Describing randomisation: patients' and the public's preferences compared with clinicians' practice

Trial participants' self-reported understanding of randomisation phrases in participation information leaflets can be high, but acceptability of some descriptions is low, especially those linked to gambling and luck

BACKGROUND

Evidence indicates that trial participants often struggle to understand participant information leaflets (PILs) for clinical trials, including the concept of randomisation. We analysed the language used to describe randomisation in PILs and determine the most understandable and acceptable description through public and participant feedback.

METHODS

We collected 280 PILs/informed consent forms and one video animation from clinical research facilities/clinical trial units in Ireland and the UK. We extracted text on how randomisation was described, plus trial characteristics. We conducted content analysis to group the randomisation phrases inductively. We then excluded phrases that appeared more than once or were very similar to others. The final list of randomisation phrases was then presented to an online panel of participants and the public. Panel members were asked to rate each phrase on a 5-point Likert scale in terms of their understanding of the phrase, confidence in their understanding and acceptability of the phrase.

RESULTS

Two hundred and eighty PILs and the transcribed text from one video animation represented 229 ongoing or concluded trials. The pragmatic content analysis generated five inductive categories: (1) explanation of why randomisation is required in trials; (2) synonyms for randomisation; (3) comparative randomisation phrases; (4) elaborative phrases for randomisation (5) and phrases that describe the process of randomisation. We had 48 unique phrases, which were shared with 73 participants and members of the public. Phrases that were well understood were not necessarily acceptable. Participants understood, but disliked, comparative phrases that referenced gambling, e.g. toss of a coin, like a lottery, roll of a die. They also disliked phrases that attributed decision-making to computers or automated systems. Participants liked plain language descriptions of what randomisation is and those that did not use comparative phrases.

CONCLUSIONS

Potential trial participants are clear on their likes and dislikes when it comes to describing randomisation in PILs. We make five recommendations for practice.

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.

Physicians' use of plain language during discussions of prostate cancer clinical trials with patients

OBJECTIVE

This study described physicians' use of plain language during patient-physician cancer clinical trial discussions.

METHODS

Video-recorded clinical interactions and accompanying transcripts were taken from a larger study of communication and clinical trials (PACCT). Interactions (n = 25) were selected if they included invitations to participate in a clinical trial. We used descriptive, qualitative discourse analysis, a method that identifies language patterns at or above the sentence level. We first excerpted discussions of clinical trials, then identified instances of plain language within those discussions. Finally, we inductively coded those instances to describe physicians' plain language practices.

RESULTS

The analysis identified four plain language practices. Lexical simplification replaced medical terminology with simpler words. Patient-centered definition named, categorized, and explained complex medical terminology. Metaphor explained medical terminology by comparing it with known concepts. Finally, experience-focused description replaced medical terminology with descriptions of patients' potential physical experiences.

CONCLUSION

These plain language practices hold promise as part of effective information exchange in discussions of cancer clinical trials. Testing is needed to identify patient preferences and the extent to which these practices address patient health literacy needs.

PRACTICE IMPLICATIONS

Pending further testing, these plain language practices may be integrated into physician clinical trial and other communication training.

A Study of a Culturally and Contextually Situated Multimedia Approach to Recruit a Hard-to-Reach Spanish-Speaking Population for a Randomized Control Trial (RCT)

Study designs involving randomization can be difficult to communicate to participants, especially those with low literacy. The literature on strategies to explain research concepts is limited, especially for non-English speakers. We measured the effectiveness of a culturally and contextually situated multimedia approach to recruit a cohort of 60 female Mexican immigrants (FMI) to a randomized control trial (RCT) to reduce social isolation and depression. This strategy was designed to explain the concept of randomization, explain what participating in the research study entailed, and ensure informed consent. Potential participants viewed a presentation explaining the study and a video including animation with voice-over explaining the concept of randomization. We administered a pre/post survey. Respondents (N = 59) reported an increase in their understanding of randomization, intention to enroll, and attitude towards participating in research. We conclude that a culturally and contextually situated multimedia approach is an effective model when recruiting underrepresented populations with low literacy for RCTs.

