The impact of socioeconomic status on access to cancer clinical trials

Diversity in decentralized clinical trials: prioritizing inclusion of underrepresented groups

BACKGROUND

The importance of more diversity of study populations in clinical trials is currently widely acknowledged. Decentralized clinical trial (DCT) approaches are presented as a potential means to broaden diversity by eliminating several barriers to participation. However, the precise meaning of, and objectives related to diversity in DCTs remain unclear. Diversity runs the risk of becoming a 'buzzword': widely acknowledged to be important, yet prone to multiple interpretations and challenging to implement in practice. We argue that the aim of increasing diversity in clinical trials requires clear and well-substantiated specifications.

METHODS

We analyze the concept of diversity and the ethical requirements surrounding fair participant selection within the context of clinical research, in order to further specify and operationalize the aim of increasing diversity in the context of DCTs.

RESULTS

Through analyzing the concept of diversity and ethical requirements for fair participant selection, we propose that diversity should be specified in a way that improves the position of the groups that are currently most underrepresented in the research context. In practice, this entails that, in order to contribute to diversity, the selection of participants should prioritize (i) gaining scientific knowledge on groups for which this is lacking, and (ii) inclusion of underrepresented groups in research when appropriate considering a study's objectives, and risks and benefits.

CONCLUSIONS

Our analysis facilitates translating the aim of increasing diversity with DCTs to more specific and actionable objectives for recruitment and inclusion. Moreover, it contributes to a further specification of the concept of diversity and fair participant selection in research contexts.

Racial and Ethnic Disparities Among Patients Enrolled in Breast Reconstruction-Related Clinical Trials

INTRODUCTION

Breast reconstruction clinical trials that reflect the racial and ethnic makeup of breast cancer disease burden are fundamental in improving breast reconstruction accessibility and outcomes. We aim to evaluate race and ethnicity reporting in breast reconstruction-related clinical trials (BRRCTs) and determine whether reported race and ethnicity of enrollees aligns with their breast cancer incidence rates in the general US population.

METHODS

All completed, US-based BRRCTs were retrospectively reviewed via ClinicalTrials.gov in February 2024. Age, race, ethnicity, and BRRCT funding source were recorded. BRRCT enrollment rates of racial and ethnic groups were compared to their expected representation rates, calculated using breast cancer incidence rate. Descriptive statistics and univariate analyses were performed.

RESULTS

Twenty-five studies representing 2603 patients were included. The mean age of enrollees was 49.4 ± 2.2 years. Seven (28%) reported enrollees' race, and 5 (20%) reported both race and ethnicity. Most enrollees were White (90.8%), followed by Black (3.5%), Asian (1.5%), and American Indian/Alaska Native (AI/AN) (0.1%). Fewer enrollees identified as Hispanic/Latino than non-Hispanic/Latino (7.6% vs 91.5%, P < 0.01). Observed enrollment rates of minority groups were lower than their respective expected representation rates (Black: 3.5% vs 24.9%, P < 0.01; Asian: 1.5% vs 23.9%, P < 0.01; AI/AN: 0.1% vs 24.9%, P < 0.01; Hispanic/Latino: 7.6% vs 45.2%, P < 0.01). Conversely, White enrollees were overrepresented when compared to the group's overall breast cancer burden (90.8% vs 26.4%; P < 0.01).

CONCLUSIONS

Over 70% of BRRCTs did not report the race or ethnicity of enrollees. When reported, racial and ethnic minorities were significantly underrepresented in BRRCTs. More diligent reporting and proactive initiatives to increase recruitment of minority groups in clinical trials are needed to strengthen the validity of BRRCTs.

Do Patients of Different Levels of Affluence Receive Different Care for Pediatric Osteosarcomas? One Institution's Experience

BACKGROUND

The published reports examining socioeconomic factors and their relationship to osteosarcoma presentation and treatment suggest an association between lower socioeconomic status and a worse response to chemotherapy and lower survivorship. However, the driving factors behind these disparities are unclear. The Child Opportunity Index was developed by diversitydatakids.org ( https://www.diversitydatakids.org/ ) in 2014 to cumulatively quantify social determinants of health in an index specifically tailored toward a pediatric population and organized by census tract. The Childhood Opportunity Index can be used to explore the relationship between a patient's socioeconomic background and disparities in osteosarcoma presentation, treatment, and outcomes.

QUESTION/PURPOSES

Are differences in a child's Childhood Opportunity Index score associated with differences in (1) time from symptom onset to first office visit for osteosarcoma, (2) timing of chemotherapy or timing and type of surgical resection, or (3) initial disease severity, development of metastatic disease, or overall survival?

METHODS

A retrospective therapeutic study was conducted using data drawn from the institutional records of a large pediatric tertiary cancer center located in the Mid-Atlantic region of the United States from the years 2006 to 2022. Our main site is in an urban setting, with ample access to public transit. Patients were excluded from analysis if they were seeking a second opinion or our institution was not the main point of orthopaedic care (20% [45 of 223]). Of the remaining patients, those with incomplete electronic medical records (24% [43 of 178]), resided in an international country (5% [9 of 178]), presented after relapse (4% [8 of 178]), or lacked 2 years of follow-up at our institution (3% [5 of 178]) were excluded as well. A total of 113 pediatric patients (children younger than 18 years) met the inclusion criteria. The Child Opportunity Index is a composite index derived from three domains (education, health and environment, and social and economic) and 29 indicators within the domains that serve to capture the cumulative effect of disparities on child well-being. National Childhood Opportunity scores were collected and scored from 1 to 100. Each score represents an equal proportion of the US population of children 18 years of age or younger. A higher number indicates higher levels of socioeconomic opportunity. The overall Childhood Opportunity Index score was then broken down into three groups representative of the child's relative socioeconomic opportunity: lowest tertile for scores < 34, middle tertile for scores between 34 and 66, and highest tertile for scores > 66. Means, ranges, medians, IQRs, and percentages were used to describe the study sample. Data analysis was conducted across the three groups (lowest tertile, middle, and highest), assessing differences in time to presentation, treatment variations, disease severity, and overall survivorship. Chi-square and Fisher exact tests were applied to compare categorical variables. Mann-Whitney U tests compared continuous data. Kaplan-Meier survival analysis, stratified by Childhood Opportunity Index tertile, was performed for a 5-year period to evaluate the development of metastatic disease and overall survivorship. A log-rank test was applied to evaluate statistical significance. Due to the small sample size, we were unable to control potential confounders such as race and insurance. However, the three domains (education, health and environment, and social and economic) encapsulated by the Childhood Opportunity Index data indirectly account for disparities related to race and insurance status.

RESULTS

There was no association between lower levels of socioeconomic opportunity, as expressed by the lack of difference between the Childhood Opportunity Index tertiles for the interval between symptom onset and first office visit (mean ± SD lowest tertile 77 ± 67 days [95% confidence interval (CI) 60 to 94], middle tertile 69 ± 94 days [95% CI 50 to 89], and highest tertile 56 ± 58 days [95% CI 41 to 71]; p = 0.3). Similarly, we found no association between lower levels of socioeconomic opportunity, as expressed by the lack of difference between the Childhood Opportunity Index tertiles and the time elapsed from the first office visit to the first chemotherapy session (lowest tertile 19 ± 12 days [95% CI 12 to 26], middle 19 ± 14 days [95% CI 11 to 26], and highest 15 ± 9.7 days [95% CI 8.4 to 21]; p = 0.31), the time to surgical resection (lowest tertile 99 ± 35 days [95% CI 87 to 111], middle 88 ± 28 days [95% CI 77 to 99], and highest 102 ± 64 days [95% CI 86 to 118]; p = 0.24), or the type of surgical resection (limb-sparing versus amputation: 84% [21 of 25] in lowest tertile, 83% [24 of 29] in the middle tertile, and 81% [48 of 59] in the highest tertile received limb-sparing surgery; p = 0.52). Finally, we found no differences in terms of disease-free survival at 5 years (lowest tertile 27% [95% CI 7.8% to 43%], middle 44% [95% CI 23% to 59%], and highest 56% [95% CI 40% to 67%]; p = 0.22), overall survival (lowest 74% [95% CI 58% to 95%], middle 82% [95% CI 68% to 98%], and highest 64% [95% CI 52% to 78%]; p = 0.27), or in terms of survivorship of the cohort, excluding patients who presented with metastatic disease (lowest 84% [95% CI 68% to 100%], middle 91% [95% CI 80% to 100%], and highest 68% [95% CI 55% to 83%]; p = 0.10).

