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Zhong J, Li P, Zheng F, Li Y, Lu W, Chen H, Cai J, Xia D, Wu Y. Association between dietary vitamin C intake/blood level and risk of digestive system cancer: a systematic review and meta-analysis of prospective studies. Food Funct 2024. [PMID: 39039956 DOI: 10.1039/d4fo00350k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
Experimental studies have shown that vitamin C has anti-cancer effects, but previous meta-analyses have indicated that the role of vitamin C in digestive system cancers (DSCs) is controversial. In this study, a systematic review and meta-analysis of the relationship between dietary intake/plasma concentration of vitamin C and the risk of DSC was conducted, evaluating 32 prospective studies with 1 664 498 participants. Dose-response and subgroup analyses were also performed. Systematic literature searches were performed in PubMed, EMBASE and Web of Science databases until 9th September 2023. Vitamin C intake significantly reduced DSCs risk (RR = 0.88, 95% confidence interval (CI) 0.83 to 0.93). The subgroup analyses showed the risks of oral, pharyngeal, and esophageal (OPE) cancers (0.81, 0.72 to 0.93), gastric cancer (0.81, 0.68 to 0.95), and colorectal cancer (0.89, 0.82 to 0.98) were negatively correlated with vitamin C intake, and the effect of vitamin C was different between colon cancer (0.87, 0.77 to 0.97) and rectal cancer (1.00, 0.84 to 1.19). However, plasma vitamin C concentration was only inversely associated with gastric cancer risk (0.74, 0.59 to 0.92). Dose-response analysis revealed that 250 and 65 mg day-1 vitamin C intakes had the strongest protective effect against OPE and gastric cancers respectively. These estimates suggest that vitamin C intake could significantly reduce gastrointestinal cancer incidence, including OPE, gastric, and colon cancers. Plasma vitamin C has a significant reduction effect on the incidence of gastric cancer only, but additional large-scale clinical studies are needed to determine its impact on the incidence of DSCs.
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Affiliation(s)
- Jiamin Zhong
- Department of Toxicology of School of Public Health and Department of Gynecologic Oncology of Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Department of Gastroenterology, Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, 310009, China
| | - Peiwei Li
- Department of Gastroenterology, Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, 310009, China
| | - Fang Zheng
- Department of Toxicology of School of Public Health and Department of Gynecologic Oncology of Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Yating Li
- Department of Toxicology of School of Public Health and Department of Gynecologic Oncology of Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Wei Lu
- Department of Colorectal Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310009, Zhejiang, China
| | - Hanwen Chen
- Department of Gastroenterology, Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, 310009, China
| | - Jianting Cai
- Department of Gastroenterology, Second Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, 310009, China
| | - Dajing Xia
- Department of Toxicology of School of Public Health and Department of Gynecologic Oncology of Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Research Unit of Intelligence Classification of Tumour Pathology and Precision Therapy, Chinese Academy of Medical Sciences (2019RU042), Hangzhou 310058, Zhejiang, China
| | - Yihua Wu
- Department of Toxicology of School of Public Health and Department of Gynecologic Oncology of Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Cancer Center, Zhejiang University, Hangzhou, Zhejiang 310058, China
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Flammia RS, Lavigne D, Tian Z, Saad F, Anceschi U, Gallucci M, Leonardo C, Preisser F, Mandel P, Chun FKH, Karakiewicz PI, Delouya G, Taussky D, Hoeh B. Trial Participation is Not Associated with Better Biochemical Recurrence-free Survival in a Large Cohort of External Beam Radiotherapy-Treated Intermediate- and High-Risk Prostate Cancer Patients. Clin Oncol (R Coll Radiol) 2023; 35:e77-e84. [PMID: 36115747 DOI: 10.1016/j.clon.2022.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 08/04/2022] [Accepted: 08/22/2022] [Indexed: 01/06/2023]
Abstract
AIMS There is a widespread belief that outcomes of cancer patients treated within clinical trials might not be representative of the outcomes obtained within standard clinical settings. We sought to investigate the effect of trial participation on biochemical recurrence (BCR) in localised, D'Amico intermediate- and high-risk prostate cancer patients treated with external beam radiotherapy (EBRT). MATERIALS AND METHODS We relied on a study population treated with EBRT between January 2001 and January 2021 at a single tertiary care centre, stratified according to trial enrolment. Separate Kaplan-Meier and multivariable Cox regression models tested BCR-free survival at 60 months within intermediate- and high-risk EBRT patients, after adjustment for covariables. Additionally, the analyses were refitted after inverse probability treatment weighting was performed separately for both risk subgroups. RESULTS Of 932 eligible patients, 635 (68%) and 297 (32%) had intermediate- and high-risk prostate cancer, respectively. Overall, 53% of patients were trial participants. BCR rates were 11 versus 5% (P = 0.27) and 12 versus 14% (P = 0.08) in trial participants versus non-participants for intermediate- and high-risk subgroups, respectively. Differences in patient and clinical characteristics were recorded. Trial participation status failed to reach predictor status in multivariable Cox regression models for BCR in both intermediate-risk (hazard ratio 1.34; 95% confidence interval 0.71-2.49; P = 0.4) and high-risk patients (hazard ratio 1.03; 95% confidence interval 0.45-2.34; P = 0.9). Virtually the same results were recorded in inverse probability treatment weighting cohorts. CONCLUSIONS Relying on a large cohort of EBRT-treated intermediate- and high-risk patients, no BCR differences were recorded between trial participants and non-participants after accounting for confounders.
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Affiliation(s)
- R S Flammia
- Department of Maternal-Child and Urological Sciences, Sapienza Rome University, Policlinico Umberto I Hospital, Rome, Italy; Cancer Prognostics and Health Outcomes Unit, Division of Urology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - D Lavigne
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada.
| | - Z Tian
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - F Saad
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada; Department of Surgery, Division of Urology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - U Anceschi
- Department of Maternal-Child and Urological Sciences, Sapienza Rome University, Policlinico Umberto I Hospital, Rome, Italy; Department of Uro-oncology, National Cancer Institute, IRCCS "IFO-Reginal Elena", Rome, Italy
| | - M Gallucci
- Department of Maternal-Child and Urological Sciences, Sapienza Rome University, Policlinico Umberto I Hospital, Rome, Italy
| | - C Leonardo
- Department of Maternal-Child and Urological Sciences, Sapienza Rome University, Policlinico Umberto I Hospital, Rome, Italy
| | - F Preisser
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - P Mandel
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - F K H Chun
- Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
| | - P I Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - G Delouya
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - D Taussky
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - B Hoeh
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada; Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt am Main, Frankfurt am Main, Germany
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3
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Howard JM, Cook GS, Tverye A, Nandy K, Margulis V, Woldu SL, Lotan Y. Outcomes of Patients with Bacillus Calmette-Guérin (BCG)-Unresponsive Non-Muscle Invasive Bladder Cancer as Defined by the U.S. Food and Drug Administration. Bladder Cancer 2022; 8:303-314. [PMID: 38993682 PMCID: PMC11181681 DOI: 10.3233/blc-211657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/31/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Limited data are available on the outcomes of patients with non-muscle invasive bladder cancer (NMIBC) unresponsive to intravesical bacillus Calmette-Guérin (BCG), as defined by the United States Food and Drug Administration. OBJECTIVE To define the outcomes of patients with BCG-unresponsive NMIBC. METHODS This was a retrospective, single-institution observational cohort study. Records of patients managed at our institution for BCG-unresponsive NMIBC between 2005 and 2020 were reviewed and clinical outcomes evaluated. RESULTS The study included 149 patients. Management was with initial radical cystectomy in 60 patients (40%) and initial bladder-sparing therapy (BST) in 89 patients (60%). Overall survival was greater among patients undergoing RC than BST (HR 1.83, 95% CI 1.04-3.22, p = 0.036), potentially due to patient selection, as no significant difference was noted for metastasis-free or cancer-specific survival. Patients opting for initial BST had high rates of treatment failure, with estimated 5-year cystectomy-free survival of only 42%. Patients who received additional lines of BST after a subsequent failure were at increased risk of having ≥pT3 or pN+ disease at cystectomy (42% for ≥2 lines BST, versus 18% for 1 line BST and 15% for initial cystectomy, p = 0.038). CONCLUSION Among patients who underwent initial BST for BCG-unresponsive NMIBC, rates of treatment failure were very high. Patients who underwent delayed cystectomy after ≥2 lines of BST had elevated rates of extravesical disease. Our observations emphasize the importance of recent and ongoing clinical trials in this clinical space.
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Affiliation(s)
- Jeffrey M Howard
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Division of Urology, Maine Medical Center, Portland, ME, USA
| | - Grayden S Cook
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Division of Urology, Brigham and Women's Hospital / Harvard Medical School, Boston, MA, USA
| | - Aaron Tverye
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Karabi Nandy
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Solomon L Woldu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Okado I, Pagano I, Cassel K, Su'esu'e A, Rhee J, Berenberg J, Holcombe RF. Clinical Research Professional Providing Care Coordination Support: A Study of Hawaii Minority/Underserved NCORP Community Site Trial Participants. JCO Oncol Pract 2022; 18:e1114-e1121. [PMID: 35294261 PMCID: PMC10530402 DOI: 10.1200/op.21.00655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/23/2021] [Accepted: 02/16/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Although effective care coordination (CC) is recognized as a vital component of a patient-centered, high-quality cancer care delivery system, CC experiences of patients who enroll and receive treatment through clinical trials (CTs) are relatively unknown. Using mixed methods, we examined perceptions of CC among patients enrolled onto therapeutic CTs through the Hawaii Minority/Underserved National Cancer Institute Community Oncology Research Program. METHODS The Care Coordination Instrument, a validated instrument, was used to measure patients' perceptions of CC among CT participants (n = 45) and matched controls (n = 45). Paired t-tests were used to compare overall and three CC domain scores (Communication, Navigation, and Operational) between the groups. Semistructured focus group interviews were conducted virtually with 14 CT participants in 2020/2021. RESULTS CT participants reported significantly higher total CC scores than non-CT participants (P = .0008). Similar trends were found for Navigation and Operational domain scores (P = .007 and .001, respectively). Twenty-nine percent of CT participants reported receiving high-intensity CC assistance from their clinical research professionals (CRPs). Content analysis of focus group discussions revealed that nearly half of the focus group discussions centered on CRPs (47%), including CC support provided by CRPs (26%). Other key themes included general CT experiences (22%) and CRP involvement as an additional benefit to CT participation (15%). CONCLUSION Our results show that patients on CTs in this study had a more positive CC experience. This may be attributable in part to CC support provided by CRPs. These findings highlight both the improved experience of treatment for patients participating in a trial and the generally unrecognized yet integral role of CRPs as part of a cancer CT care team.
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Affiliation(s)
- Izumi Okado
- University of Hawaii Cancer Center, Honolulu, HI
| | - Ian Pagano
- University of Hawaii Cancer Center, Honolulu, HI
| | - Kevin Cassel
- University of Hawaii Cancer Center, Honolulu, HI
| | | | - Jessica Rhee
- University of Hawaii Cancer Center, Honolulu, HI
| | | | - Randall F. Holcombe
- University of Hawaii Cancer Center, Honolulu, HI
- Current Affiliation: University of Vermont Cancer Center, Burlington, VT
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5
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Gifford CS, McGahan BG, Miracle SD, Minnema AJ, Murphy CV, Vazquez DE, Weaver TE, Farhadi HF. Design and feasibility of a double-blind, randomized trial of peri-operative methylnaltrexone for postoperative ileus prevention after adult spinal arthrodesis. Contemp Clin Trials 2021; 112:106623. [PMID: 34798295 DOI: 10.1016/j.cct.2021.106623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 10/30/2021] [Accepted: 11/11/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Postoperative ileus (POI) is a common complication with no proven prophylactic measures in place. While perioperative opioid use has been implicated in POI development, current treatments fail to target this disease mechanism. Methylnaltrexone (MNTX) has been used to prevent the effects of opioids on the bowel and could reduce the incidence of POI when administered preoperatively. METHODS In this phase IIb randomized controlled trial, we assessed the effect of perioperative MNTX on time-to-first-bowel movement following spinal arthrodesis surgeries. RESULTS 82 patients were randomly selected in a 1:1 ratio to be included in either the treatment or placebo groups. Comparison of relevant factors of included patients to patients who refused to participate (n = 21) and to a prior retrospective series (n = 241) revealed no differences in age, male sex, liver disease, and number of surgical levels. Overall treatment fidelity (98% adherence) and retention (100% at one-month follow-up) were high. The predicted POI incidence (9.3-11.1%) was also equivalent to a prior retrospective series. However, the overall observed POI incidence (3.7%) was lower than expected, which could reflect a superimposed 'trial effect' related to standardized care in a research setting. CONCLUSIONS Since exposure to significant opioid doses represents a barrier to enhanced recovery after surgery, the results of this innovative trial may provide further guidance for the peri-operative use of opioid-receptor blockers. Here, we show that MNTX can be effectively administered in the peri-operative period with appropriate follow-up achieved in a representative population of patients undergoing spinal surgery. TRIAL REGISTRATION NUMBERS Clinicaltrials.gov - NCT03852524 and Institutional Review Board - 2018H0260.
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Affiliation(s)
- Connor S Gifford
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Benjamin G McGahan
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Shelby D Miracle
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Amy J Minnema
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Claire V Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Daniel E Vazquez
- Department of General Surgery, Cleveland Clinic Akron General, Akron, OH, United States of America
| | - Tristan E Weaver
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - H Francis Farhadi
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States of America.
