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Norris DC, Sen S, Groisberg R, Subbiah V. Patient-Centered, Physician-Investigator Friendly Pragmatic Phase Trial Designs-The 4P Model. Mayo Clin Proc 2020; 95:2566-2568. [PMID: 33153645 DOI: 10.1016/j.mayocp.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/08/2020] [Indexed: 11/18/2022]
Affiliation(s)
| | - Shiraj Sen
- Sarah Cannon Research Institute at HealthONE, Denver, CO
| | | | - Vivek Subbiah
- The University of Texas MD, Anderson Cancer Center, Houston, TX
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Jerome RN, Edwards TL, Boswell HC, Bernard GR, Harris PA, Pulley JM. Recommendations to Facilitate Expanded Access to Investigational Therapies for Seriously Ill Patients. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:305-9. [PMID: 26445080 PMCID: PMC4767550 DOI: 10.1097/acm.0000000000000914] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
When clinical trial enrollment is not an option for seriously ill patients whose illnesses have not responded to approved treatment options, those patients and their physicians may consider gaining access to investigational therapies through a pathway established by the Food and Drug Administration (FDA) called expanded access. However, recent events have highlighted the challenging dynamics involved in accessing investigational therapies through expanded access that include a complex interplay of factors involving the patient, physician, drug company, FDA, and, increasingly, social media. The authors offer several potential strategies to streamline what is otherwise an arduous process for all involved. (1) The drug company should prospectively determine whether it will establish an expanded access program for specific drugs. (2) A central clearinghouse for companies should support registration of expanded access drugs for suitable patients. (3) The determination of whether a patient fits criteria would be made by an independent review board of clinicians. (4) An independent coordinating center is needed; academic health centers are ideally suited for that role. (5) Adequate financing of the costs of therapy need to be in place to make expanded access a reality, given frequent lack of payer coverage for therapies. (6) Further enhancement of regulatory pathways, approaches, or rules would promote expanded access. (7) Patients should explicitly acknowledge the limited data available. (8) There should be a shared, secure, technical platform to facilitate expanded access. All the authors' strategies present important prospects for improving treatment options for the most seriously ill patients.
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Affiliation(s)
- Rebecca N Jerome
- R.N. Jerome is research services consultant, Research Support Services, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee. T.L. Edwards is associate director, Research Support Services, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee. H.C. Boswell is research services consultant, Research Support Services, Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee. G.R. Bernard is associate vice chancellor for research, senior associate dean for clinical science, and principal investigator, Vanderbilt Clinical and Translational Award and Vanderbilt Institute for Clinical and Translational Research, and professor of medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee. P.A. Harris is director, Office of Research Informatics, operations director of biomedical informatics, Vanderbilt Institute for Clinical and Translational Research, and associate professor, Departments of Biomedical Informatics and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, Tennessee. J.M. Pulley is director, Research Support Services, operational director, Vanderbilt Institute for Clinical and Translational Research, and research associate professor, Medical Education and Administration, Vanderbilt University Medical Center, Nashville, Tennessee
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Paris JJ, Hawkins A. Ethics Consults in Pediatrics and Neonatology Are More Varied and Complex Than Those Reported at St. Jude's Children's Research Hospital. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:29-30. [PMID: 25970387 DOI: 10.1080/15265161.2015.1021972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Miller VA, Ittenbach RF, Harris D, Reynolds WW, Beauchamp TL, Luce MF, Nelson RM. The decision making control instrument to assess voluntary consent. Med Decis Making 2011; 31:730-41. [PMID: 21402793 PMCID: PMC3175347 DOI: 10.1177/0272989x11398666] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The decision to participate in a research intervention or to undergo medical treatment should be both informed and voluntary. OBJECTIVE The aim of the present study was to develop an instrument to measure the perceived voluntariness of parents making decisions for their seriously ill children. METHODS A total of 219 parents completed questionnaires within 10 days of making such a decision at a large, urban tertiary care hospital for children. Parents were presented with an experimental form of the Decision Making Control Instrument (DMCI), a measure of the perception of voluntariness. Data obtained from the 28-item form were analyzed using a combination of both exploratory and confirmatory factor analytic techniques. RESULTS The 28 items were reduced to 9 items representing 3 oblique dimensions: Self-Control, Absence of Control, and Others' Control. The hypothesis that the 3-factor covariance structure of our model was consistent with that of the data was supported. Internal consistency for the scale as a whole was high (0.83); internal consistency for the subscales ranged from 0.68 to 0.87. DMCI scores were associated with measures of affect, trust, and decision self-efficacy, supporting the construct validity of the new instrument. CONCLUSION The DMCI is an important new tool that can be used to inform our understanding of the voluntariness of treatment and research decisions in medical settings.
