The ethics of early stopping rules: who is protecting whom?

Methodological and ethical quality of surgical trials from 2016 to 2020

PURPOSE

Randomized controlled trials (RCTs) are the gold standard tool used to evaluate therapeutic interventions. The published results showed that progress still needs to be made not only from a methodological point of view but also from an ethical point of view. The aim of this study was to evaluate the methodological and ethical qualities of randomized clinical trials in surgery over the last few years.

METHODS

All of the articles chosen for review reported on randomized controlled surgical trials and were published in 10 international journals between 2016 and 2020. Eligible studies were identified, selected, and then evaluated based on a broad set of predetermined criteria. Methodological quality was evaluated using the Jadad scale, and ethical quality was evaluated using the Berdeu score.

RESULTS

The methodological quality score (Jadad scale) ranged from 5 to 13, with a mean of 10.0 ± 1.54. The methodological quality was insufficient (score ≤ 9) for 162 trials (31.2%). The ethical quality score ranged from 0.25 to 1, with a mean of 0.8 ± 0.11. Fifty-two articles (10%) did not state that informed consent was requested from the participants, and 21 articles (4%) did not report either research ethics committee or institutional committee protocol approval.

CONCLUSION

The randomized clinical surgical trials analyzed showed that they had satisfactory methods in only 70% of the cases and that they had respected the fundamental ethical principles in 90% of the cases. However, less than 8% of the studies reported planned interim analysis, prospectively defined stopping rules, and independent monitoring committee.

Hypoxic isolated abdominal perfusion breaks through chemoresistance in recurrent FIGO stage IIIC and IV ovarian cancer

To overcome drug resistance in relapsed ovarian cancer, an isolated perfusion system was used to generate a higher local exposure to cytostatic drugs. In addition to cisplatin as the cytostatic agent of choice, the present study combined adriamycin and mitomycin in a three drugs regime due to their increased cytotoxicity under hypoxia. A total of 107 patients, including 87 patients with relapses after previous platinum-containing therapies, 46 stage IIIC and 41 stage IV cases, were enrolled in the present study. A total of 25 patients were chemonaive, including 20 stage IIIC. The systemically pretreated patients in stage IIIC survived a median of 12.8 months, and those in stage IV 10.9 months. The overall clinical response rate of stages IIIC and IV combined was 69%. A complete decrease in ascites was found in 43% of all patients, a significant reduction in 19%. Toxicity and side effects were very mild and the bone marrow suppression was mostly grade I and never exceeded grade II. The primary clinical symptom in patients with post-therapeutic tumor necrosis, which occurred in 10-15% of all cases, was fever, fatigue and poor performance. The isolated hypoxic abdominal perfusion treatment is a potent instrument to break an existing chemoresistance without significant side effects with a good quality of life and comparatively long survival time.

Hypoxic Isolated Abdominal Perfusion (HAP) chemotherapy for non-operable advanced staged ovarian cancer with peritoneal carcinosis: an experience in 45 platinum-refractory ovarian cancer patients

In order to break through drug resistance in platinum-refractory ovarian cancer, augmented drug exposure was administered to the abdomen by means of an isolated perfusion system. Four cycles of isolated hypoxic abdominal perfusion with cisplatin, adriamycin, and mitomycin were conducted in 4-week intervals. Cisplatin and adriamycin were chosen because of their increased cytotoxicity under hypoxic conditions. Chemofiltration was performed for prophylaxis of cumulative toxicity of adriamycin and mitomycin. The study included 45 patients with recurrent epithelial ovarian cancer who had prior platinum containing therapies (3, stage Federation of Gynecology and Obstetrics (FIGO) IIIB; 20, stage FIGO IIIC; 22; stage FIGO IV). The median survival rate in stage FIGO IIIBC was 12 months, and in stage IV was 10 months. The tumor marker decreased to complete response or partial response at 17.8% and 55.6% of the patients. CT or MRI visualization showed complete response in 4.1%, and partial response was in 54.1%. Complete resolution of ascites was noted in 30% of cases and substantial reduction in another 43%. Toxicity was generally low. Quality of life was improved in the majority of cases. Bone-marrow suppression ranged between WHO grade 1 and 2, and in patients with previous third- or fourth-line chemotherapy, it was WHO grade 3. Isolated hypoxic abdominal perfusion with chemofiltration for patients with progressive and platinum-refractory stage III and IV ovarian cancer is an effective therapy, breaking through chemoresistance and offering comparably long survival at good quality of life.

