Clinical Trial Eligibility Criteria: A Structural Barrier to Diversity in Clinical Trial Enrollment

Gender, race, and ethnicity in lung cancer clinical trial participation: Analysis of 253,845 patients from 2002 to 2021

BACKGROUND

Lung cancer remains the greatest cause of cancer-related death, and multiple large studies have identified persistent racial disparities in lung cancer outcomes. In this study, we used public recording of lung cancer data on clinicaltrials.gov to sample age, gender, racial, and ethnic characteristics of participants in lung cancer clinical trials.

METHODS

ClinicalTrials.gov, a US federal government repository of clinical trials, was queried for the term "lung cancer" and several related terms. A list of all studies matching these criteria was generated, and information regarding age, gender, ethnicity, and racial breakdown of participants was analyzed. Studies that did not report results to ClinicalTrials.gov or had at least one non-US site were excluded. Hypothesis testing was performed with the Student t test and χ2 test. Trends were analyzed using Spearman testing in Python (VSCode).

RESULTS

Rates of minority (ie, nonwhite) and female participation in US lung cancer clinical trials have increased significantly (P < .01) over the 20-year period from 2002 to 2021 but still do not represent parity with lung cancer incidence. Subset analysis by intervention offered did not show any significant differences in race, gender, or ethnic participation between studies that offered surgical intervention and those involving noninvasive interventions. National Institutes of Health-funded studies do not appear to have recruited any Hispanic participants, as assessed by reporting on ClinicalTrials.gov. The rates of race and ethnicity reporting also increased significantly over the study period.

CONCLUSIONS

Our data demonstrate that there are persistent but improving racial and ethnic disparities in lung cancer clinical trials. Limitations of this study include poor reporting of results on clinicaltrials.gov. These findings demonstrate significant progress in the recruitment of minority participation, but also identify a significant role for policy changes to align participation with lung cancer incidence.

Discretionary exclusion criteria in oncology clinical trials and exclusion of people with psychiatric and cognitive disabilities

BACKGROUND

Clinical trial protocols often allow investigators discretion to determine whether individuals are eligible to participate.

OBJECTIVE

To examine the frequency and impact of discretionary eligibility criteria in oncology clinical trials, including whether they specifically target populations with psychiatric or cognitive disabilities for exclusion.

METHODS

We identified interventional Phase III and Phase IV oncology clinical trials on ClinicalTrials.gov starting between January 1, 2019, and December 31, 2023. Among these, we included trials with at least one US location, patient populations aged 18-65 or 65+, and a posted study protocol. We used descriptive statistics to capture prevalence of broad investigator discretion in eligibility criteria. We reviewed statements concerning discretionary eligibility criteria for text relating to psychiatric or cognitive disability, and we applied qualitative content analysis techniques to identify themes.

RESULTS

Ninety-six trials met inclusion criteria for this study. Of these, 82 (85.4 %) of trials allowed broad investigator discretion to determine eligibility. Content analysis revealed concerns about participants' safety (i.e., posing undue risk to patients), potential difficulties adhering to study protocols (e.g., because of patients' physical, psychiatric, or social condition), perceived ability to obtain informed consent, and completing assessments of patients to determine results of interventions. All trials required informed consent.

CONCLUSIONS

Most oncology clinical trials allow investigators broad discretion in determining the eligibility of individuals to participate. These discretionary criteria may particularly target persons with psychiatric or cognitive disabilities, excluding them from participating in clinical trials. Further research should examine whether certain rationales for excluding these populations are appropriate.

Patients' selection and trial matching in early-phase oncology clinical trials

BACKGROUND

Early-phase clinical trials (EPCT) represent an important part of innovations in medical oncology and a valuable therapeutic option for patients with metastatic cancers, particularly in the era of precision medicine. Nevertheless, adult patients' participation in oncology clinical trials is low, ranging from 2% to 8% worldwide, with unequal access, and up to 40% risk of early discontinuation in EPCT, mostly due to cancer-related complications.

DESIGN

We review the tools and initiatives to increase patients' orientation and access to early phase cancer clinical trials, and to limit early discontinuation.

RESULTS

New approaches to optimize the early-phase clinical trial referring process in oncology include automatic trial matching, tools to facilitate the estimation of patients' prognostic and/or to better predict patients' eligibility to clinical trials. Classical and innovative approaches should be associated to double patient recruitment, improve clinical trial enrollment experience and reduce early discontinuation rates.

CONCLUSIONS

Whereas EPCT are essential for patients to access the latest medical innovations in oncology, offering the appropriate trial when it is relevant for patients should increase by organizational and technological innovations. The oncologic community will need to closely monitor their performance, portability and simplicity for implementation in daily clinical practice.