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Kelada L, Robertson EG, McKay S, McGill BC, Daly R, Mazariego C, Taylor N, Tyedmers E, Armitage N, Evans HE, Wakefield CE, Ziegler DS. Communicating with families of young people with hard-to-treat cancers: Healthcare professionals' perspectives on challenges, skills, and training. Palliat Support Care 2024; 22:539-545. [PMID: 38263685 DOI: 10.1017/s1478951523001992] [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] [Indexed: 01/25/2024]
Abstract
OBJECTIVES Hard-to-treat childhood cancers are those where standard treatment options do not exist and the prognosis is poor. Healthcare professionals (HCPs) are responsible for communicating with families about prognosis and complex experimental treatments. We aimed to identify HCPs' key challenges and skills required when communicating with families about hard-to-treat cancers and their perceptions of communication-related training. METHODS We interviewed Australian HCPs who had direct responsibilities in managing children/adolescents with hard-to-treat cancer within the past 24 months. Interviews were analyzed using qualitative content analysis. RESULTS We interviewed 10 oncologists, 7 nurses, and 3 social workers. HCPs identified several challenges for communication with families including: balancing information provision while maintaining realistic hope; managing their own uncertainty; and nurses and social workers being underutilized during conversations with families, despite widespread preferences for multidisciplinary teamwork. HCPs perceived that making themselves available to families, empowering them to ask questions, and repeating information helped to establish and maintain trusting relationships with families. Half the HCPs reported receiving no formal training for communicating prognosis and treatment options with families of children with hard-to-treat cancers. Nurses, social workers, and less experienced oncologists supported the development of communication training resources, more so than more experienced oncologists. SIGNIFICANCE OF RESULTS Resources are needed which support HCPs to communicate with families of children with hard-to-treat cancers. Such resources may be particularly beneficial for junior oncologists and other HCPs during their training, and they should aim to prepare them for common challenges and foster greater multidisciplinary collaboration.
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Affiliation(s)
- Lauren Kelada
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Eden G Robertson
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Skye McKay
- School of Population Health, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
| | - Brittany C McGill
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Rebecca Daly
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Carolyn Mazariego
- School of Population Health, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
| | - Natalie Taylor
- School of Population Health, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
| | - Elijah Tyedmers
- School of Population Health, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
| | - Nicole Armitage
- Pain and Palliative Care Service, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Holly E Evans
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Claire E Wakefield
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - David S Ziegler
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
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Lavasidis G, Papaioannou K, Anagnostou N, Ketteler P, Bechrakis NE, Ntzani E. Evidence in Focus: The Sparse Landscape of Randomized Trials on Retinoblastoma Treatment. Ocul Oncol Pathol 2024; 10:53-62. [PMID: 38751498 PMCID: PMC11095627 DOI: 10.1159/000536410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 01/15/2024] [Indexed: 05/18/2024] Open
Abstract
Background Retinoblastoma, although rare, is one of the most common intraocular malignancies worldwide. Its prognosis has improved significantly in the past few decades, thanks to modern treatments, like systemic, intra-arterial, and intravitreal chemotherapy. However, regarding survival, there are significant differences between high- and low-income countries, eye salvage is still a challenge worldwide, and treatment-related toxicity needs to be carefully and sufficiently managed. Summary To appraise the strength of supporting evidence, we performed a systematic review of randomized controlled trials investigating any therapeutic protocol for retinoblastoma. Four trials with 174 participants (188 eyes) were eligible, all pertaining to different intravenous chemotherapy regimens. Vincristine, etoposide, and carboplatin (VEC) appear superior to a 5-drug combination for stage III retinoblastoma. Moreover, etoposide and carboplatin as neoadjuvant chemotherapy followed by thermochemotherapy seem to offer better local control than vincristine and carboplatin. However, increasing carboplatin dose in the VEC protocol failed to improve treatment efficacy. Key Messages Retinoblastoma is a success story of modern medicine. However, only intravenous chemotherapy has been studied through randomized trials, while evidence for the most novel retinoblastoma treatments has mainly stemmed from observational studies. International collaborations for multicenter randomized trials could overcome difficulties and increase certainty and precision in the field.