CONCLUSION

In our single-center retrospective study of 113 children who presented with osteosarcoma, we did not find an association between a patient's national socioeconomic opportunity and their time to presentation, chemotherapy treatment, time to and type of surgical resection, or disease-free and overall survival. Prior work has shown an association between socioeconomic background and disparities in osteosarcoma treatment. It is possible that these findings will be similar to those from other hospitals and geographic areas, but based on our findings, we believe that proximity to providers, access to public transit, and regional insurance policies may help diminish these disparities. Future multicenter studies are needed to further explore the role that regional variations and the aforementioned factors may play in osteosarcoma treatment to help inform the direction of public policy.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Clinical trial participation for vulnerable cancer patients in Denmark and England

BACKGROUND

New cancer therapies are introduced through clinical trials. However, eligibility criteria can pose a barrier to vulnerable patients, limiting access to potentially improved treatments and reducing generalizability of the results. The aim of this study was to investigate participation in clinical trials for vulnerable cancer patients in Denmark and compare results to England.

PATIENTS AND METHODS

We utilized population-based registries of systemic anti-cancer therapy from the North Denmark Region and England covering, respectively, 2008-2021 and 2016-2019. We included adult patients (≥18 years) who received SACT in relation to a solid cancer. Vulnerability was defined as the lowest quintile in relation to socioeconomic position. We estimated odds ratios (OR) for participation in a clinical trial.

RESULTS

We included 15,173 patients in the Danish cohort and 336,218 in the English. From these 1107 (7.3 %) and 12,502 (3.7 %) participated in a clinical trial, respectively. The adjusted OR for participating in a trial for vulnerable patients was 0.81 (95 % CI 0.68-0.96) in Denmark and 0.80 (95 % CI 0.76-0.84) in England. The strongest associations were found within gynaecological cancers.

CONCLUSION

We found associations of reduced trial participation for vulnerable individuals in both countries and consistent associations within gynaecological cancers.

"Trust Me, I'm a Doctor." How TikTok Videos from Different Sources Influence Clinical Trial Participation

This study experiments with TikTok videos to promote clinical trial participation. More specifically, it examines how short-form video sources (doctors vs. prior volunteers for clinical trials) influence perceived source credibility, self-efficacy, and behavioral intention to participate in clinical trials. Findings from this online experiment (N = 396) showed that doctor sources led to greater behavioral intention through enhancing source credibility compared to prior volunteer sources. Alternatively, prior volunteer sources increased behavioral intention via enhanced self-efficacy for participants with low trust in doctors. These findings contribute to the understanding of how short-form video sources act as heuristic cues, leading to persuasion outcomes. Overall, we recommend featuring doctors when using video-based messages to promote clinical trial participation. Also, this study emphasizes the need for health communication practitioners to consider prior volunteers as spokespersons when targeting populations with low baseline trust in doctors.

Therapeutic Clinical Trial Eligibility and Enrollment among Women with Breast Cancer: Implications for Understanding Trial Disparities

INTRODUCTION

Therapeutic clinical trials frequently lack diverse representation, hindering generalizability and exacerbating preexisting disparities in clinical outcomes. This study explored associations between breast cancer patient demographics, clinical trial eligibility, and enrollment in a National Cancer Institute (NCI)-designated cancer center.

PATIENTS AND METHODS

This prospective cohort study included patients with breast cancer screened for therapeutic clinical trials from July 2020 to January 2024. Eligibility was determined by the provider and study coordinator. Patient characteristics were abstracted from the electronic medical record. Rurality and neighborhood disadvantage were mapped by address using rural-urban commuting area codes and area deprivation index (ADI), respectively. Likelihood of eligibility and enrollment by race, rurality, and neighborhood disadvantage were evaluated using risk ratios (RR) and 95% confidence intervals (CIs) from modified Poisson regression models.

RESULTS

Of 343 patients screened for therapeutic trials, the mean age was 56 years (SD 13), 33% were Black/other race, 22% lived in highly disadvantaged areas, and 16% in rural areas. Most patients were screened for one trial (87%). Overall, 54% of patients were eligible for trials, and of those, 58% enrolled. Similar likelihoods of eligibility and enrollment were seen by race and rurality. Though not significant, patients living in highly disadvantaged areas trended toward higher likelihood of enrollment (RR 1.24, 95% CI 0.99-1.55).

CONCLUSIONS

Over half of trial-eligible patients, even across race, rurality, or neighborhood disadvantage, enrolled, surpassing the national average. In contrast to national trends, there was higher enrollment among patients of higher ADI.

Early-Stage Renal Cell Carcinoma: Who Needs Adjuvant Therapy?

Surgery is the oldest modality of kidney cancer therapy and is usually the first step in the treatment process. To improve surgical outcomes, adjuvant therapy is frequently administered to eliminate residual tumors and reduce the risk of recurrence and metastasis. However, not all patients require adjuvant treatment. The decision regarding whether to treat or not to treat renal cell carcinoma patients depends on the risk of recurrence, including tumor stage and histology, and clinical, biological, and personal risk factors. This article will address the challenges of treating renal cell carcinoma patients with adjuvant therapy and review the current evidence and ongoing clinical trials.

Thoracic Cancer Exercise Services in Australia: A Point-Prevalence Survey

BACKGROUND

Cancer guidelines recommend pre- and rehabilitation; however, current research shows these services are not well integrated into clinical practice. To date, there has been no prospective audit of Australian lung cancer exercise services or the people accessing these services. The aim of this study was to describe the exercise pre- and rehabilitation services available to people with thoracic cancer and the characteristics of people with thoracic cancer attending these services in Australia.

METHODS

Prospective, observational, multicenter, 5-day, point-prevalence study. Australian healthcare services likely to provide exercise services to people with thoracic cancer were contacted to participate. Conduct and reporting followed the CROSS guidelines.

RESULTS

A total of 397 services were contacted, and 203 responded (51%). Overall, 67% (n = 137) accepted thoracic cancer referrals, and 107 (78%) completed the survey. Most exercise services were targeted at respiratory disease (58%, n = 60) compared with 31% cancer-specific (n = 33) and 5% lung cancer-specific (n = 5). A total of 73 patients with thoracic cancer attended programs across 41 sites (38%). Mean (SD) age was 68.5 (9.7) years. Overall, 4% of patients (n = 3) were culturally and linguistically diverse, and none identified as Aboriginal or Torres Strait Islander. A total of 19 outcomes were used in 51 combinations to assess participants (n = 70), and 12 exercise interventions were delivered in 45 combinations (n = 67).

CONCLUSIONS

One-third of responding exercise programs did not offer exercise services to people with thoracic cancer. Almost two-thirds of services that accept referrals did not have a thoracic cancer patient attend their service. High heterogeneity in outcome measures and exercise interventions was observed.

Course of Mental Disorders in Early Cancer Survivorship in Relation to Socioeconomic Status: A Multi-Center Prospective Longitudinal Study (LUPE)

OBJECTIVE

Individuals with low socioeconomic status (SES) exhibit higher rates of mental disorders; however, data in oncological populations are insufficient. This study investigated the course of DSM-5 mental disorders in cancer patients, stratified by SES, over a period of 1.5 years following initial cancer diagnosis.

METHODS

This multi-center prospective longitudinal study assessed cancer patients within two months of cancer diagnosis (t1), and at 6-, 12-, and 18-month follow-up (t2-t4) using the SCID-5 interview for mental disorders based on DSM-5 criteria. Chi-square-tests were tested for frequency changes over time. A generalized linear mixed model (GLMM) was applied with fixed effects for SES and time on mental disorders.

RESULTS

Out of 1030 patients with a SCID-5 at baseline (53.2% men, 60 years), 821, 719 and 654 participated at respective follow-ups. The most common diagnoses were skin and prostate cancer. Point prevalence of mental disorders was 20.9% at baseline, decreasing to 18.2%, 14.6%, and 15.0% (t2-t4; χ2 (3) = 15.3, p = 0.002). Patients with low SES consistently showed highest prevalence rates, whereas patients with high SES showed decreasing rates of mental disorders over time, with a main effect of time (χ2 (3) = 19.9, p < 0.001) and SES (χ2 (2) = 8.8, p = 0.01) in the GLMM. Two thirds never met diagnostic criteria for a mental disorder. Sensitivity analysis among study completers (n = 592) revealed a similar pattern to the main analysis.

CONCLUSIONS

Cancer patients with low SES exhibit impaired coping with cancer-related stressors, increasing their risk for mental disorders. Social disparities affect physical and mental health, possibly via health behavior or health literacy, and need to be addressed by tailored survivorship care planning.

Association between e-health usage and consideration for clinical trial participation: An exploratory study on the mediating role of cancer-related self-efficacy and patient-centered communication

Background

The journey of any new treatment begins in the lab and through a clinical trial. Clinical trials have become an important means to promote public health causes. In digital age, e-health usage (EHU) might be a key factor to promote clinical trials. However, how consideration for clinical trial participation is impacted by EHU remains unclear.

Method

Secondary analyses were conducted on data from the Health Information National Trends Survey 2020 (HINTS 5, Cycle 4). This study proposed and tested a serial mediation model linking EHU to consideration for clinical trial participation, mediated by patient-centered communication (PCC) and cancer-related self-efficacy (CS). Analysis was performed using a sample survey targeted at individuals with chronic disease and/or family cancer history, conducted in 2020 in the United States (N = 3292).

