From screening to clinical research: the cure of leukemia and the early development of the cooperative oncology groups, 1955-1966

National Cancer Institute: Restructuring to Support the Clinical Trials of the Future

OBJECTIVES

To describe the evolution and structure of the National Cancer Institute clinical trials programs, their notable accomplishments, nurses' roles in these accomplishments, and the essential role of nursing today and in the future.

DATA SOURCES

Manuscripts, government publications, websites, and professional communications.

CONCLUSION

Change is inevitable and a constant factor in the world of advancing science and clinical research. Nurses' contribution to research and evidence-based practice will continue to grow and is vital as the scientific landscape evolves.

IMPLICATIONS FOR NURSING PRACTICE

As the understanding of cancer biology increases and clinical trials evolve, nurses will need to remain key team members and leaders in National Cancer Institute Community Oncology Research Program and National Cancer Trials Network trials and their associated infrastructure.

Managing the future: the Special Virus Leukemia Program and the acceleration of biomedical research

After the end of the Second World War, cancer virus research experienced a remarkable revival, culminating in the creation in 1964 of the United States National Cancer Institute's Special Virus Leukemia Program (SVLP), an ambitious program of directed biomedical research to accelerate the development of a leukemia vaccine. Studies of cancer viruses soon became the second most highly funded area of research at the Institute, and by far the most generously funded area of biological research. Remarkably, this vast infrastructure for cancer vaccine production came into being before a human leukemia virus was shown to exist. The origins of the SVLP were rooted in as much as shifts in American society as laboratory science. The revival of cancer virus studies was a function of the success advocates and administrators achieved in associating cancer viruses with campaigns against childhood diseases such as polio and leukemia. To address the urgency borne of this new association, the SVLP's architects sought to lessen the power of peer review in favor of centralized Cold War management methods, fashioning viruses as "administrative objects" in order to accelerate the tempo of biomedical research and discovery.

The 6-MP versus placebo clinical trial in acute leukemia

Background This article gives the status of clinical cancer research in the 1950's–1960's and tells the story of the development and conduct of the 6-mercaptopurine (6-MP) versus placebo clinical trial in acute leukemia through the initiation, design, conduct and analysis stages, with emphasis on the ethical aspects of randomizing patients to 6-MP or placebo when in remission.

Purpose The specific objective was to compare the lengths of remission for patients receiving 6-MP or placebo after achieving complete or partial remission from steroid treatment.

Methods A randomized, double-blind, placebo controlled sequential study was conducted in which patients were paired by remission status at each of the eleven institutions participating in the study, and randomized to 6-MP or placebo within each pair of patients. A preference for 6-MP or placebo was recorded depending on which patient in the pair had the longer remission. The preferences were plotted according to a restricted sequential procedure devised by Peter Armitage and, depending on which boundary of the design was crossed, a statistically significant difference could be declared favoring 6-MP, placebo or no preference.

Conclusions The trial established the efficacy of 6-MP for maintaining longer remissions in acute leukemia and led to the concept of 'adjuvant chemotherapy', namely that patients with minimal disease have a substantially better response to chemotherapy than patients with advanced disease, a concept that has been followed in many other forms of cancer. Statistically, the fact that many patients were still in remission when the study was stopped (i.e. the length of remission data for these patients was 'right censored') led to the development of a generalized Wilcoxon test and was an important influence on Cox's development of the proportional hazards model. The trial had an innovative design in the early 1960's and has been an important influence on subsequent clinical research in cancer and statistical research in survival analysis.

The successful integration of research and care: how pediatric oncology became the subspecialty in which research defines the standard of care

Pediatric oncology successfully embodies the integration of patient care with medical research. Several factors may explain this phenomenon. Specifically, the study of childhood leukemia provided scientists with principles by which they could approach other forms of cancer. Multicenter, cooperative group RCTs resulted in meaningful advances. Parents' often desperate hope for a cure, combined with clinician-investigators efforts to continually improve upon treatments resulted in important improvements in children's lives. Finally, the seemingly tolerant regulatory oversight of human subjects research in the early years of childhood cancer research paradoxically helped link research with care, thus solidifying this bond for years to come.

Medical sociology and technology: critical engagements

In this selective review of the literature on medical sociology's engagement with technology, we outline the concurrent developments of the American Sociological Association section on medicine and advances in medical treatment. We then describe theoretical and epistemological issues with scholars' treatment of technology in medicine. Using symbolic interactionist concepts, as well as work from the interdisciplinary field of science and technology studies, we review and synthesize critical connections in and across sociology's intellectual relationship with medical technology. Next, we discuss key findings in these literatures, noting a shift from a focus on the effects of technology on practice to a reconfiguration of human bodies. We also look toward the future, focusing on connections between technoscientific identities and embodied health movements. Finally, we call for greater engagement by medical sociologists in studying medical technology and the process of policy-making--two areas central to debates in health economics and public policy.

