"Like not having an arm": a qualitative study of the impact of visitor restrictions on cancer care during the COVID-19 pandemic

PURPOSE

Visitor restriction policies to prevent the spread of COVID-19 among patients and clinicians were widespread during the pandemic, resulting in the exclusion of caregivers at key points of cancer care and treatment decision-making. The aim of this study was to explore how visitor restrictions impacted cancer treatment decision-making and care from patient and physician perspectives.

METHODS

Sixty-seven interviews, including 48 cancer patients and 19 cancer and palliative care physicians from four academic cancer centers in the USA between August 2020 and July 2021.

RESULTS

Visitor restrictions that prevented caregivers from participating in clinic appointments and perioperative hospital care created challenges in cancer care that spanned three domains: practical, social, and informational. We identified eight themes that characterized challenges within the three domains across all three groups, and that these challenges had negative emotional and psychological consequences for both groups. Physicians perceived that patients' negative experiences due to lack of support through the physical presence of caregivers may have worsened patient outcomes.

CONCLUSIONS

Our data demonstrate the tripartite structure of the therapeutic relationship in cancer care with caregivers providing critical support in the decision-making and care process to both patients and physicians. Caregiver absences led to practical, psychosocial, and informational burdens on both groups, and likely increased the risk of burnout among physicians. Our findings suggest that the quality of cancer care can be enhanced by engaging caregivers and promoting their physical presence during clinical encounters.

Race and Ethnicity Reporting and Representation in Pediatric Clinical Trials

BACKGROUND AND OBJECTIVES

Representative enrollment of racial and ethnic minoritized populations in biomedical research ensures the generalizability of results and equitable access to novel therapies. Previous studies on pediatric clinical trial diversity are limited to subsets of journals or disciplines. We aimed to evaluate race and ethnicity reporting and representation in all US pediatric clinical trials on ClinicalTrials.gov.

METHODS

We performed a cross-sectional study of US-based clinical trials registered on ClinicalTrials.gov that enrolled participants aged <18 years old between October 2007 and March 2020. We used descriptive statistics, compound annual growth rates, and multivariable logistic regression for data analysis. Estimates of US population statistics and disease burden were calculated with the US Census, Kids' Inpatient Database, and National Survey of Children's Health.

RESULTS

Among 1183 trials encompassing 405 376 participants, race and ethnicity reporting significantly increased from 27% in 2007 to 87% in 2018 (P < .001). The median proportional enrollment of Asian American children was 0.6% (interquartile range [IQR], 0%-3.7%); American Indian, 0% (IQR, 0%-0%); Black, 12% (IQR, 2.9%-28.4%); Hispanic, 7.1% (IQR, 0%-18.6%); and white 66.4% (IQR, 41.5%-81.6%). Asian American, Black, and Hispanic participants were underrepresented relative to US population demographics. Compared with expected proportions based on disease prevalence and hospitalizations, Asian American and Hispanic participants were most consistently underrepresented across diagnoses.

CONCLUSIONS

While race and ethnicity reporting in pediatric clinical trials has improved, the representative enrollment of minoritized participants remains an ongoing challenge. Evidence-based and policy solutions are needed to address these disparities to advance biomedical innovation for all children.

Misinterpretation of Surgeons' Statements on Cancer Removal-The Adverse Effects of "We Got It All"

This Viewpoint describes the miscommunication and potential adverse effects of the phrase “we got it all” after cancer surgery and advises using with caution.

Cruel Apprenticeship: National Imaginaries in China’s Operating Rooms

Doctors learn to be doctors through clinical or therapeutic apprenticeships. By following, observing, and being mentored by more experienced physicians, trainees at various stages acquire embodied knowledge, affects, and ethics via both taught and hidden curricula. Previous research has demonstrated how biomedical training reproduces the social authority of scientific knowledge. This research article examines how for Chinese surgeons, apprenticeship not only immerses individuals within the scientific logics and hierarchical norms of biomedicine, but also embeds trainees within scientific imaginaries on a national scale. Drawing on ethnographic fieldwork in a Chinese academic hospital and a surrounding network of community hospitals, I examine how apprenticeship for Chinese surgical trainees extends beyond medical school and residency programmes, both in terms of temporality and geography. I examine how ‘technonational’ narratives, which permeate medical practice in China, impact the affects and ethics embodied by Chinese surgical trainees, and argue that changes in training expectations and the scope of training generates entanglements, dreams, and attachments which are cruel in their optimism. Thus, the therapeutic apprenticeship of Chinese surgical training reveals a ‘cruel apprenticeship’, a framing which encourages further exploration of the political and ethical stakes which permeate medical training and practice.

