Breaking down barriers: Expanding patient access and accelerating research

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10 years ago I was presented with an incredibly unique opportunity- to become the fifth patient with spinal cord injuries to participate in the world’s first clinical trial testing a treatment made from human embryonic stem cells. It was not only a risky and potentially life-changing decision, but also one that I had to make in less than a week. 

To make matters more complicated, I was to be poked, prodded, and extensively scanned on a daily basis for several months as part of the follow-up process. I lived nearly two hours away from the hospital and I was newly paralyzed. How would this work? I wanted my decision-making process to be solely based on the amazing science and the potential that with my participation, the field might advance. Instead, I found myself spending countless hours contemplating the extra work I was asking my family to take on in addition to nursing me back to life. 

In this instance, I was “lucky”. I had access to family and friends who were able and willing to make any kind of sacrifice to ensure my happiness. I lived quite a distance away from the hospital, but everyone around me had a car. They had the means to skip work, keep the gas tank filled, and make the tedious journey. I also had an ally, which was perhaps my biggest advantage. The California Institute for Regenerative Medicine (CIRM) was the funding agency behind the groundbreaking clinical trial and I’ll never forget the kind strangers who sat on my bedside and delighted me with stories of hope and science. 

Accelerating the research

The field of regenerative medicine has gained so much momentum since my first introduction to stem cells in a small hospital room. Throughout the decade and especially in recent years there have been benchmark FDA approvals, increased funding and regulatory support. The passage of Proposition 14 in 2020 has positioned CIRM to continue to accelerate research from discovery to clinical and to drive innovative, real-world solutions resulting in transformative treatments for patients. 

Now, thanks to Prop 14 we have some new goals, including working to try and ensure that the treatments our funding helps develop are affordable and accessible to a diverse community of patients in an equitable manner, including those often overlooked or underrepresented in the past. Unsurprisingly, one of the big goals outlined in our new 5-year Strategic Plan is to deliver real world solutions through the expansion of the CIRM Alpha Stem Cell Clinics network and the creation of a network of Community Care Centers of Excellence.

The Alpha Stem Cell Clinics and Community Care Centers of Excellence will work in collaboration to achieve a wide set of goals. These goals include enabling innovative clinical research in regenerative medicine, increasing diverse patient access to transformative therapies, and improving patient navigation of clinical trials. 

Breaking down the barriers 

The dilemma surrounding the four-hour long round-trip journey for an MRI or a vial of blood isn’t just unique to me and my experience participating in a clinical trial. It is well recognized and documented that geographic disparities in clinical trial sites as well as limited focus on community outreach and education about clinical trials impede patient participation and contribute to the well-documented low participation of under-represented patients in clinical studies.

As outlined in our Strategic Plan, the Alpha Stem Cell Clinic Network and Community Care Centers will collaboratively extend geographic access to CIRM-supported clinical trials across the state. Community Care Centers will have direct access and knowledge about the needs of their patient populations including, culturally and linguistically effective community-based education and outreach. In parallel, Alpha Stem Cell Clinics will be designed to support the anticipated outreach and education efforts of future Community Care Centers.

To learn more about CIRM’s approach to deliver real world solutions for patients, check out our new 5-year Strategic Plan

Lack of diversity leaves cloud hanging over asthma drug study

Asthma spacer, photo courtesy Wiki Media Creative Commons

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If you want to know if a new drug or therapy is going to work in the people it affects the most you need to test the drug or therapy in the people most affected by the disease. That would seem blindingly obvious, wouldn’t it? Apparently not.

Case in point. A new asthma medication, one that seemingly shows real promise in reducing attacks in children, was tested on an almost entirely white patient population, even though Black and Puerto Rican children are far more likely to suffer from asthma.

The study enrolled more than 400 children, between the ages of 6 and 11, with moderate to serious uncontrolled asthma and treated them with a medication called Dupixent. The results, published in the New England Journal of Medicine, were impressive. Children given Dupixent had an average drop in severe asthma attacks of 65 percent compared to children given a placebo.

The only problem is 90 percent of the children in the study were white. Why is that a problem? Because, according to the Asthma and Allergy Foundation of America, only 9.5 percent of white children have asthma, compared to 24 percent of Puerto Rican children and 18 percent of Black children. So, the groups most likely to suffer from the disease were disproportionately excluded from a study about a treatment for the disease.

Some people might think, “So what! If the medication works for one kid it will work for another, what does race have to do with it?” Quite a lot actually.

A study in the Journal of Allergy and Clinical Immunology concluded that: “Race/ethnicity modified the association between total IgE (an antibody in the blood that is a marker for asthma) and asthma exacerbations. Elevated IgE level was associated with worse asthma outcomes in Puerto Ricans… Our findings suggest that eligibility for asthma biologic therapies differs across pediatric racial/ethnic populations.”

