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Stewart DJ, Bradford JP, Sehdev S, Ramsay T, Navani V, Rawson NSB, Jiang DM, Gotfrit J, Wheatley-Price P, Liu G, Kaplan A, Spadafora S, Goodman SG, Auer RAC, Batist G. New Anticancer Drugs: Reliably Assessing "Value" While Addressing High Prices. Curr Oncol 2024; 31:2453-2480. [PMID: 38785465 PMCID: PMC11119944 DOI: 10.3390/curroncol31050184] [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] [Received: 02/27/2024] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/25/2024] Open
Abstract
Countries face challenges in paying for new drugs. High prices are driven in part by exploding drug development costs, which, in turn, are driven by essential but excessive regulation. Burdensome regulation also delays drug development, and this can translate into thousands of life-years lost. We need system-wide reform that will enable less expensive, faster drug development. The speed with which COVID-19 vaccines and AIDS therapies were developed indicates this is possible if governments prioritize it. Countries also differ in how they value drugs, and generally, those willing to pay more have better, faster access. Canada is used as an example to illustrate how "incremental cost-effectiveness ratios" (ICERs) based on measures such as gains in "quality-adjusted life-years" (QALYs) may be used to determine a drug's value but are often problematic, imprecise assessments. Generally, ICER/QALY estimates inadequately consider the impact of patient crossover or long post-progression survival, therapy benefits in distinct subpopulations, positive impacts of the therapy on other healthcare or societal costs, how much governments willingly might pay for other things, etc. Furthermore, a QALY value should be higher for a lethal or uncommon disease than for a common, nonlethal disease. Compared to international comparators, Canada is particularly ineffective in initiating public funding for essential new medications. Addressing these disparities demands urgent reform.
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Affiliation(s)
- David J. Stewart
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - John-Peter Bradford
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Sandeep Sehdev
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
| | - Vishal Navani
- Division of Medical Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Nigel S. B. Rawson
- Canadian Health Policy Institute, Toronto, ON M5V 0A4, Canada;
- Macdonald-Laurier Institute, Ottawa, ON K1N 7Z2, Canada
| | - Di Maria Jiang
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Princess Margaret Cancer Center, Toronto, ON M5G 2M9, Canada
| | - Joanna Gotfrit
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
| | - Paul Wheatley-Price
- Division of Medical Oncology, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada (J.G.); (P.W.-P.)
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
| | - Geoffrey Liu
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Princess Margaret Cancer Center, Toronto, ON M5G 2M9, Canada
| | - Alan Kaplan
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- Family Physicians Airway Group of Canada, Markham, ON L3R 9X9, Canada
| | - Silvana Spadafora
- Algoma District Cancer Program, Sault Ste Marie, ON P6B 0A8, Canada;
| | - Shaun G. Goodman
- University of Toronto, Toronto, ON M5S 3H2, Canada; (D.M.J.); (G.L.); (A.K.); (S.G.G.)
- St. Michael’s Hospital, Unity Health Toronto, and Peter Munk Cardiac Centre, University Health Network, Toronto, ON M5B 1W8, Canada
| | - Rebecca A. C. Auer
- Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada; (T.R.); (R.A.C.A.)
- Department of Surgery, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada
| | - Gerald Batist
- Life Saving Therapies Network, Ottawa, ON K1H 5E6, Canada; (J.-P.B.); (G.B.)
- Centre for Translational Research, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
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Integrating Systematic Reviews into Supportive Care Trial Design: The Rethinking Clinical Trials (REaCT) Program. Curr Oncol 2022; 29:9550-9559. [PMID: 36547164 PMCID: PMC9776426 DOI: 10.3390/curroncol29120750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To review the successes and challenges of integrating systematic reviews (SRs) into the Rethinking Clinical Trials (REaCT) Program. METHODS All REaCT program SRs were evaluated and descriptive summaries presented. RESULTS Twenty-two SRs have been performed evaluating standard of care interventions for the management of: breast cancer (n = 15), all tumour sites (n = 4), breast and prostate cancers (n = 2), and prostate cancer (n = 1). The majority of SRs were related to supportive care (n = 14) and survivorship (n = 5) interventions and most (19/22, 86%) confirmed the existence of uncertainty relating to the clinical question addressed in the SR. Most SRs (15/22, 68%) provided specific recommendations for future studies and results were incorporated into peer-reviewed grant applications (n = 6) and clinical trial design (n = 12). In 12/22 of the SRs, the first author was a trainee. All SRs followed PRISMA guidelines. CONCLUSION SRs are important for identifying and confirming clinical equipoise and designing trials. SRs provide an excellent opportunity for trainees to participate in research.
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Quanbeck A, Hennessy RG, Park L. Applying concepts from "rapid" and "agile" implementation to advance implementation research. Implement Sci Commun 2022; 3:118. [PMID: 36335373 PMCID: PMC9636827 DOI: 10.1186/s43058-022-00366-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/08/2022] Open
Abstract
Background The translation of research findings into practice can be improved to maximize benefits more quickly and with greater flexibility. To expedite translation, researchers have developed innovative approaches to implementation branded as “rapid” and “agile” implementation. Rapid implementation has roots in precision medicine and agile implementation has roots in systems engineering and software design. Research has shown that innovation often derives from learning and applying ideas that have impacted other fields. Implications for implementation researchers This commentary examines “rapid” and “agile” approaches to implementation and provides recommendations to implementation researchers stemming from these approaches. Four key ideas are synthesized that may be broadly applicable to implementation research, including (1) adopting a problem orientation, (2) applying lessons from behavioral economics, (3) using adaptive study designs and adaptive interventions, and (4) using multi-level models to guide implementation. Examples are highlighted from the field where researchers are applying these key ideas to illustrate their potential impact. Conclusions “Rapid” and “agile” implementation approaches to implementation stem from diverse fields. Elements of these approaches show potential for advancing implementation research, although adopting them may entail shifting scientific norms in the field.
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Affiliation(s)
- Andrew Quanbeck
- Department of Family Medicine and Community Health, University of Wisconsin-Madison, 800 University Bay Drive, Madison, WI, 53705, USA.
| | - Rose Garza Hennessy
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, P.O. Box 413, Milwaukee, WI, 53205, USA
| | - Linda Park
- Department of Family Medicine and Community Health, University of Wisconsin-Madison, 800 University Bay Drive, Madison, WI, 53705, USA
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Leddy L, Sukumar P, O'Sullivan L, Keane F, Devane D, Doran P. An investigation into the factors affecting investigator-initiated trial start-up in Ireland. Trials 2020; 21:962. [PMID: 33228755 PMCID: PMC7684941 DOI: 10.1186/s13063-020-04893-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 11/12/2020] [Indexed: 11/16/2022] Open
Abstract
Background In common with many countries, Ireland has seen an increasing trend in the number of clinical trials conducted over the past few years. Yet, as elsewhere, trialists in Ireland face several problems and barriers in the starting-up of clinical trials. These barriers impede trial activity significantly, with consequent impacts on patient care. It is critical to understand these issues, to develop approaches to facilitate trial start up. This study identifies the challenges in conducting clinical trials in Ireland and specifically the contractual, ethical, logistical, and regulatory barriers that hinder the start-up of investigator-led trials in Ireland. Methods Data for this study were collected in two stages. In the first stage, a survey was conducted among trialists in Ireland. A total of 44 trialists responded to the survey, and information was collected about their experience in conducting clinical trials, the scale and nature of their most recently completed trial, and the details of specific barriers they encountered during the starting-up of the trial. In the second stage, nine semi-structured interviews were conducted with the awardees of 2018 Irish Health Research Board’s Definitive Intervention Feasibility Award. These interviews facilitated a deeper exploration of issues and problems in conducting clinical trials in Ireland. Results This study identified several issues and bottlenecks in starting-up clinical trials in Ireland with contracts and ethical approval cited as the major issues. The data shows that site identification and activation was also problematic in some cases. Several respondents reported difficulties in accessing dedicated time for protocol development and believe that support in this area can be greatly beneficial. It was reported that availability of skilled staff members like statisticians and data managers was as an issue, especially for small trials. Conclusion This study found that several factors impact trial initiation and progression in Ireland. Delays associated with obtaining contract and ethics approval are perceived as major barriers. Specialist supports in areas such as ethics and regulatory affairs and availability of specialised staff members in areas such as statistics and data management are key actions to enable enhanced clinical trial activity in Ireland.
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Affiliation(s)
- Lauren Leddy
- UCD School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Prasanth Sukumar
- UCD School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Lydia O'Sullivan
- UCD School of Medicine, University College Dublin, Dublin 4, Ireland.,HRB Trials Methodology Research Network, NUI Galway, Galway, Ireland
| | - Fionnuala Keane
- HRB Clinical Research Coordination Ireland, Upper Mount Street, Dublin 2, Ireland
| | - Declan Devane
- HRB Trials Methodology Research Network, NUI Galway, Galway, Ireland.,National University of Ireland, Galway, Ireland
| | - Peter Doran
- UCD School of Medicine, University College Dublin, Dublin 4, Ireland.
