Author: clinicalaccelerator

In the previous posts on barriers to recruiting patients for clinical trials, I addressed some of the problems that patients and clinicians face. In this final post, I will discuss some of the difficulties faced from a healthcare systems perspective, and ways in which these might be tackled.

Funding and coordination

Undoubtedly, the major barrier to healthcare organizations taking a more active role in clinical trials and recruitment of patients is funding and available human resources. This includes both limited resources at the level of healthcare facilities themselves, and a lack of funding for clinical trial research, especially from national research organizations.

Clinical trials often require a minimum number of patients to effectively assess the success of a treatment and therefore have to remain open and actively recruiting for long periods of time. This can be extremely expensive. Also, where funding is available, it still may not be sufficient to carry out clinical trials with designs that best test particular treatment modalities.

Another issue, connected to that of limited funding, is lack of resources for study coordination. It can be very difficult for healthcare organizations to identify patients that are eligible for clinical trials. Getting healthcare professionals working together to achieve patient recruitment targets is also a challenge. These issues are compounded if the facility has only a minimal infrastructure for clinical trials, or does not have a funded clinical trials coordinator.

In OncLive’s recent article, “Tackling Patient Recruitment Challenges in Clinical Trials”, Dr. Timothy Mullet, Chief, Section of General Thoracic Surgery at University of Kentucky College of Medicine, summarized the concerns, “Those in the ivory tower want us to take care of patients efficiently, and bill for it . . . there is just no way to justify the costs, so there has to be a commitment from the enterprise that they are willing to take a loss on it.”

Insurance

Issues regarding insurance can be another major hurdle for healthcare systems to overcome when recruiting patients for clinical trials. While some insurers may provide adequate coverage for standard care, many may be unwilling to cover care outside of their facilities, even if they do not have appropriate treatment options available to patients. Where patients are uninsured this can also be a barrier to participation in clinical trials. It is sometimes possible to find resources to support uninsured patients care, but this will often delay their treatment for several months.

Strategies for tackling funding

So, how can these barriers to recruitment be overcome? The experts interviewed by OncLive had a number of recommendations. One point that was emphasized was the necessity to hardwire clinical trials awareness and recruitment into healthcare systems.

In terms of tackling funding issues, the experts suggested that healthcare organizations approached legislative bodies for additional funding, as well as private foundations that might be interested in supporting clinical trials. In addition to this, organizations should consider supporting different types of clinical trials, from those supported by industry, which have sufficient funding of their own, to cooperative and investigator initiated ones.

Strategies for tackling coordination

As well as tackling questions of funding, it is essential for healthcare organizations to recognize the importance of clinical trials, by providing appropriate support, personnel, office space and resources, and thus enabling them to achieve their goals. Organizations should consider the support that their clinicians can provide and the systems capacity that they have, and only carry out trials which will be both cost effective, and can be conducted responsibly and with good clinical practice.

In terms of strategies for overcoming coordination challenges, OncLive’s panel of experts had a range of long-term practices that would hugely improve healthcare systems’ ability to effectively run clinical trials. For example, healthcare leaders can encourage recruitment by initiating a dialogue with patients and communities about clinical trials, leading to positive publicity and increased awareness.

Other suggestions included adopting new technologies such as electronic medical records, combining practices to create large networks, and devising methods of monitoring performance to assess whether trial targets are being met. One recommendation that met with universal support from OncLive’s experts was the designation of a dedicated clinical trials coordinator: someone who knows which trials are available and can explain to patients how participation in trials could be of benefit to them, acting to coordinate the whole process.

At Clinical Accelerator we believe that patient enrolment organizations can effectively intervene in situations when investigative sites experience lack of resources. Assisting sites with screening efforts, patient recruitment and retention, even embedding into sites’ structure external dedicated study co-ordinators directly employed by a patient enrolment organization can lead to significant improvement in site performance.

Clinical trials are good for patients

In this series of blog posts, I have discussed some of the major barriers to successful recruitment of patients to clinical trials. There are many potential approaches to overcoming these obstacles. However, communication has been demonstrated to be of paramount importance. The ultimate goal of clinical trials is to help patients and improve treatments. Getting this message across to everyone involved is key to improving recruitment.

References

Tackling Patient Recruitment Challenges in Clinical Trials – http://www.onclive.com/publications/oncology-live/2014/march-2014/tackling-patient-recruitment-challenges-in-clinical-trials/

In the second installment of the Clinical Accelerator “Barriers to recruitment” blog series, I will discuss the obstacles faced by clinicians when recruiting patients for clinical trials and suggest ways in which these can be overcome.