Frontline treatment for transplant-eligible multiple myeloma: A 6474 patients network meta-analysis

Autologous transplantation continues to be the cornerstone of younger and fit multiple myeloma patients. It is known that frontline induction therapy before transplantation can influence post-transplant results. Therefore, best frontline treatment for transplant-eligible patients should be based on best available evidence to guide therapy. Furthermore, until now due to data scarcity, it was not possible to thoroughly compare lenalidomide to other regimens in this setting. We performed a systematic review and network (mixed treatment comparison) meta-analysis of 21 clinical trial publications, enrolling 6474 patients and comparing 11 different treatment frontline setting regimens regarding survival, response, and safety outcomes. OS analysis showed superiority of CRD (cyclophosphamide-lenalidomide-dexamethasone) over TD-based (thalidomide-dexamethasone, HR = 0.76,0.62-0.90), VAD-based (HR = 0.71,0.52-0.90), and Z-Dex (idarubicin-dexamethasone, HR = 0.37,0.17-0.76) regimens. Concerning PFS, VTD (bortezomib-thalidomide-dexametasone) showed superior results when compared with TD-based (HR = 0.66,0.51-0.84), VAD-based (HR = 0.61,0.46-0.82), Z-Dex (HR = 0.42,0.22-0.78), and high dose dexamethasone (Dex, HR = 0.62,0.41-0.90) regimens. Bortezomib/thalidomide regimens were not superior to lenalidomide, considering these outcomes. Also, concerning complete and overall response, VTD ranked first among other regimens, showing clear superiority over thalidomide-only containing protocols. Safety outcome evaluated infectious, cardiac, gastrointestinal, neurological, thrombotic, and hematological grade 3 to 4 adverse events. Risk of thrombotic events was higher with TAD (thalidomide-doxorubicin-dexamethasone), neurological with PAD (bortezomib-doxorubicin-dexamethasone), infectious with Dex, hematological with Z-Dex, gastrointestinal with VTD, and cardiac with PAD regimens. Our study endorses current recommendations on combined immunomodulatory drugs and proteasome inhibitors frontline regimens (in triplets) in transplant-eligible multiple myeloma patients, but also formally demonstrates the favorable performance of lenalidomide in overall and progression-free survival, when compared with bortezomib/thalidomide protocols.

Robust treatment comparison based on utilities of semi-competing risks in non-small-cell lung cancer

A design is presented for a randomized clinical trial comparing two second-line treatments, chemotherapy versus chemotherapy plus reirradiation, for treatment of recurrent non-small-cell lung cancer. The central research question is whether the potential efficacy benefit that adding reirradiation to chemotherapy may provide justifies its potential for increasing the risk of toxicity. The design uses two co-primary outcomes: time to disease progression or death, and time to severe toxicity. Because patients may be given an active third-line treatment at disease progression that confounds second-line treatment effects on toxicity and survival following disease progression, for the purpose of this comparative study follow-up ends at disease progression or death. In contrast, follow-up for disease progression or death continues after severe toxicity, so these are semi-competing risks. A conditionally conjugate Bayesian model that is robust to misspecification is formulated using piecewise exponential distributions. A numerical utility function is elicited from the physicians that characterizes desirabilities of the possible co-primary outcome realizations. A comparative test based on posterior mean utilities is proposed. A simulation study is presented to evaluate test performance for a variety of treatment differences, and a sensitivity assessment to the elicited utility function is performed. General guidelines are given for constructing a design in similar settings, and a computer program for simulation and trial conduct is provided.