Result

This study found that EHU exerted positive effects on clinical trial participation directly. Furthermore, their relationship can be mediated by PCC and CS. Only when PCC serves as the first mediator did CS exert the serial meditation effect. Annual household income significantly moderates the path from CS to consideration for clinical trial participation. For low-income groups, an increase in CS significantly expends their consideration for clinical trial participation.

Conclusion

EHU can improve PCC and CS. This can be considered as motivators for increasing participation to clinical trials. Based on the finding, information related clinical trials should be promoted through e-health channels and the information should gain better patients' understanding. Those findings throw out suggestions on building trust, addressing concerns and alleviating fears to clinical trial participation.

Ethical considerations for referral partnerships in clinical research

Recruitment challenges in clinical research are widespread, particularly for traditionally under-represented groups. Referral relationships-in which research partners and clinical partners agree to collaborate on selected research studies or programmes, with the expectation that the clinical partners refer appropriate patients as potential participants-may help alleviate these challenges. Referral relationships allow research partners access to expanded and more diverse pools of participants by increasing the engagement of medical providers, leveraging providers' connections with patients and providing structural support for study participation. Clinical partners can also benefit from the resources offered by research involvement, and patients may benefit from improved access to studies. Yet despite their potential, referral relationships can raise ethical concerns. Here, we discuss ethical considerations for referral relationships in clinical research to address these concerns. When establishing relationships, fair participant selection should guide the sites and studies involved. When defining the terms of a relationship, partners should build trust and respect, collaborating so that health centres or hospitals and communities benefit from their research involvement with the mitigation of associated burdens. When implemented, referral relationships should continue to honour fair participant selection, reduce misunderstanding or miscommunication about research and protect patients' privacy and confidentiality. Overall, when conducted ethically, referral relationships can help address study recruitment challenges and promote fair access to research opportunities.

The potential clinical utility of Whole Genome Sequencing for patients with cancer: evaluation of a regional implementation of the 100,000 Genomes Project

BACKGROUND

The 100,000 Genomes Project established infrastructure for Whole Genome Sequencing (WGS) in the United Kingdom.

METHODS

A retrospective study of cancer patients recruited to the 100,000 Genomes Project by the West Midlands Genomics Medicine Centre, evaluating clinical relevance of results.

RESULTS

After excluding samples with no sequencing data (1678/4851; 34.6%), 3166 sample sets (germline and somatic) from 3067 participants were sequenced. Results of 1256 participants (41.0%) were interpreted (excluding participants who died (308/3067; 10.0%) or were clinically excluded (1503/3067; 49.0%)). Of these, 323 (25.7%) had no variants in genes which may alter management (Domain 1 genes). Of the remaining 933 participants, 552 (59.2%) had clinical recommendations made (718 recommendations in total). These included therapeutic recommendations (377/933; 40.4%), such as clinical trial, unlicensed or licensed therapies or high TMB recommendations, and germline variants warranting clinical genetics review (85/933; 9.1%). At the last follow up, 20.2% of all recommendations were followed (145/718). However, only a small proportion of therapeutic recommendations were followed (5.1%, 25/491).

CONCLUSIONS

The 100,000 Genomes Project has established infrastructure and regional experience to support personalised cancer care. The majority of those with successful sequencing had actionable variants. Ensuring GTAB recommendations are followed will maximise benefits for patients.

Advancing health equity and the role of digital health technologies: a scoping review protocol

INTRODUCTION

Healthcare systems around the world exhibit inherent systemic inequities that disproportionately impact marginalised populations. Digital health technologies (DHTs) hold promising potential to address these inequities and to play a pivotal role in advancing health equity. However, there is a notable gap regarding a comprehensive and structured overview of existing frameworks and guidelines on advancing health equity and a clear understanding of the potential of DHTs in their implementation. To this end, our primary objectives are first to identify prevalent frameworks and guidelines that promote health equity and second to pinpoint the contemporary role of DHTs as an avenue for implementing these frameworks and guidelines. This synthesis will guide future DHTs, ensuring equitable accessibility and effectiveness and ultimately contributing to enhancing health equity among marginalised populations.

METHODS AND ANALYSIS

This work adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Reviews. To identify pertinent evidence, we will employ seven electronic databases (PubMed, EMBASE, Cochrane, PsycINFO, Scopus, Web of Science and WISO) encompassing the fields of medicine, healthcare and social sciences. Moreover, selected grey literature will be considered. We will include primary and secondary studies published in English between 2010 and 2023 that focus on (technology and non-technology-based) frameworks and guidelines for health equity improvement. Each article will undergo an independent assessment for eligibility, followed by the extraction of pertinent data from eligible sources. Subsequently, the extracted data will be subjected to qualitative and quantitative analyses, and findings will be presented using narrative and descriptive formats.

ETHICS AND DISSEMINATION

Ethical approval is deemed unnecessary for this scoping review, as it involves synthesising existing knowledge. The findings from this study will be disseminated through peer-reviewed publications.

PROTOCOL REGISTRATION

https://osf.io/94pht.

In Pursuit of Optimal Outcomes: A Framework for Quality Standards in Immune Effector Cell Therapy

Immune effector cell (IEC) therapy represents a transformative advancement in oncology, leveraging the immune system to combat various malignancies. This article outlines a comprehensive framework for establishing and maintaining quality standards in IEC therapy amidst rapid scientific and clinical advancements. We emphasize the integration of structured process measures, robust quality assurance, and meticulous outcome evaluation to ensure treatment efficacy and safety. Key components include multidisciplinary expertise, stringent accreditation protocols, and advanced data management systems, which facilitate standardized reporting and continual innovation. The collaborative effort among stakeholders-ranging from patients and healthcare providers to regulatory bodies-is crucial in delivering high-quality IEC therapies. This framework aims to enhance patient outcomes and cement the role of IEC therapy as a cornerstone of modern oncology, promoting continuous improvement and adherence to high standards across the therapeutic spectrum.

Understanding Health Equity in Patient-Reported Outcomes

Patient-reported outcomes (PROs) are measures of patients' health that are conveyed directly by individual patients. These measures serve as instruments to evaluate the impact of interventions on any aspect of patients' health, from specific symptoms to broader quality of life indicators. However, their effectiveness relies on capturing relevant factors accurately. Whereas they are commonly used in clinical trials, PROs extend their influence across health care settings, informing clinicians, health care payers, regulators, and administrators to guide quality improvement and reimbursement decisions. Neglecting health equity considerations in PRO development and implementation widens health disparities, leading to biased interpretations, medical mismanagement, and poor health outcomes among marginalized groups. To foster equitable health care, efforts must focus on considering the values of underrepresented populations in PRO design, addressing barriers to completion, enhancing representation in research, providing cultural competency training for clinicians, and allocating research funding to support health equity research. By addressing these issues, advances can be made toward fostering inclusive, equitable health care for all individuals.

Social Characteristics of Culturally and Linguistically Diverse Cancer Patients Enrolled in Early Phase Clinical Trials in South Western Sydney

INTRODUCTION

Early phase clinical trials (EPCTs) enable access to novel therapies for patients who have exhausted standard of care treatment and contribute a crucial role in drug development and research. Culturally and linguistically diverse (CALD) or socially disadvantaged patients have notably lower rates of participation in these trials. We aimed to characterise the social and cultural demographics of patients enrolled on an EPCT in South Western Sydney.

METHODS

We conducted a 10-year retrospective review of patients enrolled on a EPCT at Liverpool Hospital. CALD patients were defined as those born overseas or whose preferred language was other than English. The patient residential address was used to calculate distance travelled, and the Index of Relative Socioeconomic Disadvantage (IRSD) and Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD) scores were calculated and used as a surrogate for socioeconomic status (SES).

RESULTS

Our study included 233 patients across 39 EPCTs. Ninety-one patients (39%) were identified as CALD. The median IRSD and IRSAD scores were 941 and 944, respectively, with 62.7-67.4% of patients residing in an area with greater disadvantage compared to the median of Australia. The median distance travelled was 17 kilometres with only 12% of participants travelling more than 50 km. CALD patients were more likely to reside in an area of low SES (OR 3.4, 95% CI: 1.8-6.5, p < 0.01) and travelled shorter median distances (10 vs. 23 km) when compared to non-CALD patients.

CONCLUSION

Our study cohort contained a lower proportion of CALD patients and a higher SES than what we might have expected from our local population. Furthermore, there was a trend toward greater SES disadvantage (lower IRSD/IRSAD scores) for the CALD population. This study provides novel Australian data to support the underrepresentation of culturally diverse or disadvantaged patients on EPCTs. Future efforts should be made to reduce barriers to participation and improve equity in clinical trial participation.

Time Toxicity Experienced by Early-Phase Cancer Clinical Trial Participants

PURPOSE

Early-phase clinical trials (EP-CTs) are designed to determine optimal dosing, tolerability, and preliminary activity of novel cancer therapeutics. Little is known about the time that patients spend interacting with the health care system (eg, time toxicity) while participating in these studies.

