Peeling back the curtain: The impact of patient and provider race on clinical trial enrollment.
Authors: Frazier Rachel Marie , Andrews Courtney J. , Henderson Nicole , Eltoum Noon , Thannickal Halle H. , Wagner Lynne I. , Wallner Lauren P. , Wolff Antonio C. , Rocque Gabrielle Betty 
Published: September 2022

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Background: Optimization clinical trials testing less intense treatments are becoming more prominent in oncology due to the availability of better prognostic tools and targeted therapies. In addition to previously documented barriers, these trials are likely to face new barriers from engaging racially diverse populations due to the potential of an increased recurrence risk with reducing treatment. However, little is known about the role of race in decision-making for optimization clinical trials amongst physicians and patients. Methods: This qualitative study included a subset analysis on the influence of race in decision-making for participation in trials testing less chemotherapy. This analysis is part of a larger study, which included semi-structured interviews with patients, patient advocates, and physicians assessing barriers and facilitators to trial participation. Interviews were transcribed, and four coders evaluated transcripts for key themes and exemplary quotes using NVivo. Results: 79 participants (24 patients with breast cancer, 16 patient advocates, and 39 physicians) participated; 30% of patients and patient advocates and 26% of physicians were BIPOC (Black, Indigenous, and People of Color). Several key barriers traditionally associated with Black race were noted amongst both patients and physicians, including aggressive biology (e.g. triple negative breast cancer), younger age, socioeconomic challenges, and lack of trust in physicians and clinical trials. One physician noted, “Taking someone who already has a mistrust of medical care and talking to them about a trial of cutting medical care back, it’s challenging.” While some physicians explicitly acknowledged the role of race in decision-making, often linking race to these barriers, the majority of physicians independently highlighted these barriers while denying the explicit impact of race. Black patients noted similar barriers including emphasizing the role of having triple negative breast cancer, being young, the influence of financial strain, and medical mistrust. One Black patient commented, “I was a triple negative, and that kind was more prone to African American women, usually we don’t really survive from it as well as other races do.” Another Black woman commented, “I had a lot of family and friends that were worried that I was going to be a “guinea pig”. In contrast, White patients heavily emphasized the role of trust in their physicians when making decisions. A White woman stated the following, “I would have done whatever they (doctors) told me was the best thing to do.”. Conclusions: Factors associated with Black race can play both an overt and subconscious role in patient and provider decision-making about participation in optimization clinical trials. Multi-level interventions are needed to address these specific barriers to ensure representative participation in clinical trials for all patient populations.