Asian Americans and cancer clinical trials: a mixed-methods approach to understanding awareness and experience

The effects of Asian American Pacific Islander (AAPI) data inequities in gynecologic oncology

Asian American and Pacific Islanders (AAPI) are the fastest growing racial group in the United States. Data on AAPI communities, however, are significantly limited. The oversimplification and underreporting of this ethnically and socioeconomically heterogenous population through the use of aggregated data has deleterious effects and worsens disparities in patient treatment, outcomes, and experiences. Gynecologic oncology disparities do not exist in a vacuum, and are rooted in larger cultural gaps in our understanding and delivery of healthcare. In this paper, we aim to demonstrate how AAPI data inequities have negative downstream effects on research and public health policies and initiatives, and also provide a call to action with specific recommendations on how to improve AAPI data equity within these realms.

U.S. racial and ethnic participation in global clinical trials by therapeutic areas

WHAT IS KNOWN AND OBJECTIVE

The discussion about health equity in the United States frequently involves concerns over racial and ethnic minority under-representation in clinical trials and particularly in trials conducted in support of product approvals. The FDA has long worked to encourage diverse participation in clinical trials and through its Drug Trials Snapshots (DTS) program, the U.S. Food and Drug Administration (FDA) has moved to make trial demographic data more accessible and transparent. We conducted a demographic study of U.S. participants in clinical trials for FDA-approved new drugs (new molecular entities [NMEs], and original Biologics License Applications [BLAs]) from 2015 to 2019, as reported in DTS database with a purpose of understanding the extent to which U.S.-based trials used to support product approvals represent the racial and ethnic diversity of the U.S. population by therapeutic area.

METHODS

Participant-level trial data were collected by accessing the FDA electronic common technical document (eCTD), for the applications used to publish each Snapshot. The therapeutic area (TA) for each drug was determined by review division assignment. The demographic data were analysed and compared to U.S. census data.

RESULTS AND DISCUSSION

We examined 102,596 U.S. participants in trials of new drugs that were approved and presented in Drug Trials Snapshots between 2015 and 2019. White participation ranged from 51% in psychiatric trials to 90% in cardiovascular (CV) trials; Black or African American participation ranged from 5% in medical imaging to 45% in psychiatric trials; Asian participation ranged from 0.75% in CV to 4% in dermatologic trials; and Hispanic or Latino participation ranged from 1% in medical imaging to 22% in infectious diseases and gastroenterology trials.

WHAT IS NEW AND CONCLUSION

Our data showed variable representation of racial and ethnic minorities across therapeutic areas at the U.S. sites. Blacks or African Americans were represented at or above U.S. census estimates across most therapeutic areas, while Asians and American Indian or Alaska Natives were consistently underrepresented. Hispanic or Latino participation across most therapeutic areas was below U.S. census estimates, however, more variable, and a sizable proportion of data was missing. The next step is a comparison of trial participation based on disease prevalence and epidemiology, which is a more accurate assessment of trial diversity.

Reporting of Study Participant Demographic Characteristics and Demographic Representation in Premarketing and Postmarketing Studies of Novel Cancer Therapeutics

Importance

Adequate representation of demographic subgroups in premarketing and postmarketing clinical studies is necessary for understanding the safety and efficacy associated with novel cancer therapeutics.

Objective

To characterize and compare the reporting of demographic data and the representation of individuals by sex, age, and race in premarketing and postmarketing studies used by the Food and Drug Administration (FDA) to evaluate novel cancer therapeutics.

Design, Setting, and Participants

In this cross-sectional study, premarketing and postmarketing studies for novel cancer therapeutics approved by the FDA from 2012 through 2016 were identified. Study demographic information was abstracted from publicly available sources, and US cancer population demographic data was abstracted from US Cancer Statistics. Analyses were conducted from February 25 through September 21, 2020.

Main Outcomes and Measures

The percentages of trials reporting sex, age, and race/ethnicity were calculated, and participation to prevalence ratios (PPRs) were calculated by dividing the percentage of study participants in each demographic group by the percentage of the US cancer population in each group. PPRs were constructed for premarketing and postmarketing studies and by cancer type. Underrepresentation was defined as PPR less than 0.8.

Results

From 2012 through 2016, the FDA approved 45 cancer therapeutics. The study sample included 77 premarketing studies and 56 postmarketing studies. Postmarketing studies, compared with premarketing studies, were less likely to report patient sex (42 studies reporting [75.0%] vs 77 studies reporting [100%]; P < .001) and race (27 studies reporting [48.2%] vs 62 studies reporting [80.5%]; P < .001). Women were adequately represented in premarketing studies (mean [SD] PPR, 0.91; 95% CI, 0.90-0.91) and postmarketing studies (mean PPR, 1.00; 95% CI, 1.00-1.01). Although older adults and Black patients were underrepresented in premarketing studies (older adults: mean PPR, 0.73; 95% CI, 0.72-0.74; Black patients: mean PPR, 0.32; 95% CI, 0.31-0.32), these groups continued to be underrepresented in postmarketing studies (older adults: mean PPR, 0.75; 95% CI, 0.75-0.76; Black patients: mean PPR, 0.21; 95% CI, 0.21-0.21).

