Addressing Consent Barriers in High-Risk First-in-Human and Early Clinical Trials

Introduction

Informed consent is a cornerstone of ethical clinical research, but its implementation becomes significantly more complex in high-risk Phase 1 trials. These early-stage studies often involve first-in-human (FIH) dosing, novel mechanisms, limited preclinical safety data, and uncertain risk profiles. Participants may be healthy volunteers or vulnerable patients, and consent forms can span dozens of pages filled with technical language. Ensuring comprehension, voluntariness, and ethical transparency becomes not only a regulatory requirement but a moral imperative. This article explores the unique challenges of informed consent in high-risk early-phase trials and provides strategies for improving clarity, compliance, and participant protection.

Why Informed Consent Is Critical in Phase 1

• First-in-human risk: Unknown adverse effects, including death or irreversible toxicity
• No direct benefit: Especially in healthy volunteer trials
• Complex science: New modalities like cell/gene therapies, ADCs, or immune checkpoint inhibitors
• Intensive monitoring: Frequent hospital visits, invasive procedures, and telemetry

Key Elements of Informed Consent

Per ICH-GCP, FDA, EMA, and CDSCO guidelines, informed consent must cover:

• Purpose of the study
• Risks, benefits, and alternatives
• Duration and procedures involved
• Voluntary participation and right to withdraw
• Confidentiality and data use
• Compensation, insurance, and contact information

Challenges Unique to High-Risk Phase 1 Trials

1. Complexity of Scientific Information

• Gene editing, lipid nanoparticles, immunotherapy, and mRNA may confuse lay readers
• Participants may not understand what a “cytokine storm” or “neutralizing antibody” entails

2. Risk Communication

• Rare but serious events (e.g., organ failure, death) must be disclosed clearly
• Volunteers may underestimate risk for monetary compensation

3. Length and Density of Consent Forms

• ICFs often exceed 20–30 pages, filled with scientific and legal jargon
• Retention and true comprehension suffer due to information overload

4. Vulnerable Populations

• Terminally ill patients, elderly, low-literacy groups, or economically disadvantaged volunteers
• Coercion or therapeutic misconception may be more likely

5. Fast-Paced Enrollment Timelines

• Phase 1 trials often move quickly between cohorts
• Participants may be rushed into signing forms without thorough reflection

Best Practices for Ethical and Compliant Informed Consent

1. Simplify the Consent Language

• Target an 8th-grade reading level (Flesch-Kincaid readability)
• Use plain language explanations, visual aids, and analogies

2. Use Tiered Information Format

• Summary page: High-level overview of study purpose and risks
• Main body: Detailed procedures and scientific rationale
• Appendices: Technical definitions, sample schedule, lab lists

3. Implement Teach-Back Techniques

• Ask participants to explain the study back in their own words
• Document understanding, not just signature

4. Use Multimedia and eConsent Platforms

• Interactive videos, quizzes, and audio narration improve retention
• eConsent platforms like Medidata, REDCap, or TrialKit enable remote access and version control

5. Address Therapeutic Misconception Directly

• Clarify that the primary purpose is not treatment but to learn about safety and PK
• Use neutral wording—avoid terms like “medicine,” “therapy,” or “cure”

Consent in Special Phase 1 Scenarios

1. First-in-Human Gene Therapy

• Explain irreversibility of treatment and long-term follow-up obligations (e.g., 15 years)
• Disclose theoretical risks like insertional mutagenesis or immune escape

2. Oncology Dose-Escalation Trials

• Clarify that initial cohorts may receive sub-therapeutic doses
• Highlight that dose may change across subjects

3. Healthy Volunteer Trials with Financial Compensation

• Clearly outline payment schedule, withholding clauses, and tax implications
• Monitor for enrollment motivated solely by income

Role of Ethics Committees and Regulators

Ethics Committees / Institutional Review Boards (IRBs)

• Review readability, completeness, and local relevance of consent materials
• Assess whether risk communication is balanced and culturally appropriate

FDA

• Requires informed consent documentation per 21 CFR Part 50
• Supports eConsent with audit trails under Part 11

EMA

• Expects alignment with GDPR and ethical transparency standards
• Consent must be “freely given, specific, informed, and unambiguous”

CDSCO (India)

• Mandates audio-visual recording of informed consent for all new drugs in FIH trials
• Requires subject literacy and language-specific documentation

Monitoring and Documentation of Consent

• Maintain signed and dated consent forms with subject ID
• Use version control and change logs for amended ICFs
• Document consent discussions in source notes (PI, study coordinator)
• Train site staff on handling questions, re-consent triggers, and reporting deviations

Conclusion

High-risk early-phase studies demand a higher ethical bar for informed consent. Clinical teams must go beyond signatures to foster true understanding and voluntary participation. By simplifying content, embracing digital tools, and strengthening dialogue, sponsors and investigators can honor both regulatory expectations and participant dignity—even in the most complex trials.