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Levit LA, Garrett-Mayer E, Peppercorn J, Ratain MJ. Critical importance of correctly defining and reporting secondary endpoints when assessing the ethics of research biopsies. Clin Trials 2024:17407745241244753. [PMID: 38654414 DOI: 10.1177/17407745241244753] [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: 04/26/2024]
Abstract
This article reviews the implementation challenges to the American Society of Clinical Oncology's ethical framework for including research biopsies in oncology clinical trials. The primary challenges to implementation relate to the definitions of secondary endpoints, the scientific and regulatory framework, and the incentive structure that encourages inclusion of biopsies. Principles of research stewardship require that the clinical trials community correctly articulate the scientific goals of any research biopsies, especially those that are required for the patient to enroll on a trial and receive an investigational agent. Furthermore, it is important to sufficiently justify the characterization of secondary (as distinguished from exploratory) endpoints, protect the interest of research participants, and report accurate and complete information to ClinicalTrials.gov and the published literature.
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Affiliation(s)
- Laura A Levit
- Center for Research and Analytics, American Society of Clinical Oncology, Alexandria, VA, USA
| | - Elizabeth Garrett-Mayer
- Center for Research and Analytics, American Society of Clinical Oncology, Alexandria, VA, USA
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2
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Isaacson S, Kuczynski K, Ormsby N, Peay HL, Rennie S, Cadigan RJ, Kroon E, Phanuphak N, Ananworanich J, Jupimai T, Prueksakaew P, Henderson GE. Decision making for invasive and non-invasive optional procedures within an acute HIV research cohort in Bangkok. Contemp Clin Trials Commun 2023; 31:101054. [PMID: 36636463 PMCID: PMC9829688 DOI: 10.1016/j.conctc.2022.101054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/16/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
Clinical research regularly includes required, nontherapeutic procedures to answer research questions. Optional procedures usually offer minimal or no personal benefit and may involve harms and burdens. Members from the Bangkok SEARCH010/RV254 HIV research cohort of individuals acutely HIV-infected are recruited to six optional procedures varying in invasiveness: leukapheresis, genital secretions collection, lumbar puncture, brain MRI/MRS/DTI, colon biopsy, and lymph node biopsy. We surveyed cohort members about their first recruitment for each procedure to examine factors associated with decision making and attitudes about compensation. 406 members (68%) completed the survey. Reported procedure participation ranged from 71% (MRI) to 27% (lymph node biopsy). Respondents underwent 0-6 procedure types (median 3). Ordinal regression indicated that lower perceived HIV impact and HIV remission trial participation were associated with more procedures completed. Reports of decision difficulty varied, and feeling pressured by research staff was low overall. Notably, those who declined procedures and those who underwent more invasive procedures reported greater decision difficulty and perceived pressure. Most respondents felt compensation amounts were appropriate, although opinions differed by procedure, and for some procedures, between people who agreed and declined. There is limited literature regarding consent to and attitudes about optional research procedures. Researchers must consider how to best support voluntary decisions for procedures with little personal benefit, particularly in lower-income or marginalized populations. In this longitudinal research cohort, perceived pressure to participate may be a concern, although our finding of variation in participation rates corresponding to invasiveness is reassuring. Data from different research contexts would provide important comparators.
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Affiliation(s)
- Sinéad Isaacson
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kristine Kuczynski
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nuchanart Ormsby
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Holly L. Peay
- RTI International, Research Triangle Park, Durham, NC, USA
| | - Stuart Rennie
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - R. Jean Cadigan
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eugène Kroon
- SEARCH, Institute of HIV Research and Innovation, Bangkok, Thailand
| | | | - Jintanat Ananworanich
- Department of Global Health, Amsterdam University Medical Centers, University of Amsterdam, And Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | - Thidarat Jupimai
- Center of Excellence in Pediatric Infectious Diseases and Vaccines Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Gail E. Henderson
- Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Corresponding author.
