Enrollment of racial and ethnic minorities in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial

Prostate Cancer Foundation Screening Guidelines for Black Men in the United States

BACKGROUND

In the United States, Black men are at highest risk for being diagnosed with and dying from prostate cancer. Given this disparity, we examined relevant data to establish clinical prostate-specific antigen (PSA) screening guidelines for Black men in the United States.

METHODS

A comprehensive literature search identified 1848 unique publications for screening. Of those screened, 287 studies were selected for full-text review, and 264 were considered relevant and form the basis for these guidelines. The numbers were reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

Three randomized controlled trials provided Level 1 evidence that regular PSA screening of men 50 to 74 years of age of average risk reduced metastasis and prostate cancer death at 16 to 22 years of follow-up. The best available evidence specifically for Black men comes from observational and modeling studies that consider age to obtain a baseline PSA, frequency of testing, and age when screening should end. Cohort studies suggest that discussions about baseline PSA testing between Black men and their clinicians should begin in the early 40s, and data from modeling studies indicate prostate cancer develops 3 to 9 years earlier in Black men compared with non-Black men. Lowering the age for baseline PSA testing to 40 to 45 years of age from 50 to 55 years of age, followed by regular screening until 70 years of age (informed by PSA values and health factors), could reduce prostate cancer mortality in Black men (approximately 30% relative risk reduction) without substantially increasing overdiagnosis.

CONCLUSIONS

These guidelines recommend that Black men should obtain information about PSA screening for prostate cancer. Among Black men who elect screening, baseline PSA testing should occur between ages 40 and 45. Depending on PSA value and health status, annual screening should be strongly considered. (Supported by the Prostate Cancer Foundation.).

Dynamic data-enabled stratified sampling for trial invitations with application in NHS-Galleri

BACKGROUND

Participants of health research studies such as cancer screening trials usually have better health than the target population. Data-enabled recruitment strategies might be used to help minimise healthy volunteer effects on study power and improve equity.

METHODS

A computer algorithm was developed to help target trial invitations. It assumes participants are recruited from distinct sites (such as different physical locations or periods in time) that are served by clusters (such as general practitioners in England, or geographical areas), and the population may be split into defined groups (such as age and sex bands). The problem is to decide the number of people to invite from each group, such that all recruitment slots are filled, healthy volunteer effects are accounted for, and equity is achieved through representation in sufficient numbers of all major societal and ethnic groups. A linear programme was formulated for this problem.

RESULTS

The optimisation problem was solved dynamically for invitations to the NHS-Galleri trial (ISRCTN91431511). This multi-cancer screening trial aimed to recruit 140,000 participants from areas in England over 10 months. Public data sources were used for objective function weights, and constraints. Invitations were sent by sampling according to lists generated by the algorithm. To help achieve equity the algorithm tilts the invitation sampling distribution towards groups that are less likely to join. To mitigate healthy volunteer effects, it requires a minimum expected event rate of the primary outcome in the trial.

CONCLUSION

Our invitation algorithm is a novel data-enabled approach to recruitment that is designed to address healthy volunteer effects and inequity in health research studies. It could be adapted for use in other trials or research studies.

Health Disparities in Ovarian Cancer: Report From the Ovarian Cancer Evidence Review Conference

Health disparity, defined by the Centers for Disease Control and Prevention (CDC) as "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations," is seen across multiple diseases. We conducted an evidence review of health disparities and inequities and their mitigation strategies related to ovarian cancer as part of a CDC-sponsored project to develop educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. Our review found profound disparities in outcomes such as survival, treatment, and stage at diagnosis by factors such as race and ethnicity, insurance, socioeconomic status, and geographic location. We found little direct evidence on mitigation strategies. Studies support equivalent response to equivalent treatment between groups, suggesting that adherence to National Comprehensive Cancer Network guidelines can at least partially mitigate some of the differences.

Screening asymptomatic men for prostate cancer: A comparison of international guidelines on prostate-specific antigen testing

OBJECTIVE

To summarise and compare the key recommendations on prostate-specific antigen (PSA)-based screening for prostate cancer, and so highlight where more evidence is required to facilitate consistent recommendations.

METHODS

The Medline database and websites of 18 national screening organisations and professional associations were searched between January 2010 and November 2020 to identify screening guidelines published in English, considering recent clinical trials.

RESULTS

Population-based PSA testing of asymptomatic men is not widely recommended. Guidelines emphasize shared patient-clinician decision making. For 'average-risk' men choosing to be screened, the recommended age varies from 50-55 to 70 years, alongside consideration of life expectancy (ranging from 7-15 years). Screening intervals, when specified, are biennial (most common), annual, or determined from baseline PSA. The earliest age for screening high-risk men (frequently defined as of African descent or with a family history of prostate cancer) is 40 years, but recommendations often defer to clinical judgement.

CONCLUSIONS

Population screening of asymptomatic men is not widely recommended. Instead, balancing the potential harms and benefits of PSA testing is endorsed. Variation between guidelines stems from differing interpretations of key trials and could lead to clinician-dependent screening views. The development of clinical decision aids and international consensus on guidelines may help reduce national and international variation on how men are counselled.

Minority Enrollment in Phase II and III Clinical Trials in Urologic Oncology

PURPOSE

Proportionate minority representation in clinical trials is an important step toward addressing health care inequities. Given the paucity of data on this topic in urologic oncology, we sought to quantify the enrollment of minority patients in clinical trials studying prostate, kidney, and bladder/urothelial cancers.

METHODS

The ClincialTrials.gov database was queried for completed phase II and III interventional trials in prostate, kidney, and bladder cancers. The SEER database was used to calculate the US prevalence of these genitourinary cancers. Representation quotients (RQ) were calculated to describe the relative proportion of each racial/ethnic group enrolled in clinical trials over the proportion of persons from each group among national cancer cases by cancer type.

RESULTS

Of 341 trials that met initial eligibility criteria, only 169 (49.7%) reported data on race or ethnicity. Aggregate RQs from 2000 to 2017 showed that White patients were continually over-represented in trials for all cancer types. Black and Asian patients were poorly represented across all cancer types. When stratified by 3-year increments, the RQs remained stable for all races, from 2000 to 2017. When stratified by ethnicity, Hispanic patients were under-represented across all cancer types in the study period. When examining representation by funding source, we found that US government-funded clinical trials proportionally enroll the most diverse patient populations over those funded by academic institutions and industry. Interestingly, more than 50% of the trials examined did not report race nor ethnicity, highlighting a crucial flaw in investigator compliance with federal clinical trial mandates.

CONCLUSION

Clinical trials targeting prostate, kidney, and bladder cancers continue to under-represent racial/ethnic minority patients. On the basis of the incidence of these cancers within minority populations, efforts should focus on creating racially and ethnically inclusive cancer research.

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.

Diversity of Enrollment in Prostate Cancer Clinical Trials: Current Status and Future Directions

BACKGROUND

Although there are considerable racial and ethnic disparities in prostate cancer incidence and mortality in the United States and globally, clinical trials often do not reflect disease incidence across racial and ethnic subgroups. This study aims to comprehensively review the reporting of race and ethnicity data and the representation of race and ethnicity across prostate cancer treatment-, prevention-, and screening-based clinical trials.

METHODS

Seventy-two global phase III and IV prevention, screening, and treatment prostate cancer clinical trials with enrollment start dates between 1987 and 2016 were analyzed in this study, representing a total of 893,378 individual trial participants. Availability and representation of race and ethnicity data by trial funding type, temporal changes in the racial/ethnic diversity of participants, and geographic representation of countries were assessed.