Conclusions and Relevance

This study found that older adults and Black patients were underrepresented in postmarketing studies of novel cancer therapeutics to a similar degree that they were underrepresented in premarketing studies. These findings suggest that postmarketing studies are not associated with improvements to gaps in demographic representation present at the time of FDA approval.

Age and race distribution in patients in phase III oncology clinical trials

Background: Geriatric patients and minority patients are often under-represented in cancer clinical trials. The presence of multiple comorbidities makes geriatric patients ineligible for most clinical trials. Racial diversity may vary by geographical location and socio-economically backward areas may have a very different racial mix. The increase in cancer incidence in geriatric patients' raises the question of applicability of the results is such clinical trials. This study also explores the representation of different races in phase 3 clinical trials conducted in the past 10 years. Methods: Data about Phase III trials was extracted from the clinical trials.gov for 3 common solid organs and 3 hematological malignancies [breast, colon, lung, diffuse large B-cell lymphoma (DLBCL), acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL)]. The time period studied was for the past 10 years and included only adult patients (≥18 years). The age and race distribution of the patient population in these trials were extracted and analyzed. Results: Geriatric patients and minorities are under-represented in all phase III cancer clinical trials. The range of the proportion of geriatric patients varied from 10% to 40%. African American and Asian patients are under-represented in all phase III cancer clinical trials. Conclusions: The results of phase III clinical trials that are currently conducted on non-geriatric and Caucasian patient population may not meaningfully be applicable to geriatric patients and minorities. This study highlights the disparity of age and race for patients enrolled in clinical trials as against the patients seen in the real world.

Comparative Survival of Asian and White Metastatic Castration-Resistant Prostate Cancer Men Treated With Docetaxel

There are few data regarding disparities in overall survival (OS) between Asian and white men with metastatic castration-resistant prostate cancer (mCRPC). We compared OS of Asian and white mCRPC men treated in phase III clinical trials with docetaxel and prednisone (DP) or a DP-containing regimen. Individual participant data from 8820 men with mCRPC randomly assigned on nine phase III trials to receive DP or a DP-containing regimen were combined. Men enrolled in these trials had a diagnosis of prostate adenocarcinoma. The median overall survival was 18.8 months (95% confidence interval [CI] = 17.4 to 22.1 months) and 21.2 months (95% CI = 20.8 to 21.7 months) for Asian and white men, respectively. The pooled hazard ratio for death for Asian men compared with white men, adjusted for baseline prognostic factors, was 0.95 (95% CI = 0.84 to 1.09), indicating that Asian men were not at increased risk of death. This large analysis showed that Asian men did not have shorter OS duration than white men treated with docetaxel.

Impact of migrancy on cancer clinical trial participation: Factors associated with approach and consent in Australian-born versus migrant groups

BACKGROUND/AIMS

This study compared rates of clinical trial participation and perceived adequacy of information provided prior to consent in migrant and Australian-born cancer patients, and explored factors associated with being approached and agreeing to participate.

METHODS

We utilized data from a larger cross-sectional survey assessing disparities in patient-reported outcomes in Chinese, Arabic, or Greek migrant versus English-speaking Australian-born cancer patients. Participants completed a questionnaire eliciting demographic and disease details, communication challenges, whether invited and consented to a clinical trial, and if so, adequacy of information received.

RESULTS

A total of 566 migrants (142 Arabic, 251 Chinese, and 173 Greek) and 270 English-speaking Australian-born patients participated. Overall, 25% were approached to participate in clinical trials, and of these, 74% consented. Migrants were significantly less likely to consent if asked to participate in clinical trials (P = .009), and fewer migrants (67.2%) reported receiving sufficient information prior to deciding on trial participation (82.1%; P = .04). Perceived understanding of the health system (odds ratio [OR] = 0.71), confidence in speaking (OR = 0.75), ability to understand English (OR = 0.80), and communicate with doctors in English (OR = 0.81) were significantly related to patients' likelihood of being approached to participate in clinical trials. Perceived understanding of the health system (OR = 0.66) was significantly associated with patients agreeing to take part in cancer clinical trials.

CONCLUSIONS

Our findings identified that barriers to migrants' self-reported participation in clinical trials include perceived lack of understanding of the health system and low English proficiency. Strategies that address these barriers are needed to increase migrant patients' participation in cancer clinical trials.

