Randomized Trial of a Web-Based Intervention to Address Barriers to Clinical Trials

Cancer Patients' Perspectives and Requirements of Digital Health Technologies: A Scoping Literature Review

Digital health technologies have the potential to alleviate the increasing cancer burden. Incorporating patients' perspectives on digital health tools has been identified as a critical determinant for their successful uptake in cancer care. The main objective of this scoping review was to provide an overview of the existing evidence on cancer patients' perspectives and requirements for patient-facing digital health technologies. Three databases (CINAHL, MEDLINE, Science Direct) were searched and 128 studies were identified as eligible for inclusion. Web-based software/platforms, mobile or smartphone devices/applications, and remote sensing/wearable technologies employed for the delivery of interventions and patient monitoring were the most frequently employed technologies in cancer care. The abilities of digital tools to enable care management, user-friendliness, and facilitate patient-clinician interactions were the technological requirements predominantly considered as important by cancer patients. The findings from this review provide evidence that could inform future research on technology-associated parameters influencing cancer patients' decisions regarding the uptake and adoption of patient-facing digital health technologies.

A review of strategies and levels of community engagement in strengths-based and needs-based health communication interventions

Background

Community engagement is key in health communication interventions that seek to incorporate community voices in their planning and implementation. Understanding what approaches and strategies are currently being used can help tailor programs in different social and cultural contexts. This review explores needs-based and strengths-based approaches and consensus and conflict strategies in community-based global health communications programs. Our objective is to examine the current state of the field, outline lessons learned, and identify gaps in existing programming to help guide future interventions.

Methods

PubMed and Web of Science were searched for articles published between 2010 and 2023. Studies were included if they described a community-based health communication intervention and an ongoing or completed implementation. Interventions were coded then categorized according to their level of community engagement and as single, hybrid, or complex, depending upon the number of approaches and strategies used.

Results

The search yielded 678 results and 42 were included in the final review and analysis. A vast majority 34 (81.0%) interventions utilized a needs-based approach and 24 (57.1%) utilized a strengths-based approach. Consensus as a strategy was utilized in 38 (90.5%) of the manuscripts and 9 (21.4%) implemented a conflict strategy. Interventions that combined approaches and strategies were more likely to leverage a higher level of community engagement.

Conclusion

These results showcase the complicated nature of global health communication program planning and implementation. There is a lack of interventions that use conflict as a strategy to empower communities to act on their own behalf, even when at odds with existing power structures. Complex interventions that include all approaches and strategies demonstrate the potential for global health communication interventions to be at the cutting edge of public health practice.

Describing the content of trial recruitment interventions using the TIDieR reporting checklist: a systematic methodology review

BACKGROUND

Recruiting participants to clinical trials is an ongoing challenge, and relatively little is known about what recruitment strategies lead to better recruitment. Recruitment interventions can be considered complex interventions, often involving multiple components, targeting a variety of groups, and tailoring to different groups. We used the Template for Intervention Description and Replication (TIDieR) reporting checklist (which comprises 12 items recommended for reporting complex interventions) to guide the assessment of how recruitment interventions are described. We aimed to (1) examine to what extent we could identify information about each TIDieR item within recruitment intervention studies, and (2) observe additional detail for each item to describe useful variation among these studies.

METHODS

We identified randomized, nested recruitment intervention studies providing recruitment or willingness to participate rates from two sources: a Cochrane review of trials evaluating strategies to improve recruitment to randomized trials, and the Online Resource for Research in Clinical triAls database. First, we assessed to what extent authors reported information about each TIDieR item. Second, we developed descriptive categorical variables for 7 TIDieR items and extracting relevant quotes for the other 5 items.

RESULTS

We assessed 122 recruitment intervention studies. We were able to extract information relevant to most TIDieR items (e.g., brief rationale, materials, procedure) with the exception of a few items that were only rarely reported (e.g., tailoring, modifications, planned/actual fidelity). The descriptive variables provided a useful overview of study characteristics, with most studies using various forms of informational interventions (55%) delivered at a single time point (90%), often by a member of the research team (59%) in a clinical care setting (41%).

CONCLUSIONS

Our TIDieR-based variables provide a useful description of the core elements of complex trial recruitment interventions. Recruitment intervention studies report core elements of complex interventions variably; some process elements (e.g., mode of delivery, location) are almost always described, while others (e.g., duration, fidelity) are reported infrequently, with little indication of a reason for their absence. Future research should explore whether these TIDieR-based variables can form the basis of an approach to better reporting of elements of successful recruitment interventions.

Supporting GPs and people with hypertension to maximise medication use to control blood pressure: Protocol for a pilot cluster RCT of the MIAMI intervention

Background: Hypertension is one of the most important risk factors for stroke and heart disease. Recent international guidelines have stated that 'poor adherence to treatment - in addition to physician inertia - is the most important cause of poor blood pressure control'. The MaxImising Adherence, Minimising Inertia (MIAMI) intervention, which has been developed using a systematic, theoretical, user-centred approach, aims to support general practitioners (GPs) and people with hypertension to maximise medication use, through the facilitation of adequate information exchange within consultations about long-term antihypertensive medication use and adherence skill development. The aim of the MIAMI pilot cluster randomised controlled trial (RCT) is to gather and analyse feasibility data to allow us to (1) refine the intervention, and (2) determine the feasibility of a definitive RCT. Methods: GP practices (n = 6) will be recruited and randomised to the intervention arm (n = 3) or usual care control arm (n = 3). Each practice will recruit 10 patient participants. For a patient to be eligible they must have a diagnosis of hypertension, be on two or more anti-hypertensive medications, must not be achieving recommended blood pressure levels, and be over the age of 65 years. Participants in the intervention arm will meet their GP and receive the MIAMI intervention twice over three months. Quantitative data collection will take place at baseline and three month follow up. A pilot health economic analysis and a qualitative sub-study will also be incorporated into the study. Discussion: This pilot cluster RCT of the MIAMI intervention will allow us to gather valuable acceptability and feasibility data to further refine the intervention so it optimally designed for both GP and patient use. In particular, the qualitative component will provide an insight into GP and patient experiences of using the intervention.

Efficacy of DigiKnowItNews: Teen, a multimedia educational website for adolescents about pediatric clinical trials: study protocol for a randomized controlled trial

BACKGROUND

Pediatric research is crucial for the development of new scientific advancements, treatments, and therapies for adolescents. Yet relatively few pediatric clinical trials are conducted due to barriers to successful recruitment and retention, including knowledge and attitudes about clinical trials. Adolescents tend to experience greater autonomy to make decisions and have expressed interest in being part of the decision to participate in clinical trials. Increasing knowledge, positive attitudes, and self-efficacy related to clinical trials could positively impact the decision to participate in a pediatric clinical trial. However, there are currently few interactive, developmentally appropriate, web-based resources available to educate adolescents about clinical trials. DigiKnowItNews: Teen was created as a multimedia educational website to address the relatively low levels of enrollment in pediatric clinical trials and need for information to empower adolescents to make decisions about participating in clinical trials.

METHODS

This is a parallel group randomized controlled superiority trial to test the effectiveness of DigiKnowItNews: Teen, for improving factors related to clinical trial participation among adolescent and parents. Eligible parent-adolescent (ages 12 to 17 years) pairs will be randomly assigned to one of two conditions: intervention or wait-list control. All participants will complete pre- and post-test questionnaires and participants assigned to the intervention will receive access to review the DigiKnowItNews: Teen content for 1 week. Wait-list control participants will have the option to review DigiKnowItNews: Teen after study completion. The primary outcomes are knowledge about clinical research, attitudes, and beliefs toward pediatric clinical trials, self-efficacy for making decisions related to clinical trial participation, willingness to participate in a future clinical trial, procedural fears, and parent-adolescent communication quality. Overall feedback and satisfaction related to DigiKnowItNews: Teen will also be collected.

DISCUSSION

The trial will evaluate the effectiveness of DigiKnowIt News: Teen, an educational website about pediatric clinical trials for adolescents. If found effective in promoting factors related to future pediatric clinical trial participation, DigiKnowIt News: Teen could be used by adolescents, along with their parents, as they make the decision to participate in a clinical trial. Clinical trial researchers can also use DigiKnowIt News: Teen to aid their participant recruitment efforts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05714943. Registered on 02/03/2023.

