Offering the option of randomized clinical trials to cancer patients who overestimate their prognoses with standard therapies

Knowledge, attitudes, practices and perceptions of clinicians towards conducting clinical trials in an Academic Tertiary Care Center

Objectives:

To investigate the knowledge, attitudes practices and perceptions of clinicians concerning the conducting of clinical trials (CTs).

Methods:

A cross-sectional study was conducted on clinicians at King Fahad Medical City, Riyadh, Saudi Arabia. Data were collected using a self-administered questionnaire which divided into 5 sections: Section 1 covered respondents’ demographics. The other 4 sections explored respondents’ knowledge, attitudes, perceptions and practice towards conducting CTs.

Results:

A total of 316 clinicians completed the questionnaire. The majority were assistant consultants and consultants 125 (39.5%) and 108 (34.2%), respectively. One hundred sixty-nine (56%) respondents were not aware of the Declaration of Helsinki at all. Two hundred seventy-five (88.4%) respondents expressed interest in conducting CTs and 61.7% and participants showed their willingness to facilitate and assist in CTs conducted by other clinicians. Moreover, 112 (35.9%) respondents participated in CTs previously. Regarding the disadvantages in conducting CTs, participants indicated that the paperwork was complicated and they believed that they might lose patients from their clinical practice once they are recruited in CTs. Lack of research protected time for clinicians 295 (97.7%), and a shortage of clinical research coordinators 293 (97%) were the main problems reported by respondents.

Conclusions:

Although the majority of participants had an unsatisfactory level of knowledge and misperceptions about CTs, they showed an interest in and positive attitudes about conducting CTs.

Prognostic Value of S-Phase Fraction in 920 Breast Cancer Patients: Focus on T1N0 Status

The aim of this study was to reexamine the prognostic role of tumor cell kinetics measured by S-phase fraction (SPF) and to establish its clinically relevant threshold values. SPF was determined by flow cytometry in a group of 920 consecutive breast cancer patients, all followed at our institute for 10 years (1988 to 1998). Mean age was 60.5 years (27–89 years). Median follow-up was 63 months (3–150 months). All patients had initial surgical treatment. SPF quartiles were: Q1=3.08%, median value = 5.98%, Q3=10.22%. A significant difference in overall specific survival was obtained between two populations divided by a cutoff at Q1 (p<0.0001). A multifactorial analysis including SPF and known prognostic factors such as tumor size, node status, histological grade, ER and PR status was performed using the Cox model in a population of 719 patients: univariate analysis showed that each of these factors had significant influence on overall survival. Multivariate analysis selected three of them, ranked by decreasing order of hazard ratio (HR) value: SPF (HR: 3.88, p<0.001), tumor size (HR: 2.49, p<0.001) and nodal status (HR: 2.28, p<0.001). In addition, when tumors were stratified according to SPF quartile values, there were statistically different overall survival curves in patients with small tumors (<2 cm) and in axillary node-negative patients.

Knowledge, Attitudes and Perceptions of Saudis towards Participating in Clinical Trials

Aim

To assess the knowledge, attitudes, and perceptions of Saudis towards participating in clinical trials (CTs).

Methods

A cross-sectional study was conducted on 232 Saudi adult patients and their companions visiting adult outpatient clinics at King Fahad Medical City, Riyadh, Saudi Arabia. Data were collected using a self-administered questionnaire based on information obtained from the literature. The questionnaire was divided into four sections, one covering the respondents’ demographics, and the other three assessing knowledge, attitudes, and perceptions towards participating in CTs.

Results

A total of 148 (63.8%) respondents were males, and 52 (22.4%) participants had been invited to participate in a CT previously. Of those, 39 (75%) participated. Knowledge about the essential elements of informed consent ranged from 55.7% (number of participants needed) to 85.7% (confidentiality of personal information). The majority (163, 73.8%) of respondents was willing to participate in a CT after consulting their family physician and 130 (58.0%) respondents would be motivated to participate in a CT if they were healthy. Only 36.8% of the respondents believed that patients who participated in a CT received the best care. Moreover, 110 (48.7%) respondents believed that research was conducted in a responsible and ethical manner.

