Phase I trials in pediatric oncology: perceptions of pediatricians from the United Kingdom Children's Cancer Study Group and the Pediatric Oncology Group

End-of-Life Childhood Cancer Research: A Systematic Review

CONTEXT

Children with incurable cancer may participate in research studies at the end of life (EOL). These studies create knowledge that can improve the care of future patients.

OBJECTIVE

To describe stakeholder perspectives regarding research studies involving children with cancer at the EOL by conduct of a systematic review.

DATA SOURCES

We used the following data sources: Ovid Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science, and ProQuest (inception until August 2020).

STUDY SELECTION

We selected 24 articles published in English that examined perceptions or experiences of research participation for children with cancer at the EOL from the perspectives of children, parents, and health professionals (HPs).

DATA EXTRACTION

Two authors independently extracted data, assessed study quality, and performed thematic analysis and synthesis.

RESULTS

Eight themes were identified: (1) seeking control; (2) faith, hope, and uncertainty; (3) being a good parent; (4) helping others; (5) barriers and facilitators; (6) information and understanding; (7) the role of HPs in consent and beyond; and (8) involvement of the child in decision-making.

LIMITATIONS

Study designs were heterogeneous. Only one study discussed palliative care research.

CONCLUSIONS

Some families participate in EOL research seeking to gain control and sustain hope, despite uncertainty. Other families choose against research, prioritizing quality of life. Parents may perceive research participation as the role of a "good parent" and hope to help others. HPs have positive views of EOL research but fear that parents lack understanding of the purpose of studies and the likelihood of benefit. We identified barriers to research participation and informed consent.

Characteristics of parental decision-making for children with advanced cancer who are offered enrollment in early-phase clinical trials: A systematic review

Limited research is available on parental decision-making regarding their children's participation in pediatric phase I oncology trials compared with the adult population. The objectives of this review were to describe: (1) the process of parental decision-making in this situation; (2) the optimal communication features physicians need when proposing inclusion in such trials; and (3) the place of the child/adolescent in the assent process. Thirty relevant studies meeting inclusion criteria were identified by searching five computerized databases (PubMed, Web of Science, Cairn, Psychinfo, EM Premium). Parental decision-making is a complex process based on hopeful expectations, multiple family considerations and the child's previous cancer experience. It is highly impacted by the quality of physicians' communication. A therapeutic alliance along with an empathetic attitude and a timely delivery of accurate information is essential. Due weight should be given to the voice of children or adolescents and their optimal level of involvement may be discussed depending on their age and maturity. They should be given age-adapted information in order to empower them to be rightfully and meaningfully involved in early-phase research. This review highlights the main gaps and necessary remedial actions to support an optimal patient care management in this situation. Physicians' training in communication, structured interdisciplinary teamwork and early integration of palliative care are three key challenges which need to be implemented to actively engage in optimization strategies which would improve patient care and family support when offering enrollment in a phase I trial.

Parents', Health Care Professionals', and Scientists' Experiences of a Precision Medicine Pilot Trial for Patients With High-Risk Childhood Cancer: A Qualitative Study

PURPOSE

Children with high-risk cancers have low survival rates because current treatment options are limited. Precision medicine trials are designed to offer patients individualized treatment recommendations, potentially improving their clinical outcomes. However, parents' understanding is often limited, and expectations of benefit to their own child can be high. Health care professionals (HCPs) are often not familiar with precision medicine and might find managing families' expectations challenging. Scientists find themselves working with high expectations among different stakeholders to rapidly translate their identification of actionable targets in real time. Therefore, we wanted to gain an in-depth understanding of the experiences of all stakeholders involved in a new precision medicine pilot trial called TARGET, including parents, their child's HCPs, and the scientists who conducted the laboratory research and generated the data used to make treatment recommendations.

METHODS

We conducted semistructured interviews with all participants and analyzed the interviews thematically.