Disparity in Breast Cancer Care: Current State of Access to Screening, Genetic Testing, Oncofertility, and Reconstruction

Breast cancer is the most common cancer diagnosed in women, accounting for an estimated 30% of all new cancer diagnoses in women in 2022. Advances in breast cancer treatment have reduced the mortality rate over the past 25 years by up to 34% but not all groups have benefitted equally from these improvements. These disparities span the continuum of care from screening to the receipt of guideline-concordant therapy and survivorship. At the 2022 American College of Surgeons Clinical Congress, a panel session was dedicated to educating and discussing methods of addressing these disparities in a coordinated manner. While there are multilevel solutions to address these disparities, this article focuses on screening, genetic testing, reconstruction, and oncofertility.

Supporting GPs and people with hypertension to maximise medication use to control blood pressure: Protocol for a pilot cluster RCT of the MIAMI intervention

Background: Hypertension is one of the most important risk factors for stroke and heart disease. Recent international guidelines have stated that 'poor adherence to treatment – in addition to physician inertia - is the most important cause of poor blood pressure control'. The MaxImising Adherence, Minimising Inertia (MIAMI) intervention, which has been developed using a systematic, theoretical, user-centred approach, aims to support general practitioners (GPs) and people with hypertension to maximise medication use, through the facilitation of adequate information exchange within consultations about long-term antihypertensive medication use and adherence skill development. The aim of the MIAMI pilot cluster randomised controlled trial (RCT) is to gather and analyse feasibility data to allow us to (1) refine the intervention, and (2) determine the feasibility of a definitive RCT. Methods: GP practices (n = 6) will be recruited and randomised to the intervention arm (n = 3) or usual care control arm (n = 3). Each practice will recruit 10 patient participants. For a patient to be eligible they must have a diagnosis of hypertension, be on two or more anti-hypertensive medications, must not be achieving recommended blood pressure levels,  and be over the age of 65 years. Participants in the intervention arm will meet their GP and receive the MIAMI intervention twice over three months. Quantitative data collection will take place at baseline and three month follow up. A pilot health economic analysis and a qualitative sub-study will also be incorporated into the study. Discussion: This pilot cluster RCT of the MIAMI intervention will allow us to gather valuable acceptability and feasibility data to further refine the intervention so it optimally designed for both GP and patient use. In particular, the qualitative component will provide an insight into GP and patient experiences of using the intervention.

Digital Health Interventions for Adult Patients With Cancer Evaluated in Randomized Controlled Trials: Scoping Review

BACKGROUND

Digital care has become an essential component of health care. Interventions for patients with cancer need to be effective and safe, and digital health interventions must adhere to the same requirements.

OBJECTIVE

The purpose of this study was to identify currently available digital health interventions developed and evaluated in randomized controlled trials (RCTs) targeting adult patients with cancer.

METHODS

A scoping review using the JBI methodology was conducted. The participants were adult patients with cancer, and the concept was digital health interventions. The context was open, and sources were limited to RCT effectiveness studies. The PubMed, CINAHL, Embase, Cochrane Library, Research Information Sharing Service, and KoreaMed databases were searched. Data were extracted and analyzed to achieve summarized results about the participants, types, functions, and outcomes of digital health interventions.

RESULTS

A total of 231 studies were reviewed. Digital health interventions were used mostly at home (187/231, 81%), and the web-based intervention was the most frequently used intervention modality (116/231, 50.2%). Interventions consisting of multiple functional components were most frequently identified (69/231, 29.9%), followed by those with the self-manage function (67/231, 29%). Web-based interventions targeting symptoms with the self-manage and multiple functions and web-based interventions to treat cognitive function and fear of cancer recurrence consistently achieved positive outcomes. More studies supported the positive effects of web-based interventions to inform decision-making and knowledge. The effectiveness of digital health interventions targeting anxiety, depression, distress, fatigue, health-related quality of life or quality of life, pain, physical activity, and sleep was subject to their type and function. A relatively small number of digital health interventions specifically targeted older adults (6/231, 2.6%) or patients with advanced or metastatic cancer (22/231, 9.5%).

CONCLUSIONS

This scoping review summarized digital health interventions developed and evaluated in RCTs involving adult patients with cancer. Systematic reviews of the identified digital interventions are strongly recommended to integrate digital health interventions into clinical practice. The identified gaps in digital health interventions for cancer care need to be reflected in future digital health research.

A Systematic Review of Decision Aids in Hematologic Malignancies: What Are Currently Available and What Are We Missing?

BACKGROUND

Patient decision aids (PDAs) are tools designed to facilitate decision-making. In this systematic review, we summarized existing studies on the development and evaluation of PDAs for patients with hematologic malignancies.

PATIENTS AND METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched for articles in PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. We included studies, abstracts, and clinical trial protocols available in English involving PDAs for patients age ≥18 diagnosed with a hematologic malignancy and/or their caregivers. Data were summarized using descriptive statistics.

RESULTS

Of the 5281 titles/abstracts screened, 15 were included: 1 protocol, 7 abstracts, and 7 full-texts. Six were PDA developmental studies, 6 were pilot studies, and 3 were randomized trials. PDA formats included electronic with web content, videos, and/or audio, questionnaires, bedside instruments, and a combination of various formats. Average participant age ranged from 36.0 to 62.4 years. Patients and caregivers identified efficacy, adverse effects, cost, and quality of life as important decision-making factors. PDAs were associated with increased knowledge and patient satisfaction as well as decreased decisional conflict and attitudinal barriers. Research on PDAs for adult patients with hematologic malignancies and their caregivers is limited. Among the studies, PDAs appear to support patients in shared decision-making.

CONCLUSION

While current literature examining the use of PDAs for adults with hematologic malignancies is limited, the positive impact of PDAs on shared decision-making and patient outcomes warrants additional research in this field.

Public knowledge and information sources for clinical trials among adults in the USA: evidence from a Health Information National Trends Survey in 2020

BACKGROUND

Lack of clinical trial awareness has been identified as a barrier to clinical trial recruitment. Identifying factors associated with clinical trial knowledge could inform ongoing efforts to improve diversity in clinical trials.

METHODS

Using data from the Health Information National Trends Survey, 2020, we examined the knowledge of clinical trials, associated characteristics, sources of clinical trial information and motives to participate in clinical trials among the general population in the USA.

RESULTS

Of 3,772 US adults, 41.3% reported not knowing about clinical trials. Prevalence of having no knowledge of clinical trials was higher among Hispanic adults (51.8%) and non-Hispanic Black adults (41.8%) compared with non-Hispanic White adults (37.4%; p=0.013). Other significant predictors of knowledge about clinical trials included higher education, online health information-seeking behaviour and patient portal access. Most respondents (73.2%) reported that healthcare providers were the most trusted source of information. Helping other people (71.6%) was the primary motivation for clinical trial participation, followed by financial compensation (12.5%) and receiving better treatment (5.1%).

CONCLUSION

There is a gap in knowledge about clinical trials among the US population. Development of multimodal approaches, including online and offline information broadcasting, is needed to improve knowledge and clinical trial recruitment in diverse populations.

Equitable Representation of Latinos in Clinical Research Is Needed to Achieve Health Equity in Cancer Care

PURPOSE

Identify key barriers that keep Latinos from participating in clinical trials (CTs) and interventions proven effective in increasing their representation in clinical research.

METHODS

Utilize our own extensive research experience and review the literature to: identify key barriers, summarize strategies that have been proven effective in increasing Latino representation in CTs, issue a call to action for programs/practices and practitioners to implement what is proven effective, and make recommendations for further research to address current gaps.

RESULTS

Participation barriers are complex, multifactorial, and exist at different levels, including study design (eg, protocol complexity, patient exclusion criteria, trial duration and frequency), healthcare system barriers (eg, lack of minority staff), patient-related factors (eg, lack of awareness, low health literacy, language, social determinants of health [SDoH]), and medical team issues (eg, lack of cultural competence, lack of referrals, implicit bias, provider/patient communication). Research has shown that the most effective strategies to increase participation of underrepresented minorities in CTs include culturally sensitive educational tools aimed at community members, patients, and physicians, and strategies to address the multiple SDoH and other barriers to participation facing cancer patients and the factors that influence patient decision-making.

CONCLUSION

Raising awareness or offering clinical trials to everyone will not alone increase Latino participation. Other key barriers at different levels must also be addressed, especially SDoH and patients' contextual factors. To achieve equitable participation of Latinos and other underrepresented groups in clinical research, comprehensive approaches that address interrelated multilevel and multifactorial barriers to participation can produce a substantial, sustained impact-ensuring everyone equitably benefits from scientific advances in cancer treatment, improved cancer outcomes and quality of life, and reduced health care costs.

