Choosing a control intervention for a randomised clinical trial

Using Normalization Process Theory to Evaluate an End-of-Life Pediatric Palliative Care Web-Based Training Program for Nurses: Protocol for a Randomized Controlled Trial

BACKGROUND

Palliative care (PC) is a new concept in Iraq, and there is no training for health care specialists or the public. The lack of education and training programs is the most important barrier for PC. Intermediate training is needed for nurses who regularly manage patients with life-threatening diseases. The End-of-Life Nursing Education Consortium for pediatric palliative care (PPC) program is intended for nurses who are interested in providing care to children with life-limiting diseases or providing support in the event of an accident or unexpected death.

OBJECTIVE

Our trial aims to evaluate the effect of a web-based training course, using the Normalization Process Theory. It focuses on how complex interventions become routinely embedded in practice and on training of a sample of academic nurses in the application of PPC in routine daily practice. It hypothesizes that nurses will be able to provide PC for the pediatric population after completing the training.

METHODS

This is a multicenter, parallel, pragmatic trial in 5 health care settings spread across a single city in Babylon Province, Iraq. Participants will be recruited and stratified into 2 categories (critical care units and noncritical care units). In the experimental condition, 86 nurses will be trained in the application of PPC for 2 weeks through a web-based training course powered by the Relais Platform. The nurses will be invited to participate via email or instant messaging (WhatsApp, Telegram, or Viber). They will provide end-of-life care in addition to usual care to children and adolescents with life-limiting conditions. In the control condition, 86 nurses will continue usual care. The program's effectiveness will be assessed at the level of nurses only. We will compare baseline findings (before the intervention) with postintervention findings (after completing the training course). A further assessment will be performed 3 months after the course. As numerous unidentified factors can influence the effect of the training, we will perform a progressive evaluation to assess sample selection, application, and intervention value, as well as implementation difficulties. The nursing staff will not be blinded to the intervention, but will be blinded to the results.

RESULTS

The study trial recruitment opened in July 2020. The first outcomes became available in December 2020.

CONCLUSIONS

The trial attempts to clarify the delivery of PC at the end of life through the implementation of a web-based training course among Iraqi nurses in the pediatric field. The study strengths include the usual practice setting, staff training, readiness of staff to participate in the study, and random allocation to the intervention. However, participants may drop out after being transferred to another department during the study period.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04461561; https://clinicaltrials.gov/ct2/show/NCT04461561.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/23783.

Maximizing value and minimizing waste in clinical trial research in swine: Selecting interventions to build an evidence base

Researchers conduct a trial to compare an intervention of interest to a comparison group. Initially, researchers should determine whether a trial is evaluating superiority, equivalence, or noninferiority. This decision will guide the choice of a placebo versus active comparison group. Interventions, as well as baseline management, should be comprehensively reported to allow replication or clinical application. It is necessary to build a body of evidence across multiple trials to apply evidence-based decision-making. To achieve this, at least one intervention in every trial should be an intervention that has been used in at least one previously published trial.

Methodology for clinical research

A clinical research requires a systematic approach with diligent planning, execution and sampling in order to obtain reliable and validated results, as well as an understanding of each research methodology is essential for researchers. Indeed, selecting an inappropriate study type, an error that cannot be corrected after the beginning of a study, results in flawed methodology. The results of clinical research studies enhance the repertoire of knowledge regarding a disease pathogenicity, an existing or newly discovered medication, surgical or diagnostic procedure or medical device. Medical research can be divided into primary and secondary research, where primary research involves conducting studies and collecting raw data, which is then analysed and evaluated in secondary research. The successful deployment of clinical research methodology depends upon several factors. These include the type of study, the objectives, the population, study design, methodology/techniques and the sampling and statistical procedures used. Among the different types of clinical studies, we can recognize descriptive or analytical studies, which can be further categorized in observational and experimental. Finally, also pre-clinical studies are of outmost importance, representing the steppingstone of clinical trials. It is therefore important to understand the types of method for clinical research. Thus, this review focused on various aspects of the methodology and describes the crucial steps of the conceptual and executive stages.

Powering Bias and Clinically Important Treatment Effects in Randomized Trials of Critical Illness

OBJECTIVES

Recurring issues in clinical trial design may bias results toward the null, yielding findings inconclusive for treatment effects. This study evaluated for powering bias among high-impact critical care trials and the associated risk of masking clinically important treatment effects.

