Clinical trials: time for action

Global Breast Cancer Research: Moving Forward

Breast cancer is a major global health problem and major cause of mortality. Although mortality trends are declining in high-income countries, trends are increasing in low- and middle-income countries (LMICs). Addressing global breast cancer research is a challenging endeavor, as notable disparities and extremely heterogeneous realities exist in different regions across the world. Basic global cancer health care needs have been addressed by the World Health Organization's (WHO) proposed list of essential medicines and by resource-stratified guidelines for screening and treatment. However, specific strategies are needed to address disparities in access to health care, particularly access to new therapies. Discussions about global research in breast cancer should take into account the ongoing globalization of clinical trials. Collaboration fostered by well-established research organizations in North America and Europe is essential for the development of infrastructure and human resources in LMICs so that researchers in these countries can begin to address regional questions. Specific challenges that impact the future of global breast cancer research include increasing the availability of trials in LMICs, developing strategies to increase patient participation in clinical trials, and creation of clear guidelines for the development of real-world evidence-based research. The main objective of this review is to encourage the discussion of challenges in global breast cancer research with the hope that collectively we will be able to generate workable proposals to advance the field.

Patient perceptions concerning clinical trials in oncology patients

Background

Clinical trials are critical to scientifically evaluate promising new therapies in oncology, but patient accrual to these studies is persistently low. Patient preference plays an important role in enrollment in these trials. We performed this survey to evaluate the perceptions of newly diagnosed oncology patients about clinical trials and the reasons why they wish to or not to participate in these trials.

Methods

Patients were given a ten question survey reflective of their attitudes regarding clinical trials as a treatment option at their initial visit. The self-directed questionnaire was scored on an ordinate scale from strongly agree [1] to strongly disagree [5].

Results

Ninety three patients were surveyed in the cancer specific multispecialty clinics in an academic center. Our patients expected their providers to discuss all information relating to clinical trials and eligibility at the first visit (65.4% agree and 15.4% neutral, p < 0.0001). Patients felt their privacy and safety would be safeguarded in the University sponsored trials (56.8% agree, and 25.7% neutral, p < 0.0001). Over 80% patients showed their unwillingness to participate in randomized clinical trials (disagree 61%, neutral 19.5%, p < 0.001). Patients also showed less likelihood to participate in clinical trials as a first treatment option (48.7% disagree and 28.9% neutral, p0.0161), but were willing to consider participating in a clinical trial if the conventional treatment failed. Industry sponsored trials, phase 1 trials, investigator initiated trials with the involved tests and time commitment and altruistic reasons did not significantly deviate from the mean preference analyzed using Fisher's exact test analysis.

Conclusions

Patients consider the option of clinical trials as important in their treatment, and expect to be informed by their oncologist about such trials. Newly diagnosed cancer patients perceive randomization and first line trials negatively. Since randomization data provides new standards of care and hope for improved treatment, patients and their families must be educated of their importance.

Patient preferences for oropharyngeal cancer treatment de-escalation

BACKGROUND

The excellent prognosis of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinomas (SCCs) against severe chemoradiotherapy (CRT) toxicities has opened discussion of deintensification trials. The purpose of this study was to describe the perspective of patients with HPV-positive and HPV-negative disease toward such studies.

METHODS

Fifty-one patients with oropharyngeal SCC (post-CRT) underwent semistructured interviews contrasting toxicities of radiotherapy (RT) alone and CRT. Patients were asked what potential difference in cancer survival was acceptable to prefer RT over CRT. Initially, survival rate was the same for both treatments, then the RT rate was reduced until the preference switched. Treatment experience and preference for deintensified CRT were collected.

RESULTS

Ninety-percent of patients initially selected RT, but 69% switched to CRT after 0% to 5% reduction in survival. Patients that rated their treatment experience as mild would accept lower survival versus severe treatment (p = .02). Eighty-one percent of patients (33 of 40) indicated they preferred reduced chemotherapy in CRT.

CONCLUSION

Patients accept little difference in survival between treatments to avoid toxicity.

Bridging the gap between basic science and clinical practice: a role for community clinicians

BACKGROUND

Translating the extraordinary scientific and technological advances occurring in medical research laboratories into care for patients in communities throughout the country has been a major challenge. One contributing factor has been the relative absence of community practitioners from the US biomedical research enterprise. Identifying and addressing the barriers that prevent their participation in research should help bridge the gap between basic research and practice to improve quality of care for all Americans.