RESULTS

We interviewed 15 parents (9 mothers; 66.7% bereaved), 17 HCPs, and 16 scientists. We identified the following themes in parents' interviews: minimal understanding and need for more information, hope as a driver of participation, challenges around biopsies, timing, and drug access, and few regrets. HCP and scientist interviews revealed themes such as embracing new technologies and collaborations and challenges managing families' expectations, timing of testing and test results, and drug access.

CONCLUSION

Educating families, HCPs, and scientists to better understand the benefits and limitations of precision medicine trials may improve the transparency of the translation of discovery genomics to novel therapies, increase satisfaction with the child's care, and ameliorate the additional long-term psychosocial burden for families already affected by high-risk childhood cancer.

Well-Being of Child and Family Participants in Phase 1 Pediatric Oncology Clinical Trials

PROBLEM IDENTIFICATION

Pediatric oncology phase 1 clinical trials (P1Ts) are essential to developing new anticancer therapies; however, they raise complex ethical concerns about balancing the need for this research with the well-being of participating children. The purpose of this integrative review was to synthesize and appraise the evidence of how P1T participation, which begins with consent and ends with the transition off the P1T, can affect the well-being (either positively or negatively) of children with cancer. The Resilience in Individuals and Families Affected by Cancer Framework, which has an outcome of well-being, was used to synthesize findings.

LITERATURE SEARCH

Articles on the experiences of child (n = 21) and adult (n = 31) P1T participants were identified through systematic searches.

DATA EVALUATION

Articles were evaluated on rigor and relevance to P1T participant experiences as high, medium, or low.

SYNTHESIS

Minimal empirical evidence was found regarding the effect of P1T participation on the well-being of children with cancer. Adult P1T participant experiences provide insights that could also be important to children's P1T experiences.

IMPLICATIONS FOR PRACTICE

To achieve a balanced approach in P1T consent discussions, nurses and healthcare providers who work with children considering participation in a P1T should share the potential effect of participation on participants' well-being.

Parental Experiences of Child Participation in a Phase I Pediatric Oncology Clinical Trial: "We Don't Have Time to Waste"

Children with cancer are only eligible for phase I clinical trials (P1Ts) when no known curative therapy remains. However, the primary aims of P1Ts are not focused on directly benefiting participants. This raises ethical concerns that can be best evaluated by exploring the experiences of participants. An empirical phenomenology study, using an adapted Colaizzi method, was conducted of 11 parents' lived experiences of their child's participation in a pediatric oncology P1T. Study findings were that parents' experiences reflected what it meant to have a child fighting to survive high-risk cancer. Although elements specific to P1T participation were identified, more pervasive was parents' sense of running out of time to find an effective treatment and needing to use time they had with their child well. Even though some problems were identified, overall parents did not regret their child's P1T participation and would recommend P1Ts to other parents of children with cancer.

Physician perspectives on compassionate use in pediatric oncology

BACKGROUND

Targeted cancer treatments are almost always first studied in adults, even when there is a biologically plausible potential for efficacy in children. Through compassionate use programs, children who are not eligible for a clinical trial and for whom there are no known effective therapies may obtain access to investigational agents, including drugs under development for adults. However, little is known about pediatric oncologists' experiences with applying for and obtaining compassionate use agents.

METHODS

This study surveyed 132 pediatric oncologists to assess awareness and utilization of compassionate use programs, to identify barriers to their use, and to evaluate available institutional support and resources.

RESULTS

We found that the process of applying for access to drugs in development is poorly understood, which presents a barrier to obtaining investigational drugs. Fifty-seven percent of the pediatric oncologists applied for compassionate use. Providers from larger institutions or with more than 15 years of clinical experience were more likely to complete an application and obtain investigational agents for their patients.

CONCLUSION

Identified perceived and actual barriers to compassionate use application submission suggest pediatric oncologists may benefit from educational resources and support to ensure children with cancer equal access to investigational agents and care.

Strategies to facilitate shared decision-making about pediatric oncology clinical trial enrollment: A systematic review

OBJECTIVE

We conducted a systematic review to identify the strategies that have been recommended in the literature to facilitate shared decision-making regarding enrolment in pediatric oncology clinical trials.

