Patients' and physicians' disagreement on patients' understanding of clinical cancer trial information:a pairwise pilot study of mirroring subjective assessments compared with objective measurements

Background: Informed consent is a prerequisite for patients included in clinical trials. Trial design, inclusion criteria and legal requirements are increasingly complex. This complexity challenges design and delivery of written and oral trial information to ensure understandable information. To evaluate the level of concordance between patients' and informing physicians' assessments regarding patient understanding of trial information, we carried out a study based on paired questionnaire data from patients and their physicians. These assessments of patient understanding were further correlated with patients' factual knowledge of the information provided. Methods: This pilot study included patients and physicians immediately after the patients had received information on one of 23 ongoing phase III randomised cancer trials at two Swedish sites. In total, 46 patients and 17 physicians contributed data based on two new questionnaires with seven mirroring questions, where concordance was analysed with McNemar's test. These assessments of patients' self-estimated understanding were further correlated with the Patient Understanding of Research (Q-PUR) questionnaire that assesses factual knowledge of the information provided. Results: For each question, 47-61% of the patient-physician pairs were in concordance regarding their assessments of patients' 'fully understanding' or 'not fully understanding' various aspects of the trial information. For the discordant pairs, the physicians rated patient understanding lower than the patients themselves, for all seven questions. This difference was significant for five of the questions (P ≤ 0.017). The median Q-PUR knowledge score was 11 out of 12, but this score did not significantly correlate with the assessments, either from patients or from physicians. Conclusions: This study demonstrated a trend for physicians to rate the level of understanding of trial information among potential trial patients lower than the patients themselves. Application of Q-PUR revealed high knowledge scores, but without correlation to the assessments. These findings need validation in an independent setting, with an improved instrument with mirroring questions, and a better-matched measurement of patients' factual knowledge. These results suggest that physicians need to improve their ability to assess patient understanding of clinical trial information, in order to be able to tailor the patients' information individually

Ode till Lunds universitet : Promotionspoem 2019

Poem framfört vid doktorspromotionen i Lund 24 maj 201

Patients in Clinical Cancer Trials. Information, Understanding and Decision-Making

AbstractThe informed consent process for clinical trials (CTs) is complex. Patients must be able to understand the information given to be able to make an informed decision. This thesis aimed to explore patients’ and patient representatives’ views, factual knowledge, and perceived understanding of patient information in clinical cancer trials, and to investigate how patients’ understanding may be correlated to their decision-making and their physicians’ assessment of their understanding.In Studies I and II, focus group interviews were conducted in which patient representatives with experience of breast and colorectal cancer respectively examined informed consent documents (ICDs). Their suggestions for improving breast cancer ICDs were validated by an independent group of patient representatives. These results were then presented as a guide for writing ICDs. The main conclusion was that ICDs need better graphic design in order to facilitate readers’ orientation in and processing of information. All ICDs should therefore be designed by a team including patient representatives, professional writers and graphic designers.Study III was a questionnaire pilot study which showed that patients consider their understanding to be higher than the patient understanding assessed by their informing physicians. Neither the patients’ nor their physicians’ ratings correlated with the patients’ factual knowledge, as measured by the instrument Q-PUR. This pilot study needs validation in an independent setting. The main conclusion was that the informed consent process would benefit from informing physicians acquiring and applying specific communication skills in order to assess patient understanding more precisely, the better to tailor the information given to the needs of the individual patient.In Study IV, patients who had decided to participate in a CT were interviewed individually about how they reasoned when making this decision. The results showed that the decision to participate was often immediate and guided by emotions and a trusting relationship with health care professionals. Important factors for the decision-making process included knowledge of the right to withdraw from the CT and explicit comparisons between the treatment alternatives included, and also those not included, in the CT. Patients in palliative situations were sometimes unaware of the fact that their disease was no longer curable. For CTs in the palliative setting, the treatment alternative ‘best supportive care’ should therefore be stated as one option. The main conclusion was that these factors need to be addressed specifically in the informed consent conversations.The overall conclusions are that better graphic design of ICDs is essential and that informing physicians must acquire and apply specific communication skills in order to improve the informed consent process