Study Protocol of a Prospective Multicenter Study on Patient Participation for the Clinical Trial: Surgery as Needed Versus Surgery on Principle in Post-Neoadjuvant Complete Tumor Response of Esophageal Cancer (ESORES)

Ideally, patient-centered trial information material encourages the discussion with the treating physician, and helps patients making trade-offs regarding treatment decisions In a situation of possible equivalent treatment options in terms of overall survival (OS), it can make it easier to weigh up advantages and disadvantages. Preferences for choice of treatment in esophageal cancer (EC) are complex, and no standardized assessment tools are available. We will explore patient’s factors for treatment choice and develop a comprehensive patient information leaflet for the inclusion into randomized controlled trials (RCT) on EC. We conduct a cross-sectional, observational study based on a mixed-methods design with patients suffering from non-metastatic EC with post-neoadjuvant complete response after neoadjuvant chemotherapy (nCT) or neoadjuvant chemoradiation (nCRT), to develop patient-centered trial information material. This pilot study is performed in a concept development phase and a subsequent pilot phase. We start with patient interviews (n = 10–15) in the concept development phase to evaluate patients’ needs, and develop a Preference and Decision Aid Questionnaire (PDAQ). We pre-test the PDAQ with another n = 10 patients with EC after nCT or nCRT, former patients from a self-help organization, and n = 10 medical experts for their comments on the questionnaire. In the pilot phase, a multicenter trial using the PDAQ and additional measures is carried out (n = 120). Based on evidence of a possible equivalence in terms of OS of the treatment options “surgery as needed” and “surgery on principle” in patients with post-neoadjuvant complete response of EC, this pilot study on patient participation is conducted to assess patient’s needs and preferences, and optimize patients’ inclusion in a planned RCT. The aim is to develop patient-centered trial information material for the RCT to increase patients’ consent and compliance with the randomized treatment. The trial is registered at the German Clinical Trials Register (DRKS00022050, October 15, 2020).

Patient perspectives on chemotherapy de-escalation in breast cancer

BACKGROUND

Given excellent survival outcomes in breast cancer, there is interest in de-escalating the amount of chemotherapy delivered to patients. This approach may be of even greater importance in the setting of the COVID-19 pandemic.

METHODS

This concurrent mixed methods study included (1) interviews with patients and patient advocates and (2) a cross-sectional survey of women with breast cancer served by a charitable nonprofit organization. Questions evaluated interest in de-escalation trial participation, perceived barriers/facilitators to participation, and language describing de-escalation.

RESULTS

Sixteen patient advocates and 24 patients were interviewed. Key barriers to de-escalation included fear of recurrence, worry about decision regret, lack of clinical trial interest, and dislike for focus on less treatment. Facilitators included trust in physician recommendation, toxicity avoidance, monitoring for progression, perception of good prognosis, and impact on daily life. Participants reported that the COVID-19 pandemic made them more likely to avoid chemotherapy if possible. Of 91 survey respondents, many (43%) patients would have been unwilling to participation in a de-escalation clinical trial. The most commonly reported barrier to participation was fear of recurrence (85%). Few patients (19%) considered clinical trials themselves as a barrier to de-escalation trial participation. The most popular terminology describing chemotherapy de-escalation was "lowest effective chemotherapy dose" (53%); no patients preferred the term "de-escalation."

CONCLUSIONS

Fear of recurrence is a common concern among breast cancer survivors and patient advocates, contributing to resistance to de-escalation clinical trial participation. Additional research is needed to understand how to engage patients in de-escalation trials.

Factors associated with refusal or acceptance of older patients (≥ 65 years) to provide consent to participate in clinical research in cardiology: a qualitative study

BACKGROUND

Clinical research is an essential step in the successful translation of knowledge from basic research into concrete clinical applications, yet many people are reluctant to provide consent when actually approached to actively participate in clinical trials.

AIMS

We investigated the factors that influence older patient's (≥ 65 years) decisions to accept or refuse to participate in a prospective randomized clinical trial in secondary prevention after acute coronary syndrome.

METHODS

Qualitative approach based on individual semi-structured interviews with patients who were approached for consent to participate in a currently ongoing clinical trial was adopted. Patients were interviewed after the consent process (8 accepted; 8 refused the trial). Interviews were analysed using grounded theory methodology.

RESULTS

Sixteen patients aged ≥ 65 years participated. The main concept to emerge from these interviews is that the actual trial itself does not appear to be the primary determinant in the decision to participate in clinical research. Rather, patients' decisions to participate (or not) in clinical research appear to be primarily determined by their capacity to deal with the current health event that has disrupted their life, and by their available mental and physical resources.

DISCUSSION AND CONCLUSION

Older patients display varying levels of engagement in their own health, ranging from low engagement with high trust in the medical profession, to high engagement mirrored by distrust of the medical profession. Structural conditions, such as personal benefit from trial participation, or logistic barriers to participation, seem to affect both accepters and refusers in the same manner.