A Content Analysis of the Discussions about Clinical Trials on A Cancer-dedicated Online Forum

Enrollment rates of cancer clinical trials remain low, affecting the delivery of effective medical treatments. Recent research has documented common factors affecting trial participation, but to improve these efforts more studies are needed to further understand specific concerns and issues of potential participants in multiple contexts. Forums and other online peer-to-peer health communities are crucial to the coping and survivorship of cancer patients. Online health communities will offer valuable information to understand how patients discuss perceptions, motivations, and challenges associated with clinical trial participation, and to understand how patients provide support to each other. The present study conducted a content analysis of 270 posts shared by 154 unique users between August 2017 and January 2018 on a popular online breast cancer forum. The analysis identifies common characteristics of patient users, salient post themes, perceived barriers, emotions, and misconceptions regarding clinical trial participation. The study findings are generally consistent with previous studies but provide in-depth insights into online support between cancer patients about clinical trial participation. Implications for practice and future research are also discussed.

Ready to Make A Decision: A Model of Informational Aids to Improve Informed Participation in Clinical Trial Research

Enrollment rates for cancer clinical trials remain low, affecting the generalizability of new treatments. Research shows that many patients face significant challenges in understanding basic clinical trial vocabulary and making informed decisions about participation. Informational aids (IA) are developed to address these challenges and support decision making of cancer clinical trial participation. The present study proposed and tested a structural path model to explain the efficacy of three (i.e., interactive, non-interactive, non-cancer control) IAs. The results revealed that clinical trial participation intention was associated with attitudes and social constructs (i.e., social norm, social sharing, and cues to action). Ease of use, rather than knowledge, was the primary communication feature of IA that influenced the outcome variables. The path relations linking messages features, mediators, and outcome variables were different across all three IAs. The results therefore provide theoretical and practical implications for the use and development of IAs to support clinical trial accrual.

Engaging limited English proficient and ethnically diverse low-income women in health research: A randomized trial of a patient navigator intervention

OBJECTIVE

Evaluate a community-based navigator intervention to increase breast cancer patients' and survivors' access to information about health research participation opportunities.

METHODS

In the context of a Community Based Participatory Research collaboration, we conducted a prospective randomized controlled trial of the Health Research Engagement Intervention with pre- and post-intervention surveys (n = 133). The primary outcome was health research information-seeking behavior. Secondary outcomes were health research knowledge, willingness to participate in health research, and health empowerment. Qualitative interviews (n = 11) elucidated participant perspectives on the intervention.

RESULTS

There was no statistically significant difference between intervention and control groups' information-seeking behavior. Knowledge that not all health research studies are about drugs or treatments increased significantly from pre- to post-test among intervention group participants (32% to 48%, p = 0.012), but not in the control group (43% to 30%, p = 0.059); the difference between arms was statistically significant (p = 0.0012). Although survey responses indicated willingness to participate, qualitative interviews identified competing priorities that limited participants' motivation to seek enrollment information.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Community-based navigators are a trusted, and therefore promising link between health research and low-income underserved communities. However, systemic barriers in health research infrastructures need to be addressed to include low income, LEP and immigrant populations.

A Pilot Study to Determine the Effect of an Educational DVD in Philippine Languages on Cancer Clinical Trial Participation among Filipinos in Hawai'i

We conducted an experimental pilot study in an oncology clinic in Honolulu, Hawai'i to determine the effect of a culturally-tailored educational DVD on cancer clinical trial participation among Filipino cancer patients. Thirty-seven patients participated in the study, with 17 randomized into the control group (ie, usual education) and 20 into the intervention group (ie, usual education plus educational DVD). Participants completed pre- and post-educational questionnaires with items asking about understanding of several cancer topics, behavioral outcomes, and attitudes regarding several treatment and physician related topics. A Fisher's exact test was conducted to explore the association between enrollment into a clinical trial and group assignment. General linear models were created to determine significant differences between study groups in post-education response scores for each questionnaire item after controlling for age, gender, education, and pre-education response scores. Two participants from the control group and three participants from the intervention group enrolled into clinical trials. Results showed no significant association between clinical trial enrollment and study group assignment (P > .99). A significant difference was found between study groups on surety of joining the clinical trial suggested to them (P = .013). A multilingual educational DVD to supplement clinical trial education may positively influence Filipino cancer patients to move forward with the decision to join a cancer clinical trial. However, health literacy may serve as a major barrier to actual enrollment into the particular clinical trial available to a patient.

Socioeconomic and clinical factors are key to uncovering disparity in accrual onto therapeutic trials for breast cancer

To monitor and address disparity in accrual, patient participation in cancer clinical trials is routinely summarized by race/ethnicity. To investigate whether confounding obscures racial/ethnic disparity in participation, all women with breast cancer treated by medical oncologists at City of Hope Comprehensive Cancer Center from 2004 through 2009 were classified by birthplace and self-reported race/ethnicity, and followed for accrual onto therapeutic trials through 2010. Undetectable on univariate analysis, significantly reduced participation by subjects of African, Asian, Eastern European, Latin American, and Middle Eastern ancestries was revealed after accounting for age, socioeconomic factors, tumor and oncologist characteristics, and intrapractice clustering of patients.

