Patient income level and cancer clinical trial participation

[Impact of precariousness on breast cancer care in the Île-de-France region: Results of the DESSEIN study]

INTRODUCTION

Precariousness has been associated with an increase in breast cancer mortality, but the links between precariousness, stage at diagnosis and care pathways are little explored. The objective of the DESSEIN study was to assess the impact of precariousness on disease and care pathways.

METHODS

Prospective observational study in Île-de-France comparing precarious and non-precarious patients consulting for breast cancer and followed for 1 year.

RESULTS

In total, 875 patients were included between 2016 and 2019 in 19 institutions: 543 non-precarious patients and 332 precarious patients. Precarious patients had a more advanced stage at diagnosis (55% T1 vs. 63%, 30% N+ vs 19%, P=0.0006), had a higher risk of not receiving initially planned treatment (4 vs. 1%, P=0.004), and participated less in clinical trials (5 vs. 9%, P=0.03). Non-use of supportive oncology care was 2 times more frequent among patients in precarious situations (P<0.001). During treatment, 33% of deprived patients reported a loss of income, compared with 24% of non-deprived patients (P<0.001). At 12 months from diagnosis, lay-offs were 2 times more frequent in precarious patients (P=0.0001).

DISCUSSION

Precariousness affects all stages of the cancer history and care pathway. Particular attention needs to be paid to vulnerable populations, considering issues of accessibility and affordability of care, health literacy and possible implicit bias from the care providers.

Time Toxicity Experienced by Early-Phase Cancer Clinical Trial Participants

PURPOSE

Early-phase clinical trials (EP-CTs) are designed to determine optimal dosing, tolerability, and preliminary activity of novel cancer therapeutics. Little is known about the time that patients spend interacting with the health care system (eg, time toxicity) while participating in these studies.

METHODS

We retrospectively reviewed the electronic health records of consecutive patients enrolled in EP-CTs from 2017 to 2019 to obtain baseline characteristics and number of health care-associated days, defined as all inpatient and outpatient visits while on trial. We used univariable and multivariable analyses to identify predictors of increased time toxicity, defined as the proportion of health care-associated days among total days on trial. For ease of interpretation, we created a dichotomous variable, with high time toxicity defined as ≥20% health care-associated days during time on trial and used regression models to evaluate relationships between time toxicity and clinical outcomes.

RESULTS

Among 408 EP-CT participants (mean age, 60.5 years [standard deviation, SD, 12.6]; 56.5% female; 88.2% White; 96.0% non-Hispanic), patients had an average of 22.5% health care-associated days while on trial (SD, 13.8%). Those with GI (B = 0.07; P = .002), head/neck (B = 0.09; P = .004), and breast (B = 0.06; P = .015) cancers and those with worse performance status (B = 0.04; P = .017) and those receiving targeted therapies (B = 0.04; P = .014) experienced higher time toxicity. High time toxicity was associated with decreased disease response rates (odds ratio, 0.07; P < .001), progression-free survival (hazard ratio [HR], 2.10; P < .001), and overall survival (HR, 2.16; P < .001).

CONCLUSION

In this cohort of EP-CT participants, patients spent more than one-fifth of days on trial with health care contact. We identified characteristics associated with higher time toxicity and found that high toxicity correlated with worse clinical outcomes. These data could help inform patient-clinician discussions about EP-CTs, guide future trial design, and identify at-risk patients.

Increasing Clinical Trial Participation of Black Women Diagnosed with Breast Cancer

Despite racial disparities in breast cancer mortality, Black women remain underrepresented in clinical trials. In this mixed methods research, 48 Black women were engaged via focus group discussions and in-depth interviews to better understand the lived experience of women with breast cancer. The results of this qualitative study informed the development of a subsequent online survey to identify barriers, motivators, and other factors that influence decision-making by Black women diagnosed with breast cancer when considering clinical trial participation. Among the 257 Black survey participants, most (95%) were aware of clinical trials; of those, most viewed them as lifesaving (81%) and/or benefiting others (90%). Negative perceptions such as serious side effects (58%), not receiving real treatment (52%), or risk of potential harm (62%) were indicated. Barriers included financial expenses (49%), concerns that their condition could be made worse (29%), that they would receive a placebo (28%), or that treatment was unapproved (28%). Participants were more likely than their health care providers (HCPs) to initiate discussions of clinical trials (53% versus 33%), and 29% of participants indicated a need for more information about risks and benefits, even after having those conversations. The most trustworthy sources of information on clinical trials were HCPs (66%) and breast cancer support groups (64%). These results suggest that trusted communities are key for providing education on clinical trials. However, there is also a need for HCPs to proactively discuss clinical trials with patients to ensure that they are adequately informed about all aspects of participation.

Analysis and Optimization of Equitable US Cancer Clinical Trial Center Access by Travel Time

Importance

Racially minoritized and socioeconomically disadvantaged populations are currently underrepresented in clinical trials. Data-driven, quantitative analyses and strategies are required to help address this inequity.

Objective

To systematically analyze the geographical distribution of self-identified racial and socioeconomic demographics within commuting distance to cancer clinical trial centers and other hospitals in the US.

Design, Setting, and Participants

This longitudinal quantitative study used data from the US Census 2020 Decennial and American community survey (which collects data from all US residents), OpenStreetMap, National Cancer Institute-designated Cancer Centers list, Nature Index of Cancer Research Health Institutions, National Trial registry, and National Homeland Infrastructure Foundation-Level Data. Statistical analyses were performed on data collected between 2006 and 2020.

Main Outcomes and Measures

Population distributions of socioeconomic deprivation indices and self-identified race within 30-, 60-, and 120-minute 1-way driving commute times from US cancer trial sites. Map overlay of high deprivation index and high diversity areas with existing hospitals, existing major cancer trial centers, and commuting distance to the closest cancer trial center.

Results

The 78 major US cancer trial centers that are involved in 94% of all US cancer trials and included in this study were found to be located in areas with socioeconomically more affluent populations with higher proportions of self-identified White individuals (+10.1% unpaired mean difference; 95% CI, +6.8% to +13.7%) compared with the national average. The top 10th percentile of all US hospitals has catchment populations with a range of absolute sum difference from 2.4% to 35% from one-third each of Asian/multiracial/other (Asian alone, American Indian or Alaska Native alone, Native Hawaiian or Other Pacific Islander alone, some other race alone, population of 2 or more races), Black or African American, and White populations. Currently available data are sufficient to identify diverse census tracks within preset commuting times (30, 60, or 120 minutes) from all hospitals in the US (N = 7623). Maps are presented for each US city above 500 000 inhabitants, which display all prospective hospitals and major cancer trial sites within commutable distance to racially diverse and socioeconomically disadvantaged populations.

Conclusion and Relevance

This study identified biases in the sociodemographics of populations living within commuting distance to US-based cancer trial sites and enables the determination of more equitably commutable prospective satellite hospital sites that could be mobilized for enhanced racial and socioeconomic representation in clinical trials. The maps generated in this work may inform the design of future clinical trials or investigations in enrollment and retention strategies for clinical trials; however, other recruitment barriers still need to be addressed to ensure racial and socioeconomic demographics within the geographical vicinity of a clinical site can translate to equitable trial participant representation.

Understanding the financial cost of cancer clinical trial participation

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effects of flavonoid supplementation on the mental health of postpartum parents

Introduction

During the postpartum period, parents face psychological challenges and consequently, changes in mood and associated mood disorders have become increasingly prevalent in the 6-months following birth. Dietary flavonoids have been found to benefit mood and are therefore an appealing non-pharmacological option for potentially treating mood disorders in the postpartum. The aim of this study was to investigate whether a two-week dietary flavonoid intervention would improve mothers' and fathers' mental health in the immediate 6-month postpartum period.

Method

The study employed a randomised, parallel groups, controlled design to explore the effects of a flavonoid intervention vs. control group on several outcomes, including mood (PANAS), postpartum depression (EPDS), postpartum anxiety (PSAS-RSF-C) and quality of life (WHOQOL). Sixty participants (mothers n = 40, fathers n = 20) in the 6-month post-partum period were randomised to either a "flavonoid" or "control" condition. The flavonoid group were asked to add two flavonoid-rich foods (approximate flavonoid intake 218 mg/day) into their daily diet whilst controls (n = 23) were asked to continue with their usual diet for two-weeks (ClinicalTrials.gov (NCT04990622).

Results

Significant effects were found in the flavonoid group where mothers reported higher positive affect and lower postpartum depression after the two-week intervention relative to baseline. This finding is especially relevant as a clinical reduction in postpartum depression scores in the flavonoid group by an average 2.6 scoring points was observed, which equated to a reduction from "possible depression" at baseline to "little or no depression" at 2-weeks, which was not observed in the control group. Fathers' data was not analysed due to non-compliance with the intervention.

Discussion

This study provides evidence for the benefits of a dietary flavonoid intervention for mood and mental health in new mothers, supporting the utility of non-pharmacological, self-administrable changes to the diet for improving positive mood outcomes and reducing symptoms of postpartum depression in mothers during an especially challenging time. Further research for the effect of dietary interventions on paternal mental health is needed.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT04990622.

Socioeconomic Status and Overall Survival Among Patients With Hematological Malignant Neoplasms

Importance

In recent years, there has been a focus on reducing the socioeconomic gap in survival for hematological malignant neoplasms. Understanding recent developments is important to develop further intervention to improve care.

