The effect of physician recommendation on enrollment in the Breast Cancer Chemoprevention Trial

The role of physician characteristics in clinical trial acceptance: testing pathways of influence

Eight videotaped vignettes were developed that assessed the effects of three physician-related experimental variables (in a 2 x 2 x 2 factorial design) on clinical trial (CT) knowledge, video knowledge, information processing, CT beliefs, affective evaluations (attitudes), and CT acceptance. It was hypothesized that the physician variables (community versus academic-based affiliation, enthusiastic versus neutral presentation of the trial, and new versus previous relationship with the patient) would serve as communication cues that would interrupt message processing, leading to lower knowledge gain but more positive beliefs, attitudes, and CT acceptance. A total of 262 women (161 survivors and 101 controls) participated in the study. The manipulated variables primarily influenced the intermediary variables of post-test CT beliefs and satisfaction with information rather than knowledge or information processing. Multiple regression results indicated that CT acceptance was associated with positive post-CT beliefs, a lower level of information processing, satisfaction with information, and control status. Based on these results, CT acceptance does not appear to be based on a rational decision-making model; this has implications for both the ethics of informed consent and research conceptual models.

Participation of Asian-American women in cancer chemoprevention research: physician perspectives

To the authors' knowledge, little is known regarding the participation of Asian Americans in cancer prevention research. In 2002, the authors mailed surveys to primary care physicians in Northern California to assess their knowledge, attitudes, behaviors, and barriers concerning the participation of Asian-American women in breast cancer chemoprevention research. The response rate was 52.3% (n=306 physicians). For physician barriers, most respondents selected lack of study knowledge (73%) and effort required to establish eligibility (75%) and to explain risks and benefits (68%). For patient barriers, most physicians chose the following: physicians did not inform patients about trials (76%), limited English proficiency (78%), researcher-participant language discordance (74%), and complex protocols (69%). Significantly more Asian-American physicians than non-Asian-American physicians (but a majority of each) selected as patient barriers a lack of culturally relevant information on breast cancer, a lack of knowledge about research concepts, and fear of experimentation. A majority of Asian-American physicians also selected the following patient barriers: lack of knowledge of preventive care or breast cancer, work concern, misperception that experimental treatment is inferior, personal modesty, and lack of personal benefit. In multivariate analyses, physicians who were in practice longer, who spent more time with patients, or who knew of tools to estimate breast cancer risk were more likely to discuss such trials with Asian-American women; whereas male physicians and those who believed that Asian-American women's deference to physicians was a barrier were less likely to have discussed such trials with Asian-American women. Efforts to increase research participation among Asian Americans should include physician education and linguistically appropriate recruitment efforts.

Cancer prevention trials and primary care physicians: Factors associated with recommending trial enrollment

BACKGROUND

To explore the willingness of primary care providers (PCPs) to encourage enrollment of patients into cancer prevention trials.

METHODS

A self-administered survey was mailed to a random sample of PCPs in three geographic regions. Physicians were asked questions about their knowledge and attitudes towards cancer prevention trials. We presented a clinical vignette of a woman at high risk for breast cancer and asked if they would encourage her enrollment into a breast cancer chemoprevention trial (yes/no). Each survey included one of 16 possible clinical vignettes where patient characteristics (age, race socioeconomic status, physical mobility and co-morbidity) varied dichotomously. Bivariate analyses and logistic models were used to examine the independent effects of patient and physician characteristics on physician decisions.

RESULTS

Two hundred and sixty-six surveys (50% response) were analyzed. The mean age of respondents was 48; 54% were White, 35% Asian and 5% Black. By design physicians were evenly distributed by gender, specialty and geographic location. Overall, 53% would encourage enrollment into a breast cancer chemoprevention trial. Significant predictors of a recommendation to enroll were: geographic location in California or Georgia, younger vignette patient and anticipating an increase in patient trust after recommending enrollment.

CONCLUSION

PCPs are less likely to encourage elderly patients to enroll into cancer chemoprevention trials. Decisions differ based on geographic location and perceived trust in the patient-provider relationship. To achieve successful enrollment, trial investigators must continue to educate PCPs and ensure a strong PCP-patient relationship is maintained.

