Strategies to improve diversity, equity, and inclusion in clinical trials

Patient participation in clinical trials conducted by principal investigators who speak one or more language(s) beyond english: Exploring ethnicity as proxy for language

Background

To explore the association between ethnicity, as a proxy for language, and participation in clinical trials (CT) conducted by Principal Investigators (PI) who speak one or more language in addition to English.

Methods

This retrospective, descriptive study utilized CT participant demographic data extracted from the largest Midwestern non-profit healthcare system between January 1, 2019 and 12/31/2021. The CT participant sample (N = 4308) was divided for comparison: CT Participants of Hispanic or Latino Origin (N = 254; 5.90 %) and CT Participants of Non-Hispanic or Latino Origin (N = 4054; 94.10 %). Logistic regressions were performed to generate the crude and adjusted odds of patients of Hispanic or Latino origin participating in CTs conducted by PIs who speak another language in addition to English.

Results

Crude analysis revealed that patients of Hispanic or Latino ethnicity had 2.04 (1.58, 2.64) times greater odds of participating in CTs conducted by PIs who speak another language than English (<0.0001), which increased to 2.67 (1.97, 3.62) times greater odds after adjusting for sex, race, age and insurance (p < 0.0001).

Conclusions

Overall findings indicate that patients of Hispanic or Latino ethnicity, who are more likely to speak Spanish, have greater odds of participating in CTs conducted by PIs who speak another language beyond English. This may imply that cultural sensitivity at the top of a CT study team, as likely to be demonstrated by PIs who speak another language beyond English, may be an important contributor to reducing ethnicity- and language-based barriers to diversity in CTs and a relationship worth exploring further.

Are community oncology practices with or without clinical research programs different? A comparison of patient and practice characteristics

BACKGROUND

Expanding access to clinical trials in community settings is a potential approach to addressing disparities in accrual of historically underrepresented populations. However, little is known about the characteristics of practices that do not participate in research. We investigated differences in patient and practice characteristics of US community oncology practices with high vs low engagement in clinical research.

METHODS

We included patients from a real-world, nationwide electronic health record-derived, de-identified database who received active treatment for cancer at community oncology practices between November 1, 2017, and October 31, 2022. We assessed patient and practice characteristics and their associations with high vs low research engagement using descriptive analyses and logistic regression models.

RESULTS

Of the 178 practices, 70 (39.3%) events had high research engagement, treated 57.8% of the overall 568 540 patient cohort, and enrolled 3.25% of their patients on cancer treatment trials during the 5-year observation period (vs 0.27% enrollment among low engagement practices). Practices with low vs high research engagement treated higher proportions of the following patient groups: ages 75 years and older (24.2% vs 21.8%), non-Latinx Black (12.6% vs 10.3%) or Latinx (11.6% vs 6.1%), were within the lowest socioeconomic status quintile (21.9% vs16.5%), and were uninsured or had no documented insurance (22.2% vs 13.6%).

CONCLUSIONS

Patient groups historically underrepresented in oncology clinical trials are more likely to be treated at community practices with limited or no access to trials. These results suggest that investments to expand the clinical research footprint among practices with low research engagement could help address persistent inequities in trial representation.

Increasing Clinical Trial Participation of Black Women Diagnosed with Breast Cancer

Despite racial disparities in breast cancer mortality, Black women remain underrepresented in clinical trials. In this mixed methods research, 48 Black women were engaged via focus group discussions and in-depth interviews to better understand the lived experience of women with breast cancer. The results of this qualitative study informed the development of a subsequent online survey to identify barriers, motivators, and other factors that influence decision-making by Black women diagnosed with breast cancer when considering clinical trial participation. Among the 257 Black survey participants, most (95%) were aware of clinical trials; of those, most viewed them as lifesaving (81%) and/or benefiting others (90%). Negative perceptions such as serious side effects (58%), not receiving real treatment (52%), or risk of potential harm (62%) were indicated. Barriers included financial expenses (49%), concerns that their condition could be made worse (29%), that they would receive a placebo (28%), or that treatment was unapproved (28%). Participants were more likely than their health care providers (HCPs) to initiate discussions of clinical trials (53% versus 33%), and 29% of participants indicated a need for more information about risks and benefits, even after having those conversations. The most trustworthy sources of information on clinical trials were HCPs (66%) and breast cancer support groups (64%). These results suggest that trusted communities are key for providing education on clinical trials. However, there is also a need for HCPs to proactively discuss clinical trials with patients to ensure that they are adequately informed about all aspects of participation.

Equitable inclusion of diverse populations in oncology clinical trials: deterrents and drivers

The burden of cancer exerts a disproportionate impact across different regions and population subsets. Disease-specific attributes, coupled with genetic and socioeconomic factors, significantly influence cancer treatment outcomes. Precision oncology promises the development of safe and effective options for specific ethnic phenotypes and clinicodemographic profiles. Currently, clinical trials are concentrated in resource-rich geographies with younger, healthier, white, educated, and empowered populations. Vulnerable and marginalized people are often deprived of opportunities to participate in clinical trials. Despite consistent endeavors by regulators, industry, and other stakeholders, factors including diversity in trial regulations and patient and provider-related cultural, logistic, and operational barriers limit the inclusiveness of clinical trials. Understanding and addressing these constraints by collaborative actions involving regulatory initiatives, industry, patient advocacy groups, community engagement in a culturally sensitive manner, and designing and promoting decentralized clinical trials are vital to establishing a clinical research ecosystem that promotes equity in the representation of population subgroups.

Multi-cancer early detection (MCED) tests: prioritizing equity from bench to bedside

Multi-cancer early detection (MCED) tests are blood-based tests designed to screen for signals of multiple cancers. There is growing interest and investment in examining the potential benefits and applications of MCED tests. If MCED tests are shown to have clinical utility, it is important to ensure that all people-regardless of their demographic or socioeconomic background-equitably benefit from these tests. Unfortunately, with health care innovation, such considerations are often ignored until after inequities emerge. We urge for-profit companies, scientists, clinicians, payers, and government agencies to prioritize equity now-when MCEDs are still being developed and researched. In an effort to avoid creating and exacerbating cancer inequities, we propose 9 equity considerations for MCEDs.

