics, trial entry and outcome for 81 consecutive patients (<60 years). All patients were considered for trial entry, however the trial was not offered to 12 (15%) patients. These patients had a worse outcome than the 69 (85%) patients that were invited to participate (P = 0.04). Sixteen patients (23%) invited to participate in the trial declined and were treated on equivalent protocols. These patients had a similar outcome to those who accepted entry into the trial (P = 0.2). These results suggested that physicians exert a selection bias when evaluating patients for trial entry. Thus the overall survival estimates generated from large phase III trials may indicate that the outcome for patients with AML is better than the outcome experienced in the 'real' world. Furthermore, patients who are considered appropriate for randomization into a trial, but decline entry, experience a similar outcome to those treated on trial when treated in an equivalent manner.

Population-based assessment of survival after cytoreductive nephrectomy versus no surgery in patients with metastatic renal cell carcinoma

OBJECTIVES

To examine the population-based survival rates of patients with metastatic renal cell carcinoma (RCC) treated with cytoreductive nephrectomy (CNT) and compare them with those of patients treated without surgery.

METHODS

Of the 43,143 patients with RCC identified in the 1988-2004 Surveillance, Epidemiology, and End Results database, 5372 had metastatic RCC. Of those, 2447 were treated with CNT (45.5%) and 2925 (54.5%) were not. Univariable and multivariable Cox regression models, as well as matched and unmatched Kaplan-Meier survival analyses, were used. The covariates consisted of age, sex, tumor size, and year of diagnosis.

RESULTS

The 1-, 2-, 5-, and 10-year overall survival rate of the patients treated with CNT was 53.6%, 36.3%, 19.4%, and 12.7% compared with 18.5%, 7.4%, 2.3%, and 1.2% for the no-surgery patients, respectively. The corresponding cancer-specific survival rates were 58.1%, 40.8%, 24.3%, and 18.8% and 24.4%, 11.0%, 4.1%, and 2.9% for the same patient groups. On multivariate analysis, independent predictor status was recorded for treatment type, tumor size, and patient age (all P <.001). Also, relative to CNT, the no-surgery group had a 2.5-fold greater rate of overall and cancer-specific mortality (P <.001). In the matched analyses, virtually the same effect was recorded (hazard ratio 2.6, P <.001).

CONCLUSION

The results of our study have shown that CNT significantly improves the survival of patients with metastatic RCC.

Recruitment in the prostate, lung, colorectal, and ovarian (PLCO) cancer screening trial: the first phase of recruitment at Henry Ford Health System

OBJECTIVE

Recruitment of healthy subjects to long-term randomized controlled trials (RCTs) of cancer prevention or early detection has proven to be a difficult task. To quantify recruitment yield as well as characteristics of successfully recruited participants, we examined recruitment outcomes at 1 of the 10 centers participating in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial, a National Cancer Institute-funded RCT of cancer screening modalities.

MATERIALS AND METHODS

During the early recruitment phase of PLCO (1993-1997), data on recruitment outcome were collected at the Henry Ford Health System (HFHS) in Detroit, Michigan. In this phase, HFHS identified potential participants using patient databases. Records were used to assess recruitment success by age, sex, race, household income (using area-based U.S. Census data), and preexisting morbidity. Logistic regression was used to assess whether enrollment success differed significantly according to these factors.

RESULTS

Of 74,139 persons ages 55 to 74 invited by HFHS to participate, 8,250 (11%) ;enrolled. In multivariate analyses, the odds of enrolling were modestly but significantly higher for women, Caucasians, persons in their 60's, and persons living in census blocks with higher median household income. Persons with two or more preexisting morbidities had significantly lower odds of enrolling compared to those with one or no preexisting morbidities.

CONCLUSIONS

These data suggest that only a small fraction of persons invited to enroll in long-term RCTs of cancer screening modalities actually do so. In this urban, Midwestern setting, certain characteristics including age, race, and income influenced recruitment success, albeit modestly.

