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APPENDIX IA
RTOG 0126 (10/18/04)
SAMPLE CONSENT FOR RESEARCH STUDY
STUDY TITLE (9/18/03)
A PHASE III RANDOMIZED STUDY OF HIGH DOSE 3D-CRT/IMRT VERSUS
STANDARD DOSE 3D-CRT/IMRT IN PATIENTS TREATED FOR LOCALIZED
PROSTATE CANCER
This is a clinical trial (a type of research study). Clinical trials
include only patients who choose to take part. Please take your
time to make your decision. Discuss it with your friends and
family. The National Cancer Institute (NCI) booklet, “Taking Part
in Clinical Trials: What Cancer Patients Need To Know,” is
available from your doctor.
You are being asked to take part in this study because you have
prostate cancer.
WHY IS THIS STUDY BEING DONE? (9/18/03)
One of the standard treatment options for your stage and type of
prostate cancer is external beam radiation therapy. Modern
radiation therapy planning methods with 3-dimensional therapy or
Intensity Modulated Radiation Therapy (IMRT) allow safer
delivery of higher than conventional doses of radiation. The
purpose of this study is to compare the effects (good and bad) on
you and your cancer of the standard dose of radiation therapy (39
treatments) with a higher dose of radiation (44 treatments) to see
which treatment is better.
Both three-dimensional radiation therapy and IMRT allow the
radiation beam to treat an area that is shaped like your tumor and
also to penetrate as deeply as your tumor is located. By treating
this way, the dose of radiation to the healthy areas near your tumor
is minimized, and the dose to your tumor is maximized. This
research is being done because doses higher than the standard dose
of radiation therapy may better control your cancer without
increased toxicity.
1
This study also will study biologic factors that may help to predict
and treat prostate cancer. In addition, this study will gather
information about the effects of radiation therapy on your sexual
functioning and on your overall quality of life.
HOW MANY PEOPLE WILL TAKE PART IN THE STUDY
About 1520 people will take part in this study.
WHAT IS INVOLVED IN THE STUDY?
You will be “randomized” into one of the study groups described
below. Randomization means that you are put into a group by
chance. It is like flipping a coin. A computer will determine into
which group you are placed. You will have approximately an equal
chance of being placed in one of the following groups:
Treatment 1 (9/18/03)
If you are randomized to this treatment, you will receive the
standard dose of 3D or IMRT radiation. You will receive radiation
therapy once daily, five days a week, Monday through Friday, for a
total of 39 treatments.
Treatment 2 (9/18/03)
If you are randomized to this treatment, you will receive a higher
dose of 3D or IMRT radiation. You will receive radiation therapy
once daily, five days a week, Monday through Friday, for a total of
44 treatments.
Each radiation treatment will take 30-60 minutes.
If you take part in this study, you also will have the following tests
and procedures:

A physical examination, including a digital rectal exam,
prior to beginning treatment, every 3 months for the first
two years following treatment, every 6 months until the
fifth year, and then annually. The follow-up visits
generally take 15 to 30 minutes.
2






Blood tests prior to beginning treatment, weekly during
radiation therapy, if your doctor feels these tests are
needed, and at each follow-up visit as described above.
CT scan or MRI (Magnetic Resonance Imaging) of the
pelvis prior to treatment and an x-ray of the urethra (the
canal from the bladder that discharges urine) prior to
treatment, if your doctor feels this x-ray is indicated
Bone scan, if indicated, prior to treatment
Removal and biopsy of pelvic lymph glands, if indicated, to
evaluate your cancer prior to treatment
If your disease progresses, your physician may request a
needle biopsy of your prostate to microscopically evaluate
response to treatment.
You will be asked to complete three brief questionnaires
about your sexual and urinary functioning, bowel habits,
and overall quality of life according to the following
schedule (9/18/03):
Questionnaire
Before Treatment
3
6
9
12
Number 1X
X
X
sexual
Number 2X
X
X
X
X
urinary
Number 3X
X
X
X
X
quality of life
After two years, you will be asked to complete questionnaire
number 1 every year for 3 years and questionnaires numbers 2
and 3 every six months for 3 years. The questionnaires each
take 10-15 minutes to complete.
HOW LONG WILL I BE IN THE STUDY?
If you participate in this study, you will receive radiation therapy
for 8 to 9 weeks. Follow up will continue indefinitely, for as long
as 13 years or longer.
The researcher may decide to take you off this study if your doctor
decides it is in your best interest, if side effects become very severe
or your condition worsens, or if new information becomes
available that indicates it is in your best interest.
3
15
18
24
X
X
X
X
X
You can stop participating at any time. However, if you decide to
stop participating in the study, we encourage you to talk to the
researcher and your regular doctor first.
WHAT ARE THE RISKS OF THE STUDY?
While on the study, you are at risk for these side effects. You
should discuss these with the researcher and/or your regular doctor.