Analysis of Registered Clinical Trials in Surgical Oncology, 2008-2020

This quality improvement study characterizes surgical oncology trials, analyzes growth, identifies associations with early discontinuation or results reporting, and evaluates proportions of trials involving each neoplasm site.

Recognizing the Role of Language in the Hidden Curriculum of Undergraduate Medical Education: Implications for Equity in Medical Training

Medical education involves a transition from "outsider" to "insider" status, which entails both rigorous formal training and an inculturation of values and norms via a hidden curriculum. Within this transition, the ability to "talk the talk" designates an individual as an insider, and learning to talk this talk is a key component of professional socialization. This Article uses the framework of "patterns of medical language" to explore the role of language in the hidden curriculum of medical education, exploring how students must learn to recognize and participate fluently within patterns of medical language to be acknowledged and evaluated as competent trainees. The authors illustrate this by reframing the Association of American Medical Colleges' Core Entrustable Professional Activities for Entering Residency as a series of overlapping patterns of medical language that students are expected to master before residency. The authors propose that many of these patterns of medical language are learned through trial and error, taught via a hidden curriculum rather than through explicit instruction. Medical students come from increasingly diverse backgrounds and therefore begin medical training further from or closer to insider status. Thus, evaluative practices based on patterns of medical language, which are not explicitly taught, may exacerbate and perpetuate existing inequities in medical education. This Article aims to bring awareness to the importance of medical language within the hidden curriculum of medical education, to the role of medical language as a marker of insider status, and to the centrality of medical language in evaluative practices. The authors conclude by offering possible approaches to ameliorate the inequities that may exist due to current evaluative practices.

Analysis of Female Enrollment and Participant Sex by Burden of Disease in US Clinical Trials Between 2000 and 2020

IMPORTANCE

Although female representation has increased in clinical trials, little is known about how clinical trial representation compares with burden of disease or is associated with clinical trial features, including disease category.

OBJECTIVE

To describe the rate of sex reporting (ie, the presence of clinical trial data according to sex), compare the female burden of disease with the female proportion of clinical trial enrollees, and investigate the associations of disease category and clinical trial features with the female proportion of clinical trial enrollees.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included descriptive analyses and logistic and generalized linear regression analyses with a logit link. Data were downloaded from the Aggregate Analysis of ClinicalTrials.gov database for all studies registered between March 1, 2000, and March 9, 2020. Enrollment was compared with data from the 2016 Global Burden of Disease database. Of 328 452 clinical trials, 70 095 were excluded because they had noninterventional designs, 167 936 because they had recruitment sites outside the US, 69 084 because they had no reported results, 1003 because they received primary funding from the US military, and 314 because they had unclear sex categories. A total of 20 020 interventional studies enrolling approximately 5.11 million participants met inclusion criteria and were divided into those with and without data on participant sex.

EXPOSURES

The primary exposure variable was clinical trial disease category. Secondary exposure variables included funding, study design, and study phase.

MAIN OUTCOMES AND MEASURES

Sex reporting and female proportion of participants in clinical trials.

RESULTS

Among 20 020 clinical trials from 2000 to 2020, 19 866 studies (99.2%) reported sex, and 154 studies (0.8%) did not. Clinical trials in the fields of oncology (46% of disability-adjusted life-years [DALYs]; 43% of participants), neurology (56% of DALYs; 53% of participants), immunology (49% of DALYs; 46% of participants), and nephrology (45% of DALYs; 42% of participants) had the lowest female representation relative to corresponding DALYs. Male participants were underrepresented in 8 disease categories, with the greatest disparity in clinical trials of musculoskeletal disease and trauma (11.3% difference between representation and proportion of DALYs). Clinical trials of preventive interventions were associated with greater female enrollment (adjusted relative difference, 8.48%; 95% CI, 3.77%-13.00%). Clinical trials in cardiology (adjusted relative difference, -18.68%; 95% CI, -22.87% to -14.47%) and pediatrics (adjusted relative difference, -20.47%; 95% CI, -25.77% to -15.16%) had the greatest negative association with female enrollment.

CONCLUSIONS AND RELEVANCE

In this study, sex differences in clinical trials varied by clinical trial disease category, with male and female participants underrepresented in different medical fields. Although sex equity has progressed, these findings suggest that sex bias in clinical trials persists within medical fields, with negative consequences for the health of all individuals.