Outcomes of patients who participate in randomized controlled trials compared to similar patients receiving similar interventions who do not participate

BACKGROUND

Some people believe that patients who take part in randomised controlled trials (RCTs) face risks that they would not face if they opted for non-trial treatment. Others think that trial participation is beneficial and the best way to ensure access to the most up-to-date physicians and treatments. This is an updated version of the original Cochrane review published in Issue 1, 2005.

OBJECTIVES

To assess the effects of patient participation in RCTs ('trial effects') independent both of the effects of the clinical treatments being compared ('treatment effects') and any differences between patients who participated in RCTs and those who did not. We aimed to compare similar patients receiving similar treatment inside and outside of RCTs.

SEARCH STRATEGY

In March 2007, we searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, The Cochrane Methodology Register, SciSearch and PsycINFO for potentially relevant studies. Our search yielded 7586 new references. In addition, we reviewed the reference lists of relevant articles.

SELECTION CRITERIA

Randomized studies and cohort studies with data on clinical outcomes of RCT participants and similar patients who received similar treatment outside of RCTs.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed studies for inclusion, assessed study quality and extracted data.

MAIN RESULTS

We identified 30 new non-randomized cohort studies (45 comparisons): no new RCTs were found. This update now includes five RCTs (yielding 6 comparisons) and 80 non-randomized cohort studies (130 comparisons), with 86,640 patients treated in RCTs and 57,205 patients treated outside RCTs. In the randomised studies, patients were invited to participate in an RCT or not; these comparisons provided limited information because of small sample sizes (a total of 412 patients) and the nature of the questions they addressed. When the results of RCTs and non-randomized cohorts that reported dichotomous outcomes were combined, there were 98 comparisons; there was also heterogeneity (P < 0.00001, I(2) = 42.2%) between studies. No statistical significant differences were found for 85 of the 98 comparisons. Eight comparisons reported statistically significant better outcomes for patients treated within RCTs, and five comparisons reported statistically significant worse outcomes for patients treated within RCTs. There was significant heterogeneity (P < 0.00001, I(2) = 58.2%) among the 38 continuous outcome comparisons. No statistically significant differences were found for 30 of the 38 comparisons. Three comparisons reported statistically significant better outcomes for patients treated within RCTs, and five comparisons reported statistically significant worse outcomes for patients treated within RCTs.

AUTHORS' CONCLUSIONS

This review indicates that participation in RCTs is associated with similar outcomes to receiving the same treatment outside RCTs. These results challenge the assertion that the results of RCTs are not applicable to usual practice.

An examination of the influence of patient race and ethnicity on expressed interest in learning about cancer clinical trials

PURPOSE

A number of factors have been identified as being associated with the documented low accrual rate of minorities into cancer-related clinical trials in the USA. An important issue is the fundamental interest, or lack thereof, of these specific patient populations in actually considering study participation.

METHODS

To examine this issue, aggregate data were analyzed from a proprietary Internet-based decision support program (NexProfiler Treatment Option Tools for Cancer, NexCura, Seattle, WA, USA) embedded into approximately 100 cancer-associated Web sites where responding patients (or their families) were asked, but not required, to identify their race/ethnicity (African-American, Asian-American, Caucasian and Hispanic) and to also respond to the question, "Are you interested in learning about clinical trials?".

RESULTS

Of the > 60,000 patients who both self-identified their race/ethnicity and responded to the question regarding their desire to learn about clinical trials, approximately 10% were from the minority (non-Caucasian) groups. Of note, in all four malignancies analyzed (breast, colorectal, lung, and prostate) and in both patients < or = 60 and > 60 years of age, each of the three non-Caucasian populations expressed an interest in learning about such studies that was equal to, if not greater than, that observed in the Caucasian respondents.

CONCLUSION

Assuming these provocative results regarding self-declared desire to learn about clinical trials can be confirmed by others with similar Internet-associated databases, this analysis suggests Web-based recruitment strategies may be an effective method to communicate with minority populations in the US (and, perhaps, elsewhere) with a specific interest in considering participation in cancer clinical trials.

