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Tao DL, Kartika T, Tran A, Prasad V. Phase I trials and therapeutic intent in the age of precision oncology: What is a patient's chance of response? Eur J Cancer 2020; 139:20-26. [PMID: 32957010 DOI: 10.1016/j.ejca.2020.04.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 01/25/2023]
Abstract
The advancement of therapeutic strategies in oncology such as precision oncology has generated significant interest in better estimating the response of modern phase I cancer clinical trials. These estimates have varied widely. In this commentary, we provide an umbrella review of phase I response rates and discuss methodological reasons for variation in prior estimates which include limited use of unpublished data, the inclusion of expansion cohorts that artificially raise response rates of cumulative response rates, varying enrolment of haematologic malignancies, and increased next in class drugs.
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Affiliation(s)
- Derrick L Tao
- Division of Internal Medicine, Oregon Health & Science University, USA
| | - Thomas Kartika
- Division of Internal Medicine, Oregon Health & Science University, USA
| | - Audrey Tran
- School of Medicine, Oregon Health & Science University, USA
| | - Vinay Prasad
- Department of Epidemiology & Biostatistics, University of California, San Francisco, USA.
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2
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Crane S, Haase JE, Hickman SE. Well-Being of Child and Family Participants in Phase 1 Pediatric Oncology Clinical Trials. Oncol Nurs Forum 2019; 45:E67-E97. [PMID: 30118445 DOI: 10.1188/18.onf.e67-e97] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PROBLEM IDENTIFICATION Pediatric oncology phase 1 clinical trials (P1Ts) are essential to developing new anticancer therapies; however, they raise complex ethical concerns about balancing the need for this research with the well-being of participating children. The purpose of this integrative review was to synthesize and appraise the evidence of how P1T participation, which begins with consent and ends with the transition off the P1T, can affect the well-being (either positively or negatively) of children with cancer. The Resilience in Individuals and Families Affected by Cancer Framework, which has an outcome of well-being, was used to synthesize findings. LITERATURE SEARCH Articles on the experiences of child (n = 21) and adult (n = 31) P1T participants were identified through systematic searches. DATA EVALUATION Articles were evaluated on rigor and relevance to P1T participant experiences as high, medium, or low. SYNTHESIS Minimal empirical evidence was found regarding the effect of P1T participation on the well-being of children with cancer. Adult P1T participant experiences provide insights that could also be important to children's P1T experiences. IMPLICATIONS FOR PRACTICE To achieve a balanced approach in P1T consent discussions, nurses and healthcare providers who work with children considering participation in a P1T should share the potential effect of participation on participants' well-being.
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3
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Visalli T, Bower N, Kokate T, Andrews PA. Lack of value of juvenile animal toxicity studies for supporting the safety of pediatric oncology phase I trials. Regul Toxicol Pharmacol 2018; 96:167-177. [PMID: 29763632 DOI: 10.1016/j.yrtph.2018.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/07/2018] [Accepted: 05/11/2018] [Indexed: 02/04/2023]
Abstract
Toxicity studies in juvenile animals (JAS) are sometimes performed to support clinical trials in pediatric oncology patients, and there are differing conclusions on the value of JAS for pediatric drug development. This manuscript provides a review of the pediatric clinical data for 25 molecularly-targeted and 4 biologic anticancer therapeutics. Other publications that evaluated the value of JAS in pediatric drug development focus on differences in toxicity between juvenile animals and adult animals. The present paper examines pediatric-specific clinical findings to focus on dose setting in pediatric oncology patients and safety monitoring in terms of the potential value of JAS. Our assessment demonstrates that pediatric starting doses were safe for all 29 therapeutics examined in that no life-threatening toxicities occurred in the first cohort, and overall the ratio of the pediatric maximum tolerated dose (MTD) to the recommended adult dose was close to 1. In addition, the 4 serious adverse events (SAEs) that weren't detectable with standard monitoring plans for pediatric oncology trials would not have been detectable in a standard JAS. This review demonstrates that safe starting doses in pediatric oncology patients for these therapeutics could have been solely based on adult doses without any knowledge of findings in JAS.
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Affiliation(s)
- Thomas Visalli
- Eisai Inc., Global Nonclinical Regulatory Affairs, 155 Tice Boulevard, Woodcliff Lake, NJ 07677, United States.
| | - Nancy Bower
- Eisai Inc., Global Nonclinical Regulatory Affairs, 155 Tice Boulevard, Woodcliff Lake, NJ 07677, United States
| | - Tushar Kokate
- Eisai Inc., Global Nonclinical Regulatory Affairs, 155 Tice Boulevard, Woodcliff Lake, NJ 07677, United States
| | - Paul A Andrews
- Eisai Inc., Global Nonclinical Regulatory Affairs, 155 Tice Boulevard, Woodcliff Lake, NJ 07677, United States
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4
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Surun A, Dujaric MÉ, Aerts I, Orbach D, Jiménez I, Pacquement H, Schleiermacher G, Bourdeaut F, Michon J, Dupont JCK, Doz F. Enrollment in early-phase clinical trials in pediatric oncology: The experience at Institut Curie. Pediatr Blood Cancer 2018; 65:e26916. [PMID: 29334194 DOI: 10.1002/pbc.26916] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 10/28/2017] [Accepted: 11/06/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND The European Paediatric Regulation was introduced in 2007 to facilitate access to new medicines for children. Our study explored accessibility of early-phase trials in pediatric oncology, in line with the European Paediatric Regulation, to identify the reasons for not inviting patients to participate, parents' refusal, or inclusion failure. PROCEDURE We conducted a retrospective chart review at Institut Curie, Paris, for all pediatric patients whose cancer progressed despite known effective treatments between July 2010 and December 2013. RESULTS Out of 100 patients in the palliative phase, 52 received one or more invitations to participate in early-phase trials. Twenty parents declined the invitation, mainly prioritizing quality of life or fearing constraints. Fourteen inclusions failed despite parental approval, mostly due to rapid clinical deterioration. Five patients received no invitations because no early-phase trials were available. Major reasons for noninclusion in the 43 remaining patients were presence of exclusion criteria or other physical factors, preference for conventional treatment, constraints, psychological factors, and follow-up in another hospital after moving. CONCLUSIONS The Paediatric Regulation has led to increased availability of early-phase trials. Better timing of the proposal, designing less constraining early-phase trials, reducing waiting lists, and improving information for parents and children would facilitate pediatric access to new medicines.
