A disparity of words: racial differences in oncologist-patient communication about clinical trials

From community to scale: Using community engagement to develop and validate a patient-informed cancer communication scale

OBJECTIVE

Racial disparities in clinical communication quality are well-established but most clinical communication assessment tools are created without the collaboration of racially-diverse patient populations. Our objective was to collaborate with Black and White cancer survivors, caregivers, and advocates to develop and validate a tool to assess physicians' patient-centered communication.

METHODS

A panel of Black and White cancer survivors, caregivers, and advocates (n = 11) and researchers observed and discussed video-recorded patient-physician cancer clinical interactions to generate and refine a list of physician communication behaviors considered critical for high-quality patient-centered communication. Raters applied the 22-item scale (Patient-Informed Cancer Communication Scale; PICCS) assessing physicians' patient-centered communication to video-recorded interactions (n = 61) from a larger study. We determined constructs using scale development and factor analysis and validated the scale through correlation with existing scales.

RESULTS

Factor analysis identified five factors: treatment options; clinical relationship; prognosis and goals of treatment; explanations; and context. Treatment options, prognosis and goals of treatment, and the full scale correlated with a validated patient active participation scale. Clinical relationship and context correlated with a validated physicians' patient-centered communication scale.

CONCLUSION

This community-engaged research produced a reliable and valid scale to assess physician patient-centered communication in the context of Black and White people with cancer.

PRACTICE IMPLICATIONS

With further validation work, this scale can be used to train and assess physician communication quality when discussing cancer treatment in diverse cancer patient populations.

Racial equity in and through medical interaction scholarship: A scoping review

OBJECTIVE

We conducted a systematic scoping review to characterize the landscape of communication scholarship within racial health equity in and through the patient-provider interaction.

METHODS

We employed three waves of data collection to identify relevant articles (N = 454) about racial equity within provider-patient interactions. We iteratively developed a codebook concerning article characteristics, coding for journal names, data source, descriptive characteristics for the study samples, and presence of theory and equity in sections of the manuscripts.

RESULTS

This search identified studies (N = 206) that were published in 76 peer-reviewed scientific journals. The majority of studies reported primary data analyses and used survey and interview methodology. Many studies examined participants as patients generally rather than in reference to particular health conditions. Among those with a specific health condition, the largest proportion focused on cancer control. Very few studies included samples with Native American and Pacific Island heritage. Most studies included cisgender men and/or women, but none included transgender men or women. The vast majority of research focused on the patient experience; few centered on providers' and caregivers' experiences. The body of scholarship was largely atheoretical; the most frequently noted constructs were patient-provider communication (including patient-centered communication and patient-centered care), implicit/explicit racial bias, shared decision-making. There was wide variation in the extent to which equity was woven through the manuscripts. Equity is typically mentioned in the literature review, and racial identity in the sample may serve as a marker of racialized experiences.

CONCLUSION

This study demonstrates the need for the development of theory that elevates the centrality of health equity to attend to the bi- or multi-directional flow of communication that shapes the quality of these interactions.

PRACTICE IMPLICATIONS

These insights can serve as a strong foundation for the development of interventions to address equity in clinical interactions.

Are those all my options? Evaluating oncologists' communication strategies in treatment and clinical trial discussions by race and gender

PURPOSE

Increasing patient enrollment and promoting equity in trial participation are essential to improving cancer care outcomes. Physicians play a crucial role in decision-making, making it important to understand communication strategies used by oncologists when discussing treatment options, including clinical trial participation.

METHODS

This observational qualitative study was conducted from 2022 to 2023. We recruited US medical oncologists who treat colon cancer and have access to clinical trials. Oncologists participated in simulated telehealth encounters with standardized patients with colon cancer who identified as Black or white and were referred to discuss treatment options, including a potential clinical trial.

RESULTS

Of 107 academic physicians contacted, 47 (44%) responded, and 21 (20%) participated. The median age was 41, 43% female, and 33% non-white. Average encounter length was 44:05 minutes. One to four treatment options were discussed. Clinical trials were discussed in nearly all conversations. Average duration of clinical trial-related talk was 08:30 minutes. Conversations with Black female patients were significantly shorter than with white female patients (mean difference: 7 minutes). Recommendations varied with 9/21 oncologists recommending a clinical trial, 9/21 deferring a decision, and 3/21 recommending standard of care. In the post-encounter survey, 86% of oncologists said they recommended a trial but only 43% actually did so.

CONCLUSION

Oncologists' communication about treatment options may impact patients' decisions and trial participation. In our study, fewer than half of oncologists recommended a trial with variability in how options were presented and the length of discussion. There was also a misperception with more oncologists thinking they recommended a trial, but they did not in the encounter. A more structured approach to these complex discussions may help oncologists communicate treatment options to patients in a more equitable and effective way.

Shared decision making in routine oncology appointments with Black patients with lung cancer

PURPOSE

Poor clinician-patient communication may contribute to racialized inequities in cancer symptom burden. Shared decision-making (SDM) enhances clinician-patient communication, and could contribute to health equity for Black patients with cancer. However, research on SDM is limited for Black patients with cancer.

METHODS

This multi-method longitudinal observational study examined SDM during routine oncology follow-ups for patients with advanced lung cancer. We analyzed SDM reported by clinicians (n = 6), self-identified Black patients with lung cancer (n = 30), and coded from patient visit recordings (n = 20). We described the symptom management conversations, and examined how SDM related to patient satisfaction and symptom severity with two-sided correlations.

RESULTS

Most patients (85.0%) asked questions during appointments and discussed cancer-related symptoms (95.0%), most commonly pain/neuropathy (65.0%). Though coded SDM during symptom discussions was low, providers and patients reported high levels of SDM. Coded SDM did not statistically significantly correlate with post-appointment satisfaction (r = -.01, p > .10) or symptom burden (r = .04, p > .10). However, patient-reported SDM did relate to post-appointment satisfaction (r = .72, p = .08) and symptom burden (r = .35, p = .08) one month later.

CONCLUSIONS

Through detailed multi-method analysis, we found that coded SDM did not correspond to patient and physician-reported SDM during routine oncology appointments. Patient-reported SDM correlated to several better physical and mental health outcomes as well as overall satisfaction a month later. Our findings highlight the complexities of clinician-patient communication and the importance of studying these processes for Black patients with cancer. Future research should develop culturally-relevant methods of assessing SDM with Black patients and understand Black patients' communication needs.

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.

Latine Immigrant Perspectives on Trust of Clinical Research

Introduction: Medical mistrust impedes minority group participation in research, but there are few studies assessing determinants of Latine immigrants' trust in the clinical research enterprise. This qualitative study explored Latine immigrants' perspectives of clinical research. Methods: We conducted telephonic interviews with 20 Latine immigrants receiving care at a Federally Qualified Health Center in Los Angeles, California. Interviews were conducted between December 2021 and April 2022, and resultant data were coded using thematic analysis. Results: Six main themes emerged across two domains. First, trust was influenced by perceptions of the investigators' intentions. These perceptions were primarily based on (1) adequacy of information provided about the research, (2) perceived intent of investigators to respect their humanity, and (3) opportunities to share personal experiences. Second, trust was influenced by perceptions of the study's potential impact, including (4) risk of adverse outcomes, including health risks and risk of immigration status exposure, (5) perceived personal benefits, and (6) perceived community-level benefits. Conclusion: Researchers can build trust and promote participation among Latine immigrants by effectively communicating study objectives, risk mitigation efforts, and personal and community benefits. Enhancing the trustworthiness of clinical research can increase the relevance of scientific findings, representing one pathway to achieving health equity.