METHODS

We interviewed over 200 clinicians and other healthcare stakeholders from 2004 through 2005 to develop a conceptual framework and set of strategies for engaging a stable cadre of community clinicians in a clinical research program.

RESULTS

Lack of engagement of community practitioners, lack of necessary infrastructure, and the current misalignment of financial incentives and research participation emerged as the three primary barriers to community clinician research participation. Although every effort was made to learn key motivators for engagement in clinical research from interviewees, we did not observe their behavior and self-report by clinicians does not always track with their behavior.

CONCLUSIONS

A paradigm shift involving acknowledgement of the value of clinicians in the context of community research, establishment of a stable infrastructure to support a cohort of clinicians across time and research studies, and realignment of incentives to encourage participation in clinical research is required.

Bridging the gap between basic science and clinical practice: the role of organizations in addressing clinician barriers

Background

New National Institutes of Health policies call for expansion of practice-based research to improve the clinical research enterprise and facilitate dissemination of evidence-based medicine.

Objective

This paper describes organizational strategies that influence clinicians' decisions to participate in clinical research.

Design

We reviewed the literature and interviewed over 200 clinicians and stakeholders.

Results

The most common barriers to community clinician participation in clinical research relate to beliefs that clinical research is too burdensome and has little benefit for the participating clinician or patient. We identified a number of approaches healthcare organizations can use to encourage clinicians to participate in research, including an outreach campaign to promote the benefits of clinical research; selection of study topics of interest to clinicians; establishment and enforcement of a set of research principles valuing the clinician and patient; development of a transparent schedule of reimbursement for research tasks; provision of technological and technical assistance to practices as needed; and promotion of a sense of community among clinicians involved in practice-based research.

Conclusions

Many types of existing healthcare organizations could provide the technical and intellectual assistance community clinicians need to participate in clinical research. Multiple approaches are possible.

Seven-year follow-up of patients receiving imatinib for the treatment of newly diagnosed chronic myelogenous leukemia by the TARGET system

The TARGET system is an online database that can be easily accessed by physicians. The registration of one's own chronic myeloid leukemia (CML) patients in the TARGET system makes it possible to share experiences among physicians, and, thus, may facilitate appropriate treatment for patients. Patients were registered in the TARGET system from October 2003 to March 2010 in Japan. A total of 1236 patients from 176 hospitals were registered in Japan. We analyzed data from 639 CML chronic phase patients not receiving prior therapy registered in this system. After 90 months follow-up, high survival rates were demonstrated for imatinib-treated newly diagnosed CML patients, with event-free survival (EFS), progression-free survival (PFS), and overall survival (OS) rates of 79.1, 94.8, and 95.1%, respectively. A landmark analysis of 296 patients who showed a complete cytogenetic response (CCyR) at 12 months after the initiation of imatinib treatment revealed that, at 90 months, 99% of patients (95% CI, 98-100) had not progressed to accelerated phase (AP) or blastic crisis (BC). The patients showing a CCyR and a reduction of at least 3log levels of BCR-ABL transcripts after 18 months of treatment had an estimated survival rate without CML progression of 100% at 84 months. The probability of achieving undetectable BCR-ABL in patients by 72 months with an major molecular response (MMR) at 12 months was 86.5%, compared with 64.7% for those without an MMR (p < 0.0001). There were no new safety issues. In summary, based on this 7-year TARGET analysis, imatinib showed a continual clinical benefit as first-line therapy for newly diagnosed CML. The TARGET system may represent a more practical and general feature compared with the IRIS study.

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.

Implementation of a research awareness program in the critical care unit: effects on families and clinicians

BACKGROUND

Successful conduct of research studies in the critically ill requires communication with families, substitute decision-makers and clinicians.

OBJECTIVE

To assess the effect of a communication package on attitude, knowledge and research awareness among family members and clinicians.

METHODS

We conducted a prospective, single centre, before and after study. We distributed a validated questionnaire to family members and clinicians assessing the three domains of research attitude, knowledge and awareness before and after implementation of a research communication package consisting of an informational pamphlet and display poster.

RESULTS

Response rates for the family member survey were 22% (baseline) and 15% (post-intervention). No differences were found in the attitude, knowledge and awareness of family members following implementation of the research communication package. The global awareness score (calculated by summing the domain responses) rose 4.0 points (P=0.056). Response rates for clinicians were 36% (baseline) and 33% (post-intervention). No differences were found in attitude, knowledge and awareness and global awareness score.

