Clinical trial accrual among new cancer patients at a community-based cancer center

What do people really know and think about clinical trials? A comparison of rural and urban communities in the South

Clinical trials (CTs) have the potential to provide the most advanced medical treatments and screening options and help medically underserved individuals, including those in rural communities, obtain the medical care they need. Despite the need for access to care, CT participation remains low in rural communities. This study examined what individuals in both rural and urban communities of a Southeastern state know and think about CTs. Nineteen focus groups and eight interviews were conducted statewide with a total of 212 men and women. Discussions assessed participants' beliefs, perceptions, and sources of information about CTs, and their willingness to participate in a CT. Focus group and interview transcripts were analyzed qualitatively for themes. Urban and rural participants expressed similar beliefs about CTs. Common misperceptions were that CTs were intended for people who could not afford care and that completing a survey or participating in a focus group constituted a CT. Rural residents believed that CTs involved deception more often than urban residents, and they were less willing than urban residents to participate in a CT in the future. Urban residents more frequently discussed their distrust of the medical system as a reason for not wanting to participate. Many individuals expressed that their participation would depend on whether their doctor recommended it or whether the trial would benefit a family member's health. Findings have important implications for health communication. Messages should be developed to address misperceptions of rural and urban communities and convey the importance of CT participation to promote and protect the health of their communities.

Evaluation of eligibility and recruitment in breast cancer clinical trials

Objectives of the study were to measure recruitment rates in clinical trials and to identify patients, physicians or trials characteristics associated with higher recruitment rates. Among patients who had a clinical trial available for their cancer, 83.5% (345/413) met the eligibility criteria to at least one clinical trial. At least one trial was proposed to 33.1% (113/341) of the eligible patients and 19.7% (68/345) were recruited. Overall recruitment was 16.5% (68/413). In multivariate analyses, trial proposal and enrollment were lower for elderly patients and higher in high cancer stages. Trials from pharmaceutical industry had higher recruitment rates and trials testing hormonal therapy enrolled more patients. Breast cancer patients' accrual to a clinical trial could be improved by trying to systematically identify all eligible patients and propose a trial to those eligible and to whom the treatment is planned to be equivalent to the standard arm of the trial.

Use of the National Cancer Institute Community Cancer Centers Program screening and accrual log to address cancer clinical trial accrual

PURPOSE

Screening logs have the potential to help oncology clinical trial programs at the site level, as well as trial leaders, address enrollment in real time. Such an approach could be especially helpful in improving representation of racial/ethnic minority and other underrepresented populations in clinical trials.

METHODS

The National Cancer Institute Community Cancer Centers Program (NCCCP) developed a screening log. Log data collected from March 2009 through May 2012 were analyzed for number of patients screened versus enrolled, including for demographic subgroups; screening methods; and enrollment barriers, including reasons for ineligibility and provider and patient reasons for declining to offer or participate in a trial. User feedback was obtained to better understand perceptions of log utility.

RESULTS

Of 4,483 patients screened, 18.4% enrolled onto NCCCP log trials. Reasons for nonenrollment were ineligibility (51.6%), patient declined (25.8%), physician declined (15.6%), urgent need for treatment (6.6%), and trial suspension (0.4%). Major reasons for patients declining were no desire to participate in trials (43.2%) and preference for standard of care (39%). Major reasons for physicians declining to offer trials were preference for standard of care (53%) and concerns about tolerability (29.3%). Enrollment rates onto log trials did not differ between white and black (P = .15) or between Hispanic and non-Hispanic patients (P = .73). Other races had lower enrollment rates than whites and blacks. Sites valued the ready access to log data on enrollment barriers, with some sites changing practices to address those barriers.

CONCLUSION

Use of screening logs to document enrollment barriers at the local level can facilitate development of strategies to enhance clinical trial accrual.

The National Cancer Institute-American Society of Clinical Oncology Cancer Trial Accrual Symposium: summary and recommendations

INTRODUCTION

Many challenges to clinical trial accrual exist, resulting in studies with inadequate enrollment and potentially delaying answers to important scientific and clinical questions.

METHODS

The National Cancer Institute (NCI) and the American Society of Clinical Oncology (ASCO) cosponsored the Cancer Trial Accrual Symposium: Science and Solutions on April 29-30, 2010 to examine the state of accrual science related to patient/community, physician/provider, and site/organizational influences, and identify new interventions to facilitate clinical trial enrollment. The symposium featured breakout sessions, plenary sessions, and a poster session including 100 abstracts. Among the 358 attendees were clinical investigators, researchers of accrual strategies, research administrators, nurses, research coordinators, patient advocates, and educators. A bibliography of the accrual literature in these three major areas was provided to participants in advance of the meeting. After the symposium, the literature in these areas was revisited to determine if the symposium recommendations remained relevant within the context of the current literature.

RESULTS

Few rigorously conducted studies have tested interventions to address challenges to clinical trials accrual. Attendees developed recommendations for improving accrual and identified priority areas for future accrual research at the patient/community, physician/provider, and site/organizational levels. Current literature continues to support the symposium recommendations.

CONCLUSIONS

A combination of approaches addressing both the multifactorial nature of accrual challenges and the characteristics of the target population may be needed to improve accrual to cancer clinical trials. Recommendations for best practices and for future research developed from the symposium are provided.

Perceptions of participation in a phase I, II, or III clinical trial among African American patients with cancer: what do refusers say?

BACKGROUND

Less than 5% of all adult patients with cancer enter clinical trials. These rates are lower in racial/ethnic minority populations, negatively affecting the generalizability and validity of trial results. Many studies have identified barriers to minority enrolment, yet few have gathered in-depth insights into minority patients' reasons for trial refusal. We aimed to (1) explore trial refusal reasons in a sample of African American (AA) patients with cancer who declined trial participation and (2) gather patients' perceptions of the potential benefit of an array of decision support tools.

METHODS

Participants were 22 consecutively recruited AA patients with cancer who had declined participation in a therapeutic clinical trial. Within 3 months of the trial refusal decision, participants completed an audio-recorded semistructured interview that asked about demographic and disease information, psychosocial factors, and patients' experience with clinical trials. Two months later, participants completed a questionnaire that asked about their trial decision.

