Can the referring surgeon enhance accrual of breast cancer patients to medical and radiation oncology trials? The ENHANCE study

Integrating Systematic Reviews into Supportive Care Trial Design: The Rethinking Clinical Trials (REaCT) Program

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.

An Electronic Information Kiosk for Enhancing Patient Accrual for Cancer Clinical Trials: A Pilot and Feasibility Study

Introduction

Low accrual to clinical trials for solid tumors at our institution led to a review of possible modifiable factors within our control. This led to a pilot project to determine whether improved patient awareness could alter accrual rates to active trials.

Methods

An information kiosk was located at the patient library on the ground floor of the London Regional Cancer Program. Adult cancer patients were invited to learn more about clinical trials from our research navigator, including specific trials open in our center, and to participate in the study, which involved a brief satisfaction and demographics survey.

Results

Three hundred and eighty-six (386) patients interacted with the clinical trial information kiosk over the eight weeks it was open. Of these, 32 patients consented and filled out surveys, which indicated an overall positive interaction with the kiosk. Unfortunately, in the time period examined, clinical trial accrual rates appeared to decrease when the pre- and post-kiosk activation periods were compared (44 versus 37 patients accrued to various trials).

Conclusion

Our pilot study found that the implementation of a clinical trial information kiosk was easy to understand and useful for patients to learn more about clinical trials. Barriers to this patient satisfaction translating into increased accrual rates in our center included suboptimal kiosk location and lack of guidance to the kiosk from clerical staff. High patient satisfaction scores support the potential value of permanent clinical trial information kiosks in our cancer center, but this requires increased attention to visibility, location, and staff education.

Oncologic patients' misconceptions may impede enrollment into clinical trials: a cross-sectional study

Background

Clinical trials are an essential source for advances in oncologic care, yet the enrollment rate is only 2-4%. Patients' reluctance to participate is an important barrier. This study evaluates patients' level of understanding and attitudes towards clinical trials.

Methods

This cross-sectional study was conducted in the oncology department and day care unit at the oncology division Tel Aviv Sourasky Medical Center, Israel. From January 2015 to September 2016. Two-hundred patients’ currently receiving active anti-cancer therapy at a large tertiary hospital completed an anonymous questionnaire comprised of demographic information, past experience in clinical research and basic knowledge on clinical trials.

Results

The majority of respondents did not meet the minimum knowledge level criteria. In those who replied they would decline to participate in a clinical trial, concern were related to potential assignment to the placebo arm, provision of informed consent and trust issues with their oncologist. Those with sufficient knowledge were significantly more interested in participating. Patients with past experience in clinical trials had a higher level of academic education, were less religious, had a better understanding of medical research and were inclined to participate in future research.

Conclusions

Misperceptions of clinical trials may contribute substantially to the unwillingness to participate in them.

Clinical Trials for the Surgical Oncologist: Opportunities and Hurdles

Advancements in clinical practice usually require level one evidence from clinical trials that directly compare new approaches to standard of care. While clinical trials have provided data to guide advances in practices across surgical oncology, all too often accrual to clinical trials is slower than anticipated, and once results are presented and published, adoption in clinical practice is slow. Why and how can surgeons be successfully involved with clinical trials? An expert panel discusses the basic infrastructure of clinical trials, investigator-initiated trials, the National Clinical Trials Network, and opportunities for surgeon involvement. Two national clinical trials, NSABP B-51/RTOG 1304 and PROSPECT N1048, are discussed to highlight the role of the surgical oncologist.

What do patients with unmet medical needs want? A qualitative study of patients' views and experiences with expanded access to unapproved, investigational treatments in the Netherlands

BACKGROUND

Patients with unmet medical needs sometimes resort to non-standard treatment options, including the use of unapproved, investigational drugs in the context of clinical trials, compassionate use or named-patient programs. The views and experiences of patients with unmet medical needs regarding unapproved, investigational drugs have not yet been examined empirically.

METHODS

In this qualitative study, exploratory interviews and focus groups were held with patients with chronic or life-threatening diseases (n = 39), about topics related to non-standard treatment options, such as the search for non-standard treatment options, patients' views of the moral obligations of doctors, and the conditions under which they would or would not wish to use non-standard treatment options, including expanded access to unapproved, investigational drugs.

RESULTS

Respondents had very little knowledge about and/or experience with existing opportunities for expanded access to investigational drugs, although some respondents were actively looking for non-standard treatment options. They had high expectations of their treating physicians, assuming them to be aware of non-standard treatment options, including clinical trials elsewhere and expanded access programs, and assuming that they would inform their patients about such options. Respondents carefully weighed the risks and potential benefits of pursuing expanded access, citing concerns related to the scientific evidence of the safety and efficacy of the drug, side effects, drug-drug interactions, and the maintaining of good quality of life. Respondents stressed the importance of education and assertiveness to obtain access to good-quality health care, and were willing to pay out of pocket for investigational drugs. Patients expressed concerns about equal access to new and/or non-standard treatment options.

CONCLUSION

When the end of a standard treatment trajectory comes into view, patients may prefer that treating physicians discuss non-standard treatment options with them, including opportunities for expanded access to unapproved, investigational drugs. Although our respondents had varying levels of understanding of expanded access programs, they seemed capable of making well-considered choices with regard to non-standard treatment options and had realistic expectations with regard to the safety and efficacy of such options. Dutch patients might be less likely to fall prey to false hope than often presumed.