Effective recruitment strategies and community-based participatory research: community networks program centers' recruitment in cancer prevention studies

BACKGROUND

Community-based participatory research (CBPR) approaches that involve community and academic partners in activities ranging from protocol design through dissemination of study findings can increase recruitment of medically underserved and underrepresented racial/ethnic minority populations into biomedical research.

METHODS

Five cancer screening and prevention trials in three National Cancer Institute (Bethesda, MD)-funded Community Networks Program Centers (CNPC), in Florida, Kansas, and South Carolina, were conducted across diverse populations. Data were collected on total time period of recruitment, ratios of participants enrolled over potential participants approached, selected CBPR strategies, capacity-building development, and systematic procedures for community stakeholder involvement.

RESULTS

Community-engaged approaches used included establishing colearning opportunities, participatory procedures for community-academic involvement, and community and clinical capacity building. A relatively large proportion of individuals identified for recruitment was actually approached (between 50% and 100%). The proportion of subjects who were eligible among all those approached ranged from 25% to more than 70% (in the community setting). Recruitment rates were very high (78%-100% of eligible individuals approached) and the proportion who refused or who were not interested among those approached was very low (5%-11%).

CONCLUSIONS

Recruitment strategies used by the CNPCs were associated with low refusal and high enrollment ratios of potential subjects. Adherence to CBPR principles in the spectrum of research activities, from strategic planning to project implementation, has significant potential to increase involvement in biomedical research and improve our ability to make appropriate recommendations for cancer prevention and control programming in underrepresented diverse populations.

IMPACT

CBPR strategies should be more widely implemented to enhance study recruitment.

Application of best practice approaches for designing decision support tools: the preparatory education about clinical trials (PRE-ACT) study

OBJECTIVE

This article describes the rigorous development process and initial feedback of the PRE-ACT (Preparatory Education About Clinical Trials) web-based- intervention designed to improve preparation for decision making in cancer clinical trials.

METHODS

The multi-step process included stakeholder input, formative research, user testing and feedback. Diverse teams (researchers, advocates and developers) participated including content refinement, identification of actors, and development of video scripts. Patient feedback was provided in the final production period and through a vanguard group (N=100) from the randomized trial.

RESULTS

Patients/advocates confirmed barriers to cancer clinical trial participation, including lack of awareness and knowledge, fear of side effects, logistical concerns, and mistrust. Patients indicated they liked the tool's user-friendly nature, the organized and comprehensive presentation of the subject matter, and the clarity of the videos.

CONCLUSION

The development process serves as an example of operationalizing best practice approaches and highlights the value of a multi-disciplinary team to develop a theory-based, sophisticated tool that patients found useful in their decision making process. Practice implications Best practice approaches can be addressed and are important to ensure evidence-based tools that are of value to patients and supports the usefulness of a process map in the development of e-health tools.

Increasing Asian American participation in clinical trials by addressing community concerns

Background Asian Americans are underrepresented in clinical trials, but little is known about the factors that contribute to clinical trial participation in this population. Purpose The purpose of this study was to identify knowledge, barriers, facilitators, and cultural influences on participating in clinical trials among three Asian American ethnic groups. Concurrently, we sought to identify mechanisms and messages to facilitate dissemination of information and to identify strategies to promote clinical trial participation in this population. Methods Eight focus groups were conducted (n = 103) with Chinese (four groups), Korean (two groups), and Vietnamese (two groups) Americans. Each group was conducted with a moderator and a translator using a standardized guide. Results Participants discuss the benefits of contributing to science, future generations, and their families by being in clinical trials. Some participants think clinical trials would give hope to those with terminal illnesses. A doctor's recommendation, being sick, and needing more options for treatment are motivators for Asian Americans. Having some guarantee of treatment effectiveness and lack of side effects facilitates participation. Cultural or religious beliefs are not believed to prevent clinical trial participation. Limitations This qualitative, two-site study included three Asian American ethnic groups and is not meant to establish prevalence of beliefs. Conclusion Asian Americans need more information about clinical trials and their benefits to science and the larger community. Health-care providers can play pivotal roles in enhancing recruitment of Asian Americans. Basing recruitment goals on percentage representation in most US geographic areas does not provide sufficient numbers to allow for analysis of minorities like Asian American groups. The discovery of important group-specific harms and benefits depends on greater participation of racial/ethnic subgroups.

Twenty years post-NIH Revitalization Act: enhancing minority participation in clinical trials (EMPaCT): laying the groundwork for improving minority clinical trial accrual: renewing the case for enhancing minority participation in cancer clinical trials

BACKGROUND

The National Institutes of Health (NIH) Revitalization Act of 1993 mandated the appropriate inclusion of minorities in all NIH-funded research. Twenty years after this act, the proportion of minority patients enrolled in cancer clinical trials remains persistently low. Clinical trials are vehicles for the development and evaluation of therapeutic and preventive agents under scientifically rigorous conditions. Without representation in trials, it is projected that disparities in the cancer burden for minorities will increase.