RESULTS

Of the 72 trials analyzed, 59 (81.9%) had available race data, and 11 (15.3%) of these trials additionally reported ethnicity. Of the trials reporting data, participants were overwhelmingly white men (with the highest proportion in U.S. nonpublicly funded trials), comprising over 96% of the study population. The proportion of white participants in prostate cancer clinical trials has remained at over 80% since 1990. Geographically, Africa and the Caribbean were particularly underrepresented with only 3% of countries included.

CONCLUSIONS

Trial participants continue to be majority white despite the known racial disparities in prostate cancer clinical outcomes.

IMPACT

Current and future trials must use novel recruitment strategies to ensure enrollment of underrepresented men. Targeting the inclusion of African and Caribbean medical centers is crucial to achieve equity in representation.

Racial and Socioeconomic Disparities in the Delivery of Immunotherapy for Metastatic Melanoma in the United States

Immunotherapy for metastatic melanoma has rapidly expanded, but racial and/or socioeconomic factors often impact the type of therapies delivered for cancer care. This study addressed a crucial public health priority by evaluating disparities in administration of immunotherapy for metastatic melanoma. The National Cancer Database was queried for newly diagnosed metastatic melanoma. Patients were dichotomized based on receipt of immunotherapy based on National Cancer Database coding. Multivariable logistic regression ascertained factors associated with immunotherapy delivery. Subgroup analysis evaluated the interaction between race, insurance status, and income. Secondarily, Cox multivariate and propensity-matched Kaplan-Meier analyses assessed overall survival based on immunotherapy receipt. Of 15,941 patients meeting the selection criteria, 2448 (15.4%) received immunotherapy, and 13,493 (84.6%) did not. Temporal trends showed that utilization of immunotherapy was 8%-12% of patients between 2004 and 2010, with utilization increasing to 29.7% of patients in 2014. Immunotherapy was more likely administered to younger and healthier patients, at academic centers, and in the absence of chemotherapy and brain metastases (P<0.05 for all). African Americans, along with patients with Medicaid and lower incomes were less likely to receive immunotherapy (P<0.05 for all). As expected, immunotherapy was associated with improved overall survival (median 16.3 vs. 8.3 mo, P<0.001). Although immunotherapy for metastatic melanoma is markedly escalating, not all populations experience this rise equally. Because immunotherapy utilization is expected to amplify even further in the future, these public health and economic issues are essential to identify and address appropriately, and have implications on public health policy, pharmaceutical and insurance companies, and value-based oncology. Methods to address these inequalities are also discussed.

Racial and Insurance-related Disparities in Delivery of Immunotherapy-type Compounds in the United States

Racial and/or socioeconomic factors affect the type of therapies delivered for non-small cell lung cancer (NSCLC). Given the rapid expansion of immunotherapy for NSCLC, it is a crucial public health priority to evaluate disparities in administration thereof. The National Cancer Database (NCDB) was queried for newly diagnosed metastatic NSCLC. Patients were dichotomized based on receipt of immunotherapy-type compounds (ICs) based on NCDB coding. Multivariable logistic regression ascertained factors associated with IC delivery. Subgroup analysis, performed by univariate logistic regression modeling, evaluated the effect of race while stratifying for insurance type. Of 504,447 patients, 11,420 (2.3%) received ICs, and 493,027 (97.7%) did not. From 2004 to 2012, ≤1% of patients received ICs; however, 4.9% did so in 2013, 6.6% in 2014, and 8.7% in 2015. ICs were more likely administered to younger and healthier patients, those living farther from treating facilities, and in more educated areas (P<0.05 for all). ICs were more often delivered to adenocarcinomas, and patients who received chemotherapy but not radiotherapy (P<0.05 for all). In addition to geographic differences, uninsured and Medicaid populations received ICs less often, along with African Americans. On subgroup analysis, African Americans were less likely to receive ICs even when stratified for Medicare, Medicaid, or private insurances. Because IC utilization is expected to amplify even further going forward, these public health and economic issues are essential to identify and address appropriately, and have implications on pharmaceutical/insurance companies, value-based oncology, and public health policy. Methods to address these inequalities are also discussed.

Precision health research and implementation reviewed through the conNECT framework

BACKGROUND

Precision health is a population-based approach that incorporates big-data strategies to understand the complex interactions between biological, environmental, lifestyle, and psychosocial factors that influence health.

PURPOSE

A promising tool to facilitate precision health research and its dissemination is the ConNECT Framework.

METHODS

Here, we discuss the relationship of the five broad and synergistic principles within the ConNECT Framework as they may apply to nursing science research: (1) Integrating Context, (2) Fostering a Norm of Inclusion, (3) Ensuring Equitable Diffusion of Innovations, (4) Harnessing Communication Technology, and (5) Prioritizing Specialized Training.

DISCUSSION/CONCLUSION

The principles within this framework can be used by nurse scientists and educators to guide and disseminate precision health research.

Asian Americans are less willing than other racial groups to participate in health research

Background

Asian Americans constitute 5% of the U.S. population. Their willingness to participate in research is important to examine because it influences participation rates and the representativeness of study results.

Methods

A total of 17,339 community members participated from six diverse Clinical and Translational Award (CTSA) sites. Community members were asked about their willingness to volunteer for eight different types of health research, their expectation of monetary compensation for research participation, their trust in research and researchers, their preferred language to receive health information, and their socio-demographic background. We examined Asian Americans' willingness to participate in various types of health research studies and compared their perceptions with other racial/ethnic groups (i.e., Asian n = 485; African-American n = 9516; Hispanic/Latino n = 1889; Caucasian n = 4760; and other minority n = 689).

Results

Compared to all other racial/ethnic groups, Asian Americans were less willing to participate in all eight types of health research. However, Asian Americans reported a lower amount of fair compensation for research participation than African-Americans and Hispanics/Latinos but were as likely to trust researchers as all other racial/ethnic groups.

Conclusion

Asian Americans are less willing to participate in health research than other racial/ethnic groups, and this difference is not due to dissatisfaction with research compensation or lower trust in researchers. Lack of trust in research and language barriers should be addressed to improve representativeness and generalizability of all populations in research.

Engaging 'hard to reach' groups in health promotion: the views of older people and professionals from a qualitative study in England

BACKGROUND

Older people living in deprived areas, from black and minority ethnic groups (BME) or aged over 85 years (oldest old) are recognised as 'hard to reach'. Engaging these groups in health promotion is of particular importance when seeking to target those who may benefit the most and to reduce health inequalities. This study aimed to explore what influences them practicing health promotion and elicit the views of cross-sector professionals with experiences of working with 'hard to reach' older people, to help inform best practice on engagement.

METHODS

'Hard to reach' older people were recruited through primary care by approaching those not attending for preventative healthcare, and via day centres. Nineteen participated in an interview (n = 15) or focus group (n = 4); including some overlaps: 17 were from a deprived area, 12 from BME groups, and five were oldest old. Cross-sector health promotion professionals across England with experience of health promotion with older people were identified through online searches and snowball sampling. A total of 31 of these 44 professionals completed an online survey including open questions on barriers and facilitators to uptake in these groups. Thematic analysis was used to develop a framework of higher and lower level themes. Interpretations were discussed and agreed within the team.

RESULTS

Older people's motivation to stay healthy and independent reflected their everyday behaviour including practicing activities to feel or stay well, level of social engagement, and enthusiasm for and belief in health promotion. All of the oldest old reported trying to live healthily, often facilitated by others, yet sometimes being restricted due to poor health. Most older people from BME groups reported a strong wish to remain independent which was often positively influenced by their social network. Older people living in deprived areas reported reluctance to undertake health promotion activities, conveyed apathy and reported little social interaction. Cross-sector health professionals consistently reported similar themes as the older people, reinforcing the views of the older people through examples.

