Discussing randomised clinical trials of cancer therapy: evaluation of a Cancer Research UK training programme

Seeking informed consent to cancer clinical trials; evaluating the efficacy of doctor communication skills training

INTRODUCTION

Clinical trials have come to be regarded as the gold standard for treatment evaluation. However, many doctors and their patients experience difficulties when discussing trial participation, leading to poor accrual to trials and questionable quality of informed consent. We have previously developed a communication skills training program based on a typology for ethical communication about Phase II and III clinical trials within four categories. The training program consisted of a 1 day experiential workshop that included didactic teaching, exemplary video and role play. The aim of this study was to evaluate the effectiveness of the communication skills training workshop.

METHOD

Oncologists were recruited from three major teaching hospitals conducting oncology outpatient clinics in three Australian capital cities. Ten oncologists and 90 of their adult cancer patients who were eligible for a Phase II or III clinical trial participated. Ninety informed consent consultations were audiotaped before (n = 59) and after (n = 31) training, and fully transcribed. The presence or absence of each domain component was coded and these were summed within categories. A coding manual was produced which enabled standardization of the coding procedure. Patients completed questionnaires before and after the consultation, and doctors completed a short measure of satisfaction after the consultation.

RESULTS

Doctors increased their use of some aspects of shared decision-making behavior (t(87) = -1.945, p = 0.05) and described some aspects of essential ethical/clinical information more commonly. In addition they used less coercive behaviors (z = -1.976, p = 0.048). However, they did not provide more clinical information or structure their consultations in the recommended fashion. Patients in the post-training cohort reported more positive attitudes to clinical trials, but other outcomes were not affected by the intervention.

CONCLUSIONS

This short training programme demonstrated limited success in improving the oncologist's communication skills when gaining informed consent. A larger randomized controlled trial of extended training is now underway.

Questioning specialists' attitudes to breast cancer follow-up in primary care

BACKGROUND

National Institute for Clinical Excellence (NICE) guidelines recommend discharging asymptomatic breast care patients 3 years after diagnosis. A role for General Practitioners (GPs) and breast care nurses is proposed, together with skills training, but it remains unclear for how long breast cancer patients should be followed up, what tests should be done, and who should be conducting the follow-up. We therefore surveyed Breast Cancer Specialists.

DESIGN

A 20-point questionnaire was sent to 562 Specialists registered in the Cancer Research Clinical Trials Unit database, with questions on case-load, perceptions of follow-up, local policy and opinions on greater primary care involvement.

RESULTS

The most commonly acknowledged purpose of follow-up was detection of treatment-related morbidity. Eighty four percent of respondents adhered to a locally developed protocol with only 9% conforming to NICE guidelines. The median follow-up was 5 years. Significant factors predicting delayed discharge were younger age (P < or = 0.0001); poorer Nottingham Prognostic Index (P = 0.003); treatment factors (P = 0.002); and patient risk factors (P = 0.003). Centres with higher case-loads (>200/year) were more likely to discharge earlier. Reduced workload was perceived as the main benefit of discharge, while lack of GP oncological experience and loss of outcome data were concerns.

CONCLUSIONS

Specialists favour a risk adjusted discharge strategy and increased oncology infrastructure in primary care.

A short communication course for physicians improves the quality of patient information in a clinical trial

We investigated whether a short course in communication skills for physicians would improve the quality of informed consent in a randomized clinical adjuvant trial on breast cancer. In this prospective, case-controlled intervention study, physicians and research nurses who introduced the cancer treatment trial to patients at three of the participating hospitals first attended a one-day communication skills course. The quality of informed consent was then evaluated by addressing a standardized questionnaire, QuIC, to trial patients at the three intervention hospitals and at control hospitals. Response rate was 90.0% (n = 288). Of the patients treated by the intervention group, 73% were very satisfied with the information received compared with 56% of those of the control group (p = 0.003). The patients of the intervention group considered the time given for making their decision sufficient more often than those of the controls (98% vs. 90%, p = 0.004). The patients of the intervention group recalled more often than those of the controls that the physician had also offered other therapeutic options than the trial treatment (91% vs. 97%, p = 0.032). They also understood the main aim of the study better than the patients of the controls (89% vs. 78%, p = 0.030). In conclusion, a short communication skills course for the trial physicians and nurses improved the quality of informed consent and patient satisfaction in the trial.