METHODS

For this review article, the authors counted the frequency with which minorities were the primary focus of National Cancer Institute-sponsored clinical trials, examined citations from the PubMed database focusing on the search terms "NIH Revitalization Act of 1993" and "enhancing minority accrual to cancer clinical trials," and supplemented the review with their expertise in NIH-funded research related to minority accrual in cancer clinical trials.

RESULTS

The reporting and analyses of data based on minorities in clinical trials remain inadequate. Less than 2% of the National Cancer Institute's clinical trials focus on any racial/minority population as their primary emphasis. The current review of the literature indicated that the percentage of authors who reported their study sample by race/ethnicity ranged from 1.5% to 58%, and only 20% of the randomized controlled studies published in a high-impact oncology journal reported analyzing results by race/ethnicity. Proportionately greater population increases in minorities, accompanied by their persistent and disproportionate cancer burden, reinforce the need for their greater representation in clinical trials.

CONCLUSIONS

Renewing the emphasis for minority participation in clinical trials is warranted. Policy changes are recommended.

Twenty years post-NIH Revitalization Act: enhancing minority participation in clinical trials (EMPaCT): laying the groundwork for improving minority clinical trial accrual: renewing the case for enhancing minority participation in cancer clinical trials

BACKGROUND

The National Institutes of Health (NIH) Revitalization Act of 1993 mandated the appropriate inclusion of minorities in all NIH-funded research. Twenty years after this act, the proportion of minority patients enrolled in cancer clinical trials remains persistently low. Clinical trials are vehicles for the development and evaluation of therapeutic and preventive agents under scientifically rigorous conditions. Without representation in trials, it is projected that disparities in the cancer burden for minorities will increase.

METHODS

For this review article, the authors counted the frequency with which minorities were the primary focus of National Cancer Institute-sponsored clinical trials, examined citations from the PubMed database focusing on the search terms "NIH Revitalization Act of 1993" and "enhancing minority accrual to cancer clinical trials," and supplemented the review with their expertise in NIH-funded research related to minority accrual in cancer clinical trials.

RESULTS

The reporting and analyses of data based on minorities in clinical trials remain inadequate. Less than 2% of the National Cancer Institute's clinical trials focus on any racial/minority population as their primary emphasis. The current review of the literature indicated that the percentage of authors who reported their study sample by race/ethnicity ranged from 1.5% to 58%, and only 20% of the randomized controlled studies published in a high-impact oncology journal reported analyzing results by race/ethnicity. Proportionately greater population increases in minorities, accompanied by their persistent and disproportionate cancer burden, reinforce the need for their greater representation in clinical trials.

CONCLUSIONS

Renewing the emphasis for minority participation in clinical trials is warranted. Policy changes are recommended.

Recruiting Chinese Americans into cancer screening intervention trials: strategies and outcomes

BACKGROUND

Cancer is the leading cause of death among Asian Americans. While Asian Americans are the fastest growing minority population in the United States, they are underrepresented in cancer research and report poor adherence to cancer screening guidelines.

PURPOSE

This study utilized data from two large randomized intervention trials to evaluate strategies to recruit first-generation Chinese American immigrants from community settings and Chinese American physician practices. Findings will inform effective strategies for promoting Asian American participation in cancer control research.

METHODS

Chinese Americans who were non-adherent to annual mammography screening guidelines (Study 1 with 664 immigrant women > 40 years of age) and to colorectal cancer screening guidelines (Study 2 with 455 immigrants > 50 years of age) were enrolled from the greater Washington DC, New York City (NYC), and Philadelphia (PA) areas. Both studies trained bilingual staff to enroll Chinese-speaking participants with the aid of linguistically appropriate fliers and brochures to obtain consent. Study 1 adopted community approaches and worked with community organizations to enroll participants. Study 2 randomly selected potential participants through 24 Chinese American primary-care physician offices, and mailed letters from physicians to enroll patients, followed by telephone calls from research staff. The success of recruitment approaches was assessed by yield rates based on number of participants approached, ineligible, and consented.

RESULTS

Most participants (70%) of Study 1 were enrolled through in-person community approaches (e.g., Chinese schools, stores, health fairs, and personal networks). The final yield of specific venues differed widely (6% to 100%) due to various proportions of ineligible subjects (2%-64%) and refusals (0%-92%). The Study 2 recruitment approach (physician letter followed by telephone calls) had different outcomes in two geographic areas, partially due to differences in demographic characteristics in the DC and NYC/PA areas. The community approaches enrolled more recent immigrants and uninsured Chinese Americans than the physician and telephone call approach (p < .001). Enrollment cost is provided to inform future research studies.

LIMITATIONS

Our recruitment outcomes might not be generalizable to all Chinese Americans or other Asian American populations because they may vary by study protocols (e.g., length of trials), target populations (i.e., eligibility criteria), and available resources.