CONCLUSIONS

The study shows some shared themes across the three 'hard-to-reach' groups but also some distinct differences, suggesting that a carefully outlined strategy should be considered to reach successfully the group targeted.

Developing and testing a web-based intervention to encourage early help-seeking in people with symptoms associated with lung cancer

OBJECTIVES

To detail the development method used to produce an online, tailored, theory-based, user-centred intervention to encourage help-seeking for potential lung cancer symptoms.

DESIGN

Intervention development was structured around the person-based approach. The feasibility study involved a randomized controlled trial design.

METHODS

Intervention development drew on qualitative inquiries, the Theory of Planned Behaviour (TPB), and identifying concrete mechanisms of change to implement in the intervention (Behaviour Change Techniques). The final intervention involved two key features: (1) tailoring and (2) 'TPB components' to target beliefs about help-seeking. In an online feasibility study, we recruited people reporting potential lung cancer symptoms using mailing lists, social media, websites, and Google AdWords. Participants were randomized to the intervention, a tailored comparison group (CG) without TPB-components, an untailored CG with TPB components, or a CG with neither. Following treatment, participants clicked a button to indicate whether they wished to make an appointment and completed a TPB questionnaire.

RESULTS

A total of 130 participants reporting relevant symptoms were recruited (24% of website visitors). Participants in the intervention group reported higher intention to seek help than those who received tailored information without TPB components (p = .03). User comments indicate more support is needed for people who sought help for symptoms, but felt dismissed.

CONCLUSIONS

The potential for differential dropout in online randomized trials requires careful consideration. Future help-seeking interventions should provide support for those who have previously felt dismissed by health professionals. The feasibility study provides some evidence that our 'TPB components' were effective, but validation in a powered trial is necessary. Statement of contribution What is already known on this subject? People with lung cancer often delay presenting symptoms to health services. Some patients (or their family/friends) look up symptoms online before their diagnosis, to decide whether they should see a doctor. Interventions are needed to ensure people can find useful information online that will encourage them to seek help for relevant symptoms. What does this study add? Theory-mapping and user involvement facilitated systematic intervention development. Lung cancer help-seeking interventions should address salient beliefs and personal relevance. The potential for differential dropout in online randomized trials requires careful consideration.

Lung cancer screening: assessment of health literacy and readability of online educational resources

BACKGROUND

Lung cancer screening can reduce mortality but can be a complex, multi-step process. Poor health literacy is associated with unfavorable outcomes and decreased use of preventative services, so it is important to address barriers to care through efficient and practical education. The readability of lung cancer screening materials for patients is unknown and may not be at the recommended 6th grade reading level set by the American Medical Association. Our goals were to: (1) measure the health literacy of a lung cancer screening population from an urban academic medical center, and (2) examine the readability of online educational materials for lung cancer screening.

METHODS

We performed a retrospective cross sectional study at a single urban academic center. Health literacy was assessed using three validated screening questions. To assess the readability of educational materials, we performed a Google search using the phrase, "What is lung cancer screening?" and the Flesch-Kincaid Grade Level (FKGL) formula was used to estimate the grade level required to understand the text.

RESULTS

There were 404 patients who underwent lung cancer screening during the study period. The prevalence of inadequate/marginal health literacy was 26.7-38.0%. Fifty websites were reviewed and four were excluded from analysis because they were intended for medical providers. The mean FKGL for the 46 websites combined was 10.6 ± 2.2.

CONCLUSIONS

Low health literacy was common and is likely a barrier to appropriate education for lung cancer screening. The current online educational materials regarding lung cancer screening are written above the recommended reading level set by the American Medical Association.

Facilitating the Informed Consent Process Using Teleconsent: Protocol for a Feasibility and Efficacy Study

Background

Informed consent is among the biggest challenges in recruiting participants for clinical research studies. Researchers face many challenges in conducting clinical trials, some of which include budgetary restrictions, lack of trained personnel, and difficulty recruiting study participants—particularly minorities and participants from rural communities.

Objective

The objective of this study is to utilize telemedicine to improve the informed consent process for clinical trials and studies. We aim to assess the feasibility and efficacy of the teleconsent intervention among residents in urban and rural settings.

Methods

This study will be conducted separately yet concurrently at two institutions, the Medical University of South Carolina and the University of North Carolina at Chapel Hill, to compare results within and across institutions.

Results

Enrollment for Phase 1 began in March of 2018 and concluded in May 2018. Data transcription and analysis will be conducted through June and September of 2018.

Conclusions

In this paper, we present a novel approach for conducting informed consent using a new telemedicine modality, namely, teleconsent. Teleconsent presents the ability to conduct a live interaction among clinical research coordinators and potential participants while synchronously presenting the consent form on the screen and obtaining participant’s signature through doxy.me, the teleconsent system. Teleconsent provides potential to improve obtaining informed consent from potential clinical trial participants.

Registered Report Identifier

RR1-10.2196/11239

Considerations in the design of randomized trials to screen for type 2 diabetes

Background Randomized controlled trials (RCTs) are the most robust and valid approach to evaluate screening for diseases. Many in the diabetes research community have advocated sole reliance on RCTs for designing diabetes screening policies. However, the challenges of conducting RCTs of screening for type 2 diabetes may have been underappreciated. Purpose Discuss the key theoretical concepts and practical challenges of designing and conducting RCTs of diabetes screening. Methods Narrative and critical review of the literature pertaining to the theory and practice of designing and conducting RCTs of diabetes screening. Results We present the theoretical basis of a diabetes screening trial, using concepts developed mainly in studies of cancer screening and illustrations from the Cambridge component of the Anglo Danish Dutch Study of Intensive Treatment In peOple with screeN-detected diabetes in primary care (ADDITION-Cambridge), the only extant trial of diabetes screening. We examine design issues, including the appropriate trial question, choice of design, and duration of follow-up, and address aspects of trial implementation, including recruitment, randomization, endpoint determination, sample size requirements, and screening interval. Limitations The limited number of trials of diabetes screening did not permit us to illustrate many of the practical difficulties one encounters when implementing theoretical concepts. Conclusion When diabetes screening trials are planned, we suggest careful consideration to potential areas of practical difficulty, especially the need for particularly large sample sizes and extended follow-up, and the choice of appropriate outcomes and screening intervals.

Association between dietary pattern scores and the prevalence of colorectal adenoma considering population subgroups

AIM

The purpose of the current study is to examine the dietary patterns in a diverse cohort of individuals and to see if the identified dietary patterns predict the prevalence of adenoma in a cross-sectional study.

METHODS

Factor analysis was used to derive both sex- and population subgroup-specific dietary patterns among participants in the screening arm of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Logistic regression was used to assess associations between identified factor scores and colorectal adenoma (CRA) in sex-specific subgroups.

RESULTS

Three diet patterns were observed in this cohort: 'Fruits and vegetables', 'Western' and 'Sweet and salty'. Foods that loaded on each factor were similar between the racial subgroups. In men, being in the highest quintile of 'Western' dietary scores was associated with higher odds of any (adjusted odds ratio (aOR) = 1.21; 95% confidence interval (CI) = 1.03-1.42), advanced (aOR = 1.32; 95% CI = 1.07-1.63) or multiple (>1; aOR = 1.51; 95% CI = 1.17-1.94) adenoma, compared to those in the lowest quintile. These results were most notably seen in Caucasian men. In women, having a 'Fruits and vegetable' score in the highest quintile was associated with lower odds of multiple adenoma (>1; aOR = 0.53; 95% CI = 0.28-1.00).

