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Gerber DE, Tiro JA, McNeill LH, Williams EL, Zhu H, Lee SJC, Leavey PJ, Sadeghi N, Kapinos KA, Dornsife DL, Nguyen V, Wileyto EP, Guerra CE. Enhancing access to and diversity in cancer clinical trials through a financial reimbursement program: Protocol to evaluate a novel program. Contemp Clin Trials 2022; 121:106922. [PMID: 36096281 DOI: 10.1016/j.cct.2022.106922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 01/27/2023]
Abstract
As clinical trials have become more complex, with increasing numbers of required procedures and clinic visits, gaining access to promising new treatments has become even more challenging for many individuals. To address these barriers, we implemented a financial reimbursement and outreach program designed to increase the number and diversity of participants in cancer clinical trials at centers in Dallas, Houston, and Philadelphia. As endorsed by U.S. Food and Drug Administration (FDA) and the Texas and Pennsylvania State Legislatures, the program provides financial reimbursement for non-clinical costs (e.g., travel, lodging) to patients on cancer clinical trials with household income up to 700% the Federal poverty rate. The research study described here, centered at the Dallas site, evaluates program impact by assessing (1) numbers and diversity of patients enrolled to cancer clinical trials before and after program implementation; (2) characteristics of patients offered participation in the program who do versus do not enroll; (3) characteristics of patients enrolled in the program who do versus do not complete the reimbursement process. To evaluate perceived barriers and facilitators of program participation, we will conduct semi-structured interviews and administer the Comprehensive Score for Financial Toxicity Patient Reported Outcome Measure (COST PROM) and the Short Assessment of Health Literacy (SAHL). This program will examine how reimbursement of non-clinical costs can improve access to cancer clinical trials, with the eventual goal of increasing trial enrollment, diversity, representativeness, and generalizability.
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Affiliation(s)
- David E Gerber
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Division of Hematology-Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA; Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Jasmin A Tiro
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Lorna H McNeill
- Department of Health Disparities Research, Division of Cancer Prevention and Population Sciences, MD Anderson Cancer Center, Houston, TX, USA.
| | - Erin L Williams
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Hong Zhu
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Simon J Craddock Lee
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Patrick J Leavey
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA; Children's Health, Dallas, TX, USA.
| | - Navid Sadeghi
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Division of Hematology-Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA; Parkland Health and Hospital System, Dallas, TX, USA.
| | - Kandice A Kapinos
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX, USA; RAND Corporation, Santa Monica, CA, USA.
| | | | - Vivian Nguyen
- Abramson Cancer Center and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - E Paul Wileyto
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Carmen E Guerra
- Abramson Cancer Center and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Gerber DE, Hamann HA, Dorsey O, Ahn C, Phillips JL, Santini NO, Browning T, Ochoa CD, Adesina J, Natchimuthu VS, Steen E, Majeed H, Gonugunta A, Lee SJC. Clinician Variation in Ordering and Completion of Low-Dose Computed Tomography for Lung Cancer Screening in a Safety-Net Medical System. Clin Lung Cancer 2020; 22:e612-e620. [PMID: 33478912 DOI: 10.1016/j.cllc.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 11/19/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Less than 5% of eligible individuals in the United States undergo lung cancer screening. Variation in clinicians' participation in lung cancer screening has not been determined. PATIENTS AND METHODS We studied medical providers who ordered ≥ 1 low-dose computed tomography (LDCT) for lung cancer screening from February 2017 through February 2019 in an integrated safety-net healthcare system. We analyzed associations between provider characteristics and LDCT orders and completion using chi-square, Fisher exact, and Student t tests, as well as ANOVA and multinomial logistic regression. RESULTS Among an estimated 194 adult primary care physicians, 144 (74%) ordered at least 1 LDCT, as did 39 specialists. These 183 medical providers ordered 1594 LDCT (median, 4; interquartile range, 2-9). In univariate and multivariate models, family practice providers (P < .001) and providers aged ≥ 50 years (P = .03) ordered more LDCT than did other clinicians. Across providers, the median proportion of ordered LDCT that were completed was 67%. The total or preceding number of LDCT ordered by a clinician was not associated with the likelihood of LDCT completion. CONCLUSION In an integrated safety-net healthcare system, most adult primary care providers order LDCT. The number of LDCT ordered varies widely among clinicians, and a substantial proportion of ordered LDCT are not completed.
