Chapter 9
The
Protocol and
Its Impact on Research Activities
Robert J. Daun Hazleton Laboratories America, Madison, WI 53704 Existing Good Laboratory Practice regulations (GLPs) mandate that each study have a protocol that clearly defines the key elements of the study. Although the GLPs define the key elements of a valid protocol, the document must be designed to provide a proper balance between an exact definition of what will be done and s t i l l retain a degree of flexibility. Although a protocol is required by GLPs, it should never be regarded as a document prepared solely to meet administrative requirements. Rather, it should be considered a necessity to ensure an efficiently conducted scientific study of high quality. The purpose of this article is to discuss the impact of a well-designed protocol on the performance of the study. Examples are given as to how the protocol is used, both before study initiation and during the actual conduct of the study. Existing Good Laboratory Practice (GLP) regulations dictate that "Each study shall have an approved written protocol that clearly Indicates the objectives and all methods for the conduct of the study."(1) The term "protocol" has become a key word in the vocabulary of scientists Involved 1n health-effects studies since the late 1970's. To many, the word protocol itself has taken on a new and highly narrowed meaning. An examination of the dictionary definition of the term protocol provides a point of interest not only 1n the historical derivation of the term but also some unique insights 1n how the document should function in the current context of a regulated study. A part of Webster's(2) definition of the term protocol 1s ". . . first sheet of papyrus roll bearing the authentication and date of manufacture of the papyrus. Papyrus roll, sheets of papyrus glued together, literally, that which is glued together." Within this classical definition can be found some key Items relevant to the use of the term protocol. These two Items are "authentication" and "glued together." The study
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p r o t o c o l , as mandated by e x i s t i n g and proposed GLPs, serves as an a u t h e n t i c a t i n g document b e a r i n g the s i g n a t u r e s of key p a r t i e s to be i n v o l v e d i n the proposed s t u d y ; and i n the c u r r e n t v e r n a c u l a r , serves to "glue t o g e t h e r , " i n an o r d e r l y f a s h i o n , the s p e c i f i c o p e r a t i n g requirements of the s t u d y . The format of a study p r o t o c o l i s l e f t to the e n t i t y d e v e l o p i n g the p r o t o c o l ; however, the b a s i c requirements a r e c l e a r l y s e t f o r t h i n the GLP r e g u l a t i o n s . The f o r t h c o m i n g broad a p p l i c a t i o n of GLPs to c h e m i s t r y - b a s e d and f i e l d s t u d i e s means t h a t , f o r the f i r s t t i m e , many groups w i l l f i n d the need to d e v e l o p study p r o t o c o l s t h a t w i l l conform to the requirements of GLPs. There needs to be a r e c o g n i t i o n by the study s c i e n t i s t s t h a t development of t h i s document i s much more than an a d m i n i s t r a t i v e exercise. T h i s document, when p r o p e r l y c o n s t r u c t e d , p r o v i d e s the key working t o o l f o r the s u c c e s s f u l c o m p l e t i o n of the s t u d y . The P r o t o c o l — W h a t Does i t
Provide?