RESULTS

Few patients received positive recommendations about joining a trial. Patients gave multiple refusal reasons. Only two participants refused to join a clinical trial as a result of issues of mistrust. Most participants refused as a result of fears of additional burdens and adverse effects. Many patients and family members misunderstood trial information. Family members mostly recommended against trial participation. Most patients felt that question prompt lists or decision aids would assist information seeking and decision making.

CONCLUSION

Low rates of physician recommendations for clinical trial participation of AA patients with cancer warrant further investigation. Interventions to reduce misunderstandings and aid decision making, both within and external to the clinical interaction, need to target both patients and family members.

Enrollment of patients with lung and colorectal cancers onto clinical trials

PURPOSE

Only 2% to 5% of adult patients with cancer enroll onto clinical trials. We assessed simultaneously characteristics of patients and their physicians that may be independently associated with participation.

METHODS

CanCORS, a National Cancer Institute (NCI) -funded population-based observational cohort study of newly diagnosed patients with lung and colorectal cancers, sampled patients across five geographic areas, five health care delivery systems, and 15 Veterans Administration hospitals. We linked patient survey and medical record data with physician survey data to examine correlates of trial enrollment.

RESULTS

Among 9,901 patients, 5.3% enrolled onto trials. Of the 9,901 patients, we linked 6,506 patients to one medical oncologist, surgeon, or radiation oncologist (physicians, N = 1,325) who responded to the physician survey and was considered their primary cancer clinician decision maker. Patient age, race, disease stage, geographic region, and health insurance were independently associated with trial enrollment. Physician factors independently associated with patient trial enrollment were being a medical oncologist, practicing at an NCI-designated cancer center, taking the lead in discussing trials with patients, and receiving increased income from trial enrollment. After simultaneously adjusting for patient and physician characteristics, only being a physician practicing at an NCI-designated cancer center (odds ratio [OR], 1.65; 95% CI, 1.19 to 2.27) and patient female sex (OR, 1.36; 95% CI, 1.10 to 1.68), age > 70 versus < 50 years (OR, 0.28; 95% CI, 0.16 to 0.48), and advanced disease (OR, 1.85; 95% CI, 1.45 to 2.37) remained independently associated with trial enrollment.

CONCLUSION

Both practice environment and patient clinical and demographic characteristics are associated with cancer clinical trial enrollment; simultaneous intervention may be required when trying to increase enrollment rates.

Participation in cancer clinical trials: why are patients not participating?

BACKGROUND

Participation in cancer clinical trials is low, particularly in racial and ethnic minorities in some cases, which has negative consequences for the generalizability for study findings. The objective of this study was to determine what factors are associated with patients' participation or willingness to participate and whether these factors vary by race/ethnicity.

DESIGN

or

METHODS

. White, Hispanic, and black participants were obtained through the Florida cancer registry and who were diagnosed with breast, lung, colorectal, or prostate cancer (N = 1100). Participants were surveyed via telephone to obtain demographic information, past participation, and willingness to participate in clinical trials, as well as barriers and facilitators to participation. Logistic and Poisson regressions were performed.

RESULTS

. Respondents were on average 67.4 years old, 42.7% were male, and 50.1% were married. In this population, 7.7% of respondents had participated in a clinical trial, and 36.5% stated that they would be willing to participate. In multivariate models, blacks and Hispanics were equally likely as whites to be willing to participate in cancer trials, but Hispanics were less likely to have participated, and this was especially more likely in non-English-speaking Hispanics compared with English-speaking Hispanics. Notable barriers across race/ethnicity were mistrust and lack of knowledge of clinical trials. Limitations. Cross-sectional design limits cause-and-effect conclusions.

CONCLUSIONS

. There are racial differences in participation rates but not in willingness to participate. We hypothesize that willingness to participate is not very high because people are uninformed about participating, particularly in non-English-speaking Hispanics. Barriers and facilitators to participation vary by race. Improved understanding of cultural differences that can be addressed by physicians may restore faith, comprehension, and acceptability of clinical trials by all patients.

Barriers to recruitment of rural patients in cancer clinical trials

PURPOSE

The National Cancer Institute estimates that less than 5% of adult patients with cancer participate in clinical trials. This statistic has to improve in order for clinical trials to be more accurate and generalizable. Several studies have looked into the barriers to accrual among various patient subgroups. However, there are scant data regarding factors that act as barriers to accrual of rural patients. Our study aims to identify these barriers.

PATIENTS AND METHODS

Among patients seen at the Mary Babb Randolph Cancer Center at West Virginia University, 1,000 were randomly selected to receive a questionnaire by mail. Data obtained consisted of demographic and clinical information, as well as awareness about clinical trials, willingness to participate, and factors influencing participation. Patients had 6 weeks to respond.

RESULTS

Two hundred forty-one (24.1%) patients responded to the survey. Of these, 66.9% had heard about clinical trials, 19.6% reported that their health care team had discussed clinical trials, and 9.1% had participated in clinical trials. Respondents were more likely to be willing to participate in cancer prevention/screening trials than therapeutic trials. Regarding the decision not to participate in a clinical trial, patients cited discouragement from their oncologist, monetary burden, discouragement from family physician, commute, and lack of information as strongly or extremely influential factors.

CONCLUSION

Our findings specify the need for patient and physician education through community outreach programs. Oncologists should be trained to discuss clinical trials and to address concerns regarding their availability, utility, and accessibility. Financial counseling may play an important role in improving accrual rates as well.

Assessment of perceived cost to the patient and other barriers to clinical trial participation

PURPOSE

Less than 5% of patients with cancer participate in trials. Few studies have specifically addressed the role of cost to the patient as an influence on trial participation. Our main purpose was to determine the importance of added cost as a barrier to clinical trial participation in the community setting. Our secondary goal was to determine the most prevalent barriers to trial participation for patients.

PATIENTS AND METHODS

Four community practices in New England issued surveys to consecutive cohorts of patients with cancer. Patients were assessed for eligibility for clinical trials at their practice site. Trial-eligible patients who declined participation were asked to select reasons that contributed to their decision.

