Recruiting participants to cancer prevention clinical trials: lessons from successful community oncology networks

Clinical research nurses' perceptions of the unique needs of people of color for successful recruitment to cancer clinical trials

BACKGROUND

Clinical trials (CTs) test new medical products for safety and effectiveness. Despite federal policy aimed at generating greater inclusivity of people of color (POC) in CTs, disparity in (CT) enrollment persists. Non-Hispanic White patients comprise the majority of CT participants while Black and Hispanic patient participation has declined over the past decade. The scope of Clinical Research Nurses (CRNs) includes recruitment of participants for CTs. The aim of this phenomenological study was to describe adult oncology CRNs' lived experiences of recruiting POC cancer patients to participate in CTs. The first paper for this study identified three major themes regarding how CRNs view their role in caring for POC considering or enrolling onto cancer clinical trials (CCTs): CRNs act as advocates, care coordinators and educators. This paper focuses on two additional major themes regarding how CRNs view the unique needs of POC in clinical research: establishing and maintaining trusting relationships and recruitment infrastructure.

METHODS

Nineteen nurses participated in semi-structured one-to-one interviews and data analysis was based on Colaizzi's method.

RESULTS

CRNs described a history of past research injustices, disparate access to care, inadequate cultural training, a physician-driven recruitment structure and provider-based implicit biases that hinder POC enrollment in CTs.

CONCLUSION

Diversity in CCT enrollment requires CRNs to establish trust with POC, advocate for POC when implicit biases are observed and become competent practitioners of culturally sensitive care. Further, meaningful policy change at both federal and organizational levels must occur to ensure equitable access to novel cancer therapies.

The role of clinical research nurses in minority recruitment to cancer clinical trials

Clinical trials (CTs) are the established research mechanism designed to examine how new medical therapies are tested for safety and effectiveness. Specifically, non-Hispanic White patients still account for most CT participants and Black patient participation has declined over the past decade. Clinical Research Nurses (CRNs) whose scope of practice includes the recruitment of participants for CTs, have the potential to significantly increase minority patients participation in cancer clinical trials (CCTs). The aim of this phenomenological study was to describe adult oncology CRNs' lived experiences of recruiting minority cancer patients to participate in CTs. A total of 19 nurses participated in semi-structured one-to-one interviews and data analysis was based on Colaizzi's method. The role of CRNs was described as advocates who coordinate care, establish trust, and provide education for CT patients within physician-driven recruitment structures. The CRN's role was also described as self-taught or learn on the go with no formalized recruitment training and lack of robust cultural training. To achieve diverse patient enrollment in CCTs, CRNs and study staff need to receive training on culturally competent clinical research care and the diversity of CRNs and study teams must be increased. Further, meaningful federal and hospital policy change must occur so that minority patients have equitable access to novel cancer therapies and the role of the CRN is delineated from other healthcare staff to optimize research patient care.

Context matters: measuring implementation climate among individuals and groups

BACKGROUND

It has been noted that implementation climate is positively associated with implementation effectiveness. However, issues surrounding the measurement of implementation climate, or the extent to which organizational members perceive that innovation use is expected, supported and rewarded by their organization remain. Specifically, it is unclear whether implementation climate can be measured as a global construct, whether individual or group-referenced items should be used, and whether implementation climate can be assessed at the group or organizational level.

METHODS

This research includes two cross-sectional studies with data collected via surveys at the individual level. The first study assessed the implementation climate perceptions of physicians participating in the National Cancer Institute's (NCI) Community Clinical Oncology Program (CCOP), and the second study assessed the perceptions of children's behavioral health clinicians implementing a treatment innovation. To address if implementation climate is a global construct, we used confirmatory factor analysis. To address how implementation climate should be measured and at what level, we followed a five-step framework outlined by van Mierlo and colleagues. This framework includes exploratory factor analysis and correlations to assess differences between individual and group-referenced items and intraclass correlations, interrater agreements, and exploratory factor analysis to determine if implementation climate can be assessed at the organizational level.

RESULTS

The confirmatory factor analysis demonstrated that implementation climate is a global construct consisting of items related to expectations, support and rewards. There are mixed results, however, as to whether implementation climate should be measured using individual or group-referenced items. In our first study, where physicians were geographically dispersed and practice independently, there were no differences based on the type of items used, and implementation climate was an individual level construct. However, in the second study, in which clinicians practice in a central location and interact more frequently, group-referenced items may be appropriate. In addition, implementation climate could be considered an organizational level construct.

CONCLUSIONS

The results are context-specific. Researchers should carefully consider the study setting when measuring implementation climate. In addition, more opportunities are needed to validate this measure and understand how well it predicts and explains implementation effectiveness.

Nursing contributions in Community Clinical Oncology Research Programs

OBJECTIVES

To describe the Community Clinical Oncology Programs (CCOPs), identify the roles and functions of CCOP nurses in clinical trials, and discuss the future contributions of nurses in the National Cancer Institute (NCI) Community Oncology Research Program.

DATA SOURCES

Research and review articles, Web sites, and government reports.

CONCLUSION

The contribution of nurses in the community clinical research setting has not been defined or quantified; however, examination of the literature reveals substantial contributions from nurses in the conduct and dissemination of oncology research.

IMPLICATIONS FOR NURSING PRACTICE

Nurses outside of academic settings must be as well versed in new research as those in large institutions. Education on clinical trials and oncology research is necessary in the treatment and care of cancer patients. Experienced community-based nurses are essential to the success of the NCI Community Oncology Research Program.

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.