The study p r o t o c o l must, f i r s t and f o r e m o s t , c o n t a i n a c l e a r l y s t a t e d o b j e c t i v e of the r e s e a r c h a c t i v i t y to f o l l o w . I t has not been unusual f o r s t u d i e s to be conducted w i t h o u t a l l of the study team u n d e r s t a n d i n g the scope of the i n v e s t i g a t i o n . For example, a study conducted to determine the i d e n t i t y and r e l a t i v e q u a n t i t y of a p e s t i c i d e and i t s m e t a b o l i t e s i n the e d i b l e p o r t i o n s of f o o d - p r o d u c i n g animals should be r e s t r i c t e d to the a c t i v i t i e s n e c e s s a r y to p r o v i d e t h i s i n f o r m a t i o n . Without a c l e a r l y s t a t e d o b j e c t i v e , t h i s type of study c o u l d i n s t e a d be m a n i p u l a t e d i n t o an attempt to determine t o x i c o l o g i c a l responses or p a t h o l o g i c a l effects. The d a t a o b t a i n e d c o u l d be of q u e s t i o n a b l e v a l u e because the p r o t o c o l d e s i g n would not c o n t a i n the necessary elements to provide r e l i a b l e data. T h i s i s not to say t h a t combined s t u d i e s a r e of no v a l u e , but i f a study i s m u l t i d i s c i p l i n a r y i n n a t u r e , the study d e s i g n should c o n t a i n i n p u t from s t a f f q u a l i f i e d i n the disciplines involved. A p r o t o c o l p r o v i d e s a focus of r e s p o n s i b i l i t i e s f o r a l l members of the study team. The c o m b i n a t i o n of a c l e a r l y s t a t e d o b j e c t i v e , a l o n g w i t h a c l e a r d e f i n i t i o n of the methods and m a t e r i a l s , w i l l a v o i d c o n f u s i o n d u r i n g the study when o f t e n t h e r e i s not time f o r e x t e n s i v e c o n s u l t a t i o n among the study team. Most s t u d i e s intended f o r s u b m i s s i o n to a r e g u l a t o r y agency a r e developed to correspond to the requirements of some type of guidance document, such as the F e d e r a l I n s e c t i c i d e , F u n g i c i d e , and R o d e n t i c i d e Act (FIFRA) g u i d e l i n e s f o r p e s t i c i d e r e g i s t r a t i o n studies. By i t s very n a t u r e , a g u i d e l i n e needs to be f l e x i b l e enough to a l l o w f o r v a r i a t i o n i n a s p e c i f i c s t u d y . Because each study must be t a i l o r e d to the s p e c i f i c compound under i n v e s t i g a t i o n , i t i s w i s e to s o l i c i t r e g u l a t o r y agency r e v i e w of the study p r o t o c o l to v e r i f y t h a t the study w i l l p r o v i d e the r e q u i r e d i n f o r m a t i o n . If reviewed and approved, the p r o t o c o l can p r o v i d e a means to a v o i d c o s t l y and time-consuming study r e p e a t s . Whether a study i s performed w i t h i n the s p o n s o r i n g f a c i l i t y or by a c o n t r a c t l a b o r a t o r y , i t i s necessary t h a t t h e r e be a r e v i e w by a l l p a r t i e s i n v o l v e d . In a d d i t i o n to r e v i e w by the study d i r e c t o r and, i n the case of a c o n t r a c t e d s t u d y , the Sponsor's
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study m o n i t o r , i t i s w i s e to have the p r o t o c o l reviewed by the Q u a l i t y Assurance U n i t to v e r i f y compliance w i t h GLP p r o t o c o l requirements. In the case of a study t h a t i n v o l v e s r a d i o a c t i v e i s o t o p e s , the p r o t o c o l should be reviewed by the p e r f o r m i n g l a b o r a t o r y ' s R a d i a t i o n S a f e t y O f f i c e r to ensure t h a t a l l requirements necessary f o r worker s a f e t y and p r e v e n t i o n of i n a d v e r t e n t c o n t a m i n a t i o n are s p e c i f i e d . The signed f i n a l p r o t o c o