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CLINICAL TRIALS
SECOND EDITION
This page intentionally left blank
CLINICAL TRIALS
Study Design, Endpoints and
Biomarkers, Drug Safety,
and FDA and ICH Guidelines
SECOND EDITION

Tom Brody, Ph.D.

AMSTERDAM • BOSTON • HEIDELBERG • LONDON

NEW YORK • OXFORD • PARIS • SAN DIEGO
SAN FRANCISCO • SINGAPORE • SYDNEY • TOKYO
Academic Press is an imprint of Elsevier
Academic Press is an imprint of Elsevier
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525 B Street, Suite 1800, San Diego, CA 92101-4495, USA
50 Hampshire Street, 5th Floor, Cambridge, MA 02139, USA
The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, UK
Second Edition 2016
Copyright r 2016, 2012 Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or any information storage and retrieval system, without permission in writing from
the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our
arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be
found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any
information, methods, compounds, or experiments described herein. In using such information or methods they should
be mindful of their own safety and the safety of others, including parties for whom they have a professional
responsibility.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability
for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise,
or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
ISBN: 978-0-12-804217-5
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Acquisition Editor: Kristine Jones
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Dedication

To Shideh and Dawnia

This page intentionally left blank
 Contents

Acknowledgments xv 4. Inclusion/Exclusion Criteria, Stratification,

Preface xvii and Subgroups—Part I
Introduction xxiii I The Clinical Study Protocol is a Manual that
Abbreviations and Definitions xxvii Provides the Study Design 83
II Biochemistry of Drug Resistance 97
Biographies xxxi III FDA’s Warning Letters and Inclusion/Exclusion
Criteria 102
IV Subgroups and Subgroup Analysis 103
V FDA’s Decision-Making Processes in Evaluating
1. Origins of Drugs
Stratification and Subgroups 108
I Introduction 1 VI Concluding Remarks 113
II Structures of Drugs 2
III The 20 Classical Amino Acids 8 5. Inclusion/Exclusion Criteria, Stratification,
IV Animal Models 11
V Estimating Human Dose from Animal Studies 21
and Subgroups—Part II
VI Origin of Drugs that are Biosimilars 24 IIntroduction 115
VII Origin of Drugs that are Orphan Drugs 25 IIStaging 115
VIII Summary 29 IIIStaging Systems for Various Cancers 121
IV The Will Rogers Phenomenon 128
2. Clinical Trial Design V Other Sources of Artifacts in Data from Clinical
Trials 131
I Introduction to Regulated Clinical Trials 31
VI Concluding Remarks 131
II Study Design 35
III The Study Schema 36
IV Further Concepts in Clinical Trial Design 58 6. Blinding, Randomization, and Allocation
V FDA’s Decision-Making Processes Regarding Dose
Modification and Discontinuation 65 I Introduction 133
VI Amendments to the Clinical Study Protocol 66 II Logistics of Keeping Track of Study Subjects 136
VII Concluding Remarks 68 III Blocked Randomization 142
IV Clinical Study Protocol Randomization
3. Run-in Period Instructions 144
V Instructions for Unblinding 145
I Introduction 69 VI Summary of Unblinding 147
II FDA’s Decision-Making Processes in Evaluating Run- VII FDA Warning Letters 148
in Period 78 VIII Interactive Voice Response Systems 149
III Concluding Remarks 80 IX Concluding Remarks 153

vii
viii CONTENTS

7. Placebo Arm as Part of Clinical IX Calculating the P Value—A Working

Trial Design Example 216
X Summary 222
I Introduction 155 XI Theory Behind the Z Value and the Table
II Hawthorne Effect 156 of Areas in Tail of the Standard Normal
III The No-Treatment Arm 157 Distribution 222
IV Physical Aspects of the Placebo 157 XII Statistical Analysis by Superiority Analysis
V Active Placebo 158 versus by Noninferiority Analysis 223
VI Subjects in the Placebo Arm May Receive
Best Supportive Care or Palliative Care 158 10. Biostatistics—Part II
VII Clash Between BSC and the Endpoint of DR. JENNIFER ELDER, PH.D.
HRQoL 160
VIII Ethics of Placebos 160 I Introduction 227
IX FDA’s Decision-Making Process in Evaluating II Discussions that Impact Sample Size
the Placebo Arm 165 Determination 227
X Standard of Care 169 III Statistical Terms Commonly Used in Sample Size
Calculations 230
IV Null and Alternative Hypotheses 230
8. Intent-to-Treat Analysis versus Per V Degree of Certainty: Alpha (α) and Beta (β) 231
Protocol Analysis VI Statistical Methods for Determining Trial
Size 231
I Introduction 173
VII Continuous Variables: Testing the Difference
II ITT Analysis Contrasted With PP Analysis 176
Between Two Means 231
III Disadvantages of ITT Analysis 179
VIII Changes in Sample Size Assumptions can Yield
IV Run-In Period, as Part of the Study
Dramatic Changes to Sample Size 234
Design, is Relevant to ITT Analysis and
IX Changing Assumptions About Alpha (α)
PP Analysis 180
or Beta (β) 235
V Summary 180
X Changing Assumptions About Theta (θ) 236
VI Hypothetical Example Where Study Drug and
XI Binary Variables: Testing the Difference Between
Control Drug Have the Same Efficacy 181
Two Proportions 237
VII Modified ITT Analysis 181
XII Time to Event Variables: Testing for
VIII Start Date for Endpoints in Clinical Trials 192
Differences Between Two Groups Using the
IX FDA’s Decision-Making Processes, Relating
Logrank Test 239
to ITT Analysis and PP Analysis 194
XIII Binary Variable: Testing for Equivalence
X Concluding Remarks 200
of Two Proportions 241
XIV Other Helpful Considerations 243
9. Biostatistics—Part I XV Writing a Sample Size Section of a Clinical
Study Protocol 244
I Introduction 203
II Definitions and Formulas 208 11. Introduction to Endpoints
III Data from the Study of Machin and
Gardner 209 I FDA’s Guidance for Industry 247
IV Data Used for Constructing the Kaplan
Meier
Plot are from Subjects Enrolling at Different 12. Oncology Endpoint—Objective Response
Times 210
V Sample versus Population 211 I Introduction to Endpoints in Oncology Clinical
VI What can be Compared 212 Trials 253
VII One-Tailed Test versus Two-Tailed Test 212 II Studies Characterizing an Association Between
VIII P Value 214 Objective Response and Survival 262
 CONTENTS ix
III Avoiding Confusion When Using Objective XI Summary 298
Response as an Endpoint 263 XII Thymidine Phosphorylase as a Biomarker for
IV FDA’s Decision-Making Process in Evaluating Survival—The Meropol Study 299
Objective Response 266 XIII Drug Combinations that Include
V Concluding Remarks 268 Capecitabine 300
XIV Methodology Tip—Do Changes in mRNA
13. Oncology Endpoints: Overall Survival Expression Result in Corresponding Changes
and Progression-Free Survival in Expression of Polypeptide? 300
XV Concluding Remarks 301
I
Introduction 269
II
Advantages of PFS Over Overall Survival 272 15. Oncology Endpoint: Disease-Free Survival
III
Advantages of Overall Survival Over PFS 274
IVGuidance From Clinical Trials on Using I Introduction 303
Endpoints 275 II Difference Between DFS and PFS 304
V Concluding Remarks 287 III Ambiguity in the Name of the Endpoint,
“DFS” 304
14. Oncology Endpoints: Time to Progression IV Disease-Free Survival Provides Earlier Results on
Efficacy Than Overall Survival—The Add-On
I Introduction 289 Breast Cancer Study of Romond 305
II Agreement of Results from Objective Response, V Disease-Free Survival as an Endpoint in the
TTP, and Overall Survival—The Paccagnella Analysis of Subgroups—The Add-On Breast
Study 290 Cancer Study of Hayes 307
III Can the Value for PFS be Less Than the Value for VI Neoadjuvant Therapy versus Adjuvant Therapy
TTP? 290 for Rectal Cancer—The Roh Study 308
IV Data on the Endpoint of TTP can be Used to VII Where Efficacy of Two Different Treatments
Gain FDA-Approval 291 is the Same, Choice of Treatment Shifts to the
V TTP may be the Preferred Endpoint Where, Once Treatment that Improves Quality of Life—
the Trial is Concluded, Patients Receive The Ring Study 309
Additional Chemotherapy—The Park Study 291 VIII DFS and Overall Survival are Useful Tools for
VI The Endpoint of TTP may be Preferred Over Testing and Validating Prognostic Biomarkers—
Survival Endpoints, Where Deaths Result from The Bepler Study 310
Causes Other Than Cancer—The Llovet IX FDA’s Decision-Making Process in Evaluating
Study 292 the Endpoint of DFS 311
VII The Endpoint of Overall Survival may be Preferred X Summary 312
Over Objective Response or Over TTP, Where the
Drug Is Classed as a Cytostatic Drug—The Llovet 16. Oncology Endpoint: Time to
Study 295 Distant Metastasis
VIII TTP may Show Efficacy, Where the Endpoint of
Overall Survival Fails to Show Efficacy, Where the I Introduction 313
Number of Subjects is Small—The McDermott II TDM Data are Acquired Before Overall Survival
Study 296 Data are Acquired—The Wee Study 314
IX TTP may Show Efficacy, Where the Endpoint of III Time to Distant Metastasis Data can Reveal a
Overall Survival Failed to Show Efficacy, Where Dramatic Advantage of the Study Drug, in a
the Duration of the Trial was Too Short—The Situation Where Overall Survival Fails to Show
Cappuzzo Study 297 Any Advantage—The Roach Study 315
X Methodology Tip—Advantage of Using an IV Use of a Gene Array as a Prognostic Factor for
Endpoint that Incorporates a “Median” Breast Cancer Patients, Using the Endpoint of
Time 298 TDM—The Loi Study 317
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x CONTENTS

