Ethical and practical problems of early anti-cancer drug trials: a review of the literature

Dose Finding in Oncology Trials Guided by Ordinal Toxicity Grades Using Continuous Dose Levels

We present a Bayesian adaptive design for dose finding in oncology trials with application to a first-in-human trial. The design is based on the escalation with overdose control principle and uses an intermediate grade 2 toxicity in addition to the traditional binary indicator of dose-limiting toxicity (DLT) to guide the dose escalation and de-escalation. We model the dose-toxicity relationship using the proportional odds model. This assumption satisfies an important ethical concern when a potentially toxic drug is first introduced in the clinic; if a patient experiences grade 2 toxicity at the most, then the amount of dose escalation is lower relative to that wherein if this patient experienced a maximum of grade 1 toxicity. This results in a more careful dose escalation. The performance of the design was assessed by deriving the operating characteristics under several scenarios for the true MTD and expected proportions of grade 2 toxicities. In general, the trial design is safe and achieves acceptable efficiency of the estimated MTD for a planned sample size of twenty patients. At the time of writing this manuscript, twelve patients have been enrolled to the trial.

Patients' selection and trial matching in early-phase oncology clinical trials

BACKGROUND

Early-phase clinical trials (EPCT) represent an important part of innovations in medical oncology and a valuable therapeutic option for patients with metastatic cancers, particularly in the era of precision medicine. Nevertheless, adult patients' participation in oncology clinical trials is low, ranging from 2% to 8% worldwide, with unequal access, and up to 40% risk of early discontinuation in EPCT, mostly due to cancer-related complications.

DESIGN

We review the tools and initiatives to increase patients' orientation and access to early phase cancer clinical trials, and to limit early discontinuation.

RESULTS

New approaches to optimize the early-phase clinical trial referring process in oncology include automatic trial matching, tools to facilitate the estimation of patients' prognostic and/or to better predict patients' eligibility to clinical trials. Classical and innovative approaches should be associated to double patient recruitment, improve clinical trial enrollment experience and reduce early discontinuation rates.

CONCLUSIONS

Whereas EPCT are essential for patients to access the latest medical innovations in oncology, offering the appropriate trial when it is relevant for patients should increase by organizational and technological innovations. The oncologic community will need to closely monitor their performance, portability and simplicity for implementation in daily clinical practice.

Barriers and facilitators to the participation of subjects in clinical trials: An overview of reviews

BACKGROUND

The demand for clinical trial participants is today one of the highest it has ever been and continues to increase. At the same time, subject recruitment continues to be problematic and the major reason for clinical trial premature terminations. The literature on clinical trial recruitment, which spans several decades and includes hundreds of studies, has an abundance of findings that can be synthesized by way of an overview to provide a well-informed and complete picture of the factors that determine subject participation.

OBJECTIVES

An overview of the systematic reviews that report barriers and facilitators to clinical trial participation was conducted. The extracted data were synthesized, and a thematic framework of the factors that affect subject participation in clinical trials was developed. The overview extended across medical subjects and demographics.

METHODS

Thirty reviews that complied with the inclusion criteria were included. These reviews covered 753 relevant primary studies and reported 881 barriers and facilitators. The barriers and facilitators were thematically synthesized and a thematic framework of 20 themes was developed. The quality of the included reviews was assessed and reported.

MAIN RESULTS

Several opportunities to increase clinical trial participation, by developing interventions and changing the trial design, derived from an analysis of the thematic framework. That analysis also showed that most of the 20 themes operate mainly as a barrier or as a facilitator, and that most have an effect across medical subjects. As to the quality elements assessed, some reviews complied almost fully but most only partially.