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Affiliation(s)
- Victoria A Miller
- Department of Anesthesiology and Critical Care Medicine, the Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine (VAM)
| | - Richard F Ittenbach
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center (RFI)
| | - Diana Harris
- Center for the Integration of Genetic Healthcare Technologies, University of Pennsylvania School of Medicine (DH)
| | | | | | | | - Robert M Nelson
- Office of Pediatric Therapeutics, Office of the Commissioner, Food and Drug Administration (RMN)
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Pierce R. What a tangled web we weave: ethical and legal implications of deception in recruitment. Account Res 2008; 15:262-82. [PMID: 18972266 DOI: 10.1080/08989620802388713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Deception in human subject research is neither uncommon nor prohibited. The use of deception in the recruitment phase of clinical research has received relatively little attention. Given that informed consent is foundational to human subject research, the practice of misrepresenting the study purpose in clinical research would seem to contradict one of the fundamental tenets of ethical human subjects research. Using the example of prodromal psychosis, this article the ethical and legal implications of deception in recruitment and the sufficiency of current guidance on the practice when the study involves a stigmatizing condition, the collection of genetic samples, or both. I conclude that when these two elements are present, deception should only be used when absolutely necessary and, if used, researchers should be required to debrief participants before the collection of genetic samples and give particular attention to minimizing risks of privacy breaches.
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Affiliation(s)
- Robin Pierce
- Novel Tech Ethics, Dalhousie University, Halifax, Nova Scotia, Canada.
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Agrawal M, Hampson LA, Emanuel EJ. Ethics of Clinical Oncology Research. Oncology 2007. [DOI: 10.1007/0-387-31056-8_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Koyfman SA, Agrawal M, Garrett-Mayer E, Krohmal B, Wolf E, Emanuel EJ, Gross CP. Risks and benefits associated with novel phase 1 oncology trial designs. Cancer 2007; 110:1115-24. [PMID: 17628485 DOI: 10.1002/cncr.22878] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although aggressive dose escalation strategies were designed to improve the risk-benefit profile of phase 1 oncology trials, they have not been adequately studied. The prevalence of several novel trial designs and their association with a variety of clinical endpoints was evaluated. METHODS A review of the literature was performed to identify phase 1 oncology studies of cytotoxic agents published from 2002 through 2004. RESULTS Of 955 phase 1 oncology articles initially identified, 149 studies, comprising 4532 patients, were analyzed. Only 34% of studies utilized aggressive dose escalation schemes, 22% permitted intrapatient dose escalation, and only 28% enrolled fewer than 3 patients to any dose level. Studies that allowed intrapatient dose escalation or used fewer than 3 patients per dose were not associated with different rates of response or toxicity, nor did they increase the number of patients who received the recommended phase 2 dose. However, aggressive dose escalations were associated with increased rates of both hematologic (17% vs 10%) and nonhematologic (17% vs 13%) toxicity with similar response rates. Only studies that used conservative dose escalation designs and those that studied U.S. Food and Drug Administration (FDA)-approved agents required fewer patients to complete a trial. Trials of FDA-approved agents were also associated with higher response rates than trials of non-FDA-approved agents (10% vs 2%), without an increased risk of toxicity. CONCLUSIONS Several novel aggressive design strategies intended to improve the risk-benefit profile of phase 1 oncology trials are not associated with improved clinical outcome, and may be harmful in certain instances.