CONCLUSIONS

Of the three dietary factors, the 'Western' diet pattern was most strongly associated with prevalent CRA in Caucasian men. Further research is needed to examine the association between dietary factor scores and adenomas in the proximal colon, where there are larger racial disparities in prevalence.

Strategies to improve engagement of 'hard to reach' older people in research on health promotion: a systematic review

BACKGROUND

This systematic review aimed to identify facilitators, barriers and strategies for engaging 'hard to reach' older people in research on health promotion; the oldest old (≥80 years), older people from black and minority ethnic groups (BME) and older people living in deprived areas.

METHODS

Eight databases were searched to identify eligible studies using quantitative, qualitative, and mixed research methods. Using elements of narrative synthesis, engagement strategies, and reported facilitators and barriers were identified, tabulated and analysed thematically for each of the three groups of older people.

RESULTS

Twenty-three studies (3 with oldest-old, 16 with BME older people, 2 within deprived areas, 1 with both oldest-old and BME, 1 with both BME and deprived areas) were included. Methods included 10 quantitative studies (of which 1 was an RCT), 12 qualitative studies and one mixed-methods study. Facilitators for engaging the oldest old included gaining family support and having flexible sessions. Facilitators for BME groups included building trust through known professionals/community leaders, targeting personal interests, and addressing ethnic and cultural characteristics. Among older people in deprived areas, facilitators for engagement included encouragement by peers and providing refreshments. Across all groups, barriers for engagement were deteriorating health, having other priorities and lack of transport/inaccessibility. Feeling too tired and lacking support from family members were additional barriers for the oldest old. Similarly, feeling too tired and too old to participate in research on health promotion were reported by BME groups. Barriers for BME groups included lack of motivation and self-confidence, and cultural and language differences. Barriers identified in deprived areas included use of written recruitment materials. Strategies to successfully engage with the oldest old included home visits and professionals securing consent if needed. Strategies to engage older people from BME groups included developing community connections and organising social group sessions. Strategies to engage with older people in deprived areas included flexibility in timing and location of interventions.

CONCLUSIONS

This review identified facilitators, barriers and strategies for engaging 'hard to reach' older people in health promotion but research has been mainly descriptive and there was no high quality evidence on the effectiveness of different approaches.

Commentary: Building an Evidence Base for Promoting Informed Prostate Cancer Screening Decisions: An Overview of a Cancer Prevention and Control Program

African American (AA) men have significantly higher mortality rates from prostate cancer (PrCA) than other racial groups. Therefore, there is a critical need to identify strategies for promoting informed PrCA screening decisions among this population. This article details the community-driven, social and behavioral research being implemented by a Statewide Cancer Prevention and Control Program (CPCP) to support the development of person-to-person and technological interventions to improve the dissemination of PrCA information to AA men and their families. This article concludes with four recommendations to advance future research and practice related to the use of interventions for promoting informed PrCA decision-making among AAs. These recommendations include: 1) informing men about controversial screening recommendations; 2) including families in educational interventions about PrCA; 3) using technology as a modality for disseminating PrCA information when appropriate; and 4) aiming to create interventions that can be translated into community and clinical settings.

Applying a Conceptual Framework to Maximize the Participation of Diverse Populations in Cancer Clinical Trials

The underrepresentation of ethnically diverse populations in cancer clinical trials results in the inequitable distribution of the risks and benefits of this research. Using a case study approach, we apply a conceptual framework of factors associated with the participation of diverse population groups in cancer clinical trials developed by Dr. Jean Ford and colleagues to increase understanding of the specific strategies, and barriers and promoters addressed by these strategies, that resulted in marked success in accrual of racially and ethnically diverse populations in cancer clinical research. Results indicate that the studies presented were able to successfully engage minority participants due to the creation and implementation of multilevel, multifaceted strategies that included: culturally and linguistically appropriate outreach, education, and research studies that were accessible in local communities; infrastructure to support engagement of key stakeholders, clinicians, and organizations serving minority communities; testimonials by ethnically diverse cancer survivors; availability of medical interpretation services; and providing infrastructure that facilitated the engagement in clinical research of clinicians who care for minority patient populations. These strategic efforts were effective in addressing limited awareness of trials, lack of opportunities to participate, and acceptance of engagement in cancer clinical trials. Careful attention to the context and population characteristics in which cancer clinical trials are conducted will be necessary to address disparities in research participation and cancer outcomes. These studies illustrate that progress on minority accrual into clinical research requires intentional efforts to overcome barriers at all three stages of the accrual process: awareness, opportunity, and acceptance of participation.

Prostate Cancer Education, Detection, and Follow-Up in a Community-Based Multiethnic Cohort of Medically Underserved Men

The Prostate Outreach Project (POP) provided free prostate cancer (PCa) education and early detection to medically underserved communities. POP recruited participants in medically underserved communities. PCa education and detection events occurred in POP locations (static) or natural gathering places (mobile) within the community. PCa education was delivered by video and evaluated using a questionnaire. Screening consisted of serum prostate-specific antigen and digital rectal examination. A navigated follow-up strategy was utilized to provide medical care for participants with abnormal screening examinations (ASE). POP recruited 4,420 men, 62.8% (2,667) were African American (AA). Most participants had a high school education and no prior screening. Fifty-four percent (2,159) were uninsured and 41% (1,811) had no access to a physician. PCa knowledge increased following the educational video. Prostate-specific antigen levels were elevated in 9.8% (436), while 6.9% (233) had an abnormal digital rectal examination. Follow-up among 609 men with ASE was successful in 40% (244), despite a navigated approach. Overall, 3.3% (144) cancers were diagnosed among the POP with AA participants exhibiting a significantly higher incidence. Recruitment, education, and PCa testing among a medically underserved cohort was successful. However, failure to follow through on ASE could contribute to maintaining the disparity in PCa outcomes noted among AAs and the medically underserved if not addressed.

African American Participation in Oncology Clinical Trials--Focus on Prostate Cancer: Implications, Barriers, and Potential Solutions

In the United States, the incidence and mortality rates of many cancers, especially prostate cancer, are disproportionately high among African American men compared with Caucasian men. Recently, mortality rates for prostate cancer have declined more rapidly in African American versus Caucasian men, but prostate cancer is still the most common cancer and the second leading cause of cancer deaths in African American men in the United States. Compared with Caucasian men, prostate cancer occurs at younger ages, has a higher stage at diagnosis, and is more likely to progress after definitive treatments in African American men. Reasons for racial discrepancies in cancer are multifactorial and potentially include socioeconomic, cultural, nutritional, and biologic elements. In addition to improving access to novel therapies, clinical trial participation is essential to adequately establish the risks and benefits of treatments in African American populations. Considering the disproportionately high mortality rates noted in these groups, our understanding of the natural history and responses to therapies is limited. This review will explore African American underrepresentation in clinical trials with a focus on prostate cancer, and potentially effective strategies to engage African American communities in prostate cancer research. Solutions targeting physicians, investigators, the community, and health care systems are identified. Improvement of African American participation in prostate cancer clinical trials will benefit all stakeholders.

