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Resende H, Arai RJ, Barrios CH, Schwyter F, Teich NLS, Gomes A, Dallari AB, Bonilha LAS, Souza CMA, Francisco FR, Munhoz RR, Werutsky G, Madi M, Fernandes P, Figueiredo JM, Fedozzi F, Arruda L, Aguiar VQ, Melo AC. Improving access to cancer clinical research in Brazil: recent advances and new opportunities. Expert opinions from the 4th CURA meeting, São Paulo, 2023. Ecancermedicalscience 2024; 18:1698. [PMID: 38774565 PMCID: PMC11108048 DOI: 10.3332/ecancer.2024.1698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Indexed: 05/24/2024] Open
Abstract
Clinical research is the cornerstone of improvements in cancer care. However, it has been conducted predominantly in high-income countries with few clinical trials available in Brazil and other low-and-middle-income countries (LMIC). Of note, less than one-third of registered clinical trials addressing some of the most commonly diagnosed cancers (breast, lung and cervical) recruited patients from LMIC in the last years. The Institute Project CURA promoted the fourth CURA meeting, discussing barriers to cancer clinical research and proposing potential solutions. A meeting was held in São Paulo, Brazil, in June 2023 with representatives from different sectors: Brazilian Health Regulatory Agency (Anvisa), National Commission of Ethics in Research (CONEP), non-governmental organisations, such as the Latin American Cooperative Oncology Group, the Brazilian Society of Clinical Oncology (SBOC), Contract Research Organisations, pharmaceutical companies and investigators. A total of 16 experts pointed out achievements as shortening the time of regulatory processes involving Anvisa and CONEP, development of staff training programs, maintenance of the National Program of Oncological Attention (PRONON), and the foundation of qualified centres in North and Northeast Brazilian regions. Participants also highlighted the need to be more competitive in the field, which requires optimising ongoing policies and implementing new strategies as decentralisation of clinical research centres, public awareness campaigns, community-centered approaches, collaborations and partnerships, expansion of physicians-directed policies, exploring the role of the steering committee. Active and consistent reporting of the initiatives might help to propagate ongoing advances, increasing Brazilian participation in clinical cancer research. Engagement of all players is crucial to maintain continuous progress with further improvements in critical points including regulatory timelines and increments in qualified human resources which aligned with new educational initiatives focused on physicians and the general population will expand access to cancer clinical trials in Brazil.
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Affiliation(s)
- Heloisa Resende
- Instituto Projeto Cura, São Paulo 05507-020, SP, Brazil
- https://orcid.org/0000-0003-4692-3743
| | - Roberto J Arai
- Independent Clinical Researcher, São Paulo 01153-000, SP, Brazil
- https://orcid.org/0000-0001-5617-1042
| | - Carlos H Barrios
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, RS, Brazil
- https://orcid.org/0000-0001-6021-667X
| | | | - Nelson L S Teich
- Instituto Teich de Políticas Públicas em Saúde, Rio de Janeiro 22640-102, RJ, Brazil
- https://orcid.org/0000-0003-1352-1334
| | - Andre Gomes
- Bristol Myers Squibb, São Paulo 04719-002, SP, Brazil
| | | | - Laís A S Bonilha
- Comissão Nacional de Ética em Pesquisa (CONEP), Brasília 70719-040, DF, Brazil
| | | | - Fernando R Francisco
- Associação Brasileira de Organizações Representativas de Pesquisa Clínica- Abracro, São Paulo 01311-902, SP, Brazil
| | - Rodrigo R Munhoz
- Hospital Sírio Libanês, São Paulo 01308-050, SP, Brazil
- https://orcid.org/0000-0001-8898-2798
| | - Gustavo Werutsky
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, RS, Brazil
- https://orcid.org/0000-0001-6271-105X
| | - Marisa Madi
- Sociedade Brasileira de Oncologia Clínica (SBOC), São Paulo 01311-300, SP, Brazil
- https://orcid.org/0000-0003-1049-4932
| | - Paulo Fernandes
- Associação Brasileira de Organizações Representativas de Pesquisa Clínica- Abracro, São Paulo 01311-902, SP, Brazil
- Sail for Health, São Paulo 04543-011, SP, Brazil
| | | | - Fabio Fedozzi
- Associação Brasileira de Linfoma e Leucemia, ABRALE, São Paulo 05423-040, SP, Brazil
| | - Lilian Arruda
- Hospital São Camilo, São Paulo 05022-001, SP, Brazil
- https://orcid.org/0000-0002-7101-4325
| | - Vinícius Q Aguiar
- Centro Universitário de Volta Redonda – UNIFOA, Volta Redonda 27240-560, RJ, Brazil
- https://orcid.org/0000-0002-6257-0119
| | - Andreia C Melo
- Brazilian National Cancer Institute (INCA), Division of Clinical Research and Technological Development, Rio de Janeiro 20230-130, RJ, Brazil
- https://orcid.org/0000-0002-1201-4333
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Fountzilas E, Tsimberidou AM, Hiep Vo H, Kurzrock R. Tumor-agnostic baskets to N-of-1 platform trials and real-world data: Transforming precision oncology clinical trial design. Cancer Treat Rev 2024; 125:102703. [PMID: 38484408 DOI: 10.1016/j.ctrv.2024.102703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 04/06/2024]
Abstract
Choosing the right drug(s) for the right patient via advanced genomic sequencing and multi-omic interrogation is the sine qua non of precision cancer medicine. Traditional cancer clinical trial designs follow well-defined protocols to evaluate the efficacy of new therapies in patient groups, usually identified by their histology/tissue of origin of their malignancy. In contrast, precision medicine seeks to optimize benefit in individual patients, i.e., to define who benefits rather than determine whether the overall group benefits. Since cancer is a disease driven by molecular alterations, innovative trial designs, including biomarker-defined tumor-agnostic basket trials, are driving ground-breaking regulatory approvals and deployment of gene- and immune-targeted drugs. Molecular interrogation further reveals the disruptive reality that advanced cancers are extraordinarily complex and individually distinct. Therefore, optimized treatment often requires drug combinations and N-of-1 customization, addressed by a new generation of N-of-1 trials. Real-world data and structured master registry trials are also providing massive datasets that are further fueling a transformation in oncology. Finally, machine learning is facilitating rapid discovery, and it is plausible that high-throughput computing, in silico modeling, and 3-dimensional printing may be exploitable in the near future to discover and design customized drugs in real time.
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Affiliation(s)
- Elena Fountzilas
- Department of Medical Oncology, St Luke's Clinic, Thessaloniki, Greece; European University Cyprus, German Oncology Center, Nicosia, Cyprus
| | - Apostolia-Maria Tsimberidou
- The University of Texas MD Anderson Cancer Center, Department of Investigational Cancer Therapeutics, Houston, TX, USA.
| | - Henry Hiep Vo
- The University of Texas MD Anderson Cancer Center, Department of Investigational Cancer Therapeutics, Houston, TX, USA
| | - Razelle Kurzrock
- WIN Consortium for Precision Medicine, France; Medical College of Wisconsin, USA
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3
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Booth CM, Eisenhauer EA, Gyawali B, Tannock IF. Progression-Free Survival Should Not Be Used as a Primary End Point for Registration of Anticancer Drugs. J Clin Oncol 2023; 41:4968-4972. [PMID: 37733981 DOI: 10.1200/jco.23.01423] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/23/2023] Open
Affiliation(s)
- Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada
- Department of Oncology, Queen's University, Kingston, Canada
- Department of Public Health Sciences, Queen's University, Kingston, Canada
| | | | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada
- Department of Oncology, Queen's University, Kingston, Canada
- Department of Public Health Sciences, Queen's University, Kingston, Canada
| | - Ian F Tannock
- Division of Medical Oncology, Princess Margaret Cancer Centre and University of Toronto, Toronto, Canada
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Sherry AD, Corrigan KL, Kouzy R, Abi Jaoude J, Yang Y, Patel RR, Totten DJ, Newman NB, Das P, Taniguchi C, Minsky B, Snyder RA, David Fuller C, Ludmir E. Prevalence, trends, and characteristics of trials investigating local therapy in contemporary phase 3 clinical cancer research. Cancer 2023; 129:3430-3438. [PMID: 37382235 PMCID: PMC11349322 DOI: 10.1002/cncr.34929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/11/2023] [Accepted: 05/05/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Although most patients with cancer are treated with local therapy (LT), the proportion of late-phase clinical trials investigating local therapeutic interventions is unknown. The purpose of this study was to determine the proportion, characteristics, and trends of phase 3 cancer clinical trials assessing the therapeutic value of LT over time. METHODS This was a cross-sectional analysis of interventional randomized controlled trials in oncology published from 2002 through 2020 and registered on ClinicalTrials.gov. Trends and characteristics of LT trials were compared to all other trials. RESULTS Of 1877 trials screened, 794 trials enrolling 584,347 patients met inclusion criteria. A total of 27 trials (3%) included a primary randomization assessing LT compared with 767 trials (97%) investigating systemic therapy or supportive care. Annual increase in the number of LT trials (slope [m] = 0.28; 95% confidence interval [CI], 0.15-0.39; p < .001) was outpaced by the increase of trials testing systemic therapy or supportive care (m = 7.57; 95% CI, 6.03-9.11; p < .001). LT trials were more often sponsored by cooperative groups (22 of 27 [81%] vs. 211 of 767 [28%]; p < .001) and less often sponsored by industry (5 of 27 [19%] vs. 609 of 767 [79%]; p < .001). LT trials were more likely to use overall survival as primary end point compared to other trials (13 of 27 [48%] vs. 199 of 767 [26%]; p = .01). CONCLUSIONS In contemporary late-phase oncology research, LT trials are increasingly under-represented, under-funded, and evaluate more challenging end points compared to other modalities. These findings strongly argue for greater resource allocation and funding mechanisms for LT clinical trials. PLAIN LANGUAGE SUMMARY Most people who have cancer receive treatments directed at the site of their cancer, such as surgery or radiation. We do not know, however, how many trials test surgery or radiation compared to drug treatments (that go all over the body). We reviewed trials testing the most researched strategies (phase 3) completed between 2002 and 2020. Only 27 trials tested local treatments like surgery or radiation compared to 767 trials testing other treatments. Our study has important implications for funding research and understanding cancer research priorities.
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Affiliation(s)
- Alexander D. Sherry
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Kelsey L. Corrigan
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ramez Kouzy
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Abi Jaoude
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yumeng Yang
- Department of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Roshal R. Patel
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Radiation Oncology, Memorial Sloan–Kettering Cancer Center, New York, New York, USA
| | - Douglas J. Totten
- Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Neil B. Newman
- Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Prajnan Das
- Division of Radiation Oncology, Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cullen Taniguchi
- Division of Radiation Oncology, Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Division of Radiation Oncology, Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bruce Minsky
- Division of Radiation Oncology, Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rebecca A. Snyder
- Division of Surgery, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - C. David Fuller
- Division of Radiation Oncology, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ethan Ludmir
- Division of Radiation Oncology, Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Rubagumya F, Fundytus A, Keith-Brown S, Hopman WM, Gyawali B, Mukherji D, Hammad N, Pramesh CS, Aggarwal A, Eniu A, Sengar M, Riechelmann RSR, Sullivan R, Booth CM. Allocation of authorship and patient enrollment among global clinical trials in oncology. Cancer 2023; 129:2856-2863. [PMID: 37382190 DOI: 10.1002/cncr.34919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/11/2023] [Accepted: 03/29/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Oncology randomized controlled trials (RCTs) are increasingly global in scope. Whether authorship is equitably shared between investigators from high-income countries (HIC) and low-middle/upper-middle incomes countries (LMIC/UMIC) is not well described. The authors conducted this study to understand the allocation of authorship and patient enrollment across all oncology RCTs conducted globally. METHODS A cross-sectional retrospective cohort study of phase 3 RCTs (published 2014-2017) that were led by investigators in HIC and recruited patients in LMIC/UMIC. FINDINGS During 2014-2017, 694 oncology RCTs were published; 636 (92%) were led by investigators from HIC. Among these HIC-led trials, 186 (29%) enrolled patients in LMIC/UMIC. One-third (33%, 62 of 186) of RCTs had no authors from LMIC/UMIC. Forty percent (74 of 186) of RCTs reported patient enrollment by country; in 50% (37 of 74) of these trials, LMIC/UMIC contributed <15% of patients. The relationship between enrollment and authorship proportion is very strong and is comparable between LMIC/UMIC and HIC (Spearman's ρ LMIC/UMIC 0.824, p < .001; HIC 0.823, p < .001). Among the 74 trials that report country enrollment, 34% (25 of 74) have no authors from LMIC/UMIC. CONCLUSIONS Among trials that enroll patients in HIC and LMIC/UMIC, authorship appears to be proportional to patient enrollment. This finding is limited by the fact that more than half of RCTs do not report enrollment by country. Moreover, there are important outliers as a significant proportion of RCTs had no authors from LMIC/UMIC despite enrolling patients in these countries. The findings in this study reflect a complex global RCT ecosystem that still underserves cancer control outside high-income settings.