l p r o v i d e s w r i t t e n documentation t h a t a l l p a r t i e s a r e i n agreement as to the conduct of the s t u d y . The w e l l - c o n s t r u c t e d study p r o t o c o l p r o v i d e s a ready r e f e r e n c e f o r study s p e c i f i c i n f o r m a t i o n . The f i n a l p r o t o c o l should be sent to a l l of the key members of the study team and a copy should be p r e s e n t a t a l l s i t e s where any a c t i v i t y a s s o c i a t e d w i t h the study i s b e i n g performed. Even though the p r o t o c o l may have been reviewed by the study team, 1t i s not unusual f o r q u e s t i o n s to a r i s e d u r i n g the course of a study t h a t can be r e a d i l y r e s o l v e d by another p e r f u n c t o r y r e v i e w of the p r o t o c o l w o r d i n g . The study p r o t o c o l p r o v i d e s a v e h i c l e f o r e s t i m a t i n g the time and c o s t s of a study and makes the study team aware of any unusual s c h e d u l i n g or n o n - t y p i c a l equipment r e q u i r e d to c a r r y out the study. Although the use of the p r o t o c o l f o r c o s t i n g purposes i s of extreme importance to a c o n t r a c t l a b o r a t o r y , the same i n f o r m a t i o n i s of importance f o r n o n c o n t r a c t e d s t u d i e s . I t a l l o w s the p e r f o r m i n g f a c i l i t y to ensure t h a t a l l of the r e q u i r e d r e s o u r c e s , i n terms of t r a i n e d s t a f f , f a c i l i t i e s , and equipment, w i l l be a v a i l a b l e and i n p l a c e a t study i n i t i a t i o n . A p r o t o c o l p r o v i d e s a mechanism f o r r e v i e w of d a t a and r e p o r t s d u r i n g , and a t the c o n c l u s i o n o f , the s t u d y . A regular r e v i e w of the a c t u a l study c o n d u c t , i n r e f e r e n c e to the planned conduct as d e t a i l e d i n the p r o t o c o l , p r o v i d e s a degree of c o n f i d e n c e t h a t the r e s u l t s o b t a i n e d w i l l be c o n s i s t e n t w i t h the study o b j e c t i v e s . That i s not to say t h a t minor d e v i a t i o n s can n o t , or should n o t , occur throughout the course of the s t u d y . The GLP r e g u l a t i o n s , however, r e q u i r e t h a t these d e v i a t i o n s be noted i n the f i n a l r e p o r t of the s t u d y . The study p r o t o c o l p r o v i d e s the "master" r e f e r e n c e f o r c o m p i l a t i o n of these d e v i a t i o n s . More than a n y t h i n g e l s e , the p r o t o c o l i s a working document. I t 1s the s i n g l e most i m p o r t a n t r e f e r e n c e f o r a d d r e s s i n g common q u e s t i o n s t h a t a r i s e d u r i n g the s t u d y . As a working document, i t i s necessary t h a t m u l t i p l e c o p i e s be a v a i l a b l e f o r use by members of the study team. Once the document i s f i n a l i z e d w i t h a l l the a p p r o p r i a t e s i g n a t u r e s , i t i s i m p o r t a n t t h a t i t not be r e l e g a t e d to a f i l e where i t i s not r e a d i l y a v a i l a b l e when needed. The Major Impacts of a W e l l - D e s i g n e d P r o t o c o l on Research A c t i v i t i e s One of the major impacts of a w e l l designed p r o t o c o l i s 1n the area of p r e s t u d y p l a n n i n g . I t 1s a common o c c u r r e n c e i n the p l a n n i n g of a s t u d y , t h a t a number of changes to the i n i t i a l or d r a f t p r o t o c o l w i l l be d i c t a t e d . In t h i s f a s h i o n , the p l a n n i n g process comes f u l l c i r c l e ; the d r a f t p r o t o c o l p r o v i d e s a p l a n n i n g document, and the p l a n n i n g process i t s e l f w i l l r e s u l t i n a f i n a l p r o t o c o l r e q u i r i n g few amendments or s i g n i f i c a n t d e v i a t i o n s .