DESIGN, SETTING, AND PATIENTS

Secondary analysis of multicenter randomized trials of critically ill adults in which mortality was the main endpoint. Trials were eligible for inclusion if published between 2008 and 2018 in leading journals. Analyses evaluated for accuracy of estimated control group mortality, adaptive sample size strategy, plausibility of predicted treatment effect, and results relative to the minimal clinically important difference. The main outcome was the mortality risk difference at the study-specific follow-up interval.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 101 included trials, 12 met statistical significance for their main endpoint, five for increased intervention-associated mortality. Most trials (77.3%) overestimated control group mortality in power calculations (observed minus predicted difference, -6.7% ± 9.8%; p < 0.01). Due to this misestimation of control group mortality, in 14 trials, the intervention would have had to prevent at least half of all deaths to achieve the hypothesized treatment effect. Seven trials prespecified adaptive sample size strategies that might have mitigated this issue. The observed risk difference for mortality fell within 5% of predicted in 20 trials, of which 16 did not reach statistical significance. Half of trials (47.0%) were powered for an absolute risk reduction greater than or equal to 10%, but this effect size was observed in only three trials with a statistically significant treatment benefit. Most trials (67.3%) could not exclude clinically important treatment benefit or harm.

CONCLUSIONS

The design of most high-impact critical care trials biased results toward the null by overestimating control group mortality and powering for unrealistic treatment effects. Clinically important treatment effects often cannot be excluded.

Perspectives and experiences of people who were randomly assigned to wait-and-see approach in a gluteal tendinopathy trial: a qualitative follow-up study

OBJECTIVE

To explore participants' perspectives on, and experiences of, being assigned to a wait-and-see arm of a gluteal tendinopathy trial.

DESIGN

Descriptive qualitative.

SETTING

General community in Brisbane and Melbourne, Australia.

PARTICIPANTS

Fifteen participants who had been randomly allocated to the wait-and-see group in a recent parallel group superiority clinical trial. That trial compared the wait-and-see approach to a physiotherapist-led education plus exercise approach, and an ultrasound-guided corticosteroid injection. The wait-and-see approach involved one physiotherapy session in which participants received reassurance, general advice and encouragement to stay active for the management of gluteal tendinopathy.

DATA COLLECTION AND ANALYSIS

Semistructured interviews were conducted by four interviewers in person or over the internet, audio recorded and transcribed verbatim. Transcripts were coded and data analysed using an inductive thematic approach.

RESULTS

Five themes were extracted from the interview transcripts: (1) Feeling disenfranchised by being assigned to a wait-and-see approach; (2) the importance of having a clinical and imaging diagnosis during screening for inclusion into the clinical trial; (3) feelings regarding the effectiveness of the approach; (4) the convenient and easy to follow nature of the wait-and-see approach and (5) the connotation of wait-and-see not always being perceived as an intervention.

CONCLUSIONS

Participants found the wait-and-see approach convenient and easy to follow, yet almost always felt disenfranchised that nothing was being done. Participants highlighted the importance of a definite clinical and imaging diagnosis.

TRIAL REGISTRATION NUMBER

ACTRN12612001126808; Post-results.

Important issues in the justification of a control treatment in paediatric drug trials

OBJECTIVE

The value of comparative effectiveness trials in informing clinical and policy decisions depends heavily on the choice of control arm (comparator). Our objective is to identify challenges in comparator reasoning and to determine justification criteria for selecting a control arm in paediatric clinical trials.

DESIGN

A literature search was completed to identify existing sources of guidance on comparator selection. Subsequently, we reviewed a randomly selected sample of comparators selected for paediatric investigation plans (PIPs) adopted by the Paediatric Committee of the European Medicines Agency in 2013. We gathered descriptive information and evaluated their review process to identify challenges and compromises between regulators and sponsors with regard to the selection of the comparator. A tool to help investigators justify the selection of active controls and placebo arms was developed using the existing literature and empirical data.

RESULTS

Justifying comparator selection was a challenge in 28% of PIPs. The following challenging paediatric issues in the decision-making process were identified: use of off-label medications as comparators, ethical and safe use of placebo, duration of placebo use, an undefined optimal dosing strategy, lack of age-appropriate safety and efficacy data, and drug dosing not supported by extrapolation of safety/efficacy evidence from other populations.

CONCLUSIONS

In order to generate trials that will inform clinical decision-making and support marketing authorisations, researchers must systemically and transparently justify their selection of the comparator arm for their study. This report highlights key areas for justification in the choice of comparator in paediatric clinical trials.

When are clinical trials beneficial for study patients and future patients? A factorial vignette-based survey of institutional review board members

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.