More than Just a Number: Perspectives from Black Male Participants on Community-Based Interventions and Clinical Trials to Address Cardiovascular Health Disparities

BACKGROUND

Black Americans remain significantly underrepresented and understudied in research. Community-based interventions have been increasingly recognized as an effective model for reckoning with clinical trial participation challenges amongst underrepresented groups, yet a paucity of studies implement this approach. The present study sought to gain insight into Black male participants' perception of clinical trials before and after participating in a community-based team lifestyle intervention in the United States.

METHODS

Black Impact, a 24-week community-based lifestyle intervention, applied the American Heart Association's Life's Simple 7 (LS7) framework to assess changes in the cardiovascular health of seventy-four Black male participants partaking in weekly team-based physical activities and LS7-themed education and having their social needs addressed. A subset of twenty participants completed an exit survey via one of three semi-structured focus groups aimed at understanding the feasibility of interventions, including their perceptions of participating in clinical trials. Data were transcribed verbatim and analyzed using a content analysis, which involved systematically identifying, coding, categorizing, and interpreting the primary patterns of the data.

RESULTS

The participants reported a positive change in their perceptions of clinical trials based on their experience with a community-based lifestyle intervention. Three prominent themes regarding their perceptions of clinical trials prior to the intervention were as follows: (1) History of medical abuse; (2) Lack of diversity amongst research teams and participants; and (3) A positive experience with racially concordant research teams. Three themes noted to influence changes in their perception of clinical trials based on their participation in Black Impact were as follows: (1) Building trust with the research team; (2) Increasing awareness about clinical trials; and (3) Motivating participation through community engagement efforts.

CONCLUSIONS

Improved perceptions of participating in clinical trials were achieved after participation in a community-based intervention. This intervention may provide a framework by which to facilitate clinical trial participation among Black men, which must be made a priority so that Black men are "more than just a number" and no longer "receiving the short end of the stick".

Precision Immuno-Oncology in NSCLC through Gender Equity Lenses

Precision immuno-oncology involves the development of personalized cancer treatments that are influenced by the unique nature of an individual's DNA, immune cells, and their tumor's molecular characterization. Biological sex influences immunity; females typically mount stronger innate and adaptive immune responses than males. Though more research is warranted, we continue to observe an enhanced benefit for females with lung cancer when treated with combination chemoimmunotherapy in contrast to the preferred approach of utilizing immunotherapy alone in men. Despite the observed sex differences in response to treatments, women remain underrepresented in oncology clinical trials, largely as a result of gender-biased misconceptions. Such exclusion has resulted in the development of less efficacious treatment guidelines and clinical recommendations and has created a knowledge gap in regard to immunotherapy-related survivorship issues such as fertility. To develop a more precise approach to care and overcome the exclusion of women from clinical trials, flexible trial schedules, multilingual communication strategies, financial, and transportation assistance for participants should be adopted. The impact of intersectionality and other determinants of health that affect the diagnosis, treatment, and outcomes in women must also be considered in order to develop a comprehensive understanding of the unique impact of immunotherapy in all women with lung cancer.

Participant flow diagrams for health equity in AI

Selection bias can arise through many aspects of a study, including recruitment, inclusion/exclusion criteria, input-level exclusion and outcome-level exclusion, and often reflects the underrepresentation of populations historically disadvantaged in medical research. The effects of selection bias can be further amplified when non-representative samples are used in artificial intelligence (AI) and machine learning (ML) applications to construct clinical algorithms. Building on the "Data Cards" initiative for transparency in AI research, we advocate for the addition of a participant flow diagram for AI studies detailing relevant sociodemographic and/or clinical characteristics of excluded participants across study phases, with the goal of identifying potential algorithmic biases before their clinical implementation. We include both a model for this flow diagram as well as a brief case study explaining how it could be implemented in practice. Through standardized reporting of participant flow diagrams, we aim to better identify potential inequities embedded in AI applications, facilitating more reliable and equitable clinical algorithms.

Diversity in Oncology Clinical Trials: Current Landscape for Industry-Sponsored Clinical Trials in Asia

INTRODUCTION

There has been a growing recognition on the importance of diversity in clinical trials. Existing research has highlighted a significant demographic imbalance. Amidst this renewed focus on diversity, it is crucial to acknowledge that Asia comprises over half of the world's population. Given the region's demographic significance, we sought to compare various characteristics and growth rates for trials with sites in Asia against those without any sites in Asia.

METHODS

We performed comprehensive analyses of industry-sponsored phase 2 and 3 oncology trials registered at Clinicaltrials.gov, using drugs or biologics as investigational agents and executed between 1 January 2018 and 31 December 2022. We applied the compound annual growth rate (CAGR) as an analytical tool to track the trial growth rates over this 5-year period.

RESULTS

We identified 894 industry-sponsored phase 2 and 3 cancer studies with available study location data. Out of these, 415 trials (46.42%) had study sites in Asia. Notably, these trials with sites in Asia were also more likely to be phase 3 trials (39.76% vs 6.47%, p < 0.001), include female and paediatric populations, and be randomised trials. Interestingly, lung and stomach cancers were more commonly studied in these trials, while myeloma was less commonly studied. The number of trial sites for liver cancer was not significantly higher for Asia, even though the incidence of the disease is much higher in this region. Despite an overall declining trend in the number of clinical trials in the last 5 years, we observed a transitional positive increase in the CAGR from 2020 to 2021 for trials with sites in Asia. However, East Asia, specifically China, exhibited a disproportionate overrepresentation in these trials.

CONCLUSIONS

There are notable characteristics of clinical trials with sites in Asia. Comprehending these disparities may aid in the strategic planning to enhance a balanced representation of ethnicities in trials.

Diversity in randomized clinical trials for peripheral artery disease: a systematic review

BACKGROUND

Significant race and sex disparities exist in the prevalence, diagnosis, and outcomes of peripheral artery disease (PAD). However, clinical trials evaluating treatments for PAD often lack representative patient populations. This systematic review aims to summarize the demographic representation and enrollment strategies in clinical trials of lower-extremity endovascular interventions for PAD.