Objective

To investigate the temporal trend in associations of socioeconomic status (SES) with survival among 3 aggressive hematological malignant neoplasms: multiple myeloma (MM), acute myeloid leukemia (AML), and diffuse large B-cell lymphoma (DLBCL).

Design, Setting, and Participants

This nationwide, population-based cohort study used retrospectively collected data from 3 clinical registries of patients diagnosed in Denmark between January 1, 2005, and December 31, 2020, with follow-up until December 31, 2021. Analyses were stratified by diagnosis year (2005-2009, 2010-2014, and 2015-2020). Participants were patients aged 25 to 65 years with hematological malignant neoplasms. Patients with missing data on education were excluded. Data were analyzed from October 14, 2022, to January 2, 2024.

Exposure

Education was used as a proxy for SES and defined low- and high-SES groups based on the completion of tertiary education.

Main Outcomes and Measures

The main outcome was overall survival (OS), analyzed using Kaplan-Meier (log rank) method and Cox proportional hazards regression adjusted for age, sex, performance status, comorbidities, and disease-specific prognostic indices. Two-year OS through time and survival difference were estimated using flexible parametric survival models.

Results

A total of 5677 patients (median [IQR] age, 58 [51-62] years; 3177 [57.0%] male) were assessed, including 1826 patients with MM, 1236 patients with AML, and 2509 patients with DLBCL. The 2-year OS increased over time for patients with MM (78.8% [95% CI, 75.4%-82.3%] to 91.4% [95% CI, 89.3%-93.5%]), AML (42.2% [95% CI, 37.8%-47.1%] to 52.7% [95% CI, 48.0%-57.9%]), and DLBCL (80.1% [95% CI, 77.4%-82.8%] to 88.1% [95% CI, 86.0%-90.3%]). For MM and DLBCL, no association of SES with survival was observed after adjustment (MM: hazard ratio [HR], 0.99 [95% CI, 0.85-1.15]; DLBCL: HR, 1.08 [95% CI, 0.91-1.29]). For AML, a negative association was observed between low SES and survival (HR, 1.49 [95% CI, 1.25-1.76]), but the association was attenuated in recent years. The difference in hazard for patients with low SES and AML was observed in the first 2 years after diagnosis.

Conclusions and Relevance

These findings suggest that survival has improved among patients with these hematological malignant neoplasms. While patients with MM and DLBCL had increased survival in all groups, disparities were observed in AML outcomes, primarily in the first years after diagnosis. These results suggest that differences originate in factors specific to AML.

Effects of socioeconomic status on enrollment in clinical trials for cancer: A systematic review

BACKGROUND

To achieve equitable access to cancer clinical trials (CCTs), patients must overcome structural, clinical, and attitudinal barriers to trial enrollment. The goal of this systematic review was to study the relationship between socioeconomic status (SES), assessed either by direct or proxy measures, and CCT enrollment.

METHODS

The review team and medical librarian developed search strategies for each database to identify studies for this systematic review, which was conducted according to PRISMA guidelines. Inclusion criteria were as follows: studies published in relevant scientific journals between January 2000 and July 2022, primary sources, English literature, and studies conducted in the US. Sixteen studies fulfilled the inclusion criteria and were reviewed. The risk of bias assessment was conducted independently by two reviewers using the Newcastle Ottawa scale.

RESULTS

The initial search yielded 4070 citations, and 16 studies were included in our review. Four of the studies included used patient reported annual income as a measure of SES, while the remaining 12 studies used patient zip code as a proxy measurement of SES. Consistent with our hypothesis, 13 studies showed a positive association between high SES (patient-reported or proxy measurement) and CCT enrollment. Two studies showed a negative association, and one study showed no relationship.

CONCLUSIONS

The existing literature suggests that low SES is associated with lower participation in CCT. The small number of studies identified on this topic highlights the need for additional research on SES and other barriers to CCT participation.

Access to CAR T-cell therapy: Focus on diversity, equity and inclusion

Chimeric antigen receptor T-cell (CAR T-cell) therapy has revolutionized the treatment of hematologic malignancies in patients with relapsed or refractory disease without other treatment options. However, only a very small proportion of patients with an indication for CAR T-cell can access the treatment. The imbalance between supply and demand is magnified in minority and vulnerable populations. Limited access is multifactorial and in part a result of factors directly related to the cellular product such as cost, complex logistics and manufacturing limitations. On the other hand, the impact of diversity, equity, and inclusion (DEI) and their social and structural context are also key to understanding access barriers in cellular therapy and health care in general. CAR T-cell therapy provides us with a new opportunity to better understand and prioritize this gap, a key step towards proactively and strategically addressing access. The aim of this review is to provide an analysis of the current state of access to CAR T therapy with a focus on the influence of DEI. We will cover aspects related to the cellular product and the inseparable context of social and structural determinants. Identifying and addressing barriers is necessary to ensure equitable access to this and all future novel therapies.

Impact of Coronavirus Disease-era Clinical Trial Reform on Cancer Trial Access in Rural/Underserved Regions of the Midwest

OBJECTIVES

The coronavirus disease 2019 pandemic refocused the cancer community on bringing clinical trials closer to patients and increasing access for traditionally underserved communities. Pandemic-era deregulation increased flexibility with telemedicine visits, less frequent testing, and the ability to have tests done locally. This study evaluates the impact of 2020 cancer clinical trial reform on trial accessibility in rural/underserved regions of the Midwest.

METHODS

Publicly available clinicaltrials.gov data was accessed from January 1, 2018 to September 30, 2022 for the 3 leading causes of new cancer cases in Kentucky, Tennessee, Illinois, and Indiana. Interventional trials were categorized based on location using corresponding "Rural-Urban Commuting Area" codes (urban/metropolitan, suburban/micropolitan, small town/rural, and isolated/rural) and categorized as pre versus postpandemic (using March 15, 2020, when national regulatory guidelines were modified). Locations of trial offerings from pre and postpandemic dates were analyzed by paired t test. Comparison of trial location category by state and cancer type was analyzed by 1-way analysis of variance with pairwise multiple comparisons made using the Tukey-Kramer method.

RESULTS

Pandemic-era deregulation had no impact on increasing trial availability in suburban and small-town/rural locales ( P = 0.1259). Only 18% of trials were offered outside of urban areas, with 15% in suburban and 3% in small town/rural areas. Results varied by state ( P < 0.0001) with Illinois offering the most suburban and small-town trial availability (27%) compared with Kentucky, Indiana, and Tennessee (18%, 6%, and 2%, respectively). Trial availability in rural versus urban areas did not differ by cancer type ( P = 0.07197).

CONCLUSIONS

More work must be done to increase access to cancer clinical trials in rural and suburban areas of the United States.

Discontinuation and nonpublication of nasopharyngeal carcinoma clinical trials

OBJECTIVES

To determine the extent of research waste in the field of nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

In this cross-sectional study, we explored the rates, causes and predictors of discontinuation and nonpublication of NPC clinical trials. The sample was derived using the ClinicalTrials.gov advanced search function. Adjusted logistic regression was used to ascertain the effect of trial characteristics on completion and publication status. If a trial discontinuation explanation or publication status could not be determined through the systematic search, the corresponding author was emailed.

RESULTS

Ultimately, 311 NPC clinical trials were included (255 [82.0 %] completed and 56 [18.0 %] discontinued trials). The most common reason for trial discontinuation was poor accrual (50 %, 23/46). Industry funding (adjusted OR, 3.12; P = 0.003) and recurrent/metastatic setting (adjusted OR, 11.95; P = 0.003) were significantly associated with increased likelihood of trial discontinuation. Of the 207 completed trials included in the publication query, 141 (68.1 %) were published in peer-reviewed journals, 10 (4.8 %) had results only available on ClinicalTrials.gov, and 56 (27.1 %) remained unpublished 3 or more years after trial completion. Radiation with or without pharmacologic interventions significantly increased the potential of publication (adjusted OR, 3.20; P = 0.048). Among published trials, the median time to publication was 28.47 months (interquartile range, 15.27-44.98 months).

CONCLUSION

We identified the difficulties inherent in NPC clinical trials from completion to publication. This represents considerable research waste in NPC, thus raising ethical concerns about the concealment of clinical data and futile patient participation and attendant risks.

Eliminating Health Disparities in Atrial Fibrillation, Heart Failure, and Dyslipidemia: A Path Toward Achieving Pharmacoequity

PURPOSE OF REVIEW

Pharmacoequity refers to the goal of ensuring that all patients have access to high-quality medications, regardless of their race, ethnicity, gender, or other characteristics. The goal of this article is to review current evidence on disparities in access to cardiovascular drug therapies across sociodemographic subgroups, with a focus on heart failure, atrial fibrillation, and dyslipidemia.

RECENT FINDINGS

Considerable and consistent disparities to life-prolonging heart failure, atrial fibrillation, and dyslipidemia medications exist in clinical trial representation, access to specialist care, prescription of guideline-based therapy, drug affordability, and pharmacy accessibility across racial, ethnic, gender, and other sociodemographic subgroups. Researchers, health systems, and policy makers can take steps to improve pharmacoequity by diversifying clinical trial enrollment, increasing access to inpatient and outpatient cardiology care, nudging clinicians to increase prescription of guideline-directed medical therapy, and pursuing system-level reforms to improve drug access and affordability.