CONCLUSION

Passive dissemination of research materials was not sufficient to generate an increased awareness, knowledge, or perceived utility of research.

Clinical trial priorities among surgeons caring for breast cancer patients

BACKGROUND

Designing and prioritizing successful clinical trials benefits from increased community physician input. We surveyed practicing surgeons about current controversies in breast cancer surgery, reported practices of discussing trial participation, and perceived obstacles to trial participation.

METHODS

A 44-question survey was mailed in 2005-2006 to 2,187 randomly selected American College of Surgeons members actively seeing breast cancer patients. Responses were analyzed by surgeon sex, practice type, oncology training, professional society membership, and breast cancer patient volume.

RESULTS

A total of 923 responses were received, with 460 eligible responses remaining for analysis. Most surgeons infrequently or never discuss trial participation with breast cancer patients. Inadequate infrastructure presents the greatest physician obstacle to trial participation. Identifying proven indications for completion axillary dissection after positive sentinel node biopsy marks the highest-ranked research priority for surgeons providing breast care.

CONCLUSIONS

Understanding topics of interest among practicing surgeons and addressing common obstacles to trial participation may result in improved breast cancer patient accrual through surgeons.

What constitutes a "clinical trial"?: a survey of oncology professionals

Background

What constitutes a "clinical trial" is inconsistently defined in the medical literature. With an initiative by Cancer Care Ontario (CCO) to report institutional clinical trials activity across the province of Ontario, Canada, we sought to investigate the variability in the interpretation of the term by local oncology professionals.

Methods

A survey amongst the physicians and nurses at the Juravinski Cancer Centre at Hamilton Health Sciences, Ontario was conducted. The survey included 12 summaries of local clinical research studies, and respondents were asked which they believed represented a clinical trial. Subsequently, they were asked which of the same 12 studies they believed should be labeled as clinical trials when considering separate definitions provided by CCO and by the Ontario Cancer Research Network (OCRN).

Results

A total of 66 (54%) of 123 surveys were completed; 32/46 (70%) by physicians, 21/59 (36%) by primary care nurses, and 13/18 (72%) by clinical trial nurses. Without a standardized definition, all studies, 12/12, were considered to be clinical trials by at least 50% of respondents. When provided with the CCO definition only 6/12 studies were considered to be clinical trials by the majority of respondents, while with the OCRN definition it was 9/12 studies. Studies evaluating natural health products, non-traditional medical interventions, and non-randomized studies with standard interventions consistently ranked the lowest, regardless of the definition used.

Conclusion

Oncology professionals appear to have a broadly inclusive baseline definition of what constitutes a clinical trial. Establishing rigor and consistency in the definition of a clinical trial is important for any program, institutional or jurisdictional based comparisons of clinical trials activity, especially when used as a quality indicator of patient care.

Attitudes Toward Research Participation and Investigator Conflicts of Interest Among Advanced Cancer Patients Participating in Early Phase Clinical Trials

Purpose

Although both financial and intrinsic conflicts of interest can exist throughout the drug development process, little is known about how advanced cancer patients enrolled onto early phase clinical trials perceive investigator conflicts of interests.

Patients and Methods

We interviewed 102 advanced cancer patients enrolled onto phase I clinical trials using a standardized survey that addressed multiple issues related to conflicts of interest and research participation.

Results

Fifty-five percent of patients would not be concerned if physicians involved in running a clinical trial had financial conflicts of interest, whereas 65% of patients would be concerned if physicians involved in running a trial had intrinsic conflicts of interest. Most patients reported that potential conflicts of interest should be disclosed to patients on research trials (52% for financial conflicts of interest and 61% for more intrinsic conflicts of interest). Most patients would be willing to participate in trials after learning conflict of interest information (63%). Younger patients expressed more concern regarding financial conflict of interest than older patients (odds ratio, 6.22; 95% CI, 1.41 to 27.24).

Conclusion

Patients with advanced cancer are equally, if not more, concerned about traditional intrinsic conflicts of interest as compared with financial conflicts of interest. Patients generally believed that conflict of interest information should be disclosed to research participants. The fact that younger patients expressed more concern about financial conflicts of interest may have the potential to influence clinical trial participation rates. The actual impact of conflict of interest disclosure to research subjects needs to be evaluated more carefully.