RESULTS

Surveys were issued to 1,755 patients. Seventy-one percent of all trial-eligible patients returned surveys. Forty-four percent of nonparticipating trial-eligible patients did not recall hearing about clinical trials from their provider. The most common reasons cited by trial-eligible patients for declining trial participation were fear of adverse effects (50%) and discomfort with random assignment (44%). Twenty-eight percent cited concerns about added cost, and 12% noted cost as the most important factor in their decision.

CONCLUSION

Concerns about adverse effects and random assignment were the most common reasons cited by patients declining trial participation in four community oncology practices in New England. Cost considerations were important for a significant proportion of these patients. Many patients eligible for trial participation were not informed by their provider about the availability of research trials.

Characteristics and outcomes of patients with advanced gastric cancer who declined to participate in a randomized clinical chemotherapy trial

PURPOSE

There is insufficient data to verify whether participation in clinical trials in itself can lead to better clinical outcomes. We have analyzed the characteristics and outcomes of patients who declined to participate in a randomized trial in comparison with those who participated in the trial.

PATIENTS AND METHODS

A randomized trial for naive advanced gastric cancer was offered to 286 patients. The trial investigated the superiority of irinotecan plus cisplatin and the noninferiority of S-1 compared with continuous fluorouracil infusion. We retrospectively reviewed the characteristics and outcomes for both participants and nonparticipants in this trial.

RESULTS

Of the 286 patients, 98 (34%) declined to participate in the trial. The rate of declining was significantly higher among younger patients (P = .003), and it varied significantly between attending physicians (range, 23% to 58%; P = .004). There were no other significant correlations between rate of declining and patient characteristics. No significant differences were observed in the clinical outcomes between the participants and nonparticipants, for whom the median survival times were 367 versus 347 days, respectively. The hazard ratio for overall survival, adjusted for other confounding variables, was 1.21 (95% CI, 0.91 to 1.60). No interaction was observed between participation and the various regimens.

CONCLUSION

There was no difference in clinical outcomes between participants and nonparticipants. However, the patient's age and the doctor-patient relationship may have an effect on patient accrual to randomized trials.

Eligibility criteria in randomized phase II and III adjuvant and neoadjuvant breast cancer trials: not a significant barrier to enrollment

BACKGROUND

Clinical trial recruitment can be impeded by eligibility criteria being too numerous or too restrictive.

PURPOSE

This study's principal objective was to determine whether a specific category of eligibility criteria could be identified as a major barrier to patient enrollment.

METHODS

Nine phase II or III clinical trials, opened between June 2004 and July 2008, were selected. A retrospective cohort of women diagnosed with invasive, nonmetastatic breast cancer and potentially eligible for these clinical trials was used. All eligibility criteria were sorted into the following categories: definition of disease, precision, safety, ethical and legal, or administrative. A total of 985 patient-trials were evaluated, defined as the experimental unit since one patient could be eligible to more than one trial. Proportions of cases with 'not met' eligibility criteria were assessed for each category in each trial.

RESULTS

Two clinical trials had a 'not met' subcategory criterion of over 20%. 'Pathology' and 'consent' subcategory criteria were 'not met' in 24.2% and 92.7% of cases for the NEOCAN and NCIC CTG MA.27 trials, respectively. NCIC CTG MA.27 had the highest proportion of 'not met' subcategory due to an inclusion criterion requiring participation to two companion studies. National Surgical Adjuvant Breast and Bowel Project (NSABP) B-38 had a proportion of 18.8% of cases 'not meeting' the receptor status subcategory criterion. All other subcategories of eligibility criteria assessed were 'not met' by less than 15% of patients. Overall, few subcategories had over 10% of ineligible patients.

LIMITATIONS

Many eligibility criteria were considered 'nonevaluable' because the information evaluated would have required additional procedures not performed as part of the general practice.

CONCLUSION

The subjects from the study population are not precluded from entry in a trial because of stringent eligibility criteria. Eligibility criteria should reflect as much as possible the whole population to whom the treatment will be offered, with the exception of drugs targeting a specific receptor or pathway where only a subpopulation is hypothesized to benefit from the therapy. In the breast cancer clinical trials evaluated for the present study, no criterion precluding recruitment was shared by many or all trials and no specific eligibility criterion was consistently the reason for patients' ineligibility.

Screening intervention to identify eligible patients and improve accrual to phase II-IV oncology clinical trials

PURPOSE

Low enrolment rates in clinical trials present a barrier to the development of novel cancer therapies. Currently, only 3% of patients with cancer participate, and many studies fail to achieve necessary enrolment. The objective of this study was to evaluate whether a screening intervention to identify potentially eligible patients (PEPs) would increase accrual rates.

PATIENTS AND METHODS

Over a 4-month intervention period, PEPs for 21 phase II-IV breast, gastrointestinal, genitourinary, gynecology, and lung cancer trials were identified by a screening coordinator. This individual reviewed the electronic medical records of patients attending outpatient clinics and flagged PEPs for 10 medical oncologists at the BC Cancer Agency. Patients who were already documented to be trial eligible by physicians were not flagged. Oncologists were surveyed regarding the helpfulness and accuracy of the intervention.

RESULTS

During the intervention period, 73 patients were enrolled, compared with 61 patients enrolled in the 4 months prior and 51 patients in the 4 months after. A total of 2,098 charts were reviewed, and 120 PEPs were identified during the intervention period, resulting in 19 PEPs who enrolled and four PEPs who declined a clinical trial. Relative accrual rates adjusted for oncologist appointments were 0.85 (P = .15) before and 0.70 (P < .005) after, relative to the intervention period. Oncologist-returned surveys indicated that 67% of flags were helpful, and 70% were accurate.

CONCLUSIONS

In this study, manually screening patient records increased enrolment to specific clinical trials. A screening intervention process, involving a dedicated screening coordinator, should be considered to improve clinical trial accrual.

