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Mittal A, Moore S, Navani V, Jiang DM, Stewart DJ, Liu G, Wheatley-Price P. What Is Ailing Oncology Clinical Trials? Can We Fix Them? Curr Oncol 2024; 31:3738-3751. [PMID: 39057147 PMCID: PMC11276279 DOI: 10.3390/curroncol31070275] [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: 05/27/2024] [Revised: 06/21/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024] Open
Abstract
Evidence from phase three clinical trials helps shape clinical practice. However, a very small minority of patients with cancer participate in clinical trials and many trials are not completed on time due to slow accrual. Issues with restrictive eligibility criteria can severely limit the patients who can access trials, without any convincing evidence that these restrictions impact patient safety. Similarly, regulatory, organizational, and institutional hurdles can delay trial activation, ultimately making some studies irrelevant. Additional issues during trial conduct (e.g., mandatory in-person visits, central confirmation of standard biomarkers, and inflexible drug dosage modification) contribute to making trials non-patient-centric. These real-life observations from experienced clinical trialists can seem nonsensical to investigators and patients alike, who are trying to bring effective drugs to patients with cancer. In this review, we delve into these issues in detail, and discuss potential solutions to make clinical trials more accessible to patients.
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Affiliation(s)
- Abhenil Mittal
- North East Cancer Center, Health Sciences North, Northern Ontario School of Medicine (NOSM U), Sudbury, ON P3E5J1, Canada;
| | - Sara Moore
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, ON K1H8L6, Canada
| | - Vishal Navani
- Tom Baker Cancer Center, Alberta Health Services, Calgary, AB T2N4N2, Canada
- Cumming School of Medicine, University of Calgary, Calgary, AB T2N4N2, Canada
| | - Di Maria Jiang
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON M5G2M9, Canada (G.L.)
| | - David J. Stewart
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, ON K1H8L6, Canada
| | - Geoffrey Liu
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON M5G2M9, Canada (G.L.)
| | - Paul Wheatley-Price
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, University of Ottawa, Ottawa, ON K1H8L6, Canada
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Stewart DJ, Bradford JP, Sehdev S, Ramsay T, Navani V, Rawson NSB, Jiang DM, Gotfrit J, Wheatley-Price P, Liu G, Kaplan A, Spadafora S, Goodman SG, Auer RAC, Batist G. New Anticancer Drugs: Reliably Assessing "Value" While Addressing High Prices. Curr Oncol 2024; 31:2453-2480. [PMID: 38785465 PMCID: PMC11119944 DOI: 10.3390/curroncol31050184] [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: 02/27/2024] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/25/2024] Open
Abstract
Countries face challenges in paying for new drugs. High prices are driven in part by exploding drug development costs, which, in turn, are driven by essential but excessive regulation. Burdensome regulation also delays drug development, and this can translate into thousands of life-years lost. We need system-wide reform that will enable less expensive, faster drug development. The speed with which COVID-19 vaccines and AIDS therapies were developed indicates this is possible if governments prioritize it. Countries also differ in how they value drugs, and generally, those willing to pay more have better, faster access. Canada is used as an example to illustrate how "incremental cost-effectiveness ratios" (ICERs) based on measures such as gains in "quality-adjusted life-years" (QALYs) may be used to determine a drug's value but are often problematic, imprecise assessments. Generally, ICER/QALY estimates inadequately consider the impact of patient crossover or long post-progression survival, therapy benefits in distinct subpopulations, positive impacts of the therapy on other healthcare or societal costs, how much governments willingly might pay for other things, etc. Furthermore, a QALY value should be higher for a lethal or uncommon disease than for a common, nonlethal disease. Compared to international comparators, Canada is particularly ineffective in initiating public funding for essential new medications. Addressing these disparities demands urgent reform.
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Affiliation(s)
- David J. Stewart
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - John-Peter Bradford
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Sandeep Sehdev
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
| | - Vishal Navani
- Division of Medical Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Nigel S. B. Rawson
- Canadian Health Policy Institute, Toronto, ON M5V 0A4, Canada;
- Macdonald-Laurier Institute, Ottawa, ON K1N 7Z2, Canada
| | - Di Maria Jiang
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Princess Margaret Cancer Center, Toronto, ON M5G 2M9, Canada
| | - Joanna Gotfrit
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
| | - Paul Wheatley-Price
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Geoffrey Liu
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Princess Margaret Cancer Center, Toronto, ON M5G 2M9, Canada
| | - Alan Kaplan
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Family Physicians Airway Group of Canada, Markham, ON L3R 9X9, Canada
| | - Silvana Spadafora
- Algoma District Cancer Program, Sault Ste Marie, ON P6B 0A8, Canada;
| | - Shaun G. Goodman
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- St. Michael’s Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, Toronto, ON M5B 1W8, Canada
| | - Rebecca A. C. Auer
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Department of Surgery, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada
| | - Gerald Batist
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
- Centre for Translational Research, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
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Hu J, Zhu A, Vickers A, Allaf ME, Ehdaie B, Schaeffer A, Pavlovich C, Ross AE, Green DA, Wang G, Ginzburg S, Montgomery JS, George A, Graham JN, Ristau BT, Correa A, Shoag JE, Kowalczyk KJ, Zhang TR, Schaeffer EM. Protocol of a multicentre randomised controlled trial assessing transperineal prostate biopsy to reduce infectiouscomplications. BMJ Open 2023; 13:e071191. [PMID: 37208135 DOI: 10.1136/bmjopen-2022-071191] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Approximately one million prostate biopsies are performed annually in the USA, and most are performed using a transrectal approach under local anaesthesia. The risk of postbiopsy infection is increasing due to increasing antibiotic resistance of rectal flora. Single-centre studies suggest that a clean, percutaneous transperineal approach to prostate biopsy may have a lower risk of infection. To date, there is no high-level evidence comparing transperineal versus transrectal prostate biopsy. We hypothesise that transperineal versus transrectal prostate biopsy under local anaesthesia has a significantly lower risk of infection, similar pain/discomfort levels and comparable detection of non-low-grade prostate cancer. METHODS AND ANALYSIS We will perform a multicentre, prospective randomised clinical trial to compare transperineal versus transrectal prostate biopsy for elevated prostate-specific antigen in the first biopsy, prior negative biopsy and active surveillance biopsy setting. Prostate MRI will be performed prior to biopsy, and targeted biopsy will be conducted for suspicious MRI lesions in addition to systematic biopsy (12 cores). Approximately 1700 men will be recruited and randomised in a 1:1 ratio to transperineal versus transrectal biopsy. A streamlined design to collect data and to determine trial eligibility along with the two-stage consent process will be used to facilitate subject recruitment and retention. The primary outcome is postbiopsy infection, and secondary outcomes include other adverse events (bleeding, urinary retention), pain/discomfort/anxiety and critically, detection of non-low-grade (grade group ≥2) prostate cancer. ETHICS AND DISSEMINATION The Institutional Review Board of the Biomedical Research Alliance of New York approved the research protocol (protocol number #18-02-365, approved 20 April 2020). The results of the trial will be presented at scientific conferences and published in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER NCT04815876.
