On April 13, 2016, an article in the Wall Street Journal (WSJ) titled, “Clinical Trials Need More Subjects” underscored an important point that the rate at which the clinical researchers are able to recruit and retain patients for ‘Clinical Trials (CT)’, has now hit an all-time low. This is vindicated by studies that indicate less than 10 percent of Americans now participate in clinical trials, and only 3 to 5 percent of patients sign up for trials of new cancer therapies, in the largest CT market of the world.

As a result, about 40 percent of CTs do not recruit enough patients to meet their goals, the article highlights. Consequently, a large number of pharma industry sponsored CTs are now, reportedly, moving away from the United States. India should, therefore, take note of this development and pull up the socks.

If similar situation gets replicated in other countries too, and persists, it would be very unlikely that critical and credible medical and scientific knowledge that can significantly improve the treatment outcomes in many serious disease conditions could be meaningfully gathered and put to practice. Its other serious fallouts too, are also not terribly difficult to imagine.

A key medical research tool: 

In pursuit of the advancement of medical knowledge and patient care, CT of drugs is universally considered to be a key medical research tool, as it is the best way to learn what works best in treating various types of diseases. It goes without saying that drugs for all new types of treatments would need to be discovered first through a long and painstaking process of discovery research. These are then purified, and tested in preclinical studies, before a final decision is taken for commencement of CT on human against preset parameters, as deemed necessary.

While going through this stringent process some drugs are found to be safe and effective on human subjects and some others are not, on the contrary may be harmful.

There lies the crucial importance of CT for all scientific evidence based medicines. According to the Department of Health & Human Services of the United States, Clinical research is done only if doctors don’t know:

• whether a new approach works well with people and is safe and
• which treatments or strategies work best for certain illnesses or groups of people 

CT, though a small part in the important and lengthy process of developing newer treatments, significantly helps the health care decision makers to decide on the treatments that work best for any patient.

Broad types: 

Pharmaceutical companies usually sponsor CT for new drugs and treatments, which are carried out by the designated research teams, consisting of doctors and other related professionals in different specialized areas.

There are 4 phases in any CT, which are broadly as follows:     

• Phase I: Here, for a new treatment, an investigational drug is tested for the first time in small numbers, usually between 20 and 100, on healthy volunteers, to identify the proper dosage ranges for drug administration, while critically monitoring its method of absorption, adverse effects and toxicity profile.

• Phases II: This phase, just as Phase I studies, also tests the drug on, usually between 100 and 300 patients, suffering from the targeted disease conditions. Safety is the main goal of this phase of CT and is programmed towards adjusting treatment doses, monitoring the common side effects, and whether patient’s disease condition improve as a result of the drug. These studies are usually randomized and double-blinded, where neither the patient nor the researchers would know whether a patient is receiving the investigational drug, or a placebo, or a standard treatment.

• Phase III: In this phase, the investigational new drug goes through rigorous testing of safety, efficacy, and proper dosage levels in a large group of subjects, which may even exceed several thousand, with a specific illness or disease. The key objective is to enable the doctors to evaluate the safety and effectiveness of the treatment for various groups of patients, such as, men versus women, elderly versus young, besides many others. 

• Phase IV: Such studies are done after the drug receives the marketing approval from the drug regulator. The basic objective of these trials is usually to monitor whether the treatment offers desired benefits or gives rise to long-term side effects, which were not seen in the phase II and III trials. This phase may involve even several hundreds and thousands of patients.

It is worth noting that CT is essential to obtain marketing approval for any new treatment, as required by the drug regulators in the different countries, and takes around 6 to 8 years.

The role of patients:

Patients play a critical role in the entire scientific value chain of any drug evaluation process, especially on human. It is absolutely necessary, particularly in the regulated markets of the world, that all medicines are fully vetted through highly regulated, stringently monitored and well-scrutinized CTs, to ensure safety and effectiveness of each new drug and treatment for the patients.

No CT can take place sans the willingness and informed consent for participation of thousands of patients for any such studies held across the world. Without adequate patient participation in a CT, the drug performance data may also not be credible and thus acceptable to the drug regulator. This would, consequently, make it impossible to bring any new drug for prevention or treatment of various, often life threatening, disease conditions. 