Ability of family members to predict patient's consent to critical care research

OBJECTIVE

A European Union Directive provides for the designation of a surrogate who can consent to or refuse inclusion of an incapacitated patient in research studies. The accuracy with which surrogates consent to research on behalf of patients has not been evaluated in the intensive care unit (ICU).

METHODS

A prospective multicenter study was conducted in ten ICUs of the French Famirea study group between July and October 2004. Two hypothetical studies were simultaneously submitted to the patient, surrogate, and physician at the time that the patient was discharged to a ward. One study involved minimal risk and the other greater-than-minimal risk to the patients.

RESULTS

With the minimal risk study there was patient-surrogate discrepancy in 32% of cases and patient-physician discrepancy in 25%. Corresponding figures with the greater-than-minimal risk study were 42% and 46%. None of the collected variables differed significantly between cases with and without patient-surrogate discrepancy.

CONCLUSIONS

Family members designated to serve as surrogate decision makers may fail to accurately consent to research for critically ill patients in one-third to nearly one-half of cases.

Creating a culture of research

There is widespread concern about the ability of the current model of clinical research to keep pace with the growing need for testing new approaches to disease management and prevention. In response, important innovations are emerging in critical areas of research infrastructure and practice. However, success in fulfilling the promise of clinical research will also require a fundamental shift in the relationship between the clinical-research enterprise and all segments of society. In this article, we outline proposals to help create the necessary recognition and engage participation by patients, clinicians, health-care delivery systems, and the research community to establish the long-lasting growth needed for achieving the full potential of clinical research.

Current concepts of communication skills training in oncology

Too many patients leave their consultations with insufficient understanding about their diagnosis, prognosis, the need for further diagnostic tests, the management plans, or the therapeutic intent of treatment. This situation is not entirely due to paternalism or a lack of awareness that patients worldwide desire more information, but rather a reflection of the dismal communication skills training that most healthcare professionals receive. There have been many developments aimed at rectifying this situation, but there are still too few publications available demonstrating efficacy. Nevertheless, evidence shows that communication skills can be taught and that if taught well then the impact endures into the clinic. This chapter looks at some of the history of good evidence-based interventions to improve communication and makes a plea for more research-based evidence for improved patient outcomes following training. Unless attention and resources are given to help healthcare professionals in this core clinical skill then we will never be able to help patients and their families take an informed and educated role in their own cancer care.

Communication and communication skills training in oncology: open questions and future tasks

Based on their experience as teachers of communication skills training for oncology clinicians, the authors report their observations and reflect on open questions and future challenges with regard to communication in cancer care. Both of us have been training oncologists and oncology nurses in communication skills training (CST) for many years (Kiss 1999). This might be the reason why the editor asked us to comment on CST from a clinical point of view. We will therefore share some observations we made while doing such training and we will try to define future tasks.

Increasing participation of cancer patients in randomised controlled trials: a systematic review

BACKGROUND

There are many barriers to patient participation in randomised controlled trials of cancer treatments. To increase participation in trials, strategies need to be identified to overcome these barriers. Our aim was to assess the effectiveness of interventions to overcome barriers to patient participation in randomised controlled trials (RCTs) of cancer treatments.

METHODS

A systematic review was conducted. Published and unpublished studies in any language were searched for in fifteen electronic databases, including MEDLINE, EMBASE, CINAHL and PsycINFO, from inception to the end of 2004. Studies of any interventions to improve cancer patient participation in RCTs, which reported the change in recruitment rates, were eligible for inclusion. RCTs and non-randomised controlled trials as well as before and after studies reporting baseline rates specific to the population being investigated were included. Data were extracted by one reviewer into structured summary tables and checked for accuracy by a second reviewer. Each included study was assessed against a checklist for methodological quality by one reviewer and checked by a second reviewer. A narrative synthesis was conducted.

RESULTS

Eight studies were identified that met the inclusion criteria: three RCTs, two non-randomised controlled trials and three observational studies. Six of the studies had an intervention that had some relevance to the UK. There was no robust evidence that any of the interventions investigated led to an increase in cancer patient participation in RCTs, though one good quality RCT found that urologists and nurses were equally effective at recruiting participants to a treatment trial for prostate cancer. Although there was no evidence of an effect in any of the studies, the evidence was not of sufficient quality to be able to conclude that these interventions therefore do not work.