The prisoner as model organism: malaria research at Stateville Penitentiary

In a military-sponsored research project begun during the Second World War, inmates of the Stateville Penitentiary in Illinois were infected with malaria and treated with experimental drugs that sometimes had vicious side effects. They were made into reservoirs for the disease and they provided a food supply for the mosquito cultures. They acted as secretaries and technicians, recording data on one another, administering malarious mosquito bites and experimental drugs to one another, and helping decide who was admitted to the project and who became eligible for early parole as a result of his participation. Thus, the prisoners were not simply research subjects; they were deeply constitutive of the research project. Because a prisoner's time on the project was counted as part of his sentence, and because serving on the project could shorten one's sentence, the project must be seen as simultaneously serving the functions of research and punishment. Michel Foucault wrote about such 'mixed mechanisms' in his Discipline and punish. His shining example of such a 'transparent' and subtle style of punishment was the panopticon, Jeremy Bentham's architectural invention of prison cellblocks arrayed around a central guard tower. Stateville prison was designed on Bentham's model; Foucault featured it in his own discussion. This paper, then, explores the power relations in this highly idiosyncratic experimental system, in which the various roles of model organism, reagent, and technician are all occupied by sentient beings who move among them fluidly. This, I argue, created an environment in the Stateville hospital wing more panoptic than that in the cellblocks. Research and punishment were completely interpenetrating, and mutually reinforcing.

Investigator-led clinical research consortia: the Canadian Critical Care Trials Group

Advances in the care of critically ill patients are dependent upon rigorous clinical research undertaken to characterize natural history and risk factors, and determine optimal approaches to the management of the diseases of the critically ill patient. The Canadian Critical Care Trials Group (CCCTG) was formed in 1989 to foster such research. It has grown to become a national, multidisciplinary organization with more than 100 members, and more than 3 dozen active research programs. Its members have been highly successful in obtaining funding for, completing, and publishing well-designed studies that have informed international practice in areas such as transfusion, stress ulcer prophylaxis, long term outcomes from acute respiratory distress syndrome, diagnosis and management of infection in the intensive care unit, and end-of-life care. In the process, the CCCTG has developed a highly effective culture of scientific mentoring, and has served as a model for investigator-led critical care research groups around the world. This review summarizes the history, activities, approaches, and challenges of the CCCTG, in the conviction that investigator-led groups such as ours represent the future of intensive care unit-based research.

Between remission and cure: patients, practitioners and the transformation of leukaemia in the late twentieth century

OBJECTIVES

During the course of the 1960s and 1970s, acute leukaemia in childhood ceased to be invariably fatal and was recategorized as curable. The meaning of cure in this case, however, was problematic, as it was impossible for physicians to be certain that cancer would not return. This paper uses historical methods to explore how remission was understood by families with children with acute leukaemia during the period in which the first cures were announced, roughly 1972-77.

METHODS

These comprised documentary analysis of records of the Medical Research Council's leukaemia working parties, published papers and letters on treatments for childhood leukaemia, and interviews with eight UK paediatric oncologists practising in UK hospitals in the 1960s and 1970s.

RESULTS

Two approaches to defining 'cure' in leukaemia can be identified. The first relied on statistical assessment of survival rates. I argue that the concept of 'indefinite remission' came to serve for researchers and clinicians as a proxy measure of cure. However, the concept of 'indefinite remission' left many patients and their families quite uncertain as to whether a cure had really happened. A second approach to defining cure therefore developed. Faced with uncertainty, patients, parents and psychologists sought to develop alternative measures of success--including the notion of 'psychological cure'--that brought forward the moment of cure and its relief.

CONCLUSIONS

Changing conceptualizations of leukaemia shaped and were shaped by negotiations over the meaning of 'remission' and 'cure'. On the one hand, the statistical definition of cure was not available for years. On the other hand, psychological cure could begin from the time of first remission, even if medical absolution was not available for years.

Fifty Years of Clinical Research by the Leukemia Committee of the Cancer and Leukemia Group B

Progress in the care of patients with leukemia has been one of the great success stories in the field of oncology, and clinical research in leukemia has been the "flagship" of the Cancer and Leukemia Group B since the inception of this organization. Lessons learned from the founders' emphasis on childhood and adult leukemia have been extended broadly over the past 50 years to virtually all types of malignant diseases, and the Leukemia Committee has continued to provide leadership and key contributions. The Leukemia Committee is focused on the individualization of treatment based on distinctive biological and clinical characteristics with the aim of increasing efficacy and decreasing nonspecific toxicity. Our clinical trials in leukemia and myeloma have shifted from primarily empirically derived comparisons of different chemotherapeutic regimens to testing novel concepts such as the role of dose intensity, inhibition of specific mechanisms of drug resistance, the use of hematopoietic growth factors and monoclonal antibodies, and the utility of targeted agents. The Cancer and Leukemia Group B was the pioneer among the cooperative groups in the creation of centralized tissue repositories and the incorporation of correlative laboratory studies as an integral feature of clinical trials, a practice now termed "translational research." Considerable effort has focused on the identification of important pretreatment characteristics, such as morphologic features, immunophenotype, chromosomal abnormalities, and molecular defects, which are significantly associated with outcome in multivariable analyses and which enhance our understanding for the complex biology of these diseases.

Caring and curing: paediatric cancer services since 1960

This paper traces the history of the specialist meanings of 'cure' in paediatric oncology in the UK, how they have changed with increasing organization of the discipline, ever-rising survival rates for all childhood cancers, and with feedback from patients and families. It examines the differing ways in which those involved in researching, treating, and raising funds for work on childhood cancers have understood and used the language of cure, and speculates as to why talking about the 'cure' of survivors of childhood cancers is so problematic. The paper discusses the particular importance of holistic care in the development of paediatric oncology. Psychosocial support is delivered alongside surgery, radiotherapy and chemotherapy. The focus for support is the patient's whole family, building a tenet of palliative care into curative treatment. The concept of the 'truly cured child' is argued to have been crucial in the discipline's decision in the 1970s and 1980s to make the psychosocial needs of patients and their families central in the programme of curing children with cancer.