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Affiliation(s)
- David E Gerber
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX; Division of Hematology-Oncology, UT Southwestern Medical Center, Dallas, TX; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX.
| | - Heidi A Hamann
- Departments of Psychology and Family and Community Medicine, University of Arizona, Tucson, AZ
| | - Olivia Dorsey
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Chul Ahn
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX
| | - Jessica L Phillips
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Noel O Santini
- Parkland Health and Hospital System, Dallas, TX; Division of General Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Travis Browning
- Parkland Health and Hospital System, Dallas, TX; Department of Radiology, UT Southwestern Medical Center, Dallas, TX
| | - Cristhiaan D Ochoa
- Parkland Health and Hospital System, Dallas, TX; Division of Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX
| | | | | | - Eric Steen
- Parkland Health and Hospital System, Dallas, TX; Division of General Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Harris Majeed
- School of Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Amrit Gonugunta
- School of Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Simon J Craddock Lee
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX
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Gupta A, Ocker G, Chow PI. Recruiting breast cancer patients for mHealth research: Obstacles to clinic-based recruitment for a mobile phone app intervention study. Clin Trials 2020; 17:675-683. [PMID: 32660354 DOI: 10.1177/1740774520939247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Nearly half of newly diagnosed breast cancer patients will report clinically significant symptoms of depression and/or anxiety within the first year of diagnosis. Research on the trajectory of distress in cancer patients suggests that targeting patients early in the diagnostic pathway could be particularly impactful. Given the recent rise of smartphone adoption, apps are a convenient and accessible platform from which to deliver mental health support; however, little research has examined their potential impact among newly diagnosed cancer patients. One reason is likely due to the obstacles associated with in-clinic recruitment of newly diagnosed cancer patients for mHealth pilot studies. METHODS This article draws from our experiences of a recently completed pilot study to test a suite of mental health apps in newly diagnosed breast cancer patients. Recruitment strategies included in-clinic pamphlets, flyers, and direct communication with clinicians. Surgical oncologists and research staff members approached eligible patients after a medical appointment. Research team members met with patients to provide informed consent and review the study schedule. RESULTS Four domains of in-clinic recruitment challenges emerged: (a) coordination with clinic staff, (b) perceived burden among breast cancer patients, (c) limitations regarding the adoption and use of technology, and (d) availability of resources. Potential solutions are provided for each challenge. CONCLUSION Recruitment of newly diagnosed cancer patients is a major challenge to conducting mobile intervention studies for researchers on a pilot-study budget. To realize the impact of mobile interventions for the most vulnerable cancer patient populations, health researchers must address barriers to in-clinic recruitment to provide vital preliminary data in proposals of large-scale research projects.
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Affiliation(s)
- Alisha Gupta
- University of Virginia, Charlottesville, VA, USA
| | | | - Philip I Chow
- Center for Behavioral Health and Technology, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA, USA
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Regnante JM, Richie N, Fashoyin-Aje L, Hall LL, Highsmith Q, Louis J, Turner K, Hoover S, Lee SC, González E, Williams E, Adams H, Obasaju C, Sargeant I, Spinner J, Reddick C, Gandee M, Geday M, Dang J, Watson R, Chen MS. Operational strategies in US cancer centers of excellence that support the successful accrual of racial and ethnic minorities in clinical trials. Contemp Clin Trials Commun 2020; 17:100532. [PMID: 32055746 PMCID: PMC7005557 DOI: 10.1016/j.conctc.2020.100532] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 01/09/2020] [Accepted: 01/19/2020] [Indexed: 12/17/2022] Open
Abstract
Background Study populations in clinical research must reflect US changing demographics, especially with the rise of precision medicine. However, racial and ethnic minority groups (REMGs) have low rates of participation in cancer clinical trials. Methods Criteria were developed to identify cancer centers able to accrue a higher than average proportion of REMGs into clinical trials. Comprehensive interviews were conducted with leaders of these cancer centers to identify operational strategies contributing to enhanced accrual of REMGs. Results Eight US cancer centers reported a REMG accrual rate range in cancer research between 10 and 50% in a 12-month reporting period and met other criteria for inclusion. Fourteen leaders participated in this assessment. Key findings were that centers: had a metric collection and reporting approach; routinely captured race and ethnicity data within databases accessible to research staff; had operational standards to support access and inclusion; developed practices to facilitate sustained patient participation during clinical trials; had strategies to decrease recruitment time and optimize clinical study design; and identified low-resource strategies for REMG accrual. There was also a clear commitment to establish processes that support the patient's provider as the key influencer of patient recruitment into clinical trials. Conclusion We have identified operational practices that facilitate increased inclusion of REMGs in cancer trials. In order to establish a sustainable cancer center inclusion research strategy, it is valuable to include an operational framework that is informed by leading US cancer centers of excellence.
