I can’t stop thinking about a recent series of poignant blog posts, written by an emergency room physician affiliated with the Mayo Clinic. Her husband has been battling a terrible cancer – recurrent/metastatic head and neck squamous cell carcinoma.
Given what she does for a living, the author, Dr. Bess Stillman, is about as well-positioned to be a savvy patient advocate as anyone could possibly be.
And yet, she describes in earnest, eloquent, horrific, harrowing, infuriating detail her Herculean efforts to find and enroll her husband, Jake Seliger, in a suitable clinical trial. Jake has also written a thoughtful companion piece offering specific, constructive suggestions – an incredibly generous contribution from a person who has suffered so much.
While I plan to highlight a few key points, these riveting first-person perspectives should be required reading for everyone in medicine, everyone in biopharma, everyone involved in the regulation of clinical trials (both FDA and Institutional Review Boards [IRBs]), and every entrepreneur eagerly trying to develop “solutions” for clinical trials.
So often, those of us in medicine, as well as those of us in biopharma, talk amongst ourselves about clinical research, and the challenges of conducting clinical trials. Typically, we review this information from a physical and emotional distance – perhaps in the context of a scientific result, or a discussion of an organizational process we seek to improve.
Physicians tend to absorb trial results from medical journals and at medical conferences and think about how to apply the findings in their day-to-day practice. Biopharma companies extensively discuss the many challenges associated with study operations and are motivated to improve the performance of discrete metrics like site activation time and speed of patient enrollment.
But most of these discussions tend to be – pardon the phrase – exceedingly clinical, and ultimately quite detached from the human experience. Neither the discussions of journal data nor the tactical review of study conduct begin to convey the visceral, excruciating frustration and anguish that comes across in the writing of Dr. Stillman and Jake.
Context: Why Clinical Trials Matter
Clinical trials represent the foundational tool of medical progress; they are the standard by which potential interventions are evaluated by the biomedical community. When I was a third-year medical student, and learning about patient care in the hospital, it was routine for published clinical trial results to form the basis of our team’s discussion. It’s the way we weed out the treatments that don’t work and elevate the ones that meet the standard of safety and efficacy.
Many academic leaders have made their name through their leadership of well-controlled, carefully conducted clinical studies that advanced patient care. Sometimes, these involve huge, sprawling enterprises, as is often the case in cardiology; the TIMI study group comes to mind, founded by the legendary Dr. Eugene Braunwald, and now led by Dr. Marc Sabatine (a former MGH colleague). But trials can also involve smaller, more focused efforts – here I think of the pioneering work in reproductive endocrinology led by Dr. Bill Crowley at MGH.
Clinical trials are of course critical for biopharmaceutical companies as well; a candidate therapy needs to pass the exacting standards of FDA review in order for the company to be able to market it in the United States, for example. Most R&D dollars in big pharma are invested in the execution of clinical trials, particularly “late phase” (phase 2 and 3) studies.
Not surprisingly, the industry is constantly seeking to improve the way trials are done. A wide variety of vendors, from large contract research organizations (CROs) like IQVIA and prominent software-as-a-service (SaaS) platforms like Veeva, to a galaxy of niche startups, contribute, or aspire to contribute to the process. It’s a massive ecosystem, all ostensibly built around the idea of improving the trial process and accelerating the development of promising emerging medicines.
As clinical researchers recognize and constantly try to address, very few patients in the US actually participate in trials. The number I’ve often heard quoted is 4%; for cancer trials the fraction may be somewhat higher (see here). Dr. Stillman writes that according to “Judy Seward, head of clinical trial experience at Pfizer, only 8% of adult cancer patients take part in trials.”
Adds Dr. Stillman, “Given our recent experience, I’m amazed it’s that many.”
The Patient Perspective
Jake’s challenges, as described by Dr. Stillman, began from the moment he was failed by available (FDA-approved) medical treatment. That meant his only options were to enroll in a clinical trial.
The first problem was Jake’s “lackadaisical” and “sluggish” oncologist at the Mayo Clinic, whose approach seemed characterized more by resignation than by urgency.
