Phase I cancer trials: a crucible of competing priorities

Assessment of consent capability in psychiatric and medical studies

In order to evaluate psychiatric factors that potentially influence assessment of consent capacity, 195 IRB members read summaries of hypothetical medical (cancer vs. neuropathic pain) and psychiatric trials. They then rated research participants' capacity for consent (capable or not capable), autonomy, and decisional abilities, as well as the legal risk to the institution of the study. Levels of depression information varied across the medical disorders. Significantly fewer IRB members judged participants in the depression trial to possess adequate capacity for consent relative to 4 of 6 medical conditions; legal risk to the institution also was rated higher in the psychiatric study. While IRB members judged participants in depression trials to have less capacity for consent and to pose higher levels of institutional risk than medical trial participants, the addition of increasing information regarding depressive co-morbidities had little or no effect on judgments of medical studies. Implications are discussed relative to the apparent overprotection of participants in psychiatric trials and underprotection of those in medical trials.

Manufacturing mistrust: issues in the controversy regarding foster children in the pediatric HIV/AIDS clinical trials

The use of foster children as subjects in the pediatric HIV/AIDS clinical trials has been the subject of media controversy, raising a range of ethical and social dimensions. Several unsettled issues and debates in research ethics underlie the controversy and the lack of consensus among professional researchers on these issues was neither adequately appreciated nor presented in media reports. These issues include (1) the tension between protecting subjects from research risk while allowing them access to the possible benefits of research; (2) the blurring of the potentially conflicting roles of investigator and physician and the boundaries between research and therapy; (3) the adequacy of Institutional Review Board oversight; and (4) trust and the relationships among physicians, investigators and industry. The media controversy about the pediatric HIV/AIDS clinical trials can be seen as a means of "manufacturing mistrust" in health care, research and social services that have not always met the needs and expectations of the public. In an era of emerging infections, it is critical to the public's health that people understand the role of rigorous and ethical research in the development of safe and effective care. Investigators, journalists and the public need to become knowledgeable about major ethical issues in the conduct of research in order to engage in dialogue about balancing research risks and benefits and to be able to distinguish fact from distortion in an era of multiple and rapid transmission of information.

IRB Member Judgments of Decisional Capacity, Coercion, and Risk in Medical and Psychiatric Studies

WHILE INDIVIDUALS WITH PSYCHIATRIC illnesses are widely considered a special class of research subjects regarding decisional capacity and coercion vulnerability, those with physical illnesses often are not. IRB members (N = 127) read vignettes that described clinical research targeting one of two levels of disease severity (high/low) for psychiatric or medical diagnoses. They then rated decisional capacity, coercion, and risks for hypothetical research subjects. IRB members viewed psychiatric subjects as having greater vulnerability to coercion and less decisional capacity than medical subjects, even when medical illness was of a severity likely to engender psychiatric comorbidities. These results suggest that IRB members may inflate the vulnerability and decisional incapacity of psychiatric subjects, while discounting vulnerability and incapacity in medical subjects.

Risks and benefits of phase 1 oncology trials, 1991 through 2002

BACKGROUND

Previous reviews of phase 1 oncology trials reported a rate of response to treatment of 4 to 6 percent and a toxicity-related death rate of 0.5 percent. These results may not reflect the rates in current phase 1 oncology trials.

METHODS

We reviewed all nonpediatric phase 1 oncology trials sponsored by the Cancer Therapy Evaluation Program at the National Cancer Institute between 1991 and 2002. We report the rates of response to treatment, of stable disease, of grade 4 toxic events, and of treatment-related deaths.

RESULTS

We analyzed 460 trials involving 11,935 participants, all of whom were assessed for toxicity and 10,402 of whom were assessed for a response to therapy. The overall response rate (i.e., for both complete and partial responses) was 10.6 percent, with considerable variation among trials. "Classic" phase 1 trials of single investigational chemotherapeutic agents represented only 20 percent of the trials and had a response rate of 4.4 percent. Studies that included at least one anticancer agent approved by the Food and Drug Administration constituted 46.3 percent of the trials and had a response rate of 17.8. An additional 34.1 percent of participants had stable disease or a less-than-partial response. The overall rate of death due to toxic events was 0.49 percent. Of 3465 participants for whom data on patient-specific grade 4 toxic events were available, 14.3 percent had had at least one episode of grade 4 toxic events.

CONCLUSIONS

Overall response rates among phase 1 oncology trials are higher than previously reported, although they have not changed for classic phase 1 trials, and toxicity-related death rates have remained stable. Rates of response and toxicity vary, however, among the various types of phase 1 oncology trials.

Descriptions of benefits and risks in consent forms for phase 1 oncology trials

BACKGROUND

Ethicists have suggested that written consent forms encourage participants in phase 1 cancer trials to expect benefit from the experimental agent and to overlook serious risks.

METHODS

To evaluate the written description of direct benefit as well as risk, all consent forms for 1999 phase 1 cancer trials were compiled from 80 percent of the National Cancer Institute-designated cancer centers and from six of eight large pharmaceutical developers of anticancer drugs. In each case, we evaluated the characteristics of the trial, the descriptions of the purpose and procedures of the research, the promise of benefit, the description of risks, and the description of alternatives.

RESULTS

Of 272 forms, 268 explicitly mentioned that the trial was research, and 249 stated that the purpose of the trial was testing for safety. Nearly all forms (269) mentioned the right to withdraw from the trial. Almost all forms (260) referred to the experimental agent as "treatment" or "therapy." Only one consent form promised direct benefit to subjects. Most forms (181) mentioned death as a risk, and very few (14) mentioned cure as even a possible benefit. Most (229) stated that there was unknown risk involved and indicated that severe or permanent harms were possible (224).

CONCLUSIONS

Consent forms for phase 1 oncology studies almost never promise direct benefit to subjects, rarely mention cure, and usually communicate the seriousness and unpredictability of risk. Although there is room for improvement, the substance of these forms is unlikely to be the primary source of misunderstanding by subjects in phase 1 oncology trials.