Cancer Care during Covid-19: A multi-institutional qualitative study on physician and patient perspectives on telemedicine

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Background: The COVID19 pandemic has had significant effects on cancer care, including disruptions or delays to screening, diagnosis, treatment, and follow-up for cancer patients as well as shifts from in-person visits to telemedicine to allow for continued access to care. Methods: We conducted semi-structured in-depth interviews with fifty radiation oncologists, medical oncologists, surgical oncologists, and cancer patients or their caregivers. These physicians and patients were recruited from four different hospitals in varying geographic regions and of varying practice settings. Interviews were conducted between October 2020 and May 2021. Interviews were transcribed, then thematically coded to consensus by three researchers. Results: The COVID19 pandemic shifted cancer care from in-person visits towards telemedicine. Providers recognized the necessity and benefit of telemedicine in increasing access to care, but were generally dissatisfied with use of telemedicine. These reasons included: (1) difficulty conducting physical exam maneuvers and assessing patient status; (2) technological failures, exacerbating barriers to care; (3) absence of “connection” with patients; (4) decreased access to interdisciplinary care teams. Patient perspectives on telemedicine were similarly varied, but were overall positive. Patients appreciated the convenience of accessing telemedicine at home, particularly for those who travel long distances or have difficulty traveling. Patients cited challenges similar to their physicians: technological difficulties and the loss of human connection usually conveyed through touch and physical presence. Conclusions: Telemedicine has been a key tool to allow for continued access to care and may continue to be a visit modality after the pandemic subsides. However, telemedicine poses numerous challenges for both physicians and patients and creative solutions to allow for “human connection” via telemedicine should be sought. Further evaluation is needed to determine the effect of telemedicine on quality of care.

The surgical oncology clinical trial landscape: A cross-sectional analysis of ClinicalTrials.gov from 2008-2020

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Background: Surgical interventions are studied less often than medical or radiation interventions in oncology clinical trials. We characterized surgical oncology trials registered on ClinicalTrials.gov, analyzed funding sources and identified features associated with early discontinuation and results reporting. Methods: We employed a cross-sectional study design with descriptive, logistic regression, cox regression, time series and survival analyses. We downloaded all 270,172 studies registered on the Aggregate Analysis of the ClinicalTrials.gov database from October 1, 2008 to March 9, 2020. After excluding non-interventional trials, applying cancer/oncology specific Medical Subject Heading terms to the remaining trials and excluding phase 1 trials, 27,915 trials were identified for manual review. Primary exposure variables were trial focus: neoplasia site and treatment modality (surgical interventions included investigations of outcomes from surgical resection or intra-operative/peri-operative changes), and funding: industry, U.S. government, academic. Results: 26,815 trials were found to have true oncology content; 1,661 (6.2%) involved surgical oncology, representing 311,789 patients. Funding sources were: 82.7% by academic institutions, 10.9% by industry, and 6.2% by U.S. government. The most studied neoplasia sites were colorectal (17.4% of trials), breast (10.7%), gastric (10.5%), hepatic (8.6%), lung (7.5%), brain/CNS (6.7%) and cervical (6.6%). U.S. government funded surgical oncology trials had the lowest risk of early discontinuation (adjusted HR 0.50, 95% CI: 0.26-0.99, p<0.047) and the highest odds of results reporting (adjusted OR 1.08, 95% CI: 0.55-2.11, p=0.83) (Table 1). Conclusions: There is a paucity of surgical oncology clinical trials compared to other treatment modalities, especially in context of surgery’s role in overall cancer care. From 2008-2020 only 6.2% of trials focused on surgical oncology, and U.S. government funded trials displayed the lowest hazard of early discontinuation and highest odds of results reporting. Stakeholders should look to government funded trials as models of improvement, but must increase representation and results dissemination of surgical oncology trials to guide treatment recommendations. Surgical oncology trial features and associated early discontinuation/results reporting. [Table: see text]

Factors associated with willingness to enter care homes for the elderly and pre-elderly in west of China

The research describes willingness of urban and rural residents over age 40 to enter care homes and examines personal factors which impact their willingness. Trained investigators gathered survey responses on sociodemographic information, physical health status, lifestyle behaviors, willingness to enter care homes, and specific service needs. 34.8% of the 1186 survey participants expressed willingness to enter care homes, with lower percentage of rural residents (25.8%) expressing willingness compared to urban residents (41.6%). The decision to enter care homes is impacted by occupation for urban residents and education status for rural residents. Healthcare remains the top consideration when considering care homes.