Increasing access to clinical cancer trials and emerging technologies for minority populations: the Native American Project

Health Behavior Change Intervention Preferences Expressed by American Indian Cancer Survivors From a Southwest Tribal Community: Semistructured Interview Study

BACKGROUND

While many factors, including social determinants of health, affect cancer mortality, one modifiable risk factor that may contribute to cancer disparities is obesity. The prevalence of obesity in the American Indian/Alaska Native population is 48.1% per the Centers for Disease Control and Prevention. The overall cancer mortality for the American Indian/Alaska Native population is 18% higher than the White population as reported by the American Cancer Society. Interventions tailored to American Indian/Alaska Native communities that promote healthy lifestyle behaviors after cancer diagnosis and prior to cancer surgery (prehab) might improve cancer outcomes for this population.

OBJECTIVE

The aim of the study is to characterize the lifestyle behaviors of San Carlos Apache cancer survivors and identify preferences for the adaption of a prehab intervention.

METHODS

Semistructured interviews and validated questionnaires were completed with San Carlos Apache cancer survivors (N=4), exploring their viewpoints on healthy lifestyle and cancer risk and preferences for program development. A thematic content analysis was conducted.

RESULTS

Participants had an average BMI of 31 kg/m2 and walked 53 minutes daily. The majority of participants reported a high willingness to change eating habits (n=3, 75%). All 4 reported willingness to participate in a diet and exercise program. Important themes and subthemes were identified: (1) cancer is perceived as a serious health condition in the community (N=4, 100%); (2) environmental exposures are perceived as cancer-causing threats (n=3, 75%); (3) healthy diet, exercise, and avoiding harmful substances are perceived as mitigating cancer risk (n=3, 75%); (4) barriers to healthy habits include distance to affordable groceries (n=3, 75%) and lack of transportation (n=2, 50%); (5) there is high interest in a prehab program geared toward patients with cancer (N=4, 100%); and (6) standard monitoring practiced in published prehab programs showed early acceptability with participants (N=4, 100%).

CONCLUSIONS

Collaboration with tribal partners provided important insight that can help inform the adaptation of a culturally appropriate prehab program for San Carlos Apache patients diagnosed with cancer.

Education in gynecological brachytherapy

Brachytherapy is an essential component in the curative treatment of many gynecological malignancies. In the past decade, advances in magnetic resonance imaging and the ability to adapt and customize treatment with hybrid interstitial applicators have led to improved clinical outcomes with decreased toxicity. Unfortunately, there has been a shift in clinical practice away from the use of brachytherapy in the United States. The decline in brachytherapy is multifactorial, but includes both a lack of exposure to clinical cases and an absence of standardized brachytherapy training for residents. In other medical specialties, a clear relationship has been established between clinical case volumes and patient outcomes, especially for procedural-based medicine. In surgical residencies, simulation-based medical education (SBME) is a required component of the program to allow for some autonomy before operating on a patient. Within radiation oncology, there is limited but growing experience with SBME for training residents and faculty in gynecological brachytherapy. This review includes single institutional, multi-institutional and national initiatives using creative strategies to teach the components of gynecological brachytherapy. These efforts have measured success in various forms; the majority serve to improve the confidence of the learners, and many have also demonstrated improved competence from the training as well. The American Brachytherapy Society launched the 300 in 10 initiative in 2020 with a plan of training 30 competent brachytherapists per year over a 10 year period and has made great strides with a formal mentorship program as well as externships available to senior residents interested in starting brachytherapy programs. Moving forward, these curricula could be expanded to provide standardized brachytherapy training for all residents. SBME could also play a role in initial certification and maintenance of certification. Given the burden of disease, it would be valuable to develop similar training for providers in low and middle income countries.

Understanding Willingness to Participate in Cancer Clinical Trials Among Patients and Caregivers Attending a Minority-Serving Academic Cancer Center

Advances in cancer treatment are impeded by low accrual rates of patients to cancer clinical trials (CCTs). The national rates of recruitment of underserved groups, including racial/ethnic minorities, are limiting the generalizability of research findings and are likely to enhance inequities in cancer outcomes. The goal of this study was to examine willingness to participate (WTP) in CCTs and factors associated with this willingness among patients and caregivers attending a minority-serving university cancer center in the Southwest. A cross-sectional survey design was utilized (n = 236, 135 patients and 101 caregivers). Fear was the strongest predictor of WTP in CCTs. The only ethnic differences observed related to Spanish-speaking patients exhibiting increased WTP in CCTs, and Spanish-speaking caregivers' decreased WTP, compared to others. These results underscore the importance of future interventions to reduce CCT-related fear among patients and caregivers, with particular need for family-focused tailored interventions designed to meet the needs of Spanish-speaking patients and caregivers.