CONCLUSIONS

Use of multiple culturally relevant strategies (e.g., building trusting relationships through face-to-face enrollment, use of bilingual and bicultural staff, use of a physician letter, and employing linguistically appropriate materials) was crucial for successfully recruiting a large number of Chinese Americans in community and clinical settings. Our data demonstrate that substantial effort is required for recruitment; studies need to budget for this effort to ensure the inclusion of Asian Americans in health research.

The impact of a community-based clinical trial educational intervention among underrepresented Chinese Americans

BACKGROUND

Clinical trials are a critical resource for the discovery of new prevention, diagnostic, and treatment methods for cancer. The most effective prevention and treatment modalities are based on previous clinical trial results. However, participation in clinical trials is underrepresented by racial/ethnic minority populations, Asian Americans in particular. Asian Americans are the least represented of any ethnic groups in clinical trials. The purpose of this study is to develop and evaluate a culturally and linguistically appropriate community-based educational intervention to increase knowledge of and intent to participate in cancer clinical trials among underrepresented Chinese Americans.

METHODS

Community-Based Participatory Research approach was used to guide the development, cultural tailoring, implementation, and evaluation of clinical trial intervention. First, 22 Asian community representatives were recruited as community health educators (CHE) who received 12-hour training on clinical trial education. Second, 262 members were recruited from 11 Chinese community organizations. Of those recruited, a total of 247 eligible Chinese enrolled and participated in the clinical trial education delivered by trained CHEs. Participants completed pretest before and posttest after the intervention.

RESULTS

Fifteen of 21 measures of clinical trial knowledge showed significant changes post the intervention (P < 0.05). Education remained the sole demographic factor increasing clinical trial knowledge in multivariate analysis.

CONCLUSION

Clinical trial education should emphasize both benefits to science and the larger Asian community. This community-based clinical trial intervention demonstrated promising results and has potential to enhance recruitment and participation in clinical trial research among the underrepresented Asian Americans.

IMPACT

Improving clinical trial participation in the fast-growing Asian American population is key to dissemination of health innovations targeted to diminish health disparities.

Barriers to recruitment of rural patients in cancer clinical trials

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Problems with the collection and interpretation of Asian-American health data: omission, aggregation, and extrapolation

Asian-American citizens are the fastest growing racial/ethnic group in the United States. Nevertheless, data on Asian American health are scarce, and many health disparities for this population remain unknown. Much of our knowledge of Asian American health has been determined by studies in which investigators have either grouped Asian-American subjects together or examined one subgroup alone (e.g., Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese). National health surveys that collect information on Asian-American race/ethnicity frequently omit this population in research reports. When national health data are reported for Asian-American subjects, it is often reported for the aggregated group. This aggregation may mask differences between Asian-American subgroups. When health data are reported by Asian American subgroup, it is generally reported for one subgroup alone. In the Ni-Hon-San study, investigators examined cardiovascular disease in Japanese men living in Japan (Nippon; Ni), Honolulu, Hawaii (Hon), and San Francisco, CA (San). The findings from this study are often incorrectly extrapolated to other Asian-American subgroups. Recommendations to correct the errors associated with omission, aggregation, and extrapolation include: oversampling of Asian Americans, collection and reporting of race/ethnicity data by Asian-American subgroup, and acknowledgement of significant heterogeneity among Asian American subgroups when interpreting data.

Recommendations for enhancing clinical trials education: a review of the literature

This study aims to apply the evidence-based practice (EBP) process to determine the factors that influence patients' understanding of, participation in, and satisfaction with clinical trials, the informed consent process, and treatment decisions and to make recommendations for improving clinical trials education. Beginning with evidence retrieval, the authors identified key search terms and searched MEDLINE--Ovid, MEDLINE--PubMed, and the Cumulative Index to Nursing and Allied Health Literature to identify articles published between July 2001 and July 2006 that highlighted clinical trials education. The articles were reviewed for clinical trials patient education information, clinician methods of communicating clinical trial information to patients, and patient satisfaction with the clinical trials process, including the informed consent process. As a result, practice changes were recommended for the patient/family, staff/community, and institution. From the literature review, 81 articles were identified. Recurring themes included decision-making, patient education, staff education, and pediatrics. Most articles focused on methods and strategies aimed at improving education at the patient/family, staff/community, and institutional levels. The issues surrounding clinical trial education are complex due to multiple variables interfering with poor patient understanding of, participation in, and satisfaction with clinical trial treatment decisions. On the basis of our findings, we recommend that clinicians involved in educating patients, families, staff, and communities about clinical trials have an awareness of and understanding for very complex issues.

