Bias among some health care and research professionals could partly explain persistent racial disparities in cancer clinical trial participation, according to study results published in Cancer.

These professionals involved in recruitment of patients for clinical trials reported associating minorities with certain negative stereotypes, including noncompliance with trial activities. This may lead to differential patient referral to cancer clinical trials based upon race and ethnicity, according to the researchers.

Researchers observed several stereotypes, including perceptions that African Americans were less knowledgeable about cancer research studies, less likely to participate due to altruism or simply less likely to complete all facets of the research study.

“Prior to our study, bias had not been explored within the context of cancer clinical trials. Understanding how it manifests among professional stakeholders involved in the recruitment of minorities for cancer trials is important,” Soumya J. Niranjan, BPharm, MS, PhD, assistant professor in the department of health services administration at The University of Alabama at Birmingham, told Healio. “Acknowledging that there are biases involved in recruitment for cancer research studies is the first step toward addressing both individual and systems-level factors that contribute to disparities in clinical trial participation.”

The notion that bias among health care professionals contributes to health disparities is not new. In a 2003 report, the Institute of Medicine concluded that bias against racial minorities may affect communication or care offered.

Niranjan and colleagues sought to assess whether biases held by clinical and research staff may help explain why racial and ethnic minorities are not fully represented in clinical trials.

They interviewed 91 individuals, including cancer center leaders, principal investigators of clinical trials, referring clinicians and research staff across five U.S. cancer centers — University of Minnesota, The University of Alabama at Birmingham, Johns Hopkins University, The University of Texas MD Anderson Cancer Center and University of California, Davis. Researchers used a content analysis approach to generate themes from the interviews.

According to study results, five prominent themes emerged:

• Recruitment interactions with potential minority participants were perceived to be a challenge. Respondents noted difficulties communicating with potential minority trial participants due to language barriers and other factors.
• Potential minority participants were not perceived to be ideal study candidates after screening.
• Both clinical-level barriers and negative perceptions of minority trial participants resulted in providers withholding clinical trial opportunities from potential minority participants.
• When clinical trial recruitment practices were tailored to minority patients, a common strategy was to address research misconceptions in order to build trust.

• Race was perceived by some respondents as irrelevant when screening and recruiting potential minority participants for clinical trials.

Bias based on stereotypes of potential minority participants is concerning due to the possibility that nonwhite individuals may be offered fewer opportunities to participate in cancer research studies, Niranjan said.

“Some providers endorsed using tailored recruitment strategies, whereas others eschewed race as a factor in trial recruitment,” the researchers wrote.

The potential for bias and stereotyping among clinical and research professionals responsible for recruiting for cancer clinical trials must be considered when developing strategies to increase minority enrollment, they added.

“We hope to assess the qualitative findings of the current study in a future trial, particularly the extent to which bias is perceived by potential minority participants,” Niranjan told Healio. – by Jennifer Southall

For more information:

Soumya J. Niranjan, BPharm, MS, PhD, can be reached at The University of Alabama at Birmingham, SHPB 540, 1720 2nd Ave. South, Birmingham, AL 35294; email: soumya14@uab.edu.

Disclosures: The study was supported by grants from the National Institute on Minority Health and Health Disparities. The authors report no relevant financial disclosures.

PERSPECTIVE

Cardinale B. Smith, MD, PhD

Unfortunately, the burden of cancer in the United States unequally affects minority populations. Incidence of cancer not only is higher among blacks than whites, but also is increasing at a faster rate — 1.2% vs. 0.8% per year. Additionally, minority patients are more likely to be diagnosed with advanced-stage cancer and have higher mortality rates — 222 per 100,000 for blacks and Hispanics vs. 167 per 100,000 for whites. Clinical trial enrollment tends to be low for most patients with cancer; however, the proportion of minorities enrolled in clinical trials is far lower than that of whites. These inequities lead to substandard care.

Although multiple factors contribute to these disparities, clinician and clinical personnel-specific factors — such as limited cultural competence, stereotyping, uncertainty and bias — also play a significant role. The findings in this study build upon other research in this area linking clinician bias to disparities in communication and patient satisfaction. In this study, participants had mostly negative associations of successful referral, recruitment and retention of minority patients, whereas others stated that race was not a parameter. 

An important takeaway for clinical practice is to first recognize that bias exists in clinical trial screening and enrollment procedures. It is imperative that clinical research institutions develop training geared specifically toward mitigating bias. For all patients, regardless of minority status, there may be issues of low health literacy or barriers related to social determinants of health. Developing strategies to overcome these barriers is critical to ensure that this vulnerable population that is often underrepresented in clinical trials can receive the potential benefits of clinical trial participation. Although the authors suggest a tailored, nuanced recruitment strategy to increase minority participation in cancer clinical trials, evaluation of different models is needed to decrease this disparity.

References:

Bach PB, et al. N Engl J Med. 1999;doi:10.1056/NEJM199910143411606.

Clegg LX, et al. Arch Intern Med. 2002;doi:10.1001/archinte.162.17.1985.

Greenlee RT, et al. CA Cancer J Clin. 2001;doi:10.3322/canjclin.51.1.15.

Greenwald HP, et al. Am J Public Health. 1998;doi:10.2105/ajph.88.11.1681.

Institute of Medicine and National Research Council. Improving Palliative Care for Cancer. Washington D.C.; National Academy Press, 2001.

Jemal A, et al. CA Cancer J Clin. 2002;doi:10.3322/canjclin.52.1.23.

Wisnivesky JP, et al. Am J Respir Crit Care Med. 2005;doi:10.1164/rccm.200411-1475OC.

Cardinale B. Smith, MD, PhD

HemOnc Today Next Gen Innovator

Mount Sinai Health System

Disclosures: Smith reports no relevant financial disclosures.