Reducing Health Disparities Among African American and Black Caribbean Patients by Improving the Communication Practices of Clinical Research Coordinators

This manuscript focuses on the communication factors that affect the willingness of African Americans and Black Caribbean patients to participate in clinical trials and research studies. Low rates of research participation by members of communities of color have long been linked to health disparities. While there are many factors that contribute to low rates of accrual of African American and Black patients to clinical trials, a lack of attention to communication factors that enhance or inhibit the recruitment process is central to the problem. In this study, we describe results from the analysis of six focus groups (N = 31) consisting of African American (k = 3) and Black Caribbean (k = 3) participants. Our analyses focus on verbal and nonverbal communication behaviors and how they affect participants' willingness to participate in clinical trials. Specifically, when clinical research coordinators (CRCs) had a professional appearance, made the effort to explain a study in detail, made eye contact, took the time to listen and answer questions patiently, and gave the sense that the CRC was being truthful and transparent, patients felt respected and valued. Additionally, participants emphasized the importance of the process of developing and maintaining a trusting relationship between study participants and CRCs. The results of this study will be used to develop a clinical trial communication training program designed to enhance the communication skills of clinical research coordinators who discuss research participation with African American and Caribbean Black patients.

Disparity in hematological malignancies: From patients to health care professionals

In the recent few decades, outcomes in patients diagnosed with hematological malignancies have been steadily improving. However, the improved prognosis does not distribute equally among patients from different backgrounds. Besides cancer biology, demographic and geographic disparities have been found to impact overall survival significantly. Specifically, patients from underrepresented minorities including Black and Hispanics, and those with uninsured status, having low socioeconomic status, or from rural areas have had worse outcomes historically, which is uniformly true across all major subtypes of hematological malignancies. Similar discrepancy is also seen in the health care professional field, where a gender gap and a disproportionally low representation of health care providers from underrepresented minorities have been long existing. Thus, a comprehensive strategy to mitigate disparity in the health care system is needed to achieve equity in health care.

Addressing the Impact of Race and Ethnicity on Musculoskeletal Spine Care in the United States

➤ Despite being a social construct, race has an impact on outcomes in musculoskeletal spine care.➤ Race is associated with other social determinants of health that may predispose patients to worse outcomes.➤ The musculoskeletal spine literature is limited in its understanding of the causes of race-related outcome trends.➤ Efforts to mitigate race-related disparities in spine care require individual, institutional, and national initiatives.

Racial and ethnic disparities in knowledge, attitudes, and invitation to participate in clinical trials among cancer survivors in the United States: An analysis of the 2020 U.S. HINTS

Background

Despite the use of clinical trials to provide gold-standard evidence of cancer treatment and intervention effectiveness, racial/ethnic minorities are frequently underrepresented participants. Our objective was to evaluate racial/ethnic differences in knowledge and attitudes towards clinical trials among U.S. cancer survivors.

Methods

We leveraged the 2020 Health Informational National Trends Survey (HINTS) data (February-June 2020), which is a weighted, nationally representative survey of 3865 adults (≥18 years), including cancer survivors. We descriptively evaluated cancer survivor's (n = 553) knowledge of clinical trials, and trusted sources of information regarding clinical trials. Using Poisson regression, we estimated predictors of self-reported knowledge of clinical trials.

Results

Among cancer survivors, 82 % were NH-White and 60 % self-reported to at least have some knowledge about clinical trials. When asked about factors that would influence their decision to participate in clinical trials, participants across racial groups frequently chose "I would want to get better" and "If the standard care was not covered by my insurance." NH-White (76 %), NH-Black (78 %), and Hispanic/Latinx (77 %) cancer survivors reported their trusted source of information about clinical trials was their health care provider; NH-Asian cancer survivors reported their health care provider (51 %) as well as government health agencies (30 %) as trusted sources. Cancer survivors with only a high school degree were less likely to have any knowledge of clinical trials compared to those with a Baccalaureate degree or more (aPR:0.61;95 % CI:0.45-0.83).

Conclusion

Health care providers are a trusted source of clinical trial information.

Opportunities to Increase Science of Diversity and Inclusion in Clinical Trials: Equity and a Lack of a Control

The United States witnessed a nearly 4-fold increase in personal health care expenditures between 1980 and 2010. Despite innovations and obvious benefits to health, participants enrolled in clinical trials still do not accurately represent the racial and ethnic composition of patients nationally or globally. This lack of diversity in cohorts limits the generalizability and significance of results among all populations and has deep repercussions for patient equity. To advance diversity in clinical trials, robust evidence for the most effective strategies for recruitment of diverse participants is needed. A major limitation of previous literature on clinical trial diversity is the lack of control or comparator groups for different strategies. To date, interventions have focused primarily on (1) community-based interventions, (2) institutional practices, and (3) digital health systems. This review article outlines prior intervention strategies across these 3 categories and considers health policy and ethical incentives for substantiation before US Food and Drug Administration approval. There are no current studies that comprehensively compare these interventions against one another. The American Heart Association Strategically Focused Research Network on the Science of Diversity in Clinical Trials represents a multicenter, collaborative network between Stanford School of Medicine and Morehouse School of Medicine created to understand the barriers to diversity in clinical trials by contemporaneous head-to-head interventional strategies accessing digital, institutional, and community-based recruitment strategies to produce informed recruitment strategies targeted to improve underrepresented patient representation in clinical trials.

Problematic Integration: Racial Discordance in End-of-Life Decision Making

We describe racially discordant oncology encounters involving EOL decision-making. Fifty-eight provider interviews were content analyzed using the tenets of problematic integration theory. We found EOL discussions between non-Black providers and their Black patients were often complex and anxiety-inducing. That anxiety consisted of (1) ontological uncertainty in which providers characterized the nature of Black patients as distrustful, especially in the context of clinical trials; (2) ontological and epistemological uncertainty in which provider intercultural incompetency and perceived lack of patient health literacy were normalized and intertwined with provider assumptions about patients' religion and support systems; (3) epistemological uncertainty as ambivalence in which providers' feelings conflicted when deciding whether to speak with family members they perceived as lacking health literacy; (4) divergence in which the provider advised palliative care while the family desired surgery or cancer-directed medical treatment; and (5) impossibility when an ontological uncertainty stance of Black distrust was seen as natural by providers and therefore impossible to change. Some communication strategies used were indirect stereotyping, negotiating, asking a series of value questions, blame-guilt framing, and avoidance. We concluded that provider perceptions of Black distrust, religion, and social support influenced their ability to communicate effectively with patients.

Disparity in initiation of checkpoint inhibitors among commercially insured and Medicare Advantage patients with metastatic melanoma

BACKGROUND: Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of advanced melanoma, but racial disparities in melanoma outcomes continue. These inequities are not fully explained by individual factors. OBJECTIVE: To investigate the associations of neighborhood factors with the use of ICIs in metastatic melanoma. METHODS: We conducted a retrospective cohort study of commercially insured US adults with metastatic melanoma diagnosed between January 2011 and December 2020. We examined the associations between the county-level percentage of population from racial and ethnic minority groups and the time from metastatic melanoma diagnosis to initiating ICIs using Cox proportional hazards models adjusting for patient characteristics. RESULTS: We identified 4,052 patients with metastatic melanoma, of which 49% used ICIs. We found that the adoption of ICIs in a county declined with increasing minority quintile (quintile 1: 52.4%, quintile 2: 50.4%, quintile 3: 50.1%, quintile 4: 45.8%, and quintile 5: 44.7%). The delay in ICI initiation also went up as the percentage of minorities in a county increased (log-rank test P = 0.03). Compared with the lowest quintile, the adjusted hazard ratio of ICI initiation of the second, third, fourth, and highest minority quintile was 0.94 (95% CI = 0.81-1.08), 0.88 (95% CI = 0.76-1.02), 0.81 (95% CI = 0.68-0.97), and 0.77 (95% CI = 0.66-0.91), respectively. Secondary analysis revealed that the slower initiation was driven by the counties with the highest percentage of Hispanic population (hazard ratio = 0.74; 95% CI = 0.61-0.89) in both Cox models and sensitivity analyses. High-minority counties correlated with metro areas, higher poverty levels, and a greater number of medical oncologists. CONCLUSIONS: We found that patients with metastatic melanoma living in counties with higher proportion of minorities, particularly of Hispanic origin, are more likely to experience delays in ICI treatment. This study provides important population-level data on neighborhood-level disparity in medication use. More research is needed on the underlying provider- and system-level factors that directly contributed to the lower use of cancer medicines in high-minority areas, which can help inform the development of evidence-based medication use strategies that can improve health outcomes and equity.

