A Case-Control Study Examining Disparities in Clinical Trial Participation Among Breast Surgical Oncology Patients

Race norming and biases in surgical oncology care

Disparities in surgical oncology care may be due to race/ethnicity. Race norming, defined as the adjustment of medical assessments based on an individual's race/ethnicity, and implicit bias are specifically explored in this focused systematic review. We aim to examine how race norming and bias impact oncologic care and postsurgical outcomes, particularly in Black patient populations, while providing potential strategies to improve equitable and inclusive care.

Effects of socioeconomic status on enrollment in clinical trials for cancer: A systematic review

BACKGROUND

To achieve equitable access to cancer clinical trials (CCTs), patients must overcome structural, clinical, and attitudinal barriers to trial enrollment. The goal of this systematic review was to study the relationship between socioeconomic status (SES), assessed either by direct or proxy measures, and CCT enrollment.

METHODS

The review team and medical librarian developed search strategies for each database to identify studies for this systematic review, which was conducted according to PRISMA guidelines. Inclusion criteria were as follows: studies published in relevant scientific journals between January 2000 and July 2022, primary sources, English literature, and studies conducted in the US. Sixteen studies fulfilled the inclusion criteria and were reviewed. The risk of bias assessment was conducted independently by two reviewers using the Newcastle Ottawa scale.

RESULTS

The initial search yielded 4070 citations, and 16 studies were included in our review. Four of the studies included used patient reported annual income as a measure of SES, while the remaining 12 studies used patient zip code as a proxy measurement of SES. Consistent with our hypothesis, 13 studies showed a positive association between high SES (patient-reported or proxy measurement) and CCT enrollment. Two studies showed a negative association, and one study showed no relationship.

CONCLUSIONS

The existing literature suggests that low SES is associated with lower participation in CCT. The small number of studies identified on this topic highlights the need for additional research on SES and other barriers to CCT participation.

Adult neuro-oncology trials in the United States over 5 decades: Analysis of trials completion rate to guide the path forward

Background

Clinical trials are important to close the gap between therapeutic unmet needs and scientific advances in neuro-oncology. This study analyzes the landscape of neuro-oncology trials to identify completion rates and guide strategies for the path forward.

Methods

US-registered adult neuro-oncology clinical trials were extracted from www.clinicaltrials.gov (1966-2019), including funding source, trial type, scope, phase, and subjects' demographics. Completed trials defined as those that had completed participants' examinations or intervention administration for the purpose of the final collection of data for the primary outcome were dichotomized against those that failed to reach completion. Univariate and multivariate analyses were used to detect differences across factors comparing the last 2 decades (2000-2009, 2010-2019).

Results

Our search yielded 4522 trials, of which 1257 are eligible for this study. In 25 US states, neuro-oncology trial availability is <0.85/100,000 population. Comparing the past 2 decades, trial completion rate decreased from 88% to 64% (P < .001) and National Institutes of Health funding decreased from 47% to 24% (P < .001). Inclusion of subjects >65-year-old and women increased, while inclusion of Hispanic subjects decreased (P < .001). The top 2 reasons for lack of completion included accrual and operational difficulties. A larger proportion of women, non-Hispanic subjects, and older adults were enrolled in completed trials than in those that failed completion.

Conclusions

Our study is the first report on the neuro-oncology clinical trial landscape in the United States and supports the development of strategies to further improve access to these trials. Additionally, attention is needed to identify and modify other factors contributing to lack of completion.

Addressing Inequalities in Breast Cancer Care Delivery

Breast cancer treatment, timeliness of care, and clinical outcomes are inferior for patients of Black race and Hispanic ethnicity, and the origin of these inequities is multifactorial. Owing to aggregate reporting of data in the United States for patients of Asian, Native Hawaiian, and Pacific Islander ancestry, disparities within and across these groups are difficult to appreciate. In large part due to low prevalence, male breast cancer remains understudied, and treatment algorithms are primarily extrapolated from research conducted in female patients.

Investigating potential disparities in clinical trial eligibility and enrollment at an NCI-designated comprehensive cancer center

BACKGROUND

Although barriers to trial accrual are well-reported, few studies have explored trial eligibility and trial offers as potential drivers of disparities in cancer clinical trial enrollment.