CONCLUSION

There is not a strong evidence-base for interventions that increase cancer patient participation in randomised trials. Further research is required to evaluate the effectiveness of strategies to increase participation in cancer treatment trials.

Barriers to participation in clinical trials of cancer: a meta-analysis and systematic review of patient-reported factors

BACKGROUND

Enrolling participants onto clinical trials of cancer presents an important challenge. We aimed to identify the concerns of patients with cancer about, and the barriers to, participation in clinical trials.

METHODS

We did a systematic review to assess studies of barriers to participation in experimental trials and randomised trials for validity and content. We estimated the frequency with which patients identified particular issues by pooling across studies that presented data for barriers to participation in clinical trials as proportions.

FINDINGS

We analysed 12 qualitative studies (n=722) and 21 quantitative studies (n=5452). Two qualitative studies inquired of patients who were currently enrolled onto clinical trials, and ten inquired of patients who were eligible for enrolment onto various clinical trials. Barriers to participation in clinical trials were protocol-related, patient-related, or physician-related. The most common reasons cited as barriers included: concerns with the trial setting; a dislike of randomisation; general discomfort with the research process; complexity and stringency of the protocol; presence of a placebo or no-treatment group; potential side-effects; being unaware of trial opportunities; the idea that clinical trials are not appropriate for serious diseases; fear that trial involvement would have a negative effect on the relationship with their physician; and their physician's attitudes towards the trial. Meta-analysis confirmed the findings of our systematic review.

INTERPRETATION

The identification of such barriers to the participation in clinical trials should help trialists to develop strategies that will keep to a maximum participation and cooperation in cancer trials, while informing and protecting prospective participants adequately.

Communication and informed consent in phase 1 trials: a review of the literature

Phase 1 (P1) trials are vital to the development of cancer treatments; however, the patients involved in these trials are unlikely to receive any therapeutic benefit, and there are significant possibilities that they will experience serious side effects. Ethical requirements stipulate that patients must be adequately informed before they consent to participate in P1 trials. This review focuses on studies that have measured patient comprehension of information given during the informed consent process of P1 cancer trials. Patients consenting to participate in P1 trials currently have a limited understanding of trial purpose, an unrealistic expectation of the benefits and risks associated with trial participation and a questionable appreciation of their right to abstain or withdraw. Health care professionals recruiting to P1 trials need clear and practical guidelines and training packages designed to ensure that all details of P1 trials are communicated effectively to eligible patients.

Information needs and experiences: an audit of UK cancer patients

As part of a multi-centred UK study evaluating multidisciplinary team communication, the information needs, decision making preferences and information experiences of 394 cancer patients were audited. A majority of patients (342/394, 87%) wanted all possible information, both good and bad news. Assuming that all clinicians had equal skill, the majority of patients (350/394, 89%) expressed no preference for the sex of their doctor. The largest proportion of patients (153/394, 39%) wanted to share responsibility for decision making, preference was significantly influenced by age (chi2=17.42, df=4 P=0.002) with older patients more likely to prefer the doctor to make the decisions. A majority of patients reported receiving information regarding their initial tests (313/314, 100%), diagnosis (382/382, 100%), surgery (374/375, 100%) and prognosis (308/355, 87%), fewer recalled discussions concerning clinical trials (119/280, 43%), family history (90/320, 28%) or psychosocial issues, notably sexual well-being (116/314, 37%). Cancer patients want to be fully informed and share decision making responsibility, but do not report receiving sufficient information in all areas. Multidisciplinary cancer teams need to ensure that where appropriate, someone provides patients with information about clinical trials, familial risk and psychosocial issues. Regular audits highlight gaps and omissions in the information given to patients.

The preferences of 600 patients for different descriptions of randomisation

A total of 600 patients from cancer centres throughout the UK identified their most preferred and most disliked descriptions of randomisation found in current patient information sheets and websites. The CancerBACUP description, which describes both the process of randomisation and why it is done, was most preferred 151 out of 533 (28%) patients. The NCI description was viewed as overly technical and most disliked 185 out of 483 (38%) patients.