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GOOD LABORATORY PRACTICES
A w e l l - d e s i g n e d p r o t o c o l a l s o produces e f f i c i e n c y of e f f o r t . S t u d i e s a r e n o r m a l l y budgeted to be run one time w i t h o u t e x t e n s i v e study r e s t a r t s or r e p e a t s . In a d d i t i o n to the washed personnel e f f o r t s from repeated s t u d i e s , s u b m i s s i o n d e a d l i n e s a r e o f t e n s e v e r e l y compromised, e i t h e r d e l a y i n g the i n t r o d u c t i o n of new p r o d u c t s or r i s k i n g the c o n t i n u e d r e g i s t r a t i o n of e x i s t i n g p r o d u c t s . A w e l l - d e s i g n e d study d e s c r i b e d i n an a c c u r a t e and thorough p r o t o c o l i s o f t e n the key t o an e f f i c i e n t and p r o d u c t i v e research e f f o r t . The p r o t o c o l i s the key item i n a v o i d a n c e of c o n f u s i o n and m i s u n d e r s t a n d i n g among the v a r i o u s p a r t i e s i n v o l v e d i n a s t u d y . A l t h o u g h t h i s i s of prime importance i n cases where two e n t i t i e s ( e . g . , the Sponsor and a c o n t r a c t l a b o r a t o r y ) a r e i n v o l v e d , the same p o t e n t i a l f o r problems e x i s t s w i t h i n an i n t e r n a l s t u d y . In some cases the p o t e n t i a l may be g r e a t e r w i t h an i n t e r n a l study because p o t e n t i a l communication d i f f i c u l t i e s a r e more r e a d i l y a n t i c i p a t e d and addressed then when d e a l i n g w i t h a c o n t r a c t l a b o r a t o r y g e o g r a p h i c a l l y f a r removed. Some recommended prestudy p r a c t i c e s t h a t i n v o l v e the use of the study p r o t o c o l w i l l be discussed l a t e r . A f i n a l impact of the p r o t o c o l i s p e r t i n e n c e . It allows for a d m i n i s t r a t i v e r e v i e w to ensure t h a t the s t u d y , as designed and d e s c r i b e d , p e r t a i n s to the needs a t hand; and t h a t the r e s u l t w i l l not o n l y meet the s t a t e d study o b j e c t i v e but a l s o f u l f i l l r e g u l a t o r y agency r e q u i r e m e n t s . Some F a c t o r s to C o n s i d e r i n the Design of the P r o t o c o l A w e l l designed p r o t o c o l presupposes a w e l 1 - d e s i g n e d s t u d y . It is p o s s i b l e to d e s i g n an a c c u r a t e and thorough p r o t o c o l , complete w i t h o b j e c t i v e , t h a t does not produce the r e q u i r e d i n f o r m a t i o n . The major problem i n t h i s case c o u l d be t h a t the parameters of the study would not c o m p l e t e l y encompass the needs o u t l i n e d i n agency guidelines. For example, a p p l i c a t i o n r a t e s f o r a f i e l d r e s i d u e study may not be p r o p e r l y s e l e c t e d , or d o s i n g l e v e l s or s a c r i f i c e i n t e r v a l s may not be proper f o r a study t h a t uses domestic or l a b o r a t o r y a n i m a l s . As mentioned p r e v i o u s l y , i f q u e s t i o n s e x i s t , the p r o t o c o l should be submitted to the a p p r o p r i a t e r e g u l a t o r y agency o f f i c e f o r r e v i e w . A m b i g u i t y - t h e r e should be no statements t h a t might r e q u i r e i n t e r p r e t a t i o n by the s c i e n t i f i c s t a f f d u r i n g conduct of the study. T h i s a p p l i e s p a r t i c u l a r l y to those f a c t o r s where numbers are c r i t i c a l . Examples a r e dose r a t e s or a p p l i c a t i o n l e v e l s , s a c r i f i c e or h a r v e s t i n t e r v a l s , and r e p l i c a t i o n r e q u i r e m e n t s . The p r o t o c o l , however, must a l s o r e t a i n a degree of f l e x i b i l i t y i n those areas where exact d e f i n i t i o n i s not needed or cannot be determined p r o s p e c t i v e l y . S p e c i f i c a t i o n s should not be so d e t a i l e d t h a t there i s no a l l o w a n c e f o r e q u i v a l e n t s u b s t i t u t i o n . Usually, i t i s not necessary to s p e c i f y brand names; however, there may be times when e x p e r i e n c e d i c t a t e s t h a t a s p e c i f i c brand or manufacturer are r e q u i r e d to perform a g i v e n f u n c t i o n . In those c a s e s , of c o u r s e , s p e c i f i c i t y i s not o n l y d e s i r a b l e but mandatory.
