The adequacy of consent forms for informing patients entering oncological clinical trials

Randomized comparison of two interventions to enhance understanding during the informed consent process for research

BACKGROUND/AIMS

Many investigators have tested interventions to improve research participant understanding of information shared during the informed consent process, using a variety of methods and with mixed results. A valid criticism of most consent research is that studies are often conducted in simulated research settings rather than ongoing clinical studies. The present study rigorously tested two simple and easily adoptable strategies for presenting key consent information to participants eligible to enroll in six actual clinical trials (i.e. six parent studies).

METHODS

In collaboration with the study team from each parent study, we developed two consent interventions: a fact sheet and an interview-style video. The content of each of the intervention was based on the information shared in the consent form approved for each parent study. Participants were randomized to the standard consent process, or to one of the two interventions. Once exposed to the assigned consent mode, participants were asked to complete an assessment of understanding. The study was powered to determine whether those exposed to the fact sheet or video performed better on the consent assessment compared to those exposed to the standard consent. We also assessed participant satisfaction with the consent process.

RESULTS

A total of 284 participants were randomized to one of the three consent arms. Assessments of understanding were completed with a total of 273 participants from July 2017 to April 2019. Participants exposed to the video had better understanding scores compared to those exposed to the standard consent form process (p value = 0.020). Participants were more satisfied with the video when compared to the standard consent. Participants who received the fact sheet did not achieve higher overall understanding or satisfaction scores when compared to the standard consent process.

CONCLUSION

This randomized study of two novel consent interventions across six different clinical trials demonstrated a statistically significant difference in participant understanding based on overall scores among those exposed to the video intervention compared to those exposed to the standard consent.

An international core outcome set for evaluating interventions to improve informed consent to clinical trials: The ELICIT Study

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First internationally agreed minimum set of outcomes deemed essential to be measured in all future studies evaluating interventions to improve decisions about participating in an randomized controlled trial.

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Broad stakeholder involvement, including; potential trial participants (e.g., patients or others who could provide a lay perspective), trialists, research nurses, social scientists, clinicians, bioethicists, and research ethics committee members.

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Represents outcomes that are of core importance to multiple stakeholders and, if adopted, will improve the relevance of future trials in this field.

Objective

To develop a core outcome set for the evaluation of interventions that aim to improve how people make decisions about whether to participate in randomized controlled trials (of healthcare interventions), the ELICIT Study.

Study Design

International mixed-method study involving a systematic review of existing outcomes, semi-structured interviews, an online Delphi survey, and a face-to-face consensus meeting.

Results

The literature review and stakeholder interviews (n = 25) initially identified 1045 reported outcomes that were grouped into 40 individually distinct outcomes. These 40 outcomes were scored for importance in two rounds of an online Delphi survey (n = 79), with 18 people attending the consensus meeting. Consensus was reached on 12 core outcomes: therapeutic misconception; comfort with decision; authenticity of decision; communication about the trial; empowerment; sense of altruism; equipoise; knowledge; salience of questions; understanding, how helpful the process was for decision making; and trial attrition.

Conclusion

The ELICIT core outcome set is the first internationally agreed minimum set of outcomes deemed essential to be measured in all future studies evaluating interventions to improve decisions about participating in an randomized controlled trial. Use of the ELICIT core set will ensure that results from these trials are comparable and relevant to all stakeholders.

Registration

COMET database - http://www.comet-initiative.org/Studies/Details/595.

Comprehension and recall from the informed consent process by phase I healthy volunteers before dose administration

Aims/Background

A fundamental part of all clinical trials is informed consent, reflecting the respect for the volunteer’s autonomy. Research participation is voluntary; therefore, certain aspects of the proposed study must be disclosed so that volunteers can make an informed decision. In this study, we aimed to examine the level of comprehension and recall of healthy volunteers from the informed consent process.

Methods

The study was carried out at a single phase I clinical trials unit. A questionnaire was administered to each volunteer to assess recall of important aspects of the study at the day-1 visit following the informed consent process. The questionnaire contained seven questions regarding study objectives, route, frequency and type of drug administration, adverse effects, number of subjects previously exposed and remuneration. One point was awarded for each correct answer.

Results

A total of 266 volunteers were administered the questionnaire. The mean total score (±standard deviation) for all volunteers was 4.5 ± 1.1 points out of 7, with a range of 0.8–6.7. For all 10 studies, 91% of volunteers responded correctly when answering about the route of administration, and 90% were able to accurately state the correct payment amount. Only 7% were able to repeat the aims of the study correctly.

Conclusion

The poor performance of our study volunteers raises concerns about recall of information prior to study drug administration. This has implications for the volunteer’s safety and ability to provide true informed consent. Interventions to improve recall prior to dosing should be undertaken.