Health Literacy and Clinical Trial Participation in French Cancer Patients: A National Survey

Few studies have explored the relationship between health literacy (HL) and trial participation. In this context, we aimed to study this relationship in French cancer patients. We used data from the French national VIe après le CANcer (VICAN) survey. Two questionnaire items focused on previous invitations to participate in clinical trials and subsequent enrollment. The Single Item Literacy Screener was used to measure functional HL. In total, 1954 cancer patients responded to both VICAN surveys (two and five years after diagnosis). Mean age was 54.1 ± 12.7 years at diagnosis, and 37.6% were classified as having limited HL. One in ten (10.3%) respondents reported having been previously invited to participate in a clinical trial. Of these, 75.5% had enrolled. Limited HL was associated with fewer trial invitations but not with enrollment once invited. Multivariate analysis confirmed the negative effect of limited HL on clinical trial invitation (adjOR = 0.55 (0.39 to 0.77), p < 0.001) after adjustment for multiple characteristics. Patients with limited HL received fewer invitations to participate in trials but were likely to enroll when asked. Addressing HL is necessary to create a more inclusive health system and to reduce inequalities not only in access to innovative cancer care, but to health inequalities in general.

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.

The Role of Safety-Net Hospitals in Reducing Disparities in Breast Cancer Care

Advances in breast cancer screening and systemic therapies have been credited with profound improvements in breast cancer outcomes; indeed, 5-year relative survival rate approaches 91% in the USA (U.S. National Institutes of Health NCI. SEER Training Modules, Breast). While breast cancer mortality has been declining, oncologic outcomes have not improved equally among all races and ethnicities. Many factors have been implicated in breast cancer disparities; chief among them is limited access to care which contributes to lower rates of timely screening mammography and, once diagnosed with breast cancer, lower rates of receipt of guideline concordant care (Wu, Lund, Kimmick GG et al. in J Clin Oncol 30(2):142-150, 2012). Hospitals with a safety-net mission, such as the essential hospitals, historically have been dedicated to providing high-quality care to all populations and have eagerly embraced the role of caring for the most vulnerable and working to eliminate health disparities. In this article, we review landmark articles that have evaluated the role safety-net hospitals have played in providing equitable breast cancer care including to those patients who face significant social and economic challenges.

DigiKnowIt News: Educating youth about pediatric clinical trials using an interactive, multimedia educational website

Pediatric clinical trials allow for the testing of appropriate and effective treatments for children. However, some challenges exist with recruitment. This study examined the effectiveness of DigiKnowIt News, an interactive, multimedia website (which includes activities, videos, and comic books) designed to educate children about clinical trials. A randomized controlled trial was conducted in 2018 with 91 participants (M age = 10.92 years; SD = 2.06). Participants were randomly assigned to intervention or wait-list control groups and completed questionnaires at pretest and posttest (1 week later) about their knowledge, attitudes, beliefs about clinical trials, and self-efficacy for participating in clinical trials. Participants in the intervention group received access to DigiKnowIt News between pretest and posttest and completed a satisfaction questionnaire at posttest. At the end of the study, participants in the wait-list control group were offered the option to use the website and complete a satisfaction questionnaire. At posttest, participants in the intervention group, compared to participants in the wait-list control group, had more knowledge about clinical trials and more reported confidence for participating in clinical trials. Participants reported high levels of satisfaction with DigiKnowIt News. The findings suggest that an educational website can improve factors related to increasing rates of participation in clinical trials.

Oncologic patients' misconceptions may impede enrollment into clinical trials: a cross-sectional study

Background

Clinical trials are an essential source for advances in oncologic care, yet the enrollment rate is only 2-4%. Patients' reluctance to participate is an important barrier. This study evaluates patients' level of understanding and attitudes towards clinical trials.

Methods

This cross-sectional study was conducted in the oncology department and day care unit at the oncology division Tel Aviv Sourasky Medical Center, Israel. From January 2015 to September 2016. Two-hundred patients’ currently receiving active anti-cancer therapy at a large tertiary hospital completed an anonymous questionnaire comprised of demographic information, past experience in clinical research and basic knowledge on clinical trials.

Results

The majority of respondents did not meet the minimum knowledge level criteria. In those who replied they would decline to participate in a clinical trial, concern were related to potential assignment to the placebo arm, provision of informed consent and trust issues with their oncologist. Those with sufficient knowledge were significantly more interested in participating. Patients with past experience in clinical trials had a higher level of academic education, were less religious, had a better understanding of medical research and were inclined to participate in future research.

Conclusions

Misperceptions of clinical trials may contribute substantially to the unwillingness to participate in them.

Development and pilot test of a physician-focused cancer clinical trials communication training intervention

Objective

We describe the development and pilot test of a physician-focused, web-based training module designed to improve physician communication related to clinical trials in a diverse cancer patient population.

Methods

Researchers and stakeholders developed the training module, which included a video explaining patient-centered communication strategies for discussing trials, and re-enactments of actual clinical interactions. For the pilot test, the module was provided to physician participants in the Partnering Around Cancer Clinical Trials (PACCT) trial at two major urban cancer centers. Questionnaires assessed change in beliefs, behavioral attitudes, knowledge and comfort; and perceptions of the module.

Results

Nineteen physicians participated in the pilot test. Most were experienced in discussing trials. Assessments of change were mixed regarding beliefs; they showed marginal improvement in attitudes, and significant improvement in knowledge, but no change in comfort. Feedback on the module was favorable.

Conclusions

This stakeholder-developed physician communication training module was acceptable and effective, albeit in this small and highly-experienced physician sample. Future research should determine its effectiveness on communication in clinical settings.

Innovation

This is the first physician training module to focus on communicating about clinical trials in a diverse patient population. It offers a web-based format and re-enactments of naturally-occurring clinical interactions.

Trial Registration Number: NCT02906241

Clinical Trial Participation: A Pilot Study of Patient-Identified Barriers

BACKGROUND

Clinical trial enrollment in the United States is lacking, particularly among older adult and ethnic and racial minority populations.

OBJECTIVES

The aim of the current study was to identify patient-related barriers to clinical trial participation using a mixed-methods patient survey and to offer insights to develop evidence-based implementation strategies to address these barriers.

METHODS

A retrospective survey was conducted of patients who were not interested in participating in a clinical trial to quantify the reasons these patients chose not to participate. Directed qualitative content analysis was used to identify themes that emerged from the write-in responses.

FINDINGS

The greatest patient-reported barriers were misperceptions about placebos, a desire to not feel like a human guinea pig, uncertainty surrounding clinical trial treatment effectiveness compared to standard care, and concerns about additional appointments or tests. Oncology nurses can address patient enrollment barriers by providing targeted education and participating in the informed consent process.

The DISCO App: A pilot test of a multi-level intervention to reduce the financial burden of cancer through improved cost communication☆

Objective

Financial toxicity affects 30–50% of people with cancer in the US. Although experts recommend patients and physicians discuss treatment cost, cost discussions occur infrequently. We pilot-tested the feasibility, acceptability and influence on outcomes of the DIScussions of COst (DISCO) App, a multi-level communication intervention designed to improve cost discussions and related outcomes.

Methods

While waiting to see their physician, patients (n = 32) used the DISCO App on a tablet. Physicians were given a cost discussion tip sheet. Clinic visits were video recorded and patients completed pre- and post-intervention measures of self-efficacy for managing costs, self-efficacy for interacting with physicians, cost-related distress, and perceptions of the DISCO App. Coders observed the recordings to determine the presence of cost discussions, initiators, and topics.

Results

Most patients reported needing ≤15 min to use the DISCO App, and that it made it easier to ask cost-related questions. Findings showed increased self-efficacy for managing treatment costs (p = .02) and for interacting with physicians (p = .001). All visits included a cost discussion.

Conclusions

Prompting patients to discuss costs may improve cost treatment discussions and related outcomes.

Innovation

An app-based and tailorable treatment-cost communication intervention is feasible, acceptable, and demonstrates promise in prompting cost discussions and improving outcomes.

Trial registration: Clinical Trials.gov registration number: NCT03676920 (September 19, 2018).