Equipoise in the Enhanced Supression of the Platelet IIb/IIIa Receptor with Integrilin Trial (ESPRIT): a critical appraisal

Enhanced Supression of the Platelet IIb/IIIa Receptor with Integrilin Trial (ESPRIT) was a multicenter randomized controlled clinical trial in which participants were randomized between eptifibatide and placebo. A “clinical hold” was initially placed on the trial by the US Food and Drug Administration (FDA), which was concerned about the placebo-only control arm. The hold was lifted after additional information concerning the use of platelet glycoprotein IIb/IIIa inhibitors in clinical practice, derived from a survey of interventional cardiologists, was provided. The trial's principal investigator and colleagues have described how these issues were resolved, and advance a claim of equipoise for the trial. In this critical appraisal we examine the information and arguments proffered in support of the trial design and conclude that they evidence a misunderstanding of equipoise. We believe that a placebo-only control arm was not justified by the information provided by the trialists.

Ability of a meta-analysis to prevent redundant research: systematic review of studies on pain from propofol injection

OBJECTIVE

To examine whether, according to the conclusions of a 2000 systematic review with meta-analysis on interventions to prevent pain from propofol injection that provided a research agenda to guide further research on the topic, subsequently published trials were more often optimally blinded, reported on children, and used the most efficacious intervention as comparator; and to check whether the number of new trials published each year had decreased and whether the designs of trials that cited the review differed from those that did not.

STUDY DESIGN

Systematic review comparing old trials (published before, and included in, the review) with new trials (published afterwards).

DATA SOURCES

Medline, Cochrane, Embase, and bibliographies to January 2013.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomised studies testing any intervention to prevent pain from propofol injection in humans.

RESULTS

136 new trials (19,778 patients) were retrieved. Compared with the 56 old trials (6264 patients), the proportion of optimally blinded trials had increased from 10.7% to 38.2% (difference 27.5%, 95% confidence interval 16.0% to 39.0%, P<0.001), and the proportion of trials that used the most efficacious intervention as comparator had increased from 12.5% to 27.9% (difference 15.4%, 4.0% to 26.9%, P=0.022). The proportion of paediatric trials had increased from 5.4% to 12.5%, although this was not significant (difference 7.1%, -1.0% to 15.2%, P=0.141). The number of new trials published each year was significantly higher (median number/year 12 (range 7-20) v 2.5 (0-9), P<0.001) with no obvious decreasing trend. 72.8% (n=99) of the new trials cited the review, with their designs similar to trials not citing the review. Only 36.0% (n=49) of the new trials were considered clinically relevant since they used the most efficacious intervention as comparator or included a paediatric population.

CONCLUSIONS

The impact of the systematic review on the design of subsequent research was low. There was an improvement in the reporting of optimal blinding procedures and a tendency towards an increase in the proportion of paediatric trials. The most efficacious intervention was more often chosen as comparator but remained marginally used, and the number of trials published per year had not decreased. The use of systematic reviews should be encouraged to inform rational, and thus ethical, trial design and improve the relevance of new research.

Treatment success in cancer: industry compared to publicly sponsored randomized controlled trials

OBJECTIVE

To assess if commercially sponsored trials are associated with higher success rates than publicly-sponsored trials.

STUDY DESIGN AND SETTINGS

We undertook a systematic review of all consecutive, published and unpublished phase III cancer randomized controlled trials (RCTs) conducted by GlaxoSmithKline (GSK) and the NCIC Clinical Trials Group (CTG). We included all phase III cancer RCTs assessing treatment superiority from 1980 to 2010. Three metrics were assessed to determine treatment successes: (1) the proportion of statistically significant trials favouring the experimental treatment, (2) the proportion of the trials in which new treatments were considered superior according to the investigators, and (3) quantitative synthesis of data for primary outcomes as defined in each trial.

RESULTS

GSK conducted 40 cancer RCTs accruing 19,889 patients and CTG conducted 77 trials enrolling 33,260 patients. 42% (99%CI 24 to 60) of the results were statistically significant favouring experimental treatments in GSK compared to 25% (99%CI 13 to 37) in the CTG cohort (RR = 1.68; p = 0.04). Investigators concluded that new treatments were superior to standard treatments in 80% of GSK compared to 44% of CTG trials (RR = 1.81; p<0.001). Meta-analysis of the primary outcome indicated larger effects in GSK trials (odds ratio = 0.61 [99%CI 0.47-0.78] compared to 0.86 [0.74-1.00]; p = 0.003). However, testing for the effect of treatment over time indicated that treatment success has become comparable in the last decade.

CONCLUSIONS

While overall industry sponsorship is associated with higher success rates than publicly-sponsored trials, the difference seems to have disappeared over time.

