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Boisvert-Huneault C, Trigos Herraez D, Pinter A, Kobayashi S, Bell S, Kallsen K, Gloede T, Yagi N, Brunette S, Datsenko Y, Baehner F, Clerisme-Beaty E, Van de Kerkhof P. Understanding potential participation barriers to improve trial design and outcomes: clinical trial simulation in palmoplantar pustulosis as a case study. BMJ Open 2023; 13:e064159. [PMID: 37094891 PMCID: PMC10151841 DOI: 10.1136/bmjopen-2022-064159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 03/09/2023] [Indexed: 04/26/2023] Open
Abstract
OBJECTIVES Evaluate the experiences and perceptions of patients participating in a simulated clinical trial and identify ways to enhance future patient-centric trial designs. DESIGN International, multicentre, non-interventional, virtual clinical trial visits with patient debriefs and advisory boards. SETTING Virtual clinic visits and accompanying advisory boards. PARTICIPANTS Nine patients with palmoplantar pustulosis for simulated trial visits; 14 patients and patient representatives for advisory boards. MAIN OUTCOME MEASURES Qualitative responses to trial documentation, visit schedule and logistics, and trial design were collected during patient debriefs. Results were discussed at two virtual advisory board meetings. RESULTS Patients identified key barriers to participation and potential difficulties encountered when attending trial visits and completing assessments. They also proposed recommendations to overcome these challenges. Patients recognised the need for comprehensive informed consent forms, but recommended use of non-technical language, brevity and additional support to aid understanding. Other trial documentations should be relevant to the disease and include known efficacy and safety of the study drug. Patients were concerned about receiving placebo, stopping existing medications and being unable to receive the study drug after trial completion; therefore, patients and physicians recommended an open-label extension following trial completion. Trial visits were too numerous (n=20) and too long (3-4 hours each); patients recommended improvements to the design to make best use of their time and reduce unnecessary waiting. They also requested financial and logistical support. Patients expressed a desire for study outcomes that matter to them, related to their ability to undertake normal daily activities and not be a burden to others. CONCLUSIONS Simulated trials are an innovative method for assessing trial design and acceptance from a patient-centric perspective, enabling specific improvements to be made prior to trial initiation. Incorporation of recommendations from simulated trials could enhance trial recruitment and retention, and optimise trial outcomes and data quality.
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Affiliation(s)
| | - David Trigos Herraez
- EUROPSO, European Umbrella Federation for Psoriasis Associations, Polzela, Slovenia
| | - Andreas Pinter
- Department of Dermatology, Venereology and Allergology, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Satomi Kobayashi
- Department of Dermatology, Seibo International Catholic Hospital, Tokyo, Japan
| | - Stacie Bell
- National Psoriasis Foundation, Portland, Oregon, USA
| | | | - Tristan Gloede
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut, USA
| | | | - Steven Brunette
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut, USA
| | - Yakov Datsenko
- Boehringer Ingelheim International GmbH, Biberach, Germany
| | - Frank Baehner
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
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2
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Frankel PH, Groshen S, Beumer JH, Cleveland L, Kim ES, Karp JE. Ethics and Clinical Research: Improving Transparency and Informed Consent in Phase I Oncology Trials. J Clin Oncol 2023; 41:2155-2158. [PMID: 36724409 PMCID: PMC10448934 DOI: 10.1200/jco.22.01736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/15/2022] [Accepted: 11/18/2022] [Indexed: 02/03/2023] Open
Affiliation(s)
- Paul H. Frankel
- Department of Computational and Quantitative Medicine, City of Hope, Duarte, CA
| | - Susan Groshen
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Jan H. Beumer
- Cancer Therapeutics Program, UPMC Hillman Cancer Center, Pittsburgh, PA
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | | | - Judith E. Karp
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
