1
|
van Ravensteijn SG, Meijerink M, Nijenhuis-van Schayk R, Desar IME, Bol KF, van Herpen CML, Verheul HMW. The safety risk of information overload and bureaucracy in oncology clinical trial conduct. Eur J Cancer 2023; 183:90-94. [PMID: 36812844 DOI: 10.1016/j.ejca.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 01/31/2023]
Abstract
Performance of clinical trials has led to major therapeutic developments and substantial improvements in the field of medical oncology. To ensure patient's safety, regulatory aspects for proper clinical trial conduct have been increased over the past two decades but seem to cause information overload and ineffective bureaucracy, possibly even impacting patient safety. To put this in perspective, after the implementation of Directive 2001/20/EC in the European Union, a 90 per cent increase in trial launching time, a 25 per cent decrease in patient participation and a 98 per cent rise in administrative trial costs were reported. The time to initiate a clinical trial has increased from a few months to several years in the past three decades. Moreover, there is a serious risk that information overload with relatively unimportant data endangers the decision-making processes and distracts from essential patient safety information. It is now a critical moment in time to improve efficient clinical trial conduct for our future patients diagnosed with cancer. We are convinced that a reduction of the administrative regulations, information overload, and simplification of the procedures for trial conductance may improve patient safety. In this Current Perspective, we give insight in the current regulatory aspects of clinical research, evaluate the practical consequences of these regulations, and propose specific improvements for optimal clinical trial conduct.
Collapse
Affiliation(s)
- Stefan G van Ravensteijn
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen 6525 GA, the Netherlands
| | - Mirte Meijerink
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen 6525 GA, the Netherlands
| | | | - Ingrid M E Desar
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen 6525 GA, the Netherlands
| | - Kalijn F Bol
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen 6525 GA, the Netherlands
| | - Carla M L van Herpen
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen 6525 GA, the Netherlands
| | - Henk M W Verheul
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen 6525 GA, the Netherlands; Department of Medical Oncology, Erasmus University Medical Centre, Rotterdam 3000 CA, the Netherlands.
| |
Collapse
|
2
|
Sex and Circadian Timing Modulate Oxaliplatin Hematological and Hematopoietic Toxicities. Pharmaceutics 2022; 14:pharmaceutics14112465. [PMID: 36432655 PMCID: PMC9699532 DOI: 10.3390/pharmaceutics14112465] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/24/2022] [Accepted: 10/30/2022] [Indexed: 11/17/2022] Open
Abstract
Oxaliplatin was nearly twice as hematotoxic, with optimal circadian timing differing by 6 h, in women as compared to men with colorectal cancers. Hence, we investigated sex- and timing-related determinants of oxaliplatin hematopoietic toxicities in mice. Body-weight loss (BWL), blood cell counts, bone marrow cellularity (BMC) and seven flow-cytometry-monitored hematopoietic progenitor populations were evaluated 72 h after oxaliplatin chronotherapy administration (5 mg/kg). In control animals, circadian rhythms of circulating white blood cells showed a peak at ZT5 in both sexes, whereas BMC was maximum at ZT20 in males and ZT13h40 in females. All BM progenitor counts presented robust rhythms with phases around ZT3h30 in females, whereas only three of them rhythmically cycled in males with a ≈ -6 h phase shift. In treated females, chronotoxicity rhythms occurred in BWL, WBC, BMC and all BM progenitors with the best timing at ZT15, ZT21, ZT15h15 and ZT14h45, respectively. In males, almost no endpoints showed circadian rhythms, BWL and WBC toxicity being minimal, albeit with a substantial drop in BM progenitors. Increasing dose (10 mg/kg) in males induced circadian rhythms in BWL and WBC but not in BM endpoints. Our results suggest complex and sex-specific clock-controlled regulation of the hematopoietic system and its response to oxaliplatin.