The development and description of the comparison group in the Look AHEAD trial

Background Despite more lifestyle intervention trials, there is little published information on the development of the comparison group intervention. This article describes the comparison group intervention, termed Diabetes Support and Education Intervention and its development for the Action for HEAlth in Diabetes (Look AHEAD) trial. Look AHEAD, a randomized, controlled, multicenter trial, was designed to determine whether an Intensive Lifestyle Intervention to reduce weight and increase physical activity reduces cardiovascular morbidity and mortality in overweight volunteers with type 2 diabetes compared to the Diabetes Support and Education Intervention. The Diabetes Support and Education Committee was charged with developing the Diabetes Support and Education Intervention with the primary aim of participant retention.

Purpose The objectives were to design the Diabetes Support and Education Intervention sessions, standardize delivery across the 16 clinics, review quality and protocol adherence and advise on staffing and funding.

Methods Following a mandatory session on basic diabetes education, three optional sessions were offered on nutrition, physical activity, and support yearly for 4 years. For each session, guidelines, objectives, activities, and a resource list were created.

Conclusions Participant evaluations were very positive with hands on experiences being the most valuable. Retention so far at years 1 and 4 has been excellent and only slightly lower in the Diabetes Support and Education Intervention arm. The comparison group plays an important role in the success of a clinical trial. Understanding the effort needed to develop and implement the comparison group intervention will facilitate its implementation in future lifestyle intervention trials, particularly multicenter trials. Retention rates may improve by developing the comparison intervention simultaneously with the lifestyle intervention.

Uncertainty and equipoise: at interplay between epistemology, decision making and ethics

In recent years, various authors have proposed that the concept of equipoise be abandoned because it conflates the practice of clinical care with clinical research. At the same time, the equipoise opponents acknowledge the necessity of clinical research if there are unresolved uncertainties about the effects of proposed healthcare interventions. As equipoise represents just 1 measure of uncertainty, proposals to abandon equipoise while maintaining a requirement for addressing uncertainties are contradictory and ultimately not valid. As acknowledgment and articulation of uncertainties represent key scientific and moral requirements for human experimentation, the concept of equipoise remains the most useful framework to link the theory of human experimentation with the theory of rational choice. In this article, I show how uncertainty (equipoise) is at the intersection between epistemology, decision making and ethics of clinical research. In particular, I show how our formulation of responses to uncertainties of hoped-for benefits and unknown harms of testing is a function of the way humans cognitively process information. This approach is based on the view that considerations of ethics and rationality cannot be separated. I analyze the response to uncertainties as it relates to the dual-processing theory, which postulates that rational approach to (clinical research) decision making depends both on analytical, deliberative processes embodied in scientific method (system II), and good human intuition (system I). Ultimately, our choices can only become wiser if we understand a close and intertwined relationship between irreducible uncertainty, inevitable errors and unavoidable injustice.

Challenges to accrual predictions to phase III cancer clinical trials: a survey of study chairs and lead statisticians of 248 NCI-sponsored trials

BACKGROUND

Research on barriers to accrual has typically emphasized factors influencing participation after trial activation.

PURPOSE

We sought to identify factors influencing trial design and accrual predictions prior to trial activation associated with sufficient accrual.

METHODS

A 30-question web-based survey was sent to the study chair and lead statistician for all 248 phase III trials open in 1993-2002 by five Clinical Trials Cooperative Groups. Questions addressed prior trial experience, trial design elements, accrual predictions, and perceived accrual influences. Accrual sufficiency categorization was derived from Clinical Trials Cooperative Group records: sufficient accrual included trials closed with complete accrual or at interim analysis, insufficient accrual included trials closed with inadequate accrual. Responses were analyzed by respondent role (study chair/lead statistician) and accrual sufficiency.

RESULTS

Three hundred and nine eligible responses were included (response rate, 63%; lead statisticians, 81%; and study chairs, 45%), representing trials with sufficient (63%) and insufficient accruals (37%). Study chair seniority or lead statistician experience was not linked to accrual sufficiency. Literature review, study chair's personal experience, and expert opinion within Clinical Trials Cooperative Group most commonly influenced control arm selection. Clinical Trials Cooperative Group experience most influenced accrual predictions. These influences were not associated with accrual sufficiency. Among respondents citing accrual difficulties (41%), factors negatively influencing accrual were not consistently identified. Respondents credited three factors with positively influencing accrual: clinical relevance of study, lack of competing trials, and protocol paralleling normal practice.

LIMITATIONS

Perceptions of lead statisticians and study chairs may not accurately reflect accrual barriers encountered by participating physicians or patients. Survey responses may be subject to recall bias.