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Affiliation(s)
- Georgios Lavasidis
- Evidence-based Medicine Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
- Department of Ophthalmology, Elpis General Hospital of Athens, Athens, Greece
| | - Kyriaki Papaioannou
- Department of Pediatric Hematology and Oncology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Nikolaos Anagnostou
- Evidence-based Medicine Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Petra Ketteler
- Department of Pediatric Hematology and Oncology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Nikolaos E. Bechrakis
- Department of Ophthalmology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Evangelia Ntzani
- Evidence-based Medicine Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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Levine SB, Abbruzzese E, Mason JW. What Are We Doing to These Children? Response to Drescher, Clayton, and Balon Commentaries on Levine et al., 2022. JOURNAL OF SEX & MARITAL THERAPY 2022; 49:115-125. [PMID: 36267050 DOI: 10.1080/0092623x.2022.2136117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Stephen B Levine
- Case Western Reserve University Department of Psychiatry, 6415 Gates Mills Blvd, Mayfield Heights, 44124, United States
| | - E Abbruzzese
- Society for Evidence-Based Gender Medicine, Twin Falls, 83301-5235, United States
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Neuro-Oncology Patients as Human Research Subjects: Ethical Considerations for Cognitive and Behavioral Testing for Research Purposes. Cancers (Basel) 2022; 14:cancers14030692. [PMID: 35158959 PMCID: PMC8833547 DOI: 10.3390/cancers14030692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/22/2022] [Accepted: 01/27/2022] [Indexed: 01/25/2023] Open
Abstract
Simple Summary Previous publications have elaborated on the exposure of ethical issues surrounding the enrollment and neurological testing of brain cancer patients into clinical studies. Existing literature has been tailored to provide insight on how to overcome ethical challenges for clinical team members but not for the research component that runs in parallel. The aim of this paper is to highlight the obstacles that researchers encounter when obtaining informed consent and administering language, cognitive or behavioral tasks for the sole purpose of research. Researchers should be encouraged to practice their best judgment and effectively communicate the purpose of the study while emphasizing the voluntary participation of neurologically impaired cancer patients. The solutions proposed in this paper can serve as future reference and a guide on maintaining a transparent balance between research and clinical testing for both researchers and clinical team members in the neuro-oncology field. Abstract Language, cognition, and behavioral testing have become a fundamental component of standard clinical care for brain cancer patients. Many existing publications have identified and addressed potential ethical issues that are present in the biomedical setting mostly centering around the enrollment of vulnerable populations for therapeutic clinical trials. Well-established guides and publications have served as useful tools for clinicians; however, little has been published for researchers who share the same stage but administer tests and collect valuable data solely for non-therapeutic investigational purposes derived from voluntary patient participation. Obtaining informed consent and administering language, cognition, and behavioral tasks for the sole purpose of research involving cancer patients that exhibit motor speech difficulties and cognitive impairments has its own hardships. Researchers may encounter patients who experience emotional responses during tasks that challenge their existing impairments. Patients may have difficulty differentiating between clinical testing and research testing due to similarity of task design and their physician’s dual role as a principal investigator in the study. It is important for researchers to practice the proposed methods emphasized in this article to maintain the overall well-being of patients while simultaneously fulfilling the purpose of the study in a research setting.
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Rogers JR, Liu C, Hripcsak G, Cheung YK, Weng C. Comparison of Clinical Characteristics Between Clinical Trial Participants and Nonparticipants Using Electronic Health Record Data. JAMA Netw Open 2021; 4:e214732. [PMID: 33825838 PMCID: PMC8027910 DOI: 10.1001/jamanetworkopen.2021.4732] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Assessing generalizability of clinical trials is important to ensure appropriate application of interventions, but most assessments provide minimal granularity on comparisons of clinical characteristics. OBJECTIVE To assess the extent of underlying clinical differences between clinical trial participants and nonparticipants by using a combination of electronic health record and trial enrollment data. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data obtained from a single academic medical center between September 1996 and January 2019 to identify 1645 clinical trial participants from a diverse set of 202 available trials conducted at the center. Using an aggregated resampling procedure, nonparticipants were matched to participants 1:1 based on trial conditions, number of recent visits to a health care professional, and calendar time. EXPOSURES Clinical trial enrollment vs no enrollment. MAIN OUTCOMES AND MEASURES The primary outcome was standardized differences in clinical characteristics between participants and nonparticipants in clinical trials stratified into the 4 most common disease domains. RESULTS This cross-sectional study included 1645 participants from 202 trials (929 [56.5%] male; mean [SD] age, 54.65 [21.38] years) and an aggregated set of 1645 nonparticipants (855 [52.0%] male; mean [SD] age, 57.24 [21.91] years). The most common disease domains for the selected trials were neoplastic disease (86 trials; 737 participants), disorders of the digestive system (31 trials; 321 participants), inflammatory disorders (28 trials; 276 participants), and disorders of the cardiovascular system (27 trials; 319 participants); trials could qualify for multiple disease domains. Among 31 conditions, the percentage of conditions for which the prevalence was lower among participants than among nonparticipants per standardized differences was 64.5% (20 conditions) for neoplastic disease trials, 61.3% (19) for digestive system trials, 58.1% (18) for inflammatory disorder trials, and 38.7% (12) for cardiovascular system trials. Among 17 medications, the percentage of medications for which use was less among participants than among nonparticipants per standardized differences was 64.7% (11) for neoplastic disease trials, 58.8% (10) for digestive system trials, 88.2% (15) for inflammatory disorder trials, and 52.9% (9) for cardiovascular system trials. CONCLUSIONS AND RELEVANCE Using a combination of electronic health record and trial enrollment data, this study found that clinical trial participants had fewer comorbidities and less use of medication than nonparticipants across a variety of disease domains. Combining trial enrollment data with electronic health record data may be useful for better understanding of the generalizability of trial results.