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Affiliation(s)
- Jim Hu
- Department of Urology, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Alec Zhu
- Department of Urology, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Andrew Vickers
- Department of Urology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Behfar Ehdaie
- Department of Urology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anthony Schaeffer
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Christian Pavlovich
- Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ashley E Ross
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David A Green
- Department of Urology, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Gerald Wang
- Department of Urology, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Serge Ginzburg
- Einstein Urology, Albert Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Montgomery
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Arvin George
- Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - John N Graham
- Department of Urology, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - Benjamin T Ristau
- Department of Surgery, Division of Urology, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Andres Correa
- Department of Surgical Oncology, Division of Urology, Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
| | - Jonathan E Shoag
- Department of Urology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Keith J Kowalczyk
- Department of Urology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Tenny R Zhang
- Department of Urology, NewYork-Presbyterian Weill Cornell Medical Center, New York, New York, USA
| | - E M Schaeffer
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Jia JL, Alshamsan B, Ng TL. Temozolomide Chronotherapy in Glioma: A Systematic Review. Curr Oncol 2023; 30:1893-1902. [PMID: 36826108 PMCID: PMC9955138 DOI: 10.3390/curroncol30020147] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/08/2023] Open
Abstract
Outcomes for patients with high-grade glioma remain poor. Temozolomide (TMZ) is the only drug approved for first-line treatment of glioblastoma multiforme, the most aggressive form of glioma. Chronotherapy highlights the potential benefit of timed TMZ administration. This is based on pre-clinical studies of enhanced TMZ-induced glioma cytotoxicity dependent on circadian, oscillating expression of key genes involved in apoptosis, DNA damage repair, and cell-cycle mediated cell death. The current systematic review's primary aim was to evaluate the efficacy and toxicity of TMZ chronotherapy. A systemic review of literature following PRISMA guidelines looking at clinical outcomes on TMZ chronotherapy on gliomas was performed. The search in the English language included three databases (PubMed, EMBASE, and Cochrane) and five conferences from 1946 to April 2022. Two independent reviewers undertook screening, data extraction, and risk-of-bias assessment. A descriptive analysis was conducted due to limited data. Of the 269 articles screened, two unique studies were eligible and underwent abstraction for survival and toxicity findings. Both studies-one a retrospective cohort study (n = 166) and the other a prospective randomized feasibility study (n = 35)-were conducted by the same academic group and suggested a trend for improved overall survival, but possibly increased toxicity when TMZ was administered in the morning (vs. evening). There was limited evidence suggesting possible therapeutic value from administering TMZ in the morning, which may be consistent with the pre-clinical observations of the importance of the timing of TMZ administration in vitro. Larger, pragmatic, prospective randomized controlled trials are needed to ascertain the value of TMZ chronotherapy to provide optimized and equitable care for this population.
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Affiliation(s)
- Jason L. Jia
- Core Internal Medicine Residency Program, Department of Medicine, University of Ottawa, Ottawa, ON K1H 8L6, Canada
| | - Bader Alshamsan
- Department of Medicine, College of Medicine, Qassim University, Buraydah P.O. Box 6655, Saudi Arabia
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
| | - Terry L. Ng
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada
- Correspondence:
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Integrating Systematic Reviews into Supportive Care Trial Design: The Rethinking Clinical Trials (REaCT) Program. Curr Oncol 2022; 29:9550-9559. [PMID: 36547164 PMCID: PMC9776426 DOI: 10.3390/curroncol29120750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To review the successes and challenges of integrating systematic reviews (SRs) into the Rethinking Clinical Trials (REaCT) Program. METHODS All REaCT program SRs were evaluated and descriptive summaries presented. RESULTS Twenty-two SRs have been performed evaluating standard of care interventions for the management of: breast cancer (n = 15), all tumour sites (n = 4), breast and prostate cancers (n = 2), and prostate cancer (n = 1). The majority of SRs were related to supportive care (n = 14) and survivorship (n = 5) interventions and most (19/22, 86%) confirmed the existence of uncertainty relating to the clinical question addressed in the SR. Most SRs (15/22, 68%) provided specific recommendations for future studies and results were incorporated into peer-reviewed grant applications (n = 6) and clinical trial design (n = 12). In 12/22 of the SRs, the first author was a trainee. All SRs followed PRISMA guidelines. CONCLUSION SRs are important for identifying and confirming clinical equipoise and designing trials. SRs provide an excellent opportunity for trainees to participate in research.
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Awan A, Basulaiman B, Stober C, Clemons M, Fergusson D, Hilton J, Al Ghareeb W, Goodwin R, Ibrahim M, Hutton B, Vandermeer L, Mallick R, Vickers MM. Oral magnesium supplements for cancer treatment-induced hypomagnesemia: Results from a pilot randomized trial. Health Sci Rep 2021; 4:e443. [PMID: 34938893 PMCID: PMC8669698 DOI: 10.1002/hsr2.443] [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: 05/10/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND AIMS Optimal management of cancer treatment-induced hypomagnesemia (hMg) is not known. We assessed the feasibility of using a novel pragmatic clinical trials model to compare two commonly used oral Mg replacement strategies. METHODS Patients with grade 1 to 3 hMg while receiving either platinum-based chemotherapy or epidermal growth factor receptor inhibitors (EGFRI) were randomized to oral magnesium oxide (MgOx) or oral magnesium citrate (MgCit). The trial methodology utilized the integrated consent model. Feasibility would be successful if; accrual rate was ≥5 patients a month and if measures of patient and physician engagement, were > 50%. Secondary endpoints included; comparison of Mg levels, cardiac arrhythmias, and rates of treatment delay/hospitalizations. RESULTS From July 2016 to December 2017, an average of 1 patient a month was accrued. All 15 eligible and approached patients consented to participate in the study (100% engagement) and 7/15 were randomized to MgOx and 8/15 to MgCit. The percentage of physicians who approached patients for the study was 4 of 6 (66.6% engagement). The mean slope of change in Mg (mmol/L/day) was 0.0022 (95% CI: -0.0001 to 0.0044) for MgOx and 0.0006 (95% CI, -0.0012 to 0.0024) for MgCit (P = .2123). Three patients (20%) required IV magnesium while on the study (2 MgCit and 1 MgOx). Grade 1 diarrhea occurred in 3 patients in the MgCit arm. CONCLUSION Despite oral magnesium tolerability and meeting most of its feasibility endpoints, this study did not meet its target accrual rate. Alternative designs would be necessary for a definitive efficacy study.
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Affiliation(s)
- Arif Awan
- Department of Medicine, Division of Medical OncologyThe Ottawa Hospital Cancer CentreOttawaOntarioCanada
| | - Bassam Basulaiman
- Department of Medicine, Division of Medical OncologyThe Ottawa Hospital Cancer CentreOttawaOntarioCanada
| | - Carol Stober
- Cancer Therapeutics ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Mark Clemons
- Department of Medicine, Division of Medical OncologyThe Ottawa Hospital Cancer CentreOttawaOntarioCanada
- Cancer Therapeutics ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
- Department of MedicineUniversity of OttawaOttawaOntarioCanada
| | - Dean Fergusson
- Department of MedicineUniversity of OttawaOttawaOntarioCanada
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - John Hilton
- Department of Medicine, Division of Medical OncologyThe Ottawa Hospital Cancer CentreOttawaOntarioCanada
- Cancer Therapeutics ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Waleed Al Ghareeb
- Department of Medicine, Division of Medical OncologyThe Ottawa Hospital Cancer CentreOttawaOntarioCanada
| | - Rachel Goodwin
- Department of Medicine, Division of Medical OncologyThe Ottawa Hospital Cancer CentreOttawaOntarioCanada
| | - Mohammed Ibrahim
- Department of Medicine, Division of Medical OncologyThe Ottawa Hospital Cancer CentreOttawaOntarioCanada
| | - Brian Hutton
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Lisa Vandermeer
- Cancer Therapeutics ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Ranjeeta Mallick
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Michael M. Vickers
- Department of Medicine, Division of Medical OncologyThe Ottawa Hospital Cancer CentreOttawaOntarioCanada
- Department of MedicineUniversity of OttawaOttawaOntarioCanada
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Saunders D, Liu M, Vandermeer L, Alzahrani MJ, Hutton B, Clemons M. The Rethinking Clinical Trials (REaCT) Program. A Canadian-Led Pragmatic Trials Program: Strategies for Integrating Knowledge Users into Trial Design. Curr Oncol 2021; 28:3959-3977. [PMID: 34677255 PMCID: PMC8534460 DOI: 10.3390/curroncol28050337] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/21/2021] [Accepted: 09/28/2021] [Indexed: 11/16/2022] Open
Abstract
We reviewed patient and health care provider (HCP) surveys performed through the REaCT program. The REaCT team has performed 15 patient surveys (2298 respondents) and 13 HCP surveys (1033 respondents) that have addressed a broad range of topics in breast cancer management. Over time, the proportion of surveys distributed by paper/regular mail has fallen, with electronic distribution now the norm. For the patient surveys, the median duration of the surveys was 3 months (IQR 2.5-7 months) and the median response rate was 84% (IQR 80-91.7%). For the HCP surveys, the median survey duration was 3 months (IQR 1.75-4 months), and the median response rate, where available, was 28% (IQR 21.2-49%). The survey data have so far led to: 10 systematic reviews, 6 peer-reviewed grant applications and 19 clinical trials. Knowledge users should be an essential component of clinical research. The REaCT program has integrated surveys as a standard step of their trials process. The COVID-19 pandemic and reduced face-to-face interactions with patients in the clinic as well as the continued importance of social media highlight the need for alternative means of distributing and responding to surveys.