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3
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Navani N, Butler R, Ibrahimo S, Verma A, Evans M, Doherty GJ, Ahmed S. Optimising tissue acquisition and the molecular testing pathway for patients with non-small cell lung cancer: A UK expert consensus statement. Lung Cancer 2022; 172:142-153. [PMID: 36099709 DOI: 10.1016/j.lungcan.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/01/2022] [Accepted: 08/05/2022] [Indexed: 11/21/2022]
Abstract
Targeted therapy against actionable variants has revolutionised the treatment landscape for non-small cell lung cancer (NSCLC). Approximately half of NSCLC adenocarcinomas have an actionable variant, making molecular testing a critical component of the diagnostic process to personalise therapeutic options, optimise clinical outcomes and minimise toxicity. Recently, genomic testing in England has undergone major changes with the introduction of Genomic Laboratory Hubs, designed to consolidate and enhance existing laboratory provision and deliver genomic testing as outlined in the National Genomic Test Directory. Similar changes are ongoing in Scotland, Wales and Northern Ireland. However, multiple challenges exist with current tissue acquisition procedures and the molecular testing pathway in the UK, including quantity and quality of available tissue, adequacy rates, test availability among genomic laboratories, turnaround times, multidisciplinary team communication, and limited guidance and standardisation. The COVID-19 pandemic has added an extra layer of complexity. Herein, we summarise best practice recommendations, based on expert opinion, to overcome existing challenges in the UK. The least invasive biopsy technique should be undertaken with the aim of acquiring the greatest quality and quantity of tissue. Use of sedation should be considered to improve patient experience. Rapid on-site evaluation may also be useful to help guide adequate sampling, and liquid biopsy may be beneficial in some instances. Sample processing should be appropriate to facilitate biomarker testing, in particular, next-generation sequencing for comprehensive genomic information. Steps to optimise tissue utilisation and turnaround times, such as planning of tissue usage, limiting immunohistochemistry, tumour enrichment, and reflex testing at diagnosis, should be implemented. Guidelines for tissue acquisition and sample processing may help to improve sample adequacy to perform downstream testing. Communication among genomic laboratories will help to standardise test availability across England and local auditing could identify further areas for optimisation, including ways to improve turnaround times and adequacy rates.
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Affiliation(s)
- Neal Navani
- Lungs for Living Research Centre, UCL Respiratory, University College London, London, United Kingdom; University College London Hospitals NHS Foundation Trust, London, United Kingdom.
| | - Rachel Butler
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital, London, United Kingdom
| | | | | | - Matthew Evans
- Black Country Pathology Services, West Midlands, United Kingdom
| | - Gary J Doherty
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Samreen Ahmed
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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4
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Bittlinger M, Bicer S, Peppercorn J, Kimmelman J. Ethical Considerations for Phase I Trials in Oncology. J Clin Oncol 2022; 40:3474-3488. [PMID: 35275736 DOI: 10.1200/jco.21.02125] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Phase I trials often represent the first occasion where new cancer strategies are tested in patients. Various developments in cancer biology, methodology, regulation, and medical ethics have altered the ethical landscape of such trials. We provide a narrative review of contemporary ethical challenges in design, conduct, and reporting of phase I cancer trials and outline recommendations for addressing each. We organized our review around four topics, supplementing the first three with scoping reviews: (1) benefit/risk, (2) research biopsies, (3) therapeutic misconception and misestimation, and (4) reporting. The main ethical challenges of conducting phase I trials stem from three issues. First, phase I trials often involve higher research burden and scientific uncertainty compared with other cancer trials. Second, many patients arrive at phase I trials at a transitional point in their illness trajectory where they have exhausted standard survival-extending options. Third, phase I trial results play a major role in informing downstream drug development and regulatory decisions. Together, these issues create distinct pressures for study design, ethical review, informed consent, and reporting. Developments in methodology, regulation, cancer biology, and ethical awareness have helped mitigate some of these challenges, while introducing others. We conclude our review with a series of recommendations regarding trial design, ethical review, consent, and reporting. We also outline several unresolved questions that, if addressed, would strengthen the ethical foundation of phase I cancer trials.