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Yang GM, Ong WY, Tan J, Ding J, Ho S, Tan D, Neo P. Motivations and experiences of patients with advanced cancer participating in Phase 1 clinical trials: A qualitative study. Palliat Med 2023; 37:257-264. [PMID: 36476098 DOI: 10.1177/02692163221137105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Persons with advanced cancer may participate in Phase 1 clinical trials - first-in-human trials that are conducted with the main objectives of safety and dosing. The motivations for participation are not well understood and may include hope for cure. AIM To explore the perspectives of persons with advanced cancer in order to understand the motivations for participating in Phase 1 clinical trials, experiences while being on trial and views on palliative care provision. DESIGN Qualitative study with a constructivist stance, using thematic analysis based upon the grounded theory approach. SETTING/PARTICIPANTS 20 persons with advanced cancer who were participating in a Phase 1 clinical trial. RESULTS Many participants described how Phase 1 clinical trial participation was their last hope, as they were cognisant of their advanced disease. Information-seeking needs differed - some needed comprehensive information while others relied on the doctor's recommendation. Participants experienced varied negative and positive physical and psycho-emotional concerns, and needed to draw on multiple sources of support such as family, friends and healthcare professionals. Some could list potential benefits of palliative care but felt they did not require it yet. The overarching theme was hope and positive thinking as a way of coping. CONCLUSIONS The concepts of hope as a way of coping and the supportive presence of healthcare professionals could be weaved into a future model of palliative care to improve the illness journey for patients considering Phase 1 clinical trial participation and other persons with advanced cancer.
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Affiliation(s)
- Grace Meijuan Yang
- Division of Supportive and Palliative care, National Cancer Centre Singapore, Singapore.,Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Wah Ying Ong
- Division of Supportive and Palliative care, National Cancer Centre Singapore, Singapore
| | - Jasmine Tan
- Division of Supportive and Palliative care, National Cancer Centre Singapore, Singapore
| | | | - Shirlynn Ho
- Division of Supportive and Palliative care, National Cancer Centre Singapore, Singapore
| | - Daniel Tan
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - Patricia Neo
- Division of Supportive and Palliative care, National Cancer Centre Singapore, Singapore
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Stapleton S, Darlington ASE, de Bono JS, Wiseman T. What is the impact of targeted therapies given within phase I trials on the cognitive function of patients with advanced cancer: a mixed-methods exploratory study conducted in an early clinical trials unit. BMJ Open 2022; 12:e050590. [PMID: 36442900 PMCID: PMC9710342 DOI: 10.1136/bmjopen-2021-050590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Novel therapies such as small protein molecule inhibitors and immunotherapies are tested in early phase trials before moving to later phase trials and ultimately standard practice. A key aim of these clinical trials is to define a toxicity profile, however, the emphasis is often on safety with measurements of organ toxicity. Other subjective side effects can be under-reported because they are not measured formally within the trial protocols. The concern from clinical practice is that cognitive toxicity is poorly studied and may be under-reported in this context. This could lead to toxicity profiles of new treatments not being fully described and patients with unmet need in terms of acknowledgement and support of symptoms. This protocol outlines a framework of an exploratory study with feasibility aspects to investigate the impact and experience of cognitive changes for patients on phase I trials. METHODS AND ANALYSIS This is a mixed-methods study, combining quantitative and qualitative approaches. The sample is 30 patients with advanced cancer who are participating in phase I trials of novel therapies in the early clinical trials unit of a specialist cancer centre. A test battery of validated cognitive assessments will be taken alongside patient reported outcome measures at three time points from baseline, day eight and day 28 post start of treatment. At day 28, a semi-structured interview will be conducted and the narrative thematically analysed. Results will be integrated to offer a comprehensive description of cognitive function in this patient group. ETHICS AND DISSEMINATION The study has received full HRA and ethical approval. It is the first study to introduce formal cognitive assessments in a cancer phase I trial context. The study has the potential to highlight previously unreported side effects and more importantly unmet need in terms of care for patients who are participating in the trials.