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6
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Philip J, Le B, Pasanen L, Rosens E, Wong A, Mendis R, Boughey M, Coperchini M, Moran J, Hynson J, Weil J, Rosenthal M. Palliative Care Clinical Trials: Building Capability and Capacity. J Palliat Med 2021; 25:421-427. [PMID: 34788568 DOI: 10.1089/jpm.2021.0314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Clinical trials are a key component of expanding the evidence base in palliative care. A key strategic objective of the Victorian Comprehensive Cancer Centre (VCCC), a multisite cancer center alliance, was to increase palliative care clinical trial expertise. The palliative care services within the VCCC alliance presented substantial trial development opportunities with large number of patients and established relationships, but few trial-active centers. Objectives: To establish a multi-site "Building Capability in Palliative Care Clinical Trials" program as a service development, and to assess the strategies, activities, and the outcomes resulting from this program. Methods: A series of strategies and activities were developed linked to the key program objectives of increasing the number of clinical sites and skilled clinicians conducting clinical trials, increasing the number of trials available and patients participating, broadening research opportunities in palliative care, and establishing the program sustainability. Results: In the two years of implementation, the program resulted in the establishment and conduct of several Phase 4 postmarketing pharmacovigilance studies, nine Phase 2 and 3 trials across five palliative care services, and a Phase 1 clinical trial. During the program, 150 patients were recruited to clinical trials, and 258 prospective pharmacovigilance monitoring cases were recorded. Five investigator-initiated trials were developed by clinical trial fellows and achieved competitive (n = 3) or commercial (n = 2) funding. Clinicians reported that undertaking clinical trials had increased attention to the evidence base of care provision, and increased service research activity more broadly. Long-term sustainability remains a challenge, particularly in the context of the COVID-19 pandemic. Conclusions: Clinical trials in palliative care services are feasible, acceptable, and result in increased attention to the evidence base of care. The strategies detailing the framework, activities, and outcomes have been collated to facilitate implementation of clinical trials in other sites and with other trial-naive disciplinary groups.
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Affiliation(s)
- Jennifer Philip
- Department of Medicine, University of Melbourne, Fitzroy, Australia.,Departments of Palliative Care and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Departments of Palliative Care and Medical Oncology, Melbourne Health, Victorian Comprehensive Cancer Centre, Parkville, Australia.,Department of Palliative Care, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Brian Le
- Departments of Palliative Care and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Departments of Palliative Care and Medical Oncology, Melbourne Health, Victorian Comprehensive Cancer Centre, Parkville, Australia
| | - Leeanne Pasanen
- Department of Palliative Care, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Evelien Rosens
- Departments of Palliative Care and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Victorian Comprehensive Cancer Centre, Australia
| | - Aaron Wong
- Departments of Palliative Care and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Departments of Palliative Care and Medical Oncology, Melbourne Health, Victorian Comprehensive Cancer Centre, Parkville, Australia.,Palliative Care Service, Austin Health, Heidelberg, Australia
| | - Ruwani Mendis
- Palliative Care Service, Western Health, Footscray, Australia
| | - Mark Boughey
- Department of Palliative Care, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | | | - Juli Moran
- Palliative Care Service, Austin Health, Heidelberg, Australia
| | - Jenny Hynson
- Palliative Care Service, Royal Children's Hospital, Melbourne, Australia
| | - Jenny Weil
- Department of Palliative Care, St Vincent's Hospital Melbourne, Fitzroy, Australia
| | - Mark Rosenthal
- Departments of Palliative Care and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Departments of Palliative Care and Medical Oncology, Melbourne Health, Victorian Comprehensive Cancer Centre, Parkville, Australia
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Lapid MI, Clarke BL, Ho JB, Ouellette Y, Armbrust TL, Wright RS. Research Involving Participants With Impaired Consent Capacity: An Examination of Methods to Determine Capacity to Consent. Mayo Clin Proc 2021; 96:2806-2822. [PMID: 34736608 DOI: 10.1016/j.mayocp.2021.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 03/24/2021] [Accepted: 04/29/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To examine methods of assessing consent capacity in research protocols involving participants with impaired consent capacity, and examine instruments used to evaluate research consent capacity. METHODS A retrospective review of 330 active research protocols involving participants lacking capacity to consent over a 10-year period (January 1, 2009, through March 1, 2019) was conducted to collect protocol characteristics (medical specialty, level of risk and type of study, consent and assent procedures, and type of vulnerable or protected population). Methods to assess consent capacity are described, and instruments to assess consent capacity are summarized. RESULTS The specialties most frequently involving participants with impaired consent capacity in research were Neurology (27.3%), Critical Care (16.7%), and Surgery (10%). Type of studies are observational (43.9%), clinical trials (33%), chart review (11.5%), biobank (6.1%), and biomarker (5.5%). Minimal risk (53.3%) outnumbered greater than minimal risk (46.7%) studies. Most obtained written informed consent (77%) and assent (40.9%). The most common method to assess consent capacity was direct assessment by investigators (32.7%). Only 86 (26%) studies used instruments to assess consent capacity. Of the 13 instruments used, the most common was the Evaluation of Decision-Making Capacity for Consent to Act as a Research Subject, and is the only instrument that assesses all four components of decisional capacity: understanding, appreciation, reasoning, and choice. CONCLUSION Generally, there was lack of uniformity in determining capacity to consent to research participation. Very few studies used instruments to assess consent capacity. Institutional review boards can provide greater guidance for research consent capacity determination.
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Affiliation(s)
- Maria I Lapid
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN; Mayo Clinic Institutional Review Board and Office of Human Research Protection Program, Mayo Clinic, Rochester, MN.
| | - Bart L Clarke
- Department of Internal Medicine, Division of Endocrinology, Mayo Clinic, Rochester, MN; Mayo Clinic Institutional Review Board and Office of Human Research Protection Program, Mayo Clinic, Rochester, MN
| | - Jacqueline B Ho
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN; Mayo Clinic Undergraduate Research Employment Program, Mayo Clinic, Rochester, MN
| | - Yves Ouellette
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN; Mayo Clinic Institutional Review Board and Office of Human Research Protection Program, Mayo Clinic, Rochester, MN
| | - Tamyra L Armbrust
- Mayo Clinic Institutional Review Board and Office of Human Research Protection Program, Mayo Clinic, Rochester, MN
| | - R Scott Wright
- Department of Cardiology, Mayo Clinic, Rochester, MN; Mayo Clinic Institutional Review Board and Office of Human Research Protection Program, Mayo Clinic, Rochester, MN
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8
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Azarpazhooh A, Khazaei S, Jafarzadeh H, Malkhassian G, Sgro A, Elbarbary M, Cardoso E, Oren A, Kishen A, Shah PS. A Scoping Review of Four Decades of Outcomes in Nonsurgical Root Canal Treatment, Nonsurgical Retreatment, and Apexification Studies: Part 3-A Proposed Framework for Standardized Data Collection and Reporting of Endodontic Outcome Studies. J Endod 2021; 48:40-54. [PMID: 34688792 DOI: 10.1016/j.joen.2021.09.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Despite initiatives to standardize and improve reporting of rapidly growing endodontic outcome research studies, issues related to missing and ambiguous information are still of great concern. In this article, we propose a framework for standardized data collection and a compiled checklist for reporting of various study designs on endodontic outcome. METHODS A comprehensive search was carried out to locate randomized controlled trials, cohorts, case-control studies, or case series of >100 patients that reported on endodontic outcomes. We reviewed these articles to develop a Data Collection Template and compiled a checklist for reporting of future endodontic outcome research. RESULTS Out of 354 eligible articles previously reported in our scoping review on endodontic outcome studies, 109 articles were selected and screened for study variables or levels of categorization. Our complied Data Collection Template was developed in 19 domains to highlight important demographic, preoperative, intraoperative, and postoperative variables. Because of the specific needs for endodontic outcome literature, we also proposed a compiled checklist (consisting of 4 main domains) to facilitate the reporting of various study designs on endodontic outcome studies. This checklist included simple descriptions of the required items and examples on reporting from published endodontic studies. CONCLUSIONS By facilitating the collection and reporting of relevant research data by investigators in private practice and academia, we hope that the proposed Data Collection Template and reporting guideline can highlight the importance of standardization among clinicians and researchers while producing valid scientific information that will support evidence-based treatment decisions.
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Affiliation(s)
- Amir Azarpazhooh
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada.
| | - Saber Khazaei
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | - Hamid Jafarzadeh
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada
| | | | - Adam Sgro
- Mount Sinai Hospital, Toronto, ON, Canada
| | | | - Elaine Cardoso
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada
| | - Ariel Oren
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Anil Kishen
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada
| | - Prakesh S Shah
- Faculty of Dentistry, University of Toronto, Toronto, ON, Canada; Mount Sinai Hospital, Toronto, ON, Canada
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9
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Gidwani R, Franks JA, Enogela EM, Caston NE, Williams CP, Aswani MS, Azuero A, Rocque GB. Survival in the Real World: A National Analysis of Patients Treated for Early-Stage Breast Cancer. JCO Oncol Pract 2021; 18:e235-e249. [PMID: 34558316 DOI: 10.1200/op.21.00274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Many patient population groups are not proportionally represented in clinical trials, including patients of color, at age extremes, or with comorbidities. It is therefore unclear how treatment outcomes may differ for these patients compared with those who are well-represented in trials. METHODS This retrospective cohort study included women diagnosed with stage I-III breast cancer between 2005 and 2015 in the national CancerLinQ Discovery electronic medical record-based data set. Patients with comorbidities or concurrent cancer were considered unrepresented in clinical trials. Non-White patients and/or those age < 45 or ≥ 70 years were considered under-represented. Patients who were White, age 45-69 years, and without comorbidities were considered well-represented. Cox proportional hazards models were used to evaluate 5-year mortality by representation group and patient characteristics, adjusting for cancer stage, subtype, chemotherapy, and diagnosis year. RESULTS Of 11,770 included patients, 48% were considered well-represented in trials, 45% under-represented, and 7% unrepresented. Compared with well-represented patients, unrepresented patients had almost three times the hazard of 5-year mortality (adjusted hazard ratio [aHR], 2.71; 95% CI, 2.08 to 3.52). There were no significant differences in the hazard of 5-year mortality for under-represented patients compared with well-represented patients (aHR, 1.19; 95% CI, 0.98 to 1.45). However, among under-represented patients, those age < 45 years had a lower hazard of 5-year mortality (aHR, 0.63; 95% CI, 0.48 to 0.84) and those age ≥ 70 years had a higher hazard of 5-year mortality (aHR, 2.21; 95% CI, 1.76 to 2.77) compared with those age 45-69 years. CONCLUSION More than half of the patients were under-represented or unrepresented in clinical trials, because of age, comorbidity, or race. Some of these groups experienced poorer survival compared with those well-represented in trials. Trialists should ensure that study participants reflect the disease population to support evidence-based decision making for all individuals with cancer.
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Affiliation(s)
- Risha Gidwani
- Department of Health Management and Policy, University of California, Los Angeles, Los Angeles, CA
| | - Jeffrey A Franks
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Ene M Enogela
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Nicole E Caston
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Courtney P Williams
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Monica S Aswani
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL
| | - Gabrielle B Rocque
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL.,O'Neal Comprehensive Cancer Center; Birmingham, AL
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Norris M, Poltawski L, Calitri R, Shepherd AI, Dean SG. Hope and despair: a qualitative exploration of the experiences and impact of trial processes in a rehabilitation trial. Trials 2019; 20:525. [PMID: 31443735 PMCID: PMC6708169 DOI: 10.1186/s13063-019-3633-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 08/08/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Unanticipated responses by research participants can influence randomised controlled trials (RCTs) in multiple ways, many of which are poorly understood. This study used qualitative interviews as part of an embedded process evaluation to explore the impact participants may have on the study, but also unintended impacts the study may have on them. AIM The aim of the study was to explore participants' experiences and the impact of trial involvement in a pilot RCT in order to inform the designing and delivery of a definitive RCT. METHODS In-depth interviews with 20 participants (10 in the intervention and 10 in the control group) enrolled in a stroke rehabilitation pilot trial. A modified framework approach was used to analyse transcripts. RESULTS Participation in the study was motivated partly by a desperation to receive further rehabilitation after discharge. Responses to allocation to the control group included an increased commitment to self-treatment, and negative psychological consequences were also described. Accounts of participants in both control and intervention groups challenge the presumption that they were neutral, or in equipoise, regarding group allocation prior to consenting to randomisation. CONCLUSIONS Considering and exploring participant and participation effects, particularly in the control group, highlights numerous issues in the interpretation of trial studies, as well as the in ethics of RCTs more generally. While suggestions for a definitive trial design are given, further research is required to investigate the significant implications these findings may have for trial design, monitoring and funding. TRIAL REGISTRATION ClinicalTrials.gov, NCT02429180 . Registered on 29 April/2015.
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Affiliation(s)
- Meriel Norris
- College of Health and Life Sciences, Brunel University London, Uxbridge, UB8 3PH UK
| | | | - Raff Calitri
- University of Exeter Medical School, Exeter, EX1 2LU UK
| | - Anthony I. Shepherd
- Department of Sport and Exercise Science, University of Portsmouth, Portsmouth, PO1 2ER UK
| | - Sarah G. Dean
- University of Exeter Medical School, Exeter, EX1 2LU UK
| | - on behalf of the ReTrain Team
- College of Health and Life Sciences, Brunel University London, Uxbridge, UB8 3PH UK
- University of Exeter Medical School, Exeter, EX1 2LU UK
- Department of Sport and Exercise Science, University of Portsmouth, Portsmouth, PO1 2ER UK
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Goenka L, Rajendran S, Arumugam K, Rani J, George M. The assessment of the quality of randomized controlled trials published in Indian medical journals. Perspect Clin Res 2019; 10:79-83. [PMID: 31008074 PMCID: PMC6463507 DOI: 10.4103/picr.picr_60_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Aim: In this retrospective cross-sectional study, we sought to evaluate if the published randomized controlled trials (RCTs) reported in the year 2017 among the Indian medical journals (IMJs) complied with the Consolidated Standards of Reporting Trials (CONSORT) guidelines and identify domains where reporting could be improved. Methods: A literature search was performed using PubMed and Google Scholar to identify all the IMJs that published RCTs in the year 2017. In the archives of the identified journals, the number of published RCTs was identified and the full text was obtained. We selected articles that stated RCT in abstract and title and that evaluated the safety and efficacy of all therapeutic and preventive interventions. Results: A total of seven IMJs comprising of the Indian Journal of Anesthesia, Indian Journal of Dermatology, Venereology and Leprology, Indian Journal of Pharmacology, Indian Journal of Ophthalmology, Journal of Obstetrics and Gynaecology, Journal of Pharmacology and Pharmacotherapeutics, and Indian Journal of Medical and Pediatric Oncology that published a total of 84 RCTs were included. The mean compliance score of all the RCTs was 13.7 ± 2.66 (57%). Most RCTs had serious reporting deficiencies in the methodology and result sections. Discussion: In spite of journals making it mandatory for prospective authors to comply with the CONSORT guidelines, it is intriguing that there continues to be significant lacunae in reporting RCTs adequately in most IMJs. Conclusion: There is an urgent need to impart training to the medical community of our country in clinical research methods and reporting of RCTs.