Animations about Clinical Trial Participation for Cancer Patients and Survivors

Communicating about clinical trials and medical research is challenging. An appropriate communication is essential to reduce some of the barriers associated with poor patients' enrollment in clinical trials and with patients' uninformed consent or uninformed refusal. An experiment was conducted to assess the effects of educational animations compared to brochures with and without visuals, and with the materials currently used by the NIH. These materials focused on explaining placebos, randomization, the steps necessary to enroll in a clinical trial, and how and by who patients' protection is ensured. A total of 1194 cancer patients and survivors completed this 4 by 4 experiment through a Qualtrics panel. The findings showed that animations improved participants knowledge about and attitudes toward clinical trials and were more effective than brochures presenting information from the NIH, especially for those individuals with low motivation and low ability to comprehend health-related information. Several evidence-based theoretical explanations of the functioning of animations are provided.

Patient Recruitment in Radiation Therapy Research: An Evaluation of Local Challenges

INTRODUCTION

Locally-initiated research studies in radiation therapy (RT) aim to substantiate clinical processes and are an effective approach to gather evidence for advances in patient care, new techniques, and protocols. The aim of this study was to retrospectively quantify recruitment challenges at a radiation oncology network (RON).

METHODS

Five locally initiated studies were included for analysis through the criteria of being undertaken within 2001-2017, initiated through local research teams, and having recruitment records available. Data extraction from each study included duration, aims, patient activities, recruitment strategy, target number of participants, and number of participants who were recruited/not recruited and who withdrew from the study. Reasons for nonregistration and withdrawal were recorded if available. Two studies are presented as case studies.

RESULTS

Included studies were diverse in patient population and study aim and included patient immobilization (lung and breast cancer), evaluation of radiation-induced esophagitis, documentation of anatomical and dosimetric changes in patients with head and neck cancer, and education (breast cancer). The exclusion of non-English-speaking patients, which is significant for the RON, which covers a wide cultural and linguistic diversity, was an important limiting factor, along with RT patients' disinterest in participation.

DISCUSSION

Challenges experienced in the evaluated RON studies are similar to non-RT clinical trials and included difficulties with patients interacting with study protocol, health practitioners' influence, and patient-related inclusion issues.

CONCLUSION

The resulting database provides a foundation for continued monitoring and documentation of study recruitment practice, which could elicit positive effects on planning and implementation of future patient recruitment strategies in RT locally initiated studies.

Patients' understanding of clinical research: An Italian cancer patient survey

INTRODUCTION:

Patients' awareness of clinical research and their involvement in clinical trials is of great importance, but it is difficult to estimate the extent of knowledge on the research being undertaken.

METHODS:

We evaluated the level of knowledge about clinical research using a self-reporting survey distributed to 967 adult patients with cancer attending the Departments of Medical Oncology and Onco-Haematology Units of IRST IRCCS and 4 hospitals in the region of Emilia-Romagna, Italy. The questionnaire was composed of 10 specific items on research knowledge. Patients responding correctly to at least 8 of the 10 items were considered to have a good understanding of clinical research.

RESULTS:

The questionnaire was completed by 769 patients (response rate 79.5%). Only 19% of patients were found to have a good understanding of clinical research. Patients with higher education and those who had previous clinical trial experience showed a significantly better understanding. Fifty-three percent of patients said that they would be willing to participate in a trial studying a new drug and 75% expressed an interest in taking part in informative meetings/events about clinical studies.

CONCLUSIONS:

Our results show that patients' understanding of clinical research is limited and highlight an interest in learning more.

Variations in stakeholders' priorities and views on randomisation and funding decisions in out-of-hospital cardiac arrest: An exploratory study

BACKGROUND AND AIMS

Prehospital critical care for out-of-hospital cardiac arrest (OHCA) is a complex and largely unproven intervention. During research to examine this intervention, we noted significant differences in stakeholders' views about research, randomisation, and the funding of prehospital critical care for OHCA. We aimed to answer the following questions: What are stakeholders' priorities for prehospital research? What are stakeholders' views on randomisation of prehospital critical care? How do stakeholders consider allocation of resources in prehospital care?

METHODS

We undertook an explanatory qualitative framework analysis of interviews and focus group with 5 key stakeholder groups: patients and public, air ambulance charities, ambulance service commissioners, prehospital researchers, and prehospital critical care providers.