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Affiliation(s)
- Aurore Surun
- Department of Pediatric Oncology, Oncology Center SIREDO (Care, Innovation, Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, Paris, France
| | | | - Isabelle Aerts
- Department of Pediatric Oncology, Oncology Center SIREDO (Care, Innovation, Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, Paris, France
| | - Daniel Orbach
- Department of Pediatric Oncology, Oncology Center SIREDO (Care, Innovation, Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, Paris, France
| | - Irène Jiménez
- Department of Pediatric Oncology, Oncology Center SIREDO (Care, Innovation, Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, Paris, France
| | - Hélène Pacquement
- Department of Pediatric Oncology, Oncology Center SIREDO (Care, Innovation, Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, Paris, France
| | - Gudrun Schleiermacher
- Department of Pediatric Oncology, Oncology Center SIREDO (Care, Innovation, Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, Paris, France.,INSERM U830, Translational Research in Pediatric Oncology Team, Institut Curie Research Center, Paris, France
| | - Franck Bourdeaut
- Department of Pediatric Oncology, Oncology Center SIREDO (Care, Innovation, Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, Paris, France.,INSERM U830, Translational Research in Pediatric Oncology Team, Institut Curie Research Center, Paris, France
| | - Jean Michon
- Department of Pediatric Oncology, Oncology Center SIREDO (Care, Innovation, Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, Paris, France
| | - Jean-Claude K Dupont
- Department of Pediatric Oncology, Oncology Center SIREDO (Care, Innovation, Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, Paris, France.,Hospinnomics, Paris School of Economics, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - François Doz
- Department of Pediatric Oncology, Oncology Center SIREDO (Care, Innovation, Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, Paris, France.,Pediatrics, University Paris Descartes, Sorbonne Paris Cité, Paris, France
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5
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Ananth P, Monsereenusorn C, Ma C, Al-Sayegh H, Wolfe J, Rodriguez-Galindo C. Influence of early phase clinical trial enrollment on patterns of end-of-life care for children with advanced cancer. Pediatr Blood Cancer 2018; 65. [PMID: 28771913 DOI: 10.1002/pbc.26748] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/05/2017] [Accepted: 07/07/2017] [Indexed: 11/06/2022]
Abstract
We conducted a retrospective cohort study of 125 pediatric oncology patients who died in 2010-2014 to explore how healthcare utilization, pediatric palliative care (PPC) receipt, and end-of-life care (EOLC) differed between patients enrolled in early phase clinical trials (EP) and those not enrolled (NEP). Baseline characteristics and healthcare utilization did not significantly differ between groups. EP patients received PPC consultation closer to death than NEP patients (median days before death = 58 [interquartile range = 16-84] vs. 85 [32-173]; P = 0.04). Our findings suggest that early phase trial enrollment does not substantially alter EOLC for children with advanced cancer but may contribute to later PPC engagement. Future studies should definitively assess the relationship between trial enrollment and PPC timing.
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Affiliation(s)
- Prasanna Ananth
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Chalinee Monsereenusorn
- Department of Pediatrics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Clement Ma
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Hasan Al-Sayegh
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Joanne Wolfe
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
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6
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Dorris K, Liu C, Li D, Hummel TR, Wang X, Perentesis J, Kim MO, Fouladi M. A comparison of safety and efficacy of cytotoxic versus molecularly targeted drugs in pediatric phase I solid tumor oncology trials. Pediatr Blood Cancer 2017; 64. [PMID: 27654490 DOI: 10.1002/pbc.26258] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 07/19/2016] [Accepted: 08/10/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Prior reviews of phase I pediatric oncology trials involving primarily cytotoxic agents have reported objective response rates (ORRs) and toxic death rates of 7.9-9.6% and 0.5%, respectively. These data may not reflect safety and efficacy in phase I trials of molecularly targeted (targeted) drugs. METHODS A systematic review of pediatric phase I solid tumor trials published in 1990-2013 was performed. The published reports were evaluated for patient characteristics, toxicity information, and response numbers. RESULTS A total of 143 phase I pediatric clinical trials enrolling 3,896 children involving 53 targeted and 48 cytotoxic drugs were identified. A meta-analysis demonstrated that the ORR is 2.1-fold higher with cytotoxic drugs (0.066 vs. 0.031 per subject; P = 0.007). By contrast, the pooled estimate of the stable disease rate (SDR) is similar for cytotoxic and targeted drugs (0.2 vs. 0.23 per subject; P = 0.27). The pooled estimate of the dose-limiting toxicity rate is 1.8-fold larger with cytotoxic drugs (0.24 vs. 0.13 per subject; P = 0.0003). The hematologic grade 3-4 (G3/4) toxicity rate is 3.6-fold larger with cytotoxic drugs (0.43 vs. 0.12 per treatment course; P = 0.0001); however, the nonhematologic G3/4 toxicities and toxic deaths occur at similar rates for cytotoxic and targeted drugs. CONCLUSIONS In phase I pediatric solid tumor trials, ORRs were significantly higher for cytotoxic versus targeted agents. SDRs were similar in targeted and cytotoxic drug trials. Patients treated with cytotoxic agents were more likely to experience hematologic G3/4 toxicities than those patients receiving targeted drugs.
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Affiliation(s)
- Kathleen Dorris
- Section of Pediatric Hematology, Oncology, Bone Marrow Transplantation, Children's Hospital Colorado, Aurora, Colorado
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Dandan Li
- Consumer Credit Risk Management, Fifth Third Bank, Cincinnati, Ohio
| | - Trent R Hummel
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Xia Wang
- Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio
| | - John Perentesis
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mi-Ok Kim
- Department of Epidemiology and Biostatistics, University of California San Francisco
| | - Maryam Fouladi
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Interiano RB, McCarville MB, Wu J, Davidoff AM, Sandoval J, Navid F. Pneumothorax as a complication of combination antiangiogenic therapy in children and young adults with refractory/recurrent solid tumors. J Pediatr Surg 2015; 50:1484-9. [PMID: 25783402 PMCID: PMC4758326 DOI: 10.1016/j.jpedsurg.2015.01.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 01/13/2015] [Accepted: 01/14/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE Antiangiogenic agents show significant antitumor activity against various tumor types. In a study evaluating the combination of sorafenib, bevacizumab, and low-dose cyclophosphamide in children with solid tumors, an unexpectedly high incidence of pneumothorax was observed. We evaluated patient characteristics and risk factors for the development of pneumothorax in patients receiving this therapy. PATIENTS AND METHODS Demographics, clinical course, and radiographic data of 44 patients treated with sorafenib, bevacizumab and cyclophosphamide were reviewed. Risk factors associated with the development of pneumothorax were analyzed. RESULTS Pneumothorax likely related to study therapy developed in 11 of 44 (25%) patients of whom 33 had pulmonary abnormalities. Median age of patients was 14.7 years (range, 1.08-24.5). Histologies associated with pneumothorax included rhabdoid tumor, synovial sarcoma, osteosarcoma, Ewing sarcoma, Wilms tumor, and renal cell carcinoma. Cavitation of pulmonary nodules in response to therapy was associated with pneumothorax development (P<0.001). Median time from start of therapy to development of pneumothorax was 5.7 weeks (range, 2.4-31). CONCLUSION The development of cavitary pulmonary nodules in response to therapy is a risk factor for pneumothorax. As pneumothorax is a potentially life-threatening complication of antiangiogenic therapy in children with solid tumors, its risk needs to be evaluated when considering this therapy.
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Affiliation(s)
- Rodrigo B. Interiano
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA,Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
| | - M. Beth McCarville
- Department of Radiological Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA,Department of Radiology, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
| | - Jianrong Wu
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - Andrew M. Davidoff
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA,Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
| | - John Sandoval
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA,Department of Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
| | - Fariba Navid
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA; Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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8
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Levine DR, Johnson LM, Mandrell BN, Yang J, West NK, Hinds PS, Baker JN. Does phase 1 trial enrollment preclude quality end-of-life care? Phase 1 trial enrollment and end-of-life care characteristics in children with cancer. Cancer 2015; 121:1508-12. [PMID: 25557437 PMCID: PMC4685940 DOI: 10.1002/cncr.29230] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 11/14/2014] [Accepted: 12/01/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND End-of-life care (EOLC) discussions and treatment-related decisions, including phase 1 trial enrollment, in patients with incurable disease are complex and can influence the quality of EOLC received. The current study was conducted in pediatric oncology patients to determine whether end-of-life characteristics differed between those who were and were not enrolled in a phase 1 trial. METHODS The authors reviewed the medical records of 380 pediatric oncology patients (aged <22 years at the time of death) who died during a 3.5-year period. Of these, 103 patients with hematologic malignancies were excluded. A total of 277 patients with a diagnosis of a brain tumor or other solid tumor malignancy were divided into 2 groups based on phase 1 trial enrollment: a phase 1 cohort (PIC; 120 patients) and a non-phase 1 cohort (NPIC; 157 patients). The EOLC characteristics of these 2 cohorts were compared using regression analysis and chi-square testing. RESULTS A comparison of patients in the PIC and NPIC revealed no significant differences in either demographic characteristics (including sex, race, religious affiliation, referral origin, diagnosis, or age at diagnosis, with the exception of age at the time of death [P =.03]) or in EOLC indices (such as use or timing of do not attempt resuscitation orders, hospice use or length of stay, forgoing life-sustaining therapies, location of death, time from first EOLC discussion to death, and total number of EOLC discussions). CONCLUSIONS The results of the current study of a large cohort of deceased pediatric cancer patients indicate that enrollment on a phase 1 trial does not affect EOLC characteristics, suggesting that quality EOLC can be delivered regardless of phase 1 trial participation.