Determining clinical perspectives and strategies for improving enrollment of minoritized communities in prostate cancer clinical trials

BACKGROUND

Black men and other minoritized populations have represented 4-5% or less of participants in most practice-informing clinical trials. This study sought to assess the knowledge, attitudes, and practices of clinicians around equity and inclusion in prostate cancer clinical trial initiatives in the United States.

METHODS

An anonymous, web-based questionnaire was administered via REDCap (Research Electronic Data Capture) with questions focused on inclusivity of minoritized populations with respect to race and ethnicity in prostate cancer clinical trials research. The survey link was distributed across the United States via several professional organizations, prostate cancer groups, and social media. Responses were analyzed both quantitatively (descriptive statistics) and qualitatively (thematic analysis).

RESULTS

Overall, 131 respondents completed the survey (70% self-identified as White, 17% as Asian, and 6% as Black). Most respondents practiced in an urban setting (89%). Of those who engaged in outreach with minoritized communities during the trial design process, 69% observed improved enrollment of minoritized populations. However, 18% of respondents noted that outreach alone does not overcome existing structural barriers to participation in clinical trials. Thematic analysis identified four key areas to address for improving equity: structural, health system, trial-/study-specific, and relationship-/engagement-related factors.

CONCLUSION

Study participants demonstrated a knowledge of the importance of improving equity in prostate cancer clinical trials research. Designing trials that reduce issues associated with access and improving community outreach were emphasized as key focus areas for reducing health disparities in prostate cancer clinical trials research.

Optimizing Informed Consent in Cancer Clinical Trials

The concept of informed consent has evolved considerably over the course of the 20th century, leading to its establishment as a foundational ethical principle for the conduct of biomedical research in the United States. Even though it is now a highly regulated part of cancer research, the process of obtaining informed consent is often impeded by systemic, clinician, and patient factors that require both small- and large-scale intervention. New challenges and considerations continue to emerge due to innovations in clinical trial design, increases in utilization of genomic sequencing, and advances in genomic editing and artificial intelligence. We present a review of the history, policy, pragmatic challenges, and evolving role of the central ethical tenet of informed consent in clinical trials.

Assessing Equitable Inclusion of Underrepresented Older Adults in Alzheimer's Disease, Related Cognitive Disorders, and Aging-Related Research: A Scoping Review

BACKGROUND AND OBJECTIVES

The rapidly aging and diversifying U.S. population is challenged by increases in prevalence of Alzheimer's disease (AD) and aging-related disorders. We conducted a scoping review to assess equitable inclusion of diverse older adult populations in aging research focused on National Institutes of Health (NIH)-sponsored research.

RESEARCH DESIGN AND METHODS

The scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol. The search was limited to NIH-funded studies focusing on aging, AD, and Alzheimer's disease-related dementias (ADRD) and included adults aged 55 and older. The priority populations and health disparities put forth by the National Institute on Aging Health Disparities Framework serve as a model for guiding inclusion criteria and for interpreting the representation of these underrepresented groups, including racial-ethnic minorities, socioeconomically disadvantaged, rural populations, groups with disabilities, and lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) communities.

RESULTS

Our search identified 1,177 records, of which 436 articles were included in the analysis. Inclusion of individuals with ADRD and mild cognitive impairment, racial-ethnic minorities, rural populations, socioeconomically disadvantaged, groups with disabilities, and LGBTQ communities were poorly specified in most studies. Studies used multiple recruitment methods, conducting studies in community settings (59%) and hospitals/clinics (38%) most frequently. Incentives, convenience factors, and sustained engagement via community-based and care partners were identified as key strategies for improved retention.

DISCUSSION AND IMPLICATIONS

This scoping review identified gaps in existing literature and aims for future work, including stronger research focus on, better inclusion of, and improved data collection and reporting of older adults from underrepresented groups.

Understanding organizational perspectives from clinical research stakeholders involved in recruitment for biopharmaceutical-sponsored clinical trials in the United States: Recommendations for organizational initiatives to improve access and inclusivity in clinical research

Background

Equitable representation of racially and ethnically diverse subpopulations in clinical trials continues to be a problem, and trial participants do not always reflect the demographics of the population that the investigational product will be used to treat. The imperativeness of equitable representation of clinically relevant populations in clinical trials has implications for improving health outcomes, increasing knowledge about the safety and efficacy of new treatments across a wider population, and broadening access to innovative treatment options offered in clinical trials.

Methods

The purpose of this study was to understand organizational elements that are involved in the active implementation of racially and ethnically diverse inclusive recruitment practices for biopharmaceutical-funded trials in the United States. Semi-structured, in-depth interviews were used in this qualitative study. The interview guide was designed to explore the perceptions, practices and experiences of 15 clinical research site professionals related to recruiting diverse trial participants. Data analysis utilized an inductive coding process.

Results

Five themes were identified pertaining to the actual implementation of inclusive recruitment practices that provided explanations for organizational components: 1) provision of culturally appropriate, general disease and clinical trial education 2) organizational structure tailored for diverse recruitment 3) strong sense of mission related to improving healthcare through clinical research 4) culture of inclusion 5) inclusive recruitment practices evolving based on learning.

Conclusion

The findings from this study offer insight into improving access to clinical trials by focusing on organizational change initiatives.

Addressing multilevel barriers to clinical trial participation among Black and White men with prostate cancer through the PACCT study

BACKGROUND

Cancer clinical trial participation is low and inequitable. Partnering Around Cancer Clinical Trials (PACCT) addressed systemic and interpersonal barriers through an observational study of eligibility and an intervention to improve patient-physician communication and trial invitation rates.

METHODS

Physicians at two comprehensive cancer centers and Black and White men with prostate cancer participated. Patients were followed for 2 years to determine whether they became potentially eligible for an available therapeutic trial. Potentially eligible patients were randomized to receive a trials-focused Question Prompt List or usual care. Patient-physician interactions were video-recorded. Outcomes included communication quality and trial invitation rates. Descriptive analyses assessed associations between sociodemographic characteristics and eligibility and effects of the intervention on outcomes.

RESULTS

Only 44 (22.1%) of participating patients (n = 199) became potentially eligible for an available clinical trial. Patients with higher incomes were more often eligible (>$80,000 vs. <$40,000, adjusted OR = 6.06 [SD, 1.97]; $40,000-$79,000 vs. <$40,000, adjusted OR = 4.40 [SD, 1.81]). Among eligible patients randomized to the intervention (n = 19) or usual care (n = 25), Black patients randomized to the intervention reported participating more actively than usual care patients, while White intervention patients reported participating less actively (difference, 0.41 vs. -0.34). Intervention patients received more trial invitations than usual care patients (73.7% vs. 60.0%); this effect was greater for Black (80.0% vs. 30.0%) than White patients (80.0% vs. 66.7%).

CONCLUSIONS

Findings suggest the greatest enrollment barrier is eligibility for an available trial, but a communication intervention can improve communication quality and trial invitation rates, especially for eligible Black patients.