Collapse
|
3
|
Rizzo A, Mollica V, Santoni M, Rosellini M, Marchetti A, Massari F. Risk of toxicity with immunotherapy-tyrosine kinase inhibitors for metastatic renal cell carcinoma: a meta-analysis of randomized controlled trials. Future Oncol 2021; 18:625-634. [PMID: 34927453 DOI: 10.2217/fon-2021-0888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Few data are available regarding the safety profile of immunotherapy-tyrosine kinase inhibitor (IO-TKI) combinations in metastatic renal cell carcinoma. The authors investigated all-grade and grade 3-4 (G3-4) adverse events in trials comparing IO-TKI combinations with sunitinib monotherapy. Methods: The relative risks of several all-grade and G3-4 adverse events were analyzed. Results: Relative risks were similar between patients receiving IO-TKI combinations versus sunitinib monotherapy. However, the use of IO-TKI combinations was associated with a higher risk of all-grade and G3-4 diarrhea, all-grade hypothyroidism, G3-4 decreased appetite, all-grade and G3-4 aspartate transaminase increase and all-grade and G3-4 alanine transaminase increase. Conclusion: The results of the authors' meta-analysis suggest that risks of treatment-related adverse events should be carefully considered when choosing IO-TKI combinations in metastatic renal cell carcinoma patients.
Collapse
Affiliation(s)
- Alessandro Rizzo
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| | - Veronica Mollica
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| | | | - Matteo Rosellini
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| | - Andrea Marchetti
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| | - Francesco Massari
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| |
Collapse
|
4
|
Fatal events during clinical trials: an evaluation of deaths during breast cancer studies. Breast Cancer 2019; 26:826-834. [PMID: 31254201 DOI: 10.1007/s12282-019-00990-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Information on deaths occurring during oncological clinical trials has never been systematically assessed. Here, we examine the incidence of death and the profile of patients who died during randomized clinical breast cancer (BC) trials. METHODS Information on fatal events during German Breast Group (GBG) led BC trials was prospectively captured. Data were derived from the trial databases and death narratives. All deaths were evaluated for possible causes, underlying conditions, treatment relatedness, time point and rate of autopsies. RESULTS From 12/1996 to 01/2017, 23,387 patients were treated within 32 trials. Of those 88 (0.4%) died on therapy within 17 trials. Median age was 64 [range 35-84] years, 63.2% of patients had a body mass index (BMI) ≥ 25 kg/m2; 65.9% 1-3 and 22.7% ≥ 4 comorbidities; 61.4% 1-2 cardiovascular risk factors (CRFs); 26.4% took > 3 drugs; 81.7% had ECOG 0; 50.0% stage III, 76.7% luminal BC. The main causes of death were infection (38.6%; of those, 82.3% sepsis, 17.6% pneumonia), heart failure (14.8%), and pulmonary embolism (13.6%). Fatal events mainly occurred within the first 4 therapy cycles (55.7%), in the investigational arm (66.7%) and under anthracycline-taxane-based chemotherapy (51.1%). A relationship with the treatment was declared in 27.3% of the cases. An autopsy was performed in 13.6% of patients. CONCLUSIONS Death during study treatment was mainly related to infections, and patients with advanced disease, high BMI, underlying comorbidities, CRFs and concomitant medications. If considered for study participation these patients need careful monitoring due to their higher risk for death on study.
Collapse
|
5
|
Goungounga JA, Touraine C, Grafféo N, Giorgi R. Correcting for misclassification and selection effects in estimating net survival in clinical trials. BMC Med Res Methodol 2019; 19:104. [PMID: 31096911 PMCID: PMC6524224 DOI: 10.1186/s12874-019-0747-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 05/02/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Net survival, a measure of the survival where the patients would only die from the cancer under study, may be compared between treatment groups using either "cause-specific methods", when the causes of death are known and accurate, or "population-based methods", when the causes are missing or inaccurate. The latter methods rely on the assumption that mortality due to other causes than cancer is the same as the expected mortality in the general population with same demographic characteristics derived from population life tables. This assumption may not hold in clinical trials where patients are likely to be quite different from the general population due to some criteria for patient selection. METHODS In this work, we propose and assess the performance of a new flexible population-based model to estimate long-term net survival in clinical trials and that allows for cause-of-death misclassification and for effects of selection. Comparisons were made with cause-specific and other population-based methods in a simulation study and in an application to prostate cancer clinical trial data. RESULTS In estimating net survival, cause-specific methods seemed to introduce important biases associated with the degree of misclassification of cancer deaths. The usual population-based method provides also biased estimates, depending on the strength of the selection effect. Compared to these methods, the new model was able to provide more accurate estimates of net survival in long-term clinical trials. CONCLUSION Finally, the new model paves the way for new methodological developments in the field of net survival methods in multicenter clinical trials.
