Missing in Action: Patient Perspective on Cancer Trial Goal

Maurie Markman, MD

There is a critically important subject associated with the clinical trial experience that has had inadequate discussion within the medical literature. That is, what is the role, or roles, of the patient beyond simply agreeing to serve as a research subject? This question is far from trivial or theoretical.

Vemurafenib Example Stands Out

At the outset, let us consider that some clinical academic and bioethics experts as well as some governmental regulators have expressed the belief that clinical research and clinical care are fundamentally different endeavors. Such a belief apparently underlies decisions to conduct randomized placebo-controlled trials in order to observe an objectively measurable outcome in settings where others would strongly argue that available data clearly indicate the clinical value of an existing therapeutic strategy. However, the argument goes, if clinical research does not have to follow the ethical requirements of focusing on optimizing an individual patient’s chances for a favorable outcome—as would be the situation with clinical care—different rules would apply.A most distressing example of how a rigid focus on determining an unequivocal measurable outcome to a research question may seriously negatively influence individual patient welfare is provided by the regulatory decision several years ago to mandate a randomized phase III trial that compared the utility of a novel BRAF inhibitor, vemurafenib, with a control arm of dacarbazine, a widely recognized, highly toxic, and ineffective cytotoxic agent in the management of metastatic melanoma.¹ Remarkably, this study was undertaken at a time when overwhelming clinical data existed regarding the favorable impact of vemurafenib on the natural history of this devastating condition, but where socalled “gold-standard,” randomized phase III trial data proving an overall survival (OS) impact did not yet exist.²

The decision to require this randomized trial to document statistically significant improvement in OS, as defined by a regulatory agency, was apparently justified, at least in part, by the morally problematic argument that clinical research need not overly concern itself with what the majority of the population would almost certainly consider to be in the best interest of the individual patient (in this case, the care of a patient with metastatic melanoma). The impact of what some might label an ethically objectionable decision by a regulatory body of the United States government was poignantly captured in a feature article that appeared in The New York Times.³

Postapproval Study Dilemmas

Did the regulators ever consider asking individuals with melanoma or their families, or perhaps patients with cancer as a group, what they believed to be the appropriate clinical trial design, based on the existing data, to permit the approval of vemurafenib for noninvestigative use in metastatic melanoma? And if not, why was it considered appropriate that this critical determination be made in the absence of such input?A more recent example of the complete absence of a patientfocused perspective regarding clinical research is evident in discussions of regulatory requirements for postapproval studies, following a decision by the FDA to permit commercial sale of a given antineoplastic agent. In a commentary that appeared in the New England Journal of Medicine, the authors criticized the FDA and pharmaceutical companies for their failure to complete such studies in a timely manner.⁴

Although the editorial discussed a number of therapeutic areas, oncology was prominently highlighted. In commenting on delays in the completion of cancer-related postapproval studies, the authors noted: “Seven years later, one trial had missed deadlines for 2 milestones and had enrolled 30 patients; the other was still ongoing.” The drug in question (pralatrexate) had been shown in a nonrandomized trial involving 111 patients to produce an objective response (complete or partial) in one-quarter of patients with an uncommon lymphoma. These clinical data apparently were acceptable to the FDA to permit noninvestigative use.⁴

Again, the question to be asked is why should patients who might be candidates to receive pralatrexate—or other agents where postregulatory studies have been mandated— be required to participate in these trials if they determine such participation is not in their best interest? In fact, it is relevant to suggest that perhaps one important issue for poor accrual is that the postapproval oncology studies designed by the companies, as required by regulators, are simply of very limited or no relevance to patients. To be clear, patients and their families are appropriately focused on the welfare of the individual, not on fulfilling bureaucratic requirements.

The authors of this commentary end their missive by declaring that with current efforts to speed up the FDA’s “’slow and burdensome’ approval process, drug approval is likely to become increasingly rapid and rely on looser evidence standards.” But who exactly determines what the evidence standards should be? Perhaps it is time for patients to play a much larger role in this regulatory realm and to help make these decisions.

Finally, it is important to acknowledge that many postregulatory studies have the potential to be very useful in defining optimal doses, schedules, drug combinations, and clinical indications. However, it is likely that such trials would be far more successful in meeting their accrual goals if relevant patient populations were included in the decision-making process regarding study designs, eligibility criteria, and defining meaningful endpoints.

References

1. Chapman PB, Hauswchild A, Robert C, et al; BRIM-3 Study Group. Improved survival with vemurafenib in melanoma with BRAF V600E mutation. N Engl J Med. 2011;364(26):2507-2516. doi: 10.1056/NEJMoa1103782.
2. Flaherty KT, Puzanov I, Kim KB, et al. Inhibition of mutated, activated BRAF in metastatic melanoma. N Engl J Med. 2010;363(9):808-819. doi: 10.1056/NEHMoa1002011.
3. Harmon A. New drugs stir debate on rules of clinical trials. The New York Times. nytimes. com/2010/09/19/health/ research/19trial.html. Published September 18, 2010. Accessed December 15, 2017.
4. Woloshin S, Schwartz LM, White B. The fate of FDA postapproval studies. N Engl J Med. 2017;377(12):1114-1117. doi: 10.1056/NEJMoa1705800.