Influence of Cost-Related Considerations on Clinical Trial Participation: Results from the 2020 Health Information National Trends Survey (HINTS)

Therapeutic Clinical Trial Eligibility and Enrollment among Women with Breast Cancer: Implications for Understanding Trial Disparities

INTRODUCTION

Therapeutic clinical trials frequently lack diverse representation, hindering generalizability and exacerbating preexisting disparities in clinical outcomes. This study explored associations between breast cancer patient demographics, clinical trial eligibility, and enrollment in a National Cancer Institute (NCI)-designated cancer center.

PATIENTS AND METHODS

This prospective cohort study included patients with breast cancer screened for therapeutic clinical trials from July 2020 to January 2024. Eligibility was determined by the provider and study coordinator. Patient characteristics were abstracted from the electronic medical record. Rurality and neighborhood disadvantage were mapped by address using rural-urban commuting area codes and area deprivation index (ADI), respectively. Likelihood of eligibility and enrollment by race, rurality, and neighborhood disadvantage were evaluated using risk ratios (RR) and 95% confidence intervals (CIs) from modified Poisson regression models.

RESULTS

Of 343 patients screened for therapeutic trials, the mean age was 56 years (SD 13), 33% were Black/other race, 22% lived in highly disadvantaged areas, and 16% in rural areas. Most patients were screened for one trial (87%). Overall, 54% of patients were eligible for trials, and of those, 58% enrolled. Similar likelihoods of eligibility and enrollment were seen by race and rurality. Though not significant, patients living in highly disadvantaged areas trended toward higher likelihood of enrollment (RR 1.24, 95% CI 0.99-1.55).

CONCLUSIONS

Over half of trial-eligible patients, even across race, rurality, or neighborhood disadvantage, enrolled, surpassing the national average. In contrast to national trends, there was higher enrollment among patients of higher ADI.

Clinical trial knowledge, discussion, and participation among cancer survivors: A HINTS-SEER study

OBJECTIVES

Clinical trial knowledge and discussions about clinical trials with healthcare providers contribute to clinical trial participation and clinical trial representation. This study explored 1) the association of patient-provider communication with clinical trial knowledge, 2) how patient-provider communication impacts the associations of demographic and clinical factors with clinical trial knowledge, and 3) motivations for clinical trial participation among people with a history of cancer.

METHODS

Cross-sectional data from the 2021 Health Information National Trends Survey-Surveillance, Epidemiology, and End Results (HINTS-SEER) study included 1201 adult cancer survivors recruited from three SEER registries. Multivariable logistic regression models estimated adjusted associations of sociodemographic and clinical characteristics with clinical trial knowledge (none, a little bit/a lot) with and without the inclusion of clinical trial discussion with a healthcare provider (yes, no).

RESULTS

Approximately three-quarters of cancer survivors reported having at least "a little" knowledge about clinical trials, though only 15 % reported having discussed clinical trials with their provider. Those who reported patient-provider communication about clinical trials had 8.71 times higher odds of having some clinical trial knowledge. In multivariable logistic regression, odds of knowing at least a little bit about clinical trials were lower among adults without a college degree and among Hispanic and Non-Hispanic Asian (versus Non-Hispanic White) adults. Associations of demographic factors with clinical trial knowledge were not impacted by the inclusion of patient-provider discussion in the model. Top motivations for clinical trial participation were helping other people, new treatment, and getting better.

CONCLUSION/PRACTICE IMPLICATIONS

There is a need to ensure information about clinical trials is provided to all people with cancer and to facilitate high quality communication between patients and providers about clinical trials.

Association between e-health usage and consideration for clinical trial participation: An exploratory study on the mediating role of cancer-related self-efficacy and patient-centered communication

Background

The journey of any new treatment begins in the lab and through a clinical trial. Clinical trials have become an important means to promote public health causes. In digital age, e-health usage (EHU) might be a key factor to promote clinical trials. However, how consideration for clinical trial participation is impacted by EHU remains unclear.