A Patient Focused Solution for Enrolling Clinical Trials in Rare and Selective Cancer Indications: A Landscape of Haystacks and Needles

Participation of adult cancer patients in US based clinical trials has remained near 3% for decades. Traditional research methodology reaches a small fraction of the target population with a fixed number of predetermined sites. Solutions are needed to ethically increase patient participation and accelerate cancer trial completion. We compared enrollment outcomes of traditional and patient focused research methodologies. A patient prioritized method (Just-In-Time, JIT) was implemented in parallel with traditionally managed sites in three cancer trials. JIT research sites were initiated after candidate patients presented, while traditional sites were initiated in advance. JIT sites enrolled with mean rates no less than, and up to 2.75 fold greater than, traditional sites. Mean patients enrolled per site was comparable (JIT-1.82, traditional-1.78). There were fewer non-enrolling JIT sites (2/28, 7%) compared to traditional sites 19/52, 37%). This retrospective analysis supports JIT as a prospective solution to increase cancer clinical trial enrollment and the efficiency of clinical trial administrative activities.

Unique perception of clinical trials by Korean cancer patients

BACKGROUND

In the past few years, the number of clinical trials has increased rapidly in East Asia, especially for gastric and hepatobiliary cancer that are prevalent in Asian populations. However, the actual degree of understanding or perceptions of clinical trials by cancer patients in East Asian countries have seldom been studied.

METHODS

Between July 1st and November 30th of 2011, we conducted a prospective study to survey cancer patients regarding their awareness of, and willingness to participate in, a clinical trial. Patients with gastrointestinal/hepatobiliary cancer who visited the Hematology-Oncology outpatient clinic at Samsung Medical Center (SMC) were enrolled. A total of 21 questions were asked including four questions which used the Visual analogue scale (VAS) score.

RESULTS

In this survey study, 1,000 patients were asked to participate and 675 patients consented to participate (67.5%). The awareness of clinical trials was substantially higher in patients who had a higher level of education (p<0.001), were married (p=0.004), and had a higher economic status (p=0.001). However, the willingness to participate in a clinical trial was not affected by the level of education or economic status of patients. The most influential factors for patient willingness to participate were a physician recommendation (n=181, 26.8%), limited treatment options (n=178, 26.4%), and expectations of effectiveness of new anti-cancer drugs (n=142, 21.0%). Patients with previous experience in clinical trials had a greater willingness to participate in clinical trials compared to patients without previous experience (p<0.001).

CONCLUSIONS

This large patient cohort survey study showed that Korean cancer patients are more aware of clinical trials, but awareness did not translate into willingness to participate.

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.

Barriers to therapeutic clinical trials enrollment: differences between African-American and white cancer patients identified at the time of eligibility assessment

BACKGROUND

Clinical trials (CTs) are the mechanism by which research is translated into standards of care. Low recruitment among underserved and minority populations may result in inequity in access to the latest technology and treatments, compromise the generalizability, and lead to failure in identification of important positive or negative treatment effects among under-represented populations.

METHODS

Data were collected over a 39-month period on patient eligibility for available therapeutic cancer CTs. Reasons for ineligibility and refusal were collected. The data were captured using an automated software tool for tracking eligibility pre-enrollment. We examined characteristics associated with being evaluated for a trial, and reasons for ineligibility and refusal, overall and by patient race.

RESULTS

African-Americans (AAs) were more likely than Whites to be ineligible (odds ratio, (OR) = 1.26, 95% confidence interval (CI) = 1.0-1.58) and if eligible, to refuse participation (OR = 1.79, 95% CI = 1.27-2.52), even after adjusting for insurance, age, gender, study phase, and cancer type. White patients were more likely to be ineligible due to study-specific or cancer characteristics. AAs were more likely to be ineligible due to mental status or perceived noncompliance. Whites were more likely to refuse due to extra burden, due to concerns with randomization and toxicity, or because they express a positive treatment preference. AAs were more likely to refuse because they were not interested in CTs, because of family pressures, or they felt overwhelmed (NS)).

DISCUSSION

This study is the first to directly compare ineligibility and refusal rates and reasons captured prospectively in AA and White cancer patients. The data are consistent with earlier studies that indicated that AA patients more often are deemed ineligible and, when eligible, more often refuse participation. However, differences in reasons for ineligibility and refusal by race have implications for a cancer center to participate in CTs appropriate for the population of patients served. On a broader scale, consideration should be given to modifying eligibility criteria and other design aspects to permit broader participation of minority and other underserved groups.

Obstacles to participation in randomised cancer clinical trials: a systematic review of the literature

Accrual to clinical trials continues to be a problem in many countries including Australia despite its fundamental importance to the progress of evidence-based medicine. This paper reviews the current literature addressing the obstacles to accrual excluding those related to protocol design. An electronic search of the literature identified publications in oncology specifically addressing the obstacles to participation in clinical trials. This search was supplemented by searches of key oncology journals. Obstacles fall into three main categories - clinician, patient and system; however, there are overlaps between categories. Clinician behaviour is the most important of these. Exclusion of patients for reasons other than defined eligibility criteria, concerns about increased time requirements, and suboptimal communication with patients all affect accrual. Risk management strategies for clinical trials need to be individualised to address the obstacles most likely to negatively impact on accrual. Communication between clinician and patient appears to be a greater issue than previously recognised. Time concerns need to be addressed as generational change affects the expectations of the medical workforce.

The effect of clinical trial participation versus non-participation on overall survival in men receiving first-line docetaxel-containing chemotherapy for metastatic castration-resistant prostate cancer

What's known on the subject? and What does the study add? Previous studies have reported better outcomes in cancer patients that enrolled in clinical trials, suggesting that trial participation in itself might be beneficial. We investigated the potential positive effect of clinical trial participation on survival outcomes of patients with metastatic castration-resistant prostate cancer who were treated with first-line docetaxel-containing chemotherapy. After accounting for potential baseline inequalities, participation in a clinical trial itself was associated with significantly longer overall survival in these patients.

OBJECTIVE

• To study differences in baseline characteristics and outcomes of patients with metastatic castration-resistant prostate cancer (mCRPC) receiving first-line docetaxel-containing chemotherapy on prospective clinical studies (trial participants) versus those receiving this therapy outside of a clinical study (non-participants).

PATIENTS AND METHODS

• Records from 247 consecutive chemotherapy-naive patients who were treated with docetaxel-containing chemotherapy for mCRPC at a single high-volume centre from 1998 to 2010 were reviewed. • All patients received docetaxel either as clinical trial participants (n= 142; 11 separate studies) or as non-participants (n= 105). • Univariable and multivariable Cox regression models predicted overall survival after chemotherapy initiation.

