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Deutsch GB, Deneve JL, Al-Kasspooles MF, Nfonsam VN, Gunderson CC, Secord AA, Rodgers P, Hendren S, Silberfein EJ, Grant M, Sloan J, Sun V, Arnold KB, Anderson GL, Krouse RS. Intellectual Equipoise and Challenges: Accruing Patients With Advanced Cancer to a Trial Randomizing to Surgical or Nonsurgical Management (SWOG S1316). Am J Hosp Palliat Care 2019; 37:12-18. [PMID: 31122027 DOI: 10.1177/1049909119851471] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Prospective, randomized trials are needed to determine optimal treatment approaches for palliative care problems such as malignant bowel obstruction (MBO). Randomization poses unique issues for such studies, especially with divergent treatment approaches and varying levels of equipoise. We report our experience accruing randomized patients to the Prospective Comparative Effectiveness Trial for Malignant Bowel Obstruction (SWOG S1316) study, comparing surgical and nonsurgical management of MBO. METHODS Patients with MBO who were surgical candidates and had treatment equipoise were accrued and offered randomization to surgical or nonsurgical management. Patients choosing nonrandomization were offered prospective observation. Trial details are listed on www.clinicaltrials.gov (NCT #02270450). An accrual algorithm was developed to enhance enrollment. RESULTS Accrual is ongoing with 176 patients enrolled. Most (89%) patients chose nonrandomization, opting for nonsurgical management. Of 25 sites that have accrued to this study, 6 enrolled patients on the randomization arm. Approximately 59% (20/34) of the randomization accrual goal has been achieved. Patient-related factors and clinician bias have been the most prevalent reasons for lack of randomization. An algorithm was developed from clinician experience to aid randomization. Using principles in this tool, repeated physician conversations discussing treatment options and goals of care, and a supportive team-approach has helped increase accrual. CONCLUSIONS Experience gained from the S1316 study can aid future palliative care trials. Although difficult, it is possible to randomize patients to palliative studies by giving clinicians clear recommendations utilizing an algorithm of conversation, allotment of necessary time to discuss the trial, and encouragement to overcome internal bias.
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Affiliation(s)
- Gary B Deutsch
- Department of Surgery, Northwell Health, Lake Success, NY, USA
| | - Jeremiah L Deneve
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | | | - Camille C Gunderson
- Department of Obstetrics and Gynecology, University of Oklahoma, Oklahoma City, OK, USA
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke Cancer Institute, Durham, NC, USA
| | - Phillip Rodgers
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Samantha Hendren
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Marcia Grant
- Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA, USA
| | - Jeff Sloan
- Mayo Clinic Rochester, Rochester, MN, USA
| | - Virginia Sun
- Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA, USA
| | - Kathryn B Arnold
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Garnet L Anderson
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Robert S Krouse
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Policy, Philadelphia, PA, USA
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