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Affiliation(s)
- Sarah Stapleton
- Drug Development Unit, Royal Marsden Hospital Sutton, Sutton, UK
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | | | - J S de Bono
- Drug Development Unit, Royal Marsden Hospital Sutton, Sutton, UK
- Institute of Cancer Research Division of Cancer Therapeutics, London, UK
| | - Theresa Wiseman
- Faculty of Health Sciences, University of Southampton, Southampton, UK
- The Royal Marsden NHS Foundation Trust, London, UK
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5
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Zhang S, Shen L, Jiao B. Cognitive Dysfunction in Repeat Expansion Diseases: A Review. Front Aging Neurosci 2022; 14:841711. [PMID: 35478698 PMCID: PMC9036481 DOI: 10.3389/fnagi.2022.841711] [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: 12/22/2021] [Accepted: 02/24/2022] [Indexed: 11/16/2022] Open
Abstract
With the development of the sequencing technique, more than 40 repeat expansion diseases (REDs) have been identified during the past two decades. Moreover, the clinical features of these diseases show some commonality, and the nervous system, especially the cognitive function was affected in part by these diseases. However, the specific cognitive domains impaired in different diseases were inconsistent. Here, we survey literature on the cognitive consequences of the following disorders presenting cognitive dysfunction and summarizing the pathogenic genes, epidemiology, and different domains affected by these diseases. We found that the cognitive domains affected in neuronal intranuclear inclusion disease (NIID) were widespread including the executive function, memory, information processing speed, attention, visuospatial function, and language. Patients with C9ORF72-frontotemporal dementia (FTD) showed impairment in executive function, memory, language, and visuospatial function. While in Huntington's disease (HD), the executive function, memory, and information processing speed were affected, in the fragile X-associated tremor/ataxia syndrome (FXTAS), executive function, memory, information processing speed, and attention were impaired. Moreover, the spinocerebellar ataxias showed broad damage in almost all the cognitive domains except for the relatively intact language ability. Some other diseases with relatively rare clinical data also indicated cognitive dysfunction, such as myotonic dystrophy type 1 (DM1), progressive myoclonus epilepsy (PME), Friedreich ataxia (FRDA), Huntington disease like-2 (HDL2), and cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS). We drew a cognitive function landscape of the related REDs that might provide an aspect for differential diagnosis through cognitive domains and effective non-specific interventions for these diseases.
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Affiliation(s)
- Sizhe Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Lu Shen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Central South University, Changsha, China
- Engineering Research Center of Hunan Province in Cognitive Impairment Disorders, Central South University, Changsha, China
- Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic Diseases, Changsha, China
- Key Laboratory of Hunan Province in Neurodegenerative Disorders, Central South University, Changsha, China
| | - Bin Jiao
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Central South University, Changsha, China
- Engineering Research Center of Hunan Province in Cognitive Impairment Disorders, Central South University, Changsha, China
- Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic Diseases, Changsha, China
- Key Laboratory of Hunan Province in Neurodegenerative Disorders, Central South University, Changsha, China
- *Correspondence: Bin Jiao
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Bittlinger M, Bicer S, Peppercorn J, Kimmelman J. Ethical Considerations for Phase I Trials in Oncology. J Clin Oncol 2022; 40:3474-3488. [PMID: 35275736 DOI: 10.1200/jco.21.02125] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Phase I trials often represent the first occasion where new cancer strategies are tested in patients. Various developments in cancer biology, methodology, regulation, and medical ethics have altered the ethical landscape of such trials. We provide a narrative review of contemporary ethical challenges in design, conduct, and reporting of phase I cancer trials and outline recommendations for addressing each. We organized our review around four topics, supplementing the first three with scoping reviews: (1) benefit/risk, (2) research biopsies, (3) therapeutic misconception and misestimation, and (4) reporting. The main ethical challenges of conducting phase I trials stem from three issues. First, phase I trials often involve higher research burden and scientific uncertainty compared with other cancer trials. Second, many patients arrive at phase I trials at a transitional point in their illness trajectory where they have exhausted standard survival-extending options. Third, phase I trial results play a major role in informing downstream drug development and regulatory decisions. Together, these issues create distinct pressures for study design, ethical review, informed consent, and reporting. Developments in methodology, regulation, cancer biology, and ethical awareness have helped mitigate some of these challenges, while introducing others. We conclude our review with a series of recommendations regarding trial design, ethical review, consent, and reporting. We also outline several unresolved questions that, if addressed, would strengthen the ethical foundation of phase I cancer trials.