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In d e s i g n i n g or d e v e l o p i n g the study p r o t o c o l , 1t 1s w i s e to m i n i m i z e a s s u m p t i o n s . The f a c t t h a t s i m i l a r s t u d i e s have been done p r e v i o u s l y should not be used as a reason f o r not c l e a r l y d e f i n i n g the o p e r a t i o n s to be done. I t may be necessary to r e p l a c e some members of the study team s h o r t l y b e f o r e i n i t i a t i o n , and t h e i r a b i l i t y to r e v i e w and a s s i m i l a t e the necessary study d e t a i l s can be c r i t i c a l to s u c c e s s . In order to make the p r o t o c o l an e f f e c t i v e working document, i t i s d e s i r a b l e to keep statements as c o n c i s e and d i r e c t as possible. Avoid e x c e s s i v e v e r b i a g e . E x c e s s i v e use of d e s c r i p t i v e t e x t o n l y makes i t d i f f i c u l t to q u i c k l y f i n d the answer to q u e s t i o n s . The a p p r o p r i a t e use of w e l l - d e f i n e d and c l e a r l y spaced "headers" a l l o w s s t a f f members to l o c a t e the p e r t i n e n t s e c t i o n of a p r o t o c o l q u i c k l y w i t h o u t the need to read many pages. Many headings can be c o m p l e t e l y and a c c u r a t e l y d e f i n e d by a s i n g l e word or s h o r t phrase w i t h o u t the need f o r a complete s e n t e n c e . Another t e c h n i q u e t h a t can be employed to i n c r e a s e the ease of use of the p r o t o c o l i s to e s t a b l i s h a format and then keep the format as u n i f o r m as p o s s i b l e from one study to the n e x t . In t h i s way, members of the study team w i l l develop f a m i l i a r i t y w i t h i t and w i l l be a b l e to e a s i l y f i n d the a p p r o p r i a t e page or s e c t i o n of the p r o t o c o l f o r r e s o l u t i o n of q u e s t i o n s . An added b e n e f i t to m a i n t a i n i n g c o n s i s t e n t formats 1s found w i t h the people r e s p o n s i b l e f o r g e n e r a t i n g the documents. The time r e q u i r e d to do t h i s necessary p a r t of the o p e r a t i o n can be s i g n i f i c a n t l y reduced w i t h l e s s chance f o r e r r o r s . Some Recommended P r a c t i c e s 1n the Use of the Study
Protocol
One of the most u s e f u l p r a c t i c e s to e s t a b l i s h i n any f a c i l i t y i s the p r e - i n i t i a t i o n c o n f e r e n c e . The p r e - i n i t i a t i o n c o n f e r e n c e i s a f a c e - t o - f a c e meeting of a l l study team p a r t i c i p a n t s , e s s e n t i a l l y to do a l i n e - b y - l i n e r e v i e w of the p r o t o c o l . I t i s a t t h i s time t h a t q u e s t i o n s or c l a r i f i c a t i o n s should be brought f o r w a r d . During the p r e - i n i t i a t i o n c o n f e r e n c e the study team p a r t i c i p a n t s may d i s c o v e r t h a t m a t e r i a l i n the p r o t o c o l i s not a d e q u a t e l y d e f i n e d . The c o n f e r e n c e should be scheduled f a r enough ahead of study i n i t i a t i o n to a l l o w f o r p r e p a r a t i o n and d i s s e m i n a t i o n of a r e v i s e d p r o t o c o l b e f o r e study i n i t i a t i o n . In cases where the study i s to be preformed by a c o n t r a c t l a b o r a t o r y , a v i s i t by the Sponsor's study monitor a t the time of the p r e - I n i t i a t i o n c o n f e r e n c e i s h i g h l y desirable. I f t h i s i s not p o s s i b l e , the c o n f e r e n c e must be scheduled e a r l y enough to a l l o w Sponsor i n p u t i n t o p r o t o c o l modification. The person c h a i r i n g t h i s c o n f e r e n c e should make a p o i n t of n o t i f y i n g the study team