Effects of Communication Source and Racial Representation in Clinical Trial Recruitment Flyers

The current study was designed to examine effective message strategies that can be employed in designing mediated communication messages to improve clinical trial research participation. In the study, a total of 300 participants completed an online experiment in which they responded to five different clinical trial recruitment advertisements whose information sources varied in their credentials and race. Overall, peer-featured ads in which previous clinical trial participants communicated their prior experience in clinical trial participation, compared to expert-featured ads in which medical doctors communicated information about clinical trials, led to higher message and topic relevance, higher message credibility, more favorable attitudes toward clinical trials, and higher intentions to participate in future clinical trials. Further, there was a statistically significant interaction among source credentials, racial match (between source and participant), and participant's race on message and topic relevance such that both White and Black participants rated ads from racially mismatched peers highly effective (greater message and topic relevance); however, for doctor featured ads, White participants reported higher message and topic relevance for racially matched (White doctor) ads, and Black participants reported higher message and topic relevance for racially mismatched (White doctor) ads. We discuss theoretical and practical implications.

"There's not enough studies": Views of black breast and ovarian cancer patients on research participation

BACKGROUND

Black breast and ovarian cancer patients are underrepresented in clinical cancer trials disproportionate to the prevalence of these cancers in Black females. Historically, lower enrollment has been attributed to individualized factors, including medical mistrust, but more recently structural factors, including systemic racism, have received additional scrutiny. We interviewed Black women with a personal or family history of breast and ovarian cancer to understand their views and experiences related to research participation.

METHODS

Qualitative interviews were conducted via telephone or video conference and transcribed verbatim. Transcripts were qualitatively analyzed for iterative themes related to the offer and participation in cancer clinical trials and research studies, impact on cancer care, and recommendations to increase enrollment of Black patients.

RESULTS

Sixty-one Black women completed an interview. Participants expressed that Black women are underrepresented in cancer research, and that this negatively impacted their own care. Many cited past historical abuses, including the Tuskegee syphilis trial, as a potential factor for lower enrollment but suggested that lower enrollment was better understood in the context of the entirety of their healthcare experiences, including present-day examples of patient mistreatment or dismissal. Participants suggested that proactive community engagement, transparency, and increased representation of Black research team members were strategies likely to foster trust and bolster research participation.

CONCLUSION(S)

Medical mistrust is only a partial factor in the lower participation of Black patients in cancer research. Researchers should implement the strategies identified by our participants to promote diverse enrollment and ensure that Black patients are included in future therapeutic advances.

Clinical research nurses' perceptions of the unique needs of people of color for successful recruitment to cancer clinical trials

BACKGROUND

Clinical trials (CTs) test new medical products for safety and effectiveness. Despite federal policy aimed at generating greater inclusivity of people of color (POC) in CTs, disparity in (CT) enrollment persists. Non-Hispanic White patients comprise the majority of CT participants while Black and Hispanic patient participation has declined over the past decade. The scope of Clinical Research Nurses (CRNs) includes recruitment of participants for CTs. The aim of this phenomenological study was to describe adult oncology CRNs' lived experiences of recruiting POC cancer patients to participate in CTs. The first paper for this study identified three major themes regarding how CRNs view their role in caring for POC considering or enrolling onto cancer clinical trials (CCTs): CRNs act as advocates, care coordinators and educators. This paper focuses on two additional major themes regarding how CRNs view the unique needs of POC in clinical research: establishing and maintaining trusting relationships and recruitment infrastructure.

METHODS

Nineteen nurses participated in semi-structured one-to-one interviews and data analysis was based on Colaizzi's method.

RESULTS

CRNs described a history of past research injustices, disparate access to care, inadequate cultural training, a physician-driven recruitment structure and provider-based implicit biases that hinder POC enrollment in CTs.

CONCLUSION

Diversity in CCT enrollment requires CRNs to establish trust with POC, advocate for POC when implicit biases are observed and become competent practitioners of culturally sensitive care. Further, meaningful policy change at both federal and organizational levels must occur to ensure equitable access to novel cancer therapies.

Diversity in clinical research: public health and social justice imperatives

It is well established that demographic representation in clinical research is important for understanding the safety and effectiveness of novel therapeutics and vaccines in diverse patient populations. In recent years, the National Institutes of Health and Food and Drug Administration have issued guidelines and recommendations for the inclusion of women, older adults, and racial and ethnic minorities in research. However, these guidelines fail to provide an adequate explanation of why racial and ethnic representation in clinical research is important. This article aims to both provide the missing arguments for why adequate representation of racial and ethnic minorities in clinical research is essential and to articulate a number of recommendations for improving diversity going forward.Appropriate racial and ethnic representation and fair inclusion help (1) increase the generalisability of clinical trial results, (2) equitably distribute any benefits of clinical research and (3) enable trust in the research enterprise.

Enrollment of Racial and Ethnic Minoritized Groups in Gynecologic Oncology Clinical Trials: A Review of the Scope of the Problem, Contributing Factors, and Strategies to Improve Inclusion

Racial inequities are well-documented across the gynecologic oncology care continuum, including the representation of racial and ethnic minoritized groups (REMGs) in gynecologic oncology clinical trials. We specifically reviewed the scope of REMG disparities, contributing factors, and strategies to improve inclusion. We found systematic and progressively worsening under-enrollment of REMGs, particularly of Black and Latinx populations. In addition, race/ethnicity data reporting is poor, yet a prerequisite for accountability to recruitment goals. Trial participation barriers are multifactorial, and successful remediation likely requires multi-level strategies. More rigorous, transparent data on trial participants and effectiveness studies on REMG recruitment strategies are needed to improve enrollment.

Metrics, baseline scores, and a tool to improve sponsor performance on clinical trial diversity: retrospective cross sectional study

Objective

To develop a measure for fair inclusion in pivotal trials by assessing transparency and representation of enrolled women, older adults (aged 65 years and older), and racially and ethnically minoritized patients.

Design

Retrospective cross sectional study.

Population

Sponsors of novel oncology therapeutics that were approved by the US Food and Drug Administration over 1 January 2012 to 31 December 2017.

Data sources

Trial data from Drugs@FDA, ClinicalTrials.gov, and corresponding publications; cancer incidence demographics from US Cancer Statistics and the American Cancer Society.

Main outcome measures

Transparency measures assess whether trials publicly report participant sex, age, and racial and ethnic identity. Representation measures assess whether trial participant demographics represent more than 80% of the US patient population for studied conditions, calculated by dividing the percentage of study participants in each demographic subgroup by the percentage of the US cancer population with the studied condition per group. Composite fair inclusion measures assess average transparency and representation scores, overall and for each demographic group. Results are reported at the trial, product, and sponsor levels.

Results

Between 1 January 2012 and 31 December 2017, the FDA approved 59 novel cancer therapeutics, submitted by 25 sponsors (all industry companies) on the basis of 64 pivotal trials. All 25 sponsors (100%) reported participant sex, 10 (40%) reported age, and six (24%) reported race and ethnicity. Although 14 (56%) sponsors had adequate representation of women in trials, only six (24%) adequately represented older adults, and four (16%) adequately represented racially and ethnically minoritized patients (black, Asian, Hispanic or Latinx). On overall fair inclusion, one sponsor scored 100% and the median sponsor score was 81% (interquartile range 75-87%). More than half of sponsors (13 (56%) of 25) fairly included women, 20% (n=5) fairly included older adults, and 4% (n=1) fairly included racially and ethnically minoritized patients in trials. 80% of product had pivotal trials that fairly included women, 24% fairly included older adults, and 5% fairly included racially and ethnically minoritized patients.

Conclusions

This novel approach evaluates trials, products, and sponsors on their fair inclusion of demographic groups in research. For oncology trials, substantial room was noted for improved inclusion of older adults and patients who identify as black or Latinx and transparency around the number of participants identifying as Native Hawaiian, Pacific Islander, American Indian, and Alaska Native. These measures can be used by sponsors, ethics committees, among others, to set and evaluate trial diversity goals to help spur progress toward greater research equity in the US.