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Affiliation(s)
- Merlin Bittlinger
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
| | - Selin Bicer
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
| | | | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine (STREAM), Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
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Stapleton SE, Darlington AS, Minchom A, Pal A, Raynaud F, Wiseman T. Assessing cognitive toxicity in early phase trials - What are we missing? Psychooncology 2022; 31:405-415. [PMID: 34651364 DOI: 10.1002/pon.5834] [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: 02/01/2021] [Revised: 09/29/2021] [Accepted: 09/29/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Novel therapies, such as, small protein molecule inhibitors and immunotherapies are first tested clinically in Phase I trials. Moving on to later phase trials and ultimately standard practice. A key aim of these early clinical trials is to define a toxicity profile; however, the emphasis is often on safety. The concern is cognitive toxicity is poorly studied in this context and may be under-reported. The aim of this review is to map evidence of cognitive assessment, toxicity, and confounding factors within reports from Phase I trials and consider putative mechanisms of impairment aligned with mechanisms of novel therapies. METHODS A scoping review methodology was applied to the search of databases, including Embase, MEDLINE, Clinicaltrials.gov. A [keyword search was conducted, results screened for duplication then inclusion/exclusion criteria applied. Articles were further screened for relevance; data organised into categories and charted in a tabular format]. Evidence was collated and summarised into a narrative synthesis. RESULTS Despite the availability of robust ways to assess cognitive function, these are not routinely included in the conduct of early clinical trials. Reports of cognitive toxicity in early Phase I trials are limited and available evidence on this shows that a proportion of patients experience impaired cognitive function over the course of participating in a Phase I trial. Links are identified between the targeted action of some novel therapies and putative mechanisms of cognitive impairment. CONCLUSION The review provides rationale for research investigating cognitive function in this context. A study exploring the cognitive function of patients on Phase I trials and the feasibility of formally assessing this within early clinical trials is currently underway at the Royal Marsden.
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Affiliation(s)
- Sarah E Stapleton
- Royal Marsden Hospital Drug Development Unit, Sutton, UK
- University of Southampton, Southampton, UK
| | | | - Anna Minchom
- Royal Marsden Hospital Drug Development Unit, Sutton, UK
- Institute of Cancer Research, Sutton, UK
| | - Abhijit Pal
- Royal Marsden Hospital Drug Development Unit, Sutton, UK
- Institute of Cancer Research, Sutton, UK
| | - Florence Raynaud
- Royal Marsden Hospital Drug Development Unit, Sutton, UK
- Institute of Cancer Research, Sutton, UK
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8
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Utne I, Løyland B, Grov EK, Rasmussen HL, Torstveit AH, Paul SM, Ritchie C, Lindemann K, Vistad I, Rodríguez-Aranda C, Miaskowski C. Age-related differences in self-report and objective measures of cognitive function in older patients prior to chemotherapy. Nurs Open 2021; 9:1040-1051. [PMID: 34878233 PMCID: PMC8859071 DOI: 10.1002/nop2.1141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 10/01/2021] [Accepted: 11/16/2021] [Indexed: 12/27/2022] Open
Abstract
Aim Evaluate for differences in demographic and clinical characteristics and subjective and objective measures of cognitive function (CF) between younger older adults (YOA, 60–69 years) and older adults (OA, ≥70 years). Design Cross‐sectional. Methods Older oncology patients (n = 139) completed subjective (Attentional Function Index, European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC) CF scale) and objective (Montreal Cognitive Assessment, Trail Making Test (TMT) A & B) measures of CF prior to chemotherapy. Data were analyzed using parametric and nonparametric tests. Results No differences were found between the two groups for any of the subjective or objective CF measures, except that OA patients had higher TMT B scores. Compared with the general population, OAs had significantly higher EORTC CF scores and YOAs had significantly worse scores for all of the objective tests. Clinically meaningful difference between group differences was found for the TMT B test.
