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Ferguson RE, Leatherman SM, Woods P, Hau C, Lew R, Cushman WC, Brophy MT, Fiore L, Ishani A. Practical issues in pragmatic trials: the implementation of the Diuretic Comparison Project. Clin Trials 2023; 20:276-283. [PMID: 36992530 DOI: 10.1177/17407745231160553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
BACKGROUND/AIMS The US Department of Veterans Affairs Point of Care Clinical Trial Program conducts studies that utilize informatics infrastructure to integrate clinical trial protocols into routine care delivery. The Diuretic Comparison Project compared hydrochlorothiazide to chlorthalidone in reduction of major cardiovascular events in subjects with hypertension. Here we describe the cultural, technical, regulatory, and logistical challenges and solutions that enabled successful implementation of this large pragmatic comparative effectiveness Point of Care clinical trial. METHODS Patients were recruited from 72 Veterans Affairs Healthcare Systems using centralized processes for subject identification, obtaining informed consent, data collection, safety monitoring, site communication, and endpoint identification with minimal perturbation of the local clinical care ecosystem. Patients continued to be managed exclusively by their clinical care providers without protocol specified study visits, treatment recommendations, or data collection extraneous to routine care. Centralized study processes were operationalized through the application layer of the electronic health record via a data coordinating center staffed by clinical nurses, data scientists, and statisticians without site-based research coordinators. Study data was collected from the Veterans Affairs electronic health record supplemented by Medicare and National Death Index data. RESULTS The study exceeded its enrolled goal (13,523 subjects) and followed subjects for the 5-year study duration. The key determinant of program success was collaboration between researchers, regulators, clinicians, and administrative staff at the site level to customize study procedures to align with local clinical practice. This flexibility was enabled by designation of the study as minimal risk and determination that clinical care providers were not engaged in research by the Veterans Affairs Central Institutional Review Board. Cultural, regulatory, technical, and logistical problems were identified and solved through iterative collaboration between clinical and research entities. Paramount among these problems was customization of the Veterans Affairs electronic health record and data systems to accommodate study procedures. CONCLUSIONS Leveraging clinical care for large-scale clinical trials is feasible but requires a rethinking of traditional clinical trial design (and regulation) to better meet requirements of clinical care ecosystems. Study designs must accommodate site-specific practice variation to reduce the impact on clinical care. A tradeoff thus exists between designing trial processes tailored to expedite local study implementation versus those to produce a more refined response to the research question. The availability of a uniform and flexible electronic health record in the Department of Veterans Affairs played a major role in the success of the trial. Conducting Point of Care research in other healthcare systems without such research-friendly infrastructure presents a more formidable challenge.
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Affiliation(s)
- Ryan E Ferguson
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sarah M Leatherman
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Patricia Woods
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
| | - Cynthia Hau
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
| | - Robert Lew
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - William C Cushman
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mary T Brophy
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Louis Fiore
- VA Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, USA
| | - Areef Ishani
- Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Graff JN, Huang GD. Leveraging Veterans Health Administration Clinical and Research Resources to Accelerate Discovery and Testing in Precision Oncology. Fed Pract 2020; 37:S62-S67. [PMID: 32908354 DOI: 10.12788/fp.0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objective The promise of precision oncology, which is the ability to choose a treatment specific to the characteristics of the tumor, has arrived. There are targeted therapies based on tumor mutations in multiple cancer types, both approved and in development. The US Department of Veterans Affairs (VA) has embraced precision oncology for the treatment of patients with prostate cancer. Observations This article focuses on the efforts to bring precision oncology treatments and trials to veterans with prostate cancer through the Precision Oncology Program for Cancer of Prostate (POPCaP) Centers of Excellence (COE) and the clinical trials consortium inside POPCaP, Prostate Cancer Analysis for Therapy CHoice (PATCH). Through POPCaP, VA has analyzed hundreds of prostate cancer tumors to identify mutations and develop treatment plans for veterans with prostate cancer. PATCH will leverage the genetic data and prostate cancer expertise of POPCaP COEs to develop clinical trials for veterans that take a precision oncology approach to care. Conclusions With its extensive resources and capabilities, VA has the ability to advance a precision oncology agenda that provides veterans with the highest standard of care. It has built upon many key elements in clinical, technological and scientific fields of study that would challenge most other health care systems given the extensive costs involved.
