The association between treatment-specific optimism and depressive symptomatology in patients enrolled in a Phase I cancer clinical trial

Optimizing care in early phase cancer trials: The role of palliative care

Advancements in cancer treatment have led to improved survival rates, with early phase clinical trials (EPCTs) serving as important initial steps in evaluating novel therapies. Recent studies have shown that response rates in these trials have doubled in the last twenty years. Patients who enroll on EPCTs have advanced cancer and heightened symptomatology yet maintain a robust performance status that qualifies them for clinical trial participation. It is well established that many of these patients have needs that can be addressed by palliative care, including symptom management, value assessments, advance care planning, and psychosocial and spiritual support. Several small studies have aimed to identify the most beneficial palliative care intervention for this cohort of patients, ranging from formal clinic-based multidisciplinary palliative care interventions to home-based interventions. While outcomes have trended towards benefit for patients, especially pertaining to psychological well-being, most studies were not powered to detect additional benefits for improved physical symptom management, reduction in care utilization or increased length of time on trial. In this review, we discuss the unique palliative care needs of this population and what we can learn from results of past interventional studies. We advocate for a tailored palliative care approach that acknowledges the time toxicity experienced by patients enrolled in EPCTs and address challenges posed by shortages within the palliative care workforce.

Participants' understanding of informed consent in clinical trials: A systematic review and updated meta-analysis

Obtaining written informed consent from participants before enrolment in a study is essential. A previous study showed that only 50% of the participants in clinical trials understood the components of informed consent, and the methods of participants' understanding of informed consent were controversial. This updated meta-analysis aimed to estimate the proportion of participants in clinical trials who understand the different informed consent components. PubMed, EMBASE, the Cochrane Library, and Scopus were searched till April 2023. Therapeutic misconception, ability to name one risk, knowing that treatments were being compared, and understanding the nature of the study, the purpose of the study, the risks and side-effects, the direct benefits, placebo, randomization, voluntariness, freedom to withdraw, the availability of alternative treatment if withdrawn from the trial, confidentiality, compensation, or comprehension were evaluated. This meta-analysis included 117 studies (155 datasets; 22,118 participants). The understanding of the risks and side-effects was investigated in the largest number of studies (n = 100), whereas comparehension was investigated in the smallest number (n = 11). The highest proportions were 97.5%(95% confidence interval (CI): 97.1-97.9) for confidentiality, 95.9% (95% confidence interval (CI): 95.4-96.4) for compensation, 91.4% (95% CI: 90.7-92.1) for the nature of study, 68.1% (95% CI: 51.6-84.6) for knowing that treatments were being compared, and 67.3% (95% CI: 56.6-78) for voluntary nature of participants. The smallest proportions were the concept of placebo (4.8%, 95%CI: 4.4-5.2) and randomization(39.4%, 95%CI: 38.3-40.4). Our findings suggested that most participants understood the fundamental components of informed consent (study confidentiality, nature, compensation, voluntariness, and freedom to withdraw). The understanding of other components, such as placebo and randomization was less satisfactory.

Accuracy of Expected Symptoms and Subsequent Quality of Life Measures Among Adults With COPD

Importance

Patients' expectations for future health guide their decisions and enable them to prepare, adapt, and cope. However, little is known about how inaccurate expectations may affect patients' illness outcomes.

Objective

To assess the association between patients' expectation inaccuracies and health-related quality of life.

Design, Setting, and Participants

This cohort study of patients with severe chronic obstructive pulmonary disease (COPD) was conducted from 2017 to 2021, which included a 24-month follow-up period. Eligible participants received outpatient primary care at pulmonary clinics of a single large US health system. Data were analyzed between 2021 and 2023.

Exposure

Expectation accuracy, measured by comparing patients' self-reported expectations of their symptom burden with their actual physical and emotional symptoms 3, 12, and 24 months in the future.

Main Outcome and Measure

Health-related quality of life, measured by the St George's Respiratory Questionnaire-COPD at 3, 12, and 24 months.

Results

A total of 207 participants were included (median age, 65.5 years [range, 42.0-86.0 years]; 120 women [58.0%]; 118 Black [57.0%], 79 White [38.2%]). The consent rate among approached patients was 80.0%. Most patients reported no or only limited discussions of future health and symptom burdens with their clinicians. Across physical and emotional symptoms and all 3 time points, patients' expectations were more optimistic than their experiences. There were no consistent patterns of measured demographic or behavioral characteristics associated with expectation accuracy. Regression models revealed that overoptimistic expectations of future burdens of dyspnea (linear regression estimate, 4.68; 95% CI, 2.68 to 6.68) and negative emotions (linear regression estimate, -3.04; 95% CI, -4.78 to 1.29) were associated with lower health-related quality of life at 3 months after adjustment for baseline health-related quality of life, forced expiratory volume over 1 second, and interval clinical events (P < .001 for both). Similar patterns were observed at 12 months (dyspnea: linear regression estimate, 2.41; 95% CI, 0.45 to 4.37) and 24 months (negative emotions: linear regression estimate, -2.39; 95% CI, -4.67 to 0.12; dyspnea: linear regression estimate, 3.21; 95% CI, 0.82 to 5.60), although there was no statistically significant association between expectation of negative emotions and quality of life at 12 months.

Conclusions and Relevance

In this cohort study of patients with COPD, we found that patients are overoptimistic in their expectations about future negative symptom burdens, and such inaccuracies were independently associated with worse well-being over time. Developing and implementing strategies to improve patients' symptom expectations may improve patient-centered outcomes.

Psychosocial Aspects of Living Long Term with Advanced Cancer and Ongoing Systemic Treatment: A Scoping Review

(1) Background: Studies examining the psychosocial impact of living long term on systemic treatment in advanced cancer patients are scarce. This scoping review aimed to answer the research question “What has been reported about psychosocial factors among patients living with advanced cancer receiving life-long systemic treatment?”, by synthesizing psychosocial data, and evaluating the terminology used to address these patients; (2) Methods: This scoping review was conducted following the five stages of the framework of Arksey and O’Malley (2005); (3) Results: 141 articles published between 2000 and 2021 (69% after 2015) were included. A large variety of terms referring to the patient group was observed. Synthesizing qualitative studies identified ongoing uncertainty, anxiety and fear of disease progression or death, hope in treatment results and new treatment options, loss in several aspects of life, and worries about the impact of disease on loved ones and changes in social life to be prominent psychosocial themes. Of 82 quantitative studies included in the review, 76% examined quality of life, 46% fear of disease progression or death, 26% distress or depression, and 4% hope, while few studies reported on adaptation or cognitive aspects. No quantitative studies focused on uncertainty, loss, or social impact; (4) Conclusion and clinical implications: Prominent psychosocial themes reported in qualitative studies were not included in quantitative research using specific validated questionnaires. More robust studies using quantitative research designs should be conducted to further understand these psychological constructs. Furthermore, the diversity of terminology found in the literature calls for a uniform definition to better address this specific patient group in research and in practice.

Goals of care communication and higher-value care for patients with advanced-stage cancer: A systematic review of the evidence

CONTEXT

Goals-of-care communication (GOCC) is recommended to increase the value of cancer care near the end of life (EOL).

OBJECTIVES

Conduct a systematic review of the evidence that GOCC is associated with higher-value care.

METHODS

We searched PubMed, Scopus, Ovid MEDLINE, EMBASE, EMB Reviews, CINAHL, and PsycInfo from inception to July 2019. We analyzed the population,design, and results and the authors' definitions of GOCC. Risk of bias was assessed.