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Lee C, Werner TL, Deal AM, Krise-Confair CJ, Bentz TA, Cummings TM, Grant SC, Lee AB, Moehle J, Moffett K, Peck H, Williamson S, Zafirovski A, Shaw K, Hofacker JK. Clinical Trial Metrics: The Complexity of Conducting Clinical Trials in North American Cancer Centers. JCO Oncol Pract 2020; 17:e77-e93. [PMID: 33186085 PMCID: PMC8202063 DOI: 10.1200/op.20.00501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cancer clinical trials offices (CTOs) support the investigation of cancer prevention, early detection, and treatment at cancer centers across North America. CTOs are a centralized resource for clinical trial conduct and typically use research staff with expertise in four functional areas of clinical research: finance, regulatory, clinical, and data operations. To our knowledge, there are no publicly available benchmark data sets that characterize the size, cost, volume, and efficiency of these offices, nor whether the metrics differ by National Cancer Institute (NCI) designation. The Association of American Cancer Institutes (AACI) Clinical Research Innovation (CRI) steering committee developed a survey to address this knowledge gap.
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Affiliation(s)
- Carrie Lee
- UNC Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Theresa L Werner
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Allison M Deal
- UNC Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | - Theresa M Cummings
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD
| | - Stefan C Grant
- Wake Forest University Baptist Comprehensive Cancer, Winston Salem, NC
| | | | - Jessica Moehle
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | - Helen Peck
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | | | | | - Kate Shaw
- Association of American Cancer Institutes, Pittsburgh, PA
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6
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Schilsky RL. The National Clinical Trials Network and the cooperative groups: The road not taken. Cancer 2020; 126:5008-5013. [PMID: 32970349 DOI: 10.1002/cncr.33210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 11/10/2022]
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Chen N, Lee JJ. Bayesian cluster hierarchical model for subgroup borrowing in the design and analysis of basket trials with binary endpoints. Stat Methods Med Res 2020; 29:2717-2732. [DOI: 10.1177/0962280220910186] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Master protocol designs are often proposed to improve the efficiency of drug development with multiple subgroups. In the basket trial design, different subgroups can have similar biological pathogenesis pathways. Hence, a target therapy can result in similar responses. A good information sharing strategy between different subgroups can potentially improve the efficiency of evaluating treatment efficacy. In traditional hierarchical models, based on the exchangeability assumption, all subgroups are placed into the same sharing pool for cross subgroup information sharing. However, due to the heterogeneity between subgroups, there can be large differences in drug efficacy. Under such cases, strong borrowing across all subgroups is not suitable and no borrowing can be inefficient, because the treatment effect is analyzed in each subgroup separately. We propose a Bayesian cluster hierarchical model (BCHM) to improve the operating characteristics of estimating the treatment effect in multiple subgroups in basket trials. Bayesian nonparametric method is applied to dynamically calculate the number of clusters by conducting a multiple cluster classification based on subgroup outcomes. A hierarchical model is used to compute the posterior probability of the treatment effect, with the borrowing strength determined by the Bayesian nonparametric clustering and the similarities between subgroups. We apply the BCHM to clinical trials with binary endpoints. For treatment effect estimation, the BCHM yields lower mean squared error values, when compared to the independent analyses. In scenarios with a heterogeneous treatment effect, the BCHM provides lower mean squared error values compared to traditional hierarchical models. In addition, we can construct a loss function to optimize the design parameters. BCHM provides a balanced approach and smart borrowing, which yields better results in assessing the treatment effect in different scenarios compared to other conventional methods.
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Affiliation(s)
- Nan Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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8
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Stahel RA, Lacombe D, Cardoso F, Casali PG, Negrouk A, Marais R, Hiltbrunner A, Vyas M. Current models, challenges and best practices for work conducted between European academic cooperative groups and industry. ESMO Open 2020; 5:e000628. [PMID: 32213534 PMCID: PMC7103800 DOI: 10.1136/esmoopen-2019-000628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/15/2020] [Accepted: 01/20/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The academia-industry interface is important, and, despite challenges that inevitably occur, bears the potential for positive synergies to emerge. Perceived barriers to wider collaboration in academia-industry oncology research in Europe need to be addressed, current academic cooperative group and industry models for collaboration need to be discussed, and a common terminology to facilitate understanding of both sectors' concerns needs to be established with an eye towards improving academia-industry partnerships on clinical trials for the benefit of patients with cancer. METHODOLOGY CAREFOR (Clinical Academic Cancer Research Forum), a multi-stakeholder platform formed to improve the direction for academic clinical trials in the field of oncology in Europe, formed the CAREFOR-Industry Working Group comprised of experienced professionals from European academic cooperative groups joined by industry representatives selected based on their activities in the area of medical oncology. They jointly discussed academic cooperative groups, clinical trials conducted between academic cooperative groups and industry, examples of successful collaborative models, common legal negotiation points in clinical trial contracts, data access, and principles of interaction. RESULTS Four principles of interaction between the academia and industry are proposed: (1) clarify the roles and responsibilities of all partners involved in the study, (2) involve legal teams from an early stage; (3) acknowledge that data is an important output of the study, (4) agree on the intent of the trial prior to its start. CONCLUSIONS The CAREFOR-Industry Working Group describes current models, challenges, and effective strategies for academia-industry research in Europe with an eye towards improving academia-industry partnerships on clinical trials for patients with cancer. Current perceived challenges are explained, and future opportunities/recommendations for improvement are described for the areas of most significant impact. Challenges are addressed from both the academic and industry perspectives, and principles of interaction for the optimal alignment between academia and industry in selected areas are proposed.
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Affiliation(s)
- Rolf A Stahel
- Medical Oncology and Hematology, University Hospital Zürich, Zurich, Switzerland
| | | | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
| | - Paolo G Casali
- Medical Oncology Unit 2, National Cancer Institute: Fondazione IRCCS, Milano, Italy
| | | | - Richard Marais
- Molecular Oncology, Cancer Research UK Manchester Institute, Greater Manchester, United Kingdom
| | | | - Malvika Vyas
- Public Policy, European Society for Medical Oncology, Lugano, Switzerland
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Tate WR, Abraham I, Cranmer LD. Center-Specific Modeling Predicts Cancer Trial Accrual More Accurately Than Investigators and Random Effects Modeling at 16 Cancer Centers. JCO Clin Cancer Inform 2019; 3:1-12. [PMID: 31173517 DOI: 10.1200/cci.19.00005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Clinical trials often exceed their anticipated enrollment periods, and study sites often do not meet accrual goals. We previously reported the development and validation of a single-site accrual prediction model. Here, we describe the expansion of this methodology at 16 cancer centers (CCs) and compare an overall model versus site-specific models. METHODS This retrospective cohort study used data from treatment and supportive care intervention studies permanently closed to accrual between 2009 and 2015 at 16 United States-based CCs. Center and ClinicalTrials.gov data were used to generate both site-specific and random effects mixed models (random effect: institution). Accrual predictions were generated from each model and compared with the accrual prediction of the disease team (DT). RESULTS Sixteen institutions submitted 5,787 eligible trials (range, 93 to 697 trials per institution). Local accrual ranged from 363 to 6,716 participants; 1,053 studies (18%) accrued no participants. Actual average accrual was 8.5 participants (median, four participants). Site-specific models predicted accrual at 99% of actual and correctly predicted whether a study would accrue four or more participants 73% of the time versus DT prediction of 58%. Correlation at the category level was 30%; model sensitivity and specificity were 83% and 62%, respectively. The overall model predicted accrual 93% of actual and correctly predicted accrual of four or more participants 66% of the time, with a correlation at the category level of 28%. CONCLUSION Both regression models predicted clinical trial accrual at least as or more accurately than DT at all but one center. Site-specific models generally performed slightly better than the random effects model. This study confirms the previous finding that this method is an accurate and objective metric that can be easily implemented to improve clinical research resource allocation across multiple centers.
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Affiliation(s)
| | | | - Lee D Cranmer
- University of Washington, Seattle, WA.,Fred Hutchinson Cancer Research Center, Seattle, WA
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10
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Bentley C, Cressman S, van der Hoek K, Arts K, Dancey J, Peacock S. Conducting clinical trials-costs, impacts, and the value of clinical trials networks: A scoping review. Clin Trials 2019; 16:183-193. [PMID: 30628466 DOI: 10.1177/1740774518820060] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND A significant barrier to conducting clinical trials is their high cost, which is driven primarily by the time and resources required to activate trials and reach accrual targets. The high cost of running trials has a substantial impact on their long-term feasibility and the type of clinical research undertaken. METHODS A scoping review of the empirical literature on the costs associated with conducting clinical trials was undertaken for the years 2001-2015. Five reference databases were consulted to elicit how trials costs are presented in the literature. A review instrument was developed to extract the content of in-scope papers. Findings were characterized by date and place of publication, clinical disease area, and network/cooperative group designation, when specified. Costs were captured and grouped by patient accrual and management, infrastructure, and the opportunity costs associated with industry funding for trials research. Cost impacts on translational research and health systems were also captured, as were recommendations to reduce trial expenditures. Since articles often cited multiple costs, multiple cost coding was used during data extraction to capture the range and frequency of costs. RESULTS A total of 288 empirical articles were included. The distribution of reported costs was: patient management and accrual costs (132 articles), infrastructure costs (118 articles) and the opportunity costs of industry sponsorship (72 articles). 221 articles reported on the impact of undertaking costly trials on translational research and health systems; of these, the most frequently reported consequences were to research integrity (52% of articles), research capacity (36% of articles) and running low-value trials (34% of articles). 254 articles provided recommendations to reduce trial costs; of these, the most frequently reported recommendations related to improvements in: operational efficiencies (33% of articles); patient accrual (24% of articles); funding for trials and transparency in trials reporting (18% of articles, each). CONCLUSION Key findings from the review are: 1) delayed trial activation has costs to budgets and research; 2) poor accrual leads to low-value trials and wasted resources; 3) the pharmaceutical industry can be a pragmatic, if problematic, partner in clinical research; 4) organizational know-how and successful research collaboration are benefits of network/cooperative groups; and 5) there are spillover benefits of clinical trials to healthcare systems, including better health outcomes, enhanced research capacity, and drug cost avoidance. There is a need for more economic evaluations of the benefits of clinical research, such as health system use (or avoidance) and health outcomes in cities and health authorities with institutions that conduct clinical research, to demonstrate the affordability of clinical trials, despite their high cost.