CONCLUSION

Consistent factors explaining poor accrual were not identified, suggesting reasons for poor accrual are not well understood and warrant further study. Alternate strategies for accrual prediction are needed since Clinical Trials Cooperative Group experience is linked to successful and unsuccessful accrual.

Best supportive care: a euphemism for no care or a standard of good care?

This article seeks to address the question: Is best supportive care (BSC) in research a euphemism for no care or a standard of good care? The data regarding the ethical and methodological validity of BSC studies are reviewed. Most of the BSC studies published over the past 25 years are really treatment versus no treatment studies represented as BSC studies. By ignoring the best contemporaneous standards of BSC, standardizing practices in multicenter studies, validating participating centers, or documenting treatment delivery, researchers belie the stated intention of studying BSC. Most studies sought to evaluate if there was any benefit of a new anti-tumor treatment versus discontinuation of anti-tumor therapies. Overwhelmingly, and with few exceptions, the impact of BSC practices was not really part of the key research question. To be ethical and methodologically valid, BSC studies must incorporate standards consistent with contemporaneous, proven BSC practice standards. Work is underway to develop widely validated standards of practice for the control arm of best supportive care studies. These can be readily incorporated in to study development and evaluation.

Forging convictions: the effects of active participation in a clinical trial

This qualitative study explored non-specific influences on participation in, and outcomes of, a randomised controlled trial. It was nested within a single-blind clinical trial of western acupuncture which compared real acupuncture with two types of placebo control administered to National Health Service (NHS) patients awaiting hip and knee replacement surgery in England. Data collection (2004-2008) was based on narrative-style interviews and participant observation. The results indicate that trial recruitment and retention depend on a set of convictions forged largely as a result of contextual factors peripheral to the intervention, including the friendliness and helpfulness of research centre staff and status of the administering practitioner. These convictions also influence the reporting of the study outcomes, particularly if participants experience uncertainties when choosing an appropriate response. The findings suggest that participants in clinical trials are actively involved in shaping the research process, rather than passive recipients of treatment. Thus the outcomes of trials, notably those involving contact interventions, should be regarded not as matters of fact, but as products of complex environmental, social, interpretive and biological processes. In this paper, we develop and present a 'theory of active research participation' which offers a framework for understanding the impact of non-specific processes in clinical trials.

Effectiveness of a hand-held fan for breathlessness: a randomised phase II trial

BACKGROUND

Breathlessness is common and distressing in advanced disease. This phase II study aimed to determine the use and acceptance of a hand-held fan (HHF) to relieve breathlessness, to test the effectiveness of the HHF and to evaluate the recruitment into the study.

METHODS

RCT embedded within a longitudinal study testing a HHF over time compared to a wristband. Patients were included in the longitudinal study when suffering from breathlessness due to advanced cancer or COPD III/IV and could opt in the RCT. Primary outcome was use of the HHF and the wristband after two months. Secondary outcomes were recruitment into the trial and change of breathlessness severity after two months, measured on the modified Borg scale. Baseline data were collected in a personal interview and follow-up data by monthly postal questionnaires.

RESULTS

109 patients were recruited in the longitudinal study of which 70 patients (64%) participated in the RCT. Non-participants had statistically significant less breathlessness (Borg mean 2.6 (SD 1.48) versus 3.7 (SD 1.83); p = 0.003) and a better functional status (Karnofsky status mean 61.9 (SD 11.2) versus 66.7 (SD 11.0); p = 0.03). Attrition due to drop out or death was high in both groups. After two months, about half of the patients used the HHF but only 20% the wristband without a statistical difference (Fisher's exact test p = 0.2). 9/16 patients judged the HHF as helpful after two months and 4/5 patients the wristband. There was no difference in mean breathlessness change scores between the HHF (Borg change score: mean 0.6 (SD 2.10)) and the wristband (mean 0.8 (SD 2.67)) after two months (p = 0.90).

CONCLUSIONS

Symptom burden and low functional status did not restrain patients from participation in the study. Finding a control for a visible intervention is challenging and needs careful consideration to what is acceptable to patients. The preliminary evidence of effectiveness of the HHF could not be proved. Patients often stopped using the HHF but a small group seemed to benefit which was not necessarily related to a relief in breathlessness. Therefore, more work is necessary on selecting and identifying those who might benefit from the HHF.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01123902.

Preliminary evaluation of factors associated with premature trial closure and feasibility of accrual benchmarks in phase III oncology trials

BACKGROUND

A major challenge for randomized phase III oncology trials is the frequent low rates of patient enrollment, resulting in high rates of premature closure due to insufficient accrual.