METHODS

Following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched multiple sources (Medline, EMBASE, Cochrane, Clinicaltrials.gov, WHO clinical trial registry) for randomized controlled trials (RCTs), RCT protocols, and peer-reviewed journal publications of RCTs conducted between January 2012 and December 2022. Descriptive analysis was used to summarize trial characteristics, publication or study protocol characteristics, and the reporting of demographic characteristics. Meta-regression was used to explore associations between demographic characteristics and certain trial characteristics.

RESULTS

A total of 2,374 records were identified. Of these, 59 met the inclusion criteria, consisting of 35 trials, 14 publications, and 10 protocols. Information regarding demographic representation was frequently missing. While all 14 trial publications reported age and sex, only 4 reported race/ethnicity, and none reported socioeconomic or marital status. Additionally, only 4 publications reported clinical outcomes by demographic characteristics. Meta-regression analysis revealed that 6% more women were enrolled in non-European trials (36%) than in European trials (30%).

CONCLUSIONS

The findings of this review highlight potential issues that may compromise the reliability and external validity of study findings in lower-extremity PAD RCTs when applied to the real-world population. Addressing these issues is crucial to enhance the generalizability and impact of clinical trial results in the field of PAD, ultimately leading to improved clinical outcomes for patients in underrepresented populations.

REGISTRATION

The systematic review methodology was published in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022378304).

Racial and ethnic diversity in global neuroscience clinical trials

Background

Despite efforts to increase diversity in neuroscience trials, racial and ethnic minority groups remain underrepresented. Disparities in clinical trial participation could reflect unequal opportunities to participate and may contribute to decreased generalizability of findings and failure to identify important differences in efficacy and safety outcomes.

Methods

We retrospectively reviewed the F. Hoffmann-La Roche database for global, multicenter, neuroscience clinical trials from February 2016 to February 2021 and summarized and stratified race and ethnicity distributions by clinical trial therapeutic area and by country. These data were then compared to national population data for each study's targeted age group (available for studies conducted in the US, Canada, and the UK). The underrepresentation or overrepresentation of each racial and ethnic group was summarized.

Results

The analysis population included 8015 participants from 47 countries. Globally, 85.6 % of participants were White, 7.1 % were Asian, 1.6 % were Black, 1.3 % were American Indian or Alaska Native, less than 0.1 % were Native Hawaiian or other Pacific Islander, 0.7 % were of multiple races, and 3.6 % were of other/unknown race. White individuals predominated in all but one trial. Black individuals were underrepresented in all trials but one. Asian individuals were overrepresented in approximately 20 % of trials. In the US, 7.3 % of participants were of Hispanic or Latino ethnicity vs 16.4 % of the US population.

Conclusion

The findings and learnings from this summary and analysis demonstrate the need for continued awareness and new approaches in designing studies that reflect population diversity.

Risk-management decision-making data from a community-based sample of racially diverse women at high risk of breast cancer: rationale, methods, and sample characteristics of the Daughter Sister Mother Project survey

BACKGROUND

To understand the dynamics that limit use of risk-management options by women at high risk of breast cancer, there is a critical need for research that focuses on patient perspectives. Prior research has left important gaps: exclusion of high-risk women not in risk-related clinical care, exclusion of non-white populations, and lack of attention to the decision-making processes that underlie risk-management choices. Our objective was to create a more inclusive dataset to facilitate research to address disparities related to decision making for breast cancer risk management.

METHODS

The Daughter Sister Mother Project survey collects comprehensive information about the experiences of women at high risk of breast cancer. We collected novel measures of feelings about and reactions to cancer screenings; knowledge, barriers, and facilitators of risk-management options; beliefs related to cancer risk and risk management; and involvement with loved ones who had cancer. Eligible individuals were non-Hispanic white and non-Hispanic Black adult women who self-identified as having high risk of breast cancer and had no personal history of cancer. Between October 2018 and August 2019, 1053 respondents completed the online survey. Of these, 717 were confirmed through risk prediction modeling to have a lifetime breast cancer risk of ≥ 20%. Sociodemographic characteristics of this sample were compared to those of nationally representative samples of the US population: the 2019 Health Information National Trends Survey and the Pew Research Center report: Jewish Americans in 2020.

RESULTS

The sample of 717 women at objectively high risk of breast cancer was largely (95%) recruited from non-clinical sources. Of these respondents, only 31% had seen a genetic counselor, 34% had had genetic testing specific to breast cancer risk, and 35% had seen at least one breast or cancer care specialist. The sample includes 35% Black respondents and 8% with Ashkenazi Jewish ancestry. Although encompassing a substantial range of ages, incomes, and education levels, respondents are overall somewhat younger, higher-income, and more educated than the US population as a whole.

CONCLUSIONS

The DSM dataset offers comprehensive data from a community-based, diverse sample of women at high risk of breast cancer. The dataset includes substantial proportions of Black and Ashkenazi Jewish women and women who are not already in clinical care related to their breast cancer risk. This sample will facilitate future studies of risk-management behaviors among women who are and are not receiving high-risk care, and of variations in risk-management experiences across race and ethnicity.

Shifting from Equality toward Equity: Addressing Disparities in Research Participation for Clinical Cancer Research

AbstractThere is societal consensus that cancer clinical trial participation is unjust because some sociodemographic groups have been systematically underrepresented. Despite this, neither a definition nor an ethical explication for the justice norm of equity has been clearly articulated in this setting, leading to confusion over its application and goals. Herein we define equity as acknowledging sociodemographic circumstances and apportioning resource and opportunity allocation to eliminate disparities in outcomes, and we explore the issues and tensions this norm generates through practical examples. We assess how equality-based enrollment structures in clinical cancer research have perpetuated historical disparities and what equity-based alternatives are necessary to achieve representativeness and an expansive conception of participatory justice in clinical cancer research. This framework addresses the breadth from normative to applied by defining the justice norm of equity and translating it into practical strategies for addressing participation disparities in clinical cancer research.