METHODS

We retrospectively reviewed the electronic health records of consecutive patients enrolled in EP-CTs from 2017 to 2019 to obtain baseline characteristics and number of health care-associated days, defined as all inpatient and outpatient visits while on trial. We used univariable and multivariable analyses to identify predictors of increased time toxicity, defined as the proportion of health care-associated days among total days on trial. For ease of interpretation, we created a dichotomous variable, with high time toxicity defined as ≥20% health care-associated days during time on trial and used regression models to evaluate relationships between time toxicity and clinical outcomes.

RESULTS

Among 408 EP-CT participants (mean age, 60.5 years [standard deviation, SD, 12.6]; 56.5% female; 88.2% White; 96.0% non-Hispanic), patients had an average of 22.5% health care-associated days while on trial (SD, 13.8%). Those with GI (B = 0.07; P = .002), head/neck (B = 0.09; P = .004), and breast (B = 0.06; P = .015) cancers and those with worse performance status (B = 0.04; P = .017) and those receiving targeted therapies (B = 0.04; P = .014) experienced higher time toxicity. High time toxicity was associated with decreased disease response rates (odds ratio, 0.07; P < .001), progression-free survival (hazard ratio [HR], 2.10; P < .001), and overall survival (HR, 2.16; P < .001).

CONCLUSION

In this cohort of EP-CT participants, patients spent more than one-fifth of days on trial with health care contact. We identified characteristics associated with higher time toxicity and found that high toxicity correlated with worse clinical outcomes. These data could help inform patient-clinician discussions about EP-CTs, guide future trial design, and identify at-risk patients.

Breast cancer clinical trial participation among diverse patients at a comprehensive cancer center

This study was designed to determine the enrollment patterns in breast cancer clinical trials (CCTs) of patients with diverse backgrounds in an equal access setting and to evaluate the factors contributing to low rates of clinical trial accrual in patients of low socioeconomic status (SES). We performed a retrospective review of a prospectively maintained database of new patients seen at the Dan L. Duncan Comprehensive Cancer Center dating from 5/2015 to 9/2021, which included 3043 patients screened for breast CCTs. We compared the rate of CCT availability, eligibility, and enrollment between two patient populations: Smith Clinic, where most patients are of low SES and uninsured, and Baylor St. Luke's Medical Center (BSLMC) with mostly predominantly insured, higher income patients. We performed logistic regression to evaluate whether differences in age, clinic, race, trial type, and primary language may be underlying the differences in CCT enrollment. More patients were eligible for CCTs at Smith Clinic (53.7% vs 44.7%, p < 0.001). However, Smith Clinic patients were more likely to decline CCT enrollment compared to BSLMC (61.3% declined vs 39.4%, p < 0.001). On multivariate analysis, Black patients had a significantly higher rate of CCT refusal overall (OR = 0.26, 95% CI 0.12-0.56, p < 0.001) and BSLMC only (OR = 0.20, 95% CI 0.060-0.60, p = 0.006). Our data shows that it is likely an oversimplification to assume that equal access will lead to the elimination of CCT disparities. Efforts to diversify CCTs must include consideration of structural and institutional inequities as well as social needs.

EBCC-14 manifesto: Addressing disparities in access to innovation for patients with metastatic breast cancer across Europe

The European Breast Cancer Council (EBCC) traditionally identifies controversies or major deficiencies in the management of patients with breast cancer and selects a multidisciplinary expert team to collaborate in setting crucial principles and recommendations to improve breast cancer care. The 2024 EBCC manifesto focuses on disparities in the care of patients with metastatic breast cancer. There are several reasons for existing disparities both between and within countries. Our recommendations aim to address the stigma of metastatic disease, which has led to significant disparities in access to innovative care regardless of the gross national income of a country. These recommendations are for different stakeholders to promote the care of patients with metastatic breast cancer across Europe and worldwide.

Recruitment rates and strategies in exercise trials in cancer survivorship: a systematic review

PURPOSE

Despite clear evidence-based supporting a benefit to exercise on physical and psychological metrics in patients with cancer, recruitment to exercise trials amongst cancer survivors is suboptimal. We explore current recruitment rates, strategies, and common barriers to participation in exercise oncology trials in cancer survivorship.

METHODS

A systematic review was conducted using a pre-defined search strategy in EMBASE, CINAHL, Medline, Cochrane Library, and Web of Science. The search was performed up to 28/02/2022. Screening of titles and abstracts, full-text review, and data extraction was completed in duplicate.

RESULTS

Of the 3204 identified studies, 87 papers corresponding to 86 trials were included. Recruitment rates were highly variable with a median rate of 38% (range 0.52-100%). Trials recruiting prostate cancer patients only had the highest median recruitment rate (45.9%) vs trials recruiting colorectal cancer patients only which had the lowest (31.25%). Active recruitment strategies such as direct recruitment via a healthcare professional were associated with higher recruitment rates (rho = 0.201, p = 0.064). Common reasons for non-participation included lack of interest (46.51%, n (number of studies) = 40); distance and transport (45.3%, n = 39); and failure to contact (44.2%, n = 38).

CONCLUSIONS

Recruitment of cancer survivors to exercise interventions is suboptimal with barriers being predominantly patient-oriented. This paper provides the benchmark for current recruitment rates to exercise oncology trials, providing data for trialists planning future trial design and implementation, optimise future recruitment strategies, and evaluate their own recruitment success against current practice.

IMPLICATIONS FOR CANCER SURVIVORS

Enhanced recruitment to cancer survivorship exercise trials is necessary in facilitating the publication of definitive exercise guidelines, generalisable to varying cancer cohorts.

PROSPERO REGISTRATION NUMBER

CRD42020185968.

Socio-economic inequalities in the use of flu vaccination in Europe: a multilevel approach

BACKGROUND

The European-wide statistics show that the use of flu vaccination remains low and the differences between countries are significant, as are those between different population groups within each country. Considerable research has focused on explaining vaccination uptake in relation to socio-economic and demographic characteristics, health promotion and health behavior factors. Nevertheless, few studies have aimed to analyze between-country differences in the use of flu vaccination for the EU population. To address this gap, this study examines the socio-economic inequalities in the use of influenza vaccination for the population aged 15 years and over in all 27 EU Member States and two other non-EU countries (Iceland and Norway).

METHODS

Using data from the third wave of European Health Interview Survey (EHIS) 2019, we employed a multilevel logistic model with a random intercept for country, which allows controlling simultaneously the variations in individuals' characteristics and macro-contextual factors which could influence the use of flu vaccination. In addition, the analysis considers the population stratified into four age groups, namely adolescents, young adults, adults and elderly, to better capture heterogeneities in flu vaccination uptake.

RESULTS

The main findings confirm the existence of socio-economic inequalities between individuals in different age groups, but also of significant variation between European countries, particularly for older people, in the use of influenza vaccination. In this respect, income and education are strong proxy of socio-economic status associated with flu vaccination uptake. Moreover, these disparities within each population group are also explained by area of residence and occupational status. Particularly for the elderly, the differences between individuals in vaccine utilization are also explained by country-level factors, such as the type of healthcare system adopted in each country, public funding, personal health expenditure burden, or the availability of generalist practitioners.

CONCLUSIONS

Overall, our findings reveal that vaccination against seasonal influenza remains a critical public health intervention and bring attention to the relevance of conceiving and implementing context-specific strategies to ensure equitable access to vaccines for all EU citizens.

Impact of patient demographics and neighborhood socioeconomic variables on clinical trial participation patterns for NHL

ABSTRACT

Prior studies have demonstrated that certain populations including older patients, racial/ethnic minority groups, and women are underrepresented in clinical trials. We performed a retrospective analysis of patients with non-Hodgkin lymphoma (NHL) seen at MD Anderson Cancer Center (MDACC) to investigate the association between trial participation, race/ethnicity, travel distance, and neighborhood socioeconomic status (nSES). Using patient addresses, we ascertained nSES variables on educational attainment, income, poverty, racial composition, and housing at the census tract (CT) level. We also performed geospatial analysis to determine the geographic distribution of clinical trial participants and distance from patient residence to MDACC. We examined 3146 consecutive adult patients with NHL seen between January 2017 and December 2020. The study cohort was predominantly male and non-Hispanic White (NHW). The most common insurance types were private insurance and Medicare; only 1.1% of patients had Medicaid. There was a high overall participation rate of 30.5%, with 20.9% enrolled in therapeutic trials. In univariate analyses, lower participation rates were associated with lower nSES including higher poverty rates and living in crowded households. Racial composition of CT was not associated with differences in trial participation. In multivariable analysis, trial participation varied significantly by histology, and participation declined nonlinearly with age in the overall, follicular lymphoma, and diffuse large B-cell lymphoma (DLBCL) models. In the DLBCL subset, Hispanic patients had lower odds of participation than White patients (odds ratio, 0.36; 95% confidence interval, 0.21-0.62; P = .001). In our large academic cohort, race, sex, insurance type, and nSES were not associated with trial participation, whereas age and diagnosis were.

