Qualitative study of Oncology Clinicians' Perceptions of Barriers to Offering Clinical Trials to Underserved Populations

INTRODUCTION

Cancer clinical trials represent the "gold standard" for advancing novel cancer therapies. Optimizing trial participation is critical to ensuring the generalizability of findings across patients, yet trial enrollment rates, particularly among minority and socioeconomically disadvantaged populations, remain suboptimal.

METHODS

We conducted in-depth interviews with oncologists at a large academic medical center to explore their (1) attitudes and perceived barriers to offering clinical trials to minority and socioeconomically disadvantaged patients, and (2) recommendations for improving the enrollment of minority and socioeconomically disadvantaged patients in cancer clinical trials.

RESULTS

Of 23 medical oncologists approached, 17 enrolled (74% response rate; mean age = 47; female = 42%; White = 67%). Content analysis revealed several barriers to enrollment: (1) ethical dilemmas; (2) ambivalence about trial risks and benefits; and (3) concern about patient well-being. Concerns about the legitimacy of informed consent, perceived lack of equipoise, and fear of personal bias influenced clinicians' decisions to recommend trials during treatment discussions. Concerns about creating an imbalance between trial risks and benefits among patients with high-level needs, including patients with literacy, psychiatric, and other socioeconomic vulnerabilities, impacted clinicians' enthusiasm to engage in trial discussions. Clinicians identified patient, provider, and system-level solutions to address challenges, including increasing patient and clinician support as well as involving external personnel to support trial enrollment.

CONCLUSION

Findings reveal multi-level barriers to offering cancer clinical trials to underrepresented patients. Targeted solutions, including system level changes to support clinicians, patient financial support, and implementation of clinical trial navigation programs were recommended to help reduce access barriers and increase enrollment of underrepresented patients into cancer clinical trials.

Examining reporting and representation of patients with cancer in COVID-19 clinical trials

BACKGROUND

Patients with cancer are particularly vulnerable in the current COVID-19 pandemic. Emerging evidence suggests that patients with a cancer diagnosis are three times more likely to die from COVID-19 compared to non-cancer patients. Due to these observed risks, it is critical that emerging COVID-19 therapies demonstrate safety and efficacy among patients with cancer.

AIM

This study sought to examine reporting and representation of patients with cancer among published COVID-19 treatment-related research studies.

METHODS AND RESULTS

All published COVID-19 treatment-related clinical research studies published from March 1 to August 20, 2020 recruiting from North America and Europe were identified. The date published, study design, therapeutics studied, and study population were evaluated. Of the 343 studies identified through initial search and researcher knowledge, 55 (16%) reported on COVID-19 treatments. Twenty-one COVID-19 therapeutic studies (n = 15, prospective; n = 6, retrospective) that recruited from the United States and Europe were identified. Among these studies, eight (38%) reported on the number of trial participants with a cancer diagnosis in the publication and two (10%) specified tumor type. Four of the studies (19%) did not collect cancer history. Among studies where cancer history was available, patients with a cancer diagnosis participated at a proportion higher than overall cancer prevalence and greater than the known proportion of COVID-19 patients with cancer.

CONCLUSION

This study observed that cancer history was not uniformly collected or reported among published COVID-19 therapeutic studies. Among reported publications, we observed that patients with a cancer diagnosis were generally overrepresented. However, patients with a cancer diagnosis were notably underrepresented in outpatient COVID-19 therapeutic studies.

Addressing the Financial Burden of Cancer Clinical Trial Participation: Longitudinal Effects of an Equity Intervention

BACKGROUND

The financial burden experienced by patients with cancer represents a barrier to clinical trial participation, and interventions targeting patients' financial concerns are needed. We sought to assess the impact of an equity intervention on clinical trial patients' financial burden.

MATERIALS AND METHODS

We developed an equity intervention to reimburse nonclinical expenses related to trials (e.g., travel and lodging). From July 2015 to July 2017, we surveyed intervention and comparison patients matched by age, sex, cancer type, specific trial, and trial phase. We longitudinally assessed financial burden (e.g., trial-related travel and lodging cost concerns, financial wellbeing [FWB] with the COmprehensive Score for financial Toxicity [COST] measure) at baseline, day 45, and day 90. We used longitudinal models to assess intervention effects over time.

RESULTS

Among 260 participants, intervention patients were more likely than comparison patients to have incomes under $60,000 (52% vs. 24%, p < .001) and to report travel-related (41.0% vs. 6.8%, p < 0.001) and lodging-related (32.5% vs. 2.0%, p < .001) cost concerns at baseline. Intervention patients were more likely to report travel to appointments as their most significant financial concern (24.0% vs. 7.0%, p = .001), and they had worse FWB than comparison patients (COST score: 15.32 vs. 23.88, p < .001). Over time, intervention patients experienced greater improvements in their travel-related (-10.0% vs. +1.2%, p = .010) and lodging-related (-3.9% vs. +4.0%, p = .003) cost concerns. Improvements in patients reporting travel to appointments as their most significant financial concern and COST scores were not statistically significant.

CONCLUSION

Cancer clinical trial participants may experience substantial financial issues, and this equity intervention demonstrates encouraging results for addressing these patients' longitudinal financial burden.

IMPLICATIONS FOR PRACTICE

Clinical trials are critical for developing novel therapies for patients with cancer, yet financial barriers may discourage some patients from participating in cancer clinical trials. This study found that patients who received financial assistance from an equity intervention experienced significant improvements over time in their concerns about the cost of travel and lodging associated with clinical trials compared with comparison patients who did not receive financial assistance from the equity intervention. Among cancer clinical trial participants, an equity intervention shows potential for addressing patients' concerns regarding clinical trial-related travel and lodging expenses.