Representation of race and ethnicity among cancer survivors in trials of cognitive behavioral therapy for insomnia (CBT-I): A systematic review

PURPOSE

For cancer survivors, insomnia is highly prevalent and debilitating. Although cognitive behavioral therapy for insomnia (CBT-I) is recognized as a gold standard treatment, it is unclear whether benefits of treatment generalize to racial and ethnic minorities in the USA. This systematic review characterizes the representation of racial and ethnic diversity among cancer survivors in CBT-I clinical trials and provides recommendations for research in sleep/cancer survivorship.

METHODS

Literature searches were conducted in five electronic databases (PubMed, Cochrane Library via Ovid, PsycINFO via Ovid, Embase, Web of Science Core Collection) using concepts of CBT, insomnia, and cancer survivors. Information about CBT-I intervention details, sample racial demographics, and whether authors explicitly analyzed race and ethnicity were recorded.

RESULTS

A total of 1673 citations were retrieved, and 967 citations were uploaded to Covidence. Of these, 135 articles went through full-text review and 13 studies were included. Race and ethnicity were reported in 11/13 trials (84.6%). Of those reporting race and ethnicity, 8/11 (72.7%) trials were comprised of samples that were ≥ 85% non-Hispanic White. Among the trials that explicitly analyzed race and ethnicity, CBT-I was more effective among cancer survivors who were White and highly educated, and non-White cancer survivors were less likely to have private insurance and ability to participate in clinical trials.

CONCLUSION

Non-Hispanic White cancer survivors are overrepresented in CBT-I trials, the best available treatment for insomnia. Underrepresentation of racial and ethnic minorities likely contributes to barriers in access and uptake. Recommendations include implementing sustained efforts to expand diversity in CBT-I clinical trials for cancer survivors.

The influence of political ideology on clinical trial knowledge, invitation, and participation among adults in the United States

BACKGROUND

Clinical trials remain a critical component of medical innovation. Evidence suggests that individuals' political ideologies may impact their health behaviors. However, there is a paucity of literature examining the relationship between political ideologies and clinical trial knowledge and participation.

METHODS

Study data were derived from Health Information National Trends Survey 5 Cycle 4 (n = 3300), which was conducted from February to June 2020. We used participants' characteristics to estimate the prevalence of clinical trial knowledge and participation. We used multivariable logistic regressions to investigate whether political ideology had a significant impact on clinical trial knowledge and participation. Jack-knife replicate weights were applied for population-level estimates.

RESULTS

Most participants were White (64.2%), earned above US$50,000 (62.4%), and lived in urban areas (88.0%). About 59.2% reported having some knowledge of clinical trials, and only 8.9% had ever been invited to participate in clinical trials. A total of 37.0%, 29.5%, and 33.5% of the population endorsed moderate, liberal, and conservative political viewpoints respectively. In the adjusted logistic regression analysis, compared to conservatives, liberals (adjusted odds ratio, 1.92; 95% confidence interval, 1.31-2.80) and moderates (adjusted odds ratio, 1.43; 95% confidence interval, 1.09-1.88) had significantly greater odds of having knowledge of clinical trials. Also, liberals had higher odds of receiving invitations to participate in clinical trials (odds ratio, 1.76; 95% confidence interval, 1.08-2.85; p = 0.023) and greater odds of trial participation (odds ratio, 3.90; 95% confidence interval, 1.47-10.33; p = 0.007) compared to moderates.

CONCLUSIONS

The mechanism underlying the higher rates of clinical trial invitations to liberals is unclear and requires further comprehensive investigation. Similarly, further qualitative studies are needed to understand the attributes that promote knowledge and increased likelihood of clinical trial participation among liberals. This will provide crucial insight to help design interventions that further involve conservatives and moderates in clinical trials and scientific enterprise.

Advancing healthcare equity through dissemination and implementation science

OBJECTIVE

To provide guiding principles and recommendations for how approaches from the field of dissemination and implementation (D&I) science can advance healthcare equity.

DATA SOURCES AND STUDY SETTING

This article, part of a special issue sponsored by the Agency for Healthcare Research and Quality (AHRQ), is based on an outline drafted to support proceedings of the 2022 AHRQ Health Equity Summit and further revised to reflect input from Summit attendees.

STUDY DESIGN

This is a narrative review of the current and potential applications of D&I approaches for understanding and advancing healthcare equity, followed by discussion and feedback with Summit attendees.

DATA COLLECTION/EXTRACTION METHODS

We identified major themes in narrative and systematic reviews related to D&I science, healthcare equity, and their intersections. Based on our expertise, and supported by synthesis of published studies, we propose recommendations for how D&I science is relevant for advancing healthcare equity. We used iterative discussions internally and at the Summit to refine preliminary findings and recommendations.

PRINCIPAL FINDINGS

We identified four guiding principles and three D&I science domains with strong promise for accelerating progress toward healthcare equity. We present eight recommendations and more than 60 opportunities for action by practitioners, healthcare leaders, policy makers, and researchers.

CONCLUSIONS

Promising areas for D&I science to impact healthcare equity include the following: attention to equity in the development and delivery of evidence-based interventions; the science of adaptation; de-implementation of low-value care; monitoring equity markers; organizational policies for healthcare equity; improving the economic evaluation of implementation; policy and dissemination research; and capacity building.

Journey from an Enabler to a Strategic Leader: Integration of the Medical Affairs Function in ESG Initiatives and Values

Like most private enterprises, the pharmaceutical industry has deeply rooted environmental, social, and governance (ESG) matters that challenge its long-term sustainability. Overcoming these external challenges requires collaborative and proactive steps as well as procedures guiding the adoption of ESG principles by all internal stakeholders. Environmental challenges such as climate change, and in addition the changes in society, have resulted in the need for governance addressing and coordinating efforts. The core function of medical affairs (MA) is connecting with stakeholders within a company and also between the company and external stakeholders. In this article, we describe the involvement of MA in several aspects of ESG, as a contributor, partner, and implementer. MA has a significant opportunity to emerge as a leading function involved in ESG strategies and their tactical implementation. Although the involvement of MA in the environment pillar of ESG is less, the function can implement changes relating to the conduct of meetings, clinical studies, and the digitalization of medical education via virtual platforms. Due to its patient centricity, MA is tasked to address social determinants of health to improve patients' outcomes. As a linking function within a company and with its external stakeholders, MA can provide proactive input in policy generation and enable effective governance by adherence to standards of accountability, ethics, and compliance, as well as transparency. Championing ESG is a collective responsibility that transcends any single department. It mandates a company-wide commitment. MA represents an essential pivot point in catalyzing the integration of ESG principles within industry, contributing to a healthcare ecosystem that is not merely more sustainable and ethical but also more conducive to patient health and public well-being.