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Affiliation(s)
- Fidel Rubagumya
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
- Public Health Sciences, Queen's University, Kingston, Ontario, Canada
- Department of Oncology, Rwanda Military Hospital, Kigali, Rwanda
| | - Adam Fundytus
- British Columbia Cancer Agency, Victoria, British Columbia, Canada
| | - Sophie Keith-Brown
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Wilma M Hopman
- Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
- Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | | | - Nazik Hammad
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - C S Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Ajay Aggarwal
- Institute of Cancer Policy, King's College London, London, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Manju Sengar
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | | | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
- Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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Meirson T, Goldstein DA, Gyawali B, Tannock IF. Review of the monarchE trial suggests no evidence to support use of adjuvant abemaciclib in women with breast cancer. Lancet Oncol 2023:S1470-2045(23)00165-1. [PMID: 37146621 DOI: 10.1016/s1470-2045(23)00165-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/02/2023] [Accepted: 04/06/2023] [Indexed: 05/07/2023]
Affiliation(s)
- Tomer Meirson
- Davidoff Cancer Center, Rabin Medical Center, Petach Tikvah, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel A Goldstein
- Davidoff Cancer Center, Rabin Medical Center, Petach Tikvah, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Clalit Health Service, Tel Aviv, Israel; Optimal Cancer Care Alliance, Ann Arbor, MI, USA
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology & Departments of Oncology and Public Health Sciences, Queen's University Cancer Research Institute, Kingston, ON, Canada
| | - Ian F Tannock
- Optimal Cancer Care Alliance, Ann Arbor, MI, USA; Division of Medical Oncology, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada.
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Nardo M, Guven DC, Yikilmaz AS, Singh S, Ahmed J. Learning From Failure: Negative Trials in Oncology. JOURNAL OF IMMUNOTHERAPY AND PRECISION ONCOLOGY 2023; 6:59-60. [PMID: 37214208 PMCID: PMC10195015 DOI: 10.36401/jipo-23-x1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 02/22/2023] [Accepted: 02/22/2023] [Indexed: 05/24/2023]
Affiliation(s)
- Mirella Nardo
- Department of Investigational Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Deniz Can Guven
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
| | | | - Shambhavi Singh
- Department of Precision Oncology, Sir H N Reliance Foundation Hospital, Mumbai, India
| | - Jibran Ahmed
- Department of Investigational Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Rubagumya F, Mutebi M, Manirakiza A, Abdihamid O, Mushonga M, Vanderpuye V, Hammad N, Booth CM. Pharmaceutical industry relationships with oncologists in sub-Saharan Africa. Lancet Oncol 2023; 24:e96-e101. [PMID: 36725154 DOI: 10.1016/s1470-2045(22)00639-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/29/2022] [Accepted: 10/03/2022] [Indexed: 02/03/2023]
Abstract
Health-care systems in sub-Saharan Africa are considered to be new markets for pharmaceutical companies. This perception is particularly relevant within oncology, as the pharmaceutical industry has changed strategic priorities in the past 10 years to focus on cancer. Since the 1930s, pharmaceutical companies have used advertisements, sample drugs, gifts, paid speaking engagements, advisory boards, and trips to conferences to influence clinical practice and policy. A large amount of literature describes the commonness of these practices and their effects on the behaviour of doctors. However, these data come almost exclusively from high-income countries. Industry-doctor relationships are increasingly common in sub-Saharan Africa and other low-income and middle-income countries. Although there are undoubtedly risks of industry engagement in low-income and middle-income countries, many programmes with educational, research, and clinical value would not occur in these countries without industry support. Thus, what is known about these relationships in high-income countries will not necessarily apply in low-income and middle-income countries. There is a need for widespread discussion about industry-oncologist interactions across the African continent and context-specific data to understand the potential risks and benefits of these relationships.
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Affiliation(s)
- Fidel Rubagumya
- Department of Oncology, Rwanda Military Hospital, Kigali, Rwanda; Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, and Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.
| | - Miriam Mutebi
- Department of Surgery, Aga Khan University, Nairobi, Kenya
| | | | - Omar Abdihamid
- Garissa Cancer Center, Garissa County Referral Hospital, Garissa, Kenya
| | | | - Verna Vanderpuye
- Department of Oncology, Korle Bu Teaching Hospital, Accra, Ghana
| | - Nazik Hammad
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, and Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
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Gössling G, Rebelatto TF, Villarreal-Garza C, Ferrigno AS, Bretel D, Sala R, Giacomazzi J, William WN, Werutsky G. Current Scenario of Clinical Cancer Research in Latin America and the Caribbean. Curr Oncol 2023; 30:653-662. [PMID: 36661699 PMCID: PMC9858272 DOI: 10.3390/curroncol30010050] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/22/2022] [Accepted: 12/28/2022] [Indexed: 01/06/2023] Open
Abstract
In Latin America and the Caribbean (LAC), progress has been made in some national and regional cancer control initiatives, which have proved useful in reducing diagnostic and treatment initiation delays. However, there are still significant gaps, including a lack of oncology clinical trials. In this article, we will introduce the current status of the region's clinical research in cancer, with a special focus on academic cancer research groups and investigator-initiated research (IIR) initiatives. Investigators in LAC have strived to improve cancer research despite drawbacks and difficulties in funding, regulatory timelines, and a skilled workforce. Progress has been observed in the representation of this region in clinical trial development and conduct, as well as in scientific productivity. However, most oncology trials in the region have been sponsored by pharmaceutical companies, highlighting the need for increased funding from governments and private foundations. Improvements in obtaining and/or strengthening the LAC cancer research group's financing will provide opportunities to address cancer therapies and management shortcomings specific to the region. Furthermore, by including this large, ethnic, and genetically diverse population in the world's research agenda, one may bridge the gap in knowledge regarding the applicability of results of clinical trials now mainly conducted in populations from the Northern Hemisphere.
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Affiliation(s)
- Gustavo Gössling
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, RS, Brazil
| | - Taiane F. Rebelatto
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, RS, Brazil
| | - Cynthia Villarreal-Garza
- Breast Cancer Center Hospital Zambrano Hellion TecSalud—Tecnologico de Monterrey, Monterrey 66278, NL, Mexico
| | - Ana S. Ferrigno
- Breast Cancer Center Hospital Zambrano Hellion TecSalud—Tecnologico de Monterrey, Monterrey 66278, NL, Mexico
| | - Denisse Bretel
- Grupo de Estudios Clínicos Oncológicos del Perú (GECO PERU), Lima 15038, Peru
| | - Raul Sala
- Grupo Argentino de Investigación Clínica en Oncología (GAICO), Rosario S2124KBO, Argentina
| | - Juliana Giacomazzi
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, RS, Brazil
| | - William N. William
- Hospital BP—Beneficência Portuguesa de São Paulo, São Paulo 01323-001, SP, Brazil
| | - Gustavo Werutsky
- Latin American Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, RS, Brazil
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10
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Thominet L, Hamel LM, Baidoun F, Moore TF, Barton E, Heath EI, Carducci M, Lansey D, Eggly S. Physicians' use of plain language during discussions of prostate cancer clinical trials with patients. PATIENT EDUCATION AND COUNSELING 2022; 105:3453-3458. [PMID: 36085183 PMCID: PMC9675686 DOI: 10.1016/j.pec.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/25/2022] [Accepted: 09/01/2022] [Indexed: 05/10/2023]
Abstract
OBJECTIVE This study described physicians' use of plain language during patient-physician cancer clinical trial discussions. METHODS Video-recorded clinical interactions and accompanying transcripts were taken from a larger study of communication and clinical trials (PACCT). Interactions (n = 25) were selected if they included invitations to participate in a clinical trial. We used descriptive, qualitative discourse analysis, a method that identifies language patterns at or above the sentence level. We first excerpted discussions of clinical trials, then identified instances of plain language within those discussions. Finally, we inductively coded those instances to describe physicians' plain language practices. RESULTS The analysis identified four plain language practices. Lexical simplification replaced medical terminology with simpler words. Patient-centered definition named, categorized, and explained complex medical terminology. Metaphor explained medical terminology by comparing it with known concepts. Finally, experience-focused description replaced medical terminology with descriptions of patients' potential physical experiences. CONCLUSION These plain language practices hold promise as part of effective information exchange in discussions of cancer clinical trials. Testing is needed to identify patient preferences and the extent to which these practices address patient health literacy needs. PRACTICE IMPLICATIONS Pending further testing, these plain language practices may be integrated into physician clinical trial and other communication training.
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Affiliation(s)
- Luke Thominet
- Department of English, Floria International University, Miami, FL, USA.
| | - Lauren M Hamel
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, USA.
| | - Fatmeh Baidoun
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, USA.
| | - Tanina F Moore
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, USA.
| | - Ellen Barton
- Linguistics Program, Department of English, Wayne State University, Detroit, USA.
| | - Elisabeth I Heath
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, USA.
| | - Michael Carducci
- Johns Hopkins Medicine/Sidney Kimmel Comprehensive Cancer Center, Baltimore, USA.
| | - Dina Lansey
- Johns Hopkins Medicine/Sidney Kimmel Comprehensive Cancer Center, Baltimore, USA.
| | - Susan Eggly
- Department of Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, USA.
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Kim HS, Nam HW, Ahn HJ, Kim D, Kim YH. Relationship between Clonorchis sinensis Infection and Cholangiocarcinoma in Korea. THE KOREAN JOURNAL OF PARASITOLOGY 2022; 60:261-271. [PMID: 36041488 PMCID: PMC9441450 DOI: 10.3347/kjp.2022.60.4.261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/28/2022] [Indexed: 12/02/2022]
Abstract
This study provides an overview of the current status of clonorchiasis and cholangiocarcinoma (CCA), and their relationship in Korea during 2012–2020. Data were obtained from the Health Insurance Review & Assessment Service of Korea. Cluster, trend, and correlation analyses were performed. Gyeongsangnam-do and Seoul had the highest average number of cases (1,026 and 4,208) and adjusted rate (306 and 424) for clonorchiasis and CCA, respectively. The most likely clusters (MLC) for clonorchiasis and CCA were Busan/Gyeongsangnam-do/Ulsan/Daegu/Gyeongsangbuk-do (Relative Risk; RR=4.55, Likelihood Ratio; LLR=9,131.115) joint cluster and Seoul (RR=2.29, LLR=7,602.472), respectively. The MLC for clonorchiasis was in the southeastern part of Korea, while that for CCA was in the southern part. Clonorchiasis showed a decreasing trend in the southeastern districts, while increased in the southwestern districts. Cities in the central region had a decreasing trend, while the western districts had an increasing trend. In most adults (30–59), infection rate of clonorchiasis showed a significant decrease until 2018, while thereafter increased, although not significant. CCA showed a sharply decreasing tendency. The incidence of clonorchiasis and CCA were positively correlated. In general, the correlation was weak (r=0.39, P<0.001), but it was strongly positive around the 4 river basins (r=0.74, P<0.001). This study might provide an analytic basis for developing an effective system against clonorchiasis and CCA.
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Affiliation(s)
- Hwa Sun Kim
- Department of Family Medicine, Veterans Health Service Medical Center, Seoul 05368, Korea
| | - Ho-Woo Nam
- Department of Parasitology, College of Medicine, Catholic University of Korea, Seoul 06591, Korea
| | - Hye-Jin Ahn
- Department of Parasitology, College of Medicine, Catholic University of Korea, Seoul 06591, Korea
| | - Dongjae Kim
- Department of Biomedicine Health Science, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea
| | - Yeong Hoon Kim
- Department of Ophthalmology, College of Medicine, Catholic University of Korea, Seoul 06591, Korea
- Corresponding author ()
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Pellat A, Boutron I, Ravaud P. Availability of Results of Trials Studying Pancreatic Adenocarcinoma over the Past 10 Years. Oncologist 2022; 27:e849-e855. [PMID: 35983949 PMCID: PMC9632316 DOI: 10.1093/oncolo/oyac156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/24/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Pancreatic adenocarcinoma (PDAC) is a lethal cancer with few therapeutic options. Availability of results is a crucial step in interventional research. Our aim was to evaluate results availability for trials in patients with PDAC and explore associated factors. MATERIALS AND METHODS We performed a retrospective cohort study and searched the ClinicalTrials.gov registry for trials evaluating PDAC management with a primary completion date between 1 January 2010 and 1 June 2020. Then, we searched for results submitted on ClinicalTrials.gov and/or published. Our primary outcome was the proportion of PDAC trials with available results: submitted on ClinicalTrials.gov (either publicly available or undergoing quality control check) and/or published in a full-text article. The association of predefined trial characteristics with results availability was assessed. RESULTS We identified 551 trials of which 386 (70%) had available results. The cumulative percentage of trials with available results was 21% (95% CI, 18-25%) at 12 months after the primary completion date, 44% (95% CI, 30-48%) at 24 months and 57% (95% CI, 53-61%) at 36 months. Applicable clinical trials, required to comply with the 2007 Food and Drug Administration Amendments Act 801 and its final rule on reporting of results on ClinicalTrials.gov, were more likely to have available results over time (HR 2.1 [95% CI 1.72-2.63], P < .001). Industry-funded, small sample size, and terminated trials were less likely to have available results. Other trial characteristics showed no association with results availability. CONCLUSION Our results highlight a waste in interventional research studying PDAC.