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Affiliation(s)
- Deena R Levine
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
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9
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Patients in pediatric phase I and early phase II clinical oncology trials at Gustave Roussy: a 13-year center experience. J Pediatr Hematol Oncol 2015; 37:e102-10. [PMID: 25171452 DOI: 10.1097/mph.0000000000000237] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In the European Union, the pediatric medicines regulation in 2007 modified significantly the access to new agents in pediatric oncology. Early oncology trials are still thought to be associated with limited benefit and substantial risk. We report the characteristics and outcome of patients below 21 years enrolled in investigational trials in the Pediatric and Adolescent Department at Gustave Roussy between January 2000 and December 2012. A total of 235 patients (median age, 10.4 [0.8 to 20.7] y) were included in 26 trials (16 cytotoxic and 10 targeted agents) for a total of 260 inclusions. A total of 117 patients (50%) had brain tumors and 68 (29%) had various soft tissue and bone sarcoma. Thirteen of the 106 patients in a phase I trial experienced dose-limiting toxicity. Main severe toxicity was hematologic; none had toxic death. Grade 3 to 4 toxicities were associated with combination trials, cytotoxic agent, and at least 1 previous line of therapy. Thirty patients (12%) had objective response and 42 (16%) had stable disease for >4 months. Median overall survival was 9.0 months (95% CI, 7.5-10.5) and 73% of patients received further anticancer treatment. Phase I to II pediatric oncology trials are safe, associated with clinical benefit, and can be successfully integrated in current relapse strategies.
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10
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Saulnier Sholler GL, Bond JP, Bergendahl G, Dutta A, Dragon J, Neville K, Ferguson W, Roberts W, Eslin D, Kraveka J, Kaplan J, Mitchell D, Parikh N, Merchant M, Ashikaga T, Hanna G, Lescault PJ, Siniard A, Corneveaux J, Huentelman M, Trent J. Feasibility of implementing molecular-guided therapy for the treatment of patients with relapsed or refractory neuroblastoma. Cancer Med 2015; 4:871-86. [PMID: 25720842 PMCID: PMC4472210 DOI: 10.1002/cam4.436] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 01/20/2015] [Accepted: 01/22/2015] [Indexed: 01/06/2023] Open
Abstract
The primary objective of the study was to evaluate the feasibility and safety of a process which would utilize genome-wide expression data from tumor biopsies to support individualized treatment decisions. Current treatment options for recurrent neuroblastoma are limited and ineffective, with a survival rate of <10%. Molecular profiling may provide data which will enable the practitioner to select the most appropriate therapeutic option for individual patients, thus improving outcomes. Sixteen patients with neuroblastoma were enrolled of which fourteen were eligible for this study. Feasibility was defined as completion of tumor biopsy, pathological evaluation, RNA quality control, gene expression profiling, bioinformatics analysis, generation of a drug prediction report, molecular tumor board yielding a treatment plan, independent medical monitor review, and treatment initiation within a 21 day period. All eligible biopsies passed histopathology and RNA quality control. Expression profiling by microarray and RNA sequencing were mutually validated. The average time from biopsy to report generation was 5.9 days and from biopsy to initiation of treatment was 12.4 days. No serious adverse events were observed and all adverse events were expected. Clinical benefit was seen in 64% of patients as stabilization of disease for at least one cycle of therapy or partial response. The overall response rate was 7% and the progression free survival was 59 days. This study demonstrates the feasibility and safety of performing real-time genomic profiling to guide treatment decision making for pediatric neuroblastoma patients.
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Affiliation(s)
- Giselle L Saulnier Sholler
- Helen DeVos Children's Hospital, Grand Rapids, Michigan.,Michigan State University College of Medicine, Grand Rapids, Michigan
| | - Jeffrey P Bond
- Department of Microbiology and Molecular Genetics, University of Vermont College of Medicine, Burlington, Vermont
| | | | - Akshita Dutta
- Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Julie Dragon
- Department of Microbiology and Molecular Genetics, University of Vermont College of Medicine, Burlington, Vermont
| | | | - William Ferguson
- Cardinal Glennon Children's Hospital, St. Louis University, St. Louis, Missouri
| | - William Roberts
- UC San Diego School of Medicine and Rady Children's Hospital, San Diego, California
| | - Don Eslin
- Arnold Palmer Hospital for Children, Orlando, Florida
| | | | - Joel Kaplan
- Levine Children's Hospital, Charlotte, North Carolina
| | | | - Nehal Parikh
- Connecticut Children's Medical Center, Hartford, Connecticut
| | | | - Takamaru Ashikaga
- Medical Biostatistics, University of Vermont College of Medicine, Burlington, Vermont
| | - Gina Hanna
- Arnold Palmer Hospital for Children, Orlando, Florida
| | - Pamela Jean Lescault
- Josephine Bay Paul Center for Comparative Molecular Biology and Evolution, The Marine Biological Laboratory, Woods Hole, Massachusetts
| | - Ashley Siniard
- Translational Genomics Research Institute, Phoenix, Arizona
| | | | | | - Jeffrey Trent
- Translational Genomics Research Institute, Phoenix, Arizona
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11
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Sun W, Gaynon PS, Sposto R, Wayne AS. Improving access to novel agents for childhood leukemia. Cancer 2015; 121:1927-36. [PMID: 25678105 DOI: 10.1002/cncr.29267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 09/02/2014] [Accepted: 10/23/2014] [Indexed: 12/12/2022]
Abstract
Leukemia is the most common pediatric cancer. Despite great progress in the development of curative therapy, leukemia remains a leading cause of death from disease in childhood, and survivors are at life-long risk of complications of treatment. New agents are needed to further increase cure rates and decrease treatment-associated toxicities. The complex biology and aggressive nature of childhood leukemia, coupled with the relatively small patient population available for study, pose specific challenges to the development of new therapies. In this review, the authors discuss strategies and initiatives designed to improve access to new agents in the treatment of pediatric leukemia.