The Impact of an Online Training Program About Cancer Clinical Trials on Primary Care Physicians' Knowledge, Attitudes and Beliefs, and Behavior

Participation in cancer clinical trials (CCTs) is critical to improving cancer treatments and quality of care. However, rates of patient participation remain low. Research has shown that a trusted physician recommendation is an important influence on patients' decisions to enroll in a CCT. Improving primary care providers' (PCPs') knowledge, attitudes, and beliefs about CCTs is a promising potential path for improving CCT participation. The aim of this pilot study was to test the effect of an online educational course for PCPs about clinical trials on primary care providers' knowledge, attitudes and beliefs, and behavior. Forty-one PCPs in the New York City area participated in a 1-h online training session on cancer clinical trials. These PCPs had self-selected to complete the training in a previous survey. The objectives of the training module were to (1) educate the PCPs about clinical trials, with a focus on overcoming misconceptions; and (2) discuss roles of PCPs in partnering with oncologists to help patients gain access to clinical trials. The training module included didactics, audio excerpts, and case descriptions. Participants completed a pre-test immediately before taking the course, a post-test immediately after taking the course, and a 3-month post-course survey. All three assessments included a general T/F knowledge test, a 7-item attitude/belief scale, and a knowledge test focused specifically on local resources and access for clinical trials. Forty-one PCPs completed the module and the pre-post course surveys. Eighty percent (33/41) also completed the 3-month post-course survey. General knowledge and local knowledge increased significantly (p < .05) from pre- to post-course. At 3 months post-training, both general and local knowledge scores remained significantly increased from baseline. For those who completed the 3-month post-course survey, attitudes and beliefs increased significantly from pre- to post-course, but this change was not sustained at 3 months post-training. At 3 months post-training, 52% of the PCPs who had an interaction with a recently diagnosed cancer patient reported speaking with patients about CCTs as a result of the training. A brief online course showed significant and sustained improvement in PCPs' general and local knowledge about cancer clinical trials, which translated into self-reported behavior change. Future dissemination of the course and further research into its impact are important next steps.

Use of Video Education Interventions to Increase Racial and Ethnic Diversity in Cancer Clinical Trials: A Systematic Review

BACKGROUND

Less than 5% of eligible adult cancer survivors participate in cancer clinical trials. Survivors identifying as Black, Indigenous, and people of color (BIPOC) are less likely to participate in clinical trials compared to those identifying as non-Hispanic White. Common barriers to BIPOC participation are lack of knowledge, lack of access, and mistrust. These barriers are all factors in the disparities observed in BIPOC cancer-related morbidity and mortality. Clinical trials need adequate BIPOC representation to garner generalizable findings that can reduce or eliminate cancer disparities associated with the social construct of race.

AIM

This systematic review examined the use of video education interventions to impact BIPOC survivor participation in clinical trials.

METHODS

Web of Science, Embase, PubMed, Cochrane, PsycInfo, and CINAHL databases were queried for articles that described or tested video interventions aimed at increasing adult, BIPOC survivor clinical trial participation. Two authors independently screened articles for inclusion, appraised quality, and abstracted relevant data. All authors synthesized the data into themes through discussion and consensus.

RESULTS

The search yielded 2,512 articles. Seven selected articles described six distinct interventions. Although the six interventions reduced barriers to participation in clinical trials, their findings varied on Black and Hispanic survivors' readiness to enroll and participate in trials. Four themes emerged: (a) cultural sensitivity is needed in video development and delivery; (b) video content should be aimed to educate and change attitudes about clinical trials; (c) video interventions are feasible and acceptable; and (d) video interventions affect outcomes on intention or actual enrollment.

LINKING EVIDENCE TO ACTION

Video interventions are well-received by BIPOC survivors and may improve representation in clinical trials. Yet, video interventions are underutilized. More studies are needed to establish best practices for video interventions aimed at diversifying clinical trial participation as widening cancer disparities and rapidly changing cancer care continue to emerge.

DISCO App: study protocol for a randomized controlled trial to test the effectiveness of a patient intervention to reduce the financial burden of cancer in a diverse patient population

Background

Financial toxicity, the material and psychological burden of the cost of treatment, affects 30–50% of people with cancer, even those with health insurance. The burden of treatment cost can affect treatment adherence and, ultimately, mortality. Financial toxicity is a health equity issue, disproportionately affecting patients who are racial/ethnic minorities, have lower incomes, and are < 65 years old. Patient education about treatment cost and patient-oncologist cost discussions are recommended as ways to address financial toxicity; however, research shows cost discussions occur infrequently (Altice et al. J Natl Cancer Inst 109:djw205, 2017; Schnipper et al. J Clin Oncol 34:2925-34, 2016; Zafar et al. Oncologist 18:381-90, 2013; American Cancer Society Cancer Action Network 2010). Our overall goal is to address the burden of financial toxicity and work toward health equity through a tailorable education and communication intervention, the DISCO App. The aim of this longitudinal randomized controlled trial is to test the effectiveness of the DISCO App on the outcomes in a population of economically and racially/ethnically diverse cancer patients from all age groups.

Methods

Patients diagnosed with breast, lung, colorectal, or prostate cancer at a NCI-designated comprehensive cancer center in Detroit, MI, will be randomized to one of three study arms: one usual care arm (arm 1) and two intervention arms (arms 2 and 3). All intervention patients (arms 2 and 3) will receive the DISCO App before the second interaction with their oncologist, and patients in arm 3 will receive an intervention booster. The DISCO App, presented on an iPad, includes an educational video about treatment costs, ways to manage them, and the importance of discussing them with oncologists. Patients enter socio-demographic information (e.g., employment, insurance status) and indicate their financial concerns. They then receive a tailored list of questions to consider asking their oncologist. All patients will have up to two interactions with their oncologist video recorded and complete measures at baseline, after the recorded interactions and at 1, 3, 6, and 12 months after the second interaction. Outcome measures will assess discussions of cost, communication quality, knowledge of treatment costs, self-efficacy for treatment cost management, referrals for support, short- and longer-term financial toxicity, and treatment adherence.

Discussion

If effective, this intervention will improve awareness of and discussions of treatment cost and alleviate the burden of financial toxicity. It may be especially helpful to groups disproportionately affected by financial toxicity, helping to achieve health equity.

Trial registration

ClinicalTrials.gov NCT04766190. Registered on February 23, 2021

Demographic and Health Behavior Factors Associated With Clinical Trial Invitation and Participation in the United States

IMPORTANCE

Representative enrollment in clinical trials is critical to ensure equitable and effective translation of research to practice, yet disparities in clinical trial enrollment persist.

OBJECTIVE

To examine person-level factors associated with invitation to and participation in clinical trials.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed responses from 3689 US adults who participated in the nationally representative Health Information National Trends Survey, collected February through June 2020 via mailed questionnaires.

EXPOSURES

Demographic, clinical, and health behavior-related characteristics.

MAIN OUTCOMES AND MEASURES

History of invitation to and participation in a clinical trial, primary information sources, trust in information sources, and motives for participation in clinical trials were described. Respondent characteristics are presented as absolute numbers and weighted percentages. Associations between respondent demographic, clinical, and health behavior-related characteristics and clinical trial invitation and participation were estimated using survey-weighted logistic regression models.

RESULTS

The median (IQR) age of the 3689 respondents was 48 (33-61) years, and most were non-Hispanic White individuals (2063 [59%]; non-Hispanic Black, 452 [10%]; Hispanic, 521 [14%]), had more than a high school degree (2656 [68%]), were employed (1809 [58%]), and had at least 1 medical condition (2535 [61%]). Overall, 439 respondents (9%) had been invited to participate in any clinical trial. Respondents with increased odds of invitation were non-Hispanic Black compared with non-Hispanic White (adjusted odds ratio [aOR], 1.85; 95% CI, 1.13-3.02), had greater than a high school education compared with less than high school education (eg, ≥college degree: aOR, 4.84; 95% CI, 1.89-12.39), were single compared with married or living as married (aOR, 1.68; 95% CI, 1.04-2.73), and had at least 1 medical condition compared to none (eg, 1 medical condition: aOR, 2.25; 95% CI, 1.32-3.82). Respondents residing in rural vs urban areas had 77% decreased odds of invitation to a clinical trial (aOR 0.33; 95% CI 0.17-0.65). Of invited respondents, 199 (47%) participated. Compared with non-Hispanic White respondents, non-Hispanic Black respondents had 72% decreased odds of clinical trial participation (aOR, 0.28; 95% CI, 0.09-0.87). Respondents most frequently reported "health care providers" as the first and most trusted source of clinical trial information (first source: 2297 [59%]; most trusted source: 2597 [70%]). The most frequently reported motives for clinical trials participation were "wanting to get better" (2294 [66%]) and the standard of care not being covered by insurance (1448 [41%]).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that invitation to and participation in clinical trials may differ by person-level demographic and clinical characteristics. Strategies toward increasing trial invitation and participation rates across diverse patient populations warrant further research to ensure equitable translation of clinical benefits from research to practice.