V Use of Micro-RNA Expression Data as a 20. Endpoints for Immune Diseases

Prognostic Factor for Breast Cancer
Patients—The Foekens Study 317 I Introduction 421
VI Biology of miRNA 318 II Subsets of Multiple Sclerosis 421
VII Concluding Remarks 319 III FDA’s Decision-Making Process in Evaluating
Endpoints for Multiple Sclerosis 434
17. Neoadjuvant Therapy versus IV Concluding Remarks 436
Adjuvant Therapy
IAdvantages of Neoadjuvant Therapy 323 21. Endpoints for Infections
IIAdvantages of Adjuvant Therapy 326
I Introduction 437
IIITwo Meanings of the Word Adjuvant 327
II Clinical and Immunological Features of HCV
IV Summary of Neoadjuvant Versus Adjuvant
Infections 437
Therapy in Cancer 328
III Acute HCV versus Chronic HCV 438
V Induction Therapy versus Maintenance
IV Drugs Against HCV 439
Therapy in Autoimmune Diseases 328
V Immune Responses Against
VI Conclusions 330
HCV 442
VI Kinetics of HCV Infections 443
18. Hematological Cancers VII Responders versus Nonresponders 446
VIII Endpoints in Clinical Trials Against
I Introduction 331
HCV 447
II Myelodysplastic Syndromes 348
IX Concluding Remarks 450
III Summary 354
IV Cytogenetics of Hematological
Cancers 354
V Chromosomal Abnormalities in Solid
22. Health-Related Quality of Life Tools—
Tumors 363 Oncology
VI Endpoints in Hematological
I Introduction 451
Cancers 364
II Summary 453
VII Cytogenetics as a Prognostic
III HRQoL Tools Take on Increased Importance
Marker—The Grever Study of CLL 367
When Capturing Data on Adverse Events,
VIII Minimal Residual Disease 368
or in Trials on Palliative Treatments 454
IX Confluence of Cytogenetics and Gene
IV Scheduling the Administration of HRQoL
Expression 375
Tools 455
X Concluding Remarks 375
V HRQoL Tools in Oncology 455
VI Decisions on Counseling; Decisions on
19. Biomarkers Chemotherapy versus Surgery 467
I Introduction 377 VII Concluding Remarks 467
II Methodology Tip—Microarrays 390
III C-Reactive Protein 394
IV Biomarkers—Specialized Topics 400 23. Health-Related Quality-of-Life
V Exploring New Types of Biomarkers 403 Tools—Immune Disorders
VI Single Nucleotide Polymorphisms 408
VII Validating Biomarkers 411 I Introduction 469
VIII Biomarker Validation from FDA II Short Form SF-36 Questionnaire 469
Submissions for In Vitro Diagnostics III HRQoL Instruments Specific for Multiple
Tests 413 Sclerosis 473
IX Concluding Remarks 418 IV Concluding Remarks 477
 CONTENTS xi
24. Health-Related Quality-of-Life Tools— VII MOA of Diseases With an Immune
Infections Component 574
VIII Immune System Pathology in Inflammatory
I Introduction 479 Disorders 579
II HRQoL Tools With Chronic HCV 480 IX Cells of the Immune System 582
X Drugs that Modulate the Immune System 584
25. Drug Safety XI Immunology can be Organized as Pairs of
Concepts 590
I Introduction 483 XII Concluding Remarks 594
II Safety Definitions 492
III QT Interval Prolongation 502 27. Mechanism of Action—Part II (Cancer)
IV Stevens
Johnson Syndrome 514
V Idiosyncratic Drug Reactions 516 I Introduction 595
VI FDA’s Decision-Making Process in Evaluating II Immune Evasion 607
Adverse Events 518 III Concluding Remarks 609
VII Drug-Induced Liver Injury 519
VIII Assessing Causality 522 28. Mechanism of Action—Part III (Immune
IX Paradoxical Adverse Drug Reactions 525 Disorders)
X Capturing Adverse Events 529
XI FDA’s Warning Letters About Failure to Report I Introduction 611
SAEs 535 II Detailed Mechanism of Action of Multiple
XII Drugs that Create Risk for Infections 538 Sclerosis 616
XIII FDA’s Decision-Making Process on Adverse III Animal Models of Multiple Sclerosis 624
Events that Appear Irrelevant to the Study IV Etiology and Mechanisms of Multiple
Drug 541 Sclerosis 625
XIV Postmarketing Reporting of Adverse V Diagram of Multiple Sclerosis Mechanism 628
Events 542 VI Additional Mechanisms of Action in Multiple
XV Risk Minimization Tools 546 Sclerosis 629
XVI FDA’s Decision-Making Process in Evaluating VII Concluding Remarks 633
Risk Minimization Tools 553
XVII European Union’s Risk Management Tools 557 29. Mechanisms of Action—Part IV
XVIII Summary 558 (Infections)
XIX Patient-Reported Outcome 558
XX Summary of Reporting Systems 560 I Introduction 635
XXI Data and Safety Monitoring Committee 561 II HCV Infections 635
XXII Concluding Remarks 568 III Life Cycle of HCV 637
IV Initiating Biosynthesis of the HCV
26. Mechanism of Action of Diseases and Polypeptide 638
Drugs—Part I V Membranous Web and Lipid Droplet 638
VI NS3/4A Protease 639
IIntroduction 569 VII NS5A—HCV’s Recruiting and Assembly
IIMOA and the Package Insert 571 Protein 639
IIIMOA and Surrogate Endpoints 571 VIII NS5B—HCV’s RNA Polymerase 641
IV MOA and Expected Adverse Drug Reactions 572 IX E1 and E2—HCV’s Envelope Proteins 642
V FDA’s Warning Letter Regarding Assessing Safety X Core Protein of HCV 642
of the Study Drug, According to Its Membership in XI Innate Immune Response Against HCV 643
a Particular Class of Drugs 572 XII Chronic Inflammation 645
VI MOA and Drug Combinations 573 XIII Oncogenes and Growth Factors 647
xii CONTENTS

XIV Acquired Immune Response Against HCV 650 Drug Manufacture, and Guidance for Responding
XV Concluding Remarks 661 to FDA’s Complaints 721
V FDA’s Warning Letter Distinguished from FDA’s
30. Consent Forms Form 483 Notice 722
VI Warning Letter on Corrective Responses, by
I Introduction 663 Sponsor, for a Tumor Clinical Trial 725
II Sources of the Law in the United States 666 VII Definitions 726
III Guidance for Industry 666 VIII Failure of Sponsor to have an FDA-approved
IV Distinction Between Stopping Treatment and IND 727
Withdrawing From the Study 668 IX Institutional Review Board 729
V Ethical Doctrines 668 X Consent Forms 745
VI The Case Law 669 XI Data Monitoring Committee (DMC) 746
VII Basis for Consent Forms in the CFR 669 XII Protocol Deviations 749
VIII Summary 671 XIII Clinical Hold 754
IX Examples of Contemporary Consent Forms 671 XIV Concomitant Medications 755
X Ethical Issues Specific to Phase I Clinical Trials in XV Inclusion/Exclusion Criteria 757
Oncology 680 XVI Drug Accountability, Drug Storage, Drug
XI FDA’s Warning Letters 680 Dispensing, and Record Keeping 757
XII Decision Aids 683 XVII Withdrawal of Subjects From the Clinical
XIII Concluding Remarks 686 Trial 762
XVIII Contract Research Organizations 766
31. Package Inserts XIX Case Report Forms 769
XX Investigator’s Brochure 772
I Introduction 689 XXI Off-Label Uses 772
II Drug
Drug Interactions 695 XXII Conclusion 778
III FDA’s Decision-Making Process in Evaluating
Drug
Drug Interactions 701 33. Regulatory Approval
IV Summary of Drug
Drug Interactions 706
V Animal Toxicity Data and the Package I Origins of the Federal Food, Drug and Cosmetic
Insert 706 Act and Its Amendments 781
VI Summary 708 II Federal Food, Drug and Cosmetic Act of
VII Brand Names, Chemical Names, Packaging 708 1938 782
VIII Ambiguous Writing on Package Inserts 711 III Drug Amendments Act of 1962 784
IX Package Insert May Protect Manufacturer From IV FDA Modernization Act of 1997 and Phase IV
Liability 712 Clinical Trials 784
X Package Insert Compared With Consent V History of European Medicines Agency 785
Form 716 VI International Conference on
XI Relation Between Package Inserts to the Standard Harmonisation 787
of Care, and to Off-Label Uses 716 VII History of the Medicines and Healthcare
XII Concluding Remarks 718 Products Regulatory Agency 788
VIII Outline of Regulatory Approval in the United
32. Warning Letters States 789
IX Investigational New Drug 790
I Introduction 719 X IND and the Common Technical
II List of Topics 720 Document 793
III Warning Letter Describing Authority of FDA XI Institutional Review Board 796
Inspectors 720 XII Timeline of FDA Approval 798
IV Anecdotal Description of an FDA Inspection, XIII Special Protocol Assessment 803
FDA’s Requirements for Record Keeping During XIV Target Product Profile 804
 CONTENTS xiii
XV Company Core Data Sheet 805 III History of Patenting 832
XVI Accelerated Approval 806 IV Outline of the Patenting Process 834
XVIIRefuse to File 808 V Types of Patent Documents 836
XVIIIClinical Hold 810 VI Organization of Information in a Patent 837
XIXExemplary Account of FDA Timeline, After VII Time-line for Patenting 839
Submission of NDA or BLA 811 VIII Provisional Patent Applications 841
XX FDA Approval Letter 812 IX Sources of the Law for Patenting 842
XXI FDA Feedback at Time of Issue of the FDA X Intersections Between the FDA Review Process
Approval Letter 814 and Patents 845
XXII Processes of Administring Clinical Trials 820

34. Patents Index 847

I Introduction 829
II Services Provided by the Patent Attorney or
Agent 829
This page intentionally left blank
 Acknowledgments

I thank Julia Haynes, Molly McLaughlin, guidance on run-in periods. I am most grateful
Kristine Jones, and April Graham of Elsevier, to David Cella, Barbara Vickrey, Andrea
Inc., for their devotion and expertise in the (Andy) Trotti, and Jinny Tavee, for help on
editing and production phases of this book. health-related quality-of-life (HRQoL) instru-
I am indebted to Dr Waihei A. Chu, ments. I thank Jeffrey A. Cohen for his detailed
PharmD, for his guidance in the field of regula- responses to my questions on multiple sclerosis.
tory writing. In his own words: I thank the Also, I am grateful to Ching-Hon Pui, James B.
following people for answering specific ques- Nachman, Eric E. Hedrick, Stacey L. Berg, and
tions during the course of this project. Nearly Tanja Hartmann for their insights regarding
all of these persons are physicians and principal the leukemias. I acknowledge Margaret von
investigators in clinical trials in oncology, multi- Mehren for information on gastrointestinal stro-
ple sclerosis, and infectious diseases. Many of mal tumors. I thank Bruce A. Roe for modifying
these persons are thought-leaders in the field of my diagram of the Philadelphia chromosome,
study design or are tenured professors in medi- and I thank Adele K. Fielding for further guid-
cal schools. I thank Masha Hareli, Amit Bar-Or, ance on this chromosome. I am also grateful to
and Olaf Steve, for authoritative guidance Jake Liang and Robert E. Lanford for explaining
on multiple sclerosis. I thank Christina Slover relations between IFN-alpha and IFN-gamma,
for guidance on drug
drug interactions. I am as they apply to hepatitis C virus.
grateful to Patrick Archdeacon, Patricia Harley, I thank Martin E. Stryjewski, Jonathan S.
Michelle Eby, and Joette M. Meyer, all of the Berek, James Cassidy, Olivier Leroy, and
FDA, for information on various aspects of the Michael E. Pichichero, for help on per protocol
FDA approval process. I am grateful to Peter C. analysis and intent-to-treat analysis. I thank
Raich for granting permission to reproduce Lawrence Rubinstein, Thomas G. Roberts Jr,
his consent forms, and I thank David Cella for Thomas J. Lynch, Murray D. Norris, Bradley
sending me these forms. I thank Marc Buyse, R. Prestidge, and Igor Sherman, for informa-
Tomasz Burzykowski, Daniel J. Sargent, Gerold tion on subgroups or on inclusion/exclusion
Bepler, Sally Stenning, John Hainsworth, criteria.
Sanjiv S. Agarwala, Clifford A. Hudis, Axel I am grateful to Peter J. Barrett-Lee for infor-
Grothey, Wen-Jen Hwu, Keith Wheatley, Joseph mation on drug safety. I thank Anthony Viera
A. Sparano, Elizabeth A. Eisenhauer, Miguel for information on randomization. I thank
Martin, and Linda Colangelo, for their expert Syed Y. Zafar and Richard L. Schilsky for their
guidance on endpoints. I am deeply grateful expertise on best supportive care and palliative
to Frank Worden and Bruce E. Johnson for care. I acknowledge Karen Mosher for her

xv
xvi ACKNOWLEDGMENTS

expertise on decision aids, as it relates to I thank Tiiamari Pennanen for information on

consent forms. I am grateful to Elizabeth B. the history of the European Medicines Agency,
Andrews, Balall Naeem, Michael Klepper, and and Dominic Stevenson and Sarah Heffer for
Barry D.C. Arnold, for their knowledge advice on the Yellow Card. For the first edition
regarding the CIOMS I form. I thank Patricia of this book, I thank Jenna Elder and Harvey
Mozzicato for her time answering questions Motulsky for reviewing the draft chapter on
about the MedDRA terminology. Moreover, biostatistics.
 Preface

