Patient Preferences for Use of Archived Biospecimens from Oncology Trials When Adequacy of Informed Consent Is Unclear

BACKGROUND

Oncology research increasingly involves biospecimen collection and data sharing. Ethical challenges emerge when researchers seek to use archived biospecimens for purposes that were not well defined in the original informed consent document (ICD). We sought to inform ongoing policy debates by assessing patient views on these issues.

MATERIALS AND METHODS

We administered a cross-sectional self-administered survey to patients with cancer at an academic medical center. Survey questions addressed attitudes toward cancer research, willingness to donate biospecimens, expectations regarding use of biospecimens, and preferences regarding specific ethical dilemmas.

RESULTS

Among 240 participants (response rate 69%), virtually all (94%) indicated willingness to donate tissue for research. Most participants (86%) expected that donated tissue would be used for any research deemed scientifically important, and virtually all (94%) expected that the privacy of their health information would be protected. Broad use of stored biospecimens and data sharing with other researchers increased willingness to donate tissue. For three scenarios in which specific consent for proposed biobank research was unclear within the ICD, a majority of patient's favored allowing the research to proceed: 76% to study a different cancer, 88% to study both inherited (germline) and tumor specific (somatic) mutations, and 70% to permit data sharing. A substantial minority believed that research using stored biospecimens should only proceed with specific consent.

CONCLUSION

When debates arise over appropriate use of archived biospecimens, the interests of the research participants in seeing productive use of their blood or tissue should be considered, in addition to addressing concerns about potential risks and lack of specific consent.

IMPLICATIONS FOR PRACTICE

This survey evaluated views of patients with cancer regarding the permissible use of stored biospecimens from cancer trials when modern scientific methods are not well described in the original informed consent document. The vast majority of patients support translational research and expect that any biospecimens they donate will be used to advance knowledge. When researchers, policy makers, and those charged with research oversight debate use of stored biospecimens, it is important to recognize that research participants have an interest in productive use of their blood, tissue, or data, in addition to considerations of risks and the adequacy of documented consent.

Fear of Cancer Recurrence: A Model Examination of Physical Symptoms, Emotional Distress, and Health Behavior Change

PURPOSE

Fear of cancer recurrence is highly prevalent among adult survivors of cancer. The role of fear of recurrence in the emotional distress of survivors of cancer, as well as health behaviors that may directly affect their health, remains unclear. To advance oncology practice, this study sought to examine the extent to which fear of recurrence stemming from physical symptoms accounts for emotional distress in a large sample of adult survivors of cancer and to extend the model to explain postdiagnosis self-reported health behavior change.

METHODS

In 2016, 258 survivors of cancer at an academic hospital completed a survey of psychosocial needs. Items assessed physical symptoms (checklist), fear of cancer recurrence (Assessment of Survivor Concerns), emotional distress (anxiety and depressed mood), and health behaviors (current alcohol use, physical activity, diet, and sunscreen use, as well as changes after cancer diagnosis) informed by National Comprehensive Cancer Network survivorship guidelines. Indirect effects regression models accounting for relevant covariates (age and treatment history) used 5,000-iteration bootstrapping.

RESULTS

Higher fear of cancer recurrence was associated with greater number of physical symptoms (P < .001), greater emotional distress (P < .05), lower moderate or vigorous physical activity (P < .05), higher sunscreen use (P < .05), and postdiagnosis increases in alcohol use (P < .01) and reductions in physical activity (P < .01). Fear of cancer recurrence models accounted for almost half of the variance in distress of survivors of cancer (R² = 0.44, P < .001) and, to a lesser yet significant extent, changes in alcohol consumption (R² = 0.09, P < .001) and physical activity (R² = 0.06, P = .003).

CONCLUSION

Fear of cancer recurrence plays a central role in the emotional distress and key health behaviors of survivors of cancer. These findings support fear of cancer recurrence as a potential target for emotional health and health behavior change interventions.

Secondary Use of Patient Tissue in Cancer Biobanks

BACKGROUND

As scientific techniques evolve, historical informed consent forms may inadequately address modern research proposals, leading to ethical questions regarding research with archived biospecimens.