This struck a chord with me. As I wrote in an op-ed for the New York Times a few years ago, we had a similar experience with an oncologist at Memorial Sloan Kettering Cancer Center who was treating my uncle for pancreatic cancer. This doctor wasn’t keen to prescribe antibiotics for my uncle’s lung infection. My aunt had to fight exhaustively to ensure her husband received appropriate treatment. The medicine worked, and he enjoyed (yes, enjoyed) a number of additional months of life.
I can’t imagine what it must be like as an oncologist focused on the treatment of patients with terrible cancers. Perhaps some degree of emotional detachment is required to help these physicians do their unusually difficult job day after day. But what many patients so fervently want and need is a doctor who will engage with them through a litany of treatment failures, and stay with them, continuing to urgently, aggressively, energetically search (if this is what the patient prefers) for the best possible path forward.
ClinicalTrials.gov – a Mess
Dr. Stillman’s second challenge was the website that lists all clinical trials – clinicaltrials.gov. The good news is that all studies are listed in this database. The bad news is that it’s not especially user-friendly – which makes finding relevant trials surprisingly difficult for patients.
For starters, the search function is miserable: “If you change the wording of the search subtly,” she writes, “you’ll get different outcomes.” Searches for “Squamous cell carcinoma of the head and neck” and “Head and Neck Squamous Cell Carcinoma,” she writes, “all yield different results. There’s no apparent standardization.”
It’s also difficult to keep the different treatment options straight. For example, in some trial listings, a medicine might be referred to by the company’s internal designation (she points to “MCLA-158” as one example), or by the standardized name (“petosemtamab,” e.g.) in others. Inconsistency in nomenclature makes it difficult to keep even identical therapies straight.
Then there are the various inclusion and exclusion criteria associated with different trials. “It’s easier to find a dress to my exact specifications out of thousands on H&M.com,” she explains, “than it is to find a clinical trial” that a patient might qualify for.
How does a patient sort through such a list? Ideally, an oncologist might be able to help. But Dr. Stillman found that most oncologists had no idea how to help, other than a general suggestion that the patient go to a large cancer center that runs a lot of trials.
Far more helpful, Dr. Stillman and Jake discovered, was a skilled individual named Eileen Faucher. A biochemist who had spent years consulting for pharmaceutical companies, Faucher has now set up her own business, serving essentially as a private wilderness guide for clinical trials.
“Eileen charged a lot per hour but her fees were worth every penny: she was efficient, and without her I’d have been lost,” Dr. Stillman writes.
Similar services are cropping up to help people (who can afford the fees) make their way through the staggering complexity of our healthcare system.
Other examples include concierge physicians (who provide you their cell phone so you don’t have to endure endless phone trees to leave a message at your doctor’s office and pray someone eventually calls you back) and patient navigators, who help sort through hospital bills and insurance coverage. See also this WSJ review I wrote a few years back on a book, The Patient’s Playbook, describing the need for a “medical quarterback.”
And what about the many AI services increasingly pitching their wares to patients, hospitals, and pharmas? Unfortunately, Dr. Stillman and Jake discovered that several AI services purporting to help patients sort through clinical trial results – ostensibly, computerized, scalable version of Eileen — weren’t useful or helpful in practice. “Based on what we’ve seen so far,” Dr. Stillman writes, “the ‘AI’ tech isn’t there yet.”
The Struggle To Enroll
Once Dr. Stillman, working with Eileen, developed and refined a list of the most promising trials for Jake, she discovered how difficult it was to determine if he could enroll.
For starters, the contact info listed for many trials was inaccurate or not useful. Other times, when she reached a person at the clinical trial site, she was told the only way to receive information about the trial was by voice, read over the phone – all other modalities were prohibited. And that was when information was provided at all.
More commonly, she discovered that even when she reached someone at a trial site, almost no one would even discuss whether Jake was eligible without him first showing up for a doctor’s appointment to “establish care.”
Generally, this wasn’t allowed via telemedicine. That would constitute practicing medicine across state lines, a big no-no. However, in some places, it seems like a “don’t ask/don’t tell” system exists in which patients can assert they are calling from in-state.