This book is a pharmacology textbook. It can administering the study drug, and collecting
serve a handbook for all personnel involved in data on efficacy and safety (1).
regulated clinical trials, including employees at Also, to ensure that the book is a lively
the US Food and Drug Administration (FDA) and compelling textbook and handbook, the
and the European Medicines Agency (EMA). text provides the history of consent forms
The book quotes extensively from comments using the example of Walter Reed’s yellow
by FDA reviewers, which are published on the fever study, the history of the FDA and the
FDA’s website at the time that the FDA grants EMA, background information on assay meth-
approval to a drug. In other words, along ods in biochemistry and immunology, and
with the FDA’s approval letter, the FDA also quotations from published courtroom opinions
publishes its Medical Reviews, Clinical Reviews, relating to clinical trials.
Pharmacology Reviews, and other documents, This book fulfills various unmet needs, as
each of which includes comments from various detailed below.
FDA personnel.
The content of these reviews closely tracks
the Sponsor’s Integrated Summary of Safety (ISS), THE STUDY SCHEMA AND
submitted as part of an NDA or BLA. It is there- STUDY DESIGN
fore the case that this book provides an accurate
representation of what the FDA looks for (and The best way to communicate trial design is
complains against), during its review of submis- with a flow chart or table called the schema.
sions from a Sponsor’s phase II and phase III The author observed that the schema is
clinical trials. In all, the author made use of the rarely detailed in any explicit way by books or
Medical Reviews and Clinical Reviews that accom- journal articles. Unfortunately, books on clinical
panied about 75 of the FDA’s approval letters. trials generally refrain from disclosing much on
In this book, the words “Sponsor” and trial design, for example, regarding the various
“investigator” are sometimes used inter- goals of the run-in period, or regarding decision
changeably, though it should be noted that the trees that may modify drug dosing during the
Sponsor is the party that initiates a clinical course of an ongoing trial. This book provides a
trial, while an investigator is the party that thorough introduction to study design, includes
actually does the work, such as the work of many representative diagrams of the study
writing the Clinical Study Protocol and other schema, and details several distinct reasons for
FDA-submissions, enrolling study subjects, including a run-in period.

1
American Academy or Pediatrics Policy Statement. Off-label use of drugs in children. Pediatrics 2014;133:563
7.

xvii
xviii PREFACE

INTENT-TO-TREAT ANALYSIS This book fulfills an unmet need by providing

AND PLACEBOS a more detailed account on how to choose the
most appropriate oncology endpoint, and on
Second, the authors observed that other when to refrain from using a given endpoint.
aspects of clinical trials are inadequately
described in textbooks, for example, they were
covered only by a short paragraph. These DIAGNOSTIC TESTS
aspects include intent-to-treat (ITT) analysis,
modified ITT (mITT) analysis, and per protocol Fourth, this book takes care to integrate
(PP) analysis. ITT analysis is a term that is diagnostic tests with each disease. What are
almost universally used in clinical trials, but described are disability status questionnaires,
the available textbooks on clinical trial design HRQoL questionnaires, blood counts, flow
typically fail to describe ITT analysis, mITT cytometry, immunoassays, polymerase chain
analysis, or PP analysis, and how to choose reaction (PCR), microarrays, and magnetic res-
between these three types of data analysis. onance imaging (MRI). Moreover, this book
This book contains an entire chapter on ITT, provides an introduction to the process of
mITT, and PP analyses. It is also the case that FDA approval for diagnostics tests.
most or all books on clinical trials fail to
include any organized account of placebos.
This book has an entire chapter on placebos. MECHANISM OF ACTION
Fifth, the book describes the mechanisms of
HOW TO CHOOSE ENDPOINTS various diseases and the mechanisms of action
of various drugs. These mechanisms are inte-
Third, definitions of endpoints used in grated into the context of clinical trials, in com-
oncology clinical trials are frequently disclosed mentary demonstrating how the mechanism of
in the available textbooks, but unfortunately, action can influence the inclusion/exclusion
textbooks generally fail to state the advantages criteria, warnings on consent forms, and infor-
of any given endpoint over another, and fail to mation on package inserts. This book also
state situations where a particular endpoint describes how the mechanism of action can
gives ambiguous information or where an end- influence study design, that is, the particular
point cannot be used. These oncology end- combination and timing of administered drugs.
points include objective response rate (ORR), The book reveals that a knowledge of the mech-
overall survival (OS), progression-free survival anism of action can encourage regulatory agen-
(PFS), time to progression (TTP), time to dis- cies to allow a clinical trial to be initiated.
tant metastasis (TDM), disease-free survival
(DFS), 6-month PFS, and health-related quality
of life (HRQoL). The FDA’s Guidance for STANDARDS
Industry (2) provides a fine introduction to
these endpoints, but refrains from detailing, Sixth, the text emphasizes the role of vari-
for example, situations where any given end- ous standards that apply to clinical trials.
point is likely to be unreliable or unusable. These standards include criteria for measuring
2
U.S. Department of Health and Human Services. Food and Drug Administration. Guidance for industry. Clinical
trial endpoints for the approval of cancer drugs and biologicals; 2007 (19 pp.).
 PREFACE xix
physical fitness, such as the Eastern These two instruments are the FDA’s Form 483
Cooperative Oncology Group (ECOG) score, notices and the FDA’s Warning Letters.
Karnofsky score, and the Kurtzke Expanded Quotations from the FDA’s Warning Letters
Disability Status Scale (EDSS) score, criteria for are included at various points in this book. A
measuring tumor size and number (Response sustained account of the FDA’s Warning
Evaluation Criteria in Solid Tumors, RECIST Letters, as well as a description of their rela-
criteria), and criteria for staging tumors tion to the FDA’s Form 483, appears in one of
[Tumor Node Metastasis (TNM) staging; the last chapters in this book.
Dukes’ staging]. The text provides a warning
about potential confusion that can arise, when
two different sets of standards are applied to
one disease. This warning takes the form of a CLINICALTRIALS.GOV AND
narrative on the Will Rogers Phenomenon. OTHER REGISTRIES FOR
The administrative law, and guidance docu- CLINICAL TRIALS
ments from regulatory agencies, constitute
another type of standard. These standards ClinicalTrials.gov is a registry of clinical
are also revised from time to time. The trials, developed by the FDA and NIH, and
ICH Guidelines and the FDA’s Guidance for first operational in 2000 (3). In 2007, the Food
Industry documents constitute a recurring and Drug Administration Amendments Act
theme in this textbook. (FDAAA) imposed the requirement that spon-
sors of clinical trials register and report sum-
mary results at www.ClinicalTrials.gov (4). As
of Jan. 2009, ClinicalTrials.gov had more than
FDA’S WARNING LETTERS 67,000 registered trials (5). About one-quarter
of these trials are sponsored by pharmaceutical
This textbook uses the FDA’s Warning companies. Zarin et al. (6) describe the content
Letters as a source material. The FDA issues of this website.
Warning Letters to manufacturers of drugs, The European Union provides the EU
medical devices, foods, and dietary supple- Clinical Trials Registry, which contains infor-
ments. Generally, these letters include com- mation on clinical trials that were conducted in
plaints about a company’s failure to comply the European Union, starting after May 1, 2004.
with one or more sections of Title 21 of the This Registry contains information that was
Code of Federal regulations. The FDA uses entered by Sponsors of clinical trials. The infor-
two different instruments for complaining mation, which appears in the EudraCT data-
about failures to follow various sections of base, can be searched by the public, and the
Title 21 of the Code of Federal Regulations, for information includes the trial design, Sponsor,
the situation where the failures are detected medicine, therapeutic area, summary of results,
during an FDA inspection of the Sponsor’s and whether the trial is merely authorized, or
clinical facilities or manufacturing facilities. is ongoing or complete. EudraCT is provided
3
Steinbrook R. Public registration of clinical trials. New Engl. J. Med. 2004;351:315
7.
4
Anderson ML, et al. Compliance with results reporting at ClinicalTrials.gov. New Engl. J. Med. 2015;372:1031
9.
5
Wood AJ. Progress and deficiencies in the registration of clinical trials. New Engl. J. Med. 2009;360:824
30.
6
Zarin DA, Tse T, Williams RJ, Califf RM, Ide NC. The ClinicalTrials.gov results database—update and key issues.
New Engl. J. Med. 2011;364:852
60.
Visit https://textbookfull.com
now to explore a rich
collection of eBooks, textbook
and enjoy exciting offers!
xx PREFACE

in 24 different languages. The step at which A similar service for ongoing and completed
the user can select the language, is provided on studies is available from the International
the world wide web at: www.eudrapharm.eu/ Federation of Pharmaceutical Manufacturers &
eudrapharm/. Any member of the public can Associations (IFPMA) (http://www.ifpma.org/
input query terms such as the trade name or clinicaltrials) (11).
the chemical name of the drug. The FDA Amendments Act, enacted in Sep.
Registries that are not affiliated with any 2007. Congress expanded the requirements
governmental agency include, for example, for sponsors and investigators to post informa-
the TYSABRI Pregnancy Exposure Registry. This tion about clinical trials, including selected
registry is identified on the package insert aspects of trial results, on ClinicalTrials.gov (12).
for Tysabri, which states that, “[i]f a woman Requirements relevant to registration are set
becomes pregnant while taking TYSABRI, con- forth in Section 801 of this Act. Section 801 man-
sider enrolling her in the TYSABRI Pregnancy dates registration on ClinicalTrials.gov of all
Exposure Registry by calling 1-800-456-2255” (7). new controlled clinical investigations (other
Each study has a unique registration number. than phase I) of drugs, biologics, and devices
Another registry used for clinical trials is the subject to regulations by the FDA. This applies
International Standard Randomised Controlled to research for any condition, regardless of spon-
Trial Number (ISRCTN) (8). Where a clinical sor type, for example, industry, government, or
trial is conducted in only one country, study academic (13). New clinical studies must be reg-
information should be entered only in one regis- istered within 21 days after the first patient is
ter, to avoid duplication and confusion. enrolled, where updates of the registry informa-
However, companies that perform international tion must occur at least every 12 months.
clinical studies may be required to register their Recruitment status should be updated within 30
trial in a national clinical study register, as days of any change. Dec. 2007 was the due date
well as in an international clinical study register to start registering new studies or updating all
(9). The WHO International Clinical Trials required information fields for ongoing studies
Registry Platform (ICTRP) provides a search (14,15). One of the FDA’s Guidance for Industry
portal to locate trials from many primary regis- documents, Providing Regulatory Submissions in
tries worldwide (http://www.who.int/ictrp/ Electronic Format, provides guidance for register-
en/). This registry began operating in 2005 (10). ing your clinical trial (16).