METHODS

We identified patients with gastrointestinal (GI) or head/neck (HN) malignancies who were seen as new patients at the University of Michigan Health Rogel Cancer Center in 2016. By exhaustive review of the electronic medical record, we assessed the primary outcomes: (1) eligibility for, (2) documented offer of, and (3) enrollment in a clinical trial. All 41 of the clinical trials available to these patients were considered. Independent variables included clinical and non-clinical patient-related factors. We assessed associations between these variables and the primary outcomes using multivariable regression.

RESULTS

Of 1446 patients, 43% were female, 15% were over age 75, 6% were Black. 305 (21%) patients were eligible for a clinical trial. Among eligible patients, 154 (50%) had documentation of a trial offer and 90 (30%) enrolled. Among the GI cohort, bivariate analyses demonstrated that older age was associated with decreased trial eligibility. Bivariate analyses also demonstrated that Black race was associated with increased trial offer. After adjustment, patients 75 or older were less likely to be eligible for a clinical trial in the GI cohort; however, we found no significant associations between race and any of the outcomes after adjustment. Among eligible GI patients, we found no significant associations between non-clinical factors and enrollment. Among the HN cohort, bivariate analyses demonstrated that female sex, older age, Black race, and unpartnered marital status were associated with decreased likelihood of trial offer; however, we found no significant associations between race, age, and marital status and any of the outcomes after adjustment. We found no significant associations between non-clinical factors and eligibility after adjustment; however, women were less likely to be offered and to enroll in a clinical trial in the HN cohort.

CONCLUSION

Factors associated with eligibility, documented offer, and enrollment differed between disease site cohorts at our institution. Future work is needed to ensure the equitable inclusion of women and elderly patients in clinical trials.

Breast cancer among African American and sub-Saharan African women: a tale of global inequities a tale of global inequities

Breast Cancer is the most common female cancer worldwide with significant global disparities, particularly disadvantaging women of African Ancestry. Though the United States and Sub-Saharan Africa are seemingly very different settings, there are many important parallels between the experience of getting diagnosed and treated for breast cancer in these two geographic regions for women of African ancestry. This commentary explores the parallels and differences and proposes an agenda to move forward to narrow the disparities gaps for some of the worlds most vulnerable women.

Breast Cancer in Black Women: Racial/Ethnic Disparities Affecting Survival

Breast cancer is the most common noncutaneous malignancy affecting women in the United States, with >245,000 cases diagnosed annually. Breast cancer mortality rates have continued to trend down in the past three decades, yet racial/ethnic disparities persist, with the worst mortality rates seen in Black women. Of note, when compared by race, this downward trend is also trailing in Black women. Survival after breast cancer is mainly driven by factors related to early detection and effective therapy. These factors can be grouped into "biological" such as age, genetic mutations, tumor characteristics; and "social" such as education, income, access to care. There have been studies attributing racial disparities solely to biological factors, and there are those attributing the disparities to social factors alone. Although the exact mechanism is unclear, a relationship between both factors as relates to racial disparities in breast cancer outcomes has been demonstrated. In this report, we review factors contributing to the increased morbidity and mortality for breast cancer in Black women and explore sociological relationships. Facing the worst poverty rates compared with other races, Black women are inevitably more likely to be uninsured, have limited access to quality education, and have fewer financial resources. The goal of this review was to elucidate the complex interplay between biological and social factors contributing to racial disparities in breast cancer outcomes. We conclude by emphasizing the need for interventions made at both local and national levels.

Reporting of Participant Race and Ethnicity in Published US Pediatric Clinical Trials From 2011 to 2020

Importance

Equitable representation of participants who are members of racial and ethnic minority groups in clinical trials enhances inclusivity in the scientific process and generalizability of results.

Objective

To assess participant race and ethnicity in pediatric clinical trials published from 2011 to 2020.

Design, Setting, and Participants

This cross-sectional study examined articles reporting pediatric clinical trials conducted in the US published in 5 leading general pediatric and 5 leading general medical journals from January 1, 2011, to December 31, 2020.