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Affiliation(s)
- Luxitaa Goenka
- Department of Clinical Pharmacology, SRM MCH and RC, Kattankulathur, Kancheepuram, Chennai, Tamil Nadu, India
| | - Suramya Rajendran
- Department of Clinical Pharmacology, SRM MCH and RC, Kattankulathur, Kancheepuram, Chennai, Tamil Nadu, India
| | - Kalaiselvi Arumugam
- Department of Clinical Pharmacology, SRM MCH and RC, Kattankulathur, Kancheepuram, Chennai, Tamil Nadu, India
| | - Jamuna Rani
- Department of Clinical Pharmacology, SRM MCH and RC, Kattankulathur, Kancheepuram, Chennai, Tamil Nadu, India
| | - Melvin George
- Department of Clinical Pharmacology, SRM MCH and RC, Kattankulathur, Kancheepuram, Chennai, Tamil Nadu, India
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The effect of participation in neoadjuvant clinical trials on outcomes in patients with early breast cancer. Breast Cancer Res Treat 2018; 171:747-758. [PMID: 29951969 DOI: 10.1007/s10549-018-4829-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/06/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Clinical trials can offer novel and more advanced and/or novel treatments to cancer patients in advance of them being approved and available for all patients. While several studies have examined the effect of clinical trial participation on prognosis, there has been no clear conclusion from these studies. Therefore, we chose to test the influence of trial participation on pathological complete response (pCR) and mastectomy rates after neoadjuvant chemotherapy. METHODS In this retrospective study, all patients treated with neoadjuvant chemotherapy from 2001 to 2014 were selected. A total of 1038 patients with complete treatment, patient, and tumor characteristics were included. A total of 260 of those were treated in clinical trials. We examined whether study participation status in addition to commonly known predictors for pCR improves prediction of pCR. Similar analyses were conducted for the mastectomy rate outcome measure. Finally, survival analyses were also conducted as part of an exploratory analysis. RESULTS Study participation was an independent predictor of pCR in addition to commonly known predictors. Adjusted odds ratio (OR) for trial participants versus non-participants was 1.53 (95% CI 1.03-2.28). Additionally, study participation improved the prediction of mastectomy risk. The adjusted OR for trial participants versus non-participants was 0.62 (95% CI 0.42-0.90). Subgroup-specific differences concerning the impact of study participation could not be shown for either pCR or mastectomy rate. Survival comparisons could not be conducted due to large differences in follow-up data in patients participating in clinical trials versus those who did not participate; however, pCR was a predictor of prognosis in both groups. CONCLUSION Patients taking part in neoadjuvant chemotherapy clinical trials have a higher pCR rate and a lower mastectomy risk than patients not participating in clinical trials for their cancer care. This finding is a supporting factor for trial participation in neoadjuvant chemotherapy trials.
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Toxopeus E, van der Schaaf M, van Lanschot J, Lagergren J, Lagergren P, van der Gaast A, Wijnhoven B. Outcome of Patients Treated Within and Outside a Randomized Clinical Trial on Neoadjuvant Chemoradiotherapy Plus Surgery for Esophageal Cancer: Extrapolation of a Randomized Clinical Trial (CROSS). Ann Surg Oncol 2018; 25:2441-2448. [PMID: 29948420 PMCID: PMC6029046 DOI: 10.1245/s10434-018-6554-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Indexed: 12/11/2022]
Abstract
Background Randomized clinical trials (RCTs) can provide a high level of evidence for medical decision making, but it is unclear if the results apply to patients treated outside such trials. Objective The aim of this study was to retrospectively compare outcomes of patients with esophageal cancer treated within and outside an RCT.
Methods All patients receiving neoadjuvant chemoradiotherapy (nCRT) plus surgery for esophageal cancer between 2002 and 2008 (ChemoRadiotherapy for Esophageal cancer followed by Surgery Study [CROSS] cohort) who participated in multicenter, phase II–III trials were compared with patients who underwent the same treatment outside the trial between 2008 and 2013 (post-CROSS cohort). The differences between these cohorts were analyzed using t tests, while logistic regression models were used to evaluate adverse events. Overall and disease-free survival were calculated using the Kaplan–Meier method and Cox regression analyses. Results A total of 208 CROSS patients and 173 post-CROSS patients were included in this study. Patients from the post-CROSS cohort were older, had more co morbidities, and had poorer performance status. Clinical N stage, but not cT stage, was worse in the post-CROSS cohort. There were no statistically significant differences in adverse events (pulmonary, cardiac, or anastomotic complications) or survival between the comparison cohorts. Conclusion The outcomes of patients treated with nCRT plus esophagectomy for cancer have a high external consistency and can be extrapolated to the daily practice of physicians involved in the treatment and care of esophageal cancer patients. Electronic supplementary material The online version of this article (10.1245/s10434-018-6554-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eelke Toxopeus
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, Rotterdam, The Netherlands.
| | - Maartje van der Schaaf
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Jan van Lanschot
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, Rotterdam, The Netherlands
| | - Jesper Lagergren
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, 171 76, Stockholm, Sweden.,Division of Cancer Studies, King's College London, London, UK
| | - Pernilla Lagergren
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Ate van der Gaast
- Department of Medical Oncology, Erasmus MC - University Medical Center, Rotterdam, Rotterdam, The Netherlands
| | - Bas Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, Rotterdam, The Netherlands
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Wendler D. Innovative approaches to informed consent for randomized clinical trials: Identifying the ethical challenges. Clin Trials 2018; 15:17-20. [PMID: 29250988 PMCID: PMC5799024 DOI: 10.1177/1740774517746621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David Wendler
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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15
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de Oliveira NI, Paula MI, Felipe CR, Tedesco-Silva H, Medina-Pestana JO. Limitations of the interpretation and extrapolation of clinical trial data in kidney transplant recipients. Clin Transplant 2017; 31. [PMID: 28665496 DOI: 10.1111/ctr.13046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The risks and benefits of the participation of kidney transplant recipients in randomized clinical trials (RCTs) investigating new immunosuppressive therapies are unknown. DESIGN AND SETTING We included patients from 12 prospective phase II/III RCTs randomized to the experimental (G1, n=319) or standard-of-care internal control group (G2, n=118). We constructed two additional external control groups with (G3, n=319) or without (G4, n=319) matching inclusion/exclusion criteria based on transplant date. The primary outcome analysis was the composite clinical efficacy failure, defined as biopsy-proven acute rejection (BPAR), graft loss, death, or loss to follow-up 12 months after kidney transplantation. RESULTS Survival free of composite clinical efficacy failure was higher among participants in RCT, without difference between experimental or standard-of-care therapy (80∙3 vs 78∙0 vs 69∙9 vs 66∙1%, P<.001), respectively. Patient (98.1 vs 99.2 vs 96.9 vs 91.8 P<.001) and graft (94.0 vs 98.3 vs 90.9 vs 82.4) survivals were also higher in G1 compared to G4, but no differences in survival free of BPAR were observed (85.3 vs 78.8 vs 82.8 vs 81.2 P>.05), respectively. CONCLUSION These findings suggested that new treatments investigated in kidney transplant recipients are not associated with detectable harm compared to standard of care.
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16
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Barnard EP, AbdElmagied AM, Vaughan LE, Weaver AL, Laughlin-Tommaso SK, Hesley GK, Woodrum DA, Jacoby VL, Kohi MP, Price TM, Nieves A, Miller MJ, Borah BJ, Gorny KR, Leppert PC, Peterson LG, Stewart EA. Periprocedural outcomes comparing fibroid embolization and focused ultrasound: a randomized controlled trial and comprehensive cohort analysis. Am J Obstet Gynecol 2017; 216:500.e1-500.e11. [PMID: 28063909 DOI: 10.1016/j.ajog.2016.12.177] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 11/21/2016] [Accepted: 12/29/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Uterine fibroids are a common problem for reproductive-aged women, yet little comparative effectiveness research is available to guide treatment choice. Uterine artery embolization and magnetic resonance imaging-guided focused ultrasound surgery are minimally invasive therapies approved by the US Food and Drug Administration for treating symptomatic uterine fibroids. The Fibroid Interventions: Reducing Symptoms Today and Tomorrow study is the first randomized controlled trial to compare these 2 fibroid treatments. OBJECTIVE The objective of the study was to summarize treatment parameters and compare recovery trajectory and adverse events in the first 6 weeks after treatment. STUDY DESIGN Premenopausal women with symptomatic uterine fibroids seen at 3 US academic medical centers were enrolled in the randomized controlled trial (n = 57). Women meeting identical criteria who declined randomization but agreed to study participation were enrolled in a nonrandomized parallel cohort (n = 34). The 2 treatment groups were analyzed by using a comprehensive cohort design. All women undergoing focused ultrasound and uterine artery embolization received the same postprocedure prescriptions, instructions, and symptom diaries for comparison of recovery in the first 6 weeks. Return to work and normal activities, medication use, symptoms, and adverse events were captured with postprocedure diaries. Data were analyzed using the Wilcoxon rank sum test or χ2 test. Multivariable regression was used to adjust for baseline pain levels and fibroid load when comparing opioid medication, adverse events, and recovery time between treatment groups because these factors varied at baseline between groups and could affect outcomes. Adverse events were also collected. RESULTS Of 83 women in the comprehensive cohort design who underwent treatment, 75 completed postprocedure diaries. Focused ultrasound surgery was a longer procedure than embolization (mean [SD], 405 [146] vs 139 [44] min; P <.001). Of women undergoing focused ultrasound (n = 43), 23 (53%) underwent 2 treatment days. Immediate self-rated postprocedure pain was higher after uterine artery embolization than focused ultrasound (median [interquartile range], 5 [1-7] vs 1 [1-4]; P = .002). Compared with those having focused ultrasound (n = 39), women undergoing embolization (n = 36) were more likely to use outpatient opioid (75% vs 21%; P < .001) and nonsteroidal antiinflammatory medications (97% vs 67%; P < .001) and to have a longer median (interquartile range) recovery time (days off work, 8 [6-14] vs 4 [2-7]; P < .001; days until return to normal, 15 [10-29] vs 10 [10-15]; P = .02). There were no significant differences in the incidence or severity of adverse events between treatment arms; 86% of adverse events (42 of 49) required only observation or nominal treatment, and no events caused permanent sequelae or death. After adjustment for baseline pain and uterine fibroid load, uterine artery embolization was still significantly associated with higher opioid use and longer time to return to work and normal activities (P < .001 for each). Results were similar when restricted to the randomized controlled trial. CONCLUSION Women undergoing uterine artery embolization have longer recovery times and use more prescription medications, but women undergoing focused ultrasound have longer treatment times. These findings were independent of baseline pain levels and fibroid load.
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Clinical utility of the Revised International Staging System in unselected patients with newly diagnosed and relapsed multiple myeloma. Blood Cancer J 2017; 7:e528. [PMID: 28211889 PMCID: PMC5386331 DOI: 10.1038/bcj.2017.13] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 01/11/2017] [Indexed: 12/25/2022] Open
Abstract
We analyzed the utility of Revised International staging system (RISS) in an unselected cohort of newly diagnosed multiple myeloma (NDMM; cohort 1), and relapsed/refractory multiple myeloma (RRMM; cohort 2) patients. Cohort 1 included 1900 patients seen within 90 days of diagnosis, from 2005 to 2015, while cohort 2 had 887 patients enrolled in 23 clinical trials at Mayo Clinic. The overall survival (OS) and progression-free survival (PFS) was calculated from the time since diagnosis or trial registration. The median estimated follow up was 5 and 2.3 years for Cohorts 1 and 2, respectively. Among 1067 patients evaluable in Cohort 1, the median OS and PFS was 10 and 2.8 years for RISS stage I, 6 and 2.7 years for RISS stage II and 2.6 and 1.3 years for RISS stage III (P<0.0001). Among 456 patients evaluable in Cohort 2, the median OS and PFS was 4.3 and 1.1 years for RISS stage I, 2 and 0.5 years for RISS stage II and 0.8 and 0.2 years for RISS stage III (P<0.0001). In conclusions, RISS gives a better differentiation of NDMM as well as RRMM patients into three survival subgroups and should be used to stratify patients in future clinical trials.
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Wang XX, Dong B, Hong B, Gong YQ, Wang W, Wang J, Zhou ZY, Jiang WJ. Long-term prognosis in patients continuing taking antithrombotics after peptic ulcer bleeding. World J Gastroenterol 2017; 23:723-729. [PMID: 28216980 PMCID: PMC5292347 DOI: 10.3748/wjg.v23.i4.723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/13/2016] [Accepted: 12/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the long-term prognosis in peptic ulcer patients continuing taking antithrombotics after ulcer bleeding, and to determine the risk factors that influence the prognosis.