7
TYSABRI (natalizumab) Injection Full Prescribing Information. Biogen IDEC, Inc.; January 1, 2012 (32 pp.).
8
Thomas KB, Tesch C. Clinical trial disclosure-focusing on results. The Write Stuff. 2008;17:70
3.
9
Thomas KB, Tesch C. Clinical trial disclosure-focusing on results. The Write Stuff. 2008;17:70
3.
10
Sim I. Trial registration for public trust: making the case for medical devices. J. Gen. Intern. Med. 2008;23
(Suppl. 1):64
8.
11
Thomas KB, Tesch C. Clinical trial disclosure-focusing on results. The Write Stuff. 2008;17:70
3.
12
Wood AJ. Progress and deficiencies in the registration of clinical trials. New Engl. J. Med. 2009;360:824
30.
13
Thomas KB, Tesch C. Clinical trial disclosure-focusing on results. The Write Stuff. 2008;17:70
3.
14
Thomas KB, Tesch C. Clinical trial disclosure-focusing on results. The Write Stuff. 2008;17:70
3.
15
Wood AJJ. Progress and deficiencies in the registration of clinical trials. New Engl. J. Med. 2009;360:824
30.
16
U.S. Department of Health and Human Services. Food and Drug Administration. Providing regulatory
submissions in electronic format—drug establishment registration and drug listing; May 2009 (13 pp.).
 PREFACE xxi
Although Public Law No. 110-85 contains a patient enrollment, as a condition for publica-
section named, Section 801, the law only has tion (18). In observing that trial registration is
88 sections. Section 801 is reproduced, in part, largely voluntary, and that registries contain
below (17): only a small proportion of trials, the ICMJE
proposed that trial registration be a solution
(i) SEARCHABLE CATEGORIES.—The Director to the problem of selective awareness, and set
of NIH shall ensure that the public may, in addition forth the goal that ICMJE member journals
to keyword searching, search the entries in the regis- require (as a condition of consideration for
try data bank by 1 or more of the following criteria:
(I) The disease or condition being studied in the
publication) registration in a public trials regis-
clinical trial, using Medical Subject Headers (MeSH) try (19,20). Trials must register at or before
descriptors. the onset of patient enrollment. Hirsch (21)
(II) The name of the intervention, including any and others (22,23) provide comments on this
drug or device being studied in the clinical trial. policy. In a survey of editorial policies of 165
(III) The location of the clinical trial.
(IV) The age group studied in the clinical trial, medical journals, Hopewell et al. (24), found
including pediatric subpopulations. that 44 specially require that the clinical trial
(V) The study phase of the clinical trial. be registered before submitting the manuscript
(VI) The sponsor of the clinical trial, which may to the journal.
be the National Institutes of Health or another According to the FDA’s Guidance for
Federal agency, a private industry source, or a uni-
versity or other organization. Industry document on good pharmacovigilance
(VII) The recruitment status of the clinical trial. practices, a sponsor may establish or create a
(VIII) The National Clinical Trial number or new registry, for example, for the goals of
other study identification for the clinical trial. evaluating safety signals identified from sponta-
neous case reports or from literature reports,
The International Committee of Medical and for evaluating factors that affect the risk
Journal Editors (ICMJE) adopted the policy of adverse outcomes, such as dose, timing of
that clinical trials be registered at the onset of exposure, or patient characteristics (25).

17
Public Law 110-85. 110th Congress. September 27, 2007. Food and Drug Administration Amendments of 2007.
18
Foote M. Clinical trial registries and publication of results—a primer. In: Foote M, editor. Clinical trial registries
a practical guide for sponsors and researchers of medicinal products. Basel, Switzerland: Birkhäuser Verlag; 2006.
pp. 1
12.
19
De Angelis CD, Drazen JM, Frizelle FA, et al. Is this clinical trial fully registered?—A statement from the
International Committee of Medical Journal Editors. New Engl. J. Med. 2005;352:2436
8.
20
De Angelis CD, Drazen JM, Frizelle FA, et al. Clinical trial registration: a statement from the International
Committee of Medical Journal Editors. J. Am. Med. Assoc. 2004;292:1363
4.
21
Hirsch L. Trial registration and results disclosure:impact of US legislation on sponsors, investigators, and
medical journal editors. Curr. Med. Res. Opin. 2008;24:1683
9.
22
Bonati M, Pandolfini C. Trial registration, the ICMJE statement, and paediatric journals. Arch. Dis. Child
2006;91:93.
23
Sekeres M, Gold JL, Chan AW, et al. Poor reporting of scientific leadership information in clinical trial registers.
PLoS One 2008;3:e1610.
24
Hopewell S, Altman DG, Moher D, Schulz KF. Endorsement of the CONSORT Statement by high impact factor
medical journals: a survey of journal editors and journal ‘Instructions to Authors’. Trials 2008;9:20.
25
U.S. Department of Health and Human Services. Food and Drug Administration. Guidance for industry. Good
pharmacovigilance practices and pharmacoepidemiologic assessment; March 2005 (20 pp.).
xxii PREFACE

This book emphasizes cancer for a number of cancer clinical trials is greater than for other
of reasons. Therapy for cancer involves more diseases. In Jan. 2011, about 27,000 cancer trials,
variables, more drug candidates, and more drug 4190 trials on immunological diseases (sum of
combinations, than therapy for other diseases. arthritis, multiple sclerosis, lupus, psoriasis,
Hence, there is a greater need to provide a Crohn’s disease, and ulcerative colitis), 5180
harmonious description of trial design and end- trials on diabetes, and 690 trials on atherosclero-
points, as it applies to cancer. Also, the number sis, were identified on www.ClinicalTrials.gov.
 Introduction

Where a drug or medical device is tested laboratory values in chemistry and hematology,
on human subjects, the test may be called a or images from computed tomography and
clinical trial. Clinical trials may be conducted magnetic resonance imaging (MRI).
in an academic setting, where the goals are to In clinical trials, the main goals are captur-
obtain knowledge on the mechanism of action, ing and analyzing data on safety and efficacy.
efficacy, and pharmacokinetics of the drug. It is usually not the goal to ensure that study
Clinical trials are also conducted by the phar- subjects recover from their disorder.
maceutical industry, where the goals are to Trials intended for regulatory approval by
obtain knowledge on safety, efficacy, pharma- the US Food and Drug Administration (FDA),
cokinetics, and mechanism of action, and to as well as monitoring activities in the post-
obtain regulatory approval. approval context, are regulated by the United
The structure of clinical trials is set forth in a States Code (USC) and by the administrative
document called the Clinical Study Protocol. law, that is, the Code of Federal Regulations
Clinical Study Protocols contain a number of (CFR). The term “administrative law” refers to
common elements, or concepts, despite the the rules in the CFR. The USC contains sta-
variety of drugs being tested, and the variety of tutes, whilst the CFR contains rules. The rele-
diseases. These common elements include inclu- vant statutes are found in Title 21 of the USC
sion and exclusion criteria for the study subjects, (21 USC y355).
subgroups of the study population, methods for The relevant administrative law (or rules) is
stratifying the study subjects, techniques for found in Title 21 and Title 45 of the CFR, as
recruitment, obtaining consent, randomization, indicated below:
and allocation, and statistical methods for data
• Investigational New Drug (IND)
presentation and analysis. The Clinical Study
(21 CFR y312)
Protocol includes a summary called the synopsis
• New Drug Application (NDA)
and a flow chart called the study schema. The
(21 CFR y314)
schema provides the study design, the identity
• Investigator’s Brochures (IB) (21 CFR y312)
of the study drug and control, and an identifica-
• Integrated Summary of Safety (ISS)
tion of some of the endpoints.
(21 CFR y314.50 (d)(5))
Endpoints in any given clinical trial may
• Integrated Summary of Efficacy (ISE)
relate, for example, to tumor size, the number of
(21 CFR y314.50 (d)(5))
lesions in an organ or tissue, the concentration
• Consent form (21 CFR y50 and 45 yCFR 46)
of bacteria or viruses in the bloodstream, or to
• Package insert (21 CFR y201.10 and 21 CFR
a metabolite or hormone in the bloodstream.
y201.56)
Endpoints can take the form of relatively subjec-
• Data Monitoring Committee Charter (DMC
tive data from questionnaires filled out by study
Charter) (21 CFR y312.50 and 45 CFR y46).
subjects, or of relatively objective data, such as

xxiii
xxiv INTRODUCTION

I. GOOD CLINICAL PRACTICE data and non-clinical data. These data include
those arising apart from the study, for example,
Clinical trials intended for regulatory from reports from animal studies and from clin-
approval should conform to a set of guidelines ical trials conducted by other investigators, as
known as, Good Clinical Practice (GCP). well as data from human subjects arising from
According to the ICH Guidelines: the study itself. Most of the information set
forth in this textbook can be viewed in the con-
Good Clinical Practice is an international ethical text of Good Clinical Practice.
and scientific quality standard for designing, con- The ICH Good Clinical Practice Guidelines
ducting, recording and reporting trials that involve sets forth international standards for the qual-
the participation of human subjects. Compliance
ity, safety, and efficacy of developmental-stage
with this standard provides public assurance that
the rights, safety and well-being of trial subjects are pharmaceutical products. The ICH Good
protected, consistent with the principles that have Clinical Practice Guidelines were made binding
their origin in the Declaration of Helsinki, and that by the EU Clinical Trials Directive in 2004.2
the clinical trial data are credible 1. They require the sponsor to verify the qualifica-
tions of the investigators, obtain informed
GCP encompasses the requirement that the consent before each subject’s participation in
clinical study be approved by an independent the trial, ensure the trials are adequately moni-
ethics board, such as an Institutional Review tored, and that the institutional review board
Board (IRB), prior to initiating the clinical (IRB) reviews and approves the Clinical Study
study. GCP also encompasses the requirements Protocol, and oversee the trial.
that study subjects give informed consent prior This textbook frequently refers to the ICH
to entering the study, that records of study Guidelines and the FDA’s Guidance for
subjects be kept confidential, that investigators Industry documents, and uses these documents
be properly qualified by education and training, as anchor points for the various narratives.
that adequate medical care be given to any
study subjects who suffer from study-related
adverse events, that serious adverse events
be immediately reported to the sponsor, and II. FDA’S DECISION-MAKING
that study drugs and placebo (if any) be manu- PROCESS IN GRANTING
factured according to Good Manufacturing APPROVAL TO A DRUG
Practices (GMP).
The ICH Guideline for Good Clinical This textbook is unique in its extensive use
Practice also provides the organization and con- of documents published by the FDA at the
tent of the Clinical Study Protocol. The Clinical time the FDA grants approval to a drug. These
Study Protocol is, in essence, the instruction document are published by the FDA, in its
manual used by persons involved in conduct- response to an NDA or BLA submitted by a
ing the trial. Additionally, the ICH Guideline Sponsor. The decision-making processes lead-
for Good Clinical Practice details the organiza- ing to regulatory approval of various drugs are
tion and content of the Investigator’s Brochure available, in part, on the website of the FDA.
(IB), a document that compiles relevant clinical The available documents, which are published
1
ICH Harmonised Tripartite Guidelines. Guideline for Good Clinical Practice E6 (R1). Step 4 version, June 1996.
2
Hathaway CR, Manthei JR, Haas JB, Scherer CA. Looking abroad: clinical drug trials. Food and Drug Law
Journal. 2008; 63:673
681.
Random documents with unrelated
content Scribd suggests to you:
 'Where are we now, Betsy?' I asked presently, after trying in vain to
piece together the disjointed fragments of events of which I had been
conscious since the interrupted wedding in the chapel at Crossley Hall.