The article concluded by calling for “more studies in diverse populations for equitable treatment of minority patients with asthma.” Something that clearly didn’t happen in the Dupixent study.

While that’s more than disappointing, it’s not surprising. A recent study of vaccine clinical trials in JAMA Network Open found that:

  • Overall, white individuals made up almost 80 percent of people enrolled.
  • Black individuals were represented only 10.6 percent of the time.
  • Latino participants were represented just 11.6 percent of the time. 

Additionally, in pediatric trials, Black participants were represented just over 10 percent of the time and Latino participants were represented 22.5 percent of the time. The study concluded by saying that “diversity enrollment targets are needed for vaccine trials in the US.”

I would expand on that, saying they are needed for all clinical trials. That’s one of the many reasons why we at the California Institute for Regenerative Medicine (CIRM) are making Diversity, Equity and Inclusion an important part of everything we do, such as requiring all applicants to have a written DEI plan if they want funding from us. Dr. Maria Millan, our President and CEO, recently co-authored an article in Nature Cell Biology, driving home the need for greater diversity in basic science and research in general.

DEI has become an important part of the conversation this past year. But the Dupixent trial shows that if we are truly serious about making it part of what we do, we have to stop talking and start acting.

Lack of diversity impacts research into Alzheimer’s and dementia

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A National Institutes of Allergy and Infectious Diseases clinical trial admissions coordinator collects information from a volunteer to create a medical record. Credit: NIAID

Alzheimer’s research has been in the news a lot lately, and not for the right reasons. The controversial decision by the Food and Drug Administration (FDA) to approve the drug Aduhelm left many people wondering how, when, or even if it should be used on people battling Alzheimer’s disease. Now a new study is raising questions about many of the clinical trials used to test medications like Aduhelm.

The research, published in the journal Jama Neurology, looked at 302 studies on dementia published in 2018 and 2019. Most of these studies were carried out in North America or Europe, and almost 90 percent of those studied were white.

In an accompanying editorial in the journal, Dr. Cerise Elliott, PhD, of the National Institute on Aging (NIA) in Bethesda, Maryland, and co-authors wrote that this limited the value of the studies: “This, combined with the fact that only 22% of the studies they analyzed even reported on race and ethnicity, and of those, a median 89% of participants were white, reflects the fact that recruitment for research participation is challenging; however, it is unacceptable that studies continue to fail to report participant demographics and that publishers allow such omissions.”

That bias is made all the more glaring by the fact that recent data from the Centers for Disease Control and Prevention shows that among people 65 and older, the Black community has the highest prevalence of Alzheimer’s disease and related dementias (13.8%), followed by Latinx (12.2%), non-Hispanic white (10.3%), American Indian and Alaskan Native (9.1%), and Asian and Pacific Islander (8.4%) populations.

The researchers admitted that the limited sample size – more than 40 percent of the studies they looked at included fewer than 50 patients – could have impacted their findings. Even so this clearly suggests there is a huge divide between the people at greatest risk of developing Alzheimer’s, or some other form of dementia, and the people being studied.

In the editorial, Elliott and his colleagues wrote that without a more diverse and balanced patient population this kind of research: “will continue to underrepresent people most affected by the disease and perpetuate systems that exclude important valuable knowledge about the disease.”


There are more details on this in Medpage Today.

An editorial in the New England Journal of Medicine highlights how this kind of bias is all too common in medical research.

“For years, the Journal has published studies that simply do not include enough participants from the racial and ethnic groups that are disproportionately affected by the illnesses being studied to support any conclusions about their treatment. In the United States, for example, Black Americans have high rates of hypertension and chronic kidney disease, Hispanic Americans have the highest prevalence of nonalcoholic fatty liver disease, Native Americans are disproportionately likely to have metabolic syndrome, and Asian Americans are at particular risk for hepatitis B infection and subsequent cirrhosis, but these groups are frequently underrepresented in clinical trials and cohort studies.”

“For too long, we have tolerated conditions that actively exclude groups from critical resources in health care delivery, research, and education. This exclusion has tragic consequences and undermines confidence in the institutions and the people who are conducting biomedical research. And clinicians cannot know how to optimally prevent and treat disease in members of communities that have not been studied.”

The encouraging news is that, finally, people are recognizing the problem and trying to come up with ways to correct it. The not so encouraging is that it took a pandemic to get us to pay attention.

At CIRM we are committed to being part of the solution. We are now requiring everyone who applies to us for funding to have a written plan on Diversity, Equity and Inclusion, laying out how their work will reflect the diversity of California. We know this will be challenging for all of us. But the alternative, doing nothing, is no longer acceptable.