Randomized Trials Stopped Early for Harm in HIV/AIDS: A Systematic Survey

PURPOSE

The decision to stop trials early because of the harmful effects of the intervention is complex and requires weighing statistical, logistical, and ethical considerations. We assessed the prevalence of randomized clinical trials (RCTs) stopped early for harm in HIV/AIDS and determined the quality of reporting of methods to inform the decision to stop the trial.

METHOD

We searched 11 electronic databases and major conference abstract databases, contacted trialist and advocacy groups, and searched the Internet. We selected RCTs stopped early for harm. We extracted data on journal and year of publication, reporting of methods and funding, planned sample size, number and planning of interim analyses, stopping rules, and effect size of the harm outcomes.

RESULTS

We found 10 RCTs stopped early for harm (median, n = 85; range, 7-1227). Most interventions (n = 9) were antiviral drugs; one trial studied vitamins to prevent vertical transmission of HIV. Five studies reported a priori defined adverse events, and only 1 trial reported planned stopping guidelines. The primary harm outcomes reported across trials included toxicity, death, and increased mother-to-child transmission. Two trials were stopped due to sudden unanticipated adverse events (Stevens-Johnson syndrome, death, and encephalopathy). Relative risk point estimates for harm ranged from 1 to 6.18. Six studies reported the presence of a data safety and monitoring board.

CONCLUSION

The reporting of methods to inform the decision to stop trials for harm in this population is deficient in a variety of ways, including lack of stopping guidelines. Clinicians should interpret RCTs stopped early for harm with caution and interpret the results in light of related evidence. Trialists should improve the transparency of their decision-making regarding early stopping for harmful effects.

A systematic review of methods for studying consumer health YouTube videos, with implications for systematic reviews

Background. YouTube is an increasingly important medium for consumer health information – with content provided by healthcare professionals, government and non-government organizations, industry, and consumers themselves. It is a rapidly developing area of study for healthcare researchers. We examine the methods used in reviews of YouTube consumer health videos to identify trends and best practices.

Methods and Materials. Published reviews of consumer-oriented health-related YouTube videos were identified through PubMed. Data extracted from these studies included type of journal, topic, characteristics of the search, methods of review including number of reviewers and method to achieve consensus between reviewers, inclusion and exclusion criteria, characteristics of the videos reported, ethical oversight, and follow-up.

Results. Thirty-three studies were identified. Most were recent and published in specialty journals. Typically, these included more than 100 videos, and were examined by multiple reviewers. Most studies described characteristics of the videos, number of views, and sometime characteristics of the viewers. Accuracy of portrayal of the health issue under consideration was a common focus.

Conclusion. Optimal transparency and reproducibility of studies of YouTube health-related videos can be achieved by following guidance designed for systematic review reporting, with attention to several elements specific to the video medium. Particularly when seeking to replicate consumer viewing behavior, investigators should consider the method used to select search terms, and use a snowballing rather than a sequential screening approach. Discontinuation protocols for online screening of relevance ranked search results is an area identified for further development.

Methodological and ethical quality of randomized controlled clinical trials in gastrointestinal surgery

BACKGROUND

The randomized controlled trial (RCT) is the gold standard tool used to evaluate therapeutic interventions. Methodological and ethical aspects should be adequately reported to enable readers to make informed and justified judgments regarding the validity of a trial and the treatment effectiveness.

OBJECTIVE

The aim of this study was to evaluate the methodological and ethical qualities of randomized clinical trials in gastrointestinal surgery and to assess the relationship between these two qualities.

STUDY DESIGN

All of the articles chosen for review reported on phase III randomized controlled gastrointestinal surgical trials were published in 12 international journals during 2006 and 2007. The eligible studies were identified, selected, and then evaluated based on a broad set of predetermined criteria. The methodological quality was evaluated using the Jadad scale, and the ethical quality was evaluated using the Berdeu score.