Do Current Lung Cancer Clinical Trials Represent All Patient Populations Including Minorities?

The under-representation of racial, sexual, and gender minorities in cancer clinical trials has long been a deficit in clinical cancer research. This review aims to survey current literature to determine the participation of minorities in the United States in lung cancer clinical trials and to find educational methods that have been studied and researched in order to improve patient clinical trial enrollment. A literature search of relevant articles published since 2015 was conducted using PubMed and Google Scholar. Clinical trials conducted in the United States from Clinicaltrials.gov were also collected to determine minority patient enrollment in lung cancer clinical trials. The results of the literature search yielded 6 relevant articles about racial minority representation in lung cancer clinical trials and one relevant article about LGBTQ+ minority representation in cancer clinical trials. Collectively, the literature highlighted the under-representation of racial minorities (such as Black, Hispanic, and American Indian) in clinical trials. Many articles showed that disparities in enrollment were less significant for Asian patients with lung cancer. However, many articles did not mention minorities like Middle Eastern/North Africans and failed to mention the lack of distinguishment of South Asian minorities from Pacific Asian minorities. The findings of this literature review support the idea that current lung cancer clinical trials lack representation of minority patient populations in the United States. The inclusion of racial, sexual, and gender diversity in clinical trial patient populations will aid providers in determining appropriate therapeutics and could potentially improve lung cancer outcomes. Future directions for improving diversity in lung cancer clinical trial enrollment include the utilization of various educational tools to increase minority patient participation in trials, the inclusion of detailed demographic data in cancer clinical trial analysis, and the recruitment of providers and research staff from various minorities to conduct cancer clinical trials.

Characteristics of chief investigators and principal investigators in Australian and New Zealand radiation oncology clinical trials

INTRODUCTION

Globally, the research community is coming to realise the need for diversity, equity and inclusion (DEI) amongst research teams and leadership. Diverse teams reduce homogeneous 'group think', propagate innovation, propound support for broader more representative research and facilitate the recruitment of patients from diverse backgrounds. Given the above, this study aims to retrospectively examine the characteristics of chief investigators (CI) and principal investigators (PI) in past and present Australian and New Zealand radiation oncology clinical trials.

METHODS

Data on CI and PI characteristics were attained from the Trans Tasman Radiation Oncology Group (TROG) website as well as archived master database files provided by the TROG Scientific Committee. Data included CI and PI discipline, clinical trial activation date, institution type (private vs. public) and geographical location if in Australia. Australian and New Zealand health practitioner registration agency websites were used to determine the registered sex of the CIs and PIs and their years of experience.

RESULTS

One hundred and twenty TROG clinical trials have been initiated by 134 CIs from 1989 to 2022 and 463 TROG clinical trials have been opened by 465 PIs at their respective institutions from 2000 to 2022. Most TROG trial investigators have been radiation oncologists and those with over 10 years of experience. Only one in five trials and one in three trials have been led by female PIs and CIs, respectively. Investigators have largely been affiliated with public institutions, with only one in 100 CIs and one in eight PIs being affiliated with the private sector. TROG members from regional and rural areas in Australia have not been engaged as investigators, with all CIs and most PIs affiliated with metropolitan institutions.

CONCLUSION

This study highlights the gaps in diversity amongst CIs and PIs in TROG clinical trials. Further unpacking and understanding of issues related to CI and PI diversity are important to inform initiatives to improve researcher, leadership and patient diversity in future TROG clinical trials.

Reinventing the Clinical Audit in a Pediatric Oncology Network

Providing equal access to pediatric cancer patients regardless of their geographic location is a major goal of the Affiliate Program at St. Jude Children's Research Hospital (St. Jude). Thirty-five percent of new cancer patients enrolled on St. Jude clinical trials reside in the communities of 1 of the 8 affiliate clinics, which serve 9 states in the Southeast and Midwest United States. The affiliate clinics support participant recruitment for clinical trials and the geographic extension of St. Jude clinical care. To ensure high-quality pediatric cancer care, we instituted on-site clinical audits, however, we did not see improvement in clinical outcomes including the time to antibiotics in febrile immunocompromised patients, consistent hand-off communication, consistent documentation of oral chemotherapy, and adherence to a central line bundle in the ambulatory setting. We then moved to a more comprehensive clinical audit which involved self-reflection of clinic staff members, transparent data sharing, development of local quality champions, and engagement of senior leaders. The comprehensive approach was more successful in improving clinical outcomes including the time to antibiotics, hand-off communication, documentation of oral chemotherapy administration, and adherence to a central line bundle in the ambulatory setting.

Use of artificial intelligence for cancer clinical trial enrollment: a systematic review and meta-analysis

BACKGROUND

The aim of this study is to provide a comprehensive understanding of the current landscape of artificial intelligence (AI) for cancer clinical trial enrollment and its predictive accuracy in identifying eligible patients for inclusion in such trials.

METHODS

Databases of PubMed, Embase, and Cochrane CENTRAL were searched until June 2022. Articles were included if they reported on AI actively being used in the clinical trial enrollment process. Narrative synthesis was conducted among all extracted data: accuracy, sensitivity, specificity, positive predictive value, and negative predictive value. For studies where the 2x2 contingency table could be calculated or supplied by authors, a meta-analysis to calculate summary statistics was conducted using the hierarchical summary receiver operating characteristics curve model.

RESULTS

Ten articles reporting on more than 50 000 patients in 19 datasets were included. Accuracy, sensitivity, and specificity exceeded 80% in all but 1 dataset. Positive predictive value exceeded 80% in 5 of 17 datasets. Negative predictive value exceeded 80% in all datasets. Summary sensitivity was 90.5% (95% confidence interval [CI] = 70.9% to 97.4%); summary specificity was 99.3% (95% CI = 81.8% to 99.9%).

