Public attitudes toward participation in cancer clinical trials

Analysis of Maryland cancer patient participation in national cancer institute-supported cancer treatment clinical trials

PURPOSE

We examined the relationship of sociodemographic factors, urban/rural residence, and county-level socioeconomic factors on accrual of Maryland patients with cancer to National Cancer Institute (NCI) -sponsored cancer treatment clinical trials.

PATIENTS AND METHODS

Data were analyzed for the period 1999 to 2002 for 2,240 Maryland patients with cancer accrued onto NCI-sponsored treatment trials. The extent to which Maryland patients with cancer and patients residing in lower socioeconomic and/or rural areas were accrued to cancer trials and were representative of all patients with cancer in Maryland was determined. Data were obtained from several sources, including NCI's Cancer Therapy Evaluation Program for Maryland patients with cancer in Cooperative Group therapeutic trials, Maryland Cancer Registry data on cancer incidence, and United States Census and the Department of Agriculture.

RESULTS

For Maryland patients with cancer accrued onto NCI-sponsored treatment trials between 1999 and 2002, subgroups accrued at a higher rate included pediatric and adolescent age groups, white patients, female patients (for sex-specific tumors), patients with private health insurance, and patients residing in the Maryland National Capitol region. Moreover, between 1999 and 2002, there was an estimated annual decline (8.9% per year; P < .05) in the percentage of black patients accrued onto cancer treatment trials. Logistic regression models uncovered different patterns of accrual for female patients and male patients on county-level socioeconomic factors.

CONCLUSION

Results highlight disparities in the accrual of Maryland patients with cancer onto NCI-sponsored treatment trials based on patient age, race/ethnicity, geography of residence, and county-level socioeconomic factors. Findings provide the basis for development of innovative tailored and targeted educational efforts to improve trial accrual, particularly for the underserved.

Testing three different cancer genetics registry recruitment methods with Hispanic cancer patients and their family members previously registered in local cancer registries in Texas

OBJECTIVE

To increase accrual among Hispanics to the Cancer Genetics Network national cancer genetics registry.

METHODS

Drawing from South Texas cancer registries, 444 Hispanic men and women were randomly assigned to one of three experimental conditions: standard direct-mailed procedures (X1), X1 plus culturally tailored materials (X2), and X2 plus interpersonal phone contact (X3). Participants were also surveyed about the effectiveness of the education materials and the phone contact. A refusal survey was provided for those who declined to join the study.

RESULTS

A total of 154 individuals joined the Cancer Genetics Network. The X3 condition yielded the greatest accrual (43.2%) compared to X1 (30.9%) and X2 (29.9%; p < 0.05). Tailored materials appeared to have no effect but were highly regarded. The main reasons for not participating were a lack of interest and time requirements.

CONCLUSION

Interpersonal communication can have a powerful effect on recruitment. However, more research is needed to determine the cost-efficacy of more labor-intensive approaches to registry accrual.

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.

Clinical trial priorities among surgeons caring for breast cancer patients

BACKGROUND

Designing and prioritizing successful clinical trials benefits from increased community physician input. We surveyed practicing surgeons about current controversies in breast cancer surgery, reported practices of discussing trial participation, and perceived obstacles to trial participation.

METHODS

A 44-question survey was mailed in 2005-2006 to 2,187 randomly selected American College of Surgeons members actively seeing breast cancer patients. Responses were analyzed by surgeon sex, practice type, oncology training, professional society membership, and breast cancer patient volume.

RESULTS

A total of 923 responses were received, with 460 eligible responses remaining for analysis. Most surgeons infrequently or never discuss trial participation with breast cancer patients. Inadequate infrastructure presents the greatest physician obstacle to trial participation. Identifying proven indications for completion axillary dissection after positive sentinel node biopsy marks the highest-ranked research priority for surgeons providing breast care.

CONCLUSIONS

Understanding topics of interest among practicing surgeons and addressing common obstacles to trial participation may result in improved breast cancer patient accrual through surgeons.

Barriers to recruiting underrepresented populations to cancer clinical trials: a systematic review

Racial and ethnic minorities, older adults, rural residents, and individuals of low socioeconomic status are underrepresented among participants in cancer-related trials. The authors conducted a systematic review to determine the barriers to participation of underrepresented populations in cancer-related trials. Their search included English-language publications that reported original data on the recruitment of underrepresented groups to cancer treatment or prevention trials between 1966 and December 2005 in multiple electronic databases. They also hand-searched titles in 34 journals from January 2003 to December 2005 and they examined reference lists for eligible articles. Titles and abstracts were reviewed to identify relevant studies. Data on barriers to participation were synthesized both qualitatively and based on statistically significant associations with trial enrollment. Of 5257 studies that were cited, 65 studies were eligible for inclusion in the current analysis, including 46 studies on recruitment into cancer therapeutic trials, 15 studies on recruitment into prevention trials, and 4 studies on recruitment into both prevention and treatment trials. Numerous factors were reported as barriers to participation in cancer-related trials. However, only 20 of the studies reported statistically significant associations between hypothesized barriers and enrollment. The available evidence had limitations in quality regarding representativeness, justification of study methods, the reliability and validity of data-collection methods, potential for bias, and data analysis. The results indicated that underrepresented populations face numerous barriers to participation in cancer-related trials. The current systematic review highlighting the literature on recruitment of underrepresented populations to cancer trials and may be used as the evidence base toward developing an agenda for etiologic and intervention research to reduce the disparities in participation in cancer-related trials.

Overcoming barriers to cancer clinical trial accrual: impact of a mass media campaign

BACKGROUND

Annually, only 3% of adult patients participate in cancer clinical trials (CCT). Accrual barriers include lack of CCT awareness and uncertain third-party coverage. In 2002, a California law (SB37) required all insurers to reimburse costs related to CCT. The objective of the current study was to increase awareness of CCT and SB37 through a mass multimedia campaign (MMC) in the University of California (UC) Davis (UCD) Cancer Center catchment area. The authors assessed willingness to participate in and accrual to CCT.