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Affiliation(s)
- Weili Sun
- Children's Center for Cancer and Blood Diseases, Division of Hematology, Oncology, and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, California.,Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Paul S Gaynon
- Children's Center for Cancer and Blood Diseases, Division of Hematology, Oncology, and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, California.,Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Richard Sposto
- Children's Center for Cancer and Blood Diseases, Division of Hematology, Oncology, and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, California.,Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Alan S Wayne
- Children's Center for Cancer and Blood Diseases, Division of Hematology, Oncology, and Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, California.,Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California
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12
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Hazen RA, Zyzanski S, Baker JN, Drotar D, Kodish E. Communication about the risks and benefits of phase I pediatric oncology trials. Contemp Clin Trials 2015; 41:139-45. [PMID: 25638751 PMCID: PMC4404031 DOI: 10.1016/j.cct.2015.01.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/22/2015] [Accepted: 01/23/2015] [Indexed: 11/16/2022]
Abstract
Introduction Phase 1 pediatric oncology trials offer only a small chance of direct benefit and may have significant risks and an impact on quality of life. To date, research has not examined discussions of risks and benefits during informed consent conferences for phase 1 pediatric oncology trials. The objective of the current study was to examine clinician and family communication about risks, benefits, and quality of life during informed consent conferences for phase 1 pediatric oncology trials. Methods Participants included clinician investigators, parents, and children recruited from 6 sites conducting phase 1 pediatric oncology trials. Eighty-five informed consent conferences were observed and audiotaped. Trained coders assessed discussions of risks, benefits, and quality of life. Types of risks discussed were coded (e.g., unanticipated risks, digestive system risks, death). Types of benefits were categorized as therapeutic (e.g. discussion of how participation may or may not directly benefit child), psychological, bridge to future trial, and altruism. Results Risks and benefits were discussed in 95% and 88% of informed consent conferences, respectively. Therapeutic benefit was the most frequently discussed benefit. The impact of trial participation on quality of life was discussed in the majority (88%) of informed consent conferences. Conclusion Therapeutic benefit, risks, and quality of life were frequently discussed. The range of information discussed during informed consent conferences suggests the need for considering a staged process of informed consent for phase 1 pediatric oncology trials.
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Affiliation(s)
- Rebecca A Hazen
- Department of Pediatrics, Case Western Reserve University and Rainbow Babies and Children's Hospital, 10524 Euclid Ave, Cleveland, OH 44106, USA.
| | - Stephen Zyzanski
- Department of Family Medicine, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106, USA.
| | - Justin N Baker
- St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678, USA.
| | - Dennis Drotar
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave, Cincinnati, OH 45229-3026, USA.
| | - Eric Kodish
- Center for Ethics, Humanities, and Spiritual Care, Cleveland Clinic, 9500 Euclid Ave JJ60, Cleveland, OH 44195, USA.
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Miller VA, Cousino M, Leek AC, Kodish ED. Hope and persuasion by physicians during informed consent. J Clin Oncol 2014; 32:3229-35. [PMID: 25199753 DOI: 10.1200/jco.2014.55.2588] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To describe hopeful and persuasive messages communicated by physicians during informed consent for phase I trials and examine whether such communication is associated with physician and parent ratings of the likelihood of benefit, physician and parent ratings of the strength of the physician's recommendation to enroll, parent ratings of control, and parent ratings of perceived pressure. PATIENTS AND METHODS Participants were children with cancer (n = 85) who were offered a phase I trial along with their parents and physicians. Informed consent conferences (ICCs) were audiotaped and coded for physician communication of hope and persuasion. Parents completed an interview (n = 60), and physicians completed a case-specific questionnaire. RESULTS The most frequent hopeful statements related to expectations of positive outcomes and provision of options. Physicians failed to mention no treatment and/or palliative care as options in 68% of ICCs and that the disease was incurable in 85% of ICCs. When physicians mentioned no treatment and/or palliative care as options, both physicians and parents rated the physician's strength of recommendation to enroll in the trial lower. CONCLUSION Hopes and goals other than cure or longer life were infrequently mentioned, and a minority of physicians communicated that the disease was incurable and that no treatment and/or palliative care were options. These findings are of concern, given the low likelihood of medical benefit from phase I trials. Physicians have an important role to play in helping families develop alternative goals when no curative options remain.
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Affiliation(s)
- Victoria A Miller
- Victoria A. Miller, The Children's Hospital of Philadelphia, Philadelphia, PA; Melissa Cousino, Boston Children's Hospital, Boston, MA, and Case Western Reserve University; Angela C. Leek and Eric D. Kodish, Cleveland Clinic, Cleveland, OH
| | - Melissa Cousino
- Victoria A. Miller, The Children's Hospital of Philadelphia, Philadelphia, PA; Melissa Cousino, Boston Children's Hospital, Boston, MA, and Case Western Reserve University; Angela C. Leek and Eric D. Kodish, Cleveland Clinic, Cleveland, OH
| | - Angela C Leek
- Victoria A. Miller, The Children's Hospital of Philadelphia, Philadelphia, PA; Melissa Cousino, Boston Children's Hospital, Boston, MA, and Case Western Reserve University; Angela C. Leek and Eric D. Kodish, Cleveland Clinic, Cleveland, OH
| | - Eric D Kodish
- Victoria A. Miller, The Children's Hospital of Philadelphia, Philadelphia, PA; Melissa Cousino, Boston Children's Hospital, Boston, MA, and Case Western Reserve University; Angela C. Leek and Eric D. Kodish, Cleveland Clinic, Cleveland, OH.
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Malik L, Mejia A. Informed consent for phase I oncology trials: form, substance and signature. J Clin Med Res 2014; 6:205-8. [PMID: 24734147 PMCID: PMC3985563 DOI: 10.14740/jocmr1803w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2014] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Federal regulations state consent information should be understandable to participants; concerns have been voiced about the quality of informed consent forms (ICFs) in oncology trials. METHODS The content of ICFs for phase I studies that were conducted at a tertiary care cancer center over 3 years' period was reviewed. Information pertaining to the length of the ICF, description of study purpose, research regimen/methods, treatment agent, potential risks, benefits and alternatives to the research was extracted. RESULTS In total, 54 ICFs for phase I trials approved by the local Institutional Review Board were reviewed. Median length of ICF was 20 pages. Nearly one half of the forms (57.4%) were of first-in-human phase I studies. The main goal of research was explicitly stated as safety testing in 59.2% forms, while 37.1% studies described primary objective as dose finding. All of the forms identified serious risks, unexpected risks, possibility of death and risks to pregnant and or lactating women. A detailed estimation of the frequency or intensity of risks (range 3-8 pages) was provided qualitatively or quantitatively if known. Information regarding mechanism of action of investigational agent, study schema, dose escalation, loss of time/energy and possibility of receiving sub-therapeutic dose was missing in significant number of forms. CONCLUSION We found that these ICFs were compliant with approved guidelines and provided a thorough description of risks or potential benefits. However, there still remains room for improvement, so patients can make better informed decisions.
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Affiliation(s)
- Laeeq Malik
- Institute for Drug Development, Cancer Therapy and Research Center (CTRC), University of Texas Health Science Center, San Antonio, TX, USA
| | - Alex Mejia
- Institute for Drug Development, Cancer Therapy and Research Center (CTRC), University of Texas Health Science Center, San Antonio, TX, USA
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Clinical outcomes and survival of advanced renal cancer patients in phase I clinical trials. Clin Genitourin Cancer 2014; 12:359-65. [PMID: 24582088 DOI: 10.1016/j.clgc.2014.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 01/22/2014] [Accepted: 01/23/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND/INTRODUCTION The purpose of this study was to describe the basic demographic characteristics, and analyze the response and survival experience of advanced renal cancer subjects treated in a phase I trial. PATIENTS AND METHODS We conducted a retrospective observational study in 70 renal cancer patients participating in 25 phase I trials. Descriptive statistics, Kaplan-Meier, and multivariate Cox proportional hazards analyses were used to examine factors associated with time from study entry to treatment failure (TTF) and survival. RESULTS The median age at diagnosis was 56.50 years. Eastern Cooperative Oncology Group (ECOG) performance status was 0 for 23.19% (n = 16) of the patients; 49.18% (n = 30) had received 2 or more previous lines of systemic therapy; and 84.29% (n = 59) of patients had 2 or more metastatic sites. A median number of 4.00 cycles of treatment was delivered. Four partial responses (6.25%) and 38 cases of stable disease lasting > 4 months (43.75%) were observed. The median TTF was 16.00 weeks. In multivariate analyses, men and patients with lactate dehydrogenase > 1.5 times the upper limit of normal had a shorter TTF. The median overall survival was 45.57 weeks (319.00 days). In multivariate analysis, factors predicting shorter survival were ECOG performance status ≥ 1 (P = .023), age younger than 60 years (P = .015), albumin < 3.4 g/dL (P = .042), and liver metastases (P = .010). CONCLUSION Advanced renal cancer patients with select clinical characteristics could consider phase I trials after exhausting standard therapeutic options.