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Affiliation(s)
- Inger Utne
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Borghild Løyland
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Ellen Karine Grov
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Hege Lund Rasmussen
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Ann Helen Torstveit
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Steven M Paul
- School of Nursing, University of California, San Francisco, California, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital Morgan Institute, Boston, Massachusetts, USA
| | - Kristina Lindemann
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | - Ingvild Vistad
- Department of Obstetrics and Gynecology, Hospital of Southern Norway, Kristiansand, Norway.,Clinical Institute II, Medical department, University of Bergen, Bergen, Norway
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Duong Q, Mandrekar SJ, Winham SJ, Cook K, Jatoi A, Le-Rademacher JG. Understanding Verbosity: Funding Source and the Length of Consent Forms for Cancer Clinical Trials. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2021; 36:1248-1252. [PMID: 32385740 PMCID: PMC7648720 DOI: 10.1007/s13187-020-01757-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Consent forms are an important educational tool that helps cancer patients decide on whether or not to enroll on a clinical trial, but wordiness potentially detracts from their educational value. This single-institution study examined word counts of consent forms for all phase I, II, and III solid tumor clinical trials between 2004 and 2010. Consent forms were categorized by trial funding source: (1) pharmaceutical company; (2) National Clinical Trials Network (NCTN); (3) R01- or other non-government grants; and (4) mixed (funding from multiple sources). Three hundred fifteen consent forms were studied; these included 106 (34%) pharmaceutical company; 145 (46%) NCTN; 44 (14%) R01 type; and 20 (6%) mixed. The overall median word count was 5129 words per consent form (interquartile range (IQR) range, 4226 to 6695). The median word counts per consent form (IQR) were 5648 (4814, 6803), 5243 (4139, 6932), 4365 (3806, 5124), and 4319 (3862, 5944), respectively, based on the above funding sources, showing that pharmaceutical company trial consent forms had the highest median word count. Of note, phase of trial was associated with consent form length (phase III were wordier), and consent forms manifested a consistent increase in wordiness over time. These observations underscore a timely need to find ways to limit the verbosity of consent forms, particularly in those from pharmaceutical company trials.
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Affiliation(s)
- Quyen Duong
- Section of Cancer Center Biostatistics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Sumithra J Mandrekar
- Section of Cancer Center Biostatistics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Stacey J Winham
- Section of Computational Genomics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Kathryn Cook
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Aminah Jatoi
- Department of Oncology, Mayo Clinic, Rochester, MN, USA.
