Provider motivations and barriers to cancer clinical trial screening, referral, and operations: Findings from a survey

BACKGROUND

Provider and institutional practices have been shown to have a large impact on cancer clinical trial enrollment. Understanding provider perspectives on screening for trial eligibility is necessary to improve enrollment.

METHODS

A questionnaire about incentives, barriers, process tools, and infrastructure related to opening trials and referring patients to onsite and offsite trials was administered to diverse stakeholders, including professional societies, advocacy organizations, and industry networks. Descriptive statistics were used to summarize findings.

RESULTS

Overall, 693 responses were received, primarily from physicians (42.7%) and nurses (35.6%) employed at hospital health systems (43.7%) and academic centers (36.5%). Approximately half (49.2%) screened all patients for onsite clinical trials with screening typically done by manual chart review (81.9%). The greatest incentive reported for offering trials was providing the best treatment options for patients (67.7%). Contracting and paperwork (48.5%) were the greatest barriers to opening more onsite trials. Offsite referrals were rare.

CONCLUSIONS

Screening for trial eligibility is a largely manual and ad hoc process, with screening and referral to offsite trials occurring infrequently. Administrative and infrastructure barriers commonly prevent sites from opening more onsite trials. These findings suggest that automated trial screening tools built into workflows that screen in a site-agnostic manner could result in more frequent trial eligibility screening, especially for offsite trials. With recent momentum, in part in response to the COVID-19 pandemic, to improve clinical trial efficiencies and broaden access and participant diversity, implementing tools to improve screening and referral processes is timely and essential.

PLAIN LANGUAGE SUMMARY

There are many factors that contribute to low adult enrollment in cancer clinical trials, but previous research has indicated that provider and institutional barriers are the largest contributors to low cancer clinical trial enrollment. In this survey, we sought to gain insight into cancer clinical trial enrollment practices from the perspective of health care providers such as physicians and nurses. We found that only approximately half of respondents indicated their institution systematically screens their patients for clinical trials and this process is manual and time consuming. Furthermore, we found that providers infrequently search for and refer patients to clinical trials at other sites. Creating better screening methods could improve enrollment in clinical trials.

Consensus recommendations for improving the cancer clinical trial matching environment

Enrollment in cancer clinical trials cannot occur without first successfully identifying trials for which patients are a match based on their clinical characteristics. A lack of onsite matching trials has been identified as the single largest barrier preventing patients from participating in clinical trials. The site-agnostic cancer clinical trial matching environment is a mix of public and private tools and infrastructure that are not designed to work together to facilitate trial matching in an efficient manner. To identify policy and infrastructure solutions that could enable more effective and more frequent use of third-party site-agnostic matching, the American Cancer Society Cancer Action Network held a summit to examine challenges and propose consensus recommendations that could address those challenges. At this 2019 summit, stakeholders in this field examined these barriers and challenges and made a number of policy and infrastructure recommendations to improve the ability of this environment to work in a more coordinated and efficient manner.

Breastfeeding Among People With Human Immunodeficiency Virus in North America: A Multisite Study

BACKGROUND

In North American countries, national guidelines have strongly recommended formula over breastmilk for people with human immunodeficiency virus (HIV) because of concern for HIV transmission. However, data from resource-limited settings suggest the risk is <1% among virally suppressed people. Information regarding breastfeeding experience in high-resource settings is lacking.

METHODS

A retrospective multisite study was performed for individuals with HIV who breastfed during 2014-2022 in the United States (8 sites) and Canada (3 sites). Descriptive statistics were used for data analysis.

RESULTS

Among the 72 cases reported, most had been diagnosed with HIV and were on antiretroviral therapy prior to the index pregnancy and had undetectable viral loads at delivery. Most commonly reported reasons for choosing to breastfeed were health benefits, community expectations, and parent-child bonding. Median duration of breastfeeding was 24 weeks (range, 1 day to 72 weeks). Regimens for infant prophylaxis and protocols for testing of infants and birthing parents varied widely among institutions. No neonatal transmissions occurred among the 94% of infants for whom results were available ≥6 weeks after weaning.

CONCLUSIONS

This study describes the largest cohort to date of people with HIV who breastfed in North America. Findings demonstrate high variability among institutions in policies, infant prophylaxis, and infant and parental testing practices. The study describes challenges in weighing the potential risks of transmission with personal and community factors. Finally, this study highlights the relatively small numbers of patients with HIV who chose to breastfeed at any 1 location, and the need for further multisite studies to identify best care practices.

"The kids get haggled over": how institutional practices contribute to segregation in elementary schools

School segregation is a key topic in urban, educational and inequality research. While previous studies have mainly focused on the effects of both parental school choice and residential segregation patterns on the composition of schools, we draw attention to institutional players steering access to elementary schools as one important dimension of institutional discrimination. Combining expert interviews with school principals and the local schools department with a quantitative survey among parents, we scrutinize the interplay between institutional structures and practices and parental school choice strategies. We identify three dimensions of institutional discrimination as being particularly relevant for school access, and thus for school segregation and inequality: a school's guidelines and strategic objectives in dealing with segregation, the enrollment process, and a school's profiling and information policies. These factors prove to be rather subtle, yet crucial facets of institutional discrimination, co-producing and perpetuating spatial inequalities.