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Affiliation(s)
- Anna Pellat
- Corresponding author: Anna Pellat, MD, Gastroenterology and Digestive Oncology Unit, Hôpital Cochin, Assistance Publique des Hôpitaux de Paris, 27 rue du Faubourg Saint Jacques 75014, Paris, France. Tel: +33 689851724;
| | - Isabelle Boutron
- Université Pari Cité, Centre of Research in Epidemiology and Statistics (CRESS), Inserm U1153, Paris, France,Centre d’Épidémiologie Clinique, Hôtel Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Philippe Ravaud
- Université Pari Cité, Centre of Research in Epidemiology and Statistics (CRESS), Inserm U1153, Paris, France,Centre d’Épidémiologie Clinique, Hôtel Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France
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13
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Rubagumya F, Hopman WM, Gyawali B, Mukherji D, Hammad N, Pramesh CS, Zubaryev M, Eniu A, Tsunoda AT, Kutluk T, Aggarwal A, Sullivan R, Booth CM. Participation of Lower and Upper Middle-Income Countries in Clinical Trials Led by High-Income Countries. JAMA Netw Open 2022; 5:e2227252. [PMID: 35980637 PMCID: PMC9389348 DOI: 10.1001/jamanetworkopen.2022.27252] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 06/29/2022] [Indexed: 12/20/2022] Open
Abstract
Importance Many randomized clinical trials (RCTs) led by high-income countries (HICs) now enroll patients from lower middle-income countries (LMICs) and upper middle-income countries (UMICs). Although enrolling diverse populations promotes research collaborations, there are issues regarding which countries participate in RCTs and how this participation may contribute to global research. Objective To describe which UMICs and LMICs participate in RCTs led by HICs. Design, Setting, and Participants A cross-sectional study of all oncology RCTs published globally during January 1, 2014, to December 31, 2017, was conducted. The study cohort was restricted to RCTs led by HICs that enrolled participants from LMICs and UMICs. Study analyses were conducted in November 1, 2021, to May 31, 2022. Main Outcomes and Measures A bibliometric approach (Web of Science 2007-2017) was used to explore whether RCT participation was proportional to other measures of cancer research activity. Participation in RCTs (ie, percentage of RCTs in the cohort in which each LMIC and UMIC participated) was compared with country-level cancer research bibliometric output (ie, percentage of total cancer research bibliometric output from the same group of countries that came from a specific LMIC and UMIC). Results Among the 636 HIC-led RCTs, 186 trials (29%) enrolled patients in LMICs (n = 84 trials involving 11 LMICs) and/or UMICs (n = 181 trials involving 26 UMICs). The most common participating LMICs were India (42 [50%]), Ukraine (39 [46%]), Philippines (23 [27%]), and Egypt (12 [14%]). The most common participating UMICs were Russia (115 [64%]), Brazil (94 [52%]), Romania (62 [34%]), China (56 [31%]), Mexico (56 [31%]), and South Africa (54 [30%]). Several LMICs are overrepresented in the cohort of RCTs based on proportional cancer research bibliometric output: Ukraine (46% of RCTs but 2% of cancer research bibliometric output), Philippines (27% RCTs, 1% output), and Georgia (8% RCTs, 0.2% output). Overrepresented UMICs include Russia (64% RCTs, 2% output), Romania (34% RCTs, 2% output), Mexico (31% RCTs, 2% output), and South Africa (30% RCTs, 1% output). Conclusions and Relevance In this cross-sectional study, a substantial proportion of RCTs led by HICs enrolled patients in LMICs and UMICs. The LMICs and UMICs that participated in these trials did not match overall cancer bibliometric output as a surrogate for research ecosystem maturity. Reasons for this apparent discordance and how these data may inform future capacity-strengthening activities require further study.
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Affiliation(s)
- Fidel Rubagumya
- Department of Clinical Oncology, Rwanda Military Hospital, Kigali, Rwanda
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, Ontario, Canada
- Department of Oncology, Queen’s University, Kingston, Ontario, Canada
| | - Wilma M. Hopman
- Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, Ontario, Canada
- Department of Oncology, Queen’s University, Kingston, Ontario, Canada
- Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Deborah Mukherji
- Department of Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nazik Hammad
- Department of Oncology, Queen’s University, Kingston, Ontario, Canada
| | - C. S. Pramesh
- Department of Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Mykola Zubaryev
- Department of Surgical Oncology, National Cancer Institute of Ukraine, Kyiv, Ukraine
| | - Alexandru Eniu
- Department of Oncology, Hopital Riviera-Chablais, Rennaz, Switzerland
| | - Audrey T. Tsunoda
- Department of Oncology, Hospital Erasto Gaertner e PUCPR, Curitiba, Paraná, Brazil
| | - Tezer Kutluk
- Department of Oncology, Hacettepe University Faculty of Medicine & Cancer Institute, Ankara, Turkey
| | - Ajay Aggarwal
- Institute of Cancer Policy, King’s College London, London, United Kingdom
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Sullivan
- Institute of Cancer Policy, King's College London, London, United Kingdom
| | - Christopher M. Booth
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, Ontario, Canada
- Department of Oncology, Queen’s University, Kingston, Ontario, Canada
- Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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Santorsola M, Di Lauro V, Nasti G, Caraglia M, Capuozzo M, Perri F, Cascella M, Misso G, Ottaiano A. Tumour Burden Reporting in Phase III Clinical Trials of Metastatic Lung, Breast, and Colorectal Cancers: A Systematic Review. Cancers (Basel) 2022; 14:cancers14133262. [PMID: 35805034 PMCID: PMC9264965 DOI: 10.3390/cancers14133262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary The initial tumour burden is a strong and well-known prognostic factor in oncology. A systematic review was performed to examine if and how the initial tumour burden is reported in phase III clinical trials in the most frequent and deadly cancers. Seventy trials were selected, which mostly included biologic agents. The identification of low-burden metastatic disease was performed in 28.6% of studies; it was a stratification factor for randomisation in only 25.7% of studies. In two studies, a significant imbalance between arms in patients with low-burden disease was revealed. Our findings emphasise the need for the better assessment of tumour burden in clinical trials. Abstract Background: Randomised phase III clinical trials represent a methodological milestone to select effective drugs against metastatic cancers. In this context, and particularly in the efficacy assessment of biologic drugs, the initial metastatic tumour burden is a strong prognostic factor. Methods: A systematic literature review of randomised, phase III, first-line, clinical trials in metastatic breast, colorectal, and lung cancers, published from 2016 to 2021, was performed. Three groups of variables were collected: identity-, method- (including tumour burden assessment) and outcome-related. Results: Seventy trials were selected. A large portion of studies (41.4%) focused on the effects of biologic agents (signal inhibitors and immuno-therapies). A definition of low-burden disease based predominantly on the number of involved organs was reported in 28.6% of studies. No explicit reference to oligo-metastatic disease was found either in inclusion/exclusion criteria or in final descriptive data analyses. Disease extent, heterogeneously defined, was a stratification factor for randomisation in only 25.7% of studies. In two studies, a significant imbalance between arms in patients with low-burden disease was revealed. Conclusions: Attention to initial tumour burden in designing future clinical trials (including the harmonisation of definitions and the reporting of eventual oligo-metastatic disease, complete estimates of tumour volume, and its consideration as a stratification factor) should be increased.
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Affiliation(s)
- Mariachiara Santorsola
- Istituto Nazionale Tumori di Napoli, IRCCS “G. Pascale”, Via M. Semmola, 80131 Naples, Italy; (M.S.); (V.D.L.); (G.N.); (F.P.); (M.C.)
| | - Vincenzo Di Lauro
- Istituto Nazionale Tumori di Napoli, IRCCS “G. Pascale”, Via M. Semmola, 80131 Naples, Italy; (M.S.); (V.D.L.); (G.N.); (F.P.); (M.C.)
| | - Guglielmo Nasti
- Istituto Nazionale Tumori di Napoli, IRCCS “G. Pascale”, Via M. Semmola, 80131 Naples, Italy; (M.S.); (V.D.L.); (G.N.); (F.P.); (M.C.)
| | - Michele Caraglia
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, Via L. De Crecchio 7, 80138 Naples, Italy; (M.C.); (G.M.)
| | | | - Francesco Perri
- Istituto Nazionale Tumori di Napoli, IRCCS “G. Pascale”, Via M. Semmola, 80131 Naples, Italy; (M.S.); (V.D.L.); (G.N.); (F.P.); (M.C.)
| | - Marco Cascella
- Istituto Nazionale Tumori di Napoli, IRCCS “G. Pascale”, Via M. Semmola, 80131 Naples, Italy; (M.S.); (V.D.L.); (G.N.); (F.P.); (M.C.)
| | - Gabriella Misso
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, Via L. De Crecchio 7, 80138 Naples, Italy; (M.C.); (G.M.)
| | - Alessandro Ottaiano
- Istituto Nazionale Tumori di Napoli, IRCCS “G. Pascale”, Via M. Semmola, 80131 Naples, Italy; (M.S.); (V.D.L.); (G.N.); (F.P.); (M.C.)
- Correspondence: ; Tel.: +39-081-5903510
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15
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Efficacy in randomised trials: the time matters. Lancet Oncol 2022; 23:839-840. [DOI: 10.1016/s1470-2045(22)00187-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 11/20/2022]
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16
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Pellat A, Boutron I, Ravaud P. Availability of results of interventional studies assessing colorectal cancer from 2013 to 2020. PLoS One 2022; 17:e0266496. [PMID: 35404939 PMCID: PMC9000106 DOI: 10.1371/journal.pone.0266496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/21/2022] [Indexed: 11/18/2022] Open
Abstract
Colorectal cancer (CRC) is one of the most frequent cancers worldwide. Our aim was to evaluate the availability of results of interventional studies studying CRC. We searched the ClinicalTrials.gov registry for all interventional studies on CRC management in adults completed or terminated between 01/01/2013 and 01/01/2020. To identify results, we searched for results posted on the ClinicalTrials.gov registry and/or published in a full-text article. Our primary outcome was the proportion of CRC interventional studies with available results (i.e. posted on the ClinicalTrials.gov registry and/or published in a full-text article). Secondary outcomes were 1) median time between primary completion and earliest date of results availability, 2) the cumulative percentage of interventional studies with results available over time 3) the cumulative percentage of interventional studies with results posted on the ClinicalTrials.gov registry over time and 4) the percentage of results available in open access. We identified 763 eligible interventional studies in ClinicalTrials.gov, which included 679 198 patients. Of these, 286 (37%) trials, including 270 845 (40%) patients, did not have any results available. Median time for results availability was 32.6 months (IQ 16.1-unreached). The cumulative percentage of interventional studies with available results was 17% at 12 months, 39% at 24 months and 55% at 36 months. Results were more likely available for trials that were randomized, completed, had one trial site in the United States, and with mixed funding. The cumulative percentage of interventional studies with results posted on ClinicalTrials.gov was 2% at 12 months. Results were available in open access for 420 (420/477 = 88%) trials. Our results highlight an important waste in research for interventional studies studying CRC.
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Affiliation(s)
- Anna Pellat
- Gastroenterology and Digestive Oncology Unit, Assistance Publique des Hôpitaux de Paris, Cochin Teaching Hospital, Université de Paris, Paris, France
- Centre of Research in Epidemiology and Statistics (CRESS), Inserm U1153, Université de Paris, Paris, France
- * E-mail:
| | - Isabelle Boutron
- Centre of Research in Epidemiology and Statistics (CRESS), Inserm U1153, Université de Paris, Paris, France
- Centre d’Épidémiologie Clinique, Assistance Publique des Hôpitaux de Paris, Hôtel Dieu Hospital, Université de Paris, Paris, France
| | - Philippe Ravaud
- Centre of Research in Epidemiology and Statistics (CRESS), Inserm U1153, Université de Paris, Paris, France
- Centre d’Épidémiologie Clinique, Assistance Publique des Hôpitaux de Paris, Hôtel Dieu Hospital, Université de Paris, Paris, France
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17
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Randomized Controlled Trials in Lung, Gastrointestinal, and Breast Cancers: An Overview of Global Research Activity. Curr Oncol 2022; 29:2530-2538. [PMID: 35448181 PMCID: PMC9026406 DOI: 10.3390/curroncol29040207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/25/2022] [Accepted: 04/05/2022] [Indexed: 11/25/2022] Open
Abstract
Background: In this study, we compared and contrasted design characteristics, results, and publications of randomized controlled trials (RCTs) in gastrointestinal (GI), lung, and breast cancer. Methods: A PUBMED search identified phase III RCTs of anticancer therapy in GI, lung, and breast cancer published globally during the period 2014−2017. Descriptive statistics, chi-square tests, and the Kruskal−Wallis test were used to compare RCT design, results, and output across the cancer sites. Results: A total of 352 RCTs were conducted on GI (36%), lung (29%), and breast (35%) cancer. Surrogate endpoints were used in 55% of trials; this was most common in breast trials (72%) compared to GI (47%) and lung trials (43%, p < 0.001). Breast trials more often met their primary endpoint (54%) than GI (41%) and lung trials (41%) (p = 0.024). When graded with the ESMO-MCBS, lung cancer trials (50%, 15/30) were more likely to meet the threshold for substantial benefit. GI trials were published in journals with a substantially lower impact factor (IF; median IF 13) than lung (median IF 21) and breast cancer trials (median IF 21) (p = 0.038). Conclusions: Important differences in RCT design and output exist between the three major cancer sites. Use of surrogate endpoints and the magnitude of benefit associated with new treatments vary substantially across cancer sites.
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18
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Ottaiano A, Santorsola M, Caracò F, Caraglia M, Nasti G. Initial tumour burden and hidden oligometastatic disease in phase 3 clinical trials. Lancet Oncol 2022; 23:452-454. [DOI: 10.1016/s1470-2045(22)00034-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 12/28/2022]
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19
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Sengar M, Booth CM. Contemporary clinical trials in hematologic cancer: Have we forgotten where we came from? Eur J Cancer 2022; 167:161-163. [PMID: 35246369 DOI: 10.1016/j.ejca.2022.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Canada; Department of Oncology, Queen's University, Kingston, Canada.
