Data Monitoring in Clinical Trials
Author: David L Demets
Randomized clinical trials are the gold standard for establishing many clinical practice guidelines and are central to evidence based medicine. Obtaining the best evidence through clinical trials must be done within the boundaries of rigorous science and ethical principles. One fundamental principle is that trials should not continue longer than necessary to reach their objectives. Therefore, trials must be monitored for recruitment progress, quality of data, adherence to patient care or prevention standards, and early evidence of benefit or harm. Frequently, a group of external experts, independent from the investigators and trial sponsor, is charged with this monitoring responsibility, especially for safety and early benefit. This group is referred to by various names, such as a data monitoring committee or a data and safety monitoring board. This book, through a series of case studies presented by many distinguished clinical trial experts, illustrates the complexity of this monitoring process. The editors provide an overview of the process and a summary of a multitude of the lessons learned from the cases presented.
This book should be useful to anyone serving on a data and safety monitoring board, or planning to do so, for colleagues in academia, industry and governmental agencies, and for teaching students in biostatistics, epidemiology, clinical trials and medical ethics. No other text has as extensive a collection of cases which provide insight into the many issues, often conflicting, that must be examined before recommendations to continue or discontinue a trial can be made. While depth in statistical methods is not required, some familiarity with statistical design andanalysis issues in clinical trials is helpful. The cases cover trials which were terminated early for convincing evidence of benefit, or for harmful effects. Cases with complex issues are also included. This series of cases should provide broad background information for potential monitoring committee members and better prepare them for the challenges that may exist in the trials for which they are responsible.
Table of Contents:
| 1 | Monitoring committees : why and how | 3 |
| 2 | Lessons learned | 14 |
| 3 | FDA and clinical trial data monitoring committees | 39 |
| Introduction to case studies showing benefit from the intervention | 53 | |
| Assessing possible late treatment effects early : the diabetic retinopathy study experience | 55 | |
| Data and safety monitoring in the beta-blocker heart attack trial : early experience in formal monitoring methods | 64 | |
| Data monitoring for the aspirin component of the physicians' health study : issues in early termination for a major secondary endpoint | 73 | |
| Early termination of the stroke prevention in atrial fibrillation I trial : protecting participant interests in the face of scientific uncertainties and the cruel play of chance | 85 | |
| Early termination of the diabetes control and complications trial | 93 | |
| Data monitoring in the AIDS clinical trials group study #981 : conflicting interim results | 109 | |
| Challenges in monitoring the breast cancer prevention trial | 118 | |
| Data monitoring experience in the metoprolol CR/XL randomized intervention trial in chronic heart failure : potentially high-risk treatment in high-risk patients | 136 | |
| Stopping the randomized aldactone evaluation study early for efficacy | 148 | |
| Data monitoring in the heart outcomes prevention evaluation and the clopidogrel in unstable angina to prevent recurrent ischemic events trials : avoiding important information loss | 158 | |
| The data monitoring experience in the candesartan in heart failure assessment of reduction in mortality and morbidity program | 166 | |
| Introduction to case studies showing harmful effects of the intervention | 179 | |
| Breaking new ground : data monitoring in the coronary drug project | 183 | |
| The data monitoring experience in the cardiac arrhythmia suppression trial : the need to be prepared early | 198 | |
| Data monitoring in the prospective randomized milrinone survival evaluation : dealing with an agonizing trend | 209 | |
| Stopping the carotene and retinol efficacy trial : the viewpoint of the safety and endpoint monitoring committee | 220 | |
| Monitoring a clinical trial with waiver of informed consent : diaspirin cross-linked hemoglobin for emergency treatment of post-traumatic shock | 228 | |
| Consideration of early stopping and other challenges in monitoring the heart and estrogen/progestin replacement study | 236 | |
| Data monitoring in the antihypertensive and lipid-lowering treatment to prevent heart attack trial : early termination of the doxazosin treatment arm | 248 | |
| Data monitoring experience in the moxonidine congestive heart failure trial | 260 | |
| Data monitoring of a placebo-controlled trial of daclizumab in acute graft-versus-host disease | 269 | |
| Introduction to case studies with special issues | 281 | |
| Clinical trials of herpes simplex encephalitis : the role of the data monitoring committee | 285 | |
| The nocturnal oxygen therapy trial data monitoring experience : problem with reporting lags | 292 | |
| Stopping a trial for futility : the cooperative new Scandinavian enalapril survival study II | 302 | |
| Lessons from warfarin trials in atrial fibrillation : missing the window of opportunity | 312 | |
| Data monitoring experience in the AIDS toxoplasmic encephalitis study | 320 | |
| Data monitoring in the randomized evaluation of strategies for left ventricular dysfunction pilot study : when reasonable people disagree | 330 | |
| The data monitoring experience in the carvedilol post-infarct survival control in left ventricular dysfunction study : hazards of changing primary outcomes | 337 | |
| Controversies in the early reporting of a clinical trial in early breast cancer | 346 | |
| Making independence work : monitoring the bevacizumab colorectal cancer clinical trial | 360 |
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Troubleshoot, tune, and optimize your Oracle database efficiently and successfully every time. This book explains how to take full advantage of the revolutionary Oracle Wait Interface to quickly pinpoint--and solve--core problems and bottlenecks, and increase productivity exponentially.