RESULTS

We undertook 3 focus group discussions with a total of 23 participants and 8 interviews with a total of 9 participants. Despite sharing a common appreciation of the concepts of scientific enquiry, fairness, and beneficence, the 5 relevant stakeholder groups displayed divergent views of research and funding strategies regarding the intervention of prehospital critical care for the condition of OHCA. The reasons for this divergence could largely be explained through the different personal experiences and situational contexts of each stakeholder group. Many aspects of the strategies suggested by the stakeholder groups only partially aligned with principles of traditional evidence-based medicine, but were held with strong conviction.

DISCUSSION

Analysis of the views of 5 stakeholder groups regarding research and the funding of prehospital critical care for OHCA revealed shared values but a variety of different strategies to achieve these. This knowledge can help researchers in similar fields in the planning and presentation of their research, to maximise impact on decision making.

An observational study showed that explaining randomization using gambling-related metaphors and computer-agency descriptions impeded randomized clinical trial recruitment

OBJECTIVES

To explore how the concept of randomization is described by clinicians and understood by patients in randomized controlled trials (RCTs) and how it contributes to patient understanding and recruitment.

STUDY DESIGN AND SETTING

Qualitative analysis of 73 audio recordings of recruitment consultations from five, multicenter, UK-based RCTs with identified or anticipated recruitment difficulties.

RESULTS

One in 10 appointments did not include any mention of randomization. Most included a description of the method or process of allocation. Descriptions often made reference to gambling-related metaphors or similes, or referred to allocation by a computer. Where reference was made to a computer, some patients assumed that they would receive the treatment that was "best for them". Descriptions of the rationale for randomization were rarely present and often only came about as a consequence of patients questioning the reason for a random allocation.

CONCLUSIONS

The methods and processes of randomization were usually described by recruiters, but often without clarity, which could lead to patient misunderstanding. The rationale for randomization was rarely mentioned. Recruiters should avoid problematic gambling metaphors and illusions of agency in their explanations and instead focus on clearer descriptions of the rationale and method of randomization to ensure patients are better informed about randomization and RCT participation.

Linguistic Strategies for Improving Informed Consent in Clinical Trials Among Low Health Literacy Patients

Background

Improving informed consent to participate in randomized clinical trials (RCTs) is a key challenge in cancer communication. The current study examines strategies for enhancing randomization comprehension among patients with diverse levels of health literacy and identifies cognitive and affective predictors of intentions to participate in cancer RCTs.

Methods

Using a post-test-only experimental design, cancer patients (n = 500) were randomly assigned to receive one of three message conditions for explaining randomization (ie, plain language condition, gambling metaphor, benign metaphor) or a control message. All statistical tests were two-sided.

Results

Health literacy was a statistically significant moderator of randomization comprehension (P = .03). Among participants with the lowest levels of health literacy, the benign metaphor resulted in greater comprehension of randomization as compared with plain language (P = .04) and control (P = .004) messages. Among participants with the highest levels of health literacy, the gambling metaphor resulted in greater randomization comprehension as compared with the benign metaphor (P = .04). A serial mediation model showed a statistically significant negative indirect effect of comprehension on behavioral intention through personal relevance of RCTs and anxiety associated with participation in RCTs (P < .001).

Conclusions

The effectiveness of metaphors for explaining randomization depends on health literacy, with a benign metaphor being particularly effective for patients at the lower end of the health literacy spectrum. The theoretical model demonstrates the cognitive and affective predictors of behavioral intention to participate in cancer RCTs and offers guidance on how future research should employ communication strategies to improve the informed consent processes.

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.

What are the attitudes of strictly-orthodox Jews to clinical trials: are they influenced by Jewish teachings?

In order to explore whether and how Jewish teachings influence the attitudes of strictly-orthodox Jews to clinical trials, 10 strictly-orthodox Jews were purposively selected and interviewed, using a semi-structured schedule. Relevant literature was searched for similar studies and for publications covering relevant Jewish teachings. Thematic analysis was used to analyse transcribed interviews and explore relationships between attitudes and Jewish teachings identified in the review. Participants' attitudes were influenced in a variety of ways: by Jewish teachings on the over-riding importance of preserving life--the need to avoid risks affecting life and health, while taking risks to preserve life--and the religious obligation to help others, as well as by previous experience. Attitudes mirrored those in the general population, enabling many participants to reach conclusions that did not differ materially from those of the general population or research ethics committees.