There also may be other side effects that we cannot predict. Other
drugs will be given to make side effects less serious and
uncomfortable, such as medication to reduce irritation of the
bowel, rectum, or bladder. Inability to achieve an erection also can
be successfully treated with medication in many circumstances.
Many side effects go away shortly after the radiation therapy is
stopped, but in some cases side effects can be serious or longlasting or permanent. Some side effects do not become apparent
for months or years after all treatment has been delivered.(9/18/03)
Risks and side effects related to the radiation therapy we are
studying include:
Very Likely
Tanning or redness of skin in treatment area
Rash, itching or peeling of skin
Temporary hair loss in the treatment area
Temporary fatigue, nausea or diarrhea
Abdominal cramps
Bladder irritation with a stinging sensation
Frequency or urgency of urination
Rectal irritation with more frequent bowel movements
Less Likely, But Serious
Injury to the bladder, urethra, bowel, or other tissues in the pelvis or
abdomen
Intestinal or urinary obstruction
Inability to achieve an erection
Rarely, rectal bleeding that requires medication or burning/cutting of
tissues to stop
Risks and side effects related to the optional post-treatment
needle biopsy include bleeding, pain, possible infection, and
rarely, creation of an abnormal opening or passage.
4
Reproductive risks: Because the radiation in this study can
affect an unborn baby, you should not father a baby while on
this study. Ask about counseling and more information about
preventing pregnancy.
ARE THERE BENEFITS TO TAKING PART IN THE STUDY?
If you agree to take part in this study, there may or may not be
direct medical benefit to you. It is not known whether the higher
dose of three-dimensional radiation therapy or IMRT you could
receive will help your condition more than the standard dose. A
possible benefit of this study may be a decrease in the size of your
tumor and longer survival, but these benefits are not certain or
guaranteed. We hope the information learned from this study will
benefit other patients with prostate cancer in the future. (9/18/03)
WHAT OTHER OPTIONS ARE THERE?
You may choose to not participate in this study. Other treatments
that could be considered for your condition may include the
following: (1) external (non-3D) radiation therapy; (2) internal
radiation (seed implants or brachytherapy); (3) surgery; (4)
hormone therapy; or (5) no treatment except medications to make
you feel better. With the latter choice, your tumor could continue
to grow and your disease could spread. These treatments could be
given either alone or in combination with each other. If you decide
not to participate in this study, you still could receive 3D radiation
therapy or IMRT similar to the therapy described above. (9/18/03)
Your doctor can tell you more about your condition and the
possible benefits of the different available treatments.
Please talk to your regular doctor about these and other options.
WHAT ABOUT CONFIDENTIALITY?
5
Efforts will be made to keep your personal information
confidential. We cannot guarantee absolute confidentiality.
Records of your progress while on the study will be kept in a
confidential form at this institution and in a computer file at the
headquarters of the Radiation Therapy Oncology Group (RTOG).
Your personal information may be disclosed if required by law.
Organizations that may inspect and/or copy your research records
for quality assurance and data analysis include groups such as the
Food and Drug Administration (FDA), the National Cancer
Institute (NCI) or its authorized representatives, and other groups
or organizations that have a role in this study.
WHAT ARE THE COSTS?
Radiation therapy is a standard treatment for your prostate cancer,
and health insurers generally cover its costs. The higher dose
administered on Arm 2 may result in higher costs. Therefore,
taking part in this study may lead to added costs to you or your
insurance company. Please ask about any expected added costs or
insurance problems. (9/18/03)
In the case of injury or illness resulting from this study, emergency
medical treatment is available but will be provided at the usual
charge. No funds have been set aside to compensate you in the
event of injury.
You or your insurance company will be charged for continuing
medical care and/or hospitalization. Medicare should be considered
a health insurance provider.
You will receive no payment for taking part in this study.
WHAT ARE MY RIGHTS AS A PARTICIPANT?
Taking part in this study is voluntary. You may choose not to take
part or may leave the study at any time. Leaving the study will not
result in any penalty or loss of benefits to which you are entitled.
We will tell you about new information that may affect your
health, welfare, or willingness to stay in this study.
6
A Data Safety and Monitoring Board, an independent group of
experts, will be reviewing the data from this research throughout
the study. We will tell you about the new information from this or
other studies that may affect your health, welfare, or willingness to
stay in this study.
WHOM DO I CALL IF I HAVE QUESTIONS OR PROBLEMS?
(This section must be completed)
For information about your disease and research-related injury, you may contact:
Name
Telephone Number
For information about this study, you may contact:
Name
Telephone Number
For information about your rights as a research subject, you may contact:
(OHRP suggests that this person not be the investigator or anyone else directly involved
with the research)
Name
Telephone Number
You also may call the Project Office of the NCI Central Institutional Review Board
(CIRB) at 888-549-0715 (from the continental U.S. only) or 800-937-8281, ext. 4445
(from sites outside the continental U.S.).