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Affiliation(s)
- Deanna Saunders
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada; (D.S.); (M.L.); (L.V.)
| | - Michelle Liu
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada; (D.S.); (M.L.); (L.V.)
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada; (D.S.); (M.L.); (L.V.)
| | - Mashari Jemaan Alzahrani
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON K1H 8L6, Canada;
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and University of Ottawa, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada;
| | - Mark Clemons
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, 501 Smyth Road, Box 511, Ottawa, ON K1H 8L6, Canada; (D.S.); (M.L.); (L.V.)
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and the University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON K1H 8L6, Canada;
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8
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Nicholls SG, Carroll K, Goldstein CE, Brehaut JC, Weijer C, Zwarenstein M, Dixon S, Grimshaw JM, Garg AX, Taljaard M. Patient Partner Perspectives Regarding Ethically and Clinically Important Aspects of Trial Design in Pragmatic Cluster Randomized Trials for Hemodialysis. Can J Kidney Health Dis 2021; 8:20543581211032818. [PMID: 34367647 PMCID: PMC8317238 DOI: 10.1177/20543581211032818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cluster randomized trials (CRTs) are trials in which intact groups such as hemodialysis centers or shifts are randomized to treatment or control arms. Pragmatic CRTs have been promoted as a promising trial design for nephrology research yet may also pose ethical challenges. While randomization occurs at the cluster level, the intervention and data collection may vary in a CRT, challenging the identification of research participants. Moreover, when a waiver of patient consent is granted by a research ethics committee, there is an open question as to whether and to what degree patients should be notified about ongoing research or be provided with a debrief regarding the nature and results of the trial upon completion. While empirical and conceptual research exploring ethical issues in pragmatic CRTs has begun to emerge, there has been limited discussion with patients, families, or caregivers of patients undergoing hemodialysis. OBJECTIVE To explore with patients and families with experience of hemodialysis research the challenges raised by different approaches to designing pragmatic CRTs in hemodialysis. Specifically, their perceptions of (1) the use of a waiver of consent, (2) notification processes and information provided to participants, and (3) any other concerns about cluster randomized designs in hemodialysis. DESIGN Focus group and interview discussions of hypothetical clinical trial designs. SETTING Focus groups and interviews were conducted in-person or via videoconference or telephone. PARTICIPANTS Patient partners in hemodialysis research, defined as patients with personal experience of dialysis or a family member who had experience supporting a patient receiving hemodialysis, who have been actively involved in discussions to advise a research team on the design, conduct, or implementation of a hemodialysis trial. METHODS Participants were invited to participate in focus groups or individual discussions that were audio recorded with consent. Recorded interviews were transcribed verbatim prior to analysis. Transcripts were analyzed using a thematic analysis approach. RESULTS Two focus groups, three individual interviews, and one interview involving a patient and family member were conducted with 17 individuals between February 2019 and May 2020. Participants expressed support for approaches that emphasized patient choice. Disclosure of patient-relevant risks and information were key themes. Both consent and notification processes served to generate trust, but bypassing patient choice was perceived as undermining this trust. Participants did not dismiss the option of a waiver of consent. They were, however, more restrictive in their views about when a waiver of consent may be acceptable. Patient partners were skeptical of claims to impracticability based on costs or the time commitments for staff. LIMITATIONS All participants were from Canada and had been involved in the design or conduct of a trial, limiting the degree to which results may be extrapolated. CONCLUSIONS Given the preferences of participants to be afforded the opportunity to decide about trial participation, we argue that investigators should thoroughly investigate approaches that allow participants to make an informed choice regarding trial participation. In keeping with the preference for autonomous choice, there remains a need to further explore how consent approaches can be designed to facilitate clinical trial conduct while meeting their ethical requirements. Finally, further work is needed to define the limited circumstances in which waivers of consent are appropriate.
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Affiliation(s)
- Stuart G. Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
| | | | - Jamie C. Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
| | - Charles Weijer
- Department of Philosophy, Western University, London, ON, Canada
- Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Western University, London, ON, Canada
- Department of Family Medicine, Western University, London, ON, Canada
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- ICES, Ontario, Canada
| | - Stephanie Dixon
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- ICES, Ontario, Canada
- Lawson Research Institute, London, ON, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
| | - Amit X. Garg
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- ICES, Ontario, Canada
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- Nephrology, London Health Sciences Centre, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
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Clemons M, Simos D, Sienkiewicz M, Ng T, Zibdawi L, Basulaiman B, Awan A, Fergusson D, Vandermeer L, Saunders D, Hutton B, Amir E. A prospective multi-centre, randomized study comparing the addition of tapering dexamethasone to other standard of care therapies for taxane-associated pain syndrome (TAPS) in breast cancer patients. Support Care Cancer 2021; 29:5787-5795. [PMID: 33742240 DOI: 10.1007/s00520-021-06142-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/08/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Taxane-associated pain syndrome (TAPS) is common with docetaxel and is characterised by myalgias and arthralgias starting 2-3 days after treatment and can last for up to 7 days. Anecdotal evidence suggests that corticosteroids can reduce TAPS. This multicentre, randomized trial evaluated the effect of additional tapering dexamethasone on TAPS. METHODS 130 breast cancer patients commencing docetaxel were randomized to dexamethasone premedication (8 mg/twice daily for 3 days) or dexamethasone premedication followed by tapering dexamethasone (4 mg/daily for 2 days followed by 2 mg/daily for 2 days). The primary endpoint was absolute change in FACT-Taxane questionnaire during the first chemotherapy cycle. Secondary endpoints: proportion of patients with clinically significant TAPS, QoL, pain and toxicity. RESULTS 110/130 patients had complete data included in the primary analysis. The fall in FACT-Taxane scores was lower in the experimental group on day 5 (p = 0.05), but not on day 7 (p = 0.21). There was no difference in FACT-Taxane scores over the entire study duration (p = 0.59). Fewer patients in the experimental arm reported TAPS on day 5 (30 vs. 47%). There was a borderline significant attenuation of impairment of QoL with experimental treatment on day 5 (p = 0.06), but not day 7 (p = 0.53). Tapered schedule was associated with more dyspepsia and insomnia. CONCLUSION A tapering schedule of dexamethasone was associated with a brief reduction in docetaxel-associated symptoms which was observed only during dexamethasone exposure and did not persist after discontinuation of the drug. TRIAL REGISTRATION ClinicalTrials.gov NCT03348696.