RESULTS

• There was no significant difference between trial participation and non-participation with respect to patient age, type of primary treatment, tumour grade or clinical stage. • Multivariable analyses showed a significantly lower risk of all-cause mortality (hazard ratio 0.567; P= 0.027) among trial participants vs non-participants.

CONCLUSIONS

• Patients that were treated with docetaxel for mCRPC showed a significantly longer overall survival when enrolled in a clinical trial. • Improved survival in trial participants may reflect the better medical oversight typically seen in patients enrolled in trials, more regimented follow-up schedules, or a positive effect on caregivers' attitudes because of greater contact with medical services. • With the retrospective nature of this analysis and the small study population, prospective studies are needed to validate the present findings and to further investigate the relationship between clinical trial participation and outcomes.

Identifying barriers associated with enrollment of patients with lung cancer into clinical trials

BACKGROUND

Enrollment of patients with lung cancer into clinical trials is required to accelerate the pace of new therapy development and contribute to a better understanding of the biological characteristics of cancer.

METHODS

We conducted a retrospective chart review of all patients seen by the thoracic medical oncology team at the Vanderbilt Ingram Cancer Center (VICC) from November 2005 to November 2008 to determine the barriers associated with patient enrollment in to clinical trials.

RESULTS

One thousand forty-three patient charts were audited: 32% of patients were eligible for enrollment, and 14% enrolled in a study. There were no significant differences in protocol availability or eligibility by sex, smoking status, or age. Patients living further from the cancer center were significantly less likely to have a study protocol available (P = .009), but if a protocol was available they were more likely to be eligible for enrollment (P < .001). Significantly more protocols were available for patients with non-small-cell lung cancer (NSCLC) compared with those who had small-cell lung cancer (SCLC) (63% vs. 48%; P < .001). Patients with advanced disease were more likely to have a protocol available (P < .001) and enter a study (P = .031). The most common reasons for patients not being eligible for enrollment were poor performance status (32%) and presence of comorbid disease (27%). The most common reasons for potentially eligible patients not enrolling in a study included preference for treatment closer to home (49%) and patient refusal (43%).

CONCLUSION

Additional strategies are required to increase accrual of patients into lung cancer trials, including development of protocols for early-stage disease and modifying eligibility and performance status criteria for this unique patient population.

The relationships among knowledge, self-efficacy, preparedness, decisional conflict, and decisions to participate in a cancer clinical trial

BACKGROUND

Cancer clinical trials (CCTs) are important tools in the development of improved cancer therapies; yet, participation is low. Key psychosocial barriers exist that appear to impact a patient's decision to participate. Little is known about the relationship among knowledge, self-efficacy, preparation, decisional conflict, and patient decisions to take part in CCTs.

OBJECTIVE

The purpose of this study was to determine if preparation for consideration of a CCT as a treatment option mediates the relationship between knowledge, self-efficacy, and decisional conflict. We also explored whether lower levels of decisional conflict are associated with greater likelihood of CCT enrollment.

METHOD

In a pre-post test intervention study, cancer patients (N = 105) were recruited before their initial consultation with a medical oncologist. A brief educational intervention was provided for all patients. Patient self-report survey responses assessed knowledge, self-efficacy, preparation for clinical trial participation, decisional conflict, and clinical trial participation.

RESULTS

Preparation was found to mediate the relationship between self-efficacy and decisional conflict (p = 0.003 for a test of the indirect mediational pathway for the decisional conflict total score). Preparation had a more limited role in mediating the effect of knowledge on decisional conflict. Further, preliminary evidence indicated that reduced decisional conflict was associated with increased clinical trial enrollment (p = 0.049).

CONCLUSIONS

When patients feel greater CCT self-efficacy and have more knowledge, they feel more prepared to make a CCT decision. Reduced decisional conflict, in turn, is associated with the decision to enroll in a clinical trial. Our results suggest that preparation for decision-making should be a target of future interventions to improve participation in CCTs.

Patterns of care for non-small-cell lung cancer at an academic institution affiliated with a national cancer institute-designated cancer center

PURPOSE

Evidence-based treatment guidelines for non-small-cell lung cancer (NSCLC) exist to improve the quality of care for patients with this disease. However, how often evidence-based decisions are used for care of NSCLC is poorly understood.

PATIENTS AND METHODS

We examined patterns of care and rate of adherence to evidence-based guidelines for 185 new NSCLC patients seen between 2007 and 2009. Evidence-based care status was determined for 150 patients.

RESULTS

Eighty-one percent of the patients were white, the mean age was 66 years, 49% were women, 11% were never smokers, 83% had Eastern Cooperative Oncology Group performance status 0 to 1, 49.7% of tumors were adenocarcinomas, 57.1% of never smokers had tumors genotyped (EGFR, ALK, KRAS), and 13.3% participated in clinical trials. The rate of evidence-based treatment adherence was 94.1% (16 of 17), 100% (21 of 21) and 100% (36 of 36) in patients with stages I, II, and III NSCLC, respectively. Stage IV disease, with adherence of 76.3% (58 of 76), was correlated with a higher rate of nonadherence when compared with stages I-III (odds ratio 16.33; 95% CI, 1.94 to 137.73). In patients with stage IV disease, the rate of evidence-based adherence was 95% (72 of 76) for first-line therapy, 95.2% (40 of 42) for second-line therapy, and only 33.3% (6 of 18) for third-line therapy (P < .001). There was no significant correlation between evidence-based adherence status and the patient's age, sex, performance status, smoking history, ethnicity, or the treating physician.

CONCLUSION

These data point toward the need for improved evidence-based use of resources in the third-line setting of stage IV NSCLC.

Statewide cancer clinical trial navigation service

PURPOSE

Realizing that education and awareness are paramount in making clinical trials available to improve overall accrual rates, we sought to create a clinical trial navigation service to improve the accessibility of cancer clinical trials in Florida for physicians and patients. This study was undertaken to evaluate this service. We hoped to identify characteristics of our service that were effective in promoting clinical trial enrollment and to better understand barriers that prevented enrollment.

