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PurposeEngaging primary care providers (PCPs) in BRCA1/2 testing and results disclosure would increase testing access. The BRCA Founder OutReach (BFOR) study is a prospective study of BRCA1/2 founder mutation screening among individuals of Ashkenazi Jewish descent that sought to involve participants' PCPs in results disclosure. We used quantitative and qualitative methods to evaluate PCPs' perspectives, knowledge, and experience disclosing results in BFOR.MethodsAmong PCPs nominated by BFOR participants to disclose BRCA1/2 results, we assessed the proportion agreeing to disclose. To examine PCP's perspectives, knowledge, and willingness to disclose results, we surveyed 501 nominated PCPs. To examine PCPs' experiences disclosing results in BFOR, we surveyed 101 PCPs and conducted 10 semi-structured interviews.ResultsIn the BFOR study overall, PCPs agreed to disclose their patient's results 40.5% of the time. Two hundred thirty-four PCPs (46.7%) responded to the initial survey. Responding PCPs were more likely to agree to disclose patients' results than non-responders (57.3% vs. 28.6%, p

Objective To evaluate whether integrating breast and cervical cancer screening in Rwanda's Women's Cancer Early Detection Program led to early breast cancer diagnoses in asymptomatic women. Methods Launched in three districts in 2018-2019, the early detection programme offered clinical breast examination screening for all women receiving cervical cancer screening, and diagnostic breast examination for women with breast cancer symptoms. Women with abnormal breast examinations were referred to district hospitals and then to referral hospitals if needed. We examined how often clinics were held, patient volumes and number of referrals. We also examined intervals between referrals and visits to the next care level and, among women diagnosed with cancer, their initial reasons for seeking care. Findings Health centres held clinics > 68% of the weeks. Overall, 9763 women received cervical cancer screening and clinical breast examination and 7616 received breast examination alone. Of 585 women referred from health centres, 436 (74.5%) visited the district hospital after a median of 9 days (interquartile range, IQR: 3-19). Of 200 women referred to referral hospitals, 179 (89.5%) attended after a median of 11 days (IQR: 4-18). Of 29 women diagnosed with breast cancer, 19 were > 50 years and 23 had stage III or stage IV disease. All women with breast cancer whose reasons for seeking care were known (23 women) had experienced breast cancer symptoms. Conclusion in the short-term, integrating clinical breast examination with cervical cancer screening was not associated with detection of early-stage breast cancer among asymptomatic women. Priority should be given to encouraging women to seek timely care for symptoms. Recherche sur la mise en reuvre: integration des examens des seins dans le programme de depistage du cancer du col de l'uterus au Rwanda Objectif Evaluer si le fait d'integrer le depistage du cancer du sein et du col de l'uterus dans le Programme de detection precoce du cancer chez les femmes au Rwanda a permis de mieux diagnostiquer les cancers du sein chez les femmes asymptomatiques. Methodes Lance dans trois districts en 2018-2019, le programme de detection precoce proposait un examen clinique des seins a toutes les femmes effectuant un depistage du cancer du col de l'uterus et un examen diagnostique des seins a celles presentant des symptomes de cancer du sein. Les femmes ayant obtenu un resultat anormal lors de cet examen etaient ensuite transferees a des hopitaux de district et, si necessaire, a des hopitaux de reference. Nous nous sommes interesses a la frequence a laquelle les cliniques ont ete mises sur pied, au volume de patients et au nombre de transferts. Nous