CONCLUSIONS

AI demonstrated comparable, if not superior, performance to manual screening for patient enrollment into cancer clinical trials. As well, AI is highly efficient, requiring less time and human resources to screen patients. AI should be further investigated and implemented for patient recruitment into cancer clinical trials. Future research should validate the use of AI for clinical trials enrollment in less resource-rich regions and ensure broad inclusion for generalizability to all sexes, ages, and ethnicities.

"There's not enough studies": Views of black breast and ovarian cancer patients on research participation

BACKGROUND

Black breast and ovarian cancer patients are underrepresented in clinical cancer trials disproportionate to the prevalence of these cancers in Black females. Historically, lower enrollment has been attributed to individualized factors, including medical mistrust, but more recently structural factors, including systemic racism, have received additional scrutiny. We interviewed Black women with a personal or family history of breast and ovarian cancer to understand their views and experiences related to research participation.

METHODS

Qualitative interviews were conducted via telephone or video conference and transcribed verbatim. Transcripts were qualitatively analyzed for iterative themes related to the offer and participation in cancer clinical trials and research studies, impact on cancer care, and recommendations to increase enrollment of Black patients.

RESULTS

Sixty-one Black women completed an interview. Participants expressed that Black women are underrepresented in cancer research, and that this negatively impacted their own care. Many cited past historical abuses, including the Tuskegee syphilis trial, as a potential factor for lower enrollment but suggested that lower enrollment was better understood in the context of the entirety of their healthcare experiences, including present-day examples of patient mistreatment or dismissal. Participants suggested that proactive community engagement, transparency, and increased representation of Black research team members were strategies likely to foster trust and bolster research participation.

CONCLUSION(S)

Medical mistrust is only a partial factor in the lower participation of Black patients in cancer research. Researchers should implement the strategies identified by our participants to promote diverse enrollment and ensure that Black patients are included in future therapeutic advances.

Increasing Racial and Ethnic Equity, Diversity, and Inclusion in Cancer Treatment Trials: Evaluation of an ASCO-Association of Community Cancer Centers Site Self-Assessment

Clinical trial participants do not reflect the racial and ethnic diversity of people with cancer. ASCO and the Association of Community Cancer Centers collaborated on a quality improvement study to enhance racial and ethnic equity, diversity, and inclusion (EDI) in cancer clinical trials. The groups conducted a pilot study to examine the feasibility, utility, and face validity of a two-part clinical trial site self-assessment to enable diverse types of research sites in the United States to (1) review internal data to assess racial and ethnic disparities in screening and enrollment and (2) review their policies, programs, procedures to identify opportunities and strategies to improve EDI. Overall, 81% of 62 participating sites were satisfied with the assessment; 82% identified opportunities for improvement; and 63% identified specific strategies and 74% thought the assessment had potential to help their site increase EDI. The assessment increased awareness about performance (82%) and helped identify specific strategies (63%) to increase EDI in trials. Although most sites (65%) were able to provide some data on the number of patients that consented, only two sites were able to provide all requested trial screening, offering, and enrollment data by race and ethnicity. Documenting and evaluating such data are critical steps toward improving EDI and are key to identifying and addressing disparities more broadly. ASCO and Association of Community Cancer Centers will partner with sites to better understand their processes and the feasibility of collecting screening, offering, and enrollment data in systematic and automated ways.

Diversity of Participation in Clinical Trials and Influencing Factors: Findings from the Health Information National Trends Survey 2020

BACKGROUND

Clinical trial diversity is critical to advance health and health equity. Research addressing the discrepancy between goals of achieving clinical trial diversity and realities of study enrollment remains underdeveloped.

OBJECTIVE

This study aims to examine the association between race/ethnicity and clinical trial invitation, participation, knowledge, and sources of influence on clinical trial participation.

DESIGN AND PARTICIPANTS

A cross-sectional, observational study using nationally representative data from 3689 US adults (≥ 18 years of age) who responded to the Health Information National Trends Survey fielded from February 24 to June 15, 2020.

MAIN MEASURES

Primary outcomes included clinical trial invitation, participation, knowledge, and sources of influence on participation. The independent variable of interest is self-reported race/ethnicity.

KEY RESULTS

Respondents identifying as non-Hispanic Black (relative to non-Hispanic White) had higher odds of being invited into a clinical trial (adjusted odds ratio: 2.0, 95% confidence interval (CI): 1.1, 3.7), but no differences in odds of participation were observed by race/ethnicity. Respondents from all races/ethnicities reported that personal healthcare providers were the most trusted source of clinical trial information. Hispanic (marginal effect (ME): - 0.09; 95% CI: - 0.16, - 0.03), non-Hispanic Black (ME: - 0.11; 95% CI: - 0.18, - 0.04), and non-Hispanic other (ME: - 0.11; 95% CI: - 0.19, - 0.02) respondents had lower odds than non-Hispanic White respondents of saying they would be influenced "a lot" by their doctor encouraging participation. Non-Hispanic Black respondents had significantly lower odds (relative to non-Hispanic White) of indicating family encouragement would influence their clinical trial participation decision "a lot" (ME: - 0.09; 95%: CI: - 0.14, - 0.03).

CONCLUSION

While personal healthcare providers were trusted sources of information, racial/ethnic minority populations noted lower odds of clinical trial participation influence from providers and family. Thus, it is imperative for the healthcare, government, and industry organizations to build trust in medicine and science.

An Assessment of the Feasibility and Utility of an ACCC-ASCO Implicit Bias Training Program to Enhance Racial and Ethnic Diversity in Cancer Clinical Trials

PURPOSE

Cancer trial participants do not reflect the racial and ethnic diversity in the population of people with cancer in the United States. As a result of multiple system-, patient-, and provider-level factors, including implicit bias, cancer clinical trials are not consistently offered to all potentially eligible patients.

