Managing Accrual in Cooperative Group Clinical Trials

Impact of Broadening Trial Eligibility Criteria for Patients with Advanced Non-Small Cell Lung Cancer: Real-World Analysis of Select ASCO-Friends Recommendations

PURPOSE

Cancer clinical trials often accrue slowly or miss enrollment targets. Strict eligibility criteria are a major reason. Restrictive criteria also limit opportunities for patient participation while compromising external validity of trial results. We examined the impact of broadening select eligibility criteria on characteristics and number of patients eligible for trials, using recommendations of the American Society of Clinical Oncology (ASCO) and Friends of Cancer Research.

EXPERIMENTAL DESIGN

A retrospective, observational analysis used electronic health record data from ASCO's CancerLinQ Discovery database. Study cohort included patients with advanced non-small cell lung cancer treated from 2011 to 2018. Patients were grouped by traditional criteria [no brain metastases, no other malignancies, and creatinine clearance (CrCl) ≥ 60 mL/minute] and broadened criteria (including brain metastases, other malignancies, and CrCl ≥ 30 mL/minute).

RESULTS

The analysis cohort included 10,500 patients. Median age was 68 years, and 73% of patients were White. Most patients had stage IV disease (65%). A total of 5,005 patients (48%) would be excluded from trial participation using the traditional criteria. The broadened criteria, however, would allow 98% of patients (10,346) to be potential participants. Examination of patients included by traditional criteria (5,495) versus those added (4,851) by broadened criteria showed that the number of women, patients aged 75+ years, and those with stage IV cancer was significantly greater using broadened criteria.

CONCLUSIONS

This analysis of real-world data demonstrated that broadening three common eligibility criteria has the potential to double the eligible patient population and include trial participants who are more representative of those encountered in practice.See related commentary by Giantonio, p. 2369.

Assessing the challenges of multi-scope clinical research sites: an example from NIH HIV/AIDS clinical trials networks

RATIONALE, AIMS, AND OBJECTIVES

Large-scale, multi-network clinical trials are seen as a means for efficient and effective utilization of resources with greater responsiveness to new discoveries. Formal structures instituted within the National Institutes of Health (NIH) HIV/AIDS Clinical Trials facilitate collaboration and coordination across networks and emphasize an integrated approach to HIV/AIDS vaccine, prevention and therapeutics clinical trials. This study examines the joint usage of clinical research sites as means of gaining efficiency, extending capacity, and adding scientific value to the networks.

METHODS

A semi-structured questionnaire covering eight clinical management domains was administered to 74 (62% of sites) clinical site coordinators at single- and multi-network sites to identify challenges and efficiencies related to clinical trials management activities and coordination with multi-network units.

RESULTS

Overall, respondents at multi-network sites did not report more challenges than single-network sites, but did report unique challenges to overcome including in the areas of study prioritization, community engagement, staff education and training, and policies and procedures. The majority of multi-network sites reported that such affiliations do allow for the consolidation and cost-sharing of research functions. Suggestions for increasing the efficiency or performance of multi-network sites included streamlining standards and requirements, consolidating protocol activation methods, using a single cross-network coordinating centre, and creating common budget and payment mechanisms.

CONCLUSIONS

The results of this assessment provide important information to consider in the design and management of multi-network configurations for the NIH HIV/AIDS Clinical Trials Networks, as well as others contemplating and promoting the concept of multi-network settings.

Obstacles to participation in randomised cancer clinical trials: a systematic review of the literature

Accrual to clinical trials continues to be a problem in many countries including Australia despite its fundamental importance to the progress of evidence-based medicine. This paper reviews the current literature addressing the obstacles to accrual excluding those related to protocol design. An electronic search of the literature identified publications in oncology specifically addressing the obstacles to participation in clinical trials. This search was supplemented by searches of key oncology journals. Obstacles fall into three main categories - clinician, patient and system; however, there are overlaps between categories. Clinician behaviour is the most important of these. Exclusion of patients for reasons other than defined eligibility criteria, concerns about increased time requirements, and suboptimal communication with patients all affect accrual. Risk management strategies for clinical trials need to be individualised to address the obstacles most likely to negatively impact on accrual. Communication between clinician and patient appears to be a greater issue than previously recognised. Time concerns need to be addressed as generational change affects the expectations of the medical workforce.