avons egalement analyse les intervalles entre les transferts et les visites au niveau de soins superieur et, pour les femmes atteintes d'un cancer, les raisons initiales qui les ont incitees a consulter. Resultats Les centres de sante ont organise des cliniques > 68% des semaines. De maniere generale, 9763 femmes ont ete soumises a un depistage du cancer du col de l'uterus et a un examen clinique des seins, tandis que 7616 d'entre elles n'ont fait l'objet que d'un examen des seins. Sur les 585 femmes transferees depuis les centres de sante, 436 (74,5%) se sont rendues dans l'hopital de district apres un delai median de neuf jours (ecart interquartile, EI: 3-19). Sur les 200 femmes renvoyees vers des hopitaux de reference, 179 (89,5%) s'y sont rendues apres un delai median de 11 jours (EI: 4-18). Enfin, sur les 29 femmes ayant recu un diagnostic de cancer du sein, 19 etaient agees de 50 ans et plus, et 23 souffraient d'un cancer de stade III ou IV. Toutes les femmes atteintes d'un cancer du sein ayant partage les raisons qui les ont poussees a consulter (23 femmes) avaient ressenti des symptomes de la maladie. Conclusion A court terme, integrer un examen clinique du sein lors d'un depistage du cancer du col de l'uterus n'a pas donne lieu a une detection precoce du cancer du sein chez les femmes asymptomatiques. La priorite est d'encourager les femmes a consulter rapidement des l'apparition de symptomes. Investigacion sobre la aplicacion: inclusion de las exploraciones mamarias en un programa de deteccion del cancer de cuello uterino, Ruanda Objetivo Evaluar si la integracion de la deteccion del cancer de mama y de cuello uterino en el Programa de Deteccion Temprana del Cancer en Mujeres de Ruanda permitio realizar diagnosticos tempranos de cancer de mama en mujeres asintomaticas. Metodos Lanzado en tres distritos entre 2018 y 2019, el programa de deteccion temprana ofrecia examenes clinicos de mama a todas las mujeres que se sometian al cribado del cancer de cuello uterino y examenes mamarios diagnosticos a las mujeres con sintomas de cancer de mama. Las mujeres con examenes de mama anormales eran derivadas a hospitales de distrito y, posteriormente, a hospitales de referencia si era necesario. Se examino la frecuencia de las consultas, el volumen de pacientes y el numero de derivaciones. Tambien se examinaron los intervalos entre las derivaciones y las visitas al siguiente nivel asistencial y, entre las mujeres diagnosticadas de cancer, sus motivos iniciales para buscar asistencia. Resultados Los centros sanitarios realizaron consultas >68% de las semanas. En total, 9763 mujeres se sometieron a deteccion del cancer de cuello uterino y examen clinico de las mamas, y 7616 solo a examen de las mamas. De 585 mujeres remitidas desde los centros sanitarios, 436 (74,5%) acudieron al hospital de distrito tras una mediana de 9 dias (rango intercuartilico, IQR: 3-19). De 200 mujeres remitidas a hospitales de referencia, 179 (89,5%) acudieron tras una mediana de 11 dias (IQR: 4-18). De 29 mujeres diagnosticadas de cancer de mama, 19 tenian [greater than or equal to] 50 anos y 23 presentaban enfermedad en estadio III o estadio IV. Todas las mujeres con cancer de mama, cuyos motivos de busqueda de atencion eran conocidos (23 mujeres) habian experimentado sintomas de cancer de mama. Conclusion A corto plazo, la integracion del examen clinico de las mamas con la deteccion del cancer de cuello uterino no se asocio con la deteccion temprana del cancer de mama entre las mujeres asintomaticas. Debe darse prioridad a animar a las mujeres a buscar atencion oportuna ante los sintomas., Introduction Breast cancer incidence is increasing rapidly in sub-Saharan Africa. Even though the age-standardized incidence rates of breast cancer in sub-Saharan Africa are still lower than in higher-income regions, women [...]