METHODS

We searched seven databases for peer-reviewed literature, published 1990-2017. Of 924 articles identified, 17 studies were eligible for the review. We assessed study quality using the 'Mixed-Methods Appraisal Tool'. We coded the results and discussions of papers line-by-line using nVivo software. We categorized strategies thematically.

RESULTS

Five main themes emerged: 1) decision-making as a process, 2) individuality of the process; 3) information provision, 4) the role of communication, or 5) decision and psychosocial support. Families should have adequate time to make a decision. HCPs should elicit parents' and patients' preferences for level of information and decision involvement. Information should be clear and provided in multiple modalities. Articles also recommended providing training for healthcare professionals and access to psychosocial support for families.

CONCLUSION

High quality, individually-tailored information, open communication and psychosocial support appear vital in supporting decision-making regarding enrollment in clinical trials. These data will usefully inform future decision-making interventions/tools to support families making clinical trial decisions.

PRACTICE IMPLICATIONS

A solid evidence-base for effective strategies which facilitate shared decision-making is needed.

Enrollment in early-phase clinical trials in pediatric oncology: The experience at Institut Curie

BACKGROUND

The European Paediatric Regulation was introduced in 2007 to facilitate access to new medicines for children. Our study explored accessibility of early-phase trials in pediatric oncology, in line with the European Paediatric Regulation, to identify the reasons for not inviting patients to participate, parents' refusal, or inclusion failure.

PROCEDURE

We conducted a retrospective chart review at Institut Curie, Paris, for all pediatric patients whose cancer progressed despite known effective treatments between July 2010 and December 2013.

RESULTS

Out of 100 patients in the palliative phase, 52 received one or more invitations to participate in early-phase trials. Twenty parents declined the invitation, mainly prioritizing quality of life or fearing constraints. Fourteen inclusions failed despite parental approval, mostly due to rapid clinical deterioration. Five patients received no invitations because no early-phase trials were available. Major reasons for noninclusion in the 43 remaining patients were presence of exclusion criteria or other physical factors, preference for conventional treatment, constraints, psychological factors, and follow-up in another hospital after moving.

CONCLUSIONS

The Paediatric Regulation has led to increased availability of early-phase trials. Better timing of the proposal, designing less constraining early-phase trials, reducing waiting lists, and improving information for parents and children would facilitate pediatric access to new medicines.

Physician and nurse beliefs of phase 1 trials in pediatric oncology

BACKGROUND

In order to improve the survival of children with cancer, novel therapies must be identified. Promising agents are tested in phase 1 trials in order to identify appropriate dosing and describe toxicity in children. The identification and referral of candidate patients for phase 1 trials rely heavily on medical providers who must balance their own perceptions of phase 1 trials with the desires and willingness of the patient and his/her family.

OBJECTIVE

The goal of the present study was to evaluate and compare physician and nurse perceptions regarding the beliefs, expectations, and perceived benefits of phase 1 clinical trials.

METHODS

A survey consisting of 21 questions was sent to 419 physicians and nurses practicing pediatric oncology at 30 different institutions. With the exception of 10 demographic questions, items were either rank ordered or rated on 5-point Likert scales.

RESULTS

Ninety-four physicians and 122 nurses completed the online survey. Physicians and nurses differed in their knowledge of the goals and medical effects of phase 1 clinical trials.

CONCLUSIONS

Physicians and nurses hold positive beliefs regarding phase 1 clinical trials and support their role in the treatment of children with cancer. Education is necessary to increase nurses' knowledge of the goals and outcomes.

IMPLICATIONS FOR PRACTICE

These findings suggest that continued education of nurses as well as physicians about the goals, execution, and monitoring of phase 1 therapy would be worthwhile.

Investigating the Experiences of Childhood Cancer Patients and Parents Participating in Optional Nontherapeutic Clinical Research Studies in the UK

BACKGROUND

While the majority of childhood cancer clinical trials are treatment related, additional optional research investigations may be carried out that do not directly impact on treatment. It is essential that these studies are conducted ethically and that the experiences of families participating in these studies are as positive as possible.