SUBJECTS, MATERIALS, AND METHODS

We conducted focus groups among patients with cancer recruited from Massachusetts General Hospital to explore views on medical research, biobanking, and scenarios based on real biospecimen research dilemmas. Our multidisciplinary team developed a structured focus group guide, and all groups were recorded and transcribed. Transcripts were coded for themes by two independent investigators using NVivo software.

RESULTS

Across five focus groups with 21 participants, we found that most participants were supportive of biobanks and use of their own tissue to advance scientific knowledge. Many favor allowing research beyond the scope of the original consent to proceed if recontact is impossible. However, participants were not comfortable speaking for other patients who may oppose research beyond the original consent. This was viewed as a potential violation of participants' rights or interests. Participants were also concerned with a "slippery slope" and potential scientific abuse if research were permitted without adherence to original consent. There was strong support for recontact and reconsent when possible and for the concept of broad consent at the time of tissue collection.

CONCLUSION

Our participants support use of their tissue to advance research and generally support any productive scientific approach. However, in the absence of broad initial consent, when recontact is impossible, a case-by-case decision must be made regarding a proposal's potential benefits and harms. Many participants support broad use of their tissue, but a substantial minority object to use beyond the original consent.

IMPLICATIONS FOR PRACTICE

For prospective studies collecting tissue for future research, investigators should consider seeking broad consent, to allow for evolution of research questions and methods. For studies using previously collected tissues, researchers should attempt recontact and reconsent for research aims or methods beyond the scope of the original consent. When reconsent is not possible, a case-by-case decision must be made, weighing the scientific value of the biobank, potential benefits of the proposed research, and the likelihood and nature of risks to participants and their welfare interests. This study's data suggest that many participants support broad use of their tissue and prefer science to move forward.

Abstract PD8-06: Attitudes towards use of archived biospecimens among patients with cancer

Background: Oncology research increasingly involves biospecimen collection and data-sharing. Ethical questions have emerged when researchers seek to use archived biospecimens for purposes that were not well defined in the original informed consent document (ICD). We sought to inform ongoing debates by assessing patient views on these issues.

Methods: We administered a cross-sectional self administered anonymous paper survey among patients at the Massachusetts General Hospital Cancer Center. Survey questions addressed attitudes towards cancer research and willingness to donate biospecimens, expectations regarding use of biospecimens and protections of research participants, and preferences regarding specific ethical dilemmas regarding use of archived biospecimens. Results are descriptive with comparisons among participants on the sociodemographic and clinical characteristics using chi-square and Fisher's exact tests.

Results: 187 patients offered participation agreed and returned the survey (Response rate 66%). Mean age was 59 (range 2 to 91), 81% were women, 86% were white, and 81% were college educated. Among all participants, 67% had breast cancer and 33% metastatic disease. 34% had participated in a clinical trial, 27% had donated tissue for research and 93% indicated willingness to donate tissue for research. The vast majority of participants (94%) expected both that donated tissue would be used to help as many patients as possible and (92%) that privacy of a donors health information would be carefully protected. 33% expected that donated tissue would only be used for research they specifically approved and 44% that data would not be shared with other researchers. We presented 3 hypothetical scenarios in which researchers sought to use stored biospecimens from a breast cancer clinical trial for future research that was not described in the original iICD. For scenario 1, in which the ICD stated tissue would only be used for breast cancer research, 75% supported use of tissue to study other cancers as well. For scenario 2, in which the ICD specified somatic genetic research only, 89% supported use of tissue for germline research if deemed important by investigators. For scenario 3, in which the ICD stated that data would not be shared beyond the investigators, 72% supported data sharing within a national data repository. Only 28% of participants endorsed concerns that a patient could be identified from their genetic information and 12% were concerned with potential harms from donation to biobanks. However, 38% felt that they owned their tissue and should control how it is used. We did not detect significant differences in responses on the basis of sociodemographic characteristics, cancer type, disease stage, or research experience.

Conclusion: Patients with cancer are highly supportive of tissue donation for research and expect that donated tissue will be used to to maximize scientific results. They also expect that interests of research participants will be protected. When there is uncertainly regarding the use of archived biospecimens based on historical ICD and inability to recontact research participants, the interest of participants in seeing productive use of their tissue for science should be considered.