METHODS

Qualitative and quantitative data were gathered to inform the evaluation. This information was drawn from semistructured interview and focus groups as well as data from 6,350 patient questionnaires capturing diagnosis, stage, and treatment history. Quantitative data were analyzed by computing indices of central tendency and dispersion as well as frequency distributions. Qualitative data were analyzed using open coding to identify major themes representing the information.

RESULTS

Our navigation system increased patient awareness of trials; however, this did not lead to an increase in trial enrollment. A key barrier to enrollment was the timing of the patient's awareness of a clinical trial opportunity. Often trial options were realized after a treatment course was initiated. This frequently disqualified the patient from trial consideration. We identified factors underlying the critical role of how physician attitudes toward trials affect enrollment. We also found that government databases were incomplete. Twenty-five percent of clinical trials open in Florida were not listed with Physician Data Query or clinicaltrials.gov, and 15% to 22% were erroneously listed as having sites in Florida. Media efforts to increase patient awareness and use of the navigation service were transient. One-time educational programs did not have a long-term impact on clinical trial inquiries. Patients who spoke with clinical trial navigators were four times more likely to contact a matched trial site. Sharing a common database platform with various organizations increased the likelihood of patients finding trials near home. More than 82% of patients seeking information started their search on other Web sites.

CONCLUSION

Although we were able to overcome the barriers most commonly cited by patients, we found that taking a strictly patient-focused approach was not enough. Our results underline the critical role of health professionals in guiding patients to clinical trials, by including these options at a time when patients are likely to be eligible.

Physician-related factors involved in patient decisions to enroll onto cancer clinical trials

The development of new cancer therapies requires additional, and more complex, clinical trials. But only approximately 3% to 5% of adult cancer patients participate in cancer clinical trials. This study seeks to identify and understand the attitudes of the public and cancer survivors toward health-related decisions and cancer clinical trials to identify the key factors that must be addressed to increase that percentage.

A screening tool to enhance clinical trial participation at a community center involved in a radiation oncology disparities program

PURPOSE

To investigate the effectiveness of a screening tool to enhance clinical trial participation at a community radiation oncology center involved in a National Cancer Institute-funded disparities program but lacking on-site clinical trials personnel.

PATIENTS AND METHODS

The screening form was pasted to the front of the charts and filled out for all new patients over the 9-month period of the study, during which time five external beam radiation therapy (EBRT) trials and a patient perception study were open for accrual. Patient consent was obtained by assorted personnel at several different sites. Patients potentially eligible for a trial were identified and approached by one of the clinic staff. Patients who were under- or uninsured, age > 80 years, members of an racial/ethnic minority, or recipients of medical assistance were identified as at risk for health care disparities and were offered patient navigator services.

RESULTS

Of 196 patients consulted during the study, 144 were treated with EBRT. Of the 24 patients eligible for EBRT trials, 23 were approached (one had an incomplete screening form), and 15 accepted. Of 77 patients eligible for a patient perception trial, 72 were approached (five had incomplete forms), and 45 accepted. The eligibility and acceptance rates for EBRT trials were similar for disparities and nondisparities patients. Screening was completed for 96 patients (67%).

CONCLUSION

When completed, the screening tool ensured clinical trial accrual. The major factor limiting overall accrual was a shortage of available trials.

Assessing the impact of user-centered research on a clinical trial eHealth tool via counterbalanced research design

OBJECTIVE

Informatics applications have the potential to improve participation in clinical trials, but their design must be based on user-centered research. This research used a fully counterbalanced experimental design to investigate the effect of changes made to the original version of a website, http://BreastCancerTrials.org/, and confirm that the revised version addressed and reinforced patients' needs and expectations.

DESIGN

Participants included women who had received a breast cancer diagnosis within the last 5 years (N=77). They were randomized into two groups: one group used and reviewed the original version first followed by the redesigned version, and the other group used and reviewed them in reverse order.

MEASUREMENTS

The study used both quantitative and qualitative measures. During use, participants' click paths and general reactions were observed. After use, participants were asked to answer survey items and open-ended questions to indicate their reactions and which version they preferred and met their needs and expectations better.

RESULTS

Overall, the revised version of the site was preferred and perceived to be clearer, easier to navigate, more trustworthy and credible, and more private and safe overall. However, users who viewed the original version last had similar attitudes toward both versions.

CONCLUSION

By applying research findings to the redesign of a website for clinical trial searching, it was possible to re-engineer the interface to better support patients' decisions to participate in clinical trials. The mechanisms of action in this case appeared to revolve around creating an environment that supported a sense of personal control and decisional autonomy.

Malignant hematologic diseases in adolescents and young adults

Adolescents and young adults (AYA) with cancer have been designated as a vulnerable population by the National Cancer Institute. This group, defined by the ages of 16-39 years, has not enjoyed the same survival improvements over the past several decades as older and younger cohorts. Several barriers prevent the optimal delivery of oncologic care in this subpopulation. This review will describe these challenges in the context of the major hematologic malignancies affecting this population (acute lymphoblastic leukemia [ALL], acute myeloid leukemia [AML], Hodgkin lymphoma [HL], and non-Hodgkin lymphoma [NHL]). For example, historical differences in care delivery between pediatric and adult health care systems have created confusion about optimal treatment planning for AYAs, a population that spans the pediatric-adult divide. In the case of ALL, retrospective studies have demonstrated significantly better outcomes when AYAs are treated according to pediatric and not adult protocols. Additional challenges more specific to AYAs include increased treatment-related toxicity relative to younger patients; less access to care and, specifically, access to clinical trials; lower adherence to medications and treatment plans; and psychosocial stressors relevant to individuals at this stage of life. Recognizing and responding to these challenges in AYAs may create opportunities to improve the cancer outcomes of this group.

A sense of urgency: Evaluating the link between clinical trial development time and the accrual performance of cancer therapy evaluation program (NCI-CTEP) sponsored studies

PURPOSE

Postactivation barriers to oncology clinical trial accruals are well documented; however, potential barriers prior to trial opening are not. We investigate one such barrier: trial development time.