METHODS

Changes in CCT/SB37 awareness and willingness to participate were investigated before the MMC versus after the MMC and in UCD respondents versus UC San Diego (UCSD) catchment respondents-a control group that was not exposed to the MMC-by Pearson chi-square and logistic regression analyses.

RESULTS

Of 1081 post-MMC respondents, 957 were from UCD, and 124 from UCSD. UCD respondents had a greater awareness of CCT (59% vs 65%; P < .01) and SB37 (17% vs 32%; P < .01) compared with UCSD respondents. Willingness to participate did not change in either cohort. Awareness level predicted willingness (odds ratio, 2.3; P < .01). Blacks, Asians, and lowest income (<$25 K per year) groups were the least willing to participate (P < .01, P < .04, and P < .02, respectively). The CCT accrual rate at UCD was unchanged.

CONCLUSIONS

CCT and SB37 awareness increased significantly in the UCD cohort after the MMC. However, it was unclear whether this increase was attributable entirely to the MMC or to varying demographic variables. Enhancing patient willingness and accrual will require targeting other variables, such as physician or resource barriers, rather than just CCT and reimbursement awareness.

Using the Internet to search for cancer clinical trials: a comparative audit of clinical trial search tools

Advancing the clinical trial research process to improve cancer treatment necessitates helping people with cancer identify and enroll in studies, and researchers are using the power of the Internet to facilitate this process. This study used a content analysis of online cancer clinical trial search tools to understand what people with cancer might encounter. The content analysis revealed that clinical trial search tools were easy to identify using a popular search engine, but their functionality and content varied greatly. Most required that users be fairly knowledgeable about their medical condition and sophisticated in their web navigation skills. The ability to search by a specific health condition or type of cancer was the most common search strategy. The more complex tools required that users input detailed information about their personal medical history and have knowledge of specific clinical trial terminology. Search tools, however, only occasionally advised users to consult their doctors regarding clinical trial decision-making. This, along with the complexity of the tools suggests that online search tools may not adequately facilitate the clinical trial recruitment process. Findings from this analysis can be used as a framework from which to systematically examine actual consumer experience with online clinical trial search tools.

A Pilot Project to Develop Checklist-Based Recommendations on the Requirements for Clinical Cancer Research Centers in Countries with Limited Resources

Clinical studies are the only controlled way of comparing a new treatment to existing standards. Unfortunately, less than 5% of patients in developed countries are enrolled in clinical trials, thus strongly limiting the possibility of answering important clinical questions. Large numbers of cancer patients are treated in countries with limited resources (CLR). Here, cancer centers that are able to provide good standard of care are capable of contributing by enrolling large numbers of eligible patients into clinical trials. We present a pilot project aimed at developing a set of checklists that include all elements of infrastructure, equipment, staff, and training that a center should possess in order to enroll patients into phase II, III, and IV clinical trials. These elements will be stratified in an incremental list to contain essential, desirable, and optional items. Also, requirements for staffing and training of research staff will be developed. The development of a continuous audit program will be proposed to ensure quality control, and each potential trial center will undergo an initial audit to evaluate its suitability. The checklists may also serve as a guide for centers wishing to participate in clinical trials. The ultimate goal of this project is to increase the number of trial centers in CLR for the benefit of patients, science, and society in general.

Attitudes toward participation in breast cancer randomized clinical trials in the African American community: a focus group study

Participation of African Americans in research trials is low. Understanding the perspectives of African American patients toward participation in clinical trials is essential to understanding the disparities in participation rates compared with whites. A qualitative study was conducted to discover attitudes of the African American community regarding willingness to participate in breast cancer screening and randomized clinical trials. Six focus groups consisting of 8 to 11 African American women (N = 58), aged 30 to 65, were recruited from local churches. Focus group sessions involved a 2-hour audio-taped discussion facilitated by 2 moderators. A breast cancer randomized clinical trial involving an experimental breast cancer treatment was discussed to identify the issues related to willingness to participate in such research studies. Six themes surrounding willingness to participate in randomized clinical trials were identified: (1) Significance of the research topic to the individual and/or community; (2) level of trust in the system; (3) understanding of the elements of the trial; (4) preference for "natural treatments" or "religious intervention" over medical care; (5) cost-benefit analysis of incentives and barriers; and (6) openness to risk versus a preference for proven treatments. The majority (80%) expressed willingness or open-mindedness to the idea of participating in the hypothetical trial. Lessons learned from this study support the selection of a culturally diverse research staff and can guide the development of research protocols, recruitment efforts, and clinical procedures that are culturally sensitive and relevant.

Attitudes Toward Research Participation and Investigator Conflicts of Interest Among Advanced Cancer Patients Participating in Early Phase Clinical Trials

Purpose

Although both financial and intrinsic conflicts of interest can exist throughout the drug development process, little is known about how advanced cancer patients enrolled onto early phase clinical trials perceive investigator conflicts of interests.

Patients and Methods

We interviewed 102 advanced cancer patients enrolled onto phase I clinical trials using a standardized survey that addressed multiple issues related to conflicts of interest and research participation.

Results

Fifty-five percent of patients would not be concerned if physicians involved in running a clinical trial had financial conflicts of interest, whereas 65% of patients would be concerned if physicians involved in running a trial had intrinsic conflicts of interest. Most patients reported that potential conflicts of interest should be disclosed to patients on research trials (52% for financial conflicts of interest and 61% for more intrinsic conflicts of interest). Most patients would be willing to participate in trials after learning conflict of interest information (63%). Younger patients expressed more concern regarding financial conflict of interest than older patients (odds ratio, 6.22; 95% CI, 1.41 to 27.24).

Conclusion

Patients with advanced cancer are equally, if not more, concerned about traditional intrinsic conflicts of interest as compared with financial conflicts of interest. Patients generally believed that conflict of interest information should be disclosed to research participants. The fact that younger patients expressed more concern about financial conflicts of interest may have the potential to influence clinical trial participation rates. The actual impact of conflict of interest disclosure to research subjects needs to be evaluated more carefully.