Patient advocates' role in clinical trials: perspectives from Cancer and Leukemia Group B investigators and advocates

BACKGROUND

Patient advocates are increasingly involved in cooperative group trials, single-institution cancer programs, and peer-review of research applications. The purpose of this study was to evaluate the role and value of patient advocates from the perspective of Cancer and Leukemia Group B (CALGB) advocates and investigators.

METHODS

An online survey was sent to current and past (within 5 years) patient advocates and investigators. RESULTS.: Response rates were 72.7% (16 of 22) for advocates and 56.4% (102 of 181) for investigators. Patient advocates were more likely than investigators to report the following: the clinical trial process benefited from advocate involvement on committees (100% of advocates vs 72.1% of investigators; P < .05), advocates contribute to protocol development (92.8% vs 33.8%, respectively; P < .001), the cultural appropriateness of protocols (21.4% vs 10.4%, respectively; P < .05), advocates assist with patient accrual (78.6% vs 23.4%, respectively; P < .001), and advocates add value to concept development and protocol review (100% vs 63.2%, respectively; P < .001). Over half of advocates and investigators reported gaps in patient advocate knowledge and suggested that additional clinical trials training was needed. To improve clinical trials, advocates suggested their earlier involvement in protocol development and increased support from investigators. CALGB investigators recommended improving patient advocate selection and communication skills training:

CONCLUSIONS

The majority of patient advocates and investigators perceived benefits from advocate involvement in the clinical trials process; patient advocates placed more value on their role than investigators. The current results indicated that strategies to improve advocacy training and advocate-investigator communication may further enhance the role of patient advocates, and future studies that clarify the role of advocates in the prioritization and development of protocol, consent, and education materials, and on patient accrual, are warranted.

Challenges to accrual predictions to phase III cancer clinical trials: a survey of study chairs and lead statisticians of 248 NCI-sponsored trials

BACKGROUND

Research on barriers to accrual has typically emphasized factors influencing participation after trial activation.

PURPOSE

We sought to identify factors influencing trial design and accrual predictions prior to trial activation associated with sufficient accrual.

METHODS

A 30-question web-based survey was sent to the study chair and lead statistician for all 248 phase III trials open in 1993-2002 by five Clinical Trials Cooperative Groups. Questions addressed prior trial experience, trial design elements, accrual predictions, and perceived accrual influences. Accrual sufficiency categorization was derived from Clinical Trials Cooperative Group records: sufficient accrual included trials closed with complete accrual or at interim analysis, insufficient accrual included trials closed with inadequate accrual. Responses were analyzed by respondent role (study chair/lead statistician) and accrual sufficiency.

RESULTS

Three hundred and nine eligible responses were included (response rate, 63%; lead statisticians, 81%; and study chairs, 45%), representing trials with sufficient (63%) and insufficient accruals (37%). Study chair seniority or lead statistician experience was not linked to accrual sufficiency. Literature review, study chair's personal experience, and expert opinion within Clinical Trials Cooperative Group most commonly influenced control arm selection. Clinical Trials Cooperative Group experience most influenced accrual predictions. These influences were not associated with accrual sufficiency. Among respondents citing accrual difficulties (41%), factors negatively influencing accrual were not consistently identified. Respondents credited three factors with positively influencing accrual: clinical relevance of study, lack of competing trials, and protocol paralleling normal practice.

LIMITATIONS

Perceptions of lead statisticians and study chairs may not accurately reflect accrual barriers encountered by participating physicians or patients. Survey responses may be subject to recall bias.

CONCLUSION

Consistent factors explaining poor accrual were not identified, suggesting reasons for poor accrual are not well understood and warrant further study. Alternate strategies for accrual prediction are needed since Clinical Trials Cooperative Group experience is linked to successful and unsuccessful accrual.

RTOG physician and research associate attitudes, beliefs and practices regarding clinical trials: implications for improving patient recruitment

PURPOSE

Timely recruitment and retention of human subjects remains a leading problem in oncology clinical trials even among the national oncology clinical trial cooperative groups. The Radiation Therapy Oncology Group (RTOG) developed an exploratory survey to assess member attitudes, beliefs, and practices (ABPs) towards clinical trials that might influence patient accrual to clinical trials.

METHODS

The survey was developed using Survey Monkey(c) and emailed to principal investigators (PIs) and research associates (RAs) at 267 RTOG member institutions. Survey items were selected based on a review of the literature. PI and RA responses were matched by institution to determine whether responses varied due to job responsibilities and/or institutional practices. Principal component analysis was used to achieve variable reduction in further describing respondents' ABPs.

