Willingness to Discuss Clinical Trials Among Black vs White Men With Prostate Cancer

Abstract

IMPORTANCE Black individuals are underrepresented in cancer clinical trials. OBJECTIVE To examine whether Black and White men with prostate cancer differ in their willingness to discuss clinical trials with their physicians and, if so, whether patient-level barriers statistically mediate racial differences. DESIGN, SETTING, AND PARTICIPANTSThis cross-sectional survey study used baseline data from Partnering Around Cancer Clinical Trials, a randomized clinical trial to increase Black individuals' enrollment in prostate cancer clinical trials. Data were collected from 2016 through 2019 at 2 National Cancer Institute-designated comprehensive cancer centers; participants were Black and White men with intermediate-risk to high-risk prostate cancer. In mediation analysis, path models regressed willingness onto race and each potential mediator, simultaneously including direct paths from race to each mediator. Significant indirect effect sizes served as evidence for mediation.EXPOSURES Race was the primary exposure. Potential mediators included age, education, household income, perceived economic burden, pain/physical limitation, health literacy, general trust in physicians, and group-based medical suspicion. MAIN OUTCOMES AND MEASURESThe primary outcome was the answer to a single question: "If you were offered a cancer clinical trial, would you be willing to hear more information about it?" RESULTS A total of 205 participants were included (92 Black men and 113 White men), with a mean (range) age of 65.7 (45-89) years; 32% had a high school education or lower, and 27.5% had a household income of less than $40 000. Most (88.3%) reported being definitely or probably willing to discuss trials, but White participants were more likely to endorse this highest category of willingness than Black participants (82% vs 64%; χ 2 2 = 8.81; P = .01). Compared with White participants, Black participants were younger (F 1,182 = 8.67; P < .001), less educated (F 1,182 = 22.79; P < .001), with lower income (F 1,182 = 79.59; P < .001), greater perceived economic burden (F 1,182 = 42.46; P < .001), lower health literacy (F 1,184 = 9.84; P = .002), and greater group-based medical suspicion (F 1,184 = 21.48; P < .001). Only group-based medical suspicion significantly mediated the association between race and willingness to discuss trials (indirect effect, −0.22; P = .002). CONCLUSIONS AND RELEVANCEIn this study of men with prostate cancer, most participants were willing to discuss trials, but Black men were significantly less willing than White men. Black men were more likely to believe that members of their racial group should be suspicious of the health care system, and this belief was associated with lower willingness to discuss trials. Addressing medical mistrust may improve equity in clinical research.

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“…The fact that historically disadvantaged patients are less trusting of clinical research is well founded, given the tragic history of medical experimentation in the United States, exemplified by the infamous Tuskegee syphilis study. 97,98 However, most patients will readily participate in a trial, as evidenced in a recent systematic review and meta-analysis, which showed that more than half of patients offered a trial by their physician agreed to participate. Critically, the study also showed that non-Hispanic Black, Hispanic, and Asian patients were willing to participate at rates on par with or even higher than non-Hispanic White patients.…”

Disparities in phase 1 cancer clinical trial enrollment

“…Additionally, clinician communication quality and quantity, including specific framing of phase 1 trials, might affect patient willingness to participate 15,16 . Prior work has also suggested that Black patients with prostate cancer are less willing to discuss cancer clinical trials 18 . Risk perceptions may also play a role, with prior work suggesting that non‐White and/or Hispanic patients may be more likely than White and/or non‐Hispanic patients to perceive phase 1 trials to have a high level of risk 8 …”

A Review of Research on Disparities in the Care of Black and White Patients With Cancer in Detroit

“…High levels of patient mistrust was also associated with less favorable physician perceptions of Black patients, which, in turn, affected physician perceptions of how well these patients would tolerate treatments ( 68 ). A more recent study found that Black men with prostate cancer had higher levels of group-based medical suspicion than White men, and this race-based attitude was associated with less willingness to discuss clinical trials with their physicians ( 69 ). More current research is examining how patient and oncologist nonverbal communication may be associated with these race-based attitudes ( 70 , 71 ).…”