Improving the Clinical Treatment of Vulnerable Populations in Radiation Oncology

The increasing role of radiation oncology in optimal cancer care treatment brings to mind the adage that power is never a gift, but a responsibility. A significant part of the responsibility we in radiation oncology bear is how to ensure optimal access to our services. This article summarizes the discussion initiated at the 2019 American Society for Radiation Oncology Annual Meeting educational panel entitled “Improving the Clinical Treatment of Vulnerable Populations in Radiation Oncology: Latin, African American, Native American, and Gender/Sexual Minority Communities.” By bringing the discussion to the printed page, we hope to continue the conversation with a broader audience to better define the level of responsibility our field bears in optimizing cancer care to the most vulnerable patient populations within the United States.

The pervasive crisis of diminishing radiation therapy access for vulnerable populations in the United States, part 2: American Indian patients

INTRODUCTION

American Indian/Alaska Native (AI/AN) patients with cancer disproportionally present with more advanced stages of disease and have the worst cancer-specific survival rates of any racial/ethnic group in the United States. The presence of disparities in radiation therapy (RT) access for AI/AN patients has rarely been examined.

METHODS AND MATERIALS

National Cancer Institute (NCI) initiatives toward addressing AI/AN disparities were examined. Additionally, an extensive PubMed literature search for studies investigating RT access disparities in AI/AN patients was performed.

RESULTS

Literature describing RT access disparities for the AI/AN patient population is sparse, revealing only 3 studies, each of which described initiatives from the Walking Forward program, the NCI Cancer Disparity Research Partnership initiative to address barriers to cancer screening among AI populations in the Northern Plains region (eg, geographic remoteness and mistrust of health care providers). This program has used patient navigation, community education, and access to clinical trials for more than 4000 AI/AN patients to combat high cancer mortality rates. Over the course of its 15-year existence, the program has resulted in patients presenting with earlier stages of disease and experiencing higher cure rates. Lung cancer, the most common cause of cancer-related mortality in AI/AN patients, is the most recent and ongoing focus of the program.

CONCLUSION

The amount of information regarding RT access in AI/AN patients is limited, with nearly all peer-reviewed published progress in this area being associated with the Walking Forward program. Further initiatives from this program will hopefully inspire similar initiatives throughout the country to reduce the barriers to optimized cancer care that these patients face. Given the similarities with cancer disparities of populations worldwide, the AI/AN experience should be included within the broad issue of a global shortage of cancer care among underserved populations.

Lessons Learned from Native C.I.R.C.L.E., a Culturally Specific Resource

Cancer is now the second leading cause of death among American Indians and Alaska Natives (AIAN), and trends in cancer-related mortality over the past 2 decades show inferior control in AIAN compared to non-Hispanic Whites. The American Indian/Alaska Native Cancer Information Resource Center and Learning Exchange (Native C.I.R.C.L.E.) was developed in the year 2000 as part of a comprehensive network of partnerships to develop, maintain, and disseminate culturally appropriate cancer and other health information materials for AIAN educators and providers. Now, in its 15th year of existence, enough data has been accumulated by Native C.I.R.C.L.E. to analyze trends in the distribution of culturally relevant cancer information materials and compare access to both printed (hard copy) and online materials. The amount of culturally appropriate materials available since its creation has increased more than 10-fold. Print materials are now distributed throughout the world, and the number of materials requested from print and downloads combined are in the thousands on a monthly basis. Native C.I.R.C.L.E. is in the process of expanding its access and capabilities to target more of the lay AIAN public in order to address the digital divide.

Cancer Care Access and Outcomes for American Indian Populations in the United States: Challenges and Models for Progress

Low socioeconomic and health care access realities of being American Indian/Alaskan Native (AI/AN) in the United States combined with decades of data documenting poor cancer outcomes for this population provide a population nested within the United States that is analogous to the cancer care landscape of low- and middle-income countries internationally. We reviewed the medical literature with respect to cancer prevention, access to cancer treatment, and access to effective supportive and palliative care for AI/AN populations in the United States. Research confirms poorer cancer outcomes, suboptimal cancer screening, and high-risk cancer behaviors among AI/AN communities. AI/AN cancer patients are less likely to undergo recommended cancer surgeries, adjuvant chemotherapy, and radiation therapy than their White counterparts. Studies including both rural and urban survivors with AI cancer revealed barriers to receipt of optimal cancer symptom management and proportionally lower hospice use among AI/AN populations. Culturally tailored programs in targeted communities have been shown to mitigate the observed cancer-related health disparities among AI/AN communities. There is still much work to be done to improve cancer-related health outcomes in AI/AN communities, and the goals of the providers serving them corresponds with those propelling the growing interest in global oncology equity. Policy work and more funding are needed to continue to build upon the work that the Indian Health Service and established cancer-related health programs have begun in AI/AN communities.