The alternative to telemedicine is a lot of travel, which is expensive, time-consuming, and exhausting for cancer patients. As Dr. Stillman observes, it’s “very hard for sick patients to travel and ‘establish care’ at multiple sites.”
Even the process of “establishing care” involves multiple parts. First, a chart must be created in the hospital system (without which you don’t exist, Dr. Stillman writes). Then, you need to be seen by a physician. This physician “can’t do anything for you — even answer questions — until after your first visit (even though they can review information you send),” she explains.
It’s also at the in-person visit that you are finally told what trials are open and what you might qualify for.
Even after a patient seems like he or she might qualify, they need to demonstrate they are at just the right point in their disease; the implicit message, Dr. Stillman writes, is “please be dying, not too quickly.”
Please be dying, not too quickly
In Jake’s case, he needed to demonstrate his disease was progressing rapidly enough to qualify. But his disease progression clock would start over each time he had a dose of chemo (which wasn’t expected to be curative — he was taking it simply to try to stay alive long enough to make it into a clinical trial). On the other hand, if tests showed he had metastases to the brain, he would be considered too sick to qualify.
Strikingly, Dr. Stillman and Jake discovered considerable site-to-site variability for what was considered sufficient progression. Even at different sites associated with the same clinical trial (and thus with identical entry criteria), some physicians would decide Jake was progressing fast enough to qualify. Others thought he wasn’t – yet all these decisions were based on identical clinical and imaging information.
Lessons Learned – Digital and Data
Both Dr. Stillman and Jake discussed a number of challenges in getting access to data. Much of what they had to say reminded me this National Academy of Medicine-sponsored paper that I co-authored during the COVID pandemic.
My co-authors and I wrote this passage about connectivity and last-mile issues in the context of COVID, but similar points could be made today regarding clinical trials:
“[D]uring the initial stage of the pandemic in the U.S., decision-makers were essentially flying blind. Electronic health record (EHR) systems were mired in a sea of codes, few of which pertained to COVID-19, due to its novelty. These systems were not connected to enterprise resource planning systems, and thus lacked the ability to correlate relevant patient encounters with human resources and physical capacity. The utilization of testing, PPE, beds, and ventilators varied within and across each and every health system (and often varied even across departments within a single hospital or clinic). Public health departments in charge of implementing rules, policies, public guidance, and contact tracing operations each operated within their own data silos—often taking the form of piles of spreadsheets—and were almost always unconnected and non-interoperable with any other health care information technology (IT) system. In too many cases, the only effective communication of data between health care delivery systems and public health agencies was through a fax machine.”
Dr. Stillman shines additional light on several of the critical information gaps that collectively result in a shocking lack of awareness and coordination:
- Lack of trial awareness by oncology researchers: “Researchers didn’t have their own spreadsheet or databases of active trials,” she writes. “They didn’t know what trials were going on down the street. Sometimes they didn’t know what trials were going on in their own (very large) departments.” She also cites a damning survey from the Tufts Center for Drug Development, reporting that although “about 90% of physicians surveyed said they feel comfortable discussing clinical trials with their patients,” nevertheless, “less than 0.2% actively refer them to studies. These doctors reported that they lack access to trial information (54%), do not know where to refer patients (48%), or do not have the time to learn about active trails (33%).”
- Lack of trial awareness by researchers in the same network. Even within a given research network, such as Sarah Cannon or MD Anderson, there seems to be a lack of awareness of other trials occurring under the same organizational umbrella. “A researcher at Sarah Cannon in Denver told me that even the Denver site doesn’t know what the Nashville or Florida sites are doing…. there’s no easy internal system between hospitals, or regions,” Stillman writes, stunned by the degree “information siloing.”
- Lack of site-to-site referrals within the same study: “If one hospital thinks a patient would be a good fit for a study, but their study arm is closed, wouldn’t it be beneficial to the drug company to recommend other sites?” Dr. Stillman asks. “Shouldn’t sites coordinate with each other? That way, the overall trial can more quickly fill a given study with eligible patients.”