Citation Format: Peppercorn J, Campbell E, Rabin J, Quain K, Hlubocky F, Colyar D, Sequist L, Bardia A, Horick N, Isakoff S, Mathews D. Attitudes towards use of archived biospecimens among patients with cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD8-06.

Patient-reported priorities for survivorship care and experience discussing available services

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Background: Despite the recognized need for high quality survivorship care, barriers to identifying and addressing patients’ needs still remain. We sought to evaluate cancer survivor care priorities, awareness of available services, and factors associated with care and informational needs. Methods: A needs assessment survey was distributed to patients presenting for routine follow-up care in adult oncology clinics at the MGH Cancer Center between February and August of 2016. The survey assessed sociodemographic characteristics, and preferences for care and communication. Care priorities were selected from a list of options including open ended response. Discussion of supportive care services was assessed by the item “have any of your providers informed you about the types of supportive care services that are available to cancer patients" with response options of “yes,” “no” or “don’t know.” Results: Among 637 total respondents, 339 patients with early stage cancer completed the survey. The majority of participants were between 50-69 years old (54%), white (89%), female (64%), and college educated (80%). Breast (32%) and hematological malignancies (21%) were the most prevalent diagnoses. Commonly endorsed priorities for care included: emotional concerns related to cancer (40%), strategies to increase self-care (33%), and management of physical cancer symptoms (30%). Demographic and clinical factors associated with endorsing emotional concerns as a care priority included female gender, and moderate or greater levels of fatigue, depression, or anxiety (all p< 0.01). Factors associated with endorsing management of physical cancer symptoms as a care priority included younger age, and moderate or greater levels of fatigue or depression (all p≤0.01). Despite these priorities for care, only 41% of patients reported receiving information from providers about available supportive care services. Conclusions: Cancer survivors’ preferences for emotional support and symptom management are strongly associated with self-reported depression and fatigue. Routine screening for these issues and improvement in communication regarding available services should be prioritized in survivorship care.

Prevalence and predicators of insomnia among cancer survivors

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Background: Insomnia is prevalent among cancer survivors. However, screening and treatment is inconsistent across U.S. cancer centers. We sought to identify factors associated with moderate to severe insomnia (MSI) to inform the development of a screening and treatment program for survivors. Methods: As part of a comprehensive supportive care needs assessment, we evaluated the prevalence and correlates of insomnia among patients receiving follow-up cancer care. Patients reported on a 5 point Likert scale (0 = never to 5 = always) how often they have “problems falling or staying asleep”. MSI was defined as those who endorsed “4 = very often” or “5 = always,” and remaining responses were characterized as “No Insomnia” (NI). Descriptive statistics summarized patterns of insomnia and sleep hygiene. Chi-square and Fisher’s exact tests compared differences in sleep hygiene, fatigue, anxiety, depression, and other clinical and demographic characteristics between patients with and without insomnia. Results: Among 312 respondents, 83 (27%) endorsed MSI. Women were more likely to endorse MSI compared to men (32% vs. 19%, p = 0.02). Age was not associated with MSI. MSI was most common among patients with hematologic malignancy (36%), breast cancer (32%), gynecologic cancer (31%), and melanoma (29%). Regarding sleep hygiene: Most reported frequent exposure to bright light before sleep (89% MSI vs. 85% NI). Patients with MSI, compared to NI, were more likely to report watching the clock (86% vs. 75%, p = 0.04) and an irregular sleep schedule (47% vs. 32%, p = 0.02). Patients with MSI were also less likely to meet exercise guidelines (31% vs. 45% NI, p = 0.03) and more likely to report fatigue (29% vs. 14%, p = 0.004). Further, those with MSI were more likely to report anxiety (40% vs. 8%), fear of recurrence (74% vs. 46%), and financial concerns (35% vs. 15%) (all p < 0.001). 67% of patients with MSI were interested in supportive care to address insomnia. Conclusions: A simple one-item screener identified survivors susceptible to moderate to severe insomnia. Interventions beyond attention to sleep hygiene are needed to improve insomnia and its impact on fatigue and emotional distress. The relationships between insomnia, fitness, anxiety and distress merit further evaluation.