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Affiliation(s)
- Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada. .,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada. .,Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.
| | | | - Marta Sienkiewicz
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Terry Ng
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada
| | - Labib Zibdawi
- The Stronach Regional Cancer Centre, Newmarket, ON, Canada
| | - Bassam Basulaiman
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada
| | - Arif Awan
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada
| | - Dean Fergusson
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Deanna Saunders
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian Hutton
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Eitan Amir
- Division of Medical Oncology & Hematology, Department of Medicine, Princess Margaret Cancer Centre and the University of Toronto, Toronto, ON, Canada
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10
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Arnaout A, Zhang J, Frank S, Momtazi M, Cordeiro E, Roberts A, Ghumman A, Fergusson D, Stober C, Pond G, Jeong A, Vandermeer L, Hutton B, Clemons M. A Randomized Controlled Trial Comparing Alloderm-RTU with DermACELL in Immediate Subpectoral Implant-Based Breast Reconstruction. ACTA ACUST UNITED AC 2020; 28:184-195. [PMID: 33704185 PMCID: PMC7816190 DOI: 10.3390/curroncol28010020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/01/2020] [Accepted: 12/16/2020] [Indexed: 12/15/2022]
Abstract
Background: The effectiveness of different acellular dermal matrices (ADM) used for implant-based reconstruction immediately following mastectomy is an important clinical question. A prospective randomized clinical trial was performed to evaluate the superiority of DermACELL over Alloderm-RTU in reducing drain duration. Methods: Patients undergoing mastectomy with subpectoral immediate and permanent implant-based breast reconstruction were randomized to Alloderm-RTU or DermACELL. The primary outcome was seroma formation, measured by the duration of postoperative drain placement. Secondary outcomes included: post drain removal seroma aspiration, infection, redbreast syndrome, wound dehiscence, loss of the implant, and unplanned return to the operating room. Results: 62 patients were randomized for 81 mastectomies (41 Alloderm-RTU, 40 DermACELL). Baseline characteristics were similar. There was no statistically significant difference in mean drain duration (p = 0.16), with a trend towards longer duration in the Alloderm-RTU group (1.6 days; 95%CI, 0.7 to 3.9). The overall rate of minor and major complications were statistically similar between the two groups; although patients with Alloderm-RTU had 3 times as many infections requiring antibiotics (7.9% vs. 2.5%) with a risk difference of 5.4 (95%CI −4.5 to 15.2), and twice as many unplanned returns to the operating room (15.8% vs. 7.5%) with a risk difference of 8.3 (95% CI −5.9 to 22.5) as DermACELL. Conclusion: This is the first prospective randomized clinical trial comparing the two most commonly used human-derived ADMs. There was no statistically significant difference in drain duration, minor, or major complications between DermACELL over Alloderm-RTU in immediate subpectoral permanent implant-based breast reconstruction post-mastectomy.
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Affiliation(s)
- Angel Arnaout
- Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, ON K1Y 4E9, Canada; (A.A.); (J.Z.); (S.F.); (M.M.); (E.C.); (A.R.); (A.G.)
| | - Jing Zhang
- Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, ON K1Y 4E9, Canada; (A.A.); (J.Z.); (S.F.); (M.M.); (E.C.); (A.R.); (A.G.)
| | - Simon Frank
- Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, ON K1Y 4E9, Canada; (A.A.); (J.Z.); (S.F.); (M.M.); (E.C.); (A.R.); (A.G.)
| | - Moein Momtazi
- Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, ON K1Y 4E9, Canada; (A.A.); (J.Z.); (S.F.); (M.M.); (E.C.); (A.R.); (A.G.)
| | - Erin Cordeiro
- Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, ON K1Y 4E9, Canada; (A.A.); (J.Z.); (S.F.); (M.M.); (E.C.); (A.R.); (A.G.)
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON K1H 8L6, Canada; (D.F.); (C.S.); (A.J.); (L.V.); (B.H.)
| | - Amanda Roberts
- Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, ON K1Y 4E9, Canada; (A.A.); (J.Z.); (S.F.); (M.M.); (E.C.); (A.R.); (A.G.)
| | - Ammara Ghumman
- Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, ON K1Y 4E9, Canada; (A.A.); (J.Z.); (S.F.); (M.M.); (E.C.); (A.R.); (A.G.)
| | - Dean Fergusson
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON K1H 8L6, Canada; (D.F.); (C.S.); (A.J.); (L.V.); (B.H.)
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada
| | - Carol Stober
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON K1H 8L6, Canada; (D.F.); (C.S.); (A.J.); (L.V.); (B.H.)
| | - Gregory Pond
- Juravinski Cancer Center, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Ahwon Jeong
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON K1H 8L6, Canada; (D.F.); (C.S.); (A.J.); (L.V.); (B.H.)
| | - Lisa Vandermeer
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON K1H 8L6, Canada; (D.F.); (C.S.); (A.J.); (L.V.); (B.H.)
| | - Brian Hutton
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON K1H 8L6, Canada; (D.F.); (C.S.); (A.J.); (L.V.); (B.H.)
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada
| | - Mark Clemons
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON K1H 8L6, Canada; (D.F.); (C.S.); (A.J.); (L.V.); (B.H.)
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, ON K1H 8L6, Canada
- Correspondence: ; Tel.: +1-613-737-7700 (ext. 70170)
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11
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Hsu T, Fergusson D, Stober C, Daigle K, Moledina N, Vandermeer L, Pond G, Hilton J, Hutton B, Clemons M. A randomized clinical trial comparing physician-directed or fixed-dose steroid replacement strategies for incomplete dexamethasone dosing prior to docetaxel chemotherapy. Support Care Cancer 2020; 29:3113-3120. [PMID: 33057999 DOI: 10.1007/s00520-020-05791-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/18/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Prior to docetaxel chemotherapy, incomplete dosing of steroid premedication is common. The lack of standardized steroid replacement strategies can lead to variability in care and delays in starting docetaxel. METHODS This randomized trial compared physician-directed with fixed-dose dexamethasone. Patients who had missed at least one dose of steroid premedication were randomized to physician-directed replacement (any choice of steroid, dose or route) or to dexamethasone 8 mg oral before starting docetaxel. The primary outcome was time from randomization to starting docetaxel. Secondary outcomes included rates of acute and delayed hypersensitivity reactions, fluid retention and skin toxicity. RESULTS Of 60 eligible patients, 30 (50%) and 30 (50%) were randomized to physician-directed and fixed-dose arms, respectively. Overall tumour types: breast (42 [70%]), gastrointestinal (7 [12%]), prostate (7 [12%]) and lung (3 [7%]). Dexamethasone was most commonly incompletely taken with cycles 1 (28 [48%]) and 2 (13 [22%]) of docetaxel. Seven different replacement strategies were used in the physician-choice arm. Patients in the fixed-dose arm received docetaxel a mean of 21.2 (95% CI for the difference is 2.1 to 44.6) minutes earlier than the physician-choice arm (p = 0.033 Wilcoxon rank sum test or p = 0.073 two-sample t test). Median time to docetaxel was 47.5 vs 61 min (mean 62.2 vs 83.4 min) by arm, respectively. No significant difference in toxicity rates was observed. CONCLUSION While not meeting our predefined criteria of improving the time from randomization to starting docetaxel by 30 min, the fixed-dose replacement strategy reduced both the time to starting docetaxel and treatment variability. Fixed dosing with oral dexamethasone 8 mg should be the preferred standard of care. REGISTRATION: www.clinicaltrials.gov NCT02815319 REGISTRATION DATE: June 28, 2016.