Last resort or roll of the die? Exploring the role of metaphors in cancer clinical trials education among medically underserved populations

Improving communication about cancer clinical trials may help increase patients' understanding of medical research and their interest in participating. It is unfortunate that there is little empirical research to provide guidance on how to adapt clinical trial messages to maximize cultural sensitivity. This study examines (a) how medically underserved women conceptualize clinical trials by examining the language they use to describe them and (b) how this audience interprets metaphorical language used to explain randomization in the context of Phase III cancer clinical trials. The author conducted in-depth interviews and focus groups with 41 rural, low-income older women who either had been diagnosed with cancer or were caregivers for a person with cancer. The most commonly used lay metaphors for clinical trials had strong negative connotations and included treatment by trial and error, patients are guinea pigs, and treatment of last resort. Participants also expressed strong, unfavorable responses to conventional metaphors that equate randomization with the roll of a die or use other gambling language. Low-literacy definition approaches were unexpectedly problematic, suggesting the potential effectiveness of culturally grounded metaphors for communicating about clinical trials. Ethical implications of these findings for cancer communication are discussed.

Patient, caregiver, health professional and researcher views and experiences of participating in research at the end of life: a critical interpretive synthesis of the literature

Background

The development of the evidence-base informing end of life (EoL) care is hampered by the assumption that patients at the EoL are too vulnerable to participate in research. This study aims to systematically and critically review the evidence regarding the experiences and views of patients, caregivers, professionals and researchers about participation in EoL care research, and to identify best practices in research participation.

Methods

We searched seven electronic databases, and hand searched three journals and the bibliographies of relevant papers. Inclusion criteria were original research papers on involvement in EoL care research or its impact on participants. Critical interpretive synthesis was used to integrate the whole body of empirical evidence on this topic and generate theoretical categories from the evidence.

Results

Of a total of 239 identified studies, 20 studies met the inclusion criteria, from: the US (11), the UK (6) and Australia (3). Most focused on patients with cancer (12) and were conducted in hospices (9) or hospitals (7). Studies enquired about issues related to: EoL care research in general (5), specific research methods (13), and trial research (2). The studies evaluating willingness to participate in EoL care research showed positive outcomes across the different parties involved in research. Factors influencing willingness were mainly physical and cognitive impairment. Participating in research was a positive experience for most patients and carers but a minority experienced distress. This was related to: characteristics of the participants; the type of research; or the way it was conducted. Participatory study designs were found particularly suitable for enabling the inclusion of a wide range of participants.

Conclusion

The evidence explored within this study demonstrates that the ethical concerns regarding patient participation in EoL care research are often unjustified. However, research studies in EoL care require careful design and execution that incorporates sensitivity to participants’ needs and concerns to enable their participation. An innovative conceptual model for research participation relevant for potentially vulnerable people was developed.

'Let the computer choose?': the experience of participants in a randomised preference trial of medical versus surgical termination of pregnancy

The termination of pregnancy trial (Newcastle upon Tyne, UK), is the only randomised trial on termination of pregnancy methods incorporating a qualitative element that aimed to understand the experiences of women participating in the trial. Based on the results of this qualitative work, this article aims to provide insights into two strands of understanding; firstly, women's experience of participating in research about abortion and secondly, their experience of participating in a randomised preference trial. Semi-structured interviews were conducted of up to 90 minutes with 30 participants recruited at a single hospital site. A total of 20 women from the preference arm and 10 from the random arm were interviewed. The analysis and discussion of our findings use reflexive modernisation as a framework for understanding and interpreting some of the actions of social agents, that is, the participants and trial recruiters in the course of a clinical trial as an expert system. We found that the factors that shape women's experiences and decisions include trust in the expert system and reflexivity and agency on the part of both participants and trial recruiters.

Power of an effective clinical conversation: improving accrual onto clinical trials

The National Cancer Institute (NCI) is actively transforming clinical trials to revitalize the clinical trials system and improve patient accrual. For more than 30 years, NCI has provided information and communication resources about cancer clinical trials. The Institute supports a clinical trials Web site (www.cancer.gov/clinicaltrials) that receives nearly a half million page views a month. In addition, NCI's Cancer Information Service (800-4-CANCER, chat and e-mail) responds to 1,750 clinical trial inquiries every month. Although these numbers suggest that a high volume of clinical trial information is being exchanged between NCI, the public, and providers, most patients decide whether to participate in clinical trials during the patient-provider interaction.

Are cancer trials valid and useful for the general surgeon and surgical oncologist?

Cancer trials represent a rigorous and clear approach to testing whether an intervention or treatment will alter the outcomes of individuals with cancer in an experimental manner that is beyond the level of observational studies. As such, they remain useful and valid to the day-to-day practice of general surgeons and surgical oncologists. However, the shortcomings of current cancer clinical trials need to be recognized, especially when less than 1% of adults persons with cancer participate in cancer clinical trials, thus leaving the ability to generalize these trials to patients and their surgeons in the real-world setting an open question. Moving forward, physicians, payers, professional societies, advocates, the NCI, and other stakeholders need to develop broader cancer trials to benefit the millions of patients with cancer in the United States.