The reimbursement decision speed for oncology new drugs in China and its determinant factors

Introduction

China has initiated national price negotiations to improve access to innovative drugs. Learning the factors that contributed to the time gap from marketing authorization to reimbursement leads to more clarity to decision-making, which remains under-researched in China.

Methods

We collected new oncology drug approvals that were marketed before 30 Jun 2022, using the Listed Drug Database of the Chinese drug agency. Major information of each approval was obtained from the published review report, including the first approval region (China or the US) and the receipt of expedited review pathways (priority review and conditional approval). The reimbursement lists issued by China National Healthcare Security Administration from 2015 to 2023 were used to determine the reimbursement status of drugs. The duration from marketing authorization to reimbursement was defined as the reimbursement decision speed, and the Cox regression was performed to explore the underlying factors.

Results

A total of 186 oncology approvals were included. More than half of the approvals qualified for reimbursement (110[59.14%]), and the median reimbursement decision speed was accelerated from 540.5 days in the third-round negotiation to 448 days in the seventh-round. Domestic new drugs had a higher probability of being adopted by the Chinese payer than drugs developed by foreign companies (adjusted HR = 3.73, 95% CI 2.42 to 5.75; P < 0.001). Furthermore, new drug applications receiving the regular review pathway were more likely to be reimbursed (adjusted HR = 2.15, 95% CI 1.13 to 4.08; P = 0.020) compared to those approved under the conditional approval pathway.

Discussion

These findings indicate that the Chinese government is actively working toward improving access to new oncology drugs. The faster reimbursement decision speed for domestic drugs might be attributed to their pricing advantages and the regulator's efforts to stimulate innovation in the domestic pharmaceutical industry. However, concerns about the uncertainty in drug benefits can affect the reimbursement decision-making, which suggests the delicate tradeoff between drug accessibility and risk involved in the reimbursement process.

Socioeconomic disparities in treatment and survival in patients with hypopharyngeal malignancy

BACKGROUND

This retrospective study utilizes The Surveillance, Epidemiology, and End Results database to investigate socioeconomic factors leading to treatment disparities in hypopharyngeal malignancy.

METHODS

Treatment was compared to National Cancer Care Network guidelines. Novel analyses, including logistic modeling, allowed survival analysis and identification of socioeconomic variables not previously considered in staging and management guidelines.

RESULTS

Black and older patients, and residence in low-income areas predict lower likelihood of standard therapy (p < 0.05). Early-stage disease and standard therapy correlate with improved survival (p < 0.001). Medicaid, advanced age, advanced disease, and treatment outside of consensus guidelines correlated with lower survival (p < 0.0001).

CONCLUSIONS

There are clear socioeconomic factors impacting treatment and survival in hypopharyngeal malignancies. Standard therapy affords superior survival rate. Black, low socioeconomic status, and older patients are less likely to receive standard therapy. Education and language isolation do not predict treatment or survival. Understanding these discrepancies is paramount to palliating disparities in healthcare.

Representativeness of Patients Enrolled in the Lung Cancer Master Protocol (Lung-MAP)

PURPOSE

Lung Cancer Master Protocol (Lung-MAP), a public-private partnership, established infrastructure for conducting a biomarker-driven master protocol in molecularly targeted therapies. We compared characteristics of patients enrolled in Lung-MAP with those of patients in advanced non-small-cell lung cancer (NSCLC) trials to examine if master protocols improve trial access.

METHODS

We examined patients enrolled in Lung-MAP (2014-2020) according to sociodemographic characteristics. Proportions for characteristics were compared with those for a set of advanced NSCLC trials (2001-2020) and the US advanced NSCLC population using SEER registry data (2014-2018). Characteristics of patients enrolled in Lung-MAP treatment substudies were examined in subgroup analysis. Two-sided tests of proportions at an alpha of .01 were used for all comparisons.

RESULTS

A total of 3,556 patients enrolled in Lung-MAP were compared with 2,215 patients enrolled in other NSCLC studies. Patients enrolled in Lung-MAP were more likely to be 65 years and older (57.2% v 46.3%; P < .0001), from rural areas (17.3% v 14.4%; P = .004), and from socioeconomically deprived neighborhoods (42.2% v 36.7%, P < .0001), but less likely to be female (38.6% v 47.2%; P < .0001), Asian (2.8% v 5.1%; P < .0001), or Hispanic (2.4% v 3.8%; P = .003). Among patients younger than 65 years, Lung-MAP enrolled more patients using Medicaid/no insurance (27.6% v 17.8%; P < .0001). Compared with the US advanced NSCLC population, Lung-MAP under represented patients 65 years and older (57.2% v 69.8%; P < .0001), females (38.6% v 46.0%; P < .0001), and racial or ethnic minorities (14.8% v 21.5%; P < .0001).

CONCLUSION

Master protocols may improve access to trials using novel therapeutics for older patients and socioeconomically vulnerable patients compared with conventional trials, but specific patient exclusion criteria influenced demographic composition. Further research examining participation barriers for under represented racial or ethnic minorities in precision medicine clinical trials is warranted.

Estimating the area under the ROC curve when transporting a prediction model to a target population

We propose methods for estimating the area under the receiver operating characteristic (ROC) curve (AUC) of a prediction model in a target population that differs from the source population that provided the data used for original model development. If covariates that are associated with model performance, as measured by the AUC, have a different distribution in the source and target populations, then AUC estimators that only use data from the source population will not reflect model performance in the target population. Here, we provide identification results for the AUC in the target population when outcome and covariate data are available from the sample of the source population, but only covariate data are available from the sample of the target population. In this setting, we propose three estimators for the AUC in the target population and show that they are consistent and asymptotically normal. We evaluate the finite-sample performance of the estimators using simulations and use them to estimate the AUC in a nationally representative target population from the National Health and Nutrition Examination Survey for a lung cancer risk prediction model developed using source population data from the National Lung Screening Trial.

Disparities in US Lung Cancer Clinical Trial Enrollment

BACKGROUND

Disparities within clinical trial enrollment are well-documented, reducing the generalizability of results. Although nearly 30 years have passed since Congress passed the NIH Revitalization Act to encourage the participation of minoritized populations in clinical trials, these patients continue to be underrepresented. This study aimed to investigate lung cancer clinical trial enrollment disparities for race/ethnicity, sex, and age.

METHODS

We queried the National Institutes of Health: US National Library of Medicine database of clinical trials for all US-based lung cancer clinical trials completed between 2004 and 2021 and collected data on race and ethnicity, gender, and age breakdown. This data was compared to Surveillance, Epidemiology, and End Results (SEER) database data. Independent sample t-tests and Kruskal-Wallis's approach were used to analyze the data.

RESULTS

Of 311 eligible trials with exclusive US enrollment, 136 (44%) reported race and ethnicity breakdown for the patient cohort representing 9869 patients. Hispanic, Non-Hispanic American Indian/Alaska Native, Non-Hispanic Black, and Non-Hispanic Unreported participants were underrepresented (p = 0.001, p = 0.005, p = 0.014, p = 0.002, respectively). Non-Hispanic White participants were overrepresented (p = 0.018). Disparities worsened from 2017 to 2021 for Hispanic patients (p = 0.03). No significant differences were found for sex or age.

CONCLUSIONS

Disparities for clinical lung cancer trial enrollment have not shown statistically significant improvement since 2004, and representation remains unequal, especially for racial and ethnic minorities.

Evaluating the impact of patients' psychological and physical problems on their interest in participating in research at a cancer center with a rural catchment area

BACKGROUND

Cancer patients' participation in research trials is essential to improving their care and treatment. In a large sample of adults recently diagnosed with cancer, the aim of the current study is to investigate the relationship between cancer patients' interest in research and the psychological and physical problems they experience resulting from their cancer diagnosis.

METHOD

We analyzed data from 906 cancer patients collected during routine clinical care. Correlational analyses focused on the relationship between patients' psychological and physical problems and their interest in research. Hierarchical binary logistic regression analyses tested whether patients' psychological/physical problems as a block predicted their interest in research, above and beyond their sociodemographic characteristics.

RESULTS

Higher levels of patients' anxiety, fear of cancer treatment, difficulty managing emotions, worry, suicidal/homicidal ideation, fatigue, problems related to physical appearance, sleep difficulty, and changes to weight/appetite, were associated with a greater interest in research. Patients' psychological/physical problems, as a block, incrementally predicted their interest in research (Δχ2 = 24.34, df = 14, p = .04, Δr2=0.05), though none of the individual psychological/physical problems were found to be significant predictors. A higher level of education was significantly positively associated with an increased likelihood of being interested in research (OR = 1.26, 95%CI = 1.09, 1.46, p = .001).

CONCLUSION

Cancer patients' problems stemming from their diagnosis can be important factors in their decision to participate in research. Depending on the needs of the trial in question, researchers may want to account for patients' level of symptom burden in deciding who to approach for enrollment in a research trial.