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Affiliation(s)
- Tina Hsu
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, Ottawa, Canada.,Department of Medicine, The University of Ottawa, Ottawa, Canada
| | - Dean Fergusson
- Department of Medicine, The University of Ottawa, Ottawa, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Carol Stober
- Cancer Research Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kelly Daigle
- Department of Nursing, The Ottawa Hospital and the Ottawa Hospital Cancer Centre, Ottawa, Canada
| | - Noorza Moledina
- Department of Nursing, The Ottawa Hospital and the Ottawa Hospital Cancer Centre, Ottawa, Canada
| | - Lisa Vandermeer
- Cancer Research Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Greg Pond
- Department of Oncology, McMaster University, Hamilton, Canada
| | - John Hilton
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, Ottawa, Canada.,Department of Medicine, The University of Ottawa, Ottawa, Canada
| | - Brian Hutton
- Department of Medicine, The University of Ottawa, Ottawa, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Mark Clemons
- Division of Medical Oncology, The Ottawa Hospital Cancer Centre, Ottawa, Canada. .,Department of Medicine, The University of Ottawa, Ottawa, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada. .,Cancer Research Program, Ottawa Hospital Research Institute, Ottawa, Canada.
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12
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Apte SS, Moloo H, Jeong A, Liu M, Vandemeer L, Suh K, Thavorn K, Fergusson DA, Clemons M, Auer RC. Prospective randomised controlled trial using the REthinking Clinical Trials (REaCT) platform and National Surgical Quality Improvement Program (NSQIP) to compare no preparation versus preoperative oral antibiotics alone for surgical site infection rates in elective colon surgery: a protocol. BMJ Open 2020; 10:e036866. [PMID: 32647023 PMCID: PMC7351286 DOI: 10.1136/bmjopen-2020-036866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/24/2020] [Accepted: 06/02/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Despite 40 randomised controlled trials (RCTs) investigating preoperative oral antibiotics (OA) and mechanical bowel preparation (MBP) to reduce surgical site infection (SSI) rate following colon surgery, there has never been an RCT published comparing OA alone versus no preparation. Of the four possible regimens (OA alone, MBP alone, OA plus MBP and no preparation), randomised evidence is conflicting for studied groups. Furthermore, guidelines vary, with recommendations for OA alone, OA plus MBP or no preparation. The National Surgical Quality Improvement Program (NSQIP) has automated data collection for surgical patients. Similarly, the 'REthinking Clinical Trials' (REaCT) platform increases RCT enrolment by simplifying pragmatic trial design. In this novel RCT protocol, we combine REaCT and NSQIP to compare OA alone versus no preparation for SSI rate reduction in elective colon surgery. To our knowledge, this is the first published RCT protocol that leverages NSQIP for data collection. In our feasibility study, 67 of 74 eligible patients (90%) were enrolled and 63 of 67 (94%) were adherent to protocol. The 'REaCT-NSQIP' trial design has great potential to efficiently generate level I evidence for other perioperative interventions. METHODS AND ANALYSIS SSI rates following elective colorectal surgery after preoperative OA or no preparation will be compared. We predict 45% relative rate reduction of SSI, improvement in length of stay, reduced costs and increased quality of life, with similar antibiotic-related complications. Consent, using the 'integrated consent model', and randomisation on a mobile device are completed by the surgeon in a single clinical encounter. Data collection for the primary end point is automatic through NSQIP. Analysis of cost per weighted case, cost utility and quality-adjusted life years will be done. ETHICS AND DISSEMINATION This study is approved by The Ontario Cancer Research Ethics Board. Results will be disseminated in surgical conferences and peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03663504; Pre-results, recruitment phase.
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Affiliation(s)
- Sameer S Apte
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Husein Moloo
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ahwon Jeong
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michelle Liu
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lisa Vandemeer
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kathryn Suh
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mark Clemons
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Rebecca C Auer
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Cancer Therapeutics Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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13
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Clemons M, Stober C, Kehoe A, Bedard D, MacDonald F, Brunet MC, Saunders D, Vandermeer L, Mazzarello S, Awan A, Basulaiman B, Robinson A, Mallick R, Hutton B, Fergusson D. A randomized trial comparing vascular access strategies for patients receiving chemotherapy with trastuzumab for early-stage breast cancer. Support Care Cancer 2020; 28:4891-4899. [PMID: 32002617 DOI: 10.1007/s00520-020-05326-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/23/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Trastuzumab-based chemotherapy is usually administered through either a peripherally inserted central catheter (PICC) or a totally implanted vascular access device (PORT). As the most effective type of access is unknown, a feasibility trial, prior to conducting a large pragmatic trial, was undertaken. METHODS The trial methodology utilized the integrated consent model incorporating oral consent. Patients receiving trastuzumab-based neo/adjuvant chemotherapy for early-stage breast cancer were randomized to a PICC or PORT insertion. Feasibility was reflected through a combination of endpoints; however, the a priori definition of feasibility was > 25% of patients approached agreed to randomization and > 25% of physicians approached patients. Secondary outcomes included rates of line-associated complications such as thrombotic events requiring anticoagulation, line infections or phlebitis. RESULTS During the study period, 4/15 (26.7%) medical oncologists approached patients about study participation. Of 59 patients approached, 56 (94.9%) agreed to randomization, 29 (51.8%) were randomized to PICC and 27 (48.2%) to PORT access. Overall, 17.2% (5/29) and 14.8% (4/27) of patients had at least one line-associated complication in the PICC and PORT arms respectively. The study was terminated early due to slow accrual. CONCLUSION The study met its feasibility endpoints with respect to patient and physician engagement. However, the slow rate of accrual (56 patients in 2 years) means that conducting a large pragmatic trial would require additional strategies to make such a study possible. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02632435.
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Affiliation(s)
- Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada. .,Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Carol Stober
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Anne Kehoe
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Debbie Bedard
- Department of Nursing, Ottawa General Hospital, Ottawa, Canada
| | - Fiona MacDonald
- Department of Nursing, Ottawa General Hospital, Ottawa, Canada
| | | | - Deanna Saunders
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sasha Mazzarello
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Arif Awan
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Bassam Basulaiman
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Andrew Robinson
- Division of Medical Oncology, Cancer Centre of Southeastern Ontario, Kingston, Canada
| | | | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada
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Lackman M, Vickers MM, Hsu T. Physician-reported reasons for non-enrollment of older adults in cancer clinical trials. J Geriatr Oncol 2020; 11:31-36. [DOI: 10.1016/j.jgo.2019.01.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 11/28/2022]
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15
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Robinson A, Stober C, Fergusson D, Kehoe A, Bedard D, MacDonald F, Brunet MC, Saunders D, Mazzarello S, Vandermeer L, Joy AA, Awan A, Basulaiman B, Mallick R, Hutton B, Clemons M. A multicentre, randomized pilot trial comparing vascular access strategies for early stage breast cancer patients receiving non-trastuzumab containing chemotherapy. Breast Cancer Res Treat 2019; 178:337-345. [PMID: 31392518 DOI: 10.1007/s10549-019-05388-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 07/31/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE All vascular access strategies foradministering chemotherapy in early stage breast cancer (EBC) are associated with risks and benefits. As the most effective type of access is unknown a feasibility trial, prior to conducting a large pragmatic trial, was undertaken. METHODS The trial methodology utilized broad eligibility criteria and the integrated consent model incorporating oral consent. EBC patients receiving non-trastuzumab-containing chemotherapy were randomized to peripheral access or central line insertion. The a priori definition of feasibility was: > 25% of patients approached agreed to randomisation and > 25% of physicians approached patients. Secondary outcomes included rates of line-associated complications. RESULTS Of 159 patients approached, 150 (94.3%) agreed to randomisation, 77 (51.3%) were randomized to peripheral and 73 (48.7%) to central access. 6/26 (23.1%) of medical oncologists approached patients. Rates of complications per chemotherapy cycles in the peripheral vs central access groups with risk difference (RD) (95% CI) were: thrombotic events requiring anticoagulation [1 (0.3%) vs. 3 (1.0%), RD - 0.7(- 1.9,0.5)], line infections [0 (0%) vs. 1 (0.3%), RD - 0.3(- 0.9,0.3)], phlebitis [2 (0.6%) vs. 0 (0%), RD 0.3(- 0.3,0.8)], and tissue infiltrations [4 (1.1%) vs. 1 (0.3%), RD 0.8(- 0.4,2.1)]. Overall, 8.0% (6/75) and 7.7% (5/65) of patients had at least one of these complications in the peripheral and central access arms respectively [RD - 0.9(- 9.4,7.6)]. The study was terminated early due to slow accrual. CONCLUSION While meeting its a priori feasibility criteria for patient engagement, the slow accrual means that conducting a large pragmatic trial would require overcoming the barriers to physician recruitment. TRIAL REGISTRATION NCT02688998.