- Betty J. Foust, M.D. and Parents' Professor, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Jennifer G Le-Rademacher
- Section of Cancer Center Biostatistics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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Sommerlatte S, Schmidt H, Vordermark D, Schildmann J. Decision Making in Geriatric Oncology: Supported Versus Assisted Decision Making. J Clin Oncol 2021; 39:3760-3761. [PMID: 34533975 DOI: 10.1200/jco.21.01643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Sabine Sommerlatte
- Sabine Sommerlatte, Mmel, Faculty of Medicine, Interdisciplinary Centre for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany; Heike Schmidt, MD, Faculty of Medicine, Department of Radiation Oncology, University Hospital Halle (Saale), Institute of Health and Nursing Science, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany; Dirk Vordermark, MD, Faculty of Medicine, Department of Radiation Oncology, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, Halle, Germany; and Jan Schildmann, MD, MA, Faculty of Medicine, Interdisciplinary Centre for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Heike Schmidt
- Sabine Sommerlatte, Mmel, Faculty of Medicine, Interdisciplinary Centre for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany; Heike Schmidt, MD, Faculty of Medicine, Department of Radiation Oncology, University Hospital Halle (Saale), Institute of Health and Nursing Science, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany; Dirk Vordermark, MD, Faculty of Medicine, Department of Radiation Oncology, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, Halle, Germany; and Jan Schildmann, MD, MA, Faculty of Medicine, Interdisciplinary Centre for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Dirk Vordermark
- Sabine Sommerlatte, Mmel, Faculty of Medicine, Interdisciplinary Centre for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany; Heike Schmidt, MD, Faculty of Medicine, Department of Radiation Oncology, University Hospital Halle (Saale), Institute of Health and Nursing Science, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany; Dirk Vordermark, MD, Faculty of Medicine, Department of Radiation Oncology, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, Halle, Germany; and Jan Schildmann, MD, MA, Faculty of Medicine, Interdisciplinary Centre for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Jan Schildmann
- Sabine Sommerlatte, Mmel, Faculty of Medicine, Interdisciplinary Centre for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany; Heike Schmidt, MD, Faculty of Medicine, Department of Radiation Oncology, University Hospital Halle (Saale), Institute of Health and Nursing Science, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany; Dirk Vordermark, MD, Faculty of Medicine, Department of Radiation Oncology, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, Halle, Germany; and Jan Schildmann, MD, MA, Faculty of Medicine, Interdisciplinary Centre for Health Sciences, Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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11
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Loeff DS, Shakhsheer BA. The ethics of informed consent and shared decision-making in pediatric surgery. Semin Pediatr Surg 2021; 30:151101. [PMID: 34635277 DOI: 10.1016/j.sempedsurg.2021.151101] [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] [Indexed: 11/28/2022]
Abstract
Informed consent is a required feature in the practice of pediatric surgery. Surgeons cannot practice the trade without it and most of us learned to do it as part of our "apprenticeship" in surgical training. We were bystanders when the senior resident or attending spoke to the patient and family and we were silent witnesses to the signing of the document called a "consent." Intentional instruction about informed consent is rudimentary in most residencies. By the time we become surgical fellows, it is assumed that we have the requisite skill set to perform this "task" so we can get on with what we like to do best; operating. For many, it is viewed as a perfunctory step which, if done properly, will comply with hospital policies, might someday be exhibited during medical litigation, and ultimately it will occupy a tiny bit of memory in the hospital EMR system. However, this "thing" called the informed consent is much more than an item on a pre-op check list. The re-branding of the term "informed consent" into "shared decision-making" underscores the "re-evolution" that has occurred in thought and practice from the act of obtaining an individual's permission for treatment toward the process leading up to that act.1 It reflects some of our most important ethical values in healthcare and is still the source of scholarly inquiry and controversy. In this paper, the terms "informed consent" and "shared decision-making" will be used interchangeably but the intention is focused on the process of how physicians and their patients make choices together. If you have not thought about this topic recently, I encourage you to take a moment and explore some of the interesting and challenging questions which are still unanswered. Although the ethical principles underlying informed consent are shared by adult and pediatric medicine, there are many aspects which are unique to the medical care of children. This article highlights some of those challenges and controversies illustrated by two case studies and viewed through the lens of bioethics.
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Affiliation(s)
- Deborah S Loeff
- Section of Pediatric Surgery, Department of Surgery, UChicago Medicine, Comer Children's Hospital, Chicago, IL. and Advocate Children's Hospital, Park Ridge, IL.