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Affiliation(s)
- Colene Bentley
- 1 Department of Cancer Control Research, BC Cancer, Vancouver, BC, Canada.,2 Canadian Centre for Applied Research in Cancer Control, Vancouver, BC, Canada
| | - Sonya Cressman
- 1 Department of Cancer Control Research, BC Cancer, Vancouver, BC, Canada.,2 Canadian Centre for Applied Research in Cancer Control, Vancouver, BC, Canada
| | - Kim van der Hoek
- 1 Department of Cancer Control Research, BC Cancer, Vancouver, BC, Canada.,2 Canadian Centre for Applied Research in Cancer Control, Vancouver, BC, Canada
| | - Karen Arts
- 3 Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Janet Dancey
- 3 Ontario Institute for Cancer Research, Toronto, ON, Canada.,4 Department of Oncology, School of Medicine, Queen's University, Kingston, ON, Canada.,5 The National Cancer Institute of Canada Clinical Trials Group, Kingston, ON, Canada
| | - Stuart Peacock
- 1 Department of Cancer Control Research, BC Cancer, Vancouver, BC, Canada.,2 Canadian Centre for Applied Research in Cancer Control, Vancouver, BC, Canada.,6 Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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11
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Gobbini E, Pilotto S, Pasello G, Polo V, Di Maio M, Arizio F, Galetta D, Petrillo P, Chiari R, Matocci R, Di Costanzo A, Di Stefano TS, Aglietta M, Cagnazzo C, Sperduti I, Bria E, Novello S. Effect of Contract Research Organization Bureaucracy in Clinical Trial Management: A Model From Lung Cancer. Clin Lung Cancer 2017; 19:191-198. [PMID: 29153968 DOI: 10.1016/j.cllc.2017.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 10/10/2017] [Accepted: 10/19/2017] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Contract research organization (CRO) support is largely included in clinical trial management, although its effect in terms of time savings and benefit has not yet been quantified. We performed a retrospective multicenter analysis of lung cancer trials to explore differences in term of trial activation timelines and accrual for studies with and without CRO involvement. MATERIALS AND METHODS Results regarding study timelines from feasibility data to first patient enrollment were collected from 7 Italian thoracic oncology departments. The final accruals (screened/enrolled patients) are reported. We considered CRO/sponsor-administered and CRO-free trials according to who was responsible for the management of the crucial setup phases. RESULTS Of 113 trials, 62 (54.9%) were CRO-administered, 34 (30.1%) were sponsor-administered, and 17 (15.0%) were CRO-free. The median time from feasibility invitation to documentation obtainment was 151 days in the CRO-administered trials versus 128 in the sponsor-administered and 120 in the CRO-free trials. The time from document submission to contract signature was 142 days in the CRO-administered versus 128 in the sponsor-administered and 132 in the CRO-free trials. The time from global accrual opening to first patient enrollment was 247 days for the CRO-administered versus 194 in the sponsor-administered and 151 in the CRO-free trials. No significant differences were observed in terms of the median overall timeline: 21 months in the CRO-administered, 15 in the sponsor-administered, and 18 months in the CRO-free studies (P = .29). CONCLUSION Although no statistically significant differences were identified, the results of our analysis support the idea that bureaucratic procedures might require more time in CRO-administered trials than in sponsor-administered and CRO-free studies. This bureaucratic delay could negatively affect Italian patients' screening and enrollment compared with other countries.
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Affiliation(s)
- Elisa Gobbini
- Department of Oncology, University of Turin, Azienda Ospedaliero-Universitaria San Luigi Gonzaga, Orbassano, Italy
| | - Sara Pilotto
- Department of Medical Oncology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy.
| | - Giulia Pasello
- Department of Medical Oncology 2, Istituto Oncologico Veneto IRCCS, Padua, Italy
| | - Valentina Polo
- Department of Medical Oncology 2, Istituto Oncologico Veneto IRCCS, Padua, Italy
| | - Massimo Di Maio
- Department of Oncology, University of Turin, Mauriziano Hospital, Turin, Italy
| | - Francesca Arizio
- Department of Oncology, University of Turin, Azienda Ospedaliero-Universitaria San Luigi Gonzaga, Orbassano, Italy
| | - Domenico Galetta
- Oncology Unit, Clinical Cancer Center, "Giovanni Paolo II", Bari, Italy
| | - Patrizia Petrillo
- Oncology Unit, Clinical Cancer Center, "Giovanni Paolo II", Bari, Italy
| | - Rita Chiari
- Oncology Unit, "Santa Maria della Misericordia" Hospital, Perugia, Italy
| | - Roberta Matocci
- Oncology Unit, "Santa Maria della Misericordia" Hospital, Perugia, Italy
| | | | | | | | | | - Isabella Sperduti
- Department of Biostatistics, Regina Elena National Cancer Institute, Rome, Italy
| | - Emilio Bria
- Department of Medical Oncology, University of Verona, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Silvia Novello
- Department of Oncology, University of Turin, Azienda Ospedaliero-Universitaria San Luigi Gonzaga, Orbassano, Italy
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12
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Renfro LA, Mandrekar SJ. Definitions and statistical properties of master protocols for personalized medicine in oncology. J Biopharm Stat 2017; 28:217-228. [DOI: 10.1080/10543406.2017.1372778] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Lindsay A. Renfro
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
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13
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Day D, Monjazeb AM, Sharon E, Ivy SP, Rubin EH, Rosner GL, Butler MO. From Famine to Feast: Developing Early-Phase Combination Immunotherapy Trials Wisely. Clin Cancer Res 2017; 23:4980-4991. [PMID: 28864726 PMCID: PMC5736967 DOI: 10.1158/1078-0432.ccr-16-3064] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 06/08/2017] [Accepted: 07/07/2017] [Indexed: 12/29/2022]
Abstract
Not until the turn of this century has immunotherapy become a fundamental component of cancer treatment. While monotherapy with immune modulators, such as immune checkpoint inhibitors, provides a subset of patients with durable clinical benefit and possible cure, combination therapy offers the potential for antitumor activity in a greater number of patients. The field of immunology has provided us with a plethora of potential molecules and pathways to target. This abundance makes it impractical to empirically test all possible combinations efficiently. We recommend that potential immunotherapy combinations be chosen based on sound rationale and available data to address the mechanisms of primary and acquired immune resistance. Novel trial designs may increase the proportion of patients receiving potentially efficacious treatments and, at the same time, better define the balance of clinical activity and safety. We believe that implementing a strategic approach in the early development of immunotherapy combinations will expedite the delivery of more effective therapies with improved safety and durable outcomes.
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Affiliation(s)
- Daphne Day
- Drug Development Program, Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Arta M Monjazeb
- Department of Radiation Oncology, UC Davis Comprehensive Cancer Center, Sacramento, California
| | - Elad Sharon
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland
| | - S Percy Ivy
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland
| | - Eric H Rubin
- Merck Research Laboratories, Merck & Co., Inc., Kenilworth, New Jersey
| | - Gary L Rosner
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland
| | - Marcus O Butler
- Drug Development Program, Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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14
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Massett HA, Dilts DM, Bailey R, Berktold J, Ledsky R, Atkinson NL, Mishkin G, Denicoff A, Padberg RM, Allen MP, Silver K, Carrington K, Johnson LE. Raising Public Awareness of Clinical Trials: Development of Messages for a National Health Communication Campaign. JOURNAL OF HEALTH COMMUNICATION 2017; 22:373-385. [PMID: 28339327 DOI: 10.1080/10810730.2017.1290715] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Clinical trials are essential for developing new and effective treatments and improving patient quality of life; however, many trials cannot answer their primary research questions because they fall short of their recruitment goals. This article reports the results of formative research conducted in two populations, the public and primary care physicians, to identify messages that may raise awareness and increase interest in clinical trials and be used in a national communication campaign. Results suggested that participants were primarily motivated to participate in clinical trials out of a self-interest to help themselves first. Messages illustrated that current treatments were tested via clinical trials, helped normalize trials as routine practices, and reduced concerns over trying something new first. Participants wanted messages that portray trials as state-of-the-art choices that offer some hope, show people like themselves, and are described in a clear, concise manner with actionable steps for them to take. The study revealed some differences in message salience, with healthy audiences exhibiting lower levels of interest. Our results suggest that targeted messages are needed, and that communication with primary health-care providers is an important and necessary component in raising patient awareness of the importance of clinical trials.