Conducting randomised controlled trials: finding better ways to explain research to people with anti-social personality disorder who have low literacy levels

BACKGROUND

The involvement of people with anti-social personality disorder (ASPD) in clinical trials is necessary to developing effective treatment. Low literacy level, however, may be a barrier to their understanding and therefore their engagement in research.

AIM

Our aim was to find a preferred and most easily understandable way of communicating about research participation with men who have ASPD.

METHODS

Twenty-five men with ASPD who were using mental health services, research experienced and research naïve participated in the study. Literacy levels were assessed. A list of research terms was generated, and statements were developed to ascertain if the terms were understood. The research terms were 'randomisation', 'informed consent', 'confidentiality' and a research question 'why carry out research?' The participants ranked their preferred way of explaining these terms and the method of communicating these.

RESULTS

Those with research experience understood the research terms better. The research naïve and the research experienced men differed in literacy level. Those with below average literacy preferred shorter wordings of research terms than those with average literacy and answered fewer questions correctly. The majority stated a preference for discussion with a researcher before agreeing to take part in research. The least preferred communication methods were those that relied on technology.

CONCLUSIONS

Researchers should be able to find and use terms that are readily understood and do so. Low literacy levels impair understanding of research terms.

Clinicians' attitudes towards clinical trials of cancer therapy

Background:

Patient accrual into cancer clinical trials remains at low levels. This survey elicited attitudes and practices of cancer clinicians towards clinical trials.

Method:

The 43-item Clinicians Attitudes to Clinical Trials Questionnaire was completed by participants in an intervention study aimed at improving multi-disciplinary involvement in randomised trials. Responses from 13 items were summed to form a research-orientation score.

Results:

Eighty-seven clinicians (78%) returned questionnaires. Physicians, more often than surgeons, chose to prioritise prolonging a patient's life, recruited ⩾50% of patients into trials and attended more research-focussed conferences. Clinicians at specialist centres were more positive about trials with no-treatment arms than those at district general hospitals, more likely to believe clinician, rather than patient reluctance to participate was the greater obstacle to trial accrual, and preferred national and international to local recognition. Clinicians belonging to breast and colorectal teams were less disappointed about not enrolling patients in trials and more accepting of no-treatment arm trials. Research orientation was higher in physicians than surgeons and higher in specialist centres than district hospitals.

Conclusions:

This study provides greater understanding of clinicians’ attitudes to trials. Results have been used to inform training interventions for clinicians targeting the problem of low and selective accrual.

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

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

"Did the trial kill the intervention?" experiences from the development, implementation and evaluation of a complex intervention

Background

The development, implementation and evaluation of any new health intervention is complex. This paper uses experiences from the design, implementation and evaluation of a rehabilitation programme to shed light on, and prompt discussion around, some of the complexities involved in such an undertaking.

Methods

Semi-structured interviews were conducted with 15 trial participants and five members of staff at the conclusion of a trial evaluating a rehabilitation programme aimed at promoting recovery after stem cell transplantation.

Results

This study identified a number of challenges relating to the development and evaluation of complex interventions. The difficulty of providing a standardised intervention that was acceptable to patients was highlighted in the participant interviews. Trial participants and some members of staff found the concept of equipoise and randomisation challenging and there was discord between the psychosocial nature of the intervention and the predominant bio-medical culture in which the research took place.

Conclusions

A lack of scientific evidence as to the efficacy of an intervention does not preclude staff and patients holding strong views about the benefits of an intervention. The evaluation of complex interventions should, where possible, facilitate not restrict that complexity. Within the local environment where the trial is conducted, acquiescence from those in positions of authority is insufficient; commitment to the trial is required.

Metaphor use and health literacy: a pilot study of strategies to explain randomization in cancer clinical trials

Patients often have difficulty understanding what randomization is and why it is needed in Phase III clinical trials. Physicians commonly report using metaphorical language to convey the role of chance in being assignment to treatment; however, the effectiveness of this strategy as an educational tool has not been explored. Guided by W. McGuire's (1972) information-processing model, the purpose of this pilot study was to explore effects of metaphors to explain randomization on message acceptance and behavioral intention to participate in a Phase III clinical trial among a sample of low-income, rural women (N = 64). Participants were randomly assigned to watch a video that explained randomization using 1 of 3 message strategies: a low-literacy definition, standard metaphor (i.e., flip of a coin), or a culturally derived metaphor (i.e., sex of a baby). The influence of attention on behavioral intentions to participate in clinical trials was partially moderated by message strategy. Under conditions of low attention, participants in the culturally derived metaphor condition experienced significantly higher intentions to participate in clinical trials compared with participants in the standard metaphor condition. However, as attention increased, differences in intentions among the conditions diminished. Having a positive affective response to the randomization message was a strong, positive predictor of behavioral intentions to participate in clinical trials. The authors discuss the theoretical and practical implications of these findings.