RESULTS

The mean Jadad score was 9.7 ± 1.78. The methodological quality was insufficient in 64 RCTs (37.4 %; Jadad score <9). The mean Berdeu score was 0.36 ± 0.08. The journal impact factor, number of randomized patients, and number of centers correlated with the outcome of the Jadad score, and the journal impact factor, industry funding, and year in which the trial began correlated with the outcome of the Berdeu score. Informed consent from patients was not obtained in 7 % (n = 12) of the RCTs, and research ethics committee approval was not mentioned in 14.6 % (n = 25) of the RCTs.

CONCLUSIONS

The reporting of gastrointestinal surgery RCTs is less than optimal. In our study, the trials of higher methodological quality were more likely to provide information about their ethical aspects. These results suggest the need for more attention to be paid to the conduct of clinical research and the reporting of ethical aspects. The appropriation of the ethical rules by surgeons involved in human clinical trials could improve the methodology and reporting of RCTs in gastrointestinal surgery.

The dangers of stopping a trial too early

To ensure that participants in randomized controlled trials are protected from harm, interim analyses and review of results by an independent data monitoring committee have become standard practice. If an analysis of accumulating data partway through a trial reveals an unanticipated degree of benefit or toxicity, or differences in outcomes between the intervention and control groups are so unimpressive that any prospect of a positive result with the planned sample size is extremely unlikely, investigators may stop the trial earlier than originally scheduled. The practice of stopping randomized controlled trials early is, however, problematic, especially if the trial is stopped for apparent benefit. Concerns in trials stopped early for apparent benefit include appropriate interpretation of results and ethical problems concerning trial participants, clinicians, and society as a whole. In this article, we review the epidemiology of trials stopped early and illustrate some of the problems and controversies associated with stopping randomized controlled trials early for apparent benefit. Finally, we offer guidance for clinicians, those running clinical trials, and authors of systematic reviews.

Screening for lung cancer using low-dose spiral CT: 10 years later, state of the art

Ten years after the first papers on this subject, this editorial represents a brief review on lung cancer screening with low-dose spiral CT. The aim is to present the main theoretical and practical problems related to lung cancer screening, the historical background and results of observational studies and the main ongoing randomised controlled trials. In particular, the National Lung Screening Trial (NLST), which was interrupted early, is discussed. The opinion of the authors is that too many questions are still awaiting an answer.

Early stopping rules in oncology: considerations for clinicians

The number of cancer-related clinical trials has been rapidly increasing over the past decade. Along with this increase, oncology studies stopped early for benefit or harm have also been more common. Clinicians treating cancer patients often are faced with the challenge of having to decide whether or not to incorporate information from these new studies into their daily clinical practice. This review article explains the role of the Data and Safety Monitoring Committee in stopping trials early; provides examples of oncology trials stopped early; and reviews some of the controversies and statistical concepts associated with early stopping rules. In addition, a simple and practical approach to interpreting the findings of trials that are stopped early is provided to assist clinicians in deciding how to incorporate information from these studies into their daily practice.

Continuous safety monitoring for randomized controlled clinical trials with blinded treatment information. Part 1: Ethical considerations

The protection of patient safety is the principal responsibility of clinical trial investigators, and must be assured even if that were to prevent successful completion of a trial. Yet, the decision to prematurely stop a blinded, randomized controlled clinical trial can be extremely complicated, involving a tangle of ethical, statistical, and practical issues. Questions are quickly answered when conclusive evidence of harm has been established for trial participants, or when the potential for harm exceeds an acceptable limit of comfort for an oversight body. Less readily addressed are those situations in which early alarms warn of possible harm, but the data are too preliminary or incomplete to reach a satisfactory decision as to whether or not to stop the study. Early study termination without sufficient evidence disallows the study question from being answered and may allow an inferior treatment to remain in use, or prevent a superior one from being discovered. Even without early stopping, as a study proceeds, worrisome trends may lead to overzealous (or overly cautious) looks at study data which could jeopardize the integrity of the findings. Trial investigators and safety monitoring groups, aided by objective statistical rules and thoughtful deliberations, share responsibility for patient welfare. Statistical guidelines must not frustrate ethical concerns, but, rather, should be designed to promote the highest ethical and scientific outcomes possible, safeguarding both trial participants and the public - the ultimate beneficiaries of clinical trials.