National Cancer Institute's Cancer Disparities Research Partnership Program: Experience and Lessons Learned

PURPOSE

To increase access of underserved/health disparities communities to National Cancer Institute (NCI) clinical trials, the Radiation Research Program piloted a unique model - the Cancer Disparities Research Partnership (CDRP) program. CDRP targeted community hospitals with a limited past NCI funding history and provided funding to establish the infrastructure for their clinical research program.

METHODS

Initially, 5-year planning phase funding was awarded to six CDRP institutions through a cooperative agreement (U56). Five were subsequently eligible to compete for 5-year implementation phase (U54) funding and three received a second award. Additionally, the NCI Center to Reduce Cancer Health Disparities supported their U56 patient navigation programs.

RESULTS

Community-based hospitals with little or no clinical trials experience required at least a year to develop the infrastructure and establish community outreach/education and patient navigation programs before accrual to clinical trials could begin. Once established, CDRP sites increased their yearly patient accrual mainly to NCI-sponsored cooperative group trials (~60%) and Principal Investigator/mentor-initiated trials (~30%). The total number of patients accrued on all types of trials was 2,371, while 5,147 patients received navigation services.

CONCLUSION

Despite a historical gap in participation in clinical cancer research, underserved communities are willing/eager to participate. Since a limited number of cooperative group trials address locally advanced diseases seen in health disparities populations; this shortcoming needs to be rectified. Sustainability for these programs remains a challenge. Addressing these gaps through research and public health mechanisms may have an important impact on their health, scientific progress, and efforts to increase diversity in NCI clinical trials.

Under-representation of racial minorities in prostate cancer studies submitted to the US Food and Drug Administration to support potential marketing approval, 1993-2013

BACKGROUND

US Food and Drug Administration (FDA) approval of new drugs depends on results from clinical trials that must be generalized to the US population. However, racial minorities are frequently under-represented in clinical studies. The enrollment of racial minorities was compared in key clinical studies submitted to the FDA in the last 10 years in support of potential marketing approval for prostate cancer (PCa) prevention or treatment.

METHODS

Patient demographic data were obtained from archival data sets of large registration trials submitted to the FDA to support proposed PCa indications. Six countries/regions were analyzed: the United States, Canada, Australia, Europe, the United Kingdom, and Eastern Europe. Background racial demographics were collected from national census data.

RESULTS

Seventeen key PCa clinical trials were analyzed. These trials were conducted in the past 20 years, comprising 39,574 patients with known racial information. Most patients were enrolled in the United States, but there appeared to be a trend toward increased non-US enrollment over time. In all countries, racial minorities were generally under-represented. There was no significant improvement in racial minority enrollment over time. The United States enrolled the largest nonwhite population (7.1%).

CONCLUSIONS

Over the past 20 years, racial minorities were consistently under-represented in key PCa trials. There is a need for effective measures that will improve enrollment of racial minorities. With increased global enrollment, drug developers should aim to recruit a patient population that resembles the racial demographics of the patient population to which drug use will be generalized upon approval.

Shared decision-making for cancer care among racial and ethnic minorities: a systematic review

To assess decision-making for cancer treatment among racial/ethnic minority patients, we systematically reviewed and synthesized evidence from studies of "shared decision-making," "cancer," and "minority groups," using PubMed, PsycInfo, CINAHL, and EMBASE. We identified significant themes that we compared across studies, refined, and organized into a conceptual model. Five major themes emerged: treatment decision-making, patient factors, family and important others, community, and provider factors. Thematic data overlapped categories, indicating that individuals' preferences for medical decision-making cannot be authentically examined outside the context of family and community. The shared decision-making model should be expanded beyond the traditional patient-physician dyad to include other important stakeholders in the cancer treatment decision process, such as family or community leaders.

Shared decision-making for cancer care among racial and ethnic minorities: a systematic review

To assess decision-making for cancer treatment among racial/ethnic minority patients, we systematically reviewed and synthesized evidence from studies of "shared decision-making," "cancer," and "minority groups," using PubMed, PsycInfo, CINAHL, and EMBASE. We identified significant themes that we compared across studies, refined, and organized into a conceptual model. Five major themes emerged: treatment decision-making, patient factors, family and important others, community, and provider factors. Thematic data overlapped categories, indicating that individuals' preferences for medical decision-making cannot be authentically examined outside the context of family and community. The shared decision-making model should be expanded beyond the traditional patient-physician dyad to include other important stakeholders in the cancer treatment decision process, such as family or community leaders.