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Affiliation(s)
- Holly A Massett
- a Cancer Therapy Evaluation Program, Division of Cancer Treatment & Diagnosis , National Cancer Institute , Bethesda , Maryland , USA
| | | | - Robert Bailey
- c SalterMitchell/Marketing for Change , Alexandria , Virginia , USA
| | | | | | | | - Grace Mishkin
- a Cancer Therapy Evaluation Program, Division of Cancer Treatment & Diagnosis , National Cancer Institute , Bethesda , Maryland , USA
| | - Andrea Denicoff
- a Cancer Therapy Evaluation Program, Division of Cancer Treatment & Diagnosis , National Cancer Institute , Bethesda , Maryland , USA
| | | | - Marin P Allen
- h Office of Communications and Public Liaison, Office of the Director , National Institutes of Health , Bethesda , Maryland , USA
| | - Karen Silver
- i Office of the Assistant Secretary for Health , U. S. Department of Health and Human Services , Washington , DC , USA
| | - Kelli Carrington
- j National Institute on Minority Health and Health Disparities, National Institutes of Health , Bethesda , Maryland , USA
| | - Lenora E Johnson
- k National Heart, Lung, and Blood Institute , National Institutes of Health , Bethesda , Maryland , USA
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15
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Morgan SE, Occa A, Mouton A, Potter J. The Role of Nonverbal Communication Behaviors in Clinical Trial and Research Study Recruitment. HEALTH COMMUNICATION 2017; 32:461-469. [PMID: 27314155 DOI: 10.1080/10410236.2016.1140266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Few studies have examined the communication behaviors of those who recruit for clinical trials and research studies, particularly of nonmedical professionals who often do the bulk of recruiting. This focus-group study of 63 recruiters analyzes the ways in which nonverbal communication behaviors support the process of recruitment, using the lens of communication accommodation theory. Results indicate that recruiters first "read" potential study participants' nonverbal communication for clues about their state of mind, then use nonverbal communication to achieve a sense of convergence. Specific nonverbal communication behaviors were discussed by recruiters, including smiling, variations in the use of voice, adjusting body position, the appropriate use of physical touch, the management of eye contact, and the effect of clothing and physical appearance. Implications for recruitment practice are discussed.
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Affiliation(s)
| | - Aurora Occa
- a School of Communication , University of Miami
| | - Ashton Mouton
- b Brian Lamb School of Communication , Purdue University
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16
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Tang C, Sherman SI, Price M, Weng J, Davis SE, Hong DS, Yao JC, Buzdar A, Wilding G, Lee JJ. Clinical Trial Characteristics and Barriers to Participant Accrual: The MD Anderson Cancer Center Experience over 30 years, a Historical Foundation for Trial Improvement. Clin Cancer Res 2017; 23:1414-1421. [PMID: 28275168 DOI: 10.1158/1078-0432.ccr-16-2439] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 12/15/2016] [Accepted: 12/19/2016] [Indexed: 12/30/2022]
Abstract
Purpose: Slow-accruing clinical trials delay the translation of basic biomedical research, contribute to increasing health care costs, and may prohibit trials from reaching their original goals.Experimental Design: We analyzed a prospectively maintained institutional database that tracks all clinical studies at the MD Anderson Cancer Center (Houston, TX). Inclusion criteria were activated phase I-III trials, maximum projected accrual ≥10 participants, and activation prior to March 25, 2011. The primary outcome was slow accrual, defined as <2 participants per year. Correlations of trial characteristics with slow accrual were assessed with logistic regression.Results: A total of 4,269 clinical trials met inclusion criteria. Trials were activated between January 5, 1981, and March 25, 2011, with a total of 145,214 participants enrolled. Median total enrolment was 16 [interquartile range (IQR), 5-34], with an average enrolment rate of 8.7 participants per year (IQR, 3.3-17.7). There were 755 (18%) trials classified as slow accruing. On multivariable analysis, slow accrual exhibited robust associations with national cooperative group trials (OR = 4.16, P < 0.0001 vs. industry sponsored), time from trial activation to first enrolment (OR = 1.13 per month, P < 0.0001), and maximum targeted accrual (OR = 0.16 per log10 increase, P < 0.0001). Recursive partitioning analysis identified trials requiring more than 70 days (2.3 months) between activation and first participant enrolment as having higher odds of slow accrual (23% vs. 5%, OR = 5.56, P < 0.0001).Conclusions: We identified factors associated with slow trial accrual. Given the lack of data on clinical trials at the institutional level, these data will help build a foundation from which targeted initiatives may be developed to improve the clinical trial enterprise. Clin Cancer Res; 23(6); 1414-21. ©2017 AACR.
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Affiliation(s)
- Chad Tang
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas.
| | - Steven I Sherman
- Department of Endocrine Neoplasia and Hormonal Disorders, MD Anderson Cancer Center, Houston, Texas
| | - Mellanie Price
- Office of Vice Provost for Clinical and Interdisciplinary Research, MD Anderson Cancer Center, Houston, Texas
| | - Jun Weng
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas
| | - Suzanne E Davis
- Office of Vice Provost for Clinical and Interdisciplinary Research, MD Anderson Cancer Center, Houston, Texas
| | - David S Hong
- Department of Investigational Cancer Therapeutics, MD Anderson Cancer Center, Houston, Texas
| | - James C Yao
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Aman Buzdar
- Department of Breast Medical Oncology, MD Anderson Cancer Center, Houston, Texas
| | - George Wilding
- Office of Vice Provost for Clinical and Interdisciplinary Research, MD Anderson Cancer Center, Houston, Texas
| | - J Jack Lee
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas.
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17
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Morgan SE, Occa A, Potter J, Mouton A, Peter ME. "You Need to Be a Good Listener": Recruiters' Use of Relational Communication Behaviors to Enhance Clinical Trial and Research Study Accrual. JOURNAL OF HEALTH COMMUNICATION 2017; 22:95-101. [PMID: 28085636 DOI: 10.1080/10810730.2016.1256356] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Medical and research professionals who discuss clinical trials and research studies with potential participants face an often daunting challenge, particularly when recruiting from minority and underserved populations. This study reports on findings from a focus group study of 63 research coordinators, study nurses, professional recruiters, and other professionals in Indianapolis, IN and Miami, FL who work to recruit from minority and underserved populations. These professionals discussed the importance of creating a sense of connection with potential participants as part of the recruitment and retention process. Building a relationship, however fleeting, involved a number of concrete behaviors, including listening to personal information, expressing empathy, and then providing reciprocal self-disclosures; having repeated contact, usually by working in the same environment over an extended period of time; demonstrating respect through politeness and the use of honorifics; going the extra mile for participants; offering flexibility in scheduling follow-up appointments; and creating a sense of personal and community trust by being truthful. The implications of these findings for clinical trial and research study accrual are discussed.
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Affiliation(s)
- Susan E Morgan
- a School of Communication , University of Miami , Coral Gables , Florida , USA
| | - Aurora Occa
- a School of Communication , University of Miami , Coral Gables , Florida , USA
| | - JoNell Potter
- b Miller School of Medicine , University of Miami , Miami , Florida , USA
| | - Ashton Mouton
- c Brian Lamb School of Communication , Purdue University , West Lafayette , Indiana , USA
| | - Megan E Peter
- d Department of Health Behavior and Policy , Virginia Commonwealth University , Richmond , Virginia , USA
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18
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Renfro LA, Sargent DJ. Statistical controversies in clinical research: basket trials, umbrella trials, and other master protocols: a review and examples. Ann Oncol 2017; 28:34-43. [PMID: 28177494 PMCID: PMC5834138 DOI: 10.1093/annonc/mdw413] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In recent years, cancers once viewed as relatively homogeneous in terms of organ location and treatment strategy are now better understood to be increasingly heterogeneous across biomarker and genetically defined patient subgroups. This has produced a shift toward development of biomarker-targeted agents during a time when funding for cancer research has been limited; as a result, the need for improved operational efficiency in studying many agent-and-target combinations in parallel has emerged. Platform trials, basket trials, and umbrella trials are new approaches to clinical research driven by this need for enhanced efficiency in the modern era of increasingly specific cancer subpopulations and decreased resources to study treatments for individual cancer subtypes in a traditional way. In this review, we provide an overview of these new types of clinical trial designs, including discussions of motivation for their use, recommended terminology, examples, and challenges encountered in their application.