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Affiliation(s)
- James R. Rogers
- Department of Biomedical Informatics, Columbia University, New York, New York
| | - Cong Liu
- Department of Biomedical Informatics, Columbia University, New York, New York
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, New York
- Medical Informatics Services, New York–Presbyterian Hospital, New York, New York
| | - Ying Kuen Cheung
- Department of Biostatistics, Columbia University, New York, New York
| | - Chunhua Weng
- Department of Biomedical Informatics, Columbia University, New York, New York
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Cohen JW, Akshintala S, Kane E, Gnanapragasam H, Widemann BC, Steinberg SM, Shah NN. A Systematic Review of Pediatric Phase I Trials in Oncology: Toxicity and Outcomes in the Era of Targeted Therapies. Oncologist 2020; 25:532-540. [PMID: 31943534 DOI: 10.1634/theoncologist.2019-0615] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 11/27/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Pediatric phase I oncology trials have historically focused on safety and toxicity, with objective response rates (ORRs) <10%. Recently, with an emphasis on targeted approaches, response rates may have changed. We analyzed outcomes of recent phase I pediatric oncology trials. MATERIALS AND METHODS This was a systematic review of phase I pediatric oncology trials published in 2012-2017, identified through PubMed and EMBASE searches conducted on March 14, 2018. Selection criteria included full-text articles with a pediatric population, cancer diagnosis, and a dose escalation schema. Each publication was evaluated for patient characteristics, therapy type, trial design, toxicity, and response. RESULTS Of 3,431 citations, 109 studies (2,713 patients) met eligibility criteria. Of these, 78 (72%) trials incorporated targeted therapies. Median age at enrollment/trial was 11 years (range 3-21 years). There were 2,471 patients (91%) evaluable for toxicity, of whom 300 (12.1%) experienced dose-limiting toxicity (DLT). Of 2,143 patients evaluable for response, 327 (15.3%) demonstrated an objective response. Forty-three (39%) trials had no objective responses. Nineteen trials (17%) had an ORR >25%, of which 11 were targeted trials and 8 were combination cytotoxic trials. Targeted trials demonstrated a lower DLT rate compared with cytotoxic trials (10.6% vs. 14.7%; p = .003) with similar ORRs (15.0% vs. 15.9%; p = .58). CONCLUSION Pediatric oncology phase I trials in the current treatment era have an acceptable DLT rate and a pooled ORR of 15.3%. A subset of trials with target-specific enrollment or combination cytotoxic therapies showed high response rates, highlighting the importance of these strategies in early phase trials. IMPLICATIONS FOR PRACTICE Enrollment in phase I oncology trials is crucial for development of novel therapies. This systematic review of phase I pediatric oncology trials provides an assessment of outcomes of phase I trials in children, with a specific focus on the impact of targeted therapies. These data may aid in evaluating the landscape of current phase I options for patients and enable more informed communication regarding risk and benefit of phase I clinical trial participation. The results also suggest that, in the current treatment era, there is a rationale to increase earlier access to targeted therapy trials for this refractory patient population.
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Affiliation(s)
- Julia W Cohen
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Srivandana Akshintala
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Eli Kane
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Helen Gnanapragasam
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Brigitte C Widemann
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Seth M Steinberg
- Biostatistics and Data Management Section, National Cancer Institute, Rockville, Maryland, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
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Crane S, Haase JE, Hickman SE. Well-Being of Child and Family Participants in Phase 1 Pediatric Oncology Clinical Trials. Oncol Nurs Forum 2019; 45:E67-E97. [PMID: 30118445 DOI: 10.1188/18.onf.e67-e97] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PROBLEM IDENTIFICATION Pediatric oncology phase 1 clinical trials (P1Ts) are essential to developing new anticancer therapies; however, they raise complex ethical concerns about balancing the need for this research with the well-being of participating children. The purpose of this integrative review was to synthesize and appraise the evidence of how P1T participation, which begins with consent and ends with the transition off the P1T, can affect the well-being (either positively or negatively) of children with cancer. The Resilience in Individuals and Families Affected by Cancer Framework, which has an outcome of well-being, was used to synthesize findings. LITERATURE SEARCH Articles on the experiences of child (n = 21) and adult (n = 31) P1T participants were identified through systematic searches. DATA EVALUATION Articles were evaluated on rigor and relevance to P1T participant experiences as high, medium, or low. SYNTHESIS Minimal empirical evidence was found regarding the effect of P1T participation on the well-being of children with cancer. Adult P1T participant experiences provide insights that could also be important to children's P1T experiences. IMPLICATIONS FOR PRACTICE To achieve a balanced approach in P1T consent discussions, nurses and healthcare providers who work with children considering participation in a P1T should share the potential effect of participation on participants' well-being.