Feasibility of using a pragmatic trials model to compare two primary febrile neutropenia prophylaxis regimens (ciprofloxacin versus G-CSF) in patients receiving docetaxel-cyclophosphamide chemotherapy for breast cancer (REaCT-TC)

PURPOSE

Optimal primary febrile neutropenia (FN) prophylaxis (i.e. ciprofloxacin or granulocyte-colony stimulating factors [G-CSF]) for patients receiving docetaxel-cyclophosphamide (TC) chemotherapy is unknown. We assessed the feasibility of using a novel pragmatic comparative effectiveness trial to compare these standard-of-care options.

METHODS

Early-stage breast cancer patients receiving TC chemotherapy were randomised to either ciprofloxacin or G-CSF. Trial methodology consists of broad eligibility criteria, simply-defined endpoints, integrated consent model incorporating oral consent, and web-based randomisation in the clinic. Primary feasibility endpoints included patient and physician engagement (if > 50% of patients approached agree to participate and if > 50% of physicians approached patients for the study). Secondary clinical endpoints included the following: first occurrence rates of FN, treatment-related hospitalisation, or chemotherapy dose reduction/delay/discontinuation, as well as patient satisfaction with the oral consent process.

RESULTS

Of 204 patients approached, 91.2% (186/204) agreed to randomisation. Sixteen of twenty (80%) participating medical oncologists randomised patients. Median patient age was 57.7 (range 31.8-84.1). The 186 patients received 557 cycles of chemotherapy. Overall incidences of first events by patient (n = 186) were as follows: FN (18/186, 21.43%), treatment-related hospitalisation (11/186, 13.10%), chemotherapy reduction (19/186, 22.62%), chemotherapy discontinuation (16/186, 19.05%), and chemotherapy delays (5/186, 5.95%). A total of 37.77% (69/186) of patients and 12.39% (69/557) of chemotherapy cycles had at least one of these first events. Patients were highly satisfied with the oral consent process.

CONCLUSION

This study met its feasibility endpoints. This model offers a means of comparing standard-of-care treatments in a practical and cost-efficient manner.

TRIAL REGISTRATION

Trial registration: ClinicalTrials.gov : NCT02173262.

Randomised feasibility trial to compare three standard of care chemotherapy regimens for early stage triple-negative breast cancer (REaCT-TNBC trial)

INTRODUCTION

Despite the importance of chemotherapy in the treatment of early stage triple negative breast cancer (TNBC), no one optimal regimen has been identified. We conducted a pilot trial comparing outcomes for the three most commonly used chemotherapy regimens to assess the feasibility of conducting a larger definitive trial.

METHODS

Using integrated consent, newly diagnosed TNBC patients were randomised to one of three standard regimens: dose-dense doxorubicin-cyclophosphamide then paclitaxel, doxorubicin-cyclophosphamide then weekly paclitaxel or 5-FU-epirubicin-cyclophosphamide then docetaxel. Feasibility endpoints included; physician engagement, accrual rates, physician compliance and patient satisfaction with the integrated consent model. Our anticipated pilot trial sample size was 35 randomised patients in one year.

RESULTS

Between August 30th, 2016 and January 31st 2017, 2 patients met eligibility and were randomised. A survey of 10 participating oncologists was performed to identify potential strategies to enhance accrual. Most investigators (9/10) believed that the best regimen for TNBC was unknown, and 4/10 felt this was a pressing clinical question. Physicians' responses suggested that poor accrual was due to: a lack of interest in some study arms as oncologists already had a preferred regimen (4/10) and concerns about trial demands in busy clinics (3/10). The pilot feasibility endpoints were not met and the study was closed.

CONCLUSIONS

Despite initial interest in the trial question and multiple investigators agreeing to approach patients, this trial failed to meet feasibility endpoints. The reasons for poor accrual were multiple and require further evaluation if this important patient-centred question is to be answered.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02688803.

Novel Methodology for Comparing Standard-of-Care Interventions in Patients With Cancer

Purpose:

The current clinical trials development and conduct process is cumbersome and expensive, with the majority of studies focusing on either the development of new agents or new indications for established agents. Unfortunately, research comparing standard-of-care interventions is rarely performed, leaving many important and practical patient-centered questions unanswered. Novel clinical trial methodologies and approaches are needed.

Methods:

We have identified simple key components that, when combined, enhance the ability to both perform and increase accrual for studies that compare standard-of-care interventions. These include selection of clinically relevant and practical questions, demonstration of clinical equipoise through surveys of knowledge users and completion of systematic reviews, appropriate study design and simply defined study end points, use of an integrated consent model incorporating oral consent, efficient research ethics board approval, Web-based randomization in the clinic, real-time electronic data capture and management, and regular formal team feedback.

Results:

We have demonstrated the feasibility of this model in a pragmatic trial comparing two standard-of-care interventions (growth factor support or ciprofloxacin) for the primary prophylaxis of febrile neutropenia in patients with breast cancer receiving adjuvant docetaxel with cyclophosphamide chemotherapy. Research ethics board approval took 3 months, and 110 (72%) of 153 potentially eligible patients have agreed to participate in the study. When surveyed, 81 (85%) of 95 patients were completely satisfied with the integrated consent model process.

Conclusion:

Our proposed model contains elements that, when used alone or in combination, may allow efficient and cost-effective comparison of standard-of-care interventions.