BackgroundEvidence is needed regarding effective incentive strategies to increase clinician survey response rates. Cash cards are increasingly used as survey incentives; they are appealing because of their convenience and because in some cases their value can be reclaimed by investigators if not used. However, their effectiveness in clinician surveys is not known. In this study within the BRCA Founder OutReach (BFOR) study, a clinical trial of population-based BRCA1/2 mutation screening, we compared the use of upfront cash cards requiring email activation versus checks as clinician survey incentives.MethodsParticipants receiving BRCA1/2 testing in the BFOR study could elect to receive their results from their primary care provider (PCP, named by the patient) or from a geneticist associated with the study. In order to understand PCPs' knowledge, attitudes, experiences and willingness to disclose results we mailed paper surveys to the first 501 primary care providers (PCPs) in New York, Boston, Los Angeles and Philadelphia who were nominated by study participants to disclose their BRCA1/2 mutation results obtained through the study. We used alternating assignment stratified by city to assign the first 303 clinicians to receive a $50 up-front incentive as a cash card (N = 155) or check (N = 148). The cash card required PCPs to send an activation email in order to be used. We compared response rates by incentive type, adjusting for PCP characteristics and study site.ResultsIn unadjusted analyses, PCPs who received checks were more likely to respond to the survey than those who received cash cards (54.1% versus 41.9%, p = 0.046); this remained true when we adjusted for provider characteristics (OR for checks 1.61, 95% CI 1.01, 2.59). No other clinician characteristics had a statistically significant association with response rates in adjusted analyses. When we included an interaction term for incentive type and city, the favorable impact of checks on response rates was evident only in Los Angeles and Philadelphia.ConclusionsAn up-front cash card incentive requiring email activation may be less effective in eliciting clinician responses than up-front checks. However, the benefit of checks for clinician response rates may depend on clinicians' geographic location.Trial registrationClinicalTrials.gov ( NCT03351803 ), November 24, 2017.

Introduction: Clinical guidelines and quality improvement initiatives have identified reducing the use of end‐of‐life cancer therapies as an opportunity to improve care. We examined the extent to which oncologists differed in prescribing systemic therapies in the last 30 days of life. Methods: Using Surveillance, Epidemiology, and End Results–Medicare data, we identified patients who died of cancer from 2012 to 2017 (N = 17,609), their treating oncologists (N = 960), and the corresponding physician practice (N = 388). We used multilevel models to estimate oncologists' rates of providing cancer therapy for patients in their last 30 days of life, adjusted for patient characteristics and practice variation. Results: Patients' median age at the time of death was 74 years (interquartile range, 69–79); patients had lung (62%), colorectal (17%), breast (13%), and prostate (8%) cancers. We observed substantial variation across oncologists in their adjusted rate of treating patients in the last 30 days of life: oncologists in the 95th percentile exhibited a 45% adjusted rate of treatment, versus 17% among the 5th percentile. A patient treated by an oncologist with a high end‐of‐life prescribing behavior (top quartile), compared to an oncologist with a low prescribing behavior (bottom quartile), had more than four times greater odds of receiving end‐of‐life cancer therapy (OR, 4.42; 95% CI, 4.00–4.89). Conclusions: Oncologists show substantial variation in end‐of‐life prescribing behavior. Future research should examine why some oncologists more often continue systemic therapy at the end of life than others, the consequences of this for patient and care outcomes, and whether interventions shaping oncologist decision‐making can reduce overuse of end‐of‐life cancer therapies. We examined the extent to which oncologists differed in prescribing systemic therapies to their patients in the last 30 days of life. Results showed substantial variation in end‐of‐life prescribing behavior, with oncologists in the 95th percentile exhibiting a 45% adjusted rate of treatment, compared to just 17% among oncologists in the 5th percentile. [ABSTRACT FROM AUTHOR]

PurposeLittle is known about factors associated with unmet needs for symptom management in patients with cancer.MethodsPatients with a new diagnosis of lung and colorectal cancer from the diverse nationally representative Cancer Care Outcomes Research and Surveillance cohort completed a survey approximately 5 months after diagnosis (N = 5,422). We estimated the prevalence of unmet need for symptom management, defined as patients who report that they wanted help for at least one common symptom (pain, fatigue, depression, nausea/vomiting, cough, dyspnea, diarrhea) during the 4 weeks before the survey but did not receive it. We identified patient factors associated with unmet need by using logistic regression with random effects to account for clustering within study sites.ResultsOverall, 15% (791 of 5,422) of patients had at least one unmet need for symptom management. Adjusting for sociodemographic and clinical factors, African American race, being uninsured or poor, having early-stage lung cancer, and the presence of moderate to severe symptoms were associated with unmet need (all P < .05). Furthermore, patients who rated their physician's communication score < 80 (on a 0 to 100 scale) had adjusted rates of an unmet need for symptom management that were more than twice as high as patients who rated their physicians with a perfect communication score (23.1% v 10.0%; P < .001).ConclusionA significant minority of patients with newly diagnosed lung and colorectal cancer report unmet needs for symptom management. Interventions to improve symptom management should consider the importance of physician communication to the patient's experience of disease.