Impact of socioeconomics and race on clinical follow-up and trial enrollment and adherence in cerebral cavernous malformation

OBJECTIVES

Cerebral cavernous malformation (CCM) affects more than a million Americans but advanced care for symptomatic lesions and access to research studies is largely limited to referral academic centers MATERIALS AND METHODS: A cohort of CCM patients screened for research studies at an accredited center of excellence for CCM was analyzed. Demographics, lesion location, history of hemorrhage, insurance type and area of deprivation index (ADI) were collected. Primary outcomes were clinical follow-up within a year from initial evaluation, and enrollment and adherence in clinical trials among eligible subjects RESULTS: A majority (52.8%) of CCM patients evaluated had a high socioeconomic status (SES) (ADI 1-3), and only 11.5% were African American. Patients who had a symptomatic bleed were more likely to follow-up (p=0.01), and those with brainstem lesion were more likely to enroll/adhere in a clinical trial (p=0.02). Rates of clinical follow-up were similar across different ADI groups, insurance coverage and race. Patients who were uninsured/self-paying, and African Americans were more likely to decline/drop from clinical trials (OR 2.4, 95% CI 0.46-10.20 and OR 2.2, 95% CI 0.33-10.75, respectively), but differences were not statistically significant CONCLUSIONS: Access of disadvantaged patients to center of excellence care and research remains limited despite geographic proximity to their community. Patients with lower SES and African Americans are as likely to follow-up clinically, but there were trends of differences in enrollment/adherence in clinical trials. Mitigation efforts should target systemic causes of low access to specialized care among uninsured and African American patients.

Factors affecting the recruitment of Hispanic/Latinx American older adults in clinical trials in the United States: A scoping review

OBJECTIVE

Participation of Hispanic/Latinx American older adults (HLAOA) in clinical trials is fundamental to health equity in aging research. However, information on strategies for the successful recruitment of this population in clinical trials is limited.

DESIGN

This scoping review aims to identify hindering and facilitating factors that impact the recruitment of HLAOA in clinical trials in the United States.

METHODS

Two databases (PubMed, EMBASE) were searched for original research articles from inception until March 2022 reporting on factors that engaged HLAoa (≥65) in clinical trials. One thousand and thirteen studies were scrutinized to identify 31 eligible articles.

RESULTS

Most articles were from cancer clinical trials (14 studies). Hindering factors that impacted the recruitment of HLAoa in clinical trials were related to (i) study design and logistics challenges, (ii) challenges imposed by social determinants of health, (iii) communication barriers, and (iv) patients' mistrust, and (v) family issues. Facilitating factors include (i) effective modes of outreach, (ii) strategic clinical trial design, (iii) incorporating culturally-respectful approaches that are tailored to the participants' sociocultural background, and (iv) bridging language barriers.

CONCLUSIONS

Successful recruitment of HLAOA into clinical trials requires identifying the study question, co-designing the trial design, implementation, and evaluation in respectful collaboration with the Hispanic/Latinx community with careful attention to their needs and minimizing the study burden on this vulnerable population. Factors identified here may guide researchers to better understand the needs of HLAOA and successfully recruit them into clinical trials, leading to more equitable research that increases their representation in clinical research.

Investigating potential disparities in clinical trial eligibility and enrollment at an NCI-designated comprehensive cancer center

BACKGROUND

Although barriers to trial accrual are well-reported, few studies have explored trial eligibility and trial offers as potential drivers of disparities in cancer clinical trial enrollment.

METHODS

We identified patients with gastrointestinal (GI) or head/neck (HN) malignancies who were seen as new patients at the University of Michigan Health Rogel Cancer Center in 2016. By exhaustive review of the electronic medical record, we assessed the primary outcomes: (1) eligibility for, (2) documented offer of, and (3) enrollment in a clinical trial. All 41 of the clinical trials available to these patients were considered. Independent variables included clinical and non-clinical patient-related factors. We assessed associations between these variables and the primary outcomes using multivariable regression.

RESULTS

Of 1446 patients, 43% were female, 15% were over age 75, 6% were Black. 305 (21%) patients were eligible for a clinical trial. Among eligible patients, 154 (50%) had documentation of a trial offer and 90 (30%) enrolled. Among the GI cohort, bivariate analyses demonstrated that older age was associated with decreased trial eligibility. Bivariate analyses also demonstrated that Black race was associated with increased trial offer. After adjustment, patients 75 or older were less likely to be eligible for a clinical trial in the GI cohort; however, we found no significant associations between race and any of the outcomes after adjustment. Among eligible GI patients, we found no significant associations between non-clinical factors and enrollment. Among the HN cohort, bivariate analyses demonstrated that female sex, older age, Black race, and unpartnered marital status were associated with decreased likelihood of trial offer; however, we found no significant associations between race, age, and marital status and any of the outcomes after adjustment. We found no significant associations between non-clinical factors and eligibility after adjustment; however, women were less likely to be offered and to enroll in a clinical trial in the HN cohort.

CONCLUSION

Factors associated with eligibility, documented offer, and enrollment differed between disease site cohorts at our institution. Future work is needed to ensure the equitable inclusion of women and elderly patients in clinical trials.

Understanding potential participation barriers to improve trial design and outcomes: clinical trial simulation in palmoplantar pustulosis as a case study

OBJECTIVES

Evaluate the experiences and perceptions of patients participating in a simulated clinical trial and identify ways to enhance future patient-centric trial designs.

DESIGN

International, multicentre, non-interventional, virtual clinical trial visits with patient debriefs and advisory boards.

SETTING

Virtual clinic visits and accompanying advisory boards.

PARTICIPANTS

Nine patients with palmoplantar pustulosis for simulated trial visits; 14 patients and patient representatives for advisory boards.

MAIN OUTCOME MEASURES

Qualitative responses to trial documentation, visit schedule and logistics, and trial design were collected during patient debriefs. Results were discussed at two virtual advisory board meetings.

RESULTS

Patients identified key barriers to participation and potential difficulties encountered when attending trial visits and completing assessments. They also proposed recommendations to overcome these challenges. Patients recognised the need for comprehensive informed consent forms, but recommended use of non-technical language, brevity and additional support to aid understanding. Other trial documentations should be relevant to the disease and include known efficacy and safety of the study drug. Patients were concerned about receiving placebo, stopping existing medications and being unable to receive the study drug after trial completion; therefore, patients and physicians recommended an open-label extension following trial completion. Trial visits were too numerous (n=20) and too long (3-4 hours each); patients recommended improvements to the design to make best use of their time and reduce unnecessary waiting. They also requested financial and logistical support. Patients expressed a desire for study outcomes that matter to them, related to their ability to undertake normal daily activities and not be a burden to others.

CONCLUSIONS

Simulated trials are an innovative method for assessing trial design and acceptance from a patient-centric perspective, enabling specific improvements to be made prior to trial initiation. Incorporation of recommendations from simulated trials could enhance trial recruitment and retention, and optimise trial outcomes and data quality.

Mimicking Clinical Trials Using Real-World Data: A Novel Method and Applications

INTRODUCTION

Simulating individual-level trial data when only summary data are available is often useful for meta-analysis, forming external control arms and calibrating trial results to real-world data (RWD). The joint distribution of baseline characteristics in a trial is usually simulated by combining its summary data with RWD's correlations. However, RWD correlations may not be a perfect proxy for the trial. A misspecified correlation structure could bias any analysis in which the outcomes generating models are nonlinear or include effect modifiers.

METHODS

We developed an iterative algorithm using copula and resampling, which was based on the estimated propensity score for the likelihood of enrollment in a trial given participants' characteristics. Validation was performed using Monte Carlo simulations under different scenarios in which the marginal and joint distributions of covariates differ between trial samples and RWD. Two applications were illustrated using an actual trial and the Surveillance, Epidemiology, and End Results-Medicare data. We calculated the standardized mean difference (SMD) to assess the generalizability of the trial and explored the feasibility of generating an external control by applying a parametric Weibull model trained in RWD to predict survival in the simulated trial cohort.

RESULTS

Across all scenarios, approximated correlations derived from the algorithm were closer to the true correlations than the RWD's correlations. The algorithm also successfully reproduced the joint distribution of characteristics for the actual trial. A similar SMD was observed using simulated data and individual-level trial data. The 95% confidence intervals were overlapped between adjusted survival estimates from the simulated trial and actual trial Kaplan-Meier estimates.

CONCLUSIONS

The algorithm could be a feasible way to simulate individual-level data when only summary data are available. Further research is needed to validate our approach with larger sample sizes.

HIGHLIGHTS

The correlation structure is crucial to building the joint distribution of patient characteristics, and a misspecified correlation structure could potentially influence predicted outcomes.An iterative algorithm was developed to approximate a trial's correlation structure using published summary trial data and real-world data.The algorithm could be a feasible way to simulate individual-level trial data when only trial summary data are available.

"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.

Pintura Mural para Recolectar Datos Sensibilizantes y Fomentar la Participación en la Investigación Entre los Latinos de EE. UU

Proposito. Describir una intervención de murales implementadas con comunidad envecindarios Latinos para elevar conciencia de barreras delreclutamiento/retención de Latinos en EE. UU. en la investigación clínica,y aumentar acceso de los investigadores a conceptos de sensibilización críticos para el riguroso diseño de estudios. Fondo. Latinos en EE. UU. sufren desproporcionada de varias enfermedadescrónicas, pero son subrepresentados como investigadores y participantesen investigaciones financiadas por Institutos Nacionales de Salud. Faltade representación inhibe conciencia de necesidades Latinas para la saludy obstaculiza esfuerzos para abordar la falta de equidad en comunidadesdiversas. Las intervenciones de arte en comunidades Latinas siguensiendo reconocidas por capacidad a cerrar brechas e incrementar lacalidad y cantidad de asociaciones de investigación entre investigadores y Latinos. Método. Este artículo describe una intervención de murales puesta a prueba endos vecindarios mayormente Latinos entre 2016 y 2020. El método deldiseño fue guiado por prácticas de investigación participativas con lacomunidad enfocadas en Evaluación-Diagnóstico Planificación- Implementación-Evaluación. Resultados. Los murales abordaron muchos desafíos de participación que a menudo se asocian con la subrepresentación de los Latinos en la investigación académica y permitió entrevistas de sensibilización con miembros clave de la comunidad sobre temas de interés para investigación. Conclusión. Los métodos de investigación que reconocen las formas de arte tradicionales, como murales, crean espacio para generar confianza e iniciar interés en la participación en investigaciones, y aumentan acceso.