Effect of a clinical trial alert system on physician participation in trial recruitment

BACKGROUND

Failure to recruit a sufficient number of eligible subjects in a timely manner represents a major impediment to the success of clinical trials. Physician participation is vital to trial recruitment but is often limited.

METHODS

After 12 months of traditional recruitment to a clinical trial, we activated our electronic health record (EHR)-based clinical trial alert (CTA) system in selected outpatient clinics of a large, US academic health care system. When a patient's EHR data met selected trial criteria during the subsequent 4-month intervention period, the CTA prompted physician consideration of the patient's eligibility and facilitated secure messaging to the trial's coordinator. Subjects were the 114 physicians practicing at selected EHR-equipped clinics throughout our study. We compared differences in the number of physicians participating in recruitment and their recruitment rates before and after CTA activation.

RESULTS

The CTA intervention was associated with significant increases in the number of physicians generating referrals (5 before and 42 after; P < .001) and enrollments (5 before and 11 after; P = .03), a 10-fold increase in those physicians' referral rate (5.7/mo before and 59.5/mo after; rate ratio, 10.44; 95% confidence interval, 7.98-13.68; P<.001), and a doubling of their enrollment rate (2.9/mo before and 6.0/mo after; rate ratio, 2.06; 95% confidence interval, 1.22-3.46; P = .007).

CONCLUSIONS

Use of an EHR-based CTA led to significant increases in physicians' participation in and recruitment rates to an ongoing clinical trial. Given the trend toward the EHR implementation in health care centers engaged in clinical research, this approach may represent a much-needed solution to the common problem of inadequate trial recruitment.

Factors affecting breast cancer risk reduction practices among California physicians

BACKGROUND

Little is known about the incorporation of breast cancer risk reduction therapies into clinical practice.

METHODS

We assessed factors related to physicians' performance of breast cancer risk reduction practices through a self-administered survey. Subjects were California physicians in family medicine, internal medicine, or obstetrics/gynecology, identified through the AMA Masterfile. Physicians reported their breast cancer risk reduction practices (initiating patient counseling, referring patients for genetic evaluation, and prescribing tamoxifen or raloxifene) as well as barriers to counseling.

RESULTS

Of 1647 eligible physicians, 822 responded. Eighty-six percent reported initiating counseling, 45% referred a patient for genetic evaluation, 31% prescribed raloxifene, and 11% prescribed tamoxifen for breast cancer prevention in the past year. The leading frequent barriers to counseling were "not enough time" (40.3%) and "insufficiently informed about risk reduction options" (19.1%). Multivariate analysis showed that a training and role factors scale was negatively associated with all risk reduction practices, and number of breast cancer diagnoses per year was positively associated with referring for genetic evaluation and prescribing chemoprevention.

CONCLUSIONS

Physicians in primary care specialties report participation in several breast cancer risk reduction activities. Issues related to physician training and role in risk reduction affect the implementation of these practices.

Tamoxifen for breast cancer chemoprevention: low uptake by high-risk women after evaluation of a breast lump

PURPOSE

The Breast Cancer Prevention Trial (BCPT) published results in 1998 showing that the use of tamoxifen in high-risk women reduced the incidence of invasive breast cancer by 49%. We examined the clinical impact of the BCPT to determine whether high-risk women informed of these results would use tamoxifen for chemoprophylaxis and to investigate the factors influencing this decision.

METHODS

Of 345 women evaluated for a breast lump at a referral center, 89 were defined as high risk for but did not currently have cancer. These women were contacted about their elevated risk and informed that there exists a medication proved to reduce this risk. They were encouraged to discuss the issue with their family physician, to whom we sent copies of the 3 largest tamoxifen chemoprevention studies, including the BCPT. Follow-up was conducted by telephone to determine each woman's choice regarding tamoxifen use for chemoprevention and to ascertain her reasons for reaching this decision.