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Moerdler S, Zhang L, Gerasimov E, Zhu C, Wolinsky T, Roth M, Goodman N, Weiser DA. Physician perspectives on compassionate use in pediatric oncology. Pediatr Blood Cancer 2019; 66:e27545. [PMID: 30408307 DOI: 10.1002/pbc.27545] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 10/15/2018] [Accepted: 10/18/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Targeted cancer treatments are almost always first studied in adults, even when there is a biologically plausible potential for efficacy in children. Through compassionate use programs, children who are not eligible for a clinical trial and for whom there are no known effective therapies may obtain access to investigational agents, including drugs under development for adults. However, little is known about pediatric oncologists' experiences with applying for and obtaining compassionate use agents. METHODS This study surveyed 132 pediatric oncologists to assess awareness and utilization of compassionate use programs, to identify barriers to their use, and to evaluate available institutional support and resources. RESULTS We found that the process of applying for access to drugs in development is poorly understood, which presents a barrier to obtaining investigational drugs. Fifty-seven percent of the pediatric oncologists applied for compassionate use. Providers from larger institutions or with more than 15 years of clinical experience were more likely to complete an application and obtain investigational agents for their patients. CONCLUSION Identified perceived and actual barriers to compassionate use application submission suggest pediatric oncologists may benefit from educational resources and support to ensure children with cancer equal access to investigational agents and care.
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Affiliation(s)
- Scott Moerdler
- Division of Pediatric Hematology/Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Jersey, New Brunswick
| | - Lindy Zhang
- Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Chong Zhu
- Division of Pediatric Hematology, Oncology, and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, New York
| | | | - Michael Roth
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Texas, Houston
| | | | - Daniel A Weiser
- Division of Pediatric Hematology, Oncology, and Marrow and Blood Cell Transplantation, Children's Hospital at Montefiore, Bronx, New York.,Departments of Pediatrics and Genetics, Albert Einstein College of Medicine, Bronx, New York
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Zhang P, Crow J, Lella D, Zhou X, Samuel G, Godwin AK, Zeng Y. Ultrasensitive quantification of tumor mRNAs in extracellular vesicles with an integrated microfluidic digital analysis chip. LAB ON A CHIP 2018; 18:3790-3801. [PMID: 30474100 PMCID: PMC6310142 DOI: 10.1039/c8lc01071d] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Extracellular vesicles (EVs) present a promising liquid biopsy for cancer diagnosis. However, it remains a daunting challenge to quantitatively measure molecular contents of EVs including tumor-associated mRNAs. Herein, we report a configurable microwell-patterned microfluidic digital analysis platform combined with a dual-probe hybridization assay for PCR-free, single-molecule detection of specific mRNAs in EVs. The microwell array in our device is configurable between the flow-through assay mode for enhanced hybridization capture and tagging of mRNAs and the digital detection mode based on femtoliter-scale enzymatic signal amplification for single-molecule counting of surface-bound targets. Furthermore, a dual-probe hybridization assay has been developed to enhance the sensitivity of the digital single-molecule detection of EV mRNAs. Combining the merits of the chip design and the dual-probe digital mRNA hybridization assay, the integrated microfluidic system has been demonstrated to afford quantitative detection of synthetic GAPDH mRNA with a LOD as low as 20 aM. Using this technology, we quantified the level of GAPDH and EWS-FLI1 mRNAs in EVs derived from two cell lines of peripheral primitive neuroectodermal tumor (PNET), CHLA-9 and CHLA-258. Our measurements detected 64.6 and 43.5 copies of GAPDH mRNA and 6.5 and 0.277 copies of EWS-FLI1 fusion transcripts per 105 EVs derived from CHLA-9 and CHLA-258 cells, respectively. To our knowledge, this is the first demonstration of quantitative measurement of EWS-FLI1 mRNA copy numbers in Ewing Sarcoma (EWS)-derived EVs. These results highlight the ultralow frequency of tumor-specific mRNA markers in EVs and the necessity of developing highly sensitive methods for analysis of EV mRNAs. The microfluidic digital mRNA analysis platform presented here would provide a useful tool to facilitate quantitative analysis of tumor-associated EV mRNAs for liquid biopsy-based cancer diagnosis and monitoring.