Patient understanding of research: developing and testing of a new questionnaire

Lack of understanding or knowledge of research among patients participating in randomized clinical trials (RCTs) is common. However, there is a lack of validated measures to assess the extent of the problem. The aim of this study was to develop and pilot a questionnaire to assess knowledge and understanding of RCTs in the cancer setting. A 13-item four-part questionnaire was developed and piloted with three groups: patients with cancer who had no experience of clinical trials (n=26); patients with cancer who had previously participated in an RCT (n=26) and research nurses (n=26). The groups were compared using non-parametric anova techniques which showed a highly statistically significant difference between the nurses and both patient groups (P<0.001). The difference between the patient groups was not significant (P=0.231). Cronbach's alpha was computed at 0.77. After studying correlation of individual questions and verbatim comments from respondents, one question was removed from the questionnaire, but this did not have a major effect on the properties of the tool. Minor changes were made to six other questions and the revised tool will now be used and further tested in a large randomized controlled trial to improve informed consent in trial participation.

Patterns of participation of patients in cancer clinical trials in Ireland

BACKGROUND

In the United States the overall participation in cancer clinical trials (CCT) is less than 3% [Avis et al. in J Clin Oncol 24:1860-1867 (2006); Lara et al. in J Clin Oncol 19:1728-1733 (2001)]. In Europe there is little data on participation in such trials.

AIM

We aim to gather information on factors influencing CCT enrolment in Ireland.

METHODS

From November 2005 to 28 February 2006 all consecutive patients considered for systemic therapy were assessed for eligibility re participation in available CCTs.

RESULTS

A total of 290 patients were included. Overall 2.4% of patients were recruited to one of the available CCTs. The main reasons for failure of trial recruit were: no trial for cancer type (60%), no trial for stage (21%), ineligible by trial criteria (16.1%), patient declined (0.3%), and physician discretion (2.6%). Only one patient, who was otherwise eligible, declined entry into a clinical trial.

CONCLUSIONS

Irish patients with cancer are very willing to participate in CCTs. Current levels of recruitment compare favourably with international levels.

Community readiness to promote Latinas' participation in breast cancer prevention clinical trials

The high breast cancer (BC) mortality rates that exist among Hispanic women (Latinas) are a health disparity burden that needs to be addressed. Prevention clinical trials are a burgeoning area of cancer prevention efforts and may serve to promote parity. Unfortunately, Latinas, along with other ethnic minority women, continue to be under-represented in this form of research. Previous studies have examined individual barriers to ethnic minorities' participation, but none have assessed community factors contributing to Latinas' under-representation in these studies. The present study addressed these limitations from a community perspective by exploring which factors might inhibit Latinas' participation in clinical trials, specifically BC prevention trials. Using the Community Readiness Model (CRM), 19 key informants were interviewed in four communities, two rural and two urban, in Colorado, USA. The key informant assessment involved a semistructured interview that measured the level of community readiness to encourage participation in BC prevention activities. The results reflected a community climate that did not recognise BC as a health problem that affected Latinas in participating communities. Compared to other healthcare priorities, participation in BC prevention clinical trials was considered a low priority in these communities. Overall, leadership and community resources were not identified or allocated to encourage the participation of Latinas. The results highlight the lack of awareness regarding clinical trials among both community members and leaders. According to the CRM, strategies to enhance awareness at multiple levels in the community are necessary. This study demonstrates how the CRM can be used to better understand a community's perspective on BC, and specifically, the under-representation of Latinas in clinical trials.

Who enrolls onto clinical oncology trials? A radiation Patterns Of Care Study analysis

PURPOSE

To identify factors significantly influencing accrual to clinical protocols by analyzing radiation Patterns of Care Study (PCS) surveys of 3,047 randomly selected radiotherapy (RT) patients.

METHODS AND MATERIALS

Patterns of Care Study surveys from disease sites studied for the periods 1992-1994 and 1996-1999 (breast cancer, n = 1,080; prostate cancer, n = 1,149; esophageal cancer, n = 818) were analyzed. The PCS is a National Cancer Institute-funded national survey of randomly selected RT institutions in the United States. Patients with nonmetastatic disease who received RT as definitive or adjuvant therapy were randomly selected from eligible patients at each institution. To determine national estimates, individual patient records were weighted by the relative contribution of each institution and patients within each institution. Data regarding participation in clinical trials were recorded. The factors age, gender, race, type of insurance, and practice type of treating institution (academic or not) were studied by univariate and multivariate analyses.

RESULTS

Overall, only 2.7% of all patients were accrued to clinical protocols. Of these, 57% were enrolled on institutional review board-approved institutional trials, and 43% on National Cancer Institute collaborative group studies. On multivariate analysis, patients treated at academic facilities (p = 0.0001) and white patients (vs. African Americans, p = 0.0002) were significantly more likely to participate in clinical oncology trials. Age, gender, type of cancer, and type of insurance were not predictive.

CONCLUSIONS

Practice type and race significantly influence enrollment onto clinical oncology trials. This suggests that increased communication and education regarding protocols, particularly focusing on physicians in nonacademic settings and minority patients, will be essential to enhance accrual.

[Perceptions of patients and physicians involved in clinical trials: an overview of the literature]

OBJECTIVE - METHOD: The purpose of this review is to explore the expectations of patients and physicians prior to participate to a clinical trial and their positive or negative experiences after participating. A systematic review of Medline database from 1966 to 2005 identified 79 papers reported patients and physicians perceptions of clinical trials (only 3 in French), whom 27 English surveys conducted on patients and physicians.

RESULTS

If primary patients' motivation for enrolment was altruistic, physicians wish to help their patient. After enrolment, the most perceived positive benefit for patients and physicians are, respectively, the emotional improvement and the greater opportunity for personal benefit offered to enrolled patients. Most physicians' negative experience included logistical difficulties while patients are unease with randomisation and often uncomfortable with medical procedures. Unlike patients, all physicians' expectations seem to be fulfilled.

CONCLUSION

The knowledge of patients' and physicians' perception of participation may improve recruitment in clinical trials.