Patient representatives' views on patient information in clinical cancer trials

BACKGROUND: Patient enrolment into clinical trials is based on oral information and informed consent, which includes an information sheet and a consent certificate. The written information should be complete, but at the same time risks being so complex that it may be questioned if a fully informed consent is possible to provide. We explored patient representatives’ views and perceptions on the written trial information used in clinical cancer trials. METHODS: Written patient information leaflets used in four clinical trials for colorectal cancer were used for the study. The trials included phase I-III trials, randomized and non-randomized trials that evaluated chemotherapy/targeted therapy in the neoadjuvant, adjuvant and palliative settings. Data were collected through focus groups and were analysed using inductive content analysis. RESULTS: Two major themes emerged: emotional responses and cognitive responses. Subthemes related to the former included individual preferences and perceptions of effect, while subthemes related to the latter were comprehensibility and layout. Based on these observations the patient representatives provided suggestions for improvement, which largely included development of future simplified and more attractive informed consent forms. CONCLUSIONS: The emotional and cognitive responses to written patient information reported by patient representatives provides a basis for revised formats in future trials and add to the body of information that support use of plain language, structured text and illustrations to improve the informed consent process and thereby patient enrolment into clinical trials

Patients' reasoning regarding the decision to participate in clinical cancer trials : an interview study

BACKGROUND: Clinical cancer trials are crucial for the implementation of new treatments in the clinical setting, but it is equally crucial that patients are given the opportunity to make a well-informed decision about participation. The inclusion process is complex, including both oral and written information about the trial. The process of patients' decision-making regarding clinical cancer trials has not yet been sufficiently studied. This interview study aims to explore the process of patients' reasoning regarding the decision to participate in a clinical cancer trial.METHODS: The study is based on 27 individual face-to-face interviews with patients who had decided to participate in a clinical cancer trial. The interviews were audio-recorded and transcribed verbatim and then analysed using inductive content analysis.RESULTS: Content analysis revealed 17 subthemes grouped into five themes: (1) an unhesitating decision to participate; (2) a decision based on flimsy grounds and guided by emotion; (3) feeling safe and secure with my decision; (4) faced with a choice versus what choice do I have? and (5) hoping for help while helping others. The decision to participate in a clinical cancer trial was often immediate and guided by emotions, based on a trusting relationship with healthcare personnel rather than on careful reading of written information. Palliative patients, in particular, sometimes had unrealistic beliefs about the effectiveness of the trial treatment.CONCLUSIONS: It is vital that the decision to participate in a clinical cancer trial is preceded by an honest dialogue about possible positive and negative effects of the trial treatments, including other options such as supportive care in the palliative setting. Our findings also raise the questions of how important written information is for the decision-making process and also whether genuine informed consent is possible. To reach a higher degree of informed consent, it is most important that the oral information is given in a thorough and unbiased manner

Towards optimised information about clinical trials; identification and validation of key issues in collaboration with cancer patient advocates.

DELLSON P., NILBERT M., BENDAHL P-O., MALMSTROM P. & CARLSSON C. (2010) European Journal of Cancer Care Towards optimised information about clinical trials; identification and validation of key issues in collaboration with cancer patient advocates Clinical trials are crucial to improve cancer treatment but recruitment is difficult. Optimised patient information has been recognised as a key issue. In line with the increasing focus on patients' perspectives in health care, we aimed to study patients' opinions about the written information used in three clinical trials for breast cancer. Primary data collection was done in focus group interviews with breast cancer patient advocates. Content analysis identified three major themes: comprehensibility, emotions and associations, and decision making. Based on the advocates' suggestions for improvements, 21 key issues were defined and validated through a questionnaire in an independent group of breast cancer patient advocates. Clear messages, emotionally neutral expressions, careful descriptions of side effects, clear comparisons between different treatment alternatives and information about the possibility to discontinue treatment were perceived as the most important issues. Patients' views of the information in clinical trials provide new insights and identify key issues to consider in optimising future written information and may improve recruitment to clinical cancer trials