METHODS All clinical data of peptic ulcer patients treated from January 1, 2009 to January 1, 2014 were retrospectively collected and analyzed. Patients were divided into either a continuing group to continue taking antithrombotic drugs after ulcer bleeding or a discontinuing group to discontinue antithrombotic drugs. The primary outcome of follow-up in peptic ulcer bleeding patients was recurrent bleeding, and secondary outcome was death or acute cardiovascular disease occurrence. The final date of follow-up was December 31, 2014. Basic demographic data, complications, and disease classifications were analyzed and compared by t- or χ2-test. The number of patients that achieved various outcomes was counted and analyzed statistically. A survival curve was drawn using the Kaplan-Meier method, and the difference was compared using the log-rank test. COX regression multivariate analysis was applied to analyze risk factors for the prognosis of peptic ulcer patients.
RESULTS A total of 167 patients were enrolled into this study. As for the baseline information, differences in age, smoking, alcohol abuse, and acute cardiovascular diseases were statistically significant between the continuing and discontinuing groups (70.8 ± 11.4 vs 62.4 ± 12.0, P < 0.001; 8 (8.2%) vs 15 (21.7%), P < 0.05; 65 (66.3%) vs 13 (18.8%), P < 0.001). At the end of the study, 18 patients had recurrent bleeding and three patients died or had acute cardiovascular disease in the continuing group, while four patients had recurrent bleeding and 15 patients died or had acute cardiovascular disease in the discontinuing group. The differences in these results were statistically significant (P = 0.022, P = 0.000). The Kaplan-Meier survival curve indicated that the incidence of recurrent bleeding was higher in patients in the continuing group, and the risk of death and developing acute cardiovascular disease was higher in patients in the discontinuing group (log-rank test, P = 0.000 for both). Furthermore, COX regression multivariate analysis revealed that the hazard ratio (HR) for recurrent bleeding was 2.986 (95%CI: 067-8.356, P = 0.015) in the continuing group, while HR for death or acute cardiovascular disease was 5.216 (95%CI: 1.035-26.278, P = 0.028).
CONCLUSION After the occurrence of peptic ulcer bleeding, continuing antithrombotics increases the risk of recurrent bleeding events, while discontinuing antithrombotics would increase the risk of death and developing cardiovascular disease. This suggests that clinicians should comprehensively consider the use of antithrombotics after peptic ulcer bleeding.
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Xiao L, Lv N, Rosas LG, Karve S, Luna V, Jameiro E, Wittels N, Ma J. Use of a motivational interviewing-informed strategy in group orientations to improve retention and intervention attendance in a randomized controlled trial. HEALTH EDUCATION RESEARCH 2016; 31:729-737. [PMID: 27923862 PMCID: PMC5916227 DOI: 10.1093/her/cyw048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 09/23/2016] [Indexed: 06/06/2023]
Abstract
High retention and treatment adherence are essential to ensure the quality of evidence from clinical trials. Strategies for improving these have been explored but actual rates in lifestyle intervention trials indicate challenges. This study examined the use of a motivational interviewing-informed strategy during interactive group orientations prior to obtaining informed consent, collecting baseline data and randomization in a healthy dietary pattern intervention trial for asthma control in adults. The themes generated from small group discussions and echoed in large group discussions during the orientation sessions helped potential participants better understand the scientific rationale of the research design and procedures and the practical implications for them to participate in the study. Potential participants reported significantly lower confidence of completing the study after the group orientation. This suggests that the group orientations helped potential participants identify challenges to completing the study, have more realistic expectations about participation and be prepared if enrolled. Both retention (92% of 90 participants at 6 months) and intervention attendance (99% of 46 intervention participants attended 80% of 11 weekly group/individual sessions) were high, suggesting the motivation interviewing-informed group orientation strategy may help improve retention and adherence in clinical trials.
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Affiliation(s)
- Lan Xiao
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA 94301, USA
| | - Nan Lv
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA 94301, USA
| | - Lisa G Rosas
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA 94301, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA and
| | - Shweta Karve
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA 94301, USA
| | - Veronica Luna
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA 94301, USA
| | - Elizabeth Jameiro
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA 94301, USA
| | - Nancy Wittels
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA 94301, USA
| | - Jun Ma
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA 94301, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA and
- Department of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL 60607, USA
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Khoja L, Horsley L, Heesters A, Machin JD, Mitchell C, Clamp AR, Jayson GC, Hasan J. Does clinical trial participation improve outcomes in patients with ovarian cancer? ESMO Open 2016; 1:e000057. [PMID: 27843621 PMCID: PMC5070238 DOI: 10.1136/esmoopen-2016-000057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 04/08/2016] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Treatment on a clinical trial is considered to be beneficial to oncology patients. However, supportive evidence for this is scarce. Trial effect describes the phenomenon of improved health outcomes in patients treated with standard of care (SOC) on trial compared to those receiving SOC outside of a clinical trial. We evaluated trial effect in patients with ovarian cancer treated at our tertiary cancer centre. METHODS We performed a retrospective cohort study of patients with ovarian cancer treated at The Christie National Health Service Foundation Trust. Patients treated on one of three first-line clinical trials: (SCOTROC-4, ICON-5, ICON-7) were matched (for age, International Federation of Gynaecology and Obstetrics stage, surgical status and performance status) with individuals receiving the same SOC off trial. Survival was calculated using Kaplan-Meier methodology. RESULTS 60 patients were evaluated; 30 on trial and 30 on SOC off trial. The median progression-free survival (PFS) was 21.8 months (control group) and 25.9 months (trial group), median overall survival (OS) was 64.3 months (control group) and 68.9 months (trial group). There was no difference in PFS (log-rank test: HR 0.87 (95% CI 0.48 to 1.54), p=0.6) or OS (log-rank test: HR 0.87 (95% CI 0.46 to 1.64), p=0.7) between groups. CONCLUSIONS Patient survival was similar regardless if treated on trial or as SOC. Our findings do not support trial effect, at least in a tertiary cancer centre. Clinical trial participation in specialised cancer centres promotes best practice to the benefit of all patients. These findings may impact discussions round consent of patients to trials and organisation of oncology services.
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Affiliation(s)
- L Khoja
- The Christie NHS Foundation Trust , Manchester , UK
| | - L Horsley
- The Christie NHS Foundation Trust , Manchester , UK
| | - A Heesters
- University Health Network 550 University Avenue , Toronto, Ontario , Canada
| | - J D Machin
- The Christie NHS Foundation Trust , Manchester , UK
| | - C Mitchell
- The Christie NHS Foundation Trust , Manchester , UK
| | - A R Clamp
- The Christie NHS Foundation Trust , Manchester , UK
| | - G C Jayson
- The Christie NHS Foundation Trust , Manchester , UK
| | - J Hasan
- The Christie NHS Foundation Trust , Manchester , UK
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Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, Lancaster GA. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. BMJ 2016; 355:i5239. [PMID: 27777223 PMCID: PMC5076380 DOI: 10.1136/bmj.i5239] [Citation(s) in RCA: 1395] [Impact Index Per Article: 174.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2016] [Indexed: 12/27/2022]
Affiliation(s)
- Sandra M Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Claire L Chan
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Michael J Campbell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christine M Bond
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, Scotland, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lehana Thabane
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Gillian A Lancaster
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
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Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, Lancaster GA. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. Pilot Feasibility Stud 2016; 2:64. [PMID: 27965879 PMCID: PMC5154046 DOI: 10.1186/s40814-016-0105-8] [Citation(s) in RCA: 657] [Impact Index Per Article: 82.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 10/10/2016] [Indexed: 01/10/2023] Open
Abstract
The Consolidated Standards of Reporting Trials (CONSORT) statement is a guideline designed to improve the transparency and quality of the reporting of randomised controlled trials (RCTs). In this article we present an extension to that statement for randomised pilot and feasibility trials conducted in advance of a future definitive RCT. The checklist applies to any randomised study in which a future definitive RCT, or part of it, is conducted on a smaller scale, regardless of its design (eg, cluster, factorial, crossover) or the terms used by authors to describe the study (eg, pilot, feasibility, trial, study). The extension does not directly apply to internal pilot studies built into the design of a main trial, non-randomised pilot and feasibility studies, or phase II studies, but these studies all have some similarities to randomised pilot and feasibility studies and so many of the principles might also apply. The development of the extension was motivated by the growing number of studies described as feasibility or pilot studies and by research that has identified weaknesses in their reporting and conduct. We followed recommended good practice to develop the extension, including carrying out a Delphi survey, holding a consensus meeting and research team meetings, and piloting the checklist. The aims and objectives of pilot and feasibility randomised studies differ from those of other randomised trials. Consequently, although much of the information to be reported in these trials is similar to those in randomised controlled trials (RCTs) assessing effectiveness and efficacy, there are some key differences in the type of information and in the appropriate interpretation of standard CONSORT reporting items. We have retained some of the original CONSORT statement items, but most have been adapted, some removed, and new items added. The new items cover how participants were identified and consent obtained; if applicable, the prespecified criteria used to judge whether or how to proceed with a future definitive RCT; if relevant, other important unintended consequences; implications for progression from pilot to future definitive RCT, including any proposed amendments; and ethical approval or approval by a research review committee confirmed with a reference number. This article includes the 26 item checklist, a separate checklist for the abstract, a template for a CONSORT flowchart for these studies, and an explanation of the changes made and supporting examples. We believe that routine use of this proposed extension to the CONSORT statement will result in improvements in the reporting of pilot trials. Editor's note: In order to encourage its wide dissemination this article is freely accessible on the BMJ and Pilot and Feasibility Studies journal websites.
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Affiliation(s)
- Sandra M. Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Claire L. Chan
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Michael J. Campbell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Christine M. Bond
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, Scotland, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lehana Thabane
- Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario Canada
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Walsh EI, Turner EL, Lane JA, Donovan JL, Neal DE, Hamdy FC, Martin RM. Characteristics of men responding to an invitation to undergo testing for prostate cancer as part of a randomised trial. Trials 2016; 17:497. [PMID: 27737692 PMCID: PMC5064919 DOI: 10.1186/s13063-016-1624-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 09/24/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sociodemographic characteristics are associated with participating in cancer screening and trials. We compared the characteristics of those responding with those not responding to a single invitation for prostate-specific antigen (PSA) testing for prostate cancer as part of the Cluster randomised triAl of PSA testing for Prostate cancer (CAP). METHODS Age, rurality and deprivation among 197,763 men from 271 cluster-randomised primary care centres in the UK were compared between those responding (n = 90,300) and those not responding (n = 100,953) to a prostate cancer testing invitation. RESULTS There was little difference in age between responders and nonresponders. Responders were slightly more likely to come from urban rather than rural areas and were slightly less deprived than those who did not respond. CONCLUSION These data indicate similarities in age and only minor differences in deprivation and urban location between responders and nonresponders. These differences were smaller, but in the same direction as those observed in other screening trials. TRIAL REGISTRATION ISRCTN92187251 . Registered on 29 November 2004.
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Affiliation(s)
- Eleanor I. Walsh
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Emma L. Turner
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - J. Athene Lane
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Jenny L. Donovan
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - David E. Neal
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Freddie C. Hamdy
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Richard M. Martin
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - and the CAP & ProtecT Trial Groups
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, OX3 9DU UK
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Mhaskar R, Miladinovic B, Guterbock TM, Djulbegovic B. When are clinical trials beneficial for study patients and future patients? A factorial vignette-based survey of institutional review board members. BMJ Open 2016; 6:e011150. [PMID: 27683511 PMCID: PMC5051324 DOI: 10.1136/bmjopen-2016-011150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The ethicists believe that the goal of clinical research is to benefit future and not current (trial) patients. Many clinicians believe that the clinical trial enrolment offers best management for their patients. The objective of our study was to identify the situations when a clinical trial is beneficial for the patients enrolled in the trial and future patients. DESIGN Factorial vignette-based cross-sectional survey via the internet. PARTICIPANTS Institutional review board (IRB) members of the US Medical Schools. MAIN OUTCOME MEASURES Each participant was invited to review 9 clinical vignettes related to (1) study approval and (2) the assessment if the study is designed to help future or current patients more. RESULTS A total of 232 IRB members from 42 institutions participated. When considering approval of the trial, we found that uncertainty about treatment effects (OR=1.13; 95% CI 1.08 to 1.19) and requirement for continuation of standard therapy (OR=3.84; 95% CI 2.7 to 5.55) were the only statistically significant factors affecting IRB members' decisions to approve the study. The odds of IRB members approving a trial increased when a trial proposed to enrol patients with life-threatening versus chronic debilitating disease (OR=2.04; 95% CI 1.47 to 2.86). We also found that similar factors affected judgements related to the assessment whether the trial will benefit future or current patients more-(1) future patients: uncertainty (OR=1.27; 95% CI 1.18 to 1.37); continuation of standard treatment (OR=1.66; 95% CI 1.07 to 2.56); seriousness of condition (OR=1.78; 95% CI 1.15 to 2.28); (2) current patients: uncertainty (OR=1.54; 95% CI 1.4 to 1.7); continuation of standard therapy (OR=2.17; 95% CI 1.39 to 3.44). CONCLUSIONS IRB members view the proposed studies to be beneficial for current patients and future patients if there is uncertainty regarding treatment effects and if studies do not require stopping the current treatment. This finding supports the design and use of pragmatic trials which may reduce therapeutic misconception and improve trial enrolment, speeding up therapeutic discoveries.