RESULTS

Thirty-two articles were selected. Ten articles reported results from 8 interventions; 17 characterized participants' perspectives; and 5 were retrospective The topics, behaviors, timing, and anticipated outcomes of GOCC varied significantly and were indistinguishable from practices such as advance care planning. GOCC typically focused on treatment outcomes rather than patients' goals. Four of 5 interventions increased evidence of GOCC after clinician training. Only one reported improved patient outcomes.

CONCLUSION

No consensus exists about what GOCC entails. There is limited evidence that GOCC increases the value of EOL care.

PRACTICE IMPLICATIONS

Future studies should focus on how to engage patients in conversations about their personal goals and integrate their goals into care planning. Clinicians can encourage GOCC by explaining how patients' goals influence decisions especially as treatment options become limited.

Reasons for acceptance and refusal of early palliative care in patients included in early-phase clinical trials in a regional comprehensive cancer centre in France: protocol for a qualitative study

INTRODUCTION

A few studies have highlighted the potential synergy between early palliative care and inclusion in an early-phase clinical trial that may improve quality of life, reduce symptoms of exhaustion related to the side effects of treatment and allow patients to complete their treatment protocol. The primary objective of this qualitative study is to evaluate the reasons for acceptance or refusal of early palliative care in patients included in early-phase clinical trials.

METHOD AND ANALYSIS

All patients from the Centre Léon Bérard (Comprehensive Cancer Centre in Lyon, France) who consent to one of the early-phase clinical trials proposed at the centre will be invited to participate in this study. The cohort will consist of a subgroup (n=20) of patients who accept palliative care together with their clinical trial, and a second subgroup (n=20) of patients who decline it. Patients will be interviewed in exploratory interviews conducted by a psychology researcher before the start of their clinical trial. The interviews will be audio-recorded. Patients will also be asked to complete quality of life and anxiety/depression questionnaires both before the beginning of the treatment and at the end of their clinical trial. The content of the interviews will be analysed thematically. Descriptive and comparative statistical analysis of both cohorts will also be conducted.

ETHICS AND DISSEMINATION

Personal data will be collected and processed in accordance with the laws and regulations in force. All patients will give informed consent to participate. This study complies with reference methodology MR004 of the Commission Nationale de l'Informatique et des Libertés. The protocol has received the validation of an ethics committee (Groupe de Réflexion Ethique du CLB, number: 2020-006). The results will be disseminated through conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT04717440.

Epistemic Beliefs: Relationship to Future Expectancies and Quality of Life in Cancer Patients

CONTEXT

Expectations about the future (future expectancies) are important determinants of psychological well-being among cancer patients, but the strategies patients use to maintain positive and cope with negative expectancies are incompletely understood.

OBJECTIVES

To obtain preliminary evidence on the potential role of one strategy for managing future expectancies: the adoption of "epistemic beliefs" in fundamental limits to medical knowledge.

METHODS

A sample of 1307 primarily advanced-stage cancer patients participating in a genomic tumor testing study in community oncology practices completed measures of epistemic beliefs, positive future expectancies, and mental and physical health-related quality of life (HRQOL). Descriptive and linear regression analyses were conducted to assess the relationships between these factors and test two hypotheses: 1) epistemic beliefs affirming fundamental limits to medical knowledge ("fallibilistic epistemic beliefs") are associated with positive future expectancies and mental HRQOL, and 2) positive future expectancies mediate this association.

RESULTS

Participants reported relatively high beliefs in limits to medical knowledge (M = 2.94, s.d.=.67) and positive future expectancies (M = 3.01, s.d.=.62) (range 0-4), and relatively low mental and physical HRQOL. Consistent with hypotheses, fallibilistic epistemic beliefs were associated with positive future expectancies (b = 0.11, SE=.03, P< 0.001) and greater mental HRQOL (b = 0.99, SE=.34, P = 0.004); positive expectancies also mediated the association between epistemic beliefs and mental HRQOL (Sobel Z=4.27, P<0.001).

CONCLUSIONS

Epistemic beliefs in limits to medical knowledge are associated with positive future expectancies and greater mental HRQOL; positive expectancies mediate the association between epistemic beliefs and HRQOL. More research is needed to confirm these relationships and elucidate their causal mechanisms.

Patients in phase 1 cancer trials: psychological distress and understanding of trial information

BACKGROUND

Psychological distress may be present among patients who are considering enrollment in phase 1 cancer trials, as they have advanced cancer and no documented treatment options remain. However, the prevalence of psychological distress has not been previously investigated in larger cohorts. In complex phase 1 cancer trials, it is important to ensure adequate understanding of the study premises, such as the undocumented effects and the risk of adverse events.

MATERIALS AND METHODS

In a prospective study, patients completed questionnaires at two time points. We investigated psychological distress, measured as stress, anxiety, and depression, among patients at their first visit to the phase 1 unit (N = 229). Further, we investigated the understanding of trial information among patients who were enrolled in a phase 1 cancer trial (N = 57).

RESULTS

We enrolled 75% of 307 eligible patients. We found a lower mean score of stress in our population compared to population norms, while the mean scores of anxiety and depression were higher. A total of 9% showed moderate to severe symptoms of anxiety and 11% showed moderate to severe symptoms of depression, which indicates higher levels than cancer patients in general. A total of 46 (81% of enrolled patients) completed questionnaires on trial information and consent. The understanding of the information on phase 1 cancer trials in these patients was slightly lower than the level reported for cancer trials in general. Some aspects relating to purpose, benefit, and additional risks were understood by fewer than half of the patients.

CONCLUSION

Our results suggest that distress is not as prevalent in the population of patients referred to phase 1 cancer trials as in the general cancer population. Although patients' understanding of trial information was reasonable, some aspects of complex phase 1 cancer trials were not easily understood by enrolled patients.

Anxiety Shapes Expectations of Therapeutic Benefit in Phase I Trials for Patients With Advanced Cancer and Spousal Caregivers

PURPOSE

Advanced cancer patients (ACP) hope to receive significant therapeutic benefit from phase I trials despite terminal disease and presumed symptom burdens. We examined associations between symptom burdens and expectations of therapeutic benefit for ACP and spousal caregivers (SC) during phase I trials.

PATIENTS AND METHODS

A prospective cohort of ACP-SC enrolled in phase I trials was assessed at baseline and one month using symptom burden measures evaluating depression, state-trait anxiety, quality of life, global health, post-traumatic coping, and marital adjustment. Interviews evaluated expectations of benefit.

RESULTS

Fifty-two phase I ACP and 52 SC (N = 104) were separately assessed and interviewed at baseline and one month. Total population demographics included the following: median age 61 years (28-78), 50% male, 100% married, 90% White, and 46% ≥ college education. At T1, ACP reported symptoms of mild state anxiety, mild trait anxiety, poor global health, and quality of life. SC reported moderate state and mild trait anxiety and good global health with little disability at baseline. State anxiety was a significant predictor of ACP expectations for phase I producing the following therapeutic benefits: stabilization (P = .01), shrinkage (P < .01), and remission (P = .04). Regression analyses also revealed negative associations between SC expectation for stabilization and SC anxiety: state (P = .01) and trait (P = .02). ACP quality of life was also negatively associated with SC expectations for stabilization (P = .02) and shrinkage (P = .01).

CONCLUSION

Anxiety, both state and trait, impacts couples' beliefs regarding the likelihood of therapeutic benefit from phase I trial participation.

Reassessing the measurement and presence of therapeutic misconception in a phase 1 setting

BACKGROUND

Therapeutic misconception (TM) refers to research subjects' failure to distinguish the goals of clinical research from standard personal care. TM has traditionally been determined by questioning the patient about the research study's purpose. Recent research, however, has questioned whether TM is as prevalent as reported due to discrepancies between patient/researcher interpretations of TM questions. The authors have created an interview tool receptive to these advancements to more accurately determine the prevalence of TM.