PurposeLittle is known about the roles of genetic and molecular testing and Lynch syndrome screening in the formulation of predictive and prognostic assessments for patients with stage II colorectal cancer (CRC).MethodsFrom 2012 to 2013, we surveyed medical oncologists in the Cancer Care Outcomes Research and Surveillance Consortium and evaluated oncologists' selection of microsatellite instability (MSI) and/or immunohistochemistry (IHC) for mismatch repair (MMR) proteins, germline testing for MMR genes, BRAF and KRAS mutation analysis, and Oncotype DX in stage II CRC. Physicians were randomly assigned to receive one of three vignettes that varied by strength of CRC family history. We used multivariable logistic regression to identify physician and practice characteristics associated with test selection.ResultsAmong 327 oncologists, MSI and/or IHC for MMR proteins were most frequently selected (n = 205; 64%), with 82% versus 53% choosing MSI/IHC testing in patients with strong versus no CRC family history, respectively (adjusted odds ratio [OR], 3.87; 95% CI, 2.07 to 7.22). KRAS and Oncotype DX testing were chosen by 24% and 38% of oncologists, respectively. Graduates of non-US and Canadian medical schools and physicians compensated by fee-for-service or on the basis of productivity were more likely to choose KRAS testing versus those receiving salaries not on the basis of productivity (OR, 2.16; 95% CI, 1.17 to 3.99; and OR, 1.94; 95% CI, 1.02 to 3.66, respectively). Fee-for-service or productivity-based salaries were also associated with increased odds of Oncotype DX testing (OR, 2.04; 95% CI, 1.17 to 3.55).ConclusionAmong surveyed oncologists, we found undertesting and overtesting related to genetic and molecular testing and Lynch syndrome screening for patients with stage II CRC,highlighting the need for improved implementation, targeted education, and evaluation of organizational and financial arrangements to promote the appropriate use of such tests.

ImportancePatients with advanced-stage cancer are receiving increasingly aggressive medical care near death, despite growing concerns that this reflects poor-quality care.ObjectiveTo assess the association of aggressive end-of-life care with bereaved family members' perceptions of the quality of end-of-life care and patients' goal attainment.Design, setting, and participantsInterviews with 1146 family members of Medicare patients with advanced-stage lung or colorectal cancer in the Cancer Care Outcomes Research and Surveillance study (a multiregional, prospective, observational study) who died by the end of 2011 (median, 144.5 days after death; interquartile range, 85.0-551.0 days).ExposuresClaims-based quality measures of aggressive end-of-life care (ie, intensive care unit [ICU] admission or repeated hospitalizations or emergency department visits during the last month of life; chemotherapy ≤2 weeks of death; no hospice or ≤3 days of hospice services; and deaths occurring in the hospital).Main outcomes and measuresFamily member-reported quality rating of "excellent" for end-of-life care. Secondary outcomes included patients' goal attainment (ie, end-of-life care congruent with patients' wishes and location of death occurred in preferred place).ResultsOf 1146 patients with cancer (median age, 76.0 years [interquartile range, 65.0-87.0 years]; 55.8% male), bereaved family members reported excellent end-of-life care for 51.3%. Family members reported excellent end-of-life care more often for patients who received hospice care for longer than 3 days (58.8% [352/599]) than those who did not receive hospice care or received 3 or fewer days (43.1% [236/547]) (adjusted difference, 16.5 percentage points [95% CI, 10.7 to 22.4 percentage points]). In contrast, family members of patients admitted to an ICU within 30 days of death reported excellent end-of-life care less often (45.0% [68/151]) than those who were not admitted to an ICU within 30 days of death (52.3% [520/995]) (adjusted difference, -9.4 percentage points [95% CI, -18.2 to -0.6 percentage points]). Similarly, family members of patients who died in the hospital reported excellent end-of-life care less often (42.2% [194/460]) than those who did not die in the hospital (57.4% [394/686]) (adjusted difference, -17.0 percentage points [95% CI, -22.9 to -11.1 percentage points]). Family members of patients who did not receive hospice care or received 3 or fewer days were less likely to report that patients died in their preferred location (40.0% [152/380]) than those who received hospice care for longer than 3 days (72.8% [287/394]) (adjusted difference, -34.4 percentage points [95% CI, -41.7 to -27.0 percentage points]).Conclusions and relevanceAmong family members of older patients with fee-for service Medicare who died of lung or colorectal cancer, earlier hospice enrollment, avoidance of ICU admissions within 30 days of death, and death occurring outside the hospital were associated with perceptions of better end-of-life care. These findings are supportive of advance care planning consistent with the preferences of patients.