RESULTS

Of the 89 high-risk women, 1 decided to take tamoxifen for breast cancer chemoprevention. Only 48 women discussed tamoxifen with their family physician; in 3 cases (3.4%) the family physician recommended that the patient start taking tamoxifen, in 8 cases (9.1%) the family physician made no recommendations, and in 37 cases (42%) the family physician advised against tamoxifen. The most frequently cited factors influencing the decision not to start tamoxifen were a fear of adverse events (46.8%), the family physician's recommendation (31.9%), and a perceived low breast cancer risk (34%).

CONCLUSION

Family physicians recommended prophylactic tamoxifen to few women and even fewer women chose to take it. The major barrier appears to be concern about potential adverse effects of tamoxifen.

How do Obstetric Providers Discuss Referrals for Prenatal Genetic Counseling?

To investigate referrals of pregnant women to genetic counseling, we analysed transcripts from audiotaped first prenatal visits of 104 patients (72 actual patient visits and 32 simulated patient visits) with 32 providers (obstetricians and nurse-midwives). All patients had at least one indication for referral. Only 10% of visits with actual patients included a genetic counseling referral. When genetic counseling was discussed, it was only briefly described, primarily as an information session. This study shows that the majority of pregnant women with an indication for referral for genetic counseling are not referred. In addition, obstetric providers' inadequate descriptions of prenatal genetic counseling may result in women being poorly prepared for genetic counseling sessions.

Recruitment of patients into an internet-based clinical trials database: the experience of OncoLink and the National Colorectal Cancer Research Alliance

PURPOSE

In March 2001, the National Colorectal Cancer Research Alliance (NCCRA) and OncoLink (http://www.oncolink.org) established a database to facilitate patient enrollment onto clinical trials. This study describes the population registering with the database and identifies discrepancies between individuals registering through the Internet and those registering through a telephone call center.

METHODS

Participants registered with the NCCRA/OncoLink database through the Internet or a telephone call center. All participants entering the database completed a questionnaire regarding basic demographics, colon cancer risk factors, and indicated how they became aware of the database. Comparisons were made between individuals registering through the Internet and those registering through the telephone call center.

RESULTS

A total of 2,162 participants registered during the first 16 months of the database. Most patients registered through the Internet rather than the telephone call center (88% v 12%; P < .001). More females than males registered (73% v 27%; P < .001). The majority (89%) were white. Participants registering through the Internet were younger than those registering through the call center (mean, 48.8 v 55.0 years; P < .001). There was no difference between the two groups with regard to sex or ethnicity.

CONCLUSION

The Internet has the potential to increase the likelihood that interested individuals find appropriate clinical trials. Some of the discrepancies that are known to exist for access to the Internet were also seen for those registering with the database through the Internet. Despite these differences, the potential to increase clinical trial enrollment with this type of Internet-based database is high.

Decision-Making About Tamoxifen in Women at High Risk for Breast Cancer: Clinical and Psychological Factors

Purpose

To explore the health-related and psychological factors that influence decision making about tamoxifen (Nolvadex; AstraZeneca, Waltham, MA) chemoprevention in women at increased risk for developing breast cancer.

Methods

This study involves the assessment of 129 women eligible to take tamoxifen following cancer-risk counseling. Treatment decision and decision satisfaction were measured at 2 and 4 months following counseling. Health-related factors included physician recommendation, personal and family-related health history, and concern about side effects. Psychological factors included breast cancer–related anxiety, risk perception, and depression.

Results

At 2 months’ follow-up, 44% of participants declined tamoxifen treatment. This number increased to 49% at 4 months. Personal and family health history were not related to the decision, but history of abnormal biopsy did predict tamoxifen use. Physician recommendation was highly correlated with treatment decision. Concern about side effects was related to the decision to decline treatment. Breast cancer–related anxiety and heightened risk perception were associated with the decision to take tamoxifen. However, anxiety and psychological distress were also negatively related to treatment satisfaction.

Conclusion

Decision-making about tamoxifen is complex, and many eligible women decline treatment or remain undecided. Findings call for further educational follow-up with high-risk women after they undergo initial counseling. Factors related to misperceptions of risk and side effects, as well as psychological distress, may be particularly important targets for intervention.

Do physicians tailor their recommendations for breast cancer risk reduction based on patient's risk?