METHODS

Patients were questioned about the trial's purpose as follows: 1) "Is the trial mostly intending to help research and gain knowledge?," 2) "Is it mostly intending to help you as a person?," or 3) "Don't know." Participants were then asked what they thought this question was asking: A) "What my own intentions are for participating," B) "What the official purpose of the research study is," or C) "Not sure." A patient exhibited TM by answering that the official trial purpose was to help him or her.

RESULTS

Patients (n = 98) had a mean age of 60 years, were mostly White (64%), had a combined family annual income ≥$60,000 (61%), and 49% had a college degree. Twelve of 98 patients (12%) definitely exhibited TM. This was much lower than the author's original finding of 68% in a similar cohort. Twenty-four of 98 patients (24.5%) were unclear about what one or both questions were asking and could not be categorized.

CONCLUSIONS

Previously, a patient was thought to have TM if they answered that the purpose of the trial was to benefit to him or her. An additional query about how patients interpreted that question revealed only 12% definitely had TM.

LAY SUMMARY

Therapeutic misconception (TM) refers to research subjects' failure to distinguish the goals of clinical research from standard personal care. TM signals a basic misunderstanding of the purpose of clinical research, threatening valid informed consent to participate in clinical trials. TM has traditionally been determined by questioning patients about their research study's purpose. Recent research, however, has questioned whether TM is as prevalent due to discrepancies between patient/researcher interpretations of TM questions. By developing an interview-tool receptive to these advancements, we report a lower TM estimate in the phase 1 setting (12%) than we found previously in a similar cohort (68%).

Immune Activation and Anemia Are Associated with Decreased Quality of Life in Patients with Solid Tumors

Anemia often coincides with depression and impaired quality of life (QoL) in cancer patients. Sustained immune activation can lead to the development of anemia. Furthermore, it also may go along with changes in tryptophan and phenylalanine metabolism. The aim of our pilot study was to study the relationship between anemia, immune-mediated changes in amino acid metabolism, and the QoL and mood of cancer patients. Questionnaires to measure QoL and depression were completed by 152 patients with solid tumors. Hemoglobin, parameters of immune activation as well as tryptophan and phenylalanine metabolism were determined in the patients’ sera. Anemic patients (51.7%) presented with higher inflammatory markers, and a higher tryptophan breakdown with lower tryptophan concentrations. They reported an impaired QoL and had higher depression scores. Patients with an impaired QoL (65.8%) also suffered from more fatigue and impaired physical, emotional, and social functioning. They, furthermore, presented with higher concentrations of inflammatory markers (C-reactive protein (CRP) and neopterin) as well as higher tryptophan degradation (in men) and higher phenylalanine concentrations (in women). Sixty-one patients (40.1%) had (mostly mild) depression. In these patients, a higher degree of Th1 immune activation was found. The results of our study suggest that cancer-related anemia goes along with an impaired QoL, which is also associated with immune-mediated disturbances of tryptophan and phenylalanine metabolism.

Development of the generic, multidimensional Treatment Expectation Questionnaire (TEX-Q) through systematic literature review, expert surveys and qualitative interviews

OBJECTIVE

Patients' expectations-as a central mechanism of placebo and nocebo effects-are an important predictor of health outcomes. However, the lack of a way to assess expectations across different settings restricts progress in understanding the role of expectations and to quantify their importance in medical and psychological treatments. The aim of this study was to develop a theory-based, generic, multidimensional measure assessing patient expectations of medical and psychological treatments.

DESIGN

The Treatment Expectation Questionnaire (TEX-Q) was developed based on the integrative model of expectations and a systematic literature review of treatment expectation scales. After creating a comprehensive item pool, the scale was further refined by use of expert ratings and patient interviews.

SETTING

Patients were recruited in primary care at two hospitals in Hamburg, Germany.

PARTICIPANTS

13 scientific experts participated in the expert survey. 11 patients waiting for psychological or surgical treatments participated in the qualitative interviews.

RESULTS

The 2×2×2 multidimensional structure of the TEX-Q assesses two expectation constructs (probabilistic vs value-based) across two outcome domains with two valences (direct benefits and adverse events, broader positive and negative impact), plus process and behavioural control expectations. We examined 583 items from 38 scales identified in the systematic review and developed 78 initial items. Content validity was then rated by experts according to item fit and comprehensibility. The best 53 items were further evaluated for comprehensibility, acceptability, phrasing preference and understanding by interviewing patients prior to treatment using the 'think aloud' technique. This resulted in a first 35-item version of the TEX-Q.

CONCLUSIONS

The TEX-Q is a generic, multidimensional measure to assess patient expectations of medical and psychological treatments and allows comparison of the impact of multidimensional expectations across different conditions. The final TEX-Q will be available after psychometric validation.

Expectations and anxieties of Duchenne muscular dystrophy patients and their families during the first-in-human clinical trial of NS-065/NCNP-01

Duchenne muscular dystrophy (DMD) is a recessive X-linked genetic disease caused by a mutation in the dystrophin gene. The new drug NS-065/NCNP-01 utilizing exon-skipping therapy targeting specific deletions has been used in a first-in-human trial for the treatment of DMD. We surveyed 10 pairs of DMD participants and their parents within this clinical trial via an iPad survey form and through interviews regarding their understanding of the trial, expectations, anxieties, and reasons for participating in the trial. Approximately half of the participants actively decided to participate of their own volition, and none considered quitting the trial. This indicates that participants participated more positively in this clinical trial than previously expected. However, some potential concerns were also revealed, with one being that the desire to please those around them might be more important to the DMD participants than the effects of the drug. Another issue is the possibility of biased information originating from the study subjects' parents; while seven out of 10 of the parents told their children that the study drug might work, only four of these parents also explained that it might not work. Only two study participants received an explanation concerning the drug's side effects from their parents. This result implies that caution should be taken when family expectations are high, and there is a possibility that subjects will be given biased information from their parents.

Cortisol response to stress: The role of expectancy and anticipatory stress regulation

An exacerbated physiological response to stress is associated with the development of stress-related disorders (e.g., depression and anxiety disorders). Recently, it has been proposed that individuals with high expectancies of being able to deal with stressful situations will activate regulatory mechanisms during the anticipation of the stressful event that would improve stress regulation. To test this hypothesis, 52 women in young adulthood (M = 21.06; SD = 2.58) anticipated and performed a laboratory-based stress task after receiving positive or negative bogus feedback on their abilities to deal with stressful events. Heart rate variability and salivary cortisol were assessed throughout the experimental protocol. Participants receiving positive bogus feedback (i.e., High Expectancy group) showed a more positive anticipatory cognitive stress appraisal (i.e., they anticipated the stress task as less threatening/challenging, and they perceived that they were more able to deal with it), and they showed a lower cortisol response to stress. Moreover, a more positive anticipatory cognitive stress appraisal was associated with better anticipatory stress regulation (indexed as less decrease in heart rate variability), leading to a lower cortisol response. Our results indicate that people with positive expectancy initiate mechanisms of anticipatory stress regulation that enhance the regulation of the physiological stress response. Expectancy and anticipatory stress regulation may be key mechanisms in the development and treatment of stress-related disorders.