Clinical trials rely on healthcare professionals for the successful recruitment of patients, but lack of time can pose a huge barrier for clinicians. The requirement of clinicians to see large numbers of patients in a short space of time makes identifying appropriate patients for clinical trials a challenge.

Severe time pressures on healthcare professionals also make keeping up to date with the latest clinical trials difficult, adding a further hindrance to their ability to recruit patients. Even when a clinician manages to remain abreast of the latest trials, it can be hard to remember the specific enrollment criteria whilst in the process of caring for patients.

Another barrier to recruitment is fear amongst healthcare professionals: fear that patients might not receive the best treatment possible, or that physicians might lose their patients if they recommend participation in a clinical trial.

So how can the process be made easier for clinicians? One solution is for practices to employ a dedicated research nurse, clinical trials coordinator, or a clinical trials patient navigator whose role is to stay up to date with the latest trials.  He or she can advise physicians about those trials that are most relevant for their patients, and, just as importantly, talk with patients about what they involve.

Collaboration between researchers, nurses and physicians is also of vital importance to the success of clinical trial recruitment. Effective communication between these individuals will increase their knowledge and awareness of clinical trials and help to address any concerns. In a recent article in OncLive, a panel of clinical research experts and healthcare professionals noted that regular meetings between researchers and physicians are critical, providing a forum discuss the latest trials and any concerns or queries they might have.

Another key element to fostering successful collaborations between clinical trial practices and healthcare professionals is good communication and setting achievable targets. For example, regular communications from research organisation, such as newsletters listing current and ongoing trials, were noted as being particularly helpful for clinicians and nurses.

Practices could also consider setting individual or institution-wide goals for recruiting patients to clinical trials. Some experts have even suggested tying continuing medical education credits with trial recruitment.

Finally, focusing on the success stories and providing positive feedback is just as important, both for physicians and patients.

It is possible for well-organized clinical trial sites to implement all of these strategies. However, there is also a considerable place for patient enrolment organizations to assist the physicians with designing, planning and implementing all these or other applicable approaches. Busy investigators can outsource some of these tasks to professional patient enrolment managers or implement patient enrolment strategies as a collaborative effort with a patient enrolment organization.

In OncLive’s article, Sue Childress, Director of nursing at the Huntsman Cancer Institute at the University of Utah described her experiences with trial recruitment. “When we initially started phase I trials, the nurses were concerned that patients may not receive the best treatment possible,” she said. “After listening to their concerns and addressing them, now what I hear is that they are proud to work in a place that offers these trials. The patients don’t have to travel to Chicago or San Francisco.”

Her approach demonstrates the success that can be achieved in collaborations between clinical trials practices and healthcare professionals, with the appropriate support.

At Clinical Accelerator, we’re utilizing or encouraging all of these and many other general and project-specific strategies with our partner clinical sites. We’re firm believers that, with the correct communication and feedback mechanisms, the barriers to patient recruitment experienced by clinicians can be vastly reduced.

References

Tackling Patient Recruitment Challenges in Clinical Trials – http://www.onclive.com/publications/oncology-live/2014/march-2014/tackling-patient-recruitment-challenges-in-clinical-trials/

Here at Clinical Accelerator we know that one of the major sources of delay to clinical trails is achieving sufficient levels of patient recruitment. In the next three blog posts, I will discuss some of the barriers to enrollment and ways in which these problems can be tackled. This post will focus on how to minimize patient’s fears of taking part in clinical trials.

Communication and education: Tackling patient fear

In a recent article at OncLive¹, fear was described as one of the greatest barriers to patients and families taking part in cancer trials. In particular, patients fear being a “guinea pig” or receiving a placebo instead of treatment. Clinical trials can also be complicated and confusing for patients, leading them to turn down places in promising clinical studies because they do not understand the procedures or likely outcomes. Potential patients may believe that participation in clinical trials is a last resort, or that a drug already approved by the FDA (or by EMA in Europe) would be better than a drug that is not yet approved. Participation in clinical trials also impacts upon the patient’s families, and patients may pick a treatment option that they feel will be less of a burden for their families, rather than the right treatment for them.

So how can patients’ fears be assuaged, and recruitment into clinical trials be improved? Communication and education are key in overcoming the fear-based patient and family barriers to participation in clinical trials. Healthcare professionals play a vital role in patient recruitment and the way in which they provide information about clinical trials can reassure patients and their families, and increase clinical trial recruitment.

Communication strategies for healthcare professionals:

There are several strategies that health care professionals can follow to help assist when it comes to recruiting participants:

• Engage with patients, providing information about all the treatment options including clinical trials to patients and their families.
• Involve patients in the decision-making process
• Educate patients so that they know that clinical trials offer a type of treatment rather than a placebo.
• Designate a dedicated research nurse to explain the clinical trial options in depth.