Method

Secondary analyses were conducted on data from the Health Information National Trends Survey 2020 (HINTS 5, Cycle 4). This study proposed and tested a serial mediation model linking EHU to consideration for clinical trial participation, mediated by patient-centered communication (PCC) and cancer-related self-efficacy (CS). Analysis was performed using a sample survey targeted at individuals with chronic disease and/or family cancer history, conducted in 2020 in the United States (N = 3292).

Result

This study found that EHU exerted positive effects on clinical trial participation directly. Furthermore, their relationship can be mediated by PCC and CS. Only when PCC serves as the first mediator did CS exert the serial meditation effect. Annual household income significantly moderates the path from CS to consideration for clinical trial participation. For low-income groups, an increase in CS significantly expends their consideration for clinical trial participation.

Conclusion

EHU can improve PCC and CS. This can be considered as motivators for increasing participation to clinical trials. Based on the finding, information related clinical trials should be promoted through e-health channels and the information should gain better patients' understanding. Those findings throw out suggestions on building trust, addressing concerns and alleviating fears to clinical trial participation.

Financial Toxicity Among Patients With Advanced Solid Tumors Participating in Early-Phase Clinical Trials

PURPOSE

Financial toxicity (FT) adversely influences patient quality of life and is a barrier to clinical trial enrollment. Early-phase clinical trials (EPCTs) recruit patients who may have high baseline FT and require additional visits and procedures, potentially increasing FT.

METHODS

In this prospective survey study, we sought to assess FT at baseline and after 2 months among patients with advanced solid malignancies participating in EPCTs. Participants were age 18 years and older, were English-speaking, and were treated at the Yale Cancer Center (Yale) and the Tisch Cancer Institute at Mount Sinai (Mount Sinai). At the time of consent and 2 months later, patients completed a sociodemographic questionnaire as well as the 11-item validated Comprehensive Score for Financial Toxicity (COST) instrument. Primary outcomes were baseline COST score and change in COST score from baseline to 2 months. Lower score is associated with higher FT.

RESULTS

One hundred forty-six patients completed survey 1. Mean age was 61.5 years and 50.7% were male. The most common histologies were lung (17.8%), colorectal (16.4%), and breast (12.3%) cancers. Mean baseline COST score was 22.12 (standard deviation, 8.01). FT was associated with being a primary wage earner (P = .044) and inversely associated with age (P = .025). Seventy-one patients completed survey 2. Among 71 patients who completed both surveys, there was no significant difference in COST score between surveys 1 and 2 (P = .28). Race, ethnicity, education, and household income were not associated with baseline COST score or change in FT.

CONCLUSION

Moderate FT was reported at baseline and on trial among EPCT participants. No change in FT was observed between time points. Additional efforts should be made to decrease FT associated with EPCT participation to maximize access to novel therapies.

Remote Field Application of Digital Technology for Hearing Assessments in a Cohort of Pediatric Germ Cell Tumor Survivors

BACKGROUND

Childhood cancer survivors treated with platinum-based chemotherapy are at risk of treatment-induced hearing loss. Accurate evaluation of hearing thresholds has historically been limited to clinical audiometry, which is logistically challenging and expensive to include in epidemiologic studies. We evaluated the feasibility of using a remote, tablet-based hearing assessment in a cohort of pediatric germ cell tumor survivors treated with platinum-based chemotherapy.

METHODS

Survivors from the GCT Outcomes and Late effects Data (GOLD) study were recruited to the pilot study (n = 100). Study personnel conducted remote hearing assessments of standard and extended high frequency thresholds using validated tablet-based audiometry (SHOEBOX, Inc.). T tests and Wilcoxon rank-sum tests evaluated differences in assessment characteristics between children and adults. Agreement between self-reported and measured hearing loss was calculated using Cohen κ.