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Affiliation(s)
- Jeanne M Regnante
- Center for Sustainable Health Care Quality and Equity, 1201 15th Street, NW, Suite 340, Washington, DC, 20005, USA
| | - Nicole Richie
- Genentech, 1 DNA Way, South San Francisco, 94080, USA
| | - Lola Fashoyin-Aje
- Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Laura Lee Hall
- Center for Sustainable Health Care Quality and Equity, 1201 15th Street, NW, Suite 340, Washington, DC, 20024, USA
| | | | - J'Aimee Louis
- Center for Sustainable Health Care Quality and Equity, 1201 15th Street, NW, Suite 340, Washington, DC, 20024, USA
| | - Kenneth Turner
- Johnson & Johnson, One Johnson & Johnson Plaza, New Brunswick, NJ, 08933, USA
| | - Spencer Hoover
- Henry Ford Cancer Institute, 2850 W. Grand Blvd, Detroit, MI, 48202, Ste 2, USA
| | - Simon Craddock Lee
- Harold C. Simmons Comprehensive Cancer Center, Ut Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9179, USA
| | - Evelyn González
- Fox Chase Cancer Center/Temple Health, 333 Cottman Ave, Philadephia, PA, 19111, USA
| | - Erin Williams
- Harold C. Simmons Comprehensive Cancer Center, Ut Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9179, USA
| | - Homer Adams
- Janssen Research and Development, 800 Ridgeview Drive, Horsham PA, USA
| | - Coleman Obasaju
- Eli Lilly and Company, 893 S Delaware St, Indianapolis, IN, 46225, USA
| | - Ify Sargeant
- Ismedica Ltd, Wrinehill, Staffordshire, CW3 9BW, UK
| | - Jovonni Spinner
- Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Christopher Reddick
- Takeda Pharmaceutical Company, One Takeda Parkway, Deerfield, IL, 60015, USA
| | - Marianne Gandee
- Association of Community Cancer Centers, 11600 Nebel St. Suite 201. Rockville, MD, 20852, USA
| | - Madeline Geday
- Merck & Company, Inc, Merck and Co., Inc, 2000 Galloping Hill Road, Kenilworth, NJ, 07033, USA
| | - Julie Dang
- UC Davis Comprehensive Cancer Center, UCDCCC, 2279 45th St, Sacramento, CA, 95817, USA
| | - Rayneisha Watson
- Deloitte Consulting, 1919 N Lynn St Ste 1500, Arlington, VA, 22209, USA
| | - Moon S Chen
- Uc Davis Comprehensive Cancer Center, UCDCCC, 4501 X Street, Suite 3016, Sacramento, CA, 95817, USA
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QTc Interval-Prolonging Medications Among Patients With Lung Cancer: Implications for Clinical Trial Eligibility and Clinical Care. Clin Lung Cancer 2019; 21:21-27.e5. [PMID: 31780402 DOI: 10.1016/j.cllc.2019.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/09/2019] [Accepted: 07/25/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Concomitant medication use, including agents that prolong the corrected QT (QTc) interval, can result in the exclusion of patients with cancer from clinical trials. To estimate the potential effects on accrual, we determined the prevalence of QTc-prolonging medication prescriptions in a national patient cohort. PATIENTS AND METHODS We identified adult patients in the Veterans Affairs system with a diagnosis of lung cancer from 2003 to 2016. The use of QTc interval-prolonging medications and risk category were obtained from CredibleMeds. We calculated the prevalence of prescriptions for QTc-prolonging medications with a known or possible risk of torsade de pointes in the 3 months up to and including the date of cancer diagnosis. The rates across patient groups were compared using χ2 test. RESULTS A total of 280,068 patients were included in the present study. The mean age was 70 years, 98% were male, and 72% were white. Overall, 28.4% had been prescribed a QTc-prolonging medication, and 7.3% had been prescribed ≥2 in the 3 months before the cancer diagnosis. The most commonly prescribed QTc-prolonging medications were antimicrobial agents (14.0%), psychiatric agents (10.2%), antiemetic agents (2.6%), and cardiac medications (1.7%). Excluding the antimicrobial agents, 18.4% of the patients had been prescribed a QTc-prolonging medication. CONCLUSIONS A substantial proportion of individuals with lung cancer will be prescribed QTc-prolonging medications. These prescriptions can limit patients' eligibility for clinical trials and complicate the administration of standard cancer therapies. Further research into the actual clinical risks and optimal management of QTc-prolonging medications in cancer populations is warranted.