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Affiliation(s)
- L. A. Renfro
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, USA
| | - D. J. Sargent
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, USA
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19
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Tang C, Hess KR, Sanders D, Davis SE, Buzdar AU, Kurzrock R, Lee JJ, Meric-Bernstam F, Hong DS. Modifying the Clinical Research Infrastructure at a Dedicated Clinical Trials Unit: Assessment of Trial Development, Activation, and Participant Accrual. Clin Cancer Res 2016; 23:1407-1413. [PMID: 27852698 DOI: 10.1158/1078-0432.ccr-16-1936] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/09/2016] [Accepted: 11/06/2016] [Indexed: 11/16/2022]
Abstract
Purpose: Information on processes for trials assessing investigational therapeutics is sparse. We assessed the trial development processes within the Department of Investigational Cancer Therapeutics (ICT) at MD Anderson Cancer Center (Houston, TX) and analyzed their effects on the trial activation timeline and enrolment.Experimental Design: Data were from a prospectively maintained registry that tracks all clinical studies at MD Anderson. From this database, we identified 2,261 activated phase I-III trials; 221 were done at the ICT. ICT trials were matched to trials from other MD Anderson departments by phase, sponsorship, and submission year. Trial performance metrics were compared with paired Wilcoxon signed rank tests.Results: We identified three facets of the ICT research infrastructure: parallel processing of trial approval steps; a physician-led research team; and regular weekly meetings to foster research accountability. Separate analyses were conducted stratified by sponsorship [industry (133 ICT and 133 non-ICT trials) or institutional (68 ICT and 68 non-ICT trials)]. ICT trial development was faster from IRB approval to activation (median difference of 1.1 months for industry-sponsored trials vs. 2.3 months for institutional) and from activation to first enrolment (median difference of 0.3 months for industry vs. 1.2 months for institutional; all matched P < 0.05). ICT trials also accrued more patients (median difference of 8 participants for industry vs. 33.5 for institutional) quicker (median difference 4.8 participants/year for industry vs. 11.1 for institutional; all matched P < 0.05).Conclusions: Use of a clinical research-focused infrastructure within a large academic cancer center was associated with efficient trial development and participant accrual. Clin Cancer Res; 23(6); 1407-13. ©2016 AACR.
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Affiliation(s)
- Chad Tang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Kenneth R Hess
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dwana Sanders
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Suzanne E Davis
- Department of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Aman U Buzdar
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Office of Vice Provost for Clinical and Interdisciplinary Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Razelle Kurzrock
- Division of Hematology and Oncology, Center for Personalized Therapy, University of San Diego, La Jolla, California
| | - J Jack Lee
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Funda Meric-Bernstam
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David S Hong
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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20
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Abstract
Recent advances in genomic sequencing and omics-based capabilities are uncovering tremendous therapeutic opportunities and rapidly transforming the field of cancer medicine. Molecularly targeted agents aim to exploit key tumor-specific vulnerabilities such as oncogenic or non-oncogenic addiction and synthetic lethality. Additionally, immunotherapies targeting the host immune system are proving to be another promising and complementary approach. Owing to substantial tumor genomic and immunologic complexities, combination strategies are likely to be required to adequately disrupt intricate molecular interactions and provide meaningful long-term benefit to patients. To optimize the therapeutic success and application of combination therapies, systematic scientific discovery will need to be coupled with novel and efficient clinical trial approaches. Indeed, a paradigm shift is required to drive precision medicine forward, from the traditional "drug-centric" model of clinical development in pursuit of small incremental benefits in large heterogeneous groups of patients, to a "strategy-centric" model to provide customized transformative treatments in molecularly stratified subsets of patients or even in individual patients. Crucially, to combat the numerous challenges facing combination drug development-including our growing but incomplete understanding of tumor biology, technical and informatics limitations, and escalating financial costs-aligned goals and multidisciplinary collaboration are imperative to collectively harness knowledge and fuel continual innovation.
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Affiliation(s)
- Daphne Day
- Drug Development Program, Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, M5G 2M9, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada.,OICR Research Fellow, Ontario Institute for Cancer Research, Toronto, Ontario, M5G 0A3, Canada
| | - Lillian L Siu
- Drug Development Program, Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, M5G 2M9, Canada. .,Department of Medicine, University of Toronto, Toronto, Ontario, M5S 1A8, Canada.
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21
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Schilsky RL. Finding the Evidence in Real-World Evidence: Moving from Data to Information to Knowledge. J Am Coll Surg 2016; 224:1-7. [PMID: 27989954 DOI: 10.1016/j.jamcollsurg.2016.10.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 10/03/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Richard L Schilsky
- Executive Office, American Society of Clinical Oncology, Alexandria, VA.
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22
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Steering Committee Of The Blood And Marrow Transplant Clinical Trials Network. The Blood and Marrow Transplant Clinical Trials Network: An Effective Infrastructure for Addressing Important Issues in Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1747-1757. [PMID: 27418009 PMCID: PMC5027144 DOI: 10.1016/j.bbmt.2016.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 07/08/2016] [Indexed: 12/01/2022]
Abstract
Hematopoietic cell transplantation (HCT) is a rapidly evolving field with active preclinical and clinical development of new strategies for patient assessment, graft selection and manipulation, and pre- and post-transplantation drug and cell therapy. New strategies require evaluation in definitive clinical trials; however, HCT trials face unique challenges, including the relatively small number of transplantations performed at any single center, the diverse indications for HCT requiring dissimilar approaches, the complex nature of the intervention itself, the risk of multiple complications in the immediate post-transplantation period, and the risk of important, though infrequent, late effects. The Blood and Marrow Transplant Clinical Trials Network (BMT CTN) was established by the US National Heart Lung and Blood Institute and the National Cancer Institute to meet these challenges. In its 15 years as a network, the BMT CTN has proven to be a successful infrastructure for planning, implementing, and completing such trials and for providing definitive answers to questions leading to improvements in the understanding and practice of HCT. It has opened 37 trials, about one-half phase 2 and one-half phase 3, enrolled more than 8000 patients, and published 57 papers addressing important issues in the treatment of patients with life-threatening malignant and nonmalignant blood disorders. This review describes the network's accomplishments, key components of its success, lessons learned over the past 15 years, and challenges for the future.
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23
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Stewart DJ, Batist G, Kantarjian HM, Bradford JP, Schiller JH, Kurzrock R. The Urgent Need for Clinical Research Reform to Permit Faster, Less Expensive Access to New Therapies for Lethal Diseases. Clin Cancer Res 2016; 21:4561-8. [PMID: 26473192 DOI: 10.1158/1078-0432.ccr-14-3246] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High costs of complying with drug development regulations slow progress and contribute to high drug prices and, hence, mounting health care costs. If it is exorbitantly expensive to bring new therapies to approval, fewer agents can be developed with available resources, impeding the emergence of urgently needed treatments and escalating prices by limiting competition. Excessive regulation produces numerous speed bumps on the road to drug authorization. Although an explosion of knowledge could fuel rapid advances, progress has been slowed worldwide by inefficient regulatory and clinical research systems that limit access to therapies that prolong life and relieve suffering. We must replace current compliance-centered regulation (appropriate for nonlethal diseases like acne) with "progress-centered regulation" in lethal diseases, where the overarching objective must be rapid, inexpensive development of effective new therapies. We need to (i) reduce expensive, time-consuming preclinical toxicology and pharmacology assessments, which add little value; (ii) revamp the clinical trial approval process to make it fast and efficient; (iii) permit immediate multiple-site trial activation when an eligible patient is identified ("just-in-time" activation); (iv) reduce the requirement for excessive, low-value documentation; (v) replace this excessive documentation with sensible postmarketing surveillance; (vi) develop pragmatic investigator accreditation; (vii) where it is to the benefit of the patient, permit investigators latitude in deviating from protocols, without requiring approved amendments; (viii) confirm the value of predictive biomarkers before requiring the high costs of IDE/CLIA compliance; and (ix) approve agents based on high phase I-II response rates in defined subpopulations, rather than mandating expensive, time-consuming phase III trials.
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Affiliation(s)
- David J Stewart
- The University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Gerald Batist
- Segal Cancer Centre, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - John-Peter Bradford
- Bradford Bachinski Limited and the Life Saving Therapies Network, Ottawa, Ontario, Canada
| | - Joan H Schiller
- The University of Texas Southwestern, Dallas, TX and Free to Breathe
| | - Razelle Kurzrock
- University of California San Diego Moores Cancer Center, San Diego, California
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24
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Jacobus SJ, Rajkumar SV, Weiss M, Stewart AK, Stadtmauer EA, Callander NS, Dreosti LM, Lacy MQ, Fonseca R. Randomized phase III trial of consolidation therapy with bortezomib-lenalidomide-Dexamethasone (VRd) vs bortezomib-dexamethasone (Vd) for patients with multiple myeloma who have completed a dexamethasone based induction regimen. Blood Cancer J 2016; 6:e448. [PMID: 27471864 PMCID: PMC5030380 DOI: 10.1038/bcj.2016.55] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- S J Jacobus
- Dana Farber Cancer Institute – ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | | | - M Weiss
- ThedaCare, Appleton, WI, USA
| | - A K Stewart
- Mayo Clinic in Arizona, Scottsdale, AZ, South Africa
| | | | | | - L M Dreosti
- University of Pretoria, Pretoria, South Africa
| | | | - R Fonseca
- Mayo Clinic in Arizona, Scottsdale, AZ, South Africa
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25
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Morgan SE, Mouton A, Occa A, Potter J. Clinical Trial and Research Study Recruiters' Verbal Communication Behaviors. JOURNAL OF HEALTH COMMUNICATION 2016; 21:765-72. [PMID: 27259754 DOI: 10.1080/10810730.2016.1157654] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The lack of accrual to research studies and clinical trials is a persistent problem with serious consequences: Advances in medical science depend on the participation of large numbers of people, including members of minority and underserved populations. The current study examines a critical determinant of accrual: the approach of patients by professional recruiters who request participation in research studies and clinical trials. Findings indicate that recruiters use a number of verbal strategies in the communication process, including translating study information (such as simplifying, using examples, and substituting specific difficult or problematic words), using linguistic reframing or metaphors, balancing discussions of research participation risks with benefits, and encouraging potential participants to ask questions. The identification of these verbal strategies can form the basis of new communication protocols that will help medical and nonmedical professionals communicate more clearly and effectively with patients and other potential participants about research studies and clinical trials, which should lead to increased accrual in the future.