A mixed methods and triangulation model for increasing the accuracy of adherence and sexual behaviour data: the Microbicides Development Programme

Background

The collection of accurate data on adherence and sexual behaviour is crucial in microbicide (and other HIV-related) research. In the absence of a “gold standard” the collection of such data relies largely on participant self-reporting. After reviewing available methods, this paper describes a mixed method/triangulation model for generating more accurate data on adherence and sexual behaviour in a multi-centre vaginal microbicide clinical trial. In a companion paper some of the results from this model are presented [1].

Methodology/Principal Findings

Data were collected from a random subsample of 725 women (7.7% of the trial population) using structured interviews, coital diaries, in-depth interviews, counting returned gel applicators, focus group discussions, and ethnography. The core of the model was a customised, semi-structured in-depth interview. There were two levels of triangulation: first, discrepancies between data from the questionnaires, diaries, in-depth interviews and applicator returns were identified, discussed with participants and, to a large extent, resolved; second, results from individual participants were related to more general data emerging from the focus group discussions and ethnography. A democratic and equitable collaboration between clinical trialists and qualitative social scientists facilitated the success of the model, as did the preparatory studies preceding the trial. The process revealed some of the underlying assumptions and routinised practices in “clinical trial culture” that are potentially detrimental to the collection of accurate data, as well as some of the shortcomings of large qualitative studies, and pointed to some potential solutions.

Conclusions/Significance

The integration of qualitative social science and the use of mixed methods and triangulation in clinical trials are feasible, and can reveal (and resolve) inaccuracies in data on adherence and sensitive behaviours, as well as illuminating aspects of “trial culture” that may also affect data accuracy.

Diversity of participants in clinical trials in an academic medical center: the role of the 'Good Study Patient?'

BACKGROUND

Only 2.5% of adults and even fewer minorities participate in cancer therapeutic trials. Researchers have concluded that many barriers to participation stem from how recruitment is performed by clinician investigators. The objective of the current research was to document specifically how these barriers impede recruitment in the clinical setting.

METHODS

The authors conducted a case study of recruitment in an academic medical center using ethnographic research methods (direct observation of provider-patient interactions and in-depth interviews with providers) to collect data. Qualitative data analysis was used to identify themes related to the provider's role in the recruitment processes.

RESULTS

In the clinics that were studied, the authors observed that providers subjectively assessed which patients seemed to be 'good study patients' to target for recruitment. 'Good study patients' were identified as those who were able to adhere to complex trial protocols, thus helping clinician researchers to complete studies in a timely and efficient manner. These patients were perceived as meticulous, proactive, and compliant; they were considered good communicators; and they were embedded in the kinds of strong social support networks that facilitated their trials participation.

CONCLUSIONS

The providers that were studied sought 'good study patients' for therapeutic trials because they wanted to perform studies in a timely and efficient manner. Future research should examine whether providers in other settings also target their recruitment efforts for this or other reasons. Further research also should consider whether differentially recruiting 'good patients' can impact the ethnic/racial diversity or other characteristics of trial participants in ways that may bias the outcomes or conclusions of therapeutic trials.

Cancer patients' awareness of clinical trials, perceptions on the benefit and willingness to participate: Korean perspectives

To understand patients' perceptions of clinical trials (CTs) is the principal step in the enrolment of patients to CTs. However, these perceptions in eastern countries are very rare. From 12 February 2007 to 13 April 2007, we consecutively distributed the questionnaire to 842 cancer patients who initiated a first cycle of chemotherapy regardless of each treatment step in the Seoul National University Hospital. Younger age, higher educational degree, higher economic status, and possession of private cancer insurance were related with significantly higher awareness of CTs (P=0.001, P=0.006, P=0.002, and P=0.009, respectively). However, unlike awareness, perceptions on benefits of CTs were not changed according to age, educational degree, and economic status (P=0.709, P=0.920, and P=0.847, respectively). Willingness was also not changed according to age, educational degree, economic status, and private cancer insurance (P=0.381, P=0.775, P=0.887, and P=0.392, respectively). Instead, males and heavily treated patients had more positive perceptions on benefits (P=0.002 and P=0.001, respectively) and more willingness to participate in CTs (OR=1.17, 1.14–2.75: OR=1.59, 1.01–2.51, respectively). In summary, cancer patients' awareness of CTs, perceptions on the benefit in CTs, and willingness to participate are differently influenced by diverse medical and social conditions. This information would be very helpful for investigators to properly conduct CTs in eastern cancer patients.

Recruitment of minority and underserved populations in the United States: the Centers for Population Health and Health Disparities experience

OBJECTIVE

The recruitment of minority and underserved individuals to research studies is often problematic. The purpose of this study was to describe the recruitment experiences of projects that actively recruited minority and underserved populations as part of The Centers for Population Health and Health Disparities (CPHHD) initiative.

METHODS

Principal investigators and research staff from 17 research projects at eight institutions across the United States were surveyed about their recruitment experiences. Investigators reported the study purpose and design, recruitment methods employed, recruitment progress, problems or challenges to recruitment, strategies used to address these problems, and difficulties resulting from Institutional Review Board (IRB) or Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements. Additionally, information was collected about participant burden and compensation. Burden was classified on a three-level scale. Recruitment results were reported as of March 31, 2007.