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Affiliation(s)
- Shlomo A Koyfman
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, USA
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Linden HM, Reisch LM, Hart A, Harrington MA, Nakano C, Jackson JC, Elmore JG. Attitudes toward participation in breast cancer randomized clinical trials in the African American community: a focus group study. Cancer Nurs 2007; 30:261-9. [PMID: 17666974 PMCID: PMC3908682 DOI: 10.1097/01.ncc.0000281732.02738.31] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Participation of African Americans in research trials is low. Understanding the perspectives of African American patients toward participation in clinical trials is essential to understanding the disparities in participation rates compared with whites. A qualitative study was conducted to discover attitudes of the African American community regarding willingness to participate in breast cancer screening and randomized clinical trials. Six focus groups consisting of 8 to 11 African American women (N = 58), aged 30 to 65, were recruited from local churches. Focus group sessions involved a 2-hour audio-taped discussion facilitated by 2 moderators. A breast cancer randomized clinical trial involving an experimental breast cancer treatment was discussed to identify the issues related to willingness to participate in such research studies. Six themes surrounding willingness to participate in randomized clinical trials were identified: (1) Significance of the research topic to the individual and/or community; (2) level of trust in the system; (3) understanding of the elements of the trial; (4) preference for "natural treatments" or "religious intervention" over medical care; (5) cost-benefit analysis of incentives and barriers; and (6) openness to risk versus a preference for proven treatments. The majority (80%) expressed willingness or open-mindedness to the idea of participating in the hypothetical trial. Lessons learned from this study support the selection of a culturally diverse research staff and can guide the development of research protocols, recruitment efforts, and clinical procedures that are culturally sensitive and relevant.
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Affiliation(s)
- Hannah M Linden
- Department of Medicine, Seattle Cancer Care Alliance, University of Washington, Seattle, WA 98109, USA.
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Agrawal M, Grady C, Fairclough DL, Meropol NJ, Maynard K, Emanuel EJ. Patients' Decision-Making Process Regarding Participation in Phase I Oncology Research. J Clin Oncol 2006; 24:4479-84. [PMID: 16983117 DOI: 10.1200/jco.2006.06.0269] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose This study assesses the decision-making process of patients enrolling in phase I oncology studies. Patients and Methods Participants were eligible if they had consented to participate in a phase I cancer study at one of five cancer centers, understood English, and were older than 18 years. Trained interviewers conducted structured in-person interviews. Results Of the 163 participants, 88% were white, 96% had health insurance, and 51% were college graduates or post graduates. Overall, 81% were aware of hospice, but only 6% had seriously considered hospice for themselves; 84% were aware of palliative care and 10% seriously considered it for themselves; and 7% considered getting no treatment at all. Overall, 75% reported moderate or a lot of pressure to participate in the phase I study because their cancer was growing, whereas 7% reported such pressure from the study investigators and 9% felt such pressure from their families. For 63% of patients, the most important information for decision making was that the phase I drug killed cancer cells; only 12% reported that the adverse effects of the drug(s) was the most useful information. More than 90% of patients said they would still participate in the study even if the experimental drug caused serious adverse effects, including a 10% chance of dying. Conclusion Patients are aware of many alternatives to phase I studies, but do not seriously consider them. Very few experience pressure from family or researchers to participate in research. Their main goal is to fight their cancer, and almost no adverse effect, including death, would dissuade them from enrolling.
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Affiliation(s)
- Manish Agrawal
- Department of Clinical Bioethics, Warren G. Magnuson Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-1156, USA.
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Daugherty CK, Fitchett G, Murphy PE, Peterman AH, Banik DM, Hlubocky F, Tartaro J. Trusting God and medicine: spirituality in advanced cancer patients volunteering for clinical trials of experimental agents. Psychooncology 2005; 14:135-46. [PMID: 15386780 DOI: 10.1002/pon.829] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The purpose of this study was to examine the role of spirituality in terminally ill cancer patients who volunteer for clinical trials of experimental agents. Information about spirituality (FACIT-Sp), quality of life (FACT-G), awareness of prognosis, and decision-making preferences was obtained from 162 advanced cancer patients who volunteered for phase I trials. In a multivariable model, phase I patients had slightly higher levels of spirituality (p<0.001) than a group of 156 advanced cancer patients who were not participants in phase I trials. For the phase I patients, spirituality was positively associated with quality of life (Spearman rho=0.36, p<0.001). There was little association between either spirituality or religious problem-solving style and phase I patients' awareness of their prognosis or decision-making preferences. One phase I patient who said, 'I put faith in doctors and God,' expressed these patients' willingness to trust both God and medicine.
