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Dam MS, Green S, Bogicevic I, Hillersdal L, Spanggaard I, Rohrberg KS, Svendsen MN. Precision patients: Selection practices and moral pathfinding in experimental oncology. Sociol Health Illn 2022; 44:345-359. [PMID: 34993996 DOI: 10.1111/1467-9566.13424] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 12/03/2021] [Accepted: 12/16/2021] [Indexed: 06/14/2023]
Abstract
This paper addresses selection practices in a Danish phase 1 unit specialised in precision medicine in the field of oncology. Where precision medicine holds the ambition of selecting genetically fit medicine for the patient, we find that precision medicine in the early trial setting is oriented towards selecting clinically and genetically fit patients for available treatment protocols. Investigating how phase 1 oncologists experience and respond to the moral challenges of selecting patients for early clinical trials, we show that inclusion criteria and patient categories are not always transparent to patients. Lack of transparency about inclusion criteria has been interpreted as morally problematic. Yet drawing on social science studies of 'unknowing', we argue that silence and non-transparency in interactions between oncologists and patients are crucial to respect the moral agency of patients at the edge of life and recognise them as belonging to the public of Danish health care. In the discussion, we consider the practice of placing 'unfit' patients on a waiting list for trial participation. Rather than representing an ethical and political problem, we argue, the waiting list can act as a valve enabling oncologists to navigate the scientific and as well as the moral uncertainties in phase 1 oncology.
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Affiliation(s)
- Mie S Dam
- Centre for Medical Science and Technology Studies, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Sara Green
- Centre for Medical Science and Technology Studies, Department of Science Education, University of Copenhagen, Copenhagen, Denmark
| | - Ivana Bogicevic
- Centre for Medical Science and Technology Studies, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Line Hillersdal
- Centre for Medical Science and Technology Studies, Department of Anthropology, University of Copenhagen, Copenhagen, Denmark
| | - Iben Spanggaard
- The Phase I Unit, Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | | | - Mette N Svendsen
- Centre for Medical Science and Technology Studies, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Rodon J, Soria JC, Berger R, Batist G, Tsimberidou A, Bresson C, Lee JJ, Rubin E, Onn A, Schilsky RL, Miller WH, Eggermont AM, Mendelsohn J, Lazar V, Kurzrock R. Challenges in initiating and conducting personalized cancer therapy trials: perspectives from WINTHER, a Worldwide Innovative Network (WIN) Consortium trial. Ann Oncol 2015; 26:1791-8. [PMID: 25908602 DOI: 10.1093/annonc/mdv191] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 04/13/2015] [Indexed: 12/11/2022] Open
Abstract
Advances in 'omics' technology and targeted therapeutic molecules are together driving the incorporation of molecular-based diagnostics into the care of patients with cancer. There is an urgent need to assess the efficacy of therapy determined by molecular matching of patients with particular targeted therapies. WINTHER is a clinical trial that uses cutting edge genomic and transcriptomic assays to guide treatment decisions. Through the lens of this ambitious multinational trial (five countries, six sites) coordinated by the Worldwide Innovative Networking Consortium for personalized cancer therapy, we discovered key challenges in initiation and conduct of a prospective, omically driven study. To date, the time from study concept to activation has varied between 19 months at Gustave Roussy Cancer Campus in France to 30 months at the Segal Cancer Center, McGill University (Canada). It took 3+ years to be able to activate US sites due to national regulatory hurdles. Access to medications proposed by the molecular analysis remains a major challenge, since their availability through active clinical trials is highly variable over time within sites and across the network. Rules regarding the off-label use of drugs, or drugs not yet approved at all in some countries, pose a further challenge, and many biopharmaceutical companies lack a simple internal mechanism to supply the drugs even if they wish to do so. These various obstacles should be addressed to test and then implement precision medicine in cancer.
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Affiliation(s)
- J Rodon
- Vall D'Hebron Institute of Oncology and Universitat Autonoma de Barcelona, Barcelona, Spain
| | - J C Soria
- Gustave Roussy Cancer Campus Grand Paris, Villejuif, France
| | - R Berger
- Oncology Institute, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - G Batist
- Segal Cancer Center, Jewish General Hospital Mcgill University, Montreal Quebec Consortium de Recherche en Oncologie Clinique, Quebec, Canada
| | - A Tsimberidou
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | | | - J J Lee
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - E Rubin
- The National Institute of Biotechnology in the Negev, Ben Gurion University, Beer-Sheva, Israel
| | - A Onn
- Oncology Institute, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - R L Schilsky
- American Society of Clinical Oncology (ASCO), Alexandria
| | - W H Miller
- Segal Cancer Center, Jewish General Hospital Mcgill University, Montreal Quebec Consortium de Recherche en Oncologie Clinique, Quebec, Canada
| | - A M Eggermont
- Gustave Roussy Cancer Campus Grand Paris, Villejuif, France
| | - J Mendelsohn
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - V Lazar
- Gustave Roussy Cancer Campus Grand Paris, Villejuif, France
| | - R Kurzrock
- Center for Personalized Cancer Therapy, UC San Diego-Moores Cancer Center, La Jolla, USA
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Tuxen IV, Jønson L, Santoni-Rugiu E, Hasselby JP, Nielsen FC, Lassen U. Personalized oncology: genomic screening in phase 1. APMIS 2014; 122:723-33. [PMID: 25046202 DOI: 10.1111/apm.12293] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 06/03/2014] [Indexed: 12/23/2022]
Abstract
Improvements in cancer genomics and tumor biology have reinforced the evidence of cancer development driven by numerous genomic alterations. Advanced genomics technology can be used to characterize genomic alterations that potentially drive tumor growth. With the possibility of screening thousands of genes simultaneously, personalized molecular medicine has become an option. New treatments are being investigated in phase 1 trials around the world. Traditionally, the goal of phase 1 studies was to determine the optimal dose and assess dose-limiting toxicity of a potential new experimental drug. Only a limited number of patients will benefit from the treatment. However, introducing genomic mapping to select patients for early clinical trials with targeted molecular therapy according to the genomic findings, may lead to a better outcome for the patient, an enrichment of phase 1 trials, and thereby accelerated drug development. The overall advantage is to determine which mutation profiles correlate with sensitivity or lack of resistance to specific targeted therapies. The utility and current limitations of genomic screening to guide selection to Phase 1 clinical trial will be discussed.
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Affiliation(s)
- Ida Viller Tuxen
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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