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Lee SJC, Murphy CC, Geiger AM, Gerber DE, Cox JV, Nair R, Skinner CS. Conceptual Model for Accrual to Cancer Clinical Trials. J Clin Oncol 2019; 37:1993-1996. [PMID: 31166822 PMCID: PMC6879309 DOI: 10.1200/jco.19.00101] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2019] [Indexed: 12/22/2022] Open
Affiliation(s)
| | | | | | - David E. Gerber
- The University of Texas Southwestern Medical Center, Dallas, TX
| | - John V. Cox
- The University of Texas Southwestern Medical Center, Dallas, TX
| | - Rasmi Nair
- The University of Texas Southwestern Medical Center, Dallas, TX
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Garcia S, Bisen A, Yan J, Xie XJ, Ramalingam S, Schiller JH, Johnson DH, Gerber DE. Thoracic Oncology Clinical Trial Eligibility Criteria and Requirements Continue to Increase in Number and Complexity. J Thorac Oncol 2017; 12:1489-1495. [PMID: 28802905 PMCID: PMC5610621 DOI: 10.1016/j.jtho.2017.07.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/12/2017] [Accepted: 07/17/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Eligibility criteria and screening procedures are designed to optimize the scientific yield and maximize the safety of clinical trials. However, they may also heighten trial complexity, hinder enrollment, decrease generalizability, and increase costs. We analyzed the types and number of eligibility criteria and screening procedures among thoracic oncology clinical trials sponsored or endorsed by the Eastern Cooperative Oncology Group. METHODS We identified trials and obtained protocols from the Eastern Cooperative Oncology Group website. Eligibility criteria were grouped and categorized as comorbidity (classified by organ system), administrative requirements, prior treatment, and measurable disease requirements. Associations between trial characteristics and eligibility criteria were analyzed by using the Kruskal-Wallis and Wilcoxon tests. RESULTS A total of 74 lung cancer trials activated in 1986-2016 were identified. The total number of eligibility criteria was associated with trial principal therapy (a median of nine for surgical, 18 for radiation, and 20 for medical therapy [p = 0.02]), trial primary end point (a median of 20 for overall survival, 28 for progression-free survival, and 17 for other [p = 0.001]), number of therapies (p = 0.05), and year of activation (a median of 16 for 1986-1995, 19 for 1996-2005, and 27 for 2006-2016 [P < 0.001]). The increase in trial eligibility requirements over time was limited to medical therapy trials. Over time, there was also an increase in blood test screening procedures (p = 0.05) but not in imaging, cardiac assessment, or pulmonary function screening procedures. CONCLUSIONS The number of eligibility criteria and screening procedures in medical therapy lung cancer clinical trials continues to rise. Continued efforts to simplify protocol eligibility and procedures are warranted to promote trial adherence, enrollment, completion, and generalizability.
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Affiliation(s)
- Sandra Garcia
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ajit Bisen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jingsheng Yan
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Xian-Jin Xie
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Suresh Ramalingam
- Department of Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Joan H Schiller
- Inova Schar Cancer Institute, Inova Health System, Falls Church, Virginia
| | - David H Johnson
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David E Gerber
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.
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Time and Effort Required for Tissue Acquisition and Submission in Lung Cancer Clinical Trials. Clin Lung Cancer 2017; 18:626-630. [PMID: 28576594 DOI: 10.1016/j.cllc.2017.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 04/24/2017] [Accepted: 04/25/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Increasingly, analysis of tumor tissue samples for predictive and pharmacodynamic biomarkers is incorporated into lung cancer clinical trials. We determined the time and effort required for tissue acquisition and submission. PATIENTS AND METHODS We analyzed data from patients enrolled from 2009 to 2016 at UT Southwestern onto lung cancer trials with mandatory or optional submission of tumor tissue. We collected dates of treatment-related events and staff communications; nature of tissue requirement and biomarker analysis; and location of archival tissue. Associations between case characteristics, clinical intervals, and number of staff communications were analyzed by Fisher's exact test, Wilcoxon 2-sample test, and Kruskal-Wallis test. RESULTS We identified 129 patients enrolled onto 19 clinical trials, of whom 108 (84%) ultimately received study therapy. For cases in which tissue submission was required if available or optional, 16% and 0%, respectively, had tissue sent. The median interval between consent and treatment was 28 (interquartile range, 11-43) days if tissue was requested and 7 (interquartile range, 6-13) days if tissue was not requested (P < .001). Among cases with requested tissue, the median number of related research staff communications was 3 (range, 0-10). Over time, the number of staff communications increased (P < .001). Location of archival tissue was not associated with number of staff communications or treatment intervals. CONCLUSION Lung cancer clinical trial requirements for tissue acquisition and submission affect the time to treatment initiation and require increasing staff effort. Improved systems to expedite these processes, as well as use of blood- or imaging-based biomarkers, may help address these issues.