Interventions to improve access to clinical trials in urologic oncology

INTRODUCTION

Most cancer patients are never enrolled in clinical trials, resulting in missed potential therapeutic benefits to patients and barriers to drug development and approval. With a focus on urologic oncology clinical trials, we reviewed the current literature on barriers to accrual and present effective interventions to overcome these barriers.

METHODS

PubMed was searched for articles regarding physician referral and patient accrual to clinical trials in urologic oncology from January 2000 through June 2021. Studies were included if they were in English, related to clinical trial utilization or patient accrual in urologic oncology, peer-reviewed, primary research, survey, or systematic review, and pertained to clinical trials in the U.S. Major overlapping themes related to barriers to accrual and effective interventions were identified.

RESULTS

Thirty-six studies met our inclusion criteria. Barriers fall into three categories: 1) provider; 2) patient; or 3) structural. Provider barriers include issues such as poor funding, logistical challenges, and time constraints. Patient barriers include cost, distrust of medical institutions, and lack of knowledge regarding ongoing studies. Structural barriers include lack of time and resources in community settings and difficulty with physician referrals. Effective strategies identified include increasing provider referrals through continuing education and referral pathways, increasing patient education through patient-centered marketing material, and decreasing structural barriers through patient navigation programs and community partnerships.

CONCLUSIONS

We identified barriers and potential multipronged strategies targeted at patients, providers, and practices to increase clinical trial enrollment. We hope these strategies will benefit patients and providers and facilitate research development.

Challenges to Recruiting Men on Active Surveillance for Prostate Cancer in Clinical Chemoprevention Trials

Clinical trials play a critical role in evidence-based medicine, when rigorous scientific methodology is utilized to discover and test the effectiveness and safety of new drugs to prevent or cure diseases, including cancer. Participation in clinical trials thus becomes key to successful completion of these trials. Although it is estimated that >70% of Americans are inclined to participate in clinical trials, less than 5% of adult cancer patients participate in clinical trials. There is thus a large gap between those inclined to participate in clinical trials and actual participation in clinical trials. As with trials targeting men with prostate cancer (PCa) on active surveillance (AS), where the target population is mostly over 50 years of age, others have observed several challenges with recruitment and accrual in clinical trials. The participation rate is currently unavailable for men on primary and secondary chemoprevention trials. Additionally, with unanticipated environmental factors such as a pandemic or other natural emergencies that may severely impact the economy, personal property, travel and person-to person contact for study-related procedures, there is a need to continuously identify these challenges and determine solutions to recruitment barriers in chemoprevention trials to ensure timely completion of early phase trials. Recent studies regarding the impact of the pandemic on clinical trial recruitment have shown that cancer prevention trials were relatively more negatively impacted compared to cancer treatment trials. The goal of this manuscript is to review our experience in continuously evaluating the protocol and patient level challenges to recruiting subjects on AS for PCa in this cancer chemoprevention trial conducted at the Comprehensive Cancer Center (CCC) and report the contemporary strategies that we are utilizing to continue to recruit subjects in this trial. We provide data from our current trial as an example while discussing future strategies to improve overall clinical trial recruitment. These strategies can inform future design of contemporary cancer chemoprevention trials and, additionally, better select, focus and invest in strategies that are the most productive and efficient for recruiting target populations.

Socioeconomic Barriers to Randomized Clinical Trial Retention in Patients Treated With Adjuvant Radiation for Early-Stage Breast Cancer

PURPOSE

Socioeconomic barriers contribute to breast cancer clinical trial enrollment disparities. We sought to identify whether socioeconomic disadvantage also is associated with decreased trial retention.

METHODS AND MATERIALS

We performed a secondary analysis of 253 (of 287) patients enrolled in a randomized phase 3 trial of conventionally fractionated versus hypofractionated whole-breast irradiation. The outcome of trial retention versus dropout was defined primarily based on whether the patient completed breast cosmesis outcomes assessment at 3-year follow-up, and secondarily, at 5-year follow-up. Associations of retention with severity of socioeconomic disadvantage, quantified by patients' home neighborhood area deprivation index (ADI) rank (1 [least] to 100 [most deprivation]), were tested using the Kruskal-Wallis test and multivariate logistic regression. Associations of retention with patients' use of social resource assistance were analyzed using the χ² test.

RESULTS

In total, 21.7% (n = 55) of patients dropped out by 3 years and 36.7% (n = 92) by 5 years. Median ADI was 36.5 (interquartile range, 22-57) for retained and 46.0 (interquartile range, 29-60) for dropout patients. Dropout was associated with more severe socioeconomic deprivation (ADI ≥45 vs <45) at 3 years (odds ratio, 3.63; 95% confidence interval, 1.62-8.15; P = .002) and 5 years (odds ratio, 2.55; 95% confidence interval, 1.37-4.76; P = .003). While on study, patients who ultimately dropped out were more likely to require resource assistance for practical (transportation, housing, financial) than psychological needs (distress, grief) or advance care planning (P = .03).

CONCLUSIONS

In this study, ADI was associated with disparities in clinical trial retention of patients with breast cancer receiving adjuvant radiation treatment. Results suggest that developing multidimensional interventions that extend beyond routine social determinants needs screening are needed, not only to enhance initial clinical trial access and enrollment but also to enable robust long-term retention of socioeconomically disadvantaged patients and improve the validity and generalizability of reported long-term trial clinical and patient-reported outcomes.

Patient hesitancy in perioperative clinical trial enrollment during the COVID-19 pandemic

The COVID-19 pandemic has caused tremendous disruptions to non-COVID-19 clinical research. However, there has been little investigation on how patients themselves have responded to clinical trial recruitment during the COVID-19 pandemic. To investigate the effect of the COVID-19 pandemic on rates of patient consent to enrollment into non-COVID-19 clinical trials, we carried out a cross-sectional study using data from the Nitric Oxide/Acute Kidney Injury (NO/AKI) and Minimizing ICU Neurological Dysfunction with Dexmedetomidine-Induced Sleep (MINDDS) trials. All patients eligible for the NO/AKI or MINDDS trials who came to the hospital for cardiac surgery and were approached to gain consent to enrollment were included in the current study. We defined "Before COVID-19" as the time between the start of the relevant clinical trial and the date when efforts toward that clinical trial were deescalated by the hospital due to COVID-19. We defined "During COVID-19" as the time between trial de-escalation and trial completion. 5,015 patients were screened for eligibility. 3,851 were excluded, and 1,434 were approached to gain consent to enrollment. The rate of consent to enrollment was 64% in the "Before COVID-19" group and 45% in the "During COVID-19" group (n = 1,334, P<0.001) (RR = 0.70, 95% CI 0.62 to 0.80, P<0.001). Thus, we found that rates of consent to enrollment into the NO/AKI and MINDDS trials dropped significantly with the onset of the COVID-19 pandemic. Patient demographic and socioeconomic status data collected from electronic medical records and patient survey data did not shed light on possible explanations for this observed drop, indicating that there were likely other factors at play that were not directly measured in the current study. Increased patient hesitancy to enroll in clinical trials can have detrimental effects on clinical science, patient health, and patient healthcare experience, so understanding and addressing this issue during the COVID-19 pandemic is crucial.

Demographic recruitment bias of adults in United States randomized clinical trials by disease categories between 2008 to 2019: a systematic review and meta-analysis

To promote health equity within the United States (US), randomized clinical trials should strive for unbiased representation. Thus, there is impetus to identify demographic disparities overall and by disease category in US clinical trial recruitment, by trial phase, level of masking, and multi-center status, relative to national demographics. A systematic review and meta-analysis were conducted using MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov, between 01/01/2008 to 12/30/2019. Clinical trials (N = 5,388) were identified based on the following inclusion criteria: study type, location, phase, and participant age. Each clinical trial was independently screened by two researchers. Data was pooled using a random-effects model. Median proportions for gender, race, and ethnicity of each trial were compared to the 2010 US Census proportions, matched by age. A second analysis was performed comparing gender, race, and ethnicity proportions by trial phase, multi-institutional status, quality, masking, and study start year. 2977 trials met inclusion criteria (participants, n = 607,181) for data extraction. 36% of trials reported ethnicity and 53% reported race. Three trials (0.10%) included transgender participants (n = 5). Compared with 2010 US Census data, females (48.3%, 95% CI 47.2-49.3, p < 0.0001), Hispanics (11.6%, 95% CI 10.8-12.4, p < 0.0001), American Indians and Alaskan Natives (AIAN, 0.19%, 95% CI 0.15-0.23, p < 0.0001), Asians (1.27%, 95% CI 1.13-1.42, p < 0.0001), Whites (77.6%, 95% CI 76.4-78.8, p < 0.0001), and multiracial participants (0.25%, 95% CI 0.21-0.31, p < 0.0001) were under-represented, while Native Hawaiians and Pacific Islanders (0.76%, 95% CI 0.71-0.82, p < 0.0001) and Blacks (17.0%, 95% CI 15.9-18.1, p < 0.0001) were over-represented. Inequitable representation was mirrored in analysis by phase, institutional status, quality assessment, and level of masking. Between 2008 to 2019 representation improved for only females and Hispanics. Analysis stratified by 44 disease categories (i.e., psychiatric, obstetric, neurological, etc.) exhibited significant yet varied disparities, with Asians, AIAN, and multiracial individuals the most under-represented. These results demonstrate disparities in US randomized clinical trial recruitment between 2008 to 2019, with the reporting of demographic data and representation of most minorities not having improved over time.

