Training community health workers about cancer clinical trials

Training to Increase Minority Enrollment in Lupus Clinical Trials With Community Engagement: Enhancing Lupus Clinical Trial Recruitment Through Provider and Community Health Worker Engagement

OBJECTIVE

This study evaluates the effectiveness of the Training to Increase Minority Enrollment in Lupus Clinical Trials with Community Engagement (TIMELY) program on enhancing referrals of underrepresented patients to lupus clinical trials. TIMELY leverages two existing American College of Rheumatology online educational initiatives: Materials to Increase Minority Involvement in Clinical Trials (MIMICT), a continuing medical education activity for health care providers, and the community health worker (CHW) Lupus Clinical Trials Training (LuCTT). TIMELY introduced a unique roundtable meeting format to build on the existing online educational programs and facilitate discussions between local clinical trial sites and provider and CHW participants.

METHODS

This study used an online pretest and posttest design to assess changes in theory-based behavioral predictors of lupus clinical trial referrals and engagement (ie, knowledge, attitudes, self-efficacy, and intentions) among providers and CHWs. Participants completed MIMICT or LuCTT and then were eligible to participate in roundtable meetings. Paired t-tests were used to assess changes in composite scores before and after the intervention for each of the outcomes.

RESULTS

The final sample included 40 providers and 18 CHWs. Knowledge scores increased significantly for both providers (P < 0.01) and CHWs (P < 0.001) on completion of MIMICT and LuCTT, respectively. After participating in the TIMELY roundtable, providers' composite scores for self-efficacy and intentions significantly increased (P < 0.001). Provider self-efficacy gains were sustained at three months' follow-up (P < 0.001).

CONCLUSION

These promising findings highlight the potential and opportunities for the TIMELY program to improve behavioral predictors of trial referrals, including CHW knowledge and providers' knowledge, self-efficacy, and intentions to refer underrepresented patients to lupus clinical trials.

Disparities in Clinical Trial Participation: Multilevel Opportunities for Improvement

Current data demonstrate ongoing inequities in surgical oncology clinical trials and understanding these disparities is vital to creating a more just and equitable health care system. Analysis of participatory patterns in cooperative group surgical oncology trials demonstrates complex relationships between race, socioeconomic status, and participation in these trials at the patient level. Further analysis reveals that provider-level implicit bias plays a significant role in access to clinical trials by minority populations. Holistic approaches to addressing disparities in clinical trial participation include creating a more robust pipeline of minority surgeon-scientists, engaging in partnerships with community advocates, and promoting public policy.

Delivering Equitable Care to Underserved Neuro-oncology Populations

It is widely recognized that subspecialized multidisciplinary care improves neuro-oncology outcomes. Optimizing patient outcomes relies on the expertise of the treating physicians, neuroradiology and neuropathology, and supportive services familiar with common neurologic syndromes that occur after brain tumor diagnosis and treatment. Despite an increasing number of providers, patient access to specialized multidisciplinary care and clinical trials remains limited. Barriers to equitable health care exist across the United States, with marginalized communities being impacted disproportionately. Such disparity causes increased morbidity and mortality for patients from backgrounds with various elements of diversity. Limited attention to this inequity has resulted in an incomplete understanding of the spectrum of experiences that patients with neuro-oncologic diseases encounter. Clinical trials represent the highest standard and quality of care in medicine, but inclusion of under-represented and underserved groups consistently lags behind counterpart participants from majority racial and ethnic groups. Through provider education as it pertains to issues from bias and health literacy to increasing clinical trial enrollment and offering opportunities through telemedicine, opportunities for improving access to high-quality neuro-oncologic care are explored.

The State of Lupus Clinical Trials: Minority Participation Needed

In the United States, the reported prevalence of lupus is 100,000 to 500,000 patients. Lupus disproportionately affects minority populations, including African Americans and Latinos, and the associated health disparities are substantial. Women are at a higher risk of lupus than men and lupus prevalence is the highest in African Americans and Latinos compared to non-Hispanic whites. African Americans and Latinos also have increased disease symptom severity, experience more lupus-related complications, and have a two- to three-fold mortality rate compared to non-Hispanic Whites. Lupus clinical trials offer opportunities for quality care and can result in new treatment options, but African Americans and Latinos are underrepresented in clinical trials because of substantial patient- and provider-side barriers. In conjunction with the limited knowledge of clinical trials that potential participants may have, the healthcare staff approaching participants have limited time to adequately educate and explain the aspects of clinical trials. Indeed, ninety percent of clinical trials fail to meet their recruitment goals on time, so a multi-faceted approach is necessary to address the issue of low minority participation in clinical trials.