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Lu H, Blatt J, Corey SJ. Trends, Outcomes, and Characteristics of Pediatric Oncology Phase I and II Studies: A Systematic Review. Pharmaceut Med 2013. [DOI: 10.1007/s40290-013-0021-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Miller VA, Baker JN, Leek AC, Hizlan S, Rheingold SR, Yamokoski AD, Drotar D, Kodish E. Adolescent perspectives on phase I cancer research. Pediatr Blood Cancer 2013; 60:873-8. [PMID: 23034985 PMCID: PMC3538102 DOI: 10.1002/pbc.24326] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 08/21/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aim of this study was to examine adolescent patients' perspectives on their understanding and decision making about a pediatric phase I cancer study. PROCEDURE Participants included adolescents ages 14-21 years with cancer (N = 20), all of whom attended a phase I study consent conference. Participants responded to closed- and open-ended questions on a verbally administered structured interview, which assessed aspects of understanding and decision making about the phase I study. RESULTS All participants decided to enroll in the phase I study. The majority of participants understood that participation was voluntary, entailed risks, and that they could withdraw. Most also believed that participation in the phase I study would increase the length of their lives. The most frequent reasons for enrolling were positive clinical benefit, needing an option, impact on quality of life, and few side effects or fewer than those of current or past treatments. Eighty-five percent of participants reported that they themselves made the final decision about enrollment in the phase I study. CONCLUSIONS Most participants hoped or expected that the phase I study would provide a direct benefit (increased survival time or cure) and reported that they themselves were the final decision-maker about enrollment. Clinicians may underestimate the role of adolescents, especially if they believe that parents typically make such decisions. Future research should assess the actual participation of children and adolescents during the informed consent process and explore the role of hope in their decision making about phase I studies.
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Affiliation(s)
- Victoria A. Miller
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Justin N. Baker
- Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, Memphis, TN
| | - Angela C. Leek
- Department of Bioethics, Cleveland Clinic, Cleveland, OH
| | - Sabahat Hizlan
- Department of Bioethics, Cleveland Clinic, Cleveland, OH
| | - Susan R. Rheingold
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Dennis Drotar
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Eric Kodish
- Center for Ethics, Humanities and Spiritual Care, Cleveland Clinic, Cleveland, OH
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Cousino MK, Zyzanski SJ, Yamokoski AD, Hazen RA, Baker JN, Noll RB, Rheingold SR, Geyer JR, Alexander SC, Drotar D, Kodish ED. Communicating and understanding the purpose of pediatric phase I cancer trials. J Clin Oncol 2012; 30:4367-72. [PMID: 23071225 DOI: 10.1200/jco.2012.42.3004] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Quality informed consent should provide a clear understanding of the purpose of the research. Given the ethical challenges of pediatric phase I cancer trials, it is important to investigate physician-parent communication during informed consent conferences (ICCs) and parental understanding of the purpose of these studies. METHODS In the multisite Informed Consent in Pediatric Phase I Cancer Trials study, 85 ICCs for phase I research between June 2008 and May 2011 were directly observed, and 60 parents were subsequently interviewed. The scientific purpose was defined as composite understanding of drug safety, dose finding, and dose escalation. We determined the frequency with which physicians explained these and other phase I-related concepts during the ICC. Parent interviews were analyzed to determine understanding. RESULTS The child was present at 83 of 85 ICCs. Only 32% of parents demonstrated substantial understanding of the scientific purpose of phase I cancer trials; 35% demonstrated little or no understanding. Parents of higher socioeconomic status and racial majority status were more likely to understand the scientific purpose. Factors associated with understanding included physician explanation of the goal of the applicable phase I protocol offered (explained in 85% of ICCs) and explanation of the dose cohorts (explained in 43% of ICCs). Physicians explained drug safety in 23% of ICCs, dose finding in 52% of ICCs, and dose escalation in 53% of ICCs. CONCLUSION Many parents of children participating in phase I trials do not understand the purpose of these trials. Physician-parent communication about the purpose of phase I research is lacking during ICCs.
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Truong TH, Weeks JC, Cook EF, Joffe S. Altruism among participants in cancer clinical trials. Clin Trials 2011; 8:616-23. [DOI: 10.1177/1740774511414444] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Patients’ motivations for participation in cancer clinical trials are incompletely understood. Even less is known about the factors that influence participants’ motivations for enrolling in trials. Purpose We studied the reasons why adult patients and parents of pediatric patients agree to participate in cancer trials. We focused on the role of altruism across all phases of trial. Methods We surveyed adult patients and parents of pediatric patients participating in phase I, II, or III cancer clinical trials. We asked respondents why they agreed to enroll, and examined correlates of altruistic motivation using univariate and multivariate analyses. Results Among 205 adults and 48 parents of children participating in cancer trials, 47% reported that altruistic motivations were ‘very important’ to their decisions to enroll. In multivariate analysis with phase III trial participants as the reference group, phase I trial participants least often identified altruism as a ‘very important’ motivation for enrolling (phase I OR 0.4, 95% CI (confidence interval) 0.2–0.8; phase II OR 0.9, 95% CI 0.5–1.5, overall P = 0.017). Thirty-three respondents (13%) reported being motivated primarily by altruism. In multivariate analysis, participants with poor prognoses—defined as an expected 5-year disease-free survival of ≤10%—reported altruism as their primary motivation less often than those with better prognoses (OR 0.2, 95% CI 0.1–0.5, P = 0.001). Altruistic motivations did not differ between adult patients and parents of pediatric participants. Limitations The data are derived from related academic medical centers in one city, and the study sample reflects limited sociodemographic diversity, thereby limiting generalizability to other settings. Conclusions Although cancer trial participants commonly report that altruism contributed to their decision to enroll, it is rarely their primary motivation for study participation. Participants in early phase trials and those with poor prognoses are least often motivated by altruism.
