For rare diseases, the interplay between sponsors and Clinical Research Organizations (CROs) can significantly impact the outcomes of a study. Recent experiences in a rare pediatric trial uncovered several insights that apply across the spectrum of rare disease research. This trial, conducted on behalf of a prominent biopharmaceutical company, encountered several challenges that offer valuable lessons for optimizing future rare disease studies.
In this article, we will look at the lessons learned from this trial and demonstrate that success in rare indications demands not only scientific rigor but also operational finesse, adaptive strategies, and seamless collaboration between sponsors and CROs. These insights offer a roadmap for enhancing the efficiency and effectiveness of future rare disease clinical trials.
The earlier the CRO is involved, the better
The first lesson learned is that leveraging CRO expertise from the earliest stages of trial planning can prevent many issues and set the stage for a more smoothly executed study.
CROs specializing in rare diseases bring a wealth of knowledge about the unique challenges these trials face, from regulatory nuances to operational intricacies. Their early involvement can help shape protocols that are not only scientifically sound but also practically feasible. In this trial, earlier CRO engagement could have informed more realistic timelines, appropriate site selection criteria, and robust IP management strategies.
The sponsor's initial plans, developed without the benefit of a CRO's practical experience in rare disease trials, didn’t account for the nuanced recruitment strategies necessary for such a specialized pediatric patient population. The result was a series of recruitment difficulties that plagued the study from its outset. The lack of early CRO involvement meant that other inefficiencies, like potential IP accountability issues, were not identified and addressed in the protocol design phase.
Experienced CRO partners bring a repository of knowledge to the table
They understand the nuances of patient recruitment in small populations, the complexities of site management when dealing with specialized centers, and the critical nature of precise IP handling in studies where every dose counts.
In this rare pediatric trial, the sponsor's decision to sideline initial CRO advice on crucial aspects— such as recruitment strategies and IP labeling led to significant setbacks. This scenario underscores the importance of not just engaging a CRO, but actively leveraging their expertise throughout the trial process.
The lesson here is twofold. Sponsors should look for CROs with proven track records in the specific therapeutic area, but more importantly, they should create a collaborative environment where CRO insights are valued and integrated into the trial strategy. This might involve regular strategy sessions, open channels for CRO feedback on protocol design and operational plans, and a willingness to adjust approaches based on CRO recommendations. By fully utilizing CRO experience, sponsors can better navigate the known risks of rare disease trials more effectively, streamlining processes and ultimately accelerating the path to potential treatments for patients who often have few or no therapeutic options.
Clear IP accountability plans
Patient recruitment challenges and limited quantities of study drug make accurate tracking of IP paramount. This simple practice ensures data integrity, supports patient safety, and facilitates regulatory compliance.
In this rare pediatric study, the sponsor chose to skip clear individual identification numbers on drug bottles, which led to significant tracking issues. The lack of individual identification numbers in this trial not only complicated the reconciliation process but also potentially compromised the quality of data collected. This oversight necessitated additional work to retroactively track and verify drug dispensation, consuming valuable time and resources.
Implementing a strong IP accountability plan from the outset can prevent many of the issues encountered in this trial. It allows for real-time tracking of drug usage, facilitates accurate dosing records, and simplifies end-of-study reconciliation. Moreover, it provides a clear chain of custody for the IP, which is crucial for maintaining the integrity of the trial and ensuring compliance with Good Clinical Practice (GCP) guidelines.
The lesson learned here is that IP accountability should be a priority in trial planning, particularly in rare disease studies where the margin for error is slim.
Establish realistic and achievable criteria for site participation
This rare pediatric study encountered significant challenges due to overly stringent site selection criteria, leading to the loss of several high-quality research centers, including a prestigious children's hospital. This situation highlights the delicate balance required in setting standards that ensure data quality without unnecessarily excluding valuable research partners. Flexibility in certain criteria may be necessary to include sites with strong potential but perhaps lacking in some specific areas. In such cases, additional training or support could be provided to bring these sites up to the required standard, rather than excluding them outright.
The key lesson is that site selection criteria should be carefully calibrated to the realities of rare disease research. While maintaining high standards is crucial, there must be room for pragmatism. Engaging with potential sites early can provide valuable insights into what criteria are realistic and what support might be needed. By striking the right balance, sponsors can ensure a robust network of qualified sites, enhancing the overall quality and feasibility of their rare disease trials.
Challenges with research facilities
This rare pediatric trial experienced significant challenges associated with relying on standalone research facilities, highlighting the importance of understanding and accounting for the limitations of different site types in rare disease studies.
Standalone research facilities often offer advantages such as dedicated research staff and streamlined processes. However, they may lack the full range of specialized departments and equipment found in larger academic or hospital settings. In this trial, the absence of certain in-house capabilities led to difficulties in conducting some of the required tests, resulting in delays and potential compromises in data collection. While some trials may benefit from the focused approach of standalone facilities, others may require the comprehensive resources of larger institutions.
The core lesson here is the importance of aligning protocol requirements with site capabilities from the outset. This may involve adapting the protocol to the realities of available research settings or providing additional support to enhance site capabilities. By anticipating and planning for these challenges, sponsors can create a more resilient and effective research network, better equipped to handle the complex demands of rare disease trials.
Effective communication and flexibility matter
This rare pediatric trial underscored the critical importance of maintaining open communication channels and demonstrating flexibility in addressing site needs. The sponsor's closed approach led to multiple screen failures and additional costs, highlighting how inflexibility can hinder study progress and potentially compromise data quality.
The sponsor's inability to adjust their approach in response to site feedback resulted in unnecessary participant exclusions and increased expenses. This rigidity not only affected immediate study outcomes but also risked damaging relationships with valuable research partners.
While it's crucial to recognize that flexibility does not mean compromising scientific integrity or regulatory compliance, finding creative solutions within the bounds of good clinical practice to address the unique challenges of rare disease research is good practice.
The key lesson is that a collaborative, flexible approach can significantly improve study outcomes. By maintaining open lines of communication and demonstrating willingness to adapt to site needs, sponsors can create an environment conducive to high-quality research. This approach not only enhances the current study but also builds stronger relationships with sites, potentially benefiting future rare disease trials.
Proactive site management impacts efficiency and timelines in rare clinical trials
The initial delays in site activation experienced in this study not only pushed back timelines but also risked losing potential participants to competing trials or disease progression. In the end, we decided to have one of our team members take over the Confidential Disclosure Agreement (CDA) process. This decision was partly due to the pharmaceutical company being based in Australia and the lengthy time it took to get the CDA document to the sites and work with them to sign and proceed with Protocol and Investigator’s Brochure (IB) delivery.
The primary lesson here is the value of a proactive, rather than reactive, approach to site management. By closely monitoring site progress, anticipating potential issues, and being willing to adjust strategies and resources as needed, sponsors and CROs can significantly enhance the efficiency of rare disease trials. This proactive stance not only helps to keep studies on track but also demonstrates commitment to sites and patients, fostering stronger relationships and potentially improving long-term research outcomes in the challenging field of rare disease clinical trials.
Key takeaways from this rare disease case study
The unique demands of rare disease trials often need a nuanced approach that should be reflected in the protocol design, site selection, and operational execution. In this study, early decisions about CRO involvement and use of their expertise were impactful. The sponsor's initial strategy, while ambitious, underestimated the complexities of conducting a trial in a patient population with limited natural history data and heterogeneous disease progression.
Success in rare disease trials takes scientific rigor, operational excellence, and adaptive thinking working together. Integrating these hard-won insights into cutting-edge strategies and emerging technologies shows a pathway to more efficient, effective, and patient-centric rare disease trials.
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