Collapse
Affiliation(s)
- Juste Aristide Goungounga
- Aix Marseille Univ, INSERM, IRD, SESSTIM Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
| | - Célia Touraine
- Aix Marseille Univ, INSERM, IRD, SESSTIM Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France.,Unité de Biométrie, Institut du Cancer de Montpellier (ICM), Univ Montpellier, Montpellier, France
| | - Nathalie Grafféo
- INSERM U1153, Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRESS), ECSTRA Team, Hôpital Saint Louis, Paris, France.,Université Paris Diderot, Paris, France
| | - Roch Giorgi
- Aix Marseille Univ, APHM, INSERM, IRD, SESSTIM (Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale), Hop Timone, BioSTIC (Biostatistique et Technologies de l'Information et de la Communication), Marseille, France.
| | | |
Collapse
|
6
|
Man J, Ritchie G, Links M, Lord S, Lee CK. Treatment-related toxicities of immune checkpoint inhibitors in advanced cancers: A meta-analysis. Asia Pac J Clin Oncol 2018; 14:141-152. [DOI: 10.1111/ajco.12838] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 11/18/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Johnathan Man
- Cancer Care Centre; St George Hospital; Gray Street Kogarah Sydney NSW Australia
| | - Georgia Ritchie
- Cancer Care Centre; St George Hospital; Gray Street Kogarah Sydney NSW Australia
- School of Medicine; University of New South Wales; High St Kensington NSW Australia
| | - Matthew Links
- Cancer Care Centre; St George Hospital; Gray Street Kogarah Sydney NSW Australia
| | - Sally Lord
- National Health and Medical Research Council Clinical Trials Centre; The University of Sydney; Camperdown NSW Australia
- School of Medicine; The University of Notre Dame; Oxford St Darlinghurst NSW Australia
| | - Chee Khoon Lee
- Cancer Care Centre; St George Hospital; Gray Street Kogarah Sydney NSW Australia
- National Health and Medical Research Council Clinical Trials Centre; The University of Sydney; Camperdown NSW Australia
| |
Collapse
|
7
|
Abstract
This article describes the clinical relevance of toxicity of therapies administered to patients with cancer, putting the patient, rather than disease, at the center of the evaluation of safety of anti-cancer therapy. Hence, the implications of adverse events are described from the patient perspective, focusing on the impact of patient safety on quality of life and efficacy of treatment. Issues revolving around other types of safety, such as financial toxicity, are also discussed. The role played by genetics in the assessment of a patient’s risk of adverse events is also discussed, both in relation to the potential of genomic research and in the context of current tools of fruition in clinical care.