EXPERIMENTAL DESIGN

National Cancer Institute Cancer Therapy Evaluation Program (CTEP)-sponsored trials for all therapeutic, nonpediatric phase I, I/II, II, and III studies activated between 2000 and 2004 were investigated for an 8-year period (n = 419). Successful trials were those achieving 100% of minimum accrual goal. Time to open a study was the calendar time from initial CTEP submission to trial activation. Multivariate logistic regression analysis was used to calculate unadjusted and adjusted odds ratios (OR), controlling for study phase and size of expected accruals.

RESULTS

Among the CTEP-approved oncology trials, 37.9% (n = 221) failed to attain the minimum accrual goals, with 70.8% (n = 14) of phase III trials resulting in poor accrual. A total of 16,474 patients (42.5% of accruals) accrued to those studies were unable to achieve the projected minimum accrual goal. Trials requiring less than 12 months of development were significantly more likely to achieve accrual goals (OR, 2.15; 95% confidence interval, 1.29-3.57, P = 0.003) than trials with the median development times of 12 to 18 months. Trials requiring a development time of greater than 24 months were significantly less likely to achieve accrual goals (OR, 0.40; 95% confidence interval, 0.20-0.78; P = 0.011) than trials with the median development time.

CONCLUSIONS

A large percentage of oncology clinical trials do not achieve minimum projected accruals. Trial development time appears to be one important predictor of the likelihood of successfully achieving the minimum accrual goals.

Barriers to participation in cancer prevention clinical trials

BACKGROUND

Cancer prevention clinical trials seek to enroll individuals at increased risk for cancer. Little is known about attitudes among physicians and at-risk individuals towards cancer prevention clinical trials. We sought to characterize barriers to prevention trial participation among medical oncologists and first-degree relatives of their patients.

METHODS

Physician participants were practicing oncologists in Pennsylvania. Eligible first-degree participants were adult relatives of a cancer patient being treated by one of the study physicians. The influence of perceived psychosocial and practical barriers on level of willingness to participate in cancer prevention clinical trials was investigated.

RESULTS

Response rate was low among physicians, 137/478 (29%), and modest among eligible first-degree relatives, 82/129 (64%). Lack of access to an eligible population for prevention clinical trials was the most commonly cited barrier to prevention clinical trials among oncologists. Nearly half (45%) of first-degree relatives had not heard of cancer prevention clinical trials, but 68% expressed interest in learning more, and 55% expressed willingness to participate. In the proportional odds model, greater information source seeking/responsiveness (i.e., interest in learning more about clinical prevention trials from more information sources) (p = 0.04), and having fewer psychosocial barriers (p = 0.02) were associated with a greater willingness to participate.

CONCLUSIONS

Many individuals who may be at greater risk for developing cancer because of having a first-degree relative with cancer are unaware of the availability of clinical cancer prevention trials. Nonetheless, many perceive low personal risk associated with these studies, and are interested in learning more.

Time to activate lung cancer clinical trials and patient enrollment: a representative comparison study between two academic centers across the atlantic

PURPOSE

Activation of clinical trials is a lengthy process. We studied the procedures and time required to activate lung cancer clinical trials in a US academic center compared with a European center.

METHODS

A retrospective review was performed of all thoracic oncology therapeutic trials submitted for regulatory review between 2001 and 2008 at Washington University School of Medicine (WUSM; St Louis, MO) and the University of Torino (UT; Torino, Italy). A process map was drafted by both institutions to establish the order of required events.

RESULTS

We reviewed 137 therapeutic thoracic oncology trials from WUSM (n = 83) and UT (n = 54). The median times from submission to opening a trial were 163 days for WUSM and 112.5 days for UT (P = .048). The median times for regulatory approval were 75 days for WUSM and 31 days for UT (P < .001). The difference is more pronounced in a homogeneous subset of phase II, industrial-sponsored trials for the median calendar time from submission to opening a trial (239.5 days for WUSM v 112.5 days for UT; P < .001) and time for regulatory approval (99 days for WUSM v 13.5 days for UT; P < .001). The median number of patients accrued at WUSM was 7.4 patients per study compared with an average of 37 patients per study at UT. The proportion of trials that enrolled 20 patients or more represented 22.2% of trials at UT but only 1.1% of trials at WUSM.

CONCLUSION

It takes additional steps and significantly longer time to activate a therapeutic thoracic clinical trial at a representative US site (WUSM) compared with a European site (UT).

Automated matching software for clinical trials eligibility: measuring efficiency and flexibility

BACKGROUND

Clinical trials (CT) serve as the media that translates clinical research into standards of care. Low or slow recruitment leads to delays in delivery of new therapies to the public. Determination of eligibility in all patients is one of the most important factors to assure unbiased results from the clinical trials process and represents the first step in addressing the issue of under representation and equal access to clinical trials.

METHODS

This is a pilot project evaluating the efficiency, flexibility, and generalizibility of an automated clinical trials eligibility screening tool across 5 different clinical trials and clinical trial scenarios.

RESULTS

There was a substantial total savings during the study period in research staff time spent in evaluating patients for eligibility ranging from 165h to 1329h. There was a marked enhancement in efficiency with the automated system for all but one study in the pilot. The ratio of mean staff time required per eligible patient identified ranged from 0.8 to 19.4 for the manual versus the automated process.

CONCLUSION

The results of this study demonstrate that automation offers an opportunity to reduce the burden of the manual processes required for CT eligibility screening and to assure that all patients have an opportunity to be evaluated for participation in clinical trials as appropriate. The automated process greatly reduces the time spent on eligibility screening compared with the traditional manual process by effectively transferring the load of the eligibility assessment process to the computer.

Recommendations for research priorities in breast cancer by the Coalition of Cancer Cooperative Groups Scientific Leadership Council: systemic therapy and therapeutic individualization

Over 9,000 women with breast cancer are enrolled annually on clinical trials sponsored by the National Cancer Institute (NCI), accounting for about one-third of all patients enrolled on NCI-sponsored trials. Thousands are also enrolled on pharmaceutical-sponsored studies. Although breast cancer mortality rates have recently declined for the first time in part due to systemic therapeutic advances, coordinated efforts will be necessary to maintain this trend. The Coalition of Cancer Cooperative Groups convened the Scientific Leadership Council in breast cancer (BC), an expert panel, to identify priorities for future research and current trials with greatest practice-changing potential. Panelists formed a consensus on research priorities for chemoprevention, development and application of molecular markers for predicting therapeutic benefit and toxicity, intermediate markers predictive of therapeutic effect, pathogenesis-based therapeutic approaches, utilization of adaptive designs requiring fewer patients to achieve objectives, special and minority populations, and effects of BC and treatment on patients and families. Panelists identified 13 ongoing studies as High Priority and identified gaps in the current trial portfolio. We propose priorities for current and future clinical breast cancer research evaluating systemic therapies that may serve to improve the efficiency of clinical trials, identify individuals most likely to derive therapeutic benefit, and prioritize therapeutic strategies.