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

BACKGROUND

People experiencing financial burden are underrepresented in clinical trials.

OBJECTIVE

Describe the prevalence of cost-related considerations influential to trial participation and their associations with person-level characteristics.

DESIGN

This cross-sectional study used and assessed how three cost-related considerations would influence the decision to participate in a hypothetical clinical trial.

PARTICIPANTS

A total of 3682 US adult respondents to the Health Information National Trends Survey MAIN MEASURES: Survey-weighted multivariable logistic regression estimated associations between respondent characteristics and odds of reporting cost-related considerations as very influential to participation.

KEY RESULTS

Among 3682 respondents, median age was 48 (IQR 33-61). Most were non-Hispanic White (60%), living comfortably or getting by on their income (74%), with ≥ 1 medical condition (61%). Over half (55%) of respondents reported at least one cost-related consideration as very influential to trial participation, including if usual care was not covered by insurance (reported by 42%), payment for participation (24%), or support for participation (24%). Respondents who were younger (18-34 vs. ≥ 75, adjusted odds ratio [aOR] 4.3, 95% CI 2.3-8.1), more educated (high school vs. <high school, aOR 2.1, 95% CI 1.1-4.1), or with lower perceived income (having difficulty vs. living comfortably, aOR 2.1, 95% CI 1.1-3.8) had higher odds of reporting any cost-related consideration as very influential to trial participation. Non-Hispanic Black vs. non-Hispanic White respondents had 29% lower odds (95% CI 0.5-0.9) of reporting any cost-related consideration as very influential to trial participation.

CONCLUSIONS

Cost-related considerations would influence many individuals' decisions to participate in a clinical trial, though prevalence of these concerns differed by respondent characteristics. Reducing financial barriers to trial participation may promote equitable trial access and greater trial enrollment diversity.

WITHDRAWN-Administrative Duplicate Publication: Mural Painting to Collect Sensitizing Data and Encourage Research Participation Among U.S. Latinos

Purpose

To describe a mural-based intervention that can be implemented in partnership with community members in Latino neighborhoods in order to improve awareness of barriers to recruitment/retention of U.S. Latinos in clinical research, while augmenting researchers’ access to sensitizing concepts critical for rigorous study design. Background. Latinos in the United States suffer disproportionately from several chronic illnesses but are under-represented as researchers and participants in the National Institutes of Health–funded research. This lack of representation inhibits a nuanced awareness of the health needs of U.S. Latinos and hampers efforts to address a persistent lack of health equity among U.S. Latinos and other communities of color. Art-based interventions implemented in Latino communities are increasingly being recognized for their ability to bridge this gap and positively affect the quality and quantity of research partnerships between clinical researchers and U.S. Latinos.

Method

This article describes a mural-based intervention piloted in two predominantly Latino neighborhoods between 2016 and 2020. The design of this method was guided by community-partnered participatory research practices and involved an Assessment–Diagnosis–Planning–Implementation–Evaluation approach.

Results

Mural painting addressed many of the participation challenges often associated with under-representation of Latinos in academic research and allowed for sensitizing interviews with key community members surrounding topics of interest to the research team.

Conclusion

Research methods that acknowledge traditional art forms, such as mural painting, create a space for building trust and spark interest in future research participation, while augmenting researchers’ access to sensitizing concepts that may improve the cultural competence of future studies, projects, and interventions.

Ineligible, Unaware, or Uninterested? Associations Between Underrepresented Patient Populations and Retention in the Pathway to Cancer Clinical Trial Enrollment

PURPOSE

Cancer clinical trials can benefit current and future patients; however, Black patients, rural residents, and patients living in disadvantaged areas are often underrepresented. Using an adapted version of Unger and colleagues' model of the process of clinical trial enrollment, we evaluated the relationship between underrepresented patient populations and trial end points.

METHODS

This retrospective study included 512 patients with breast or ovarian cancer who were prescribed a therapeutic drug at the University of Alabama at Birmingham from January 2017 to February 2020. Patient eligibility was assessed using open clinical trials. We estimated odds ratios and 95% CIs using logistic regression models to examine the relationship between underrepresented patient populations and trial enrollment end points: eligibility, interest, offer, enrollment, and declining enrollment.

RESULTS

Of the patients in our sample, 27% were Black, 18% were rural residents, and 19% lived in higher disadvantaged neighborhoods. In adjusted models, each comparison group had similar odds of being eligible for a clinical trial. Black versus White patients had 0.40 times the odds of interest in clinical trials and 0.56 times the odds of enrollment. Patients living in areas of higher versus lower disadvantage had 0.46 times the odds of enrolling and 3.40 times the odds of declining enrollment when offered.

CONCLUSION

Eligibility did not drive clinical trial enrollment disparities in our sample; however, retention in the clinical trial enrollment process appears to vary by group. Additional work is needed to understand how interventions can be tailored to each population's specific needs.

Major Adverse Cardiac Events With Immune Checkpoint Inhibitors: A Pooled Analysis of Trials Sponsored by the National Cancer Institute-Cancer Therapy Evaluation Program

PURPOSE

Major adverse cardiac events (MACEs) because of immune checkpoint inhibitors (ICIs) are infrequent immune-related adverse events (irAEs) that comprise a spectrum of cardiac toxicities with variable manifestations. ICI-related MACEs can lead to significant morbidity and mortality, hence the need to better define presentations of MACEs and their association with noncardiac irAEs in ICI-treated patients.

METHODS

We conducted a retrospective pooled analysis of MACE captured in the serious adverse events reporting database of the National Cancer Institute-Cancer Therapy Evaluation Program for National Cancer Institute-sponsored investigational clinical trials between June 2015 and December 2019. Patients were eligible if they had been treated with anti-programmed cell death protein-1 (anti-PD-1)/programmed cell death-ligand 1 (anti-PD-L1) alone or with additional anticancer therapies.

RESULTS

A total of 6,925 participants received anti-PD-(L)1-based therapies; 48% (n = 3,354) were treated with single-agent anti-PD-(L)1 therapy. Of 6,925 patients, 0.6% (n = 40) qualified as ICI-related MACE, with 77.5% (n = 31 of 40) being ≥ grade 3. Myocarditis accounted for 45% (n = 18 of 40) of total ICI-MACEs. Concurrent multisystem involvement with other noncardiac irAEs was seen in 65% (n = 26 of 40). Most patients with myocarditis (83%, n = 15 of 18) had one or more noncardiac irAEs associated. Incidence of MACE was higher with anti-PD-(L)1 + targeted therapies compared with anti-PD-(L)1 + anti-cytotoxic T-cell lymphocyte-4 combinations (2.1% v 0.9%, P = .08). There was a higher incidence of myocarditis with anti-PD-(L)1-based combination therapies versus single-agent anti-PD-(L)1 therapies (0.36%, n = 13 of 3,571 v 0.15%, n = 5 of 3,354, P = .08). Deaths related to myocarditis were identified in 22.5% (n = 4 of 18). All four patients who died had concurrent myositis.

CONCLUSION

Increasing patient and prescriber awareness in understanding patterns of ICI-MACE and associated noncardiac irAEs should be emphasized. Better characterization of the risk of MACE with the concurrent use of non-ICI-based anticancer therapies with anti-PD-(L)1 treatments is needed.

Using a qualitative sub-study to inform the design and delivery of randomised controlled trials on medicinal cannabis for symptom relief in patients with advanced cancer

BACKGROUND

Recruitment for randomised controlled trials in palliative care can be challenging; disease progression and terminal illness underpin high rates of attrition. Research into participant decision-making in medicinal cannabis randomised controlled trials (RCTs) is very limited. Nesting qualitative sub-studies within RCTs can identify further challenges to participation, informing revisions to study designs and recruitment practices. This paper reports on findings from a qualitative sub-study supporting RCTs of medicinal cannabis for symptom burden relief in patients with advanced cancer in one Australian city.

METHODS

Semi-structured qualitative interviews were conducted with 48 patients with advanced cancer, eligible to participate in a medicinal cannabis RCT (n=28 who consented to participate in an RCT; n=20 who declined). An iterative and abductive approach to thematic analysis and data collection fostered exploration of barriers and enablers to participation.

RESULTS

Key enablers included participants' enthusiasm and expectations of medicinal cannabis as beneficial (to themselves and future patients) for symptom management, especially after exhausting currently approved options, and a safer alternative to opioids. Some believed medicinal cannabis to have anti-cancer effects. Barriers to participation were the logistical challenges of participating (especially due to driving restrictions and fatigue), reluctance to interfere with an existing care plan, cost, and concerns about receiving the placebo and the uncertainty of the benefit. Some declined due to concerns about side-effects or a desire to continue accessing cannabis independent of the study.