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20
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Hsu S, Rosen KJ, Cupertino A, Temple L, Fleming F. Generalizability of Randomized Controlled Trials in Rectal Cancer. J Gastrointest Surg 2022; 26:453-465. [PMID: 34755313 DOI: 10.1007/s11605-021-05192-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 10/26/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND The generalizability of outcomes from randomized controlled trials (RCTs) in oncology is a frequent concern. Given the prevalence and multidisciplinary management of rectal cancer, understanding the generalizability of rectal cancer RCTs is critical to surgical oncologists. METHODS An exhaustive literature review identified 100 non-metastatic rectal cancer RCTs published in English over the past 10 years investigating surgery, chemotherapy, or radiotherapy. In order to evaluate the representativeness of these RCTs compared to the USA and each continent's rectal cancer populations, demographic characteristics were stratified by surgical versus chemoradiotherapy (CRT) trial and by continent then compared with the National Cancer Database and CANCER TODAY using chi-squared and Welch's t-tests. RESULTS Of the 100 trials identified, 65% enrolled significantly younger patients, and 38% enrolled a significantly greater proportion of males than the US rectal cancer population. These demographic differences were more prominent among CRT trials than surgical trials. Half of all trials enrolled patients who were on average more than 7 years younger and enrolled a 5% greater proportion of males than their respective continental rectal cancer populations. Patients enrolled in trials had more advanced cancers than their corresponding continental populations. Sociodemographic data was rarely reported. CONCLUSION Patients enrolled in trials were younger, predominantly male, and had advanced stage cancer when compared to the rectal cancer population. Sociodemographic variables are underreported, further limiting equal participation in clinical trials. Future rectal cancer RCTs should strive to recruit representative samples. To enhance recruitment of women and underrepresented minorities, tailored recruitment strategies must be implemented.
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Affiliation(s)
- Shawn Hsu
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA.
| | - Katherine J Rosen
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - AnaPaula Cupertino
- Community Outreach & Engagement, Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Larissa Temple
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Fergal Fleming
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
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Moreau Bachelard C, Coquan E, du Rusquec P, Paoletti X, Le Tourneau C. Risks and benefits of anticancer drugs in advanced cancer patients: A systematic review and meta-analysis. EClinicalMedicine 2021; 40:101130. [PMID: 34746718 PMCID: PMC8548931 DOI: 10.1016/j.eclinm.2021.101130] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 12/14/2022] Open
Abstract
UNLABELLED Background: Randomized clinical trials (RCTs) of anticancer drugs without active comparators in patients who have exhausted standard of care treatment options are debated. We aimed to quantify the safety and the efficacy of anticancer drugs in advanced cancer patients who have exhausted standard of care treatments from RCTs without active comparators.Methods: This systematic review and meta-analysis was conducted according to preferred reporting Items for systematic review and Meta-Analyses (PRISMA) guidelines (CRD42021243968). A systematic literature search of English language publications from January 1, 2000, to January 7, 2021, was performed using MEDLINE (PubMed). Eligible trials included all RCTs evaluating anticancer drugs in adult patients with advanced solid tumors with a control arm without any anticancer drug consisting of best supportive care with or without a placebo. RCTs performed in the adjuvant, neoadjuvant or maintenance settings were excluded, as were clinical trials evaluating anticancer drugs in combination with radiotherapy. Two authors (C.M.B. and E.C.) independently reviewed the studies for inclusion. Data from published reports were extracted by investigators, and random-effects meta-analysis was performed to estimate the overall hazard ratios (HRs) of progression-free survival (PFS) and overall survival (OS). Correlations between severe toxicity and efficacy was assessed using R2 measures.Findings: Of 3551 studies screened, 128 eligible trials were found involving 47,432 patients. The HRs for PFS and OS were 0·58 [95%CI: 0·53-0·63] and 0·82 [95%CI: 0·78-0·85]. The absolute benefits however were limited with PFS and OS gains of 2·1 and 0·5 months. The absolute excesses in all grade, severe grade III, IV and V (death) adverse events between the two arms were +13·9%, 10·2%, and +0·5%. A weak correlation was measured between the excess of severe toxicity and efficacy (all R² < 0·2).Interpretation: Anticancer drugs evaluated in RCTs against no active treatment benefited trial participants. Severe toxicity did not significantly correlate with efficacy. FUNDING None.
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Affiliation(s)
- Camille Moreau Bachelard
- Department of Drug Development and innovation (D3i), Institut Curie, Paris and Saint-Cloud, 26, rue d'Ulm, Paris 75005, France
- Department of Medical Oncology, Institut de Cancerologie de l'Ouest, Nantes, France
| | - Elodie Coquan
- Department of Medical Oncology, Center François Baclesse, Caen, France
| | - Pauline du Rusquec
- Department of Drug Development and innovation (D3i), Institut Curie, Paris and Saint-Cloud, 26, rue d'Ulm, Paris 75005, France
- INSERM U900 Research unit, Saint-Cloud, France
| | - Xavier Paoletti
- INSERM U900 Research unit, Saint-Cloud, France
- Paris-Saclay University, Paris, France
| | - Christophe Le Tourneau
- Department of Drug Development and innovation (D3i), Institut Curie, Paris and Saint-Cloud, 26, rue d'Ulm, Paris 75005, France
- INSERM U900 Research unit, Saint-Cloud, France
- Paris-Saclay University, Paris, France
- Corresponding author at: Department of Drug Development and innovation (D3i), Institut Curie, Paris and Saint-Cloud, 26, rue d'Ulm, Paris 75005, France.
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22
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Fundytus A, Wells JC, Sharma S, Hopman WM, Del Paggio JC, Gyawali B, Mukherji D, Hammad N, Pramesh CS, Aggarwal A, Sullivan R, Booth CM. Industry Funding of Oncology Randomised Controlled Trials: Implications for Design, Results and Interpretation. Clin Oncol (R Coll Radiol) 2021; 34:28-35. [PMID: 34479769 DOI: 10.1016/j.clon.2021.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/24/2021] [Accepted: 08/02/2021] [Indexed: 11/19/2022]
Abstract
AIMS Most randomised controlled trials (RCTs) in oncology are now funded by the pharmaceutical industry. We explore the extent to which RCT design, results and interpretation differ between industry-funded and non-industry-funded RCTs. MATERIALS AND METHODS In this cross-sectional analysis, a structured literature search was used to identify all oncology RCTs published globally during 2014-2017. Industry funding was identified based on explicit statements in the publication. Descriptive statistics were used to compare elements of trial methodology and output between industry- and non-industry-funded RCTs. RESULTS The study sample included 694 RCTs; 71% were funded by industry. Industry-funded trials were more likely to test systemic therapy (97% versus 62%; P < 0.001), palliative-intent therapy (71% versus 41%; P < 0.001) and study breast cancer (20% versus 12%; P < 0.001). Industry-funded trials were larger (median sample size 474 versus 375; P < 0.001) and more likely to meet their primary end point (49% versus 41%; P < 0.001). Among positive trials, there were no differences in the magnitude of benefit between industry- and non-industry-funded RCTs. Trials funded by industry were published in journals that had a significantly higher median impact factor (21, interquartile range 7, 28) than non-industry-funded trials (impact factor 12, interquartile range 5, 24; P = 0.005); this persisted when adjusted for whether a trial was positive or negative. CONCLUSIONS The vast majority of oncology RCTs are now funded by industry. Industry-funded trials are larger, more likely to be positive, predominantly test systemic therapies in the palliative setting and are published in higher impact journals than trials without industry support.
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Affiliation(s)
- A Fundytus
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada; Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - J C Wells
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada; Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - S Sharma
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - W M Hopman
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - J C Del Paggio
- Department of Oncology, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - B Gyawali
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada; Department of Oncology, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - D Mukherji
- American University of Beirut Medical Center, Beirut, Lebanon
| | - N Hammad
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - C S Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - A Aggarwal
- Institute of Cancer Policy, King's College London, London, UK; London School of Hygiene and Tropical Medicine, London, UK
| | - R Sullivan
- Institute of Cancer Policy, King's College London, London, UK
| | - C M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada; Department of Oncology, Queen's University, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.
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23
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Sorigue M, Kuittinen O. Robustness and pragmatism of the evidence supporting the European Society for Medical Oncology guidelines for the diagnosis, treatment, and follow-up of follicular lymphoma. Expert Rev Hematol 2021; 14:655-668. [PMID: 34128764 DOI: 10.1080/17474086.2021.1943351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Results of randomized clinical trials may not be entirely applicable to clinical practice. The present manuscript aims to explore the pragmatism and robustness of the evidence that supports the European Society for Medical Oncology (ESMO) follicular lymphoma (FL) guidelines.Methods & design: Analysis of all trials used to support positive, therapeutic, oncological recommendations in the 2020 ESMO FL guidelines. Predefined data points were extracted from each trial. Pragmatism was assessed by means of the PRECIS-2 tool, the difference in overall survival in the interventions compared and the source of funding. Robustness was assessed by means of the fragility index and the p value.Results: 28 trials were included. The full protocol or a protocol summary was provided for 12 (43%). Based on the PRECIS-2 domains, trials were considered pragmatic in organization, analysis and flexibility and explanatory in eligibility. Robustness was high, with 4/24 (17%) trials with p values between 0.05 and 0.005 and a median fragility index of 18.Conclusions: Results of trials to support ESMO recommendations in FL were robust. Pragmatism was high in some domains but modest to low in others and the pattern was similar across trials. Transparency in the publication of trial protocols was suboptimal.
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Affiliation(s)
- Marc Sorigue
- Department of Hematology, ICO-IJC-Hospital Germans Trias I Pujol, LUMN, UAB, Badalona, Spain
| | - Outi Kuittinen
- Department of Oncology and Radiotherapy, Oulu University Hospital, Oulu; Institute of Clinical Medicine, Faculty of Health Medicine, University of Eastern Finland & Department of Oncology, Kuopio University Hospital, Kuopio, Finland
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24
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Ludmir EB, Mainwaring W, Lin TA, Miller AB, Jethanandani A, Espinoza AF, Mandel JJ, Lin SH, Smith BD, Smith GL, VanderWalde NA, Minsky BD, Koong AC, Stinchcombe TE, Jagsi R, Gomez DR, Thomas CR, Fuller CD. Factors Associated With Age Disparities Among Cancer Clinical Trial Participants. JAMA Oncol 2021; 5:1769-1773. [PMID: 31158272 DOI: 10.1001/jamaoncol.2019.2055] [Citation(s) in RCA: 153] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Seminal investigation 2 decades ago alerted the oncology community to age disparities in participation in cooperative group trials; less is known about whether these disparities persist in industry-funded research. Objective To characterize the age disparities among trial enrollees on randomized clinical trials (RCTs) of common cancers in clinical oncology and identify factors associated with wider age imbalances. Data Sources Phase 3 clinical oncology RCTs were identified through ClinicalTrials.gov. Study Selection Multiarm RCTs assessing a therapeutic intervention for patients with breast, prostate, colorectal, or lung cancer (the 4 most common cancer disease sites) were included. Data Extraction and Synthesis Trial data were extracted from ClinicalTrials.gov. Trial screening and parameter identification were independently performed by 2 individuals. Data were analyzed in 2018. Main Outcomes and Measures The difference in median age (DMA) between the trial participant median age and the population-based disease-site-specific median age was determined for each trial. Results Three hundred two trials met inclusion criteria. The trials collectively enrolled 262 354 participants; 249 trials (82.5%) were industry-funded. For all trials, the trial median age of trial participants was a mean of 6.49 years younger than the population median age (95% CI, -7.17 to -5.81 years; P < .001). Age disparities were heightened among industry-funded trials compared with non-industry-funded trials (mean DMA, -6.84 vs -4.72 years; P = .002). Enrollment criteria restrictions based on performance status or age cutoffs were associated with age disparities; however, industry-funded trials were not more likely to use these enrollment restrictions than non-industry-funded trials. Age disparities were also larger among trials that evaluated a targeted systemic therapy and among lung cancer trials. Linear regression modeling revealed a widening gap between trial and population median ages over time at a rate of -0.19 years annually (95% CI, -0.37 to -0.01 years; P = .04). Conclusions and Relevance Age disparities between trial participants and the incident disease population are pervasive across trials and appear to be increasing over time. Industry sponsorship of trials is associated with heightened age imbalances among trial participants. With an increasing role of industry funding among cancer trials, efforts to understand and address age disparities are necessary to ensure generalizability of trial results as well as equity in trial access.
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Affiliation(s)
- Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston
| | | | - Timothy A Lin
- The University of Texas MD Anderson Cancer Center, Houston.,Baylor College of Medicine, Houston, Texas
| | | | - Amit Jethanandani
- The University of Texas MD Anderson Cancer Center, Houston.,The University of Tennessee Health Science Center, Memphis
| | | | | | - Steven H Lin
- The University of Texas MD Anderson Cancer Center, Houston
| | | | - Grace L Smith
- The University of Texas MD Anderson Cancer Center, Houston
| | | | - Bruce D Minsky
- The University of Texas MD Anderson Cancer Center, Houston
| | - Albert C Koong
- The University of Texas MD Anderson Cancer Center, Houston
| | | | | | - Daniel R Gomez
- The University of Texas MD Anderson Cancer Center, Houston.,Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles R Thomas
- Oregon Health and Science University, Portland.,Deupty Editor, JAMA Oncology
| | - C David Fuller
- The University of Texas MD Anderson Cancer Center, Houston
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25
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Design, organisation and impact of treatment optimisation studies in breast, lung and colorectal cancer: The experience of the European Organisation for Research and Treatment of Cancer. Eur J Cancer 2021; 151:221-232. [PMID: 34023561 DOI: 10.1016/j.ejca.2021.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 03/29/2021] [Accepted: 04/09/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment optimisation studies (TOSs) are clinical trials which aim to tackle research questions that are often left unaddressed within the current drug development paradigm due to a lack of financial and regulatory incentives to undertake them. Examples include comparative effectiveness, therapeutic sequencing and dose de-escalation studies. Trials of this nature have historically been primarily carried out by academic institutions and not-for-profit organisations such as the European Organisation for Research and Treatment of Cancer (EORTC). OBJECTIVES Our objective was to conduct an in-depth analysis of the breast, lung and colorectal cancer TOSs that have been performed by the EORTC in the past four decades. METHODS We searched the EORTC clinical trials database for relevant studies and subsequently analysed them based on a number of predefined criteria relating to their design, organisation and scientific impact. RESULTS The 113 EORTC TOSs examined in this analysis were mainly standard-sized, international, multicentre phase III trials using a relatively simple, randomised, open-label design and comparing pharmacological combination regimens against standard-of-care treatments in terms of their potential to improve overall survival of patients with cancer. Although they were typically financially and/or materially supported by the industry, their legal sponsor was nearly always an independent party that did not benefit monetarily from their outcomes. If meaningful findings were obtained, their results, regardless of whether positive or negative, were published in high-impact journals, and the corresponding articles usually received a considerable number of citations. CONCLUSIONS Our analysis provides an empirical framework for setting up future TOSs based on the EORTC experience in oncology.
