The Importance of Minority Participation in Clinical Trials Lovell A. Jones, Ph.D., Research Faculty...
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The Importance of Minority Participation in
Clinical Trials
Lovell A. Jones, Ph.D., Research Faculty
Texas A & M University Corpus Christi
Professor EmeritusUniversity of Texas M. D. Anderson
Cancer CenterUniversity of Texas Graduate School of
Biomedical Sciences
Bridging the Gap Between Community Needs and Clinical Research
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1st Annual National African American Breast CancerConference
Houston, TexasApril 1999
National Minority Cancer Awareness Week
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Race Perhaps the single most
defining issue in the history of American society
Harold Freeman, M.D.
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In our societywe see, value, and behave toward one another through a
powerful lens of race.
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A Recent Local Example of a Critical Disparity
Houston Chronicle, Feb 5, 2008
Black women in Houston are 45% more likely to die of breast cancer than white women
The racial disparity gap in breast cancer mortality rates in Houston is higher than the national average …and worsening
Recent data suggest that
African American women in
Houston are now equally
likely to get breast cancer as
Caucasians…which is highly
unusual in the U.S.!
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NH Black and NH White Breast Cancer Mortality, Houston, 1995-2004
Age-Adjusted Female Breast Cancer Mortality for Houston, Per 100,000 Women
41.3
28.2
32.8
40.8
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NH Black and NH White Breast Cancer Mortality Rates, Chicago, 1980-2005
Age-Adjusted Female Breast Cancer Mortality for Chicago, Per 100,000 Population
38.1
37.4
41.4
19.2
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How Have WeDefined RaceIn America?
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How Do We Explain Racial And Ethnic
Disparities In Health?
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Definitions of Race1) A local, geographic or global human population distinguished
as a more or less distinct group by genetically transmitted physical characteristics.
2) A group of people united or classified together on the basis of common history, nationality, or geographic distribution...
3) Human beings considered as a group.The American Heritage Dictionary of the English Language, 1992
4) A vague, unscientific term for a group of genetically related people who share certain physical characteristics.
5) A distinct ethnic group characterized by traits that are transmitted through their offspring.
Mosby’s Medical, Nursing, and Allied Health Dictionary, 1994
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Jackson, 2004
PREDOMINANT AFRICAN CULTURAL INFLUENCES ON AFRICAN AMERICANS
• Bight of Benin region traditions• Yoruba
• West Central Africa region traditions• Kongo
• Upper Guinea Coast region traditions• Various Mande-speaking groups
• Bight of Bonny region traditions• Ibo and Ejaham
• Senegambian region traditions• Wolof, Bambara, Mandingo, Fulbe
• Gold Coast region traditions• Various Akan-speaking groups
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85% variation 85% variation withinwithin ““racerace””
15% variation 15% variation betweenbetween ““racesraces””
Marcus Feldman, Ph.D.Population Geneticist, Stanford University
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Figure 3. The migration of modern Homo sapiens.The scheme outlined above begins with a radiation from East Africa to the rest of Africa
about 100 kya and is followed by an expansion from the same area to Asia, probably by two routes, southern and northern between 60 and 40 kya. Oceania, Europe and America were
settled from Asia in that order.
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Likely Genetic Connections Between the Bight of Bonny and
the Chesapeake Bay Populations
The largest component of Africans brought to the Chesapeake Bay came from the hinterlands of the Bight of Bonny West Africa. This area includes SE Nigeria, W Cameroon, Equatorial Guinea, and N Gabon.
Redrawn from Jackson 2008
Chesapeake Bay Region
Bight of Bonny Region
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Over 50% of the Breast patients at UNTH Enugu, Nigeria in 2004-2005
showed a high incidence of premenopausal patients in the 20-40
years age range.
Over 50% of the Breast patients at UNTH Enugu, Nigeria in 2004-2005
showed a high incidence of premenopausal patients in the 20-40
years age range.
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Fatimah Jackson, Ph.D. 2006 Transforming Anthropology 14(2):126-130.
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SO WHICH OF THESE INDIVIDUALS ISBIOLOGICALLY WHITE NON-HISPANIC, WHITE HISPANIC,
ASIAN, AFRICAN AMERICAN OR NATIVE AMERICA?
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68% European16% West African16% Native American
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Diseases with prevalence differences
• Obesity (> in African-American women and Native American, and Hispanic populations)
• Type 2 diabetes (> in Native American, Hispanic, and African-American populations)
• Hypertension (> in African-American populations)• End Stage Renal Disease (> in Native American, Hispanic, and
African-American populations)• Cancer
• Skin cancer (> in European-American)• Prostate Cancer (> in African-American)• Lung Cancer (> in African-American)• Breast Cancer (early age of onset in African American)
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INSANITY: Continuing to do things the same way and expecting a different outcome.
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If You Always Do What You Have Always Done.... You’ll Always Get What You Always Got!
Unfortunately, when we approach efforts to deal with the lack of real progress in addressing health disparities, we tend to fall back to what we have done before. It may be under a different name or packaged in a different box, but ultimately it is the same strategy.