Parents', Health Care Professionals', and Scientists' Experiences of a Precision Medicine Pilot Trial for Patients With High-Risk Childhood Cancer: A Qualitative Study

PURPOSE

Children with high-risk cancers have low survival rates because current treatment options are limited. Precision medicine trials are designed to offer patients individualized treatment recommendations, potentially improving their clinical outcomes. However, parents' understanding is often limited, and expectations of benefit to their own child can be high. Health care professionals (HCPs) are often not familiar with precision medicine and might find managing families' expectations challenging. Scientists find themselves working with high expectations among different stakeholders to rapidly translate their identification of actionable targets in real time. Therefore, we wanted to gain an in-depth understanding of the experiences of all stakeholders involved in a new precision medicine pilot trial called TARGET, including parents, their child's HCPs, and the scientists who conducted the laboratory research and generated the data used to make treatment recommendations.

METHODS

We conducted semistructured interviews with all participants and analyzed the interviews thematically.

RESULTS

We interviewed 15 parents (9 mothers; 66.7% bereaved), 17 HCPs, and 16 scientists. We identified the following themes in parents' interviews: minimal understanding and need for more information, hope as a driver of participation, challenges around biopsies, timing, and drug access, and few regrets. HCP and scientist interviews revealed themes such as embracing new technologies and collaborations and challenges managing families' expectations, timing of testing and test results, and drug access.

CONCLUSION

Educating families, HCPs, and scientists to better understand the benefits and limitations of precision medicine trials may improve the transparency of the translation of discovery genomics to novel therapies, increase satisfaction with the child's care, and ameliorate the additional long-term psychosocial burden for families already affected by high-risk childhood cancer.

Development of the State Optimism Measure

BACKGROUND

Optimism, or positive expectations about the future, is associated with better health. It is commonly assessed as a trait, but it may change over time and circumstance. Accordingly, we developed a measure of state optimism.

METHODS

An initial 29-item pool was generated based on literature reviews and expert consultations. It was administered to three samples: sample 1 was a general healthy population (n = 136), sample 2 was people with cardiac disease (n = 96), and sample 3 was persons recovering from problematic substance use (n = 265). Exploratory factor analysis and item-level descriptive statistics were used to select items to form a unidimensional State Optimism Measure (SOM). Confirmatory factor analysis (CFA) was performed to test fit.

RESULTS

The selected seven SOM items demonstrated acceptable to high factor loadings on a single dominant factor (loadings: 0.64-0.93). There was high internal reliability across samples (Cronbach's alphas: 0.92-0.96), and strong convergent validity correlations in hypothesized directions. The SOM's correlations with other optimism measures indicate preliminary construct validity. CFA statistics indicated acceptable fit of the SOM model.

CONCLUSIONS

We developed a psychometrically-sound measure of state optimism that can be used in various settings. Predictive and criterion validity will be tested in future studies.

Reflections on translation: Views of participants in a multisite Canadian CCSVI clinical trial

Background

We sought to characterize the perspectives of participants in Canada's phase I/II chronic cerebrospinal venous insufficiency (CCSVI) clinical trial prior to and after the disclosure of trial results.

Methods

This was a researcher-administered survey of individuals who participated in Canada's CCSVI trial (Clincialtrials.gov, NCT01864941) about their (1) motivations for participating, (2) understanding of the trial process, and (3) perspectives on the social value of the trial.

Results

A total of 63 participants completed the survey. Participants were motivated to participate by altruism (mean score = 4.56 out of 5) and a desire to access the intervention in Canada (mean score = 3.63 out of 5). Many participants expected medical benefits, such as partial disease reversal (mean score = 3.32 out of 5). Participants felt strongly that the crossover trial design promoted fairness (mean score = 4.65 out of 5). Participants' familiarity with the CCSVI controversy increased significantly after the results were revealed (p = 0.0001). Despite negative trial results, participants still felt that the trial was an appropriate use of tax dollars (mean score = 4.68 out of 5). Many (38%) upheld the belief that further CCSVI research is necessary (responses of 4 out of 5 or higher).

Conclusions

There is a strong movement in science today to ensure that research agendas reflect the perspectives of multiple stakeholders, including research participants. While previous work suggests that negative findings adversely affect trust in science, the perspectives of participants in this study demonstrate that good trial design and resilience can prevail over expected tensions.

Relationship among symptom clusters, quality of life, and treatment-specific optimism in patients with cancer

PURPOSE

There is increasing evidence that disease and therapy-related symptoms frequently co-occur in so-called symptom clusters (SCs), which may significantly impair quality of life in patients with cancer. Although psychosocial resources may play pivotal roles in maintaining or improving quality of life, they have been neglected in SC research. Therefore, we aim to identify SCs and their relative impact on quality of life when psychosocial resources are accounted for.

METHODS

Patients with cancer (n = 304) undergoing chemotherapy or chemo-radiation therapy participated in a cross-sectional survey consisting of measures assessing symptoms, quality of life, resilience, treatment-specific optimism (TSO), and social support. Exploratory factor analyses and multiple regression analyses were used to identify SCs and significant explanatory variables of overall quality of life.

RESULTS

Fatigue-pain, anxiety-depression, cancer therapy-related toxicity, and nausea-vomiting clusters were identified. In our final model, the fatigue-pain cluster (β = - 0.41, p < 0.001), nausea-vomiting cluster (β = - 0.28, p < 0.001), TSO (β = 0.21, p < 0.001), and receiving chemo-radiation treatment (β = - 0.11, p = 0.03) accounted for 44% of variance in overall quality of life. However, the identified SCs explained quality of life in patients with varying levels of TSO to a different extent.

CONCLUSIONS

Our findings indicate that the TSO of patients may be a major factor to consider in managing SCs, because-depending on its level-different SCs and even clusters encompassing comparatively less distressing symptoms (i.e., cancer therapy-related toxicities) may strongly affect quality of life.

Do Patients With Advanced Cancer Have the Ability to Make Informed Decisions for Participation in Phase I Clinical Trials?

Purpose Patients with advanced cancer (ACPs) participating in phase I clinical trials inadequately understand many elements of informed consent (IC); however, the prevalence and impact of cognitive impairment has not been described. Patients and Methods ACPs enrolled onto phase I trials underwent neuropsychological assessment to evaluate cognitive functioning (CF) covering the following domains: memory (Hopkins Verbal Learning Test), executive functioning (Trail Making Test B), language (Boston Naming Test-Short Version and Controlled Oral Word Association Test), attention (Trail Making Test A and Wechsler Adult Intelligenence Scale-IV Digit Span), comprehension (Wechsler Adult Intelligence Scale-IV), and quality of life (Functional Assessment of Cancer Therapy-Cognitive Function). Structured interviews evaluated IC and decisional capacity. Psychological measures included distress (Hospital Anxiety Depression Scale) and depression (Beck Depression Inventory-II). Results One hundred eighteen ACPs on phase I trials were evaluated, with CF ranging from mild impairment to superior performance. Only 45% of ACPs recalled physician disclosure of the phase I trial purpose. The 50% of ACPs who correctly identified the phase I research purpose had greater CF compared with ACPs who did not, as revealed by the mean T scores for memory (37.2 ± 5.6 v 32.5 ± 5.1, respectively; P = .001), attention (29 ± 2.7 v 26.9 ± 2.4, respectively; P < .001), visual attention (35.2 ± 6.6 v 31.5 ± 6.2, respectively; P = .001), and executive function (38.9 ± 7.5 v 34 ± 7.1, respectively; P < .001). Older ACPs (≥ 60 years) were less likely to recall physician disclosure of phase I purpose than younger ACPs (30% v 70%, respectively; P = .02) and had measurable deficits in total memory (34.2 ± 5.0 v 37.3 ± 5.6, respectively; P = .002), attention (24.5 ± 2.6 v 28 ± 2.8, respectively; P < .001), and executive function (32.8 ± 7.3 v 36.4 ± 7.6, respectively; P = .01). Older ACPs, compared with younger ACPs, also had greater depression scores (10.6 ± 9.2 v 8.1 ± 5.2, respectively; P = .03) and lower quality-of-life scores (152 ± 29.6 v 167 ± 20, respectively; P = .03). After adjustment by age, no psychological or neuropsychological variable was further significantly associated with likelihood of purpose identification. Conclusion CF seems to play a role in ACP recall and comprehension of IC for early-phase clinical trials, especially among older ACPs.