Conclusions

The present study assessed the current understanding of CTs among Saudi participants. Although the majority of participants had an acceptable level of knowledge about CTs, they exhibited conditional attitudes and misperceptions towards participating in a CT. Increased patient awareness may improve patients’ attitudes towards ethical conduct of CTs.

Evaluating the reliability of the Attitudes to Randomized Trial Questionnaire (ARTQ) in a predominantly African American sample

Purpose

To evaluate the reliability of the Attitudes to Randomized Trial Questionnaire (ARTQ) in measuring perceptions of cancer clinical trials in a predominantly African American (AA) sample in South Carolina (SC).

Methods

Principal Component Analysis (PCA) and Cronbach’s alpha estimates were used to assess the reliability of the ARTQ in a convenience sample of 315 participants (81.4 % AA) who were recruited from 2008 to 2013, and who live in eleven different counties in South Carolina with high rates of racial disparities in cancer mortality rates.

Results

Slightly more than half of the 315 participants had at least a college education (77.9 %), 84.8 % were female, and 53.1 % had an annual income of $40,000 or more. In this study, PCA confirmed that the ARTQ is unidimensional. Cronbach’s alpha for the ARTQ was 0.86.

Conclusion

The ARTQ displayed strong evidence of high statistical reliability. This analysis has great implications for future research because it represents the first test of reliability of the ARTQ in a predominantly African American sample and lays the groundwork for use of the ARTQ in future studies in diverse populations.

Removing barriers to participation in clinical trials, a conceptual framework and retrospective chart review study

BACKGROUND

Enrollment in interventional therapeutic clinical trials is a small fraction of all patients who might participate given reasonable access.

METHODS

A hierarchical approach is utilized in measuring staged participation from trial availability to patient enrollment. Our framework suggests that concern for justice comes in the design and eligibility criteria for clinical trials; attention to beneficence is given in the eligibility and physician triage stages. The remaining four stages rely on respect for persons. An example is given where reasons for nonparticipation or barriers to participation in prostate cancer clinical trials are examined within the framework. In addition, medical oncology patients with an initial six month consultation are tracked from one stage to the next by race using the framework to assess participation comparability.

RESULTS

We illustrated seven transitions from being a patient to enrollment in a clinical trial in a small study of prostate cancer cases who consulted SKCCC Medical Oncology Department in early 2010. Pilot data suggest transition probabilities as follows: 65% availability, 84% eligibility, 92% patient triage, 89% trials discussed, 45% patient interested, 63% patient consented, and 92% patient enrolled. The average transition probability was 77.7%. The average transition probability, patient-trial-fit was 50%; opportunity was 51%, and acceptance was 66.7%. Trial availability, patient interest and patient consented were three transitions that were below the average; none were statistically significant.

CONCLUSIONS

The framework may serve to streamline comprehensive reporting of clinical trial participation to the benefit of patients and the ethical conduct of clinical trials.

Measuring cancer clinical trial understanding

Researchers, practitioners, and participants in cancer clinical trials must have a clear understanding of clinical trials if participation in them is to be solicited ethically and effectively. A valid and reliable measure of cancer clinical trial understanding did not exist prior to a 2005 study conducted for the Coalition of Cooperative Cancer Groups. This report outlines a measure derived from that study, discusses the rationale for its component items, examines its psychometric properties, and demonstrates the relationship of this measure to the enrollment decision. Data from national samples of cancer survivors and the general public demonstrate the measure's validity and reliability. Results are discussed as they relate to patient understanding of clinical trials, informed decision making, and health communication processes.