Major reasons for not enough patient participation:

There are many reasons for not enough patients volunteering to participate in the CT, even in India. Some of the major reasons have been identified as follows:

• Patients often are not aware that such trials also offer a treatment option. In many cases, their doctors too may not be explaining it effectively to them, as a part of their professional discourse. Several studies conclude that trust in a physician is a main reason patients decide to participate in CT.

• Some patients, after reading media reports, interacting with some NGOs and also from word of mouth, mistrust the CT process and suffer from fear of being a guinea pig.

• At times, complicated protocols, and eligibility requirements may also be discouraging.

• Many patients, especially in India, are not very clear about the exact insurance (financial) cover the study provides for them, along with other payments for the care that they would receive during the trial, or for any drug-related long term untoward incident even after completion of the CT.

All these need to be effectively addressed. 

India attractiveness for CT:

The number of CT conducted in India had increased with a rapid pace till 2012, driven by cost arbitrage, treatment-naïve patient population, qualified English speaking medical research professionals that the country offers. According to available reports, in 2009, outside the United States, India was the second most preferred country to conduct CT. Incidentally, at that time, the CT guidelines in India were too loose, quite discretionary, patient-unfriendly and with many gaping holes. This scenario has changed dramatically since 2013, with consequent adverse impact on the number of CT in India.

A 2009 study conducted by Ernst & Young and the Federation of Indian Chambers of Commerce and Industry of India (FICCI), states that India participates in over 7 percent of all global phase III and 3.2 percent of all global phase II trials. The major reasons of India attraction of the global players to conduct CT in the country, were highlighted as follows:

• Cost of Clinical Trial (CL) is significantly less in India than most other countries of the world
• Huge treatment-naïve patient pool with different disease pattern and demographic profile
• Easy to enroll volunteers, as it is not very difficult to persuade poor and less educated people as ‘willing’ participants. This may not be so easy now with the recent amendment of CT guidelines. 

However, there is an urgent need for a world class capacity building in this area to reap a rich harvest.

Improving CT regulations in India: 

Not so long ago, it came to light with the help of ‘Right To Information (RTI)’ query that more than 2,000 people in India died as a result of Serious Adverse Events (SAEs) caused during drug trials from 2008-2011 and only 22 of such cases, which is just around 1 percent, received any compensation. That too was a meager average sum of around US$ 4,800 per family.

It has been widely reported that pharmaceutical companies often blame deaths, that occur during trials, on a person’s pre-existing medical condition, and not related to CT.

This gloomy situation is now gradually improving. According to an August 2015 research article titled “Impact of new regulations on clinical trials in India”, published in International Journal of Clinical Trials, 2015 Aug; 2 (3): 56-58, there was a need of strict vigilance and regulations for conducting CT in India, which was much easier than in North America or Europe. In India, the trial participants were exploited because of illiteracy, poverty and lack of awareness of their basic rights in this area. The Central Drugs Standard Control Organization (CDSCO) has now taken a noteworthy step by launching online Clinical Trial Registry-India (CTRI) ensuring accountability, transparency and information sharing on clinical trials in the public domain.

Followed by a tough intervention of the Supreme Court in 2013, Indian Government brought in amendments to the CT guidelines of Schedule Y, in December 2014 which came into force effective June 2015. These long-overdue amendments are expected to strengthen the CT process in India and effectively protect the rights, desired safety and general well-being of the participating subjects, while generating authentic clinical data for new drugs or treatment.

Informed consent:

Obtaining informed consent of the participating patients, is absolutely necessary for the researchers. This has recently been made stringent in India effective June 07, 2013. From that date, to make the sCT process transparent and ensure requisite confidentiality, an audio-visual recording of the ‘informed consent’ process has been made mandatory in the country.

A valid consent would mean that the participants have well understood the risks and benefits of the treatment during the CT period and after, along with the general procedures that he or she would need to undergo during the given time-frame.

However, the question that is still being debated, primarily because of the continuing challenge in defining in each case, beyond any scope of doubt, what should be universally considered as an adequate level of information given to the patients to obtain consent of participation in the CT. 