Investigator Disclosure and Advanced Cancer Patient Understanding of Informed Consent and Prognosis in Phase I Clinical Trials

PURPOSE

Advanced cancer patients (ACPs) who participate in phase I clinical trials often report a less-than-ideal understanding of the required elements of informed consent (IC) and unrealistic expectations for anticancer benefit and prognosis. We examined phase I clinical trial enrollment discussions and their associations with subsequent ACP understanding.

METHODS

Clinical encounters about enrollment in phase I trials between 101 ACPs and 29 oncologists (principal investigators [PIs] and fellows) at three US academic medical institutions were recorded. The Roter Interaction Analysis System was used for analysis. ACPs completed follow-up questionnaires to assess IC recall.

RESULTS

PIs disclosed the following phase I IC elements to ACPs in encounters: trial purpose in 40%; specific physical risks in 60%; potential specific medical benefits gained by trial participation (eg, disease stabilization) in 48.2%; and alternatives to phase I trial participation in 47.1%, with 1.1% of encounters containing palliative and 2.3% hospice information. PIs provided ACP-specific prognoses in 29.0% of encounters but used precise terms of death in only 4.7% and terminal in 1.2%. A significant association existed between PI disclosure of the trial purpose as dosage/toxicity, and ACPs subsequently correctly recalled trial purpose versus PIs who did not disclose it (85% v 13%; P < .05).

CONCLUSION

Many oncologists provide incomplete disclosures about phase I trials to ACPs. When disclosure of certain elements of IC occurs, it seems to be associated with better recall, especially with regard to the research purpose of phase I trials.

Interest in initiating an early phase clinical trial: results of a longitudinal study of advanced cancer patients

OBJECTIVE

Enhanced recruitment of patients with advanced cancer (ACP) to early phase (EP) trials is needed. However, selective recruitment may affect the kinds of patients who are recruited. To address whether ACP who initiate EP trial enrollment differ from those who do not, we prospectively surveyed ACP well in advance of potential trial recruitment and followed them over time to identify those who initiated the recruitment process.

METHODS

EP trial initiation was defined as a patient being referred for screening to an active EP trial. Depression and anxiety were assessed with the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Scale (GAD-7), respectively. Demographic and disease characteristics, functional status, and patient preferences regarding decision making were examined as possible predictors of EP trial initiation.

RESULTS

Of the 78 advanced cancer patients in the cohort studied, 21 (27%) initiated EP trial participation, while 57 (73%) did not. Of those who initiated this process, 14 (67%) went on to enroll in an EP study. Level of depression severity was associated with EP trial initiation, with rates of initiation nearly three times higher (35% vs. 12%, p = 0.054) among patients with minimal to mild levels of depression compared to those with moderate or higher levels of depression. EP trial initiation was not associated with demographic or socioeconomic variables, cancer type, functional status, quality of life, or decision-making variables.

CONCLUSIONS

The presence of elevated depressive symptoms may be associated with the EP trial recruitment and enrollment processes. This possible relationship warrants further study. Copyright © 2016 John Wiley & Sons, Ltd.

Qualitative analysis of clinical research coordinators' role in phase I cancer clinical trials

Background

Clinical research coordinators play a pivotal role in phase I cancer clinical trials.

Purpose

We clarified the care coordination and practice for patients provided by clinical research coordinators in phase I cancer clinical trials in Japan and elucidated clinical research coordinators' perspective on patients' expectations and understanding of these trials.

Method

Fifteen clinical research coordinators participated in semi-structured interviews regarding clinical practices; perceptions of patients' expectations; and the challenges that occur before, during, and after phase I cancer clinical trials.

Discussion

Qualitative content analysis showed that most clinical research coordinators observed that patients have high expectations from the trials. Most listened to patients to confirm patients' understanding and reflected on responses to maintain hope, but to avoid excessive expectations; clinical research coordinators considered avoiding unplanned endings; and they aimed to establish good relationships between patients, medical staff, and among the professional team.

Conclusions

Clinical research coordinators were insightful about the needs of patients and took a meticulous approach to the phase I cancer clinical trial process, allowing time to connect with patients and to coordinate the inter-professional research team. Additionally, education in advanced oncology care was valuable for comforting participants in cancer clinical trials.

Understanding how coping strategies and quality of life maintain hope in patients deliberating phase I trial participation

OBJECTIVE

This study aimed to understand how hope and motivation of patients considering phase I trial participation are affected by psychological factors such as coping strategies and locus of control (LoC) and general well-being as measured by the quality of life (QoL).

METHODS

An exploratory cross-sectional study was performed in patients with incurable cancer (N = 135) referred to our phase I unit for the first time. Patients were potentially eligible for phase I trial participation and participated in our study while deliberating phase I trial participation. We used questionnaires on hope, motivation to participate, coping, LoC, and QoL. To investigate the nature and magnitude of the relationships between the scales, a structural equation modeling (SEM) was fitted to the data.

RESULTS

Hope significantly predicted the motivation to participate in phase I trials. Predictors of hope were a combination of flexible and tenacious goal pursuit (both P < .01), internal LoC (P < .01), and QoL (P < .01). The SEM showed an exact fit to the data, using a null hypothesis significance test: chi-square (8) = 9.30, P = .32.

CONCLUSIONS

Patients considering phase I trial participation seem to use a pact of tenacious and flexible coping and control to stay hopeful. Furthermore, hope and QoL positively affected each other. The psychological pact may promote an adaptation enabling them to adjust to difficult circumstances by unconsciously ignoring information, called dissonance reduction. This mechanism may impair their ability to provide a valid informed consent. We suggest including a systematic exploration of patients' social context and values before proposing a phase I trial.

Psychological Disorders and Psychosocial Resources of Patients with Newly Diagnosed Bladder and Kidney Cancer: A Cross-Sectional Study

PURPOSE

Psychological disorders have been proven to be associated with poor physiological, psychological and immune outcomes in cancer patients. However, despite of many challenges of the changed self-image/body image and the altered sexual/urinary function, relatively little is known about psychological disorders of patients with newly diagnosed bladder and kidney cancer. We aimed to investigate the prevalence of depression, anxiety, post-traumatic stress disorder (PTSD) and the associated psychosocial factors among bladder/kidney cancer patients.

METHODS

A cross-sectional study was conducted of consecutive inpatients with bladder/kidney cancer in the First Affiliated Hospital of China Medical University in Liaoning Province, northeast China. A total of 489 early-stage cancer patients eligible for this study completed questionnaires on demographic and clinical variables, depression, anxiety, PTSD, perceived social support and positive psychological variables (hope, optimism and resilience) anonymously during October 2013 and August 2014. Hierarchical regression analysis was used to examine the relationships between psychosocial resources and psychological disorders, while controlling for possible covariates.

RESULTS

The prevalence of depression, anxiety and PTSD was 77.5%, 69.3% and 25.2%, respectively, while 24.9% of patients had psychological co-morbidity. Psychosocial resources together explained more than one-third of the variance on psychological disorders. Under standardized estimate (β) sequence, patient's perception of social support from family was significantly associated with depression, anxiety and PTSD (p < 0.01). Optimism and resilience showed integrated and independent effects on psychological disorders, and hope represented the significant association with PTSD only (p < 0.01).