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Affiliation(s)
- Tony H Truong
- Division of Haematology/Oncology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Jane C Weeks
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - E Francis Cook
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Steven Joffe
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Children’s Hospital, Boston, MA, USA
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Horton TM, Sposto R, Brown P, Reynolds CP, Hunger SP, Winick NJ, Raetz EA, Carroll WL, Arceci RJ, Borowitz MJ, Gaynon PS, Gore L, Jeha S, Maurer BJ, Siegel SE, Biondi A, Kearns PR, Narendran A, Silverman LB, Smith MA, Zwaan CM, Whitlock JA. Toxicity assessment of molecularly targeted drugs incorporated into multiagent chemotherapy regimens for pediatric acute lymphocytic leukemia (ALL): review from an international consensus conference. Pediatr Blood Cancer 2010; 54:872-8. [PMID: 20127846 PMCID: PMC2857540 DOI: 10.1002/pbc.22414] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
One of the challenges of incorporating molecularly targeted drugs into multi-agent chemotherapy (backbone) regimens is defining dose-limiting toxicities (DLTs) of the targeted agent against the background of toxicities of the backbone regimen. An international panel of 22 pediatric acute lymphocytic leukemia (ALL) experts addressed this issue (www.ALLNA.org). Two major questions surrounding DLT assessment were explored: (1) how toxicities can be best defined, assessed, and attributed; and (2) how effective dosing of new agents incorporated into multi-agent ALL clinical trials can be safely established in the face of disease- and therapy-related systemic toxicities. The consensus DLT definition incorporates tolerance of resolving Grade 3 and some resolving Grade 4 toxicities with stringent safety monitoring. This functional DLT definition is being tested in two Children's Oncology Group (COG) ALL clinical trials.
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Affiliation(s)
- Terzah M. Horton
- Texas Children’s Cancer Center/Baylor College of Medicine, Houston, TX
| | - Richard Sposto
- USC-CHLA Institute for Pediatric Clinical Research, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Patrick Brown
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - C. Patrick Reynolds
- Cancer Center, School of Medicine Texas Tech University Health Sciences Center, Lubbock, TX
| | - Stephen P. Hunger
- The University of Colorado Denver School of Medicine and The Children’s Hospital, Aurora, CO
| | - Naomi J. Winick
- Pediatric Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Robert J. Arceci
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | | | - Paul S. Gaynon
- USC-CHLA Institute for Pediatric Clinical Research, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Lia Gore
- The University of Colorado Denver School of Medicine and The Children’s Hospital, Aurora, CO
| | - Sima Jeha
- St. Jude Children’s Research Hospital, Memphis, TN
| | - Barry J. Maurer
- Cancer Center, School of Medicine Texas Tech University Health Sciences Center, Lubbock, TX
| | - Stuart E. Siegel
- USC-CHLA Institute for Pediatric Clinical Research, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Andrea Biondi
- Centro M. Tettamanti, Clinica Pediatrica Università, Milano-Bicocca Hospital, S. Gerardo, Monza, Italy
| | - Pamela R. Kearns
- Innovative Therapies for Children with Cancer (ITCC), and Institute for Cancer Studies, University of Birmingham, UK
| | - Aru Narendran
- Southern Alberta Children’s Cancer Program, Calgary, Alberta, Canada
| | | | - Malcolm A. Smith
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD
| | - C. Michel Zwaan
- Erasmus Medical Center/Sophia Children’s Hospital, Netherlands, and I-BFM SG New Agents Working Group
| | - James A. Whitlock
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University, Nashville, TN
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Haylett WJ. Ethical Considerations in Pediatric Oncology Phase I Clinical Trials According to The Belmont Report. J Pediatr Oncol Nurs 2009; 26:107-12. [DOI: 10.1177/1043454208328764] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Whether to suggest enrollment of pediatric oncology patients with advanced or refractory disease into a Phase I clinical trial may present a significant ethical dilemma for health care professionals. Phase I trials are experimental and unpredictable by nature, yet health care professionals must ensure the trial's therapeutic intent as well as address the many vulnerabilities of the child with terminal cancer. After reviewing the role and phases of clinical research in pediatric oncology, this article discusses ethical considerations in Phase I clinical trials according to The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects in Research and discusses specific applications of these key ethical principles.
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Kim A, Fox E, Warren K, Blaney SM, Berg SL, Adamson PC, Libucha M, Byrley E, Balis FM, Widemann BC. Characteristics and outcome of pediatric patients enrolled in phase I oncology trials. Oncologist 2008; 13:679-89. [PMID: 18586923 DOI: 10.1634/theoncologist.2008-0046] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To describe the characteristics of pediatric subjects who enroll in phase I trials, to determine the associations between pre-enrollment characteristics and the risk for toxicity, and to analyze response and survival outcomes. EXPERIMENTAL DESIGN Pre-enrollment characteristics and study outcomes were retrospectively analyzed for children with refractory solid tumors treated in one of 16 phase I trials with similar eligibility criteria at the National Cancer Institute between 1992 and 2005. RESULTS The 262 subjects analyzed had received a median of two (range, 0-9) prior chemotherapy regimens, and were on one (range, 0-12) concomitant medication. The Eastern Cooperative Oncology Group performance status scores for subjects were 0 (29%), 1 (48%), and 2 (19%); 19% had received a prior stem cell transplantation and 73% had received prior radiation. Approximately 90% of subjects were evaluable for the primary trial endpoints (toxicity and pharmacokinetics). Seventeen percent of subjects experienced a dose-limiting toxicity (DLT), 5% discontinued the study drug because of toxicity, and a drug-related death occurred in one subject (0.4%). Variables associated with a higher risk for developing a DLT, by multiple logistic regression analysis, were drug dose and prior radiation, for myelosuppressive agents, and drug dose and performance status, for nonmyelosuppressive agents. The complete and partial response rate was 4%; however, 17% of subjects had stable disease (received three or more cycles). The median overall survival time from the time of enrollment was five months. CONCLUSIONS Primary trial objectives are achieved in approximately 90% of subjects with the standard phase I trial design and eligibility criteria despite the intensification of frontline and salvage therapies in pediatric subjects with cancer.
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Affiliation(s)
- Aerang Kim
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, 10 Center Drive, Building 10-CRC, Room 1-3872, Bethesda, MD 20892, USA.
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Mack JW, Joffe S, Hilden JM, Watterson J, Moore C, Weeks JC, Wolfe J. Parents' views of cancer-directed therapy for children with no realistic chance for cure. J Clin Oncol 2008; 26:4759-64. [PMID: 18779605 DOI: 10.1200/jco.2007.15.6059] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Previous literature suggests that parents often wish to continue cancer-directed therapy for their children with incurable cancer. We assessed parents' experiences with treatment for their children with cancer and no realistic chance of cure. PATIENTS AND METHODS We administered questionnaires to 141 parents of children with cancer who died after receiving care at one of two cancer centers. Parents were asked whether the child benefited and suffered from treatment administered after the parent recognized that cure was not a realistic expectation, and whether they would recommend cancer-directed therapy to other families of children with advanced cancer. RESULTS Fifty-three (38%) of 141 children received cancer-directed therapy after the parent recognized that the child had no realistic chance for cure. Most of these parents felt that their child had experienced at least some suffering resulting from the therapy (61%, 31 of 51) and little to no benefit (57%, 29 of 51). Fifty-one (38%) of 135 parents overall would recommend standard chemotherapy and 46 (33%) of 140 would recommend experimental chemotherapy to families of children with advanced cancer. Even parents who would not recommend standard chemotherapy generally felt the physician should offer it (91%, 88 of 97). Parents who reported that their children experienced suffering resulting from cancer-directed therapy (odds ratio = 0.46; P = .02) were less likely to recommend standard chemotherapy to other families. CONCLUSION Although many parents choose treatment for their children with incurable cancer, bereaved parents often would not recommend such therapy. Parents who felt their children suffered as a result of cancer treatment were particularly unlikely to recommend it.
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Affiliation(s)
- Jennifer W Mack
- Center for Outcomes and Policy Research and Department of Pediatric Oncology, Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115, USA.