'On the high road to Brighthelmstone. Travelling as fast as we can

towards our dear home!' cried Betsy delightedly. 'We have had enough of
the great world, you and I, mistress, to last us all our lives. When Sir Hubert
came hastily into Sion House that day you disappeared, declaring you had
been kidnapped, and demanded a litter, horses and men, aye, and me also to
ride inside and nurse you if you were ill—that he might go after you—Lady
Jane saw him herself, and promised everything he asked. Then she added
that she was herself expecting hourly to be sent for to the Tower. "It is not
likely," she said, "that my cousin, Queen Mary, will suffer me to be at large,
when my freedom might, any day, cause danger to herself; therefore if you
succeed, as I trust you will, in rescuing my dear Margery, I pray you take
her to her father's house, where she will be safer than either here at Sion
House, or with me in the Tower. For my own sake," she said, "I would fain
have her near me, but for hers I wish her down at Brighthelmstone with her
own people."'

'Did Lady Jane say that?'

'Yes, mistress; I remember every word, and Sir Hubert agreed that he
would take you to your home. He is therefore doing so.'

'Where is he?' I asked quickly.

'He is riding on before our litter, to see if the road is clear and safe.'

'I would fain speak with him.'

'Mistress, you cannot just now. He is out of sight and hearing. "Take care
of your mistress," he said to me, "and I will ride on in front." There are
other riders behind. We are well protected now. It was such a job to get hold
of you, mistress,' continued Betsy, 'that we don't mean to lose you again.
There was much fighting to do before we could get into the Hall, I can tell
you; but, first of all, we found the Duke of Northumberland's men were not
much good, and we had to travel ever so far to get some picked men, quite
gentlemen some of them, to come over and help.'

'Then Sir Hubert never was a prisoner at Crossley Hall?' asked I,

thinking of the man in the dungeon, and of all that I had gone through in
order to get him liberated.

Betsy laughed at the idea. 'Sir Hubert said he had had a narrow escape of
being taken prisoner when you were,' she said. 'There were six to one, but
he fought valiantly, and they could not take him, though he was unable to
rescue you.'

Lying there in the litter, listening to Betsy's talk and looking on her
familiar face, whilst the sweet country air fanned me pleasantly, bringing
with it, too—or I could fancy so—a breath of the salt sea air in which I had
grown up and lived most of my life, I could almost fancy that the Wheel of
Time had gone back a little, and I was once more in my father's litter with
Betsy, leaving home for the first time for Sion House and the service of
Lady Jane Grey. I had to pull myself together before I could realize that far
from being in my father's litter going to Isleworth, I was in one of the Duke
of Northumberland's litters, returning in it to my old home.

'You will like to see Master Jack and Master Hal again,' said Betsy
cheerily, and of course your father and Master Montgomery too, not to
mention Timothy and John and Joseph.'

'Yes, that I shall,' I said, but half absently, for though I was returning to
them, there was another love drawing my heart away from them back to the
more hazardous life in the great metropolis, wherein was my sweet
mistress, Lady Jane. 'For my own sake, I would rather have her with me,'
those had been her words about me, and it needed not long thinking about
them on my part to make of them my law. Lady Jane would rather have me
with her, therefore I must go to Lady Jane. I said so to Betsy, much to her
amazement and consternation.

'But, mistress, dear mistress, consider,' she cried. 'Before this she has
probably been taken to the Tower, where she will be a prisoner. It will be
very different from what it was before,' she continued. 'She will be in
another part of the Tower, away from the Royal Palace that she was in
before, and they will never allow you to go to her, or, once you go,' she
went on inconsequently, 'you will never be permitted to return. Your life
won't be safe for a minute, when once you are amongst the State prisoners.
They will burn you alive and behead you,' she continued wildly, tears
rolling down her face at the idea, 'and then where will you be, my sweet,
precious Mistress Margery?' and she caught hold of my hands as if she
would keep me away from the Tower by main force.

And then my litter suddenly stopped, and Sir Hubert rode alongside, and,
stooping over his horse's head, looked earnestly into my face.

'My dearest,' he said to me, lifting his hat with one hand and reining in
his horse with the other, 'what is the matter?'

I told him that he was taking me in the wrong direction, for that I
desired, above all things, to return to Lady Jane.

'Well, that is what I desire too,' he said instantly, 'or at least I wish to be
in the neighbourhood of her father, that we may together discuss and plan
measures——' He stopped short, looking suspiciously around. 'You
understand?' he said.

Yes, I understood. He was still not without hope that Mary might be
dethroned, and Lady Jane reinstated as Queen. What it is to be young! All
things seem possible to the very young, especially when they are greatly
desired.

'But Lady Jane Grey wished me to take you to your home, Margery,' he
said, 'and indeed I know you would be safer there.'

'Yes,' said I, 'but that does not matter.'

'Would you not like to be back with Jack and Hal and your father?' he
asked.

For a moment—I was so young and they were so very dear—I wavered.
Then I made answer stoutly, 'I want, above all things, to return to my dear
lady. If you love me, dearest, you will take me to her.'

'And if she chides me for disobedience?'

'I will bear the blame,' I said; 'I will bear all the blame.'

We had a little more talk about it, and then, the language of our hearts
being one and the same, straightway turned about and retraced our steps,
making a detour, that we might avoid the dangerous neighbourhood of
Crossley Hall.

A couple of hours later, Sir Hubert, who had been riding on before,
returned to us, saying anxiously, 'Margery, we are pursued. Quite a large
company of horsemen have appeared in sight from the direction of Crossley
Hall, and they are gaining upon us.'

'Oh,' cried I, 'what shall we do? It would be worse than death to fall
again into the hands of Sir Claudius!'

'You never shall,' said Sir Hubert, 'whilst I live and a strong arm can
prevent it.'

At that moment a solitary horseman, riding towards us from the opposite

direction, stopped short, and, looking hard at us, exclaimed—

'Why, is it thou again? And still pursued by the rabble? Thou wilt be
killed yet!'

'Master Jack Fish!' exclaimed I. 'You remember him, Hubert, and what a
good friend he was to us when we were in that shed?'

'Oh, yes, I remember him perfectly,' and my dear one greeted him in a
very friendly way, rapidly explaining the situation.

'Thou art in great danger,' said Jack Fish gravely. 'Thine enemy will stick
at nothing to be revenged on thee. I caught a good glimpse of his horsemen
when I was on that hill, and there are four times as many of them as there
are of thee.'
 'What shall we do?' I exclaimed.

Jack Fish looked at me pityingly. 'Madam,' he said, 'thou in that litter art
in the position of the greatest danger. Thy litter is a target towards which all
will aim. Sir Knight, is it absolutely impossible to separate the lady from
her litter?'

'Well, no,' replied Sir Hubert. 'Margery'—he turned to me—'can you ride
well? Could you accompany us on horseback?'

'Yes. That I could!' I exclaimed. 'I have been used to riding from my
babyhood. A man's saddle? Oh, yes, of course I can ride on that. I can ride
without a saddle, if you like,' and I thought of the many gallops across the
downs I had had in the old days with Hal and Jack.

'Hurrah! Bravo!' cried my lover triumphantly. 'Now we shall circumvent

the enemy!' He was about to choose me a horse, when the sight of Betsy
reminded him of her, and he asked, 'Your maid? Can she ride?'

'That I can, sir,' Betsy answered for herself. 'Am I not a farmer's
daughter?'

'You will do well,' exclaimed Master Jack Fish, and with that, setting
spurs to his horse, he galloped off, not caring for our pursuers to see him
with us.

'He is a shrewd man and a good friend,' observed Sir Hubert. Then he
quickly arranged that Betsy and I should ride two of his men's horses,
whilst their owners rode behind two of the other men.

That done, the party broke up. Sir Hubert, accompanied by me and my
woman, and followed by half his company, continuing straight forward on
the road to London, whilst the other half of the men took the litter in the
direction of Guildford.

In this way we fortunately escaped from our would-be captors, who, we

afterwards heard, had a sharp encounter with the company escorting the
litter, in which they were only beaten off with tremendous difficulty and the
loss of the litter, which fell into their hands.

CHAPTER XX

A Trying Experience

By the time we reached the vicinity of the outlying suburbs of London

City another danger menaced. It was impossible for so large a company of
horsemen to approach the metropolis unchallenged, and we were brought to
a standstill at Ditton by the cry from two police officials—

'Halt, sirs! Halt! Are you for Queen Mary?'

A VOICE OF THUNDER DEMANDED, "ARE YOU FOR QUEEN
MARY?"
 Now, we were none of us for Queen Mary, and we were all honest folk
and true, who hated and abhorred a lie; there was nothing for it therefore
but that we should hold our peace and try to rush from the position by
galloping past our questioners, who, when they found that they were
baulked, fired their pistols after us, but fortunately without doing any of our
party a mischief.

'We shall have to separate,' said Sir Hubert when, at last, we deemed it
safe to slacken our pace and pull up our steeds for a brief confabulation.
'Every moment that we are together now increases our danger, for news of
us will fly round in every direction, and any moment we may be
apprehended and taken before the magistrates—that is, if they can get hold
of us. Once in Court,' he added, gravely, 'our fate is certain—I, for one, will
never declare fealty to the Papist Mary.'

'Nor I,' said I, in whispered words, but he heard them, and, turning to me,
said earnestly, 'You are a woman, and I pray you do not get mixed up with
political matters, which might endanger your dear head.'

I could not make any rejoinder, for Sir Hubert's friends now began to
discuss several matters, in which they wanted his guidance before parting
from him. A born leader of men was my Hubert, and there was no hesitancy
in his firm voice as he gave out peremptory advice and commands.

I fancy that I see him now, sitting erect on his fine horse, with
enthusiasm and earnest hope lighting up his countenance, as, after listening
to all, he quietly settled every knotty point in as few words as possible.
Betsy's objections to being parted from me took him a little longer to
overrule than everything else, but he would allow no one except himself to
remain with me. It was only for a few hours, he said, and the smaller my
party the safer would be my position. And he picked out a worthy man to
escort Betsy into London, and take her to London Bridge, where we were to
join her. However, Betsy would not consent to the plan until I also bade her
authoritatively to say no more, but obey in every particular. Then she left
me, weeping and declaring that she should see my face no more, for we
should both perish by the dangers of the way.
 'And when you arrive in London,' she went on, in her inconsequent way,
'people will recognize that you have been with Lady Jane Grey, when she
was queen, and then you will be burnt and beheaded as well for high
treason, or whatever they call it, and I shall have all the misery of returning
to Sussex alone, to acquaint your father with the fearful tidings!'