Factors associated with enrollment in cancer genetics research

Previous studies have identified low patient accrual in large-scale cancer clinical trials, particularly for underrepresented groups, such as ethnic minorities, females, and patients >65 years. As there have been few studies examining participation in cancer genetics epidemiologic research, our objective was to identify clinical and demographic factors predicting enrollment in these studies. A total of 1,111 patients diagnosed with colorectal cancer presenting to a gastrointestinal oncology clinic were approached to enroll in a study investigating the role of the MSH6 gene in familial colorectal cancer. Patient consent was sought for providing a blood specimen for DNA analysis and review of medical records/tumor specimens and contacting family members to confirm the family history of cancer. Seven predictor variables for enrollment (age, sex, ethnicity, family history of colorectal cancer in a first-degree relative, presence of children, insurance type, and type of visit) were analyzed using logistic regression analysis to determine the effect on decision to enroll. Of 1,111 patients approached, 696 (62.6%) enrolled in the study. Of these approached individuals, 4.2% were of nonwhite ethnicity and 33.5% were age > or =65 years. Patients of white ethnicity [odds ratio (OR), 2.10; P = 0.018], males (OR, 1.47; P = 0.002), those ages < or =65 years (OR, 1.42; P = 0.009), and those with a first-degree relative with colorectal cancer (OR, 1.57; P = 0.005) were significantly more likely to enroll. Fewer than 4% of all participants denied permission for the study researchers to access information from medical records or to be recontacted by researchers to discuss the enrollment of additional family members. Our data suggest that, once subjects decided to enroll, the majority (88%) was comfortable with consenting to all study components, including the creation of cell lines and future recontact. Low participation rates for ethnic minorities, females, and elderly patients are similar for both cancer genetics and clinical trial studies.

Randomized clinical trials for hematopoietic stem cell transplantation: lessons to be learned from the European experience

We evaluated the number and characteristics of randomized controlled trials (RCTs) addressing hematopoietic stem cell transplantation (HSCT) for patients with hematological malignancies, comparing the productivity of US and Europe. A MEDLINE search was conducted to identify all published RCTs for the management of adult patients with hematological malignancies from January 1992 to December 2003. Eighty-three of the 306 trials identified included HSCT as one of the treatment arms. The US produced 25, Europe 54, and all other countries four. Four European countries, France, Italy, Germany, and UK (FIGU), produced 32 out of the 54 European studies. Significant differences emerged when focus of the study and accrual numbers were analyzed. Trials comparing HSCT to standard dose therapy represented 34.9% of the 83 trials and 59.4% of FIGU trials, but only 4% of US studies (P = 0.001). US trials accrued a mean of 110.2 patients per study, as compared to 222.6 in FIGU studies (P = 0.006) and 205.3 when all non-US countries are considered (P = 0.01). Our conclusions are that US transplant RCT have focused on issues other than the comparison of HSCT to standard therapies. There is serious paucity of US trials defining the role of HSCT in the management of hematological malignancies.

Editorial clubs as a new teaching tool in postgraduate training

BACKGROUND

We report an editorial club as a novel method of teaching systems-based competency in a hematology/oncology fellowship program.

METHOD

Editorial clubs focus on topics of broad economic, political, and legal ramifications of hematology/oncology and thereby help to develop systems competency as required by the Accreditation Council for Graduate Medical Education.

RESULTS

We began our program in 2001 and report on its functioning and outcome in a group of hematology/oncology fellows at the University of Arkansas for Medical Sciences.

CONCLUSION

Topics were diverse, fellows and faculty attendance was excellent, and fellows reported improved systems-based competency.

Randomized Phase II Designs in Cancer Clinical Trials: Current Status and Future Directions

Purpose

Randomized phase II (RPh2) designs are popular in cancer clinical trials because of the smaller sample size requirements when multiple treatments are being evaluated. We reviewed the use of RPh2 designs and give comments on future directions.

Design

The trial design, statistical properties, conduct, data analysis, results, and reporting were examined in RPh2 trials reported from 1986 to 2002.

Results

A statistical design was reported in only 46% of the 266 cancer trials, and approximately half of those provided inadequate information. Most studies applied randomization to achieve patient comparability, while embedding a one-sample phase II design within each treatment arm. Seventy-five percent of the trials’ accruals were within ± 10% of their targets. The average accrual rate was 3.3 patients per month. Planned interim analyses were reported in 27% of the trials, and 56% of the trials were stopped early; 69%, 13%, 13%, and 4% of the trial discontinuations were because of lack of efficacy, efficacy, toxicity, and slow accrual, respectively. Thirty-nine trials (14%) recommended or started phase III evaluations, with four positive reports in six phase III studies identified.