Impact of patient navigation on cancer diagnostic resolution among Northwest Tribal communities

The patient navigator model has not been widely implemented in American Indian/Alaska Native (AI/AN) communities, but may be effective in improving cancer outcomes for this population. Subjects were enrolled from eight clinics at Tribes throughout the Northwest (n = 1,187). Four clinics received navigation. Time between abnormal finding and definitive diagnosis was recorded. We examined whether odds of obtaining definitive diagnosis by 60, 90, and 365 days differed between the two groups. The odds of definitive diagnosis within 365 days for navigated subjects was 3.6 times (95 % CI, 1.47, 8.88; p = 0.01) the odds for control subjects. The outcome at 60 and 90 days did not significantly differ between the two groups. Our findings indicate that patient navigation did not significantly impact chance of diagnosis by 60 or 90 days from abnormal finding. However, it did improve the chance of avoiding extreme delays in obtaining a definitive diagnosis.

Barriers to cancer clinical trial participation among American Indian and Alaska Native tribal college students

PURPOSE

American Indians and Alaska Natives (AIs/ANs) have some of the highest cancer-related mortality rates of all US racial and ethnic groups, but they are underrepresented in clinical trials. We sought to identify factors that influence willingness to participate in cancer clinical trials among AI/AN tribal college students, and to compare attitudes toward clinical trial participation among these students with attitudes among older AI/AN adults.

METHODS

Questionnaire data from 489 AI/AN tribal college students were collected and analyzed along with previously collected data from 112 older AI/AN adults. We examined 10 factors that influenced participation in the tribal college sample, and using chi-square analysis and these 10 factors, we compared attitudes toward research participation among 3 groups defined by age: students younger than 40, students 40 and older, and nonstudent adults 40 and older.

FINDINGS

About 80% of students were willing to participate if the study would lead to new treatments or help others with cancer in their community, the study doctor had experience treating AI/AN patients, and they received payment. Older nonstudent adults were less likely to participate on the basis of the doctor's expertise than were students (73% vs 84%, P = .007), or if the study was conducted 50 miles away (24% vs 41%, P= .001).

CONCLUSIONS

Finding high rates of willingness to participate is an important first step in increasing participation of AIs/ANs in clinical trials. More information is needed on whether these attitudes influence actual behavior when opportunities to participate become available.

Personalized medicine: challenge and promise

The new health care buzz words include "personalized or individualized medicine." Populations such as American Indians and Alaska Natives potentially have much to gain from this new science to overcome the known health disparities in these populations. This will require participation and acceptance of diverse populations. This article reviews the promise and challenges of individualizing cancer care using principles of community-based participatory research.

A pre-post survey analysis of satisfaction with health care and medical mistrust after patient navigation for American Indian cancer patients

PURPOSE

To assess the impact of patient navigation (PN) on satisfaction with health care and medical mistrust among American Indians (AI) undergoing cancer treatment.

METHODS

This was a pre-post cohort survey study of 52 AI cancer patients who participated in a culturally-tailored PN program during their cancer treatment. Surveys were administered prior to and after cancer treatment assessing medical mistrust and satisfaction with health care using two Likert-type scales.

RESULTS

Participation refusal rate was 7%. Mean scale scores for satisfaction with health care were significantly improved after PN compared with pre-navigation (p<.0001; Wilcoxon signed-rank test). There was no significant difference in the mean scale scores for medical mistrust after PN compared with those observed prior to treatment (p=.13).

CONCLUSIONS

American Indian cancer patients who received PN services during their cancer treatment showed improvement in levels of satisfaction with health. However, no improvements were observed in levels of medical mistrust.

Metrics for evaluating patient navigation during cancer diagnosis and treatment: crafting a policy-relevant research agenda for patient navigation in cancer care

BACKGROUND

Racial and ethnic minorities as well as other vulnerable populations experience disparate cancer-related health outcomes. Patient navigation is an emerging health care delivery innovation that offers promise in improving quality of cancer care delivery to these patients who experience unique health-access barriers. Metrics are needed to evaluate whether patient navigation can improve quality of care delivery, health outcomes, and overall value in health care during diagnosis and treatment of cancer.

METHODS

Information regarding the current state of the science examining patient navigation interventions was gathered via search of the published scientific literature. A focus group of providers, patient navigators, and health-policy experts was convened as part of the Patient Navigation Leadership Summit sponsored by the American Cancer Society. Key metrics were identified for assessing the efficacy of patient navigation in cancer diagnosis and treatment.

RESULTS

Patient navigation data exist for all stages of cancer care; however, the literature is more robust for its implementation during prevention, screening, and early diagnostic workup of cancer. Relatively fewer data are reported for outcomes and efficacy of patient navigation during cancer treatment. Metrics are proposed for a policy-relevant research agenda to evaluate the efficacy of patient navigation in cancer diagnosis and treatment.