METHODS

A questionnaire study was carried out to investigate the key factors that influence why families choose to participate in optional nontherapeutic research studies, the level of understanding of the trials involved, and the experiences of participation.

RESULTS

A total of 100 participants from six UK centers were studied; 77 parents, 10 patients >16 years, and 13 patients aged 8-15 years. Ninety-seven percent of parents and 90% of patients felt that information provided prior to study consent was of the right length, with 52% of parents and 65% of patients fully understanding the information provided. Seventy-four percent of parents participated in research studies in order to "do something important", while 74% of patients participated "to help medical staff". Encouragingly, <5% of participants felt that their clinical care would be negatively affected if they did not participate. Positive aspects of participation included a perception of increased attention from medical staff. Negative aspects included spending longer periods in hospital and the requirement for additional blood samples. Ninety-six percent of parents and 87% of patients would participate in future studies.

CONCLUSIONS

The study provides an insight into the views of childhood cancer patients and their parents participating in nontherapeutic clinical research studies. Overwhelmingly, the findings suggest that participation is seen as a positive experience.

Nurses’ Perceptions of Phase I Clinical Trials in Pediatric Oncology: A Review of the Literature

A review of literature was conducted to explore nurses’ perceptions of phase I clinical trials in pediatric oncology. Specifically, nurses’ perceptions of the goals and outcomes, the nurse’s role, and the informed consent process in pediatric oncology phase I clinical trials were investigated. Findings on possible factors influencing the nurses’ perceptions and the quality of work-life of nurses working at pediatric phase I clinical trial centers were also searched. However, despite an extensive review of published works, no studies on nurses’ perceptions of phase I trials in pediatric oncology were found. Therefore, this literature review consists of findings in similar or related studies such as nurses’ perceptions of experimental therapies in the adult setting, adult patients’ perceptions, parents’ perceptions, or oncologists’perceptions of phase I clinical trials.

Innovations for phase I dose-finding designs in pediatric oncology clinical trials

Phase I oncology clinical trials are designed to identify the optimal dose that will be recommended for phase II trials. In pediatric oncology, the conduct of those trials raises specific challenges, as the disease is rare with limited therapeutic options. In addition, the tolerance profile is known from adult trials. This paper provides a review of the major recent developments in the design of these trials, inspired by the need to cope with the specific challenges of dose finding in cancer pediatric oncology. We reviewed simulation studies comparing designs dedicated to address these challenges. We also reviewed the design used in published dose-finding trials in pediatric oncology over the period 2009-2014. Three main fields of innovation were identified. First, designs that were developed in order to relax the rules for more flexible inclusions. Second, methods to incorporate data emerging from adult studies. Third, designs accounting for toxicity evaluation at repeated cycles in pediatric oncology. In addition to this overview, we propose some further directions for designing pediatric dose-finding trials.

Does phase 1 trial enrollment preclude quality end-of-life care? Phase 1 trial enrollment and end-of-life care characteristics in children with cancer

BACKGROUND

End-of-life care (EOLC) discussions and treatment-related decisions, including phase 1 trial enrollment, in patients with incurable disease are complex and can influence the quality of EOLC received. The current study was conducted in pediatric oncology patients to determine whether end-of-life characteristics differed between those who were and were not enrolled in a phase 1 trial.

METHODS

The authors reviewed the medical records of 380 pediatric oncology patients (aged <22 years at the time of death) who died during a 3.5-year period. Of these, 103 patients with hematologic malignancies were excluded. A total of 277 patients with a diagnosis of a brain tumor or other solid tumor malignancy were divided into 2 groups based on phase 1 trial enrollment: a phase 1 cohort (PIC; 120 patients) and a non-phase 1 cohort (NPIC; 157 patients). The EOLC characteristics of these 2 cohorts were compared using regression analysis and chi-square testing.