ObjectiveConcerns about over-treatment have led to practice guidelines discouraging active treatment of prostate cancer (PCa) in men with limited life expectancies and/or low-risk tumors. We evaluated treatment patterns for older veterans with localized PCa, particularly those with low-risk features.MethodsWe used VA Cancer Registry data to identify men aged 65+ diagnosed with clinically localized PCa between January 1st, 2003 and December 31st, 2008. We obtained baseline data on demographics, tumor characteristics, comorbidities, and initial treatment within 6 months of diagnosis: radical prostatectomy, radiotherapy, primary androgen-deprivation therapy (PADT), or no active treatment. National VA surveys provided facility data, including academic affiliation, availability of oncologic specialists, and distance to radiotherapy facilities. Multinomial regression analyses determined associations between patient and facility characteristics and cancer treatment for men with localized (stageResults17,206 veterans had localized PCa, 32% age 75+, 12% had comorbidity scores ≥3, and 33% had low-risk tumors. Overall, 39% received radiotherapy, 6% surgery, 20% PADT, and 35% no active treatment. For those with low-risk cancers, older men (RR=0.36, 95% CI 0.30-0.43) and sicker men (RR=0.75, 95% CI 0.62-0.90) were less likely to receive surgery or radiotherapy versus no active treatment. Over time, more of these men received no active treatment (from 41% to 57%, P

Individual physicians are widely believed to play a large role in patients' decisions about end-of-life care, but little empirical evidence supports this view. We developed a novel method for measuring the relationship between physician characteristics and hospice enrollment, in a nationally representative sample of Medicare patients. We focused on patients who died with a diagnosis of poor-prognosis cancer in the period 2006-11, for whom palliative treatment and hospice would be considered the standard of care. We found that the proportion of a physician's patients who were enrolled in hospice was a strong predictor of whether or not that physician's other patients would enroll in hospice. The magnitude of this association was larger than that of other known predictors of hospice enrollment that we examined, including patients' medical comorbidity, age, race, and sex. Patients cared for by medical oncologists and those cared for in not-for-profit hospitals were significantly more likely than other patients to enroll in hospice. These findings suggest that physician characteristics are among the strongest predictors of whether a patient receives hospice care-which mounting evidence indicates can improve care quality and reduce costs. Interventions geared toward physicians, both by specialty and by previous history of patients' hospice enrollment, may help optimize appropriate hospice use.

ImportanceShared decision making is associated with improved patient-reported outcomes of cancer treatment, but not all patients prefer to participate in medical decisions. Results from studies of the effect of matching between actual and preferred medical decision roles on patients' perceptions of care quality have been conflicting.ObjectivesTo determine whether shared decision making was associated with patient ratings of care quality and physician communication and whether patients' preferred decision roles modified those associations.Design, setting, and participantsWe performed a population- and health system-based survey of participants in the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study diagnosed with lung and/or colorectal cancer between 2003 and 2005 (56% with colorectal cancer, 40% with non-small-cell lung cancer, and 5% with small-cell lung cancer). The CanCORS study included 9737 patients (cooperation rate among patients contacted, 59.9%) treated in integrated care delivery systems, academic institutions, private offices, and Veterans Affairs hospitals. The medical records were abstracted between October 11, 2005, and April 30, 2009; all analyses were conducted between 2013 and 2014.InterventionsWe surveyed patients specifically about their preferred roles in cancer treatment decisions and their actual roles in decisions about surgery, chemotherapy, and radiation therapy. We analyzed the responses of 5315 patients who completed baseline surveys and reported decision roles for a total of 10 817 treatment decisions and assessed associations of patients' decision roles with patient-reported quality of care and physician communication.Main outcomes and measuresThe outcomes (identified before data collection) included patient-reported excellent quality of care and top ratings (highest score) on a physician communication scale.ResultsAfter adjustment, patients describing physician-controlled (vs shared) decisions were less likely to report excellent quality of care (odds ratio [OR], 0.64; 95% CI, 0.54-0.75; P