| | - Baddr A Shakhsheer
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis Children's Hospital, Saint Louis, Missouri
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Torstveit AH, Miaskowski C, Løyland B, Grov EK, Guren MG, Ritchie CS, Paul SM, Kleven AG, Utne I. Common and distinct characteristics associated with self-reported functional status in older patients with cancer receiving chemotherapy. Eur J Oncol Nurs 2021; 54:102033. [PMID: 34537538 DOI: 10.1016/j.ejon.2021.102033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/04/2021] [Indexed: 01/12/2023]
Abstract
PURPOSE To evaluate for inter-individual differences in two subjective measures of functional status in older patients (n = 112), as well as to determine which demographic, clinical, and symptom characteristics, and levels of cognitive function, were associated with initial levels and with the trajectory of the two measures. METHODS Functional status was assessed using self-report measures of physical function (PF) and role function (RF) from the European Organization for Research and Treatment of Cancer Core Quality-of-Life Questionnaire at the initiation of chemotherapy and at 1, 3, 6, 9, and 12 months after its initiation. Hierarchical linear modeling was used to assess inter-individual differences in and characteristics associated with initial levels and changes in PF and RF. RESULTS Characteristics associated with decreases in PF at the initiation of chemotherapy were higher numbers of comorbidities and higher depression, pain, and dyspnea scores. For initial levels of poorer RF, lower Karnofsky Performance Status scores and higher pain and fatigue scores were the associated characteristics. Characteristic associated with worse trajectories of PF was not having had surgery. For RF, worse trajectories were associated with lower cognitive function and higher RF at enrollment. Characteristic associated with both lower initial levels and improved trajectories of PF was having lower performance status at enrollment. CONCLUSIONS Older patients undergoing chemotherapy experience reduced functional performance. Characteristics associated with decrements in PF and RF need to be assessed and interventions implemented to maintain and increase functional status in older oncology patients.
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Affiliation(s)
- Ann Helen Torstveit
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet-Oslo Metropolitan University, Oslo, Norway
| | | | - Borghild Løyland
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet-Oslo Metropolitan University, Oslo, Norway
| | - Ellen Karine Grov
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet-Oslo Metropolitan University, Oslo, Norway
| | - Marianne Grønlie Guren
- Department of Oncology and K G Jebsen Colorectal Cancer Research Center, Oslo University Hospital, Oslo, Norway
| | | | - Steven M Paul
- School of Nursing, University of California, San Francisco, CA, USA
| | - Anne Grethe Kleven
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet-Oslo Metropolitan University, Oslo, Norway
| | - Inger Utne
- Department of Nursing and Health Promotion, Faculty of Health Sciences, OsloMet-Oslo Metropolitan University, Oslo, Norway.
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13
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Garrett SB, Matthews TM, Abramson CM, Koenig CJ, Hlubocky FJ, Daugherty CK, Munster PN, Dohan D. Before Consent: Qualitative Analysis of Deliberations of Patients With Advanced Cancer About Early-Phase Clinical Trials. JCO Oncol Pract 2020; 16:e56-e63. [PMID: 31603726 PMCID: PMC6993554 DOI: 10.1200/jop.19.00256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2019] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients with advanced cancer and oncologists deliberate about early-phase (EP) trials as they consider whether to pursue EP trial enrollment. We have limited information about those deliberations and how they may facilitate or impede trial initiation. This study describes these deliberations and their relationship to trial initiation. PATIENTS AND METHODS We collected longitudinal, ethnographic data on deliberations of patients with advanced cancer at two academic medical centers. We used constant comparative and framework analyses to characterize the deliberative process and its relationship to trial initiation. RESULTS Of 96 patients with advanced cancer, 26% initiated EP enrollment and 19% joined a trial. Constant comparative analysis revealed two foci of deliberation. Setting the stage focused on patient and physician support for EP trial involvement, including patients' interest in research and oncologists' awareness of trials and assessment of patient fit. Securing a seat focused on eligibility for and entrance to a specific trial and involved trial availability, treatment history, disease progression, and enrollment timing. Patients enrolled in a trial only when both stages could be successfully navigated. CONCLUSION Ethnographic data revealed two foci of deliberation about EP trial enrollment among patients with advanced cancer. Physician support played a consequential role in both stages, but enrollment also reflected factors beyond the control of any specific individual. Insights from this study, combined with other recent studies of trial enrollment, advance our understanding of the complex process of EP trial accrual and may help identify strategies to improve rates of participation.