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26
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Del Paggio JC, Berry JS, Hopman WM, Eisenhauer EA, Prasad V, Gyawali B, Booth CM. Evolution of the Randomized Clinical Trial in the Era of Precision Oncology. JAMA Oncol 2021; 7:728-734. [PMID: 33764385 PMCID: PMC7995135 DOI: 10.1001/jamaoncol.2021.0379] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/10/2021] [Indexed: 01/10/2023]
Abstract
IMPORTANCE The randomized clinical trial (RCT) in oncology has evolved since its widespread adoption in the 1970s. In recent years, concerns have emerged regarding the use of putative surrogate end points, such as progression-free survival (PFS), and marginal effect sizes. OBJECTIVE To describe contemporary trends in oncology RCTs and compare these findings with earlier eras of RCT design and output. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of systemic therapy RCTs in breast, colorectal, and non-small cell lung cancer published in 7 major journals between 2010 and 2020. This strategy replicates prior work and allows for comparison of trends with RCTs published between 1995 to 2004 and 2005 to 2009. MAIN OUTCOMES AND MEASURES Data on RCT design, funding, results, and reporting were extracted from the published RCT report. Findings from the current period (2010-2020) were compared with data from RCTs published from 1995 to 2004 and 2005 to 2009. Descriptive and bivariate statistics were used to analyze temporal trends. RESULTS The cohort included 298 RCTs (132 [44%] breast, 111 [37%] non-small cell lung cancer, 55 [19%] colorectal cancer). Experimental treatment included molecular inhibitor (171 of 298 [57%]), cytotoxic (83 of 298 [28%]), hormone (15 of 298 [5%]), and immune (24 of 298 [8%]) therapies. Sixty-nine percent (206 of 298) of RCTs were of palliative intent. The most common primary end point is now PFS; this has increased substantially over time (from 0% [0 of 167] to 18% [25 of 137] to 42% [125 of 298]; P < .001). Of 298 RCTs, 265 (89%) are now funded by industry (previously 95 of 167 [57%] and 107 of 137 [78%]; P < .001). Fifty-eight percent (173 of 298) of trials met their primary end point. Among positive trials, median improvement in overall survival and PFS was 3.4 and 2.9 months, respectively. More than one-third (117 of 298 [39%]) of reports used a professional medical writer; this increased substantially during the study period (from 3 of 27 [11%] in 2010 to 12 of 18 [67%] in 2020; P < .001). CONCLUSIONS AND RELEVANCE This cohort study suggests that contemporary oncology RCTs now largely measure putative surrogate end points and are almost exclusively funded by the pharmaceutical industry. The increasing role of medical writers warrants attention. To demonstrate that new cancer treatments are high value, the oncology community needs to consider the extent to which study end points and target effect size provide meaningful benefit to patients.
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Affiliation(s)
- Joseph C. Del Paggio
- Department of Medical Oncology, Thunder Bay Regional Health Sciences Centre and Northern Ontario School of Medicine, Thunder Bay, Canada
| | - John S. Berry
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Queen’s University, Kingston, Canada
| | - Wilma M. Hopman
- Kingston General Health Research Institute, Kingston, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Canada
| | | | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California at San Francisco
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Queen’s University, Kingston, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Canada
- Department of Oncology, Queen’s University, Kingston, Canada
| | - Christopher M. Booth
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Queen’s University, Kingston, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Canada
- Department of Oncology, Queen’s University, Kingston, Canada
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27
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Sharma S, Wells JC, Hopman WM, Del Paggio JC, Gyawali B, Hammad N, Hay AE, Booth CM. Cancer, Clinical Trials, and Canada: Our Contribution to Worldwide Randomized Controlled Trials. ACTA ACUST UNITED AC 2021; 28:1518-1527. [PMID: 33924380 PMCID: PMC8167552 DOI: 10.3390/curroncol28020143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/31/2021] [Accepted: 04/09/2021] [Indexed: 12/23/2022]
Abstract
Canada has a long tradition of leading practice-changing clinical trials in oncology. Here, we describe methodology, results, and interpretation of oncology RCTs with Canadian involvement compared to RCTs from other high-income countries (HICs). A literature search identified all RCTs evaluating anti-cancer therapies published 2014–2017. RCTs were classified based on the country affiliation of first authors. The study cohort included 636 HIC-led RCTs; 155 (24%) had Canadian authors. Three-quarters (112/155, 72%) of Canadian RCTs were conducted in the palliative setting, compared to two thirds (299/481, 62%) of RCTs from other HICs (p = 0.022). Canadian RCTs were more likely than those from other HICs to be supported by industry (85% vs. 69%, p < 0.001). The proportion of positive Canadian trials that met the ESMO-MCBS threshold for substantial clinical benefit was comparable to RCTs without Canadian authors (29% vs. 32%, p = 0.137). Thirteen percent (20/155) of all Canadian trials were affiliated with the Canadian Cancer Trials Group (CCTG). Canada plays a meaningful role in the global cancer research ecosystem but is overly reliant on industry support. The very low proportion of trials that identify a new treatment with substantial clinical benefit is worrisome. A renewed investment in cancer clinical trials is needed in Canada.
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Affiliation(s)
- Shubham Sharma
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON K7L 3N6, Canada; (S.S.); (J.C.W.); (B.G.)
| | - J. Connor Wells
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON K7L 3N6, Canada; (S.S.); (J.C.W.); (B.G.)
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada;
| | - Wilma M. Hopman
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada;
| | - Joseph C. Del Paggio
- Department of Oncology, Northern Ontario School of Medicine, Thunder Bay, ON P3E 2C6, Canada;
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON K7L 3N6, Canada; (S.S.); (J.C.W.); (B.G.)
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada;
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada;
| | - Nazik Hammad
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada;
| | - Annette E. Hay
- Department of Medicine, Queen’s University, Kingston, ON K7L 3N6, Canada;
- Canadian Cancer Trials Group, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Christopher M. Booth
- Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, ON K7L 3N6, Canada; (S.S.); (J.C.W.); (B.G.)
- Department of Oncology, Queen’s University, Kingston, ON K7L 5P9, Canada;
- Department of Public Health Sciences, Queen’s University, Kingston, ON K7L 3N6, Canada;
- Correspondence:
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28
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Del Paggio JC, Fundytus AM, Hopman WM, Pater JL, Chen BE, Brundage MD, Hay AE, Booth CM. Application of Value Frameworks to the Design of Clinical Trials: the Canadian Cancer Trials Group Experience. J Natl Cancer Inst 2021; 113:1422-1428. [PMID: 33760057 DOI: 10.1093/jnci/djab051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/01/2021] [Accepted: 03/22/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Use of value framework thresholds in the design of clinical trials may increase the proportion of randomized controlled trials (RCTs) that identify clinically meaningful advances for patients. Existing frameworks have not been applied to the research output of a cooperative cancer trials group. We apply value frameworks to the RCT output of the Canadian Cancer Trials Group (CCTG). METHODS Statistical design, study characteristics, and results of all published phase III trials of CCTG were abstracted. We applied the European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) and American Society of Clinical Oncology Net Health Benefit (ASCO-NHB) to study results and the statistical power calculations to identify the proportion of all trials that were designed to detect a substantial clinical benefit. RESULTS During 1979-2017, CCTG published 113 phase III trials; 52.2% (59 of 113) of these trials were positive. Half (50.4%, 57 of 113) of trials were conducted in the palliative setting. In 37.2% (42 of 113) of trials the primary endpoint was overall survival; DFS or PFS was used in 38.9% (44 of 113) of trials. The ESMO-MCBS could be applied to the power calculation for 69 trials; 73.9% (51 of 69) of these trials were designed to detect an effect size that could meet ESMO-MCBS thresholds for substantial benefit. Among the 51 positive trials for which the ESMO-MCBS could be applied, 41.1% (21 of 51) met thresholds for substantial benefit. CONCLUSIONS Most CCTG phase III trials were designed to detect clinically meaningful differences in outcome, although less than half of positive trials met the threshold for substantial benefit. Application of value frameworks to the design of clinical trials is practical and may improve research efficiency and treatment options for patients.
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Affiliation(s)
- Joseph C Del Paggio
- Department of Medical Oncology, Thunder Bay Regional Health Sciences Centre and Northern Ontario School of Medicine, Thunder Bay, Canada
| | - Adam M Fundytus
- Department of Oncology, Queen's University, Kingston, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Wilma M Hopman
- Department of Public Health Sciences, Queen's University, Kingston, Canada.,Kingston General Hospital Research Institute, Kingston, ON, Canada
| | - Joseph L Pater
- Department of Public Health Sciences, Queen's University, Kingston, Canada.,Canadian Cancer Trials Group, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Bingshu E Chen
- Department of Public Health Sciences, Queen's University, Kingston, Canada.,Canadian Cancer Trials Group, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Michael D Brundage
- Department of Oncology, Queen's University, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Annette E Hay
- Department of Medicine, Queen's University, Kingston, Canada.,Canadian Cancer Trials Group, Queen's Cancer Research Institute, Kingston, ON, Canada
| | - Christopher M Booth
- Department of Oncology, Queen's University, Kingston, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, ON, Canada
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29
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Wells JC, Sharma S, Del Paggio JC, Hopman WM, Gyawali B, Mukherji D, Hammad N, Pramesh CS, Aggarwal A, Sullivan R, Booth CM. An Analysis of Contemporary Oncology Randomized Clinical Trials From Low/Middle-Income vs High-Income Countries. JAMA Oncol 2021; 7:379-385. [PMID: 33507236 DOI: 10.1001/jamaoncol.2020.7478] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance The burden of cancer falls disproportionally on low-middle-income countries (LMICs). It is not well known how novel therapies are tested in current clinical trials and the extent to which they match global disease burden. Objectives To describe the design, results, and publication of oncology randomized clinical trials (RCTs) and examine the extent to which trials match global disease burden and how trial methods and results differ across economic settings. Design, Setting, and Participants In this retrospective cohort study, a literature search identified all phase 3 RCTs evaluating anticancer therapies published from 2014 to 2017. Randomized clinical trials were classified based on World Bank economic classification. Descriptive statistics were used to compare RCT design and results from high-income countries (HICs) and low/middle-income countries (LMICs). Statistical analysis was conducted in January 2020. Main Outcomes and Measures Differences in the design, results, and output of RCTs between HICs and LMICs. Results The study cohort included 694 RCTs: 636 (92%) led by HICs and 58 (8%) led by LMICs. A total of 601 RCTs (87%) tested systemic therapy and 88 RCTs (13%) tested radiotherapy or surgery. The proportion of RCTs relative to global deaths was higher for breast cancer (121 RCTs [17%] and 7% of deaths) but lower for gastroesophageal cancer (38 RCTs [6%] and 14% of deaths), liver cancer (14 RCTs [2%] and 8% of deaths), pancreas cancer (14 RCTs [2%] and 5% of deaths), and cervical cancer (9 RCTs [1%] and 3% of deaths). Randomized clinical trials in HICs were more likely than those in LMICs to be funded by industry (464 [73%] vs 24 [41%]; P < .001). Studies in LMICs were smaller than those in HICs (median, 219 [interquartile range, 137-363] vs 474 [interquartile range, 262-743] participants; P < .001) and more likely to meet their primary end points (39 of 58 [67%] vs 286 of 636 [45%]; P = .001). The observed median effect size among superiority trials was larger in LMICs compared with HICs (hazard ratio, 0.62 [interquartile range, 0.54-0.76] vs 0.84 [interquartile range, 0.67-0.97]; P < .001). Studies from LMICs were published in journals with lower median impact factors than studies from HICs (7 [interquartile range, 4-21] vs 21 [interquartile range, 7-34]; P < .001). Publication bias persisted when adjusted for whether a trial was positive or negative (median impact factor: LMIC negative trial, 5 [interquartile range, 4-6] vs HIC negative trial, 18 [interquartile range, 6-26]; LMIC positive trial, 9 [interquartile range, 5-25] vs HIC positive trial, 25 [interquartile range, 10-48]; P < .001). Conclusions and Relevance This study suggests that oncology RCTs are conducted predominantly by HICs and do not match the global burden of cancer. Randomized clinical trials from LMICs are more likely to identify effective therapies and have a larger effect size than RCTs from HICs. This study suggests that there is a funding and publication bias against RCTs led by LMICs. Policy makers, research funders, and journals need to address this issue with a range of measures including building capacity and capability in RCTs.