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Abstract
Clinical research has led to great advances in cancer therapy for children, and a greater proportion of children than adults with cancer participate in clinical trials. Despite this success, there remain important ethical challenges in conducting this research. There are challenges in obtaining informed consent and assent when children are research subjects; challenges arising from study design issues in phase III, II, or I clinical trials; and challenges related to the development of new classes of drugs, especially molecularly targeted therapies. It is important for researchers and clinicians to understand these challenges so that progress in cancer treatment is achieved in a sound ethical and regulatory fashion.
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Affiliation(s)
- Stacey L Berg
- Texas Children's Cancer Center, 6621 Fannin Street, MC3-3320, Houston, Texas 77030, USA.
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Chang A. An exploratory survey of nurses' perceptions of phase I clinical trials in pediatric oncology. J Pediatr Oncol Nurs 2008; 25:14-23. [PMID: 18187597 DOI: 10.1177/1043454207311742] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study suggests that nurses' perceptions of pediatric oncology phase I clinical trials are diverse and mixed but are more likely to be positive than negative. Improving future treatments, medical benefit, improved quality of life, and hope were cited as potential benefits of phase I clinical trials, but nurses felt that families were hoping for a cure. Toxicities, false hope, and decreased quality of life were perceived as potential negative outcomes. Acting as a patient advocate was viewed as the most important nursing role, and providing information was identified to be the most important purpose of informed consent. Although not statistically significant, data suggest that age, experience, and practice setting may influence nurses' perceptions. Younger or less experienced nurses were more likely to report either positive or negative perceptions, whereas older or more experienced nurses expressed mixed or moderate perceptions. Inpatient nurses reported more negative perceptions compared with outpatient nurses. The respondents report that caring for patients on phase I had both positive and negative effects on their quality of nursing work life.
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Affiliation(s)
- Ann Chang
- Haematology/Oncology/BMT/Immunology at The Hospital for Sick Children, Toronto, Ontario, Canada.
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26
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Devine S, Dagher RN, Weiss KD, Santana VM. Good clinical practice and the conduct of clinical studies in pediatric oncology. Pediatr Clin North Am 2008; 55:187-209, xi-xii. [PMID: 18242321 PMCID: PMC2276977 DOI: 10.1016/j.pcl.2007.10.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This article discusses the principles that guide good clinical practice standards, with particular emphasis on how they to relate to pediatric oncology research and recent efforts at harmonization. The authors review the clinical trials process and the roles of the participants, highlighting the pivotal role of the clinical investigator and the research team, and briefly review the historical aspects of drug development regulations in the United States and the current regulatory paths for pediatric oncology drug development. Where relevant, historical events that underlie many of the regulations and their current applications are described, and practical examples are provided.
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Affiliation(s)
- Susan Devine
- Department of Hematology/Oncology, Hospital for Sick Children, Toronto, Ontario, CA
| | - Ramzi N. Dagher
- Office of Oncology Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Karen D. Weiss
- Office of Oncology Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Victor M. Santana
- Department of Oncology, St. Jude Children's Research Hospital, Memphis,Tennesse, USA,Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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Zieber S, Friebert S. Pediatric cancer care: special issues in ethical decision making. Cancer Treat Res 2008; 140:93-115. [PMID: 18283772 DOI: 10.1007/978-0-387-73639-6_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Sarah Zieber
- Vanderbilt Children's Hospital, Department of Pediatrics, Nashville, TN 37232-6310, USA
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Baker JN, Barfield R, Hinds PS, Kane JR. A process to facilitate decision making in pediatric stem cell transplantation: the individualized care planning and coordination model. Biol Blood Marrow Transplant 2007; 13:245-54. [PMID: 17317576 DOI: 10.1016/j.bbmt.2006.11.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Accepted: 11/13/2006] [Indexed: 11/24/2022]
Abstract
Providers of care for children undergoing stem cell transplantation (SCT) skillfully combine the roles of scientist and clinician. As scientists, they apply scientific methods and disease theory in the creation and testing of new therapies and in the careful observation and exploration of treatment outcomes. As clinicians, they are capable of intuitively delivering care in a patient- and family-centered context of meaning and life values. The specialty of SCT has inherent aspects that make treatment decision making complex and potentially contentious. Having a strategy ready to implement in advance or at the time when treatment decisions need to be made will facilitate and enhance the decision making process for both the health care team and family members. Here we introduce the individualized care planning and coordination (ICPC) model as a practical approach to facilitate ethical and effective decision making in pediatric SCT settings. The ICPC is a 3-step model comprising (1) relationship--understanding the illness experience from the perspective of the patient and family, sharing relevant information, and assessing ongoing needs; (2) negotiation--prognosticating, establishing goals of care, and discussing treatment options; and (3) plan--generating a comprehensive plan of care that includes life and medical plans. Based on a foundation of a care of competence, empathy, compassion, communication, and quality, the ICPC model aims to diminish contentious family-staff interactions that can lead to mistrust and help guide treatment decision making. The ICPC model enhances communication among patients, families, and clinicians by revealing patient and family values and medical and quality-of-life priorities before reaching or even during critical decision points in the transplantation process.
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Affiliation(s)
- Justin N Baker
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
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Affiliation(s)
- Steven Joffe
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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30
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Abstract
In this article, I examine whether Phase I pediatric oncology trials offer "the prospect of direct benefit," a concept found in Subpart D of the Code of Federal Regulations (CFR), the guidelines that provide additional protections to pediatric research subjects. In research that offers the prospect of direct benefit, children can be exposed to greater risk than in other research and their dissent can be overridden. I argue that Phase I trials do not offer the prospect of direct benefit and classifying them as if they do fails to acknowledge the moral relevance of the researchers' intent. In Subpart D, research that does not provide the prospect of direct benefit can be approved locally if it does not expose the children to more than a minor increase over minimal risk. If the risks are greater, the research must be approved nationally. To avoid the need for national review for Phase I oncology trials, I propose a new research category that incorporates the concept of "secondary direct benefit." In this category, the child's dissent would be dispositive. This new category would improve the protections provided to children by incorporating intentions into Subpart D, the absence of which is a serious flaw in our current regulatory schema.
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Affiliation(s)
- Lainie Ross
- Department of Pediatrics and the MacLean Center for Clinical Medical Ethics, University of Chicago, Illinois 60637, USA.
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Carlson C, Reilly M, Hitchens A. An innovative approach to the care of patients on phase I and phase II clinical trials: the role of the experimental therapeutics nurse. J Pediatr Oncol Nurs 2006; 22:353-64. [PMID: 16216897 DOI: 10.1177/1043454205281763] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The tremendous strides in survival rates for childhood malignancies in large part can be attributed to the clinical trial mechanism. New and innovative therapies are being developed in the laboratory in an attempt to find a cure for those children who have relapsed or have refractory disease. Phase I and phase II clinical trials move this science from the laboratory to the patient's bedside. With increasing frequency, the oncology staff nurse may be managing the care of a patient receiving a phase I or phase II study drug. Administration of these agents goes beyond what is familiar, requires specialized knowledge, and demands a skill set beyond what is required for standard oncology care. At The Children's Hospital of Philadelphia, the role of the experimental therapeutics nurse was created in an effort to improve the process for identification, treatment, and follow-up of patients receiving these therapies. The broader role of nursing in clinical trials, the multidisciplinary challenges of experimental therapies, and the development of an innovative approach to caring for patients on phase I/II studies are discussed.