Participant Perspectives in an HIV Cure-Related Trial Conducted Exclusively in Women in the United States: Results from AIDS Clinical Trials Group 5366

Women remain underrepresented in HIV research. The AIDS Clinical Trials Group (ACTG) 5366 study was the first HIV cure-related trial conducted exclusively in women. Our multidisciplinary team integrated participant-centered reports into the ACTG 5366 protocol to elicit their perspectives. We nested mixed-methods surveys at the enrollment and final study visits to assess ACTG 5366 participants' perceptions and experiences. Of 31 participants enrolled in the ACTG 5366, 29 study agreed to complete the entry questionnaire and 27 completed the exit survey. The majority of study participants were nonwhite. We identified societal and personal motivators for participation, understanding of risks and benefits, and minor misconceptions among some trial participants. Stigma was pervasive for several women who joined the study, and served as a motivator for study participation. Reimbursements to defray costs of study participation were reported to facilitate involvement in the trial by about one-third of participants. Almost all respondents reported positive experiences participating in the ACTG 5366 trial. The ACTG 5366 study showed that it is possible to recruit and retain women in HIV cure-related research and to embed participant-centered outcomes at strategic time points during the study. The findings could help in the design, implementation, recruitment, and retention of women in HIV cure-related research and highlight the value of assessing psychosocial factors in HIV cure-related research participation.

A Model of Cancer Clinical Trial Decision-making Informed by African-American Cancer Patients

BACKGROUND

Clinical trials are critical to advancing cancer treatment. Minority populations are underrepresented among trial participants, and there is limited understanding of their decision-making process and key determinants of decision outcomes regarding trial participation.

METHODS

To understand research decision-making among clinical trial-eligible African-American cancer patients at Johns Hopkins, we conducted seven focus groups (n=32) with trial-offered patients ≥ 18 years diagnosed with lung, breast, prostate, or colorectal cancer ≤ 5 years. Three "acceptor" and four "decliner" focus groups were conducted. Questions addressed: attitudes towards clinical trials, reasons for accepting or declining participation, and recommendations to improve minority recruitment and enrollment. Data were transcribed and analyzed using traditional approaches to content and thematic analysis in NVivo 9.0. Data coding resulted in themes that supported model construction.

RESULTS

Participant experiences revealed the following themes when describing the decision-making process: Information gathering, Intrapersonal perspectives, and Interpersonal influences. Decision outcomes included the presence or absence of decision regret and satisfaction. From these themes, we generated a Model of Cancer Clinical Trial Decision-making.

CONCLUSION

Our model should be tested in hypothesis-driven research to elucidate factors and processes influencing decision balance and outcomes of trial-related decision-making. The model should also be tested in other disparities populations and for diagnoses other than cancer.

"I didn't really understand it, I just thought it'd help": exploring the motivations, understandings and experiences of patients with advanced lung cancer participating in a non-placebo clinical IMP trial

BACKGROUND

Few studies have explored in depth the experiences of patients with advanced cancer who are participating in clinical investigational medicinal product trials. However, integrated qualitative studies in such trials are needed to enable a broader evaluation of patient experiences in the trial, with important ethical and practical implications for the design and conduct of similar trials and treatment regimes in the future.

METHODS

Ten participants were recruited from the control and intervention arms of FRAGMATIC: a non-placebo trial for patients with advanced lung cancer. Participants were interviewed at up to three time points during their time in the trial. Interviews were analysed using Interpretive Phenomenological Analysis.

RESULTS

Patients were motivated to join the trial out of hope of medical benefit and altruism. Understanding of randomisation was mixed and in some cases poor, as was appreciation of trial purpose and equipoise. The trial was acceptable to and evaluated positively by most participants; participants receiving the intervention focused on the potential treatment benefits they hoped they would receive, whilst participants in the control arm found alternative reasons, such as altruism, personal fulfilment and positive attention, to commit to and perceive benefits from the trial. However, whilst experiences were generally very positive, poor understanding, limited engagement with trial information and focus on treatment benefits amongst some participants give cause for concern.