How to Get Older People Included in??Clinical Studies

Older people are systematically excluded from many clinical research studies. In this review, we examine the reasons for this state of affairs and summarise the current knowledge of strategies to increase the rate of participation of older people in clinical studies. Older people want to participate in clinical research and are driven by a mixture of altruism and self-interest. They are often excluded by overt age cut-offs or covert exclusions based on co-morbidity and frailty. Other barriers to participation include communication and cognitive difficulties, transport difficulties, low income and self-imposed agism. Possible strategies to improve recruitment of older people to clinical studies include abolishing age limits, reducing exclusion criteria, and allowing sufficient study time (to recruit and deal with older patients) and money (for reimbursement of their participation costs) in study protocols. Involving older people and their attending health professionals in the design of study protocols may also be helpful. Providing transportation, easy physical access to research institutions and use of personalised and face-to-face recruitment also pay dividends. A variety of recruitment methods have been found to be effective, but tailoring the strategy to the condition and population under study is necessary. Together, these strategies should improve the representation of older people in clinical research and ensure that the evidence base is relevant and useful to all those caring for older people.

The Influence of Race on the Attitudes of Radiation Oncology Patients Towards Clinical Trial Enrollment

OBJECTIVES

Enrollment of adult cancer patients in clinical trials remains low, particularly in the minority population. Understanding patient attitudes towards clinical trials during the recruitment process may enhance accrual. Unfortunately, data describing patient attitudes towards clinical trials are limited, particularly in the radiation oncology clinic setting.

METHODS

A piloted questionnaire assessing basic demographics and attitudes toward clinical trials was offered in 2 radiation oncology clinics between April 2003 and October 2003. The questionnaire was completed by 166 patients. The mean age of the patients completing the questionnaire was 56 years (range, 15-84 years). Of the 166 patients included in the analysis, 108 (65%) were White. The most common cancer diagnoses included prostate (19%), head and neck (16%), and breast (14%).

RESULTS

There was no statistical difference between Whites and non-Whites regarding their interest in learning about clinical trials (84.3% versus 84.9%, P = 0.92); nor was there a significant difference in the rate of previous or current trial enrollment (21.3% versus 34.0%, P = 0.08). White patients were more likely to gather information about clinical trials from the Internet (30.6% versus 11.3%, P = 0.007), and they were more likely to use physicians as a source of this information (50.0% versus 34.0%, P = 0.05). Non-White patients were more likely to obtain information about clinical trials from other patients (24.5% versus 12.0%, P = 0.04). In addition, more non-White patients believed they had been treated on clinical trials without their knowledge (21.6% versus 9.3%, P = 0.032). Patients differed somewhat in their expectations of clinical trials. More non-Whites indicated that they would need a >50% chance of benefiting from a trial (64.4% versus 45.0%, P = 0.03) to enroll on that trial, though there were no statistical differences in outlook towards potential toxicities associated with treatment on a clinical trial.

CONCLUSIONS

Minority patients historically enroll in clinical trials at a significantly lower rate. Our study of radiation oncology patients documents significant differences in attitudes towards clinical trials between Whites and non-Whites. Understanding the differences in attitudes may allow physicians to overcome barriers that would otherwise hinder the enrollment of non-White patients into clinical trials.

Factors associated with enrollment in cancer genetics research

Previous studies have identified low patient accrual in large-scale cancer clinical trials, particularly for underrepresented groups, such as ethnic minorities, females, and patients >65 years. As there have been few studies examining participation in cancer genetics epidemiologic research, our objective was to identify clinical and demographic factors predicting enrollment in these studies. A total of 1,111 patients diagnosed with colorectal cancer presenting to a gastrointestinal oncology clinic were approached to enroll in a study investigating the role of the MSH6 gene in familial colorectal cancer. Patient consent was sought for providing a blood specimen for DNA analysis and review of medical records/tumor specimens and contacting family members to confirm the family history of cancer. Seven predictor variables for enrollment (age, sex, ethnicity, family history of colorectal cancer in a first-degree relative, presence of children, insurance type, and type of visit) were analyzed using logistic regression analysis to determine the effect on decision to enroll. Of 1,111 patients approached, 696 (62.6%) enrolled in the study. Of these approached individuals, 4.2% were of nonwhite ethnicity and 33.5% were age > or =65 years. Patients of white ethnicity [odds ratio (OR), 2.10; P = 0.018], males (OR, 1.47; P = 0.002), those ages < or =65 years (OR, 1.42; P = 0.009), and those with a first-degree relative with colorectal cancer (OR, 1.57; P = 0.005) were significantly more likely to enroll. Fewer than 4% of all participants denied permission for the study researchers to access information from medical records or to be recontacted by researchers to discuss the enrollment of additional family members. Our data suggest that, once subjects decided to enroll, the majority (88%) was comfortable with consenting to all study components, including the creation of cell lines and future recontact. Low participation rates for ethnic minorities, females, and elderly patients are similar for both cancer genetics and clinical trial studies.

Influence of tumor type, disease status, and patient age on self-reported interest regarding participation in cancer clinical trials

There is limited information available regarding the reasons cancer patients decide to enter clinical trials. To explore this issue, aggregate responses to the question, "Are you interested in learning about clinical trials for your condition?" obtained from >115,000 cancer patients (or their families) who entered data into 1 of several proprietary decision-support programs embedded within approximately 100 well-established cancer-related Internet sites were analyzed. The percentage of patients (or their families) who expressed interest in learning about clinical trials ranged from as low as 21% (endometrial and cervix cancer patients >80 years of age; n=178) to as high as 85% (recurrent ovarian cancer patients, age 51-60; n=842). Patients >80 years of age, regardless of sex, tumor type, or status of disease, were considerably less likely to be interested in clinical trial information than younger individuals. Whereas there were no differences between males and females in their desire to obtain information, patients with self-declared more "serious conditions" (e.g., metastatic breast cancer, recurrent prostate cancer), and those with specific cancers having a widely recognized poor prognosis (e.g., nonsmall cell lung cancer), were more likely to request study information. In the current evaluation of a large database of individuals who elected to participate in 1 of several cancer-related decision-support programs, major differences in self-expressed interest in obtaining information regarding clinical trials was observed. Particularly notable was the reduced desire to gather such information among the very elderly, and the increased interest by patients with the most serious cancer-related conditions.