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Affiliation(s)
- J Connor Wells
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Shubham Sharma
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Joseph C Del Paggio
- Department of Oncology, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Wilma M Hopman
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Bishal Gyawali
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Deborah Mukherji
- Department of Hematology/Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nazik Hammad
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - C S Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Ajay Aggarwal
- Institute of Cancer Policy, King's College London, London, United Kingdom.,Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Sullivan
- Institute of Cancer Policy, King's College London, London, United Kingdom
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,Department of Oncology, Queen's University, Kingston, Ontario, Canada.,Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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30
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Pasalic D, Tang C, Jagsi R, Fuller CD, Koong AC, Ludmir EB. Association of Industry Sponsorship With Cancer Clinical Trial Accrual. JAMA Oncol 2021; 6:1625-1627. [PMID: 32815984 DOI: 10.1001/jamaoncol.2020.1284] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Dario Pasalic
- The University of Texas MD Anderson Cancer Center, Houston
| | - Chad Tang
- The University of Texas MD Anderson Cancer Center, Houston
| | | | - C David Fuller
- The University of Texas MD Anderson Cancer Center, Houston
| | - Albert C Koong
- The University of Texas MD Anderson Cancer Center, Houston
| | - Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston
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31
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Luyendijk M, Vernooij RWM, Blommestein HM, Siesling S, Uyl-de Groot CA. Assessment of Studies Evaluating Incremental Costs, Effectiveness, or Cost-Effectiveness of Systemic Therapies in Breast Cancer Based on Claims Data: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1497-1508. [PMID: 33127021 DOI: 10.1016/j.jval.2020.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 04/10/2020] [Accepted: 05/11/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Large secondary databases, such as those containing insurance claims data, are increasingly being used to compare the effects and costs of treatments in routine clinical practice. Despite their appeal, however, caution must be exercised when using these data. In this study, we aimed to identify and assess the methodological quality of studies that used claims data to compare the effectiveness, costs, or cost-effectiveness of systemic therapies for breast cancer. METHODS We searched Embase, the Cochrane Library, Medline, Web of Science, and Google Scholar for English-language publications and assessed the methodological quality using the Good Research for Comparative Effectiveness principles. This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under number CRD42018103992. RESULTS We identified 1251 articles, of which 106 met the inclusion criteria. Most studies were conducted in the United States (74%) and Taiwan (9%) and were based on claims data sets (35%) or claims data linked to cancer registries (58%). Furthermore, most included large samples (mean 17 130 patients) and elderly patients, and they covered various outcomes (eg, survival, adverse events, resource use, and costs). Key methodological shortcomings were the lack of information on relevant confounders, the risk of immortal time bias, and the lack of information on the validity of outcomes. Only a few studies performed sensitivity analyses. CONCLUSIONS Many comparative studies of cost, effectiveness, and cost-effectiveness have been published in recent decades based on claims data, and the number of publications has increased over time. Despite the availability of guidelines to improve quality, methodological issues persist and are often inappropriately addressed or reported.
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Affiliation(s)
- Marianne Luyendijk
- Department of Research and Development, Netherlands Comprehensive Cancer Center, Utrecht, The Netherlands; Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands.
| | - Robin W M Vernooij
- Department of Research and Development, Netherlands Comprehensive Cancer Center, Utrecht, The Netherlands
| | - Hedwig M Blommestein
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Center, Utrecht, The Netherlands; Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands
| | - Carin A Uyl-de Groot
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
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32
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Buergy D, Riedel J, Sarria GR, Ehmann M, Scafa D, Grilli M, Wenz F, Hofheinz RD. Unfinished business: Terminated cancer trials and the relevance of treatment intent, sponsors and intervention types. Int J Cancer 2020; 148:1676-1684. [PMID: 33045097 DOI: 10.1002/ijc.33342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 11/08/2022]
Abstract
The aim of the study was to report on the association of trial sponsors with intervention type, treatment intent, recruitment success and reasons to terminate cancer trials. The ClinicalTrials database was searched for interventional Phase 3 cancer trials (01/2006-05/2017). Noncancer studies and ongoing studies were excluded, permanently suspended studies were counted as terminated. Trials were stratified according to sponsors (industry/nonindustry), intervention type, setting (curative/palliative) and intent of intervention (curative/symptom-control/life-extending). We identified 345 terminated trials and 1137 completed studies as a control group. The frequency of premature termination did not differ significantly between sponsors. Time to termination was shorter but recruitment per month prior to termination was higher in industry-sponsored studies (7.0 vs 2.2 patients/month; P < .001). Drug interventions were more common in industry-sponsored, all other interventions in nonindustry-sponsored settings (P < .001). Life-extending palliative interventions occurred more frequently, symptom-control interventions in a curative setting less frequently in industry-sponsored trials (both P < .001). Intervention, setting and intent were not associated with termination in industry-sponsored trials. In nonindustry-sponsored trials, the frequency of drug interventions and life-extending (noncurative) interventions were increased in terminated trials (both P < .05); symptom-control interventions in curative settings occurred more frequently in completed studies. Industry-sponsored trials were more often terminated due to toxicity/inefficacy while lack of accrual occurred more frequently in nonindustry-sponsored trials (P < .01). Interventions, treatment setting/intent and reasons for termination differed between sponsor types. In nonindustry-sponsored trials, drug interventions and life-extending (noncurative) interventions were associated with premature termination and symptom-control interventions (curative setting) were associated with trial completion.
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Affiliation(s)
- Daniel Buergy
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Julian Riedel
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Michael Ehmann
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Maurizio Grilli
- Library for the Medical Faculty of Mannheim, Heidelberg University, Mannheim, Germany
| | - Frederik Wenz
- Board of Directors, Freiburg Medical Center, Freiburg, Germany
| | - Ralf D Hofheinz
- Day Treatment Center (TTZ), Interdisciplinary Tumor Center Mannheim (ITM) and 3rd Medical Clinic, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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33
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Charlton V. NICE and Fair? Health Technology Assessment Policy Under the UK's National Institute for Health and Care Excellence, 1999-2018. HEALTH CARE ANALYSIS 2020; 28:193-227. [PMID: 31325000 PMCID: PMC7387327 DOI: 10.1007/s10728-019-00381-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The UK's National Institute for Health and Care Excellence (NICE) is responsible for conducting health technology assessment (HTA) on behalf of the National Health Service (NHS). In seeking to justify its recommendations to the NHS about which technologies to fund, NICE claims to adopt two complementary ethical frameworks, one procedural-accountability for reasonableness (AfR)-and one substantive-an 'ethics of opportunity costs' (EOC) that rests primarily on the notion of allocative efficiency. This study is the first to empirically examine normative changes to NICE's approach and to analyse whether these enhance or diminish the fairness of its decision-making, as judged against these frameworks. It finds that increasing formalisation of NICE's approach and a weakening of the burden of proof laid on technologies undergoing HTA have together undermined its commitment to EOC. This implies a loss of allocative efficiency and a shift in the balance of how the interests of different NHS users are served, in favour of those who benefit directly from NICE's recommendations. These changes also weaken NICE's commitment to AfR by diminishing the publicity of its decision-making and by encouraging the adoption of rationales that cannot easily be shown to meet the relevance condition. This signals a need for either substantial reform of NICE's approach, or more accurate communication of the ethical reasoning on which it is based. The study also highlights the need for further empirical work to explore the impact of these policy changes on NICE's practice of HTA and to better understand how and why they have come about.
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Affiliation(s)
- Victoria Charlton
- Department of Global Health and Social Medicine, King's College London, 40 Aldwych, London, WC2B 4BG, UK.
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34
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Broes S, Saesen R, Lacombe D, Huys I. Past, Current, and Future Cancer Clinical Research Collaborations: The Case of the European Organisation for Research and Treatment of Cancer. Clin Transl Sci 2020; 14:47-53. [PMID: 32799428 PMCID: PMC7877867 DOI: 10.1111/cts.12863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/14/2020] [Indexed: 12/21/2022] Open
Abstract
Although collaborations between academic institutions and industry have led to important scientific breakthroughs in the discovery stage of the pharmaceutical research and development process, the role of multistakeholder partnerships in the clinical development of anticancer medicines necessitates further clarification. The benefits associated with such cooperation could be undercut by the conflicting goals and motivations of the actors included. The aim of this review was to identify and characterize past, present, and future stakeholder partnership models in cancer clinical research through the lens of the European Organisation for Research and Treatment of Cancer (EORTC). Based on the analysis of several landmark EORTC trials performed across the span of three decades, four existing models of stakeholder cooperation were delineated and characterized. Additionally, a hypothetical fifth model representing a potential future collaborative framework for cancer clinical research was formulated. These models mainly differ in terms of the nature and responsibilities of the partners included and show that clinical research partnerships in oncology have evolved over time from small‐scale academia‐industry collaborations to complex interdisciplinary cooperation involving many different stakeholders.
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Affiliation(s)
- Stefanie Broes
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Robbe Saesen
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Denis Lacombe
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Isabelle Huys
- Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, Katholieke Universiteit Leuven, Leuven, Belgium
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35
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Cheng S, Cheung MC, Jiang DM, McDonald E, Arciero VS, Ezeife DA, Rahmadian A, Chambers A, Sabarre KA, Parmar A, Chan KKW. Are Surrogate Endpoints Unbiased Metrics in Clinical Benefit Scores of the ASCO Value Framework? J Natl Compr Canc Netw 2020; 17:1489-1496. [PMID: 31805528 DOI: 10.6004/jnccn.2019.7333] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 06/18/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clinical benefit scores (CBS) are key elements of the ASCO Value Framework (ASCO-VF) and are weighted based on a hierarchy of efficacy endpoints: hazard ratio for death (HR OS), median overall survival (mOS), HR for disease progression (HR PFS), median progression-free survival (mPFS), and response rate (RR). When HR OS is unavailable, the other endpoints serve as "surrogates" to calculate CBS. CBS are computed from PFS or RR in 39.6% of randomized controlled trials. This study examined whether surrogate-derived CBS offer unbiased scoring compared with HR OS-derived CBS. METHODS Using the ASCO-VF, CBS for advanced disease settings were computed for randomized controlled trials of oncology drug approvals by the FDA, European Medicines Agency, and Health Canada in January 2006 through December 2017. Mean differences of surrogate-derived CBS minus HR OS-derived CBS assessed the tendency of surrogate-derived CBS to overestimate or underestimate clinical benefit. Spearman's correlation evaluated the association between surrogate- and HR OS-derived CBS. Mean absolute error assessed the average difference between surrogate-derived CBS relative to HR OS-derived CBS. RESULTS CBS derived from mOS, HR PFS, mPFS, and RR overestimated HR OS-derived CBS in 58%, 68%, 77%, and 55% of pairs and overall by an average of 5.62 (n=90), 6.86 (n=110), 29.81 (n=101), and 3.58 (n=108), respectively. Correlation coefficients were 0.80 (95% CI, 0.70-0.86), 0.38 (0.20-0.53), 0.20 (0.00-0.38), and 0.01 (-0.18 to 0.19) for mOS-, HR PFS-, mPFS-, and RR-derived CBS, respectively, and mean absolute errors were 11.32, 12.34, 40.40, and 18.63, respectively. CONCLUSIONS Based on the ASCO-VF algorithm, HR PFS-, mPFS-, and RR-derived CBS are suboptimal surrogates, because they were shown to be biased and poorly correlated to HR OS-derived CBS. Despite lower weighting than OS in the ASCO-VF algorithm, PFS still overestimated CBS. Simple rescaling of surrogate endpoints may not improve their validity within the ASCO-VF given their poor correlations with HR OS-derived CBS.
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Affiliation(s)
- Sierra Cheng
- aOdette Cancer Centre, Sunnybrook Health Sciences Centre, and
| | - Matthew C Cheung
- aOdette Cancer Centre, Sunnybrook Health Sciences Centre, and.,bDepartment of Medicine, University of Toronto
| | | | - Erica McDonald
- aOdette Cancer Centre, Sunnybrook Health Sciences Centre, and
| | | | | | | | | | | | - Ambika Parmar
- aOdette Cancer Centre, Sunnybrook Health Sciences Centre, and
| | - Kelvin K W Chan
- aOdette Cancer Centre, Sunnybrook Health Sciences Centre, and.,bDepartment of Medicine, University of Toronto.,dCanadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
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36
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Ludmir EB, Fuller CD, Moningi S, Mainwaring W, Lin TA, Miller AB, Jethanandani A, Espinoza AF, Verma V, Smith BD, Smith GL, VanderWalde NA, Holliday EB, Guadagnolo BA, Stinchcombe TE, Jagsi R, Gomez DR, Minsky BD, Rödel C, Fokas E. Sex-Based Disparities Among Cancer Clinical Trial Participants. J Natl Cancer Inst 2020; 112:211-213. [PMID: 31350545 DOI: 10.1093/jnci/djz154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 11/13/2022] Open
Abstract
Landmark investigation two decades ago demonstrated sex-based disparities among participants in cancer cooperative group trials. Although federal efforts have aimed to improve representation of female patients in government-sponsored research, less is known about sex disparities in the broader landscape of modern oncologic randomized controlled trials. Using ClinicalTrials.gov, we identified randomized controlled trials related to colorectal or lung cancer (the two most common non-sex-specific disease sites). Among the 147 included trials, the proportion of female patients enrolled on trial was on average 6.8% (95% confidence interval = -8.8% to -4.9%) less than the proportion of female patients in the population by disease site (P < .001). Whereas no statistically significant underrepresentation of women was noted within the 26 cooperative group trials, sex disparities were markedly heightened for the 121 noncooperative-group-sponsored trials. Furthermore, underrepresentation of women did not improve with time. Future efforts should therefore focus on addressing these pervasive sex-based enrollment disparities beyond cooperative group trials alone.