WHERE CAN I GET MORE INFORMATION?
You may call the NCI’s Cancer Information Service at
1–800–4–CANCER (1–800–422–6237) or TTY: 1–800–332–
8615
Visit the NCI’s Web sites for comprehensive clinical trials
information http://cancertrials.nci.nih.gov or for accurate cancer
information including PDQ http://cancernet.nci.nih.gov.
7
CancerFax: Includes NCI information about cancer treatment,
screening, prevention, and supportive care. To obtain a contents list,
dial 301-402-5874 or 800-624-2511 from a fax machine handset and
follow the recorded instructions.
SIGNATURE (8/23/02)
I have read all the above, asked questions, and received answers concerning
areas I did not understand. I have had the opportunity to take this consent
form home for review or discussion.
I willingly give my consent to participate in this program. Upon signing this
form I will receive a copy. I may also request a copy of the protocol (full
study plan).
_____________________
Patient’s Name
____________________
Signature
___________
Date
_____________________
Name of Person Obtaining Consent
__________________
Signature
___________
Date
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APPENDIX IB (8/23/02)
RTOG 0126 (10/18/04)
CONSENT FORM FOR USE OF TISSUE AND BLOOD FOR RESEARCH
ABOUT USING TISSUE AND BLOOD FOR RESEARCH (7/10/07)
You have had or will have a biopsy (or surgery) to see if you have
cancer. Your doctor has removed or will remove some body tissue
to do some tests. The results of these tests will be given to you by
your doctor and will used to plan your care.
We would like to keep some of the tissue that is left over for future
research. If you agree, this tissue will be kept and may be used in
research to learn more about cancer and other diseases.
In addition, you will have blood tests before you start treatment.
We would like to keep about four teaspoons of blood for future
research as well. If you agree, this blood will be kept and may be
used in research to learn more about cancer and other diseases.
One specific test will analyze whether your blood contains certain
genes and if the side effects you had on radiation are related to
these genes. We will then try to see if these genes can help us learn
about why some people get worse side effects than others.
Your tissue and blood may be helpful for research whether you do
or do not have cancer. The research that may be done with your
tissue and blood is not designed specifically to help you. It might
help people who have cancer and other diseases in the future.
Reports about research done with your tissue and blood will not be
given to you or your doctor. These reports will not be put in your
health record. The research will not have an affect on your care.
THINGS TO THINK ABOUT (7/10/07)
The choice to let us keep the left over tissue and blood for future
research is up to you. No matter what you decide to do, it will
not affect your care.
If you decide now that your tissue and blood can be kept for
research, you can change your mind at any time. Just contact us
and let us know that you do not want us to use your tissue and
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blood and then any tissue and blood that remains will no longer be
used for research; or, you may request that your tissue be returned
to you or your designee.
In the future, people who do research may need to know more
about your health.
While the [treating institution/treating
physician] may give them reports about your health, it will not give
them your name, address, phone number, or any other information
that will let the researchers know who you are.
Sometimes tissue and blood are used for genetic research (about
diseases that are passed on in families). Even if your tissue and
blood is used for this kind of research, the results will not be put in
your health records.
Your tissue and blood will be used only for research and will not
be sold. The research done with your tissue and blood may help to
develop new products in the future.
BENEFITS (7/10/07)
The benefits of research using tissue and blood include learning
more about what causes cancer and other diseases, how to prevent
them, and how to treat them.
RISKS
The greatest risk to you is the release of information from your
health records. The [treating institution/treating physician] will
protect your records so that your name, address, and phone number
will be kept private. The chance that this information will be given
to someone else is very small.
MAKING YOUR CHOICE (7/10/07)
Please read each sentence below and think about your choice.
After reading each sentence, circle “Yes” or “No”. No matter
what you decide to do, it will not affect your care. If you have
any questions, please talk to your doctor or nurse, or call our
research review board at [IRB’s phone number].
1.
My tissue/blood may be used for the research in the current study.
Yes
No
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2.
My tissue/blood may be kept for use in research to learn about, prevent or treat
cancer.
Yes
3.
My tissue/blood may be kept for use in research to learn about, prevent or treat
other health problems (for example: diabetes, Alzheimer’s disease, or heart
disease).
Yes
4.
No
My blood may be kept for use in future research to learn about the
correlation between genes and radiation side effects.
Yes
5.
No
No
Someone from [treating institution/treating physician] may contact me in
the future to ask me to take part in more research.
Yes
No
Participant statement:
I have read and received a copy of this consent form. I have been given an opportunity discuss the
information with my doctor/nurse, and all of my questions/concerns have been answered to my satisfaction.
My answers above and my signature below indicate my voluntary participation in this research.
Patient’s Name
Signature
Date
Witness statement:
I have explained the information in this consent form to the patient and have answered any questions
raised. I have witnessed the patient’s signature.
_
Name of Person Obtaining Consent
Signature
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_________
Date
×

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