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Physician Perspectives on Reducing Curative Cancer Treatment Intensity for Populations Underrepresented in Clinical
Gabrielle B Rocque1,2,3, Courtney Andrews4, Valerie M Lawhon1
1Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
Background:
Historically, clinical trials involved adding novel agents to standard of care to improve survival. There has been a shift to an individualized approach with testing less intense treatment, particularly in breast cancer where risk of recurrence is low. Little is known about physician perspectives on delivering less intense treatment for patients who are not well represented in clinical trials.
Methods:
Open-ended, individual qualitative interviews with medical oncologists explored their perspectives on trials that test less intense treatment for patients with cancer, with a focus on breast cancer. Interviews were audio-recorded and transcribed. Four independent coders utilized a content analysis approach to analyze transcripts using NVivo. Major themes and exemplary quotes were extracted.
Results:
Of the 39 participating physicians, 61.5% felt comfortable extrapolating, 30.8% were hesitant, and 7.7% would not feel comfortable extrapolating trial outcomes to underrepresented populations. Facilitators of comfort included the sentiment that "biology is biology" (such that the cancer characteristics were what mattered), the strength of the evidence, inclusion of subset analysis on underrepresented populations, and prior experience making decisions with limited data. Barriers to extrapolation included potential harm over the patient's lifetime, concerns about groups that had minimal participants, application to younger patients, and extending findings to diverse populations. Universally, broader inclusion in trials testing lowering chemotherapy was desired.
Conclusions:
The majority (92%) of physicians reported that they would de-implement treatment for patients poorly represented in clinical trials testing less treatment, while expressing concerns about applicability to specific subpopulations. Further work is needed to increase clinical trial representation of diverse populations to safely and effectively optimize treatment for patients with cancer.
Trial Registration:
NCT03248258.
Insights
Physicians are willing to de-escalate cancer treatment for underrepresented groups but desire broader clinical trial inclusion. Ensuring diverse representation is crucial for optimizing patient care and treatment strategies.
Area of Science:
- Oncology
- Clinical Trial Design
- Health Disparities
Background:
- Shift from standard of care to individualized, less intense treatments in oncology.
- Focus on breast cancer with low recurrence risk highlights need for adapted treatment strategies.
- Limited understanding of physician views on applying less intense treatments to patients underrepresented in clinical trials.
Purpose of the Study:
- To explore medical oncologists' perspectives on using less intense treatment strategies for cancer patients.
- To investigate physician comfort levels in extrapolating clinical trial data to underrepresented populations.
- To identify facilitators and barriers to de-escalating treatment based on clinical trial evidence.
Main Methods:
- Qualitative study using open-ended, individual interviews with 39 medical oncologists.
- Content analysis of transcribed interviews using NVivo by four independent coders.
- Extraction of major themes and exemplary quotes related to treatment de-escalation and trial extrapolation.
Main Results:
- A majority of physicians (61.5%) felt comfortable extrapolating trial outcomes, while 30.8% were hesitant and 7.7% uncomfortable.
- Facilitators included 'biology is biology' sentiment, strong evidence, subset analyses, and prior experience with limited data.
- Barriers involved concerns about long-term harm, small participant groups, applicability to younger patients, and diverse populations.
Conclusions:
- Most physicians (92%) would de-implement treatment for patients poorly represented in trials, despite applicability concerns.
- Broader inclusion of diverse populations in clinical trials for less intense chemotherapy is universally desired.
- Increased clinical trial representation is essential for safe and effective treatment optimization in diverse cancer patient groups.
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