When our company was broken up into twos and threes, Sir Hubert and I
rode on at a brisk pace, and did not draw rein until we reached the River
Thames at Kingston, a very pretty little town.

The glory of the brilliant summer day was waning then; the sunset was
obscured and clouded over by dark clouds; only its reflection lingered a
little over the silvery waters of the Thames.

'We cannot reach London to-day,' said I, looking inquiringly at my

companion.

I had been so happy riding along by his side that I had not realized that
even the longest day comes to an end at last and night will follow. But he—
he should have thought of that.

'No. Of course not. I have ascertained that Sir William Wood and Lady
Caroline are staying with some friends at a house at Kingston. It is
somewhere near the river. I thought that you would like to stay the night
with Lady Caroline.'

'Oh, yes, I should,' I replied, cheerfully, for it was very pleasant to think
of being with a gentlewoman again, after all the rough experiences I had
been through.

'If only I could find the place!' exclaimed Sir Hubert. 'We shall attract
observation if we go about on horseback seeking it. News will arrive here,
if it has not already arrived, of what happened at Ditton, and we shall be
arrested on suspicion.'

'What shall we do then?'

 'Leave our horses at an inn, and take a walk along the riverside until we
find the house where our friends are. I know it is a house by the river
because I have been there.'

I made no objection to this, and we went to an inn, where they were

pleased to take our horses, as also to serve us with light refreshment, of ale
and bread and cheese for Sir Hubert and milk and cake for me, after
hurriedly partaking of which we went out and walked down the street.

As we did so I noticed a little group of men standing near the river were
regarding my companion with great curiosity, but concluded that this was
due to the fine manly presence and dignified mien of Sir Hubert.

It was a little startling, however, to find that, while we were searching

for the house we wanted, we occasionally encountered one or another of
these individuals, apparently watching us with interest.

'Those men get upon my nerves,' I said at last. 'We meet them
everywhere.'

Sir Hubert laughed.

'I have been thinking that the men of Kingston have a strange similarity
of appearance,' he said. 'Can they possibly be the same men?'

I answered, 'Yes, I am sure of it. And I do not like to see them so

frequently.'

'But who is this?' exclaimed Sir Hubert with delight.

It was Sir William Wood, who, coming suddenly round a corner, almost
ran into my dear knight's arms.

'The very man I want!' cried he. 'You have been long in coming, Hubert,
my friend!'

'And now that I am here, before we discuss anything, there is this lady,
Mistress Margery Brown, to bring to a place of safety for the night. I hope
Lady Caroline is at Kingston.'
 'She is,' replied Lady Caroline's husband, shaking hands cordially with
me, 'but I must tell you that we are hiding here. Our hostess, Lady Mary
Peterson, dared not have us staying with her openly. Even now I have only
ventured to leave the house by a subterranean passage from the cellars to
yonder clump of willows by the river, and if you wish to remain over the
night with us you will have to accompany me that way. But who are those
men?' He asked the question with anxiety, pointing as he did so to two of
the men who were following us about.

They stood near a thick hedge, which partly screened them from
observation.

'Oh, those! I have an account to settle with them,' cried Sir Hubert
angrily, at once giving chase to the rascals.

There was a spice of boyishness always about Sir William, and now, like
a boy, he forgot all about me and ran off to aid Sir Hubert in the pursuit.

I was left alone, and neither Sir Hubert nor Sir William heard my pitiful
little cry—

'Oh, do not leave me!'

By the light of the moon, which had now risen, I saw my escort
disappear, with feelings of great misgiving, and sat down disconsolately
upon a big boulder by the river side.

It was very lonely there. The water flowed placidly by, with scarcely a
murmur. A corncrake in a field behind made mournful music, with
monotonous persistence. A dog howled somewhere on the other side of the
river. From the town behind us proceeded subdued sounds of horses' hoofs,
men's voices, the clashing of steel and, presently, the ringing of the curfew
bell.

What a long time my knights were in catching, or frightening, or

punishing the spies, if the men were spies, and it seemed evident that they
were. Supposing that they had run in the direction of their fellows, and the
two knights following them were caught in a trap, overpowered by numbers
and taken to prison for rebelling against Queen Mary, what could I do all by
myself?

I was horribly frightened, and clasped my hands and strained my eyes in

my endeavour to see one or other of my knights returning for me. But in
vain. No one was visible. Should I go forward and look for them? No;
better to remain where they had left me, lest I missed them altogether.

I sat still, leaning my head upon my hand, and tried to wait as patiently
as I could. Would that dog never cease howling? What was that approaching
on the river? A boat? It must be, for now the soft beating of oars upon the
water was plainly to be heard.

Oh, why did not Sir Hubert, or at least Sir William, return? There were
men in the boat—four men, two were rowing. Why, at a gesture from the
one sitting in the stern of the boat, did the oarsmen stop rowing? Now they
were approaching the bank where I sat. They must have seen me, and
indeed my figure, silhouetted against the sky, must have been conspicuous.

They were getting out now—at least two of the men were—and coming
towards me.

But what was this? Oh joy! The men whom I now saw more clearly were
none other than my two good knights, returning to me in all haste.

Sir Hubert seized my trembling hands.

'You have been left too long, my love!' he said. 'But indeed we could not
help it. What do you think? The men we ran after were no foes, after all. Far
from it, they were friends. When we had knocked them down, and they
found out who we were, mostly from Sir William, whom they had seen
before, they informed us that they belonged to a small party of men that the
Duke of Suffolk had sent out here to look for me. They had come down to
Kingston by boat, and were hoping to meet with me and take me to London
City by water.'

'Then that was why they stared so hard at us, and followed us about?' I
said inquiringly.
 'Exactly. They were not sure that it was I, until Sir William and I had
knocked a little sense into them!'

'Shall you go with them?' I asked. 'And I, what shall I do?'

'Well, you mast come too. You want to be with Lady Jane. I think that I
had better take you to her father, whom the queen has pardoned and set free.
He will know best how to get you into the Tower, and to his daughter.'

'But it is night,' I said.

Sir Hubert was eager to go that very moment to the Duke, but, looking
down upon me, he suddenly perceived my weariness and weakness.

'Poor Margery!' he said, with infinite tenderness, 'you are worn out!
What shall we do with her, Sir William?'

'Leave her with me,' said Sir William at once. 'I will take her straight to
Lady Caroline, and we will all three follow you to London to-morrow,
probably by water, as that will attract the least observation.'

After a hurried discussion we agreed to this, and Sir Hubert, who I saw
must have received some political information which greatly excited him,
took a hasty, though affectionate, leave of me there, by the Thames, within
sight of Kingston Bridge, which was so soon to be the scene of a very
daring exploit. And we parted, little knowing what was to happen before we
met again, he going to the boat to be rowed down to London City, I going
with Sir William through the subterranean passage to the great house, where
Lady Caroline received me as a sister, and assisted me to bed with her own
hands.

I was so tired that I fell asleep the moment my head touched the pillow.
But my dreams were troubled. For in them, over and over again, I saw Sir
Hubert in a boat, pulling against the stream, and unable to get on, whilst I,
standing on the river bank, besought him to make haste to Lady Jane, who
in the Tower was in sore need of succour. And still he tried to go to her, but
in vain; the boat heaved and tossed, but did not advance at all, in spite of
every effort. And I wept in my sleep, because he could not go to Lady Jane.
 CHAPTER XXI

Queen Mary's Boon

'Oh, help me!' I implored. 'Help me to get into the Tower!'

The Court physician to whom I appealed shook his head gravely.

'It is a difficult matter for an outsider to get in there,' he said, 'and, if I

mistake not, you are one who would be liable to be suspected, by reason of
your having been there before with the unfortunate Lady Jane Grey.'

'Then you remember me? I thought you would. I am Margaret Brown,' I

faltered.

'Mistress Margaret Brown,' said he, very gently, 'I will give you one
word of advice, and that is, go home to your friends.'

'Alas!' I said, wringing my hands, 'I have no friend—save one—so dear

as she who is imprisoned in the Tower. Help me to get to her, Dr.
Massingbird, I implore you. She said that it would be a comfort to her to
have me there, and she is in sore need of comfort!'

'Poor lady! Poor young lady! So sinned against, and yet so innocent; and
made a tool of by that wicked man who has met with his just fate. I mean
Northumberland.'

'Yes,' said I. 'It was he and his ambition that ruined my dear lady.'

We were standing talking together in Thames Street, not far from the
Bulwark Gate of the great Tower of London. For a week I had been making
many endeavours to get into the Tower, but, owing to the great precautions
which were being taken against treachery—especially during Queen Mary's
residence there—every attempt of mine to effect an entrance was in vain. I
had found Betsy all right on London Bridge, where she stayed twelve hours
waiting for me, in spite of every effort made to dislodge her from her
position, and she and I were lodging, with the Woods, in apartments in the
Strand.

Sir William Wood and Lady Caroline had no power to assist me to get
into the Tower; they were obliged to keep as quiet as possible, only going
out at night, owing to Sir William's partisanship of Lady Jane, whilst, for
the same reason, Sir Hubert Blair, too, was compelled to remain hidden
until certain plans were matured. He could not help me, and indeed I had
not seen him since we parted on Kingston Bridge. As for the Duke of
Suffolk, he was quite unable to assist me to go to his daughter, for, having
been liberated after two or three days' imprisonment, owing to the
intercession of his wife who prostrated herself before Mary, pleading that
he was delicate and that his health would suffer if he were not set free, upon
which Her Majesty graciously forgave him, he was most ungratefully
busying himself with secret schemes for ousting her from the throne and
reinstating Queen Jane. Always careless of the latter's feelings, whether she
had her favourite gentlewoman with her in her imprisonment, or not, was a
matter of indifference to him. Others who had made my acquaintance
during the queen's short reign cut me dead, or treated me with scanty
civility upon my reappearing on the scene. There was not one of those fine
Court ladies who had formerly professed to admire and love Queen Jane
who would lift a hand to help her now that she was in affliction and
imprisonment. I was thinking sadly about this, as I returned from my last
fruitless effort to gain ingress into the Tower, when I met one of the
physicians who had attended Queen Jane during her illness in the royal
palace. He was a truly benevolent man, and although he was evidently
going somewhere in a hurry, he got out of his coach when I called to him, to
inquire what I wanted.

'I am very hurried just now,' he said, temporizing, 'The fact is Queen
Mary cannot sleep; evil, unpleasant thoughts trouble her, from the moment
in which she lies down in bed until it is well nigh time to rise again, and
potions and drugs do not cure the malady. But I bethought me of King Saul,
to whom David played when he was distracted in that manner, until the evil
spirits no longer troubled him, so I told Her Majesty that I would slip out of
the Tower and go and fetch a young female singer, who would sing to her so
beautifully that she would fall into a natural sleep. I heard a girl singing
very sweetly in a friend's house in the Strand once, but whether I shall be
able to find her or not I know not. It is growing late. The curfew bell has
rung; the streets will not be very safe to be out in soon, and yet I must try to
find the girl, if Queen Mary is to sleep.'