CONCLUSIONS

The findings support revisions to subsequent medicinal cannabis RCT study designs, namely, omitting a requirement that participants attend weekly hospital appointments. These findings highlight the value of embedding qualitative sub-studies into RCTs. While some challenges to RCT recruitment are universal, others are context (population, intervention, location) specific. A barrier to participation found in research conducted elsewhere-stigma-was not identified in the current study. Thus, findings have important implications for those undertaking RCTs in the rapidly developing context of medical cannabis.

Envisioning clinical trials as complex interventions

Clinical trials are critical components of modern health care and infrastructure. Trials benefit society through scientific advancement and individual patients through trial participation. In fact, billions of dollars are spent annually in support of these benefits. Despite the massive investments, clinical trials often fail to accomplish their primary aims and trial enrollment rates remain low. Prior efforts to improve trial conduct and enrollment have had limited success, perhaps due to oversimplification of the complex, multilevel nature of trials. For these reasons, the authors propose applying implementation science to the clinical trials context. In this commentary, the authors posit clinical trials as complex, multilevel evidence-based interventions with significant societal and individual benefits yet with persistent gaps in implementation. An application of implementation science concepts to the clinical trials context as means to build common vocabulary and establish a platform for applying implementation science and practice to improve clinical trial conduct is introduced. Applying implementation science to the clinical trials context can augment improvement efforts and build capacity for better and more efficient evidence-based care for all patients and trial stakeholders throughout the clinical trials enterprise.

The ethical anatomy of payment for research participants

In contrast to most publications on the ethics of paying research subjects, which start by identifying and analyzing major ethical concerns raised by the practice (in particular, risks of undue inducement and exploitation) and end with a set of—more or less well-justified—ethical recommendations for using payment schemes immune to these problems, this paper offers a systematic, principle-based ethical analysis of the practice. It argues that researchers have a prima facie moral obligation to offer payment to research subjects, which stems from the principle of social beneficence. This principle constitutes an ethical “spine” of the practice. Other ethical principles of research ethics (respect for autonomy, individual beneficence, and justice/fairness) make up an ethical “skeleton” of morally sound payment schemes by providing additional moral reasons for offering participants (1) recompense for reasonable expenses; and (2a) remuneration conceptualized as a reward for their valuable contribution, provided (i) it meets standards of equality, adequacy and non-exploitation, and (ii) it is not overly attractive (i.e., it does not constitute undue inducement for participation or retention, and does not encourage deceptive behaviors); or (2b) remuneration conceptualized as a market-driven price, provided (i) it is necessary and designed to help the study achieve its social and scientific goals, (ii) it does not reinforce wider social injustices and inequalities; (iii) it meets the requirement of non-exploitation; and (iv) it is not overly attractive. The principle of justice provides a strong ethical reason for not offering recompenses for lost wages (or loss of other reasonably expected profits).

Patient Experience in Clinical Trials: Quality of Life, Financial Burden, and Perception of Care in Patients With Multiple Myeloma or Lymphoma Enrolled on Clinical Trials Compared With Standard Care

PURPOSE

Patients' concerns regarding clinical trial (CT) participation include apprehension about side effects, quality of life (QoL), financial burden, and quality of care.

METHODS

We prospectively evaluated the experience of patients with multiple myeloma or lymphoma who were treated on CTs (CT group, n = 35) versus patients treated with standard approaches (non-CT group, n = 88) focusing on QoL, financial burden of care, and patients' perception of quality of care over a 1-year period.

RESULTS

There were no significant differences in any of the patient-reported outcomes in CT versus non-CT groups. We observed an initial decline in overall QoL in the first 3 months across both groups, driven primarily by physical and functional well-being. QoL gradually improved and was above baseline by month 12. Patients reported highest improvement in the functional well-being subdomain. Patients in both groups reported high satisfaction with the quality of care received, and there were no differences in overall satisfaction, communication with team, or access to care. At baseline, 16%-19% of patients reported financial burden, which increased to a peak of 33% in the CT group and to 49% in the non-CT group over the course of 1 year. There was no significant difference in financial burden in the two groups overall. Most of the patients reported getting all the care that was deemed medically necessary in both groups. However, a significant proportion of patients reported having to make other kinds of financial sacrifices because of their cancer (CT group: 33% of patients at baseline and 21%-40% over 1 year; non-CT group: 19% at baseline and 25%-36% over 1 year).

CONCLUSION

Patients treated on CTs reported comparable QoL and quality of care with the non-CT group. A high proportion of patients reported financial burden over time in both groups. Our findings can serve as a guide to educate patients regarding CT participation and highlight the need to address the significant financial burden experienced by patients with cancer.

Willingness to participate in various nontherapeutic cancer research activities among urban and rural African American and Latinx healthy volunteers

PURPOSE

Inclusion of racial/ethnic minorities in cancer research can reduce disparities in health outcomes; however, data regarding barriers and motivators to participation are sparse. This study assessed African American (AA) and Latinx healthy volunteers' perspectives regarding willingness to participate in noninvasive and invasive research activities.

METHODS

Using a 38-item questionnaire adapted from the Tuskegee Legacy Project Questionnaire, we assessed willingness to participate in 12 research activities, offering 27 possible barriers and 14 motivators. The sample was segmented into four subgroups by AA/Latinx and rural/urban.

RESULTS

Across five states and Puerto Rico, 533 participants completed questionnaires. Overall, participants were more willing to participate in noninvasive versus invasive procedures, although, all subgroups were willing to participate in research if asked. Rural AA were most willing to complete a survey or saliva sample, while rural Latinx were least willing. Urban AA were least willing to provide cheek swab, while rural counterparts were most willing. Self-benefit and benefit to others were among the top three motivators for all subgroups. Curiosity was a primary motivator for urban AA while obtaining health information motivated rural Latinx. Primary barriers included fears of side effects and being experimented on, lack of information, and lack of confidentiality.

CONCLUSIONS

Latinx and AAs are willing to participate in the continuum of nontherapeutic research activities suggesting their lack of participation may be related to not being asked. Inclusive enrollment may be achieved by assessing needs of participants during the design phase of a study in order to reduce barriers to participation.

Disparities in Clinical Care and Research in Renal Cell Carcinoma

Disparities in cancer screening, prevention, therapy, clinical outcomes, and research are increasingly recognized and pervade all malignancies. In response, several cancer research and clinical care organizations have issued policy statements to acknowledge and address barriers to achieving health equity in cancer care. The increasingly specialized nature of oncology warrants a disease-focused appraisal of existing disparities and potential solutions. Although clear improvements in clinical outcomes have been recently observed for patients with renal cell carcinoma (RCC), these improvements have not been equally shared across diverse populations. This review describes existing RCC cancer disparities and their potential contributing factors and discusses opportunities to improve health equity in clinical research for all patients with RCC.

Barriers to Enrollment in Rheumatology Research: Who, What, Where, When, and Why?

Despite the evidence that complicated rheumatic diseases are more prevalent and severe in ethnic minorities, rheumatology research is afflicted with inadequate patient representation. It is lacking in ethnic and socioeconomic diversity. The objective of this study is to identify barriers to enrollment in rheumatology research and propose possible solutions to overcome these barriers.

In this study, 184 patients from two rheumatology clinics (Safety Net clinic, a university-based clinic) were surveyed for concerns regarding participation in clinical research. Patients were asked to rank their top five of eight concerns. Data were then stratified by self-reported ethnicity and clinic site to determine ranking differences in both groups.

Fear of risks associated with clinical research was ranked as the primary barrier in all ethnicities. More non-Hispanic Whites (NHW) (24.4%) ranked work responsibilities as a primary barrier compared to Hispanics (10%). Fear of discovering a serious illness as a primary barrier was more frequent at the Safety Net clinic (25%) compared to the university-based clinic (6.3%) and ranked more frequently in the top five in Hispanics compared to NHW.

Fears associated with research risks, work responsibilities, and fear of discovering a serious illness were the top-ranked barriers to enrollment in research among patients. However, differences in rankings between ethnicities and clinic sites were identified. This sheds light on the importance of health literacy and the responsibility of researchers in addressing gaps in communication while acknowledging potential cultural components that warrant further investigation.

Incidence of safety events after immune checkpoint inhibitor initiation for advanced-stage non-small-cell lung cancer: a real-world study

Aim: To describe the incidence of safety events after immune checkpoint inhibitor (ICI) initiation for advanced-stage non-small-cell lung cancer. Methods: Retrospective cohort study using the HealthCore Integrated Research Database in the USA to examine the incidence of prespecified safety events of interest after ICI initiation (n = 5278). Results: The most common safety events after ICI initiation included malaise/fatigue (incidence rate [IR]: 70.7 per 100 person-years; 95% CI: 66.5-75.1) and nausea/vomiting (IR: 32.4; 30.0-34.8). Other potential immune-mediated events, including colitis (IR: 7.11; 6.26-8.04) and pneumonitis (IR: 5.47; 4.76-6.25), were less frequent but higher than after any systemic anti-cancer therapy. No safety event rate substantially increased 6 months after ICI initiation. Conclusion: This large real-world study reports the incidence of safety events with ICI regimens for advanced-stage non-small-cell lung cancer.

Association of Remote Technology Use and Other Decentralization Tools With Patient Likelihood to Enroll in Cancer Clinical Trials

IMPORTANCE

Logistical challenges such as travel time and distance to a clinical trial site can be a barrier to patient participation. The association of remote technology use and other decentralization tools that can reduce these barriers with likelihood to enroll in cancer trials is not well understood.