The attitudes of 1066 patients with cancer towards participation in randomised clinical trials

Background:

Barriers to randomised clinical trial (RCT) recruitment include failure to identify eligible patients, reluctance of staff to approach them and attitudes of some health-care professionals and patients. As part of a larger UK prospective study examining the communication and involvement in RCTs of 22 multidisciplinary teams in Wales, we also assessed the attitudes of patients they treat towards trials.

Methods:

Out of 1146 patients attending outpatient departments who were approached, 1146 (93%) completed the seven-item Attitudes to Randomised Trials Questionnaire (ARTQ), probing their general attitudes towards medical research and likely participation in a hypothetical two-arm RCT.

Results:

Randomisation initially deterred many patients from endorsing a willingness to participate. However, if information about the trial logic, voluntary nature and rights to withdraw were provided, together with further treatment details, 83% (886 out of 1066) would potentially participate. Other variables associated with a positive inclination towards participation included previous trial experience (P<0.01), male gender (P<0.01) and younger age, with patients ⩾70 years less likely to consider trial entry (P<0.01).

Conclusion:

The majority of patients were receptive to RCT participation. Many of those initially disinclined because of randomisation would consider joining if given further details that form part of standard GCP consent guidelines. These data show the importance and need for clear communication and information to encourage RCT participation. Evidence-based training courses are available to assist with this.

Towards optimised information about clinical trials; identification and validation of key issues in collaboration with cancer patient advocates

Clinical trials are crucial to improve cancer treatment but recruitment is difficult. Optimised patient information has been recognised as a key issue. In line with the increasing focus on patients' perspectives in health care, we aimed to study patients' opinions about the written information used in three clinical trials for breast cancer. Primary data collection was done in focus group interviews with breast cancer patient advocates. Content analysis identified three major themes: comprehensibility, emotions and associations, and decision making. Based on the advocates' suggestions for improvements, 21 key issues were defined and validated through a questionnaire in an independent group of breast cancer patient advocates. Clear messages, emotionally neutral expressions, careful descriptions of side effects, clear comparisons between different treatment alternatives and information about the possibility to discontinue treatment were perceived as the most important issues. Patients' views of the information in clinical trials provide new insights and identify key issues to consider in optimising future written information and may improve recruitment to clinical cancer trials.

Participating in a cancer clinical trial? The balancing of options in the loneliness of autonomy: a grounded theory interview study

Cancer patients asked to participate in a randomised trial including chemotherapy at two university centres and a satellite centre were interviewed about perceptions and experiences (14 trial participating and 15 trial declining patients). The central phenomenon was a constant, cautious balancing of personal options searching for maximised effect, personal safety, trust, confidence and being cared for. Almost all developed a treatment preference and this was decisive for choices. Trial participants strongly wished to get the experimental treatment perceived as superior. They felt their freedom of choice being limited by randomisation. In contrast, trial decliners almost all focused on graver adverse effects related to the experimental treatment. A trusting and confident doctor-patient relationship was valued strongly. Yet, most breast cancer patients treated at the two large centres experienced a general lack of personal trust, confidence and being taken care of. The major reason was patients meeting too many physicians perceived as incompetent and unprepared. In contrast, the ovarian cancer patients treated at the satellite centre were content and satisfied with the main reason being the low number of physicians who were perceived as prepared, empathetic and knowledgeable. All patients expressed a feeling of "loneliness of autonomy" lacking sufficient knowledge and other resources to make educated choices.

When "no" might not quite mean "no"; the importance of informed and meaningful non-consent: results from a survey of individuals refusing participation in a health-related research project

Background

Low participation rates can lead to sampling bias, delays in completion and increased costs. Strategies to improve participation rates should address reasons for non-participation. However, most empirical research has focused on participants' motives rather than the reasons why non-participants refuse to take part. In this study we investigated the reasons why older people choose not to participate in a research project.

Methods

Follow-up study of people living in Tayside, Scotland who had opted-out of a cross-sectional survey on activities in retirement. Eight hundred and eighty seven people aged 65–84 years were invited to take part in a home-based cross-sectional survey. Of these, 471 refused to take part. Permission was obtained to follow-up 417 of the refusers. Demographic characteristics of people who refused to take part and the reasons they gave for not taking part were collected.