of any o p e r a t i o n s t h a t a r e new or t h a t d i f f e r from the usual study p r o c e d u r e . Another p r a c t i c e t h a t has been found to be e x t r e m e l y u s e f u l i s the c l e a r d e s i g n a t i o n of the f i n a l p r o t o c o l . Many times a d r a f t p r o t o c o l w i l l go through s e v e r a l minor r e v i s i o n s b e f o r e i t i s finalized. T h i s can then r e s u l t i n study team members having a v e r s i o n of the p r o t o c o l t h a t does not i n c o r p o r a t e a l l of the f i n a l changes. One way to a v o i d t h i s p o t e n t i a l problem i s to p r i n t the f i n a l p r o t o c o l on a s p e c i f i c - c o l o r e d paper thereby d i s t i n g u i s h i n g i t from e a r l i e r v e r s i o n s . Any f u r t h e r changes are then made by
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amendments t h a t , when s i g n e d , a r e a l s o c o p i e d to the s p e c i f i c c o l o r e d paper and become an i n t e g r a l p a r t of the working document. As mentioned e a r l i e r , the p r o t o c o l should be r e a d i l y a v a i l a b l e to a l l p e r s o n n e l i n v o l v e d i n the study f o r p r i o r r e v i e w and f o r use d u r i n g the a c t u a l conduct of the s t u d y . General Comments I f t e c h n i q u e s a r e employed t h a t a r e new or n o n - r o u t i n e to some members of the study team, these need to be expanded on i n the protocol. As s t a t e d e a r l i e r , m i n i m i z e a s s u m p t i o n s . Do not i n c l u d e items t h a t a r e r o u t i n e i f they a r e c l e a r l y d e f i n e d by I n t e r n a l Standard O p e r a t i n g Procedures (SOPs). Reference s h o u l d , however, be made i n the p r o t o c o l t h a t these items a r e SOP d r i v e n . Examples might be s u b j e c t s such as s a f e t y p r o c e d u r e s , wearing a p p a r e l , and h a n d l i n g use and d i s p o s a l of radioisotopes. Do not i n c l u d e brand or t r a d e names u n l e s s necessary to the s u c c e s s f u l conduct of the s t u d y . Avoid a s i m p l e r e g u r g i t a t i o n of agency g u i d e l i n e s . The g u i d e l i n e s a r e t h e r e f o r a s s i s t a n c e i n d e s i g n i n g a study to meet c e r t a i n s c i e n t i f i c requirements. The p r o t o c o l and subsequent study should be designed u s i n g s c i e n t i f i c judgment a p p r o p r i a t e to the s p e c i f i c t e s t m a t e r i a l to be i n v e s t i g a t e d . Ensure t h a t the p r o t o c o l meets the requirements f o r compliance w i t h GLPs, and s c i e n t i f i c a l l y addresses g u i d e l i n e requirements. I t 1s a l s o i m p o r t a n t to be aware t h a t i n some cases more r e c e n t l y p u b l i s h e d r e p o r t i n g addenda and s t a n d a r d e v a l u a t i o n procedures c o n t a i n i n f o r m a t i o n c r i t i c a l to proper study d e s i g n , and t h e r e f o r e , p r o t o c o l developement. I f t h e r e i s a q u e s t i o n , check w i t h the r e g u l a t o r y agency. I t can be seen t h a t the p r o t o c o l i s much more than a document n e c e s s a r y to meet an a d m i n i s t r a t i v e r e q u i r e m e n t . Proper development and deployment a r e the keys to p r o v i d i n g a v a l i d scientific investigation. O u t s i d e of a w e l l - d e s i g n e d s t u d y , t h e r e i s no s i n g l e document or f a c t o r t h a t can be as c r u c i a l to the success of a study as the p r o t o c o l .
Literature Cited 1. 40 CFR 160.120. 2. Webster's Third New International Dictionary, Babcock Gove, P. Ed., Merriam Webster, Inc.; Springfield, Massachusetts 1986; p. 1824. R E C E I V E D January 29, 1988