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Affiliation(s)
- Christopher K Daugherty
- Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL 60612-3833, USA
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Horstmann E, McCabe MS, Grochow L, Yamamoto S, Rubinstein L, Budd T, Shoemaker D, Emanuel EJ, Grady C. Risks and benefits of phase 1 oncology trials, 1991 through 2002. N Engl J Med 2005; 352:895-904. [PMID: 15745980 DOI: 10.1056/nejmsa042220] [Citation(s) in RCA: 318] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous reviews of phase 1 oncology trials reported a rate of response to treatment of 4 to 6 percent and a toxicity-related death rate of 0.5 percent. These results may not reflect the rates in current phase 1 oncology trials. METHODS We reviewed all nonpediatric phase 1 oncology trials sponsored by the Cancer Therapy Evaluation Program at the National Cancer Institute between 1991 and 2002. We report the rates of response to treatment, of stable disease, of grade 4 toxic events, and of treatment-related deaths. RESULTS We analyzed 460 trials involving 11,935 participants, all of whom were assessed for toxicity and 10,402 of whom were assessed for a response to therapy. The overall response rate (i.e., for both complete and partial responses) was 10.6 percent, with considerable variation among trials. "Classic" phase 1 trials of single investigational chemotherapeutic agents represented only 20 percent of the trials and had a response rate of 4.4 percent. Studies that included at least one anticancer agent approved by the Food and Drug Administration constituted 46.3 percent of the trials and had a response rate of 17.8. An additional 34.1 percent of participants had stable disease or a less-than-partial response. The overall rate of death due to toxic events was 0.49 percent. Of 3465 participants for whom data on patient-specific grade 4 toxic events were available, 14.3 percent had had at least one episode of grade 4 toxic events. CONCLUSIONS Overall response rates among phase 1 oncology trials are higher than previously reported, although they have not changed for classic phase 1 trials, and toxicity-related death rates have remained stable. Rates of response and toxicity vary, however, among the various types of phase 1 oncology trials.
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Affiliation(s)
- Elizabeth Horstmann
- Department of Clinical Bioethics, Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, Md 20892-1156, USA
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Asai A, Ohnishi M, Nishigaki E, Sekimoto M, Fukuhara S, Fukui T. Focus group interviews examining attitudes toward medical research among the Japanese: a qualitative study. BIOETHICS 2004; 18:448-470. [PMID: 15462026 DOI: 10.1111/j.1467-8519.2004.00409.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVES the purpose of ths study is to explore laypersons' attitudes towards and experiences of medical research, and to compare them with those of physicians in Japan. Designs and Participants: fourteen Japanese adults from the general public and seven physicians participated in one of three focus interviews. SETTING Osaka, Japan. RESULTS trust and distrust in the physician by whom the participants were invited to participate in research played a considerable role in their decisions about participation. That the participants felt an obligation to participate was also expressed. The lay participants perceived medical research as something entirely outside of their world. A greater willingness to volunteer for research was expressed if there were direct benefits to themselves or their families. Research methods such as use of placebos, double blinds, and randomisations seemed to cause negative attitudes to medical research. All physicians were convinced of the need for medical research, including double-blinded randomised control trials, and its significant role in medical progress. Most physicians thought that the greater awareness of the need for medical research in the community and a better understanding of the psychology of potential research participants were necessary and urgent. CONCLUSIONS there is a good possibility that the lay public and medical professionals have sharply different beliefs about and attitudes towards every aspect of medical research. Building up a better and equal patient-doctor relationship based on trust is a key issue in medical research, and it is mandatory to fill the gap in perception regarding medical research between them through fully informed debates.
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Affiliation(s)
- Atsushi Asai
- Department of Biomedical Ethics, School of Public Health, Kyoto University Graduate School of Medicine, Konoe-cho, Yoshido, Sakyo-ku, Kyoto, Japan.