Moving Forward on Consent Practices in Australia

Allowing persons to make an informed choice about their participation in research is a pre-eminent ethical and legal requirement. Almost universally, this requirement has been addressed through the provision of written patient information sheets and consent forms. Researchers and others have raised concerns about the extent to which such forms-particularly given their frequent lengthiness and complexity-provide participants with the tools and knowledge necessary for autonomous decision-making. Concerns are especially pronounced for certain participant groups, such as persons with low literacy and Indigenous persons. Multimedia strategies have the potential to usefully supplement current consent practices in Australia; however, information is needed about the need for supplementary consent practices, along with drivers for and barriers against adoption. This study initiates the required evidence base through an audit of informed consent practices for medical research in the Australian state of Tasmania to assess the need for, and current uptake of, supplementary consent strategies. Drivers for and barriers against adoption of multimedia consent practices were explored in detail through interviews with key stakeholders, including researchers, HREC chairs and members, and research participants, including Indigenous participants.

What advanced cancer patients with limited treatment options know about clinical research: a qualitative study

PURPOSE

Discussions between oncologists and advanced cancer patients (ACPs) may touch on the complex issue of clinical trial participation. Numerous initiatives have sought to improve the quality of these potentially difficult conversations. However, we have limited data about what ACPs know about clinical research as they enter such discussions as, to date, such research has focused on the period following informed consent. This study examines ACPs' understanding of clinical research in the treatment period before consent.

METHODS

We conducted in-depth interviews with adult ACPs with limited treatment options at four clinics in an academic medical center. So as not to influence patients' perspectives, interviewers probed patients' knowledge of clinical research only if the patient first brought up the topic. Interviews (40-60 min) were audio-recorded, transcribed, and analyzed thematically and via quantitative content analysis by an interdisciplinary team.

RESULTS

Of 78 patients recruited, 56 (72%) spontaneously brought up the topic of clinical research during interview and are included in this analysis. Qualitative thematic analysis and quantitative content analysis revealed that patients' knowledge varied in terms of (1) accuracy and (2) specificity (level of detail). ACPs who spoke with high specificity were not always accurate, and ACPs with accurate knowledge included both high- and low-specificity speakers.

CONCLUSIONS

ACPs' knowledge of clinical research is variable. Patients who can discuss the technical details of their care may or may not understand the broader purpose and procedures of clinical trials. Understanding this variability is important for improving patient-provider communication about clinical research and supporting efforts to provide individualized care for ACPs.

Patient perceptions concerning clinical trials in oncology patients

Background

Clinical trials are critical to scientifically evaluate promising new therapies in oncology, but patient accrual to these studies is persistently low. Patient preference plays an important role in enrollment in these trials. We performed this survey to evaluate the perceptions of newly diagnosed oncology patients about clinical trials and the reasons why they wish to or not to participate in these trials.

Methods

Patients were given a ten question survey reflective of their attitudes regarding clinical trials as a treatment option at their initial visit. The self-directed questionnaire was scored on an ordinate scale from strongly agree [1] to strongly disagree [5].

Results

Ninety three patients were surveyed in the cancer specific multispecialty clinics in an academic center. Our patients expected their providers to discuss all information relating to clinical trials and eligibility at the first visit (65.4% agree and 15.4% neutral, p < 0.0001). Patients felt their privacy and safety would be safeguarded in the University sponsored trials (56.8% agree, and 25.7% neutral, p < 0.0001). Over 80% patients showed their unwillingness to participate in randomized clinical trials (disagree 61%, neutral 19.5%, p < 0.001). Patients also showed less likelihood to participate in clinical trials as a first treatment option (48.7% disagree and 28.9% neutral, p0.0161), but were willing to consider participating in a clinical trial if the conventional treatment failed. Industry sponsored trials, phase 1 trials, investigator initiated trials with the involved tests and time commitment and altruistic reasons did not significantly deviate from the mean preference analyzed using Fisher's exact test analysis.

Conclusions

Patients consider the option of clinical trials as important in their treatment, and expect to be informed by their oncologist about such trials. Newly diagnosed cancer patients perceive randomization and first line trials negatively. Since randomization data provides new standards of care and hope for improved treatment, patients and their families must be educated of their importance.

Involvement and (Potential) Influence of Care Providers in the Enlistment Phase of the Informed Consent Process: the case of aids clinical trials

This article draws on ethnographic field data collected during an investigation of the informed consent process and AIDS clinical trials. It describes the involvement of care providers (physicians, nurse practitioners, physician assistants) during the enlistment, or recruitment, phase of the informed consent process. It shows that sometimes care providers are involved in the receipt, evaluation and distribution of information on clinical trials through their interactions with research professionals and patients. It suggests that the involvement of care providers has the potential to influence the informed consent process. Some of the ethical and practice considerations of this are discussed.

A pilot study of simple interventions to improve informed consent in clinical research: feasibility, approach, and results

BACKGROUND

Research suggests that participants do not always adequately understand studies. While some consent interventions increase understanding, methodologic challenges have been raised in studying consent outside of actual trial settings. This study examined the feasibility of testing two consent interventions in actual studies and measured effectiveness of interventions in improving understanding.

