Beyond Participation: Evaluating the Role of Patients in Designing Oncology Clinical Trials

Historically, subject matter experts and healthcare professionals have played a pivotal role in driving oncology clinical trials. Although patients have been key participants, their deliberate and active contribution to the design and decision-making process has been limited. This scoping review aimed to examine the existing literature to scope the extent of active patient engagement in the design of oncology clinical trials and its corresponding influence on trial outcomes. We conducted a systematic search using two databases, namely MEDLINE (Ovid) and EMBASE, to identify relevant studies exploring patient engagement in cancer-related clinical research design. We identified seven studies that met the eligibility criteria. The studies highlighted the benefits of active patient involvement, such as improved recruitment strategies, and the attainment of more patient-centered trial outcomes. The influence of patient involvement varied from tangible developments like patient-friendly resources to indirect impacts like improved patient experiences and potentially higher adherence to trial intervention. The future of clinical trials should prioritize patients' values and perspectives, with regulatory bodies fostering these practices through clear guidelines. As the concept of patient centricity takes root in oncology research, the involvement of patients should evolve beyond mere participation.

RAPID framework for improved access to precision oncology for lethal disease: Results from a modified multi-round delphi study

Introduction

Predictive oncology, germline technologies, and adaptive seamless trials are promising advances in the treatment of lethal cancers. Yet, access to these therapies is stymied by costly research, regulatory barriers, and structural inequalities worsened by the COVID-19 pandemic.

Methods

To address the need for a comprehensive strategy for rapid and more equitable access to breakthrough therapies for lethal cancers, we conducted a modified multi-round Delphi study with 70 experts in oncology, clinical trials, legal and regulatory processes, patient advocacy, ethics, drug development, and health policy in Canada, Europe, and the US. Semi-structured ethnographic interviews (n = 33) were used to identify issues and solutions that participants subsequently evaluated in a survey (n = 47). Survey and interview data were co-analyzed to refine topics for an in-person roundtable where recommendations for system change were deliberated and drafted by 26 participants.

Results

Participants emphasized major issues in patient access to novel therapeutics including burdens of time, cost, and transportation required to complete eligibility requirements or to participate in trials. Only 12% of respondents reported satisfaction with current research systems, with "patient access to trials" and "delays in study approval" the topmost concerns.

Conclusion

Experts agree that an equity-centered precision oncology communication model should be developed to improve access to adaptive seamless trials, eligibility reforms, and just-in-time trial activation. International advocacy groups are a key mobilizer of patient trust and should be involved at every stage of research and therapy approval. Our results also show that governments can promote better and faster access to life-saving therapeutics by engaging researchers and payors in an ecosystem approach that responds to the unique clinical, structural, temporal, and risk-benefit situations that patients with life-threatening cancers confront.

Treatment Access, Health Economics, and the Wave of a Magic Wand

New drugs are expensive, in part due to excessive drug development costs. Governments are trying to reduce drug prices. This can delay access to effective agents. A country’s access to new drugs correlates with prices they agree to pay. After Health Canada approves a drug, the Canadian Agency for Drug and Technologies in Health (CADTH) assesses it. CADTH’s approval is usually contingent on it costing ≤CAD 50,000 per quality adjusted life year (QALY) gained. This value (unchanged from the 1970s) is inappropriately low. An inflation-adjusted CAD 50,000 1975 QALY should translate into a CAD 250,000 2021 QALY. CADTH’s target also does not consider that drug development costs have risen much faster than inflation or that new precision therapies may only be used in small populations. In a separate process, proposals from the Patented Medicines Price Review Board (PMPRB) would decrease initial Canadian drug prices by 20%, but prices would fall further as sales increased, with ultimate price reductions of up to 80%. PMPRB claims its proposal would not reduce drug access, but multiple analyses strongly suggest otherwise. Government price controls target the symptom (high prices), not the disease. They translate into shortages without solving the problem. CADTH and PMPRB approaches both threaten access to effective drugs.

The need for speed in advanced non-small cell lung cancer: A population kinetics assessment

BACKGROUND

Systemic therapy prolongs overall survival (OS) in advanced non-small cell lung cancer (NSCLC), but diagnostic tests, staging and molecular profiling take time, and this can delay therapy initiation. OS approximates first-order kinetics.

