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Indian Journal of Medical and Paediatric Oncology
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ORIGINAL ARTICLE
Year : 2020  |  Volume : 41  |  Issue : 3  |  Page : 295-298  

Clinical trials facing “Serious Adverse Events” during the ongoing COVID-19 pandemic


1 Department of Oncology, Shalby Cancer and Research Institute, Mumbai, Maharashtra, India
2 Department of Medical Oncology/BMT, Asian Institute of Medical Sciences, Faridabad, Haryana, India
3 Department of Medical Oncology, Basavatarakam Indo American Cancer Hospital, Hyderabad, Telangana, India
4 Department of Medical Oncology, HCG Hospitals, Bengaluru, Karnataka, India

Date of Submission19-Apr-2020
Date of Decision26-Apr-2020
Date of Acceptance26-May-2020
Date of Web Publication27-Jun-2020

Correspondence Address:
Dr. Purvish M Parikh
Department of Oncology, Shalby Cancer and Research Institute, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmpo.ijmpo_173_20

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  Abstract 

Aims and Objectives: The ongoing COVID-19 pandemic is having a profound impact on the current clinical trials. We wanted to document the extent of the disruption amongst Indian clinical trial sites. Materials and Methods: We conducted an online survey among oncologists in India with active trials to document their experience with challenges and novel solutions. Results: A total of 60 oncologists replied of which 40 had ongoing trials with open recruitment. Majority of them had stopped screening (55%) and recruitment (62.5%). Almost half of the sites did not have adequate infrastructure (47.5%). Almost all the sites had enrolled patients worried about the impact of COVID-19 on their health outcome (up to 87.5%). The majority of sites had problems with adherence to study schedule of events (87.5%) and administration of study medication (42.5%). A total of 55% of the sites had provided the option of virtual visits. Both investigators (75%) and sponsors/contract research organizations (67.5%) had reached out to each other to maintain study integrity. More than half the centers had difficulty related to adverse events and serious adverse events (documentation and reporting; up to 75%). Discussion: Regulatory authorities in several countries have announced guidelines on the conduct of clinical trials during the COVID-19 pandemic. Whether the disruption lasts for a short or long time, its impact on clinical trials is going to be irreparable.

Keywords: Compliance, lockdown, recruitment, research, standard operating procedures


How to cite this article:
Parikh PM, Mehta P, Krishna Kumar MVT, Govind Babu K. Clinical trials facing “Serious Adverse Events” during the ongoing COVID-19 pandemic. Indian J Med Paediatr Oncol 2020;41:295-8

How to cite this URL:
Parikh PM, Mehta P, Krishna Kumar MVT, Govind Babu K. Clinical trials facing “Serious Adverse Events” during the ongoing COVID-19 pandemic. Indian J Med Paediatr Oncol [serial online] 2020 [cited 2020 Aug 3];41:295-8. Available from: http://www.ijmpo.org/text.asp?2020/41/3/295/288075


  Introduction Top


With the global COVID-19 severe acute respiratory syndrome coronavirus 2 pandemic having infected almost 1.5 million patients across more than 200 nations, we are faced with unique challenges changing how we live in a little over 4 months.[1] This has put at risk the future of almost all the ongoing clinical trials (262,366 registered on clinicaltrial.gov).[2] Unprecedented circumstances not envisaged in “business continuity disaster preparedness” have brought to reality our worst nightmare. All aspects of clinical trials are under threat – be it recruitment, immediate care of ongoing patients, adhering to study schedule of events, monitoring or compliance with reporting to drug authorities, and/or ethics committees/institutional review boards (ECs/IRBs). This will also affect the robustness of the data generated as well as its analysis to follow in the medium and long term.

We anticipate that most stakeholders would be “learning on the job” on how to deal with challenges thrown up by the COVID-19 pandemic. Doctors are currently between a hard place and the rock, having to juggle two competing responsibilities. As a medical professional, our first priority will remain to help tackle the ongoing pandemic and save the lives of as many patients as possible. At the same time, we feel ethically obliged to fulfill our obligations as principal/co-investigators for ongoing clinical trials. This means that we have to triage our professional time allotment during these trying times.[3]

Hence, we decided to conduct a survey among oncology principal investigators (PIs) from India, the results of which are being reported here.


  Methods Top


We initially participated in online discussions and agreed to the format of the final 19 questions and their respective answer options. The multiple-choice questions were then converted into an online Google form. The link to this Google form was then forwarded through WhatsApp discussion groups involving oncologists. The online survey was open for 24h on March 27, 2020. The replies received were downloaded as an Excel sheet. Unique E-mail addresses of responders were used to confirm that there were no duplicate entries. Thereafter, we tabulated and analyzed the results limited to those responders who had at least one ongoing clinical trial.