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Affiliation(s)
- Peng Zhang
- Department of Chemistry, University of Kansas, Lawrence, KS USA
| | - Jennifer Crow
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Divya Lella
- Department of Chemistry, University of Kansas, Lawrence, KS USA
| | - Xin Zhou
- Department of Chemistry, University of Kansas, Lawrence, KS USA
| | - Glenson Samuel
- Division of Hematology Oncology and Bone Marrow Transplantation, Children’s Mercy Hospitals & Clinics, Kansas City, MO, USA
| | - Andrew K. Godwin
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
- University of Kansas Cancer Center, Kansas City, KS, USA
| | - Yong Zeng
- Department of Chemistry, University of Kansas, Lawrence, KS USA
- University of Kansas Cancer Center, Kansas City, KS, USA
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Zhang P, Samuel G, Crow J, Godwin AK, Zeng Y. Molecular assessment of circulating exosomes toward liquid biopsy diagnosis of Ewing sarcoma family of tumors. Transl Res 2018; 201:136-153. [PMID: 30031766 PMCID: PMC6424494 DOI: 10.1016/j.trsl.2018.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/18/2018] [Accepted: 05/27/2018] [Indexed: 12/16/2022]
Abstract
Ewing sarcoma was first described in 1921 in the Proceedings of the New York Pathological Society by an eminent American pathologist from Cornell named James R. Ewing as a "diffuse endothelioma of bone." Since this initial description, more has been discovered regarding Ewing sarcoma and in the 1980's both Ewing sarcoma and peripheral primitive neuroectodermal tumors due to their similar features and shared identical genetic abnormality were grouped into a class of cancers entitled Ewing sarcoma family of tumors (ESFTs). Ewing sarcoma is the second most common pediatric osseous malignancy followed by osteosarcoma, with highest incidence among 10-20 years old. Ewing sarcoma is consistently associated with chromosomal translocation and functional fusion of the EWSR1 gene to any of several structurally related transcription factor genes of the E26 transformation-specific family. These tumor-specific molecular rearrangements are useful for primary diagnosis, may provide prognostic information, and present potential therapeutic targets. Therefore, ways to rapidly and efficiently detect these defining genomic alterations are of clinical relevance. Within the past decade, liquid biopsies including extracellular vesicles (EVs), have emerged as a promising alternative and/or complimentary approach to standard tumor biopsies. It was recently reported that fusion mRNAs from tumor-specific chromosome translocations can be detected in Ewing sarcoma cell-derived exosomes. Within this review, we overview the current advances in Ewing sarcoma and the opportunities and challenges in exploiting circulating exosomes, primarily small bioactive EVs (30-180 nm), as developing sources of biomarkers for diagnosis and therapeutic response monitoring in children and young adult patients with ESFT.
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Affiliation(s)
- Peng Zhang
- Department of Chemistry, University of Kansas, Lawrence, Kansas
| | - Glenson Samuel
- Division of Hematology, Oncology and Bone Marrow Transplant, Children's Mercy Hospitals & Clinics, Kansas City, Missouri
| | - Jennifer Crow
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Andrew K Godwin
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas; University of Kansas Cancer Center, Kansas City, Kansas.
| | - Yong Zeng
- Department of Chemistry, University of Kansas, Lawrence, Kansas; University of Kansas Cancer Center, Kansas City, Kansas.
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Howard AF, Goddard K, Rassekh SR, Samargandi OA, Hasan H. Clinical significance in pediatric oncology randomized controlled treatment trials: a systematic review. Trials 2018; 19:539. [PMID: 30290839 PMCID: PMC6173909 DOI: 10.1186/s13063-018-2925-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/19/2018] [Indexed: 12/16/2022] Open
Abstract
Background Clinical significance in a randomized controlled trial (RCT) can be determined using the minimal clinically important difference (MCID), which should inform the delta value used to determine sample size. The primary objective was to assess clinical significance in the pediatric oncology randomized controlled trial (RCT) treatment literature by evaluating: (1) the relationship between the treatment effect and the delta value as reported in the sample size calculation, and (2) the concordance between statistical and clinical significance. The secondary objective was to evaluate the reporting of methodological attributes related to clinical significance. Methods RCTs of pediatric cancer treatments, where a sample size calculation with a delta value was reported or could be calculated, were systematically reviewed. MEDLINE, EMBASE, and the Cochrane Childhood Cancer Group Specialized Register through CENTRAL were searched from inception to July 2016. Results RCTs (77 overall; 11 and 66), representing 95 (13 and 82) randomized questions were included for non-inferiority and superiority RCTs (herein, respectively). The minority (22.1% overall; 76.9 and 13.4%) of randomized questions reported conclusions based on clinical significance, and only 4.2% (15.4 and 2.4%) explicitly based the delta value on the MCID. Over half (67.4% overall; 92.3 and 63.4%) reported a confidence interval or standard error for the primary outcome experimental and control values and 12.6% (46.2 and 7.3%) reported the treatment effect, respectively. Of the 47 randomized questions in superiority trials that reported statistically non-significant findings, 25.5% were possibly clinically significant. Of the 24 randomized questions in superiority trials that were statistically significant, only 8.3% were definitely clinically significant. Conclusions A minority of RCTs in the pediatric oncology literature reported methodological attributes related to clinical significance and a notable portion of statistically insignificant studies were possibly clinically significance. Electronic supplementary material The online version of this article (10.1186/s13063-018-2925-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A Fuchsia Howard