'It's going to shorten your life': framing of oncologist-patient communication about prognosis

In this qualitative study, we used grounded theory techniques to analyze transcripts of 29 first-time encounters between oncologists and patients referred to them with previously diagnosed, incurable cancer. We found that 23 (79%) of the transcripts included 166 examples of prognostic talk. The language used ranged from general to personal, with 25% of statements mentioning no patients (e.g., 'the tumor will usually come back'), 13% mentioning patients other than the current patient (e.g., 'some patients with tumor response will be around for 2-5 years'), 11% mentioning the current patient in the context of others (e.g., 'on average, people like you live a couple of years'), and 51% directly focusing on the patient (e.g., 'this thing's going to kill you eventually'). More statements pertained to treatment-related prognosis than to disease-related prognosis (67 versus 33%). While 31% of statements focused on negative outcomes (loss framing), the remainder either focused on positive outcomes (gain framing) or discussed a combination of positive and negative outcomes (mixed framing). When discussions focused on negative outcomes, general and indirect language was commonly used, perhaps to buffer the patient from news of the poor prognosis.

Audio-visual presentation of information for informed consent for participation in clinical trials

BACKGROUND

Informed consent is a critical component of clinical research. Different methods of presenting information to potential participants of clinical trials may improve the informed consent process. Audio-visual interventions (presented for example on the Internet, DVD, or video cassette) are one such method.

OBJECTIVES

To assess the effects of providing audio-visual information alone, or in conjunction with standard forms of information provision, to potential clinical trial participants in the informed consent process, in terms of their satisfaction, understanding and recall of information about the study, level of anxiety and their decision whether or not to participate.

SEARCH STRATEGY

We searched: the Cochrane Consumers and Communication Review Group Specialised Register (searched 20 June 2006); the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library, issue 2, 2006; MEDLINE (Ovid) (1966 to June week 1 2006); EMBASE (Ovid) (1988 to 2006 week 24); and other databases. We also searched reference lists of included studies and relevant review articles, and contacted study authors and experts. There were no language restrictions.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing audio-visual information alone, or in conjunction with standard forms of information provision (such as written or oral information as usually employed in the particular service setting), with standard forms of information provision alone, in the informed consent process for clinical trials. Trials involved individuals or their guardians asked to participate in a real (not hypothetical) clinical study.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion and extracted data. Due to heterogeneity no meta-analysis was possible; we present the findings in a narrative review.

MAIN RESULTS

We included 4 trials involving data from 511 people. Studies were set in the USA and Canada. Three were randomised controlled trials (RCTs) and the fourth a quasi-randomised trial. Their quality was mixed and results should be interpreted with caution. Considerable uncertainty remains about the effects of audio-visual interventions, compared with standard forms of information provision (such as written or oral information normally used in the particular setting), for use in the process of obtaining informed consent for clinical trials. Audio-visual interventions did not consistently increase participants' levels of knowledge/understanding (assessed in four studies), although one study showed better retention of knowledge amongst intervention recipients. An audio-visual intervention may transiently increase people's willingness to participate in trials (one study), but this was not sustained at two to four weeks post-intervention. Perceived worth of the trial did not appear to be influenced by an audio-visual intervention (one study), but another study suggested that the quality of information disclosed may be enhanced by an audio-visual intervention. Many relevant outcomes including harms were not measured. The heterogeneity in results may reflect the differences in intervention design, content and delivery, the populations studied and the diverse methods of outcome assessment in included studies.

AUTHORS' CONCLUSIONS

The value of audio-visual interventions for people considering participating in clinical trials remains unclear. Evidence is mixed as to whether audio-visual interventions enhance people's knowledge of the trial they are considering entering, and/or the health condition the trial is designed to address; one study showed improved retention of knowledge amongst intervention recipients. The intervention may also have small positive effects on the quality of information disclosed, and may increase willingness to participate in the short-term; however the evidence is weak. There were no data for several primary outcomes, including harms. In the absence of clear results, triallists should continue to explore innovative methods of providing information to potential trial participants. Further research should take the form of high-quality randomised controlled trials, with clear reporting of methods. Studies should conduct content assessment of audio-visual and other innovative interventions for people of differing levels of understanding and education; also for different age and cultural groups. Researchers should assess systematically the effects of different intervention components and delivery characteristics, and should involve consumers in intervention development. Studies should assess additional outcomes relevant to individuals' decisional capacity, using validated tools, including satisfaction; anxiety; and adherence to the subsequent trial protocol.