CONCLUSIONS

The high prevalence of psychological disorders in newly diagnosed patients with early-stage bladder/kidney cancer should receive more attention in Chinese medical settings. Additionally, in consideration of the different protective effects of psychosocial resources, the present study demonstrated that one complete psychological intervention integrating the associated psychosocial factors are necessary to ameliorate psychological disorders so as to provide patients with a more holistic cancer care.

Ethical Challenges in Early-Phase Pediatric Research for Life-Limiting Illness

Research with children is necessary to assure more effective treatments and potential cures of childhood illnesses. Ethical conduct of research requires minimizing the inherent risks of research, especially when it involves vulnerable populations such as children. Duchenne muscular dystrophy (DMD) is a progressive and fatal disease with no Food and Drug Administration-approved treatment. Clinical trials investigating so-called gene therapies are viewed by many in the DMD community with great promise. The goal of research is to secure generalizable knowledge and not directly benefit patients, yet many parents of boys with DMD hope, and even expect, that their sons will derive medical benefit by participating in early-phase "gene therapy" trials, raising concern for the therapeutic misconception. Physician-investigators must assist patient-subjects to distinguish realistic from unrealistic hope while maintaining reasonable expectations. In this article, I examine the therapeutic misconception and related concepts as framed within the context of "gene therapy" for DMD.

Participants' understanding of informed consent in clinical trials over three decades: systematic review and meta-analysis

OBJECTIVE

To estimate the proportion of participants in clinical trials who understand different components of informed consent.

METHODS

Relevant studies were identified by a systematic review of PubMed, Scopus and Google Scholar and by manually reviewing reference lists for publications up to October 2013. A meta-analysis of study results was performed using a random-effects model to take account of heterogeneity.

FINDINGS

The analysis included 103 studies evaluating 135 cohorts of participants. The pooled proportion of participants who understood components of informed consent was 75.8% for freedom to withdraw at any time, 74.7% for the nature of study, 74.7% for the voluntary nature of participation, 74.0% for potential benefits, 69.6% for the study's purpose, 67.0% for potential risks and side-effects, 66.2% for confidentiality, 64.1% for the availability of alternative treatment if withdrawn, 62.9% for knowing that treatments were being compared, 53.3% for placebo and 52.1% for randomization. Most participants, 62.4%, had no therapeutic misconceptions and 54.9% could name at least one risk. Subgroup and meta-regression analyses identified covariates, such as age, educational level, critical illness, the study phase and location, that significantly affected understanding and indicated that the proportion of participants who understood informed consent had not increased over 30 years.

CONCLUSION

The proportion of participants in clinical trials who understood different components of informed consent varied from 52.1% to 75.8%. Investigators could do more to help participants achieve a complete understanding.

Clinical trial participation as part of end-of-life cancer care: associations with medical care and quality of life near death

CONTEXT

Clinical trials are a common therapeutic option for patients with advanced incurable cancer.

OBJECTIVES

To examine the associations between trial participation and end-of-life (EOL) outcomes, including aggressive care and quality of life (QOL).

METHODS

Coping with Cancer, a multicenter prospective cohort study of patients with metastatic cancer, progressed after at least first-line chemotherapy. Baseline chart review documented clinical trial participation. Baseline interviews assessed psychosocial characteristics and EOL preferences. Caregiver interview and chart review assessed medical care and QOL near death. The primary outcome was aggressive EOL care (ventilation, resuscitation, or intensive care unit admission in last week of life). Propensity score weighting balanced patient characteristics that differed by trial participation, including care preferences and EOL discussion. Propensity score-weighted regression models estimated the effect of trial participation on outcomes.

RESULTS

Of 352 patients followed to death, 37 were enrolled in a clinical trial at baseline. In propensity score-weighted analyses, trial participation was significantly associated with aggressive EOL care (21.6% vs. 12.0%, adjusted odds ratio [AOR] 2.04, 95% confidence interval [CI] 1.00-4.15), late hospice enrollment (51.4% vs. 42.2%, AOR 1.96, 95% CI 1.10-3.50), hospital death (48.6% vs. 25.7%, AOR 2.74, 95% CI 1.37-5.47), intensive care unit death (16.2% vs. 6.3%, AOR 3.53, 95% CI 1.29-9.65), and inferior QOL near death (least squares mean 5.93 vs. 7.69, P<0.001). Controlling for EOL care, trial enrollment was no longer associated with QOL near death (P=0.342).

CONCLUSION

Clinical trial participation is associated with aggressive EOL care. Aggressive EOL care appears to explain the association between trial participation and QOL near death.

Prevalence and associated positive psychological variables of depression and anxiety among Chinese cervical cancer patients: a cross-sectional study

BACKGROUND

The prevalence of depression and anxiety and its associated factors in cervical cancer are not well evaluated in China. Meanwhile, with increasing attention given to positive psychological variables in oncology field, there is a need to conduct a study to explore the integrative effects of positive psychological variables on depression/anxiety so as to provide patients a more holistic cancer care. The aim of this study was to assess the prevalence of depression/anxiety as well as the integrative effects of hope, optimism and general self-efficacy on depression/anxiety among Chinese cervical cancer patients.

METHODS

A multi-centre, cross-sectional study was conducted of consecutive inpatients at the Liaoning Cancer Hospital & Institute and the Shengjing Hospital of China Medical University in Liaoning Province, northeast China. A total of 224 cervical cancer patients eligible for this study completed questionnaires on demographic and clinic variables, Hospital Anxiety and Depression Scale, Herth Hope Index, Life Orientation Scale-Revised, and General Self-Efficacy Scale during February and August 2013.

RESULTS

The prevalence of depression and anxiety was 52.2% and 65.6% in cervical cancer patients. The anxiety score was significantly higher in patients at the period of 4-6 months after diagnose and at cancer stage II. Hierarchical regression analyses indicated that hope, optimism and general self-efficacy as a whole accounted for 31.3% variance of depression and 35.6% variance of anxiety. Under standardized estimate (β) sequence, hope, optimism and general self-efficacy significantly associated with depression, respectively; hope and optimism were also significant individual predictors of anxiety.

CONCLUSIONS

The high prevalence of depression and anxiety among cervical cancer patients should receive more attention in Chinese medical settings. More importantly, efforts to develop the integrated psychosocial interventions are effective and necessary to alleviate depression/anxiety in cervical cancer patients by synthesizing and integrating the individual protective effects of hope, optimism and general self-efficacy.

I've had a good life, what's left is a bonus: factor analysis of the Mental Adjustment to Cancer Scale in a palliative care population

BACKGROUND

The Mental Adjustment to Cancer Scale is an assessment tool commonly used to measure coping in cancer patients, which characterises adaptive coping under the label of 'fighting spirit'.

AIM

This study explores adaptation in patients with advanced cancer, by examining the factor structure of the Mental Adjustment to Cancer Scale. Further aims were to examine associations between types of coping and psychological outcomes measured at the same time (time 1) and 4 weeks after referral to palliative care services (time 2).

DESIGN

A cross-sectional study with a follow-up assessment 4 weeks later. Factor analysis examined the structure of the Mental Adjustment to Cancer Scale at time 1.

SETTING/PARTICIPANTS

A total of 275 patients with advanced cancer receiving palliative care, of whom 193 took part at follow-up.

RESULTS

This study provided evidence for the internal consistency and validity of a new scale of 'acceptance and positivity' for use in advanced cancer patients. Patients with a desire for hastened death had lower acceptance and positivity, and patients with higher global quality of life reported a higher level. Social support was positively associated with acceptance and positivity. Higher scores on the acceptance and positivity scale were associated with reduced odds of a desire for hastened death at time 2.