- School of Nursing, The University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
| | - Karen Goddard
- Department of Radiation Oncology, BC Cancer, Vancouver, BC, V5Z 4E6, Canada
| | - Shahrad Rod Rassekh
- Division of Hematology/Oncology, BC Children's Hospital, Vancouver, BC, V6H 3N1, Canada
| | - Osama A Samargandi
- Division of Plastic Surgery, QEII Health Sciences Centre, Halifax, NS, B3H 3A7, Canada
| | - Haroon Hasan
- Department of Radiation Oncology, BC Cancer, Vancouver, BC, V5Z 4E6, Canada.,Epi Methods Consulting, Toronto, ON, M5V 0C4, Canada
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Laibhen-Parkes N, Kimble LP, Melnyk BM, Sudia T, Codone S. An Adaptation of the Original Fresno Test to Measure Evidence-Based Practice Competence in Pediatric Bedside Nurses. Worldviews Evid Based Nurs 2018; 15:230-240. [PMID: 29729660 DOI: 10.1111/wvn.12289] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Instruments used to assess evidence-based practice (EBP) competence in nurses have been subjective, unreliable, or invalid. The Fresno test was identified as the only instrument to measure all the steps of EBP with supportive reliability and validity data. However, the items and psychometric properties of the original Fresno test are only relevant to measure EBP with medical residents. Therefore, the purpose of this paper is to describe the development of the adapted Fresno test for pediatric nurses, and provide preliminary validity and reliability data for its use with Bachelor of Science in Nursing-prepared pediatric bedside nurses. METHODS General adaptations were made to the original instrument's case studies, item content, wording, and format to meet the needs of a pediatric nursing sample. The scoring rubric was also modified to complement changes made to the instrument. Content and face validity, and intrarater reliability of the adapted Fresno test were assessed during a mixed-methods pilot study conducted from October to December 2013 with 29 Bachelor of Science in Nursing-prepared pediatric nurses. RESULTS Validity data provided evidence for good content and face validity. Intrarater reliability estimates were high. LINKING EVIDENCE TO ACTION The adapted Fresno test presented here appears to be a valid and reliable assessment of EBP competence in Bachelor of Science in Nursing-prepared pediatric nurses. However, further testing of this instrument is warranted using a larger sample of pediatric nurses in diverse settings. This instrument can be a starting point for evaluating the impact of EBP competence on patient outcomes.
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Affiliation(s)
- Natasha Laibhen-Parkes
- Clinical Assistant Professor, Georgia Baptist College of Nursing, Mercer University, Atlanta, GA, USA
| | - Laura P Kimble
- Professor and Piedmont Healthcare Endowed Chair in Nursing, Georgia Baptist College of Nursing, Mercer University, Atlanta, GA, USA
| | - Bernadette Mazurek Melnyk
- Associate Vice President for Health Promotion, University Chief Wellness Officer, Dean and Professor, College of Nursing, and Professor of Pediatrics & Psychiatry, College of Medicine, The Ohio State University, Columbus, OH, USA, and Editor, Worldviews on Evidence-Based Nursing, Sigma, Indianapolis, IN, USA
| | - Tanya Sudia
- Associate Dean for Research and Scholarship, Interim Graduate Program Director and Professor, Louise Herrington School of Nursing, Baylor University, Dallas, TX, USA
| | - Susan Codone
- Associate Professor, Technical Communication, Mercer University, Macon, GA, USA
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Shader RI, Livingston CH. Informed Consent and Assent in Pediatric Oncology Trials. Clin Ther 2017; 39:231-234. [DOI: 10.1016/j.clinthera.2017.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/13/2017] [Indexed: 10/20/2022]
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Bornhorst M, Hwang EI. Experimental Therapeutic Trial Design for Pediatric Brain Tumors. J Child Neurol 2016; 31:1421-32. [PMID: 26353880 DOI: 10.1177/0883073815604221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 08/11/2015] [Indexed: 11/17/2022]
Abstract
Pediatric brain tumors are the leading cause of cancer-related death during childhood. Since the first pediatric brain tumor clinical trials, the field has seen improved outcomes in some, but not all tumor types. In the past few decades, a number of promising new therapeutic agents have emerged, yet only a few of these agents have been incorporated into clinical trials for pediatric brain tumors. In this review, the authors discuss the process of and challenges in pediatric clinical trial design; this will allow for highly efficient and effective clinical trials with appropriate endpoints to ensure rapid and safe investigation of novel therapeutics for children with brain tumors.