MATERIALS AND METHODS

ASCO and ACCC evaluated the utility (pre- and post-test knowledge changes) and feasibility (completion rates, curriculum satisfaction metrics, survey questions, and interviews) of a customized online training program combined with facilitated peer-to-peer discussion designed to help research teams identify their own implicit biases and develop strategies to mitigate them. Discussion focused on (1) specific elements of the training modules; (2) how to apply lessons learned; and (3) key considerations for developing a facilitation guide to support peer-to-peer discussions in cancer clinical research settings. We evaluated discussion via a qualitative assessment.

RESULTS

Participant completion rate was high: 49 of 50 participating cancer programs completed training; 126 of 129 participating individuals completed the training (98% response rate); and 119 completed the training and evaluations (92% response rate). Training increased the mean percentage change in knowledge scores by 19%-45% across key concepts (eg, causes of health disparities) and increased the mean percentage change in knowledge scores by 10%-31% about strategies/actions to address implicit bias and diversity concerns in cancer clinical trials. Knowledge increases were sustained at 6 weeks. Qualitative evaluation validated the utility and feasibility of facilitated peer-to-peer discussion.

CONCLUSION

The pilot implementation of the training program demonstrated excellent utility and feasibility. Our evaluation affirms that an online training designed to raise awareness about implicit bias and develop strategies to mitigate biases among cancer research teams is feasible and can be readily implemented in cancer research settings.

Virtual Community Engagement for Retention of Black Men in Clinical Research

Black American men have worse cardiovascular health compared with their White counterparts, yet are highly underrepresented in clinical trials. In 2020, Black men were recruited to participate in Black Impact, a community-based lifestyle intervention to increase cardiovascular health. Due to the research pause during the Coronavirus Disease (COVID-19) pandemic, a virtual community engagement (VCE) process was co-designed with community stakeholders and evaluated for its effect on retention for the clinical trial. VCE via weekly virtual video conference sessions occurred for 9 weeks as a run-in phase prior to in-person research activities. Data collected during sessions included attendance, anecdotes on acceptability, and topical requests for subsequent weeks. Content analysis was performed on scribe notes from sessions to ascertain themes describing the implementation and participant perceptions of the VCE. Descriptive statistics were used to analyze quantitative data. The VCE provided opportunities to co-create a safe atmosphere in small groups, discuss mental health, foster trust, capitalize on the power of spirituality, and establish a brotherhood. Following the VCE run-in phase, 74 of 100 participants remained engaged for participation in the Black Impact study. The VCE described provides a framework that can be used to retain Black men during study delays or disruptions through fostering engagement and building community among participants and researchers.

IMPROVING DIVERSE PARTICIPATION IN CANCER CLINICAL TRIALS

Despite significant improvement in overall cancer mortality (>30% since 1991), these survival benefits have not been experienced by all groups uniformly especially in those of diverse heritage. Drivers of cancer health inequity are multi-factorial including more adverse social determinants of health, later stage cancer presentation, decreased health care access, decreased health literacy, and cultural barriers to prompt cancer care. Adding to these disparities is the historical inclusion of primarily well-insured Caucasian patients into cancer clinical trials leading to deep gaps in understanding both the efficacy and safety of new therapies in the actual populations for which these medications will be used. The need for trial accruals to reflect the U.S. population (i.e., diverse) is essential across diseases, but especially those in which certain minority populations are overrepresented (Latinos and hepatocellular carcinoma, African Americans and myeloma and prostate cancer). Strategies and new legislation to increase diversity in trial accruals are outlined and discussed.

Addressing Transportation Insecurity Among Patients With Cancer

Health-care-related transportation insecurity is common in the United States. Patients with cancer are especially vulnerable because cancer care is episodic in nature, occurs over a prolonged period, is marked by frequent clinical encounters, requires intense treatments, and results in substantial financial hardship. As a result of transportation insecurity, patients with cancer may forego, miss, delay, alter, and/or prematurely terminate necessary care. Limited data suggest that these alterations in care have the potential to increase the rates of cancer recurrence and mortality and exacerbate disparities in cancer incidence, severity, and outcomes. Transportation insecurity also negatively impacts at the informal caregiver, provider, health system, and societal levels. Recognizing that transportation is a critical determinant of outcomes for patients with cancer, there are ongoing efforts to develop evidence-based protocols to identify at-risk patients and address transportation insecurity at federal policy, health system, not-for-profit, and industry levels. In 2021, the National Cancer Policy Forum of the National Academies of Science, Engineering, and Medicine sponsored a series of webinars addressing key social determinants of health including food, housing, and transportation among patients with cancer. This commentary summarizes the formal presentations and discussions related to transportation insecurity and will 1) discuss the heterogeneous nature of transportation insecurity among patients with cancer; 2) characterize its prevalence along the cancer continuum; 3) examine its multilevel consequences; 4) discuss measurement and screening tools; 5) highlight ongoing efforts to address transportation insecurity; 6) suggest policy levers; and 7) outline a research agenda to address critical knowledge gaps.

Digital Health Equity: Addressing Power, Usability, and Trust to Strengthen Health Systems

BACKGROUND

Without specific attention to health equity considerations in design, implementation, and evaluation, the rapid expansion of digital health approaches threatens to exacerbate rather than ameliorate existing health disparities.

METHODS

We explored known factors that increase digital health inequity to contextualize the need for equity-centered informatics. This work used a narrative review method to summarize issues about inequities in digital health and to discuss future directions for researchers and clinicians. We searched literature using a combination of relevant keywords (e.g., "digital health", "health equity", etc.) using PubMed and Google Scholar.

RESULTS

We have highlighted strategies for addressing medical marginalization in informatics according to vectors of power such as race and ethnicity, gender identity and modality, sexuality, disability, housing status, citizenship status, and criminalization status.

CONCLUSIONS

We have emphasized collaboration with user and patient groups to define priorities, ensure accessibility and localization, and consider risks in development and utilization of digital health tools. Additionally, we encourage consideration of potential pitfalls in adopting these diversity, equity, and inclusion (DEI)-related strategies.