The Influence of Race on the Attitudes of Radiation Oncology Patients Towards Clinical Trial Enrollment

OBJECTIVES

Enrollment of adult cancer patients in clinical trials remains low, particularly in the minority population. Understanding patient attitudes towards clinical trials during the recruitment process may enhance accrual. Unfortunately, data describing patient attitudes towards clinical trials are limited, particularly in the radiation oncology clinic setting.

METHODS

A piloted questionnaire assessing basic demographics and attitudes toward clinical trials was offered in 2 radiation oncology clinics between April 2003 and October 2003. The questionnaire was completed by 166 patients. The mean age of the patients completing the questionnaire was 56 years (range, 15-84 years). Of the 166 patients included in the analysis, 108 (65%) were White. The most common cancer diagnoses included prostate (19%), head and neck (16%), and breast (14%).

RESULTS

There was no statistical difference between Whites and non-Whites regarding their interest in learning about clinical trials (84.3% versus 84.9%, P = 0.92); nor was there a significant difference in the rate of previous or current trial enrollment (21.3% versus 34.0%, P = 0.08). White patients were more likely to gather information about clinical trials from the Internet (30.6% versus 11.3%, P = 0.007), and they were more likely to use physicians as a source of this information (50.0% versus 34.0%, P = 0.05). Non-White patients were more likely to obtain information about clinical trials from other patients (24.5% versus 12.0%, P = 0.04). In addition, more non-White patients believed they had been treated on clinical trials without their knowledge (21.6% versus 9.3%, P = 0.032). Patients differed somewhat in their expectations of clinical trials. More non-Whites indicated that they would need a >50% chance of benefiting from a trial (64.4% versus 45.0%, P = 0.03) to enroll on that trial, though there were no statistical differences in outlook towards potential toxicities associated with treatment on a clinical trial.

CONCLUSIONS

Minority patients historically enroll in clinical trials at a significantly lower rate. Our study of radiation oncology patients documents significant differences in attitudes towards clinical trials between Whites and non-Whites. Understanding the differences in attitudes may allow physicians to overcome barriers that would otherwise hinder the enrollment of non-White patients into clinical trials.

Why Cancer Patients Enter Randomized Clinical Trials: Exploring the Factors That Influence Their Decision

Purpose

Few interventions have been designed and tested to improve recruitment to clinical trials in oncology. The multiple factors influencing patients' decisions have made the prioritization of specific interventions challenging. The present study was undertaken to identify the independent predictors of a cancer patient's decision to enter a randomized clinical trial.

Methods

A list of factors from the medical literature was augmented with a series of focus groups involving cancer patients, physicians, and clinical research associates (CRAs). A series of questionnaires was developed with items based on these factors and were administered concurrently to 189 cancer patients, their physicians, and CRAs following the patient's decision regarding trial entry. Forward logistic regression modeling was performed using the items significantly correlated (by univariate analysis) with the decision to enter a clinical trial.

Results

A number of items were significantly correlated with the patient's decision. In the multivariate logistic regression model, the patient's perception of personal benefit was the most important, with an odds ratio (OR) of 3.08 (P < .05). CRA-related items involving supportive aspects of the decision-making process were also important. These included whether the CRA helped with the decision (OR = 1.71; P < .05), and whether the decision was hard for the patient to make (OR = 0.52; P < .05).

Conclusion

Strategies that better address the potential benefits of trial entry may result in improved accrual. Interventions or aids that focus on the supportive aspects of the decision-making process while respecting the need for information and patient autonomy may also lead to meaningful improvements in accrual.