Consultations about randomised controlled trials are shorter and less in-depth for socioeconomically disadvantaged patients compared to socioeconomically advantaged patients: qualitative analysis across three trials

BACKGROUND

Patients from socioeconomically disadvantaged backgrounds are underserved in randomised controlled trials, yet they experience a much greater burden of disease compared with patients from socioeconomically advantaged areas. It is crucial to make trials more inclusive to ensure that treatments and interventions are safe and effective in real-world contexts. Improving how information about trials is verbally communicated is an unexplored strategy to make trials more inclusive. This study examined how trials are communicated verbally, comparing consultations involving patients from the most and least socioeconomically disadvantaged areas.

METHODS

Secondary qualitative analysis of 55 trial consultation transcripts from 41 patients, sampled from 3 qualitative studies embedded in their respective UK multi-site, cancer-related randomised controlled trials. Patients living in the most and least socioeconomically disadvantaged areas, defined using English Indices of Multiple Deprivation decile scores, were purposively sampled. Analysis was largely thematic and drew on the constant comparison method.

RESULTS

Recruiters communicated clinical uncertainty in a similar way for patients living in different socioeconomic areas. Consultations with disadvantaged patients were, on average, half the duration of those with advantaged patients, and tended to involve recruiters providing less in-depth explanations of trial concepts, used phrasing that softened trial arm risks, and described trial processes (e.g. randomisation) using informal or metaphorical phrasing. Disadvantaged and advantaged patients differed in the concerns they expressed; disadvantaged patients voiced fewer concerns and asked fewer questions but were also less likely to be invited to do so by recruiters.

CONCLUSION

Interactions about trials unfolded in different ways between patients living in different socioeconomic areas, likely due to both patient- and recruiter-related factors. We present considerations for recruiters when discussing trials with patients from socioeconomically disadvantaged backgrounds, aimed at enhancing trial communication. Future research should examine disadvantaged patients' and recruiters' experiences of verbal trial communication to inform guidance that addresses the needs and preferences of underserved groups.

Prostate cancer metastasis and health disparities: a systematic review

BACKGROUND

Prostate cancer (PCa), one of the most prevalent malignancies affecting men, significantly contributes to increased mortality rates worldwide. While the causative death is due to advanced metastatic disease, this occurrence disproportionately impacts men of African descent compared to men of European descent. In this review, we describe potential mechanisms underlying PCa metastases disparities and current treatments for metastatic disease among these populations, differences in treatment outcomes, and survival rates, in hopes of highlighting a need to address disparities in PCa metastases.

METHODS

We reviewed existing literature using databases such as PubMed, Google Scholar, and Science Direct using the following keywords: "prostate cancer metastases", "metastatic prostate cancer disparity", "metastatic prostate cancer diagnosis and treatment", "prostate cancer genetic differences and mechanisms", "genetic differences and prostate tumor microenvironment", and "men of African descent and access to clinical treatments". The inclusion criteria for literature usage were original research articles and review articles.

RESULTS

Studies indicate unique genetic signatures and molecular mechanisms such as Epithelial-Mesenchymal Transition (EMT), inflammation, and growth hormone signaling involved in metastatic PCa disparities. Clinical studies also demonstrate differences in treatment outcomes that are race-specific, for example, patients of African descent have a better response to enzalutamide and immunotherapy yet have less access to these drugs as compared to patients of European descent.

CONCLUSIONS

Growing evidence suggests a connection between a patient's genetic profile, the prostate tumor microenvironment, and social determinants of health that contribute to the aggressiveness of metastatic disease and treatment outcomes. With several potential pathways highlighted, the limitations in current diagnostic and therapeutic applications that target disparity in PCa metastases warrant rigorous research attention.

Basket Trials: Past, Present, and Future

Large-scale tumor molecular profiling has revealed that diverse cancer histologies are driven by common pathways with unifying biomarkers that can be exploited therapeutically. Disease-agnostic basket trials have been increasingly utilized to test biomarker-driven therapies across cancer types. These trials have led to drug approvals and improved the lives of patients while simultaneously advancing our understanding of cancer biology. This review focuses on the practicalities of implementing basket trials, with an emphasis on molecularly targeted trials. We examine the biologic subtleties of genomic biomarker and patient selection, discuss previous successes in drug development facilitated by basket trials, describe certain novel targets and drugs, and emphasize practical considerations for participant recruitment and study design. This review also highlights strategies for aiding patient access to basket trials. As basket trials become more common, steps to ensure equitable implementation of these studies will be critical for molecularly targeted drug development.

Social Representativeness and Intervention Adherence-A Systematic Review of Clinical Physical Activity Trials in Breast Cancer Patients

Objectives

Representativeness in physical activity randomised controlled trials (RCT) in breast cancer patients is essential to analyses of feasibility and validity considering privileged- social groups. A step-by-step exclusion of less privileged groups through the trial process could reinforce health inequality. This study aimed at examining representativeness in breast cancer (BC) physical activity trials, investigate associations between socio-economic status (SES) and intervention adherence, and explore associations between representativeness and the relationship between SES and intervention adherence.

Methods

Systematic, computerised searches were performed in PubMed, CINAHL, AMED, EMBASE and PsycINFO. Additional citation-based searches retrieved 37 articles. Distributions of education level, ethnicity, and marital status in study samples were compared to national populations data to estimate representativeness in less privileged groups.

Results

A preponderance of studies favoured educated, married and white patients. Only six studies reported SES-adherence associations, hampering conclusions on this relationship and possible associations between representativeness and an SES-adherence relationship.

Conclusion

Less educated, unmarried and non-white individuals may be underrepresented in BC physical activity RCTs, while SES-adherence associations in such trials are inconclusive. Unintentional social misrepresentations may indicate that disguised inequity warrants revived attention.

Social deprivation independently impacts clinical outcomes in patients with chronic lymphocytic leukemia

Not available.

Analysis and Optimization of Equitable US Cancer Clinical Trial Center Access by Travel Time

Importance

Racially minoritized and socioeconomically disadvantaged populations are currently underrepresented in clinical trials. Data-driven, quantitative analyses and strategies are required to help address this inequity.

Objective

To systematically analyze the geographical distribution of self-identified racial and socioeconomic demographics within commuting distance to cancer clinical trial centers and other hospitals in the US.

Design, Setting, and Participants

This longitudinal quantitative study used data from the US Census 2020 Decennial and American community survey (which collects data from all US residents), OpenStreetMap, National Cancer Institute-designated Cancer Centers list, Nature Index of Cancer Research Health Institutions, National Trial registry, and National Homeland Infrastructure Foundation-Level Data. Statistical analyses were performed on data collected between 2006 and 2020.

Main Outcomes and Measures

Population distributions of socioeconomic deprivation indices and self-identified race within 30-, 60-, and 120-minute 1-way driving commute times from US cancer trial sites. Map overlay of high deprivation index and high diversity areas with existing hospitals, existing major cancer trial centers, and commuting distance to the closest cancer trial center.

Results

The 78 major US cancer trial centers that are involved in 94% of all US cancer trials and included in this study were found to be located in areas with socioeconomically more affluent populations with higher proportions of self-identified White individuals (+10.1% unpaired mean difference; 95% CI, +6.8% to +13.7%) compared with the national average. The top 10th percentile of all US hospitals has catchment populations with a range of absolute sum difference from 2.4% to 35% from one-third each of Asian/multiracial/other (Asian alone, American Indian or Alaska Native alone, Native Hawaiian or Other Pacific Islander alone, some other race alone, population of 2 or more races), Black or African American, and White populations. Currently available data are sufficient to identify diverse census tracks within preset commuting times (30, 60, or 120 minutes) from all hospitals in the US (N = 7623). Maps are presented for each US city above 500 000 inhabitants, which display all prospective hospitals and major cancer trial sites within commutable distance to racially diverse and socioeconomically disadvantaged populations.

Conclusion and Relevance

This study identified biases in the sociodemographics of populations living within commuting distance to US-based cancer trial sites and enables the determination of more equitably commutable prospective satellite hospital sites that could be mobilized for enhanced racial and socioeconomic representation in clinical trials. The maps generated in this work may inform the design of future clinical trials or investigations in enrollment and retention strategies for clinical trials; however, other recruitment barriers still need to be addressed to ensure racial and socioeconomic demographics within the geographical vicinity of a clinical site can translate to equitable trial participant representation.

Factors influencing clinical trial participation of women with fibromyalgia across the United States: a cross-sectional survey

Although fibromyalgia is a widespread chronic pain condition where 90 percent of patients are women, they are underrepresented in Randomized Clinical Trials (RCTs). We aim to describe the willingness to participate, assess different factors, and explore the impact of sociodemographic and clinical characteristics on perceived barriers to trial participation. This is a cross-sectional survey targeting women with fibromyalgia. Univariate and multivariate logistic regression were performed. Of the 436 women with fibromyalgia, 56 percent were very likely to participate in RCTs. Minorities expressed less interest than non-minorities, while higher pain scores, previous participation, and younger patients reported a higher interest. Barriers significantly associated with a reduced willingness were: the participant's perception (side effects, distance, potential negative impact), the center (reputation), the trial protocol (number of visits, placebo), and trial awareness by their physician. In a multivariate analysis, older age, low education, lower income, and higher pain scores were associated with perceived barriers to RCT participation. Despite the high interest to participate, factors such as side effects, the center's distance, number of visits, placebo treatments, and the institution's reputation must be considered in clinical trials for women with fibromyalgia.