RESULTS

A comparison of patients in the PIC and NPIC revealed no significant differences in either demographic characteristics (including sex, race, religious affiliation, referral origin, diagnosis, or age at diagnosis, with the exception of age at the time of death [P =.03]) or in EOLC indices (such as use or timing of do not attempt resuscitation orders, hospice use or length of stay, forgoing life-sustaining therapies, location of death, time from first EOLC discussion to death, and total number of EOLC discussions).

CONCLUSIONS

The results of the current study of a large cohort of deceased pediatric cancer patients indicate that enrollment on a phase 1 trial does not affect EOLC characteristics, suggesting that quality EOLC can be delivered regardless of phase 1 trial participation.

Patients in pediatric phase I and early phase II clinical oncology trials at Gustave Roussy: a 13-year center experience

In the European Union, the pediatric medicines regulation in 2007 modified significantly the access to new agents in pediatric oncology. Early oncology trials are still thought to be associated with limited benefit and substantial risk. We report the characteristics and outcome of patients below 21 years enrolled in investigational trials in the Pediatric and Adolescent Department at Gustave Roussy between January 2000 and December 2012. A total of 235 patients (median age, 10.4 [0.8 to 20.7] y) were included in 26 trials (16 cytotoxic and 10 targeted agents) for a total of 260 inclusions. A total of 117 patients (50%) had brain tumors and 68 (29%) had various soft tissue and bone sarcoma. Thirteen of the 106 patients in a phase I trial experienced dose-limiting toxicity. Main severe toxicity was hematologic; none had toxic death. Grade 3 to 4 toxicities were associated with combination trials, cytotoxic agent, and at least 1 previous line of therapy. Thirty patients (12%) had objective response and 42 (16%) had stable disease for >4 months. Median overall survival was 9.0 months (95% CI, 7.5-10.5) and 73% of patients received further anticancer treatment. Phase I to II pediatric oncology trials are safe, associated with clinical benefit, and can be successfully integrated in current relapse strategies.

Physician perceptions and beliefs of phase I trials in pediatric oncology

The identification and referral of candidate patients for phase I trials relies heavily on pediatric oncologists who must balance their own perceptions of phase I trials with the desires of the patient and his/her family. A survey was sent to 419 physicians practicing pediatric oncology at 30 different institutions. Results indicated significant differences between physicians who practiced at institutions that participated in phase I consortia versus those who did not. The findings of the survey may be used to enhance the design and execution of phase I trials and to educate oncologists about the goals of phase I trials.

Communicating and understanding the purpose of pediatric phase I cancer trials

PURPOSE

Quality informed consent should provide a clear understanding of the purpose of the research. Given the ethical challenges of pediatric phase I cancer trials, it is important to investigate physician-parent communication during informed consent conferences (ICCs) and parental understanding of the purpose of these studies.

METHODS

In the multisite Informed Consent in Pediatric Phase I Cancer Trials study, 85 ICCs for phase I research between June 2008 and May 2011 were directly observed, and 60 parents were subsequently interviewed. The scientific purpose was defined as composite understanding of drug safety, dose finding, and dose escalation. We determined the frequency with which physicians explained these and other phase I-related concepts during the ICC. Parent interviews were analyzed to determine understanding.

RESULTS

The child was present at 83 of 85 ICCs. Only 32% of parents demonstrated substantial understanding of the scientific purpose of phase I cancer trials; 35% demonstrated little or no understanding. Parents of higher socioeconomic status and racial majority status were more likely to understand the scientific purpose. Factors associated with understanding included physician explanation of the goal of the applicable phase I protocol offered (explained in 85% of ICCs) and explanation of the dose cohorts (explained in 43% of ICCs). Physicians explained drug safety in 23% of ICCs, dose finding in 52% of ICCs, and dose escalation in 53% of ICCs.

CONCLUSION

Many parents of children participating in phase I trials do not understand the purpose of these trials. Physician-parent communication about the purpose of phase I research is lacking during ICCs.

Ethical issues in health research in children

Health research is a moral duty because it is the foundation for evidence-based care by all health care practitioners. Specific Canadian policies and regulations govern the conduct of human research; ethics review of research is required before research is conducted. Research in children poses important challenges with regard to informed consent and assent, vulnerability and potential conflicts of interest (COI). Paediatric health researchers should advocate for research participation by children, while being attentive to mitigating risks.