CONCLUSIONS

By exploring longitudinally the psychological, emotional and cognitive domains of trial participation, we consider potential harms and benefits of participation in non-placebo trials amongst patients with advanced lung cancer and identify several implications for future research with and care for patients with advanced cancer.

TRIAL REGISTRATION

ISRCTN80812769 . Registered on 8 July 2005.

Why do patients decline surgical trials? Findings from a qualitative interview study embedded in the Cancer Research UK BOLERO trial (Bladder cancer: Open versus Lapararoscopic or RObotic cystectomy)

BACKGROUND

Surgical trials have typically experienced recruitment difficulties when compared with other types of oncology trials. Qualitative studies have an important role to play in exploring reasons for low recruitment, although to date few such studies have been carried out that are embedded in surgical trials. The BOLERO trial (Bladder cancer: Open versus Lapararoscopic or RObotic cystectomy) is a study to determine the feasibility of randomisation to open versus laparoscopic access/robotic cystectomy in patients with bladder cancer. We describe the results of a qualitative study embedded within the clinical trial that explored why patients decline randomisation.

METHODS

Ten semi-structured interviews with patients who declined randomisation to the clinical trial, and two interviews with recruiting research nurses were conducted. Data were analysed for key themes.

RESULTS

The majority of patients declined the trial because they had preferences for a particular treatment arm, and in usual practice could choose which surgical method they would be given. In most cases the robotic option was preferred. Patients described an intuitive 'sense' that favoured the new technology and had carried out their own inquiries, including Internet research and talking with previous patients and friends and family with medical backgrounds. Medical histories and lifestyle considerations also shaped these personalised choices. Of importance too, however, were the messages patients perceived from their clinical encounters. Whilst some patients felt their surgeon favoured the robotic option, others interpreted 'indirect' cues such as the 'established' reputation of the surgeon and surgical method and comments made during clinical assessments. Many patients expressed a wish for greater direction from their surgeon when making these decisions.

CONCLUSION

For trials where the 'new technology' is available to patients, there will likely be difficulties with recruitment. Greater attention could be paid to how messages about treatment options and the trial are conveyed across the whole clinical setting. However, if it is too difficult to challenge such messages, then questions should be asked about whether genuine and convincing equipoise can be presented and perceived in such trials. This calls for consideration of whether alternative methods of generating evidence could be used when evaluating surgical techniques which are established and routinely available.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

ISRCTN38528926 (11 December 2008).

Ethical challenges in cancer research in children

Clinical research has led to great advances in cancer therapy for children, and a greater proportion of children than adults with cancer participate in clinical trials. Despite this success, there remain important ethical challenges in conducting this research. There are challenges in obtaining informed consent and assent when children are research subjects; challenges arising from study design issues in phase III, II, or I clinical trials; and challenges related to the development of new classes of drugs, especially molecularly targeted therapies. It is important for researchers and clinicians to understand these challenges so that progress in cancer treatment is achieved in a sound ethical and regulatory fashion.

Why patients don't take part in cancer clinical trials: an overview of the literature

Clinical trials have been recognized extensively within the literature as a crucial component in the research, development and evaluation of treatment strategies within health care services. However, it has also been acknowledged that clinicians and researchers have historically experienced problems in terms of attaining adequate recruitment to clinical trials. The purpose of this review is to explore some of these questions and, more importantly, provide possible explanations for non-participation in clinical trials, with specific reference to the field of cancer research. In addition, approaches that have been used by researchers in order to explore the issue of non-participation, and suggestions in terms of the ways that further research into this key area may be undertaken, are also be considered.

Informed consent and decision-making: patients' experiences of the process of recruitment to phases I and II anti-cancer drug trials

This paper presents an examination of the process of recruitment in cancer clinical trials. This research was undertaken as part of a larger study which sought to assess the psychosocial impact of participation in phases I and II anti-cancer drug trials from the patient's perspective. Through a combination of in-depth interviews with 55 patients who were offered participation in a clinical trial, and reading ease assessments of the written information they were given, patients' experiences of recruitment to the trial and their perceptions of the informed consent process were obtained. The results indicate that patients decisions may be influenced by the way information was presented to them verbally and that the written information was difficult for them to understand. This aspect of the research identified the powerful influence of the verbal consultation when seeking consent for trial involvement, the lack of understanding patients had of what they were taking part in and the need to address the readability of the written information with which they are provided.