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Gerber DE, Reimer T, Williams EL, Gill M, Loudat Priddy L, Bergestuen D, Schiller JH, Kirkpatrick H, Craddock Lee SJ. Resolving Rivalries and Realigning Goals: Challenges of Clinical and Research Multiteam Systems. J Oncol Pract 2016; 12:1020-1028. [PMID: 27624948 PMCID: PMC5455413 DOI: 10.1200/jop.2016.013060] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This article describes the care processes for a 64-year-old man with newly diagnosed advanced non-small-cell lung cancer who was enrolled in a first-line clinical trial of a new immunotherapy regimen. The case highlights the concept of multiteam systems in cancer clinical research and clinical care. Because clinical research represents a highly dynamic entity-with studies frequently opening, closing, and undergoing modifications-concerted efforts of multiple teams are needed to respond to these changes while continuing to provide consistent, high-level care and timely, accurate clinical data. The case illustrates typical challenges of multiteam care processes. Compared with clinical tasks that are routinely performed by single teams, multiple-team care greatly increases the demands for communication, collaboration, cohesion, and coordination among team members. As the case illustrates, the described research team and clinical team are separated, resulting in suboptimal function. Individual team members interact predominantly with members of their own team. A considerable number of team members lack regular interaction with anyone outside their team. Accompanying this separation, the teams enact rivalries that impede collaboration. The teams have misaligned goals and competing priorities that create competition. Collective identity and cohesion across the two teams are low. Research team and clinical team members have limited knowledge of the roles and work of individuals outside their team. Recommendations to increase trust and collaboration are provided. Clinical providers and researchers may incorporate these themes into development and evaluation of multiteam systems, multidisciplinary teams, and cross-functional teams within their own institutions.
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Affiliation(s)
- David E. Gerber
- University of Texas Southwestern Medical Center and Texas Oncology, Dallas, TX; and Purdue University, West Lafayette, IN
| | - Torsten Reimer
- University of Texas Southwestern Medical Center and Texas Oncology, Dallas, TX; and Purdue University, West Lafayette, IN
| | - Erin L. Williams
- University of Texas Southwestern Medical Center and Texas Oncology, Dallas, TX; and Purdue University, West Lafayette, IN
| | - Mary Gill
- University of Texas Southwestern Medical Center and Texas Oncology, Dallas, TX; and Purdue University, West Lafayette, IN
| | - Laurin Loudat Priddy
- University of Texas Southwestern Medical Center and Texas Oncology, Dallas, TX; and Purdue University, West Lafayette, IN
| | - Deidi Bergestuen
- University of Texas Southwestern Medical Center and Texas Oncology, Dallas, TX; and Purdue University, West Lafayette, IN
| | - Joan H. Schiller
- University of Texas Southwestern Medical Center and Texas Oncology, Dallas, TX; and Purdue University, West Lafayette, IN
| | - Haskell Kirkpatrick
- University of Texas Southwestern Medical Center and Texas Oncology, Dallas, TX; and Purdue University, West Lafayette, IN
| | - Simon J. Craddock Lee
- University of Texas Southwestern Medical Center and Texas Oncology, Dallas, TX; and Purdue University, West Lafayette, IN
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Increased Patient Enrollment to a Randomized Surgical Trial Through Equipoise Polling of an Expert Surgeon Panel. Ann Surg 2016; 264:81-6. [DOI: 10.1097/sla.0000000000001483] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Gerber DE, Lakoduk AM, Priddy LL, Yan J, Xie XJ. Temporal Trends and Predictors for Cancer Clinical Trial Availability for Medically Underserved Populations. Oncologist 2015; 20:674-82. [PMID: 26018661 DOI: 10.1634/theoncologist.2015-0083] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 04/01/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Lack of access to available cancer clinical trials has been cited as a key factor limiting trial accrual, particularly among medically underserved populations. We examined the trends and factors in clinical trial availability within a major U.S. safety-net hospital system. MATERIALS AND METHODS We identified cancer clinical trials activated at the Harold C. Simmons Cancer from 1991 to 2014 and recorded the characteristics of the trials that were and were not activated at the Parkland Health and Hospital System satellite site. We used univariate and multivariate logistic regression to determine the association between trial characteristics and nonactivation status, and chi-square analysis to determine the association between the trial characteristics and the reasons for nonactivation. RESULTS A total of 773 trials were identified, of which 152 (20%) were not activated at Parkland. In multivariable analysis, nonactivation at Parkland was associated with trial year, sponsor, and phase. Compared with the 1991-2006 period, clinical trials in the 2007-2014 period were almost eightfold more likely not to be activated at Parkland. The most common reasons for nonactivation at Parkland were an inability to perform the study procedures (27%) and the startup costs (15%). CONCLUSION Over time, in this single-center setting, a decreasing proportion of cancer clinical trials were available to underserved populations. Trial complexity and costs appeared to account for much of this trend. Efforts to overcome these barriers will be key to equitable access to clinical trials, efficient accrual, and the generalizability of the results. IMPLICATIONS FOR PRACTICE Despite numerous calls to increase and diversify cancer clinical trial accrual, the present study found that cancer clinical trial activation rates in a safety-net setting for medically underserved populations have decreased substantially in recent years. The principal reasons for study nonactivation were expenses and an inability to perform the study-related procedures, reflecting the increasing costs and complexity of cancer clinical trials. Future efforts need to focus on strategies to mitigate the increasing disparity in access to clinical research and cutting-edge therapies, which also threatens to hinder study accrual, completion rates, and generalizability.