Cynthia Davidson, APRN Clinical Operations Manager for the Center for Investigational Therapeutics (Phase I Trials) at the Huntsman Cancer Institute told OncLive, “It is important to provide one-on-one communication with the patient and family on all the treatment options. Spend the extra effort needed— however much time it may be—allowing the patients to have some control over their decisions.”

Choice of communication method: Targeting your patients’ needs

Various types of media can be effectively employed to educate and recruit patients to clinical trial studies. As has been previously discussed on the Clinical Accelerator blog (Patient recruitment: is social media the cure for this headache?), the use of social media, such as Facebook and Twitter, as well as online patient communities is becoming a new recruitment ground for clinical trials, and these are also ideal places to provide information and support to possible clinical trial candidates.

More traditional methods of communication can also be important, with advertisements and word of mouth providing an essential means of education to patients. For trials in which the recruitment of patients from minority groups is required, developing relationships within the community, providing specific outreach and education, is of particular importance.

It is also vital to have the ability to address any potential language barriers. Ensuring that participants who do not share their first language with the healthcare professionals feel confident that they understand the clinical trial process and can have any questions they have can be adequately addressed, is vital to recruitment.

Financial concerns

Another important barrier to patient participation in clinical trials are worries about the costs of taking part. Depending the country of residence, these costs might include travel, time off work, and the cost of procedures, particularly if the patient is uninsured. In the United States, The Affordable Healthcare for America Act (2014) should mitigate worries surrounding participation in clinical trials and insurance, as provides protection to those taking part. However, patients may still be concerned that there will be unexpected costs that are not covered by their insurance. Some patients have limited insurance plans with minimal out-of-network benefits, and many patients do not know the rights they have within their plans.

Strategies for addressing financial concerns

In OncLive’s recent interviews, six clinical trial experts gave this advice in helping to allay patients’ financial concerns (some of these are primarily applicable to the situation in the United States and some are universal):

• Connect patients to financial counsellors or social workers to identify resources.
• Set up patient assistance programs, in partnership with private foundations and coordinate with local hotels and businesses to help with travel expenses.
• Provide reimbursement from the trial for some travel expenses, including food, lodging, and transportation.
• Advocate for patients to insurance companies.
• Encourage patient participation in the Health Insurance Exchange Marketplace.

Patient-centric recruitment

For successful recruitment of patients to clinical trials studies, communicating with candidates in a way that gives them confidence that participation is the right choice for them is key. Be prepared to go the extra mile and spend the necessary time with patients and involve them with the decision making process.

References

Tackling Patient Recruitment Challenges in Clinical Trials – http://www.onclive.com/publications/oncology-live/2014/march-2014/tackling-patient-recruitment-challenges-in-clinical-trials/

There’s no doubt about it, a strong investment climate in BioPharma, biotech and other Life Science industries means more money for clinical trials. Here at Clinical Accelerator we keep a keen eye on market trends, and this August new data has been published on the health of venture capital investments in the biotechnology sector.

In the aftermath of the global financial crisis, we have seen some reduction of the investment appetite in the biotech sector and some misconceptions started to form about higher risks associated with such investments¹, with many investors preferring to put their capital into technology-related sectors, such as software, information technology and eCommerce.² However, the idea that returns in Life Science venture investing lag behind other venture capital sectors is beginning to lose credence, with data on venture returns showing that life science startups have out performed other sectors over the last decade³.

A comparison of data from the second quarter of this year showed that “U.S. venture capital funding for BioPharma companies jumped more than 25% by dollar value during the second quarter compared with the second three months of 2013.”⁴

This is undoubtedly due, in part, to the VCs capitalizing on increased exit opportunities, and particularly the initial public offerings (IPO) boom, which has seen healthcare IPOs dominate. A comparison of the first half of this year with 2013 showed Life Science companies raising $4.7 billion globally in 68 IPOs versus 66 in the whole of 2013⁵, and “according to IPO Scoop, 33 percent of the 288 market debuts have been healthcare companies”.⁶ The majority of biotech investment is in drugs for humans, at $1.4 billion, up 36% from the year-ago quarter.⁴

Greg Vlahos, life sciences partner at PwC, told the online news site GEN that the “IPO boom, and rising valuations give VCs more “liquidity” or assets that can be quickly converted to cash, allowing them to raise more money for investing in more companies.”

A recent article in Forbes² highlighted data from Correlation Ventures analysis of return distributions in VC financings of BioPharma. As the author Bruce Booth points out, this further supports “the thesis that BioPharma venture investing, in contrast to common perception, has actually outperformed most other non-biotech venture sectors at most of the percentiles of performance.”