Overall survival as the outcome for randomized clinical trials with effective subsequent therapies

We review how overall survival (OS) comparisons should be interpreted with increasing availability of effective therapies that can be given subsequently to the treatment assigned in a randomized clinical trial (RCT). We examine in detail how effective subsequent therapies influence OS comparisons under varying conditions in RCTs. A subsequent therapy given after tumor progression (or relapse) in an RCT that works better in the standard arm than the experimental arm will lead to a smaller OS difference (possibly no difference) than one would see if the subsequent therapy was not available. Subsequent treatments that are equally effective in the treatment arms would not be expected to affect the absolute OS benefit of the experimental treatment but will make the relative improvement in OS smaller. In trials in which control arm patients cross over to the experimental treatment after their condition worsens, a smaller OS difference could be observed than one would see without cross-overs. In particular, use of cross-over designs in the first definitive evaluation of a new agent in a given disease compromises the ability to assess clinical benefit. In disease settings in which there is not an intermediate end point that directly measures clinical benefit, OS should be the primary end point of an RCT. The observed difference in OS should be considered the measure of clinical benefit to the patients, regardless of subsequent therapies, provided that the subsequent therapies used in both treatment arms follow the current standard of care.

Statistical decisions and the interim analyses of clinical trials

This paper analyzes statistical decisions during the interim analyses of clinical trials. After some general remarks about the ethical and scientific demands of clinical trials, I introduce the notion of a hard-case clinical trial, explain the basic idea behind it, and provide a real example involving the interim analyses of zidovudine in asymptomatic HIV-infected patients. The example leads me to propose a decision analytic framework for handling ethical conflicts that might arise during the monitoring of hard-case clinical trials. I use computer simulations to show how the framework can assist in reconciling certain ethical conflicts. The framework is partial, lacking the precision of a complete systematization of statistical monitoring procedures in practice.

Living with cancer: perspectives on a five year journey

This is a personal story of the lived experience of the authors, both nurses, who as partners face ovarian cancer. We describe the initial impact of such a diagnosis and its immediate life-changing consequences, treatment decisions and sequelae, remission and recurrence, and choices about living with a chronic illness and the ever-present specter of death. We recognize that our experience is uniquely ours, yet we believe it has meaning for all patients and caregivers, as well as the many health professionals who treat, care for, guide and comfort those who bear the burden of cancer.

Stopping or reporting early for positive results in randomized clinical trials: the National Cancer Institute Cooperative Group experience from 1990 to 2005

Randomized clinical trials are designed with stopping boundaries to guide data monitoring committees with their decision making concerning ongoing trials. In particular, when extremely positive results are seen and a boundary is crossed, the data monitoring committee may recommend releasing the results earlier to the public than at the definitive final analysis time specified in the protocol. For trials that are still accruing, this also means stopping accrual. Because the information about treatment efficacy is more limited in an early analysis than in a final analysis, questions have been raised about the appropriateness of incorporating early stopping for positive results in trial designs. In particular, there are concerns that treatment effects seen early may not be real or may be overly optimistic. To examine this issue, we collected information about treatment efficacy on National Cancer Institute Cooperative Group trials that were stopped early for positive results (information both at the time the trial was stopped/released and at times of further follow-up). Twenty-seven such trials were located. For 17 of 18 of these trials with sufficient follow-up information, the treatment effect was similar or only slightly smaller at last follow-up compared with the stopping/release time. We critically evaluate reasons why one might be concerned about early stopping for positive results. We conclude that for trials with well-designed interim monitoring plans, the ability to stop early for positive results is an important component of the trial design, allowing the public to benefit as soon as possible from the study conclusions.