BACKGROUND: Shared decision-making is an important component of patient-centered care and is associated with improved outcomes. To the authors' knowledge, little is known concerning the extent and predictors of the involvement of a patient's family in decisions regarding cancer treatments. METHODS: The Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium is a large, multiregional, prospective cohort study of the cancer care and outcomes of patients with lung and colorectal cancer. Participants reported the roles of their families in decision-making regarding treatment. Multinomial logistic regression was used to assess patient factors associated with family roles in decisions. RESULTS: Among 5284 patients, 80 (1.5%) reported family-controlled decisions, with the highest adjusted rates (12.8%) noted among non-English-speaking Asians. Among the 5204 remaining patients, 49.4% reported equally sharing decisions with family, 22.1% reported some family input, and 28.5% reported little family input. In adjusted analyses, patients who were married, female, older, and insured more often reported equally shared decisions with family (all P

PurposeThere have been numerous reports of shortages of injectable drugs for cancer in the last decade. We assessed physician experiences with drug shortages in a population-based cohort of medical oncologists caring for patients with lung or colorectal cancer.MethodsWe surveyed medical oncologists caring for patients with lung or colorectal cancer in the Cancer Care Outcomes Research and Surveillance Consortium from 2012 to 2013 (participation rate, 53%). Oncologists reported experiences with shortages of leucovorin, fluorouracil, dexamethasone, cyanocobalamin, paclitaxel, cisplatin, and etoposide in the prior year and whether they had used a less-effective alternative because of a shortage. We used multivariable logistic regression to assess for associations between physician or practice characteristics and encountering shortages.ResultsAmong 330 respondents, 74% reported experiences with a shortage of at least one drug in our survey, and 28% reported using a less-effective alternative because of a shortage. Although physician demographic characteristics did not predict reports of drug shortages, practice characteristics did. Veterans Affairs (VA) oncologists were less likely to report experiencing any shortage than oncologists in single-specialty group practice (odds ratio [OR], 0.4; 95% CI, 0.2 to 0.9). The reported use of a less effective alternative to any drug was also less common among VA oncologists (OR, 0.3; 95% CI, 0.1 to 0.9) and oncologists affiliated with health maintenance organizations (OR, 0.4; 95% CI, 0.2 to 0.9) compared with physicians in single-specialty groups.ConclusionMost oncologists encountered drug shortages in the year before our survey, but experiences with shortages varied with practice structure. Further research is needed to quantitatively assess the impact of drug shortages on patients and evaluate various strategies for managing them.

ContextRelatively few data are available about symptoms among cancer patients.ObjectivesTo describe the prevalence and severity of symptoms among a large, representative cohort of newly diagnosed cancer patients.MethodsWe collected survey data about symptoms (pain, fatigue, depression, nausea/vomiting, cough, dyspnea, and diarrhea) from 5422 patients with incident lung and colorectal cancer from the diverse, nationally representative Cancer Care Outcomes Research and Surveillance Consortium cohort. We described the prevalence of any symptoms and moderate/severe symptoms approximately four to six months after diagnosis. We used logistic regression to identify patient and clinical characteristics associated with symptoms, and calculated adjusted proportions of patients with symptoms.ResultsIn total, 5067 (93.5%) patients reported at least one symptom in the four weeks before their survey, with 51% reporting at least one moderate/severe symptom. Lung cancer patients reported more symptoms than colorectal cancer patients. Patients who received treatment or had more comorbidities were more likely to report symptoms. For example, after adjustment, patients who received chemotherapy during the six weeks before the survey were more likely than others to report at least one symptom (97.3% vs. 90.8%, P