A community-academic partnership to explore informational needs of African American women as a primer for cancer clinical trial recruitment

Background: African Americans (AAs) are less likely to participate in cancer clinical trials (CCTs) despite experiencing disproportionately higher rates of cancer mortality. As a way to address these ongoing disparities, this study sought to qualitatively explore informational needs regarding CCTs among AA women and identify message considerations for educational information targeting AA women and their community. Methods: Three focus groups were conducted in which AA women viewed a DVD created as a decisional tool for CCT participation and provided feedback regarding content. Results: Results indicated general fear regarding CCTs, which is partially attributable to the impact of historic research abuses, lack of information regarding CCTs, and lack of cultural relevance of the education and outreach materials for AA communities. Recruitment of AAs to CCTs may be enhanced by educational and outreach approaches that increase awareness of CCTs as well as involvement of the AA community in developing such interventions. Conclusion: Interventions should include the perspectives of AA women, as key stakeholders and decision-makers for their family and provide research information in a multimedia format that will facilitate family discussion and decision-making regarding CCTs.

Patient Navigation As a Model to Increase Participation of African Americans in Cancer Clinical Trials

PURPOSE

Less than 10% of patients enrolled in clinical trials are minorities. The patient navigation model has been used to improve access to medical care but has not been evaluated as a tool to increase the participation of minorities in clinical trials. The Increasing Minority Participation in Clinical Trials project used patient navigators (PNs) to enhance the recruitment of African Americans for and their retention in therapeutic cancer clinical trials in a National Cancer Institute-designated comprehensive cancer center.

METHODS

Lay individuals were hired and trained to serve as PNs for clinical trials. African American patients potentially eligible for clinical trials were identified through chart review or referrals by clinic nurses, physicians, and social workers. PNs provided two levels of services: education about clinical trials and tailored support for patients who enrolled in clinical trials.

RESULTS

Between 2007 and 2014, 424 African American patients with cancer were referred to the Increasing Minority Participation in Clinical Trials project. Of those eligible for a clinical trial (N = 378), 304 (80.4%) enrolled in a trial and 272 (72%) consented to receive patient navigation support. Of those receiving patient navigation support, 74.5% completed the trial, compared with 37.5% of those not receiving patient navigation support. The difference in retention rates between the two groups was statistically significant (P < .001). Participation of African Americans in therapeutic cancer clinical trials increased from 9% to 16%.

CONCLUSION

Patient navigation for clinical trials successfully retained African Americans in therapeutic trials compared with non-patient navigation trial participation. The model holds promise as a strategy to reduce disparities in cancer clinical trial participation. Future studies should evaluate it with racial/ethnic minorities across cancer centers.

Training in Patient Navigation: A Review of the Research Literature

Despite the proliferation of patient navigation programs designed to increase timely receipt of health care, little is known about the content and delivery of patient navigation training, or best practices in this arena. The current study begins to address these gaps in understanding, as it is the first study to comprehensively review descriptions of patient navigation training in the peer-reviewed research literature. Seventy-five patient navigation efficacy studies published since 1995, identified through PubMed and by the authors, were included in this narrative review. Fifty-nine of the included studies (79%) mentioned patient navigation training, and 55 of these studies additionally provided a description of training. Most studies did not thoroughly document patient navigation training practices. Additionally, several topics integral to the role of patient navigators, as well as components of training central to successful adult learning, were not commonly described in the research literature. Descriptions of training also varied widely across studies in terms of duration, location, format, learning strategies employed, occupation of trainer, and content. These findings demonstrate the need for established standards of navigator training as well as for future research on the optimal delivery and content of patient navigation training.