A Direct Patient-Provider Relationship With the Medical Physicist Reduces Anxiety in Patients Receiving Radiation Therapy

PURPOSE

The complex technological processes involved in radiation therapy can be intimidating to patients, causing increased treatment-related anxiety and reduced satisfaction. An intervention was implemented to provide direct consultations between patients and medical physicists to reduce patient anxiety and improve patient satisfaction. A randomized clinical trial was conducted to test the intervention's effect on anxiety, distress, treatment adherence, technical understanding, and satisfaction in patients receiving radiation therapy.

METHODS AND MATERIALS

Eligible patients were recruited into "intervention" and "standard of care" arms within a phase 2 screening randomized trial. Intervention-arm patients met with a medical physicist who provided technical information and addressed patient questions or concerns at the time of treatment simulation and before the first treatment. In addition to baseline information collected before randomization, participants were surveyed (1) before simulation, (2) before the first treatment, and (3) before the completion of treatment to evaluate the study endpoints. Primary endpoints included patient anxiety and distress. Secondary endpoints included patient treatment adherence, overall satisfaction, and technical understanding of treatment. Patients in the intervention arm were surveyed before and after each physicist meeting.

RESULTS

Participant anxiety was significantly reduced in the intervention arm (difference, -0.29; 95% confidence interval, -0.57 to -0.02; P = .038). No differences in distress or treatment adherence were observed between groups. Although measures of technical understanding and satisfaction were evaluated as exploratory objectives, participants in the intervention group were more likely to feel that technical aspects of treatment were adequately explained (difference, 0.78; 95% confidence interval, 0.03-1.54), and all measures of technical understanding and satisfaction were considerably higher in the intervention group at the time of the first visit.

CONCLUSIONS

The establishment of a direct patient-provider relationship with the medical physicist reduced anxiety in patients receiving radiation therapy. In addition, increases in patient understanding of the technical aspects of care and in satisfaction were observed at the initiation of treatment.

Pain, No Gain?: A Narrative Analysis Exploring the Accounts of Older African American Patients and Their Discussion of Pain Management Related to Chronic Illness

Drawing from interviews conducted as part of a study of older African Americans with multimorbidity, we argue how various forms of racism work together to shape communication between doctors and patients. By focusing on what patients say about pain, we highlight patient descriptions of their relationships with pain management, their interactions with healthcare providers, and how they navigate understanding their chronic conditions. Our documentation of patient experience with stigmas and biases suggests what is needed for more empathetic and effective communication within the doctor and patient relationship. We conclude by using the interview data to propose addressing racial inequality in health care in the United States through educational reform and training initiatives grounded in rhetorical research.

Racial and ethnic disparities in early treatment with immunotherapy for advanced HCC in the United States

BACKGROUND AND AIMS

Immunotherapy has emerged as an effective treatment for patients with advanced-stage HCC. We aimed to investigate the efficacy of immunotherapy for advanced HCC in a nationwide cohort and racial and ethnic disparities in access to immunotherapy.

APPROACH AND RESULTS

We used the US National Cancer Database to identify patients with tumor-node-metastasis stage 3 or 4 HCC between 2017 and 2018. We performed multivariable Cox regression to identify factors associated with overall survival (OS) and logistic regression to identify factors associated with receipt of immunotherapy. Of the 3,990 patients treated for advanced HCC, 3,248 (81.4%) patients received chemotherapy and 742 (18.6%) patients received immunotherapy as a first-line treatment. Immunotherapy was associated with improved OS compared with chemotherapy (adjusted HR: 0.76, 95% CI: 0.65-0.88) after adjusting for covariates. There were racial and ethnic disparities in access to immunotherapy, with Hispanic (adjusted OR [aOR]: 0.63, 95% CI: 0.46-0.83) and Black patients (aOR: 0.71, 95% CI: 0.54-0.89) less likely to receive immunotherapy compared with White patients. There was a significant interaction between race-ethnicity and facility type, with higher disparity observed in nonacademic centers (interaction p = 0.004).

CONCLUSIONS

Immunotherapy was associated with improved OS compared with chemotherapy in advanced HCC. There are significant disparities in early access to immunotherapy, likely due to differential access to clinical trials and experimental therapies. A comprehensive approach to monitoring and eliminating racial-ethnic disparities in the management of advanced HCC is urgently needed.

Disparities in awareness of and willingness to participate in cancer clinical trials between African American and White cancer survivors

BACKGROUND

Cancer clinical trials (CCTs) are essential for cancer care, yet the evidence is scarce when it comes to racial disparities in CCT participation among cancer survivors in the Midwest. This study aimed to 1) assess disparities in the awareness of and willingness to participate in CCTs between African American and White cancer survivors; and 2) compare perceptions about CCTs between the two racial groups.

METHODS

The study was based on cross-sectional data from the survey "Minority Patient Participation in Cancer Clinical Trials" that collected information from 147 Black and White cancer survivors from Nebraska between 2015 and 2016. Chi-square tests and logistic regressions were used to assess differences between Black and White cancer survivors regarding their awareness, willingness, and perceptions associated with CCT participation.

RESULTS

After adjusting for the effects of socio-demographic, health status, and psychosocial variables, Black cancer survivors were much less likely than White cancer survivors to be aware of CCTs (AOR 0.26; CI 0.08-0.81), to express willingness to participate in CCTs (AOR 0.03; CI 0.01, 0.32) and to actually participate in CCTs (AOR 0.13; CI 0.04-0.38). Black cancer survivors reported a lower level of trust in physicians and were less likely than White cancer survivors to believe that CCTs make a significant contribution to science.

CONCLUSIONS

Relative to White cancer survivors, Black cancer survivors had much lower awareness of and willingness to participate in CCTs. Part of these differences might be related to the differential perception of CCTs, psychosocial factors, and trust in physicians between the two groups.

Community-Based Participatory Research (CBPR) to Enhance Participation of Racial/Ethnic Minorities in Clinical Trials: A 10-Year Systematic Review

There has not been a significant improvement in the rate of clinical trial accrual in more than 20 years. Worse, the challenge of inadequate representation among racial and ethnic minorities also persists, deepening disparities in health. Community-Based Participatory Research (CBPR) is a participatory communication method that centers on effective dialogue between researchers and community stakeholders with the goal of creating an equitable partnership for health and social change. The objective of the current study was to provide an update since a systematic review in 2012, on the current status of the empirical research, with a particular focus on the elements of CBPR methods used to improve the rate of accrual of members of racial and ethnic minority communities for clinical trials. Our systematic review found a large increase in the number of CBPR related studies and studies related to racial and ethnic representation in research. More than 85% of studies employing CBPR methods saw statistically positive outcomes. Specifically, the elements of CBPR that are associated with these positive outcomes include community partner participation in (1) a study advisory committee, (2) data collection, (3) the development of interventions, and (4) participant recruitment. However, the results of our study indicate that researchers need to be more transparent about the extent of community participation as well as more thoroughly and accurately describe the nature of the partnership with members of minority communities in order to build upon the scientific literature on community-engaged methods.

Toward a basic science of communication in serious illness

High-quality communication can mitigate suffering during serious illness. Innovations in theory and technology present the opportunity to advance serious illness communication research, moving beyond inquiry that links broad communication constructs to health outcomes toward operationalizing and understanding the impact of discrete communication functions on human experience. Given the high stakes of communication during serious illness, we see a critical need to develop a basic science approach to serious illness communication research. Such an approach seeks to link "what actually happens during a conversation" - the lexical and non-lexical communication content elements, as well as contextual factors - with the emotional and cognitive experiences of patients, caregivers, and clinicians. This paper defines and justifies a basic science approach to serious illness communication research and outlines investigative and methodological opportunities in this area. A systematic understanding of the building blocks of serious illness communication can help identify evidence-informed communication strategies that promote positive patient outcomes, shape more targeted communication skills training for clinicians, and lead to more tailored and meaningful serious illness care.