PURPOSE

We conducted a pilot study to determine the extent of trial closure due to poor accrual, feasibility of identifying trial factors associated with sufficient accrual, impact of redesign strategies on trial accrual, and accrual benchmarks designating high failure risk in the clinical trials cooperative group (CTCG) setting.

METHODS

A subset of phase III trials opened by five CTCGs between August 1991 and March 2004 was evaluated. Design elements, experimental agents, redesign strategies, and pretrial accrual assessment supporting accrual predictions were abstracted from CTCG documents. Percent actual/predicted accrual rate averaged per month was calculated. Trials were categorized as having sufficient or insufficient accrual based on reason for trial termination. Analyses included univariate and bivariate summaries to identify potential trial factors associated with accrual sufficiency.

RESULTS

Among 40 trials from one CTCG, 21 (52.5%) trials closed due to insufficient accrual. In 82 trials from five CTCGs, therapeutic trials accrued sufficiently more often than nontherapeutic trials (59% vs 27%, p = 0.05). Trials including pretrial accrual assessment more often achieved sufficient accrual than those without (67% vs 47%, p = 0.08). Fewer exclusion criteria, shorter consent forms, other CTCG participation, and trial design simplicity were not associated with achieving sufficient accrual. Trials accruing at a rate much lower than predicted (<35% actual/predicted accrual rate) were consistently closed due to insufficient accrual.

LIMITATIONS

This trial subset under-represents certain experimental modalities. Data sources do not allow accounting for all factors potentially related to accrual success.

CONCLUSION

Trial closure due to insufficient accrual is common. Certain trial design factors appear associated with attaining sufficient accrual. Defining accrual benchmarks for early trial termination or redesign is feasible, but better accrual prediction methods are critically needed. Future studies should focus on identifying trial factors that allow more accurate accrual predictions and strategies that can salvage open trials experiencing slow accrual.

Improving the Methodologic and Ethical Validity of Best Supportive Care Studies in Oncology: Lessons From a Systematic Review

Purpose

To systematically review the best supportive care (BSC) literature and to evaluate the ethical and methodologic validity issues by using widely acknowledged criteria.

Methods

Two search strings that included both cancer and supportive as terms (with random article type, or review or meta-analysis) explored databases from 1966 to 2008. Citations, abstracts, and papers were reviewed for inclusion criteria, and relevant data were extracted by two independent researchers. Data were validated for accuracy. Ethical and methodologic validity were evaluated by using the criteria derived from the Helsinki Requirements of the WMA; CONSORT statements for the evaluation of reports of randomized, controlled trials; and the universal requirements for ethical clinical research.

Results

Forty-three published papers were identified that described 32 studies, 20 of which incorporated the design of treatment plus supportive care (SC) versus SC alone, and 12 of which incorporated the design of treatment versus SC. Most of the studies had poor compliance to critical Helsinki requirements, to methodologic precautions derived from the CONSORT statement for studies involving a nonpharmacologic arm, and to four of seven universal requirements for ethical clinical research.

Conclusion

Lack of rigor in BSC studies has contributed to a generation of research with widespread ethical and methodologic shortcomings. Ad hoc SC and lack of standardization of SC delivery may be sources of systematic bias or error in BSC trials. Rectifying these shortcomings in future studies demands greater vigilance toward these issues by researchers, institutional review boards, editors, and peer reviewers. Given the prevalence of overlooked problems that are later identified, currently open BSC studies should be reevaluated by institutional review boards and researchers to check for ethical and methodologic validity, and identified shortcomings should be addressed.

Platelet transfusion practices among neonatologists in the United States and Canada: results of a survey

OBJECTIVE

In the absence of scientific evidence, current neonatal platelet transfusion practices are based on physicians' preferences, expert advice, or consensus-driven recommendations. We hypothesized that there would be significant diversity in platelet transfusion triggers, product selection, and dosing among neonatologists in the United States and Canada.

METHODS

A Web-based survey on neonatal platelet transfusion practices was distributed to all members of the American Academy of Pediatrics Perinatal Section in the United States and to all physicians listed in the 2005 Canadian Neonatology Directory.

RESULTS

The overall response rate was 37% (1060 of 2875). In the United States, 37% (1007 of 2700) responded, of which 52% practiced at academic centers. Thirty percent (53 of 175) of Canadians responded, of whom 94% practiced at academic centers. As hypothesized, there was significant practice diversity in both countries. The survey also revealed that platelet transfusions are frequently administered to nonbleeding neonates with platelet counts of >50 x 10(9)/L. This practice is particularly prevalent among neonates with specific clinical conditions, including indomethacin treatment, preceding procedures, in the postoperative period, or with intraventricular hemorrhages.