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Affiliation(s)
- Susan E Morgan
- a School of Communication , University of Miami , Coral Gables , Florida , USA
| | - Ashton Mouton
- b Brian Lamb School of Communication , Purdue University , West Lafayette , Indiana , USA
| | - Aurora Occa
- c School of Communication , University of Miami , Coral Gables , Florida , USA
| | - Jonell Potter
- d Miller School of Medicine , University of Miami , Coral Gables , Florida , USA
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26
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Butler J, Fonarow GC, O'Connor C, Adams K, Bonow RO, Cody RJ, Collins SP, Dunnmon P, Dinh W, Fiuzat M, Georgiopoulou VV, Grant S, Kim SY, Kupfer S, Lefkowitz M, Mentz RJ, Misselwitz F, Pitt B, Roessig L, Schelbert E, Shah M, Solomon S, Stockbridge N, Yancy C, Gheorghiade M. Improving cardiovascular clinical trials conduct in the United States: recommendation from clinicians, researchers, sponsors, and regulators. Am Heart J 2015; 169:305-14. [PMID: 25728719 DOI: 10.1016/j.ahj.2014.12.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 12/10/2014] [Indexed: 12/21/2022]
Abstract
Advances in medical therapies leading to improved patient outcomes are in large part related to successful conduct of clinical trials that offer critical information regarding the efficacy and safety of novel interventions. The conduct of clinical trials in the United States, however, continues to face increasing challenges with recruitment and retention. These trends are paralleled by an increasing shift toward more multinational trials where most participants are enrolled in countries outside the United States, bringing into question the generalizability of the results to the American population. This manuscript presents the perspectives and recommendations from clinicians, researchers, sponsors, and regulators who attended a meeting facilitated by the Food and Drug Administration to improve upon the current clinical trial trends in the United States.
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Affiliation(s)
- Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, NY.
| | | | | | | | - Robert O Bonow
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert J Cody
- Cardiovascular & Metabolism, Janssen Pharmaceuticals, Raritan, NJ
| | | | - Preston Dunnmon
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Wilfried Dinh
- Department of Cardiology, Witten University, Witten, Germany; Global Drug Discovery, Clinical Sciences, Bayer Pharma AG, Berlin, Germany
| | - Mona Fiuzat
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | - Stephen Grant
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - So-Young Kim
- Global Clinical Development, Bayer HealthCare AG, Wuppertal, Germany
| | | | | | - Robert J Mentz
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Frank Misselwitz
- Global Clinical Development, Bayer HealthCare AG, Wuppertal, Germany
| | - Bertram Pitt
- Division of Cardiology, University of Michigan School of Medicine, Ann Arbor, MI
| | - Lothar Roessig
- Global Clinical Development, Bayer HealthCare AG, Wuppertal, Germany
| | - Erik Schelbert
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, PA
| | - Monica Shah
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Scott Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Norman Stockbridge
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Clyde Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL
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Pincus HA, Abedin Z, Blank AE, Mazmanian PE. Evaluation and the NIH clinical and translational science awards: a "top ten" list. Eval Health Prof 2014; 36:411-31. [PMID: 24214661 DOI: 10.1177/0163278713507061] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Since 2006, a total of 61 Clinical and Translational Science Institutes (CTSAs) have been funded by the National Institutes of Health (NIH), with the aim of reducing translation time from a bench discovery to when it impacts patients. This special issue of Evaluation & the Health Professions focuses on evaluation within and across the large, complex system of the CTSA Program of NIH. Through insights gained by reading the articles in this special edition and the experience of the authors, a "top ten" list of lessons learned and insights gained is presented. The list outlines issues that face those who evaluate the influence of the CTSA Program, as they work to anticipate what will be needed for continuing success. Themes include (1) considering the needs of stakeholders, (2) the perspective of the evaluators, (3) the importance of service improvement, (4) the importance of teams and people, (5) costs and return on investments, (6) methodology considerations to evaluate the CTSA enterprise, (7) innovation in evaluation, (8) defining the transformation of research, (9) evaluating the long-term impact of the CTSAs on public health, and (10) contributing to science policy formulation and implementation. The establishment of the CTSA Program, with its mandated evaluation component, has not only influenced the infrastructure and nature of translational research but will continue to impact policy and management in science.
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Affiliation(s)
- Harold Alan Pincus
- Irving Institute for Clinical and Translational Research, Columbia University Medical Center, New York, NY, USA
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Hirsch BR, Zafar SY. Comparative effectiveness research: moving medical oncology forward. Semin Radiat Oncol 2014; 24:49-53. [PMID: 24314342 DOI: 10.1016/j.semradonc.2013.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Comparative effectiveness research (CER) is critically needed in medical oncology to improve the care being delivered to oncology patients. As medical oncologists are forced to rely on insufficient data as a part of daily treatment decision making, and as the cancer treatment landscape evolves quickly relative to other areas of medicine, CER is particularly pressing in our field. Continued reliance on randomized clinical trials is a part of the solution, but it cannot be the sole answer. As new and richer data sources become available addressing quality of life, resource utilization, and other critical elements, the implementation of CER will advance. Its true power will lie in linkages to "learning health systems" and real-time application to the day-to-day practice of medicine.
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Affiliation(s)
- Bradford R Hirsch
- Duke Cancer Institute, Durham, NC; Duke Clinical Research Institute, Durham, NC.
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Rosas SR, Schouten JT, Dixon D, Varghese S, Cope MT, Marci J, Kagan JM. Evaluating protocol lifecycle time intervals in HIV/AIDS clinical trials. Clin Trials 2014; 11:553-9. [PMID: 24980279 DOI: 10.1177/1740774514540814] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Identifying efficacious interventions for the prevention and treatment of human diseases depends on the efficient development and implementation of controlled clinical trials. Essential to reducing the time and burden of completing the clinical trial lifecycle is determining which aspects take the longest, delay other stages, and may lead to better resource utilization without diminishing scientific quality, safety, or the protection of human subjects. PURPOSE In this study, we modeled time-to-event data to explore relationships between clinical trial protocol development and implementation times, as well as to identify potential correlates of prolonged development and implementation. METHODS We obtained time interval and participant accrual data from 111 interventional clinical trials initiated between 2006 and 2011 by National Institutes of Health's HIV/AIDS Clinical Trials Networks. We determined the time (in days) required to complete defined phases of clinical trial protocol development and implementation. Kaplan-Meier estimates were used to assess the rates at which protocols reached specified terminal events, stratified by study purpose (therapeutic, prevention) and phase group (pilot/phase I, phase II, and phase III/IV). We also examined several potential correlates to prolonged development and implementation intervals. RESULTS Even though phase grouping did not determine development or implementation times of either therapeutic or prevention studies, overall we observed wide variation in protocol development times. Moreover, we detected a trend toward phase III/IV therapeutic protocols exhibiting longer developmental (median 2½ years) and implementation times (>3 years). We also found that protocols exceeding the median number of days for completing the development interval had significantly longer implementation. LIMITATIONS The use of a relatively small set of protocols may have limited our ability to detect differences across phase groupings. Some timing effects present for a specific study phase may have been masked by combining protocols into phase groupings. Presence of informative censoring, such as withdrawal of some protocols from development if they began showing signs of lost interest among investigators, complicates interpretation of Kaplan-Meier estimates. Because this study constitutes a retrospective examination over an extended period of time, it does not allow for the precise identification of relative factors impacting timing. CONCLUSION Delays not only increase the time and cost to complete clinical trials but they also diminish their usefulness by failing to answer research questions in time. We believe that research analyzing the time spent traversing defined intervals across the clinical trial protocol development and implementation continuum can stimulate business process analyses and re-engineering efforts that could lead to reductions in the time from clinical trial concept to results, thereby accelerating progress in clinical research.
