Access to clinical trials among oncology patients: results of a cross sectional survey

Cancer Patient Perspectives on Clinical Trial Discussion and Informed Consent Through Telemedicine

PURPOSE

Clinical trials are integral for patients with cancer but remain inaccessible to many because of barriers including geographic and transportation challenges. This study aimed to evaluate cancer patients' preferences for telemedicine versus in-person visits for clinical trial discussions and informed consent (IC).

METHODS

An electronic survey was administered to first-time telemedicine users at Memorial Sloan Kettering Cancer Center from 2021 to 2023. The survey assessed patients' preferences for telemedicine versus in-person visits for the IC process and their comfort with discussing clinical trials virtually. The primary outcome was the proportion of patients who indicated that they preferred a telemedicine visit for the IC process. Patient comfort and preference for discussing clinical trials through telemedicine versus an in-person visit was also explored. Structured responses provided quantitative data over the 2021-2023 observation period and demographic variations. To gain a more detailed understanding, unstructured free-text responses describing clinical trial discussions were also analyzed through language modeling.

RESULTS

Overall, 57% of patients (540/955) preferred telemedicine, 26% (249/955) had no preference, and 17% (166/955) preferred in-person visits for the IC process. The preference for telemedicine remained consistent across the 2021-2023 observation period. Most patients reported no difference between a telemedicine versus in-person visit for clinical trial discussion, including asking questions, sharing concerns, declining participation, and asking for more time to make a decision. Language modeling analysis revealed areas for improvement.

CONCLUSION

A majority of patients at a comprehensive cancer center who participated in clinical trial discussions through telemedicine reported a preference for telemedicine to complete the IC process. Telemedicine thus represents a valuable tool for reducing barriers to clinical trial participation, particularly in reducing travel and time barriers.

Prospective Study of Patient, Nursing, and Oncology Provider Perspectives on Telemedicine Visits for Renal Cell Carcinoma Clinical Trials

PURPOSE

Clinical trials enable renal cell carcinoma (RCC) patients to receive promising investigational agents, yet access may be limited. Telemedicine (TM) is an increasingly utilized platform that can expand access, but perspectives on its use in clinical trial care are unknown.

PATIENTS AND METHODS

A prospective study was conducted between Jan 2023 - Oct 2023 at Memorial Sloan Kettering Cancer Center. RCC patients enrolled on therapeutic clinical trials who had prior TM visits were eligible. Surveys in English were distributed to patients, treating clinical trial nurses (CTNs), and oncology providers engaged in clinical trials.

RESULTS

39 patients, 7 CTNs, and 15 oncology providers were included in our analysis. Regarding clinical trial care, 26 patients (67%) preferred in-person, 4 (11%) preferred TM, and 9 (22%) had no preference. However, 25 patients (64%) reported TM provided an equal quality of care, and 38 (97%) reported a positive or neutral experience. Conversely, 7 CTNs (100%) and 11 providers (73%) preferred in-person care while 4 (27%) indicated no preference. Most, including 6 CTNs (86%) and 13 providers (87%), reported that TM quality of care was inferior. However, most, including 7 CTNs (100%) and 14 providers (93%), reported a positive experience with TM.

CONCLUSIONS

In this study, one third of RCC participants preferred TM or had no preference, and a majority felt TM delivered equal quality of care. Providers, however, preferred in-person visits and reported inferior quality of care with TM. These findings warrant further evaluation of safety and feasibility to optimize TM integration for clinical trial care delivery.

Increasing patient participation in oncology clinical trials

AIM

Timely recruitment of eligible participants is essential for the success of clinical trials, with insufficient accrual being the leading cause for premature termination of both oncology and non-oncology trials.

METHODS

In this paper we further elaborate on the challenges for patient participation in oncology trials from physician, patient, healthcare system, and some trial-related perspectives.

RESULTS

We present strategies such as use of digital healthcare technologies, real-world data and real-world evidence, decentralized clinical trials, pragmatic trial designs, and supportive services to increase patient participation.

CONCLUSIONS

Multifaceted measures are necessary to increase patient participation, especially for those who are under-represented in cancer trials.

Factors associated with enrolment in clinical trials among women with early-stage breast cancer

Background

Clinical trials allow development of innovative treatments and ameliorate the quality of clinical care in oncology. Data show that only a minority of patients are enrolled in clinical trials. We assessed enrolment in clinical trials and its correlates among women with early breast cancer.

Methods

We included 9516 patients with stage I-III breast cancer from the multicenter, prospective CANTO study (NCT01993498), followed-up until year 4 (Y4) post-diagnosis. We assessed factors associated with enrolment using multivariable logistic regression. In exploratory, propensity score matched analyses, we used multiple linear regression to evaluate the relationship of enrolment in clinical trials with the European Organisation for Research and Treatment of Cancer Quality Of Life (QoL) questionnaire (EORTC QLQ-C30) Summary Score and described clinical outcomes (distant disease event, invasive disease event, and death by any cause) according to enrolment.