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Affiliation(s)
- Miriam Bornhorst
- Department of Pediatric Hematology-Oncology, Children's National Medical Center, Washington, DC, USA Brain Tumor Institute, Washington, DC, USA
| | - Eugene I Hwang
- Department of Pediatric Hematology-Oncology, Children's National Medical Center, Washington, DC, USA Gilbert Family Neurofibromatosis Institute, Centers for Cancer and Immunology Research & Neuroscience Research, Children's National Medical Center, Washington, DC, USA
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Ethical issues of clinical trials in paediatric oncology from 2003 to 2013: a systematic review. Lancet Oncol 2016; 17:e187-97. [DOI: 10.1016/s1470-2045(16)00142-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/05/2016] [Accepted: 02/18/2016] [Indexed: 11/20/2022]
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Abstract
BACKGROUND In pediatric oncology, many oncologists invite their own patients to participate in research. Inclusion within a dependent relationship is considered to potentially compromise voluntariness of consent. Currently, it is unknown to what extent those involved in pediatric oncology experience the dependent relationship as a threat to voluntary informed consent, and what they see as safeguards to protect voluntary informed consent within a dependent relationship. AIM We performed a qualitative study among key actors in pediatric oncology to explore their experiences with the dependent relationship and voluntary informed consent. METHODS We conducted three focus groups and 25 semi-structured, in-depth interviews with pediatric oncologists, research coordinators, Research Ethics Committee members, parents of children with cancer, and adolescents with cancer. RESULTS Professionals regarded the dependent relationship both as a potential threat to and as a positive influence on voluntary decision making. Parents and adolescents did not feel as though dependency upon the oncologist influenced their decisions. They valued the involvement of their own physician in the informed consent process. The professionals suggested three strategies to protect voluntariness: emphasizing voluntariness; empowering families; involvement of an independent person. CONCLUSIONS Although the dependent relationship between pediatric oncologists, patients and parents may be problematic for voluntary informed consent, this is not necessarily the case. Moreover, the involvement of treating physicians may even have a positive impact on the informed consent process. Although we studied pediatric oncology, our results may also apply to many other fields of pediatric medicine where research and care are combined, for example, pediatric rheumatology, neurology and nephrology. Clinical trials in these fields are inevitably often designed, initiated and conducted by medical specialists closely involved in patient care.
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Dekking SAS, van der Graaf R, Kars MC, Beishuizen A, de Vries MC, van Delden JJM. Balancing research interests and patient interests: a qualitative study into the intertwinement of care and research in paediatric oncology. Pediatr Blood Cancer 2015; 62:816-22. [PMID: 25728244 DOI: 10.1002/pbc.25444] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 01/05/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Traditionally, in ethical guidelines and in research ethics literature, care and research are clearly separated based on their different objectives. In contrast, in paediatric oncology, research and care are closely combined. Currently, it is unknown how relevant actors in paediatric oncology perceive this combination of research and care. We conducted a qualitative study into the experiences of those involved in Dutch paediatric oncology with the intertwinement of research and care and the dual role of paediatric oncologists as researchers and treating physicians. PROCEDURE A qualitative study approach, using two focus groups and 19 semi-structured, in-depth interviews with paediatric oncologists, research coordinators, parents of children with cancer, and adolescents with cancer. RESULTS Four themes characterize how actors experience the intertwinement of research and care in paediatric oncology. First, research is considered of major importance, and paediatric oncology professionals convey this message to patients and their parents. Second, there is ambiguity about categorization of studies into cancer therapy as either research or treatment. Third, role conflicts appear within the work of the paediatric oncologists. Finally, the various benefits of combining treatment with research are emphasized. CONCLUSIONS Research is regarded as a fundamental and indispensable characteristic of paediatric oncology practice. Paediatric oncology professionals, parents, and patients have a very positive outlook on combining research and care, but they may not be sufficiently critical with respect to potential conflicts. Increased reflection on how to optimally combine research and care could serve as an important protection of the interests of children with cancer and their parents.
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Affiliation(s)
- Sara A S Dekking
- University Medical Centre Utrecht, Julius Centre for Health Sciences and Primary Care, Department of Medical Humanities, Utrecht, The Netherlands
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Abstract
The principal aim of phase I studies is to define the recommended dosing of drugs for phase II studies through assessment of drug pharmacokinetics and observation of the drug's toxicity profile. In the setting of pediatric oncology, the use of an experimental drug in phase I study is offered when prognosis is poor. Thus, phase I oncology studies are not given to patients with a primary purpose of an intent to cure. They may offer little to no treatment benefit and carry a potential toxic effect. They may offer other benefits such as improved quality of life and relief of pain, however. Three parties are involved in the informed consent process: the parents, patients, and physicians. Families report hope as the main cause for enrollment. Physicians focus on providing information so families can decide about participation. Physicians also try to maintain hope despite understanding the nature of the disease. This makes the informed consent complicated for all parties involved in the process. The purpose of this review is to discuss the aims of phase I studies in pediatric oncology and to convey the ethical challenges that patients, parents, and physicians are facing when discussing informed consent with potential study participants.