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Affiliation(s)
- Andrew Robinson
- Division of Medical Oncology, Cancer Centre of Southeastern Ontario, Kingston, Canada
| | - Carol Stober
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Dean Fergusson
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Anne Kehoe
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Debbie Bedard
- Department of Nursing, The Ottawa Hospital, Ottawa, Canada
| | | | | | - Deanna Saunders
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sasha Mazzarello
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lisa Vandermeer
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Anil A Joy
- Division of Medical Oncology, Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, AB, Canada
| | - Arif Awan
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Bassam Basulaiman
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Brian Hutton
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Mark Clemons
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Canada.
- Department of Medicine, University of Ottawa, Ottawa, Canada.
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Canada.
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16
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When oncologic treatment options outpace the existing evidence: Contributing factors and a path forward. J Cancer Policy 2019. [DOI: 10.1016/j.jcpo.2019.100188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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17
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Creating a pragmatic trials program for breast cancer patients: Rethinking Clinical Trials (REaCT). Breast Cancer Res Treat 2019; 177:93-101. [DOI: 10.1007/s10549-019-05274-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
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18
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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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19
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Awan AA, Paterson A, Clemons M. De-Escalation of Bone-Modifying Agents in Patients With Bone Metastases: The Best of Times and the Worst of Times? J Oncol Pract 2019; 14:465-467. [PMID: 30096270 DOI: 10.1200/jop.18.00393] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Arif A Awan
- McGill University, Montreal, Quebec; University of Calgary, Calgary, Alberta; and The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Alexander Paterson
- McGill University, Montreal, Quebec; University of Calgary, Calgary, Alberta; and The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Mark Clemons
- McGill University, Montreal, Quebec; University of Calgary, Calgary, Alberta; and The Ottawa Hospital and University of Ottawa, Ottawa, Canada
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20
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Clemons M, Mazzarello S, Hilton J, Joy A, Price-Hiller J, Zhu X, Verma S, Kehoe A, Ibrahim MF, Sienkiewicz M, Stober C, Vandermeer L, Hutton B, Mallick R, Fergusson D. Feasibility of using a pragmatic trials model to compare two primary febrile neutropenia prophylaxis regimens (ciprofloxacin versus G-CSF) in patients receiving docetaxel-cyclophosphamide chemotherapy for breast cancer (REaCT-TC). Support Care Cancer 2018; 27:1345-1354. [PMID: 30099602 DOI: 10.1007/s00520-018-4408-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 08/03/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE Optimal primary febrile neutropenia (FN) prophylaxis (i.e. ciprofloxacin or granulocyte-colony stimulating factors [G-CSF]) for patients receiving docetaxel-cyclophosphamide (TC) chemotherapy is unknown. We assessed the feasibility of using a novel pragmatic comparative effectiveness trial to compare these standard-of-care options. METHODS Early-stage breast cancer patients receiving TC chemotherapy were randomised to either ciprofloxacin or G-CSF. Trial methodology consists of broad eligibility criteria, simply-defined endpoints, integrated consent model incorporating oral consent, and web-based randomisation in the clinic. Primary feasibility endpoints included patient and physician engagement (if > 50% of patients approached agree to participate and if > 50% of physicians approached patients for the study). Secondary clinical endpoints included the following: first occurrence rates of FN, treatment-related hospitalisation, or chemotherapy dose reduction/delay/discontinuation, as well as patient satisfaction with the oral consent process. RESULTS Of 204 patients approached, 91.2% (186/204) agreed to randomisation. Sixteen of twenty (80%) participating medical oncologists randomised patients. Median patient age was 57.7 (range 31.8-84.1). The 186 patients received 557 cycles of chemotherapy. Overall incidences of first events by patient (n = 186) were as follows: FN (18/186, 21.43%), treatment-related hospitalisation (11/186, 13.10%), chemotherapy reduction (19/186, 22.62%), chemotherapy discontinuation (16/186, 19.05%), and chemotherapy delays (5/186, 5.95%). A total of 37.77% (69/186) of patients and 12.39% (69/557) of chemotherapy cycles had at least one of these first events. Patients were highly satisfied with the oral consent process. CONCLUSION This study met its feasibility endpoints. This model offers a means of comparing standard-of-care treatments in a practical and cost-efficient manner. TRIAL REGISTRATION Trial registration: ClinicalTrials.gov : NCT02173262.
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Affiliation(s)
- Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, The University of Ottawa, Ottawa, Canada.
- Cancer Research Program, The Ottawa Hospital Research Institute, Ottawa, Canada.
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Sasha Mazzarello
- Cancer Research Program, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - John Hilton
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, The University of Ottawa, Ottawa, Canada
- Cancer Research Program, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Anil Joy
- Division of Medical Oncology, Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Canada
| | - Julie Price-Hiller
- Division of Medical Oncology, Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Canada
| | - Xiaofu Zhu
- Division of Medical Oncology, Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, Canada
| | - Shailendra Verma
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, The University of Ottawa, Ottawa, Canada
| | - Anne Kehoe
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, The University of Ottawa, Ottawa, Canada
| | - Mohammed Fk Ibrahim
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, The University of Ottawa, Ottawa, Canada
| | - Marta Sienkiewicz
- Cancer Research Program, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Carol Stober
- Cancer Research Program, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lisa Vandermeer
- Cancer Research Program, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada
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21
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LeVasseur N, Fergusson D, Clemons M. Unnecessary variation in practice: how to improve cancer care through pragmatic trials. Curr Oncol 2018; 25:e263-e264. [PMID: 30111970 PMCID: PMC6092054 DOI: 10.3747/co.25.3922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Oncologists are frequently faced with multiple “reasonable” treatment options, without sufficient evidence to choose one over the other[...]