The summarized data from Correlation Ventures provides a number of key observations. Firstly, CV data from 20,000 aggregate financings showed that returns of greater than 5x are higher in BioPharma than other sectors, with a rate of 11.5% versus 9.8% for other sectors. Given the size of the dataset this is almost certainly a real difference, and is also consistent with prior analysis at the company level. The data also shows that there are surprisingly similar frequencies of greater than 20x returns across BioPharma and other sectors, with figures suggesting that 1 out of 60 financings are reaching returns at these levels.

In his article, Mr Booth also noted that the CV dataset demonstrates that it is only when we look at returns greater than x50 that BioPharma begins to “numerically lag other venture sectors, where only 1-out-of-300 financings reach those return levels.” However, he went on comment that this was based on a “very small and noisy” dataset.

CV’s final major observation was that the rates of loss for BioPharma financings are lower those for the rest of venture capital, with 57% of BioPharma financings yielding returns lower than their invested capital versus 66% in other sectors. When looking at previous dollar weighted analysis, we see that the figures are even more favourable towards biotech. For example, Adam Street Partners data show a 36% loss ratio for biotech compared with 59% for the Internet.

“These data are further confirmation of the relative attractiveness of biotech venture capital in the asset class,” Mr Booth commented. He went on to say, “A recent report from Jon Norris at Silicon Valley Bank highlights the resurgence in returns in healthcare with over $12.5B in potential Limited Partnership (LP) distributions in 2013 alone.”

With strong mergers and acquisitions and IPOs through 2013 and 2014, and with the continuing demand for innovation from Big Pharma/Biotech, returns and LP perceptions of the sector have strengthened and are likely to continue to improve.

This is an excellent sign for the R&D industry that will surely lead to new investment. At Clinical Accelerator we are confident that this positive financial climate will create an environment in which more clinical trials can get underway.

References:

1. Life Sciences: The Rodney Dangerfield of Venture Capital (2011) – http://lifescivc.com/2011/07/life-sciences-the-rodney-dangerfield-of-venture-capital/
2. Data Insight: The Return Distribution Of BioPharma VC Financings (2014) – http://www.forbes.com/sites/brucebooth/2014/08/11/data-insight-the-return-distribution-of-biopharma-vc-financings/
3. Booth, B. L. and B. Salehizadeh (2011). “In defense of life sciences venture investing.” Nat Biotechnol 29(7): 579-583.
4. GEN News Highlights – VC Funding Revives with Market in Q2 (2014) – http://www.genengnews.com/gen-news-highlights/vc-funding-revives-with-market-in-q2/81250282/
5. Strong IPO Market for Life Sciences Companies Defines First Half of 2014 (2014) – http://www.cnbc.com/id/101807104#
6. Coelacanths And Other IPO Thoughts Before The Autumn Markets Return (2014) – http://www.xconomy.com/national/2014/08/26/coelacanths-and-other-ipo-thoughts-before-the-autumn-markets-return/

Transparency of data is paramount to scientific communities worldwide and a sine qua non for the unbiased technological advancement. This, naturally, also refers to scientific research in medicine. As we read on through the European Medicines Agency’s (EMA) mission and responsibilities, transparency comes as its integral and prominent feature. As part of its operations, the Agency is taking noticeable actions in order to address growing demand for the accessibility of data and results from clinical trials submitted as part of the marketing authorisation process.

A staggering response that followed the release of Policy 70 for public consultation in June 2013 reflects the interest of various stakeholders such as pharmaceutical industry, academia, patients and healthcare professionals, health-technology-assessment bodies, national medicines regulators, the members of the European Parliament, the European Ombudsman and European Commission in the availability of clinical data for further scientific scrutiny and reuse. Since the publication of the EMA previous policy on access to documents in November 2010 until April 2013 over 1.9 million pages containing clinical trial data were released in response to requests by patient organisation, pharmaceutical companies, healthcare professionals, academia, not-for-profit organisations, regulatory bodies and other individuals or institutions.

The Agency has long ago acknowledged potential gains for the public domain arising from open review and independent re-analyses of data after the medicinal product has been authorised. Availability of clinical trial data should lead to more efficient development of new therapies, bolster better-informed use of medicines, and facilitate verification of the regulatory authority’s decisions by third parties. However, concern remains regarding patient confidentiality, possible conflict of interests and independent analyses’ vulnerability to distortion as well as the risk of moving the research and drug development activities outside of the EU to avoid data sharing. In order to minimise these risks measures are taken ensuring best possible protection of patient personal information and the prevention of unfair commercial use of data, particularly outside the EU.

It should be once again clearly stated that the EMA has publicly recognised the potential benefits for public health of re-analyses of data for marketed drugs by independent academics and researchers, and acknowledged that regulators do not have a monopoly on science.