Achieving high cancer control trial enrollment in the community setting: an analysis of the Community Clinical Oncology Program

Determining the factors that lead to successful enrollment of patients in cancer control clinical trials is essential as cancer patients are often burdened with side effects such as pain, nausea, and fatigue. One promising intervention for increasing enrollment in cancer control trials is the National Cancer Institute's Community Clinical Oncology Program (CCOP). In this article, we examined CCOP staffing, policies, and procedures associated with enrollment in control trials. Data were obtained from three sources: the online CCOP, MB-CCOP, and Research Base Management System, CCOP Annual Progress Reports, and a survey of CCOP Administrators conducted in 2011. We analyzed cancer control trial accrual in 2011 among 46 CCOPs using multivariate regression. Three factors were significant predictors of accrual. First, having a team of staff dedicated to enrolling patients in control and prevention trials, compared to having no dedicated staff, was associated on average with an additional 30 patients enrolled in control trials (p<0.05). Second, CCOPs that recognized physicians for enrolling a large number of patients compared to CCOPs that did not recognize high enrolling physicians enrolled on average an additional 25 patients in control trials (p<0.05). Lastly, the number of cancer control trials available was also associated with enrollment (β=5.50, p<0.00). Our results indicate that CCOPs looking to increase enrollment in control trials should consider dedicating a team of staff to enroll patients in these types of trials. In addition, CCOPs or other volunteer research systems looking to increase physician participation should consider recognizing high enrolling physicians.

A method for analyzing the business case for provider participation in the National Cancer Institute's Community Clinical Oncology Program and similar federally funded, provider-based research networks

BACKGROUND

The Community Clinical Oncology Program (CCOP) plays an essential role in the efforts of the National Cancer Institute (NCI) to increase enrollment in clinical trials. Currently, there is little practical guidance in the literature to assist provider organizations in analyzing the return on investment (ROI), or business case, for establishing and operating a provider-based research network (PBRN) such as the CCOP. In this article, the authors present a conceptual model of the business case for PBRN participation, a spreadsheet-based tool and advice for evaluating the business case for provider participation in a CCOP organization.

METHODS

A comparative, case-study approach was used to identify key components of the business case for hospitals attempting to support a CCOP research infrastructure. Semistructured interviews were conducted with providers and administrators. Key themes were identified and used to develop the financial analysis tool.

RESULTS

Key components of the business case included CCOP start-up costs, direct revenue from the NCI CCOP grant, direct expenses required to maintain the CCOP research infrastructure, and incidental benefits, most notably downstream revenues from CCOP patients. The authors recognized the value of incidental benefits as an important contributor to the business case for CCOP participation; however, currently, this component is not calculated.

CONCLUSIONS

The current results indicated that providing a method for documenting the business case for CCOP or other PBRN involvement will contribute to the long-term sustainability and expansion of these programs by improving providers' understanding of the financial implications of participation.

Organizational designs for achieving high treatment trial enrollment: a fuzzy-set analysis of the community clinical oncology program

PURPOSE

To examine the organizational design features that were consistently associated in 2010 with high levels of patient enrollment onto National Cancer Institute (NCI) cancer treatment trials among the oncology practices and hospitals participating in the NCI Community Clinical Oncology Program (CCOP).

METHODS

Fuzzy-set qualitative comparative analysis was used to identify the recipes (ie, combinations of organizational design features) that CCOPs used to achieve high levels of patient enrollment onto NCI treatment trials in 2010. Four organizational design features were examined: number of open treatment trials with at least one patient enrolled, number of newly diagnosed patients with cancer, number of CCOP-affiliated physicians, and number of CCOP-affiliated hospitals or practices where patient enrollment could occur. Data were obtained from NCI data systems and CCOP grant progress reports.

RESULTS

Two recipes were consistently associated with high levels of patient enrollment onto NCI treatment trials in 2010: having many open treatment trials and many new patients with cancer, and having many open treatment trials and many affiliated hospitals or practices. Together, these recipes accounted for nearly two thirds of CCOP membership in the high-performance set in 2010.

CONCLUSION

No single organizational design feature, by itself, was consistently associated with high levels of patient enrollment onto NCI treatment trials in 2010. Having a large menu of active treatment trials may be necessary to achieve high-patient enrollment performance, but this is not sufficient unless combined with either large patient volume or many participating sites.

Increasing participation in prevention research: strategies for youths, parents, and schools

TOPIC

Subject participation is a critical concern for clinicians and researchers involved in prevention programs, especially for intensive interventions that require randomized assignment and lengthy youth and parent involvement.

PURPOSE

This article describes details of an integrated approach used to recruit and retain at-risk high school youths, their parents, and high schools to two different comprehensive, "indicated" prevention programs.

SOURCES USED

Parent and youth recruitment and retention data for the two studies is provided in support of the approach described. A coordinated, multilevel approach, organized around cross-cutting issues, is described in detail as a response to the challenges of including vulnerable populations in intervention research.

CONCLUSION

Methods are relevant to nurse clinicians who deliver prevention programs, and are important to clinical research that relies upon adequate participation in research programs.

Translating research into evidence-based practice: the National Cancer Institute Community Clinical Oncology Program

The recent rapid acceleration of basic science is reshaping both our clinical research system and our healthcare delivery system. The pace and growing volume of medical discoveries are yielding exciting new opportunities, yet we continue to face old challenges to maintain research progress and effectively translate research into practice. The National Institutes of Health and individual government programs increasingly are emphasizing research agendas that involve evidence development, comparative-effectiveness research among heterogeneous populations, translational research, and accelerating the translation of research into evidence-based practice as well as building successful research networks to support these efforts. For more than 25 years, the National Cancer Institute Community Clinical Oncology Program has successfully extended research into the community and facilitated the translation of research into evidence-based practice. By describing its keys to success, this article provides practical guidance to cancer-focused, provider-based research networks as well as those in other disciplines.