RESULTS

PIs and RAs reported similar recruitment concerns [kappa=0.55, 95% CI (0.51, 0.60)]. Five components related to recruitment concerns were identified: presentation of trials to patients, barriers and recruitment risks, staff involvement, access for underrepresented populations, and familial involvement (patient). Nearly one of four (24%) respondents perceived that patients did not understand what randomization means. Staff issues included nearly a third of respondents not having a formal mechanism at their institution for eligibility screening, and similarly, about one of three respondents felt that unrepresented patient populations would benefit from translated consent forms.

CONCLUSIONS

Findings of this survey inform RTOG strategies for addressing opportunities for improvement, including clinician/patient education and a best practices tool box that in the future would include successful mechanisms for eligibility screening and recruitment.

An essential partnership: patient advocates and cooperative groups

Cancer patient advocates have been working with the National Cancer Institute (NCI)-sponsored cooperative groups since the early 1990s. These partnerships have evolved over time and have become integral to each cooperative group as they strive to develop and validate better cancer treatments so that patients live longer. Patient advocates are now involved in concept and protocol development in disease, modality, and administrative committees to confirm that requirements are relevant and feasible for cancer patients. Approval and activation steps also are key focus areas, as are recruitment plans. Patient advocates also participate in executive decisions in some cooperative groups to concentrate efforts on clinical trial results that improve patients' live rather than solely answering interesting scientific questions. Patient advocates also contribute collectively through the Patient Advisory Board (PAB) to the Coalition of Cancer Cooperative Groups by sharing best practices, addressing emerging research issues, and challenging cooperative group leadership to work together in new ways. These voluntary efforts with NCI and the cooperative groups endeavor to help fix problems in the research enterprise so that tangible results can be implemented more quickly for people.

Influence of clinical communication on patients' decision making on participation in clinical trials

PURPOSE

To investigate how communication among physicians, patients, and family/companions influences patients' decision making about participation in clinical trials.

PATIENTS AND METHODS

We video recorded 235 outpatient interactions occurring among oncologists, patients, and family/companions (if present) at two comprehensive cancer centers. We combined interaction analysis of the real-time video-recorded observations (collected at Time 1) with patient self-reports (Time 2) to determine how communication about trial offers influenced accrual decisions.

RESULTS

Clinical trials were explicitly offered in 20% of the interactions. When offers were made and patients perceived they were offered a trial, 75% of patients assented. Observed messages (at Time 1) directly related to patients' self-reports regarding their decisions (2 weeks later), and how they felt about their decisions and their physicians. Specifically, messages that help build a sense of an alliance (among all parties, including the family/companions), provide support (tangible assistance and reassurance about managing adverse effects), and provide medical content in language that patients and family/companions understand are associated with the patient's decision and decision-making process.

CONCLUSION

In two urban, National Cancer Institute-designated comprehensive cancer centers, a large percentage of patients are not offered trials. When offered a trial, most patients enroll. The quality and quantity of communication occurring among the oncologist, patient, and family/companion when trials are discussed matter in the patient's decision-making process. These findings can help increase physician awareness of the ways that messages and communication behaviors can be observed and evaluated to improve clinical practice and research.

Some design issues of strata-matched non-randomized studies with survival outcomes

Non-randomized studies for the evaluation of a medical intervention are useful for quantitative hypothesis generation before the initiation of a randomized trial and also when randomized clinical trials are difficult to conduct. A strata-matched non-randomized design is often utilized where subjects treated by a test intervention are matched to a fixed number of subjects treated by a standard intervention within covariate based strata. In this paper, we consider the issue of sample size calculation for this design. Based on the asymptotic formula for the power of a stratified log-rank test, we derive a formula to calculate the minimum number of subjects in the test intervention group that is required to detect a given relative risk between the test and standard interventions. When this minimum number of subjects in the test intervention group is available, an equation is also derived to find the multiple that determines the number of subjects in the standard intervention group within each stratum. The methodology developed is applied to two illustrative examples in gastric cancer and sarcoma.

How have patient advocates in the United States benefited cancer research?

Cancer patient advocates represent those affected by cancer and have a broad view of cancer research. They are involved in many diverse cancer research committees, where they can help tackle old problems from new perspectives that often differ from government, academic, medical and scientific approaches. In this role, patient advocates have aided the development of educational dialogue between investigators and patient communities and assisted in streamlining cancer research policies and clinical trials.