Barriers in conducting clinical trials in oncology in the developing world: A cross-sectional survey of oncologists

The International Collaboration for Research methods Development in Oncology (CReDO) workshops: shaping the future of global oncology research

Low-income and middle-income countries (LMICs) have a disproportionately high burden of cancer and cancer mortality. The unique barriers to optimum cancer care in these regions necessitate context-specific research. The conduct of research in LMICs has several challenges, not least of which is a paucity of formal training in research methods. Building capacity by training early career researchers is essential to improve research output and cancer outcomes in LMICs. The International Collaboration for Research methods Development in Oncology (CReDO) workshop is an initiative by the Tata Memorial Centre and the National Cancer Grid of India to address gaps in research training and increase capacity in oncology research. Since 2015, there have been five CReDO workshops, which have trained more than 250 oncologists from India and other countries in clinical research methods and protocol development. Participants from all oncology and allied fields were represented at these workshops. Protocols developed included clinical trials, comparative effectiveness studies, health services research, and observational studies, and many of these protocols were particularly relevant to cancer management in LMICs. A follow-up of these participants in 2020 elicited an 88% response rate and showed that 42% of participants had made progress with their CReDO protocols, and 73% had initiated other research protocols and published papers. In this Policy Review, we describe the challenges to research in LMICs, as well as the evolution, structure, and impact of CReDO and other similar workshops on global oncology research.

Geographic disparities in access to cancer clinical trials in India

Introduction

The current study was aimed at quantifying the disparity in geographic access to cancer clinical trials in India.

Methods

We collated data of cancer clinical trials from the Clinical Trial Registry of India and data on state-wise cancer incidence from the Global Burden of Disease Study. The total sample size for each clinical trial was divided by the trial duration to get the sample size per year. This was then divided by the number of states in which accrual was planned to get the sample size per year per state (SSY).For interventional trials investigating a therapy, the SSY was divided by the number of incident cancers in the state to get the SSY per 1,000 incident cancer cases. The SSY data was then mapped to visualise the geographical disparity.

Results

We identified 181 ongoing studies, of which 132 were interventional studies. There was a substantial inter-state disparity-with a median SSY of 1.55 per 1,000 incident cancer cases (range 0.00-296.81 per 1,000 incident cases) for therapeutic interventional studies. Disparities were starker when cancer site-wise SSY was considered. Even in the state with the highest SSY, only 29.7% of the newly diagnosed cancer cases have an available slot in a therapeutic cancer clinical trial. Disparities in access were also apparent between academic (range: 0.21-226.60) and industry-sponsored trials (range: 0.17-70.21).

Conclusion

There are significant geographic disparities in access to cancer clinical trials in India. Future investigations should evaluate the reasons and mitigation approaches for such disparities.

Implementing oncology clinical trials in Nigeria: a model for capacity building

Background

There is both higher mortality and morbidity from cancer in low and medium income countries (LMICs) compared with high income countries (HICs). Clinical trial activities and development of more effective and less toxic therapies have led to significant improvements in morbidity and mortality from cancer in HICs. Unfortunately, clinical trials remain low in LMICs due to poor infrastructure and paucity of experienced personnel to execute clinical trials. There is an urgent need to build local capacity for evidence-based treatment for cancer patients in LMICs.

Methods

We conducted a survey at facilities in four Teaching Hospitals in South West Nigeria using a checklist of information on various aspects of clinical trial activities. The gaps identified were addressed using resources sourced in partnership with investigators at HIC institutions.

Results

Deficits in infrastructure were in areas of patient care such as availability of oncology pharmacists, standard laboratories and diagnostic facilities, clinical equipment maintenance and regular calibrations, trained personnel for clinical trial activities, investigational products handling and disposals and lack of standard operating procedures for clinical activities. There were two GCP trained personnel, two study coordinators and one research pharmacist across the four sites. Interventions were instituted to address the observed deficits in all four sites which are now well positioned to undertake clinical trials in oncology. Training on all aspects of clinical trial was also provided.

Conclusions

Partnerships with institutions in HICs can successfully identify, address, and improve deficits in infrastructure for clinical trial in LMICs. The HICs should lead in providing funds, mentorship, and training for LMIC institutions to improve and expand clinical trials in LMIC countries.

Clinical trials in low and middle-income countries - Successes and challenges

Gynecologic malignancies affect women in low and middle-income countries (LMICs) at equal or higher rates compared to high income countries (HICs), yet practice guidelines based on clinical trials performed in HICs do not routinely account for resource disparities between these regions. There is a need and growing interest for executing clinical trials in LMICs. This has led to the creation of multinational cooperative groups and the initiation of several ongoing clinical trials in Mexico, China, and Korea. In this article we describe the challenges involved in initiating clinical trials in LMICs, review current efforts within surgical, medical, and radiation oncology, and introduce high priority topics for future research.

Second-Line Treatment Selection in Patients With Non-Small-Cell Lung Cancer of Adenocarcinoma Histology: Findings From a European Survey of Treating Physicians

BACKGROUND

Guidelines provide treatment recommendations for advanced non-small-cell lung cancer (NSCLC), but physicians must also consider other factors. We surveyed physicians treating NSCLC to determine their therapy goals, drivers of treatment choice, current prescribing behavior, and therapy expectations.

MATERIALS AND METHODS

In 2015, an online survey was conducted of 500 pulmonologists/oncologists treating lung adenocarcinoma in Germany, France, Italy, Spain, and the United Kingdom, comprising screening and therapy decision questions.

RESULTS

On average, physicians had 14.7 years of experience and treated 79 patients/3 months with stage IIIb/IV NSCLC. In patients with Eastern Cooperative Oncology Group (ECOG) 0-1, "prolonged survival/extending life" was the main therapy goal of physicians for first- (63%) and second-line (40%) patients; improvement in quality of life (QoL) was the main goal of 14% of physicians for second-line patients. For patients with ECOG ≥2, the main goal of second-line therapy was improvement in QoL (26%) or tumor-related symptoms (23%). Most (57%) physicians strongly agreed that they preferred a second-line treatment that extends overall survival (OS) while maintaining QoL; their greatest dissatisfaction with available second-line treatment options was the inability to "stop tumor progression over the long term" (66%). Physicians expected new therapies to become available within 12 months that would provide improvements in progression-free survival (83%) or OS (69%).

CONCLUSION

OS is important for second-line treatments in patients with stage IIIb/IV NSCLC, although QoL improvements should not be underestimated. This survey highlights the wait faced by patients and physicians as treatments transition from clinical trials to clinical practice.