Outcomes of patients who participate in randomised controlled trials compared to similar patients receiving similar interventions who do not participate

BACKGROUND

Some people believe that patients who take part in randomised controlled trials (RCTs) face risks that they would not face if they opted for non-trial treatment. Others think that trial participation is beneficial and the best way to ensure access to the most up to date physicians and treatments.

OBJECTIVES

To assess the effects of patient participation in RCTs ('trial effects') independent both of the effects of the clinical treatments being compared ('treatment effects') and any differences between patients who participated in RCTs and those who did not.

SEARCH STRATEGY

In May 2001, we searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, The Cochrane Methodology Register, SciSearch and PsycINFO for potentially relevant studies. Our search yielded over 10,000 references. In addition, we reviewed the reference lists of relevant articles and wrote to over 250 investigators to try to obtain further information.

SELECTION CRITERIA

Randomised studies and cohort studies with data on clinical outcomes of RCT participants and similar patients who received similar treatment outside of RCTs.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently assessed studies for inclusion, assessed study quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

We included five randomised studies (yielding 6 comparisons) and 50 non-randomised cohort studies (85 comparisons), with 31,140 patients treated in RCTs and 20,380 patients treated outside RCTs. In the randomised studies, patients were invited to participate in an RCT or not; these comparisons provided limited information because of small sample sizes (a total of 412 patients) and the nature of the questions they addressed. There was statistically significant heterogeneity (P < 0.002, I(2) = 36.2%) among the 73 dichotomous outcome comparisons; none of the potential explanatory factors we investigated helped to explain this heterogeneity. No statistically significant differences were found for 63 of the 73 comparisons. Eight comparisons reported statistically significant better outcomes for patients treated within RCTs, and two comparisons reported statistically significant worse outcomes for patients treated within RCTs. There were no statistically significant differences in heterogeneity (P = 0.53, I(2) = 0%) or in outcomes (SMD 0.01, 95% CI -0.10 to 0.12) of patients treated within and outside RCTs in the 18 comparisons which had used continuous outcomes.

AUTHORS' CONCLUSIONS

This review indicates that participation in RCTs is not associated with greater risks than receiving the same treatment outside RCTs. These results challenge the assertion that the results of RCTs are not applicable to usual practice.

Cisplatin plus etoposide chemotherapy followed by thoracic irradiation and paclitaxel plus cisplatin consolidation therapy for patients with limited stage small cell lung carcinoma

PURPOSE

To evaluate the efficacy and tolerance of a cisplatin plus etoposide regimen followed by thoracic radiotherapy (TRT) and paclitaxel plus cisplatin consolidation chemotherapy in patients with limited stage small cell lung cancer (SCLC).

PATIENTS AND METHODS

Thirty-nine patients with limited SCLC were enrolled onto this study. Patients received three courses of cisplatin 75 mg/m2 i.v., day 1 and etoposide 100 mg/m2 i.v., days 1-3 (EP regimen), followed by TRT (45-56 Gy administered in 15 fractions), and three courses of paclitaxel 175 mg/m2 i.v., day 1 and cisplatin, as previously, on day 2 (PP regimen); cycles were repeated every 21 days.

RESULTS

All patients were evaluable for toxicity and 34 for response. The overall response rate was 67% (CR: 26%; PR: 41%; intention-to-treat analysis) (95% CI: 53.0-84.2%). After a median follow-up period of 15 months, the median survival time was 15 months, the median time to tumor progression 8.3 months and the 1-year survival rate 53.8%. Grade 3/4 neutropenia occurred in 39% and 36% of patients receiving EP and PP regimens, respectively. The incidence of febrile neutropenia was 5% and 3% for EP and PP regimens, respectively. Other hematologic and non-hematologic toxicities were mild, with the exception of esophagitis occurring in 36% of patients during and/or immediately after radiotherapy.

CONCLUSION

Consolidation therapy with PP after sequential EP and thoracic radiotherapy is feasible and well-tolerated; however, the efficacy results are comparable with those previously obtained in the same patients' population using a combination of EP and TRT.

