In a busy practice, physicians have little time to ask for written informed consent and this might be a threshold to ask patients, especially when the trial involves acute patients. A written patient information sheet is important, but detailed personal, oral information should always prevail. This information can then be adapted to the patients level of understanding. Furthermore, all the paperwork does not motivate to accrue more patients. A win-win situation in which the physician receives reports on their personal series might also stimulate them to fill in the forms and might also stimulate participation.
Motivation is important and low accrual is more due to the doctor than to the patient.
In The Netherlands, an intensive consultant system is organized through comprehensive cancer centers. Physicians from university hospitals visit the community hospitals at their oncology meetings and stress the importance of trial participation, especially since the majority of primary operable patients are treated in those community hospitals. Yearly, approximately 1750 new rectal cancer patients are operated on with curative intent. Our trial has no upper age limit, since otherwise with the aging population increasing numbers of patients could not participate and trial results would be less generalizable. The performance status of each individual patient is more important.