Sociodemographic Predictors of Breast Reconstruction Procedure Choice: Analysis of the Mastectomy Reconstruction Outcomes Consortium Study Cohort

Background. To promote patient-centered care, it is important to understand the impact of sociodemographic factors on procedure choice for women undergoing postmastectomy breast reconstruction. In this context, we analyzed the effects of these variables on the reconstructive method chosen. Methods. Women undergoing postmastectomy breast reconstruction were recruited for the prospective Mastectomy Reconstruction Outcomes Consortium Study. Procedure types were divided into tissue expander-implant/direct-to-implant and abdominally based flap reconstructions. Adjusted odds ratios were calculated from logistic regression. Results. The analysis included 2,203 women with current or previous breast cancer and 202 women undergoing prophylactic mastectomy. Compared with women <40 years old with current or previous breast cancer, those 40 to 59 were significantly more likely to undergo an abdominally based flap. Women working or attending school full-time were more likely to receive an autologous procedure than those working part-time or volunteering. Women undergoing prophylactic mastectomy who were ≥50 years were more likely to undergo an abdominal flap compared to those <40. Conclusions. Our results indicate that sociodemographic factors affect the reconstructive procedure received. As we move forward into a new era of patient-centered care, providing tailored treatment options to reconstruction patients will likely lead to higher satisfaction and better outcomes for those we serve.

Occurrence of Distal Colorectal Neoplasia Among Whites and Blacks Following Negative Flexible Sigmoidoscopy: An Analysis of PLCO Trial

BACKGROUND

It is unclear whether the higher rate of colorectal cancer (CRC) among non-Hispanic blacks (blacks) is due to lower rates of CRC screening or greater biologic risk.

OBJECTIVE

We aimed to evaluate whether blacks are more likely than non-Hispanic whites (whites) to develop distal colon neoplasia (adenoma and/or cancer) after negative flexible sigmoidoscopy (FSG).

DESIGN

We analyzed data of participants with negative FSGs at baseline in the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial who underwent repeat FSGs 3 or 5 years later. Subjects with polyps or masses were referred to their physicians for diagnostic colonoscopy. We collected and reviewed the records of diagnostic evaluations.

PARTICIPANTS

Our analytic cohort consisted of 21,550 whites and 975 blacks.

MAIN MEASURES

We did a comparison by race (whites vs. blacks) in the findings of polyps or masses at repeat FSG, the follow-up of abnormal test results and the detection of colorectal neoplasia at diagnostic colonoscopy.

KEY RESULTS

At the follow-up FSG examination, 304 blacks (31.2 %) and 4183 whites (19.4 %) had abnormal FSG, [adjusted relative risk (RR) = 1.00; 95 % confidence interval (CI), 0.90-1.10]. However, blacks were less likely to undergo diagnostic colonoscopy (76.6 % vs. 83.1 %; RR = 0.90; 95 % CI, 0.84-0.96). Among all included patients, blacks had similar risk of any distal adenoma (RR = 0.86; 95 % CI, 0.65-1.14) and distal advanced adenoma (RR = 1.01; 95 % CI, 0.60-1.68). Similar results were obtained when we restricted our analysis to compliant subjects who underwent diagnostic colonoscopy (RR = 1.01; 95 % CI, 0.80-1.29) for any distal adenoma and (RR = 1.18; 95 % CI, 0.73-1.92) for distal advanced adenoma.

CONCLUSIONS

We did not find any differences between blacks and whites in the risk of distal colorectal adenoma 3-5 years after negative FSG. However, follow-up evaluations were lower among blacks.

Recruitment challenges in clinical research including cancer patients and their caregivers. A randomized controlled trial study and lessons learned

BACKGROUND

To test seven different strategies for recruitment in a randomized controlled trial, to report documented response data from each strategy, and to discuss recruitment challenges.

METHODS

We used 5 opt-in (potential participants have to do something active to contact or be contacted by the researcher) and 2 opt-out (potential participants have the option to decline being contacted about a study) recruitment strategies from February 2013 until July 2014 to contact 1562 cancer patient candidates for participation in a randomized controlled trial. For each of these cancer patients a caregiver was also invited to take part in the study.

RESULTS

Of the 1562 candidates, 22.6 % were ineligible on initial contact, 56.7 % declined to participate on initial contact, and 8.9 % agreed orally to participate but did not complete the enrollment. The 2 opt-out strategies, on-site recruitment and routine care letters recruitment, yielded the highest number of recruited participants with 79 dyads and 58 dyads respectively, constituting 42.7 % and 31.4 % of the total number of enrolled candidates. The 5 opt-in recruitment approaches yielded 49 dyads for the study. Almost half of these dyads were recruited using the approach termed "relying on providers at the hospital."

CONCLUSIONS

In this study, opt-out recruitment strategies appeared to be the most effective.

TRIAL REGISTRATION

Registration number NCT01867723 , registered February 2012.

Characterization of the Hispanic or latino population in health research: a systematic review

The size and diversity of the Hispanic population in the United States has dramatically increased, with vast implications for health research. We conducted a systematic review of the characterization of the Hispanic population in health research and described its implications. Relevant studies were identified by searches of PubMed, Embase Scopus, and Science/Social Sciences Citation Index from 2000 to 2011. 131 articles met criteria. 56% of the articles reported only "Hispanic" or "Latino" as the characteristic of the Hispanic research population while no other characteristics were reported. 29% of the articles reported language, 27% detailed country of origin and 2% provided the breakdown of race. There is great inconsistency in reported characteristics of Hispanics in health research. The lack of detailed characterization of this population ultimately creates roadblocks in translating evidence into practice when providing care to the large and increasingly diverse Hispanic population in the US.

Reaching Hard to Reach Populations with Hard to Communicate Messages: Efficacy of a Breast Health Research Champion Training Program

A Breast Health Research Champion training program was a developed targeting self-identified community breast health advocates from a predominant African-American community with a significant breast cancer mortality disparity. Twelve individuals completed the program that provided training in breast cancer risk and screening, breast cancer research, biospecimen in cancer research, and human research subject protection. The training emphasized four key messages to be disseminated to the community. Trainees hosted a minimum of two social chats with individuals from their social networks and functioned as community researchers, acquiring consent and gathering follow-up data from attendees. Trainees reached 199 individuals from their social networks, and chats were diverse in the venue selected, mode of message transmission, and the audience reached. Post/pre questionnaire data from attendees at the chats showed significant improvement in knowledge, attitudes, and intended behaviors as it relates to breast cancer screening, clinical research, and biospecimen in research. Forty percent of attendees provided 4-week follow-up information. Of respondents eligible for mammography, 38 % had taken action to be screened, and 86 % of respondents had spoken about the information to someone else in their social network. Trainees expressed feelings of empowerment after completing the project, "feeling like the expert," and all trainees were surprised at the enthusiastic response from attendees of their chats. Trainees continued to disseminate the information learned from the training program during the 6 months following the training, reaching an additional 786 individuals in the community.

Evaluating a community-partnered cancer clinical trials pilot intervention with African American communities

Cancer clinical trial (CCT) accrual and retention rates remain disproportionately low among African Americans. Awarenesss and access to trials are crucial facilitators of trial participation. Strategies developed within a community-based participatory framework (CBPR) are potential solutions to increase awareness and access to CCTs. In this study, we describe the pilot phase of three innovative community-centered modules to improve basic CCT knowledge, awareness of locations to access CCT information, and opportunities to participate in CCTs. Four community organizations completed Community Bridges to CCT training-of-the-trainer and recruited adult African American volunteers to participate in one of three CCT education modules: a workshop about CCTs, a role play describing one person's experience with CCTs, or a call and response session reviewing myths and facts about CCTs. Pre- and post-test surveys were collected and analyzed using McNemar agreement statistic to evaluate changes in knowledge and attitudes regarding trials. Trainers enrolled 125 participants in the call and response (n = 22), role play (n = 60), and workshop (n = 43) modules. Module participants were mostly African American, female, and with a mean age of 53 years. Comparison of pre- and post-test responses demonstrates favorable changes in awareness of CCTs and where to access CCTs across the sample. Analysis by module type indicates significant increases for participants in the call and response (p < 0.01) and role play modules (p < 0.001), but not the workshop module. Despite measures taken to increase the participation and retention rate of African Americans in clinical trials, little advancement has been made. Developing tailored community education modules on CCTs within the CBPR framework is a promising innovation to increase knowledge about CCTs and favorable attitudes about participation that are known precursors to trial enrollment.