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Affiliation(s)
- Julie N Graff
- is Section Chief of Hematology/Oncology at VA Portland Health Care System in Oregon. is Acting Deputy Chief Research and Development - Enterprise Optimization and Director, Cooperative Studies Program in the Office of Research and Development, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC. Julie Graff is also an Associate Professor of Medicine at Knight Cancer Institute, Oregon Health Sciences University in Portland
| | - Grant D Huang
- is Section Chief of Hematology/Oncology at VA Portland Health Care System in Oregon. is Acting Deputy Chief Research and Development - Enterprise Optimization and Director, Cooperative Studies Program in the Office of Research and Development, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, DC. Julie Graff is also an Associate Professor of Medicine at Knight Cancer Institute, Oregon Health Sciences University in Portland
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Do N, Grossman R, Feldman T, Fillmore N, Elbers D, Tuck D, Dhond R, Selva L, Meng F, Fitzsimons M, Ajjarapu S, Ayandeh S, Hall R, Do S, Brophy M. The Veterans Precision Oncology Data Commons: Transforming VA data into a national resource for research in precision oncology. Semin Oncol 2019; 46:314-320. [PMID: 31629530 DOI: 10.1053/j.seminoncol.2019.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 09/17/2019] [Indexed: 01/14/2023]
Abstract
The Department of Veterans Affairs (VA) has a strong track record providing high-quality, evidence-based care to cancer patients. In order to accelerate discoveries that will further improve care for Veterans with cancer, the VA has partnered with the Center for Translational Data Science at the University of Chicago and the Open Commons Consortium to establish a data sharing platform, the Veterans Precision Oncology Data Commons (VPODC). The VPODC makes clinical, genomic, and imaging data from the VA available to the research community at large. In this paper, we detail our motivation for data sharing, describe the VPODC, and outline our collaboration model. By transforming VA data into a national resource for research in precision oncology, the VPODC seeks to foster innovation through collaboration and resource sharing that will ultimately lead to improved care for Veterans with cancer.
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Affiliation(s)
- Nhan Do
- VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts.
| | | | - Theodore Feldman
- VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts
| | - Nathanael Fillmore
- VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts
| | - Danne Elbers
- VA Boston Healthcare System, University of Vermont, Burlington, Vermont
| | - David Tuck
- VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts
| | - Rupali Dhond
- VA Boston Healthcare System, Boston, Massachusetts
| | - Luis Selva
- VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts
| | - Frank Meng
- VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts
| | | | - Samuel Ajjarapu
- VA Boston Healthcare System, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Robert Hall
- VA Boston Healthcare System, Boston, Massachusetts
| | - Stephanie Do
- VA Boston Healthcare System, College of William and Mary, Williamsburg, Virginia
| | - Mary Brophy
- VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts
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Dalton WS, Sullivan D, Ecsedy J, Caligiuri MA. Patient Enrichment for Precision-Based Cancer Clinical Trials: Using Prospective Cohort Surveillance as an Approach to Improve Clinical Trials. Clin Pharmacol Ther 2018; 104:23-26. [PMID: 29570791 PMCID: PMC6032821 DOI: 10.1002/cpt.1051] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 02/12/2018] [Accepted: 02/16/2018] [Indexed: 12/12/2022]
Abstract
Technological advances have led to the identification of biomarkers and development of novel target-based therapies. While some novel therapies have improved patient outcomes, the prevalence and diversity of biomarkers and targets in patient populations, especially patients with cancer, has created a challenge for the design and performance of clinical trials. To address this challenge we propose that prospective cohort surveillance of patients may be a solution to promote clinical trial matching for patients in need.