RESULTS

We were able to reach 136/168 (81%) eligible participants, of which 100 (74%) agreed to participate. Successful completion of the remote hearing assessment was high [97%; 20 children (ages 7-17), 77 adults (ages 18-31)]. The mean assessment length was 37.6 minutes, and the mean turnaround time was 8.3 days. We observed hearing loss at standard frequencies in 21% of participants. Agreement between self-reported and measured hearing loss was significant (P value = 1.41 × 10-7), with 83.5% concordance.

CONCLUSIONS

Hearing loss measured using the remote assessment aligns with self-reporting and rates of hearing loss reported in the literature for this population.

IMPACT

Remote application of tablet-based audiometry is a feasible and efficacious method for measuring hearing in epidemiologic studies with participants spread across large geographic areas.

Prevalence of financial hardship and health-related social needs among patients with missed radiology appointments

PURPOSE

We aimed to evaluate the prevalence of financial hardship and Health-Related Social Needs (HRSN) among patients who missed their radiology appointment.

METHODS

English-speaking adult patients, with a missed outpatient imaging appointment at any of a tertiary care imaging centers between 11/2022 and 05/2023 were eligible. We measured self-reported general financial worry using Comprehensive Score for Financial Toxicity (COST), imaging hardship (worry that the current imaging is a financial hardship to patient and their family), material hardship (e.g., medical debt), cost-related care nonadherence, and HRSNs including housing instability, food insecurity, transportation problems, and utility help needs.

RESULTS

282 patients were included (mean age 54.7 ± 15.0 years; 70.7 % female). Majority were non-Hispanic White (52.4 %), followed by Asian (23.0 %) and Hispanic (16.0 %) racial/ethnic background. Most missed appointments were patient-initiated (74.8 %); 13.5 % due to cost or insurance coverage and 6.4 % due to transportation and parking. Mean COST score was 26.8 with 44.4 % and 28.8 % reporting their illness and imaging as a source of financial hardship. 18.3 % and 35.2 % endorsed cost-related care nonadherence and material hardship. 32.7 % had at least one HRSNs with food insecurity the most common (25.4 %). Only 12.5 % were previously screened for financial hardship or HRSNs. Having comorbidity and living in more disadvantaged neighborhoods was associated with higher report of financial hardship and HRSNs.

CONCLUSION

Financial hardship and HRSNs are common among those who miss radiology appointments. There needs to be more rigorous screening for financial hardship and HRSNs at every health encounter and interventions should be implemented to address these.

Health-care organization characteristics in cancer care delivery: an integrated conceptual framework with content validation

Context can influence cancer-related outcomes. For example, health-care organization characteristics, including ownership, leadership, and culture, can affect care access, communication, and patient outcomes. Health-care organization characteristics and other contextual factors can also influence whether and how clinical discoveries reduce cancer incidence, morbidity, and mortality. Importantly, policy, market, and technology changes are transforming health-care organization design, culture, and operations across the cancer continuum. Consequently, research is essential to examine when, for whom, and how organizational characteristics influence person-level, organization-level, and population-level cancer outcomes. Understanding organizational characteristics-the structures, processes, and other features of entities involved in health care delivery-and their dynamics is an important yet understudied area of care delivery research across the cancer continuum. Research incorporating organizational characteristics is critical to address health inequities, test care delivery models, adapt interventions, and strengthen implementation. The field lacks conceptual grounding, however, to help researchers identify germane organizational characteristics. We propose a framework identifying organizational characteristics relevant for cancer care delivery research based on conceptual work in health services, organizational behavior, and management science and refined using a systematic review and key informant input. The proposed framework is a tool for organizing existing research and enhancing future cancer care delivery research. Following a 2012 Journal of the National Cancer Institute monograph, this work complements National Cancer Institute efforts to stimulate research addressing the relationship between cancer outcomes and contextual factors at the patient, provider, team, delivery organization, community, and health policy levels.

Understanding the financial cost of cancer clinical trial participation

BACKGROUND

Though financial hardship is a well-documented adverse effect of standard-of-care cancer treatment, little is known about out-of-pocket costs and their impact on patients participating in cancer clinical trials. This study explored the financial effects of cancer clinical trial participation.