OBJECTIVE

To investigate how physicians tailor their recommendations for breast cancer prevention and risk reduction.

DESIGN

Cross-sectional, mail survey.

PARTICIPANTS

Random sample of primary care physicians in California (N = 822).

MEASUREMENTS AND MAIN RESULTS

Six standardized patient scenarios were used to assess how women's breast cancer risk factors influence physicians' recommendations for screening mammography, counseling about lifestyle behaviors, genetic testing, the use of tamoxifen, prophylactic surgery, and referral to a breast specialist. Over 90% of physicians endorsed mammography for all of the scenarios. Similarly, approximately 80% of physicians endorsed counseling about lifestyle factors for all of the scenarios. Five-year risk of developing breast cancer and family history were both strongly associated with each of the 6 recommendations. Importantly, however, physicians were more likely to endorse the discussion of genetic testing, the use of tamoxifen, and prophylactic surgery for women with a family history of breast cancer compared with women at a higher risk of developing breast cancer but without a family history. Obstetrician-gynecologists were more likely to endorse most of these practices compared with internists.

CONCLUSIONS

Mammography and counseling about lifestyle behaviors are widely endorsed by physicians for breast cancer prevention and risk reduction. Whereas physicians are generally able to tailor their recommendations for prevention and risk reduction based on risk, they may perhaps underutilize genetic evaluation and newer therapeutic options for primary prevention for women who are at high risk of developing breast cancer but do not have a family history.

To refer or not to refer: Factors that affect primary care provider referral of patients with cancer to clinical treatment trials

BACKGROUND

Despite breakthroughs in experimental cancer treatment, relatively few patients participate in cancer clinical treatment trials (CCTTs). Primary care providers (PCPs) have a strong influence on patients' decisions to participate in a CCTT.

METHODS

To determine factors that influence PCP referral of patients to CCTTs, we conducted a descriptive survey of 571 Michigan PCPs.

RESULTS

Attendance at CCTT educational sessions consistently predicted referral. Provider attitudes regarding CCTT perceived knowledge, access, and comfort with responsibilities when patients were in a CCTT also predicted referral.

CONCLUSIONS

Findings support allocating funds to provide CCTT education to PCPs to increase numbers of patients willing to participate in CCTTs.

Adjuvant Chemotherapy for Breast Cancer: How Presentation of Recurrence Risk Influences Decision-Making

Purpose: The purpose of this study was to examine the impact of four methods of communicating survival benefits on chemotherapy decisions. We hypothesized that the four methods of communicating mathematically equivalent risk information would lead to different chemotherapy decisions.

Methods: Each participant received two hypothetical scenarios regarding their mother (a postmenopausal woman with an invasive, lymph node-negative, hormone receptor-positive breast cancer) and was asked to decide whether they would encourage their mother to take chemotherapy in addition to surgery and tamoxifen. In the part 1, participants received one of four methods of describing the chemotherapy survival benefit: (1) relative risk reduction, (2) absolute risk reduction, (3) absolute survival benefit, or (4) number needed to treat. In part 2, each participant received all four methods. Following each decision, participants were asked to rate their confidence and confusion regarding their decision.

Results: Participants included 203 preclinical medical students. In part 1, participants who received relative risk reduction information were significantly more likely to endorse chemotherapy. In part 2, there were no treatment decision differences when participants received all four methods of communicating survival benefits of chemotherapy. However, receiving all four methods led to significantly higher ratings of confusion. In deciding on endorsing chemotherapy, participants understood the information best when presented with data in the absolute survival benefit format.

Conclusion: These results support the hypothesis that the method used to present information about chemotherapy influences treatment decisions. Absolute survival benefit is the most easily understood method of conveying the information regarding benefit of treatment.

Management of the high-risk patient

Comprehensive breast cancer risk management is a practical tool that can now be regarded as a necessary clinical component of women's health. Risk assessment is the starting point for counseling women about risk, and it facilitates rational decision-making about prophylactic surgery, initiation of screening at an early age, and initiating preventive interventions. The availability of risk assessment models permit rapid risk calculation during routine clinical encounters, and risk profiles can be easily updated at subsequent clinical visits. Clinicians can now incorporate risk assessment and management into their routine screening and health maintenance appointments. Additional prospective clinical trials should be conducted to define the optimal use of existing management strategies, develop refined risk assessment instruments that incorporate additional risk-factor information, and evaluate populations for whom validated risk-assessment approaches do not yet exist.