Collapse
Affiliation(s)
- Federico Innocenti
- Eshelman School of Pharmacy, Center for Pharmacogenomics and Individualized Therapy, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| |
Collapse
|
8
|
Ding PN, Lord SJ, Gebski V, Links M, Bray V, Gralla RJ, Yang JCH, Lee CK. Risk of Treatment-Related Toxicities from EGFR Tyrosine Kinase Inhibitors: A Meta-analysis of Clinical Trials of Gefitinib, Erlotinib, and Afatinib in Advanced EGFR-Mutated Non-Small Cell Lung Cancer. J Thorac Oncol 2016; 12:633-643. [PMID: 28007626 DOI: 10.1016/j.jtho.2016.11.2236] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 11/09/2016] [Accepted: 11/24/2016] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Gefitinib, erlotinib, and afatinib are tyrosine kinase inhibitors (TKIs) used for treatment of advanced EGFR-mutated NSCLC. Estimating differences in toxicity between these EGFR TKIs is important for personalizing treatment. METHODS We performed a meta-analysis of randomized trials that compared EGFR TKI therapy against chemotherapy or placebo. We extracted data from the EGFR TKI arm for indirect comparisons to estimate the relative risk for toxic death, grade 3 to 4 (G3/4) adverse events (AEs), and discontinuation of treatment because of AE for each EGFR TKI. RESULTS Sixteen trials included 2535 patients with mutated or wild-type EGFR. Toxic deaths were rare (1.7%), with pneumonitis being most frequent cause and no significant differences between EGFR TKIs. Overall, 40% of patients experienced G3/4 AEs. The risk for G3/4 AEs was lower with gefitinib (29.1%) than with erlotinib (54.1%) or afatinib (42.1%) (p < 0.01). Discontinuation of treatment because of AEs occurred in 7.7% of patients, with no significant differences between EGFR TKIs. Diarrhea (in 53.3% of cases) and rash (in 66.5%) were the most frequent AEs. The risk for rash was higher with afatinib (84.8%) than with erlotinib (62.0%) or gefitinib (62.0%) (p < 0.01). The risk for diarrhea was higher with afatinib (91.7%) than with erlotinib (42.4%) or gefitinib (44.4%) (p < 0.01). The risk for increased liver enzyme levels was higher with gefitinib (61.7%) than with erlotinib (17.8%) or afatinib (20.1%) (p < 0.01). A risk-benefit contour was used to assess the trade-off between efficacy and toxicity for different EGFR TKIs. CONCLUSIONS EGFR TKIs are well tolerated, with less than 10% of patients discontinuing treatment because of AEs. The profile of and risk for toxicities vary between EGFR TKIs and can be used to inform the selection of treatment.
Collapse
Affiliation(s)
- Pei Ni Ding
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Sydney, Australia; Department of Medical Oncology, Liverpool Hospital, Sydney, Australia
| | - Sarah J Lord
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Sydney, Australia; School of Medicine, The University of Notre Dame, Sydney, Australia
| | - Val Gebski
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Sydney, Australia
| | - Matthew Links
- Cancer Care Centre, St. George Hospital, Sydney, Australia
| | - Victoria Bray
- Department of Medical Oncology, Liverpool Hospital, Sydney, Australia
| | - Richard J Gralla
- Albert Einstein College of Medicine, Jacobi Medical Center, New York, New York
| | - James Chih-Hsin Yang
- Graduate Institute of Oncology, National Taiwan University and Department of Oncology, National Taiwan University Hospital, Taipei, Republic of China
| | - Chee Khoon Lee
- National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Sydney, Australia; Cancer Care Centre, St. George Hospital, Sydney, Australia.
| |
Collapse
|
9
|
Davoodi S, Safdari R, Ghazisaeidi M, Mohammadzadeh Z, Azadmanjir Z. Prevention and Early Detection of Occupational Cancers - a View of Information Technology Solutions. Asian Pac J Cancer Prev 2016; 16:5607-11. [PMID: 26320424 DOI: 10.7314/apjcp.2015.16.14.5607] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Thousands of people die each year from cancer due to occupational causes. To reduce cancer in workers, preventive strategies should be used in the high-risk workplace. The effective prevention of occupational cancer requires knowledge of carcinogen agents. Like other areas of healthcare industry, occupational health has been affected by information technology solutions to improve prevention, early detection, treatment and finally the efficiency and cost effectiveness of the healthcare system. Information technology solutions are thus an important issue in the healthcare field. Information about occupational cancer in information systems is important for policy makers, managers, physicians, patients and researchers; because examples that include high quality data about occupational cancer patients and occupational cancer causes are able to determine the worker groups which require special attention. As a result exposed workers who are vulnerable can undergo screening and be considered for preventive interventions.
Collapse
Affiliation(s)
- Somayeh Davoodi
- Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran E-mail :
| | | | | | | | | |
Collapse
|