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Affiliation(s)
| | - Daniel Sullivan
- Clinical Science, H. Lee Moffitt Cancer CenterTampaFloridaUSA
| | - Jeffrey Ecsedy
- Translational Medicine, Takeda Pharmaceuticals International CoCambridgeMassachusettsUSA
| | - Michael A. Caligiuri
- Ohio State University Comprehensive Cancer Center; The James Cancer Hospital and Solove Research InstituteOhio State UniversityColumbusOhioUSA
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Pettit SD, Kirch R. Do current approaches to assessing therapy related adverse events align with the needs of long-term cancer patients and survivors? CARDIO-ONCOLOGY (LONDON, ENGLAND) 2018; 4:5. [PMID: 32154005 PMCID: PMC7048033 DOI: 10.1186/s40959-018-0031-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/30/2018] [Indexed: 01/29/2023]
Abstract
The increasing efficacy of cancer therapeutics means that the timespan of cancer therapy administration is undergoing a transition to increasingly long-term settings. Unfortunately, chronic therapy-related adverse health events are an unintended, but not infrequent, outcome of these life-saving therapies. Historically, the cardio-oncology field has evolved as retrospective effort to understand the scope, mechanisms, and impact of treatment-related toxicities that were already impacting patients. This review explores whether current systemic approaches to detecting, reporting, tracking, and communicating AEs are better positioned to provide more proactive or concurrent information to mitigate the impact of AE's on patient health and quality of life. Because the existing tools and frameworks for capturing these effects are not specific to cardiology, this study looks broadly at the landscape of approaches and assumptions. This review finds evidence of increasing focus on the provision of actionable information to support long-term health and quality of life for survivors and those on chronic therapy. However, the current means to assess and support the impact of this burden on patients and the healthcare system are often of limited relevance for an increasingly long-lived survivor and patient population.
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Affiliation(s)
- Syril D. Pettit
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC USA
- Health and Environmental Sciences Institute, Washington DC, USA
| | - Rebecca Kirch
- National Patient Advocate Foundation, Washington DC, USA
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Lee CSE, Fiore LD. Defining next generation medicine for the patient through translational care: big data scientist training enhancement program (BD-STEP). CONVERGENT SCIENCE PHYSICAL ONCOLOGY 2017. [DOI: 10.1088/2057-1739/aa9264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Stucky A, Sedghizadeh PP, Mahabady S, Chen X, Zhang C, Zhang G, Zhang X, Zhong JF. Single-cell genomic analysis of head and neck squamous cell carcinoma. Oncotarget 2017; 8:73208-73218. [PMID: 29069864 PMCID: PMC5641207 DOI: 10.18632/oncotarget.18021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 05/10/2017] [Indexed: 01/16/2023] Open
Abstract
Head and neck squamous cell carcinoma (HNSCC) incidence or rates have increased dramatically recently with little improvement in patient outcomes. There is an unmet need in HNSCC to develop reliable molecular markers capable of evaluating patient risks and advising treatments. This review focuses on recent developments in single-cell molecular analysis of cancer, and its applications for HNSCC diagnosis and treatments. For proof of concept, we examined gene expression levels of 62 patients with HNSCC, and correlate the gene expression profiles to single-cell gene expression profiles obtained from a pilot single-cell study of CCR5-positive breast carcinoma cells. The single-cell molecular analyses complemented the lysate data and reveals heterogeneity of oncogenesis pathways with the cancer cell population. Our single-cell molecular analysis indicated that molecular heterogeneity exists in HNSCC and should be addressed in treatment strategy of HNSCC. Single-cell molecular technology can have significant impact on diagnosis, therapeutic decision making, and prognosis of HNSCC.
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Affiliation(s)
- Andres Stucky
- Division of Periodontology, Diagnostic Sciences and Dental Hygiene, and Division of Biomedical Sciences, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
| | - Parish P Sedghizadeh
- Division of Periodontology, Diagnostic Sciences and Dental Hygiene, and Division of Biomedical Sciences, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
| | - Susan Mahabady
- Division of Periodontology, Diagnostic Sciences and Dental Hygiene, and Division of Biomedical Sciences, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
| | - Xuelian Chen
- Division of Periodontology, Diagnostic Sciences and Dental Hygiene, and Division of Biomedical Sciences, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
| | - Cheng Zhang
- Division of Periodontology, Diagnostic Sciences and Dental Hygiene, and Division of Biomedical Sciences, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA.,Department of Hematology and Blood Transfusion, Xinqiao Hospital, Third Military Medical University, Chongqing, P. R. China
| | - Gang Zhang
- Division of Periodontology, Diagnostic Sciences and Dental Hygiene, and Division of Biomedical Sciences, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA.,Department of Oral and Maxillofacial Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, P. R. China
| | - Xi Zhang
- Division of Periodontology, Diagnostic Sciences and Dental Hygiene, and Division of Biomedical Sciences, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA.,Department of Hematology and Blood Transfusion, Xinqiao Hospital, Third Military Medical University, Chongqing, P. R. China
| | - Jiang F Zhong
- Division of Periodontology, Diagnostic Sciences and Dental Hygiene, and Division of Biomedical Sciences, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA
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