Conclusion

There is a trend of increasing use of RPh2 designs in cancer research. Continued improvement in study design, conduct, analysis, and reporting is required to enhance the quality of RPh2 designs. The accrual rate and success rate of the trials remain low, and therefore, futility stopping rules to terminate ineffective treatment arm(s) should be implemented more frequently. More innovative, flexible RPh2 designs are needed to facilitate the development of effective cancer treatments.

Why Cancer Patients Enter Randomized Clinical Trials: Exploring the Factors That Influence Their Decision

Purpose

Few interventions have been designed and tested to improve recruitment to clinical trials in oncology. The multiple factors influencing patients' decisions have made the prioritization of specific interventions challenging. The present study was undertaken to identify the independent predictors of a cancer patient's decision to enter a randomized clinical trial.

Methods

A list of factors from the medical literature was augmented with a series of focus groups involving cancer patients, physicians, and clinical research associates (CRAs). A series of questionnaires was developed with items based on these factors and were administered concurrently to 189 cancer patients, their physicians, and CRAs following the patient's decision regarding trial entry. Forward logistic regression modeling was performed using the items significantly correlated (by univariate analysis) with the decision to enter a clinical trial.

Results

A number of items were significantly correlated with the patient's decision. In the multivariate logistic regression model, the patient's perception of personal benefit was the most important, with an odds ratio (OR) of 3.08 (P < .05). CRA-related items involving supportive aspects of the decision-making process were also important. These included whether the CRA helped with the decision (OR = 1.71; P < .05), and whether the decision was hard for the patient to make (OR = 0.52; P < .05).

Conclusion

Strategies that better address the potential benefits of trial entry may result in improved accrual. Interventions or aids that focus on the supportive aspects of the decision-making process while respecting the need for information and patient autonomy may also lead to meaningful improvements in accrual.

Establishing the multidisciplinary care of patients with cancer in the state of Delaware

Delaware has the fifth highest cancer death rate in the U.S. As part of a comprehensive program to decrease the cancer mortality and incidence in the state, an infrastructure to establish the multidisciplinary care of patients with cancer was established. In May 2002, Christiana Care Health Services opened the Helen F. Graham Cancer Center to meet the specific need for coordinated and centralized comprehensive cancer care. This effort took the cooperation of many individuals in a community-based teaching hospital, the largest of six acute care hospitals in the state. These efforts have led to a 13% accrual rate to the Community Clinical Oncology Program funded by the National Cancer Institute. The effort also led to the establishment of multidisciplinary disease site centers with representation from the three major physician disciplines of surgery, medical oncology, and radiation oncology. In addition, translational research projects, a tissue procurement center, and genetic counseling and testing with the establishment of a high-risk family cancer registry and collaborative efforts with hospitals across the state were established. The current article reviewed the continued success of this program in the state of Delaware in the effort to reduce the cancer incidence and mortality.

Evaluación de los proyectos de investigación clínica en un centro monográfico de cáncer

BACKGROUND AND OBJECTIVE

The number of clinical trials in cancer patients has experienced an important growth during last years. However, it is difficult to find data showing this activity in Spanish Hospitals. This study analyses the clinical trials data bases between 1996 and 2002 in a cancer center.

MATERIAL AND METHODS

We perform a descriptive analysis of data from: selection of protocols, origin of proposals, sponsors, investigators, studies performed and published; demographic data about patients and phase of the studies in which they have been included.

RESULTS

Evaluation was undertaken with a standardised protocol review assessment. 337 proposals of clinical trials were evaluated during 1996-2002, with a decreasing acceptance index (62.5% to 39.18%, respectively), the number of proposals has grown from 16 in 1996 to 74 in 2002. The general recruitment index was 6.64%. Between 1995-2002, 1479 patients were registered; only 5% were older than 75 years. Pharmaceutical Companies sponsored the majority of the studies, although Co-operative Groups promote an important number of studies, especially in Haematology and Radiotherapy. Thirteen studies performed between 1996-1998 had been published, and 3 more are accepted for publication (69.5%).

CONCLUSIONS

The number of patients included in clinical trials is limited and older patients are not well represented in them.