METHODS

We used OS of chemo-naive NSCLC patients on a placebo/best supportive care trial arm to estimate % of patients dying while awaiting therapy. We digitized survival curves from eight studies, calculated OS half-life, then estimated the proportion surviving after different times of interest (t_n ) using the formula: X = exp - t n ∗ 0 .693 / t 1 / 2 , where EXP signifies exponential, * indicates multiplication, 0.693 is the natural log of 2, and t_1/2 is the survival half-life in weeks.

RESULTS

Across trials, the OS half-life for placebo/best supportive care in previously untreated NSCLC was 19.5 weeks. Hence, based on calculations using the formula above, if therapy were delayed by 1, 2, 3, or 4 weeks then 4%, 7%, 10%, and 13% of all patients, respectively, would die while awaiting treatment. Others would become too sick to consider therapy even if still alive.

CONCLUSIONS

This quantifies why rapid baseline testing and prompt therapy initiation are important in advanced NSCLC. It also illustrates why screening procedures for clinical trial inclusion must be faster. Otherwise, it is potentially hazardous for a patient to be considered for a trial due to risk of death or deterioration while awaiting eligibility assessment. It is also important to not delay initiation of systemic therapy for procedures that add relatively little value, such as radiotherapy for small, asymptomatic brain metastases.

Abstract 5489: The cost of delaying therapy for advanced non-small cell lung cancer (NSCLC): a population kinetics assessment

Background: Systemic therapy prolongs overall survival (OS) in advanced NSCLC. The best outcome requires the best therapy choice. To choose the best therapy requires baseline diagnostic tests, staging and molecular profiling, but patients are at risk of deteriorating and dying while awaiting testing prior to therapy initiation. OS follows first order kinetics. We used population kinetics assessments to estimate % of patients dying while awaiting therapy initiation.

Method: For 1st line studies in advanced NSCLC that included a placebo or best supportive care (BSC) arm we digitized published OS curves, used GraphPad Prism 7 for exponential decay nonlinear regression analysis, calculated OS half-life (t1/2) and assessed data fit to 1 and 2 phase decay models. The proportion of patients “x” surviving after a time of interest tn was calculated by the Excel formula x =EXP(-tn*0.693/t1/2) where * indicates multiplication and 0.693 is the natural logarithm of 2.

Results: We identified 7 trials and a meta-analysis. Across studies, the median OS t1/2 with 1st line placebo/BSC was 19.3 weeks. Hence, by 1, 2, 3 and 4 weeks after study entry 4%, 7%, 10% and 13% of patients, respectively, would have died (ie, 4% of the remaining patients with each passing week). This is in keeping with most OS curves showing rapid decline from the outset. OS curves fit 2 phase decay models in 5 studies, indicating a distinct short survival subgroup (on average, 89% of patients in these trials) and a longer surviving subgroup (potentially from having initiated systemic therapy when progression was detected). The short survival subgroup had a median OS t1/2 across studies of 11.3 weeks. The earliest deaths would be expected to occur predominantly in this short survival subgroup, in which 5%, 9%, 13% and 17% had died by 1, 2, 3 and 4 weeks respectively.

Conclusions: Since OS follows first order kinetics, OS decline was probably following approximately the same rate prior to patient inclusion on these trials. In addition, since patients may deteriorate rapidly, others may have become too sick to consider therapy even if still alive. Rapid deterioration and short OS help explain why less than 25% of Ontario patients make it on to systemic therapy for advanced NSCLC despite the therapy being government funded. Since diagnostic, staging and molecular profiling procedures are needed before optimal therapy can start, these procedures must happen rapidly. It also illustrates why we must make screening procedures for clinical trial inclusion much faster. Otherwise patients are at risk of deteriorating rapidly or dying while awaiting eligibility assessment. It is also important to not delay initiation of systemic therapy for procedures such as radiotherapy for asymptomatic brain metastases. Any inefficiency that delays systemic therapy initiation may worsen patient outcome.

Citation Format: David J. Stewart, Donna Maziak, Marcio Gomes, Michael Fung-Kee-Fung, Carole Dennie, Harman Sekhon, Bryan Lo, John-Peter Bradford, Sara Moore, Neil Reaume. The cost of delaying therapy for advanced non-small cell lung cancer (NSCLC): a population kinetics assessment [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5489.