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Affiliation(s)
| | - Jeffrey T Schouten
- Office of HIV/AIDS Network Coordination, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | | | - Joe Marci
- Division of Acquired Immunodeficiency Syndrome, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, United States Government, Bethesda, MD, USA
| | - Jonathan M Kagan
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, United States Government, Bethesda, MD, USA
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Steensma DP, Kantarjian HM. Impact of cancer research bureaucracy on innovation, costs, and patient care. J Clin Oncol 2014; 32:376-8. [PMID: 24395852 DOI: 10.1200/jco.2013.54.2548] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Social media has potential in clinical trials for pointing out trial issues, addressing barriers, educating, and engaging multiple groups involved in cancer clinical research. Social media is being used in clinical trials to highlight issues such as poor accrual and barriers; educate potential participants and physicians about clinical trial options; and is a potential indirect or direct method to improve accrual. We are moving from a passive "push" of information to patients to a "pull" of patients requesting information. Patients and advocates are often driving an otherwise reluctant health care system into communication. Online patient communities are creating new information repositories. Potential clinical trial participants are using the Twittersphere and other sources to learn about potential clinical trial options. We are seeing more organized patient-centric and patient-engaged forums with the potential to crowd source to improve clinical trial accrual and design. This is an evolving process that will meet many individual, institutional, and regulatory obstacles as we move forward in a changed research landscape.
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Abbott D, Califf R, Morrison BW, Pierre C, Bolte J, Chakraborty S. Cycle Time Metrics for Multisite Clinical Trials in the United States. Ther Innov Regul Sci 2013; 47:152-160. [PMID: 30227522 DOI: 10.1177/2168479012464371] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Conducting randomized controlled trials entails a prolonged, costly study start-up (SSU) process that may create significant delays. Optimizing the operational aspects of multisite trials requires identifying benchmarks in the SSU process and the potential delays associated with them. We engaged in a collaborative effort to identify and describe key SSU intervals that correspond with necessary procedures and processes for activating multisite clinical trials in the US. After developing definitions for SSU benchmarks and obtaining data from research coordinating entities, we identified factors that were significantly associated with reduced cycle times, including the use of central institutional review boards for study approval and status as a private practice or independent research site. However, small sample sizes and large proportions of missing data hamper the interpretability of our results. Future development of standard measures of SSU efficiency will be critical to analyzing and improving study initiation processes at US research sites.
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Affiliation(s)
- Diana Abbott
- 1 Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC, USA
| | - Robert Califf
- 1 Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC, USA
| | | | | | - Jean Bolte
- 1 Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC, USA
| | - Swati Chakraborty
- 1 Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC, USA
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Doroshow JH. Timely completion of scientifically rigorous cancer clinical trials: an unfulfilled priority. J Clin Oncol 2013; 31:3312-4. [PMID: 23960175 DOI: 10.1200/jco.2013.51.3192] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- James H Doroshow
- National Cancer Institute, National Institutes of Health, Bethesda, MD
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Abstract
Clinical research management (CRM) is a critical resource for the management of clinical trials and it requires proper evaluation. This article advances a model of evaluation that has three local levels, plus one global level, for evaluating the value of CRM. The primary level for evaluation is that of the study or processes level. The managerial or aggregate level concerns management of the portfolio of trials under the control of the CRM office. The third, often overlooked level of evaluation, is the strategic level, whose goal is encapsulated in the phrase, "doing the right trials, while doing trials right." The global ("plus one") evaluation level concerns the need to evaluate the ever-increasing number of multi-institutional and multinational studies. As there are host of evaluation metrics, this article provides representative examples of metrics at each level and provides methods that can aid in the selecting appropriate metrics for an organization.
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Affiliation(s)
- David M Dilts
- Oregon Health & Science University, Portland, OR, USA
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Abrams JS, Mooney MM, Zwiebel JA, Korn EL, Friedman SH, Finnigan SR, Schettino PR, Denicoff AM, Kruhm MG, Montello M, Misra RR, Ansher SS, DiPiazza KJ, Souhan EM, Wickerham DL, Giantonio BJ, O'Donnell RT, Sullivan DM, Soto NI, Fleming GF, Prindiville SA, Petryshyn RA, Hautala JA, Grad O, Zuckerman BL, Meyer RM, Yao JC, Baker LA, Buckner JC, Hortobagyi GN, Doroshow JH. Implementation of timeline reforms speeds initiation of National Cancer Institute-sponsored trials. J Natl Cancer Inst 2013; 105:954-9. [PMID: 23776198 DOI: 10.1093/jnci/djt137] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The National Cancer Institute (NCI) organized the Operational Efficiency Working Group in 2008 to develop recommendations for improving the speed with which NCI-sponsored clinical trials move from the idea stage to a protocol open to patient enrollment. METHODS Given the many stakeholders involved, the Operational Efficiency Working Group advised a multifaceted approach to mobilize the entire research community to improve their business processes. New staff positions to monitor progress, protocol-tracking Web sites, and strategically planned conference calls were implemented. NCI staff and clinical teams at Cooperative Groups and Cancer Centers strived to achieve new target timelines but, most important, agreed to abide by absolute deadlines. For phase I-II studies and phase III studies, the target timelines are 7 months and 10 months, whereas the absolute deadlines were set at 18 and 24 months, respectively. Trials not activated by the absolute deadline are automatically disapproved. RESULTS The initial experience is encouraging and indicates a reduction in development times for phase I-II studies from the historical median of 541 days to a median of 442 days, an 18.3% decrease. The experience with phase III studies to date, although more limited (n = 25), demonstrates a 45.7% decrease in median days. CONCLUSIONS Based upon this progress, the NCI and the investigator community have agreed to reduce the absolute deadlines to 15 and 18 months for phase I-II and III trials, respectively. Emphasis on initiating trials rapidly is likely to help reduce the time it takes for clinical trial results to reach patients in need of new treatments.
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Affiliation(s)
- Jeffrey S Abrams
- Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Rockville, MD 20852, USA.
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Adamson PC. The Children's Oncology Group's 2013 five year blueprint for research. Pediatr Blood Cancer 2013; 60:955-6. [PMID: 23255253 PMCID: PMC4580969 DOI: 10.1002/pbc.24399] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 10/18/2012] [Indexed: 01/10/2023]
Affiliation(s)
- Peter C. Adamson
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Tice DG, Carroll KA, Bhatt KH, Belknap SM, Mai D, Gipson HJ, West DP. Characteristics and Causes for Non-Accrued Clinical Research (NACR) at an Academic Medical Institution. J Clin Med Res 2013; 5:185-93. [PMID: 23671544 PMCID: PMC3651069 DOI: 10.4021/jocmr1320w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2013] [Indexed: 11/13/2022] Open
Abstract
Background The impact of non-accrued clinical research (NACR) represents an important economic burden that is under consideration as the U.S. Department of Health and Human Services looks into reforming the regulations governing IRB review. NACR refers to clinical research projects that fail to enroll subjects. A delineation of the issues surrounding NACR is expected to enhance subject accrual and to minimize occurrence of NACR. The authors assessed demographics, characteristics, and reasons for NACR at an academic medical center, including time trends, funding source, research team (principal investigator, department), IRB resource utilization (IRB level of review, number of required IRB reviews, initial IRB turn-around time, and duration of NACR). Methods The authors analyzed data from 848 clinical research study closures during 2010 and 2011 to determine proportion, incidence, and characteristics of NACR. Studies with subject enrollment during the same time period were used as a comparative measure. Results Data from 704 (83.0%) study closures reported enrollment of 1 or more subjects while 144 (17.0 %) reported NACR (zero enrollment). PI-reported reasons for NACR included: 32 (22.2%) contract or funding issues; 43 (30.0%) insufficient study-dedicated resources; 41 (28.4%) recruitment issues; 17 (11.8%) sponsor-initiated study closure and 11 (7.6%) were “other/reason unreported”. Conclusions NACR is not uncommon, affecting about one in six clinical research projects in the study population and reported to be more common in some other institutions. The complex and fluid nature of research conduct, non-realistic enrollment goals, and delays in both the approval and/or accrual processes contribute to NACR. Results suggest some simple strategies that investigators and institutions may use to reduce NACR, including careful feasibility assessment, reduction of institutional delays, and prompt initiation of subject accrual for multi-center studies using competitive enrollment. Institutional action to support investigators in the conduct clinical research is also encouraged to reduce likelihood of NACR.
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Affiliation(s)
- Debra G Tice
- Northwestern University, Institutional Review Board Office, 750 N. Lake Shore Drive, Room 725I, Chicago, IL 60611, USA
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Achieving palliative care research efficiency through defining and benchmarking performance metrics. Curr Opin Support Palliat Care 2013; 6:533-42. [PMID: 23080309 DOI: 10.1097/spc.0b013e32835a7cb4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Research efficiency is gaining increasing attention in the research enterprise, including palliative care research. The importance of generating meaningful findings and translating these scientific advances to improved patient care creates urgency in the field to address well documented system inefficiencies. The Palliative Care Research Cooperative Group (PCRC) provides useful examples for ensuring research efficiency in palliative care. RECENT FINDINGS Literature on maximizing research efficiency focuses on the importance of clearly delineated process maps, working instructions, and standard operating procedures in creating synchronicity in expectations across research sites. Examples from the PCRC support these objectives and suggest that early creation and employment of performance metrics aligned with these processes are essential to generate clear expectations and identify benchmarks. These benchmarks are critical in effective monitoring and ultimately the generation of high-quality findings that are translatable to clinical populations. Prioritization of measurable goals and tasks to ensure that activities align with programmatic aims is critical. SUMMARY Examples from the PCRC affirm and expand the existing literature on research efficiency, providing a palliative care focus. Operating procedures, performance metrics, prioritization, and monitoring for success should all be informed by and inform the process map to achieve maximum research efficiency.