Room to move: Physical activity and exercise barriers in the cancer clinic

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Background: Exercise can improve outcomes and quality of life following cancer diagnosis. The American College of Sports Medicine (ACSM) recommends 150 minutes of moderate aerobic activity for patients with cancer. We sought to evaluate exercise patterns and barriers to exercise among patients presenting for follow-up care. Methods: Patients were recruited from the outpatient cancer clinic and completed a self-administered survey focused on symptoms, lifestyle and needs. Participants reported height, weight, weekly time performing moderate-to-vigorous aerobic activity, time spent strength training and perceived barriers to exercise. Descriptive statistics characterized the sample and patterns of exercise. An independent-samples t-test examined differences in strength training between patients currently on and off treatment; Chi-square examined differences among those meeting or not meeting ACSM activity guidelines. Results: Of 637 patients surveyed, 590 (93%) completed exercise questions (55% female; median age 60-69). The most common cancer diagnoses were breast (26%), hematologic (18%) and gastrointestinal (12%). Over half (57%; n = 352) were overweight (BMI ≥ 25) and 26% (n = 161) were obese (BMI ≥ 30). Patients engaged in moderate-to-vigorous aerobic exercise an average of 110 min/week and in strength training for 30 min/week. 71% did not meet ACSM aerobic exercise guidelines; 62% reported no strength training and 29% reported no exercise. 76% of respondents reported at least one barrier to exercise. Common barriers included other illness (35%), lack of free time (21%), fatigue (8%) and boredom with exercise (8%). Most participants (60%; n = 351) decreased exercise after cancer diagnosis. Participants currently on therapy were significantly less likely to meet ACSM aerobic activity guidelines (p = 0.04) and reported doing less strength training (p < 0.001) than those not on therapy. Over half of participants (53%) expressed interest in receiving more information about exercise and physical activity services. Conclusions: There is potential to improve activity, fitness and cancer outcomes through increasing exercise among patients with cancer. Accessible, engaging exercise interventions are needed.

Fear of recurrence among cancer survivors

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Background: Fear of cancer recurrence (FoCR) following definitive cancer therapy is often reported by patients, but little is known about who is most likely to be impacted, how FoCR influences emotional distress, and what interventions may mitigate patients’ FoCR. We sought to determine the prevalence of FoCR among cancer survivors and to evaluate potential predictors of FoCR in this population. Methods: As part of a comprehensive supportive care needs assessment, we evaluated the prevalence of FoCR among patients receiving follow-up cancer care at our institution as well as factors associated with FoCR. Elevated FoCR was measured with a single item: “I worry about my cancer coming back” rated on a 4-point Likert scale (1 = “not at all” to 4 = ”very much”); responses of 3 or 4 were considered positive for FoCR. Descriptive statistics were used to characterize patterns of FoCR. Chi-square and Fisher’s exact tests compared differences in emotional, clinical, and demographic characteristics between participants with and without FoCR, as well as interest in and knowledge of survivorship services. Results: Of 636 patients who completed the survey, 318/636 (50.0%) patients had curable cancer and had either completed cancer therapy or were completing maintenance treatment. On inquiry, 167/318 (53%) reported FoCR. Those with FoCR were more likely to be female (p < 0.002) and under the age of 70 (p < 0.003). They were also more likely to be sad (25% vs. 14%, p < 0.015), anxious (40% vs. 21% p < 0.0005), feel uncertain about the future (30% vs. 14%, p < 0.0005), have problems managing stress (26% vs. 13%, p < 0.003), and were more likely to worry about dying (55% vs. 8%, p < 0.0001) and to fear another cancer (74% vs. 8% p < 0.0001). Education level, cancer type, knowledge of and interest in support services, and survivorship care plan receipt were not associated with FoCR. Conclusions: Patient FoCR is prevalent among more than half of survivors of cancer and is associated with emotional distress that is insufficiently addressed by survivor care planning and supportive services. Clinicians can and should screen for and address this issue. Future research is needed to develop and test interventions, beyond care plans, to address FoCR in both low risk and high risk patient populations.