Informed consent for pediatric phase 1 cancer trials: physicians' perspectives

BACKGROUND

This study was conducted to gather pediatric oncologists' opinions about and suggestions for improvement of informed consent (IC) in pediatric phase 1 cancer trials.

METHODS

A questionnaire designed to elicit perspectives was distributed to 146 physicians at 6 participating institutions. A total of 103 completed surveys were returned for a 71% response rate.

RESULTS

Pediatric oncologists believe providing information so families can decide about phase 1 study entry is the most important goal of the IC process (ICP). The majority of physicians (64%) report that they describe the phase 1 study without any attempt to influence parents' decisions. Several answers provided by physicians were associated with their gender and prior IC training. Male physicians were significantly more likely to endorse the no-attempt-to-influence approach, whereas female physicians were more likely to suggest to parents that other children will benefit from what is learned in phase 1 studies. Responses to an open-ended question provided 63 suggestions for improvement of the ICP, including document and training changes and tools to enhance physician-family communication.

CONCLUSIONS

Pediatric oncologists tended to present phase 1 trials as an option rather than a strong recommendation and were reluctant to influence decisions of families about these studies. They believe most but not all parents understand key concepts involved in consent to this type of research, and had ample suggestions for how to improve the ICP. Future research and education efforts around this ethically challenging topic were warranted.

The ethics of phase 0 oncology trials

Recent guidance from the Food and Drug Administration supports the conduct of a new type of exploratory clinical trial, commonly called phase 0 clinical trials. Proponents argue that phase 0 clinical trials have the potential to expedite the development of new oncology drugs while exposing fewer research subjects to the risks of experimental treatments. At the same time, phase 0 oncology trials raise important ethical concerns that have received little attention. In particular, there is a question of whether it is ethical to enroll individuals in research that offers them no potential for clinical benefit. Further concern focuses on the inclusion of terminally ill and consequently vulnerable cancer patients in these trials. To evaluate these concerns, this article considers relevant empirical data from phase 1 oncology trials and develops several recommendations regarding the conduct of phase 0 clinical trials in oncology.

An exploratory survey of nurses' perceptions of phase I clinical trials in pediatric oncology

This study suggests that nurses' perceptions of pediatric oncology phase I clinical trials are diverse and mixed but are more likely to be positive than negative. Improving future treatments, medical benefit, improved quality of life, and hope were cited as potential benefits of phase I clinical trials, but nurses felt that families were hoping for a cure. Toxicities, false hope, and decreased quality of life were perceived as potential negative outcomes. Acting as a patient advocate was viewed as the most important nursing role, and providing information was identified to be the most important purpose of informed consent. Although not statistically significant, data suggest that age, experience, and practice setting may influence nurses' perceptions. Younger or less experienced nurses were more likely to report either positive or negative perceptions, whereas older or more experienced nurses expressed mixed or moderate perceptions. Inpatient nurses reported more negative perceptions compared with outpatient nurses. The respondents report that caring for patients on phase I had both positive and negative effects on their quality of nursing work life.

Phase I research and the meaning of direct benefit

In this article, I examine whether Phase I pediatric oncology trials offer "the prospect of direct benefit," a concept found in Subpart D of the Code of Federal Regulations (CFR), the guidelines that provide additional protections to pediatric research subjects. In research that offers the prospect of direct benefit, children can be exposed to greater risk than in other research and their dissent can be overridden. I argue that Phase I trials do not offer the prospect of direct benefit and classifying them as if they do fails to acknowledge the moral relevance of the researchers' intent. In Subpart D, research that does not provide the prospect of direct benefit can be approved locally if it does not expose the children to more than a minor increase over minimal risk. If the risks are greater, the research must be approved nationally. To avoid the need for national review for Phase I oncology trials, I propose a new research category that incorporates the concept of "secondary direct benefit." In this category, the child's dissent would be dispositive. This new category would improve the protections provided to children by incorporating intentions into Subpart D, the absence of which is a serious flaw in our current regulatory schema.