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Affiliation(s)
- David E Gerber
- Division of Hematology-Oncology, Department of Internal Medicine, Department of Cell Biology, Division of Biostatistics, Department of Clinical Sciences, and Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Oncology Clinic, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Ashley M Lakoduk
- Division of Hematology-Oncology, Department of Internal Medicine, Department of Cell Biology, Division of Biostatistics, Department of Clinical Sciences, and Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Oncology Clinic, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Laurin L Priddy
- Division of Hematology-Oncology, Department of Internal Medicine, Department of Cell Biology, Division of Biostatistics, Department of Clinical Sciences, and Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Oncology Clinic, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Jingsheng Yan
- Division of Hematology-Oncology, Department of Internal Medicine, Department of Cell Biology, Division of Biostatistics, Department of Clinical Sciences, and Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Oncology Clinic, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Xian-Jin Xie
- Division of Hematology-Oncology, Department of Internal Medicine, Department of Cell Biology, Division of Biostatistics, Department of Clinical Sciences, and Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Oncology Clinic, Parkland Health and Hospital System, Dallas, Texas, USA
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Laccetti AL, Pruitt SL, Xuan L, Halm EA, Gerber DE. Effect of prior cancer on outcomes in advanced lung cancer: implications for clinical trial eligibility and accrual. J Natl Cancer Inst 2015; 107:djv002. [PMID: 25667420 DOI: 10.1093/jnci/djv002] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Prior cancer is a common exclusion criterion in lung cancer trials. This practice reflects concerns that prior cancer may affect trial conduct or outcomes. However, the impact of prior cancer on survival in lung cancer is not known. METHODS We identified patients older than age 65 years with stage IV lung cancer diagnosed between 1992 and 2009 in the Surveillance, Epidemiology, and End Results-Medicare linked registry. Prior cancer was characterized by type, stage, and timing. All-cause and lung cancer-specific survival were compared between patients with and without prior cancer using propensity score-adjusted Cox regression. RESULTS Overall, 102 929 patients with stage IV lung cancer were identified, of whom 14.7% had a history of prior cancer. More than two-thirds (76.0%) of prior cancers were localized or regional stage; most were diagnosed five or fewer years prior to the lung cancer diagnosis. In propensity score-adjusted analysis, patients with prior cancer had better all-cause (hazard ratio [HR] = 0.93, 95% confidence interval [CI] = 0.91 to 0.94) and lung cancer-specific (HR = 0.81, 95% CI = 0.79 to 0.82) survival. In a simulated clinical trial-eligible population (age <75 years, no comorbidity, treated with chemotherapy), similar trends were noted. In subset analyses according to stage, type, and timing of prior cancer, no group of patients with prior cancer had inferior survival compared with patients without prior cancer. CONCLUSION Among patients with stage IV lung cancer, prior cancer does not convey an adverse effect on clinical outcomes, regardless of prior cancer stage, type, or timing. Broader inclusion in clinical trials of advanced lung cancer patients with a history of prior cancer should be considered.
