Racial Bias May Impact Minority Participation in Cancer Trials

Racial and ethnic biases held by research and clinical professionals could contribute to low minority participation in oncology clinical trials, according to a study recently published in Cancer, a journal from the American Cancer Society.

Currently, the percentage of racial and ethnic minorities participating in cancer trails is 15% to 20%. This percentage is persistently lower than the US minority population as a whole (36.3%). To ensure outcomes are generalizable to the population, it is essential to include diverse patients in clinical trials.

“To the best of our knowledge, the current research is limited to self-reported provider barriers.…Bias has not been explored within the context of cancer clinical trials and how it may be manifested among professional stakeholders,” researchers said.

In this study, the first of its kind, researchers conducted a series of 91 qualitative interviews at 5 US cancer centers among 4 stakeholder groups: cancer center leaders, principal investigators, referring clinicians, and research staff. According to researchers, bias can take 3 forms: prejudice (negative attitudes), stereotypes (categorical beliefs), and discrimination (unequal treatment).

Interviews were completed in 2010 and responses encompassed the following themes:

• Interactions with potential minority participants were perceived to be challenging
• Potential minority participants are not perceived to be ideal study candidates
• A combination of clinic-based barriers and negative perceptions of minority study participants leads to providers withholding clinical trial opportunities from potential minority participants
• When clinical trial recruitment practices were tailored to minority patients, addressing misconceptions to build trust was a common strategy
• For some respondents, race was viewed as irrelevant when screening and recruiting potential minority participants for clinical trials

Race is a fundamental social determinant of health and can shape access to important resources, including participation in cancer clinical trials. “Not only did some respondents view racial and ethnic minorities as less promising participants, some respondents reported withholding trial opportunities from minorities based on these perceptions,” researchers found.

“Examples of the stereotypes we observed included 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,” said Soumya Niranjan, PhD, lead author of the paper. She emphasized that even race-neutral stances can lead to problems, as they may overlook well-established methods of engaging and recruiting participants in a culturally tailored manner.

“African Americans I think have less knowledge. We take a little bit more time to explain to African American [sic] I think if they have more questions because we know they are not more knowledgeable, so I think it takes time. They have a lot of questions.” — Principal investigator

Raegan W. Durant, MD, senior author, stressed that the results do not indicate that “all research and healthcare professionals are biased or that all minorities are being deprived of opportunities to participate in cancer research studies.”

However, the findings demonstrate long-term significance as “biases potentially exist in virtually all forms of human interaction, and recruitment for cancer research studies is no exception,” Durant said. She continued, “Once we acknowledge the potential presence of this bias in this context, we can better identify it, measure it, and begin to think about how best to address it."

“To get them to understand that requires a lot of ground work, you know, and a lot of education, and you know, when you’re pushed to see 20 patients in a day, and when the, the metric that is used to measure your performance is how much patients you put through the hospital, and that’s the overriding pressure on you, clinical trials will fall by the wayside, and I would imagine that trust is more difficult to build in certain.” — Referring physician

Although the interviews were conducted in 2010 and professional perspectives may have evolved over time, researchers note that recent data suggest bias does currently influence decision making in healthcare settings, similar to those in which clinical trial recruitment takes place.

For example, a 2016 study found implicit racial bias helped to entrench false beliefs on pain perceptions and treatment among black Americans. While individuals with medical training were less likely to endorse false beliefs—such as that black people have thicker skin or heal more quickly—researchers found higher endorsements of these beliefs among people without medical training. Participants with medical training (medical students and residents) endorsed 11.55%, on average, of false beliefs, whereas laypeople endorsed 22.43% of the beliefs, on average, according to AJMC.com.

“Marginalized populations, such as the homeless or people of color are…more likely to be presumed to be noncompliant with their medication, but they’re also more likely to be presumed to be medication-seeking or having an ulterior motive other than trying to receive needed care,” the article states.

In addition, a review published in 2015 found “most healthcare providers have implicit biases (positive attitudes toward whites and negative attitudes toward people of color), and this holds true regardless of the race or ethnicity of the provider.”

Authors of the current Cancer study note that one way to increase minority participation in oncology trials, and reduce bias in recruitment, is to implement clear, honest communication strategies. Adopting an interventional framework that was originally meant to prevent unconscious racial attitudes and stereotypes among medical trainees and physicians can also be helpful in this context.

“Despite the best intentions to provide qual clinical trial access to all patients, disparities in clinical trial participation persist and may lead to unacceptable increases in morbidity and mortality for some individuals,” researchers conclude. In contrast to a biased or race-neutral approach, “a tailored, nuanced recruitment strategy” could increase minority participation in cancer clinical trials.

Reference

Niranjan SJ, Martin MY, Fouad MN, et al. Bias and stereotyping among research and clinical professionals: perspectives on minority recruitment for oncology clinical trials [published online March 9, 2020]. Cancer. doi: 10.1002/cncr.32755.