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Affiliation(s)
- Rahul Mhaskar
- USF Program for Comparative Effectiveness Research and Evidence-Based Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Branko Miladinovic
- USF Program for Comparative Effectiveness Research and Evidence-Based Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Thomas M Guterbock
- University of Virginia, Center for Survey Research, Charlottesville, Virginia, USA
| | - Benjamin Djulbegovic
- USF Program for Comparative Effectiveness Research and Evidence-Based Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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AbdElmagied AM, Vaughan LE, Weaver AL, Laughlin-Tommaso SK, Hesley GK, Woodrum DA, Jacoby VL, Kohi MP, Price TM, Nieves A, Miller MJ, Borah BJ, Gorny KR, Leppert PC, Lemens MA, Stewart EA. Fibroid interventions: reducing symptoms today and tomorrow: extending generalizability by using a comprehensive cohort design with a randomized controlled trial. Am J Obstet Gynecol 2016; 215:338.e1-338.e18. [PMID: 27073063 DOI: 10.1016/j.ajog.2016.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 03/31/2016] [Accepted: 04/04/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Uterine fibroids are an important source of morbidity for reproductive-aged women. Despite an increasing number of alternatives, hysterectomies account for about 75% of all fibroid interventional treatments. Evidence is lacking to help women and their health care providers decide among alternatives to hysterectomy. Fibroid Interventions: Reducing Symptoms Today and Tomorrow (NCT00995878, clinicaltrials.gov) is a randomized controlled trial to compare the safety, efficacy, and economics of 2 minimally invasive alternatives to hysterectomy: uterine artery embolization and magnetic resonance imaging-guided focused ultrasound surgery. Although randomized trials provide the highest level of evidence, they have been difficult to conduct in the United States for interventional fibroid treatments. Thus, contemporaneously recruiting women declining randomization may have value as an alternative strategy for comparative effectiveness research. OBJECTIVE We sought to compare baseline characteristics of randomized participants with nonrandomized participants meeting the same enrollment criteria and to determine whether combining the 2 cohorts in a comprehensive cohort design would be useful for analysis. STUDY DESIGN Premenopausal women with symptomatic uterine fibroids seeking interventional therapy at 3 US academic medical centers were randomized (1:1) in 2 strata based on calculated uterine volume (<700 and ≥700 cc(3)) to undergo embolization or focused ultrasound surgery. Women who met the same inclusion criteria but declined randomization were offered enrollment in a parallel cohort. Both cohorts were followed up for a maximum of 36 months after treatment. The measures addressed in this report were baseline demographics, symptoms, fibroid and uterine characteristics, and scores on validated quality-of-life measures. RESULTS Of 723 women screened, 57 were randomized and 49 underwent treatment (27 with focused ultrasound and 22 with embolization). Seven of the 8 women randomized but not treated were assigned to embolization. Of 34 women in the parallel cohort, 16 elected focused ultrasound and 18 elected embolization. Compared with nonrandomized participants, randomized participants had higher mean body mass index (28.7 vs 25.3 kg/m(2); P = .01) and were more likely to be gravid (77% vs 47%; P = .003) and smokers (42% vs 12%; P = .003). Age, race, uterine volume, number of fibroids, and baseline validated measures of general and disease-specific quality of life, pain, depression, and sexual function did not differ between the groups. When we performed a comprehensive cohort analysis and analyzed by treatment arm, the only baseline difference observed was a higher median McGill Pain Score among women undergoing focused ultrasound (10.5 vs 6; P = .03); a similar but nonsignificant trend was seen in visual analog scale scores for pain (median, 39.0 vs 24.0; P = .06). CONCLUSION Using a comprehensive cohort analysis of study data could result in additional power and greater generalizability if results are adjusted for baseline differences.
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Affiliation(s)
- Ahmed M AbdElmagied
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; Department of Obstetrics and Gynecology, Women Health Hospital, Assiut University, Assiut, Egypt
| | - Lisa E Vaughan
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | | | | | - Vanessa L Jacoby
- Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Maureen P Kohi
- Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA
| | - Thomas M Price
- Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | - Angel Nieves
- Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | | | - Bijan J Borah
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
| | | | - Phyllis C Leppert
- Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | - Maureen A Lemens
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
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Perry J, Wöhlke S, Heßling AC, Schicktanz S. Why take part in personalised cancer research? Patients' genetic misconception, genetic responsibility and incomprehension of stratification-an empirical-ethical examination. Eur J Cancer Care (Engl) 2016; 26. [PMID: 27507437 DOI: 10.1111/ecc.12563] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2016] [Indexed: 01/25/2023]
Abstract
Therapeutic misconception is a well-known challenge for informed decision-making for cancer research participants. What is still missing, is a detailed understanding of the impact of "personalised" treatment research (e.g. biomarkers for stratification) on research participants. For this, we conducted the first longitudinal empirical-ethical study based on semi-structured interviews with colorectal cancer patients (n = 40) enrolled in a biomarker trial for (neo)adjuvant treatment, analysing the patients' understanding of and perspectives on research and treatment with qualitative methods. In addition to therapeutic misconception based on patients' confusion of research and treatment, and here triggered by misled motivation, information paternalism or incomprehension, we identified genetic misconception and genetic responsibility as new problematic issues. Patients mainly were not aware of the major research aim of future stratification into responders and non-responders nor did they fully acknowledge this as the aim for personalised cancer research. Thus, ethical and practical reflection on informed decision-making in cancer treatment and research should take into account the complexity of lay interpretations of modern personalised medicine. Instead of very formalistic, liability-oriented informed consent procedures, we suggest a more personalised communication approach to inform and motivate patients for cancer research.
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Affiliation(s)
- J Perry
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - S Wöhlke
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - A C Heßling
- Department of General Practice, University Medical Center Göttingen, Göttingen, Germany
| | - S Schicktanz
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Göttingen, Germany
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Risk of Vascular Thrombotic Events Following Discontinuation of Antithrombotics After Peptic Ulcer Bleeding. J Clin Gastroenterol 2016; 50:e40-4. [PMID: 26084008 DOI: 10.1097/mcg.0000000000000354] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
GOALS To evaluate whether the risk of cardiovascular events increases when antithrombotics are discontinued after ulcer bleeding. BACKGROUND Peptic ulcer bleeding associated with antithrombotics has increased due to the increase in the proportion of elderly population. Little is known about the long-term effects of discontinuing antithrombotics after peptic ulcer bleeding. The aim of this study was to evaluate whether the risk of cardiovascular events increases when antithrombotics are discontinued after ulcer bleeding. STUDY We reviewed the medical records of patients with ulcer bleeding who were taking antiplatelet agents or anticoagulants at the time of ulcer bleeding. Cox-regression model was used to adjust for potential confounders, and analyzed association between discontinuation of antithrombotic drugs after ulcer bleeding and thrombotic events such as ischemic heart disease or stroke. RESULTS Of the 544 patients with ulcer bleeding, 72 patients who were taking antithrombotics and followed up for >2 months were analyzed. Forty patients discontinued antithrombotics after ulcer bleeding (discontinuation group) and 32 patients continued antithrombotics with or without transient interruption (continuation group). Thrombotic events developed more often in discontinuation group than in the continuation group [7/32 (21.9%) vs. 1/40 (2.5%), P=0.019]. Hazard ratio for thrombotic event when antithrombotics were continuously discontinued was 10.9 (95% confidence interval, 1.3-89.7). There were no significant differences in recurrent bleeding events between the 2 groups. CONCLUSIONS Discontinuation of antithrombotics after peptic ulcer bleeding increases the risk of cardiovascular events. Therefore, caution should be taken when discontinuing antithrombotics after ulcer bleeding.
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Does Participation in a Randomized Clinical Trial Change Outcomes? An Evaluation of Patients Not Enrolled in the SPRINT Trial. J Orthop Trauma 2016; 30:156-61. [PMID: 27326429 DOI: 10.1097/bot.0000000000000533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the extent to which knowledge from clinical trial protocols is transferred to nonparticipating patients. DESIGN Retrospective review of prospectively collected data from a large clinical trial. SETTING Six level-1 international trauma centers. METHODS We compared rates and timing of reoperation in a subset of patients enrolled in the Study to Prospectively evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) to concurrent patients who were eligible but not enrolled. This was a retrospective review of prospectively collected trial data. The records of 6 of the original SPRINT centers were searched for non-SPRINT patients who underwent intramedullary nailing of a closed tibial fracture. The rate and timing of reoperation were compared. A P < 0.05 was considered significant. RESULTS One hundred fourteen non-SPRINT patients were compared with 328 patients enrolled in SPRINT from those same sites. There were 7 reoperations (6.1%) in non-SPRINT patients versus 18 (5.2%) in SPRINT patients [odds ratio (OR) 1.19, 95% confidence interval (CI) 0.41 to 3.13; P = 0.811]. There was no difference in the time to reoperation between the SPRINT and non-SPRINT patients (6.2 vs. 6.8 months, 95% CI of the difference -3.8 to 2.6; P = 0.685) or in the proportion of patients who underwent reoperation before 6 months (29% vs. 43%; OR 1.75; 95% CI 0.18 to 15.41; P = 0.647). CONCLUSIONS Patients not enrolled in SPRINT had similarly low rates of reoperation for nonunion, and the average time to reoperation for both groups was longer than 6 months. A 6-month waiting period may have allowed slow-to-heal fractures adequate time to heal, thereby reducing the rate of diagnosis of nonunion. As such, this waiting period could contribute to lower-than-expected reoperation rates for nonunion. It is possible that clinical trials may beneficially influence the care of nonenrolled patients.
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Lantos JD, Wendler D, Septimus E, Wahba S, Madigan R, Bliss G. Considerations in the evaluation and determination of minimal risk in pragmatic clinical trials. Clin Trials 2015; 12:485-93. [PMID: 26374686 DOI: 10.1177/1740774515597687] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Institutional review boards, which are charged with overseeing research, must classify the riskiness of proposed research according to a federal regulation known as the Common Rule (45 CFR 46, Subpart A) and by regulations governing the US Food and Drug Administration codified in 21 CFR 50. If an institutional review board determines that a clinical trial constitutes "minimal risk," there are important practical implications: the institutional review board may then allow a waiver or alteration of the informed consent process; the study may be carried out in certain vulnerable populations; or the study may be reviewed by institutional review boards using an expedited process. However, it is unclear how institutional review boards should assess the risk levels of pragmatic clinical trials. Such trials typically compare existing, widely used medical therapies or interventions in the setting of routine clinical practice. Some of the therapies may be considered risky of themselves but the study comparing them may or may not add to that pre-existing level of risk. In this article, we examine the common interpretations of research regulations regarding minimal-risk classifications and suggest that they are marked by a high degree of variability and confusion, which in turn may ultimately harm patients by delaying or hindering potentially beneficial research. We advocate for a clear differentiation between the risks associated with a given therapy and the incremental risk incurred during research evaluating those therapies as a basic principle for evaluating the risk of a pragmatic clinical trial. We then examine two pragmatic clinical trials and consider how various factors including clinical equipoise, practice variation, research methods such as cluster randomization, and patients' perspectives may contribute to current and evolving concepts of minimal-risk determinations, and how this understanding in turn affects the design and conduct of pragmatic clinical trials.
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Affiliation(s)
- John D Lantos
- Children's Mercy Bioethics Center, Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, MO, USA
| | - David Wendler
- National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Edward Septimus
- Department of Internal Medicine, Texas A&M Health Science Center, Houston, TX, USA Clinical Services Group, Hospital Corporation of America, Nashville, TN, USA
| | - Sarita Wahba
- Patient-Centered Outcomes Research Institute, Washington, DC, USA
| | - Rosemary Madigan
- Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Geraldine Bliss
- Research Support Committee, Phelan-McDermid Syndrome Foundation, Venice, FL, USA
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Thabane L, Kaczorowski J, Dolovich L, Chambers LW, Mbuagbaw L. Reducing the confusion and controversies around pragmatic trials: using the Cardiovascular Health Awareness Program (CHAP) trial as an illustrative example. Trials 2015; 16:387. [PMID: 26329614 PMCID: PMC4557925 DOI: 10.1186/s13063-015-0919-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 08/20/2015] [Indexed: 01/19/2023] Open
Abstract
Abstract Knowledge translation (KT) involves implementation of evidence-based strategies and guidelines into practice to improve the process of care and health outcomes for patients. Findings from pragmatic trials may be used in KT to provide patients, healthcare providers and policymakers with information to optimize healthcare decisions based on how a given strategy or intervention performs under the real world conditions. However, pragmatic trials have been criticized for having the following problems: i) high rates of loss to follow-up; ii) nonadherence to study intervention; iii) unblinded treatment and patient self-assessment, which can potentially create bias; iv) being less perfect experiments than efficacy trials; v) sacrificing internal validity to achieve generalizability; and vi) often requiring large sample sizes to detect small treatment effects in heterogeneous populations. In this paper, we discuss whether these criticisms hold merit, or if they are simply driven by confusion about the purpose of pragmatic trials. We use the Cardiovascular Health Awareness Program (CHAP) trial - a community randomized pragmatic trial designed to assess whether offering a highly organized, community-based CHAP intervention compared to usual care can reduce cardiovascular disease-related outcomes - to address these specific criticisms and illustrate how to reduce this confusion. Trial registration Current controlled trials ISRCTN50550004 (9 May 2007).
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Affiliation(s)
- Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. .,Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada. .,Departments of Paediatrics and Anaesthesia, McMaster University, Hamilton, ON, Canada. .,Centre for Evaluation of Medicine, St Joseph's Healthcare, Hamilton, ON, Canada. .,Department of Family Medicine, McMaster University, McMaster Innovation Park, Hamilton, ON, Canada. .,Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada.
| | - Janusz Kaczorowski
- Department of Family Medicine, McMaster University, McMaster Innovation Park, Hamilton, ON, Canada. .,Department of Family and Emergency Medicine, Université de Montréal, Montreal, QC, Canada. .,University of Montreal Hospital Research Centre (CRCHUM), Montreal, QC, Canada.
| | - Lisa Dolovich
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. .,Centre for Evaluation of Medicine, St Joseph's Healthcare, Hamilton, ON, Canada. .,Department of Family Medicine, McMaster University, McMaster Innovation Park, Hamilton, ON, Canada.
| | - Larry W Chambers
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
| | - Lawrence Mbuagbaw
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. .,Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada. .,Centre for the Development of Best Practices in Health, Yaoundé Central Hospital, Yaoundé, Cameroon.