Breast cancer patients' attitudes toward clinical trials in the radiation oncology clinic versus those searching for trial information on the Internet

Web-based clinical trials matching systems including breast cancer patients are expanding rapidly. However, limited data exist regarding the demographics and attitudes of breast cancer patients using the Internet to search for clinical trials information. Biases in patient populations could be introduced by recruiting patients to trials through the Internet. This study was designed to compare breast cancer patients in the radiation oncology clinic to those using the Internet to search for clinical trials information. A piloted questionnaire assessing demographics and attitudes regarding clinical trials was offered through the radiation oncology clinic at the University of Pennsylvania and on the OncoLink website (http://www.oncolink.org). The questionnaire consisted of 18 questions and was answered by a total of 157 patients with breast cancer. Breast cancer patients using the Web were more likely to be interested in clinical trials testing new drugs or therapies (71 [53%] versus 4 [17%], p = 0.002). More clinic patients indicated they would need a greater than 50% chance of benefiting from a trial (12 [52%] versus 33 [25%], p = 0.01) and a less than 10% potential for serious toxicity from a trial (15 [65%] versus 51 [38%], p = 0.02) for consideration of enrollment. African Americans were more likely than other races to have never used the Internet to search for cancer-related information (4 [40%] versus 18 [12%], p = 0.01), more likely to indicate that they need a greater than 50% chance of benefit to enroll in clinical trials (8 [80%] versus 37 [25%], p = 0.001), and less likely to be interested in clinical trials testing new drugs or therapies (1 [10%] versus 73 [50%], p = 0.01). Breast cancer patients have different attitudes regarding clinical trials based on race, Internet usage, and previous trial enrollment. Biases may be introduced with recruitment for clinical trials through the Internet. Radiation oncologists must consider these issues when offering clinical trials information through the Internet.

Why don’t cancer patients enter clinical trials? A review

Despite widespread agreement about the value of clinical trials, the proportion of patients who are enrolled in such trials is often considered to be too low. A comprehensive literature search was carried out for the period 1980 to the present, in order to review current data on barriers and facilitators to the development of multicentre clinical trials. Of 364 articles initially identified, 35 articles and 1 book were selected in order to assess the reasons that doctors and/or patients participate in clinical trials. This review emphasises the fact that doctors play a key role in the development and non-development of clinical trials. More studies, in particular studies outside the United States of America (USA), are needed in order better to understand doctors' attitudes towards clinical trials. Such studies should combine multivariate analyses and comparative approaches in order to associate doctors' behaviours with their individual characteristics, with the organisational context of their working environment and with the healthcare system.

Randomized clinical trials for hematopoietic stem cell transplantation: lessons to be learned from the European experience

We evaluated the number and characteristics of randomized controlled trials (RCTs) addressing hematopoietic stem cell transplantation (HSCT) for patients with hematological malignancies, comparing the productivity of US and Europe. A MEDLINE search was conducted to identify all published RCTs for the management of adult patients with hematological malignancies from January 1992 to December 2003. Eighty-three of the 306 trials identified included HSCT as one of the treatment arms. The US produced 25, Europe 54, and all other countries four. Four European countries, France, Italy, Germany, and UK (FIGU), produced 32 out of the 54 European studies. Significant differences emerged when focus of the study and accrual numbers were analyzed. Trials comparing HSCT to standard dose therapy represented 34.9% of the 83 trials and 59.4% of FIGU trials, but only 4% of US studies (P = 0.001). US trials accrued a mean of 110.2 patients per study, as compared to 222.6 in FIGU studies (P = 0.006) and 205.3 when all non-US countries are considered (P = 0.01). Our conclusions are that US transplant RCT have focused on issues other than the comparison of HSCT to standard therapies. There is serious paucity of US trials defining the role of HSCT in the management of hematological malignancies.

Predictors of enrollment in lung cancer clinical trials

BACKGROUND

Clinical trials may offer patients innovative therapeutic options with potentially better outcomes, which are particularly relevant for patients afflicted with lung carcinoma, because current therapies provide only modest survival benefits. Only approximately 5% of patients with newly diagnosed cancer participate in clinical trials nationwide, and African-American (AA) patients are particularly under-represented.

METHODS

To determine predictors of clinical trials enrollment, the authors reviewed the medical records of 427 patients with lung carcinoma (175 AA patients and 252 non-AA patients) who were eligible for clinical trials between 1994 and 1998 at the Karmanos Cancer Institute in Detroit, Michigan. Logistic regression analysis was used to assess the association of patient demographic characteristics and clinical trial enrollment.

RESULTS

Ninety-one patients (21%) were enrolled onto a lung cancer clinical trial during the period of the current study. Enrollment was associated significantly with race (P < 0.001), gender (P = 0.048), age (P = 0.005), and insurance type (P = 0.024). After multivariable adjustment, only race and gender remained significant predictors of enrollment. AA patients were less likely to enroll than non-AA patients (odds ratio [OR], 0.485; 95% confidence interval [95% CI], 0.243-0.966), and men were more likely than women to enroll (OR, 1.812; 95% CI, 1.033-3.178).

CONCLUSIONS

The current results suggest disparities by race and gender in the enrollment of patients onto lung cancer clinical trials and support the need to improve educational and outreach endeavors that would make clinical trials available to a wider range of eligible patients.

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

BACKGROUND

To the authors' knowledge, only limited data are available regarding clinical trial accrual patterns and the barriers encountered among newly diagnosed patients seen at community-based cancer centers.

METHODS

In the current study, the authors prospectively collected clinical and sociodemographic data from all adult patients seen at a community-based cancer center who had new cancers diagnosed between 2003-2004. Clinical trial enrollment decisions were noted and factors that prevented accrual were identified.