METHODS

This cross-sectional analysis used survey data collected in December 2022 and May 2023 from individuals with cancer previously served by Patient Advocate Foundation, a nonprofit organization providing social needs navigation and financial assistance to US adults with a chronic illness. Surveys included questions on cancer clinical trial participation, trial-related financial hardship, and sociodemographic data. Descriptive and bivariate analyses were conducted using Cramer's V to estimate the in-sample magnitude of association. Associations between trial-related financial hardship and sociodemographics were estimated using adjusted relative risks (aRR) and corresponding 95% confidence intervals (CI) from modified Poisson regression models with robust standard errors.

RESULTS

Of 650 survey respondents, 18% (N = 118) reported ever participating in a cancer clinical trial. Of those, 47% (n = 55) reported financial hardship as a result of their trial participation. Respondents reporting trial-related financial hardship were more often unemployed or disabled (58% vs. 43%; V = 0.15), Medicare enrolled (53% vs. 40%; V = 0.15), and traveled >1 h to their cancer provider (45% vs. 17%; V = 0.33) compared to respondents reporting no hardship. Respondents who experienced trial-related financial hardship most often reported expenses from travel (reported by 71% of respondents), medical bills (58%), dining out (40%), or housing needs (40%). Modeling results indicated that respondents traveling >1 h vs. ≤30 min to their cancer provider had a 2.2× higher risk of financial hardship, even after adjusting for respondent race, income, employment, and insurance status (aRR = 2.2, 95% CI 1.3-3.8). Most respondents (53%) reported needing $200-$1000 per month to compensate for trial-related expenses. Over half (51%) of respondents reported less willingness to participate in future clinical trials due to incurred financial hardship. Notably, of patients who did not participate in a cancer clinical trial (n = 532), 13% declined participation due to cost.

CONCLUSION

Cancer clinical trial-related financial hardship, most often stemming from travel expenses, affected almost half of trial-enrolled patients. Interventions are needed to reduce adverse financial participation effects and potentially improve cancer clinical trial participation.

The influence of political ideology on clinical trial knowledge, invitation, and participation among adults in the United States

BACKGROUND

Clinical trials remain a critical component of medical innovation. Evidence suggests that individuals' political ideologies may impact their health behaviors. However, there is a paucity of literature examining the relationship between political ideologies and clinical trial knowledge and participation.

METHODS

Study data were derived from Health Information National Trends Survey 5 Cycle 4 (n = 3300), which was conducted from February to June 2020. We used participants' characteristics to estimate the prevalence of clinical trial knowledge and participation. We used multivariable logistic regressions to investigate whether political ideology had a significant impact on clinical trial knowledge and participation. Jack-knife replicate weights were applied for population-level estimates.

RESULTS

Most participants were White (64.2%), earned above US$50,000 (62.4%), and lived in urban areas (88.0%). About 59.2% reported having some knowledge of clinical trials, and only 8.9% had ever been invited to participate in clinical trials. A total of 37.0%, 29.5%, and 33.5% of the population endorsed moderate, liberal, and conservative political viewpoints respectively. In the adjusted logistic regression analysis, compared to conservatives, liberals (adjusted odds ratio, 1.92; 95% confidence interval, 1.31-2.80) and moderates (adjusted odds ratio, 1.43; 95% confidence interval, 1.09-1.88) had significantly greater odds of having knowledge of clinical trials. Also, liberals had higher odds of receiving invitations to participate in clinical trials (odds ratio, 1.76; 95% confidence interval, 1.08-2.85; p = 0.023) and greater odds of trial participation (odds ratio, 3.90; 95% confidence interval, 1.47-10.33; p = 0.007) compared to moderates.

CONCLUSIONS

The mechanism underlying the higher rates of clinical trial invitations to liberals is unclear and requires further comprehensive investigation. Similarly, further qualitative studies are needed to understand the attributes that promote knowledge and increased likelihood of clinical trial participation among liberals. This will provide crucial insight to help design interventions that further involve conservatives and moderates in clinical trials and scientific enterprise.