CONCLUSIONS

Patient navigation is understudied with respect to its use in cancer diagnosis and treatment. Core metrics are defined to evaluate its efficacy in improving outcomes and mitigating health-access barriers.

Community-based participatory development, implementation, and evaluation of a cancer screening educational intervention among American Indians in the Northern Plains

The study describes the creation and implementation of a culturally appropriate cancer education intervention, and assesses its efficacy among American Indians in a community with documented cancer-related disparities. Education workshops were developed and conducted on three western South Dakota reservations and in Rapid City by trained community representatives. Over 400 individuals participated in the 2-h workshops. Participants answered demographic questions, questions about previous cancer screening (to establish baseline screening rates), and completed a pre- and post-workshop quiz to assess learning. Participants demonstrated significant increases in cancer screening-related knowledge levels. Surveys reveal that participants found the information of high quality, great value and would recommend the program to friends. Pre-workshop data reveals cancer screening rates well below the national average. Workshop participants increased their knowledge about cancer etiology and screening. This intervention may represent an effective tool for increasing cancer screening utilization among American Indians.

Addressing Cancer Disparities Among American Indians through Innovative Technologies and Patient Navigation: The Walking Forward Experience

Purpose/Objective(s): American Indians (AIs) present with more advanced stages of cancer and, therefore, suffer from higher cancer mortality rates compared to non-AIs. Under the National Cancer Institute (NCI) Cancer Disparities Research Partnership (CDRP) Program, we have been researching methods of improving cancer treatment and outcomes since 2002, for AIs in Western South Dakota, through the Walking Forward (WF) Program. Materials/Methods: This program consists of (a) a culturally tailored patient navigation program that facilitated access to innovative clinical trials in conjunction with a comprehensive educational program encouraging screening and early detection, (b), surveys to evaluate barriers to access, (c) clinical trials focusing on reducing treatment length to facilitate enhanced participation using brachytherapy and intensity modulated radiotherapy (IMRT) for breast and prostate cancer, as AIs live a median of 140 miles from the cancer center, and (d) a molecular study (ataxia telangiectasia mutated) to address whether there is a specific profile that increases toxicity risks. Results: We describe the design and implementation of this program, summary of previously published results, and ongoing research to influence stage at presentation. Some of the critical outcomes include the successful implementation of a community-based research program, development of trust within tribal communities, identification of barriers, analysis of nearly 400 navigated cancer patients, clinical trial accrual rate of 10%, and total enrollment of nearly 2,500 AIs on WF research studies. Conclusion: This NCI funded pilot program has achieved some initial measures of success. A research infrastructure has been created in a community setting to address new research questions and interventions. Efforts underway to promote cancer education and screening are presented, as well as applications of the lessons learned to other health disparity populations – both nationally and internationally.

Patient navigation for American Indians undergoing cancer treatment: utilization and impact on care delivery in a regional healthcare center

BACKGROUND

A study was undertaken to assess patient navigation utilization and its impact on treatment interruptions and clinical trial enrollment among American Indian cancer patients.

METHODS

Between February 2004 and September 2009, 332 American Indian cancer patients received patient navigation services throughout cancer treatment. The patient navigation program provided culturally competent navigators to assist patients with navigating cancer therapy, obtaining medications, insurance issues, communicating with medical providers, and travel and lodging logistics. Data on utilization and trial enrollment were prospectively collected. Data for a historical control group of 70 American Indian patients who did not receive patient navigation services were used to compare treatment interruptions among those undergoing patient navigation during curative radiation therapy (subgroup of 123 patients).

RESULTS

The median number of contacts with a navigator was 12 (range, 1-119). The median time spent with the navigator at first contact was 40 minutes (range, 10-250 minutes), and it was 15 minutes for subsequent contacts. Patients treated with radiation therapy with curative intent who underwent patient navigation had fewer days of treatment interruption (mean, 1.7 days; 95% confidence interval [CI], 1.1-2.2 days) than historical controls who did not receive patient navigation services (mean, 4.9 days; 95% CI, 2.9-6.9 days). Of the 332 patients, 72 (22%; 95% CI, 17%-26%) were enrolled on a clinical treatment trial or cancer control protocol.

CONCLUSIONS

Patient navigation was associated with fewer treatment interruptions and relatively high rates of clinical trial enrollment among American Indian cancer patients compared with national reports.

Intention to receive cancer screening in Native Americans from the Northern Plains

BACKGROUND

Native Americans are disproportionately affected by cancer morbidity and mortality. This study examined intention to receive cancer screening in a large sample of Native Americans from the Northern Plains, a region with high cancer mortality rates.