RESULTS

There was a total of 1012 new cancer patients. In 587 patients (58%), clinical trials appropriate for the diagnosis and stage of disease were not available. Among those patients for whom trials were available, 19.8% did not meet eligibility criteria, and only 9.9% of patients were enrolled. Although more trials were found to be available for women compared with men (51% vs. 32%; P < 0.01), the accrual rates were equal (11.2% vs. 7.6%; P = 0.24). Elderly patients comprised approximately 59.4% of those patients with available trials, but they were less likely to be enrolled (5.1% vs. 16.8%; P < 0.01). The major barriers to nonparticipation can be grouped into protocol limitations (68.1%), physician triage (16%), and patient decisions (15.9%). The overall accrual rate when all patients were included was 4% (42 of 1012 patients).

CONCLUSIONS

At the study institution, participation in clinical trials is reported to be low. The unavailability of appropriate clinical trials represents the most significant barrier. Continuing efforts to encourage physicians and to educate patients remain necessary. If the current study findings are found to be applicable to other community-based cancer centers, making a larger variety of clinical trials available to the community may help to improve the accrual of patients to national cancer clinical trials.

Recruitment and participation in clinical trials: socio-demographic, rural/urban, and health care access predictors

BACKGROUND

Recruitment and participation in clinical trials by minorities, particularly African Americans and rural underserved populations, are low. This report examines predictors of clinical trial recruitment and participation for adult Marylanders.

METHODS

A cross-sectional design was used to survey 5154 adults (18 years and older) residing in 13 of the 24 jurisdictions in Maryland, including urban Baltimore City, and the rural regions of Western Maryland and the Eastern Shore. The survey, conducted between December 2001 and March 2003, used Computer-Assisted Telephone Interviewing and random-digit dialing procedures. Primary dependent variables included "ever asked to participate" (i.e., recruited) and "participated" in clinical trials.

RESULTS

11.1% of the respondents had been recruited to clinical trials. In addition, 59.4% of the respondents recruited to clinical trials actually participated in a clinical trial. Among respondents recruited to clinical trials, black and middle income respondents were significantly less likely to actually participate in clinical trials; whereas, respondents who received information about clinical trials from their health care provider, who were knowledgeable about clinical trials, and those who had the time commitment were significantly more likely to participate in clinical trials.

CONCLUSIONS

These results suggest serious gaps in efforts to recruit racial/ethnic minorities and residents of rural regions into clinical trials. The findings provide the basis for the development and implementation of community-based educational programs for both the general public and health care professionals, and to enhance availability of community-based clinical trials, especially in the rural areas of the state.

Understanding cancer patients' experience and outcomes: development and pilot study of the Cancer Care Outcomes Research and Surveillance patient survey

GOALS OF WORK

The National Cancer Institute's Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium is conducting a population-based study of newly diagnosed patients with lung and colorectal cancer to describe the experience of persons living with cancer and to understand which barriers present the most significant obstacles to their receipt of appropriate care. The keystone to this effort is the baseline patient survey administered approximately 4 months after diagnosis.

PATIENTS AND METHODS

We developed a survey to obtain information from patients newly diagnosed with lung and colorectal cancer about their personal characteristics, decision making, experience of care, and outcomes. We conducted a pilot study to evaluate the feasibility of a lengthy and clinically detailed interview in a convenience sample of patients within 8 months of diagnosis (n=71).

MAIN RESULTS

The median length of the interviews was 75 min for patients with lung cancer (range 43-130) and 82 min for patients with colorectal cancer (range 46-119). Most patients had received some form of treatment for their cancer: 66.1% had undergone surgery, 28.2% had received radiation therapy, and 54.9% were treated with chemotherapy. In addition, 26.7% reported their overall health was less than 70 on a 0-100 scale, demonstrating that patients with substantial health impairment were able to complete the survey.

CONCLUSIONS

A clinically detailed survey of newly diagnosed lung and colorectal cancer patients is feasible. A modified version of this survey is being fielded by the CanCORS Consortium and should provide much needed population-based data regarding patients' experiences across the continuum of cancer care and their outcomes.

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.

Factors that influence Spanish- and English-speaking participants' decision to enroll in cancer randomized clinical trials

Cancer randomized clinical trial (RCT) participation is low, particularly among ethnic and racial minorities. Hispanic enrollment is far below their representation in the US population, yet their cancer burden is higher. Little is known from the patient perspective about factors which influence the decision to enroll in RCTs. We asked Spanish- and English-speaking individuals what factors influence decisions about cancer RCT participation. Eight focus groups were conducted with 55 participants (25 Spanish and 30 English-speaking). The groups were taped, transcribed, and analyzed for themes. Six major themes emerged: patient-provider communication, personal relationship with provider, involvement of significant others in decision making, role of faith, need for information, and impact of discrimination on decision making. Both similarities (e.g. need for comprehensive information) and differences (e.g. need for provider acknowledgement of emotional and spiritual concerns) were found between Spanish- and English-speaking participants. Among Spanish-speaking participants, level of education was differentially related to decision-making themes. Implications for providers are discussed.

Factors Affecting Older African American Women's Decisions to Join the PLCO Cancer Screening Trial

Purpose

The purpose of this study is to describe the factors associated with the decisions of older African American women to join the PLCO (Prostate, Lung, Colorectal and Ovarian) Cancer Screening Trial when recruited.

Methods

African American women between ages 55 and 74 years who were never diagnosed with a PLCO cancer were eligible for our study. Two methods of recruitment were used. First, mailings were sent to a random sample of women describing the PLCO followed by a telephone call to determine interest in the PLCO. If women were not interested in PLCO but consented to participate in our study, they were interviewed immediately. Second, we followed up with African American women who responded to mass mailings sent out before the start of our study by the Pittsburgh PLCO office. Women completed an interview about their cancer and clinical trial knowledge, attitudes, beliefs, and behaviors. The responses of women who joined the PLCO Trial are contrasted with the responses of women who did not join.

Results

Numerous factors were associated with the decision of older African American women to join the PLCO, including perceptions of cancer prevention and detection, the experience of having a loved one with cancer, knowledge of and experience with clinical trials, and beliefs regarding the benefits and risks of clinical trial participation.

Conclusion

Minority recruitment to cancer clinical trials could be increased by designing interventions focused on individual, organizational, and community needs.