  Results Top


Over a 24-h period, a total of 60 oncologists responded to the survey. This was on the day that the global COVID-19-positive cases were just under 600,000.[1] Of these, 20 did not have an open ongoing clinical trial [Table 1], Q1]. Hence, the results represent the 40 responders who had active ongoing clinical trials and met this sole inclusion criterion. Incidentally, all of them were involved in trials whose objective(s) were unrelated to COVID-19 [Table 1], Q2].
Table 1: Replies to the 19 multiple-choice question online survey among oncologists

Click here to view


Screening and recruitment [Table 1], Q3 and Q4]: The majority of sites had stopped screening (22/40, 55%) and recruitment (25/40, 62.5%). About one-third (15/40, 37.5%) were still screening and recruiting. Three centers were not sure.

Staffing and space [Table 1], Q5]: The sites were almost equally divided among those who still had adequate staff and space to look after trial patients (18/40, 45%) and those who did not (19/40, 47.5%). Once more, three sites were not sure.

Patient concerns about COVID-19 pandemic [Table 1], Q6–8]: The majority of sites (33/40, 82.5%) made it a point to discuss additional risk related to COVID-19, even though it was not part of the approved informed consent. On their own, patients asked questions regarding their concerns about the COVID-19 pandemic in 35/40 (87.5%) centers. A total of 3 (7.5%) centers had patients who withdrew consent/discontinue on the trial due to COVID-19 fears. Another 8 (20%) centers had documented withdrawal of consent by their patients, where the reason was not disclosed. This gives a total of 11/40 (27.5%) sites who had one or more patients withdrawing consent.

Protocol compliance and deviations [Table 1], Q9–12]: Difficulties in adherence to scheduling and compliance were faced by 35/40 (87.5%) sites. So also, challenges in performing timely trial-related investigation were reported by 31/40 (77.5%) sites. Problems with providing investigational product (IP) were faced by 17/40 (42.5%) centers. A total of 22/40 (55%) centers had already incorporated the option of virtual visits in place of in-person visits.

Sponsor/contract research organization (CRO)/EC/IRB communication [Table 1], Q13–16]: PI/co-PI from 30/40 (75%) had already reached out to their respective sponsors or CROs for clarity regarding their trial during the COVID-19 pandemic. Similarly, 27/40 (67.5%) centers had received communication from their sponsors or CROs. A total of 15/40 (37.5%) sites reported difficulty in reporting serious adverse events (SAEs)/protocol deviations/protocol violations as required by the protocol. While EC/IRB remained functional in 15/40 (37.5%) sites, it was not operational in an equal number (14/40, 35%). At 11/40 (27.5) sites, it was not clear whether the EC/IRB was able to do its activity or not.

Safety data-related adverse events and SAE [Table 1], Q17–19]: A total of 23/40 (57.5%) sites had developed new standard operating procedures (SOPs) to facilitate adverse event reporting and 26/40 (65%) had done the same for SAE reporting. Admission of patients due to SAE while the COVID-19 pandemic was ongoing was reported by 7/40 (17.5%) sites.


  Discussion Top


A PubMed search using “COVID-19” done on March 28, 2020, revealed 1795 references, which became 3075 references by April 8, 2020, an increase of 71% in the short span of 12 days.[4],[5] This is a reflection of the health-care professionals' commitment and focus on tackling the COVID-19 pandemic. With the number of deaths crossing an astounding figure of more than 80,000, the current unprecedented disaster has impacted all walks of our lives, including ongoing clinical trials. In our study, the first proof was the fact that only about one-third (37.5%) of responding oncology centers continued to screen and recruit new patients [Table 1].

While research priorities should be and remain focused on prevention, mitigation, or treatment of COVID-19, our responsibility toward other ongoing clinical trials should not be forgotten.[6] One of the challenges that we could identify was regarding the adequacy of sufficient space and staff for trial-related activities. It was a stumbling block in 47.5% of the sites included in this study. Redeployment of medical staff for COVID-19 duties coupled with the inability of the nonmedical staff to reach their place of work due to travel restrictions (e.g., lockdown) results in only a skeletal staff available for clinical trials. In addition, some hospitals may have to redeploy clinical trial space to expand inpatients' capacity. Images of hoards of COVID-19 patients lying in hospital corridors (especially from the USA, Spain, and Italy) confirm this to be a reality.[7],[8],[9]

The majority of sites (33/40, 82.5%) made it a point to discuss additional risk related to COVID-19, even though it was not part of the trial requirement. We believe that this is a very important initiative by the investigators, since evidence was quickly emerging from China (confirmed later from Italy) that cancer patients did poorly if infected with COVID-19.[10] On their own, patients asked questions regarding their COVID-19 pandemic concern in 35/40 (87.5%) centers. A total of 27.5% of centers experience patients withdrawing consent, which is exceedingly high and has not been reported earlier from India.[11] We can only assume that the COVID-19 pandemic was the reason, even if that has not been disclosed formally. These data were generated when the global burden of COVID-19-positive cases was just under 600,000. It has now almost tripled and its impact on withdrawal from trials is also likely to be significant.