Participation of Black Americans in Cancer Clinical Trials: Current Challenges and Proposed Solutions

Low participation of Black Americans in cancer clinical trials is a well-established predicament. Many factors resulted in this current dilemma with racism being the fundamental unit. Here, we discuss some current challenges and proposed solutions to help in increasing the enrollment of Black Americans in cancer clinical trials. We suggest implementing the least acceptable race-specific percentage as a new bar that registrational clinical trials need to pass before cancer drugs approval. Clinical trials will continue to draw the future of cancer therapeutics in which we believe that a prompt improvement of Black Americans participation is warranted.

Randomized trial of a web-based nurse education intervention to increase discussion of clinical trials

Background

Clinical trials are a critical source of evidence for oncology care, yet very few patients participate. Among healthcare providers, nurses spend the most time with cancer patients and are the most highly trusted professionals. We developed and evaluated an educational program for oncology nurses targeting knowledge, attitudes, self-efficacy and perceived norms to facilitate discussion about clinical trials and support patient decision making.

Methods

A nationwide sample of oncology nurses were randomly assigned to receive general clinical trials education delivered as text (attention control) vs. tailored video vignettes (intervention) in a web-based continuing education program. Participants completed a baseline assessment and follow up assessments immediately after the educational program and three months later. The primary outcome was intention to discuss clinical trials with patients. Secondary outcomes were knowledge and attitudes about clinical trials, self-efficacy, and perceived norms.

Results

1393 nurses enrolled and completed the educational program and post-intervention assessment (720 control, 673 video). Both text education and tailored video education increased intention to discuss clinical trials with patients, with a greater effect in the video group (p < .0001). Likewise, knowledge, attitudes, perceived behavioral control, and perceived norms were all improved with education in both groups, and the magnitude of benefit was greater (p < .001) for the video group in all outcomes except knowledge.

Conclusion

A one-time online educational program for oncology nurses improves knowledge, attitudes, self-efficacy and intention to engage patients in discussions about clinical trials. A tailored video format was associated with a greater effect than standard text only material.

Automated Electronic Health Record-Based Tool for Identification of Patients With Metastatic Disease to Facilitate Clinical Trial Patient Ascertainment

PURPOSE

To facilitate identification of clinical trial participation candidates, we developed a machine learning tool that automates the determination of a patient's metastatic status, on the basis of unstructured electronic health record (EHR) data.

METHODS

This tool scans EHR documents, extracting text snippet features surrounding key words (such as metastatic, progression, and local). A regularized logistic regression model was trained and used to classify patients across five metastatic categories: highly likely and likely positive, highly likely and likely negative, and unknown. Using a real-world oncology database of patients with solid tumors with manually abstracted information as reference, we calculated sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). We validated the performance in a real-world data set, evaluating accuracy gains upon additional user review of tool's outputs after integration into clinic workflows.

RESULTS

In the training data set (N = 66,532), the model sensitivity and specificity (% [95% CI]) were 82.4 [81.9 to 83.0] and 95.5 [95.3 to 96.7], respectively; the PPV was 89.3 [88.8 to 90.0], and the NPV was 94.0 [93.8 to 94.2]. In the validation sample (n = 200 from five distinct care sites), after user review of model outputs, values increased to 97.1 [85.1 to 99.9] for sensitivity, 98.2 [94.8 to 99.6] for specificity, 91.9 [78.1 to 98.3] for PPV, and 99.4 [96.6 to 100.0] for NPV. The model assigned 163 of 200 patients to the highly likely categories. The error prevalence was 4% before and 2% after user review.

CONCLUSION

This tool infers metastatic status from unstructured EHR data with high accuracy and high confidence in more than 75% of cases, without requiring additional manual review. By enabling efficient characterization of metastatic status, this tool could mitigate a key barrier for patient ascertainment and clinical trial participation in community clinics.

Navigating choice in the face of uncertainty: using a theory informed qualitative approach to identifying potential patient barriers and enablers to participating in an early phase chimeric antigen receptor T (CAR-T) cell therapy trial

OBJECTIVES

Bench to bedside translation of groundbreaking treatments like chimeric antigen receptor T (CAR-T) cell therapy depends on patient participation in early phase trials. Unfortunately, many novel therapies fail to be adequately evaluated due to low recruitment rates, which slows patient access to emerging treatments. Using the Theoretical Domains Framework (TDF), we sought to identify potential patient barriers and enablers to participating in an early phase CAR-T cell therapy trial.

DESIGN

We used qualitative semistructured interviews to identify potential barriers and enablers to patients' hypothetical participation in an early phase CAR-T cell therapy trial. We used the TDF and directed content analysis to identify relevant domains based on frequency, relevance and the presence of conflicting beliefs.

PARTICIPANTS

Canadian adult patients diagnosed with haematological malignancies.

RESULTS

In total, we interviewed 13 participants (8 women, 5 men). Participants ranged in age from 18 to 73 (median=56) and had been living with haematological cancer from a few months to several years. We found participants were unfamiliar with CAR-T cell therapy but wished to know more about treatment safety, efficacy and trial logistics (domains: knowledge, beliefs about consequences). They were motivated by altruistic considerations, though many prioritised personal health benefits despite recognising the goals (ie, establishing safety) of early phase clinical trials (domains: goals, intentions). Every participant valued receiving medical advice from their haematologists and oncologists, though some preferred impartial medical experts to inform their decision making (domain: social influences). Finally, participants indicated that improving access to financial and social supports would improve their trial participation experience (domain: environmental context and resources).

CONCLUSION

Using the TDF allowed us to identify factors that might undermine participation to a CAR-T cell therapy trial and to optimise recruitment processes by considering patient perspectives to taking part in early phase trials.Trial regestration: NCT03765177; Pre-results.

An Evaluation of Clinical Trial Multimedia to Support Hispanic Cancer Patients' Informational and Decision-Making Needs

The inclusion of diverse populations in clinical trial research is a social justice imperative. Creating the communicative tools that can support cancer patients across varied cultural backgrounds in processing complex clinical trial information, to achieve informed consent, has been a challenge. This study sought to evaluate specific clinical trial multimedia-a website, four animations, and a decision aid-to meet the decision-making and informational needs of Hispanic patients. The multimedia content was positively evaluated by Hispanic cancer patients. However, the discussions also yielded important steps for culturally adapting these tools to account for particular informational needs and cultural values that would be important to incorporate into these, and future, clinical trial multimedia interventions that target Hispanic populations.

Does a video clip enhance recruitment into a parenting trial? Learnings from a study within a trial

Background

Reaching recruitment targets in randomised controlled trials is a challenge. Media tools are increasingly used to engage participants, yet there is a paucity of research into the use of video to optimise recruitment. We therefore tested whether adding a participant information video clip to a standard participant information sheet improved recruitment into a parenting trial.

Methods

One hundred seven participants were randomised to receive either a participant information sheet (n = 51) or an informational video clip (n = 56) as part of an email contact following a screening phase. All participants went on to receive the information sheet as part of the existing consent procedure.

Results

The video condition did not increase the odds of recruitment into the trial, such that those in the video condition were significantly less likely to participate in the main trial (OR = 0.253, CI = 0.104–0.618, p = 0.003).

Conclusion

The introduction of a video clip into the recruitment stages of a parenting trial did not lead to an improvement in recruitment; however, the small sample size precludes definitive inferences. We offer reflections on challenges encountered in implementing the SWAT and suggestions for other researchers seeking to embed recruitment SWATs into similar trials.

Trial registration

Current controlled trials ISRCTN 58327365. Registered on 19 March 2015.

SWAT registration

SWAT 106; Effects of a video clip on recruitment into a randomised trial. Registered on 20 December 2016.

Clinical trials knowledge and attitudes of Vietnamese- and Anglo-Australian cancer patients: A cross-sectional study

AIM

Low participation in cancer clinical trials by culturally and linguistically diverse (CALD) patients limits access to cutting-edge treatments and generalizability of results. This is the first study exploring trials knowledge/attitudes and their association with trial participation in Vietnamese- and Anglo-Australian cancer patients.