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.

From bench to bedside: the realities of reducing global prostate cancer disparity in black men

Prostate cancer in black men of African descent has a different tumour biology compared to those of other races. Its clinical manifestations depict a more aggressive disease with higher morbidity and mortality. This study proposes, through a literature search, identifying applied laboratory and clinical research in prostate cancer directed to improve outcomes and decrease global disparities of prostate cancer in black men of African descent. This review identified five categories pertinent for research: prostate-specific antigen (PSA) testing for early detection and screening, the potential of epigenetics, cultural determinants and health-seeking behaviours, other biomarkers for prostate cancers, and the economics of treating advanced prostate cancer. The analysis revealed that in developed countries, men of African descent are underrepresented in the sampling pools in both laboratory and clinical research, and thus the applicability and relevance of these results to men of African descent are circumspect. However, developing countries with high populations of black males have limited laboratory and clinical research publications. This is due to limited funding to support research programmes and basic clinical services for early detection and treatment. The study concludes that for the involvement of developing countries in bench research, they should do it in collaboration, like fostering partnerships with credible academic-based institutions and organisations. This requires a realm of transparency, respect, protection of the rights and dignity of the patients, and an equity in participation and sharing of the benefits to be accrued. The current transatlantic and Caribbean collaborations in research, education, and health service delivery in prostate cancer care for men of African descent exemplify the successes of such partnerships.

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.

The influence of health disparities on targeting cancer prevention efforts

Despite the advances in cancer medicine and the resultant 20% decline in cancer death rates for Americans since 1991, there remain distinct cancer health disparities among African Americans, Hispanics, Native Americans, and the those living in poverty. Minorities and the poor continue to bear the disproportionate burden of cancer, especially in terms of stage at diagnosis, incidence, and mortality. Cancer health disparities are persistent reminders that state-of-the-art cancer prevention, diagnosis, and treatment are not equally effective for and accessible to all Americans. The cancer prevention model must take into account the phenotype of accelerated aging associated with health disparities as well as the important interplay of biological and sociocultural factors that lead to disparate health outcomes. The building blocks of this prevention model will include interdisciplinary prevention modalities that encourage partnerships across medical and nonmedical entities, community-based participatory research, development of ethnically and racially diverse research cohorts, and full actualization of the prevention benefits outlined in the 2010 Patient Protection and Affordable Care Act. However, the most essential facet should be a thoughtful integration of cancer prevention and screening into prevention, screening, and disease management activities for hypertension and diabetes mellitus because these chronic medical illnesses have a substantial prevalence in populations at risk for cancer disparities and cause considerable comorbidity and likely complicate effective treatment and contribute to disproportionate cancer death rates.

African American participation in health-related research studies: indicators for effective recruitment

OBJECTIVE

To elucidate factors that influence African American willingness to participate in health-related research studies.

METHODS

The African American Alzheimer disease research study group at North Carolina A&T State University designed an in-person questionnaire and surveyed more than 700 African American adults on their willingness to participate in health-related research studies. The questionnaire was distributed and collected in a nonclinical setting during the years 2008 and 2009. This study was approved by the North Carolina A&T State University Institutional Review Board.

RESULTS

Of the 733 valid respondents, 16% had previously participated in a health-related research study. Of these, more than 90% were willing to participate again in future research studies. Of the 614 who had never participated in a research study, more than 70% expressed willingness to participate. The majority (75%) of experienced research study participants (RSP) were older than 40 years compared with 45% of non-research study participants. Experienced research participants were also twice as likely to have a college degree compared with non-research study participants. Seventy-three percent of non-research study participants were willing to participate in research studies in the future. The factors that were probable impediments to participation included lack of time and trust. Men with knowledge of the Tuskegee Syphilis Study were 50% less likely to be willing to participate compared with those who had not heard of Tuskegee Syphilis Study.

CONCLUSIONS

African Americans are willing to participate in health-related research studies. Several factors such as the appropriate incentives, community trust building, outreach, and community partnership creation are necessary for engaging minority participants. Incorporating factors that target African American enrollment in research design and implementation, such as increased training of minority health ambassadors and African American researchers and public health specialists, are needed to better engage minorities across generations, in research.

The National Cancer Institute-American Society of Clinical Oncology Cancer Trial Accrual Symposium: summary and recommendations

INTRODUCTION

Many challenges to clinical trial accrual exist, resulting in studies with inadequate enrollment and potentially delaying answers to important scientific and clinical questions.

METHODS

The National Cancer Institute (NCI) and the American Society of Clinical Oncology (ASCO) cosponsored the Cancer Trial Accrual Symposium: Science and Solutions on April 29-30, 2010 to examine the state of accrual science related to patient/community, physician/provider, and site/organizational influences, and identify new interventions to facilitate clinical trial enrollment. The symposium featured breakout sessions, plenary sessions, and a poster session including 100 abstracts. Among the 358 attendees were clinical investigators, researchers of accrual strategies, research administrators, nurses, research coordinators, patient advocates, and educators. A bibliography of the accrual literature in these three major areas was provided to participants in advance of the meeting. After the symposium, the literature in these areas was revisited to determine if the symposium recommendations remained relevant within the context of the current literature.

RESULTS

Few rigorously conducted studies have tested interventions to address challenges to clinical trials accrual. Attendees developed recommendations for improving accrual and identified priority areas for future accrual research at the patient/community, physician/provider, and site/organizational levels. Current literature continues to support the symposium recommendations.

CONCLUSIONS

A combination of approaches addressing both the multifactorial nature of accrual challenges and the characteristics of the target population may be needed to improve accrual to cancer clinical trials. Recommendations for best practices and for future research developed from the symposium are provided.

A systematic review of the factors influencing African Americans' participation in cancer clinical trials

OBJECTIVE

This systematic review was conducted to synthesize the existing evidence regarding key considerations influencing African Americans' participation in cancer clinical trials (CCTs).

METHODS

The PubMed and PsycINFO databases were searched to identify peer-reviewed publications during the last decade (2002-2011) that met our inclusionary criteria. Our search utilized Boolean combinations of the following terms: "clinical trial"; "cancer"; "neoplasm"; "African American"; "Black"; "caregiver"; "decision making"; "recruitment"; "companion"; "family"; "significant other"; and "social support".

RESULTS

A total of 267 articles were identified in the database searches. Of these articles, a total of 31 were determined to meet the inclusion criteria and were retained for review. Key issues that emerged as impediments to a successful recruitment of African Americans to CCTs included negative attitudes towards clinical trials, low levels of knowledge and awareness regarding CCTs, religious beliefs, and structural barriers, such as transportation, childcare, and access to health care. Recommendations from physicians, family members, and friends may promote CCT participation. Multimedia, and culturally-appropriate recruitment approaches may also be effective in soliciting participation among African Americans.

CONCLUSION

Existing research underscores the importance of social support from family and friends, cultural appropriateness and sensitivity from physicians and in the design of the CCT, and enhanced education among African Americans in decision-making processes. As African Americans are underrepresented in CCTs, targeted strategies to enhance recruitment efforts and improve cancer treatment outcomes are essential.