CONCLUSIONS

There is great variability in platelet transfusion practices among US and Canadian neonatologists, suggesting clinical equipoise in many clinical scenarios. Prospective randomized clinical trials to generate evidence-based neonatal platelet transfusion guidelines are needed.

Treatment success in cancer: new cancer treatment successes identified in phase 3 randomized controlled trials conducted by the National Cancer Institute-sponsored cooperative oncology groups, 1955 to 2006

BACKGROUND

The evaluation of research output, such as estimation of the proportion of treatment successes, is of ethical, scientific, and public importance but has rarely been evaluated systematically. We assessed how often experimental cancer treatments that undergo testing in randomized clinical trials (RCTs) result in discovery of successful new interventions.

METHODS

We extracted data from all completed (published and unpublished) phase 3 RCTs conducted by the National Cancer Institute cooperative groups since their inception in 1955. Therapeutic successes were determined by (1) assessing the proportion of statistically significant trials favoring new or standard treatments, (2) determining the proportion of the trials in which new treatments were considered superior to standard treatments according to the original researchers, and (3) quantitatively synthesizing data for main clinical outcomes (overall and event-free survival).

RESULTS

Data from 624 trials (781 randomized comparisons) involving 216 451 patients were analyzed. In all, 30% of trials had statistically significant results, of which new interventions were superior to established treatments in 80% of trials. The original researchers judged that the risk-benefit profile favored new treatments in 41% of comparisons (316 of 766). Hazard ratios for overall and event-free survival, available for 614 comparisons, were 0.95 (99% confidence interval [CI], 0.93-0.98) and 0.90 (99% CI, 0.87- 0.93), respectively, slightly favoring new treatments. Breakthrough interventions were discovered in 15% of trials.

CONCLUSIONS

Approximately 25% to 50% of new cancer treatments that reach the stage of assessment in RCTs will prove successful. The pattern of successes has become more stable over time. The results are consistent with the hypothesis that the ethical principle of equipoise defines limits of discoverability in clinical research and ultimately drives therapeutic advances in clinical medicine.

Ethics and research in critical care

BACKGROUND

The past few years have witnessed several controversies regarding the ethics of conducting research involving critically ill patients, and such research is ethically challenging.

DISCUSSION

Research ethics is a changing field, one that is influenced by empirical data, contemporary events, and new ideas regarding aspects of clinical trial design and protection of human subjects. We describe recent thoughts regarding several aspects of research ethics in the critical care context.

CONCLUSION

The ability of the research community to conduct research ethically and to maintain public trust would benefit from heightened awareness to the principles and requirements that govern such research.

Are experimental treatments for cancer in children superior to established treatments? Observational study of randomised controlled trials by the Children's Oncology Group

OBJECTIVES

To assess how often new treatments for childhood cancer assessed in phase III randomised trials are superior or inferior to standard treatments and whether the pattern of successes and failures in new treatments is consistent with uncertainty being the ethical basis for enrolling patients in such trials.

DESIGN

Observational study.

SETTING

Phase III randomised controlled trials carried out under the aegis of the Children's Oncology Group between 1955 and 1997, regardless of whether they were published.

MAIN OUTCOME MEASURES

Overall survival, event free survival, and treatment related mortality.

RESULTS

126 trials were included, involving 152 comparisons and 36,567 patients. The odds ratio for overall survival with experimental treatments was 0.96 (99% confidence interval 0.89 to 1.03), indicating that new treatments are as likely to be inferior as they are to be superior to standard treatments. This result was not affected by publication bias, methodological quality, treatment type, disease, or comparator.

CONCLUSIONS

New treatments in childhood cancer tested in randomised controlled trials are, on average, as likely to be inferior as they are to be superior to standard treatments, confirming that the uncertainty principle has been operating.

When being ‘tired of living’ plays an important role in a request for euthanasia or physician-assisted suicide: patient characteristics and the physician's decision

BACKGROUND

In the Netherlands physicians are allowed to grant requests for euthanasia or physician-assisted suicide (EAS) if they meet several requirements of due care. According to jurisprudence, a physician is not allowed to end the life of a patient whose request for EAS is based on being 'tired of living', because such a request falls outside the medical domain. Our previous studies have shown that in spite of this, such requests are made approximately 400 times a year.

OBJECTIVES

To learn more about patients who request EAS because they are tired of living, and about factors that influence the decision of the physician.

DESIGN

Questionnaires (n=4842) completed by general practitioners (n=3994).