METHODS

Participants enrolling in any of eight ongoing clinical trials were sequentially assigned to one of three different informed consent strategies for enrollment in their clinical trial. Control participants received standard consent procedures for their trial. Participants in the first intervention arm received a bulleted fact sheet summarizing key study information. Participants in the second intervention arm received the bulleted fact sheet and also engaged in a feedback Q&A session. Later, patients answered closed- and open-ended questions to assess patient understanding and literacy. Descriptive statistics, Wilcoxon -Mann -Whitney and Kruskal-Wallis tests were generated to assess correlations; regression analysis determined predictors of understanding.

RESULTS

144 participants enrolled. Using regression analysis, participants receiving the second intervention scored 7.6 percentage points higher (p = .02) on open-ended questions about understanding than participants in the control, although unadjusted comparisons did not reach statistical significance.

CONCLUSIONS

Our study supports the hypothesis that patients receiving both bulleted fact sheets and a Q&A session had higher understanding compared to standard consent. Fact sheets and short structured dialog are quick to administer and easy to replicate across studies and should be tested in larger samples.

Parental informed consent in pediatric cancer trials: a population-based survey in Germany

BACKGROUND

Ensuring adequate parental consent is a key issue of ethical practice in pediatric oncology. In Germany, however, knowledge about parental comprehension and satisfaction with the informed consent procedure is limited, and representative data on parents' perspectives are still missing. Based on data collected by means of a population-based survey, we evaluated the parental recall of the informed consent process for pediatric clinical trials, and how they rated the consent process retrospectively.

PROCEDURE

A standardized survey was carried out among 1,465 parents whose children were first diagnosed in 2005 with a disease defined by ICCC-3 in the German Childhood Cancer Registry (response: 55.1%). The survey's primary objective was to assess how well parents were able to recall of the informed consent process. To evaluate the results, we set up a second survey among 581 parents who had given consent recently for their child's participation in a clinical trial (response: 53.5%).

RESULTS

Approximately 81% of the parents in the population-based survey correctly remembered whether or not their child had been enrolled in a clinical trial or treated off-trial. The ability to recall accurately is significantly lower if the parents have a migration background or if their child was not a trial participant. However, parents who recalled the child's trial participation status incorrectly felt as adequately informed as parents who recalled it correctly.

CONCLUSIONS

Our results identified weak points and vulnerable subgroups in the parental consent process in pediatric oncology in Germany.

Patient-doctor agreement on recall of clinical trial discussion across cultures

BACKGROUND

The purpose was to investigate patient-doctor agreement on clinical trial discussion cross-culturally.

METHODS

In the International Breast Cancer Study Group Trial 33-03 on shared decision-making for early breast cancer in Australian/New Zealand (ANZ) and Swiss/German/Austrian (SGA) centers, doctor and patient characteristics plus doctor stress and burnout were assessed. Within 2 weeks post-consultation about treatment options, the doctor and patient reported independently, whether a trial was discussed. Odds ratios of agreement for covariables were estimated by generalized estimating equations for each language cohort, with doctor as a random effect.

RESULTS

In ANZ, 21 doctors and 339 patients were eligible; in SGA, 41 doctors and 427 patients. In cases where the doctor indicated 'no trial discussed', 82% of both ANZ and SGA patients agreed; if the doctor indicated 'trial discussed', 50% of ANZ and 38% of SGA patients agreed, respectively. Factors associated with higher agreement were: low tumor grade and fewer patients recruited into clinical trials in SGA; public institution, patient born in ANZ (versus other), higher doctor depersonalization and personal accomplishment in ANZ.

CONCLUSION

There is discordance between oncologists and their patients regarding clinical trial discussion, particularly when the doctor indicates that a trial was discussed. Factors contributing to this agreement vary by culture.

When expectations predict experience: the influence of psychological factors on chemotherapy toxicities

CONTEXT

Patients with cancer undergoing similar treatments experience variable severity and frequency of side effects not adequately explained by pharmacological mechanisms, suggesting psychological influence.

OBJECTIVES

First, this study aimed to further examine the relationship between patients' expectations of multiple chemotherapy-related toxicities and experiences. Second, this study aimed to explore the impact of anxiety and cancer coping styles to aid in informing interventions to lessen such expectations.

METHODS

A total of 59 eligible, consenting patients with cancer rated their expectations of 20 chemotherapy toxicities on 100-point linear analogue self-assessment indicators before treatment and completed the Spielberger State Anxiety Inventory and the Mental Adjustment to Cancer scale. Patients then rated their experience of side effects after one chemotherapy session.

RESULTS

Regressions controlling primary treating nurse influence and patient performance status showed toxicity experience was significantly predicted by patient expectations of mood changes, bleeding, skin itchiness, hair loss, feeling tired, and sleep disturbance (β=0.30-0.55). Anxiety was significantly related to expectations of nervousness and mood changes; the coping style Fighting Spirit showed no significant associations, whereas conversely, Anxious Preoccupation showed some degree of association with all 20 toxicities (r=0.11-0.34).