A need to try everything: patient participation in phase I trials

RATIONALE

The area of phase I trials is fraught with ethical dilemmas and controversy. Most existing research focuses on issues of human rights and the informed consent procedure. Little attention has been given to patients' perceptions of participating in such trials.

DESIGN

This paper describes a study using qualitative interviews and open-stem questionnaires to begin to explore patients' own perceptions of any benefits from participating in phase I trials.

RESULTS

Findings suggest that for some patients, phase I trials fulfil a need to try everything in their fight against cancer. The study also suggests that being on treatment allows some patients to construct their lives meaningfully by providing a supportive structure and enabling hope. Implications for nursing practice and further research are discussed.

Enhancing cancer clinical trial management: recommendations from a qualitative study of trial participants' experiences

Using a qualitative approach, a total of 55 adult patients with advanced cancer were interviewed to examine their perceptions of participating in early phase anti-cancer drug trials. Patients' views and experiences were explored, primarily through the use of in-depth interviews, with additional information accessed through two widely-used quality of life questionnaires, at the beginning of, during and after trial participation. The picture of trial participation established from this work suggests that it is a dynamic process, that has a different meaning and impact according to the stage of trial involvement the patient is experiencing. The findings identify how patients perceived the offer of the trial, dealt with the trial treatment, and came to terms with trial conclusion. The insight and understanding that this work provides in terms of the impact of trial involvement over time as well as details of patients' information, decision-making and support needs has significant implications for cancer clinical trial management. The recommendations put forward in this paper focus on acknowledging the contribution trial participants make to cancer research, enhancing the process of preparing patients for trial participation, recognizing the need for continuing care, the incorporation of patients and potential patients' views into the clinical trials system, and educating the public about clinical trials.

Coping with new treatments for cancer: a feasibility study of daily diary measures

This article describes a study of the feasibility and value of using daily diary measures to assess coping, adjustment and symptoms in patients participating in phase I clinical trials of new anticancer drugs. Ten patients (six women, four men) with advanced metastatic cancer were studied during a four-week phase I trial. Measures of psychological well-being, mental adjustment and symptoms were determined prior to treatment, and participants also completed daily ratings of psychological coping responses, mood and symptoms. Completion rates for diaries were high, and the amount of missing data averaged only 3.2% per patient. Overall, the most frequently endorsed coping responses were 'acceptance' and 'positive reinterpretation and growth'. There were systematic variations in coping by seeking social support across the trial, with more frequent use during phases of hospitalisation. Idiosyncratic fluctuations in patterns of coping were also observed. Positive daily mood was greater among patients who coped by ignoring their condition, and was also correlated with fighting spirit. Daily symptoms were inversely associated with positive mood and with fighting spirit. It is concluded that the daily diary approach is feasible, and may help to increase understanding of the experience of patients taking part in experimental anticancer drug trials.

Ethical dimensions of psychiatric research: a constructive, criterion-based approach to protocol preparation. The Research Protocol Ethics Assessment Tool (RePEAT)

Preparing experimental protocols that are ethically sound, possess scientific merit, and meet institutional and national standards for human subject protections is a key responsibility of psychiatric investigators. This task has become increasingly complex due to developments in biomedical science, bioethics, and society at large. Practical and constructive approaches to help investigators in their efforts to create protocols that are ethically acceptable have nevertheless received little attention. To better address this gap, the Research Protocol Ethics Assessment Tool (RePEAT) was developed as an educational instrument to help assure that ethically important elements, including scientific design features, are explicitly addressed by investigators in their work with protocols involving human participants. The RePEAT is a brief evaluative checklist that reflects rigorous ethical standards, particularly with respect to criteria for studies that may involve individuals with compromised decisional abilities. For this reason, it may be especially beneficial as a self-assessment tool for investigators and protocol reviewers in psychiatry. To stimulate education and dialogue, this report presents the RePEAT and outlines its content, format, use, and limitations.