METHODS

Eligible patients diagnosed with cancer in the past 10 years were invited to complete a self-report questionnaire comprising validated measures of: trials knowledge and attitudes, preferred information amount, preferred decision-making involvement, health literacy, and past and future (i.e. hypothetical) trial participation. Multivariable linear regression evaluated correlates of trials knowledge/attitudes. Multinomial logistic regression estimated the relationship between trials knowledge/attitudes and possible future trial participation.

RESULTS

Vietnamese-Australian participants (n = 50) had more negative attitudes regarding trials than Anglo-Australians (n = 100; B = -9.28; 95% confidence interval [CI], -17.60 to -0.97; P = 0.029), but similar knowledge (B = -0.91; 95% CI, -2.27 to 0.44; P = 0.18). Future trial participation was associated with positive attitudes (odds ratio [OR] = 1.08; 95% CI, 1.04-1.12; P < 0.001) and greater knowledge (OR = 1.30; 95% CI, 1.04-1.62; P = 0.02), but not Vietnamese background (OR = 0.95; 95% CI, 0.27-3.32; P = 0.93).

CONCLUSION

Despite poorer attitudes regarding trials in Vietnamese-Australians, Vietnamese background was not associated with less likely future trial participation, suggesting low trial participation by CALD patients may be more due to opportunity barriers. Improving knowledge and attitudes may increase trial participation generally.

Patient Education Programs in Pediatric Atopic Dermatitis: A Systematic Review of Randomized Controlled Trials and Meta-Analysis

INTRODUCTION

Patient education is crucial for improving disease outcomes in atopic dermatitis (AD). This review aims to summarize evidence about the effectiveness of educational programs for parents of pediatric AD patients.

METHODS

PubMed and Embase (inception to Feb 2020) were searched and randomized controlled trials (RCTs) in English were included. Risk of bias was assessed using Cochrane risk of bias tools and quality of evidence was assessed by Grading of Recommendations Assessment, Development and Evaluation (GRADE). Pooled standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated for the disease severity instrument (Scoring of Atopic Dermatitis, SCORAD) and quality of life (QoL) instruments using the random-effects model.

RESULTS

A total of 13 RCTs were included in the systematic review. The meta-analysis of SCORAD contained seven studies with a total of 1853 patients. The reduction in disease severity (SCORAD) was larger in the treatment group (SMD = - 8.22, 95% CI = - 11.29, - 5.15; P < 0.001; I2  =  78.6%). Subgroup analyses revealed that the association was modified by the frequency of sessions (P for Cochran Q  <  0.01) and the duration of follow-up (P for Cochran Q   <  0.01). No significant effect-modification was observed for disease severity and borderline significance was observed for session delivery (individual vs group session). The pooled effect sizes for QoL measures including Dermatitis Family Index (SMD = - 0.65, 95% CI = - 1.49, 0.18), Children's Dermatology Life Quality Index (SMD = - 1.61, 95% CI = - 3.76, 0.55; I2= 89.0%) and Infants' Dermatology Quality of Life Index (SMD = 0.30, 95% CI = - 1.04, 1.63; I2= 63.1%) were not significant.

CONCLUSIONS

Structured patient education is beneficial and should be implemented for the management of AD patients. However, an optimal delivery mode needs to be determined.

Barriers to Participation in Therapeutic Clinical Trials as Perceived by Community Oncologists

PURPOSE

Despite considerable research on the barriers to enrollment in cancer therapeutic trials, few studies have elicited barriers from the perspective of community physicians, who provide the majority of cancer care. The purpose of this study was to characterize barriers to and facilitators of cancer therapeutic trials as perceived by oncologists in community practices.

METHODS

Twenty semistructured interviews were conducted with oncologists at six community sites affiliated with City of Hope National Medical Center from March to June 2018. Responses were recorded digitally and transcribed. Data were analyzed using qualitative content analysis.

RESULTS

Of the 20 participants, 4 (20%) were women, 13 (65%) had > 10 years of practice experience, and 16 (80%) reported that < 5% of their patients were enrolled in a therapeutic trial. Participants identified four system-level barriers: lack of appropriate trials for community-based settings, insufficient infrastructure support, restrictive eligibility criteria, and financial limitations; three physician-level barriers: lack of awareness of available trials, lack of knowledge of trial details, and lack of time; and two patient-level barriers: patient burden and negative beliefs/attitudes toward research. Efforts aimed to increase trial availability, clinical trial support personnel, and physician knowledge were identified as major facilitators.

CONCLUSION

Community oncologists face numerous complex, multifaceted barriers to cancer therapeutic trial enrollment. Although expanding clinical research beyond the academic setting allows access to a larger and more diverse patient population, increasing generalizability and relevance of trial findings, there remains a substantial need for new strategies to improve cancer research delivery in the community.

Discordant attitudes and beliefs about cancer clinical trial participation between physicians, research staff, and cancer patients

BACKGROUND/AIMS

Essential to bringing innovative cancer treatments to patients is voluntary participation in clinical trials but approximately 8% of American cancer patients are enrolled onto a trial. We used a domain-oriented framework to assess barriers to cancer clinical trial enrollment.

METHODS

Physicians (MD, DO, fellows, residents) and research staff (physician assistants, nurse practitioners, staff and research nurses, clinical assistants, and program coordinators) involved in clinical research at a comprehensive cancer center completed an online survey in 2017; adult cancer patients not currently enrolled in a trial were interviewed in 2018. To inform the construct of our physician/staff and patient surveys and to assess barriers to clinical trial enrollment, we first conducted in-depth interviews among 14 key informants representing medical, hematologic, gynecologic, neurologic, radiation oncology, as well as members of the clinical research team (one clinical research coordinator, one research nurse practitioner). Perceived structural, provider- and patient-level barriers to clinical trial enrollment were assessed. Differences in perceptions, attitudes, and beliefs toward clinical trial enrollment between (1) physicians and staff, (2) patients by ethnicity, and (3) physicians/staff and patients were examined.

RESULTS

In total, 120 physicians/staff involved in clinical research (39.2% physicians, 60.8% staff; 48.0% overall response rate) and 150 cancer patients completed surveys. Nearly three-quarters of physician/staff respondents reported difficulty in keeping track of the eligibility criteria for open studies but was more often cited by physicians than staff (84.4% vs 64.3%, p = 0.02). Physicians more often reported lack of time to present clinical trial information than did staff(p < 0.001); 44.0% of staff versus 18.2% of physicians reported patient family interaction as a clinical trial enrollment barrier (p = 0.007). Hispanic patients more often stated they would join a trial, even if standard therapy was an option compared to non-Hispanic patients (47.7% vs 20.8%, p = 0.002). Comparing the beliefs and perceptions of physicians/staff to those of patients, patients more often reported negative beliefs about clinical trial enrollment (e.g. being in a trial does not help patients personally, 32.9% vs 1.8%, p < 0.001) but less often felt they had no other options when agreeing to join (38.1% vs 85.6%, p < 0.001), and less often refused clinical trial enrollment due to lack of understanding (9.1% vs 63.3%, p = 0.001) than reported by physicians/staff.

CONCLUSION

Our findings indicate a wide gap between physician/staff and patient attitudes and beliefs about clinical trial enrollment and highlight the importance of focusing future initiatives to raise awareness of this incongruency. Reconciling these differences will require tailored education to reduce implicit biases and dispel misperceptions. Strategies to improve the quality of patient-provider communication and address infrastructure and resource issues are also needed to improve patient enrollment onto cancer clinical trials.

Physician Perceptions of the Use of Social Media for Recruitment of Patients in Cancer Clinical Trials

IMPORTANCE

Social media campaigns have been successfully implemented in nontherapeutic trials. However, evidence to support their utility in cancer therapeutic trials is limited.

OBJECTIVE

To examine physician attitudes toward and perceptions of social media use for therapeutic trial recruitment of patients with cancer.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study engaged 44 physicians (24 academic based and 20 community based) at the main academic and 6 affiliated community sites of City of Hope in Duarte, California. Semistructured interviews were conducted in person or by telephone from March to June 2018. An interview guide was developed to explore perceptions of social media use for accrual of cancer therapeutic trials. Responses were recorded digitally and transcribed. Data were analyzed using qualitative content analysis.

MAIN OUTCOMES AND MEASURES

Physicians' perceptions of the advantages and disadvantages of using social media for clinical trial recruitment, strategies to improve uptake of social media in clinical trials, and the barriers and facilitators to social media use for professional purposes in general.