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Affiliation(s)
- Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - C David Fuller
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shalini Moningi
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Timothy A Lin
- The University of Texas MD Anderson Cancer Center, Houston, TX.,Baylor College of Medicine, Houston, TX
| | | | - Amit Jethanandani
- The University of Texas MD Anderson Cancer Center, Houston, TX.,The University of Tennessee Health Science Center, Memphis, TN
| | | | - Vivek Verma
- Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | | | - Grace L Smith
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Emma B Holliday
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Daniel R Gomez
- The University of Texas MD Anderson Cancer Center, Houston, TX.,Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bruce D Minsky
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claus Rödel
- University of Frankfurt, Frankfurt, Germany.,German Cancer Research Center, Heidelberg, Germany.,German Cancer Consortium, Frankfurt, Germany.,Frankfurt Cancer Institute, Frankfurt, Germany
| | - Emmanouil Fokas
- University of Frankfurt, Frankfurt, Germany.,German Cancer Research Center, Heidelberg, Germany.,German Cancer Consortium, Frankfurt, Germany.,Frankfurt Cancer Institute, Frankfurt, Germany
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37
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Hoverman JR. Rethinking clinical oncology drug research in an era of value-based cancer care: A role for chemotherapy pathways. Cancer Med 2020; 9:5306-5311. [PMID: 32524722 PMCID: PMC7404003 DOI: 10.1002/cam4.3193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/15/2020] [Accepted: 05/15/2020] [Indexed: 01/05/2023] Open
Abstract
The United States spends nearly 1/5th of its GDP on healthcare. Yet, to achieve value-based care, the Economist describes the US healthcare system as handicapped by multiple, disparate silos that prevent the organization and sharing of data. This paper explores the current state of clinical oncology drug research and its relationship to value-based cancer care. Clinical Chemotherapy Pathways are proposed as a unifying structure to bring together disparate sources of data to increase value.
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Affiliation(s)
- J. Russell Hoverman
- Value‐based ProgramsUS Oncology/McKesson Specialty HealthTexas OncologyDallasTXUSA
- US Oncology/McKesson Specialty HealthThe WoodlandsTXUSA
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38
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Schirrmacher V, Sprenger T, Stuecker W, Van Gool SW. Evidence-Based Medicine in Oncology: Commercial Versus Patient Benefit. Biomedicines 2020; 8:biomedicines8080237. [PMID: 32717895 PMCID: PMC7460025 DOI: 10.3390/biomedicines8080237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 12/12/2022] Open
Abstract
At times of personalized and individualized medicine the concept of randomized- controlled clinical trials (RCTs) is being questioned. This review article explains principles of evidence-based medicine in oncology and shows an example of how evidence can be generated independently from RCTs. Personalized medicine involves molecular analysis of tumor properties and targeted therapy with small molecule inhibitors. Individualized medicine involves the whole patient (tumor and host) in the context of immunotherapy. The example is called Individualized Multimodal Immunotherapy (IMI). It is based on the individuality of immunological tumor-host interactions and on the concept of immunogenic tumor cell death (ICD) induced by an oncolytic virus. The evidence is generated by systematic data collection and analysis. The outcome is then shared with the scientific and medical community. The priority of big pharma studies is commercial benefit. Methods used to achieve this are described and have damaged the image of RCT studies in general. A critical discussion is recommended between all partners of the medical health system with regard to the conduct of RCTs by big pharma companies. Several clinics and institutions in Europe try to become more independent from pharma industry and to develop their own modern cancer therapeutics. Medical associations should include references to such studies from personalized and individualized medicine in their guidelines.
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39
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Komorowski AS, MacKay HJ, Pezo RC. Quality of adverse event reporting in phase III randomized controlled trials of breast and colorectal cancer: A systematic review. Cancer Med 2020; 9:5035-5050. [PMID: 32452660 PMCID: PMC7367648 DOI: 10.1002/cam4.3095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Clinical trial reports often emphasize efficacy over harms, leading to misinterpretation of the risk-to-benefit ratio of new therapies. Clear and sufficiently detailed reporting of methods and results is especially important in the abstracts of trial reports, as readers often base their assessment of a trial on such information. In this study, we evaluated the quality of adverse event (AE) reporting and abstract quality in phase III randomized controlled trials (RCTs) of systemic therapies in breast and colorectal cancer. METHODS Medline, EMBASE, Cochrane Database of RCTs, and Cochrane Database of Systematic Reviews were searched from November 2005 to September 2018. Phase III RCTs evaluating systemic therapies in breast or colorectal cancer were included. Each article was independently reviewed by two investigators using a standardized data extraction form based on guidelines developed by the Consolidated Standards of Reporting Trials (CONSORT) group. Descriptive statistics, bivariate analysis, and multivariable linear regression were used to analyze data. All statistical tests were two-sided. RESULTS Of 166 RCTs identified, 99.4% reported harms in the manuscript body, and 59.6% reported harms in the abstract. Reporting was restricted to severe harms in 15.6% of RCTs. Statistical comparison of AE rates went unreported in 59.0% of studies. Information regarding AEs leading to dose reductions, treatment discontinuations, or study withdrawals went unreported in 59.3%, 18.7%, and 86.8% of studies, respectively. Recently published RCTs (P = .009) and those sponsored at least partially by for-profit companies (P = .003) had higher abstract quality scores. CONCLUSIONS Breast and colorectal cancer phase III RCTs inadequately report CONSORT-compliant AE data. Improved guideline adherence and abstract reporting is required to properly weigh benefits and harms of new oncologic therapies. SYSTEMATIC REVIEW REGISTRATION NUMBER CRD42019140673.
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Affiliation(s)
- Adam S. Komorowski
- Division of Medical MicrobiologyMcMaster UniversityHamiltonONCanada
- Sunnybrook Research InstituteSunnybrook Health Sciences CentreTorontoONCanada
| | - Helen J. MacKay
- Division of Medical OncologySunnybrook Health Sciences CentreTorontoONCanada
- Department of MedicineUniversity of TorontoTorontoONCanada
| | - Rossanna C. Pezo
- Division of Medical OncologySunnybrook Health Sciences CentreTorontoONCanada
- Department of MedicineUniversity of TorontoTorontoONCanada
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Neel DV, Shulman DS, Ma C, Bourgeois F, DuBois SG. Sponsorship of oncology clinical trials in the United States according to age of eligibility. Cancer Med 2020; 9:4495-4500. [PMID: 32351000 PMCID: PMC7333829 DOI: 10.1002/cam4.3083] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 04/05/2020] [Accepted: 04/08/2020] [Indexed: 12/19/2022] Open
Abstract
Background The sponsorship mix of trials relevant to young people with cancer has not been reported. Understanding this sponsorship mix may have implications for policies and regulations related to pediatric cancer drug development. Methods We analyzed sponsorship of interventional trials first opened in the United States from 2007 to 2018 using the ClinicalTrials.gov registry. A total of 51 781 trials across non‐oncology disciplines and 18 431 oncology trials were classified according to lower age of eligibility (≥18 years vs < 18 years). Studies were stratified according to sponsorship (industry vs non‐industry). Trial characteristics were compared by sponsorship category. Trends in sponsorship were tracked over time. Results Within oncology trials for patients ≥ 18 years, sponsorship was 33% industry and 67% non‐industry. Among oncology trials that included patients < 18 years, sponsorship was 16.6% industry and 83.4% non‐industry (P < .001). 15.5% of industry‐sponsored trials in non‐oncology disciplines included patients < 18 years, whereas only 5.2% of industry‐sponsored oncology trials were open to patients < 18 years (P < .001). Relative to trials with non‐industry sponsors, there was a statistically significant increase in industry sponsorship of oncology trials that included patients < 18 years over time (P < .001). Trial characteristics differed significantly according to sponsor type regardless of age of eligibility. Conclusions Interventional oncology trials that include patients < 18 years are less likely to be industry‐sponsored compared to oncology trials exclusively in patients ≥ 18 years. Compared to other medical disciplines, a smaller proportion of industry‐sponsored oncology trials included patients < 18 years. Trial sponsorship is associated with differential trial characteristics, such as trial duration and number of patients enrolled, regardless of age.
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Affiliation(s)
| | - David S Shulman
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Clement Ma
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Florence Bourgeois
- Pediatric Therapeutics and Regulatory Science Initiative, Computational Health Informatics Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven G DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
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Suh CH, Kim HS, Jung SC, Choi CG, Kim SJ, Kim KW. Optimized Image-Based Surrogate Endpoints in Targeted Therapies for Glioblastoma: A Systematic Review and Meta-Analysis of Phase III Randomized Controlled Trials. Korean J Radiol 2020; 21:471-482. [PMID: 32193895 PMCID: PMC7082650 DOI: 10.3348/kjr.2019.0839] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 12/19/2019] [Indexed: 01/11/2023] Open
Abstract
Objective We aimed to determine the optimized image-based surrogate endpoints (IBSEs) in targeted therapies for glioblastoma through a systematic review and meta-analysis of phase III randomized controlled trials (RCTs). Materials and Methods A systematic search of OVID-MEDLINE and EMBASE for phase III RCTs on glioblastoma was performed in December 2017. Data on overall survival (OS) and IBSEs, including progression-free survival (PFS), 6-month PFS (6moPFS), 12-month PFS (12moPFS), median PFS, and objective response rate (ORR) were extracted. Weighted linear regression analysis for the hazard ratio for OS and the hazard ratios or odds ratios for IBSEs was performed. The associations between IBSEs and OS were evaluated. Subgroup analyses according to disease stage (newly diagnosed glioblastoma versus recurrent glioblastoma), types of test treatment, and types of response assessment criteria were performed. Results Twenty-three phase III RCTs published between 2000 and 2017, including 8387 patients, met the inclusion criteria. OS showed strong correlations with PFS (standardized β coefficient [R] = 0.719), 6moPFS (R = 0.647), and 12moPFS (R = 0.638). OS showed no correlations with median PFS and ORR. In subgroup analysis according to types of therapies, PFS showed the highest correlations with OS in targeted therapies for cell cycle pathways (R = 0.913) and growth factor receptors and their downstream pathways (R = 0.962). 12moPFS showed the highest correlation with OS in antiangiogenic therapy (R = 0.821). The response assessment in neuro-oncology criteria provided higher correlation coefficients between OS and IBSEs than the Macdonald criteria. Conclusion Overall, PFS is an optimized IBSE in targeted therapies for glioblastoma; however, 12moPFS is optimal in antiangiogenic therapy.
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Affiliation(s)
- Chong Hyun Suh
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ho Sung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Seung Chai Jung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Choong Gon Choi
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Joon Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kyung Won Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Affiliation(s)
- Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Courtney Davis
- Department of Global Health and Social Medicine, King's College London, London, UK
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Raphael MJ, Robinson A, Booth CM, O'Donnell J, Palmer M, Eisenhauer E, Brundage M. The Value of Progression-Free Survival as a Treatment End Point Among Patients With Advanced Cancer: A Systematic Review and Qualitative Assessment of the Literature. JAMA Oncol 2019; 5:1779-1789. [PMID: 31556921 DOI: 10.1001/jamaoncol.2019.3338] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE It is unclear whether patients with advanced cancer value surrogate end points, particularly progression-free survival (PFS). Despite this uncertainty, surrogate end points form the basis of regulatory approval for the majority of new cancer treatments. OBJECTIVE To summarize and qualitatively assess studies evaluating whether patients with advanced cancer understand and value PFS. EVIDENCE REVIEW MEDLINE, Embase, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature databases were searched from database inception to November 12, 2018. Articles eligible for inclusion investigated patient understanding, preference, or perceived value of disease progression or PFS in the setting of advanced cancer. Three authors independently reviewed and extracted data from all studies eligible for inclusion. FINDINGS In total, 17 studies representing 3646 patients were included. Of these studies, 15 specifically aimed to assess patients' values toward, and their willingness to trade off toxic effects for gains or losses in the end point of PFS. All studies examined used widely disparate definitions when attempting to describe the meaning of PFS to patients. Ten studies specifically presented patients with the term progression-free survival as an attribute choice. In the words used to define the attribute of PFS, 6 studies used the term survival. Five studies clarified that PFS may not translate into better overall survival, and 5 studies explained that improvements in PFS may not reflect how well the patient may feel. No study clarified that a PFS event could represent either progression or death, and no study defined for the patient what constituted progression. The studies assessed herein underrepresented ethnic and racial minorities (mean percentage of white patients, 88%; range, 77%-96%). Values and preferences may vary across cultural backgrounds given that different relative preferences were assigned to cost and efficacy outcomes in North American vs Asian studies, although only a few studies were evaluated. CONCLUSIONS AND RELEVANCE The existing literature evaluating patients' understanding, preferences, and values toward the end point of PFS was severely limited by the heterogeneity of methods, attribute selection, and descriptions used to define PFS to patients. High-quality studies are needed that clearly define PFS for patients and that systematically document their understanding of the term. Only then can it be assessed whether PFS is an end point of value to patients with advanced cancer.
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Affiliation(s)
- Michael J Raphael
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
| | - Andrew Robinson
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
| | - Christopher M Booth
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Jennifer O'Donnell
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
| | - Michael Palmer
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
| | | | - Michael Brundage
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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Vanderbeek AM, Ventz S, Rahman R, Fell G, Cloughesy TF, Wen PY, Trippa L, Alexander BM. To randomize, or not to randomize, that is the question: using data from prior clinical trials to guide future designs. Neuro Oncol 2019; 21:1239-1249. [PMID: 31155679 PMCID: PMC6784282 DOI: 10.1093/neuonc/noz097] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Understanding the value of randomization is critical in designing clinical trials. Here, we introduce a simple and interpretable quantitative method to compare randomized designs versus single-arm designs using indication-specific parameters derived from the literature. We demonstrate the approach through application to phase II trials in newly diagnosed glioblastoma (ndGBM). METHODS We abstracted data from prior ndGBM trials and derived relevant parameters to compare phase II randomized controlled trials (RCTs) and single-arm designs within a quantitative framework. Parameters included in our model were (i) the variability of the primary endpoint distributions across studies, (ii) potential for incorrectly specifying the single-arm trial's benchmark, and (iii) the hypothesized effect size. Strengths and weaknesses of RCT and single-arm designs were quantified by various metrics, including power and false positive error rates. RESULTS We applied our method to show that RCTs should be preferred to single-arm trials for evaluating overall survival in ndGBM patients based on parameters estimated from prior trials. More generally, for a given effect size, the utility of randomization compared with single-arm designs is highly dependent on (i) interstudy variability of the outcome distributions and (ii) potential errors in selecting standard of care efficacy estimates for single-arm studies. CONCLUSIONS A quantitative framework using historical data is useful in understanding the utility of randomization in designing prospective trials. For typical phase II ndGBM trials using overall survival as the primary endpoint, randomization should be preferred over single-arm designs.