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Koenig BA, Back AL, Crawley LM. Qualitative methods in end-of-life research: recommendations to enhance the protection of human subjects. J Pain Symptom Manage 2003; 25:S43-52. [PMID: 12691696 DOI: 10.1016/s0885-3924(03)00060-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Qualitative research has the potential to contribute important new knowledge to care near the end of life, but research is often hampered by questions about how best to protect dying patients and their family members who serve as research subjects. Due to lack of familiarity with the techniques of ethnographic or observational research, as well as concerns about the vulnerability of the dying, members of Institutional Review Boards (IRBs) are often unable to evaluate the benefits and potential harms of studies. In addition, policies derived from standards based on interventional medical research or clinical trials may be applied inappropriately. We offer comprehensive recommendations aimed at improving the translation of human subjects guidelines into meaningful protections for subjects in qualitative studies, including education for IRBs. Policies must be flexible and should be guided by empirical findings documenting the actual impact of research participation, rather than a priori assumptions about patient vulnerability. Sensitive topics, such as drug use, may require added protections.
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Affiliation(s)
- Barbara A Koenig
- Stanford University Center for Biomedical Ethics, 701A Welch Road #1105, Palo Alto, CA 94304, USA
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A Staff Dialogue on Phase I Trials: Psychosocial Issues Faced by Patients, Their Families, and Caregivers. Oncologist 2002. [DOI: 10.1634/theoncologist.7-suppl_2-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Lucchi-Angellier E. [Patients' rights during medical research and specifics in oncology (in France)]. Rev Med Interne 2001; 22:1097-108. [PMID: 11817121 DOI: 10.1016/s0248-8663(01)00474-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Clinical research in oncology is part of the care, instead of being theoretical, because it can offer new drugs to patients who are suffering from severe illnesses, but also because it offers better practices. The vulnerability of patients suffering from cancers, at each stage of the disease, requires special protection. Because of its multiple aspects, clinical research in oncology asks ethical questions. Medical deontology and laws, national and supranational, allow research with respect to the subject. The present article reviews these texts. CURRENT KNOWLEDGE AND KEY POINTS The rights of the person involved in clinical trials essentially consist of information and consent, but also the right to refuse, and the confidentiality of data collected. More subtle rights are now emerging because of new technologies, such as genetics. One of them is the right to be protected as a member of the human race, which is in continuity with human rights. FUTURE AND PROJECTS Finally, medical responsibility during research is increasing. It responds to the right of each person to see that his dignity is respected, although this dignity may be difficult to define. One of the more pertinent questions in building 'evidence-based ethics' concerns research into the evaluation by the persons themselves involved in the research.
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Affiliation(s)
- E Lucchi-Angellier
- Laboratoire d'éthique médicale, 156, rue de Vaugirard, 75015 Paris, France.
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Benjamin S, Kroll ME, Cartwright RA, Clough JV, Gorst DW, Proctor SJ, Ross JRY, Taylor PRA, Wheatley K, Whittaker JA, Stiller CA. Haematologists' approaches to the management of adolescents and young adults with acute leukaemia. Br J Haematol 2000. [DOI: 10.1111/j.1365-2141.2000.02489.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Benjamin S, Kroll ME, Cartwright RA, Clough JV, Gorst DW, Proctor SJ, Ross JR, Taylor PR, Wheatley K, Whittaker JA, Stiller CA. Haematologists' approaches to the management of adolescents and young adults with acute leukaemia. Br J Haematol 2000; 111:1045-50. [PMID: 11167738 DOI: 10.1046/j.1365-2141.2000.02489.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Approaches to the management of adolescents and young adults with acute leukaemia were investigated by sending a questionnaire to hospitals identified as having diagnosed or treated patients aged 15-29 years. The responses demonstrated the types of hospital treating these patients, the haematologists' perceived practice for entry of patients to Medical Research Council (MRC) leukaemia trials and reasons for non-entry. Data were linked to MRC trials data to determine the proportion of patients aged 15-29 years at diagnosis in responding hospitals actually treated in MRC leukaemia trials in the 5 years preceding the questionnaire. Eighty-two per cent of haematologists stated that they entered patients 'always' or 'whenever possible' for acute myeloid leukaemia (AML) and 76% for acute lymphoblastic leukaemia (ALL), but actual entry rates from the study hospitals were 46% of 239 AML patients and 36% of 182 ALL patients. The reasons most commonly reported for not entering eligible patients to national leukaemia trials were clinician preference for one arm of an MRC trial, a regional study or non-trial protocol, and concern about workload and ethical approval.