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Mack JW, Wolfe J. Early integration of pediatric palliative care: for some children, palliative care starts at diagnosis. Curr Opin Pediatr 2006; 18:10-4. [PMID: 16470155 DOI: 10.1097/01.mop.0000193266.86129.47] [Citation(s) in RCA: 140] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Pediatric palliative care, with its emphasis on symptom management and quality of life, is an important aspect of care of children with life-threatening illnesses. We review recent publications with implications for care of these children. RECENT FINDINGS Invasive and life-sustaining measures continue to be part of care for many children with life-threatening illnesses, even at the end of life. While these measures may seem reasonable when recovery is possible, they may not fit with a family's preferences for end-of-life care. One possible cause of the prevalence of invasive measures in children at the end of life is that complex illness trajectories in children make it difficult to predict the timing of death. Inadequate communication by clinicians can also lead to poor preparation for the end-of-life period. Early integration of palliative care allows for improved symptom management, parental adjustment, and preparation for the end-of-life care period. Families who have the opportunity to prepare for the end-of-life period, including learning what to expect, are more likely to feel that their care has been of high quality. Bereaved parents also recognize the value of talking about death with their children. SUMMARY Early integration of palliative care can allow children and families to make decisions about care that fit with their values, and should become a standard of care for all children with life-threatening illnesses.
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Affiliation(s)
- Jennifer W Mack
- Departments of Pediatric Oncology and the Center for Outcomes and Policy Research, Dana-Farber Cancer Institute and the Department of Medicine, Children's Hospital, Boston, Massachusetts 02115, USA
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Lee DP, Skolnik JM, Adamson PC. Pediatric Phase I Trials in Oncology: An Analysis of Study Conduct Efficiency. J Clin Oncol 2005; 23:8431-41. [PMID: 16293874 DOI: 10.1200/jco.2005.02.1568] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To determine the efficacy and safety of pediatric phase I oncology trials in the era of dose-intensive chemotherapy and to analyze how efficiently these trials are conducted. Methods Phase I pediatric oncology trials published from 1990 to 2004 and their corresponding adult phase I trials were reviewed. Dose escalation schemes using fixed 30% dose increments were studied to theoretically determine whether trials could be completed utilizing fewer patients and dose levels. Results Sixty-nine pediatric phase I oncology trials enrolling 1,973 patients were identified. The pediatric maximum-tolerated dose (MTD) was strongly correlated with the adult MTD (r = 0.97). For three-fourths of the trials, the pediatric and adult MTD differed by no more than 30%, and for more than 85% of the trials, the pediatric MTD was less than or equal to 1.6 times the adult MTD. The median number of dose levels studied was four (range, two to 13). The overall objective response rate was 9.6%, the likelihood of experiencing a dose-limiting toxicity was 24%, and toxic death rate was 0.5%. Conclusion Despite the strong correlation between the adult and pediatric MTDs, more than four dose levels were studied in 40% of trials. There appeared to be little value in exploring dose levels greater than 1.6 times the adult MTD. Limiting pediatric phase I trials to a maximum of four doses levels would significantly shorten the timeline for study conduct without compromising safety.
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Affiliation(s)
- Debra P Lee
- Division of Clinical Pharmacology & Therapeutics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Ulrich CM, Grady C, Wendler D. Palliative care: a supportive adjunct to pediatric phase I clinical trials for anticancer agents? Pediatrics 2004; 114:852-5. [PMID: 15342863 DOI: 10.1542/peds.2003-0913-l] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Connie M Ulrich
- Department of Clinical Bioethics, Warren G. Magnuson Clinical Center National Institutes of Health Bethesda, MD 20892, USA.
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Abstract
The care of children with advanced cancer is multifaceted. Treatment should focus on continued efforts to control the underlying illness whenever possible. At the same time, children and their families should have access to interdisciplinary care aimed at promoting optimal physical, psychological and spiritual wellbeing. Open and compassionate communication can best facilitate meeting the goals of these children and families. However, there remain significant barriers to achieving optimal care related to lack of formal education, reimbursement issues and the emotional impact of caring for a dying child. Future research efforts should focus on ways to enhance communication, symptom management and quality of life for children with advanced cancer and their families. As efforts to break down barriers and create the evidence base continue, we conclude as follows: this is a most rewarding part of the practice of medicine. A kind word and caring attitude are remembered for decades.
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Affiliation(s)
- Joanne Wolfe
- Children's Hospital and Dana-Farber Cancer Institute, Boston, MA 02115, USA
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36
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Himelstein B. Commentary. Eur J Cancer 2002. [DOI: 10.1016/s0959-8049(02)00224-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Dickens DS, Kozielski R, Khan J, Forus A, Cripe TP. Cyclooxygenase-2 expression in pediatric sarcomas. Pediatr Dev Pathol 2002; 5:356-64. [PMID: 12024286 DOI: 10.1007/s10024-002-0005-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2001] [Accepted: 03/10/2002] [Indexed: 12/20/2022]
Abstract
Therapies for metastatic pediatric sarcomas have reached maximum tolerated doses, but continue to provide suboptimal cure rates. Additionally, these treatments are associated with numerous short- and long-term side effects. Therefore, the search for newer, less toxic therapeutic agents is warranted. Overexpression of the inducible enzyme, cyclooxygenase-2 (COX-2), has been discovered in a variety of adult solid tumors and numerous studies have shown COX-2 inhibitors to have significant antiproliferative effects. Therefore, we sought to determine the expression of COX-2 in pediatric sarcomas. We evaluated rhabdomyosarcoma (RMS), osteosarcoma (OS), and Ewing sarcoma (EWS) samples for COX-2 expression by immunohistochemical analysis as well as by cDNA microarray analysis. COX-2 expression was detected in 48/58 (82.8%) tumors by immunohistochemistry and in an additional 52/59 (88.1%) tumors tested by microarray gene analysis. There was a trend toward increased COX-2 expression in metastatic rhabdomyosarcoma and osteosarcoma, though it did not reach clinical significance. The degree of COX-2 immunoreactivity did not vary significantly with other clinicopathologic features such as age, gender, or histologic classification. We conclude that the majority of these pediatric sarcoma samples express COX-2 to varying degrees. Therefore, studies testing the efficacy of COX-2 inhibitors in the treatment of pediatric sarcomas are warranted.
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Affiliation(s)
- David S Dickens
- Department of Pediatrics, Division of Hematology/Oncology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
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Bernstein ML, Reaman GH, Hirschfeld S. Developmental therapeutics in childhood cancer. A perspective from the Children's Oncology Group and the US Food and Drug Administration. Hematol Oncol Clin North Am 2001; 15:631-55. [PMID: 11676277 DOI: 10.1016/s0889-8588(05)70240-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Drug development in pediatric oncology has been reviewed, concentrating on overall development issues and COG studies of cytotoxic compounds. A variety of interesting molecules with more specific targeting are becoming available. The challenges that remain include the availability of such compounds for pediatric trial and their study in a timely fashion, and the subsequent incorporation of the new agents into more up-front regimens, with the ultimate shared goal of curing more children with less toxicity.
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Affiliation(s)
- M L Bernstein
- Service of Hematology-Oncology, Sainte-Justine Hospital, Department of Pediatrics, University of Montreal, Montreal, Québec, Canada
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39
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Estlin EJ, Ablett S. Practicalities and ethics of running clinical trials in paediatric oncology - the UK experience. Eur J Cancer 2001; 37:1394-98; discussion 1399-401. [PMID: 11435071 DOI: 10.1016/s0959-8049(01)00124-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- E J Estlin
- Royal Manchester Children's Hospital, Hospital Lane, Pendlebury, M27 4HA, Manchester, UK.
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