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Affiliation(s)
- Merlin Bittlinger
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
| | - Selin Bicer
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
| | | | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
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5
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Percutaneous Core Needle Biopsy: Considerations in the Pediatric Patient. Tech Vasc Interv Radiol 2021; 24:100779. [PMID: 34895707 DOI: 10.1016/j.tvir.2021.100779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Image-guided percutaneous biopsy is the cornerstone of solid tissue diagnosis. The ability to safely sample tissue in locations that previously required surgery or necessitated empiric therapy has allowed for more personalized treatment options, as well as more rapid development of novel therapeutics. In children, these same advantages are accompanied by a smaller margin for error and rapidly expanding indications. The intent of this review is to outline the role of image-guided biopsy in the management of childhood disease, how this role is changing, and the practical aspects of managing and performing pediatric biopsies.
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Olympios N, Collet L, Paesmans M, Jungels C, Kotecki N, Awada A, Aftimos P. Analyses of the Rationale and Implementation of Research Biopsies in Oncology Clinical Trials at a Tertiary Cancer Center. Oncologist 2021; 26:1062-1070. [PMID: 34286890 PMCID: PMC8649004 DOI: 10.1002/onco.13906] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/09/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Biomarkers in clinical trials have led to massive incorporation of research biopsies, with potentially risks and no direct benefit for patients. In 2018, the American Society of Clinical Oncology (ASCO) released an ethical framework to provide guidance on incorporating research biopsies in cancer clinical trials. MATERIALS AND METHODS We collected biopsy requirements of cancer clinical trials conducted at Institut Jules Bordet (IJB) between 2015 and 2019 to examine adherence with the ASCO Ethical Framework. We used logistic regression models to test the association between the request for biopsy, the request for tissue, and the adherence to the ASCO framework as well as some trial characteristics. RESULTS Between January 2015 and December 2019, 178 oncological studies were conducted at IJB. Of these, 138 (78%) were sponsored by industry, 132 (74%) were phase II and III studies, and 141 (79%) concerned metastatic disease. Tissue was required for inclusion for 119 (67%) studies, among which 59 required at least one new biopsy. Adherence to ASCO's Ethical Framework was 67% for studies requiring tissue and went down to 39% for studies requiring at least one new biopsy. In multivariate analysis, requests for tissue or new biopsies increased in early-phase studies (p < .001, p < .001, respectively) and in studies investigating innovative treatments (immunotherapy or targeted therapies; p < .01, p = .02). Compliance to the ASCO framework significantly decreased with time (p < .001) and in early-phase studies (p < .001). CONCLUSION Numerous studies required tissue or new biopsies for exploratory objectives of unknown clinical utility. Requests for tissue increased over the years, whereas compliance to ASCO's Ethical Framework decreased. IMPLICATIONS FOR PRACTICE In 2019, the American Society of Clinical Oncology (ASCO) developed an ethical framework to provide guidance on incorporating research biopsies in clinical trials. This study underlines the growing request for tissue in clinical trials with potentially no impact on drug development and no benefit to actual or future patients. Adherence to ASCO's Ethical Framework decreases through time. These results highlight the importance of improving the ethics of research biopsies. ASCO's Ethical Framework offers an opportunity to improve quality of care in clinical research by maximizing scientific utility and allowing for clinically meaningful correlative science and safe access to innovative treatments for a maximum number of patients.