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Affiliation(s)
- Andrew L Laccetti
- Department of Internal Medicine (ALL, EAH, DEG), Department of Clinical Sciences (SLP, LX, EAH), Harold C. Simmons Cancer Center (SLP, EAH, DEG), University of Texas Southwestern Medical Center, Dallas, TX
| | - Sandi L Pruitt
- Department of Internal Medicine (ALL, EAH, DEG), Department of Clinical Sciences (SLP, LX, EAH), Harold C. Simmons Cancer Center (SLP, EAH, DEG), University of Texas Southwestern Medical Center, Dallas, TX
| | - Lei Xuan
- Department of Internal Medicine (ALL, EAH, DEG), Department of Clinical Sciences (SLP, LX, EAH), Harold C. Simmons Cancer Center (SLP, EAH, DEG), University of Texas Southwestern Medical Center, Dallas, TX
| | - Ethan A Halm
- Department of Internal Medicine (ALL, EAH, DEG), Department of Clinical Sciences (SLP, LX, EAH), Harold C. Simmons Cancer Center (SLP, EAH, DEG), University of Texas Southwestern Medical Center, Dallas, TX
| | - David E Gerber
- Department of Internal Medicine (ALL, EAH, DEG), Department of Clinical Sciences (SLP, LX, EAH), Harold C. Simmons Cancer Center (SLP, EAH, DEG), University of Texas Southwestern Medical Center, Dallas, TX.
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Braun KL, Tsark JU, Powers A, Croom K, Kim R, Gachupin FC, Morris P. Cancer patient perceptions about biobanking and preferred timing of consent. Biopreserv Biobank 2014; 12:106-12. [PMID: 24749877 DOI: 10.1089/bio.2013.0083] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Little is known about how cancer patients feel about donating their tissue, especially in a multiethnic population. Structured interviews were conducted with 30 patients recently diagnosed with cancer, referred to the study by six cancer surgeons and oncologists and by other patients in the study. The participants reported a variety of cancers, and the sample reflected the racial distribution of Hawai`i, including Caucasians (23%), Native Hawaiians and Pacific Islanders (27%), Asians (37%), Hispanics (7%), Native Americans (3%), and African Americans (3%). The interview questions and analysis were guided by the Framework Approach, with interview questions based on pre-set aims. Findings suggest that most cancer patients would donate cancer tissue to science, especially if informed that doing so could help researchers find causes of and cures for cancer. Patients varied on when in their cancer journey they would be most receptive to being asked for a donation, however two-thirds thought they would be more receptive if approached after surgery. Only three of the 30 patients said they would want to be re-consented each time their tissue is requested for research. They identified their physician as the preferred messenger regarding tissue donation. No obvious differences were seen by race. Findings confirm those of other researchers who have reported broad support for biobank participation if informed consent and confidentiality could be assured. Given that the physician was seen as the key messenger about biobanking, more education is needed around cancer tissue collection for physicians, as well as for cancer patients.
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Affiliation(s)
- Kathryn L Braun
- 1 Office of Public Health Studies, University of Hawai'i , Honolulu, Hawai'i
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Gerber DE, Laccetti AL, Xuan L, Halm EA, Pruitt SL. Impact of prior cancer on eligibility for lung cancer clinical trials. J Natl Cancer Inst 2014; 106:dju302. [PMID: 25253615 DOI: 10.1093/jnci/dju302] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND In oncology clinical trials, the assumption that a prior cancer diagnosis could interfere with study conduct or outcomes results in frequent exclusion of such patients. We determined the prevalence and characteristics of this practice in lung cancer clinical trials and estimated impact on trial accrual. METHODS We reviewed lung cancer clinical trials sponsored or endorsed by the Eastern Oncology Cooperative Group for exclusion criteria related to a prior cancer diagnosis. We estimated prevalence of prior primary cancer diagnoses among lung cancer patients using Surveillance Epidemiology and End Results (SEER)-Medicare linked data. We assessed the association between trial characteristics and prior cancer exclusion using chi-square analysis. All statistical tests were two-sided. RESULTS Fifty-one clinical trials (target enrollment 13072 patients) were included. Forty-one (80%) excluded patients with a prior cancer diagnosis as follows: any prior (14%), within five years (43%), within two or three years (7%), or active cancer (16%). In SEER-Medicare data (n = 210509), 56% of prior cancers were diagnosed within five years before the lung cancer diagnosis. Across trials, the estimated number and proportion of patients excluded because of prior cancer ranged from 0-207 and 0%-18%. Prior cancer was excluded in 94% of trials with survival primary endpoints and 73% of trials with nonsurvival primary endpoints (P = .06). CONCLUSIONS A substantial proportion of patients are reflexively excluded from lung cancer clinical trials because of prior cancer. This inclusion criterion is applied widely across studies, including more than two-thirds of trials with nonsurvival endpoints. More research is needed to understand the basis and ramifications of this exclusion policy.