- Lack of information for patients from sponsors about site availability: “I tried contacting various drug company trial contacts directly, to see if they’d provide me with a list of all sites and openings,” Dr. Stillman writes, adding “I was only able to get contact information. I couldn’t get real-time information about availability, not because it didn’t exist, but because no one would give it to me.”
- Inability of a PI (“Principal Investigator” – researcher leading a study at a site) to know, in their own study, if spots are available: “Even the PI hosting a trial often don’t know in real-time if a participant spot is available,” Dr. Stillman writes. She shares an example of requesting a spot for Jake in a trial and then finding out two days later the study was closed by sponsor to new participants.
Regulatory Challenges and Opportunities
Dr. Stillman’s frustration extends to regulators, both at the federal level and with local Institutional Review Boards.
For instance, she learned about data suggesting that a fecal transplant procedure can make some non-responders to the PD-1 inhibitor pembrolizumab (Keytruda – see here for more the remarkable history of this blockbuster product) start responding to the drug.
She pursued this idea as a course of treatment for Jake. Yet, she struggled to get permission to do this, she reports, explaining that the FDA cracked down on the fecal transplant procedure after two deaths (out of what she estimates are 10,000 procedures).
Her local IRB, she says, also hasn’t been eager to approve this procedure. With understandable acidity, she writes, “Luckily for Jake, the FDA and IRB will protect him from being one of the 2 in 10,000 patients who died from a fecal transplant by denying him this potentially life-saving therapy so that he could have a 99%+ chance of dying from his cancer. I feel safer.”
I’ve discussed the need for an approach to regulation that places a greater premium on the harms that can be done by delaying access to promising experimental medicines, and the value (see here) of a more personalized approach to regulation.
Glimpsing the Underbelly of Clinical Trial Operations
The challenge of contemporary evidence generation has been discussed very thoughtfully by Matt Herper at STAT, here. I’ve emphasized the need to learn from real world experience here. But if you really want to understand some of the gnarly operational issues associated with getting clinical trials up and running, you owe it to yourself to read this (now deleted but archived at the link provided) blog post, from an anonymous (but credible) clinical trials operations expert.
The author offers an unvarnished, behind-the-scenes view of how the trial process works from the in-the-trenches, operations side, starting with clinical site selection, which the author notes is “superficially quite reasonable,” yet “actually going through this process is an extended exercise in sheer absurdity.”
And on set-up process for clinical sites: “There are so many examples of horrible, atrocious inefficiencies that I encountered while dealing with the logistics of clinical trial setup that I could easily triple the length of this section if I wanted to.”
Much like Dr. Stillman’s articles, the anonymous author’s depiction of the messy reality of clinical trials operations and set-up offers urgently needed visibility into what’s actually going on. Uncomfortable as it is to read, the description provides an essential alternative to the abstracted, idealized version of trials so often shared on PowerPoint, and discussed in planning meetings. Everyone — including (perhaps especially) senior leaders and decision-makers — deserve, and would likely benefit from, a candid look into how the sausage actually gets made.
Aiming To Do Better
Both Dr. Stillman and Jake strive to be constructive. They highlight what patient-centricity (the core value expressed by every stakeholder in the clinical trial process) actually looks like from the patient’s perspective.
What’s needed, they suggest, is a far more convenient way to identify, prioritize, learn about, qualify for, enroll in, and participate in relevant clinical trials.
What’s needed, they suggest, is a far more convenient way to identify, prioritize, learn about, qualify for, enroll in, and participate in relevant clinical trials
Most of the people I know involved in the clinical research enterprise aspire to deliver this, yet it’s clear from Dr. Stillman and Jake just how far from this ideal we collectively seem to be.
As Dr. Stillman concludes, hopefully,
“There’s a future that can support the interests of patients who are willing to take part in trials, the patients who will benefit from the results, the doctors who are trying to do what’s right for their patients, as well as the interests of the pharmaceutical companies supporting the trials.
There’s a better path. We’re just not on it. Yet.”