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Affiliation(s)
- Nathalie Olympios
- Medical Oncology Clinic, Institut Jules Bordet, Université Libre de BruxellesBrusselsBelgium
| | - Laetitia Collet
- Medical Oncology Clinic, Institut Jules Bordet, Université Libre de BruxellesBrusselsBelgium
| | - Marianne Paesmans
- Data Centre, Institut Jules Bordet, Université Libre de BruxellesBrusselsBelgium
| | - Christiane Jungels
- Medical Oncology Clinic, Institut Jules Bordet, Université Libre de BruxellesBrusselsBelgium
- Clinical Trials Conduct Unit (CTCU), Institut Jules Bordet, Université Libre de BruxellesBrusselsBelgium
| | - Nuria Kotecki
- Medical Oncology Clinic, Institut Jules Bordet, Université Libre de BruxellesBrusselsBelgium
- Clinical Trials Conduct Unit (CTCU), Institut Jules Bordet, Université Libre de BruxellesBrusselsBelgium
| | - Ahmad Awada
- Medical Oncology Clinic, Institut Jules Bordet, Université Libre de BruxellesBrusselsBelgium
| | - Philippe Aftimos
- Medical Oncology Clinic, Institut Jules Bordet, Université Libre de BruxellesBrusselsBelgium
- Clinical Trials Conduct Unit (CTCU), Institut Jules Bordet, Université Libre de BruxellesBrusselsBelgium
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7
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Weinfurtner K, Cho J, Ackerman D, Chen JX, Woodard A, Li W, Ostrowski D, Soulen MC, Dagli M, Shamimi-Noori S, Mondschein J, Sudheendra D, Stavropoulos SW, Reddy S, Redmond J, Khaddash T, Jhala D, Siegelman ES, Furth EE, Hunt SJ, Nadolski GJ, Kaplan DE, Gade TPF. Variability in biopsy quality informs translational research applications in hepatocellular carcinoma. Sci Rep 2021; 11:22763. [PMID: 34815453 PMCID: PMC8611010 DOI: 10.1038/s41598-021-02093-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/18/2021] [Indexed: 12/19/2022] Open
Abstract
In the era of precision medicine, biopsies are playing an increasingly central role in cancer research and treatment paradigms; however, patient outcomes and analyses of biopsy quality, as well as impact on downstream clinical and research applications, remain underreported. Herein, we report biopsy safety and quality outcomes for percutaneous core biopsies of hepatocellular carcinoma (HCC) performed as part of a prospective clinical trial. Patients with a clinical diagnosis of HCC were enrolled in a prospective cohort study for the genetic, proteomic, and metabolomic profiling of HCC at two academic medical centers from April 2016 to July 2020. Under image guidance, 18G core biopsies were obtained using coaxial technique at the time of locoregional therapy. The primary outcome was biopsy quality, defined as tumor fraction in the core biopsy. 56 HCC lesions from 50 patients underwent 60 biopsy events with a median of 8 core biopsies per procedure (interquartile range, IQR, 7–10). Malignancy was identified in 45/56 (80.4%, 4 without pathology) biopsy events, including HCC (40/56, 71.4%) and cholangiocarcinoma (CCA) or combined HCC-CCA (5/56, 8.9%). Biopsy quality was highly variable with a median of 40% tumor in each biopsy core (IQR 10–75). Only 43/56 (76.8%) and 23/56 (41.1%) samples met quality thresholds for genomic or metabolomic/proteomic profiling, respectively, requiring expansion of the clinical trial. Overall and major complication rates were 5/60 (8.3%) and 3/60 (5.0%), respectively. Despite uniform biopsy protocol, biopsy quality varied widely with up to 59% of samples to be inadequate for intended purpose. This finding has important consequences for clinical trial design and highlights the need for quality control prior to applications in which the presence of benign cell types may substantially alter findings.