Main Outcomes and Measures

Reporting of participant race and ethnicity and comparison of enrolled participants vs US census populations of pediatric racial and ethnic groups in published clinical trials.

Results

The study included 612 articles reporting pediatric clinical trials during the study period, with 565 618 total participants (median per trial, 200 participants [IQR, 90-571 participants]). Of the 612 articles, 486 (79.4%) reported participant race and 338 (55.2%) reported participant ethnicity. From 2011 to 2020, relative rates of reporting of participant race increased by 7.9% per year (95% CI, 0.2%-16.3% per year) and reporting of ethnicity increased by 11.4% per year (95% CI, 4.8%-18.4% per year). Among articles reporting race and ethnicity, the method of assignment was not reported in 261 of 511 articles (51.1%) and 207 of 359 articles (57.7%), respectively. Black/African American children were enrolled proportionally more than the US population of Black/African American children (odds ratio [OR], 1.88; 95% CI, 1.87-1.89). Hispanic/Latino children were enrolled commensurately with the US population of Hispanic/Latino children (OR, 1.02; 95% CI, 1.01-1.03). American Indian/Alaska Native (OR, 0.82; 95% CI, 0.79-0.85), Asian (OR, 0.56; 95% CI, 0.55-0.57), and Native Hawaiian/Pacific Islander (OR, 0.66; 95% CI, 0.61-0.72) children were enrolled significantly less compared with the respective US populations of these groups. White children were enrolled less than expected (OR, 0.84; 95% CI, 0.84-0.85) but represented 188 156 (46.0%) of participants in trials reporting race or ethnicity.

Conclusions and Relevance

This cross-sectional study revealed that the proportion of published pediatric clinical trials that reported participant race and ethnicity increased from 2011 to 2020, but participant race and ethnicity were still underreported. Disparities existed in pediatric clinical trial enrollment of American Indian/Alaska Native, Asian, and Native Hawaiian/Pacific Islander children. The greater representation of Black/African American children compared with the US population suggests inclusive research practices that could be extended to other historically disenfranchised racial and ethnic groups.

Disparity in Clinical Trial Participation Among Patients with Gastrointestinal Cancer

BACKGROUND

Clinical trial participation among cancer patients remains low. We sought to examine the impact of patient- and system-level factors on clinical trial participation among gastrointestinal (GI) surgical patients.

STUDY DESIGN

Adult patients with a GI cancer who underwent oncologic surgery who were enrolled in National Cancer Institute (NCI)-funded clinical trials from 2000 through 2019 were compared with trial-eligible adult patients in the National Cancer Database (NCDB) between 2004 and 2017. Multivariable logistic regression was used to identify factors associated with clinical trial participation.

RESULTS

Participants from 36 NCI-funded clinical trials (n = 10,518) were compared with 2,255,730 trial-eligible nonparticipants from the NCDB. Patients aged 65 years or younger (odds ratio [OR] = 0.5, 95% CI 0.47-0.53), Medicare (OR = 0.46, 95% CI 0.43-0.49) or Medicaid (OR = 0.51, 95% CI 0.46-0.58) insurance, as well as lower levels of education (OR = 0.82, 95% CI 0.75-0.89) were associated with a lower likelihood of clinical trial enrollment. Black (OR = 0.72, 95% CI 0.67-0.78) and Asian/Pacific Islander (OR = 0.96, 95% CI 0.85-1.08) patients were less likely to participate in trials vs White patients. There were interactions between race/ethnicity and income; high-income (OR = 0.67, 95% CI 0.55-0.81) and low-income Black (OR = 0.75, 95% CI 0.66-0.87) patients were less likely, respectively, to participate than high- or low-income White individuals (p < 0.001).

CONCLUSIONS

Clinical trial participation is low among adult GI cancer patients who undergo surgery in the US. Programs aimed at improving trial participation among vulnerable populations are needed to improve trial participation.

Disparities in Clinical Trial Participation: Multilevel Opportunities for Improvement

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

Associations between frailty and cancer-specific mortality among older women with breast cancer

PURPOSE

Frailty is assessed when making treatment decisions among older women with breast cancer (BC), which in turn impacts survival. We evaluated associations between pre-diagnosis frailty and risks of BC-specific and all-cause mortality in older women.