Results

Overall, 1716 patients (18%) were enrolled in a clinical trial until Y4 post-diagnosis of breast cancer. Socioeconomic factors were not associated with enrolment. Centres of intermediate volume were most likely to enrol patients in clinical trials [versus low volume, odds ratio 1.45 (95% confidence interval (CI) 1.08-1.95), P = 0.0124]. Among 2118 propensity score matched patients, enrolment was associated with better QoL at Y4 (adjusted mean difference versus not enrolled 1.37, 95% CI 0.03-2.71, P = 0.0458), and clinical outcomes (enrolled versus not enrolled, distant disease event 7.3% versus 10.1%, P = 0.0206; invasive disease event 8.2% versus 10.5%, P = 0.0732; death by any cause 2.8% versus 3.7%, P = 0.2707).

Conclusions

In this large study, one in five patients enrolled on a clinical trial until Y4 after diagnosis of early breast cancer. Geographical and centre-related factors were significantly associated with enrolment in clinical trials. Inclusion in clinical trials seemed associated with improved QoL and clinical outcomes. Access to innovation for early-stage breast cancer patients should be encouraged and facilitated by overcoming organizational and geographical barriers to recruitment.

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The proportion of patients who access innovation through participation in clinical trials is generally limited.

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Rate of enrolment in clinical trials among women with early breast cancer exceeded what previously found in other settings.

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Clinical and geographical factors were associated to access to innovation in clinical trials.

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Enrolment in clinical trials is associated with better quality of life and clinical outcomes.

Facility volume-survival relationship in patients with early-stage pancreatic adenocarcinoma treated with neoadjuvant chemotherapy followed by pancreatoduodenectomy

BACKGROUND

There is evidence that neoadjuvant therapy is associated with improved survival compared with upfront pancreatectomy for pancreatic adenocarcinoma. Treatment at high-volume pancreatic surgery centers is associated with improved short-term postoperative outcomes compared with low-volume centers. We compared overall survival of patients with early-stage pancreatic adenocarcinoma who received neoadjuvant therapy before resection stratified by facility volume.

METHODS

Patients with clinical T0 to T2 pancreatic adenocarcinoma who received neoadjuvant therapy before pancreatoduodenectomy were identified in the National Cancer Database (2010-2016). High-volume pancreatic surgery centers performed ≥36 pancreatectomies/year. Patients were matched 1:1 by propensity score. Pathologic outcomes, postoperative outcomes, and overall survival were compared.

RESULTS

Before matching, 1,449 patients were treated at low-volume centers and 250 at high-volume pancreatic surgery centers. After matching, there were 177 patients per group. High-volume pancreatic surgery centers were more commonly academic/research facilities (99.4% vs 54.0%; P < .001), and patients traveled greater distances (65 vs 13 miles; P < .001). Time from diagnosis to neoadjuvant therapy and surgery was similar. Treatment at high-volume pancreatic surgery centers was associated with shorter duration of stay (7 vs 8 days; P = .003) and lower 90-day mortality rate after pancreatoduodenectomy (0.0% vs 5.0%; P = .01). Patients treated at high-volume pancreatic surgery centers had improved overall survival (36.3 vs 29.4 months; P = .03; hazard ratio 0.73). On subset analysis of academic/research facilities, high-volume pancreatic surgery centers remained associated with shorter duration of stay, lower 90-day mortality, and greater overall survival.

CONCLUSION

The majority of patients treated with neoadjuvant therapy for early-stage pancreatic adenocarcinoma received care at low-volume centers. Treatment at high-volume pancreatic surgery centers was associated with improved overall survival and short-term postoperative outcomes.

Comparative Assessment of Non-trial Access to Investigational Medical Products in the U.S. and Japan

The U.S. and Japan have preapproval access systems for patients who have exhausted approved treatment options. We compare the systems of both countries and discuss some ethical concerns surrounding non-trial access to investigational drugs. Notable points of comparison of the two countries' systems include cost of non-trial access to investigational drugs and purpose of the non-trial access system. All stakeholders and the public must understand the ethical issues associated with non-trial preapproval access systems. The current non-trial access programs in both countries depends on pharmaceutical companies' voluntary decisions about whether patients get access to investigational products. Moreover, the potential for inequity of access raises ethical concerns. Non-trial preapproval access is an exceptional way to practice medicine with various ethical and safety concerns, so we suggest that the scope and eligibility for using these pathways should thus be limited.

Barriers to Participation in Therapeutic Clinical Trials as Perceived by Community Oncologists

PURPOSE

Despite considerable research on the barriers to enrollment in cancer therapeutic trials, few studies have elicited barriers from the perspective of community physicians, who provide the majority of cancer care. The purpose of this study was to characterize barriers to and facilitators of cancer therapeutic trials as perceived by oncologists in community practices.

METHODS

Twenty semistructured interviews were conducted with oncologists at six community sites affiliated with City of Hope National Medical Center from March to June 2018. Responses were recorded digitally and transcribed. Data were analyzed using qualitative content analysis.