The policy on publication of the clinical board was discussed at the Management Board meeting on June 12, 2014. According to the minutes published at the EMA webpage, the Management Board endorsed the general approach, and also the proposal to include a more user-friendly solution for academic and non-commercial research purposes.

The draft policy will be discussed again at the Management Board meeting in October 2014. If approved, the policy will serve as a complementary tool preceding the implementation of the new clinical trials regulation foreseen to come into force earliest in May 2016.

References:

European Medicines Agency policy on access to documents (related to medicinal products for human and veterinary use). EMA, November 30, 2010.

http://www.ema.europa.eu/docs/en_GB/document_library/Other/2010/11/WC500099473.pdf

Publication and access to clinical-trial data (draft for public consultation). EMA, June 24, 2013.

www.ema.europa.eu/docs/en_GB/document_library/Other/2013/06/WC500144730.pdf

European Medicines Agency agrees policy on publication of clinical trial data with more user-friendly amendments. EMA, June 12, 2014.

http://www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/news/2014/06/news_detail_002124.jsp&mid=WC0b01ac058004d5c1

Release of data from clinical trials. EMA.

http://www.ema.europa.eu/ema/index.jsp?curl=pages/special_topics/general/general_content_000555.jsp&mid=WC0b01ac0580607bfa

Minutes of the 84th meeting of the EMA Management Board held in London, 12 June 2014.

http://www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/events/2013/08/event_detail_000740.jsp&mid=WC0b01ac058004d5c3

Eichler H-G, Abadie E, Breckenridge A, Leufkens H, Rasi G (2012) Open Clinical Trial Data for All? A View from Regulators. PLoS Med 9(4): e1001202.

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001202

Difficulties in recruiting patients

One of the biggest problems in conducting clinical trials successfully is patient recruitment. Another challenge is assuring diversity in clinical trials enrolment which is essential for eliminating health disparities as low enrollment and participation of racial/ethnic minorities and underserved patients affects the generalisability of research results for these groups (Baquet). Many factors affect enrolment into clinical trials such as race, socioeconomic status, access to healthcare, and cultural beliefs (Baquet). How the pharmaceutical industry is viewed along with participating healthcare professionals is also a major factor. According to Shavers-Hornday et al., and Harris et al., limited access to information on available trials by the general public, a lack of understanding and knowledge of the role of clinical research in the development of interventional treatment, coupled with existing attitudes toward research, including mistrust of researchers or research institutions, perpetuate existing fear, influence participation off African American patients in the US. Transposed to Eastern Europe, especially in those countries with history of conflict between state and the people, those fears are palpable and may play a role in the enrolment of patients into clinical trials.

Being culturally sensitive

Since the majority of large pharmaceutical companies are based in the West, practices are generally created to suit those Western countries. For example, in Western countries the initial stages of investigator identification, selection and recruitment are often automated and no contact is made with any person until the data from the Investigators’ online questionnaires are analyzed. In contrast, the process in Eastern Europe typically involves interaction with people from start to finish, over the telephone and in person, in the language of the land (Niedzielska).

Educating patients and healthcare professionals

Therefore, creating a culturally appropriate enrolment system of communication and education for pharmaceutical companies, health practitioners and patients is key to improving the buy-in from patients to overcome any issues stopping people taking part in clinical trials. Ideas and techniques can be garnered from those implemented in Western countries. A holistic approach involving patients, their families’, clinical specialists, nurses, surgeons, social workers, and primary care providers in the recruitment process will ultimately improve patient participation. Educating patients and their families about the benefits and risks of relevant clinical trials are essential to overcoming any fear-based barriers. Ensuring that healthcare professionals’ are involved from the start plays a big part in patient confidence.

Using modern technology

Educating people via all popular channels of communication, and involving all parties throughout the recruitment process will help build relationships. Since culture is evolving in tandem with advancing technology, the role of social media is taking on a more prominent role, with infomercials on YouTube, that are shared over Facebook and Twitter for example. Coupled with traditional forms of communication such as word of mouth, advertisements, and relationships throughout communities, this combination can be very powerful. Consequently, a holistic but personalised approach will help improve the rate of patients enrolling and committing to clinical trials until completion.

References:

Shavers-Hornaday VL, Lynch CF, Burmeister LF, Torner JC. Why are African Americans under-represented in medical research studies? Impediments to participation. Ethn Health. 1997;2(1-2):31–45.

Baquet CR. The Role of State Legislation and Policy in Addressing Disparities in Clinical Trials. Eliminating Disparities in Clinical Trials (EDICT). http://www.bcm.edu/edict/PDF/State_Legislation.pdf

Harris Y, Gorelick PB, Samuels P, Bempong I. Why African Americans may not be participating in clinical trials. J Natl Med Assoc. 1996;88(10):630–4.