Collaborative development of clinical trials education programs for African-American community-based organizations

This paper describes the use of a unique "Learning and Feedbackˮ approach to customize cancer clinical trials education programs for Community Bridges, a peer training intervention designed for African-American communities in North Carolina. Generic community education modules were demonstrated with key community leaders who were designated as trainers. Quantitative and qualitative assessments were provided on understanding of content, comfort with material, and cultural relevance. The generic materials were adapted into three revised modules, all featuring key messages about cancer clinical trials, discussion regarding distrust of medical research, common misconceptions about trials, patient protections, and a call to action to prompt increased inquiry about locally available trials. The revised modules were then used as part of a train-the-trainer program with 12 African-American community leaders. ENACCT's use of the Learning and Feedback process is an innovative method for culturally adapting clinical trials education.

State-of-the-science of patient navigation as a strategy for enhancing minority clinical trial accrual

BACKGROUND

Patient navigation programs are emerging that aim to address disparities in clinical trial participation among medically underserved populations, including racial/ethnic minorities. However, there is a lack of consensus on the role of patient navigators within the clinical trial process as well as outcome measures to evaluate program effectiveness.

METHODS

A review of the literature was conducted of PubMed, Medline, CINHAL, and other sources to identify qualitative and quantitative studies on patient navigation in clinical trials. The search yielded 212 studies, of which only 12 were eligible for this review.

RESULTS

The eligible studies reported on the development of programs for patient navigation in cancer clinical trials, including training and implementation among African Americans, American Indians, and Native Hawaiians. A low rate of clinical trial refusal (range, 4%-6%) was reported among patients enrolled in patient navigation programs. However, few studies reported on the efficacy of patient navigation in increasing clinical treatment trial enrollment.

CONCLUSIONS

Outcome measures are proposed to assist in developing and evaluating the efficacy and/or effectiveness of patient navigation programs that aim to increase participation in cancer clinical trials. Future research is needed to evaluate the efficacy of patient navigators in addressing barriers to clinical trial participation and increasing enrollment among medically underserved cancer patients.

Helping cancer patients across the care continuum: the navigation program at the Queen's Medical Center

Research suggests that cancer patient navigation improves care, but few reports describe the variety of patients managed by a hospital-based navigation program. Differences in navigated patients by the intensity (low, medium, or high) of navigation services they received were examined. The 835 clients seen by the navigators in a hospital-based cancer center were first stratified by quarter and by four ethnic groups. Randomized selection from each group assured there would be equal representation for analysis of Hawaiians, Filipinos, Japanese, and Whites and even numbers over all time intervals. Five professionals extracted data from these case records on demographics, type/stage of cancer, diagnosis and treatment dates, barriers, and navigator actions. Clients had breast (30.0%), lung (15.8%), esophageal (6.7%), colon (5.8%), ovarian (4.2%), prostate (3.3%), and other cancers (34.2%). The median number of actions taken on behalf of a client was 4 (range 1-83), and the median number of days a case was open was 14 (range 1-216). High intensity cases (those receiving more assistance over longer periods of time) were more likely than low-intensity cases to need help with education and reassurance, transportation, care coordination, and covering costs. Although there were no demographic differences across intensity groups, Neighbor Island patients from Hawai'i, Maui, Moloka'i, Lana'i and Kaua'i were more likely to need help with arranging travel, care coordination, and costs associated with getting treatment (all at P=.05), and patients on public insurance were more likely to have stage 4 cancer (P=.001) and to need help with costs (P=.006). Findings suggest that this hospital-based navigation program is filling a real need of patients across the cancer care continuum. A triage protocol and an integrated data capture system could help improve the targeting and documentation of cancer patient navigation services.

Cancer patient navigator tasks across the cancer care continuum

Cancer patient navigation (PN) programs have been shown to increase access to and utilization of cancer care for poor and underserved individuals. Despite mounting evidence of its value, cancer patient navigation is not universally understood or provided. We describe five PN programs and the range of tasks their navigators provide across the cancer care continuum (education and outreach, screening, diagnosis and staging, treatment, survivorship, and end-of-life). Tasks are organized by their potential to make cancer services understandable, available, accessible, affordable, appropriate, and accountable. Although navigators perform similar tasks across the five programs, their specific approaches reflect differences in community culture, context, program setting, and funding. Task lists can inform the development of programs, job descriptions, training, and evaluation. They also may be useful in the move to certify navigators and establish mechanisms for reimbursement for navigation services.