RESULTS

Of the 44 participants, 16 (36%) were women, 30 (68%) had more than 10 years of practice experience, 24 (55%) practiced in academia, and 20 (45%) practiced in the community. Physicians most commonly cited increased trial awareness and visibility as an advantage of using social media for trial recruitment. Cited disadvantages were increased administrative burden and risk of misinformation. Physicians also reported a need for institutional-level interventions (eg, restructuring of clinical trial offices to include personnel with social media expertise), increased evidence-based approaches to social media use, and more physician training on the use of social media. Perceived facilitators to professional social media use were networking and education; barriers included lack of time and lack of evidence of benefit.

CONCLUSIONS AND RELEVANCE

In this qualitative study, physicians recognized the benefits of using social media for clinical trial recruitment but noted that barriers, including increased administrative burden, increased time, and the risk of misinformation, remain. Future interventions to address these concerns are a required first step in increasing digital engagement for clinical trial accrual purposes.

Engaging limited English proficient and ethnically diverse low-income women in health research: A randomized trial of a patient navigator intervention

OBJECTIVE

Evaluate a community-based navigator intervention to increase breast cancer patients' and survivors' access to information about health research participation opportunities.

METHODS

In the context of a Community Based Participatory Research collaboration, we conducted a prospective randomized controlled trial of the Health Research Engagement Intervention with pre- and post-intervention surveys (n = 133). The primary outcome was health research information-seeking behavior. Secondary outcomes were health research knowledge, willingness to participate in health research, and health empowerment. Qualitative interviews (n = 11) elucidated participant perspectives on the intervention.

RESULTS

There was no statistically significant difference between intervention and control groups' information-seeking behavior. Knowledge that not all health research studies are about drugs or treatments increased significantly from pre- to post-test among intervention group participants (32% to 48%, p = 0.012), but not in the control group (43% to 30%, p = 0.059); the difference between arms was statistically significant (p = 0.0012). Although survey responses indicated willingness to participate, qualitative interviews identified competing priorities that limited participants' motivation to seek enrollment information.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Community-based navigators are a trusted, and therefore promising link between health research and low-income underserved communities. However, systemic barriers in health research infrastructures need to be addressed to include low income, LEP and immigrant populations.

Evaluating a Video-Based, Personalized Webpage in Genitourinary Oncology Clinical Trials: A Phase 2 Randomized Trial

Background

The pace of drug discovery and approvals has led to expanding treatments for cancer patients. Although extensive research exists regarding barriers to enrollment in oncology clinical trials, there are limited studies evaluating processes to optimize patient education, oral anticancer therapy administration, and adherence for patients enrolled in clinical trials. In this study, we assess the feasibility of a video-based, personalized webpage for patients enrolled in genitourinary oncology clinical trials involving 1 or more oral anticancer therapy.

Objective

The primary objective of this trial was to assess the differences in the number of patient-initiated violations in the intervention arm compared with a control arm over 4 treatment cycles. Secondary objectives included patient satisfaction, frequently asked questions by patients on the intervention arm, patient-initiated calls to study team members, and patient-reported stress levels.

Methods

Eligible patients enrolling on a therapeutic clinical trial for a genitourinary malignancy were randomized 2:1 to the intervention arm or control arm. Patients randomized to the intervention arm received access to a video-based, personalized webpage, which included videos of patients’ own clinic encounters with their providers, instructional videos on medication administration and side effects, and electronic versions of educational documents.

Results

A total of 99 patients were enrolled (89 were evaluable; 66 completed 4 cycles). In total, 71% (40/56) of patients in the intervention arm had 1 or more patient-initiated violation compared with 70% (23/33) in the control arm. There was no difference in the total number of violations across 4 cycles between the 2 arms (estimate=−0.0939, 95% CI−0.6295 to 0.4418, P value=.73). Median baseline satisfaction scores for the intervention and control arms were 72 and 73, respectively, indicating high levels of patient satisfaction in both arms. Median baseline patient-reported stress levels were 10 and 13 for the intervention and control arms, respectively, indicating low stress levels in both arms at baseline.

Conclusions

This study is among the first to evaluate a video-based, personalized webpage that provides patients with educational videos and video recordings of clinical trial appointments. Despite not meeting the primary endpoint of reduced patient-initiated violations, this study demonstrates the feasibility of a video-based, personalized webpage in clinical trials. Future research assessing this tool might be better suited for realms outside of clinical trials and might consider the use of an endpoint that assesses patient-reported outcomes directly. A major limitation of this study was the lack of prior data for estimating the null hypothesis in this population.

Investigation of a multimedia, computer-based approach to improve knowledge, attitudes, self-efficacy, and receptivity to cancer clinical trials among newly diagnosed patients with diverse health literacy skills

BACKGROUND

Enrollment in therapeutic cancer trials remains low, and is especially challenging for patients with low health literacy. The authors tested an interactive technology designed for patients with diverse health literacy skills with the aim of improving patient receptiveness, willingness, knowledge, self-efficacy, and positive attitudes regarding clinical trials.

METHODS

Patients presenting for their first oncology appointment were eligible. Patients viewed an interactive teaching video concerning clinical trials that was adapted from the National Institutes of Health. Validated surveys assessing receptiveness, willingness, knowledge, self-efficacy, and positive attitudes regarding clinical trials were administered before and after the test.

RESULTS

A total of 120 patients with cancer were enrolled. Approximately 80% were non-Hispanic white, 33% were female, 69% had >high school education, and 8% reported an income <$20,000. Approximately 33% scored within the low health literacy range. Changes between pretest and posttest demonstrated increases in knowledge (P < .001), self-efficacy (P < .001), and positive beliefs (P = .004); a slight decrease in willingness (P = .009); and no difference in patient receptivity (P = .31). Higher health literacy was associated with improved willingness (P = .049) and non-Hispanic white race was associated with improved receptivity (P = .034).

CONCLUSIONS

Interactive technology that was designed for patients with diverse health literacy skills demonstrated the ability to improve knowledge, self-efficacy, and positive beliefs regarding cancer clinical trials. Contrary to the hypothesis of the current study, patients with lower health literacy did not appear to derive a greater advantage from this technology. There was no improvement noted with regard to patient willingness or receptivity, and clinical trial enrollment remained at historical institutional levels. Talking touchscreen technology has a potential role as an important element in informed decision making for patients, but likely needs to be coupled with more robust and multitargeted interventions.

Financial Toxicity and Equitable Access to Clinical Trials

Financial barriers to clinical trial enrollment are an area of active investigation. Financial toxicity as a concept describes how high costs and financial burden can lead to compromised care and outcomes. Despite the potential to yield large survival benefits and improved access to cutting-edge therapies, less than 5% of adult patients with cancer are enrolled in a clinical trial. Disparities in trial enrollment exist along age, ethnic, and sociodemographic lines, with younger, poorer, nonwhite patients with private insurance-the exact population who may be at highest risk for financial toxicity-less likely to participate. Cost and insurance concerns remain an obstacle for clinical trial enrollment for certain patient populations. Changing the clinical trial paradigm with a focus on addressing structural and clinical barriers to clinical trial enrollment is paramount. This includes expanding access to clinical trials within community populations, advocating for health policy changes to guarantee insurance coverage of clinical trial standard-of-care health care, and considering noncoercive financial assistance (particularly for indirect costs like travel and lodging) for participants to defray their additional costs of participation. Additional steps toward education, cost transparency, and expansion of foundation assistance may also improve equitable access to clinical trials for all.

Attitudes and Preferences Toward a Hypothetical Trial of an Internet-Administered Psychological Intervention for Parents of Children Treated for Cancer: Web-Based Survey

BACKGROUND

Clinical trials are often challenged with issues of recruitment and retention. Little is known concerning general attitudes and preferences toward trial design and willingness to participate among parents of children treated for cancer. Furthermore, willingness to participate in internet-administered psychological interventions remains unexplored. In this study, we examined attitudes and preferences of the population regarding study procedures for a hypothetical trial of an internet-administered psychological intervention. In addition, differences in the response rate between modes of study invitation and willingness to engage in internet-administered interventions were examined.

OBJECTIVE

The primary objective of this study was to examine attitudes and preferences toward participating in an internet-administrated psychological intervention. The secondary objective was to examine the response rates and help-seeking behavior among parents of children treated for cancer.

METHODS

A cross-sectional, Web-based survey was conducted with parents of children who had completed cancer treatment. This Web-based survey examined self-reported emotional distress, prior help-seeking and receipt of psychological support, past research participation, attitudes toward research, preferences concerning recruitment procedures, and attitudes toward different types of trial design.