CONCLUSION

Adaptation to advanced cancer differs from adaptation to early stage cancer, comprising a general acceptance of the illness and trying to make the most of the time that is left. Individuals with low social support were less likely to evidence appropriate adaptation to their illness.

Optimism, social support, and mental health outcomes in patients with advanced cancer

OBJECTIVE

Optimism and social support serve as protective factors against distress in medically ill patients. Very few studies have specifically explored the ways in which these variables interact to impact quality of life (QOL), particularly among patients with advanced cancer. The present study examined the role of optimism as a moderator of the relationship between social support and anxiety, depression, hopelessness, and QOL among patients with advanced cancer.

METHODS

Participants (N = 168) completed self-report assessments of psychosocial, spiritual, and physical well-being, including social support, optimism, hopelessness, depressive and anxious symptoms, and QOL. Hierarchical multiple regression analyses were conducted to determine the extent to which social support and optimism were associated with depressive and anxious symptomatology, hopelessness and QOL, and the potential role of optimism as a moderator of the relationship between social support and these variables.

RESULTS

Higher levels of optimism were significantly associated with fewer anxious and depressive symptoms, less hopelessness, and better QOL. Higher levels of perceived social support were also significantly associated with better QOL. Additionally, optimism moderated the relationship between social support and anxiety, such that there was a strong negative association between social support and anxiety for participants with low optimism.

CONCLUSIONS

This study highlights the importance of optimism and social support in the QOL of patients with advanced cancer. As such, interventions that attend to patients' expectations for positive experiences and the expansion of social support should be the focus of future clinical and research endeavors.

A literature review of the social and psychological needs of ovarian cancer survivors

OBJECTIVE

To identify and comprehensively present the psychosocial needs of ovarian cancer (OvCa) survivors, including young survivors <45 years of age.

METHODS

A literature review was conducted using keywords specific to psychosocial health and OvCa survivorship to identify peer-reviewed, original research articles published in English between January 2000 and December 2010; 28 articles were identified as relevant. Articles were abstracted and results categorized according to six psychosocial domains: quality of life (QoL), social support and relationships, self-image and sexual functioning, psychological distress and functioning, fear of death/recurrence, and personal growth and coping. Findings unique to young survivors are presented when applicable. Psychosocial measurement tools used in relevant studies are also presented.

RESULTS

Physical complications and side effects have significant impact on OvCa survivors' psychosocial health. Access to social support services and relational support is critical, as feelings of isolation are common. Survivors report low levels of sexual activity and satisfaction, potentially causing strain on personal relationships, and survivors experience high levels of distress, depression, and anxiety. However, QoL can improve after diagnosis for some OvCa survivors, many of whom report spiritual growth and strengthened personal relationships. Younger survivors are likely to have greater distress and lower QoL compared with older survivors.

CONCLUSIONS

OvCa is the deadliest of all gynecologic cancers, greatly impacting the psychosocial health of survivors. Increased awareness of psychosocial health among OvCa survivors themselves, their social support system, and their health care providers is necessary to adequately address their unique needs.

Unrealistic optimism and the ethics of phase I cancer research

One of the most pressing ethical challenges facing phase I cancer research centres is the process of informed consent. Historically, most scholarship has been devoted to redressing therapeutic misconception, that is, the conflation of the nature and goals of research with those of therapy. While therapeutic misconception continues to be a major ethical concern, recent scholarship has begun to recognise that the informed consent process is more complex than merely a transfer of information and therefore cannot be evaluated only according to how well an individual understands such information. Other components of decision-making operate independently of understanding and yet still may compromise the quality of informed consent. Notable among these components is unrealistic optimism, an event-specific belief that one has a better chance of receiving benefit than others similarly situated. In this article, we consider responses to interviews with parents who had recently completed an informed consent conference for enrolling their child in a phase I cancer clinical trial to examine how this influence manifests and how investigators might address it during informed consent.

Testing the utility of a cancer clinical trial specific Question Prompt List (QPL-CT) during oncology consultations

OBJECTIVE

A Question Prompt List (QPL) is a proven, simple intervention to aid patients to be active participants in consultations with their physicians by asking questions. We aimed to further develop and test the efficacy of a targeted QPL for clinical trials (QPL-CT).

METHODS

Breast, Lung and Genitourinary cancer patients who were facing a discussion about a therapeutic clinical trial completed short pre- and post-consultation questionnaires and used the QPL-CT in their discussions with their oncologists.

RESULTS

30 participants were recruited from 6 oncologists. All QPL-CT questions were selected by at least one-third of participants. Participants mostly wanted and asked questions about personal trial benefit. Oncologists provided information about personal benefit to varying degrees, thus patients did not ask some questions. Patients were still left with some unasked and unanswered questions.

CONCLUSION

The QPL-CT has potential as a simple, inexpensive intervention to aid such communication. Further investigation is needed to demonstrate the efficacy of the QPL-CT in improving cancer patient outcomes.

PRACTICE IMPLICATIONS

These preliminary finding suggest that important areas of clinical trials are overlooked in clinical consultations. The QPL-CT may be an effective method to encourage oncologists to endorse patient question asking about clinical trials and prompt patient questions.

Therapeutic misconception, misestimation, and optimism in participants enrolled in phase 1 trials

BACKGROUND

Ethical concerns about phase 1 trials persist. Important conceptual advances have been made in understanding concepts used to describe misunderstanding. However, a systematic, empirical evaluation of the frequency of misunderstanding incorporating recent developments is lacking.

METHODS

The authors queried 95 participants in phase 1 trials to provide a more sophisticated estimate of the proportion who had therapeutic misconception (TM), defined as misunderstanding the research purpose or how research differs from individualized care, and therapeutic misestimation (TMis), defined as incorrectly estimating the chance of a research trial benefit as >20% or underestimating risk as 0%.

RESULTS

Sixty-five of 95 respondents (68.4%) had TM, which was associated in a multivariate analysis with lower education and family income (P = .008 and P = .001, respectively), but TM was not associated with the vulnerability of having hardly any treatment options. Eighty-nine of 95 respondents (94%) had TMis, although only 18% reported this was a factual estimate. Although the risks of investigational agents and those exacerbated by research, such as uncertain outcomes, were mentioned (39% and 41% of respondents, respectively), risks novel to research, such as research biopsies, were rarely mentioned (3% of respondents). Although most of these respondents believed that their chance of benefit was greater and that their risk was lower than the population chance (optimists) (54.6%), a substantial minority of respondents (37.6%) were pessimists.

CONCLUSIONS

TM continues to be prevalent. Estimates of personal benefit were not usually meant to report facts, it remains unknown whether respondents in the current study had TMis. Although they are not more vulnerable, phase 1 participants need improved understanding of key TM concepts, with attention to risks that are not present in standard of care.

Treatment-related optimism protects quality of life in a phase II clinical trial for metastatic renal cell carcinoma

BACKGROUND

Patients on clinical trials often experience declining quality of life (QOL). Little is known about the psychosocial variables that buffer against decline.

PURPOSE

This study aims to examine correlations between psychosocial variables and QOL over the course of a clinical trial in patients with metastatic renal cell cancer.

METHODS

At baseline, 114 participants completed measures of treatment-related optimism, social support, and QOL (Functional Assessment of Cancer Therapy-General). QOL was also assessed 2, 4, and 8 weeks after the start of treatment with low-dose or intermediate-dose interferon.

RESULTS

QOL decreased significantly in the intermediate-dose group but not in the low-dose group (p < .01). The decline was less severe for patients who had high rather than low treatment optimism (p = .03). A higher level of social support was significantly associated with higher baseline QOL (p < .05) but a more rapid decline in QOL over time (p < .01).