A bold thought came to me as he was speaking. The good physician was

in search of a girl who could sing well, who in fact could sing Queen Mary
to sleep, and I, who could sing well, wanted above all things to get into the
Tower; it therefore seemed conclusive that I must be the girl to sing for the
queen. But Queen Mary? I would rather that it had been Queen Jane.

'Doctor,' I said entreatingly, 'I am your girl. Your sweet singer, you
know,' I hurriedly explained, seeing that he did not understand. 'I can sing
very sweetly, though I say it myself. Take me to Queen Mary.'

'You!' The good man looked amazed. 'I am afraid it would not do,' he
said. 'Supposing now that Her Majesty found out that you had been in the
Tower with Queen Jane?'

'I don't think that that would make so much difference,' I said. 'A singer
may sing to any one.'

After a little more demur, to my intense satisfaction, Dr. Massingbird

consented to take me, only stipulating that I should conceal my real name
and position from the queen, and appear before her as a professional singer
only. He also made me promise that I would do Queen Mary no harm in any
way when admitted into her presence—for these were days in which
treachery was common.

Under his care, escorted by him, in scarcely an hour from the time in
which we met in Thames Street, I was entering the royal apartments of the
ancient palace[1] in the mighty Tower of London.
 [1] This palace of the old kings of England has long since disappeared. It
was at the south-east of the Tower.—ED.

I must confess candidly that, whilst outwardly appearing dignified and

calm, I was inwardly in a state of great trepidation and timidity. Always
overawed by the vastness and gloom of the mighty fortress, even when
there with Queen Jane, while she was in power and every effort was made
to display its riches and magnificence, it can easily be understood, that I
was many times more so now when, late at night under an assumed
character, yet at heart an adherent of the imprisoned ex-queen, I ventured
alone, except for the presence of the physician, himself a servant, into the
palace of the reigning monarch. Curious glances were cast at me by guards
and sentinels, squires and dames, lords and ladies, as we ascended the great
oaken staircase and passed through a long gallery into a spacious hall, with
narrow Gothic windows of stained glass, hung with tarnished cloth of gold
curtains. Here the furniture was large and splendid, the windows were in
deep recesses, whilst there was a gallery round the upper part of the room.

'Wait a little here, until I return,' said my guide, signing to me to sit down
on an old oak chair.

The physician went away, leaving me, as I at first thought, alone, but, in
a little while, my eyes became accustomed to the dim light, and I saw that
in some of the embrasures by the windows, men and women sat, or stood
engaged in earnest conversation. A few of them appeared to be foreigners;
from their dress I imagined they were Spaniards, and two or three of these
were monks, the sight of whom there recalled to my mind Sir Hubert Blair's
prediction in Woodleigh Castleyard, that if Mary reigned, the country would
be plunged into Roman Catholicism and brought into alliance with Spain,
upon which a door would be thrown open for the Inquisition, with all its
horrors.

At that moment I heard a girl, standing in a recess near, saying to a tall

man, who from his dress and bearing seemed to be of noble birth—
 'The queen means well. She is cautious about beginning, but in time she
will do all that she is bidden by the Holy Church. At present she is racked
with indecision and gloomy forebodings——'

'But she has the iron will of her father, King Hal—you see him there in
that portrait, painted by Holbein, over the chimneypiece. What a man that
was!' exclaimed the other.

The girl shrugged her shoulders.

'Mary has a very different creed from his, fortunately,' she said, 'and she
hankers after Spain—all may yet be well for our Church!'

I heard no more, for at that moment Dr. Massingbird, returning,

accompanied by a lady of the bedchamber, desired me to go with her to
Queen Mary, who had already retired for the night.

'I have done all I could for you,' added the physician, aside, in a low
tone. 'I have brought you here. But you will have to get out again as you
best can, for I cannot dance attendance upon you any longer.'

I tried to thank him, and to say that I should be all right, but, not
listening to me, he said—

'I have announced you as a poor singer named Meg Brown! having
clipped off a bit of your name. God grant you may come to no harm, my
child!'

Then he hurried away.

I followed the lady to Queen Mary's bedchamber, walking silently after

her into the splendidly furnished bedroom, where I had been before with
Queen Jane. How it reminded me of her! But this was a very different
woman lying upon the great bed, with its silk and gold counterpane.

Mary was about forty years old—a little woman, slender and delicate in
appearance. She did not in the least resemble her father, King Henry VIII.
Her features were not bad, and her eyes were bright—so bright indeed that
they frightened me when, all at once, I discovered them fixed upon my face.

'Who are you?' demanded the queen, in a voice which was thick and loud
like a man's.

I was still more alarmed, and felt at that moment as if those bright,
piercing eyes were looking into the very depths of my heart.

I knelt for one moment, but quickly rose from the ground, with a prayer
in my heart that I might be forgiven bowing in the house of Rimmon and
before the wrong queen.

'I am Meg Brown, madam. At your service,' I said, adding, as she

remained quiet, 'a poor young singing-girl.'

'You don't seem to have much boldness in speech, Meg. How, then, can
you have the courage to sing?'

I clasped my hands tightly together, with an inward prayer for help, and,
in a moment, from the extremity of fear passed to a state of blessed
confidence.

'Only hear me,' I said. 'I can sing, madam.'

'Can you?' The piercing eyes sought to read my innermost soul.

'Yes, madam. Once, when I was a child, Master Montgomery, our curate,
took me to see a poor woman who had lost her baby and was almost dead
with grief. She could not weep, nor sleep, nor eat; the trouble was killing
her. But I sang to her, and she cried like a child, and prayed to God and
recovered. And another time,' I spoke more clearly now, 'when some
serving-men and women had a great quarrel, and were fighting in a truly
terrible manner, I stood up and sang, and sang until they fell upon their
knees and burst out into tears and prayers. After that, Master Montgomery
always fetched me to sing to people when he could do nothing with them.'
 'Wonderful!' said Queen Mary, in a rather satirical manner. 'But those
were only poor folk; it remains to be seen whether you can sing to a queen.'

'God,' said I, half to myself and half to her, 'Who helped me to sing to
His poor, can help me to sing to'—I was going to say His queen, but
substituted 'a queen.'

'And is not the poor queen His, too?' asked the woman, who was reading
my heart.

'He knows,' I said, trembling a little, lest she should take umbrage at my
daring. 'He knows them that are His.'

Mary did not say anything to this. She turned her head away from me
with a peevish movement.

I was afraid to speak, and therefore waited in silence until she spoke
again.

'Sing to me,' she said.

'What shall I sing?'

'I am greatly troubled,' she replied at length. 'Sing what you sang to that
poor mother who had lost her child.'

It was one of Martin Luther's cradle songs, translated for me, when a
child, by Master Montgomery, who fitted it to a tender little tune of his own
composing. I loved it well, but it seemed a strange song to sing to the
mightiest woman in the land, the Queen of England. Perhaps, however, as
she said she was greatly troubled, she might be in need of comforting. I
thought of that, and standing there, with my hands tightly clasped before
me, sang as I had never sung before—

Sleep well, my dear, sleep safe and free;

The holy angels are with thee,
Who always see thy Father's face,
And never slumber nights nor days.
 There was a quick movement on the bed, and Mary opened wide eyes of
amazement, but she did not interrupt, and I went on singing, until, gaining
confidence, my voice rang out clearly and triumphantly in the last verse—

Sleep now, my dear, and take thy rest;

And if with riper years thou'rt blest
Increase in wisdom, day and night,
Till thou attain'st th' eternal light!

For a little time there was silence in the room, when I ended, and then,
with a heaving sigh, the deep voice came from the bed—

'I'm only a frail woman, though I am queen, and I need wisdom. But go
on singing, child. Go on singing.'

I began a favourite hymn of Master Montgomery's, and it brought to my

mind so many memories that sobs trembled in my voice, as I sang—

When my dying hour must be,

Be not absent then from me;
In that dreadful hour I pray,
Jesus, come without delay,
See and set me free!
When thou biddest me depart
Whom I cleave to with my heart,
Lover of my soul, be near,
With Thy saving Cross appear,
Show Thyself to me.

Mary lay so still when I ended that I thought she was asleep; but no, she
was awake, and as I looked closely at her, I perceived that tears were slowly
stealing down her face.
 I fell on my knees by the bedside, but I was not kneeling to her, as she
seemed to think, when opening her eyes and looking at me, she said, in a
softer tone than before—

'Child, do you want something?'

Did I want something? Yes, I wanted something so much, that now when
the time had come for asking for it, I could not say a word,

'Your singing is marvellously sweet,' continued Queen Mary. 'Yet it has

not sent me to sleep. I should like to hear you every night. Will you stay
here in the palace and sing to me every night? You shall have a fair wage.'

'I do not want a wage,' I answered, thanking her. 'But I crave a boon at
your hands, madam.'

'And that is——'

'That I may be allowed to go to Lady Jane Grey——'

'Lady Jane! My cousin? Methinks that you are a bold girl to ask that,'
exclaimed the queen, starting up in bed and speaking very angrily.

I rose slowly, and, with clasped hands, stood before her, pleading my
love for her sweet cousin and beseeching that I might be allowed to attend
Lady Jane in her prison. I described her youth, her innocence, and the great
unwillingness with which she had permitted herself to be dragged into the
dangerous position of queen, and also mentioned the quickness and
satisfaction with which she abandoned the undesired sovereignty.

'You plead well, Meg,' said the Queen, when I stopped, partly because
my breath failed, 'and you have a wonderful voice for singing, aye, and for
speaking. If I let you go to Lady Jane, and allow you to attend her in her
prison, will you come and sing to me when I require you?'

'I will. I will,' I exclaimed delightedly. 'I will sing you to sleep whenever
you like, madam.'
 'Nay, not to sleep, Meg, not to sleep,' said Queen Mary. 'As a promoter
of sleep you are a failure, for your singing awakens me out of the sleep of
years, making me feel as if I should never want to sleep again.'

She then rang a hand-bell, and on the entrance of a gentlewoman,

commanded that I should be taken to the Brick Tower, to attend upon the
Lady Jane Grey.

CHAPTER XXII

With Lady Jane

I did not find Lady Jane in bed, in the gloomy quarters where she was
confined. Separated from her husband, who was imprisoned in the
Beauchamp Tower, and left entirely alone, she was passing the time in
prayer, meditation, and studying the philosophic and holy writings, from
which she imbibed deep draughts of resignation and wisdom.

Like a child exhausted with play after having acted a difficult part, and
like one worn with the strain that has been put upon her in the battle of life,
she was simply waiting at the foot of the Cross, and I found her on her
knees, weeping gently as she prayed.

The warder, who conducted me to her apartment, retired, bolting the

door after him, and I stood by it a little while, unwilling to interrupt my dear
lady and noticing with dismay the iron-barred windows of the room and the
stone walls, partly concealed by tapestry. I saw also that the furniture—a
table and some chairs—was of carved oak. and the deep window-seats were
covered with velvet, as was also the seat of the oak chair before which the
poor young prisoner knelt.
 Perhaps she heard some one enter—certainly the warder made noise
enough as he closed the door—and therefore, ending her prayer, she arose
and looked round.

The next moment I was folded in her arms, and we were crying together.

'Oh, Margery! My poor Margery!' she said, at last, when we were a little
calmer. 'Where have you been? Why, dear,' looking at me more closely,
'what have they done to you? You look so pale and thin! How did you get
into the Tower?'