Impact of race and ethnicity on early mortality in multiple myeloma: a SEER analysis

Over the past two decades, there have been significant advances in the treatment of multiple myeloma which has led to an improvement in overall survival.1,2 However, a notable proportion of patients continue to experience early mortality (EM), defined as 2 years from the time of diagnosis. This raises the possibility that improvements in myeloma survival have not extended equally to all groups. Using the latest data drawn from the Surveillance Epidemiology and End Results database of patients in the United States spanning 2000-2019, we study impact of important sociodemographic factors on EM. Through regression modeling, we demonstrate that patients diagnosed from 2000-2005, of older age, male sex, and of certain racial minority status (non-Hispanic Black and Hispanic) have higher odds of EM. Of these factors, minority status contributed to worse 2-year overall survival as well. We evaluate whether income, as a surrogate to access to care, could potentially explain this finding, but find that race has a distinct relationship with EM that is not modified by income. This is further reinforced by subgroup analysis. After characterizing groups vulnerable to EM, we examine reasons for these disparities and potential avenues to address them.

Geographic disparity in the distribution of cancer clinical trials in the United States and the associated factors

BACKGROUND

Little is known regarding the geographic disparity in the distribution of phase 1-3 clinical trials of new cancer treatments in the US and the associated factors.

OBJECTIVE

To examine county-level variation in the number of phase 1-3 cancer clinical trials and the associations between county characteristics and having phase 1-3 cancer clinical trials.

METHODS

We identified phase 1-3 cancer clinical trials started in the US between January 2008 and December 2022 from the Aggregate Analysis of ClinicalTrials.gov database. We analyzed the distribution of phase 1-3 cancer clinical trials at the county level. Using a mixed-effects regression with states as random intercepts, we estimated the associations between a county's median age, median household income, percentage of population from racial and ethnic minority groups, proportion of population aged 25 years or older with an educational attainment of bachelor's degree or higher, rurality, cancer incidence rate, and number of medical oncologists per population with having any phase 1-3 cancer clinical trial in a county.

RESULTS

After excluding trials that were suspended, terminated, and withdrawn, a total of 14,977 phase 1-3 cancer clinical trials started in the United States between January 2008 and December 2022 were included in the primary analysis. Only 1,333 out of 3,143 counties (42.4%) had 1 or more trial during this period. Counties that were rural, with lower median household income, a less educated population, fewer medical oncologists per population, and lower cancer incidence rates demonstrated a significantly lower likelihood of having phase 1-3 cancer clinical trials.

CONCLUSIONS

Our study revealed substantial geographic disparities in the distribution of phase 1-3 cancer clinical trials. Limited trial availability in low-income, low-education, low-oncologist, and rural areas can be a significant barrier to patient participation, potentially hindering adoption and worsening outcomes in disadvantaged populations.

A systematic review of risk factors associated with depression and anxiety in cancer patients

Depression and anxiety are common comorbid conditions associated with cancer, however the risk factors responsible for the onset of depression and anxiety in cancer patients are not fully understood. Also, there is little clarity on how these factors may vary across the cancer phases: diagnosis, treatment and depression. We aimed to systematically understand and synthesise the risk factors associated with depression and anxiety during cancer diagnosis, treatment and survivorship. We focused our review on primary and community settings as these are likely settings where longer term cancer care is provided. We conducted a systematic search on PubMed, PsychInfo, Scopus, and EThOS following the PRISMA guidelines. We included cross-sectional and longitudinal studies which assessed the risk factors for depression and anxiety in adult cancer patients. Quality assessment was undertaken using the Newcastle-Ottawa assessment checklists. The quality of each study was further rated using the Agency for Healthcare Research and Quality Standards. Our search yielded 2645 papers, 21 of these were eligible for inclusion. Studies were heterogenous in terms of their characteristics, risk factors and outcomes measured. A total of 32 risk factors were associated with depression and anxiety. We clustered these risk factors into four domains using an expanded biopsychosocial model of health: cancer-specific, biological, psychological and social risk factors. The cancer-specific risk factors domain was associated with the diagnosis, treatment and survivorship phases. Multifactorial risk factors are associated with the onset of depression and anxiety in cancer patients. These risk factors vary across cancer journey and depend on factors such as type of cancer and individual profile of the patients. Our findings have potential applications for risk stratification in primary care and highlight the need for a personalised approach to psychological care provision, as part of cancer care.

Effective interventions to increase representation of under-served groups in randomised trials in UK and Ireland: a scoping literature review

Background

Participants in clinical trials often do not reflect the populations that could benefit from the treatments being investigated. There are known barriers to trial participation for under-served groups, but limited evidence on strategies to alleviate these barriers to improve representation. This scoping review aimed to identify effective interventions and design features that improve the representation `of under-served groups in trials, focusing on the UK and Ireland.

Methods

We included methodological research studies that reported interventions to improve representation of ethnic minority groups, socioeconomically disadvantaged groups, older people, or those with impaired capacity to consent to randomised controlled trials, conducted in the UK and Ireland, published between 2000-2021. Systematic searches were conducted in November 2021 and data were independently extracted by two authors and narratively synthesised.

Results

Seven studies were included: one randomised controlled study embedded in five trials, one mixed-methods study, and five studies reporting 'lessons learnt' from one trial. We categorised the 47 reported interventions or strategies into nine broad themes: Recruitment sites, recruitment settings, community engagement, and communication with participants, incentives, inclusion criteria, flexibility, patient documentation, and the consent process. Only 28/47 interventions were evaluated, 23 of which were comparison of recruitment pathways.The randomised study found that a £100 incentive mentioned in the invitation letter increased positive responses overall across drug trials in cardiovascular disease and hypertension, but not for older people or those living in the most deprived areas. Invitation letters via GPs and working with communities were reported as successful recruitment pathways in recruiting different under-served populations.

Conclusions

Interventions aiming to improve the recruitment of under-served groups in the UK and Ireland were reported across seven papers, but their effectiveness was rarely rigorously evaluated. Included studies were context specific. Using a variety of recruitment methods is likely to help achieve a more diverse cohort.

Efficacy-effectiveness gaps in oncology: Looking beyond survival

The efficacy-effectiveness (EE) gap describes the differences in survival seen in clinical trials and routine clinical practice, where patients in real-world practice often have inferior outcomes compared to trial populations. However, EE gaps may exist beyond survival outcomes, including gaps in quality of life, toxicity, cost-effectiveness, and patient time, and these EE gaps should also influence patient and clinician treatment decisions. Failure to clearly acknowledge these EE gaps may cause patients, clinicians, and health care systems to have unrealistic expectations of the benefits of therapy across a range of important clinical and economic domains. In this commentary, the authors review the evidence supporting the existence of EE gaps in quality of life, time toxicity, cost and toxicities, and urge for further research into this important topic.

Ethics Along the Continuum of Research Involving Persons with Disorders of Consciousness

Interest in disorders of consciousness (DoC) has grown substantially over the past decade and has illuminated the importance of improving understanding of DoC biology; care needs (use of monitoring, performance of interventions, and provision of emotional support); treatment options to promote recovery; and outcome prediction. Exploration of these topics requires awareness of numerous ethics considerations related to rights and resources. The Curing Coma Campaign Ethics Working Group used its expertise in neurocritical care, neuropalliative care, neuroethics, neuroscience, philosophy, and research to formulate an informal review of ethics considerations along the continuum of research involving persons with DoC related to the following: (1) study design; (2) comparison of risks versus benefits; (3) selection of inclusion and exclusion criteria; (4) screening, recruitment, and enrollment; (5) consent; (6) data protection; (7) disclosure of results to surrogates and/or legally authorized representatives; (8) translation of research into practice; (9) identification and management of conflicts of interest; (10) equity and resource availability; and (11) inclusion of minors with DoC in research. Awareness of these ethics considerations when planning and performing research involving persons with DoC will ensure that the participant rights are respected while maximizing the impact and meaningfulness of the research, interpretation of outcomes, and communication of results.