CONCLUSION

Findings support the growing contention that patient expectations influence experience, negatively impacting quality of life. As it is unethical to withhold treatment information, research into screening for at-risk patients and offering brief interventions to minimize Anxious Preoccupation could be one way to reduce overall side effect burden, perhaps in the case of many medical interventions.

Outcomes of informed consent among parents of children in cancer clinical trials

BACKGROUND

Clinical trials are central to pediatric oncology, yet the process and outcomes of informed consent are poorly understood. We evaluated correlates of understanding among parents of pediatric trial participants, and explored differences in the process and outcome of informed consent between parents and a comparison group of adult participants.

PROCEDURE

We administered the Quality of Informed Consent (QuIC) to parents of children who were newly enrolled onto a cancer trial. We identified independent correlates of knowledge among parents, and compared parents' knowledge to that of a contemporaneous group of adult participants, using multiple linear regression models.

RESULTS

Parents (n = 47) were less likely than adult participants (n = 204) to report having enough time to learn about the trial (64% vs. 87%, P = 0.001) or sufficient opportunity for questions (79% vs. 93%, P = 0.01), and reported lower overall satisfaction with the consent process (71% vs. 90%, P = 0.002). The mean parental knowledge score was 73.6 (95% confidence interval [CI] 69.5-77.8, theoretical maximum 100). Knowledge did not differ between parents and adult trial participants. In multivariate analysis, two predictors were significantly associated with higher parent knowledge scores: consent sought by the study's principal investigator (increment 13.6, CI 2.7-24.6) and physician-reported poor prognosis (increment 13.8, 95% CI 5.4-22.1).

CONCLUSIONS

Although we observed no differences in knowledge between parents of pediatric cancer trial participants and their adult counterparts, parents report more problems with the informed consent process for their trials. The increased prevalence of problems is likely due to clinical and contextual differences between pediatric and adult trials.

Repeated assessments of informed consent comprehension among HIV-infected participants of a three-year clinical trial in Botswana

BACKGROUND

Informed consent (IC) has been an international standard for decades for the ethical conduct of clinical trials. Yet frequently study participants have incomplete understanding of key issues, a problem exacerbated by language barriers or lack of familiarity with research concepts. Few investigators measure participant comprehension of IC, while even fewer conduct interim assessments once a trial is underway.

METHODS AND FINDINGS

We assessed comprehension of IC using a 20-question true/false quiz administered in 6-month intervals in the context of a placebo-controlled, randomized trial for the prevention of tuberculosis among HIV-infected adults in Botswana (2004-2009). Quizzes were offered in both Setswana and English. To enroll in the TB trial, participants were required to have ≥ 16/20 correct responses. We examined concepts understood and the degree to which understanding changed over three-years. We analyzed 5,555 quizzes from 1,835 participants. The participants' highest education levels were: 28% primary, 59% secondary, 9% tertiary and 7% no formal education. Eighty percent of participants passed the enrollment quiz (Quiz1) on their first attempt and the remainder passed on their second attempt. Those having higher than primary education and those who took the quiz in English were more likely to receive a passing score on their first attempt (adjusted odds ratios and 95% confidence intervals, 3.1 (2.4-4.0) and 1.5 (1.2, 1.9), respectively). The trial's purpose or procedures were understood by 90-100% of participants, while 44-77% understood randomization, placebos, or risks. Participants who failed Quiz1 on their initial attempt were more likely to fail quizzes later in the trial. Pass rates improved with quiz re-administration in subsequent years.

CONCLUSIONS

Administration of a comprehension quiz at enrollment and during follow-up was feasible in a large, international collaboration and efficiently determined IC comprehension by trial participants. Strategies to improve understanding of concepts like placebos and randomization are needed. Comprehension assessments throughout a study may reinforce key concepts.

Communication about standard treatment options and clinical trials: can we teach doctors new skills to improve patient outcomes?

BACKGROUND

The International Breast Cancer Study Group conducted a phase III trial in Australian/New Zealand (ANZ) and Swiss/German/Austrian (SGA) centres on training doctors in clear and ethical information delivery about treatment options and strategies to encourage shared decision making.

METHODS

Medical, surgical, gynaecological and radiation oncologists, and their patients for whom adjuvant breast cancer therapy was indicated, were eligible. Doctors were randomised to participate in a workshop with standardised teaching material and role playing. Patients were recruited in the experimental and control groups before and after the workshop.

RESULTS

In ANZ centres, 21 eligible doctors recruited a total of 304 assessable patients. In SGA centres, 41 doctors recruited 390 patients. The training was well accepted. There was no overall effect on patient decisional conflict (primary endpoint) 2 weeks after the consultation. Overall, patients were satisfied with their treatment decision, their consultation and their doctors' consultation skills. Considerable variation was observed in patient outcomes between SGA and ANZ centres; the effect sizes of the intervention were marginal (<0.2).