Unequal burden of disease, unequal participation in clinical trials: solutions from African American and Latino community members

African Americans and Latinos are underrepresented in clinical trials. The purpose of this study was to elicit solutions to participation barriers from African Americans and Latinos. Fifty-seven adults (32 African Americans, 25 Latinos) ages 50 years and older participated. The Institute of Medicine's Unequal Treatment conceptual framework was used. Six racially/ ethnically homogenous focus groups were conducted at five sites in three counties. Themes within groups and cross-cutting themes were identified. The NVIVO program was used for data classification. The data were reviewed for final coding and consensus. Shared solutions included addressing costs, recruiting in community contexts, conducting community and individualized patient education, and sharing patient safety information. Participants were unanimously in favor of clinical trials navigation recruitment interventions. Solutions specific to African Americans included diversifying research teams, recognizing past research abuses, and increasing community trust. Solutions specific to Latinos included providing low-literacy materials, providing Spanish-speaking clinicians and advocates, and clarifying that immigration status would neither be documented nor prevent participation. Solutions from African Americans and Latinos reflect their cultural backgrounds and historical experiences. The results suggest the importance of developing a tailored, barriers-focused navigation intervention to improve participation among diverse racial and ethnic populations.

Predictors of adverse smoking outcomes in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial

BACKGROUND

The impact of lung cancer screening on smoking behavior is unclear. The aims of this ancillary study of the Prostate Lung Colorectal and Ovarian Cancer Screening Trial were to produce risk prediction models to identify individuals at risk of relapse or continued smoking and to evaluate whether cancer-screening variables affect long-term smoking outcomes.

METHODS

Participants completed a baseline questionnaire at trial enrollment and a supplemental questionnaire 4-14 years after enrollment, which assessed several cancer-related variables, including family history of cancer, comorbidities, and tobacco use. Multivariable logistic regression models were used to predict smoking status at completion of the supplemental questionnaire. The models' predictive performances were evaluated by assessing discrimination via the receiver operator characteristic area under the curve (ROC AUC) and calibration. Models were internally validated using bootstrap methods.

RESULTS

Of the 31&emsp14;694 former smokers on the baseline questionnaire, 1042 (3.3%) had relapsed (ie, reported being a current smoker on the supplemental questionnaire). Of the 6807 current smokers on the baseline questionnaire, 4439 (65.2%) reported continued smoking on the supplemental questionnaire. Relapse was associated with multiple demographic, medical, and tobacco-related characteristics. This model had a bootstrap median ROC AUC of 0.862 (95% confidence interval [CI] = 0.858 to 0.866) and a calibration slope of 1.004 (95% CI = 0.978 to 1.029), indicating excellent discrimination and calibration. Predictors of continued smoking also included multiple demographic, medical, and tobacco-related characteristics. This model had an ROC AUC of 0.611 (95% CI = 0.605 to 0.614) and a slope of 1.006 (95% CI = 0.962 to 1.041), indicating modest discrimination. Neither the trial arm nor the lung-screening result was statistically significantly associated with smoking outcomes.

CONCLUSION

These models, if validated externally, may have public health utility in identifying individuals at risk for adverse smoking outcomes, who may benefit from relapse prevention and smoking cessation interventions.

Assessing an intervention to improve clinical trial perceptions among predominately African-American communities in South Carolina

BACKGROUND

African Americans (AA) are not well-represented in cancer clinical trials despite having significantly higher cancer mortality rates than their European-American (EA) counterparts.

OBJECTIVES

The purpose of this study was to evaluate a program to improve perceptions of cancer clinical trials among AA.

METHODS

The program was conducted in a convenience sample of 195 participants (75.4% AA) who lived in counties with high racial disparities in cancer mortality rates and who were recruited by community partners. The 30-minute program, part of a larger 3.5-hour cancer education program, was developed by the National Institutes of Health (NIH)/National Cancer Institute (NCI). It was modified to include additional pictures of AA, AA-specific cancer mortality data, and information about the Tuskegee Syphilis Study and the resulting improved participant protection measures.

MEASURES

The seven-item Attitudes to Randomized Trial Questionnaire (ARTQ) was used to evaluate changes in trial perceptions from pre- to posttest. Additional survey items assessed general demographic characteristics.

RESULTS

Slightly more than half of the participants had at least a college diploma (54.4%), 45.1% were married/living as married, 53.3% were female, and 45.6% had an annual household income of less than $40,000. For each ARTQ item, most participants who had less favorable perceptions of trials at pretest changed to more positive perceptions at posttest (p < .001).

CONCLUSIONS

Providing cancer clinical trial information led to more positive perceptions of cancer clinical trials. In future studies, the program could be used to help potential trial participants make informed decisions about participation; trial enrollment rates could then be evaluated.

A randomized trial to assess the effect of a research informational pamphlet on telephone survey completion rates among older Latinos

PURPOSE OF THE STUDY

To assess the effects of receiving a research informational pamphlet produced by the federal Office for Human Research Protections on telephone survey participation rates of older Latinos, and illustrate the feasibility of nesting recruitment studies within other funded studies when stand alone funding for recruitment studies is limited.

DESIGN AND METHODS

Latino patients aged ≥50 with ≥1 visit during the preceding year (N=1314) were sampled from three community clinics and a multi-specialty medical group. Patients were randomly assigned to receive or not receive a pamphlet that contained information on research participation in the initial mailing for the telephone survey study. Survey participation rates were compared between the pamphlet and no pamphlet groups.

RESULTS

In a multivariate model, women (OR=1.4; 95% CI 1.1, 1.8), and those with public insurance (vs. no insurance; OR=1.7; 95% CI 1.1, 2.5) were more likely to participate, while those age 65+ (vs. age 50-54; OR=0.6; 95% CI 0.4, 0.8) were less likely to participate; there was no significant difference by pamphlet group (OR=0.8; 95% CI 0.7, 1.1). Nesting of the randomized trial of the recruitment pamphlet within the funded study required minimal additional resources.

IMPLICATIONS

Recruitment methods that are more intensive than a pamphlet may be needed to enhance survey participation rates among older Latinos. Nesting recruitment trials within funded studies is a promising and efficient approach for testing recruitment strategies.

Attempts to reach the oldest and frailest: recruitment, adherence, and retention of urban elderly persons to a falls reduction exercise program

PURPOSE OF THE STUDY

To assess the recruitment, adherence, and retention of urban elderly, predominantly African Americans to a falls reduction exercise program.

DESIGN AND METHODS

The randomized controlled trial was designed as an intervention development pilot study. The goal was to develop a culturally sensitive intervention for elderly persons who suffered a fall and visited an emergency department (ED). Participants were taught exercises during 4 on-site group classes and encouraged to continue exercising at home for 12 weeks and attend additional on-site monthly classes. The protocol included a specifically designed intervention for increasing retention through trained community interventionists drawn from the participants' neighborhoods.

RESULTS

The screening of 1,521 ED records after falling yielded the recruitment of 204 patients aged 65 years and older. Half were randomized into the falls prevention program. Of the 102 people in the intervention group, 92 completed the final 6-month assessment, 68 attended all on-site sessions, but only 1 reported exercising at home all 12 weeks. Those who lived alone were more likely (p = .03) and those with symptoms of depression were less likely (p = .05) to attend all on-site exercise classes. The final recruitment rate was estimated as 31.8%. The final retention rates were 90.2% and 87.3% for the intervention and control groups, respectively.

IMPLICATIONS

Recruitment of frail elderly African American patients is resource intensive. Adherence to the on-site exercise classes was better than to the home-based component of the program. These findings have implications for the design of future community-based exercise programs and trials.