Boosting and broadening recruitment to UK cancer trials: towards a blueprint for action

Recruitment and retention in cancer trials are long-standing issues, exacerbated by the COVID-19 pandemic. The UK National Institute of Health Research and leading clinicians have emphasised the urgency to achieve and surpass prepandemic levels of participation. Data from a recent UK trial demonstrated the impact of COVID-19 and highlighted factors that limited recruitment. In response to this worldwide problem, studies have identified strategies for remediation at the levels of funding, the research environment, study design and trial team-related aspects, yet evidence of progress is lacking. Equality, diversity and inclusivity have become central to UK health and social policy during the 2000s. The need for greater inclusivity in trials has become a particular concern for cancer researchers and funders in the UK and in the USA, in recognition of potential bias in results. In the UK trials, the lack of standardised recording of ethnicity data renders interpretation difficult and caution is required in comparisons with the USA. Recently, the focus of concern has shifted away from the impact of deprivation and low socioeconomic status on trial participation. Barriers created by these factors and their frequent intersection with ethnicity should not be overlooked. The UK has adopted an advisory approach to broadening recruitment, publishing policy documents, guidance and toolkits. In the USA, by contrast, action on inclusion is increasingly mandated. Within the UK paradigm, the cancer research community is strongly encouraged to adopt a coordinated approach towards standardised digital data collection and embed and evaluate innovative, cocreated, locally relevant strategies.

Involvement of Diverse Populations in Transfusion Medicine Research

Communities of color and diverse communities (eg, race, socioeconomic status, language, sexual orientation etc.) have not been recruited and enrolled equitably to participate in research studies in transfusion medicine. The exclusion of diverse communities in transfusion research can lead to health disparities lack of access to approved therapeutics and unequal allocation of interventions, resulting in missed opportunities to optimize health for individuals and communities. Involvement of diverse populations in research goes beyond inclusion as research subjects. Strategies should include specific studies on health conditions of importance to diverse communities with stable funding sources and specific funding announcements to develop projects led by diverse researchers, mentorship of diverse researchers, and openness to various ways of communicating research plans. Qualitative approaches and interdisciplinary collaboration should be supported to enhance inclusivity.

Reporting and Representativeness of Race, Ethnicity, and Socioeconomic Status in Systemic Sclerosis Randomized Trials: An Observational Study

OBJECTIVE

To assess how and to what extent socioeconomic status and ethnicity/race of participants are reported in randomized controlled trials (RCTs) on systemic sclerosis (SSc), and to estimate the representativeness of different ethnic/racial groups in SSc RCTs.

METHODS

We searched all published RCTs on SSc indexed in PubMed. We retrieved information on main features of RCTs published from 2000 onward and recorded for each study whether race/ethnicity was reported; how ethnicity/race was defined and assigned; and the number of patients included for each racial/ethnic group. Multivariable logistic regression was used to identify factors associated with race/ethnicity reporting. Proportion of races/ethnicities included in US-based RCTs on SSc was examined and compared with US demographic data.

RESULTS

We included 106 studies, mostly conducted in Europe (42%) or North America (25%), published after 2010 (74%), and enrolling a total of 6,693 patients. About one-third of studies provided information about race/ethnicity, with no improved reporting over time. Only 2 papers reported patient's socioeconomic status. Study location (US or intercontinental) was the only significant factor associated with a better reporting of race/ethnicity in multivariable analysis. In studies where race/ethnicity was reported, White patients were mostly represented (79%), followed by Asian (7%), and African American (6%). In the sensitivity analysis limited to studies from the US, underrepresentation of African American patients was observed in the 2000-2010 time period, but not later.

CONCLUSION

Documentation of race/ethnicity and socioeconomic status is poor in RCTs on SSc. More effort should be made to document race/ethnicity and socioeconomic status and to promote diversity in SSc RCTs.

Inequality factors in access to early-phase clinical trials in oncology in France: results of the EGALICAN-2 study

BACKGROUND

Investigation of the disparities in the access to experimental treatment in early-phase clinical trials is lacking. The objective of the EGALICAN-2 study was to identify the factors underpinning such inequalities.

METHODS

A national prospective survey was conducted in 11 early-phase clinical trial centers (CLIP2) certified by the French National Cancer Institute. Sociodemographic, socioeconomic and medical data were collected. Univariate logistic regression models were carried out to estimate odds ratios and 90% confidence intervals associated with the effect of each study variable. A multivariate logistic regression model was built to explore the independent factors associated with the administration of the experimental treatment (C1D1). A post hoc analysis was carried out excluding female cancer patients.

RESULTS

Between 2015 and 2016, 1355 patients referred from 11 CLIP2 centers in France were included in the study. Eight hundred and forty-eight patients received C1D1 (73%) and 320 patients (27%) were screening failure. Median age was 58 years (range 17-97 years) and 667 patients (54%) were female. Most patients had a metastatic disease (n = 751, 87%). In the multivariate logistic regression analysis, the significant independent factors associated with C1D1 were male sex, initial care received in a hospital with an early-phase unit and living in wealthy metropolitan areas (P values <0.05). In the post hoc analysis, the sex factor was no longer significant [odds ratio = 1.21 (95% confidence interval 0.86-1.70), P value = 0.271].

CONCLUSIONS

This study investigated the factors producing social inequalities in the context of early-phase clinical trials in oncology. Our research highlights factors of sex, care pathway and geographic location. Gynecological cancer was found to impact C1D1 significantly, unlike breast cancer. The results of this study should contribute to improve patient access to early-phase clinical trials.

Clinical trial reform in the post-COVID era

The COVID-19 pandemic precipitated the acute and efficient rollout of telehealth and virtual health care around the world. This review article focuses on the adoption of virtual care in the management of oncology patients, and discusses how virtual care offers the potential for large-scale, positive impacts on access to clinical trials. Virtual care during and following the peak of the pandemic has been found to be both safe and efficacious for oncology patients. Features, such as wearable health technologies, remote monitoring, home visits, and investigations being done closer to home, represent just some of the strengths of the virtual assessment rollout that were successfully utilized. One of the primary criticisms of oncological clinical trials is that clinical trial participants are not always representative of the patient populations treated in routine practice. This is in part due to stringent inclusion criteria and more broadly pertains to a lack of access to clinical trials, many of which are geographic as most trials are conducted in an urban, academic, or 'centralized' center. This paper seeks to discuss the barriers to clinical trial participation and to propose that the virtual care transformation that occurred during the pandemic has equipped oncological clinicians and researchers with the tools to better address these obstacles. A review of the literature on the impact of the virtual care rollout during and after the peak of the COVID-19 pandemic both locally and abroad was conducted. It is proposed that improving patient access through the decentralization of clinical trials has the potential to enhance evidence-based, real-world data, and to produce generalizable trial results that ultimately improve patient outcomes.

Factors affecting the recruitment of Hispanic/Latinx American older adults in clinical trials in the United States: A scoping review

OBJECTIVE

Participation of Hispanic/Latinx American older adults (HLAOA) in clinical trials is fundamental to health equity in aging research. However, information on strategies for the successful recruitment of this population in clinical trials is limited.

DESIGN

This scoping review aims to identify hindering and facilitating factors that impact the recruitment of HLAOA in clinical trials in the United States.

METHODS

Two databases (PubMed, EMBASE) were searched for original research articles from inception until March 2022 reporting on factors that engaged HLAoa (≥65) in clinical trials. One thousand and thirteen studies were scrutinized to identify 31 eligible articles.

RESULTS

Most articles were from cancer clinical trials (14 studies). Hindering factors that impacted the recruitment of HLAoa in clinical trials were related to (i) study design and logistics challenges, (ii) challenges imposed by social determinants of health, (iii) communication barriers, and (iv) patients' mistrust, and (v) family issues. Facilitating factors include (i) effective modes of outreach, (ii) strategic clinical trial design, (iii) incorporating culturally-respectful approaches that are tailored to the participants' sociocultural background, and (iv) bridging language barriers.

CONCLUSIONS

Successful recruitment of HLAOA into clinical trials requires identifying the study question, co-designing the trial design, implementation, and evaluation in respectful collaboration with the Hispanic/Latinx community with careful attention to their needs and minimizing the study burden on this vulnerable population. Factors identified here may guide researchers to better understand the needs of HLAOA and successfully recruit them into clinical trials, leading to more equitable research that increases their representation in clinical research.

Multifactorial Study on the Impact of Educational Level, Employment Status, and the Need for Extraordinary Care on the Economic Impact of Cancer Patients

Cancer is one of the major socio-health problems in the world. The level of education, the profession and/or employment status of the patient and the family can influence the amount of household income, the additional expenditure, and the possible socio-economic impact of the disease. The main objective of the study is to analyse and evaluate the influence of the level of education, the employment status of the patient, and the need for care and how these factors influence the additional expenditure and the possible socio-economic impact.

METHODS

descriptive cross-sectional randomised observational epidemiological study without replacement at the Hospital Universitario de Salamanca (CAUSA).

RESULTS

total sample (n = 365) comprised 53.2% of patients with no education or primary education, 25.8% with secondary education and 21.1% with higher education. Overall, 36.4% of patients were employed, 10.1% were self-employed, 53.0% were not employed, and 38.9% were experiencing other conditions. Significant statistics were found for educational level, employment status of the patient and main caregivers in terms of financial expenditure.

CONCLUSIONS

Oncology patients with more education spend more on home help and/or accompanying the patient and transfers to the hospital for treatment. Higher incomes are not synonymous with higher expenditure in the sample. The patient's main caregivers are a fundamental pillar of the patient's household income and additional spending on orthopaedic material.

