Optimisation of pharmacy content in clinical cancer research protocols: Experience of the United Kingdom Chemotherapy and Pharmacy Advisory Service

Background

Clarity and accuracy of the pharmacy aspects of cancer clinical trial protocols is essential. Inconsistencies and ambiguities in such protocols have the potential to delay research and jeopardise both patient safety and collection of credible data. The Chemotherapy and Pharmacy Advisory Service was established by the UK National Cancer Research Network, currently known as National Institute for Health Research Clinical Research Network, to improve the quality of pharmacy-related content in cancer clinical research protocols. This article reports the scope of Chemotherapy and Pharmacy Advisory Service, its methodology of mandated protocol review and pharmacy-related guidance initiatives and its current impact.

Methods

Over a 6-year period (2008–2013) since the inception of Chemotherapy and Pharmacy Advisory Service, cancer clinical trial protocols were reviewed by the service, prior to implementation at clinical trial sites. A customised Review Checklist was developed and used by a panel of experts to standardise the review process and report back queries and inconsistencies to chief investigators. Based on common queries, a Standard Protocol Template comprising specific guidance on drug-related content and a Pharmacy Manual Template were developed. In addition, a guidance framework was established to address ‘ad hoc’ pharmacy-related queries. The most common remarks made at protocol review have been summarised and categorised through retrospective analysis. In order to evaluate the impact of the service, chief investigators were asked to respond to queries made at protocol review and make appropriate changes to their protocols. Responses from chief investigators have been collated and acceptance rates determined.

Results

A total of 176 protocols were reviewed. The median number of remarks per protocol was 26, of which 20 were deemed clinically relevant and mainly concerned the drug regimen, support medication, frequency and type of monitoring and drug supply aspects. Further analysis revealed that 62% of chief investigators responded to the review. All responses were positive with an overall acceptance rate of 89% of the proposed protocol changes.

Conclusion

Review of pharmacy content of cancer clinical trial protocols is feasible and exposes many undetected clinically relevant issues that could hinder efficient trial conduct. Our service audit revealed that the majority of suggestions were effectively incorporated in the final protocols. The refinement of existing and development of new pharmacy-related guidance documents by Chemotherapy and Pharmacy Advisory Service might aid in better and safer clinical research.

Participation of teenagers and young adults (TYA) in cancer clinical trials (CCT): What can we learn from six years of accrual data in England?

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Background: We reported underrepresentation of TYA in CTT in England, 2005-06. Since 2005 national healthcare policies and research initiatives aimed at increasing participation of TYA in CCT have been implemented. We aimed to determine if this has improved accrual rates (AR). Methods: We analyzed accrual by age during 2005-2010 to UK Cancer Research Network interventional trials recruiting newly diagnosed patients (pts) with leukaemia, lymphoma, bone/soft tissue sarcoma, central nervous system and germ cell tumours. AR were expressed as the ratio of pts entered onto trial compared to population incidence cases for 2005-08; for 2009-10, mean incidence of 2005-08 was used. Results: 2005-10 showed an AR increase of 10.3% for pts 10-14 yrs, 17.9% for pts 15-19 yrs but only 4.6% for pts 20-24 yrs (Table). In 2010 AR was 54.4% for pts 10-14 yrs, 43.3% for 15-19 yr olds and 20.6% for pts 20-24. Annual increases of AR were observed for pts 15-19 yrs, but in no other age groups, 0-59 yrs. We looked at AR for children and younger teenagers , 5-14 yrs, vs older TYA, 15-24 yrs. Overall, AR for 5-14 yr olds was greater, 53.7% vs 23.0% for pts 15-24 yrs; however, during 2005-10 AR increased by 9.7% for pts aged 15-24 compared to 7.8% for pts aged 5-14. Conclusions: AR for TYA has improved in between 2005-10. Most benefit is evident for older teenagers; AR for young adults remain disappointing. Changes relate to increased trial availability and access, centralisation of care for TYA, amendments to age eligibility criteria to reflect tumour biology and increased collaboration between adult and paediatric clinical research groups. Strategies to improve AR for young adults require further development. [Table: see text]

Rates of inclusion of teenagers and young adults in England into National Cancer Research Network clinical trials: report from the National Cancer Research Institute (NCRI) Teenage and Young Adult Clinical Studies Development Group

Poor inclusion rates into clinical trials for teenagers and young adults (TYA; aged 13-24 years) have been assumed but not systematically investigated in England. We analysed accrual rates (AR) from 1 April 2005 up to 31 March 2007 to National Cancer Research Network (NCRN) Phase III trials for the commonest tumour types occurring in TYA and children: leukaemia, lymphoma, brain and central nervous system, bone sarcomas and male germ cell tumours. AR for 2005-2007 were 43.2% for patients aged 10-14 years, 25.2% for patients aged 15-19 years, and 13.1% for patients aged 20-24 years in the tumour types analysed. Compared with accrual from 1 April 2005 to 31 March 2006, AR between 1 April 2006 and 31 March 2007 increased for those aged 10-14 and 15-19 years, but fell for those aged 20-24 years. AR varied considerably among cancer types. Despite four trials being available, patients over 16 years with central nervous system tumours were not recruited. Rates of participation in clinical trials in England from 2005 to 2007 were much lower for TYA older than 15 years compared with children and younger teenagers. The variations in open trials, trial age eligibility criteria and extent of trial activation in treatment centres in part explain this observation. Other possible influences, such as difficulties associated with the consent of TYA require further evaluation. Closer dialogue between those involved in planning and running trials for children and for adults is necessary to improve trial availability and recruitment. Further research is required to identify trends in trial availability and accrual for those tumours constituting the remaining 26% of TYA cancers.