CONCLUSIONS

Shared decision making remains a challenge. A sustained training effect may require more intensive training tailored to the local setting. Cross-cultural differences need attention in conducting trials on communication interventions.

Protecting vulnerable research subjects in critical care trials: enhancing the informed consent process and recommendations for safeguards

Although critically ill patients represent a vulnerable group of individuals, guidelines in research ethics assert that ethically acceptable research may proceed with such vulnerable subjects if additional safeguards are in place to minimize the risk of harm and exploitation. Such safeguards include the proper obtainment of informed consent that avoids the presence of the therapeutic misconception and the assessment of decisional capacity in critically ill patients recruited for research. Also discussed in this review are additional safeguards for such vulnerable subjects, as well as the issues involved with proxy consent. Heightened awareness to principles of ethics and provision of additional safeguards to enhance protections of vulnerable subjects would help to maintain the public trust in the research endeavor.

Impact of life-threatening risk information on the evolution of patients' anxiety and risk recall: the specific context of informed consent for experimental stem cell transplant

OBJECTIVE

This study examines risk recall and evolution of patients' anxiety after transmission of life-threatening risk information in an informed consent procedure for experimental HSCT.

METHODS

Informed consent interviews were audio-recorded and transcribed. Patient risk recall was obtained through comparing information provided in the interview to information recalled by patients following the interview. The evolution of patients' anxiety was assessed through comparing patients' post- to patients' pre-interview anxiety using the STAI-State. Physicians' communication skills and risk framing were analyzed.

RESULTS

Twenty patients were included. Patients recalled on average 4 risks (S.D.=1.6) out of 9 different risks transmitted (S.D.=2) which corresponds to a recall rate of 44% (S.D.=15.5). Patients' anxiety remained on average stable (Mean=0.4; S.D.=9.1). Linear regression analysis showed that risk recall was predicted positively by the number of risks transmitted (B=.30; P=.032) and by patients' problem-focused coping (B=.21; P=.008). The evolution of anxiety was predicted positively by the number of times benefits were transmitted (B=.83; P=.003) and negatively by the level of anxiety before the interview (B=-.50; P=.001).

CONCLUSION

Results show the limits of patients' risk recall in the context of informed consent for a life-threatening procedure.

PRACTICE IMPLICATIONS

This study highlights the necessity to develop strategies allowing tailoring of risk transmission to every patient's needs.

Improving informed consent to chemotherapy: a randomized controlled trial of written information versus an interactive multimedia CD-ROM

OBJECTIVE

This randomized controlled trial aimed to determine whether an interactive CD-ROM improved cancer patients' recall of chemotherapy treatment information over standard written information, and whether demographic, cognitive, and psychological factors better predicted recall than this format of delivery.

METHODS

One-hundred-and-one new patients about to commence chemotherapy were randomized to receive written information or a CD-ROM containing treatment information before giving informed consent. Patients' recall, concentration, short-term memory, reading comprehension, anxiety, depression, and coping styles were assessed with standardized measures pre-treatment. Seventy-seven patients completed tests for recall of treatment information before their second chemotherapy session.

RESULTS

Intention-to-treat analyses indicated no significant differences between the written information and CD-ROM groups across recall questions about number of drugs received (p=.43), treatment length (p=.23), and treatment goal (p=.69). Binary logistic regressions indicated that for groups combined different variables predicted each of the recall questions.

CONCLUSION

An interactive CD-ROM did not improve cancer patients' recall of treatment information enough to warrant changes in consent procedures.

PRACTICE IMPLICATIONS

Different variables predicted recall of different treatment aspects highlighting the complex nature of attempting to improve patient recall. Attending to the effect of depression on patient knowledge and understanding appears paramount.

Improvement of informed consent and the quality of consent documents

Guidelines on informed consent intend to protect patients and promote ethical research conduct. To give informed consent, individuals should understand the purpose, process, risks, benefits, and alternatives to research (or a proposed clinical intervention) and make a free, voluntary decision about whether to participate. Many participants have incomplete understanding of various features of clinical trials. Issues associated with the length, format, and language of documents for written informed consent are common. Here, we analyse the written consent form, particularly in the context of clinical research, and the discussions that take place between clinician or investigator and patient. We review strategies to improve consent forms, particularly the use of plain language. Recommendations are made on discussions between investigator and patient to improve participant comprehension and satisfaction with the informed-consent process.

Informed consent in the intensive care unit: ensuring understanding in a complex environment

PURPOSE OF REVIEW

Informed consent in the intensive care unit continues to receive marked attention. As greater numbers of patients enter into the intensive care unit with devastating illness, patients and families are faced with more complex medical problems and decisions regarding therapy. Furthermore, research investigations of critical illness add a level of complexity to informed consent and decision making that mandates a careful approach.

RECENT FINDINGS

Publications in the past year evidence the potential obstacles for appropriate informed consent. Physicians demonstrate variability in interpretation for the need for informed consent and frequently lack formal training in communicating informed consent. Critical care researchers must communicate the goals and benefits of trial participation carefully, avoiding the demonstrably common pitfall of therapeutic misconception. Excellent consensus statements now exist to guide the researcher in pursuing critical care research, creating informed consent documentation, and recognizing the appropriate setting for waiver of consent. As expected, extended discussion is the most effective tool for improving the quality of informed consent.