BackgroundQuality care for patients with cancer often requires access to specialty providers, but little is known about barriers to referring cancer patients for specialized care. Referral barriers may also lessen physician career satisfaction. The study was aimed at determining what factors are associated with these barriers and whether greater barriers are associated with low career satisfaction.MethodsThis cross-sectional study examined 1562 primary care physicians (PCPs) and 2144 specialists responding to the multiregional Cancer Care Outcomes Research and Surveillance Consortium physician survey. The prevalence of physician-reported barriers to referring cancer patients for more specialized care (restricted provider networks, preauthorization requirements, patient inability to pay, lack of surgical subspecialists, and excessive patient travel time) was assessed. The 5 items were averaged to calculate a barrier score. A multivariate linear regression was used to determine physician and practice setting characteristics associated with the barrier score, and a multivariate logistic regression was used to analyze the association of the barrier score with physician career satisfaction.ResultsThree in 5 physicians reported always, usually, or sometimes encountering any barrier to cancer patient specialty referrals. In adjusted analyses of PCPs and specialists, international medical graduates, physicians practicing in solo or government-owned practices, and physicians with

BackgroundClinical trials are essential to establish the effectiveness of new cancer therapies, but less than 5% of adults with cancer enroll in trials. In addition to ineligibility or lack of available trials, barriers to enrollment may include limited patient awareness about the option of participation.MethodsWe surveyed a multiregional cohort of patients with lung or colorectal cancer (or their surrogates) three to six months after diagnosis. We assessed whether respondents reported learning that clinical trial participation might be an option, and, if so, with whom they discussed trials. We used logistic regression to assess the association of patient characteristics with discussing trial participation and enrolling in trials. All statistical tests were two-sided.ResultsOf 7887 respondents, 1114 (14.1%) reported discussing the possibility of clinical trial participation; most learned about trials from their physicians, and 287 patients (3.6% of all patients, 25.8% of trial discussants) enrolled. Among 2173 patients who received chemotherapy for advanced (stage III/IV lung or stage IV colorectal) cancer, 25.7% discussed trials, and 7.6% (29.5% of trial discussants) enrolled. Discussions were less frequent among older patients, African American or Asian vs white patients, and those with lower incomes and more comorbidity. Enrollment was higher among patients reporting shared vs physician-driven decisions (all P < .05).ConclusionsIn this population-based cohort, only 14% of patients discussed participation in clinical trials. Discussions were more frequent among advanced cancer patients but were still reported by a minority of patients. Strategies to expand access to trials and facilitate patient-provider communication about participation may accelerate development of better cancer therapeutics.

BackgroundAdjuvant therapy plays a major role in treating colorectal cancer, and physicians' views of its effectiveness influence treatment decisions. We assessed physicians' views of the relative benefits and risks of adjuvant chemotherapy and radiotherapy for stages II and III colon and rectal cancers.MethodsThe Cancer Care Outcomes Research and Surveillance Consortium surveyed a geographically dispersed population of medical oncologists, radiation oncologists, and surgeons in the United States about the benefits and risks of adjuvant therapies for colorectal cancer. We used logistic regression to assess the association of physician and practice characteristics with beliefs about adjuvant therapies.ResultsAmong 1,296 respondents, > 90% believed the benefits of adjuvant therapies for stage III colorectal cancer outweigh the risks. Only 21.9%, 50%, and 50.4% believed in the net benefit of chemotherapy for stage II colon cancer, chemotherapy for stage II rectal cancer, and radiation for stage II rectal cancer, respectively. Younger physicians were less likely than others to perceive adjuvant therapy for stage II colorectal cancer as beneficial. Medical oncologists were more likely than surgeons and radiation oncologists to endorse the benefits of adjuvant chemotherapy and radiation for stage II rectal cancer, but less likely for stage II colon cancer.ConclusionsPhysicians largely agreed that the benefits of adjuvant chemotherapy for stage III colon cancer, as well as chemotherapy, and radiation for stage III rectal cancer, outweigh the risks, consistent with strong evidence, but were divided over the net benefit of adjuvant therapies for stage II colorectal cancer, where evidence is inconsistent.