End-of-life care preferences of pediatric patients with cancer

PURPOSE

The viewpoint of the terminally ill child at the time of an end-of-life decision has not been formally investigated. We identified the preferences of children and adolescents with advanced cancer about their end-of-life care and the factors that influenced their decisions.

PATIENTS AND METHODS

Pediatric patients 10 or more years of age were interviewed within 7 days of participating in one of the following three end-of-life decisions: enrollment onto a phase I trial (n = 7), adoption of a do not resuscitate order (n = 5), or initiation of terminal care (n = 8). The patient, a parent, and the primary pediatric oncologist were interviewed separately by using open-ended interview questions.

RESULTS

Twenty patients, aged 10 to 20 years (mean, 17 years and 4 months), with a refractory solid tumor (n = 12), brain tumor (n = 4), or leukemia (n = 4) participated. Eighteen patients (90%) accurately recalled all of their treatment options and identified their own death as a consequence of their decision. The factors that were most frequently identified included the following: for patients, caring about others (n = 19 patients); for parents, the child's preferences (n = 18 parents); and for physicians, the patient's prognosis and comorbid conditions (n = 14 physicians).

CONCLUSION

These children and adolescents with advanced cancer realized that they were involved in an end-of-life decision, understood the consequences of their decision, and were capable of participating in a complex decision process involving risks to themselves and others. The decision factors most frequently reported by patients were relationship based; this finding is contrary to existing developmental theories.

Confronting the Issues of Therapeutic Misconception, Enrollment Decisions, and Personal Motives in Genetic Medicine-Based Clinical Research Studies for Fatal Disorders

Genetic medicine-based therapies have unlocked the potential for ameliorating diseases previously considered inevitably fatal. Inherent in the clinical trials of genetic medicines are ethical issues of therapeutic misconception, enrollment decisions as they relate to the risks and benefits of research, and the complex relationships among funding sources, investigators, and the families of affected individuals. The purpose of this paper is to help define these complex issues relevant to the use of genetic medicines and to describe the strategy we have used to confront these issues in a phase I trial of adeno-associated virus-mediated gene transfer to the central nervous system of children with late infantile neuronal ceroid lipofuscinosis (LINCL), a fatal lysosomal storage disease associated with progressive neurodegeneration and death by mid-childhood. Our approach to these challenges should provide a useful paradigm for investigators initiating other genetic medicine- based studies to treat inevitably fatal diseases.

Parents' views of their children's participation in phase I oncology clinical trials

Data from two descriptive studies regarding decision making in pediatric oncology were analyzed using qualitative, secondary analysis techniques to describe how parents view their children's participation in phase I oncology clinical trials. A conceptual framework on family management styles (defining, managing, and consequence themes) was used as an organizational framework to analyze the available parental data. Parents defined or viewed their situation in relationship to their choices and expectations, health care provider expectations, children's illness situation, and family and personal situations. These themes are contrasted to clinical, parental, and ethical perspectives from the literature to make recommendations for further research emphasizing the concerns of families.

Ethical approval for multicentre clinical trials in children. Contrasting systems in three European countries

Pan-European collaboration in studies of novel therapies and treatment strategies in childhood cancer is playing an increasing role in the attempt to improve cure rates. Differences in the systems of various countries with regard to drug control and ethical issues may lead to problems and delays. This applies in particular to phase I/II studies in children where the ethical considerations may be complex. In this review, the systems in three large countries-UK, France and Germany-are reviewed and current moves within the European Community towards a more standard approach are discussed.

Quality-of-life-adjusted survival analysis of high-dose adjuvant interferon alpha-2b for high-risk melanoma patients using intergroup clinical trial data

PURPOSE

High-dose adjuvant interferon alpha-2b (IFN alpha 2b) for high-risk melanoma is a 1-year regimen that improves relapse-free and overall survival but has significant toxicity. A quality-of-life--adjusted survival (QAS) analysis analysis of two cooperative group phase III trials, E1684 and E1690/S9111/C9190, was performed, incorporating patient values (utilities) for the toxicity of IFN alpha 2b treatment and melanoma recurrence.