Data and safety monitoring boards: some enduring questions

Data Safety and Monitoring Boards (DSMBs) have been referred to as a "growth industry," and this trend continues to be fueled by recent FDA guidance and the NIH's requirement that DSMBs be employed in virtually all phase III clinical trials. The widening role of DSMBs has been sporadically questioned on ethical grounds, but growth has continued, despite the fact that many of the questions endure, unanswered, save for repeated references to safeguarding the scientific integrity of trials. This may be about to change. The recently appointed director of the Office for Human Research Protections (OHRP), Jerry Menikoff, is on record as regarding current practices--where consent forms often promise what the DSMB has been assembled to specifically not provide--as constituting fraudulent behavior. That is, a subject may inherently rely on, to their detriment, information that has been misrepresented in the consent document. In this paper, we assemble some of the enduring questions and top them off with Menikoff's tour de force to present what we hope will be a compelling argument to require that consent forms fairly represent what the DSMB will do--and not do--with trial data as they accumulate. We argue that DSMBs should be used only in rare circumstances, and question the practice of precluding principal investigators from DSMB membership, but our main thrust is to ensure that DSMBs, when used at all, are properly described in trial consent forms.

Statistical analysis in cancer clinical trials

Evidence suggests that over the long term (>5 years), tamoxifen should be replaced with an agent such as an aromatase inhibitor. Recent decisions to terminate several large clinical trials, in view of emerging efficacy data with the aromatase inhibitors, indicate that there is a need for guidelines that determine when trials should be discontinued. As a result of the interim efficacy analysis and subsequent discontinuation of the NCIC MA.17 trial, the National Surgical Adjuvant Breast and Bowel Project B-33 study was unblinded after a median of 10 months of treatment. The B-33 trial, nevertheless, demonstrated a statistically significant improvement in relapse-free survival indicating that exemestane is likely to be a valuable treatment option in postmenopausal women with early breast cancer who remain disease-free following 5 years of tamoxifen therapy.

Rationale and delineation of a composite index of relative antitumoural efficacy (In-RATE)

Over the last decades, the development of new drugs has allowed cancer patients to experience several lines of chemotherapy, the objective of which is a long term stabilization of the tumour. The objectives of this work was to delineate a composite index of relative antitumoural efficacy (In-RATE) of a regimen over another, including response rate (RR), median time to progression (TTP) and progression rate (PR). When considering two treatments a and b, the In-RATE was defined as RRa/RRb x TTPa/TTPb x PRb/PRa. Values significantly superior or inferior to 1 reveal an advantage for treatment a or b, respectively. The applicability of the In-RATE to published randomized trials in four frequent tumour types (colorectal, non-small cell lung, advanced ovarian and metastatic breast cancers) was suggested to more precisely distinguish the effects of different drugs, and sometimes to detect a significant difference when the published data did not conclude to statistical difference.

Decision making in adjuvant trials in breast cancer: the NCIC CTG MA.17 trial as an example

Decision-making regarding early closure and reporting of clinical trial results became a topic of intense debate following the reporting of the MA.17 adjuvant endocrine therapy trial. This trial was terminated at the first planned interim analysis when a highly significant improvement in disease free survival (DFS) was found. It has been suggested that the criterion for early stopping be made stricter when DFS is the primary study endpoint by ensuring that the targeted effect size is excluded. Our purpose is to examine this approach and to determine whether applying such a criterion would have affected the decision to terminate MA17. The sample size assumptions and the interim analysis of MA17 were reviewed and an appropriate method employed to convert hazard ratios (HR) to absolute differences. Expressed in relative terms, the effect size of MA17 was an HR of 0.78, and the upper boundary (0.75) of the confidence limits around the observed HR (0.57) excluded this value. In absolute terms, the lower confidence limit (3.1%) of best estimate of the 4 year difference in DFS (5.4%) excludes the difference (2.5%) used in the calculation of the targeted HR. We conclude that although the decision to release the results of the interim analysis of MA17 and allow patients on placebo to take letrozole was justified, methods for analyzing and interpreting interim results can be improved.