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Hazen RA, Zyzanski S, Baker JN, Drotar D, Kodish E. Communication about the risks and benefits of phase I pediatric oncology trials. Contemp Clin Trials 2015; 41:139-45. [PMID: 25638751 PMCID: PMC4404031 DOI: 10.1016/j.cct.2015.01.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 01/22/2015] [Accepted: 01/23/2015] [Indexed: 11/16/2022]
Abstract
Introduction Phase 1 pediatric oncology trials offer only a small chance of direct benefit and may have significant risks and an impact on quality of life. To date, research has not examined discussions of risks and benefits during informed consent conferences for phase 1 pediatric oncology trials. The objective of the current study was to examine clinician and family communication about risks, benefits, and quality of life during informed consent conferences for phase 1 pediatric oncology trials. Methods Participants included clinician investigators, parents, and children recruited from 6 sites conducting phase 1 pediatric oncology trials. Eighty-five informed consent conferences were observed and audiotaped. Trained coders assessed discussions of risks, benefits, and quality of life. Types of risks discussed were coded (e.g., unanticipated risks, digestive system risks, death). Types of benefits were categorized as therapeutic (e.g. discussion of how participation may or may not directly benefit child), psychological, bridge to future trial, and altruism. Results Risks and benefits were discussed in 95% and 88% of informed consent conferences, respectively. Therapeutic benefit was the most frequently discussed benefit. The impact of trial participation on quality of life was discussed in the majority (88%) of informed consent conferences. Conclusion Therapeutic benefit, risks, and quality of life were frequently discussed. The range of information discussed during informed consent conferences suggests the need for considering a staged process of informed consent for phase 1 pediatric oncology trials.
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Affiliation(s)
- Rebecca A Hazen
- Department of Pediatrics, Case Western Reserve University and Rainbow Babies and Children's Hospital, 10524 Euclid Ave, Cleveland, OH 44106, USA.
| | - Stephen Zyzanski
- Department of Family Medicine, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106, USA.
| | - Justin N Baker
- St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678, USA.
| | - Dennis Drotar
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave, Cincinnati, OH 45229-3026, USA.
| | - Eric Kodish
- Center for Ethics, Humanities, and Spiritual Care, Cleveland Clinic, 9500 Euclid Ave JJ60, Cleveland, OH 44195, USA.
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Laibhen-Parkes N, Codone S. Web-based evidence based practice educational intervention to improve EBP competence among BSN-prepared pediatric bedside nurses: a mixed methods pilot study. ACTA ACUST UNITED AC 2014. [DOI: 10.7243/2056-9157-1-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Affiliation(s)
- John D. Lantos
- Professor of Pediatrics University of Missouri – Kansas City
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Unguru Y, Sill AM, Kamani N. The experiences of children enrolled in pediatric oncology research: implications for assent. Pediatrics 2010; 125:e876-83. [PMID: 20351001 DOI: 10.1542/peds.2008-3429] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Most children with cancer enroll in clinical research trials. Whenever possible, children must provide their assent before enrolling in research studies. We studied what children aged 7 to 18 with cancer understand about research, their research-related treatment, and their preferences for inclusion in decision-making. PROCEDURE Thirty-seven face-to-face, audiorecorded interviews using a novel, semi-structured tool, the quality-of-assent instrument, were conducted. Exploratory univariate and bivariate analyses of the quantitative data elucidated patterns and trends of understanding and preferences. RESULTS Nineteen of the 37 children (51%) did not know or recall that their treatment was considered research, and 19 of 22 (86%) did not understand their doctor when he or she discussed the trial. More children enrolled in trials to help future children with cancer (27 of 37 [73%]), than to get better personally (22 of 37 [60%]). Irrespective of age, children with Hodgkin's disease, germ-cell tumors, and leukemia had significantly greater research awareness and appreciation than children with other cancers (P = .019 and P < .001, respectively). Although all children wanted to be involved in decision-making, 18 of 37 (49%) did not have or recall having a role in deciding to enroll in their trial, and 14 of 37 (38%) did not feel free to dissent to trial enrollment. Only 4 of 37 children (11%) discussed increased decision-making roles with parents, and only 7 of 37 (19%) discussed them with their doctors. CONCLUSIONS Most children have limited understanding of research despite physicians' explanations. Many children reported that they feel minimally involved in the decision to enroll in clinical trials. Tools to assist investigators ascertain that children understand what they are agreeing to when they assent to research and to determine their preferences for inclusion in research may help make assent more meaningful.
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Affiliation(s)
- Yoram Unguru
- Division of Pediatric Hematology/Oncology, Herman and Walter Samuelson Children's Hospital at Sinai, 2401 W Belvedere Ave, Baltimore, MD 21215-5271, USA.
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