RESULTS

According to the physicians, 17% of patients who requested EAS were 'tired of living'. Of 139 patients in whose request for EAS being tired of living played a major role, 47% suffered from cancer, 25% suffered from another severe disease and 28% had no severe disease. In all three groups the same three symptoms occurred most frequently, 'feeling bad', 'tired', and 'not active'. Each of these symptoms occurred in more than half of the patients in each group. Most of the requests from patients with cancer were granted, but those from patients who had some other severe disease, or no severe disease at all, were refused. Factors that were related to granting a request were: the presence of unbearable and hopeless suffering, the absence of alternatives, and the absence of depressive symptoms.

CONCLUSIONS

Being tired of living can play a major role in requests for EAS, both in the absence and the presence of a severe disease. The high occurrence of symptoms in the absence of a classifiable severe disease implies that physical symptoms are prevalent in this group of patients, leaving the legal requirement for EAS of 'a medical cause' open to interpretation in the more complex medical practice.

Controversial choice of a control intervention in a trial of ventilator therapy in ARDS: standard of care arguments in a randomised controlled trial

When evaluating an innovative intervention in a randomised controlled trial (RCT), choosing an appropriate control intervention is necessary for a clinically meaningful result. An RCT reported in 2000 addressed the relative merits of two tidal volume ventilatory strategies, 6 ml/kg (innovative) and 12 ml/kg (control), in patients with acute respiratory distress syndrome. Critics claim that the 12 ml/kg volume did not represent the clinical practice standard at that time, and that lower tidal volumes had been used in some patients prior to randomisation. The trialists responded that current practice involved the use of a broad range of tidal volumes, including 12 ml/kg. Appropriate control interventions for RCTs can be ensured by: a systematic review of the relevant literature; a formal survey of expert clinicians; and publication of the proposed research protocol to solicit critical appraisal. A global survey of experts during the RCT's design stage would have been of probative value in determining the appropriate control tidal volume. Hypothetical, but plausible, results of such a survey are presented and examined to demonstrate the value of this method.

Evaluation of new treatments in radiation oncology: are they better than standard treatments?

CONTEXT

The superiority of innovative over standard treatments is not known. To describe accurately the outcomes of innovations that are tested in randomized controlled trials (RCTs) 3 factors have to be considered: publication rate, quality of trials, and the choice of the adequate comparator intervention.

OBJECTIVE

To determine the success rate of innovative treatments by assessing preferences between experimental and standard treatments according to original investigators' conclusions, determining the proportion of RCTs that achieved primary outcomes' statistical significance, and performing meta-analysis to examine if the summary point estimate favored innovative vs standard treatments.

DATA SOURCES

Randomized controlled trials conducted by the Radiation Therapy Oncology Group (RTOG).

STUDY SELECTION

All completed phase 3 trials conducted by the RTOG since its creation in 1968 until 2002. For multiple publications of the same study, we used the one with the most complete primary outcomes and with the longest follow-up information.

DATA EXTRACTION

We used the US National Cancer Institute definition of completed studies to determine the publication rate. We extracted data related to publication status, methodological quality, and treatment comparisons. One investigator extracted the data from all studies and 2 independent investigators extracted randomly about 50% of the data. Disagreements were resolved by consensus during a meeting.

DATA SYNTHESIS

Data on 12,734 patients from 57 trials were evaluated. The publication rate was 95%. The quality of trials was high. We found no evidence of inappropriateness of the choice of comparator. Although the investigators judged that standard treatments were preferred in 71% of the comparisons, when data were meta-analyzed innovations were as likely as standard treatments to be successful (odds ratio for survival, 1.01; 99% confidence interval, 0.96-1.07; P = .5). In contrast, treatment-related mortality was worse with innovations (odds ratio, 1.76; 99% confidence interval, 1.01-3.07; P = .008). We found no predictable pattern of treatment successes in oncology: sometimes innovative treatments are better than the standard ones and vice versa; in most cases there were no substantive differences between experimental and conventional treatments.

CONCLUSION

The finding that the results in individual trials cannot be predicted in advance indicates that the system and rationale for RCTs is well preserved and that successful interventions can only be identified after an RCT is completed.

The importance of preservation of the ethical principle of equipoise in the design of clinical trials: relative impact of the methodological quality domains on the treatment effect in randomized controlled trials

Previous research has identified methodological problems in the design and conduct of randomized trials that could, if left unaddressed, lead to biased results. In this report we discuss one such problem, inadequate control intervention, and argue that it can be by far the most important design characteristic of randomized trials in overestimating the effect of new treatments. Current guidelines for the design and reporting of randomized trials, such as the Consolidated Standards of Reporting Trials (CONSORT) statement, do not address the choice of the comparator intervention. We argue that an adequate control intervention can be selected if people designing a trial explicitly take into consideration the ethical principle of equipoise, also known as "the uncertainty principle."