The impact of describing clinical trial treatments as new or standard

Concern has been expressed over a possible widespread belief amongst patients in trials, that a new treatment is better than the standard, despite the lack of evidence of such superiority. A sample of the general public (N = 130) read a leaflet describing a hypothetical trial comparing two similar treatments for either arthritis or back-pain. Half read that both treatments were standard and generally available; half that one was new and available only within the trial. Participants rated any preference for one or the other treatment, gave written reasons, and indicated their willingness to enter the randomized trial. Fifteen participants subsequently talked through their answers. Most participants expressed no preference for either treatment when both were described as standard. When one was new more people with the arthritis (but not the back-pain) scenario expressed a preference (chi2 = 5.44, P = 0.031). Importantly, this was not more likely to be for the new treatment. Rationally, those who preferred a freely available treatment were less likely to participate in the trial (chi2 = 23.3, P < 0.001). The mere description of a trial treatment as new was insufficient to engender a preference for it over a standard treatment, although it may contribute to preference under certain additional circumstances.

Public attitudes toward participation in cancer clinical trials

PURPOSE

The objective of this study is to understand the attitudes of American adults toward participation in cancer clinical trials.

METHODS

A national probability sample of 1,000 adults aged 18 and older living in noninstitutional settings was interviewed by telephone by Harris Interactive during March and April 2000. One participant was selected from each household selected for the study. The resulting data were weighted to reflect the full adult population of the United States as reported in Current Population Reports. An Index of Participation in a Cancer Clinical Trial was computed, using a confirmatory factor analysis and converting the factor scores into a 0-to-100 scale.

RESULTS

Approximately 32% of American adults (64 million individuals) indicate that they would be very willing to participate in a cancer clinical trial if asked to do so. An additional 38% of adults (76 million individuals) scored in a range that indicates that they are inclined to participate in a cancer clinical trial if asked, but hold some questions or reservations about participation. Projected rates of diagnosis, eligibility, and recruitment indicate that substantially more patients are willing to participate than are actually accrued.

CONCLUSION

These results indicate that the primary problem with accrual is not the attitudes of patients, but rather that the loss of potential participants is the result of the unavailability of an appropriate clinical trial and the disqualification of large numbers of patients. The pool of willing patients is further reduced by the reluctance of some physicians to engage in accrual.

Factors that influence the recruitment of patients to Phase III studies in oncology: the perspective of the clinical research associate

BACKGROUND

The multiple determinants of a patient's decision to enter into a clinical trial have been explored largely from the perspectives of patients and their physicians. Little research has involved clinical research associates (CRAs) formally, despite their central role in the process of recruitment. The current study was initiated to explore the factors that influence the decision of patients with cancer regarding clinical trial entry, specifically from the perspective of the CRA.

METHODS

Two focus groups of CRAs from the Hamilton Regional Cancer Center were organized. A skilled facilitator guided both groups through exploratory and subsequent confirmatory phases of discussions, which were audiotaped for review and coding using a process of consensus employing intercoder triangulation.

RESULTS

The two groups identified a number of factors that they believed influenced the recruitment process. Numerous physician and patient factors were reaffirmed, such as the impression of the scientific merit of a study or the sense of personal benefit, respectively. More uniquely, CRAs identified information transfer within the informed consent process as a major aspect of their specialized role. It was believed that full disclosure of information, in terms of both the content and the techniques and styles of delivery, was an important predictor of recruitment success. The groups quickly reached consensus on which factors they believed were the most important overall with respect to influencing study recruitment.

CONCLUSIONS

CRAs appear to have a unique role in the process of recruiting patients to active clinical trials. They believe that they have an important influence on recruitment success. Further research to validate this impression is required, because, ultimately, a greater understanding of the relative roles of physician and patient factors and, potentially, CRA factors will be important in the development of ethical and supportive strategies to optimize the recruitment of patients with cancer into randomized clinical trials.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Understanding the utility of adjuvant systemic therapy for primary breast cancer

PURPOSE

Physicians and patients require quantitative information on the expected benefits of adjuvant therapy for primary breast cancer to make appropriate treatment decisions. To date, there has not been any widely available method for estimating the benefits from adjuvant systemic therapy, in terms of long-term disease-free survival probabilities, in patients with primary breast cancer.

