Recruitment and early retention of women with advanced breast cancer in a complementary and alternative medicine trial

Influences on clinical trial participation: Enhancing recruitment through a gender lens - A scoping review

Background

Suboptimal clinical trial recruitment contributes to research waste. Evidence suggests there may be gender-based differences in willingness to participate in clinical research. Identifying gender-based differences impacting the willingness of trial participation may assist trial recruitment.

Objectives

To examine factors that influence the willingness of men and women to participate in clinical trials and to identify modifiable factors that may be targeted to optimise trial participation.

Material and methods

Electronic databases were searched with key words relating to 'gender', 'willingness to participate' and 'trial'. Included studies were English language and reported gender-based differences in willingness to participate in clinical trials, or factors that influence a single gender to participate in clinical trials. Studies were excluded if they described the demographic factors of trial participants or if the majority of participants were pregnant. Extracted data were coded, categorized, analysed thematically and interpreted using Arksey and O'Malley's framework.

Results

Sixty-three studies were included. Two main themes were identified: trial characteristics and participant characteristics. A number of gender-based differences moderating willingness to participate were observed although only one, 'concern for self' was found to influence actual trial participation rates between genders.

Conclusion

The relationship between factors influencing willingness to participate in clinical trials is complex. The influence of gender on willingness to participate, while important, may be moderated by other factors including socioeconomic status, ethnicity and health condition. Exploring factors that influence willingness to participate specific to a study cohort likely offers the most promise to optimise trial recruitment of that cohort.

A brief bedside visual art intervention decreases anxiety and improves pain and mood in patients with haematologic malignancies

Treatment of cancer-related symptoms represents a major challenge for physicians. The purpose of this pilot study was to determine whether a brief bedside visual art intervention (BVAI) facilitated by art educators improves mood, reduces pain and anxiety in patients with haematological malignancies. Thirty-one patients (21 women and 10 men) were invited to participate in a BVAI where the goal of the session was to teach art technique for ~30 min. Primary outcome measures included the change in visual analog scale, the State-Trait Anxiety Inventory and the Positive and Negative Affect Schedule scale, from baseline prior to and immediately post-BVAI. Total of 21 patients (19 women and two men) participated. A significant improvement in positive mood and pain scores (p = .003 and p = .017 respectively) as well as a decrease in negative mood and anxiety (p = .016 and p = .001 respectively) was observed. Patients perceived BVAI as overall positive (95%) and wished to participate in future art-based interventions (85%). This accessible experience, provided by artists within the community, may be considered as an adjunct to conventional treatments in patients with cancer-related mood symptoms and pain, and future studies with balanced gender participation may support the generalisability of these findings.

An Integrative Review of Scientific Evidence for Reconnective Healing

Background: Biofield therapies offer a novel, non-invasive approach to treating chronic diseases based on assessing and adjusting an individual's physiological and emotional responses through their bio-energetic field. Reconnective Healing^™ (RH) is defined as: “…not just energy healing, but instead a more comprehensive spectrum of healing composed of energy, light, and information.”

Objectives: Several biofield therapies, such as Reiki, Therapeutic Touch and Johrei, have already been reviewed in the literature but RH has received little attention even though it is taught and practiced worldwide. This review provides a critical assessment of RH as a healing modality.

Methods: Scientific research articles published in peer-reviewed journals addressing RH were identified using relevant databases and archives. Information was extracted from each article that met selection criteria for evaluation of quality of reporting and design. This review summarizes and critically evaluates the five currently published peer-reviewed research papers involving RH and assesses whether RH provides consistent physiological outcomes between the studies.

Results: These results, taken together, suggest: (i) exposure of a healer or healee to RH, either directly or indirectly, amplifies their degree of autonomic arousal and energy, (ii) RH can reduce pain and improve range of motion in people with shoulder limitations, and (iii) when individuals experience RH as a group, their autonomic nervous systems simultaneously show sudden similar responses consistent with the idea that RH is mitigated by entrainment of biofields.

Conclusions: Since these studies are extremely varied in design it is not possible at this point to reach conclusions about the general effectiveness of RH. More clinical and physiological research performed on different populations under a range of conditions is needed in order to support this healthcare approach.

Dyadic recruitment in complementary therapy studies: experience from a clinical trial of caregiver-delivered reflexology

PURPOSE

As home-based care continues to be a growing trend in health care, involvement of friend and family caregivers in the management of illness becomes essential. However, before nurses can prepare caregivers to engage in various types of care, an evidence base needs to be established via randomized controlled trials (RCTs). Research suggests that recruiting cancer patients and their friend or family caregivers into RCTs presents challenges. The purpose of this paper is to illustrate the barriers to recruitment of patient-caregiver dyads into a RCT of caregiver-delivered reflexology and to recommend strategies to address such barriers.