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Affiliation(s)
- Kelley Weinfurtner
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA.,Penn Image-Guided Interventions Laboratory, University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua Cho
- Penn Image-Guided Interventions Laboratory, University of Pennsylvania, Philadelphia, PA, USA.,Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Ackerman
- Penn Image-Guided Interventions Laboratory, University of Pennsylvania, Philadelphia, PA, USA.,Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - James X Chen
- Vascular & Interventional Specialists of Charlotte Radiology, Charlotte, NC, USA
| | - Abashai Woodard
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Wuyan Li
- Penn Image-Guided Interventions Laboratory, University of Pennsylvania, Philadelphia, PA, USA.,Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - David Ostrowski
- Penn Image-Guided Interventions Laboratory, University of Pennsylvania, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael C Soulen
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Mandeep Dagli
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Susan Shamimi-Noori
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey Mondschein
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Deepak Sudheendra
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Shilpa Reddy
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J Cresenz VA Medical Center, Philadelphia, PA, USA
| | - Jonas Redmond
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J Cresenz VA Medical Center, Philadelphia, PA, USA
| | - Tamim Khaddash
- Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J Cresenz VA Medical Center, Philadelphia, PA, USA
| | - Darshana Jhala
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Evan S Siegelman
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Emma E Furth
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen J Hunt
- Penn Image-Guided Interventions Laboratory, University of Pennsylvania, Philadelphia, PA, USA.,Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory J Nadolski
- Penn Image-Guided Interventions Laboratory, University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J Cresenz VA Medical Center, Philadelphia, PA, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA.,Penn Image-Guided Interventions Laboratory, University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J Cresenz VA Medical Center, Philadelphia, PA, USA
| | - Terence P F Gade
- Penn Image-Guided Interventions Laboratory, University of Pennsylvania, Philadelphia, PA, USA. .,Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA. .,Division of Interventional Radiology, University of Pennsylvania, Philadelphia, PA, USA. .,Corporal Michael J Cresenz VA Medical Center, Philadelphia, PA, USA. .,Radiology and Cancer Biology, University of Pennsylvania Perelman School of Medicine, 652 BRB II/III, 421 Curie Blvd, Philadelphia, PA, 19104-6160, USA.
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8
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Vogl DT, Sallée V, Hendricks MC, Redlinger Tabery C, Blair ML, Dahlmeier E, Meagher EA, Cohen RB, Vonderheide RH. A unique window of opportunity for practical reform of cancer clinical trials. Cancer 2021; 127:2855-2860. [PMID: 33849079 DOI: 10.1002/cncr.33585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/15/2021] [Accepted: 03/22/2021] [Indexed: 11/11/2022]
Abstract
With rapid modifications in cancer clinical trial operations necessitated by the global pandemic over the last year, there is now an unprecedented opportunity to reform clinical research permanently and solidify innovative practices that have clearly been effective. On the basis of the authors' experience and recommendations from other institutions, a set of specific proposals for clinical trial reform are identified that can be implemented immediately by sponsors, regulators, and study sites. Improvements in clinical trial processes should include increased leverage of technology to facilitate remote trial activity and electronic documents, more efficient and effective communication of adverse event information, and better study design to optimize inclusion criteria, required research procedures, and data collection. The authors suggest that such reform will preserve patient safety and study integrity, address unnecessary and inefficient pre-pandemic constraints, improve access to clinical trials for patients, and speed improvements in cancer care.
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Affiliation(s)
- Dan T Vogl
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vicki Sallée
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria C Hendricks
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colleen Redlinger Tabery
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Meghan L Blair
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erica Dahlmeier
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emma A Meagher
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roger B Cohen
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert H Vonderheide
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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9
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Biondo A, Pal A, Riisnaes R, Shinde R, Tiu C, Lockie F, Baker C, Bertan C, Crespo M, Ferreira A, Pereira R, Figueiredo I, Miranda S, Gurel B, Carreira S, Banerji U, de Bono J, Lopez J, Tunariu N, Minchom A. Research Related Tumour Biopsies in Early-Phase Trials with Simultaneous Molecular Characterisation - a Single Unit Experience. Cancer Treat Res Commun 2021; 27:100309. [PMID: 33549985 DOI: 10.1016/j.ctarc.2021.100309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 01/28/2023]
Abstract
Early-phase cancer clinical trials are becoming increasingly accessible for patients with advanced cancer who have exhausted standard treatment options and later phase trial options. Many of these trials mandate research tissue biopsies. Research biopsies have been perceived as ethically fraught due to the perception of potential coercion of vulnerable human subjects. We performed an audit of two years of practice to assess the safety of ultrasound (US)-guided research biopsies, and to look at the yield of a simultaneous tumour next-generation sequencing (NGS) and immunohistochemistry (IHC) molecular characterisation programme. We show that in our institution, US-guided research biopsies were safe, produced adequate tumour content and in a selected subset who underwent in-house NGS sequencing, showed a high rate of actionable mutations with 30% having a Tier 1 variant. Nevertheless, these research biopsies may only provide direct benefit for a minority of patients and we conclude with a reflection on the importance of obtaining truly informed consent.