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Affiliation(s)
- Alyssa M Vanderbeek
- Program in Regulatory Science, Boston, Massachusetts
- Department of Biostatistics and Computational Biology, Boston, Massachusetts
| | - Steffen Ventz
- Program in Regulatory Science, Boston, Massachusetts
- Department of Biostatistics and Computational Biology, Boston, Massachusetts
| | - Rifaquat Rahman
- Department of Radiation Oncology, Boston, Massachusetts
- Center for Neuro-Oncology, Boston, Massachusetts, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Radiation Oncology Program, Boston, Massachusetts
| | - Geoffrey Fell
- Program in Regulatory Science, Boston, Massachusetts
- Department of Biostatistics and Computational Biology, Boston, Massachusetts
| | - Timothy F Cloughesy
- UCLA Neuro-Oncology Program and Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Patrick Y Wen
- Center for Neuro-Oncology, Boston, Massachusetts, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lorenzo Trippa
- Program in Regulatory Science, Boston, Massachusetts
- Department of Biostatistics and Computational Biology, Boston, Massachusetts
| | - Brian M Alexander
- Program in Regulatory Science, Boston, Massachusetts
- Department of Radiation Oncology, Boston, Massachusetts
- Center for Neuro-Oncology, Boston, Massachusetts, Dana-Farber Cancer Institute, Boston, Massachusetts
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Naci H, Davis C, Savović J, Higgins JPT, Sterne JAC, Gyawali B, Romo-Sandoval X, Handley N, Booth CM. Design characteristics, risk of bias, and reporting of randomised controlled trials supporting approvals of cancer drugs by European Medicines Agency, 2014-16: cross sectional analysis. BMJ 2019; 366:l5221. [PMID: 31533922 PMCID: PMC6749182 DOI: 10.1136/bmj.l5221] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To examine the design characteristics, risk of bias, and reporting adequacy of pivotal randomised controlled trials of cancer drugs approved by the European Medicines Agency (EMA). DESIGN Cross sectional analysis. SETTING European regulatory documents, clinical trial registry records, protocols, journal publications, and supplementary appendices. ELIGIBILITY CRITERIA Pivotal randomised controlled trials of new cancer drugs approved by the EMA between 2014 and 2016. MAIN OUTCOME MEASURES Study design characteristics (randomisation, comparators, and endpoints); risk of bias using the revised Cochrane tool (bias arising from the randomisation process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result); and reporting adequacy (completeness and consistency of information in trial protocols, publications, supplementary appendices, clinical trial registry records, and regulatory documents). RESULTS Between 2014 and 2016, the EMA approved 32 new cancer drugs on the basis of 54 pivotal studies. Of these, 41 (76%) were randomised controlled trials and 13 (24%) were either non-randomised studies or single arm studies. 39/41 randomised controlled trials had available publications and were included in our study. Only 10 randomised controlled trials (26%) measured overall survival as either a primary or coprimary endpoint, with the remaining trials evaluating surrogate measures such as progression free survival and response rates. Overall, 19 randomised controlled trials (49%) were judged to be at high risk of bias for their primary outcome. Concerns about missing outcome data (n=10) and measurement of the outcome (n=7) were the most common domains leading to high risk of bias judgments. Fewer randomised controlled trials that evaluated overall survival as the primary endpoint were at high risk of bias than those that evaluated surrogate efficacy endpoints (2/10 (20%) v 16/29 (55%), respectively). When information available in regulatory documents and the scientific literature was considered separately, overall risk of bias judgments differed for eight randomised controlled trials (21%), which reflects reporting inadequacies in both sources of information. Regulators identified additional deficits beyond the domains captured in risk of bias assessments for 10 drugs (31%). These deficits included magnitude of clinical benefit, inappropriate comparators, and non-preferred study endpoints, which were not disclosed as limitations in scientific publications. CONCLUSIONS Most pivotal studies forming the basis of EMA approval of new cancer drugs between 2014 and 2016 were randomised controlled trials. However, almost half of these were judged to be at high risk of bias based on their design, conduct, or analysis, some of which might be unavoidable because of the complexity of cancer trials. Regulatory documents and the scientific literature had gaps in their reporting. Journal publications did not acknowledge the key limitations of the available evidence identified in regulatory documents.
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Affiliation(s)
- Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London WC2A 2AE, UK
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Courtney Davis
- Department of Global Health and Social Medicine, King's College London, London, UK
| | - Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK
| | - Jonathan A C Sterne
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK
| | - Bishal Gyawali
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Cancer Research Institute, Queen's University at Kingston, Kingston, Ontario, Canada
| | - Xochitl Romo-Sandoval
- Department of Health Policy, London School of Economics and Political Science, London WC2A 2AE, UK
| | - Nicola Handley
- Department of Global Health and Social Medicine, King's College London, London, UK
| | - Christopher M Booth
- Cancer Research Institute, Queen's University at Kingston, Kingston, Ontario, Canada
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Smittenaar R, Bomb M, Rashbass J, Kipps E, Dodwell D. Early breast cancer in England: Evidence into practice. J Cancer Policy 2019. [DOI: 10.1016/j.jcpo.2019.100186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Gyawali B, Hwang TJ, Vokinger KN, Booth CM, Amir E, Tibau A. Patient-Centered Cancer Drug Development: Clinical Trials, Regulatory Approval, and Value Assessment. Am Soc Clin Oncol Educ Book 2019; 39:374-387. [PMID: 31099613 DOI: 10.1200/edbk_242229] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Historically, patient experience, including symptomatic toxicities, physical function, and disease-related symptoms during treatment or their perspectives on clinical trials, has played a secondary role in cancer drug development. Regulatory criteria for drug approval require that drugs are safe and effective, and almost all drug approvals have been based only on efficacy endpoints rather than on quality-of-life (QoL) assessments. In contrast to Europe, information regarding the impact of drugs on patients' QoL is rarely included in oncology drug labeling in the United States. Until recently, patient input and preferences have not been incorporated into the design and conduct of clinical trials. In recent years, a more in-depth understanding of cancer biology, as well as regulatory changes focused on expediting cancer drug development and approval, has allowed earlier access to novel therapeutic agents. Understanding the implications of these expedited programs is important for oncologists and patients, given the rapid expansion of these programs. In this article, we provide an overview of the role of QoL in the regulatory drug-approval process, key issues regarding trial participation from the patient perspective, and the implications of key expedited approval programs that are increasingly being used by regulatory bodies for cancer care.
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Affiliation(s)
- Bishal Gyawali
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Thomas J Hwang
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kerstin Noelle Vokinger
- 1 Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,2 Institute for Primary Care and Health Outcomes Research, University of Zürich, Zürich, Switzerland
| | - Christopher M Booth
- 3 Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada.,4 Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Eitan Amir
- 5 Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Ariadna Tibau
- 6 Department of Oncology, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau and Universitat Autònoma de Barcelona, Barcelona, Spain
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Jachno K, Heritier S, Wolfe R. Are non-constant rates and non-proportional treatment effects accounted for in the design and analysis of randomised controlled trials? A review of current practice. BMC Med Res Methodol 2019; 19:103. [PMID: 31096924 PMCID: PMC6524252 DOI: 10.1186/s12874-019-0749-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 05/07/2019] [Indexed: 01/09/2023] Open
Abstract
Background Most clinical trials with time-to-event primary outcomes are designed assuming constant event rates and proportional hazards over time. Non-constant event rates and non-proportional hazards are seen increasingly frequently in trials. The objectives of this review were firstly to identify whether non-constant event rates and time-dependent treatment effects were allowed for in sample size calculations of trials, and secondly to assess the methods used for the analysis and reporting of time-to-event outcomes including how researchers accounted for non-proportional treatment effects. Methods We reviewed all original reports published between January and June 2017 in four high impact medical journals for trials for which the primary outcome involved time-to-event analysis. We recorded the methods used to analyse and present the main outcomes of the trial and assessed the reporting of assumptions underlying these methods. The sample size calculation was reviewed to see if the effect of either non-constant hazard rates or anticipated non-proportionality of the treatment effect was allowed for during the trial design. Results From 446 original reports we identified 66 trials with a time-to-event primary outcome encompassing trial start dates from July 1995 to November 2014. The majority of these trials (73%) had sample size calculations that used standard formulae with a minority of trials (11%) using simulation for anticipated changing event rates and/or non-proportional hazards. Well-established analytical methods, Kaplan-Meier curves (98%), the log rank test (88%) and the Cox proportional hazards model (97%), were used almost exclusively for the main outcome. Parametric regression models were considered in 11% of the reports. Of the trials reporting inference from the Cox model, only 11% reported any results of testing the assumption of proportional hazards. Conclusions Our review confirmed that when designing trials with time-to-event primary outcomes, methodologies assuming constant event rates and proportional hazards were predominantly used despite potential efficiencies in sample size needed or power achieved using alternative methods. The Cox proportional hazards model was used almost exclusively to present inferential results, yet testing and reporting of the pivotal assumption underpinning this estimation method was lacking. Electronic supplementary material The online version of this article (10.1186/s12874-019-0749-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kim Jachno
- School of Public Health and Preventive Medicine, Monash University, Level 4, 553 St. Kilda Road, Melbourne, 3004, Australia.
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, Level 4, 553 St. Kilda Road, Melbourne, 3004, Australia
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Level 4, 553 St. Kilda Road, Melbourne, 3004, Australia
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Li XL, Cao HJ, Zhang YJ, Hu RX, Lai BY, Zhao NQ, Hu H, Xie ZG, Liu JP. Attitude and willingness of attendance for participating in or completing acupuncture trials: a cross-sectional study. Patient Prefer Adherence 2019; 13:53-61. [PMID: 30636870 PMCID: PMC6309016 DOI: 10.2147/ppa.s173202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To explore the influence of patients' participation in and completing the acupuncture clinical trials through a cross-sectional survey. In addition, we explored potential factors involved in improving patient's compliance to treatment, thus enhancing the quality of acupuncture clinical studies. METHODS A survey was conducted at outpatient department of acupuncture and metabolic diseases in two hospitals in Beijing. The semi-structured questionnaire was designed based on literature review and Delphi methods. It contains 15 questions related to patients' experience and attitude. SPSS 22.0 was used for analyses. OR and 95% CI were used for dichotomous outcomes. Logistic regression analysis (LRA) and multi-LRA were used to explore the factors influencing patients' participation or completion and the relationship between demographic characteristics and potential factors. RESULTS A survey was conducted from April to September 2016. Five hundred patients were consecutively sampled to fill semi-structured questionnaires regardless of their types of disease. The participants (75.2% were female) were in the age range of 15-85 years and all of them completed the survey. The effect and safety of acupuncture therapy were considered to be the deciding factors by 92% and 96% of the respondents, respectively. Only 40 of the surveyed participants (8.0%) had previously participated in the clinical trials. The LRA showed they paid more attention to treatment regimen (frequency and session of treatment) when deciding whether or not to participate in the trials (OR 1.54, 95% CI 1.02-2.34). Multivariate LRA showed that elder people considered cost (OR 1.36, 95% CI 1.09-1.70) to be an important factor, while the participants having medical insurance (OR 1.45, 95% CI -0.20-0.93) thought informed consent was important. Meanwhile, participants with higher education preferred regular follow-up (OR 1.16, 95% CI 0.02-0.28). CONCLUSION After providing adequate information regarding the potential benefits and harms of the acupuncture treatment, completion of the treatment within the specific time regimen was found to be the most important factor affecting patient's compliance. Other factors, such as cost and regular follow-up, should also be given special consideration.
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Affiliation(s)
- Xin-Lin Li
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Chaoyang District, Beijing 100029, China,
| | - Hui-Juan Cao
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Chaoyang District, Beijing 100029, China,
| | - Ya-Jing Zhang
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Chaoyang District, Beijing 100029, China,
| | - Rui-Xue Hu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Chaoyang District, Beijing 100029, China,
| | - Bao-Yong Lai
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Chaoyang District, Beijing 100029, China,
| | - Nan-Qi Zhao
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Chaoyang District, Beijing 100029, China,
| | - Hui Hu
- The Department of Acupuncture and Metabolic Diseases, Eastern Hospital Affiliated to Beijing University of Chinese Medicine, Fengtai District, Beijing, China
| | - Zhan-Guo Xie
- The Department of Acupuncture and Moxibustion, First People's Hospital of Dongcheng District, Beijing, China
| | - Jian-Ping Liu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Chaoyang District, Beijing 100029, China,
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Hwang TJ, Gyawali B. Association between progression‐free survival and patients’ quality of life in cancer clinical trials. Int J Cancer 2018; 144:1746-1751. [DOI: 10.1002/ijc.31957] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 10/07/2018] [Accepted: 10/22/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Thomas J. Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women's Hospital Boston MA
- Harvard Medical School Boston MA
| | - Bishal Gyawali
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women's Hospital Boston MA
- Harvard Medical School Boston MA
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