RESULTS

Of all the parents invited, 32.0% (112/350) completed the survey, with no difference in response rate between modes of study invitation (χ²₁=0.6, P=.45). The majority (80/112, 71.4%) of parents responded that they had experienced past emotional distress. Responses indicated high (56/112, 50.0%) or somewhat high trust in research (51/112, 45.5%), and the majority of parents would accept, or maybe accept, internet-administered psychological support if offered (83/112, 74.1%). In addition, responses showed a preference for postal study invitation letters (86/112, 76.8%), sent by a researcher (84/112, 75.0%) with additional study information provided on the Web via text (81/112, 72.3%) and video (66/112, 58.9%). Overall, parents responded that trials utilizing a waiting list control, active alternative treatment control, or a patient-preference design were acceptable.

CONCLUSIONS

Parents of children treated for cancer appear willing to participate in trials examining internet-administered psychological support. Findings of this study will inform the design of a feasibility trial examining internet-administered psychological support for the population.

Empowering Latina breast cancer patients to make informed decisions about clinical trials: a pilot study

Minority representation in clinical trials is vital for researchers to assess differential effects in outcomes of therapies on biological and genetic characteristics among groups. This study assessed the effect of Choices, a bilingual multi-component intervention, on perceived understanding of clinical trials, agreement with stages of decision readiness and consideration of clinical trials as a treatment option, among Latina breast cancer patients. This randomized controlled pilot study compared Choices with a control condition providing general clinical trial information to eligible patients. Seventy-seven Latina breast cancer patients were randomly assigned to either Choices (n = 38) or the control (n = 39). Choices included three components: an educational interactive video, a low-literacy booklet, and care coordination by patient navigation (i.e., educational and psychosocial support, coordinating appointments, translating, interacting with the medical team). Choices was more effective than the control in improving perceived understanding of clinical trials (p = .033) and increasing consideration of clinical trials as a treatment option (p = .008). Additionally, intervention participants showed significant changes between baseline and post-intervention on agreement with stages of decision readiness statements (p < .002) than control participants (p > .05); the percentage of intervention women in agreement with preparation to action statements increased from 52.8% at baseline to 86.1% at post-intervention, and those in agreement with ready to action stages rose from 50.0% to 88.9%. Computer-based videos and care coordination provided by patient navigation-specifically tailored to Latinos-are effective strategies to successfully address awareness, and improved decision-making skills to make informed decisions about clinical trial participation.

CancerLinQ: Origins, Implementation, and Future Directions

Rapid-learning health systems have been proposed as a potential solution to the problem of quality in medicine, by leveraging data generated from electronic health systems in near-real time to improve quality and reduce cost. Given the complex, dynamic nature of cancer care, a rapid-learning health system offers large potential benefits to oncology practice. In this article, we review the rationale for developing a rapid-learning health system for oncology and describe the sequence of events that led to the development of ASCO’s CancerLinQ (Cancer Learning Intelligence Network for Quality) initiative, as well as the current state of CancerLinQ, including its importance to efforts such as the Beau Biden Cancer Moonshot. We then review the considerable challenges facing optimal implementation of a rapid-learning health system such as CancerLinQ, including integration of rapidly expanding multiomic data, capturing big data from a variety of sources, an evolving competitive landscape, and implementing a rapid-learning health system in a way that satisfies many stakeholders, including patients, providers, researchers, and administrators.

Importance of incorporating measures of attitude in planning and evaluating nursing education

Learners' attitudes towards a topic or behavior has long been recognized as an important component in the evaluation of formal education as well as in achieving desired behavior change. However, attitudes are frequently neglected and evaluation of outcomes from continuing nursing education often includes only changes in knowledge and learner satisfaction. We describe measurement of attitudes of oncology nurses towards holding discussions with patients about the option of participating in a clinical trial, in comparison to what can be learned from measuring knowledge alone. This article illustrates important insights that can be gained through inclusion of measures of attitude in both designing and evaluating continuing education using data from a larger on-going study.

Participant Outcomes from Methods of Recruitment for Videogame Research

OBJECTIVE

The most productive methods of recruitment for a videogame for health (G4H) trial are not known. Success or failure of recruitment methods has been reported for a variety of clinical trials, but few specifically for G4H trials. This study's goal was to recruit 444 overweight or obese (body mass index percentile between the 84.5th-99.4th percentiles) children between the ages of 10-12 years. The article reports the results of different methods of participant recruitment.

MATERIALS AND METHODS

Participants had to agree to three fasting blood samples (baseline, immediately after, and 2 months later); be willing to wear an accelerometer for 7 days at each assessment; read and speak English fluently (because the games were in English); have no history of any condition that would affect what he/she could eat or how much physical activity he/she could get; and have an eligible home computer purchased in the last 5 years with high-speed internet. Hardware criteria reflected the types of computers upon which Diab-Nano could be effectively played. Recruitment was conducted over a 35-month period and included electronic media, print advertising, community recruitment, and an internal volunteer list. Respondents were guided to a web-based screening questionnaire that asked for source of hearing about the study.

RESULTS

Although diverse recruitment methods were used, slow recruitment resulted in obtaining only 45% of the recruitment goal (n = 199). Electronic media (e.g., radio, television, and internet), which reached millions of targeted parents, resulted in only 76 respondents, of whom 13 became participants; print media (e.g., magazine, newsletter/newspaper, and mail), which also reached large numbers of parents, resulted in 192 respondents, of whom 19 became participants; community recruitment (e.g., school, friend or family, doctors office, flyer, work, community program) resulted in 162 respondents, of whom 38 became participants; and the internal volunteer list resulted in 413 respondents, of whom 128 became participants.

CONCLUSION

Inclusionary and exclusionary criteria and restricted access by gatekeepers could be deterrents to successful recruitment. The documented payoff of alternative comprehensive methods of recruitment should benefit other investigations in optimally allocating their recruitment resources.

Addressing Financial Barriers to Patient Participation in Clinical Trials: ASCO Policy Statement

Research conducted through clinical trials is essential for evaluating new treatment modalities, establishing new standards of cancer care, and ultimately improving and prolonging the lives of patients with cancer. However, participation in trials has been low, and this is attributable to various factors including patient financial barriers. Such financial barriers include the rising cost of cancer care; a lack of transparency in coverage policy; and the perception of ethical, compliance, or institutional impediments to patient financial support. ASCO convened a roundtable discussion with a variety of stakeholders to define the scope of the problem, as well as to identify clinical practice and policy solutions applicable at the institutional and system-wide levels. This statement summarizes key discussions from the ASCO Roundtable, as well as findings from the literature, and provides ASCO's recommendations for overcoming financial barriers that may otherwise prevent participation in clinical trials. These recommendations broadly address the following key areas: (1) improving the policy environment for coverage of clinical trials; (2) facilitating transparency among providers, patients, and payers for trial-related out-of-pocket costs; (3) refuting the specter of inducement to enable targeted financial support for patients; and (4) improving the available data on costs of cancer clinical trials.

The Role of Oncology Nurses in Discussing Clinical Trials

PURPOSE/OBJECTIVES

To describe oncology nurses' experiences discussing clinical trials with their patients, and to assess barriers to these discussions.
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RESEARCH APPROACH

A qualitative study designed to elicit narratives from oncology nurses. 
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SETTING

Community- and academic-based oncology clinics throughout the United States.
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PARTICIPANTS

33 oncology nurses involved in direct patient care in community-based and large hospital-based settings. The sample was drawn from members of the Oncology Nursing Society. 
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METHODOLOGIC APPROACH

In-depth interviews were conducted and analyzed using a 
immersion/crystallization approach to identify themes and patterns. The analyses highlight specific issues, examples, and contexts that present challenges to clinical trial discussions with patients.
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FINDINGS

Oncology nurses view their roles as patient educators and advocates to be inclusive of discussion of clinical trials. Barriers to such discussions include lack of knowledge and strategies for addressing patients' common misconceptions and uncertainty about the timing of discussions.
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INTERPRETATION

These data indicate that enabling nurses to actively engage patients in discussions of clinical trials requires educational interventions to build self-efficacy and close knowledge gaps. 
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IMPLICATIONS FOR NURSING

Oncology nurses can play a critical role in advancing cancer care by supporting patients in decision making about clinical trial participation. This will require training and education to build their knowledge, reduce barriers, and increase their self-efficacy to fulfill this responsibility in various clinical settings.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.