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Affiliation(s)
- Andrea Biondo
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Abhijit Pal
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Ruth Riisnaes
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Rajiv Shinde
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Crescens Tiu
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Fran Lockie
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Chloe Baker
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Claudia Bertan
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Mateus Crespo
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Ana Ferreira
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Rita Pereira
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Ines Figueiredo
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Susana Miranda
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Bora Gurel
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Suzanne Carreira
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Udai Banerji
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Johann de Bono
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Juanita Lopez
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Nina Tunariu
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT
| | - Anna Minchom
- Drug Development Unit, Royal Marsden Hospital/The Institute of Cancer Research, Downs Road, Sutton, SM2 5PT.
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10
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PI3K pathway protein analyses in metastatic breast cancer patients receiving standard everolimus and exemestane. J Cancer Res Clin Oncol 2020; 146:3013-3023. [PMID: 32566979 PMCID: PMC7519923 DOI: 10.1007/s00432-020-03291-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/12/2020] [Indexed: 11/26/2022]
Abstract
Purpose Everolimus plus exemestane (EVE/EXE) is a registered treatment option for ER-positive, HER2-negative (ER +/HER2-) metastatic breast cancer (MBC), but resistance mechanisms limit efficacy. We aimed to find markers that might help select patients with a higher chance on benefit from EVE/EXE. Methods Immunohistochemistry (IHC) of PTEN, p-AKT(Thr308), p-AKT(Ser473), p-4EBP1, p-p70S6K, p-S6RP(Ser240/244), p-ERK1/2 and p-S6RP (Ser235/236) was performed on primary tumour tissue and on biopsies immediately taken from ER +/HER2- MBC patients before the start of standard EVE/EXE (Eudract 2013-004120-11). Unsupervised hierarchical clustering was executed to create heatmaps to distinguish subgroups of preferentially activated and less-activated PI3K/MAPK proteins. Uni- and multivariate Cox models were used for associations with PFS. Results Primary tumour tissue from 145 patients was retrieved. Median PFS was 5.4 months. Patients without (neo)adjuvant therapy (p = 0.03) or bone only disease (p = 0.04) had longer PFS on EVE/EXE. In primary tumours, neither single proteins nor PI3K/MAPK-associated heatmap subgroups were significantly associated with PFS. In 21 patients a non-osseous biopsy obtained before dosing was useful for continuous scoring, which demonstrated upregulation of several proteins as compared to readings in corresponding primary tumour tissues. These comparisons revealed that increased expression of p-4EBP1 was significantly associated with worse PFS (multivariate HR 3.69, p = 0.05). Conclusions IHC of single proteins or heatmap subgroups of the differentially activated PI3K/MAPK pathways was not able to discriminate patients on EVE/EXE with poor or better PFS. Upregulation of p-4EBP1 in pre-treatment biopsies as compared to levels in primary tumours pointed towards shorter PFS. Electronic supplementary material The online version of this article (10.1007/s00432-020-03291-x) contains supplementary material, which is available to authorized users.