A pilot study to establish a clinical model to perform phase II studies of breast cancer chemopreventive agents in women at high risk with biomarkers as surrogate endpoints for activity

PURPOSE

Use of surrogate end point biomarkers in phase II trials may help select agents that appear to have activity and might be evaluated in future phase III definitive trials of breast cancer prevention. We performed a pilot clinical trial to establish the logistics for a clinical model to perform phase II studies of breast cancer chemopreventive agents in women at high risk with novel imaging techniques and candidate surrogate end point biomarkers for activity. We chose tamoxifen to establish proof of principal with a known effective agent.

EXPERIMENTAL DESIGN

Women at a high risk of developing a new breast cancer and for whom tamoxifen was recommended were eligible. The women underwent baseline and 3 and 6 months mammogram and magnetic resonance imaging (MRI) of one breast to identify areas of water-like intensity (epithelial) and to determine the changes over time and MRI-directed core breast biopsies of these areas for surrogate end point biomarkers analysis.

RESULTS

From August 1999 to March 2001, 26 women underwent baseline imaging and core biopsies. Sixteen women took tamoxifen and 10 chose not to. Overall, 79% of the samples contained glandular tissue evaluable for histology, but only 66% of the samples were evaluable for marker analysis. Only 12 patients had specimens with glandular tissue sufficient for marker analysis both at baseline and in at least one follow-up. Because of the small number of women with matched samples, marker analysis was not informative.

CONCLUSIONS

This study shows the feasibility of obtaining serial core breast biopsies from women at a high risk of developing a new breast cancer. Patient participation in this model is satisfactory, and such a model may provide indication of drug activity. MRI-directed biopsy did not provide a high yield of evaluable samples, and additional work on adequate collection of epithelial tissue for surrogate end point biomarker analysis is thus necessary.

Mothers' attitudes to the randomized controlled trial (RCT): the case of acute lymphoblastic leukaemia (ALL) in children

OBJECTIVES

Survival rates for childhood cancer have improved substantially partly as a result of national and international randomized clinical trials (RCT). However, the decision for families is complex and emotional. Our aim was to describe the views of mothers of children newly diagnosed with ALL regarding consent to randomized controlled trials.

DESIGN

Qualitative interview to explore mothers knowledge, and reasons for involving their child in RCTs. Interviews took place in mothers' homes.

PARTICIPANTS

Fifty mothers of children with newly diagnosed ALL (age 4-16 years; mean = 7.4) recruited through research nurses at outpatient appointments.

RESULTS

All but three families had consented for their child to be treated in the RCT, although there was wide variation in their understanding of the aims, costs and benefits. Most mothers reported the aim of the trial to compare 'old' and 'new' treatments.

CONCLUSION

Despite detailed verbal and written information, mothers were poorly informed about the purpose of the trial, and possibility of side effects. Individual preferences for either standard or new treatment were routinely reported. The data raise questions about the extent to which families give truly informed consent to recruitment of their child to an RCT.

How Italian health consumers feel about clinical research: a questionnaire survey

BACKGROUND

Because little information is available about the public's awareness of and attitudes toward clinical research, we planned a survey on a convenience sample of health consumers.

METHODS

A cross-sectional national survey was carried out using a questionnaire with seven multiple choice questions and two scenarios. A convenience sample of 2000 individuals aged 18 years and older was interviewed in nine out of 21 Italian regions.

RESULTS

Sixty-nine per cent reported they were aware of the existence of clinical research and 45% were aware of ethics committees; 29% and 49% indicated they would agree to participate in a prevention study or therapeutic randomized clinical trial, respectively. These percentages decreased when we asked about giving permission for a younger relative. Participants' awareness, opinions and attitudes varied significantly according to socio-demographic and geographical variables. People who were aware of clinical research tended to have a more open attitude toward participation [preventive study: odds ratio (OR) 1.6, 95% confidence interval (CI) 1.3-2.0, P = 0.001; therapeutic study: OR 1.3, 95% CI 1.1-1.6, P = 0.003), even after adjustment for confounding factors. A comparison with an independent and random sample of Italian citizens documented a difference in relevant case-mix factors and a different profile in terms of awareness, opinion and attitudes, which held after statistical adjustment.

CONCLUSIONS

Health consumers are generally not very aware of clinical research, and their attitudes towards participation seem to be related to the level of awareness. A few variables, such as age, sex, schooling and area of residence, are related to the study questions. These findings may help with the implementation of educational interventions, and underline the need to create meaningful partnerships between health professionals and consumer associations.

Randomized Phase II Designs in Cancer Clinical Trials: Current Status and Future Directions

Purpose

Randomized phase II (RPh2) designs are popular in cancer clinical trials because of the smaller sample size requirements when multiple treatments are being evaluated. We reviewed the use of RPh2 designs and give comments on future directions.

Design

The trial design, statistical properties, conduct, data analysis, results, and reporting were examined in RPh2 trials reported from 1986 to 2002.

Results

A statistical design was reported in only 46% of the 266 cancer trials, and approximately half of those provided inadequate information. Most studies applied randomization to achieve patient comparability, while embedding a one-sample phase II design within each treatment arm. Seventy-five percent of the trials’ accruals were within ± 10% of their targets. The average accrual rate was 3.3 patients per month. Planned interim analyses were reported in 27% of the trials, and 56% of the trials were stopped early; 69%, 13%, 13%, and 4% of the trial discontinuations were because of lack of efficacy, efficacy, toxicity, and slow accrual, respectively. Thirty-nine trials (14%) recommended or started phase III evaluations, with four positive reports in six phase III studies identified.

Conclusion

There is a trend of increasing use of RPh2 designs in cancer research. Continued improvement in study design, conduct, analysis, and reporting is required to enhance the quality of RPh2 designs. The accrual rate and success rate of the trials remain low, and therefore, futility stopping rules to terminate ineffective treatment arm(s) should be implemented more frequently. More innovative, flexible RPh2 designs are needed to facilitate the development of effective cancer treatments.