Parents' attitudes to children's participation in randomized controlled trials

OBJECTIVE

To explore parents' attitudes to children's participation in randomized controlled trials.

STUDY DESIGN

Qualitative analysis of focus group discussions involving 33 parents from a pediatric teaching hospital and local school in Australia. Parents varied in age, gender, ethnicity, level of education, research experience, and child's health status. The transcribed discussions were analyzed by theme linkage using the constant comparative method.

RESULTS

Parents balance risks and benefits when deciding about trial participation for their child. Perceived benefits include the offer of hope, better care of their child, the opportunity to access new treatments, healthcare professionals and health information, meeting others in similar circumstances, and helping others. Perceived risks include potential side effects, being randomized to ineffective treatments, and the inconvenience of participation. The decision for trial participation is also influenced by parental factors (parents' knowledge, beliefs, and emotional responses), child factors (the child's health status and preference about participation), trial factors (the use of placebos and uncertainties of participation), and doctor factors (doctor's recommendations and communication of trial information).

CONCLUSIONS

Educating parents about trials, improving communication between trialists, pediatricians, and parents, increasing incentives while decreasing inconveniences, and providing decision aids for parents may increase parents' willingness to participate in trials.

Impact of individual physicians on enrollment of patients into clinical trials

The National Cancer Institute is committed to increasing enrollment of cancer patients in clinical treatment trials. The factors that achieve successful results are poorly understood. This study analyzes the role of individual physicians in recruitment of patients in clinical trials. A retrospective review was undertaken of all patients with untreated endometrial, cervical, or ovarian cancer potentially eligible for a multi-institutional phase III trial cared for by the Section of Gynecologic Oncology at the University of Oklahoma from July 1, 1998 to September 30, 1999. Patient variables assessed included age, insurance status, cancer diagnosis, and enrollment onto clinical trial. There was no difference in faculty patients with regard to cancer type, age, or insurance status. There was a significant difference (p < 0.01) between faculty in offering protocol therapy and likelihood of successfully enrolling patients. Successful enrollment was correlated with faculty experience and principal investigator status. This study shows that availability of patients, patient variances, support staff, and institutional commitment are secondary to individual physician factors in determining successful enrollment of patients onto clinical trials.

Public attitudes toward participation in cancer clinical trials

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pediatricians' attitudes toward randomized controlled trials involving children

OBJECTIVE

To examine pediatricians' attitudes toward children's participation in randomized controlled trials (RCTs) and identify possible barriers to participation.

STUDY DESIGN

Qualitative analysis of focus group discussions involving 16 pediatricians and 5 trainees from a pediatric teaching hospital in Australia. Doctors varied in occupation, experience, research activity, age, sex, ethnicity, and parenthood experience. A professional facilitator conducted the semistructured group discussions. The transcribed audiotapes were analyzed by theme linkage by using the constant comparative method.

RESULTS

Pediatricians believed parents balanced perceived gains and risks when deciding about trial participation. They thought the child's condition, parents' health beliefs and personal attributes, and the doctors' beliefs and relationship with the investigators influenced parents' attitudes. Perceived gains included professional benefits for pediatricians, improved patient care, convenience for the families and themselves, and scientific advancement. Perceived risks included inconvenience, inadequate resources, and potential harms to the patient and doctor-patient relationship. Pediatricians with previous research experience were most knowledgeable about RCTs and perceived greatest gains from trial participation. Pediatricians' personal treatment preferences hindered trial support.

CONCLUSIONS

This study suggests that children's participation in trials will be enhanced by increasing pediatricians' awareness of RCTs through education and involvement in trials and by improving the gains-risk balance.