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Kalkman S, van Thiel GJMW, Grobbee DE, van Delden JJM. Pragmatic randomized trials in drug development pose new ethical questions: a systematic review. Drug Discov Today 2015; 20:856-62. [PMID: 25794600 DOI: 10.1016/j.drudis.2015.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 03/02/2015] [Accepted: 03/11/2015] [Indexed: 11/19/2022]
Abstract
Implementation of pragmatic design elements in drug development could bridge the evidence gap that currently exists between the knowledge we have regarding the efficacy of a drug versus its true, comparative effectiveness in real life. We performed a review of the literature to identify the ethical challenges thus far related to pragmatic trials. The three central ethical questions identified for pragmatic trials are: (i) what level of oversight should pragmatic trials require; (ii) do randomized patients face additional risks; and (iii) is a waiver of informed consent ethically defensible? Despite the fact all reviewed publications dealt with post-launch pragmatic trials, these results could serve as an important starting point for conceptualizing which challenges could potentially arise in the pre-launch setting.
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Affiliation(s)
- Shona Kalkman
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands.
| | - Ghislaine J M W van Thiel
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Diederick E Grobbee
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Johannes J M van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Enright K, Grunfeld E, Yun L, Moineddin R, Ghannam M, Dent S, Eisen A, Trudeau M, Kaizer L, Earle C, Krzyzanowska MK. Population-Based Assessment of Emergency Room Visits and Hospitalizations Among Women Receiving Adjuvant Chemotherapy for Early Breast Cancer. J Oncol Pract 2015; 11:126-32. [DOI: 10.1200/jop.2014.001073] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The authors conclude that emergency room visits and hospitalization are common among patients with early breast cancer receiving chemotherapy and significantly higher than among controls.
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Affiliation(s)
- Katherine Enright
- Trillium Health Partners–Credit Valley Hospital, Mississauga; Institute for Clinical Evaluative Sciences; Sunnybrook Odette Cancer Centre; Cancer Care Ontario; Princess Margaret Cancer Centre; University of Toronto; Ontario Institute for Cancer Research, Toronto; and Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - Eva Grunfeld
- Trillium Health Partners–Credit Valley Hospital, Mississauga; Institute for Clinical Evaluative Sciences; Sunnybrook Odette Cancer Centre; Cancer Care Ontario; Princess Margaret Cancer Centre; University of Toronto; Ontario Institute for Cancer Research, Toronto; and Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - Lingsong Yun
- Trillium Health Partners–Credit Valley Hospital, Mississauga; Institute for Clinical Evaluative Sciences; Sunnybrook Odette Cancer Centre; Cancer Care Ontario; Princess Margaret Cancer Centre; University of Toronto; Ontario Institute for Cancer Research, Toronto; and Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - Rahim Moineddin
- Trillium Health Partners–Credit Valley Hospital, Mississauga; Institute for Clinical Evaluative Sciences; Sunnybrook Odette Cancer Centre; Cancer Care Ontario; Princess Margaret Cancer Centre; University of Toronto; Ontario Institute for Cancer Research, Toronto; and Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - Mohammad Ghannam
- Trillium Health Partners–Credit Valley Hospital, Mississauga; Institute for Clinical Evaluative Sciences; Sunnybrook Odette Cancer Centre; Cancer Care Ontario; Princess Margaret Cancer Centre; University of Toronto; Ontario Institute for Cancer Research, Toronto; and Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - Susan Dent
- Trillium Health Partners–Credit Valley Hospital, Mississauga; Institute for Clinical Evaluative Sciences; Sunnybrook Odette Cancer Centre; Cancer Care Ontario; Princess Margaret Cancer Centre; University of Toronto; Ontario Institute for Cancer Research, Toronto; and Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - Andrea Eisen
- Trillium Health Partners–Credit Valley Hospital, Mississauga; Institute for Clinical Evaluative Sciences; Sunnybrook Odette Cancer Centre; Cancer Care Ontario; Princess Margaret Cancer Centre; University of Toronto; Ontario Institute for Cancer Research, Toronto; and Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - Maureen Trudeau
- Trillium Health Partners–Credit Valley Hospital, Mississauga; Institute for Clinical Evaluative Sciences; Sunnybrook Odette Cancer Centre; Cancer Care Ontario; Princess Margaret Cancer Centre; University of Toronto; Ontario Institute for Cancer Research, Toronto; and Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - Leonard Kaizer
- Trillium Health Partners–Credit Valley Hospital, Mississauga; Institute for Clinical Evaluative Sciences; Sunnybrook Odette Cancer Centre; Cancer Care Ontario; Princess Margaret Cancer Centre; University of Toronto; Ontario Institute for Cancer Research, Toronto; and Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - Craig Earle
- Trillium Health Partners–Credit Valley Hospital, Mississauga; Institute for Clinical Evaluative Sciences; Sunnybrook Odette Cancer Centre; Cancer Care Ontario; Princess Margaret Cancer Centre; University of Toronto; Ontario Institute for Cancer Research, Toronto; and Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
| | - Monika K. Krzyzanowska
- Trillium Health Partners–Credit Valley Hospital, Mississauga; Institute for Clinical Evaluative Sciences; Sunnybrook Odette Cancer Centre; Cancer Care Ontario; Princess Margaret Cancer Centre; University of Toronto; Ontario Institute for Cancer Research, Toronto; and Ottawa Hospital Cancer Centre, Ottawa, Ontario, Canada
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Lamont EB, Schilsky RL, He Y, Muss H, Cohen HJ, Hurria A, Meilleur A, Kindler HL, Venook A, Lilenbaum R, Niell H, Goldberg RM, Joffe S. Generalizability of trial results to elderly Medicare patients with advanced solid tumors (Alliance 70802). J Natl Cancer Inst 2015; 107:336. [PMID: 25432408 PMCID: PMC4271075 DOI: 10.1093/jnci/dju336] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 07/17/2014] [Accepted: 09/18/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In the United States, patients who enroll in chemotherapy trials seldom reflect the attributes of the general population with cancer, as they are often younger, more functional, and have less comorbidity. We compared survival following three chemotherapy regimens according to the setting in which care was delivered (ie, clinical trial vs usual care) to determine the generalizability of clinical trial results to unselected elderly Medicare patients. METHODS Using SEER-Medicare data, we estimated survival for elderly patients (ie, age 65 years or older, n = 14097) with advanced pancreatic or lung cancer following receipt of one of three guideline-recommended first-line chemotherapy regimens. We compared their survival to that of similarly treated clinical trial enrollees, without age restrictions, with the same diagnosis and stage (n = 937). All statistical tests were two-sided. RESULTS Trial patients were 9.5 years younger than elderly Medicare patients. Medicare patients were more often white and tended to live in areas of greater educational attainment than trial enrollees. For each tumor type, Medicare patients who were 75 years or older had median survivals that were six to eight weeks shorter than those of trial patients (4.3 vs 5.8 months following treatment with single agent gemcitabine for advanced pancreatic cancer, P = .03; 7.3 vs 8.9 months following treatment with carboplatin and paclitaxel for stage IV non-small cell lung cancer, P = .91; 8.2 vs 10.2 months following treatment with CDDP/ VP16 for extensive stage small cell lung cancer, P ≤ .01), whereas younger Medicare patients had survival times that were similar to those of trial patients. CONCLUSIONS Results of clinical trials for advanced pancreatic cancer and lung cancers tended to correctly estimate survival for Medicare patients aged 65 to 74 years, but to overestimate survival for older Medicare patients by six to eight weeks. These estimates of Medicare patients' survival may aid subsequent patients and their oncologists in treatment decision-making.
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Affiliation(s)
- Elizabeth B Lamont
- Massachusetts General Hospital Cancer Center, Boston, MA (EL); Departments of Medicine, and Health Care Policy, Harvard Medical School, Boston, MA (EL, YH, AM); American Society of Clinical Oncology, Alexandria, VA (RLS); Department of Medicine, University of North Carolina, Chapel Hill, NC (HM); Department of Medicine, Duke University, Durham, NC (HJC); City of Hope, Duarte, CA (AH); Department of Medicine, University of Chicago, Chicago, IL (HLK); Department of Medicine, University of California San Francisco, San Francisco, CA (AV); Yale Cancer Center, New Haven, CT (RL); Department of Medicine, the University of Tennessee, Memphis, TN (HN); Department of Medicine, Ohio State University, Columbus, OH (RMG); Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (SJ).
| | - Richard L Schilsky
- Massachusetts General Hospital Cancer Center, Boston, MA (EL); Departments of Medicine, and Health Care Policy, Harvard Medical School, Boston, MA (EL, YH, AM); American Society of Clinical Oncology, Alexandria, VA (RLS); Department of Medicine, University of North Carolina, Chapel Hill, NC (HM); Department of Medicine, Duke University, Durham, NC (HJC); City of Hope, Duarte, CA (AH); Department of Medicine, University of Chicago, Chicago, IL (HLK); Department of Medicine, University of California San Francisco, San Francisco, CA (AV); Yale Cancer Center, New Haven, CT (RL); Department of Medicine, the University of Tennessee, Memphis, TN (HN); Department of Medicine, Ohio State University, Columbus, OH (RMG); Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (SJ)
| | - Yulei He
- Massachusetts General Hospital Cancer Center, Boston, MA (EL); Departments of Medicine, and Health Care Policy, Harvard Medical School, Boston, MA (EL, YH, AM); American Society of Clinical Oncology, Alexandria, VA (RLS); Department of Medicine, University of North Carolina, Chapel Hill, NC (HM); Department of Medicine, Duke University, Durham, NC (HJC); City of Hope, Duarte, CA (AH); Department of Medicine, University of Chicago, Chicago, IL (HLK); Department of Medicine, University of California San Francisco, San Francisco, CA (AV); Yale Cancer Center, New Haven, CT (RL); Department of Medicine, the University of Tennessee, Memphis, TN (HN); Department of Medicine, Ohio State University, Columbus, OH (RMG); Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (SJ)
| | - Hyman Muss
- Massachusetts General Hospital Cancer Center, Boston, MA (EL); Departments of Medicine, and Health Care Policy, Harvard Medical School, Boston, MA (EL, YH, AM); American Society of Clinical Oncology, Alexandria, VA (RLS); Department of Medicine, University of North Carolina, Chapel Hill, NC (HM); Department of Medicine, Duke University, Durham, NC (HJC); City of Hope, Duarte, CA (AH); Department of Medicine, University of Chicago, Chicago, IL (HLK); Department of Medicine, University of California San Francisco, San Francisco, CA (AV); Yale Cancer Center, New Haven, CT (RL); Department of Medicine, the University of Tennessee, Memphis, TN (HN); Department of Medicine, Ohio State University, Columbus, OH (RMG); Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (SJ)
| | - Harvey Jay Cohen
- Massachusetts General Hospital Cancer Center, Boston, MA (EL); Departments of Medicine, and Health Care Policy, Harvard Medical School, Boston, MA (EL, YH, AM); American Society of Clinical Oncology, Alexandria, VA (RLS); Department of Medicine, University of North Carolina, Chapel Hill, NC (HM); Department of Medicine, Duke University, Durham, NC (HJC); City of Hope, Duarte, CA (AH); Department of Medicine, University of Chicago, Chicago, IL (HLK); Department of Medicine, University of California San Francisco, San Francisco, CA (AV); Yale Cancer Center, New Haven, CT (RL); Department of Medicine, the University of Tennessee, Memphis, TN (HN); Department of Medicine, Ohio State University, Columbus, OH (RMG); Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (SJ)
| | - Arti Hurria
- Massachusetts General Hospital Cancer Center, Boston, MA (EL); Departments of Medicine, and Health Care Policy, Harvard Medical School, Boston, MA (EL, YH, AM); American Society of Clinical Oncology, Alexandria, VA (RLS); Department of Medicine, University of North Carolina, Chapel Hill, NC (HM); Department of Medicine, Duke University, Durham, NC (HJC); City of Hope, Duarte, CA (AH); Department of Medicine, University of Chicago, Chicago, IL (HLK); Department of Medicine, University of California San Francisco, San Francisco, CA (AV); Yale Cancer Center, New Haven, CT (RL); Department of Medicine, the University of Tennessee, Memphis, TN (HN); Department of Medicine, Ohio State University, Columbus, OH (RMG); Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (SJ)
| | - Ashley Meilleur
- Massachusetts General Hospital Cancer Center, Boston, MA (EL); Departments of Medicine, and Health Care Policy, Harvard Medical School, Boston, MA (EL, YH, AM); American Society of Clinical Oncology, Alexandria, VA (RLS); Department of Medicine, University of North Carolina, Chapel Hill, NC (HM); Department of Medicine, Duke University, Durham, NC (HJC); City of Hope, Duarte, CA (AH); Department of Medicine, University of Chicago, Chicago, IL (HLK); Department of Medicine, University of California San Francisco, San Francisco, CA (AV); Yale Cancer Center, New Haven, CT (RL); Department of Medicine, the University of Tennessee, Memphis, TN (HN); Department of Medicine, Ohio State University, Columbus, OH (RMG); Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (SJ)
| | - Hedy L Kindler
- Massachusetts General Hospital Cancer Center, Boston, MA (EL); Departments of Medicine, and Health Care Policy, Harvard Medical School, Boston, MA (EL, YH, AM); American Society of Clinical Oncology, Alexandria, VA (RLS); Department of Medicine, University of North Carolina, Chapel Hill, NC (HM); Department of Medicine, Duke University, Durham, NC (HJC); City of Hope, Duarte, CA (AH); Department of Medicine, University of Chicago, Chicago, IL (HLK); Department of Medicine, University of California San Francisco, San Francisco, CA (AV); Yale Cancer Center, New Haven, CT (RL); Department of Medicine, the University of Tennessee, Memphis, TN (HN); Department of Medicine, Ohio State University, Columbus, OH (RMG); Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (SJ)
| | - Alan Venook
- Massachusetts General Hospital Cancer Center, Boston, MA (EL); Departments of Medicine, and Health Care Policy, Harvard Medical School, Boston, MA (EL, YH, AM); American Society of Clinical Oncology, Alexandria, VA (RLS); Department of Medicine, University of North Carolina, Chapel Hill, NC (HM); Department of Medicine, Duke University, Durham, NC (HJC); City of Hope, Duarte, CA (AH); Department of Medicine, University of Chicago, Chicago, IL (HLK); Department of Medicine, University of California San Francisco, San Francisco, CA (AV); Yale Cancer Center, New Haven, CT (RL); Department of Medicine, the University of Tennessee, Memphis, TN (HN); Department of Medicine, Ohio State University, Columbus, OH (RMG); Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (SJ)