METHODS

A survey was administered orally to 975 individuals in 2004-2006 from three reservations and among the urban Native American community in the service region of the Rapid City Regional Hospital. Data analysis was conducted in 2009.

RESULTS

About 63% of the sample planned to receive cancer screening. In multivariate analyses, individuals who planned to receive cancer screening were women, responsible for four or more people, received physical examinations at least yearly and had received prior cancer screening. They also were more likely to hold the belief that most people would go through cancer treatment even though these treatments can be emotionally or physically uncomfortable. About 90% of those who did not plan to receive cancer screening would be more likely to intend to receive cancer screening if additional resources were available.

CONCLUSIONS

In an area of high cancer morbidity and mortality, over one-third of screening eligible individuals did not plan to receive cancer screening. Future research should evaluate the potential for improving cancer screening rates through interventions that seek to facilitate increased knowledge about cancer screening and access to cancer screening services in the community.

Cancer screening in Native Americans from the Northern Plains

BACKGROUND

Native Americans from the Northern Plains have the highest age-adjusted cancer mortality compared to Native Americans from any other region in the U.S.

PURPOSE

This study examined the utilization and determinants of cancer screening in a large sample of Native Americans from the Northern Plains.

METHODS

A survey was administered orally to 975 individuals in 2004-2006 from three reservations and among the urban Native-American community in the service region of the Rapid City Regional Hospital. Data analysis was conducted in 2007-2008.

RESULTS

Forty-four percent of individuals reported ever receiving any cancer screening. Particularly low levels were found for breast, cervical, prostate, and colon cancer screening. In multivariate analyses, the strongest determinant of receiving cancer screening overall or cancer screening for a specific cancer site was recommendation for screening by a doctor or nurse. Other determinants associated with increased likelihood of ever having cancer screening included older age, female gender, and receiving physical exams more than once a year. Increased age was a determinant of breast cancer screening, and receiving physical exams was associated with cervical cancer screening.

CONCLUSIONS

Cancer screening was markedly underutilized in this sample of Native Americans from the Northern Plains. Future research should evaluate the potential for improving cancer screening.

Involving American Indians and medically underserved rural populations in cancer clinical trials

PURPOSE

To assess cancer clinical trial recruitment and reasons for nonaccrual among a rural, medically underserved population served by a community-based cancer care center.

METHODS

We prospectively tracked clinical trial enrollment incidence among all new patients presenting at the Rapid City Regional Cancer Care Institute. Evaluating physicians completed questionnaires for each patient regarding clinical trial enrollment status and primary reasons for nonenrollment. Patients who identified as American Indian were referred to a program where patients were assisted in navigating the medical system by trained, culturally competent staff.

RESULTS

Between September 2006 and January 2008, 891 new cancer patients were evaluated. Seventy-eight patients (9%; 95% confidence intervals, 7-11%) were enrolled on a clinical treatment trial. For 73% (95% confidence intervals, 69-75%) of patients (646 of 891) lack of relevant protocol availability or protocol inclusion criteria restrictiveness was the reason for nonenrollment. Only 45 (5%; 95% confidence intervals, 4-7%) patients refused enrollment on a trial. Of the 78 enrolled on a trial, 6 (8%; 95% confidence intervals, 3-16%) were American Indian. Three additional American Indian patients were enrolled under a nontreatment cancer control trial, bringing the total percentage enrolled of the 94 American Indians who presented to the clinic to 10% (95% confidence intervals, 5-17%).

LIMITATIONS

Eligibility rates were unable to be calculated and cross validation of the number in the cohort via registries or ICD-9 codes was not performed.

CONCLUSION

Clinical trial participation in this medically underserved population was low overall, but approximately 3-fold higher than reported national accrual rates. Lack of availability of protocols for common cancer sites as well as stringent protocol inclusion criteria were the primary obstacles to clinical trial enrollment. Targeted interventions using a Patient Navigation program were used to engage AI patients and may have resulted in higher clinical trial enrollment among this racial/ethnic group.

Assessing cancer stage and screening disparities among Native American cancer patients

OBJECTIVE

Disparities in cancer-related health outcomes exist among Native Americans. This article assesses barriers to timely and effective cancer care among Native American cancer patients.

METHODS

We conducted a community-based participatory survey of newly diagnosed cancer patients to assess their basic knowledge of cancer screening and their beliefs about cancer management. Sociodemographic and cancer-related information was obtained from medical records. Mean scores for correct answers to the screening knowledge battery were tabulated and analyzed by race/ethnicity and sociodemographic characteristics. Multivariable regression models were used to adjust for sociodemographic characteristics in evaluating the association between screening knowledge and race/ethnicity.