CONCLUSION

Treatment optimism was favorably associated with QOL.

Reasons given by patients for participating, or not, in Phase 1 cancer trials

BACKGROUND

Communication with patients contemplating Phase 1 cancer trial participation can be challenging. Controversy exists as to whether they are provided with sufficient information to give genuinely informed consent. We present data examining the reasons patients gave for trial entry.

METHOD

Following discussions with oncologists about Phase 1 trials, participants completed a 19-item study specific 'accept or decline measure' exploring hope, expectations of benefit, altruism, concerns, and general perceptions of the trial information. They also completed 2 standardised questionnaires measuring psychological morbidity and predisposition towards optimism.

RESULTS

Forty patients completed the study questionnaires. Patients were generally optimistic with few concerns about the experimental nature of Phase 1 trials. Most 36/40 (90%) consented to trial entry. Fifty-one percent thought the trial was the only treatment option available. The four main reasons for trial entry were: expectation of some medical benefit (21%); trial the best available option (21%); to maintain hope (15%) and to help with research (13%). Only one patient gave altruism as their main reason for trial participation.

CONCLUSION

Patients considering Phase 1 trials may be a self-selected group with optimistic expectations of personal benefit driving trial entry rather than altruism. Achieving genuinely informed consent and avoidance of therapeutic misconceptions in such patients may be difficult.

Outlook and adaptation in advanced cancer: a systematic review

'Fighting spirit' in early-stage cancer comprises optimism about prognosis, a belief that the disease and/or its effects are controllable, and a determination to cope with the situation using various active coping methods. It is associated with better adjustment. In advanced cancer, the usefulness of this coping style is contentious. This systematic review identified eight studies that investigated these qualities in advanced cancer. They provided some evidence that positive attitude and self-efficacy may be associated with better emotional adjustment; active, problem-focused coping appears to be adaptive and avoidant coping maladaptive. However, major methodological flaws make any conclusions highly speculative. Further research in this area using larger samples and longitudinal design is required.

Patient willingness to undergo pharmacodynamic and pharmacokinetic tests in early phase oncology trials

BACKGROUND

Increasingly, early phase clinical trials involve pharmacodynamic (PD) and pharmacokinetic (PK) assays as well as frequent imaging studies. The authors conducted a prospective study examining patients' willingness to undergo such tests and the number of tests the patients would tolerate.

METHODS

A prospective, correlative study was conducted using a self-reported questionnaire to measure patients' willingness on a scale from 1 (not willing) to 10 (very willing) to undergo various procedures (eg, tumor and skin biopsies, blood tests) and imaging studies (eg, magnetic resonance imaging, echocardiogram). In addition, correlations were assessed between the number and type of tests and demographics, previous test experience, inconvenience, and insurance coverage. Sixty-one patients (22 women and 39 men) with advanced malignancies were enrolled. Descriptive, nonparametric, and parametric inferential statistics were used.

RESULTS

Overall willingness to undergo study-required tests was very high. Patients were most willing to undergo urine, blood, ultrasound, x-rays, echocardiogram, and computed tomography studies and were least willing to undergo tumor and skin biopsies and magnetic resonance imaging (all P ≤ .01). Significant inverse relations were observed between the frequency of a particular test and patient's willingness to undergo such tests. Inconvenience and prior negative experiences for more invasive tests (eg, skin biopsies) modestly affected willingness to undergo these tests again. College education, insurance coverage, and the requirement of tests for enrollment were correlated positively with willingness to undergo tests.

CONCLUSIONS

The current findings provide the first prospectively collected data on patients' willingness to undergo PK/PD tests and imaging studies associated with early stage oncology drug trials and can serve as basis for further exploration toward the design of patient-friendly, biomarker-driven clinical studies in oncology.

What oncologists believe they said and what patients believe they heard: an analysis of phase I trial discussions

PURPOSE; Evaluation of the communication and informed consent process in phase I clinical trial interviews to provide authentic, practice-based content for inclusion in a communication skills training intervention for health care professionals.

PATIENTS AND METHODS

Seventeen oncologists and 52 patients from five United Kingdom cancer centers consented to recording of phase I trial discussions. Following each consultation, clinicians completed questionnaires indicating areas they felt they had discussed, and researchers conducted semistructured interviews with patients examining their recall and understanding. Patients and oncologists also completed the Life Orientation Test-Revised questionnaire, measuring predisposition toward optimism. Independent researchers coded the consultations identifying discussion of key information areas and how well this was done. Observed levels of agreement were analyzed for each consultation between oncologist-coder, oncologist-patient, and patient-coder pairs.

RESULTS

In several key areas, information was either missing or had been explained but was interpreted incorrectly by patients. Discussion of prognosis was a frequent omission, with patients and coders significantly more likely to agree that oncologists had not discussed it (odds, 4.8; P < .001). In contrast, coders and oncologists were more likely to agree that alternate care plans to phase I trial entry had been explained (odds, 2.5; P = .023).

CONCLUSION

These data indicate that fundamental components of communication and information sharing about phase I trial participation are often missing from interviews. Important omissions included discussion of prognosis and ensuring patient understanding about supportive care. These findings will inform educational initiatives to assist communication about phase I trials.

Motivation for health information seeking and processing about clinical trial enrollment

Low patient accrual in clinical trials poses serious concerns for the advancement of medical science in the United States. Past research has identified health communication as a crucial step in overcoming barriers to enrollment. However, few communication scholars have studied this problem from a sociopsychological perspective to understand what motivates people to look for or pay attention to information about clinical trial enrollment. This study applies the model of Risk Information Seeking and Processing (RISP) to this context of health decision making. By recognizing the uncertainties embedded in clinical trials, we view clinical trial enrollment as a case study of risk. With data from a random-digit-dial telephone survey of 500 adults living in the United States, we used structural equation modeling to test the central part of the RISP model. In particular, we examined the role of optimistic feelings, as a type of positive affect, in motivating information seeking and processing. Our results indicated that rather than exerting an indirect influence on information seeking through motivating a psychological need for more information, optimistic feelings have more direct relationships with information seeking and processing. Similarly, informational subjective norms also exhibit a more direct relationship with information seeking and processing. These results suggest merit in applying the RISP model to study health decision making related to clinical trial enrollment. Our findings also render practical implications on how to improve communication about clinical trial enrollment.

Seeking informed consent to Phase I cancer clinical trials: identifying oncologists' communication strategies

PURPOSE

Phase I clinical trials are the gateway to effective new cancer treatments. Many physicians have difficulty when discussing Phase I clinical trials. Research demonstrates evidence of suboptimal communication. Little is known about communication strategies used by oncologists when recruiting patients for Phase I trials. We analyzed audio recorded Phase I consultations to identify oncologists' communication strategies.

PATIENTS AND METHODS

Subjects were consecutive cancer patients from six medical oncologists attending one of three outpatient clinics at a major Cancer Center in the United States. Sixteen patients signed informed consent for audio recording of their consultations in which a Phase I study was discussed. These were transcribed in full and analyzed to identify communication strategies.

RESULTS

Six communication themes emerged from the analysis: (1) orienting, (2) educating patients, (3) describing uncertainty and prognosis, (4) persuading, (5) decision making, and (6) making a treatment recommendation. As expected, although there was some common ground between communication in Phase I and the Phase II and III settings, there were distinct differences.

CONCLUSIONS

Oncologists used persuasive communication, made explicit recommendations, or implicitly expressed a treatment preference and were choice limiting. This highlights the complexity of discussing Phase I trials and the need to develop strategies to aid oncologists and patients in these difficult conversations. Patient centered communication that values patient preferences while preserving the oncologist's agenda can be a helpful approach to these discussions.