Capturing users' experiences of participating in cancer trials

Randomized controlled trials are accepted to be the research design of choice to evaluate the effectiveness of health care interventions and are commonly used to evaluate cancer treatments. There are concerns, however, that levels of recruitment to trials are often much lower than anticipated, particularly in cancer trials. Several research methods have been used to collect aspects of users' experiences of participating in cancer trials. Perhaps the most common method has been through measures of outcome and the impact of treatments on quality of life (QoL), using standardized schedules to capture physical, social and psychological health. In some areas of cancer, individual patient testimonies illuminate particular issues or narratives. Another body of research has grown around issues of user involvement in trials, including surveys of recruitment and participation, as well as investigations of patient preferences and experiences of participation. We searched MEDLINE and the Cochrane Trials Library from 1995 to 2001 for relevant publications. In this article, we review the literature in these areas and examine whether users' experiences of participating in cancer trials can be used to assist in the design or conduct of trials.

The use of a prognostic table to aid decision making on adjuvant therapy for women with early breast cancer

AIM

Understanding the likely net benefit of chemotherapy for the individual patient helps physicians to give objective information. A prognostic table has been constructed detailing the percentage absolute survival advantage offered by polychemotherapy for patients with early breast cancer, according to their age and the Nottingham Prognostic Index of their tumour. This study aims to assess its first year of use in the Leicestershire Breast Unit.

METHOD

Demographic, pathological and treatment data were collected prospectively onto the Leicestershire breast cancer database. Patients with a potential survival advantage of 2% or greater in the year 01/05/99 to 30/04/00 (after the prognostic table was used routinely to determine oncology referrals) were identified. Chemotherapy usage was compared with the previous year's patient group.

RESULTS

Two hundred and eighty-eight had early breast cancer, requiring surgery, eligible for consideration of adjuvant therapy. Of these, 98% of women with a potential survival advantage of 6% or more received chemotherapy. Ninety-one percent of those with a survival advantage of 4% or more was seen by an oncologist. Of those with a 2% survival advantage, 48% were referred to discuss the issues with an oncologist. Use of the table resulted in increased chemotherapy rates for women with a 4% potential survival advantage.

CONCLUSIONS

We have found the prognostic table to be a useful and workable tool and advocate its use.

Maximizing Efficiency of Enrollment for School-Based Educational Research

In this observational study, influences on research enrollment were examined in the context of an educational research study. Recruitment materials were sent to parents of kindergartners in one of 23 classes across 7 public schools, as an invitation to enroll in a longitudinal study. For the 7 classes from 2 of the schools, the school principal prepared a cover letter as an introduction to the educational study. Inclusion of this cover letter was associated with a significantly swifter pace of recruitment and, to a lesser degree, with an increase in the number of children enrolled. However, when potential confounding variables were controlled, no significant increase in final enrollment count was associated with including the cover letter. Thus, inclusion of a cover letter from the school principal did not appear to dramatically increase the number of parents who elected to enroll their child in the educational study, and it did significantly decrease (by 6 weeks) the number of weeks required to achieve final enrollment counts.

The study of tamoxifen and raloxifene: preliminary enrollment data from a randomized breast cancer risk reduction trial

Tamoxifen reduced the risk of invasive breast cancer by 49% among women at increased risk for breast cancer in the Breast Cancer Prevention Trial P-1, and raloxifene reduced breast cancer incidence by more than 70% in the Multiple Outcomes of Raloxifene Evaluation osteoporosis trial. These findings led the National Surgical Adjuvant Breast and Bowel Project to design and launch the Study of Tamoxifen and Raloxifene. Risk-eligible women are = 35 years of age and postmenopausal; they have either lobular carcinoma in situ (LCIS) or a 5-year risk of invasive breast cancer of at least 1.67% as determined by the Gail model. Participants are randomly assigned to receive either tamoxifen 20 mg or raloxifene 60 mg daily. The trial opened for accrual on July 1, 1999. After 32 months of recruitment at 194 clinical centers in North America, risk assessments have been performed in 107,855 women (83.8% white, 9.4% black, 3.8% Hispanic, 3.1% other race/ethnic groups). Of the eligible patients, 12,637 have been randomized (20.9% of risk-eligible women); the median age is 58 years (mean, 58 years), and the median 5-year risk of breast cancer is 3.3% (mean, 4.0%). LCIS was reported in 8.4% of women prior to randomization. Gail model risk was = 3.0% in 5 years for 59.3% of white women, 45.0% of black women, and 44.5% of Hispanic women. The trial will recruit a total of 22,000 postmenopausal women and is powered to demonstrate superior efficacy of either agent or their equivalence in reducing the incidence of primary breast