Moral reasoning as a model for health promotion

The paper describes a model of moral reasoning used to guide the conduct of health researchers and recommends that this model be applied in health promotion. It argues that this model is a more appropriate and sound way of thinking about the means and ends of health education, with implications for both research and practice. When faced with ethical dilemmas about the most appropriate course of action in health research, investigators and bioethicists conduct normative analyses to identify good reasons for choosing one option over another. These reasons provide the grounds for determining what one should do, and for changing past practices in light of new moral considerations. Since the research community seems to think that this is a good way to guide and change their own behavior, this model of moral reasoning appears to have relevance and potential application to the field of health education, which engages in analogous processes of seeking to inform and change the behaviors of the lay public. The article sets this approach in the context of a humanistic understanding of human motivation and presents two case examples to illustrate the process of moral reasoning. The humanistic model outlined here helps to explain why health promotion has not made much progress in developing effective behavior change programs and it offers a more promising prospect for demonstrating success by identifying a broader range of relevant outcomes. The paper concludes by recommending that greater attention be paid to the ethical dimensions of human agency in order to develop a more coherent body of knowledge to advance both research and practice in health promotion.

Media reporting of tenofovir trials in Cambodia and Cameroon

BACKGROUND

Two planned trials of pre-exposure prophylaxis tenofovir in Cambodia and Cameroon to prevent HIV infection in high-risk populations were closed due to activist pressure on host country governments. The international news media contributed substantially as the primary source of knowledge transfer regarding the trials. We aimed to characterize the nature of reporting, specifically focusing on the issues identified by media reports regarding each trial.

METHODS

With the aid of an information specialist, we searched 3 electronic media databases, 5 electronic medical databases and extensively searched the Internet. In addition we contacted stakeholder groups. We included media reports addressing the trial closures, the reasons for the trial closures, and who was interviewed. We extracted data using content analysis independently, in duplicate.

RESULTS

We included 24 reports on the Cambodian trial closure and 13 reports on the Cameroon trial closure. One academic news account incorrectly reported that it was an HIV vaccine trial that closed early. The primary reasons cited for the Cambodian trial closure were: a lack of medical insurance for trial related injuries (71%); human rights considerations (71%); study protocol concerns (46%); general suspicions regarding trial location (37%) and inadequate prevention counseling (29%). The primary reasons cited for the Cameroon trial closure were: inadequate access to care for seroconverters (69%); participants not sufficiently informed of risks (69%); inadequate number of staff (46%); participants being exploited (46%) and an unethical study design (38%). Only 3/23 (13%) reports acknowledged interviewing research personnel regarding the Cambodian trial, while 4/13 (30.8%) reports interviewed researchers involved in the Cameroon trial.

CONCLUSION

Our review indicates that the issues addressed and validity of the media reports of these trials is highly variable. Given the potential impact of the media in formulation of health policy related to HIV, efforts are needed to effectively engage the media during periods of controversy in the HIV/AIDS epidemic.

Decision making process in oncology practice: Is the information available and what should it consist of?

In terms of systemic chemotherapy, the oncologist is often faced with the difficulty to discriminate between several options, at least according to evidence-based medicine. The aim of the present report was to assess to what extent the efficacy-related parameters required for the decision making process are reported in clinical trials. The analysis was restricted to lung, breast, colorectal and ovarian cancers. It included 135 phase II trials published in 1999, and 79 phase III trials published between 1991 and 2000. Response duration was mentioned in one-half and one-fourth of phases II and III trials, respectively. Only one-half of the trials reported time to progression (TTP). Finally, 28% of phase II and 44% of phase III trials reported RR, TTP and progression rates. The study indicates that the information available from reported clinical trials needs to be upgraded and homogenised in order to improve the decision making process in oncology.