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Voyten J, Holtzman MP, Pantanowitz L, Dhir R, Beasley HS, Cuda J, Monaco SE. Lessons learned from clinical trial queries on small biopsy collections: importance of rapid on-site evaluation. J Am Soc Cytopathol 2020; 9:461-468. [PMID: 32499137 DOI: 10.1016/j.jasc.2020.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Small biopsies and cytology specimens have become increasingly important for clinical trials and biomarker testing. Thus, institutions must ensure that adequate lesional material meeting the specifications for a multitude of different protocols is available. This can be achieved using rapid on-site evaluation (ROSE). The aim of the present study was to determine the recent clinical trial biopsy characteristics and study the feedback on these collections at our institution. MATERIALS AND METHODS Clinical trial biopsies performed at our institution and trial feedback (including "queries") were analyzed from the 2017 to 2019. The query data were reviewed in detail, in addition to any protocol modifications related to biopsy requirements and study protocol changes. RESULTS A total of 698 biopsy collections were performed for clinical trial purposes for 95 trials, with most requiring biopsies at >1 time point (63.2%), for phase I or II trials (92.6%), and for specific tumor types (67.4%). Only 18 of the trials (18.9%) requiring fresh tissue biopsies provided feedback. The feedback included data from 90 cases (12.9%), of which 27 (30.0%) had queries regarding insufficient (n = 10; 37.0%) or borderline (n = 17; 63.0%) tumor tissue. Only 1 (3.7%) of these had had ROSE by cytology. ROSE was performed in accordance with institutional guidelines (45.3%), as required by the study (1.1%), or because of trial modification (5.3%). CONCLUSIONS The present investigation has shown the high volume of clinical trial biopsies managed at our academic cancer center. Feedback from the trials was low at 18.9% and frequently involved suboptimal cases without ROSE used at acquisition. This has led to more widespread adoption of ROSE to mitigate insufficient biopsy specimens and repeat procedures. The high volume of clinical trial biopsies and variability in trial needs necessitates a collaborative multidisciplinary network, including cytology services, to facilitate these important biopsies for patients with cancer.
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Affiliation(s)
- Jamie Voyten
- Clinical Research Services, UPMC Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Matthew P Holtzman
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Liron Pantanowitz
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rajiv Dhir
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - H Scott Beasley
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jackie Cuda
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sara E Monaco
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Parseghian CM, Tam AL, Yao J, Ensor J, Ellis LM, Raghav K, Overman MJ. Assessment of Reported Trial Characteristics, Rate of Publication, and Inclusion of Mandatory Biopsies of Research Biopsies in Clinical Trials in Oncology. JAMA Oncol 2019; 5:402-405. [PMID: 30383128 DOI: 10.1001/jamaoncol.2018.4640] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Research biopsies are frequently incorporated within clinical trials in oncology and are often a mandatory requirement for trial enrollment. However, limited information is available regarding the extent and completeness of research biopsy reporting. Objectives To determine the rate of research biopsy reporting for clinical trials registered in ClinicalTrials.gov and determine the clinical trial factors that correlated with research biopsy reporting. Design, Setting, and Participants ClinicalTrials.gov (CTG) was searched for all oncologic therapeutic clinical trials with completion dates between January 1, 2000, and January 1, 2015, with end point category terms including biopsy, biopsies, or tissue. The date of the final publication search was March 12, 2018. Trials conducting only diagnostic biopsies or trials using bone marrow biopsies or liquid biopsies were excluded. Credit for biopsy reporting was given for any mention of performing or results from tissue biopsies in publications. Clinical trials were compared with the highest level of corresponding publication or registry report. Fisher exact test was used for analysis. Results A total of 301 clinical trials were identified, with a median of 37 patients (range, 1-1310 patients) enrolled per trial. After a median follow-up time of 5.8 years from trial completion, 244 of 301 trials (81.1%) reported results: publications in 195 (64.8%) and CTG registry in 49 (16.3%). Reporting of trial results was associated with later-stage trials (phase 2/3) (137 of 153 [89.5%] for phase 2/3 vs 107 of 148 [72.3%] for phase 1 or 1/2 trials; P < .001). Results from research biopsies were reported in 153 of 301 (50.8%) trials or in 153 of 244 (62.7%) trials with published results. Rates varied by type of presentation: 142 of 195 publications (72.8%) vs 11 of 49 CTG reports (22.4%) (P < .001). Conducting mandatory biopsies (82.1% [101 of 123] vs 43.0% [52 of 121]; P < .001), early-phase clinical trials (70.1% [75 of 107] vs 56.9% [78 of 137]; P = .03), and listing the biopsy as a primary objective in CTG (76.3% [45 of 59] vs 58.4% [108 of 185]; P = .01) was associated with improved biopsy reporting. Trials that met their primary end point (71.9% [115 of 160] vs 45.2% [38 of 84]; P < .001) and those published in higher-impact journals (81.1% [77 of 95] vs 65.0% [65 of 100]; P = .01) had improved biopsy reporting. Mandatory biopsies and biopsy reporting increased over time with similar slopes (P = .58). Conclusions and Relevance Despite ethical obligations to report research biopsies, only 50.8% of all trials that included a research biopsy-related end point in CTG reported on these biopsy-related results. Improved efforts are needed to report results obtained from research biopsies.
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Affiliation(s)
- Christine M Parseghian
- Division of Cancer Medicine, Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston
| | - Alda L Tam
- Division of Diagnostic Imaging, Department of Interventional Radiology, The University of Texas M.D. Anderson Cancer Center, Houston
| | - James Yao
- Division of Cancer Medicine, Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston
| | - Joe Ensor
- Houston Methodist Cancer Center, Houston Methodist Research Institute Methodist, Houston, Texas
| | - Lee M Ellis
- Division of Surgery, Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston
| | - Kanwal Raghav
- Division of Cancer Medicine, Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston
| | - Michael J Overman
- Division of Cancer Medicine, Department of Gastrointestinal Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston
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Levit LA, Peppercorn JM, Tam AL, Marron JM, Mathews DJ, Levit K, Roach N, Ratain MJ. Ethical Framework for Including Research Biopsies in Oncology Clinical Trials: American Society of Clinical Oncology Research Statement. J Clin Oncol 2019; 37:2368-2377. [DOI: 10.1200/jco.19.01479] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In contrast to clinical biopsies, where tissue is collected to inform patient care, research biopsies are performed for scientific purposes to potentially enhance understanding of the biologic bases of cancer and drug action, thereby improving diagnosis and treatment, but they may offer no direct benefit to participants and have known risks. The widespread use of research biopsies that do not have the potential to directly benefit participants has come under scrutiny, with critics raising ethical concerns related to the adequacy of participant protections, informed consent, and participant understanding of the risks and benefits, as well as the scientific impact of research biopsies on drug development and treatment. This manuscript presents the American Society of Clinical Oncology’s (ASCO’s) ethical framework for incorporation of research biopsies in trials. The framework provides guidance on the circumstances to include optional and mandatory biopsies, as well as provides recommendations to stakeholders on necessary steps for improving the conduct of research biopsies overall.
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Affiliation(s)
| | | | - Alda L. Tam
- University of Texas MD Anderson Cancer Center, Houston, TX
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Pilié PG, LoRusso PM, Yap TA. Precision Medicine: Progress, Pitfalls, and Promises. Mol Cancer Ther 2018; 16:2641-2644. [PMID: 29203693 DOI: 10.1158/1535-7163.mct-17-0904] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 10/06/2017] [Accepted: 10/11/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Patrick G Pilié
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Timothy A Yap
- The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Overman MJ, Ellis LM, Joffe S. Ethics and the Underreporting of Research Biopsy Findings in Clinical Trials. JAMA Oncol 2018; 4:1041-1042. [PMID: 29799989 DOI: 10.1001/jamaoncol.2018.1002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Michael J Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Lee M Ellis
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia
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