RESULTS

The survey response rate was 62%. Of 165 patients, 52 were Native American and 113 were white. Native Americans with cancers for which a screening test is available presented with significantly higher rates of advanced-stage cancer (p=0.04). Native Americans scored lower on the cancer screening knowledge battery (p=0.0001). In multivariable analyses adjusting for age, gender, income, education level, employment status, and geographic distance from the cancer center, Native American race/ethnicity was the only factor significantly predictive of lower screening knowledge. Native Americans expressed more negative attitudes toward cancer treatment in some of the items regarding impacts and burden of cancer treatment.

CONCLUSIONS

Native American cancer patients presented with higher rates of advanced-stage disease for screening-detectable cancers, lower levels of basic cancer screening knowledge, and more negative attitudes about cancer treatment than white patients. Public health interventions regarding screening and cancer education are needed.

Medical mistrust and less satisfaction with health care among Native Americans presenting for cancer treatment

PURPOSE

To assess barriers to cancer care among Native Americans, whose health outcomes compare unfavorably with those of the general U.S. population.

METHODS AND PATIENTS

We undertook a comparative community-based participatory research project in which newly-diagnosed cancer patients were prospectively surveyed using novel scales for medical mistrust and satisfaction with health care. Socio-demographic information was obtained. Mean scale scores for mistrust and satisfaction were analyzed by race. Multivariable models were used to adjust for income, education level, and distance lived from cancer care institute.

RESULTS

Participation refusal rate was 38%. Of 165 eligible patients, 52 were Native American and 113 where non-Hispanic White. Native Americans expressed significantly higher levels of mistrust (p=0001) and lower levels of satisfaction (p=.0001) with health care than Whites. In multivariable analyses, race was the only factor found to be significantly predictive of higher mistrust and lower satisfaction scores.

CONCLUSION

Native Americans exhibit higher medical mistrust and lower satisfaction with health care.

Establishing a patient navigator program to reduce cancer disparities in the American Indian communities of Western South Dakota: initial observations and results

BACKGROUND

American Indians (AIs) in the Northern Plains region suffer disproportionately high cancer mortality rates compared with the general US population and with AIs from other regions in the United States.

METHODS

The National Cancer Institute developed the Cancer Disparity Research Partnership to address these inequities. This initiative in Rapid City, South Dakota, attempts to lower cancer mortality rates for AIs by access to innovative clinical trials, behavioral research, and a genetic study. Patient navigation is a critical part of the program. Two navigation strategies are described: navigators at the cancer center and navigators on each reservation. A retrospective analysis was performed to determine if navigated patients (n = 42) undergoing potentially curative radiotherapy had fewer treatment interruptions compared with nonnavigated patients (n = 74).

RESULTS

A total of 213 AIs with cancer have undergone patient navigation. For those undergoing cancer treatment, the median number of patient navigation interactions was 15 (range 1 to 95), whereas for those seen in follow-up after their cancer treatment, the median number of contacts was 4 (range 1 to 26). AIs who received navigation services during curative radiation treatment had on average 3 fewer days of treatment interruptions compared to AIs who did not receive navigation services during curative radiation treatment (P = .002, N = 116).

CONCLUSIONS

Early findings suggest that patient navigation is a critical component in addressing cancer disparities in this population. The program has established trust with individual cancer patients, with the tribal councils, and with the general population on each of the three reservations of western South Dakota.

Establishing trusting partnerships for successful recruitment of American Indians to clinical trials

BACKGROUND

Cancer mortality rates among American Indians (AIs) in the Northern Plains are among the highest in the nation. Reasons for this disparity are unclear but are probably due to multiple barriers. AIs appear to experience more intense side effects from therapeutic radiation compared with other populations. This differential response to treatment, a disparity in itself, might be overcome if the molecular reasons were better understood.

METHODS

The National Cancer Institute developed the Cancer Disparity Research Partnership to address these inequities. This initiative, known as the Walking Forward program, attempts to lower cancer mortality rates for AIs by increasing access to innovative clinical trials, behavioral research, patient navigation, and the ataxia telangiectasia mutated (ATM) gene study. The ATM component of the project was initiated to determine if there is a molecular basis for this apparent differential response to therapeutic radiation. Successful implementation of the genetic study relied on achieving a trusting partnership with AIs since a lack of trust has historically been a barrier to performing research in this population. The authors detail the nature of building partnerships and trust by utilizing lessons learned.

RESULTS

Establishing a trusting partnership between a community hospital and AIs in South Dakota resulted in successful recruitment to this ATM clinical trial. To date, 26 AIs and 40 non-AIs have consented to participate in this ATM analysis. Their shared human desire to assist others, especially family and community members, and their demonstrated responsiveness to community priorities by academic researchers are the primary reasons for participant eagerness to enroll on this study.