Increasing accrual in cancer clinical trials with a focus on minority enrollment: The William Beaumont Hospital Community Clinical Oncology Program Experience

BACKGROUND

The authors reviewed changes in accrual to cancer clinical trials over the last 2 decades at their institution with a focus on minority participation after the implementation of a community clinical oncology program (CCOP) and an aggressive, education-orientated minority outreach program (MOP).

METHODS

Data on patient enrollment in clinical trials for the years 1988 to 2010 was obtained from the William Beaumont Hospital (WBH) Cancer Clinical Trials Office. The type and number of cancers diagnosed and treated during the same period were obtained from the WBH tumor registry data. The MOP was initiated in the fall of 2003 with a focus on culture-specific cancer education.

RESULTS

With the development of the CCOP, clinical trials accrual increased significantly by 10-fold (P = .001). The primary service area for the CCOP consistently averaged an 85% to 90% Caucasian population. During the same period, the minority population for the service area remained stable between 8.8% and 10% and did not change significantly. From 1999 to 2004, the WBH tumor registry data demonstrated that minorities represented 8.6% of cancers registered, whereas the average yearly minority enrollment from 2002 to 2004 was 5.4%. After initiation of the MOP, minority accrual doubled to 11% by 2010 with stable minority demographics.

CONCLUSIONS

The current findings support the importance of a CCOP in supporting the accrual of patients to national clinical trials and increasing access to state-of-the art research. These data also strongly support focusing additional energy and educational efforts on targeting minority representation in clinical trials.

Recruitment and retention results for a population-based cervical cancer biobehavioral clinical trial

OBJECTIVE

Minority and low-income cancer patients are underrepresented in clinical trials, contributing to diminished access to state-of-the-art care and disparities in cancer outcomes including survivorship issues. In cervical cancer, there is a disproportionate disease burden among minority and underserved women and persistent quality of life disruption. We encountered significant challenges in both recruitment and retention in a randomized biobehavioral clinical trial for cervical cancer survivors, identified through California Cancer Registries, leading to this investigation.

METHODS

To determine differential rates of accrual and retention, data from our trial are analyzed using descriptive statistics, logistic regression and multivariate analysis of variance. Ethnic differences in associations between covariables and attrition rates were tested by interaction factors. Process evaluation and focus group data were obtained to inform improvement strategies.

RESULTS

Of eligible subjects with viable phone numbers, 29% enrolled and 71% actively or passively refused. Enrolled Hispanic women were more likely to have less education (p<0.001), lower income (p=0.003), and more children (p=0.028). The dropout rate was associated with less education (p=0.012), foreign-birth (p=0.061), speaking Spanish in the home (p=0.012). Reported reasons for active refusal were 'too busy' for all women, 'too emotional' for non-Hispanic women, 'too ill' and phlebotomy for Hispanic women. Subsequent focus groups identified specific strategies to improve study materials.

CONCLUSION

Although population-based recruitment of minority and underserved cancer patients continues to be a challenge, specific sociodemographic and disease variables can predict accrual difficulties. The information herein, taken together with disease and culturally relevant strategies, can be useful when recruiting underserved cancer survivors.

Perspective: The case for research justice: inclusion of patients with limited English proficiency in clinical research

Persons with limited English proficiency (LEP) constitute a growing portion of the U.S. population, yet they are underrepresented in clinical research. This inherently limits the societal benefits of the research and its generalizability to ethnic populations living in the United States. To illustrate the complexity associated with including LEP participants in clinical research, the authors critically evaluated LEP consent requirements posted on the Web sites of 134 academic health centers in March 2008. They found wide variability with regard to consent policies and striking interinstitutional differences in posted IRB policies and attitudes toward consent of LEP patients in research. The authors argue this variation highlights competing concerns between autonomy and justice. Outcomes-based justice requires inclusion of LEP patients in the research, yet the consent process is often resource-intensive and complex. The authors suggest that more uniform and specific guidance from federal agencies for enrollment of LEP patients in clinical research be established and that this guidance explicitly recalibrate the current balance between autonomy and justice. Investigators and institutional review boards should also develop streamlined best practices to reduce unnecessary effort and expense associated with recruitment of LEP individuals. LEP individuals should have fair access to clinical research in order to fully realize individual and societal benefits of their participation and to ensure the generalizability of scientific discovery.

Community events as viable sites for recruiting minority volunteers who agree to be contacted for future research

Reaching out to medically underserved racial/ethnic groups is a key challenge in population research. To increase their participation opportunities, we asked adults attending community events to complete a survey about their health concerns and invited them to join a registry of individuals agreeing to future study invitation. Approximately 66% of the 2298 survey responders joined the registry. Multivariate analysis showed that Hispanics were more likely to agree to contact than Whites. Agreers endorsed a wider range of health concerns than non-agreers.

A review of African American-white differences in risk factors for cancer: prostate cancer

OBJECTIVE

African American men have higher prostate cancer incidence rates than White men, for reasons not completely understood. This review summarizes the existing literature of race-specific associations between risk factors and prostate cancer in order to examine whether associations differ.

METHODS

We reviewed epidemiologic studies published between January 1970 and December 2008 that reported race-specific effect estimates. We focused mainly on modifiable risk factors related to lifestyle and health. A total of 37 articles from 21 study populations met our inclusion criteria.

RESULTS

We found no evidence of racial differences in associations between prostate cancer and alcohol intake, tobacco use, and family history of prostate cancer. Research suggests that a modest positive association may exist between height and prostate cancer risk (all prostate cancer and advanced prostate cancer) among Whites only. No clear patterns were observed for associations with physical activity, weight/body mass index, dietary factors, occupational history, sexual behavior, sexually transmissible infections, and other health conditions.

DISCUSSION

Our results suggest few differences in prostate cancer risk factors exist between racial groups and underscore areas where additional research is needed. Future studies should enroll higher numbers of African American participants and report results for advanced prostate cancer.

Cancer screening trials: nuts and bolts

The most rigorous and valid approach to evaluating cancer screening modalities is the randomized controlled trial (RCT). RCTs are major undertakings and the intricacies of trial design, operations, and management are generally underappreciated by the typical researcher. The purpose of this article is to inform the reader of the "nuts and bolts" of designing and conducting cancer screening RCTs. Following a brief introduction as to why RCTs are critical in evaluating screening modalities, we discuss design considerations, including the choice of design type and duration of follow-up. We next present an approach to sample-size calculations. We then discuss aspects of trial implementation, including recruitment, randomization, and data management. A discussion of commonly employed data analyses comes next, and includes methods for the primary analysis (comparison of cause-specific mortality rates between the screened and control arms for the cancer of interest), as well as for secondary endpoints such as sensitivity. We follow with a discussion of sequential monitoring and interim analysis techniques, which are used to examine the primary outcome while the trial is ongoing. We close with thoughts on lessons learned from past cancer screening RCTs and provide recommendations for future trials. Throughout the presentation we illustrate topics with examples from completed or ongoing RCTs, including the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial and the National Lung Screening Trial (NLST).

Quality assurance of endoscopy in colorectal cancer screening

This chapter explores the concept of quality assurance of colorectal cancer screening. It argues that effective quality assurance is critical to ensure that the benefits of screening outweigh the harms. The three key steps of quality assurance, definition of standards, measurement of standards and enforcement of standards, are explained. Quality is viewed from the perspective of the patient and illustrated by following the path of patients accessing endoscopy within screening services. The chapter discusses the pros and cons of programmatic versus non-programmatic screening and argues that quality assurance of screening can and should benefit symptomatic services. Finally, the chapter emphasises the importance of a culture of excellence underpinned by continuous quality improvement and effective service leadership.