D L Niedzielska. The Reality of Clinical Trials in Central and Eastern Europe. Journal of Clinical Research Best Practises. Vol. 9, No. 5, May 2013

For decades, we have accepted that patient enrollment is the source of delays with cost implications that can make a trial fail.

10 years ago, social media may have seemed too unknown for clinical trial specialists to involve in recruitment.

Independent tests performed over the last five years now support its credibility as a digital tool that reliably cuts costs, improves timelines and offers further benefits through patient relationships.

Evolution of the approach to recruitment is now following the pattern of commercial marketing to embrace social media, just more slowly.

Traditional approaches

A US study, conducted in 2009 and published in 2010, correctly predicted social media’s great potential to facilitate recruitment (Applied Clinical Trials, 2010).

During June, July and August of 2009, the investigators compared the efficacy and cost of three direct outreach approaches to patients with rheumatoid arthritis and multiple sclerosis: direct mail to a third-party contact list, email to a third-party contact list and contact via the social network http://iGuard.org/, an internet-based service for monitoring medication.

Specifically, they identified the proportion of outreach attempts that led to completion of their online survey – considered to represent interest in a clinical trial _– and the cost of a single such interest.

Patient recruitment cost

Analysis of the results suggested that direct mail outreach generated a response by 3.6% (n=905) of patients (905/25,000), of whom 78% were interested in enrolling in the clinical trial. At a unit cost of 86 cents ($0.86; 0.64 euros; £0.51) per direct mail outreach, the cost per person interested was $30 (22.35 euros; £17.84).

Email outreach generated a much lower response rate than direct mail at 0.5% (n= 157) of the 30,000 people approached. However, the rate of interest per outreach was very similar at 80%, giving a cost per recruitment interest of $100 (74.51 euros; £59.45).

The http://iGuard.org/ strategy polled 3657 members during the study period. Of these members, 482 responded (13.2%) and 75% of responders showed interest in the trial. This gave a much reduced unit cost per interest, at $4.25 (3.17 euros; £2.53)– just 14% of the cost per interest of direct mail and 4% of the cost per interest of email outreach.

Social hits clinical

As we enter a period of ‘patient-centricity’, in which pharmaceutical companies are desperate to sell themselves as being patient focused, it is unsurprising that the demonstrated benefits of social media for clinical trial recruitment are becoming absorbed.

Patient communities are a prime source of potential trial candidates as high numbers of patients with chronic conditions are drawn to these communities to learn about their diagnosis, share their concerns and stories, and gain peer support.

Perfect position

One company that has embraced the potential of these patient hubs is MyHealthTeam, which hosts digital platforms for people suffering from breast cancer, multiple sclerosis, Crohn’s and ulcerative colitis, and autism.

Administrators of these four platforms are ideally positioned to identify those patients with these chronic diseases who exhibit the precise profile sought by a pharmaceutical company or contract research organization for clinical trials.

Pick of the bunch

Better still, they can select those patients with the right disease features who are located in the right area – close to a centre running the trial.

Community members who are selected in this way and who have also given consent to be contacted by the community administrators are sent a private email, inviting them to take part in a pre-screening survey, the website Applied Clinical Trials reports. Members who pass the screening survey are asked if they would like to be contacted by the pharmaceutical company.

Proof in practice

The benefits of this patient-friendly approach are demonstrated by the experience of pharmaceutical company Biogen Idec (Eyeforpharma, 2014). Before partnering with MyHealthTeam, Biogen Idec screened about six patients per week for potential inclusion in a clinical trial. After the partnership was formed, the number of patients screened rose to 800 patients in just two weeks.

Outlook

Social media looks poised to launch into a principle role within patient recruitment. Currently only 11% of trials take advantage of this shortcut to patients. Biogen Idec found that social media generated a first-wave response rate of 15% – a nudge greater than the 13.2% response rate achieved using http://iguard.org and reported in 2010. They say this is a reliably higher response than traditional outreach programmes.

Combined with the lower cost of social media outreach and the fact that delayed recruitment so often drags the time to product launch and hence the period of market exclusivity, social media looks highly promising.

We are keeping our eyes firmly on this space and encourage you to seriously consider the benefits of social media for your own trials.

References

Applied Clinical Trials (2010) Direct-to-patient enrollment strategies: http://www.appliedclinicaltrialsonline.com/appliedclinicaltrials/CRO%2FSponsor/Direct-to-Patient-Enrollment-Strategies/ArticleStandard/Article/detail/686202

Eyeforpharma (2014) Social media on trial: http://www.eyeforpharma.com/patient-clinical-trials/social-media-on-trial.php

With the finances involved and continuing risk of failure, the importance of careful feasibility assessment and judgment is absolute.