METHODS

This paper reports on a nurse-directed RCT that involved recruitment efforts unique to a caregiver-delivered reflexology protocol for advanced-stage breast cancer patients. Ineligibility due to caregiver-related reasons, consent among eligible patients (out of 551 approached patients), and reasons for refusal were analyzed.

RESULTS

Almost one-third of patients were found to be ineligible due to the lack of a caregiver to participate with them and provide this form of social support. Among eligible patients, the consent rate for this dyadic study is much lower than that of previous RCTs of reflexologist-delivered reflexology that enrolled just patients, not dyads.

CONCLUSION

Implications for nursing practice and research include addressing the need for greater social support for patients and strategies for problem-solving refusal reasons during study enrollment.

Concordance between patient reports of cancer-related symptoms and medical records documentation

CONTEXT

Two sources of symptom data, patient report and medical records documentation, have been used in studies focusing on chronic conditions. The concordance of patient-reported cancer-related symptoms and clinician reports as documented in the medical records needs to be evaluated.

OBJECTIVES

To compare patient reports with medical record documentation of 12 disease- and treatment-related symptoms for women with advanced breast cancer undergoing chemotherapy or hormonal therapy for cancer control.

METHODS

Women (n=384) were recruited from 13 oncology clinics in the midwestern U.S. They completed telephone interviews at intake, five, and 11 weeks, where they reported the presence of 12 symptoms using a checklist. Medical records were abstracted when women completed the study. The concordance between patient reports and medical record documentation was assessed using percent agreement, kappa statistics, and McNemar's tests. Administration of medication for symptoms and patient characteristics were investigated in relation to the agreement of the two sources of data.

RESULTS

Poor to slight agreement was found, and disagreement was significant for all 12 symptoms. The concordance between symptom presence in the medical record and administration of medication for the management of those symptoms was moderate. Patient characteristics were not associated with agreement, except for age. The agreement was higher for older women for the symptom of mouth sores.

CONCLUSION

Medical records may not provide adequate documentation of symptoms, and collection of patient-reported symptom data from women with advanced breast cancer is critical to quality clinical management.

Factors associated with attrition from a randomized controlled trial of meaning-centered group psychotherapy for patients with advanced cancer

OBJECTIVE

The generalizability of palliative care intervention research is often limited by high rates of study attrition. This study examined factors associated with attrition from a randomized controlled trial comparing meaning-centered group psychotherapy (MCGP), an intervention designed to help advanced cancer patients sustain or enhance their sense of meaning to the supportive group psychotherapy (SGP), a standardized support group.

METHODS

Patients with advanced solid tumor cancers (n = 153) were randomized to eight sessions of either the MCGP or SGP. They completed assessments of psychosocial, spiritual, and physical well-being pretreatment, midtreatment, and 2 months post-treatment. Attrition was assessed in terms of the percent of participants who failed to complete these assessments, and demographic, psychiatric, medical, and study-related correlates of attrition were examined for the participants in each of these categories.

RESULTS

The rates of attrition at these time points were 28.1%, 17.7%, and 11.1%, respectively; 43.1% of the participants (66 of 153) completed the entire study. The most common reason for dropout was patients feeling too ill. Attrition rates did not vary significantly between study arms. The participants who dropped out pretreatment reported less financial concerns than post-treatment dropouts, and the participants who dropped out of the study midtreatment had poorer physical health than treatment completers. There were no other significant associations between attrition and any demographic, medical, psychiatric, or study-related variables.

CONCLUSIONS

These findings highlight the challenge of maintaining advanced cancer patients in longitudinal research and suggest the need to consider alternative approaches (e.g., telemedicine) for patients who might benefit from group interventions but are too ill to travel.

Patient education integrated with acupuncture for relief of cancer-related fatigue randomized controlled feasibility study

Background

Cancer-related fatigue (CRF) is a prominent clinical problem. There are calls for multi-modal interventions.

Methods

We assessed the feasibility of delivering patient education integrated with acupuncture for relief of CRF in a pilot randomized controlled trial (RCT) with breast cancer survivors using usual care as control. Social cognitive and integrative medicine theories guided integration of patient education with acupuncture into a coherent treatment protocol. The intervention consisted of two parts. First, patients were taught to improve self-care by optimizing exercise routines, improving nutrition, implementing some additional evidence-based cognitive behavioral techniques such as stress management in four weekly 50-minute sessions. Second, patients received eight weekly 50-minute acupuncture sessions. The pre-specified primary outcome, CRF, was assessed with the Brief Fatigue Inventory (BFI). Secondary outcomes included three dimensions of cognitive impairment assessed with the FACT-COGv2.