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Affiliation(s)
- N. LeVasseur
- Division of Medical Oncology and Department of Medicine, The Ottawa Hospital and University of Ottawa
| | - D. Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, and
| | - M. Clemons
- Division of Medical Oncology and Department of Medicine, The Ottawa Hospital and University of Ottawa
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, and
- The Ottawa Hospital Research Institute, Ottawa, ON
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22
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Hilton J, Stober C, Mazzarello S, Vandermeer L, Fergusson D, Hutton B, Clemons M. Randomised feasibility trial to compare three standard of care chemotherapy regimens for early stage triple-negative breast cancer (REaCT-TNBC trial). PLoS One 2018; 13:e0199297. [PMID: 30040817 PMCID: PMC6057636 DOI: 10.1371/journal.pone.0199297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 03/19/2018] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Despite the importance of chemotherapy in the treatment of early stage triple negative breast cancer (TNBC), no one optimal regimen has been identified. We conducted a pilot trial comparing outcomes for the three most commonly used chemotherapy regimens to assess the feasibility of conducting a larger definitive trial. METHODS Using integrated consent, newly diagnosed TNBC patients were randomised to one of three standard regimens: dose-dense doxorubicin-cyclophosphamide then paclitaxel, doxorubicin-cyclophosphamide then weekly paclitaxel or 5-FU-epirubicin-cyclophosphamide then docetaxel. Feasibility endpoints included; physician engagement, accrual rates, physician compliance and patient satisfaction with the integrated consent model. Our anticipated pilot trial sample size was 35 randomised patients in one year. RESULTS Between August 30th, 2016 and January 31st 2017, 2 patients met eligibility and were randomised. A survey of 10 participating oncologists was performed to identify potential strategies to enhance accrual. Most investigators (9/10) believed that the best regimen for TNBC was unknown, and 4/10 felt this was a pressing clinical question. Physicians' responses suggested that poor accrual was due to: a lack of interest in some study arms as oncologists already had a preferred regimen (4/10) and concerns about trial demands in busy clinics (3/10). The pilot feasibility endpoints were not met and the study was closed. CONCLUSIONS Despite initial interest in the trial question and multiple investigators agreeing to approach patients, this trial failed to meet feasibility endpoints. The reasons for poor accrual were multiple and require further evaluation if this important patient-centred question is to be answered. TRIAL REGISTRATION ClinicalTrials.gov NCT02688803.
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Affiliation(s)
- John Hilton
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
- * E-mail:
| | - Carol Stober
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Sasha Mazzarello
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Lisa Vandermeer
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, The Ottawa Hospital and University of Ottawa School of Epidemiology, Ottawa, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, The Ottawa Hospital and University of Ottawa School of Epidemiology, Ottawa, Canada
- Department of Public Health and Preventative Medicine, The University of Ottawa, Ottawa, Canada
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Canada
- Department of Public Health and Preventative Medicine, The University of Ottawa, Ottawa, Canada
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23
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Goldstein CE, Giraudeau B, Weijer C, Taljaard M. When and how should we cluster and cross over: methodological and ethical issues. Can J Anaesth 2018; 65:760-765. [PMID: 29728919 PMCID: PMC5995989 DOI: 10.1007/s12630-018-1131-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 03/09/2018] [Accepted: 03/12/2018] [Indexed: 12/16/2022] Open
Affiliation(s)
- Cory E Goldstein
- Rotman Institute of Philosophy, Western University, London, ON, Canada.
| | - Bruno Giraudeau
- Université de Tours, Université de Nantes, INSERM SPHERE U1246, Tours, France.,INSERM CIC, CHRU de Tours, Tours, France
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Monica Taljaard
- Rotman Institute of Philosophy, Western University, London, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Stewart DJ, Stewart AA, Wheatley-Price P, Batist G, Kantarjian HM, Schiller J, Clemons M, Bradford JP, Gillespie L, Kurzrock R. The importance of greater speed in drug development for advanced malignancies. Cancer Med 2018; 7:1824-1836. [PMID: 29601671 PMCID: PMC5943431 DOI: 10.1002/cam4.1454] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/10/2018] [Accepted: 02/09/2018] [Indexed: 12/13/2022] Open
Abstract
It takes on average 6-12 years to develop new anticancer drugs from discovery to approval. Effective new agents prolong survival. To demonstrate the importance of rapid drug approval, we calculated life-years potentially saved if selected agents were approved more rapidly. As illustrative examples, we used 27 trials documenting improvements in survival. We multiplied improvement in median survival by numbers of patients dying annually and multiplied this by number of years from drug discovery until approval. For every year by which time to drug approval could have been shortened, there would have been a median number of life-years potentially saved of 79,920 worldwide per drug. Median number of life-years lost between time of drug discovery and approval was 1,020,900 per example. If we were able to use available opportunities to decrease the time required to take a drug from discovery to approval to 5 years, the median number of life-years saved per example would have been 523,890 worldwide. Various publications have identified opportunities to speed drug development without sacrificing patient safety. While many investigational drugs prove to be ineffective, some significantly prolong survival and/or reduce suffering. These illustrative examples suggest that a substantial number of life-years could potentially be saved by increasing the efficiency of development of new drugs for advanced malignancies.
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Affiliation(s)
- David J Stewart
- The University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Paul Wheatley-Price
- The University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Gerald Batist
- Segal Cancer Centre, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Joan Schiller
- The Inova Dwight and Martha Schar Cancer Institute, Fairfax, Virginia and Lung Cancer Research Foundation, New York, USA
| | - Mark Clemons
- The University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital, Ottawa, Ontario, Canada
| | - John-Peter Bradford
- Bradford Bachinski Limited and the Life Saving Therapies Network, Ottawa, Ontario, Canada
| | | | - Razelle Kurzrock
- University of California San Diego Moores Cancer Center, San Diego, California
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A multi-center pragmatic, randomized, feasibility trial comparing standard of care schedules of filgrastim administration for primary febrile neutropenia prophylaxis in early-stage breast cancer. Breast Cancer Res Treat 2017; 168:371-379. [PMID: 29214415 DOI: 10.1007/s10549-017-4604-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 11/30/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The most effective duration of filgrastim as primary febrile neutropenia (FN) prophylaxis in early breast cancer (EBC) patients is unknown. Despite significant differences in cost and toxicity, no prospective trial has been performed to optimize practice. We assessed the feasibility of using a novel pragmatic trial model to compare the most commonly used schedules of filgrastim. METHODS Early breast cancer patients receiving chemotherapy were randomized to 5, 7, or 10 days of filgrastim as primary FN prophylaxis. The trial methodology integrated broad eligibility criteria, simply defined endpoints, an integrated consent model incorporating oral consent, and web-based randomization in the clinic. Feasibility was reflected through a combination of primary endpoints including patient and physician engagement (if > 50% of appropriate patients approached agree to participate, and if > 50% of physicians approached patients for the study). Secondary endpoints included the first occurrence rates of FN, treatment-related hospital admission, or chemotherapy dose reductions/delays/discontinuation. RESULTS From May 2015 to August 2016, 142/149 (95.3%) patients approached agreed to participate and were randomized. Seventeen of 24 (70.8%) medical oncologists approached and randomized patients. The 142 patients received a total of 495 cycles of chemotherapy. Aggregate incidences of a first event by patient were FN (8/142, 5.6%), treatment-related hospitalization (6/142, 4.2%), chemotherapy discontinuation (7/142, 4.9%), chemotherapy delays (5/142, 3.5%), and chemotherapy dose reduction (18/142, 12.7%). Overall, 31.7% (45/142) of patients and 9.0% (45/495) of chemotherapy cycles were associated with one of these first events. CONCLUSION This study met its feasibility endpoints. This novel pragmatic trial approach offers a means of comparing standard of care treatments in a practical and cost-effective manner. The trial will now be expanded to compare rates of FN between the three filgrastim schedules. TRIAL REGISTRATION ClinicalTrials.gov: NCT02428114.
