Tracking clinical trial accrual strategies and barriers via a Web-based screening tool

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Background: The National Cancer Institute Community Cancer Centers Program (NCCCP) has developed a web based tracking tool to monitor screening of patients for clinical trial participation. The system is designed to collect data from multiple research sites throughout the geographically diverse group. The log blindly collects patient demographics, successful trial entry, and reasons for trial enrollment failure. Methods: Seven NCCCP sites utilized the log during the 60 day open accrual period for the Wake Forrest WFU 07–02–03 cancer control trial (chronic lymphocytic leukemia COLD- fX) in Novermber 2008 and December 2008. Results: 327 chronic lymphocytic leukemia patients were screened mostly by chart review. 162 (50%) were eligible for study entry. 45 (14%) entered the trial. 103 (31%) eligible patients declined entry. Of the 103, 72 (70%) did not wish to participate in research, 15 (15%) had travel constraints, 5 (5%) perceived excess toxicity, 9 (9%) gave no reason. 14 (3%) eligible had their physician decline entry. Overall, 28% of eligible patients entered the trial. 165 (50%) were trial ineligible. 82 (50%) for prior therapy, 30 (18%) for co morbid conditions, 10 (6%) missed an entry time requirement, 39 (24%) have incomplete data. Conclusions: The NCCCP trial screening log successfully captures real time clinical trial participation data from a diverse network of clinical trial sites. This data base will allow future analysis of individual clinical trial and site accrual barriers and empower strategies to increase trial participation.

No significant financial relationships to disclose.

Is it cost-effective to add erlotinib to gemcitabine in advanced pancreatic cancer?

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Background: Single agent gemcitabine has been considered the standard of care in advanced pancreatic cancer since 1996. A recent 569 patient randomized trial comparing gemcitabine alone with gemcitabine + erlotinib as first line therapy found a small but statistically significant difference in survival (6.0 vs 6.4 months, respectively, p = .028). The impact on survival may be small, but with nearly 33,000 new cases of pancreatic cancer per year, the impact on health care costs with the use of the combined regimen may be large. Using the known survival data and costs, we analyzed the incremental cost-effectiveness of adding erlotinib. Methods: Costs for a six month course of gemcitabine were developed using Medicare reimbursement from the January, 2006 CMS Drug Payment Table and Physician Fee Schedule assuming no change in infusion reimbursement. Since erlotinib is not approved as a Medicare Part B drug, costs were developed from wholesale and retail sources. Drug dosing and schedules were based on the clinical trial protocol leading to approval. Incremental cost effectiveness of adding erlotinib was calculated. Results: Six month course of gemcitabine alone costs $23,493. The addition of erlotinib increases cost by $12,156 wholesale or $16,613 retail. Given an increase of 0.4 months in median survival over gemcitabine alone, the addition of erlotinib costs $364,680 per year of life gained (YLG) wholesale and $498,379/YLG retail. Sensitivity analyses were conducted assuming shorter therapy of 4 and 5 months. In order to be cost effective even at the $100,000/YLG level, six months of erlotinib would have to be reduced to 20% of the current retail cost (lowered to $18.52 per tablet.) Conclusions: Adding erlotinib to gemcitabine does not approach cost effectiveness at even the highest year per life gained parameters. Such impacts on health care costs, especially for very small gains, become more pressing as all health care costs continue to increase.

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Phase II study of recombinant alpha-2 interferon in resistant multiple myeloma

A multicenter phase II study of INTRON, recombinant alpha-2 interferon (Schering Corp, Kenilworth, NJ), in patients with relapsing or refractory myeloma was initiated. Patients received either intravenous therapy for two weeks followed by subcutaneous therapy or subcutaneous dosing from initiation of treatment. Of 38 evaluable patients, 19 were refractory and 19 had relapsed at entry. Twenty-five of 38 had received prior treatment with multiple drugs. Responses were seen among 2/19 refractory patients and 5/19 relapsing patients. Three of seven responders continue to respond for more than one year while receiving maintenance therapy. Most patients experienced improvement in bone pain, and one patient, with a complete response, had healing of bone lesions. Survival curves show a statistically significant improvement in survival for responders v nonresponders. INTRON was well-tolerated with only four patients discontinuing treatment due to adverse effects. Thirty-two percent of patients had hematologic toxicity requiring dose adjustment; however, there was no evidence of cumulative hematologic toxicity. No patients developed serum neutralizing factors to interferon. Additional trials are warranted to study the activity of INTRON in previously untreated patients.

The thoracic windows for electrical ventricular defibrillation current

The thoraces of dogs were mapped out to identify those areas where defibrillating current gains easiest access to the heart. Of all of the transchest and chest-to-back electrode locations, the lowest current dose (0.6 amp. per kilogram of body weight) was found with one electrode over the apex-beat area with transchest electrodes and slightly anterior to the apex-beat area with chest-to-back electrodes.