"No One Really Likes Crying in School": The Influences of Classroom and Institutional Dynamics Upon Student Absenteeism During COVID-19

The COVID-19 pandemic has worsened the already problematic issue of student absenteeism. This study uniquely employs an ecological agency approach to better understand student absenteeism during COVID-19. Using a case study methodology, the study captures the experiences of two absentee students within a United States suburban high school during the 2020-2021 school year to better understand the institutional structures motivating their daily decision to attend or miss school. In the remote learning environment, rigorous curricular expectations, minimal social interactions, teacher-led instruction as a response to student disengagement from student-led instruction, and lower teacher expectations contributed to the participants' daily decision to miss school. In the remote, hybrid, and full-time in-person learning spaces, staff apathy toward bullying, minimal space to escape feelings of anxiety, and fewer tutoring outlets motivated student absenteeism. Therefore, the school environment can better promote attendance during COVID-19 by establishing an in-school space to escape heightened anxiety, academic supports to reduce grade-induced anxiety, shifting from nonintervention to prosocial instructional interventions in all learning environments, teacher voices in policy design, reducing teacher-led instruction, and shifting teacher beliefs to an asset mindset. Recommendations for future research are included.

Bridges or Barriers? How Interactions between Individuals and Institutions Condition Community College Transfer

Institutional practices and conditions at community colleges can improve rates of transfer, as can access to transfer student capital. However, we know little about how institutions attempt to build students' transfer capital, or about students' experiences within community colleges as they accumulate transfer capital. In this paper, we examine how students' institutional experiences, particularly their engagement with student supports at community colleges and transfer destinations, influence their understanding of, and ability to navigate, the transfer process. We view the accumulation of transfer student capital as an interactionist model between the students and their institution, where students' transfer knowledge and success is conditioned by an interaction between their background and institutional conditions. We draw on longitudinal qualitative interview data with transfer-intending community college students over the course of 3 years to understand how students access, receive, and accumulate transfer capital as they work toward their educational goals. By leveraging student experiences, our study can inform community colleges and transfer destinations about practices and policies interpreted as most effective from the perspective of students. Our work also connects to broader conversations about how institutions reproduce, ameliorate, or exacerbate inequalities based on student background.

The Impact of Hospital Resources and Availability of Professional Lactation Support on Maternity Care: Results of Breastfeeding Surveys 2009-2014

BACKGROUND

Breastfeeding provides maternal and infant health benefits. Maternity care practices encompassed in the 10 Steps to Successful Breastfeeding are positively associated with improved breastfeeding outcomes. This study assessed changes in maternity care practices and lactation support.

MATERIALS AND METHODS

In 2009, 2011, and 2014, New York (NY) hospitals providing maternity care services were surveyed to assess the implementation of 9 of the 10 Steps to Successful Breastfeeding, professional lactation support, distribution of formula and discharge packs, and patient and hospital barriers to breastfeeding success. Generalized estimating equations were used to evaluate changes over time.

RESULTS

Surveys were completed by 138/138 (2009), 128/129 (2011), and 125/125 (2014) NY hospitals. During this time period, the percent of hospitals reporting implementation of Steps 2, 4, 6, or 9 increased, and the mean number of 9 steps implemented increased from 4.3 to 5.3. Hospitals distributing formula samples at discharge to breastfeeding mothers decreased significantly from 39 (32%) to 3 (2%). Professional lactation staffing ratios (N/1,000 births) of both International Board Certified Lactation Consultants and Certified Lactation Counselors increased between 2009 and 2011, but then decreased between 2011 and 2014. Reported barriers to breastfeeding support changed, with reductions in mixed messages from staff, but increases in lack of financial resources for breastfeeding support, inadequate prenatal education, mothers not being prepared, and family not being receptive to breastfeeding.

CONCLUSIONS

Between 2009 and 2014, NY hospitals reported increased barriers and a reduction in professional lactation support, which may have contributed to the limited improvements in breastfeeding support.

Social justice in education: how the function of selection in educational institutions predicts support for (non)egalitarian assessment practices

Educational institutions are considered a keystone for the establishment of a meritocratic society. They supposedly serve two functions: an educational function that promotes learning for all, and a selection function that sorts individuals into different programs, and ultimately social positions, based on individual merit. We study how the function of selection relates to support for assessment practices known to harm vs. benefit lower status students, through the perceived justice principles underlying these practices. We study two assessment practices: normative assessment-focused on ranking and social comparison, known to hinder the success of lower status students-and formative assessment-focused on learning and improvement, known to benefit lower status students. Normative assessment is usually perceived as relying on an equity principle, with rewards being allocated based on merit and should thus appear as positively associated with the function of selection. Formative assessment is usually perceived as relying on corrective justice that aims to ensure equality of outcomes by considering students' needs, which makes it less suitable for the function of selection. A questionnaire measuring these constructs was administered to university students. Results showed that believing that education is intended to select the best students positively predicts support for normative assessment, through increased perception of its reliance on equity, and negatively predicts support for formative assessment, through reduced perception of its ability to establish corrective justice. This study suggests that the belief in the function of selection as inherent to educational institutions can contribute to the reproduction of social inequalities by preventing change from assessment practices known to disadvantage lower-status student, namely normative assessment, to more favorable practices, namely formative assessment, and by promoting matching beliefs in justice principles.