Financial compensation process:

Currently, the calculation of financial compensation, wherever applicable, is based on a well-defined formula. This system has been made mandatory for the sponsor in India for any trial related injuries or death. Such compensation has to be paid, even when the trial related injury is discerned after the completion of the CT. The concerned participants would receive this compensation over and above the free medical management of injury, which in any case has to be provided by the sponsor.

Hence patient safety and compensation related issues pertaining to CT in India have, to a great extent, been addressed, though there is still more scope for improvement on an ongoing basis.

Another major issue still to be addressed:

It is generally expected that when CT of a new drug is conducted by the global pharma players in India with the participation of Indian patients, the same drug when launched in other countries would also be made available in India for the benefit of Indian patients. 

Unfortunately, the situation is not so, as indicated by a paper titled, “A critical appraisal of clinical trials conducted and subsequent drug approvals in India and South Africa”, published in the BMJ Open on August 31, 2015.

The objective of this study was to assess the relation between the number of clinical trials conducted and respective new drug approvals in India and South Africa.

The study found that out of CTs with the participation of test centers in India and/or South Africa, 39.6 percent (India) and 60.1 percent (South Africa) CTs led to market authorization in the EU/USA, without a New Drug Application (NDA) approval in India or South Africa. 

The paper concluded, despite an increase in CT activities, there is a clear gap between the number of trials conducted and market availability of these new drugs in India and South Africa. Hence, the drug regulatory authorities, investigators, institutional review boards and patient groups should direct their efforts to ensuring availability of new drugs in the market that have been tested and researched on their population, the article suggested. 

I hope, the CDSCO would take remedial measures to address this situation, soon.

Indian pharma players should get their act together:

In view of the international media reports on alleged ‘CT data fudging’ by some of the larger Indian players in the pharma and relator sectors, there is an urgent need of the Indian pharma players to get their acts together, without any further delay.

On April 15, 2016, Reuters reported, “India’s Alkem Laboratories has been accused by Germany’s health regulator of fudging data on clinical trials of an antibiotic and brain disorder drug, becoming the third Indian firm to be scrutinized since 2014 for suspected manipulation of trial data.” However, a day later Alkem said that it was submitting suitable clarifications to the European Medical Agency (EMA).

Be that as it may, if the allegation for such gross violations of basic ethical standards is true, it would bring shame not just to the companies concerned, but also to India as a trusted source for pharma products and services. Such alleged foul play has the potential to ultimately shatter the stakeholders’ confidence, including patients, on CTs done by the Indian players, both for the local and global markets. 

Conclusion:

At the long last, after a grueling experience and tough intervention of the Supreme Court of India, CTs conducted in India are now reasonably well regulated and generally seem to comply with ethical requirements and standards. The question of human ‘guinea pigs’ and its associated concerns have also been adequately addressed by the CDSCO now.

Gradually improving the CT regulatory environment in India, barring some avoidable aberrations, offers some significant direct and indirect benefits to all concerned. Indian pharma is, therefore, expected to handle this sensitive opportunity with great care and following the highest ethical standards. 

This, in turn, would help bring to the market robust evidence-based new drugs and treatment for many types of diseases, and at the same time could facilitate their early access to many patients, at a time of dire need.

Through increasing access to CT, the participating patients would be able to avail several important benefits, such as, new and still unavailable treatment options, especially for those serious ailments, where other existing drugs either are not working effectively with satisfactory results, not affordable to many, or not working at all. In that sense, CT could offer to a sizeable number patients several other treatment options to choose from, especially, for many life-threatening diseases. This important benefit needs to be explained to the patients from credible sources, and thus merits serious consideration by the practicing medical professionals.

However, it is also a fact, particularly, in India that some people are lured to, or voluntarily enroll themselves for CT with an objective to make some extra money. Let me hasten to add that there are many other patients for whom the compensation for participation in the CT is no more than just an extra bonus.

Hence, improved patient participation with informed consent, to avail an important medical option in the disease treatment process, encouraged by the doctors without having any vested interest, has a great potential to create a win-win situation, for all concerned.

By: Tapan J. Ray 

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.