RESULTS

Of the 20 participants, 4 (20%) were women, 13 (65%) had > 10 years of practice experience, and 16 (80%) reported that < 5% of their patients were enrolled in a therapeutic trial. Participants identified four system-level barriers: lack of appropriate trials for community-based settings, insufficient infrastructure support, restrictive eligibility criteria, and financial limitations; three physician-level barriers: lack of awareness of available trials, lack of knowledge of trial details, and lack of time; and two patient-level barriers: patient burden and negative beliefs/attitudes toward research. Efforts aimed to increase trial availability, clinical trial support personnel, and physician knowledge were identified as major facilitators.

CONCLUSION

Community oncologists face numerous complex, multifaceted barriers to cancer therapeutic trial enrollment. Although expanding clinical research beyond the academic setting allows access to a larger and more diverse patient population, increasing generalizability and relevance of trial findings, there remains a substantial need for new strategies to improve cancer research delivery in the community.

Decision-making in HIV clinical trials: a study with patients enrolled in antiretroviral trials

OBJECTIVE

To explore the decisional process of people living with human immunodeficiency virus (HIV) currently enrolled in antiretroviral clinical trials.

METHOD

Cross-sectional retrospective study. Outcome variables were reasons to participate, perceived decisional role (Control Preference Scale), the Decisional Conflict Scale and the Decisional Regret Scale. Descriptive statistics were calculated, and associations among these variables and with sociodemographic and clinical characteristics were analyzed with non-parametric techniques.

RESULTS

Main reasons to participate were gratitude towards Fundación Huesped (47%), the doctor's recommendation (32%), and perceived difficulty to access treatment in a public hospital (28%). Most patients thought that they made their decision alone (54.8%) or collaboratively with the physician (43%). Decisional conflict was low, with only some conflict in the support subscale (median=16.67). Education was the only significant correlate of the total decisional conflict score (higher in less educated patients; p=0.018), whereas education, recent diagnosis, living alone, lower age, being man and doctor's recommendation to go to Fundación Huésped related to higher conflict in different subscales. Nobody regretted to participate.

CONCLUSIONS

The decision making regarding participation in HIV trials, from the perspective of participants, was made respecting their autonomy and with very low decisional conflict. Currently, patients show no signs of regret. However, even in this favorable context, results highlight the necessity of enhancing the decision support in more vulnerable patients (e.g., less educated, recently diagnosed or with less social support), thus warranting equity in the quality of the decision making process.

Where Can Patients Obtain Information on the Preapproval Access Pathway to Investigational Treatment in Japan? A Survey of Patient Advocacy Organizations' Websites

Investigational treatments are those that have been approved for testing in humans but are not yet available as an approved treatment option. For many patients with a terminal illness who have no approved treatment option and are not eligible for a clinical trial, investigational treatments are the last resort. However, not much is known about the dissemination of information by patient advocacy organizations (PAOs). We evaluated the quantity and quality of information on preapproval access to investigational therapies provided by Japanese PAO websites between January 24 and March 29, 2019. A total of 49 PAOs were identified. Of these, 16 (33%) provided no relevant information. The most frequent information provided was the PAO's own clinical trial finder or list of clinical trials (n = 15, 31%); of the 10 cancer-related PAOs, 5 (50%) provided this information. Nine (18%) PAOs had developed patient registries or provided a link to relevant registries. Only 1 PAO (2%) provided a link about the Ministry of Health, Labour, and Welfare trials that described the process and regulations of clinical trials. Our results indicate that PAOs do not disseminate adequate information on preapproval pathways. We suggest that the government involve PAOs in disseminating this information to both patients and physicians.

Financial Toxicity and Equitable Access to Clinical Trials

Financial barriers to clinical trial enrollment are an area of active investigation. Financial toxicity as a concept describes how high costs and financial burden can lead to compromised care and outcomes. Despite the potential to yield large survival benefits and improved access to cutting-edge therapies, less than 5% of adult patients with cancer are enrolled in a clinical trial. Disparities in trial enrollment exist along age, ethnic, and sociodemographic lines, with younger, poorer, nonwhite patients with private insurance-the exact population who may be at highest risk for financial toxicity-less likely to participate. Cost and insurance concerns remain an obstacle for clinical trial enrollment for certain patient populations. Changing the clinical trial paradigm with a focus on addressing structural and clinical barriers to clinical trial enrollment is paramount. This includes expanding access to clinical trials within community populations, advocating for health policy changes to guarantee insurance coverage of clinical trial standard-of-care health care, and considering noncoercive financial assistance (particularly for indirect costs like travel and lodging) for participants to defray their additional costs of participation. Additional steps toward education, cost transparency, and expansion of foundation assistance may also improve equitable access to clinical trials for all.

Improving Oncology Clinical Trial Participation and Experience

Cancer patients are underrepresented in clinical trial populations because of protocol-, physician-, and patient-related barriers. We engaged focus groups of patients who had participated in breast and ovarian cancer trials to identify concerns regarding their experiences. The lessons learnt are applicable to improving patient experience during future trials.