HFSA Position Statement The Impact of Healthcare Disparities on Patients with Heart Failure

Heart Failure (HF) remains a condition associated with high morbidity, mortality, and associated costs. Although the number of medical and device-based therapies available to treat HF are expanding at a remarkable rate, disparities in the risk for incident HF and treatments delivered to patients are also of growing concern. These disparities span across racial and ethnic groups, socioeconomic status, and apply across the spectrum of HF from Stage A to Stage D. The complexity of HF risk and treatment is further impacted by the number of patients who experience the downstream impact of social determinants of health. The purpose of this document is to highlight the known healthcare disparities that exist in the care of patients with HF, and to provide a context for how clinicians and researchers should assess both biologic and social determinants of HF risk in vulnerable populations. Furthermore, this document will provide a framework for future steps that can be utilized to help diminish inequalities in access and clinical outcomes over time, and offer solutions to help reduce disparities within HF care.

Access and Representation: A Narrative Review of the Disparities in Access to Clinical Trials and Precision Oncology in Black men with Prostate Cancer

OBJECTIVE

To provide commentary on the disparities in access to clinical trials and precision oncology specific to Black men with Prostate Cancer (PCa) in the United States and lend a general framework to aid in closing these gaps.

MATERIALS AND METHODS

The ideas, commentaries and data presented in this narrative review were synthesized by utilizing qualitative and quantitative studies, reviews, and randomized control trials performed between 2010 and 2021. We searched PubMed using the key words "Medicaid", "Medicare", "clinical trials", "African Americans", "Black", "underrepresentation", "access", "Prostate Cancer", "minority recruitment", "racial disparities", "disparity", "genomics", "biomarkers", "diagnostic" "prognostic", "validation", "precision medicine", and "precision oncology" to identify important themes, trends and data described in the current review. Keywords were used alone and combination with both "AND" and "OR" terms.

RESULTS

Black men with prostate cancer (PCa) in the United States have earlier onset of disease, present with more advanced stages, and worse prostate cancer-specific survival than their White counterparts. Potential causative factors vary from disparities in health care access to differences in tumor immunobiology and genomics along with disparate screening rates, management patterns and underrepresentation in clinical and translational research such as clinical trials and precision oncology.

CONCLUSION

To avoid increasing the racial disparity in PCa outcomes for Black men, we must increase inclusion of Black men into precision oncology and clinical trials, using multilevel change. Underrepresentation in clinical and translational research may potentiate poorly validated risk calculators and biomarkers, leading to poor treatment decisions in high-risk populations. Relevant actions include funding to include minority-serving institutions as recruitment sites, and inclusion of evidence based recruitment methods in funded research to increase Black representation in clinical trials and translational research.

Pilot Feasibility Study of a Video Intervention to Educate Patients with Breast Cancer About Clinical Trials

The purpose of this project was to develop and test the feasibility and preliminary efficacy of a video about cancer clinical trials (CCTs) developed for breast cancer patients. We developed 2 brief 7-min videos that focused on breast cancer patients describing their experiences participating in CCTs, supplemented with doctors and research staff explaining key research concepts. One video was culturally tailored to Black patients and the other to White patients. To assess feasibility study, participants and their care providers completed a survey to evaluate their satisfaction with the video. Eligibility criteria for the study included ≥ 21 years of age, English-speaking, no prior experience participating in a CCT, and being potentially eligible for breast CCT enrollment. Preliminary efficacy was evaluated with a pretest-posttest design using a single item asking about intent to enroll in a clinical trial. The mean age of the patient sample (n = 50) was 53.0 years, and 50.0% were Black. Participants reported that the video was in the right length, useful, and easy to understand. Providers' evaluation (n = 5) revealed that viewing the video helped prepare patients for further CCT discussion. Preliminary efficacy showed no statistically significant difference in participant interest in CCT enrollment pre- and post-video. Changes in patients' intent in enrollment were associated with age and education. Culturally adapted video interventions can be helpful in supporting both patients and providers throughout the CCT education process but additional work is needed to improve enrollment into clinical trials.

Nonverbal Synchrony: An Indicator of Clinical Communication Quality in Racially-Concordant and Racially-Discordant Oncology Interactions

Objectives

The aim of this cross-sectional study was to apply a novel software to measure and compare levels of nonverbal synchrony, as a potential indicator of communication quality, in video recordings of racially-concordant and racially-discordant oncology interactions. Predictions include that the levels of nonverbal synchrony will be greater during racially-concordant interactions than racially-discordant interactions, and that levels of nonverbal synchrony will be associated with traditional measures of communication quality in both racially-concordant and racially-discordant interactions.

Design

This is a secondary observational analysis of video-recorded oncology treatment discussions collected from 2 previous studies.

Setting

Two National Cancer Institute-designated Comprehensive Cancer Centers and another large urban cancer center.

Participants

Participants from Study 1 include 161 White patients with cancer and 11 White medical oncologists. Participants from Study 2 include 66 Black/African-American patients with cancer and 17 non-Black medical oncologists. In both studies inclusion criteria for patients was a recent cancer diagnosis; in Study 2 inclusion criteria was identifying as Black/African American.

Main outcome measures

Nonverbal synchrony and communication quality.

Results

Greater levels of nonverbal synchrony were observed in racially-discordant interactions than in racially-concordant interactions. Levels of nonverbal synchrony were associated with indicators of communication quality, and these associations were more consistently found in racially-discordant interactions.

Conclusion

This study advances clinical communication and disparities research by successfully applying a novel approach capturing the unconscious nature of communication, and revealing differences in communication in racially-discordant and racially-concordant oncology interactions. This study highlights the need for further exploration of nonverbal aspects relevant to patient-physician interactions.

Development and pilot test of a physician-focused cancer clinical trials communication training intervention

Objective

We describe the development and pilot test of a physician-focused, web-based training module designed to improve physician communication related to clinical trials in a diverse cancer patient population.

Methods

Researchers and stakeholders developed the training module, which included a video explaining patient-centered communication strategies for discussing trials, and re-enactments of actual clinical interactions. For the pilot test, the module was provided to physician participants in the Partnering Around Cancer Clinical Trials (PACCT) trial at two major urban cancer centers. Questionnaires assessed change in beliefs, behavioral attitudes, knowledge and comfort; and perceptions of the module.

Results

Nineteen physicians participated in the pilot test. Most were experienced in discussing trials. Assessments of change were mixed regarding beliefs; they showed marginal improvement in attitudes, and significant improvement in knowledge, but no change in comfort. Feedback on the module was favorable.

Conclusions

This stakeholder-developed physician communication training module was acceptable and effective, albeit in this small and highly-experienced physician sample. Future research should determine its effectiveness on communication in clinical settings.

Innovation

This is the first physician training module to focus on communicating about clinical trials in a diverse patient population. It offers a web-based format and re-enactments of naturally-occurring clinical interactions.

Trial Registration Number: NCT02906241

Opportunities for theory-informed decision science in cancer control

Cancer prevention and control involves navigation of complex clinical decisions, often laden with uncertainty and/or intricate interpersonal dynamics, which have implications for both physical health and quality of life. Cancer decision-making research in recent decades has primarily focused on working to improve the quality of decisions by providing patients with detailed information about their choices and through an increased emphasis in medicine on the importance of shared decision making. This emphasis is reflective of a model of decision making that emphasizes knowledge, options, and deliberative synthesis of information as primary to decision making; yet, decades of research in psychology, decision science, and behavioral economics have taught us that our decisions are not influenced only by our objective knowledge of facts, but by our emotions, by the influence of others, and by biased cognitive processes. We present a conceptual framework for a future of research in decision science and cancer that is informed by decision science theories. Our framework incorporates greater recognition of the interpersonal dynamics of shared decision making, including the biases (including cognitive heuristics and race-based bias) that may affect multiple actors in the decision-making process, and emphasizes study of the interaction between deliberative and affective psychological processes as they relate to decision making. This work should be conducted with an eye toward informing efforts to improve decision making across the cancer care continuum, through interventions that are also informed by theory.