METHODS

Baseline prognostic information for primary breast cancer patients was estimated by asking 11 breast cancer specialists to complete a questionnaire on baseline prognosis and then using mean values. Data on the relative benefits of adjuvant therapy were culled from systematic reviews and randomized controlled trials. A computer algorithm was developed to calculate 10-year absolute outcome data. Results from this evaluation were compared with a previously described actuarial algorithm.

RESULTS

Individual prognostic estimates varied within a group of breast cancer specialists, but mean values of their estimates closely followed published data. Translation of expected benefits of adjuvant therapy from relative to absolute terms was performed with a simple computer algorithm. The data were translated into tabular forms to facilitate user-friendly clinical use.

CONCLUSION

The provided data should facilitate a better understanding of the absolute magnitude of benefit for available systemic adjuvant therapies in individual women with primary breast cancer. This should allow patients to make more informed decisions about their options.

Reasons for accepting or declining to participate in randomized clinical trials for cancer therapy

This paper reports on the reasons why patients agreed to or declined entry into randomized trials of cancer following discussions conducted by clinicians in both District General and University Hospitals. Two hundred and four patients completed a 16-item questionnaire following the consultation, of these 112 (55%) were women with breast cancer. Overall results showed that 147 (72.1%) patients accepted entry to a randomized clinical trial (RCT). The main reasons nominated for participating in a trial were that 'others will benefit' (23.1%) and 'trust in the doctor' (21.1%). One of the main reasons for declining trial entry was that patients were 'worried about randomization' (19.6%). There was a significantly higher acceptance rate for trials providing active treatment in every arm 98 (80.6%) compared with those trials with a no treatment arm 46 (60.5%), chi2 test P= 0.003. The study outlines a number of factors that appear to influence a patient's decision to accept or decline entry into an RCT of cancer therapy. An important factor is whether or not the trial offers active treatment in all arms of the study. Communication that promotes trust and confidence in the doctor is also a powerful motivating influence.

Strategic physician communication and oncology clinical trials

PURPOSE

Clinical trials are the primary means for determining new, effective treatments for cancer patients, yet the number of patients that accrue is relatively limited. The purpose of this study was to explore the relationship between physician behavior and patient accrual to a clinical trial by videotaping the interaction.

PATIENTS AND METHODS

Forty-eight patient-physician interactions involving 12 different oncologists were videotaped in several clinics at the H. Lee Moffitt Cancer Center and Research Institute (Tampa, FL). The purpose of each interaction was to present the possibility of a clinical trial to the patient. A coding system, the Moffitt Accrual Analysis System, was developed by the authors to code behaviors that represented both the legal-informational and social influence models of communication behavior. Thirty-two patients agreed to participate in the clinical trial.

RESULTS

Videotaping was found to be a viable, valid, and reliable method for studying the interaction. Physicians who were observed to use both models of influence were found to enroll more patients. Thus, patients were more likely to accrue to the trial when their physician verbally presented items normally included in an informed consent document and when they behaved in a reflective, patient-centered, supportive, and responsive manner. Discussion of benefits, side effects, patient concerns and resources to manage the concerns were all associated with accrual.

CONCLUSION

This research has implications for modifying physician behavior and, thus, increasing the numbers of patients accruing to oncology clinical trials.