CONCLUSIONS

The relatively rapid approval of the ATM genetic study by multiple tribal organizations and the successful accrual of AIs on this study reflect the trusting partnerships achieved at the patient and community levels.

Radiotherapy treatment delays and their influence on tumour control achieved by various fractionation schedules

There is often a considerable delay from initial tumour diagnosis to the start of radiotherapy treatment. This paper extends the calculations of a previous paper on the effects of delays before the initiation of radiotherapy treatment to include results from a variety of practical fractionation regimes for three different types of tumour: squamous cell carcinoma (head and neck), breast and prostate. The linear quadratic model of radiation effect, logarithmic tumour growth (coupled with delay times where relevant) and the Poisson model for tumour control probability (TCP) are used to calculate the change in TCP for delays between diagnosis and treatment. Within the limitations of radiobiological modelling, these data can be used to tentatively assess the interactions between delays, dose fractionation and TCP. The results show that delays in the start of radiotherapy treatment do have an adverse effect on tumour control for fast-growing tumours. For example, calculations predict a reduction in local tumour control of up to 1.5% per week's delay for head and neck cancers treated following surgery. In addition, there may be a variety of fractionation regimes that will yield very similar clinical results for each tumour type. It is shown theoretically that, for the tumour types considered here, it is possible to increase the dose per fraction and decrease the number of fractions while maintaining or increasing TCP relative to standard 2 Gy fractionation regimes, although there may be some advantage to using hyperfractionated regimes for head and neck cancers in order to reduce normal tissue effects.

Clinical trial resources on the internet must be designed to reach underrepresented minorities

PURPOSE

Internet-based clinical trial information services are being developed to increase recruitment to studies. However, there are limited data that evaluate their ability to reach elderly and underrepresented minority populations. This study was designed to evaluate the ability of an established clinical trials registry to reach these populations based on expected Internet use.

PATIENTS AND METHODS

This study compares general Internet users to participants who enrolled in an Internet based colorectal cancer clinical trials registry established by OncoLink (www.oncolink.org) and the National Colorectal Cancer Research Alliance. Observed rates of demographic groupings were compared to those established for general Internet users.

RESULTS

Two thousand, four hundred and thirty-seven participants from the continental United States used the Internet to register for the database. New England, the Mid-Atlantic region, and the Southeast had the highest relative frequency of participation in the database, whereas the Upper Midwest, California, and the South had the lowest rates. Compared to general Internet users, there was an overrepresentation of women (73% vs. 50%) and participants over 55 years old (27% vs. 14%). However, there was an underrepresentation of minorities (10.3% vs. 22%), particularly African Americans (3.1% vs. 8%) and Hispanics (2.8% vs. 9%).

DISCUSSION

The Internet is a growing medium for registry into clinical trials databases. However, even taking into account the selection bias of Internet accessibility, there are still widely disparate demographics between general Internet users and those registering for clinical trials, particularly the underrepresentation of minorities. Internet-based educational and recruitment services for clinical trials must be designed to reach these underrepresented minorities to avoid selection biases in future clinical trials.

Lay patient navigator program implementation for equal access to cancer care and clinical trials: essential steps and initial challenges

BACKGROUND

Disparities in cancer detection, treatment, and outcomes among racial/ethnic minorities and low-income patients are well documented. One way to reduce these disparities is to use patient navigators to address barriers to care. However, little information about optimal characteristics of navigator programs or considerations for those interested in setting up such programs is available.

METHODS

The design and implementation of a patient navigator program for underserved cancer patients in an urban, nonacademic community hospital setting is described. The program, which used lay navigators, was conceived as a component of the Urban Latino African American Cancer (ULAAC) Disparities Project in South Los Angeles, a National Cancer Institute (NCI)-sponsored project to improve cancer care and clinical trial access for minority and low-income patients.

RESULTS

Careful initial planning, including input from a community advisory committee, was essential to smooth program implementation. Thirty-one volunteers completed navigator training in the program's first year of operation. Of 135 patients offered navigation services, 75 (56%) accepted, and preliminary feedback from patients, navigators, and providers suggests high levels of satisfaction with navigation. Standardized templates used by navigators and staff to record key information are proving helpful for monitoring quality and outcomes (such as effectiveness in addressing specific barriers to care) and continually improving the program.

CONCLUSIONS

The ULAAC program represents a viable model for developing lay navigator programs in community hospitals. Preliminary assessments suggest that the program has a positive effect on minority and low-income cancer patients' experience with care and reduces barriers to care. Additional time and research are needed, however, to fully assess the impact on care and outcomes.