African American participation in cancer clinical trials

Background

According to the Food and Drug Administration, African Americans (AAs) have been habitually underrepresented in cancer clinical trials (CCTs). This under-enrolment has contributed to cancer disparities despite the implementation of policies to improve AA accrual. This systematic review aimed to determine (1) Why AAs are participating in CCT at lower rates compared to other ethnic/racial groups and (2) Are there any tools that have definitively improved AA participation or addressed the barriers associated with their lack of participation.

Methods

Searches were carried out in PubMed, Project MUSE and EBSCO which were confined to four databases (BASE, PsycINFO, CINAHL and MEDLINE). Literature published between 2010 and 2020 were filtered with the inclusion and exclusion criteria and then a mixed methods appraisal tool was used to check the quality of the articles. Studies were separated into two categories to extract and synthesise data based on the emerging themes.

Results

Frequent reasons for a lack of participation involved provider related issues, family concerns, health literacy and trust among others. Interventions cited as successful in improving AA participation or addressing a barrier often revolved around community-based participatory research and educational CCT videos/tools.

Recommendations/Conclusion

Educating AA patients about the biomedical research process, addressing concerns about CCTs, building trust with community members and improving communication with healthcare providers could improve AA participation in CCTs. Future interventions should consider the effect of diversified healthcare teams in addressing trust deficit in CCTs among AAs. Healthcare practitioners seeking to consent AA into CCTs and biomedical research could consider incorporating cultural competence into their practice for effective interaction with this population and to address their questions about biomedical research.

Supplemental Cancer Screening for Women With Dense Breasts: Guidance for Health Care Professionals

Mammography is the standard for breast cancer screening. The sensitivity of mammography in identifying breast cancer, however, is reduced for women with dense breasts. Thirty-eight states have passed laws requiring that all women be notified of breast tissue density results in their mammogram report. The notification includes a statement that differs by state, encouraging women to discuss supplemental screening options with their health care professionals (HCPs). Several supplemental screening tests are available for women with dense breast tissue, but no established guidelines exist to direct HCPs in their recommendation of preferred supplemental screening test. Tailored screening, which takes into consideration the patient's mammographic breast density and lifetime breast cancer risk, can guide breast cancer screening strategies that are more comprehensive. This review describes the benefits and limitations of the various available supplemental screening tests to guide HCPs and patients in choosing the appropriate breast cancer screening.

Parent and Clinician Perspectives on Challenging Parent-Clinician Relationships in Pediatric Oncology

IMPORTANCE

Parents of children with cancer value strong therapeutic relationships with oncology clinicians, but not every relationship is positive.

OBJECTIVE

To identify the prevalence of challenging parent-clinician relationships in pediatric oncology and factors associated with these challenges from parent and clinician perspectives.

DESIGN, SETTING, AND PARTICIPANTS

This survey was conducted among parents and oncology clinicians of children with cancer within 3 months of diagnosis from November 2015 to July 2019 at Dana-Farber Cancer Institute/Boston Children's Hospital and Texas Children's Hospital. Participants were 400 parents of children with cancer and 80 clinicians (ie, oncology physicians and nurse practitioners). Parents completed surveys about relationships with 1 to 2 primary oncology clinicians; clinicians completed surveys about relationships with parents. Data were analyzed from July 2020 to August 2021.

EXPOSURES

At least 3 previous clinical visits between parent and clinician.

MAIN OUTCOMES AND MEASURES

The Relationship Challenges Scale Parent Version and Clinician Version were developed and used to measure threats to the therapeutic alliance. For the Relationship Challenges Scale-Parent version, relationships were considered challenging if a parent responded to any single question in the 2 lowest of 4 possible categories. For the Relationship Challenges Scale-Clinician version, challenges were considered to be present if a clinician reported responses in the 3 lowest of 6 possible response categories to any question.

RESULTS

Among 400 parents, there were 298 [74.5%] women, 25 Asian individuals (6.3%), 28 Black individuals (7.0%), 97 Hispanic individuals (24.3%), 223 White individuals (55.8%), and 10 individuals (2.4%) with other race or ethnicity; race and ethnicity data were missing for 17 (4.3%) individuals. Among 80 clinicians, there were 57 (71.3%) women, 38 attending physicians (47.5%), 32 fellows (40.0%), and 10 nurse practitioners (12.5%). Parents identified 676 unique relationships with clinicians, and clinician reports were available for 338 relationships. Among 338 relationships with paired parent and clinician surveys, 81 relationships (24.0%) were considered challenging by parents, 127 relationships (37.6%) were considered challenging by clinicians, and 33 relationships (9.8%) were considered challenging by parent and clinician. Parents with Asian or other race or ethnicity (odds ratio [OR] vs White parents, 3.62; 95% CI, 1.59-8.26) or who had lower educational attainment (OR for ≤high school vs >high school, 3.03; 95% CI, 1.56-5.90) were more likely to experience relationships as challenging. Clinicians used a variety of strategies more frequently in 127 relationships in which they perceived challenges vs 211 relationships in which they did not perceive challenges, such as holding regular family meetings (22 relationships [17.3%] vs 13 relationships [6.2%]; P = .009) and offering extra time and attention (66 relationships [52%] vs 60 relationships [28.4%]; P < .001). However, these strategies were not used with increased frequency when parents experienced relationships as challenging vs when parents did not experience this.

CONCLUSIONS AND RELEVANCE

This survey study found that nearly one-quarter of parents of children with cancer reported challenges in the therapeutic relationship with their oncologist and that clinicians used strategies to improve relationships more frequently when they experienced the relationship as challenging. These findings suggest that new strategies are needed to improve experiences for parents and to help clinicians recognize and attend to parents whose experiences are suboptimal.

A Review of Research on Disparities in the Care of Black and White Patients With Cancer in Detroit

Racial disparities in cancer incidence and outcomes are well-documented in the US, with Black people having higher incidence rates and worse outcomes than White people. In this review, we present a summary of almost 30 years of research conducted by investigators at the Karmanos Cancer Institute's (KCI's) Population Studies and Disparities Research (PSDR) Program focusing on Black-White disparities in cancer incidence, care, and outcomes. The studies in the review focus on individuals diagnosed with cancer from the Detroit Metropolitan area, but also includes individuals included in national databases. Using an organizational framework of three generations of studies on racial disparities, this review describes racial disparities by primary cancer site, disparities associated with the presence or absence of comorbid medical conditions, disparities in treatment, and disparities in physician-patient communication, all of which contribute to poorer outcomes for Black cancer patients. While socio-demographic and clinical differences account for some of the noted disparities, further work is needed to unravel the influence of systemic effects of racism against Black people, which is argued to be the major contributor to disparate outcomes between Black and White patients with cancer. This review highlights evidence-based strategies that have the potential to help mitigate disparities, improve care for vulnerable populations, and build an equitable healthcare system. Lessons learned can also inform a more equitable response to other health conditions and crises.

The influence of gender and race on heart failure self-care

OBJECTIVES

To explore gender and racial differences in heart failure (HF) self-care processes and examine whether gender and race predict HF self-care.

METHODS

A secondary analysis of baseline data (n = 107) from a longitudinal HF study (54.2% males; 56% non-Caucasians) was conducted. The self-care of heart failure index was used to measure self-care maintenance, management, and confidence. Descriptive statistics and univariate analyses examined gender and racial differences in HF self-care outcomes. Multiple linear regression examined whether gender and race predicted HF self-care maintenance, management, and confidence.