Results

Due to difficulties in recruitment, we tried several methods that led to the development of a tailored recruitment strategy: we enlisted oncologists into the core research team and recruited patients completing treatment from oncology waiting rooms. Compared to usual care control, the intervention was associated with a 2.38-point decline in fatigue as measured by the BFI (90% Confidence Interval from 0.586 to 5.014; p <0.10). Outcomes associated with cognitive dysfunction were not statistically significant.

Conclusions

Patient education integrated with acupuncture had a very promising effect that warrants conducting a larger RCT to confirm findings. An effective recruitment strategy will be essential for the successful execution of a larger-scale trial.

Trial registration

NCT00646633

Coordination and management of multisite complementary and alternative medicine (CAM) therapies: experience from a multisite reflexology intervention trial

BACKGROUND

Multisite randomized clinical trials allow for increased research collaboration among investigators and expedite data collection efforts. As a result, government funding agencies typically look favorably upon this approach. As the field of complementary and alternative medicine (CAM) continues to evolve, so do increased calls for the use of more rigorous study design and trial methodologies, which can present challenges for investigators.

PURPOSE

To describe the processes involved in the coordination and management of a multisite randomized clinical trial of a CAM intervention.

METHODS

Key aspects related to the coordination and management of a multisite CAM randomized clinical trial are presented, including organizational and site selection considerations, recruitment concerns and issues related to data collection and randomization to treatment groups. Management and monitoring of data, as well as quality assurance procedures are described. Finally, a real world perspective is shared from a recently conducted multisite randomized clinical trial of reflexology for women diagnosed with advanced breast cancer.

RESULTS

The use of multiple sites in the conduct of CAM-based randomized clinical trials can provide an efficient, collaborative and robust approach to study coordination and data collection that maximizes efficiency and ensures the quality of results.

CONCLUSIONS

Multisite randomized clinical trial designs can offer the field of CAM research a more standardized and efficient approach to examine the effectiveness of novel therapies and treatments. Special attention must be given to intervention fidelity, consistent data collection and ensuring data quality. Assessment and reporting of quantitative indicators of data quality should be required.

Thujone-Rich Fraction of Thuja occidentalis Demonstrates Major Anti-Cancer Potentials: Evidences from In Vitro Studies on A375 Cells

Crude ethanolic extract of Thuja occidentalis (Fam: Cupressaceae) is used as homeopathic mother tincture (TOΦ) to treat various ailments, particularly moles and tumors, and also used in various other systems of traditional medicine. Anti-proliferative and apoptosis-inducing properties of TOΦ and the thujone-rich fraction (TRF) separated from it have been evaluated for their possible anti-cancer potentials in the malignant melanoma cell line A375. On initial trial by S-diphenyltetrazolium bromide assay, both TOΦ and TRF showed maximum cytotoxic effect on A375 cell line while the other three principal fractions separated by chromatography had negligible or no such effect, because of which only TRF was further characterized and subjected to certain other assays for determining its precise anti-proliferative and apoptotic potentials. TRF was reported to have a molecular formula of C₁₀H₁₆O with a molecular weight of 152. Exposure of TRF of Thuja occidentalis to A375 cells in vitro showed more cytotoxic, anti-proliferative and apoptotic effects as compared with TOΦ, but had minimal growth inhibitory responses when exposed to normal cells (peripheral blood mononuclear cell). Furthermore, both TOΦ and TRF also caused a significant decrease in cell viability, induced inter-nucleosomal DNA fragmentation, mitochondrial transmembrane potential collapse, increase in ROS generation, and release of cytochrome c and caspase-3 activation, all of which are closely related to the induction of apoptosis in A375 cells. Thus, TRF showed and matched all the anti-cancer responses of TOΦ and could be the main bio-active fraction. The use of TOΦ in traditional medicines against tumors has, therefore, a scientific basis.

Methodological issues in trials of complementary and alternative medicine interventions

BACKGROUND

Complementary and alternative medicine (CAM) use is widespread among cancer patients. Information on safety and efficacy of CAM therapies is needed for both patients and healthcare providers. Well-designed randomized clinical trials of CAM therapy interventions can inform both clinical research and practice.

OBJECTIVES

The aim of this study was to review important issues that affect the design of randomized clinical trials for CAM interventions.

METHODS

Using the methods component of the Consolidated Standards for Reporting Trials as a guiding framework and a National Cancer Institute-funded reflexology study as an exemplar, methodological issues related to participants, intervention, objectives, outcomes, sample size, randomization, blinding, and statistical methods were reviewed.

DISCUSSION

Trials of CAM interventions designed and implemented according to appropriate methodological standards will facilitate the needed scientific rigor in CAM research. Interventions in CAM can be tested using proposed methodology, and the results of testing will inform nursing practice in providing safe and effective supportive care and in improving the well-being of patients.