SUMMARY

Quality of informed consent for the critically ill improves as attention is paid to standardizing indications and formalizing training for physicians. In research, conflicts of interest should be recognized and used to guide the investigator's dialogue on research benefits and risks. Patient safety must be maintained as the primary priority; however, waiver of consent may be considered in situations in which the benefit to medical knowledge far exceeds patient risk.

Recommendations for informed consent forms for critical care clinical trials

BACKGROUND

Many subjects enrolled in research studies have a limited understanding of the research to which they consented.

OBJECTIVE

To develop recommendations to enhance comprehensiveness and understanding of informed consent forms used in critical care clinical trials.

DESIGN

Consensus process.

RECOMMENDATIONS

We provide recommendations regarding the U.S. federally required basic and additional elements of informed consent as applied to critical care clinical trials. We also identify issues that investigators need to address, if relevant, in the informed consent forms of critical care clinical trials. These include the description, in understandable language, of complex and detailed experimental protocols that are the focus of the clinical trial, disclosure of death as a risk factor if mortality is an outcome variable, and the identification of who can legally serve as the prospective subject's surrogate. We also offer suggestions to enhance subjects' understanding of informed consent forms.

CONCLUSIONS

The literature on informed consent forms suggest that shorter informed consent forms written at a lower reading level, when read carefully, might provide better subject understanding. Prospective evaluation is needed to determine whether our recommendations enhance the informed consent process.

Relationships between patients' pre-treatment expectations of toxicities and post chemotherapy experiences

A lack of adequate pharmacological explanations for side effect variation following chemotherapy suggests psychological factors may contribute to toxicity experience. This research aimed to determine if patients' expectations were associated with perceived toxicities for a wider range of chemotherapy toxicities than previously researched, including subjective and objective side effects. Eighty-seven chemotherapy-naive patients rated their expectations of 20 common side-effects before treatment, and then rated their experiences following their first chemotherapy dose. Hierarchical multiple regression analyses revealed that expectations of the inability to concentrate, hair loss, and diarrhoea prior to treatment had the strongest associations with the experience of symptoms. Expectations of encountering problems with sleep and sex, changes in taste or appetite, weakness, and nervousness, all showed moderate associations, and expectations of mood changes, feelings of tiredness, and nausea all showed weak associations with experience. These outcomes suggest that subjective side effects may be more prone to influence by expectation given their ambiguous nature. However, further research needs to be conducted into the effect expectations have on the treatment process, including the impact of other psychological factors. The current overriding emphasis placed on personal autonomy and fully informed consent may set up negative expectations which translate into adverse experiences to the detriment of the patient.

Informing breast cancer patients about clinical trials: a randomized clinical trial of an educational booklet

BACKGROUND

To evaluate the impact of an educational booklet on women's knowledge of and willingness to participate in a randomized clinical trial of treatment for breast cancer.

MATERIALS AND METHODS

Women undergoing surgery for newly diagnosed early stage breast cancer were randomized to receive, or not, an information booklet explaining the need for and manner in which randomized trials are conducted.

RESULTS

Eighty-three women with newly diagnosed early stage breast cancer completed a questionnaire assessing attitudes to random clinical trials (RCTs) and were randomized to receive usual information treatment options provided from their oncologist, or the educational booklet in addition to usual information from their oncologist (42 usual information, 41 booklet). Fewer women who received the clinical trials booklet (40% versus 47%) would consider participating in the hypothetical clinical trial (P = 0.6). Mean knowledge scores increased for both groups; moreover, women who did not receive the booklet showed similar improvements to women who received the booklet [mean difference 0.09, 95% confidence interval (CI) -0.66 to 0.83]. In a multivariate analysis women who would consider participating in the clinical trial were more anxious [odds ratio (OR) 5.9, P = 0.02] had involved lymph nodes (OR 5.8, P = 0.02) and were less influenced by negative aspects of clinical trials (OR 7.7, P = 0.0001). After adjustment for these variables women who received the educational booklet were significantly less likely to consider trial participation (OR 0.22, P = 0.05).

CONCLUSIONS

Educating women about clinical trials in this manner appears ineffective in improving recruitment to RCTs. Women appear to be more influenced by their perception of risk than understanding. This finding has ethical implications for communication of information about RCTs.

[Patients' rights during medical research and specifics in oncology (in France)]

PURPOSE

Clinical research in oncology is part of the care, instead of being theoretical, because it can offer new drugs to patients who are suffering from severe illnesses, but also because it offers better practices. The vulnerability of patients suffering from cancers, at each stage of the disease, requires special protection. Because of its multiple aspects, clinical research in oncology asks ethical questions. Medical deontology and laws, national and supranational, allow research with respect to the subject. The present article reviews these texts.