METHODS

We conducted a retrospective cohort study of Medicare beneficiaries ages ≥ 65 years with stage I-III BC using the Surveillance, Epidemiology and End Results-Medicare Health Outcome Survey Data Resource. Frailty was measured using the deficit-accumulation frailty index, categorized as robust, pre-frail, or frail, at baseline and during follow-up. Fine and Gray competing risk and Cox proportional hazards models were used to estimate subdistribution hazard ratios (SHR) and hazard ratios (HR) with 95% confidence intervals (CI) for BC-specific and all-cause mortality, respectively.

RESULTS

Among 2411 women with a median age of 75 years at BC diagnosis, 49.5% were categorized as robust, 29.4% were pre-frail and 21.1% were frail. Fewer frail women compared to robust women received breast-conserving surgery (52.8% vs. 61.5%, frail vs. robust, respectively) and radiation (43.5% vs. 51.8%). In multivariable analyses, degree of frailty was not associated with BC-specific mortality (frail vs robust SHR 1.47, 95% CI 0.97-2.24). However, frail women with BC had higher risks of all-cause mortality compared to robust women with BC (HR 2.32, 95% CI 1.84-2.92).

CONCLUSION

Among a cohort of older women with BC, higher degrees of frailty were associated with higher risk of all-cause mortality, but not BC-specific mortality. Future study should examine if preventing progression of frailty may improve all-cause mortality.

COVID-19 Vaccine Acceptance and Beliefs among Black and Hispanic Americans

The introduction of COVID-19 vaccines is a major public health breakthrough. However, members of US Black and Hispanic communities, already disproportionately affected by the COVID-19 virus, may be less willing to receive the vaccine. We conducted a broad, representative survey of US adults (N = 1,950) in order to better understand vaccine beliefs and explore opportunities to increase vaccine acceptance among these groups. The survey results suggested that Black and Hispanic individuals were less willing than Whites to receive the vaccine. US Blacks and Hispanics also planned to delay receiving the COVID-19 vaccine for a longer time period than Whites, potentially further increasing the risk of contracting COVID-19 within populations that are already experiencing high disease prevalence. Black respondents were less likely to want the COVID-19 vaccine at all compared with Whites and Hispanics, and mistrust of the vaccine among Black respondents was significantly higher than other racial/ethnic groups. Encouragingly, many Black and Hispanic respondents reported that COVID-19 vaccine endorsements from same-race medical professionals would increase their willingness to receive it. These respondents said they would also be motivated by receiving more information on the experiences of vaccine study participants who are of their own race and ethnicity. The results have implications for improved messaging of culturally-tailored communications to help reduce COVID-19 vaccine hesitancy among communities disproportionately impacted by the pandemic.

A population-based study of invitation to and participation in clinical trials among women with early-stage breast cancer

PURPOSE

Although many studies clearly demonstrate disparities in cancer clinical trial enrollment, there is a lack of consensus on potential causes. Furthermore, virtually nothing is known about associations between patients' decision-making style and their participation in clinical trials.

METHODS

Women with newly diagnosed, stage 0-II breast cancer reported to the Georgia and Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registries in 2013-2014 were surveyed approximately seven months after diagnosis. We investigated two primary outcome variables: (1) invitation to participate in a clinical trial, (2) participation in a clinical trial. We evaluated bivariate associations using Chi-squared tests and used multivariable logistic regression models to investigate associations between patient variables, including decision-making style, and the primary outcomes.

RESULTS

2578 patients responded (71% response rate); 30% were > age 65, 18% were black, 18% were Latina, 29% had ≤ high school education. 10% of patients reported invitation to participate in a clinical trial; 5% reported participation in a clinical trial. After adjustment younger age, receipt of chemotherapy or radiation, disease stage, and a more rational (versus more intuitive) decision-making style were associated with a higher odds of invitation to participate. Being married was associated with a higher odds of participation; having an annual family income ≥ $40,000 was associated with a lower odds of participation.

CONCLUSIONS

10% of patients reported invitation to participate in a clinical trial, and half of these reported participation. Invitation to participate varied by age and decision-making style, and participation varied by marital status and income.