RESULTS

Univariate analyses indicated that Caucasians reported significantly better self-care maintenance (p = 0.042), while non-Caucasians reported significantly better self-care management (p = 0.003). Males had significantly higher self-care confidence scores versus women (p = 0.017). Multiple regression analysis indicated Caucasian race predicted significantly worse self-care management (β = -11.188; p = 0.006) versus non-Caucasian, while male gender predicted significantly higher self-care confidence scores (β = 7.592; p = 0.010) versus female gender. Gender nor race significantly predicted self-care maintenance.

DISCUSSION

Although gender and race may influence HF self-care, other factors may be more important. More research is needed to identify individual factors that contribute to HF self-care to improve education and intervention.

Race and ethnicity representation in clinical trials: findings from a literature review of Phase I oncology trials

Aim: To provide an assessment of published literature on the demographic representation in Phase I trials of biopharmaceutical oncology agents. Materials & methods: We conducted a rapid evidence assessment to identify demographic representation reported in Phase I clinical trials for biopharmaceutical oncology agents published in 2019. Results: Globally, the population was predominantly White/Caucasian (62.2%). In the USA, the distribution was heavily skewed toward White/Caucasian (84.2%), with minimal representation of Blacks/African-Americans (7.3%), Asians (3.4%), Hispanics/Latinos (2.8%) or other race/ethnicity groups. Conclusion: Our data highlight that Phase I oncology trials do not reflect the population at large, which may perpetuate health disparities. Further research is needed to understand and address barriers to participation, particularly among under-represented groups.

Reporting of Study Participant Demographic Characteristics and Demographic Representation in Premarketing and Postmarketing Studies of Novel Cancer Therapeutics

Importance

Adequate representation of demographic subgroups in premarketing and postmarketing clinical studies is necessary for understanding the safety and efficacy associated with novel cancer therapeutics.

Objective

To characterize and compare the reporting of demographic data and the representation of individuals by sex, age, and race in premarketing and postmarketing studies used by the Food and Drug Administration (FDA) to evaluate novel cancer therapeutics.

Design, Setting, and Participants

In this cross-sectional study, premarketing and postmarketing studies for novel cancer therapeutics approved by the FDA from 2012 through 2016 were identified. Study demographic information was abstracted from publicly available sources, and US cancer population demographic data was abstracted from US Cancer Statistics. Analyses were conducted from February 25 through September 21, 2020.

Main Outcomes and Measures

The percentages of trials reporting sex, age, and race/ethnicity were calculated, and participation to prevalence ratios (PPRs) were calculated by dividing the percentage of study participants in each demographic group by the percentage of the US cancer population in each group. PPRs were constructed for premarketing and postmarketing studies and by cancer type. Underrepresentation was defined as PPR less than 0.8.

Results

From 2012 through 2016, the FDA approved 45 cancer therapeutics. The study sample included 77 premarketing studies and 56 postmarketing studies. Postmarketing studies, compared with premarketing studies, were less likely to report patient sex (42 studies reporting [75.0%] vs 77 studies reporting [100%]; P < .001) and race (27 studies reporting [48.2%] vs 62 studies reporting [80.5%]; P < .001). Women were adequately represented in premarketing studies (mean [SD] PPR, 0.91; 95% CI, 0.90-0.91) and postmarketing studies (mean PPR, 1.00; 95% CI, 1.00-1.01). Although older adults and Black patients were underrepresented in premarketing studies (older adults: mean PPR, 0.73; 95% CI, 0.72-0.74; Black patients: mean PPR, 0.32; 95% CI, 0.31-0.32), these groups continued to be underrepresented in postmarketing studies (older adults: mean PPR, 0.75; 95% CI, 0.75-0.76; Black patients: mean PPR, 0.21; 95% CI, 0.21-0.21).

Conclusions and Relevance

This study found that older adults and Black patients were underrepresented in postmarketing studies of novel cancer therapeutics to a similar degree that they were underrepresented in premarketing studies. These findings suggest that postmarketing studies are not associated with improvements to gaps in demographic representation present at the time of FDA approval.

Immune-Based Cancer Treatment: Addressing Disparities in Access and Outcomes

Avoidable differences in the care and outcomes of patients with cancer (i.e., cancer care disparities) emerge or worsen with discoveries of new, more effective approaches to cancer diagnosis and treatment. The rapidly expanding use of immunotherapy for many different cancers across the spectrum from late to early stages has, predictably, been followed by emerging evidence of disparities in access to these highly effective but expensive treatments. The danger that these new treatments will further widen preexisting cancer care and outcome disparities requires urgent corrective intervention. Using a multilevel etiologic framework that categorizes the targets of intervention at the individual, provider, health care system, and social policy levels, we discuss options for a comprehensive approach to prevent and, where necessary, eliminate disparities in access to the clinical trials that are defining the optimal use of immunotherapy for cancer, as well as its safe use in routine care among appropriately diverse populations. We make the case that, contrary to the traditional focus on the individual level in descriptive reports of health care disparities, there is sequentially greater leverage at the provider, health care system, and social policy levels to overcome the challenge of cancer care and outcomes disparities, including access to immunotherapy. We also cite examples of effective government-sponsored and policy-level interventions, such as the National Cancer Institute Minority-Underserved Community Oncology Research Program and the Affordable Care Act, that have expanded clinical trial access and access to high-quality cancer care in general.

Examining the dynamic nature of nonverbal communication between Black patients with cancer and their oncologists

BACKGROUND

Although communication quality is associated with patient outcomes, racial disparities in communication exist, disproportionately burdening Black patients. However, most communication research focuses on verbal behaviors in predominantly White patient populations. We used a newly developed and theory-guided network analysis that examines the dynamic interplay and behavioral convergence and divergence between Black patients with cancer and their oncologists during cancer treatment discussions.

METHODS

We applied a nonverbal behavioral coding system to thin slices of video recordings of Black patients and their oncologists discussing treatment. We then estimated 3 networks: 1) a temporal network to determine whether a nonverbal behavior predicts another nonverbal behavior at the next time point in an interaction, and how much each nonverbal behavior influences other nonverbal behaviors and is influenced by other nonverbal behaviors; 2) a contemporaneous network to determine whether a nonverbal behavior co-occurs with other nonverbal behaviors at the same time point in an interaction; and 3) a between-dyads network to examine the covariation between nonverbal behaviors across all dyads.

RESULTS

Black patients (n = 74) and their non-Black physicians (n = 15) showed a mix of convergence and divergence in their nonverbal behaviors at the same points in time, from one time point to the next, and across dyads. Across analyses, convergence was most likely to occur when physicians matched their behaviors to their patients; especially with smiling, gaze, leaning, and laughter behaviors.

CONCLUSION

Our findings reveal patterns of modifiable behaviors that can potentially inform interventions to reduce disparities in clinical communication and, in turn, treatment and mortality disparities.

Health Communication and Decision Making about Vaccine Clinical Trials during a Pandemic

The COVID-19 pandemic has magnified the importance of clinical trials for finding a safe and effective vaccine to protect against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19. Although communication about vaccines and vaccine hesitancy were challenges long before COVID-19, the twin facts of a pandemic and an "infodemic" of health information, misinformation, and disinformation have raised new challenges for vaccine-related communication and decision-making. The goal of this commentary is to highlight strategies to improve communication and decision-making for adults considering participation in COVID-19 vaccine clinical trials. First, I present a general conceptual model for clinical trial participation that can be applied to various vaccine and other clinical trial contexts. Next, I introduce the ASK (Assume, Seek, Know) approach for enhancing clinical trial participation: (1) assume that all patients will want to know their options, (2) seek the counsel of stakeholders, and (3) know your numbers. The ideas presented in this commentary are intended to enhance vaccine-specific clinical trial communication, decision-making, and literacy, while dually offering strategies and resources that may help reduce vaccine hesitancy and increase vaccine uptake over time.