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Affiliation(s)
- David E Gerber
- Harold C. Simmons Cancer Center (DEG, EAH, SLP), Department of Internal Medicine (DEG, ALL, EAH), and Department of Clinical Sciences (LX, EAH, SLP), University of Texas Southwestern Medical Center, Dallas, TX.
| | - Andrew L Laccetti
- Harold C. Simmons Cancer Center (DEG, EAH, SLP), Department of Internal Medicine (DEG, ALL, EAH), and Department of Clinical Sciences (LX, EAH, SLP), University of Texas Southwestern Medical Center, Dallas, TX
| | - Lei Xuan
- Harold C. Simmons Cancer Center (DEG, EAH, SLP), Department of Internal Medicine (DEG, ALL, EAH), and Department of Clinical Sciences (LX, EAH, SLP), University of Texas Southwestern Medical Center, Dallas, TX
| | - Ethan A Halm
- Harold C. Simmons Cancer Center (DEG, EAH, SLP), Department of Internal Medicine (DEG, ALL, EAH), and Department of Clinical Sciences (LX, EAH, SLP), University of Texas Southwestern Medical Center, Dallas, TX
| | - Sandi L Pruitt
- Harold C. Simmons Cancer Center (DEG, EAH, SLP), Department of Internal Medicine (DEG, ALL, EAH), and Department of Clinical Sciences (LX, EAH, SLP), University of Texas Southwestern Medical Center, Dallas, TX
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Nurmi SM, Pietilä AM, Kangasniemi M, Halkoaho A. Nurse leaders' perceptions of the ethical recruitment of study subjects in clinical research. J Nurs Manag 2014; 23:1020-8. [PMID: 25087484 DOI: 10.1111/jonm.12248] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2014] [Indexed: 11/26/2022]
Abstract
AIM The aim of this study was to describe nurse leaders' perceptions of ethical recruitment in clinical research. BACKGROUND Nurse leaders are expected to get involved in clinical research, but there are few studies that focus on their role, particularly the ethical issues. METHOD Qualitative data were collected from ten nurse leaders using thematic one-to-one interviews and analysed with content analysis. RESULTS Nurse leaders considered clinical research at their workplace in relation to the key issues that enabled ethical recruitment of study subjects in clinical research. These were: early information and collaboration for incorporating clinical research in everyday work, an opportune and peaceful recruitment moment and positive research culture. CONCLUSION Getting involved in clinical research is part of the nurse leader's professional responsibility in current health care. They have an essential role to play in ensuring that recruitment is ethical and that the dignity of study subjects is maintained. IMPLICATIONS FOR NURSING MANAGEMENT The duty of nurse leaders is to maintain good contact with other collaborators and to ensure good conditions for implementing clinical research at their site. This requires a comprehensive understanding of the overall situation on their wards. Implementing clinical research requires careful planning, together with educating, supporting and motivating nursing staff.
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Affiliation(s)
- Sanna-Maria Nurmi
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Anna-Maija Pietilä
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.,Social and Health Care Services, Kuopio, Finland
| | - Mari Kangasniemi
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Arja Halkoaho
- Kuopio University Hospital, Science Service Centre, Kuopio, Finland
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Patients' rationale for declining participation in a cancer-associated weight loss study. J Cachexia Sarcopenia Muscle 2014; 5:121-5. [PMID: 24622952 PMCID: PMC4053567 DOI: 10.1007/s13539-014-0128-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/08/2014] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Fewer than 5 % of cancer patients participate in clinical research. Although this paltry rate has led to extensive research on this topic, previous studies have not sought verbatim comments in a real-time, comprehensive manner to understand why patients decline. METHODS This study used a low-risk, non-interventional parent study that focused on cancer-associated weight loss to understand patients' reasons for declining research participation. A research assistant wrote down the name and verbatim reason of all patients who declined to participate. These comments with accompanying patient demographic data are the subject of this report. RESULTS Of the 334 patients, 51 (15 %) declined parent study enrollment; three comment-related themes emerged: (1) a repelling sense of too much institutional research, (2) overwhelming personal health issues, and (3) a low likelihood of returning to the institution. In univariate and multivariate analyses, only age (older) and gender (female) were associated with non-enrollment. Interestingly, 41 patients with fatigue scores of 7 or worse and 26 with pain scores of 7 or worse were enrolled. CONCLUSIONS Although many factors were associated with declining to participate in research, symptom severity was not. Upfront education might help cancer patients better prioritize their participation in research, particularly as some patients felt overwhelmed by too much research in the institution; and for now, investigators should continue to keep asking patients for their participation.
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