Nursing, morality, and emotions: phase I and phase II clinical trials and patients with cancer

This article reflects three nurses' views of the moral dimensions of their work in caring for patients receiving phases I and II of cancer clinical trials in a dedicated cancer clinical trials unit (CCTU). The nurses took part in a semistructured, tape-recorded, group interview in which they talked about any aspect of their work that they felt demonstrated its ethical or moral dimensions. The nurses were not employed as research nurses, but had chosen to specialize in cancer and palliative care in a CCTU environment. Three key themes emerged from the interview: being valued and moral distress; caring in a climate of scientific research; and care, cure, and consequences for moral reasoning. Working in an environment suffused with moral conflicts can be painful and damaging for the professionals involved. It would appear that if nurses are to function effectively, they need to be proactive in promoting an exploration of the role that emotions play in moral decision making and in examining the contribution of emotions to what they care about and why. A commitment to a shared understanding and valuing of divergent ethical reasoning in and across professional cultures of care and research paradigms also appears to be necessary. The terms "ethics" and "morals" are used interchangeably throughout this article.

Investigating psychosocial aspects of participation in early anti-cancer drug trials: towards a choice of methodology

This paper presents the methodological approach and research methods chosen to explore psychosocial aspects of participation in early anti-cancer drug trials from the perspective of those actually involved. The paper describes how an appropriate methodology, or principles of reasoning behind the choice of research methods, emerged. The choice of methodology was based on three elements: first, an understanding of the competing philosophies about how research can be approached and conducted; second, the author's view of the subject area; and third, a consideration of previous research approaches which have investigated psychosocial aspects of cancer clinical trials. A qualitative methodology situated within an interpretative paradigm was eventually chosen as the most appropriate means of exploring trial participants' experiences and the aim and objectives of the research were developed within this methodological framework.

Analysis and presentation. Clinical trials on prostate cancer

OBJECTIVE

To present guidelines for the analysis and presentation of clinical trials on prostate cancer.

METHODS

Textbooks in statistics and oncology were searched for information, as were separate articles on the topic. Previously published advice was fused with own experience.

RESULTS

Minimum key points are given for the sections: Introduction, Materials and Methods, Results, Discussion, and Summary. The importance of 1 primary question in any clinical trial is stressed. The value of a detailed presentation of the trial design, the patient population and the inclusion/exclusion criteria, the characterization of the disease, the treatment schedules, and toxicity is underlined. Application of various statistical methods for different endpoints is suggested. Maturity of data, time for publication, and avoidance of publication bias are discussed. Some common pitfalls in the statistical analyses of clinical results are indicated. The impact of prognostic factors, proper staging procedures, and secondary treatments on the interpretation of survival analysis is pointed out. A shift from the (mis-)use of the P value in favor of confidence intervals is strongly encouraged. The use of comparing the survival of responders versus nonresponders is to be abandoned. A few practical hints concerning the presentation are offered. The minimum of data that should be presented in absolute numbers is indicated. Also, the data that should be provided in both graphic and numeric format are exemplified. Examples of essential graphic illustrations are provided. The need for improvements in the design analysis, and presentation of clinical trials is reemphasized. Finally, numerous references are listed. The article is addressed not only to authors and readers of clinical trials, but also to editors of medical journals.

CONCLUSION

The suggested guidelines may be useful in the analysis, presentation, and interpretation of clinical trials on prostate cancer. Moreover, compliance with these guidelines may facilitate comparisons with other similar trials and also, the incorporation of single studies into metaanalyses.