Generalizability of cancer clinical trial results

BACKGROUND

The generalizability of clinical trial results is questionable, because fewer than 5% of cancer patients participate. The authors examined the comparability of clinical trial participants and nonparticipants and the potential impact of differences.

METHODS

A retrospective cohort of 19,340 cancer patients who were diagnosed between January 1990 and December 1997 was characterized by trial participation. The distributions of prognostically important factors among trial participants were compared with the distributions among nonparticipants and the population of patients diagnosed during the same period in the Surveillance, Epidemiology, and End Results population. The impact of these factors on survival was examined by using a Cox proportional hazards analysis.

RESULTS

Trial participants were younger and had better performance status and fewer comorbid conditions compared with nonparticipants. However, participants were more likely to have locally advanced disease, positive lymph node status, poorly differentiated tumors, liver metastases, and multiple metastatic sites. The former factors were associated with significantly longer survival, whereas the later factors were associated with significantly shorter survival.

CONCLUSIONS

The lack of comparability between trial participants and nonparticipants called into question the generalizability of clinical trial results. Although selective recruitment for clinical trials is justified, the authors encourage the use of population-based trials of effectiveness in "all comers."

Factors influencing inclusion of patients with malignancies in clinical trials

Participation in clinical trials remains low and is a central issue in oncology. The authors identified, through a systematic review, 75 papers published up to August 2004 that report barriers to recruitment of patients in clinical trials. These barriers range from patient preference and concern about information/consent to clinical problems with protocols. Strategies to overcome barriers on the part of patients and clinicians are needed and should be carefully evaluated. Thirty-three (44%) papers reported factors related to patients as influencing the inclusion of patients, 28 (37%) reported clinician's related factors, and 37 (49%) other factors from either specific groups of patients (30 papers, 40%) and/or other scopes (13 papers, 17%). No differences in prevalence were found between papers dedicated to hematologic malignancies and solid tumors. Factors related to clinicians as influential were more frequently reported before 1995 (70%) than thereafter (25%; P = 0.0009). Reporting specific groups of patients as influential was more frequent in North American articles (50%) than in others (14%, P = 0.008). Patients' barriers included mostly patient preference (12 papers), concern about information and/or consent (11 papers), worry about uncertainty (7 papers), and/or relationship with medical team (7 papers). Concerning clinicians, incompatibility of protocol with normal practice (nine papers), problems in complying with the protocol (eight papers), and/or consent procedure (eight papers) were the most reported factors. The remaining factors mostly relied on specific groups of patients (30 papers), notably age of patients (18 papers) and/or minority population (11 papers, all from the USA). Strategies to overcome these barriers are needed and should be carefully evaluated.

Non-enrolment of ovarian cancer patients in clinical trials: reasons and background

BACKGROUND

Some retrospective analyses have suggested that participation in clinical trials is associated with better outcome. However, it is not clear to what extent selection bias contributes to this observation.

PATIENTS AND METHODS

We evaluated the reasons for non-enrolment of ovarian cancer patients in clinical trials. All patients with ovarian cancer not enrolled in clinical studies and treated in 2001 in the participating centres were documented retrospectively and compared with patients enrolled in clinical trials at the same institutions during the same time period.

RESULTS

Two hundred and seventy-four patients with advanced ovarian cancer (FIGO stage IIB-IV) were included, of whom 139 (51%) and 135 (49%) patients were enrolled in this study and in prospective clinical trials, respectively. Ninety-four of 274 patients (34%) did not meet the inclusion criteria for clinical trials. Of 180 eligible patients, 28 (16%) refused participation and a further 17 patients (9%) were not recruited although they met the inclusion criteria. The non-study patients were older (66.7 versus 57.2 years; P <0.0001), underwent less radical surgery (hysterectomy, oophorectomy and omentectomy performed: 61.2% versus 80.7%; P = 0.001; rate of lymphadenectomy 30.9% versus 45.2%; P = 0.015) and more frequently had bulky residual disease (residual disease >2 cm: 36.2% versus 20%; P = 0.016). However, 62% of the non-study patients were treated with the same chemotherapy as in the standard arm of the respective clinical studies.