Systematic review of barriers to the recruitment of older patients with cancer onto clinical trials

PURPOSE

Older patients are significantly underrepresented in cancer clinical trials. A literature review was undertaken to identify the barriers that impede the accrual of this vulnerable population onto clinical trials and to determine what specific strategies are needed to improve the representation of older patients in research studies.

METHODS

A systematic literature search was undertaken using several different strategies to identify relevant articles.

RESULTS

Nine of 31 relevant papers from 159 citations were included. Age is a significant barrier to recruitment; only a quarter to one third of potentially eligible older patients are enrolled onto trials. Physicians' perceptions, protocol eligibility criteria with restrictions on comorbid conditions, and functional status to optimize treatment tolerability are the most important reasons resulting in the exclusion of older patients. Other barriers include the lack of social support and the need for extra time and resources to enroll these patients. Conversely, older patients do not view their age as an important reason for refusing trials.

CONCLUSION

Specific clinical trials confined to older patients should be conducted to evaluate tumor biology, treatment tolerability, and the effect of comorbid conditions. Protocol designs need to stratify for age and be less restrictive with respect to exclusions on functional status, comorbidity, and previous cancers, such that results are generalizable to older patients. Physician education to dispel unfounded perceptions, improved access to available clinical trials, and provision of personnel and resources to accommodate the unique requirements of an older population are possible solutions to remove the barriers of ageism.

Implementation and Evaluation of a Central Coordination Office for Clinical Trials in a Tertiary Care Hospital

BACKGROUND

Controlled clinical trials are essential tools for establishing new standards in patient care. Nevertheless, the majority of cancer patients are not treated within clinical trials. We report about a project now running for 7 years that was started in order to enhance the recruitment of patients into clinical trials, to improve trial-related quality, and to comply with the regulatory issues related to these studies.

MATERIAL AND METHODS

We established a Central Coordination Office (CCO) for clinical trials, an associated internal clinical trials review board, a register of active clinical trials, and a computer-based medical information system at our department.

RESULTS

Inpatient recruitment into clinical trials at our department improved over the last 7 years from 40% in 1997 to 70% in 2003. The internal review board approved 276 trial projects since its establishment. A clinical trials register is now in its 9th edition. Currently, 50 to 60 clinical trials in oncology/hematology are active while 10 to 20 new trials are being implemented per year. All clinical trials comply with the regulatory requirements, and trial documentation is provided in a timely manner.

CONCLUSIONS

The establishment of a CCO for clinical trials substantially improves and maintains patient recruitment into clinical trials and improves the quality of clinical research.

Evidence-based practice requires evidence

Patient Safety Leading Article Series, 2004. Continuing the Journal's ‘Patient Safety’ series, David Rothenberger explains why we must transform our culture to become a genuinely evidence-seeking profession.

An Evaluation of Barriers to Accrual in the Era of Legislation Requiring Insurance Coverage of Cancer Clinical Trial Costs in California

PURPOSE

Clinical trials are essential to improve cancer therapy, but only 3% of newly diagnosed adult cancer patients enroll annually. We previously conducted a prospective analysis of factors affecting trial accrual at the UC Davis Cancer Center between 1997 and 2000. It was found that the accrual rate was 14% and that patients with private insurance were significantly less likely than patients with government insurance to enroll, suggesting that fear of insurance denial was a barrier. In 2002, a new California law (SB37) required insurers to reimburse routine costs of care for cancer trials.

METHODS

To assess the impact of SB37 on accrual, we repeated our study using the same sur vey instrument. Oncologists seeing new patients at the UC Davis Cancer Center from August to November 2002 completed questionnaires that inquired about patient characteristics and eligibility, protocol availability, and patient willingness to participate.

RESULTS

Physicians considered clinical trials for 55% (118/216) of patients, but trials were available for only 53% (62/118). Eligibility criteria were met by 82% (51/62). Of these, 69% (35/51) agreed to participate (vs 51% previously). No patient declined to participate because of insurance limitations (vs 8% previously). Furthermore, insurance type was no longer a significant factor in determining whether patients would enroll. This suggests that although the overall rate of accrual is only slightly increased after passage of SB37, patients may be more willing to enroll. Efforts to increase participation must include enhancing physician and patient awareness of SB37.

Evaluación de los proyectos de investigación clínica en un centro monográfico de cáncer

BACKGROUND AND OBJECTIVE

The number of clinical trials in cancer patients has experienced an important growth during last years. However, it is difficult to find data showing this activity in Spanish Hospitals. This study analyses the clinical trials data bases between 1996 and 2002 in a cancer center.

MATERIAL AND METHODS

We perform a descriptive analysis of data from: selection of protocols, origin of proposals, sponsors, investigators, studies performed and published; demographic data about patients and phase of the studies in which they have been included.

RESULTS

Evaluation was undertaken with a standardised protocol review assessment. 337 proposals of clinical trials were evaluated during 1996-2002, with a decreasing acceptance index (62.5% to 39.18%, respectively), the number of proposals has grown from 16 in 1996 to 74 in 2002. The general recruitment index was 6.64%. Between 1995-2002, 1479 patients were registered; only 5% were older than 75 years. Pharmaceutical Companies sponsored the majority of the studies, although Co-operative Groups promote an important number of studies, especially in Haematology and Radiotherapy. Thirteen studies performed between 1996-1998 had been published, and 3 more are accepted for publication (69.5%).

CONCLUSIONS

The number of patients included in clinical trials is limited and older patients are not well represented in them.

Rural cancer patients' perspectives on clinical trials: a qualitative study

BACKGROUND

To increase the participation of low-income, rural cancer patients in clinical trials, a better understanding of patients' attitudes, knowledge, and beliefs is needed.

METHODS

In-depth interviews were conducted with 17 cancer patients living in rural West Virginia.

RESULTS

Patients had limited knowledge regarding clinical trials. Factors that might influence their decisions to participate include location of the treatment facility, physician recommendation, disease status, side effects of the treatment, and the perceived effectiveness of treatment.

CONCLUSIONS

Rural, low-income cancer patients should be better informed about clinical trials, when applicable. Physician trust may enhance willingness to participate if clinical trials are close to home.