OBJECTIVE

To assess the association of remote technology and other decentralization tools used to reduce participation-related time and travel with the likelihood to enroll in cancer clinical trials.

DESIGN, SETTING, AND PARTICIPANTS

Between July 6 and September 8, 2021, a 41-question, cross-sectional, internet-based survey was administered to patients with cancer and survivors of cancer in the US who had been diagnosed with or treated for cancer in the past 7 years.

MAIN OUTCOMES AND MEASURES

Increase in self-reported likelihood to enroll in cancer clinical trials that use remote technology and other decentralization tools to decrease the need for travel to the trial site.

RESULTS

There were 1183 survey respondents, with a mean (SD) age of 58.2 (12.5) years. Respondents self-reported their gender, race and ethnicity, cancer type, and treatment status. Of the 1183 respondents, 848 (72%) were female, 296 (25%) were male, 8 (1%) were other/nonbinary, and 31 (3%) declined to answer. With regard to race, 28 respondents (3%) were American Indian or Alaska Native, 25 (2%) were Asian, 234 (20%) were Black or African American, 20 (2%) were Native Hawaiian or Other Pacific Islander, 825 (70%) were White, and 51 (4%) declined to answer. With regard to ethnicity, 115 respondents (10%) were Hispanic, Latino/Latina, or of Spanish origin, whereas 1017 (86%) were not and 51 (4%) declined to answer. Regarding cancer type and treatment status, 483 respondents (41%) either had or had survived breast cancer and 325 (28%) were being treated for cancer during the survey period. Individuals older than 55 years were more likely to say that they would only participate in trials no farther from their home than their regular care health care practitioner compared with younger respondents (26% vs 16%, respectively; P = .02). Higher-income earners (ie, those in households earning >$125 000/y) were significantly more likely than lower-income earners (ie, those in households earning <$70 000/y) to say they would participate in trials requiring additional effort (62% vs 41%, respectively; P = .03). If given the opportunity to enroll in a cancer clinical trial that required travel farther than their regular care, a majority of respondents (range, 60%-85%) indicated that they would be more likely to participate if the trial used remote technology and other tools to decrease the need for travel to a trial site.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, the survey findings suggest that cancer clinical trials leveraging remote technology and decentralization tools to reduce patient time and travel burden associated with participation may increase the patient consent rate.

Age Differences in Clinical Trial Understanding in Non-Hodgkin Lymphoma Patients

BACKGROUND

Clinical trials are often an important component of cancer care but are misunderstood by many patients. Few studies have examined age differences in clinical trial understanding in older versus younger adults, especially among patients with indolent non-Hodgkin lymphoma (NHL), a slowly progressive and not typically curable cancer diagnosed primarily in older adults.

PATIENTS AND METHODS

Participants aged ≥21 years with a diagnosis of NHL were recruited from a single academic medical center in an urban setting. Age was dichotomized as <65 and ≥65 years. Clinical trial understanding was assessed using a four-item survey of potential goals of a clinical trial, with responses including "yes," "no," and "I don't know." Survey responses were examined by age using Chi-square tests.

RESULTS

The sample was comprised of 74 patients who were predominantly non-Latino White, with a mean age of 60.4 years (SD = 12.27). Compared to younger patients, older patients were more likely to respond "I don't know" to the clinical trial goals of reducing the lymphoma (41.4% vs. 13.3%; P = .023) and keeping the lymphoma from worsening (41.4% vs. 13.3%; P = .017). Age differences for the remaining goals were not statistically significant. Similar findings emerged when the sample was restricted to patients under active surveillance.

CONCLUSION

Relative to younger adults, older adults may have a less nuanced understanding of clinical trial goals. Therefore, older adults may benefit from developmentally-tailored interventions to improve clinical trial understanding. Future research should examine the relationship between clinical trial understanding and enrollment by age using validated measures in diverse samples.

Access to early-phase clinical trials in older patients with cancer in France: the EGALICAN-2 study

Background

Patients and methods

Results

Conclusions

•

Older patients are underrepresented in early-phase clinical trials (17.7%) compared with the number of new cases (50%).

•

The rate of signed informed consent was similar across age groups (92.7% in younger patients versus 90.6% in older patients).

•

The rate of screening failure was consistent across all age groups (28.5% in younger patients versus 24.3% in older patients).

•

In older patients the initial care received in the center having a phase I unit was associated with study drug administration.

Role of decentralized clinical trials in cancer drug development: Results from a survey of oncologists and patients

As a result of the unprecedented challenges imposed by the COVID-19 pandemic on enrollment to cancer clinical trials, there has been an urgency to identify and incorporate new solutions to mitigate these difficulties. The concept of decentralized or hybrid clinical trials has rapidly gained currency, given that it aims to reduce patient burden, increase patient enrollment and retention, and preserve quality of life, while also increasing the efficiency of trial logistics. Therefore, the clinical trial environment is moving toward remote collection and assessment of data, transitioning from the classic site-centric model to one that is more patient-centric.

Comparison of Patients With Head and Neck Cancer in Randomized Clinical Trials and Clinical Practice: A Systematic Review

Importance

When patient populations in randomized clinical trials deviate too much from the general population, it undermines the relevance for daily practice.

Objective

To investigate if patients with head and neck cancer in randomized clinical trials are representative of the clinically treated population.

Evidence Review

A systematic literature search was performed for randomized clinical trials on head and neck cancer evaluating an intervention to improve outcome with total sample size of 100 patients or greater and published between 2009 and 2019. Outcome measures were age, performance status, and recruitment rate. National cancer registries provided reference data. Databases that were searched included MEDLINE and Epub Ahead of Print; Embase; Cochrane Central Register of Controlled Trials; and ClinicalTrials.gov. Abstracts of search results were retrieved to assess selection criteria by 2 reviewers independently. After the selection procedure was completed by both reviewers, the results were compared and reviewed once more to reach consensus. Full articles were downloaded to retrieve general study information and outcome data.

Findings

A total of 16 927 publications were identified, resulting in 87 compliant randomized clinical trials with a total of 34 241 patients. Half of the trials included all major head and neck sites, and one-third were exclusively for nasopharynx cancers. The experimental intervention was systemic treatment in 47 (54%) studies, radiotherapy in 23 (26%), and other in 17 (20%). Median sample size was 332, and median duration of accrual was 4.6 years. Median accrual per center per year for head and neck and nasopharynx trials was 5.4 and 39.7 patients, respectively. Median age of patients in head and neck trials was 57 years, which was 7 years younger than in cancer registries. More than 70% of patients had a World Health Organization performance score of 0 to 1 or a Karnofsky performance status of 90 to 100.

Conclusions and Relevance

In this systematic review, patients in head and neck randomized clinical trials had a very good performance status, and half of them were younger than 57 years, while half of the clinical population was older than 64 years. In more than 50% of the head and neck trials, the yearly accrual per center was less than 6 patients, suggesting overly restrictive recruitment. Critical appraisal of trial population characteristics is recommended before results are implemented in clinical guidelines and general practice.

The psychosocial responses of patients in cancer clinical trials: are they a barrier to participation?

Introduction:

This paper aims to discuss the psychosocial concomitants with involvement in oncology clinical trials, focusing on barriers that can impact upon participation. It will conclude with some recommendations for strategies to address potential psychosocial barriers with the aim of increasing trial participation rates.

Materials and methods:

A literature search was carried out using CINAHL, PubMed and EMCare databases with the following keywords for filtering: psychological distress, clinical trials, participation and oncology. The final selection of papers that met the inclusion criteria for this review was manually subjected to Critical Appraisal Skills Programme tool for relevance.

Results:

Thirteen papers were included in the review. The dominant theme within the literature is psychosocial obstacles to oncology clinical trial participation. Five key barriers were identified: anxiety and fear; ethnicity and social background; tensions between scientific objectives and personal motivations to participation; tensions between personal benefits versus altruism; carer perspectives.

Conclusions:

The key barriers discussed led to the identification of a set of strategies to help mediate conflicting tensions and motivations of trial enrolment with a view to increasing participation rates. Further prospective research garnering primary data investigating both the psychological and psychosocial factors influencing cancer clinical trial participation for patients needs to be undertaken.

Examining allostatic load, neighborhood socioeconomic status, symptom burden and mortality in multiple myeloma patients

The objective of this study is to examine the association between neighborhood socioeconomic status (nSES) and baseline allostatic load (AL) and clinical trial endpoints in patients enrolled in the E1A11 therapeutic trial in multiple myeloma (MM). Study endpoints were symptom burden (pain, fatigue, and bother) at baseline and 5.5 months, non-completion of induction therapy, overall survival (OS) and progression-free survival (PFS). Multivariable logistic and Cox regression examined associations between nSES, AL and patient outcomes. A 1-unit increase in baseline AL was associated with greater odds of high fatigue at baseline (adjusted OR [95% CI] = 1.21 [1.08–1.36]) and a worse OS (adjusted hazard ratio, [95% CI] = 1.21 [1.06–1.37]). High nSES was associated with worse baseline bother (middle OR = 4.22 [1.11–16.09] and high 4.49 [1.16–17.43]) compared to low nSES. There was no association between AL or nSES and symptom burden at 5.5 months, non-completion of induction therapy or PFS. Additionally, there was no association between nSES and OS. AL may have utility as a predictive marker for OS among patients with MM and may allow individualization of treatment. Future studies should standardize and validate AL patients with MM.