CURRENT KNOWLEDGE AND KEY POINTS

The rights of the person involved in clinical trials essentially consist of information and consent, but also the right to refuse, and the confidentiality of data collected. More subtle rights are now emerging because of new technologies, such as genetics. One of them is the right to be protected as a member of the human race, which is in continuity with human rights.

FUTURE AND PROJECTS

Finally, medical responsibility during research is increasing. It responds to the right of each person to see that his dignity is respected, although this dignity may be difficult to define. One of the more pertinent questions in building 'evidence-based ethics' concerns research into the evaluation by the persons themselves involved in the research.

Does an HIV clinical trial information booklet improve patient knowledge and understanding of HIV clinical trials?

OBJECTIVES

To evaluate the impact of an information booklet on HIV clinical trials, Clinical Trials in HIV and AIDS: Information For People Who Are Thinking About Joining a Trial, in addition to the standard trial information (SI) on patients' knowledge; understanding and attitudes about clinical trials; and to investigate patients' motivations and reasons for enrolling or not enrolling in a clinical trial.

METHODS

Fifty HIV-1 positive patients who attended the HIV clinic at a west London hospital were randomized to receive either SI alone (n = 27) or SI and a 16 page information booklet explaining the principles and procedures of HIV clinical trials (n = 23). A self-administered questionnaire was used at baseline to assess past experience and attitudes to clinical trials (10 questions), knowledge and understanding of HIV treatments (8 questions) and clinical trials (11 questions). At 2-6 months after randomization, a second interviewer-administered questionnaire addressed the patient's assessment of the usefulness and comprehensiveness of the information provided by the SI and information booklet, whether or not the patient had enrolled in a clinical trial and reasons for enrolling/not enrolling, knowledge of specific aspects of the trial protocol the patient was eligible to join (13 questions) and general knowledge of clinical trial procedures (repeat of 11 baseline questions). Changes in the attitudes and scores on knowledge and understanding of clinical trials were compared for the two groups.

RESULTS

In both groups, patient knowledge of clinical trial procedures improved significantly over the study period. The median score increased from 30 at baseline to 35/44 at follow-up (SI only) vs. 24-31/44 (SI plus booklet), but this did not differ significantly between the two groups. However, knowledge of the specific trial protocol was poor [median score 13/25, interquartile range (IQR) 8-14], and there was no difference in the scores for the two groups. The prime motivations for joining a clinical trial were to benefit personal health and to gain access to new treatments. Potential side-effects were the main concern of prospective trial participants.

CONCLUSIONS

This small trial shows that, while the patients' general knowledge and understanding of clinical trials improved over time, this was not improved by the information booklet and recollection of the details of the relevant trial protocol remained poor.

Literacy, comprehension, and informed consent in clinical research

Institutional review boards (IRBs) and informed consent have recently come under increasing scrutiny. The provision of appropriate and understandable information and its comprehension are key elements of the informed consent process. This article examines how literacy and other factors might impact on comprehension of the information provided. Better understanding of these issues and how to best address them are crucial to allowing clinical research subjects to participate as well-informed and willing partners in scientific inquiry.

Attitudes towards and participation in randomised clinical trials in oncology: a review of the literature

BACKGROUND

Clinical trials are the principal means by which new treatment approaches are evaluated in medicine. It has been argued that randomised clinical trials provide the highest standard of care and at the same time help to contribute to scientific knowledge. However, only a relatively small proportion of cancer patients receive treatment as part of a formal clinical trial. This article provides a broad review of the issues pertinent to physician and patient participation in randomised clinical trials.

METHODS

Search of computerised electronic databases (Medline, Psychlit, Cinhail, Embase).

RESULTS

There are a variety of physician and patient characteristics which have previously been shown to influence participation in randomised clinical trials. Additionally, ethical concerns about randomised trials in general and the additional requirements of informed consent for clinical trials, may impact on recruitment. Whilst there is some research examining strategies to improve patient understanding about clinical trials and promote patient involvement in clinical decision-making, there are deficiencies in these areas. In particular there is a paucity of research examining the association between knowledge about clinical trials, anxiety associated with a new cancer diagnosis and willingness to participate in randomised clinical trials.

CONCLUSIONS

Further research also is needed to evaluate strategies to better inform patients about clinical trials.

Barriers to participation in randomised controlled trials: a systematic review

METHOD

A systematic review of three bibliographic databases from 1986 to 1996 identified 78 papers reporting barriers to recruitment of clinicians and patients to randomised controlled trials.

RESULTS

Clinician barriers included: time constraints, lack of staff and training, worry about the impact on the doctor-patient relationship, concern for patients, loss of professional autonomy, difficulty with the consent procedure, lack of rewards and recognition, and an insufficiently interesting question. Patient barriers included: additional demands of the trial, patient preferences, worry caused by uncertainty, and concerns about information and consent.