It was not surprising that almost all the sites faced difficulties in adherence to trial schedule of events (such as hospital visits, investigations, and administration of IP). In order to reduce deviations, just over half the centers had commenced virtual visits. Now that the Medical Council of India has notified telemedicine guidelines (March 25, 2020), all health-care facilities will be able to connect with their patients remotely and effectively.[12]

Effective lines of communication are key to the success of any project. In this instance, the investigators were more proactive in communicating with the other party (75%) as compared to the trial sponsors/CROs (67.5%). This is to be lauded. In spite of such efforts, some difficulty still existed in complying with mandatory reporting specified in trial protocols. The importance of using alternate pathways and backup options in disasters and emergencies needs further emphasis. Our survey showed that ECs were either nonoperational (35%) or their status not communicated to the investigators (another 27.5%). State- and country-wide lockdowns to tackle the COVID-19 pandemic did test disaster preparedness plans quite severely and showed us that that real-world situations are sometimes quite different from what we have anticipated in the past.

With the COVID-19 pandemic taking the lives of more than 89,000 humans, emphasis is back on safety. We have previously reported on how efforts are ongoing to protect frontline health-care workers in this war.[13] Protecting trial patients also requires timely recognition of and prompt management of adverse events and SAEs. To address this, majority of sites had actually developed new SOPs to identify and report them among their trial patients. It is interesting to note that SAE admissions were required in a significant fraction of trial sites. Segregated access to health-care facilities, identification of COVID-19 status, and admission in appropriate wards are key to the safety of such trial patients. To reduce their risk of contacting COVID-19 infection while in hospital, additional prophylaxis and/or mitigation methods may be required to accelerate recovery and timely discharge from the hospital.

This survey results will help us better understand the challenges faced by clinical trials while fighting the COVID-19 pandemic. Corrective measures will prevent irreparable consequences to the integrity of trial data. Authorities stepping in to help provide guidelines include examples from India, the UK, and the USA.[14],[15],[16],[17]


  Conclusion Top


We are assuming that ongoing clinical trials (as well as normal life) shall remain disrupted for at least 3 months from now. Will it influence the evaluation of their data by regulatory authorities? Where trial subjects had been impacted by COVID-19 infections, it certainly will. This might also be the case where data to evaluate the primary objective have significant gaps or deviations. However, the darkest of clouds will have a silver lining. We are hoping that the resilience of fellow investigators will lead to innovative solutions, trial rules might be rewritten, and protocols may have a new section of alternative options in case of disasters.[18] We hope all of us can come together to bring the clinical trials out of the SAE that they are suffering from right now.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Available from: https://www.worldometers.info/coronavirus/. [Last accessed on 2020 Mar 29].  Back to cited text no. 1
    
2.
Trends, Charts, and Maps. Available from: https://clinicaltrials.gov/ct2/resources/trends. [Last accessed on 2020 Mar 16].  Back to cited text no. 2
    
3.
Thornton J. Clinical trials suspended in UK to prioritise covid-19 studies and free up staff. BMJ 2020;368:m1172.  Back to cited text no. 3
    
4.
Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term= covid-19. [Last accessed on 2020 Mar 28].  Back to cited text no. 4
    
5.
Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term= covid-19. [Last accessed on 2020 Apr 08].  Back to cited text no. 5
    
6.
McDermott MM, Newman AB. Preserving clinical trial integrity during the coronavirus pandemic. JAMA 2020. [Ahead of Print].  Back to cited text no. 6
    
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Zhang L, Zhu F, Xie L, Wang C, Wang J, Chen R, et al. Clinical characteristics of COVID-19-infected cancer patients: A retrospective case study in three hospitals within Wuhan, China. Ann Oncol 2020. [Ahead of Print].  Back to cited text no. 10
    
11.
Dabhade S, Pandit P, Tiwari S, Pandit D, Chopra A. Reasons for patient's withdrawal from clinical trials of rheumatoid arthritis in India. J Orthop Allied Sci 2015;3:8-11.  Back to cited text no. 11
  [Full text]  
12.
Available from: https://www.mohfw.gov.in/pdf/Telemedicine.pdf. [Last accessed on 2020 Mar 28].  Back to cited text no. 12
    
13.
Purvish MP, Prashant M, Shweta B, Shyam A, Amol P, Atul B, Ranjit S. Protecting healthcare professionals and workers (other than COVID-19 management facilities) from contamination during COVID-19 pandemic. Indian J Med Sci 2020;72:3-4.  Back to cited text no. 13
    
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MHRA. Managing Clinical Trials during Coronavirus (COVID-19); 19 March, 2020. Available from: https://www.gov.uk/guidance/managing-clinical-trials-during-coronavirus-COVID-19. [Last accessed on 2020 Apr 08].  Back to cited text no. 15
    
16.
FDA Guidance on Conduct of Clinical Trials of Medical Products During COVID-19 Pandemic: Guidance for Industry, Investigators, and Institutional Review Boards. US Food and Drug Administration; March, 2020. Available from: https://www.fda.gov/regulatory-information/search-fda-guidance-documents/fda-guidance-conduct-clinical-trials-medical-products-during-COVID-19-pandemic. [Last accessed on 2020 Apr 08].  Back to cited text no. 16
    
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18.
Dean NE, Gsell PS, Brookmeyer R, Crawford FW, Donnelly CA, Ellenberg SS, et al. Creating a framework for conducting randomized clinical trials during disease outbreaks. N Engl J Med 2020;382:1366-9.  Back to cited text no. 18
    



 
 
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