RESULTS

Recruitment attainment ranged from 52% to 184% of the participant recruitment goals. Commonly reported recruitment problems included administrative issues, and difficulties with establishing community partnerships and contacting potential participants. Long study questionnaires, extended follow-up, and narrow eligibility criteria were also problematic. The majority of projects reported difficulties with IRB approvals, though few reported issues related to HIPAA requirements. Attempted solutions to recruitment problems varied across Centers and included using multiple recruitment sites and sources and culturally appropriate invitations to participate. Participant burden and compensation varied widely across the projects, however, accrual appeared to be inversely associated with the amount of participant burden for each project.

CONCLUSION

Recruitment of minority and underserved populations to clinical trials is necessary to increase study generalizbility and reduce health disparities. Our results demonstrate the importance of flexible study designs which allow adaptation to recruitment challenges. These experiences also highlight the importance of involving community members and reducing participant burden to achieve success in recruiting individuals from minority and underserved populations.

Testing targeted approaches to enhance Cancer Genetics Network minority recruitment within Asian populations

BACKGROUND/AIMS

Asian Americans have been underrepresented in cancer research. The purpose of this study was to evaluate the efficacy of a multiple arm recruitment approach in improving Asian recruitment into the Cancer Genetics Network (CGN).

METHODS

1,096 potential participants, identified through cancer registries located at University of California, Irvine (UCI) and Fred Hutchinson Cancer Research Center (FHCRC), were randomly assigned to receive one of four recruitment approaches.

RESULTS

A 6.2% gain in Asian participation into the CGN was achieved over a 2-year period at FHCRC and UCI, which contributed a 2% CGN-wide increase in overall Asian enrollment. Site-specific differences in recruitment success by study arm were observed.

CONCLUSION

Novel recruitment approaches can assist in improving recruitment of Asian populations into cancer genetic research studies.

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.

Recruiting diverse patients to a breast cancer risk communication trial--waiting rooms can improve access

Low participation among underserved populations in health research constrains progress in public health practices. From 2003 to 2005, Women's Health Clinic patients at the VCU Health System were recruited to a trial investigating breast cancer risk communication. In secondary analyses, we examined dimensions of the recruitment of these diverse women. The sample characteristics (age, insurance, race and previous mammograms) were compared to the overall clinic. Of recruitment attempts for eligible women, 45% consented; of those who declined, the top cited reasons were lack of time (40%) and lack of interest (18%). Of 899 participants, 35% qualified for the indigent care program, compared to 31% of the overall clinic (P<0.001). Forty-five percent of participants were African American, compared to 54% of overall clinic patients (P<0.001). Participants were younger (50 vs. 53 years, P<0.001) than the overall clinic population. Nonrepresentative enrollment of patients in clinical trials is common and could lead to suboptimal applicability of findings. Although there were statistically significant race and age differences between the study sample and the overall population, we demonstrate that waiting room recruitment can engage diverse women in a clinical trial and cancer risk communication.

Asian American Network for Cancer Awareness, Research, and Training's legacy. The first 5 years

The Asian American Network for Cancer Awareness, Research, and Training (AANCART) is the first special populations network for Asian Americans on a national basis and includes collaborating organizations from Boston, New York, Houston, Seattle, San Francisco, Los Angeles, Hawaii, and Sacramento (where it is headquartered at the University of California, Davis). NCI funding of AANCART in 2000 brought together investigators and leaders from 9 cities across 6 states to establish an infrastructure for addressing cancer awareness, research, and training. Since 2000, AANCART has conducted needs assessments, held community awareness activities and trainings, trained trainees, sponsored National Asian American Cancer Control Academies, and produced presentations, publications, and grants. All specific aims have been attained, including the establishment of an infrastructure to promote Asian American cancer awareness, research, and training in 4 targeted regions; the establishment of partnerships to promote accrual to clinical trials, training, and pilot studies; and the formulation and successful implementation of grant-funded research to reduce the cancer burden among Asian Americans. AANCART's first 5 years have increased cancer awareness, trained special populations scientists, and advanced the field of Asian American cancer control research. Cancer 2006. (c) 2006 American Cancer Society.

The NCI's Cancer Information Service's Research Continuum Framework: integrating research into cancer education practice (1999-2004)

Between 1999 and 2004, the National Cancer Institute's (NCI) Cancer Information Service's (CIS) Research Initiative supported over 50 research projects representing a broad range of activities from research capacity building, development, implementation to diffusion and dissemination. These research activities are represented in the CIS Research Continuum Framework which the authors describe through a number of short case studies. Based on the experiences and successes of the CIS, other professionals working in the cancer field might consider establishing collaborative relationships across the research continuum and participating in research that has relevancy to advances in cancer education.