| | - Rogerio Lilenbaum
- Massachusetts General Hospital Cancer Center, Boston, MA (EL); Departments of Medicine, and Health Care Policy, Harvard Medical School, Boston, MA (EL, YH, AM); American Society of Clinical Oncology, Alexandria, VA (RLS); Department of Medicine, University of North Carolina, Chapel Hill, NC (HM); Department of Medicine, Duke University, Durham, NC (HJC); City of Hope, Duarte, CA (AH); Department of Medicine, University of Chicago, Chicago, IL (HLK); Department of Medicine, University of California San Francisco, San Francisco, CA (AV); Yale Cancer Center, New Haven, CT (RL); Department of Medicine, the University of Tennessee, Memphis, TN (HN); Department of Medicine, Ohio State University, Columbus, OH (RMG); Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (SJ)
| | - Harvey Niell
- Massachusetts General Hospital Cancer Center, Boston, MA (EL); Departments of Medicine, and Health Care Policy, Harvard Medical School, Boston, MA (EL, YH, AM); American Society of Clinical Oncology, Alexandria, VA (RLS); Department of Medicine, University of North Carolina, Chapel Hill, NC (HM); Department of Medicine, Duke University, Durham, NC (HJC); City of Hope, Duarte, CA (AH); Department of Medicine, University of Chicago, Chicago, IL (HLK); Department of Medicine, University of California San Francisco, San Francisco, CA (AV); Yale Cancer Center, New Haven, CT (RL); Department of Medicine, the University of Tennessee, Memphis, TN (HN); Department of Medicine, Ohio State University, Columbus, OH (RMG); Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (SJ)
| | - Richard M Goldberg
- Massachusetts General Hospital Cancer Center, Boston, MA (EL); Departments of Medicine, and Health Care Policy, Harvard Medical School, Boston, MA (EL, YH, AM); American Society of Clinical Oncology, Alexandria, VA (RLS); Department of Medicine, University of North Carolina, Chapel Hill, NC (HM); Department of Medicine, Duke University, Durham, NC (HJC); City of Hope, Duarte, CA (AH); Department of Medicine, University of Chicago, Chicago, IL (HLK); Department of Medicine, University of California San Francisco, San Francisco, CA (AV); Yale Cancer Center, New Haven, CT (RL); Department of Medicine, the University of Tennessee, Memphis, TN (HN); Department of Medicine, Ohio State University, Columbus, OH (RMG); Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (SJ)
| | - Steven Joffe
- Massachusetts General Hospital Cancer Center, Boston, MA (EL); Departments of Medicine, and Health Care Policy, Harvard Medical School, Boston, MA (EL, YH, AM); American Society of Clinical Oncology, Alexandria, VA (RLS); Department of Medicine, University of North Carolina, Chapel Hill, NC (HM); Department of Medicine, Duke University, Durham, NC (HJC); City of Hope, Duarte, CA (AH); Department of Medicine, University of Chicago, Chicago, IL (HLK); Department of Medicine, University of California San Francisco, San Francisco, CA (AV); Yale Cancer Center, New Haven, CT (RL); Department of Medicine, the University of Tennessee, Memphis, TN (HN); Department of Medicine, Ohio State University, Columbus, OH (RMG); Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (SJ)
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Wilson MK, Collyar D, Chingos DT, Friedlander M, Ho TW, Karakasis K, Kaye S, Parmar MKB, Sydes MR, Tannock IF, Oza AM. Outcomes and endpoints in cancer trials: bridging the divide. Lancet Oncol 2015; 16:e43-52. [PMID: 25638556 DOI: 10.1016/s1470-2045(14)70380-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cancer is not one disease. Outcomes and endpoints in trials should incorporate the therapeutic modality and cancer type because these factors affect clinician and patient expectations. In this Review, we discuss how to: define the importance of endpoints; make endpoints understandable to patients; improve the use of patient-reported outcomes; advance endpoints to parallel changes in trial design and therapeutic interventions; and integrate these improvements into trials and practice. Endpoints need to reflect benefit to patients, and show that changes in tumour size either in absolute terms (response and progression) or relative to control (progression) are clinically relevant. Improvements in trial design should be accompanied by improvements in available endpoints. Stakeholders need to come together to determine the best approach for research that ensures accountability and optimises the use of available resources.
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Affiliation(s)
- Michelle K Wilson
- University of Toronto Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | | | - Michael Friedlander
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Tony W Ho
- AstraZeneca, Wilmington DE 19850-5437, USA
| | | | - Stan Kaye
- Drug Development Unit and Gynaecology Unit, Royal Marsden Hospital and Institute of Cancer Research, London, UK
| | | | - Matthew R Sydes
- MRC Clinical Trials Unit, University College London, London, UK
| | - Ian F Tannock
- University of Toronto Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Amit M Oza
- University of Toronto Princess Margaret Cancer Centre, Toronto, ON, Canada.
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Karthikesalingam A, Holt PJ. Benefits and pitfalls of national mortality audits. ANZ J Surg 2014; 84:601-2. [PMID: 25159564 DOI: 10.1111/ans.12656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Alan Karthikesalingam
- Department of Outcomes Research, St George's Vascular Institute, St George's Hospital, London, UK
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Physicians declining patient enrollment in a critical care trial: a case study in thromboprophylaxis. Intensive Care Med 2014; 39:2115-25. [PMID: 24022796 DOI: 10.1007/s00134-013-3074-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 08/10/2013] [Indexed: 01/08/2023]
Abstract
PURPOSE To analyze the frequency, rationale and determinants of attending physicians requesting that their eligible patients not be approached for participation in a thromboprophylaxis trial. METHODS Research personnel in 67 centers prospectively documented eligible non-randomized patients due to physicians declining to allow their patients to be approached. RESULTS In 67 centers, 3,764 patients were enrolled, but 1,460 eligible patients had no consent encounter. For 218 (14.9 %) of these, attending physicians requested that their patients not be approached. The most common reasons included a high risk of bleeding (31.2 %) related to fear of heparin bioaccumulation in renal failure, the presence of an epidural catheter, peri-operative status or other factors; specific preferences for thromboprophylaxis (12.4 %); morbid obesity (9.6 %); uncertain prognosis (6.4 %); general discomfort with research (3.7 %) and unclear reasons (17.0 %). Physicians were more likely to decline when approached by less experienced research personnel; considering those with[10 years of experience as the reference category, the odds ratios (OR) for physician refusals to personnel without trial experience was 10.47 [95 % confidence interval (CI) 2.19-50.02] and those with less than 10 years experience was 1.72 (95 % CI 0.61-4.84). Physicians in open rather than closed units were more likely to decline (OR 4.26; 95 % CI 1.27-14.34). Refusals decreased each year of enrollment compared to the pilot phase. CONCLUSIONS Tracking, analyzing, interpreting and reporting the rates and reasons for physicians declining to allow their patients to be approached for enrollment provides insights into clinicians' concerns and attitudes to trials. This information can encourage physician communication and education, and potentially enhance efficient recruitment.
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Is it possible to change phenotype progression in Crohn's disease in the era of immunomodulators? Predictive factors of phenotype progression. Am J Gastroenterol 2014; 109:1026-36. [PMID: 24796767 DOI: 10.1038/ajg.2014.97] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 03/10/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Crohn's disease (CD) induces cumulative structural damage, initially characterized by a non-stenosing non-penetrating behavior (B1) with progression over time to a fibro-stenosing (B2) and/or penetrating phenotype (B3). Our aim was to assess the long-term evolution of disease behavior of CD and determine what factors predict phenotype progression. METHODS This was a study based on prospectively collected data from a CD database in an inflammatory bowel disease outpatient clinic. B1 corresponds to a non-stenosing non-penetrating disease, B2 to a stenosing behavior, and B3 to a penetrating one. RESULTS Seven hundred and thirty-six patients with CD (368 female) were followed up for 12.3 years (± 8.4), with 87.0% of them exhibiting B1 phenotype at diagnosis. Of these patients, 28.5% progressed to B2 phenotype and 23.5% to B3. Fifty percent of the patients started azathioprine treatment before phenotype change and 13.9% started anti-tumor necrosis factor-α (anti-TNFα) treatment before phenotype change. Monotherapy with azathioprine before phenotype change as well as combination therapy with azathioprine/anti-TNFα before phenotype change delayed disease progression (B1-B2 or B3) in comparison with patients who did not receive treatment (P<0.001). The hazard ratio (HR) for disease progression was lower for both monotherapy with azathioprine (HR: 0.15, P<0.001) or combination therapy with anti-TNFα (HR: 0.33, P<0.001). Upper gastrointestinal tract involvement, male gender, and steroid use were associated with an early progression of phenotype from B1 to B2 or B3 (P<0.001). The HR for disease progression was higher in patients who used steroids without criteria of dependence or resistance (HR: 2.67, P<0.001) and was even higher in patients with criteria of dependence or resistance (HR: 6.44, P<0.001). Longer delays between CD diagnosis and beginning of therapy with azathioprine and/or anti-TNFα were associated with disease progression. The longer the duration of treatment, the less likely the disease progression. CONCLUSIONS Monotherapy with azathioprine before behavior change as well as combination therapy with azathioprine and anti-TNFα before behavior change delays phenotype progression of CD, whereas upper gastrointestinal tract involvement, male gender, and steroid use with or without criteria of steroid dependence are associated with a higher risk for disease progression.
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Unger JM, Barlow WE, Martin DP, Ramsey SD, Leblanc M, Etzioni R, Hershman DL. Comparison of survival outcomes among cancer patients treated in and out of clinical trials. J Natl Cancer Inst 2014; 106:dju002. [PMID: 24627276 DOI: 10.1093/jnci/dju002] [Citation(s) in RCA: 174] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Clinical trials test the efficacy of a treatment in a select patient population. We examined whether cancer clinical trial patients were similar to nontrial, "real-world" patients with respect to presenting characteristics and survival. METHODS We reviewed the SWOG national clinical trials consortium database to identify candidate trials. Demographic factors, stage, and overall survival for patients in the standard arms were compared with nontrial control subjects selected from the Surveillance, Epidemiology, and End Results program. Multivariable survival analyses using Cox regression were conducted. The survival functions from aggregate data across all studies were compared separately by prognosis (≥50% vs <50% average 2-year survival). All statistical tests were two-sided. RESULTS We analyzed 21 SWOG studies (11 good prognosis and 10 poor prognosis) comprising 5190 patients enrolled from 1987 to 2007. Trial patients were younger than nontrial patients (P < .001). In multivariable analysis, trial participation was not associated with improved overall survival for all 11 good-prognosis studies but was associated with better survival for nine of 10 poor-prognosis studies (P < .001). The impact of trial participation on overall survival endured for only 1 year. CONCLUSIONS Trial participation was associated with better survival in the first year after diagnosis, likely because of eligibility criteria that excluded higher comorbidity patients from trials. Similar survival patterns between trial and nontrial patients after the first year suggest that trial standard arm outcomes are generalizable over the long term and may improve confidence that trial treatment effects will translate to the real-world setting. Reducing eligibility criteria would improve access to clinical trials.
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Affiliation(s)
- Joseph M Unger
- Affiliations of authors: SWOG Statistical Center, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (JMU, WEB, ML); University of Washington, Department of Health Services Research, Seattle, WA (DPM); Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA (SDR, RE); Division of Hematology/Oncology, Columbia University, New York, NY (DLH)
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Artus M, van der Windt D, Jordan KP, Croft PR. The clinical course of low back pain: a meta-analysis comparing outcomes in randomised clinical trials (RCTs) and observational studies. BMC Musculoskelet Disord 2014; 15:68. [PMID: 24607083 PMCID: PMC4007531 DOI: 10.1186/1471-2474-15-68] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 02/25/2014] [Indexed: 02/07/2024] Open
Abstract
Background Evidence suggests that the course of low back pain (LBP) symptoms in randomised clinical trials (RCTs) follows a pattern of large improvement regardless of the type of treatment. A similar pattern was independently observed in observational studies. However, there is an assumption that the clinical course of symptoms is particularly influenced in RCTs by mere participation in the trials. To test this assumption, the aim of our study was to compare the course of LBP in RCTs and observational studies. Methods Source of studies CENTRAL database for RCTs and MEDLINE, CINAHL, EMBASE and hand search of systematic reviews for cohort studies. Studies include individuals aged 18 or over, and concern non-specific LBP. Trials had to concern primary care treatments. Data were extracted on pain intensity. Meta-regression analysis was used to compare the pooled within-group change in pain in RCTs with that in cohort studies calculated as the standardised mean change (SMC). Results 70 RCTs and 19 cohort studies were included, out of 1134 and 653 identified respectively. LBP symptoms followed a similar course in RCTs and cohort studies: a rapid improvement in the first 6 weeks followed by a smaller further improvement until 52 weeks. There was no statistically significant difference in pooled SMC between RCTs and cohort studies at any time point:- 6 weeks: RCTs: SMC 1.0 (95% CI 0.9 to 1.0) and cohorts 1.2 (0.7to 1.7); 13 weeks: RCTs 1.2 (1.1 to 1.3) and cohorts 1.0 (0.8 to 1.3); 27 weeks: RCTs 1.1 (1.0 to 1.2) and cohorts 1.2 (0.8 to 1.7); 52 weeks: RCTs 0.9 (0.8 to 1.0) and cohorts 1.1 (0.8 to 1.6). Conclusions The clinical course of LBP symptoms followed a pattern that was similar in RCTs and cohort observational studies. In addition to a shared ‘natural history’, enrolment of LBP patients in clinical studies is likely to provoke responses that reflect the nonspecific effects of seeking and receiving care, independent of the study design.