The importance of greater speed in drug development for advanced malignancies

It takes on average 6-12 years to develop new anticancer drugs from discovery to approval. Effective new agents prolong survival. To demonstrate the importance of rapid drug approval, we calculated life-years potentially saved if selected agents were approved more rapidly. As illustrative examples, we used 27 trials documenting improvements in survival. We multiplied improvement in median survival by numbers of patients dying annually and multiplied this by number of years from drug discovery until approval. For every year by which time to drug approval could have been shortened, there would have been a median number of life-years potentially saved of 79,920 worldwide per drug. Median number of life-years lost between time of drug discovery and approval was 1,020,900 per example. If we were able to use available opportunities to decrease the time required to take a drug from discovery to approval to 5 years, the median number of life-years saved per example would have been 523,890 worldwide. Various publications have identified opportunities to speed drug development without sacrificing patient safety. While many investigational drugs prove to be ineffective, some significantly prolong survival and/or reduce suffering. These illustrative examples suggest that a substantial number of life-years could potentially be saved by increasing the efficiency of development of new drugs for advanced malignancies.

The Urgent Need for Clinical Research Reform to Permit Faster, Less Expensive Access to New Therapies for Lethal Diseases

High costs of complying with drug development regulations slow progress and contribute to high drug prices and, hence, mounting health care costs. If it is exorbitantly expensive to bring new therapies to approval, fewer agents can be developed with available resources, impeding the emergence of urgently needed treatments and escalating prices by limiting competition. Excessive regulation produces numerous speed bumps on the road to drug authorization. Although an explosion of knowledge could fuel rapid advances, progress has been slowed worldwide by inefficient regulatory and clinical research systems that limit access to therapies that prolong life and relieve suffering. We must replace current compliance-centered regulation (appropriate for nonlethal diseases like acne) with "progress-centered regulation" in lethal diseases, where the overarching objective must be rapid, inexpensive development of effective new therapies. We need to (i) reduce expensive, time-consuming preclinical toxicology and pharmacology assessments, which add little value; (ii) revamp the clinical trial approval process to make it fast and efficient; (iii) permit immediate multiple-site trial activation when an eligible patient is identified ("just-in-time" activation); (iv) reduce the requirement for excessive, low-value documentation; (v) replace this excessive documentation with sensible postmarketing surveillance; (vi) develop pragmatic investigator accreditation; (vii) where it is to the benefit of the patient, permit investigators latitude in deviating from protocols, without requiring approved amendments; (viii) confirm the value of predictive biomarkers before requiring the high costs of IDE/CLIA compliance; and (ix) approve agents based on high phase I-II response rates in defined subpopulations, rather than mandating expensive, time-consuming phase III trials.

Non-reinforcing effects of giving 'dessert' in rats

We investigated in rats whether giving a sweet substance following a food (a 'dessert') would reinforce a preference for that food. The sweet substance had the reverse effect--rats preference for a flavor decreased if the flavor was given in a food preceding a sweet substance (saccharin or sucrose). If the substances were given in the reverse order, so the sweet substance preceded the food, the rats preferred a sweet substance that had been followed by food to one that had not been followed by food. We suggested two hypotheses to account for the data. Perhaps the sweet substance elicits a negative reaction that is unpleasant unless food is given. Thus, food following a sweet substance is reinforcing, while a sweet substance following food is not. A not incompatible alternative is that anticipatory contrast or comparison effects are involved. Assuming the sweet substance is preferred to the non-sweet, following food by a sweet substance could make the food less valued (anticipatory negative contrast), whereas following a sweet substance by food could make the sweet substance more valued (anticipatory positive contrast).

Conditioned flavor preferences based on delayed caloric consequences

In four experiments we showed that rats prefer a flavor associated with a delayed edible consequence if the delayed consequence contains calories; the greater the number of calories, the greater the preference. We obtained conditioned preferences with delayed consequences of dextrose plus quinine, 8% polycose, 8% sucrose, 10 g of high fat mash, and 14 g of lab chow. No conditioned preferences were obtained with delayed consequences of saccharin, 10 g of low fat mash, 1% polycose, or 1% sucrose. Thus, it seems that flavor preferences based on delayed caloric consequences occur only if there are appreciable calories in the consequence.