Multimodal data fusion for cancer biomarker discovery with deep learning

Technological advances now make it possible to study a patient from multiple angles with high-dimensional, high-throughput multi-scale biomedical data. In oncology, massive amounts of data are being generated ranging from molecular, histopathology, radiology to clinical records. The introduction of deep learning has significantly advanced the analysis of biomedical data. However, most approaches focus on single data modalities leading to slow progress in methods to integrate complementary data types. Development of effective multimodal fusion approaches is becoming increasingly important as a single modality might not be consistent and sufficient to capture the heterogeneity of complex diseases to tailor medical care and improve personalised medicine. Many initiatives now focus on integrating these disparate modalities to unravel the biological processes involved in multifactorial diseases such as cancer. However, many obstacles remain, including lack of usable data as well as methods for clinical validation and interpretation. Here, we cover these current challenges and reflect on opportunities through deep learning to tackle data sparsity and scarcity, multimodal interpretability, and standardisation of datasets.

Characteristics of Clinical Trial Sites for Novel Transcatheter Mitral and Tricuspid Valvular Therapies

Importance

Racial and ethnic minority and socioeconomically disadvantaged patients have been underrepresented in randomized clinical trials. Efforts have focused on enhancing inclusion of minority groups at sites participating at clinical trials; however, there may be differences in the patient populations of the sites that participate in clinical trials.

Objective

To identify any differences in the racial, ethnic, and socioeconomic composition of patient populations among candidate sites in the US that did vs did not participate in trials for novel transcatheter therapies.

Design, Setting, and Participants

This cross-sectional analysis used Medicare Provider Claims from 2019 for patients admitted to hospitals in the US. All clinical trials for transcatheter mitral and tricuspid valve therapies and the hospitals participating in each of the trials were identified using ClinicalTrials.gov. Hospitals with active cardiac surgical programs that did not participate in the trials were also identified. Data analysis was performed between July 2021 and July 2022.

Exposures

Multivariable linear regression models were used to identify differences in racial, ethnic, and socioeconomic characteristics among patients undergoing cardiac surgery or transcatheter aortic valve replacement at trial vs nontrial hospitals.

Main Outcome and Measures

The main outcome of the study was participation in a clinical trial for novel transcatheter mitral or tricuspid valve therapies.

Results

A total of 1050 hospitals with cardiac surgery programs were identified, of which 121 (11.5%) participated in trials for transcatheter mitral or tricuspid therapies. Patients treated in trial hospitals had a higher median zip code-based household income (difference of $5261; 95% CI, $2986-$7537), a lower Distressed Communities Index score (difference of 5.37; 95% CI, 2.59-8.15), and no significant difference in the proportion of patients dual eligible for Medicaid (difference of 0.86; 95% CI, -2.38 to 0.66). After adjusting for each of the socioeconomic indicators separately, there was less than 1% difference in the proportion of Black and Hispanic patients cared for at hospitals participating vs not participating in clinical trials.

Conclusions and Relevance

In this cohort study among candidate hospitals for clinical trials for transcatheter mitral or tricuspid valve therapies, trial hospitals took care of a more socioeconomically advantaged population than nontrial hospitals, with a similar proportion of Black and Hispanic patients. These data suggest that site selection efforts may improve enrollment of socioeconomically disadvantaged patients but may not improve the enrollment of Black and Hispanic patients.

Socioeconomic Barriers to Randomized Clinical Trial Retention in Patients Treated With Adjuvant Radiation for Early-Stage Breast Cancer

PURPOSE

Socioeconomic barriers contribute to breast cancer clinical trial enrollment disparities. We sought to identify whether socioeconomic disadvantage also is associated with decreased trial retention.

METHODS AND MATERIALS

We performed a secondary analysis of 253 (of 287) patients enrolled in a randomized phase 3 trial of conventionally fractionated versus hypofractionated whole-breast irradiation. The outcome of trial retention versus dropout was defined primarily based on whether the patient completed breast cosmesis outcomes assessment at 3-year follow-up, and secondarily, at 5-year follow-up. Associations of retention with severity of socioeconomic disadvantage, quantified by patients' home neighborhood area deprivation index (ADI) rank (1 [least] to 100 [most deprivation]), were tested using the Kruskal-Wallis test and multivariate logistic regression. Associations of retention with patients' use of social resource assistance were analyzed using the χ² test.

RESULTS

In total, 21.7% (n = 55) of patients dropped out by 3 years and 36.7% (n = 92) by 5 years. Median ADI was 36.5 (interquartile range, 22-57) for retained and 46.0 (interquartile range, 29-60) for dropout patients. Dropout was associated with more severe socioeconomic deprivation (ADI ≥45 vs <45) at 3 years (odds ratio, 3.63; 95% confidence interval, 1.62-8.15; P = .002) and 5 years (odds ratio, 2.55; 95% confidence interval, 1.37-4.76; P = .003). While on study, patients who ultimately dropped out were more likely to require resource assistance for practical (transportation, housing, financial) than psychological needs (distress, grief) or advance care planning (P = .03).

CONCLUSIONS

In this study, ADI was associated with disparities in clinical trial retention of patients with breast cancer receiving adjuvant radiation treatment. Results suggest that developing multidimensional interventions that extend beyond routine social determinants needs screening are needed, not only to enhance initial clinical trial access and enrollment but also to enable robust long-term retention of socioeconomically disadvantaged patients and improve the validity and generalizability of reported long-term trial clinical and patient-reported outcomes.

Differences Among Clinical Trials and Registries on Surgical and Percutaneous Coronary Interventions

BACKGROUND

A need exists for systematic evaluation of the differences in baseline characteristics and early outcomes between patients enrolled in randomized controlled trials (RCTs) and clinical practice for coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).

METHODS

Systematic searches were conducted to identify RCTs comparing CABG vs PCI and CABG or PCI registries. Sixteen predefined baseline characteristics and 30-day mortality were extracted from the included studies. Pooled proportion and mean with 95% CI were calculated for binary and continuous outcomes, respectively, by using the random effects model.

RESULTS

Fourteen RCTs and 10 registries including more than 2 million patients were included. Registry patients who underwent CABG had a higher prevalence of hypertension, smoking, reduced left ventricular ejection fraction, and prior myocardial infarction, but a lower prevalence of single-vessel disease when compared with CABG-treated patients included in RCTs. Regarding PCI, hypertension, hyperlipidemia, left main coronary artery disease, triple-vessel coronary disease, and NYHA functional class <IV were significantly more prevalent among patients in RCTs, whereas age, reduced left ventricular ejection fraction, and smoking were more represented among PCI registry patients. Thirty-day mortality was higher in registries for both PCI-treated and CABG-treated patients.

CONCLUSIONS

There were significant differences in baseline characteristics and 30-day mortality between patients enrolled in RCTs comparing CABG vs PCI and CABG and PCI registries. However, results were mixed, and the discrepancy was less than seen in other fields.

Predictors of participants' retention-socioeconomic factors or nonadherence: insights from a urological clinical prospective study

BACKGROUND

To investigate various patient-level variables, specifically socioeconomic status, as risk factors for withdrawal in a recently completed clinical study. We specifically investigated a non-interventional prospective study assessing the role of novel imaging as a biomarker for cancer upgradation in prostate cancer for this objective.

METHODS

In this retrospective analysis, we assessed the association between various patient-level factors including clinic-demographic factors, socioeconomic status, and the number of non-adherences with the participants' retention or withdrawal from the study. For socioeconomic status (SES), we used the zip code-based Economic Innovation Group Distressed Community Index (DCI) which classifies into five even distress tiers: prosperous, comfortable, mid-tier, at-risk, or distressed. Low SES was defined as those with a DCI Distress tier of at-risk or distressed. We compared values between the two retention and withdrawal groups using t-test, chi-square test, and logistic regression analysis.

RESULTS

Of 273 men screened, 123 men were enrolled. Among them, 86.2% (106/123) retained through the study whereas 13.8% (17/123) withdrew from the study. The mean (SD) age was 64 (6.4) years. Overall, 31.7% (39/123) were Hispanics and 24.3% (30/123) were African Americans. The median (IQR) DCI score was 34 (10.3, 68.1) and 30.8% (38/123) of patients belonged to low SES. The median DCI score in participants who retained in the study was statistically similar to those who withdrew from the study (p=0.4). Neither the DCI tiers (p=0.7) nor the low SES (p=0.9) were associated with participants' retention or withdrawal of the study. In terms of non-adherence, all participants in the withdrawn group had at least one non-adherent event compared to 48.1% in the retained group (p<0.001). Repetitive non-adherence was significantly higher in participants who withdrew from the study vs those who retained in the study [88.2% vs 16.9%, p <0.001]. On multivariate logistic regression analysis, the number of non-adherences (OR=12.5, p<0.001) and not DCI (OR=0.99, p=0.7) appeared to be an independent predictor for participants' retention or withdrawal from the study.

CONCLUSIONS

Expanding diverse inclusion and limiting withdrawal with real-time non-adherence monitoring will lead to more efficient clinical research and greater generalizability of results.