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Affiliation(s)
| | | | | | | | | | | | | | - Daniel Dohan
- University of California San Francisco, San Francisco, CA
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14
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Dionne-Odom JN, Ejem D, Wells R, Barnato AE, Taylor RA, Rocque GB, Turkman YE, Kenny M, Ivankova NV, Bakitas MA, Martin MY. How family caregivers of persons with advanced cancer assist with upstream healthcare decision-making: A qualitative study. PLoS One 2019; 14:e0212967. [PMID: 30865681 PMCID: PMC6415885 DOI: 10.1371/journal.pone.0212967] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/12/2019] [Indexed: 12/27/2022] Open
Abstract
Aims Numerous healthcare decisions are faced by persons with advanced cancer from diagnosis to end-of-life. The family caregiver role in these decisions has focused on being a surrogate decision-maker, however, little is known about the caregiver’s role in supporting upstream patient decision-making. We aimed to describe the roles of family caregivers in assisting community-dwelling advanced cancer patients with healthcare decision-making across settings and contexts. Methods Qualitative study using one-on-one, semi-structured interviews with community-dwelling persons with metastatic cancer (n = 18) and their family caregivers (n = 20) recruited from outpatient oncology clinics of a large tertiary care academic medical center, between October 2016 and October 2017. Transcribed interviews were analyzed using a thematic analysis approach. Findings Caregivers averaged 56 years and were mostly female (95%), white (85%), and the patient’s partner/spouse (70%). Patients averaged 58 years and were mostly male (67%) in self-reported “fair” or “poor” health (50%) with genitourinary (33%), lung (17%), and hematologic (17%) cancers. Themes describing family member roles in supporting patients’ upstream healthcare decision-making were: 1) seeking information about the cancer, its trajectory, and treatments options; 2) ensuring family and healthcare clinicians have a common understanding of the patient’s treatment plan and condition; 3) facilitating discussions with patients about their values and the framing of their illness; 5) posing “what if” scenarios about current and potential future health states and treatments; 6) addressing collateral decisions (e.g., work arrangements) resulting from medical treatment choices; 6) originating healthcare-related decision points, including decisions about seeking emergency care; and 7) making healthcare decisions for patients who preferred to delegate healthcare decisions to their family caregivers. Conclusions These findings highlight a previously unreported and understudied set of critical decision partnering roles that cancer family caregivers play in patient healthcare decision-making. Optimizing these roles may represent novel targets for early decision support interventions for family caregivers.
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Affiliation(s)
- J. Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- * E-mail:
| | - Deborah Ejem
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Rachel Wells
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Amber E. Barnato
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, United States of America
| | - Richard A. Taylor
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Gabrielle B. Rocque
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Yasemin E. Turkman
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Matthew Kenny
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Nataliya V. Ivankova
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Marie A. Bakitas
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Michelle Y. Martin
- Center for Innovation in Health Equity Research, University of Tennessee Health Science Center, Memphis, Tennessee, United States of America
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15
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Schildmann J, Bruns F. Informed Consent and Phase I Trials: Cognitive Failure and Additional Challenges to Informed Decision Making. J Clin Oncol 2019; 37:169. [PMID: 30433847 DOI: 10.1200/jco.18.01136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jan Schildmann
- Jan Schildmann, MD, PhD, and Florian Bruns, MD, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Florian Bruns
- Jan Schildmann, MD, PhD, and Florian Bruns, MD, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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16
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Hlubocky FJ, Daugherty CK. Reply to J. Schildmann et al. J Clin Oncol 2019; 37:170-171. [DOI: 10.1200/jco.18.01495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Fay J. Hlubocky
- Fay J. Hlubocky, PhD, and Christopher K. Daugherty, MD, The University of Chicago, Chicago, IL
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