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Affiliation(s)
- S Benjamin
- Childhood Cancer Research Group, University of Oxford, Oxford, UK.
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Abstract
Recent studies have made it clear that there are substantial opportunities to improve end-of-life care. Doing so will require solid evidence on which to base clinical and policy decisions and this, in turn, will require a focused research effort. However, research that involves patients near the end of life creates numerous ethical challenges. Moreover, the inclusion of dying patients in research may make many providers uncomfortable. In short, there seems to be something ethically unique, and uniquely challenging, about palliative care research. This paper considers 4 arguments for this unique status: 1) dying patients are especially vulnerable; 2) adequate informed consent may be difficult to obtain; 3) balancing research and clinical roles is particularly difficult; and 4) the risks and benefits of palliative research are difficult to assess. We conclude that the first three of these arguments are weak, and that special guidelines are not needed. We suggest, however, that the fourth argument may have some merit, and should be the focus of discussion among investigators, providers, and patients.
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Affiliation(s)
- D J Casarett
- Department of Medicine, University of Pennsylvania, Philadelphia 19104, USA
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Abstract
This article reflects three nurses' views of the moral dimensions of their work in caring for patients receiving phases I and II of cancer clinical trials in a dedicated cancer clinical trials unit (CCTU). The nurses took part in a semistructured, tape-recorded, group interview in which they talked about any aspect of their work that they felt demonstrated its ethical or moral dimensions. The nurses were not employed as research nurses, but had chosen to specialize in cancer and palliative care in a CCTU environment. Three key themes emerged from the interview: being valued and moral distress; caring in a climate of scientific research; and care, cure, and consequences for moral reasoning. Working in an environment suffused with moral conflicts can be painful and damaging for the professionals involved. It would appear that if nurses are to function effectively, they need to be proactive in promoting an exploration of the role that emotions play in moral decision making and in examining the contribution of emotions to what they care about and why. A commitment to a shared understanding and valuing of divergent ethical reasoning in and across professional cultures of care and research paradigms also appears to be necessary. The terms "ethics" and "morals" are used interchangeably throughout this article.
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Affiliation(s)
- M Krishnasamy
- Macmillan Practice Development Unit, Centre for Cancer and Palliative Care Studies, Royal Marsden Hospital NHS Trust, London, United Kingdom
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Daugherty CK. Impact of therapeutic research on informed consent and the ethics of clinical trials: a medical oncology perspective. J Clin Oncol 1999; 17:1601-17. [PMID: 10334550 DOI: 10.1200/jco.1999.17.5.1601] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To create a more meaningful understanding of the informed consent process as it has come to be practiced and regulated in clinical trials, this discussion uses the experience gained from the conduct of therapeutic research that involves cancer patients. DESIGN After an introduction of the ethical tenets of the consent process in clinical research that involves potentially vulnerable patients as research subjects, background that details the use of written consent documents and of the term "informed consent" is provided. Studies from the cancer setting that examine the inadequacies of written consent documents, and the outcome of the consent process itself, are reviewed. Two ethically challenging areas of cancer clinical research, the phase I trial and the randomized controlled trial, are discussed briefly as a means of highlighting many dilemmas present in clinical trials. Before concluding, areas for future research are discussed. RESULTS Through an exclusive cancer research perspective, many current deficiencies in the informed consent process for therapeutic clinical trials can be critically examined. Also, new directions for improvements and areas of further research can be outlined and discussed objectively. The goals of such improvements and research should be prevention of further misguided or ineffective efforts to regulate the informed consent process. CONCLUSION To ignore this rich and interesting perspective potentially contributes to continued misunderstanding and apathy toward fulfilling the regulatory and ethically obligatory requirements involved in an essential communication process between a clinician-investigator and a potentially vulnerable patient who is considering clinical trial participation.
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Affiliation(s)
- C K Daugherty
- Section of Hematology-Oncology and the MacLean Center for Clinical Medical Ethics, University of Chicago, IL 60637-1470, USA.
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A Staff Dialogue on Phase I Trials: Psychosocial Issues Faced by Patients, Their Families, and Caregivers. Oncologist 1998. [DOI: 10.1634/theoncologist.3-5-357] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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