Factors that influence the eligibility of cases for inclusion in clinical trials. The Lung Cancer Chemotherapy Study Group of the Japan Clinical Oncology Group

Generalization and representativeness of phase III immune checkpoint blockade trials in non-small cell lung cancer

Background

Strict eligibility criteria for patient enrollment in phase III trials raise questions regarding generalization to ineligible patients. We evaluated whether pivotal phase III trials of immune checkpoint blockades (ICBs) represent the overall population of non‐small cell lung cancer (NSCLC) patients.

Methods

We reviewed the inclusion and exclusion criteria of three phase III trials (CheckMate057, CheckMate017, and KEYNOTE‐010). Stage IIIB or IV NSCLC patients diagnosed from 2011 to 2013 at Seoul National University Hospital (cohort 1) were reviewed. We also analyzed the criteria in 53 patients with NSCLC who were treated with nivolumab or pembrolizumab as routine practice (cohort 2).

Results

Among the 715 patients in cohort 1, 499 (69.9%) were ineligible for the three trials. Reasons for ineligibility included: no prior platinum doublet treatment (23.6%), lack of tissue availability (22.7%), Eastern Cooperative Oncology Group performance status > 1 (14.1%), steroid use (18.2%), active cerebral nervous system metastasis (8.3%), hepatitis B/hepatitis C/human immunodeficiency virus (8.0%), and no measurable lesion (7.3%). EGFR mutations were more common in the ineligible group. In cohort 2, 67.9% of patients were classified as ineligible. Treatment outcomes of ICB in cohort 2 appeared inferior to those in the three pivotal trials, with a response rate of 11.3% and median progression‐free survival of 1.67 months.

Conclusion

Only 30% of NSCLC patients were eligible for ICB phase III trials. The actual efficacy in the 70% of ineligible patients is unknown. These findings suggest a huge gap between practice‐changing phase III trials and the overall population of NSCLC patients.

Eligibility determination for clinical trials: development of a case review process at a chiropractic research center

Background

Systematic procedures addressing the limitations of eligibility determination are needed to improve the quality of participant recruitment and enrollment in randomized clinical trials. This paper describes an eligibility determination process developed by and in use at a chiropractic research center engaged in community recruitment for clinical trials studying spinal pain conditions.

Methods

A team of investigators developed a case review process for application across clinical trials involving chiropractic care. Study personnel representing key study roles including research clinicians, study coordinators, a project manager, and at least one investigator convene in person to determine eligibility for participants following baseline study visit examinations. The research clinician who performed the eligibility examination presents the case and a moderator leads the case review panel through a structured discussion including diagnosis, eligibility criteria, definition review, and clinical precautions. Panel members provide clinical recommendations and determine final eligibility using a structured and moderated voting process.

Results

Through the case review process for three externally funded clinical trials for participants with neck and low back pain, we presented 697 cases, rendering 472 participants eligible for enrollment and excluding 225 individuals. The most common reasons for case review exclusions across the three trials included neck or back pain not meeting diagnostic classifications, safety concerns related to treatment or testing, referral for further evaluation or treatment, and compliance concerns.

Conclusions

The case review process uses the expertise of study coordinators, research clinicians, project managers, and investigators to render eligibility decisions consistent with study aims for the duration of the trial. This formal eligibility determination process includes steps designed to mitigate the potential for participant misclassification from clinician advocacy or misunderstanding of eligibility criteria, and helps ensure that participants can safely take part in study procedures.

Trial registration

The three trials discussed in this article were registered in ClinicalTrials.gov with the ID numbers of NCT00830596 (27 January 2009), NCT01312233 (04 March 2011), and NCT01765751 (30 May 2012).