To what extent weak – or no – feasibility assessment contributes to clinical trial failures is a challenging question.

Feasibility study

The usual way to assess feasibility is first to carry out a feasibility study. This is an investigation done to test if the full trial can be performed. It asks essential questions about:

• potential barriers to recruitment of participants
• which sites would meet the project’s budget and timeline while reliably producing good quality data
• parameters required for the substantive trial

Participants

According to Forbes (2012) it takes an average of $4 billion (2.94 billion euros, £2.35 billion) to develop a drug, a significant part of which is spent on clinical development. Before investing this heavily in clinical research, it needs to be demonstrated that:

• there are enough eligible participants
• participants at potential investigation sites are willing to be randomized
• participants are enthusiastic about clinical trials, with good rates of follow-up, questionnaire response, treatment adherence / compliance.

Study parameters

As well as gauging the behavior of participants, the feasibility study should assess the readiness of clinicians to recruit their patients to enroll and essential practical details for the trial. These may include:

• measurable characteristics of the proposed outcome measure
• designing an appropriate outcome measure
• standard deviation of the outcome measure (this may be needed to decide the required sample size)
• accessibility of data (potential of a database)
• time taken to gather and analyse the data.

Pilot trial

Another assessment often performed before commitment to the full trial is the pilot study. This is a scaled-down version of the full trial that is run to assess whether the study processes, such as randomization and follow-up, will run smoothly.

Assessing the feasibility of a clinical trial accurately and comprehensively before deciding to conduct a clinical trial is clearly essential.

Funding: route of progression

The EME (Efficacy and Mechanism Evaluation), PHR (Public Health Research), HTA (Health Technology Assessment) and RfPB (Research for Patient Benefit) programmes agreed that bids for funding, and commissioning briefs, should include the series of criteria required to progress to the full trial.

Responsibility

An important decision before initiating research is who will be responsible for the feasibility question. Do you want to use a clinical research organization or take care of the essential specifics in house?

Site selection

Deciding on which investigational sites to use is also imperative and will be the dedicated subject of one of our future posts.

References

Forbes 2012. The truly staggering cost of inventing new drugs. http://www.forbes.com/fdc/welcome_mjx.shtml

UCLAN Univesrity of Central Lancashire. http://www.uclan.ac.uk/schools/health/assets/Feasibility_and_pilot_studies.pdf

Lancaster GA, Dodd S, Williamson PR. Design and analysis of pilot studies: recommendations for good practice. J Eval Clin Pract 2004, 10:307-12.

Arain M, Campbell MJ, Cooper CL, Lancaster GA. What is a pilot or feasibility study? A review of current practice and editorial policy. BMC Medical Research Methodology 2010, 10:67.

Julious SA. Sample size of 12 per group rule of thumb for a pilot study. Pharmaceutical Statistics 2005, 4:287–291.

As I cast my eyes over the news that everolimus (Afinitor) failed to slip smoothly through Phase III trials for treatment of advanced liver cancer – as it has for advanced kidney cancer, certain cases of advanced breast cancer and specific tumours of the pancreas – I was struck by the discordance of this result.

In addition to its proven benefits in advanced tumours at these other sites, everolimus was shown to prevent tumour progression and improve survival in preclinical models. This led me to consider the many flaws of clinical trial design that may, or may not, lead to the ‘right’ answer.

Study flaws that may mislead

Professor Pal Czobor, Senior Scientific Advisor Semmelweis University, Budapest, Hungary, and Dr Phil Skolnick, National Institute of Drug Abuse, authored a thought-provoking article about compliance (Mol Interv, 2011). They suggest the extent to which patient non-compliance has damaged the results of clinical trials ­– and I extrapolate this to their consequent conclusions, licenses and approvals – has been underestimated.

They propose: “One step to improving the design of clinical trials may lie in better attempts to analyze patient compliance during drug testing and clinical development.” Hear here!

Borderline results

On closer inspection of the trial results I see that it did not only “not (significantly) improve overall survival in patients with advanced liver cancer”, the difference was borderline or actually worse for everolimus (JAMA, 2014a). The investigators reported death rates of 83.7% in the everolimus group, compared with 82.1% with placebo. Median overall survival was marginally better with everolimus than placebo at 7.6 versus 7.3 months.

Lead author Dr Andrew X. Zhu, from the Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, pointed towards other possible deficiencies. He admitted to the news website Medscape that the Phase I/II findings may not have been as positive as people had thought (Medscape, 2014).

Phase II weakness

He said: “I think the early phase I/II data with everolimus in advanced HCC were perhaps somewhat weak, in the sense that we only performed a single-arm trial. We do not have a randomized trial to tell us the extent to which the efficacy observed was really due to the drug-induced benefit or just because of some selection bias in patients.”