Feasibility of oncology clinical trial-embedded evaluation of social determinants of health

Social determinants of health (SDoH) are associated with stark disparities in cancer outcomes, but systematic SDoH data collection is virtually absent from oncology clinical trials. Trial-based SDoH data are essential to ensure representation of marginalized populations, contextualize outcome disparities, and identify health-equity intervention opportunities. We report the feasibility of a pediatric oncology multicenter therapeutic trial-embedded SDoH investigation. Among 448 trial participants, 392 (87.5%) opted-in to the embedded SDoH study; 375 (95.7%) completed baseline surveys, with high longitudinal response rates (88.9-93.1%) over 24 months. Trial-embedded SDoH data collection is feasible and acceptable and must be consistently included within future oncology trials.

Efficacy of COVID-19 vaccines by race and ethnicity

OBJECTIVES

Vaccine uptake amongst ethnic minority populations has been persistently lower, which may be because of socio-economic factors such as health literacy and health insurance status. This review aimed to assess to what extent COVID-19 clinical trials have considered the impact of race and ethnicity on COVID-19 vaccine safety and efficacy.

STUDY DESIGN

This was a systematic review.

METHODS

Data regarding ethnicity in COVID-19 vaccine clinical trials were systematically reviewed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in this systematic review, which ran from inception until June 2021. Three international databases, PubMed, Scopus and Web of Science, were used to conduct systematic article searches. Only two studies reported vaccine efficacy among ethnic minority groups.

RESULTS

The efficacy of the mRNA-1273 vaccine was confirmed to be 95% in Caucasians and 97.5% in 'people of colour' in a study by Baden et al. In another study by Polack et al., BNT162b2 mRNA vaccine efficacy was reported to be 95.2% in Caucasians, 100% in Afro-Caribbean or African Americans, 94.2% in Hispanic or Latinx and 95.4% in non-Hispanic, non-Latinx people.

CONCLUSIONS

Given the highly differing effect of COVID-19 on the Afro-Caribbean, Hispanic and South Asian populations, it is imperative for COVID-19 vaccine clinical trials to thoroughly assess the safety and efficacy of vaccines in different ethnicities and, if necessary, develop ethnicity-specific protocols, which can minimise the disproportionate effect of COVID-19 on ethnic minority populations.

Flexibility, adaptation, and roles of patient navigators in oncology during COVID-19

BACKGROUND

The impact of COVID-19 on cancer care during the first 6 months of the pandemic has been significant. The National Navigation Roundtable Workforce Development Task Group conducted a national survey to highlight the role of patient navigators (PNs).

METHODS

An anonymous online survey captured how cancer care navigation changed during 2 phases: 1) March 13 to May 31, 2020; and 2) June 1 to September 4, 2020. Differences between the 2 time periods for categorical variables were assessed using χ² tests, and 1-way analyses of variance were used for ordinal variables.

RESULTS

Almost one-half of PNs expected changes in duties (49%) during phase 1. By phase 2, PNs showed greater confidence in retaining PN work (P < .001) and reduced changes to duties (P < .01). PNs reported new training on COVID-19 and telehealth during phase 1 (64% and 27%, respectively) and phase 2 (54% and 19%, respectively). Significant decreases in service delays were identified by phase 2 for cancer screening (P < .001), preventive care (P < .001), medical treatment (P < .01), cancer treatment (P < .001), and cancer survivorship services (P < .01). PNs reported that the top patient issues were COVID-19 concerns, medical care disruptions, and finances, and there were decreases in medical care disruptions (P < .01) during phase 2. PNs addressed myths related to mask use, COVID-19 spread, disbelief, risk, clinical changes, transmission prevention, and finances/politics.

CONCLUSIONS

The PN role demonstrated resiliency and adaptability. Both clinical and nonclinical oncology PNs identified key patient needs and can provide connections with patient populations that have been economically and socially marginalized, which is necessary to build trust throughout the pandemic.

Moving Beyond Patient-Level Drivers of Racial/Ethnic Disparities in Childhood Cancer

Racial/ethnic disparities in childhood cancer survival persist despite advances in cancer biology and treatment. Survival rates are consistently lower among non-Hispanic Black and Hispanic children as compared with non-Hispanic White children across a range of hematologic cancers and solid tumors. We provide a framework for considering complex systems and social determinants of health in research examining the drivers of racial/ethnic disparities in childhood cancer survival, given that pediatric patients' interactions with the healthcare system are filtered through their caregiver, family, and societal structure. Dismantling the multi-level (patient, family, healthcare system, and structural) barriers into modifiable drivers is critical to developing policies and interventions toward equitable health outcomes. This commentary highlights areas at the family, healthcare system, and society levels that merit closer examination and proposes actions and interventions to support improvements across these levels. See recently published article in the November issue of CEBP, Racial/Ethnic Disparities in Childhood Cancer Survival in the United States p. 2010.

Racial Disparities and Cardiometabolic Risk: New Horizons of Intervention and Prevention

PURPOSE OF REVIEW

Cardiometabolic diseases are a leading cause of morbidity and mortality in the USA and disproportionately impact racial and ethnic minorities. Multiple factors contribute to this disparity including genetic and socioeconomic factors, the latter of which contributes to disparities both through systemic barriers such as healthcare access and by directly impacting metabolism through epigenetics and environment-related alterations in the gut microbiome. This review will discuss advances in medicine that can be used to identify, prognosticate, and treat cardiometabolic diseases, and how these may be used to address existing disparities.

RECENT FINDINGS

There is growing research aimed at identifying novel cardiometabolic disease targets and expanding the use of existing pharmacotherapies based on comorbidities. Advances in metabolomics and genomics can give insight into an individual's unique biochemical profile, providing the means for earlier identification of disease and specific treatment targets. Moreover, developments in telehealth and related medical device technologies can expand access to underserved minority populations and improve control of chronic conditions such as diabetes and hypertension. Precision medicine may be integral to bridging the racial gap in cardiometabolic disease outcomes. Developments in genomics, metabolomics, wearable medical devices, and telehealth can result in personalized treatments for patients that account for the socioeconomic and genetic factors that contribute to poor health outcomes in minorities. As research in this field rapidly progresses, special efforts must be made to ensure inclusion of racial and ethnic minority populations in clinical research and equal access to all treatment modalities.