CONCLUSIONS

Study patients differ substantially from non-study patients, thus hampering generalisation of study results. Our results suggest that at least some inclusion criteria for clinical trials should be modified to increase study participation without compromising safety.

Difficulties in performing clinical trials of antithrombotic therapy in neonates and children

The practice of evidence-based medicine is based on the results of properly designed, conducted and analyzed studies. Evidence for the safety and efficacy of therapies is established through clinical trials. However, there are a number of difficulties in the design and management of clinical trials in children. We explore the theoretical and ethical issues and difficulties of designing and conducting clinical trials in children, and illustrate the ways in which these challenges were encountered in two clinical trials assessing anticoagulant therapy in children with thrombophilia (PROTEKT (PROphylaxis of ThromboEmbolism in Kids Trial) and REVIVE (REVIparin in Venous ThromboEmbolism)). Means for overcoming these challenges are also addressed.

Why institutions do not participate in ovarian cancer trials -- results from a survey in Germany

INTRODUCTION

There is evidence that cancer patients treated in clinical trials have significantly better outcomes than patients who are not enrolled in study protocols. In ovarian cancer, engagement in clinical trials is an indicator for the quality of care. However, information about the causes for withholding subjects from entering a clinical trial is sparse.

METHODS

From May to November 2003, a questionnaire comprising 5 different dimensions was sent to all gynecological departments in Germany with at least 45 hospital beds. Eligible institutions had not participated in ovarian cancer trials run by either of the two German ovarian cancer study groups, that is, the Arbeitsgemeinschaft Gynakologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR) or the Nord-Ostdeutsche Gesellschaft fur Gynakologische Onkologie (NOGGO), since 1999. The questionnaire could be returned anonymously.

RESULTS

The overall response rate was 42.6% (118 of 277 institutions). Altogether, 85 clinics signaled they are not participating in clinical trials for patients with ovarian cancer. The most commonly noted arguments of non-participants in a statistically weighted ranking list were limited resources for documentation (84.7%), or for informing patients (82.4%), and high costs of study treatment (65.9%). About 47.1% of non-participants stated patients declined informed consent, and that taking part in a trial is an additional burden. Administrative services refused permission to take part in the survey in 4.7% of all cases.

CONCLUSIONS

Inadequate infrastructures are the most relevant barriers for gynecological departments in Germany to participate in clinical trials. The reported data underline the need for intensifying continued education, and to strengthen awareness of the importance of clinical trials in gynecologic oncology.

Chemotherapy for cancer patients who present late

Doctors should not overlook the potential benefits of chemotherapy in patients with incurable cancer

Economics of the clinical management of lung cancer in France: an analysis using a Markov model

To evaluate, according to the histologic type and initial stage, the mean cost (MC) of managing patients with lung cancer and the costs of the different management phases. A Markov approach was used to model these costs, based on the management of a representative nation-wide sample of 428 patients with newly diagnosed lung cancer. The 18-month MC ranged from US$ 20 691 (95% CI: 5777–50 380 for diffuse non-small-cell lung cancer (NSCLC) to US$ 31 833 (95% CI: 15 866–64 455) for localised small-cell lung cancer (SCLC); first-line treatment costs ranged from 33.8% of MC for medically inoperable localised NSCLC to 74.6% for diffuse SCLC; second- or third-line treatment costs ranged from 7.8% of MC for surgically treated localised NSCLC to 32% for locally advanced NSCLC; and the cost of palliative care ranged from 9.1% of MC for locally advanced NSCLC to 39.9% for medically inoperable localised NSCLC. The cost of first-line chemotherapy and the percentage of actively treated patients impacted more on MC than did the cost of second- or third-line chemotherapy regimens or the cost of palliative care. In conclusion, this model provides a robust economic analysis of the cost of lung cancer management, and will be useful for assessing the economic consequences of future changes in patient management.