CONCLUSIONS

To overcome barriers to clinician recruitment, the trial should address an important research question and the protocol and data collection should be as straightforward as possible. The demands on clinicians and patients should be kept to a minimum. Dedicated research staff may be required to support clinical staff and patients. The recruitment aspects of a randomised controlled trial should be carefully planned and piloted. Further work is needed to quantify the extent of problems associated with clinician and patient participation, and proper evaluation is required of strategies to overcome barriers.

National efforts to improve the informed consent process

OBJECTIVES

To inform oncology nurses about several national efforts to improve the informed consent document and process.

DATA SOURCES

A federally funded grant program to stimulate research of informed consent, an initiative from the National Cancer Institute to improve informed consent documents in cancer clinical trials, and a model consent document developed by the National Action Plan on Breast Cancer.

CONCLUSIONS

These initiatives assist investigators and institutional review boards in presenting relevant and understandable information to potential clinical trial participants.

IMPLICATIONS FOR NURSING PRACTICE

These national efforts will raise awareness of providing potential research participants with clear information to assist them in making an educated, informed decision.

Impact of therapeutic research on informed consent and the ethics of clinical trials: a medical oncology perspective

PURPOSE

To create a more meaningful understanding of the informed consent process as it has come to be practiced and regulated in clinical trials, this discussion uses the experience gained from the conduct of therapeutic research that involves cancer patients.

DESIGN

After an introduction of the ethical tenets of the consent process in clinical research that involves potentially vulnerable patients as research subjects, background that details the use of written consent documents and of the term "informed consent" is provided. Studies from the cancer setting that examine the inadequacies of written consent documents, and the outcome of the consent process itself, are reviewed. Two ethically challenging areas of cancer clinical research, the phase I trial and the randomized controlled trial, are discussed briefly as a means of highlighting many dilemmas present in clinical trials. Before concluding, areas for future research are discussed.

RESULTS

Through an exclusive cancer research perspective, many current deficiencies in the informed consent process for therapeutic clinical trials can be critically examined. Also, new directions for improvements and areas of further research can be outlined and discussed objectively. The goals of such improvements and research should be prevention of further misguided or ineffective efforts to regulate the informed consent process.

CONCLUSION

To ignore this rich and interesting perspective potentially contributes to continued misunderstanding and apathy toward fulfilling the regulatory and ethically obligatory requirements involved in an essential communication process between a clinician-investigator and a potentially vulnerable patient who is considering clinical trial participation.

Psychological distress among cancer patients and informed consent

This study examines the relationships between satisfaction with information provided, understanding of consent procedures, and levels of anxiety/depression in a sample of patients undergoing radiotherapy for cancer. One hundred patients completed a 13-item self-report questionnaire and the Hospital Anxiety and Depression Scale (HADS). Twenty-two percent of patients could not recall signing a consent form and, for those who did recall, the level of understanding for what they had consented to was patchy. One fourth of patients could not recall being told of the side-effects from radiotherapy and were unable to list even common side-effects, such as tiredness, skin irritation, and sickness. No patient had been told about the low risk of second malignancy. Twenty-eight percent of patients were unhappy with the amount of information offered to them. Thirty percent of patients reached caseness for adjustment disorder +/- anxiety/depression. Thirteen percent of patients reached caseness for major depression. There was a significant correlation between patients who scored highly on the HADS and dissatisfaction with the information provided. Clinical implications and possible mechanisms of these findings are discussed.

Informed consent for clinical trials: in search of the "best" method

OBJECTIVE

To review the literature on comparisons between different methods of obtaining informed consent for clinical trials.

DESIGN

Eight hundred and twelve articles were traced, in the process of conducting a systematic review of the ethics of clinical trials, by searching a number of sources: bibliographic databases (Medline, Psychlit and BIDS science and social science indices), hand searches, personal contacts, an original collection and a systematic follow-up of reference lists. Fourteen research reports were found which provided comparative data on different methods of obtaining informed consent. Eleven of these used a randomised design. Studies were classified according to three outcome measures (anxiety, consent rate and understanding).

RESULTS

The results of the various studies suggest that giving people more information and more time to reflect tends to be associated with a lower consent rate. There seems to be an optimal level of information about side-effects such that patients are not overburdened by detail, while grasping the most important risks. More information in general is associated with greater awareness of the research nature of the trial, voluntariness of participation, right to withdraw and (available) alternative treatments. This result does not, however, extend to explanations of the concept of randomisation on which the literature is contradictory--sometimes more information is associated with increased understanding of the concept and sometimes it is not. Although divulging less information seems to be associated with less anxiety, there is evidence of an interaction with knowledge--high levels of knowledge are significantly associated with less anxiety, irrespective of consent method. The more that patients know before they are invited to participate in a trial, the better equipped they are to cope with the informed consent procedure.

CONCLUSION

There is some evidence to suggest that there is an optimal amount of information which enhances patient understanding and which might, in turn, reduce anxiety. However. the studies were not altogether conclusive. More work needs to be carried out, especially on public understanding of science and on how different ways of explaining scientific concepts affect that understanding.