Characteristics and outcomes of patients with advanced non-small-cell lung cancer who declined to participate in randomised clinical chemotherapy trials

There are inadequate data on the outcomes of patients who declined to participate in randomised clinical trials as compared with those of participants. We retrospectively reviewed the patient characteristics and treatment outcomes of both participants and non-participants in the two randomised trials for chemotherapy-naive advanced non-small-cell lung cancer. Trial 1 compared four platinum-based combination regimens. Trial 2 compared two sequences of carboplatin plus paclitaxel and gefitinib therapies. Nineteen of 119 (16%) and 153 (37%) patients declined to participate in Trials 1 and 2, respectively. Among the background patient characteristics, the only variable associated with trial participation or declining was the patients' attending physicians (P<0.001). Important differences were not observed in the clinical outcomes between participants and non-participants, for whom the response rates were 30.6 vs 34.2% and the median survival times were 489 vs 461 days, respectively. The hazard ratio for overall survival, adjusted for other confounding variables, was 0.965 (95% confidence interval: 0.73–1.28). In conclusion, there was no evidence to suggest any difference in the characteristics and clinical outcomes between participants and non-participants. Trial designs and the doctor–patient relationship may have an impact on the patient accrual to randomised trials.

Identification of cancer care and protocol characteristics associated with recruitment in breast cancer clinical trials

PURPOSE

It is estimated that only 5% of patients with cancer participate in a clinical trial. Barriers to participation may relate to available protocols, physicians, and patients, but few data exist on barriers related to cancer care environments and protocol characteristics.

METHODS

The primary objective was to identify characteristics of cancer care environments and clinical trial protocols associated with a low recruitment into breast cancer clinical trials. Secondary objectives were to determine yearly recruitment fraction onto clinical trials from 1997 to 2002 in Ontario, Canada, and to compare recruitment fraction among years. Questionnaires were sent to hospitals requesting characteristics of cancer care environments and to cooperative groups/pharmaceutical companies for information on protocols and the number of patients recruited per hospital/year. Poisson regression was used to estimate the recruitment fraction.

RESULTS

Questionnaire completion rate varied between 69% and 100%. Recruitment fraction varied between 5.4% and 8.5% according to year. More than 30% of patients were diagnosed in hospitals with no available trials. In multivariate analysis, the following characteristics were associated with recruitment: use of placebo versus not (relative risk [RR] = 0.80; P = .05), nonmetastatic versus metastatic trial (RR = 2.80; P < .01), and for nonmetastatic trials, protocol allowing an interval of 12 weeks or longer versus less than 12 weeks (from diagnosis, surgery, or end of therapy) before enrollment (RR = 1.36; P < .01).

CONCLUSION

Allowable interval of 12 weeks or longer to randomly assign patients in clinical trials could help recruitment. In our study, absence of an available clinical trial represented the largest barrier to recruitment.

American Society of Clinical Oncology Statement on minimum standards and exemplary attributes of clinical trial sites

PURPOSE

To describe both minimum requirements for a site conducting quality clinical trials and attributes of an exemplary site.

METHODS

Minimum requirements and exemplary attributes were selected based on literature review, prevailing regulatory requirements, and consensus among a group of community and academic clinical researchers.

RESULTS

To provide guidance to oncologists who wish to conduct patient-oriented research, recommendations are made to assist in the development and implementation of high-quality research programs with the priority of protecting the welfare and rights of trial participants. A quality research site complies with the International Conference on Harmonisation (ICH) Good Clinical Practice (GCP) guidelines, the accepted international ethical and scientific quality standards for designing, conducting, recording, and reporting trials involving human participants. Recognizing that many research sites conduct clinical trials in compliance with accepted GCP standards, supplemental attributes of an exemplary research site that exceed the GCP criteria are also described. These attributes include diversification of clinical trial mix, high accrual activity, participation in the trial development process, maintenance of high educational standards, quality assurance, multidisciplinary involvement in the clinical trial process, and promotion of clinical trial awareness programs.

CONCLUSION

Meeting the minimum criteria ensures conduct of quality clinical trials; however, some sites may wish to incorporate value-added attributes to exceed GCP compliance. These attributes are proposed as performance goals rather than requirements, recognizing that all sites conducting research will not necessarily meet each attribute but may still conduct high-quality clinical trials.

Different rates of clinical trial enrollment between adolescents and young adults aged 15 to 22 years old and children under 15 years old with cancer at a children's hospital

BACKGROUND

Over the last 30 years significant strides have been made in cure rates for children with cancer, but these improvements have not been seen in adolescents and young adults. The reasons for this lack of progress are multifactorial, but it is clear greater cure rates are correlated with controlled clinical trials. Our objective was to see if pediatric patients over the age of 15 had a lower rate of clinical trial enrollment, and if so, why.

METHODS

We retrospectively analyzed the clinical data on all patients with new oncology diagnoses at Children's Hospital of Pittsburgh (CHP) diagnosed over a 5-year period from July 2001 to June 2006.

RESULTS

Six hundred and forty new oncology patients were seen at CHP over this time, 501 under 15 years old and 139 patients aged 15 to 22. Thirty-six percent of all patients were treated on a clinical trial, including 38% of the younger patients and 27% of the older patients (P=0.03). Fifty-seven percent in the older group were not enrolled on a clinical trial because one was not available versus 41% in the younger group (P=0.04). There were no significant differences between the age groups when other reasons were analyzed.

CONCLUSIONS

A significantly lower proportion of adolescents and young adults patients (aged 15 to 22) were placed on a treatment trial than younger patients. The lack of an open clinical trial was the main reason for this deficit. Interventions to address this discrepancy need to be instituted on a national level.