PATIENTS AND METHODS

Quality-Adjusted Time Without Symptoms or Toxicity methodology was used with melanoma patient utilities and trial data to estimate the effect of IFN alpha 2b on QAS. The increase or decrease in QAS that patients could expect from treatment was estimated based on their utilities. Eleven utility predictor questions were tested to identify patients with utilities that result in decreased QAS.

RESULTS

Using E1684 data, IFN alpha 2b would result in an increase in QAS for all sets of patient utilities. This benefit was significant (P <.05) for 16% of patients. Using E1690/S9111/C9190 data, 77% of patients would experience a benefit in QAS from IFN alpha 2b and 23% would experience a decrease in QAS; neither of these effects was statistically significant. Using utility predictors and the E1690/S9111/C9190 analysis, a decision rule was formulated that helps identify patients in whom IFN alpha 2b may detract from QAS.

CONCLUSION

Most patients experienced improvement in QAS in both trials, but this benefit was statistically significant in only 16% of patients in E1684. Change in QAS depends more on the utility for IFN alpha 2b toxicity than on the utility for melanoma recurrence. Cancer patients probably have higher utilities for IFN alpha 2b toxicity than members of the general population and will tend to favor IFN alpha 2b treatment as a result.

[Patients' rights during medical research and specifics in oncology (in France)]

PURPOSE

Clinical research in oncology is part of the care, instead of being theoretical, because it can offer new drugs to patients who are suffering from severe illnesses, but also because it offers better practices. The vulnerability of patients suffering from cancers, at each stage of the disease, requires special protection. Because of its multiple aspects, clinical research in oncology asks ethical questions. Medical deontology and laws, national and supranational, allow research with respect to the subject. The present article reviews these texts.

CURRENT KNOWLEDGE AND KEY POINTS

The rights of the person involved in clinical trials essentially consist of information and consent, but also the right to refuse, and the confidentiality of data collected. More subtle rights are now emerging because of new technologies, such as genetics. One of them is the right to be protected as a member of the human race, which is in continuity with human rights.

FUTURE AND PROJECTS

Finally, medical responsibility during research is increasing. It responds to the right of each person to see that his dignity is respected, although this dignity may be difficult to define. One of the more pertinent questions in building 'evidence-based ethics' concerns research into the evaluation by the persons themselves involved in the research.

Developmental therapeutics in childhood cancer. A perspective from the Children's Oncology Group and the US Food and Drug Administration

Drug development in pediatric oncology has been reviewed, concentrating on overall development issues and COG studies of cytotoxic compounds. A variety of interesting molecules with more specific targeting are becoming available. The challenges that remain include the availability of such compounds for pediatric trial and their study in a timely fashion, and the subsequent incorporation of the new agents into more up-front regimens, with the ultimate shared goal of curing more children with less toxicity.

Ethical issues in research and innovative therapy in children with mood disorders

Research involving children with mood disorders should generally offer a reasonable prospect of benefit to those involved, unless the risks are minimal. While federal regulations require a prospect of direct benefit, from an ethical perspective indirect benefits, such as the advantages of being in a clinical trial, are relevant. Standard care should not be presumed to be preferable to treatment in the context of a clinical trial, particularly if it has not been evaluated in well designed studies involving groups comparable to the patient. Similarly, active treatments in a controlled trial should not be presumed to be preferable to placebos, particularly in studies involving mood disorders where the placebo effect is more likely to be substantial. Innovative therapy-using approved drugs for unapproved purposes-may be more problematic than research, on theoretical and empirical grounds. Studies with no prospect of direct benefit and more than minimal risk are problematic when the patient is incompetent to provide meaningful consent. Whether or not a controlled trial involving children with mood disorders can be ethically justified depends on several factors, including the validity of standard treatment, the seriousness of the disorder, the likelihood of adverse consequences if treatment is delayed, the burden of the proposed intervention, and value judgments by parents, working collaboratively with a caring physician.