Lovell A. Jones 1999
Moms “Jackie” Mabley
THE GRASSROOTS DEFINTION OF INSANITY
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CLINICAL TRIALSCLINICAL TRIALS
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• Fear of unethical treatment• Distrust of the investigator’s motives• An incomplete understanding of their benefits,
responsibilities, risk, and the safeguards for study subjects• The investigators’ apparent lack of respect for the
subjects and their cultures.• The history of episodic research without long-term
program having, tangible benefits• Cost and/or lack of insurance• Lack of access to clinical trials (transportation,
child care, time off of work) and • lack of true partnerships in study design
Barriers to Clinical Trials
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TOP TEN REASONS
WHY MINORITIES ARE NOT ENROLLED
ON CLINICAL TRIALS
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10. Time consuming for physicians and staff to explain and translate protocols and consent forms.
9. Lack of awareness of existing protocols by physicians and the community
8. Concept of being guinea pigs prevails7. Lack of bilingual providers and the use of translators.6. Time-consuming for patients who cannot take time off from work
and/or children. 5. Financial constraints and requirements of costly diagnostic
procedures at specific times during the course of their treatment.4. Treatment protocols not available at the patient's preferred
treatment site.3. Different tumor incidence in minority groups compared to whites.2. Lack of protocols specific for cancer seen most often in minority
populations.1. The number one reason, the biggest of them all, lack of
understanding of minorities' knowledge, attitudes and practices regarding cancer with resulting poor protocol planning.
Top Ten Reasons For Minorities Not Being Enrolled Into Clinical Trials
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LACK OF PHYSICIAN RECOMMENDATION
&PHYSICIAN BIAS
NUMBER 1 REASONMINORITIES DO NOT
PARTICIPATE IN CLINICAL TRIALS
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PERCEPTION VS REALITY
A PERSON’S PERCEPTION IS A PERSON’SREALITY
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Unconscious Discrimination
• When one holds a negative stereotype about a group and meets someone who fits the stereotype s/he will discriminate against that individual
• Stereotype-linked bias is an – Automatic process– Unconscious process
• It occurs even among persons who are not prejudiced
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WHO YOU ARE SHAPES HOW YOU LOOK AT
PROBLEMS
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BIOPSYCHOSOCIAL RESEARCH
IF THE PROBLEMS ARE IN THE IF THE PROBLEMS ARE IN THE COMMUNITY, THEN COMMUNITY, THEN
COMMUNITIES MUST BE COMMUNITIES MUST BE INVOLVED IN DETERMINING INVOLVED IN DETERMINING
THE SOLUTIONSTHE SOLUTIONS
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MODIFIED PATIENT NAVIGATOR PROGRAM
Participant Recruitment
ScreeningClinical Findings
Additional Test Enroll in the Study
Referred For Treatment Continued Follow up
Health Outcome
Impact on Recruitment
(-)
(+)
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* FAROS expands the Freeman model to include CHW to navigate older Latinos through screening & PN at the point of suspicious findings onward
to the community and life after cancer.
FAROS
Screening
The Patient Navigation ModelThe Cancer Care Continuum
Community HealthWorkers
Community HealthWorkers
Patient Navigators
Health Referral Specialist
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IMPaCT Report Date Range: 09/01/2006 to 01/31/2010
Patients Educated about CT and IMPaCT 292 Enrolled in IMPaCT Not Enrolled in IMPACT Total Patients Potentially Eligible for CT 93 40 133 Enrolled in IMPaCT Not Enrolled in IMPACT Not Yet Consented to CT (Recruitment): 30 29 Ineligible: 8 (27%) 14 (48%) Pending: 0 (0%) 1 (3%) Eligible: 22 (73%) 14 (48%) Declined CT 5 (23%) 13 (93%) Enrolled in CT 17 (77%) 1 (7%)
Currently Enrolled in CT 2 0 Completed CT 14 1
Withdrawn Self 1 0 Enrolled in IMPaCT Not Enrolled in IMPACT Already Consented to CT (Retention): 63 11 Ineligible: 0 (0%) 1 (9%) Pending: 0 (0%) 0 (0%) Eligible: 63 (100%) 10 (91%) Declined CT 0 (0%) 0 (0%) Enrolled in CT 63 (100%) 10 (100%)
Currently Enrolled in CT 14 3 Completed CT 43 7
Withdrawn Self 6 0
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•Trust Respect
Solutions
•
Partnership•
CommunicationFlexibility
• Knowledge
••
SIX KEY WORDS TO THE SOLUTION
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a
Gilism #1001Gibert Friedell, M.D.
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QUESTIONS
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Contact InformationLovell A. Jones, Ph.D.Professor EmeritusU.T. Distinguished Teaching ProfessorUniversity of Texas M.D. Anderson Cancer CenterUniversity of Texas Graduate School of Biomedical SciencesCo-Founder, Intercultural Cancer CouncilChair, Board of Directors, Children and Neighbors Defeat Obesity (CAN DO) Houston11511 Mulholland DriveStafford, Texas. [email protected]://stylemagazine.com/staff/dr-lovell-jones/