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26
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Toward Establishing Core Outcome Domains For Trials in Kidney Transplantation: Report of the Standardized Outcomes in Nephrology-Kidney Transplantation Consensus Workshops. Transplantation 2017; 101:1887-1896. [PMID: 28737661 DOI: 10.1097/tp.0000000000001774] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treatment decisions in kidney transplantation requires patients and clinicians to weigh the benefits and harms of a broad range of medical and surgical interventions, but the heterogeneity and lack of patient-relevant outcomes across trials in transplantation makes these trade-offs uncertain, thus, the need for a core outcome set that reflects stakeholder priorities. METHODS We convened 2 international Standardized Outcomes in Nephrology-Kidney Transplantation stakeholder consensus workshops in Boston (17 patients/caregivers; 52 health professionals) and Hong Kong (10 patients/caregivers; 45 health professionals). In facilitated breakout groups, participants discussed the development and implementation of core outcome domains for trials in kidney transplantation. RESULTS Seven themes were identified. Reinforcing the paramount importance of graft outcomes encompassed the prevailing dread of dialysis, distilling the meaning of graft function, and acknowledging the terrifying and ambiguous terminology of rejection. Reflecting critical trade-offs between graft health and medical comorbidities was fundamental. Contextualizing mortality explained discrepancies in the prioritization of death among stakeholders-inevitability of death (patients), preventing premature death (clinicians), and ensuring safety (regulators). Imperative to capture patient-reported outcomes was driven by making explicit patient priorities, fulfilling regulatory requirements, and addressing life participation. Specificity to transplant; feasibility and pragmatism (long-term impacts and responsiveness to interventions); and recognizing gradients of severity within outcome domains were raised as considerations. CONCLUSIONS Stakeholders support the inclusion of graft health, mortality, cardiovascular disease, infection, cancer, and patient-reported outcomes (ie, life participation) in a core outcomes set. Addressing ambiguous terminology and feasibility is needed in establishing these core outcome domains for trials in kidney transplantation.
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Jacobs C, Clemons M, Mazzarello S, Hutton B, Joy AA, Brackstone M, Freedman O, Vandermeer L, Ibrahim M, Fergusson D, Hilton J. Enhancing accrual to chemotherapy trials for patients with early stage triple-negative breast cancer: a survey of physicians and patients. Support Care Cancer 2017; 25:1881-1886. [PMID: 28127659 DOI: 10.1007/s00520-017-3580-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 01/09/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE The optimal chemotherapy regimen for patients with early stage triple-negative breast cancer (TNBC) remains unknown. The purpose of the study is to survey physicians and breast cancer patients about preferred chemotherapy regimens for early stage TNBC and clinical trial strategies. METHODS A standardised online questionnaire was developed and circulated to medical oncologists known to treat breast cancer. A separate questionnaire was given to patients who had received chemotherapy for breast cancer. RESULTS The questionnaire was completed by 41/84 medical oncologists (48.8% response rate) and 74 patients. The most commonly used neoadjuvant and adjuvant chemotherapy regimens for TNBC were dose-dense doxorubicin and cyclophosphamide (AC)-paclitaxel (P), dose-dense AC followed by weekly P and fluorouracil, epirubicin, cyclophosphamide-docetaxel (FEC-D). The majority of medical oncologists (80%) would be willing to enrol patients in trials evaluating the most effective chemotherapy regimen for TNBC. Oncologists favoured a three arm trial design comparing currently available standard of care treatments (36%) and trials of novel or non-standard of care agents 22% (9/41). Sixty percent (41/74) of patients indicated that they would be willing to be enrolled in trials evaluating various adjuvant regimens for TNBC. Both oncologists and patients were interested in novel consent approaches such as using the integrated consent model. CONCLUSION Optimisation of chemotherapy for TNBC is an important and unmet clinical need. It is apparent that various chemotherapy regimens are used for patients with early stage TNBC. The majority of medical oncologists and patients are interested in entering trials to optimise chemotherapy choices.
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Affiliation(s)
- Carmel Jacobs
- Public Health and Preventative Medicine, University of Ottawa School of Epidemiology, Ottawa, Canada.,Division of Medical Oncology and Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Mark Clemons
- Division of Medical Oncology and Department of Medicine, University of Ottawa, Ottawa, Canada.,The Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.,Public Health and Preventative Medicine, University of Ottawa School of Epidemiology, Ottawa, Canada
| | - Sasha Mazzarello
- The Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Brian Hutton
- Public Health and Preventative Medicine, University of Ottawa School of Epidemiology, Ottawa, Canada
| | - Anil A Joy
- Division of Medical Oncology, Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Canada
| | | | | | - Lisa Vandermeer
- The Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Mohammed Ibrahim
- Division of Medical Oncology and Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Dean Fergusson
- The Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada
| | - John Hilton
- Division of Medical Oncology and Department of Medicine, University of Ottawa, Ottawa, Canada. .,The Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
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Fernandes R, Mazzarello S, Stober C, Vandermeer L, Dudani S, Ibrahim MFK, Majeed H, Perdrizet K, Shorr R, Hutton B, Fergusson D, Clemons M. Optimal primary febrile neutropenia prophylaxis for patients receiving docetaxel-cyclophosphamide chemotherapy for breast cancer: a systematic review. Breast Cancer Res Treat 2016; 161:1-10. [PMID: 27783280 DOI: 10.1007/s10549-016-4028-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 10/18/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Due to the high rate of febrile neutropenia (FN) with docetaxel-cyclophosphamide (DC) chemotherapy, primary FN prophylaxis is recommended. However, the optimal choice of prophylaxis [i.e., granulocyte-colony stimulating factors (G-CSF) or antibiotics] is unknown. A systematic review was performed to address this knowledge gap. METHODS Embase, Ovid Medline, Pubmed, the Cochrane database of systematic reviews, and Cochrane register of controlled trials were searched from 1946 to April 2016 for studies evaluating primary prophylactic FN treatments in breast cancer patients receiving DC chemotherapy. Outcome measures evaluated included: incidence of FN and treatment-related hospitalizations, chemotherapy dose reduction/delays/discontinuations, and adverse events. Screening and data collection were performed by two independent reviewers. RESULTS Of 2105 identified records, 7 studies (n = 2535) met the pre-specified eligibility criteria. Seven additional studies (n = 621) were identified from prior systematic reviews. There were 3 randomized controlled trials (RCTs) (n = 2256) and 11 retrospective studies (n = 900). Study sample sizes ranged from 30 to 982 patients (median 99.5), evaluating pegfilgrastim (n = 1274), filgrastim (n = 1758), and oral ciprofloxacin (n = 108). Given the heterogeneity of patients and study design, a narrative synthesis of results was performed. Median FN rates with and without primary prophylaxis were 6.6 % (IQR 3.9-10.6 %) and 31.3 % (IQR 25-33 %), respectively. No FN-related deaths were reported. No RCT directly compared G-CSF with antibiotic interventions. CONCLUSIONS Primary FN prophylaxis reduces the incidence of FN. Despite considerable cost and toxicity differences between G-CSF and antibiotics, there is insufficient data to make a recommendation of one strategy over another.
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Affiliation(s)
- Ricardo Fernandes
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada
| | | | - Carol Stober
- Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Shaan Dudani
- Department of Medicine, Division of General Internal Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Mohamed F K Ibrahim
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada
| | - Habeeb Majeed
- Department of Medicine, Division of General Internal Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | - Kirstin Perdrizet
- Department of Medicine, Division of General Internal Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Canada
| | | | - Brian Hutton
- Department of Medicine, Clinical Epidemiology Program, The Ottawa Hospital and University of Ottawa, Ottawa, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Dean Fergusson
- Department of Medicine, Clinical Epidemiology Program, The Ottawa Hospital and University of Ottawa, Ottawa, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Mark Clemons
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre and University of Ottawa, 501 Smyth Road, Box 912, Ottawa, ON, K1H 8L6, Canada. .,Ottawa Hospital Research Institute, Ottawa, Canada. .,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada.
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