Clinical trial metrics: Protocol performance and resource utilization from 14 cancer centers

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Background: Observations at the authors’ institutions and by Dilts et al (JCO 2008, abstr 6534) indicate a high percentage of industry (IND)- and cooperative group (CG)-sponsored therapeutic clinical trials (TCTs) with minimal enrollment. We observed most of the enrollment from a small proportion of the TCTs. To determine if this data was representative of other cancer centers (CCs) we examined accrual to IND- and CG-sponsored adult TCTs from 14 CCs. Methods: Accrual data to IND- and CG-sponsored TCTs was obtained from 14 U.S. CCs. Data for the 3-year period from 2005 through 2007 was analyzed. Pediatric TCTs were excluded. Results: Of 2,685 TCTs, 1455 (54.2%) did not accrue any patients (pts). Only 713 (26.6%) TCTs enrolled > 2 pts and these TCTs provided 88.8% of the total enrollment. Resource utilization: We estimate > 230,000 hours (median: 3,773 hours per CC per year) were devoted to study start up and regulatory maintenance for the 1,455 TCTs that did not accrue any pts (Guidance Document for Implementing Effective Cancer Clinical Trials, www.c-changetogether.org/pubs/default.asp). Conclusions: Approximately 90% of the accrual to IND and CG TCTs is from 26% of these TCTs. Significant resources are used on TCTs that do not contribute significantly to overall accrual. Effective rules governing selection of IND and CG TCTs for activation are needed. Effective rules will enable centers to re-direct valuable resources to useful activities without adverse effect on overall enrollment.

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No significant financial relationships to disclose.

Evaluation of the half-life of intravenous human cytomegalovirus immune globulin in patients receiving partially mismatched related donor bone marrow transplantation

STUDY OBJECTIVE

To evaluate the pharmacokinetics and use of intravenous human cytomegalovirus immune globulin (CytoGam) in allogeneic bone marrow transplantation (BMT).

DESIGN

Prospective, nonrandomized, nonblinded, single-center study.

SETTING

University teaching hospital.

PATIENTS

Five consecutive patients with hematologic malignancies receiving partially mismatched related donor BMT with a uniform conditioning regimen including total body irradiation and chemotherapy.

INTERVENTION

Serum immunoglobulin and cytomegalovirus (CMV) titers were measured before and 24 hours after the first CytoGam infusion on day -6 during the conditioning regimen.

MEASUREMENTS AND MAIN RESULTS

These levels were measured every 5 days, and a second dose was administered when the CMV titer returned to 25-50% of the 24-hour level. The half-life of CytoGam was approximately 7 days.

CONCLUSION

We believe this is the first report of CytoGam's half-life in allogeneic BMT. The information may prove vital in a future study in which the agent's potential beneficial effects can be maximized.

Partially mismatched related-donor bone marrow transplantation for pediatric patients with acute leukemia: younger donors and absence of peripheral blasts improve outcome

PURPOSE

To extend access to bone marrow transplantation (BMT), we used partially mismatched related donors (PMRD) for pediatric patients with acute leukemia. In this report we sought to determine pretransplantation factors that might predict outcome.

PATIENTS AND METHODS

Of 67 such patients, 43 had acute lymphocytic leukemia and 24 had acute myelogenous leukemia. At the time of transplantation, 41 patients were in relapse. Donors included 40 parents, 24 siblings, and three cousins. HLA disparity of two to three major antigens was detected in two thirds of the donor-recipient pairs. Conditioning therapy, including total-body irradiation and chemotherapy followed by graft-versus-host disease (GvHD) prophylaxis with partial T-cell depletion of the graft using T10B9 or OKT3, was combined with posttransplantation immunosuppression.

RESULTS

Estimated probability (EP) of engraftment was 0.96 and was not affected by donor-antigen mismatch (AgMM; P =.732). EP of grades 2 to 4 acute GvHD was 0.24 and was not affected by recipient AgMM (P =.796). EP of disease-free survival was 0.26 at 3 years but improved to 0.45 when donors were younger than 30 years (P<.001). EP of relapse at 3 years was 0.41 and reduced with younger donors' age. For patients who were in relapse at the time of transplantation, absence of blasts was associated with a lower relapse rate (0.46 v. 0.84; P =. 083), similar to that of patients in remission.

CONCLUSION

PMRD-BMT in pediatric leukemia resulted in high engraftment and low GvHD rates. To improve outcomes, younger donors should be sought, and clinicians should attempt to reduce peripheral blasts in patients who are in relapse.

A multivariate approach for assessing severity of acute graft-versus-host disease in bone marrow transplantation

Patients undergoing bone marrow transplantation are at high risk of developing acute graft-versus-host disease (GVHD) which is a primary limiting factor for this procedure inasmuch as it is responsible for high morbidity rates and is associated with poor survival outcome. To provide improved treatment assessment and better interpretation of clinical outcomes, we need a precise and objective assessment of GVHD. Severity of GVHD is commonly assessed using an imprecise categorical grading system that incorporates skin, gut and liver grades, as well as subjective assessment of clinical performance. These organ grades are based on arbitrary cutpoints of skin rash, diarrhoea volume and bilirubin level. The International Bone Marrow Transplant Registry proposed an alternative grading system based on different combinations of organ involvement and provided estimates of relative risk of treatment failure. On the basis of that work, we developed an empirical mathematical model that quantifies GVHD severity, and that uses continuous, rather than categorical, daily measurements for each organ system. We use model-predicted values as an index of severity for any combination of values. The proposed index allows a more precise comparison of GVHD profiles across different treatment protocols and also permits more refined analyses to address relationships between GVHD and clinical outcomes.