Nurses' unique roles in randomized clinical trials

Nurses are in an ideal position to promote patients' awareness of the role played by clinical trials in the advancement of health science and the subsequent improvement of patient care. The history of clinical trials and the four phases of clinical trials are described. Nurses' professional roles in clinical trial participation, such as helping the patient to identify open clinical trials and acting as clinical interpreter and patient advocate during the patient's participation in a trial, are detailed. Professional considerations that must be addressed by the nurse are reviewed and include ensuring that the trial has received approval from an Institutional Review Board for the participation of human subjects; that the responsibilities of participation are congruent with the nurse's personal values and workplace obligations; and that once engaged, the nurse can make the commitment to sustain participation in the trial. Most important, the nurse must keep the patient's needs and values uppermost in mind during the evaluation of potential clinical trials. Nurses have a critical role to play in the promotion of clinical trials, the recruitment of patients for clinical trial participation, the education of the patient and family, and the clinical care and support of patients throughout their participation in clinical trials.

Attitudes of patients to randomised clinical trials of cancer therapy

The aim of this study was to test an instrument which might be useful for doctors in explaining the randomisation procedure to an individual patient. The sample comprised 323 patients with cancer attending for out-patient appointments and/or chemotherapy treatment in two major cancer centres in the U.K. 315 patients completed a self-report questionnaire--The Attitudes to Randomised Trials Questionnaire (ARTQ). The results show that the majority of subjects 287 (91.1%) believe that patients should be asked to take part in medical research, but only 242 (76.8%) would be prepared to take part in a study comparing two treatments. If treatment was randomised, only 141 (44.8%) would agree to participate. When given further information about the randomisation procedure, 119 (68.4%) of the 174 (55.2%) who initially said 'no' to randomisation or who were unsure, would change their minds and take part in a trial. The ARTQ discriminated between three categories of patient with the following prevailing attitudes: (a) those who seem comfortable with the concept of randomisation; (b) those with some concerns, who with fuller explanation are prepared to consider randomisation; and (c) those firmly against randomisation and participation in trials whatever information is provided. Prior knowledge of patients' attitudes might assist communication about trials and encourage more doctors to approach eligible patients.

Clinicians' attitudes to clinical trials of cancer therapy

Progress in the assessment and introduction of new treatments is impeded by the failure to recruit eligible patients into clinical trials. Little is known about the attitudes of U.K. cancer specialists towards trial participation, therefore a postal survey was conducted of 553 British clinical, medical and surgical oncologists. A 45-item questionnaire was returned by 357 clinicians (65% response rate). Although 353 (99%) of respondents stated that they were participating in trials, median 3 (range 0-62), 269 (75%) of clinicians were entering fewer than 50% of eligible patients. Differences were seen between professional groups within oncology; medical oncologists placed more emphasis on research than on clinical activities, felt greater pressure to participate in trials and were more likely to value being known by national and international colleagues than did surgeons or clinical oncologists. Surgeons were more likely to rely on clinical experience rather than enter patients into a trial but were more likely to keep patients on study following relapse. The survey identified constraints imposed by the healthcare system which impede trial participation including lack of time, communication difficulties and conflicts between the role of clinician and scientist. Such factors need consideration when trials are designed. Comparison of British data with those from the U.S. clinicians were broadly similar. The few differences found suggest that the more protocol-driven culture of the U.S. might encourage recruitment and a greater commitment to keep patients on trials.

Behavioral aspects of clinical trials. An integrated framework from behavior theory

A less-than-optimal proportion of patients with cancer are entered into National Cancer Institute-sponsored clinical trials. This article reviews the literature on accrual in oncology clinical trials to characterize the extent of the problem, identify reasons for low accrual, and suggest ways to promote accrual. Four well known theories of health behavior (the Health Belief Model, Subjective Expected Utility Theory, Protection Motivation Theory, and the Theory of Reasoned Action) point to central concepts involved in understanding patient health-related behavior: (1) the probability that an unwelcomed health event will happen to a patient, (2) the severity of that event if it does occur, (3) the effectiveness of a particular behavior (such as taking part in a clinical trial) to modify the severity, and (4) the cost of adopting that behavior. These concepts form a framework for integrating the available information about accrual to clinical oncology trials. Patient and physician factors previously related to clinical trials suggest specific recommendations for increasing accrual to clinical oncology trials.