Chemoprevention of breast cancer with selective estrogen receptor modulators: views from broadly diverse focus groups of women with elevated risk for breast cancer

Selective estrogen receptor modulators (SERMs) are anti-estrogens that selectively antagonize the proliferative effects of estrogens on breast cells, thereby inhibiting or reversing neoplastic progression to clinical breast cancer. The goal is to administer these agents to healthy women with an elevated risk for breast cancer. The study reported here assessed the knowledge and attitude of 26 broadly selected women with an elevated risk for breast cancer who participated in three focus groups (eight to ten per group) that discussed the use of SERMs, such as tamoxifen and raloxifen. Data were analyzed by cross-case procedure using variable-oriented strategies. Acceptance of breast cancer chemoprevention treatment with SERMs was found to be influenced by various factors, including a knowledge of breast cancer risk factors, the perception of personal risk for breast cancer, and the perception of barriers and benefits to receiving chemoprevention treatment. The issues involved in making the decision to accept treatment with SERMs are discussed. Most of the participants in the groups indicated they were unlikely to accept breast cancer chemoprevention treatment with SERMs.

Cancer clinical trial patients in the information age: a pilot study

PURPOSE

The purpose of this pilot study was to explore the cancer clinical trial patient's perception and use of electronic information and communication.

DESCRIPTION OF STUDY

A total of 42 participants who self-reported they had enrolled, or were enrolled, in a cancer clinical trial completed a Web-based clinical trials survey questionnaire linked to a cancer-specific Web site. The questionnaire was used to obtain written responses to open-ended questions regarding the perception and use of electronic information and communication.

RESULTS

The pilot study findings document that more than one third of the respondents use the Internet to seek clinical trials information. Results also describe the impact of the Internet in helping these patients to identify what questions to ask their healthcare providers. The findings underscore the desire of patients to communicate not only with others on the same clinical trial, but also with their healthcare providers via the Internet.

CLINICAL IMPLICATIONS

When providing care to cancer clinical trial patients in the information age, online information seeking and the desire for electronic communication must increasingly be acknowledged, understood, and supported. A proactive and comprehensive approach to addressing patient information and support needs can facilitate patient empowerment and satisfaction.

Genetic testing for colorectal carcinoma susceptibility: focus group responses of individuals with colorectal carcinoma and first-degree relatives

BACKGROUND

Colorectal carcinoma (CRC) may be the most frequent form of hereditary cancer. Genetic counseling and testing for heritable CRC is a promising approach for reducing the high incidence and mortality rates associated with the disease. Patients with CRC or those with at least one family member with the disease are the most likely persons to request or be offered genetic testing in the clinical or research setting. Currently, however, little is known about the behavioral, psychosocial, ethical, legal, and economic outcomes of CRC genetic counseling and testing.

METHODS

Eight focus group interviews, four for CRC patients (n = 28) and four for first-degree relatives (n = 33), were conducted to obtain insights into attitudes, beliefs, and informational needs about genetic testing for hereditary CRC.

RESULTS

Focus group interviews revealed a general lack of knowledge about cancer genetics and genetic testing; worry about confidentiality issues; strong concern for family members, particularly children; and a need for primary care providers to be informed about these issues. Major perceived advantages of genetic testing included improving health-related decisions, guiding physicians in making recommendations for surveillance, and informing relatives about risk potential. Disadvantages included potential discrimination, adverse psychologic effects, and financial costs associated with testing.

CONCLUSIONS

As knowledge and media coverage of genetics continue to expand, it becomes increasingly important to continue efforts on behalf of, and in partnership with, those individuals most affected by genetic testing for hereditary cancer syndromes. These findings provide data needed to develop and implement informational, educational, counseling, and research-oriented programs that are sensitive to individuals' concerns and preferences.