In the published paper itself, the research team suggest several possible explanations (JAMA, 2014b). The failure could be simply another failed trial for a drug for this notoriously difficult-to-treat cancer, they propose. More usefully, however, they reflect on the difficulty of assessing efficacy signals from phase II trials.

Surrogate inconsistency

They note that surrogate endpoints such as time to progression, progression-free survival, and response rate, for instance, inconsistently predict overall survival in phase 3 trials.

Further to this general concern, they note some of the added complications associated with assessing the safety and efficacy of targeted therapies for hepatocellular carcinoma.

They write: “In the absence of well-characterized and validated predictive bio-markers, targeted agents will likely continue to have a high risk of failure if Phase III trials are conducted in unselected populations.”

The quandary continues…

This sounds very sensible to me. On closer study of the method of action, everolimus specifically inhibits mTOR (mammalian target of rapamycin) – an enzyme with a central role in cell proliferation. It does not, however, appear to be a pharmaceutical specifically targeted to a specific genetic difference, or a cumulative change specific to cancerous cells within the tumour, treatments that act in limited populations. The quandary continues…

There remain a host of bumps at the Phase II selection point that will become unearthed with time. Their eventual management will make the journey to approval a great deal smoother.

References

JAMA (2014a) Drug everolimus does not improve overall survival in patients with advanced liver cancer. http://media.jamanetwork.com/news-item/drug-everolimus-does-not-improve-overall-survival-in-patients-with-advanced-liver-cancer/

JAMA (2014b) Effect of Everolimus on survival in Advanced Hepatocellular Carcinoma After Failure of Sorafenib: The EVOLVE-1 Randomized Controlled Trial. http://jama.jamanetwork.com/article.aspx?articleid=1884577

Medscape (2014) Everolimus fails to improve overall survival in advanced HCC. http://www.medscape.com/viewarticle/827651#2

Mol Interv (2011) The secrets of a successful clinical trial: Compliance, compliance and compliance. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3109858/pdf/0110107.pdf

Let’s look at the greatest failures of last year’s clinical trials and consider where better processes could reduce the chances of defeat or of how much is written-down.

The ten clinical trials conducted in 2013 that resulted in most financial damage incurred costs of between $1.7 million (£1.0 million or 1.25 million euros by Ziopharm Oncology) and $525 million (£309 million or 385 million euros by Sanofi).

The findings, which were reported in Genetic Engineering and Biotechnology News, highlight that half (five) of the failed studies had been for cancer indications and that four were conducted after the licensing of a drug to a biopharma giant. Indications of the other products whose trials failed included rheumatoid arthritis, heart disease, depression and asthma.

So what went wrong?

In the majority of cases, the projects failed because the data did not meet the study’s primary endpoint. In the most devastating example, Sanofi measured the ability of benzamide (4-iodo-3-nitrobenzamide) to treat newly diagnosed, metastic (phase IV) squamous, non-small-cell lung cancer and platinum-resistant ovarian cancer when added to gemcitabine / carboplatin chemotherapy, compared with gemcitabine/carboplatin alone, in the Phase III ECLIPSE trial.

The top four Failure List of sponsors and products in order of increasing write-downs reads:

Client		Product	Therapeutic area	Write-down
Sanofi		Benzamide (4-iodo-3-nitrobenzamide)	Newly diagnosed, metastatic (stage IV) squamous non-small-cell lung cancer and platinum-resistant ovarian cancer and platinum-resistant ovarian cancer	$525 million (£309 million or 385 million euros)
GSK	Phase III STABILITY	Oral inhibitor of lipoprotein-associated phospholipase A2	Major adverse cardiovascular event from composite of MI, stroke and cardiovascular death	Postulated$255.7 million (£150 million or 187.6 million euros)
Merck & Co.		Adenosine A2A receptor antagonist	Parkinson’s disease	Second quarter impairment charge: $181 million (132.8 million euros or £106.2 million).
AZ and Rigel	Phase III OSKIRA-3	Fostamitinib plus methotrexate oral spleen tyrosine kinase inhibitor	Rheumatoid arthritis	$136 million pre-tax impairment (£79.8 million or 99.8 million euros

Clearly, the cost of supporting these trials is vast and informed prevention would be invaluable.

Rescue / survival measures

Two product protection strategies reported include development of a compound in another indication and evaluation of the long-term maintenance effects of a treatment that fails to demonstrate strong improvements in priority endpoints.

Reflecting on the huge losses at stake, we wonder what the best survival strategies are that clinical trial specialists have employed to salvage investment after disappointing Phase III and Phase IV findings.