Results

54% of those invited to take part in the original cross-sectional survey refused to do so. However, 61% of these individuals went on to participate in the follow-up study and provided reasons for their original refusal. For the vast majority of people initial non-participation did not reflect an objection to participating in research in principle but frequently stemmed from barriers or misunderstandings about the nature or process of the project itself. Only 28% indicated that they were "not interested in research". The meaningfulness of expressions of non-consent may therefore be called into question. Hierarchical log-linear modelling showed that refusal was independently influenced by age, gender and social class. However, this response pattern was different for the follow-up study in which reasons for non-participation in the first survey were sought. This difference in pattern and response rates supports the likely importance of recruitment issues that are research and context specific.

Conclusion

An expression of non-consent does not necessarily mean that a fully informed evaluation of the pros and cons of participation and non-participation has taken place. The meaningfulness of expressions of non-consent may therefore be a cause for concern and should be subject to further research. Many reasons for non-participation may be specific to a particular research topic or population. Information sheets should reflect this by going beyond standardised guidelines for their design and instead proactively seek out and address areas of concern or potential misunderstanding. The use of established behavioural theory in their design could also be considered.

Attitudes towards clinical research among cancer trial participants and non-participants: an interview study using a Grounded Theory approach

The attitudes of women patients with cancer were explored when they were invited to participate in one of three randomised trials that included chemotherapy at two university centres and a satellite centre. Fourteen patients participating in and 15 patients declining trials were interviewed. Analysis was based on the constant comparative method. Most patients voiced positive attitudes towards clinical research, believing that trials are necessary for further medical development, and most spontaneously argued that participation is a moral obligation. Most trial decliners, however, described a radical change in focus as they faced the actual personal choice. Almost no one got an impression of clinical equipoise between treatments in the trials, and most patients expressed discomfort with randomisation. A patient's choice to participate was mainly determined by whether the primary focus was on treatment effect or on adverse effects. Both knowledge about and feelings towards trials originated mostly from the media, although paradoxically the media were largely seen as untrustworthy. Mistrust was shown towards the pharmaceutical industry, and although most patients originally trusted that doctors primarily pursued the interest of patients, they did not trust the adequacy of doctors or industry in maintaining self-regulation. Thus, public control measures were judged to be essential.

The preferences of 600 patients for different descriptions of randomisation

A total of 600 patients from cancer centres throughout the UK identified their most preferred and most disliked descriptions of randomisation found in current patient information sheets and websites. The CancerBACUP description, which describes both the process of randomisation and why it is done, was most preferred 151 out of 533 (28%) patients. The NCI description was viewed as overly technical and most disliked 185 out of 483 (38%) patients.

Discussing randomised clinical trials of cancer therapy: evaluation of a Cancer Research UK training programme

OBJECTIVE

To evaluate a training intervention aimed at improving healthcare professionals' communication with cancer patients about randomised clinical trials.

DESIGN

Before and after evaluation of training programme.

SETTING

Members of the National Cancer Research Network, Scottish Trials Network, and the Welsh Cancer Trials Network.

PARTICIPANTS

101 healthcare professionals (33 clinicians and 68 research nurses).

INTERVENTION

Four modules delivered by a trained facilitator using videotapes and interactive exercises to cover general issues about discussing randomised clinical trials with patients, problems specific to adjuvant trials, trials with palliation as the goal, and trials where patients had a strong preference for one treatment arm.

MAIN OUTCOME MEASURES

Before and after the intervention, participants were videotaped discussing a trial with an actor portraying a patient. These consultations were assessed for presence of information required by good clinical practice guidelines. The actor patients gave an assessment after each interview. Participants reported their self confidence about key aspects of trial discussion.

RESULTS

Analysis of the videotaped consultations showed that, after intervention, significantly more participants displayed key communication behaviours such as explaining randomisation (69 v 81, odds ratio 2.33, P = 0.033), checking patients' understanding (11 v 31, odds ratio 3.22, P = 0.002), and discussing standard treatment (73 v 88, odds ratio 4.75, P = 0.005) and side effects (69 v 85, odds ratio 3.29, P = 0.006). Participants' self confidence increased significantly (P < 0.001) across all areas. Actor patients' ratings of participants' communication showed significant improvements for 12/15 key items.

CONCLUSION

This intensive 8 hour intervention significantly improved participants' confidence and competence when communicating about randomised clinical trials.