'It took me a week to get in,' I said, beginning to answer her last question
first, and then, as we sat together on one of the window seats, I proceeded
to tell her all that had befallen me since I was carried off from Isleworth.

Lady Jane was very sympathizing when she heard of all my danger,
distress and trouble in Crossley Hall, and was delighted that my valiant
knight, Sir Hubert Blair, had rescued me, with a strong hand. But when I
proceeded to tell her that he was now in London bent upon fighting for her
and deep in schemes with her father, to bring about a change of monarchy,
she was greatly concerned and not a little distressed.

'Why did not you stop them, Margery?' she said. 'You know so well that I
do not think it right to be queen, when my cousins Mary and Elizabeth are
living. You are well aware how I disliked to be queen, and how gladly I
gave it up.'

'Yes, madam, I told Sir Hubert Blair all,' replied I, 'but he said that they
looked at the matter in this light. There were the people of England to
consider, the multitude of human beings who, in the one case, would be
plunged back into Roman Catholicism, in the other would enjoy the
Reformed faith, and freedom to worship God in their own tongue and read
His Divine Word for themselves. He said, madam, that you must not think
of your own wishes, but must sacrifice yourself for the good of the people.'

I thought I had stated Sir Hubert's argument clearly and well, yet Lady
Jane shook her head.
 'We must not do evil that good may come,' she said. 'And have I any
right to take another person's possession because it seems to me that I can
administer it better than the rightful owner?'

'But think of the suffering that may come upon our good Protestants if
Mary reigns?' I urged. 'They say that she will do everything that her Roman
Church enjoins, and the horrors—the horrors of the Inquisition—may be
brought to this land of ours,' and I poured out all that Sir Hubert had related
of that horrible institution.

'God grant that it may never come to England!' said my mistress, when I
ended. After which she added, thoughtfully, 'I think that Queen Mary is not
so bigoted as some people imagine, and she has behaved very leniently in
several ways since her elevation to the throne. She forgave my father and
set him free, and, although the Emperor Charles, to whom she looks up so
much, has advised her to have me executed, she has refused——'

'I should think so!' I interrupted. 'Oh, dear madam, what a wicked wretch
that emperor must be!'

'People always look at things from their own point of view, or the point
of view of those dearest to them,' said my mistress. 'The Emperor Charles,
considering the welfare of Mary, sees that while I live there will be always a
danger of some enthusiasts, like your Sir Hubert, starting up to try and put
me on the throne again—and in that case, besides the danger to the reigning
monarch, there would be many slain, much blood would be shed, and you
must remember Sir Hubert's argument about the duty of considering the
welfare of the many. If my death will put away this danger to so many, then
I had better die, dear Margery.'

'No! No! No!' I cried. 'It would be the foulest shame in the world for one
so innocent and good as you to be killed—and remember your argument,
they must not do evil that good may come.'

Lady Jane smiled.

'Well done, little Margery!' she said, adding, 'Now tell me how you
managed to get into the Tower.'
 I told her, upon which she remarked—

'You see Mary has a good heart—you touched it with your singing, and
she allowed you to come to me,' adding, to my delight, 'To have you with
me is the one thing I wanted, next to my natural wish to be with my
husband. They have separated us, you know, Margery. He is imprisoned in
another tower.'

'It is hard,' I said.

'And I have great anxiety about him,' went on my dear lady. 'Doubtless
the priests are endeavouring to convert him to Romanism, and since they
succeeded with his father——'

'Madame, did the Duke of Northumberland give up his faith?'

'Yes,' she answered sadly. 'He was not brave, not heroic; he gave way on
all sides when death was imminent. But they have killed him. He is dead,
and we must say nothing, except good, of the dead.'

She quoted a Latin proverb to that effect,[1] but it was strange to my

ears, and I have so far forgotten it as not to be able to write it down.

[1] De mortuis nil nisi bonum.—ED.

I could not help thinking that Northumberland's ambition was in reality

his religion, but could not say so after those words of Lady Jane's.

'He was beheaded on Tower Hill,' she continued, 'and oh! God grant that
the same fate may not befall my dear lord!'

The days passed slowly and quietly for me and my dear lady in her
prison in the Tower. Queen Mary did not send for me to come and sing to
her any more. She went to stay for a while at Richmond Palace, and, then
again, we heard that she was at Whitehall, and sometimes she was in her
palace in the Tower, but that made no difference to us. Certain privileges
were accorded by her to Lady Jane, and of course I shared them. For
instance, we were allowed to walk across the green to St. Peter's Church
occasionally, where Lady Jane much enjoyed the fine music, and liked to
join in the services. On these occasions she would look up at the
Beauchamp Tower, as we passed it, wondering how her husband was and
what he was doing. My heart ached for her many a time, when I saw her
wistful face upturned to the windows of the Tower, as she vainly tried to see
the face she loved. At least Mary might have permitted them to meet
occasionally, if she could not permit them to enjoy each other's constant
society. But a day was coming, though I knew it not then, when they would
be allowed to be together, at least for a short time. Lady Jane was also
permitted to walk in the queen's garden—this was a pleasure to her, who so
dearly loved fresh air and flowers. Sometimes she would talk about the
gardens at Sion House, and the Thames flowing by them, and wonder if we
should ever go there again. At other times she would tell me about
Bradgate, where she had been brought up and where her tutor, Mr. Roger
Ascham, used to marvel because she preferred to sit reading Plato to joining
her young companions in the sport of hunting. It was well that she preferred
books, as they were now her solace when it would not have been possible
for her to have had the other pastime.

In the beginning of October Lady Jane was allowed to meet her husband
once more, but the occasion was most melancholy, for they were both being
conducted to the Guildhall, together with Archbishop Cranmer and Lord
Ambrose Dudley, Lord Guildford Dudley's brother, to be tried on the charge
of high treason. Lady Jane pleaded guilty, and they were all convicted of
high treason and condemned to death as traitors. Lady Jane's sentence was
that she was to be beheaded or burnt to death, at the queen's pleasure, and
Judge Morgan, who pronounced it, was afterwards so deeply afflicted in his
mind at the remembrance that he died, raving.

Many people were exceedingly grieved for the poor young creature, who
had been made a tool of by her ambitious relatives, sorely against her will,
and the touching grace and meekness of her demeanour, as well as her
misfortunes, caused them to follow her weeping and lamenting her hard
fate, as she was being reconducted to the Tower.
 The queen, however, appears to have had no intention at that time of
carrying out Lady Jane's sentence, nor indeed that of the others who were
condemned with her, but thought it better to please her partisans by keeping
them in prison under sentence of death. To Lady Jane, indeed, Mary granted
more indulgences, such as permitting her to walk on Tower Hill, where I
always accompanied her.

The autumn passed slowly into winter. I often thought of my beloved,

wondering what he was doing and dreading inexpressibly to hear of his one
day being brought into the Tower, through the Traitors' Gate. I wrote to him
two or three letters, sending them off as I found opportunity, in which I told
him guardedly, lest they should fall into the wrong hands, that Lady Jane,
above all things, desired that no effort should be made to replace her in
what she felt had been a false position. But I received no sign that my dear
knight ever got my poor little epistles, and indeed it would not have been
strange if they had never reached his hands.

At length, however, I heard of him. One day there was a great

commotion in the Tower, armed men springing up everywhere, guns
bristling on all sides, the defences of the whole fortress being looked to, and
military commands being called out in all directions.

'What is it, warder? What is happening?' Lady Jane inquired, in her

gentle way.

Then the warder informed us that they were expecting that the Tower
would be assailed by a large force, which was coming to attack it, under a
leader who had begun to carry all before him.

'Who is he?' asked Lady Jane.

'Madam, he is a knight, who owns property and a castle in Kent, where

he began the rebellion. His name,' added the man, 'is Sir Thomas Wyatt, and
he is accompanied by several gentlemen, and amongst them Sir Hubert
Blair, who is notoriously active against the Government.'

'Margery,' said my dear lady, when the warder had retired, 'if we could
have prevented this! If we only could have prevented it!'
 'I wrote to Sir Hubert Blair again and again after I knew your wishes,'
said I, 'but I think he cannot have received my missives, or perchance his
friend, Sir Thomas Wyatt, heeds not his advice.'

Even as I spoke I was hoping that these valiant knights, who were
carrying all before them, would indeed succeed in their great enterprise.

'There will be a terrible amount of bloodshed!' sighed my mistress.

'God will be on the side of the right,' said I.

'Yes. On the side of the right,' she rejoined with emphasis. Then she
continued, with another sigh, 'If this fails, my life will be the forfeit, and
justly, too, for the words of those who said Queen Mary would not be safe
upon her throne whilst I live will have proved true.'

Another time, as we were returning from St. Peter's Chapel, she paused,
and, looking at a certain spot on the green, where a scaffold was wont to be
erected for the more private execution of State prisoners, the tears came into
her eyes, and I knew that she was apprehending a similar fate.

However, I had every confidence in my brave and valiant hero, and often
lay awake at night, thinking of all that would happen when he and the Duke
of Suffolk once more placed my Lady Jane upon the throne.

I thought, when all that was settled, and my dear lady, with her husband
by her side, no longer depended so entirely on her Margery for
companionship and love, and my beloved, with his work accomplished, had
leisure to be happy, he and I might have time to get married, and then we
would go together to see my home and my dear old father, Hal and Jack,
and, too, Master Montgomery in his parsonage, and the villagers and our
servants. After which Sir Hubert would take me to his own beautiful place,
Harpton Hall, where we should live together in great happiness and
prosperity. But I am glad to think that I always said to myself, 'If the Lord
will,' and resolved that, even if things went contrary and we did not have
quite such a good time, I would be resigned and thankful for smaller
mercies.
 But of what was really going to happen I had not the faintest conception.

CHAPTER XXIII

Wyatt's Insurrection

I heard full particulars afterwards of the insurrection, but at the time,

shut up in the Tower, knew little of its course.

Sir Thomas Wyatt, though professedly a Romanist, having seen the

horrors of the Inquisition in Spain, had risen in revolt against Mary because
of her Spanish marriage. He first raised the standard of revolt in Kent,
where many joined him, and amongst them Sir Hubert Blair, who thought
he could thus best serve Lady Jane, whilst the Duke of Suffolk, who was
openly for his daughter, was making a similar attempt in the Midlands, and
Sir Peter Carew in the West; the latter's object being to place the Princess
Elizabeth on the throne.

At Rochester, where Sir Thomas Wyatt, accompanied by his aide-de-

camp, Sir Hubert Blair, encamped in the ruins of the old castle, and held the
bridge with cannon and well-armed Kentish men, there was a great scene.
The Duke of Norfolk, with a detachment of Guards from London, was to
have forced the bridge, but a certain Captain Brett, who was deputed by him
to lead five hundred men against it, turning, addressed his followers thus—

'Masters, we are about to fight against our native countrymen of England

and our friends, in a quarrel unrightful and wicked; for they, considering the
great miseries that are like to fall upon us if we shall be under the rule of the
proud Spaniards, or strangers, are here assembled to make resistance to
their coming, for the avoiding of the great mischiefs likely to alight not only
upon themselves, but upon every one of us and the whole realm, wherefore