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Quasi-random reflections on randomized controlled trials and comparative effectiveness research. Clin Trials 2012; 9:22-6. [DOI: 10.1177/1740774511433285] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Comparative effectiveness research (CER) is still an evolving framework for which much needs to be done to improve the ability of randomized controlled trials (RCTs) to supply the necessary evidence. Perhaps, most important is to start with a clearly specified decision and decision maker in mind when the RCTs are designed. Second is to initiate RCTs with clinically relevant outcomes and comparators earlier in the evaluation process. Third is to specify and measure factors that might modify the intervention’s effect, subject to logistical constraints of complexity and cost, so the trial is maximally informative, about how and to whom the intervention should be administered. It will be necessary to borrow observational methodologies and approaches to extract meaningful causal and subgroup inferences from such trials. Process variables should be seen as potentially part of that framework of effect-modifying factors, perhaps amenable to embedded experimental assessment with a trial. Perhaps most importantly, we need to improve the nationwide CER infrastructure to allow for rapid initiation and accrual for CER trials to reduce the trade-off that often exists between the speed of evidence development and its quality.
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Dilts DM, Rosenblum D, Trochim WM. A virtual national laboratory for reengineering clinical translational science. Sci Transl Med 2012; 4:118cm2. [PMID: 22277966 PMCID: PMC3691381 DOI: 10.1126/scitranslmed.3002951] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Clinical research is burdened by inefficiencies and complexities, with a poor record of trial completion, none of which is desirable. The Clinical and Translational Science Award (CTSA) Consortium, including more than 60 clinical research institutions, supports a unified national effort to become, in effect, a virtual national laboratory designed to identify, implement, evaluate, and extend process improvements across all parts of clinical research, from conception to completion. If adequately supported by academic health centers, industry, and funding agencies, the Consortium could become a test bed for improvements that can dramatically reduce wasteful complexity, thus increasing the likelihood of clinical trial completion.
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Affiliation(s)
- David M Dilts
- Knight Cancer Institute, Oregon Health and Science University, Portland, OR 97239, USA
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Rosenblum D, Alving B. The role of the clinical and translational science awards program in improving the quality and efficiency of clinical research. Chest 2011; 140:764-767. [PMID: 21896519 DOI: 10.1378/chest.11-0710] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Recognizing the need to increase the efficiency and quality of translating basic discovery into treatment and prevention strategies for patients and the public, the National Institutes of Health (NIH) announced the Clinical and Translational Science Awards (CTSAs) in 2006. Academic health centers that competed successfully for these awards agreed to work as a consortium and in cooperation with the NIH to improve the translation process by training the next generation of investigators to work in interdisciplinary teams, developing public-private partnerships in the movement of basic discovery to preclinical and clinical studies and trials, improving clinical research management, and engaging with communities to ensure their involvement in shaping research questions and in implementing research results. The CTSAs have addressed the crucial need to improve the quality and efficiency of clinical research by (1) providing training for clinical investigators and for bench researchers to facilitate their participation in the clinical and translational research environment, (2) developing more systematic approaches to clinical research management, and (3) engaging communities as active participants in the design and conduct of clinical research studies and trials and as leaders in implementing health advances that are of high importance to them. We provide an overview of the CTSA activities with attention to these three areas, which are essential to developing efficient clinical research efforts and effective implementation of research results on a national level.
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Affiliation(s)
- Daniel Rosenblum
- National Center for Research Resources, National Institutes of Health, Bethesda, MD
| | - Barbara Alving
- National Center for Research Resources, National Institutes of Health, Bethesda, MD.
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Abstract
The rapid pace of discoveries in tumor biology, imaging technology, and human genetics hold promise for an era of personalized oncology care. The successful development of a handful of new targeted agents has generated much hope and hype about the delivery of safer and more effective new treatments for cancer. The design and conduct of clinical trials has not yet adjusted to a new era of personalized oncology and so we are more in transition to that era than in it. With the development of treatments for breast cancer as a model, we review the approaches to clinical trials and the development of novel therapeutics in the prior era of population oncology, the current transitional era, and the future era of personalized oncology.
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Affiliation(s)
- Michael L. Maitland
- Section of Hematology/Oncology, Associate Director, Committee on Clinical Pharmacology and Pharmacogenomics, University of Chicago
| | - Richard L. Schilsky
- Corresponding author: , MC 2115, 5841 S. Maryland Ave., Chicago, IL 60637, U of C Phone: (773) 834-3914, U of C Fax: (773) 834-3915, Assistant: Michelle Scheuer ()
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Kitterman DR, Cheng SK, Dilts DM, Orwoll ES. The prevalence and economic impact of low-enrolling clinical studies at an academic medical center. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2011; 86:1360-6. [PMID: 21952064 PMCID: PMC3203249 DOI: 10.1097/acm.0b013e3182306440] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
PURPOSE The authors assessed the prevalence and associated economic impact of low-enrolling clinical studies at a single academic medical center. METHOD The authors examined all clinical studies receiving institutional review board (IRB) review between FY2006 and FY2009 at Oregon Health & Science University (OHSU) for recruitment performance and analyzed them by type of IRB review (full-board, exempt, expedited), funding mechanism, and academic unit. A low-enrolling study included those with zero or one participant at the time of study termination. The authors calculated the costs associated with IRB review, financial setup, contract negotiation, and department study start-up activities and the total economic impact on OHSU of low-enrolling studies for FY2009. RESULTS A total of 837 clinical studies were terminated during the study period, 260 (31.1%) of which were low-enrolling. A greater proportion of low-enrolling studies were government funded than industry funded (P=.006). The authors found significant differences among the various academic units with respect to percentages of low-enrolling studies (from 10% to 67%). The uncompensated economic impact of low-enrolling studies was conservatively estimated to be nearly $1 million for FY2009. CONCLUSIONS A substantial proportion of clinical studies incurred high institutional and departmental expense but resulted in little scientific benefit. Although a certain percentage of low-enrolling studies can be expected in any research organization, the overall number of such studies must be managed to reduce the aggregate costs of conducting research and to maximize research opportunities. Effective, proactive interventions are needed to address the prevalence and impact of low enrollment.
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Affiliation(s)
- Darlene R Kitterman
- Investigator Support and Integration Services, Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland, Oregon 97239, USA.
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Cheng SK, Dietrich MS, Dilts DM. Predicting accrual achievement: monitoring accrual milestones of NCI-CTEP-sponsored clinical trials. Clin Cancer Res 2011; 17:1947-55. [PMID: 21447723 DOI: 10.1158/1078-0432.ccr-10-1730] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The need to increase the number oncology clinical trials with sufficient enrollments is a well-known issue, particularly for trials targeting therapeutic applications. It is critical to identify early predictors of eventual study accrual achievement. EXPERIMENTAL DESIGN All nonpediatric phase I, I/II, II, and III therapeutic studies supported by the National Cancer Institute Cancer Therapy Evaluation Program (NCI-CTEP) between 2000 and 2007 (n = 764) were analyzed for accrual performance. Accrual achievement is defined as those enrolling 100% or more of the stated minimum accrual goal at the time of trial closure. Two accrual milestones were analyzed per trial: time to first patient enrollment and expected time to accrual goal. Multivariate logistic regression analysis was used to calculate the OR with respect to the likelihood of clinical trial accrual achievement. RESULTS A total of 81.5% (n = 623) of the trials did not achieve the projected accrual goals within the anticipated accruing period. Furthermore, 37.2% (n = 284) of trials failed to achieve the minimum projected accrual at study closure regardless of time the trial was open. Trials that accrue the first enrollment beyond 2 months (n = 379, 49.6%) are significantly less likely to achieve the accrual performance than those trials that enroll patients under 2 months (OR: 0.637, 95% CI: 0.464-0.875, P = 0.005). Of the studies that are open beyond the anticipated enrollment period (n = 603), those do not achieve at least 60.0% of the projected minimum accrual (n = 391, 64.8%) have a significantly less likelihood of achieving final accruals by study closure (OR: 0.190, 95% CI: 0.055-0.652, P = 0.008). CONCLUSIONS The time to first patient enrollment and expected time to accrual goal are shown to be valid measures to evaluate the likelihood of achieving the minimum projected accrual.
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Affiliation(s)
- Steven K Cheng
- Center for Management Research in Healthcare, Oregon Health & Science University, Portland, Oregon, USA
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Abstract
Cancer clinical trials in the US are at a major crossroads. Current government-sponsored research is some of the best in the world, but the field shares a worrying number of similarities with the American auto industry in its heyday. For clinical research to survive, the field must transform itself now to prevent a similar decline.
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Markman M. Proposal to Rigorously Evaluate the Clinical Benefits Associated with a Novel Anti-Neoplastic Strategy outside the Confines of a Randomized Trial. Oncology 2010; 79:321-3. [DOI: 10.1159/000324716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Accepted: 12/29/2010] [Indexed: 11/19/2022]
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