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Affiliation(s)
- Majid Artus
- Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK.
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Magro F, Rodrigues-Pinto E, Santos-Antunes J, Vilas-Boas F, Lopes S, Nunes A, Camila-Dias C, Macedo G. High C-reactive protein in Crohn's disease patients predicts nonresponse to infliximab treatment. J Crohns Colitis 2014; 8:129-36. [PMID: 23932786 DOI: 10.1016/j.crohns.2013.07.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 06/21/2013] [Accepted: 07/13/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Infliximab (IFX) is effective in treating Crohn's disease (CD) and C-reactive protein (CRP) is a useful biomarker in assessing inflammatory activity. AIM Correlate CRP levels before beginning of IFX, at week 14 and CRP delta within the first year of IFX treatment. METHODS Retrospective study of CD patients undergoing treatment with IFX. Primary nonresponse (PNR) was defined as no symptomatic improvement and CRP persistently elevated; sustained response (SR) as symptomatic improvement for at least 1 year without therapeutic adjustment; response after therapeutic adjustment (RTA) as analytic and clinical response but requiring IFX dose/frequency adjustment or association with another drug. RESULTS Baseline CRP levels were higher in PNR compared with SR (26.2mg/L vs 9.6 mg/L, p=0.015) and RTA (26.2mg/L vs 7.6 mg/L, p=0.007). CRP levels greater than 15 mg/L at baseline predict PNR with 67% sensitivity and 65% specificity. Lower CRP levels at week 14 were more likely to predict SR relative to RTA (3.1mg/L vs 7.6 mg/L p=0.019) and PNR (3.1mg/L vs 9.1mg/L; p=0.013). CRP levels greater than 4.6 mg/L at week 14 predict PNR with 67% sensitivity and 62% specificity. A higher CRP delta between beginning of treatment and week 14 is more likely to predict SR relative to RTA (5.2mg/L vs 0.6 mg/L p=0.027). CONCLUSION CRP levels at week 14 were associated with SR in patients treated with IFX, independently of baseline CRP serum levels. High inflammatory burden at beginning of IFX treatment was correlated with a worse response.
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Affiliation(s)
- Fernando Magro
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal; Institute of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Portugal; IBMC - Institute for Molecular and Cell Biology, University of Porto, Porto, Portugal.
| | | | - João Santos-Antunes
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal; Department of Biochemistry, Faculty of Medicine, University of Porto, Portugal
| | - Filipe Vilas-Boas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Susana Lopes
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Amadeu Nunes
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Claudia Camila-Dias
- CIDES - Department of Health Information and Decision Sciences, Faculty of Medicine, University of Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
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Box Bayes J. What are the attitudes of strictly-orthodox Jews to clinical trials: are they influenced by Jewish teachings? JOURNAL OF MEDICAL ETHICS 2013; 39:643-646. [PMID: 23268364 DOI: 10.1136/medethics-2012-100658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
In order to explore whether and how Jewish teachings influence the attitudes of strictly-orthodox Jews to clinical trials, 10 strictly-orthodox Jews were purposively selected and interviewed, using a semi-structured schedule. Relevant literature was searched for similar studies and for publications covering relevant Jewish teachings. Thematic analysis was used to analyse transcribed interviews and explore relationships between attitudes and Jewish teachings identified in the review. Participants' attitudes were influenced in a variety of ways: by Jewish teachings on the over-riding importance of preserving life--the need to avoid risks affecting life and health, while taking risks to preserve life--and the religious obligation to help others, as well as by previous experience. Attitudes mirrored those in the general population, enabling many participants to reach conclusions that did not differ materially from those of the general population or research ethics committees.
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Ezell JM, Saltzgaber J, Peterson E, Joseph CLM. Reconnecting with urban youth enrolled in a randomized controlled trial and overdue for a 12-month follow-up survey. Clin Trials 2013; 10:775-82. [PMID: 23983157 DOI: 10.1177/1740774513498320] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Retention of study participants in randomized controlled trials (RCTs) is crucial to study validity. PURPOSE We analyzed the results of four retention strategies used to reconnect with urban teens enrolled in a school-based RCT and overdue for a 12-month follow-up survey. METHODS Traditional retention strategies used to reconnect with teens categorized as 'unable to contact' were weekly redials of nonworking telephone numbers and mailings to the student's home. Nontraditional retention strategies were obtaining assistance from school administration and performing outreach on Facebook. RESULTS Of the 422 students enrolled, 125 (29.5%) were overdue for a 12-month follow-up survey, but had no working telephone number (unable to contact). We made 196 attempts to contact these 125 students, of which 82 attempts (41.8%) were successful in 'reconnecting' with the student. Using 'mailed reminder letters' as the referent category, odds ratios (95% confidence intervals) for the association between the strategy used and reconnecting were 4.60 (1.8-11.8), 1.94 (1.01-3.73), and 2.91 (0.58-14.50), respectively, for telephone number redials, Facebook outreach, and school administration assistance. Of the 422 students, 380 (90%) ultimately completed the 12-month follow-up survey. LIMITATIONS Retention strategies were not applied hierarchically or systematically. We were unable to determine student preference for a particular strategy. Findings are likely only applicable to similar study populations. CONCLUSION A mix of traditional retention strategies and more contemporary methods was effective in reconnecting with urban teenagers enrolled in a school-based RCT and in controlling attrition during the 12-month follow-up survey period.
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Affiliation(s)
- Jerel M Ezell
- aDepartment of Public Health Sciences, Henry Ford Hospital, Henry Ford Health System, Detroit, MI, USA
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Field KM, Drummond KJ, Yilmaz M, Tacey M, Compston D, Gibbs P, Rosenthal MA. Clinical trial participation and outcome for patients with glioblastoma: multivariate analysis from a comprehensive dataset. J Clin Neurosci 2013; 20:783-9. [PMID: 23639619 DOI: 10.1016/j.jocn.2012.09.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 09/14/2012] [Indexed: 11/28/2022]
Abstract
Glioblastoma multiforme (GBM) is the most common malignant brain tumor in adults. Although multiple clinical and tumor-related variables affect survival outcomes, the effect of clinical trial participation has not been explored. The aim of this study was to determine whether clinical trial participation improves outcome for patients with GBM. Data from patients with GBM were accessed from a dataset collected over 12 years (1998-2010) at two institutions. Univariable and multivariate logistic regression analyses were performed to look for relationships between clinical trial participation, other baseline clinical and sociodemographic variables and overall survival (OS). In total, 542 patients were identified and included in the analysis; median age was 62 years. Sixty-one patients (11%) were enrolled in a clinical trial. Clinical trial enrollment was associated with improved median survival (14.5 months compared to 6.3 months, p < 0.001) and this difference remained significant in multivariate analysis (hazard ratio 0.67, p = 0.046). Age, poor performance status and operation type were also independent predictors for OS in multivariate analysis. Disease site, socioeconomic status and co-morbidity did not affect survival outcome. This is the first study in patients with GBM to suggest a survival benefit from clinical trial participation, independent of age and performance status; while also confirming the importance of other previously reported prognostic factors. This should encourage clinicians to offer trial therapies to patients with GBM and encourage patients to participate in available studies.
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Affiliation(s)
- Kathryn M Field
- Department of Medical Oncology, Royal Melbourne Hospital, Victoria, Australia.
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Kass NE, Faden RR, Goodman SN, Pronovost P, Tunis S, Beauchamp TL. The research-treatment distinction: a problematic approach for determining which activities should have ethical oversight. Hastings Cent Rep 2013; Spec No:S4-S15. [PMID: 23315895 DOI: 10.1002/hast.133] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Menikoff J. The Unbelievable Rightness of Being in Clinical Trials. Hastings Cent Rep 2013; Spec No:S30-1. [DOI: 10.1002/hast.136] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Debate surrounding the SUPPORT study highlights the absence of consensus regarding what information should be disclosed to potential research participants. Some commentators endorse the view that clinical research should be subject to high disclosure standards, even when it is testing standard-of-care interventions. Others argue that trials assessing standard-of-care interventions need to disclose only the information that is disclosed in the clinical care setting. To resolve this debate, it is important to identify the ethical concerns raised by clinical research and determine what consent process is needed to address them.
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Hannouf MB, Brackstone M, Xie B, Zaric GS. Evaluating the efficacy of current clinical practice of adjuvant chemotherapy in postmenopausal women with early-stage, estrogen or progesterone receptor-positive, one-to-three positive axillary lymph node, breast cancer. Curr Oncol 2012; 19:e319-28. [PMID: 23144580 DOI: 10.3747/co.19.1038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE We evaluated the benefit of the current clinical practice of adjuvant chemotherapy for postmenopausal women with early-stage, estrogen- or progesterone-receptor-positive (er/pr+), one-to-three positive axillary lymph node (1-3 ln+), breast cancer (esbc). METHODS Using the Manitoba Cancer Registry, we identified all postmenopausal women diagnosed with er/pr+ 1-3 ln+ esbc during the periods 1995-1997, 2000-2002, and 2003-2005 (n = 156, 161, and 171 respectively). Treatment data were obtained from the Manitoba Cancer Registry and by linkage with Manitoba administrative databases. Seven-year survival data were available for the 1995-1997 and 2000-2002 populations. Using Cox regression, we assessed the independent effect of the clinical practice of adjuvant chemotherapy on disease-free (dfs) and overall survival (os). RESULTS Clinical breast cancer treatments did not differ significantly between the 2000-2002 and 2003-2005 populations. Adjuvant chemotherapy was administered in 103 patients in the 2000-2002 population (64%) and in 44 patients in the 1995-1997 population [28.2%; mean difference: 36%; 95% confidence interval (ci): 31% to 40%; p < 0.0001]. Compared with 1995-1997, 2000-2002 was not significantly associated with an incremental dfs benefit for patients over a period of 7 years (2000-2002 vs. 1995-1997; adjusted hazard ratio: 0.98; 95% ci: 0.64 to 1.4). CONCLUSIONS The treatment standard of adjuvant chemotherapy in addition to endocrine therapy may not be effective for all women with er/pr+ 1-3 ln+ esbc. There could be a subgroup of those women who do not benefit from adjuvant chemotherapy as expected and who are therefore being overtreated. Further studies with a larger sample size are warranted to confirm our results.
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Affiliation(s)
- M B Hannouf
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON
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Sostres C, Gargallo CJ. Gastrointestinal lesions and complications of low-dose aspirin in the gastrointestinal tract. Best Pract Res Clin Gastroenterol 2012; 26:141-51. [PMID: 22542152 DOI: 10.1016/j.bpg.2012.01.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 01/20/2012] [Accepted: 01/24/2012] [Indexed: 01/31/2023]
Abstract
Low dose aspirin (ASA) use has been associated with a wide range of adverse side effects in the upper gastrointestinal (GI) tract, which range from troublesome symptoms without mucosal lesions to more serious toxicity, including ulcers, GI bleeding, perforation and even death. Upper GI symptoms in low dose ASA users are common but often careless or misinterpreted and they are not always related to the presence of mucosal injury. Usually, low dose ASA related ulcers are reasonably small and asymptomatic, and probably heal over a period of weeks to a few months. But, the real clinical problem occurs when the ulcer results in a GI complication (mostly bleeding). The estimated average excess risk of symptomatic or complicated ulcer related to low dose ASA is five cases per 1000 ASA users per year. Death is the worst outcome of GI complications in low dose ASA users, but data about this aspect are scarce. Current evidence indicates that low dose ASA can damage the lower GI tract also, but the real size of the problem is still unknown.
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Affiliation(s)
- Carlos Sostres
- Service of Digestive Diseases, University Hospital Lozano Blesa, Zaragoza, Spain.
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Engström C, Jamieson GG, Devitt PG, Irvine T, Watson DI. Impact of participation in randomized trials on outcome following surgery for gastro-oesophageal reflux. Br J Surg 2012; 99:381-6. [PMID: 22231692 DOI: 10.1002/bjs.8666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2011] [Indexed: 01/24/2023]
Abstract
BACKGROUND Patients may be unwilling to participate in clinical trials if they perceive risks. Outcomes were evaluated following surgery for gastro-oesophageal reflux in patients recruited to randomized trials compared with patients not in trials. METHODS This study compared outcomes of patients who had surgery for reflux within or outside randomized trials between 1994 and 2009. The choice of procedure outside each trial was according to surgeon or patient preference. Clinical outcomes were determined 1 and 5 years after surgery using a standardized questionnaire, with analogue scales to assess heartburn, dysphagia and overall satisfaction. Subgroup analysis was undertaken for those aged less than 75 years undergoing laparoscopic Nissen fundoplication. RESULTS Some 417 patients entered six randomized trials evaluating surgery for reflux and 981 underwent surgery outside the trials. The trial group contained a higher proportion of men and younger patients, and patients in trials were more likely to have undergone Nissen fundoplication. At 1 year, patients in the trials had slightly lower heartburn scores and less abdominal bloating, but otherwise similar outcomes to those not in the trials. At 5 years there were no differences, except for a slightly higher dysphagia score for liquids in the trial group. For the subgroup analysis, demographic data were similar for both groups. There were no differences at 1 year, but at 5 years patients enrolled in the trials had higher scores for dysphagia for liquids and heartburn. All of the statistically significant differences were thought unlikely to be clinically relevant. CONCLUSION Participation in a randomized trial assessing surgery for reflux did not influence outcomes.
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Affiliation(s)
- C Engström
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
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