Effect of rurality and neighborhood disadvantage on clinical trial interest and decision-making style in patients with cancer living in the Deep South.

Abstract

110 Background: Patients living in rural or disadvantaged settings are historically underrepresented in clinical trials. This study sought to understand associations between neighborhood characteristics and both interest in clinical trial participation and decision-making style preference. Methods: This cross-sectional study used patient-reported outcome data from patients with cancer treated at the University of Alabama at Birmingham from January 2017 to May 2019. Rural-Urban Commuting Area Codes (RUCA) scores were used to determine rurality of patient residence. Area Deprivation Index (ADI) values (range 0-100) were used to identify patients living in the most disadvantaged (top 15%) census block groups. The Control Preferences Scale captured decision-making preference. Likelihood of interest in clinical trial participation by rurality and neighborhood disadvantage was estimated using risk ratios (RR) and 95% confidence intervals (CI) from modified Poisson regression models. Multinomial regression was used to calculate RRs and 95% CIs estimating likelihood of preferred decision-making style by rurality and neighborhood disadvantage. Models were adjusted for age, sex, race, cancer type, cancer stage, ECOG performance status, and phase of care. Results: Of 1005 patients with cancer, mean age was 67 (SD 11), 68% were female, and 74% white. Gynecologic cancer (32%) was the most prevalent diagnosis, followed by hematologic (20%) and breast (15%) cancer. Of this sample, 16% of patients lived in a rural setting and 18% lived in a disadvantaged neighborhood. Interest in clinical trial participation was no different for patients living in rural vs. urban (RR 0.93, 95% CI 0.73-1.17) or disadvantaged vs. non-disadvantaged neighborhoods (RR 0.88, 95% CI 0.69-1.13). Patients living in rural vs. urban settings trended toward increased likelihood of preferring physician- to patient-driven decision-making (RR 1.67, 95% CI 0.95-2.94). Patients living in disadvantaged vs. non-disadvantaged neighborhoods trended toward increased likelihood of preferring physician- to patient-driven decision-making (RR 1.39, 95% CI 0.82-2.35). Conclusions: Though clinical trial participation interest was similar, patients with cancer living in rural vs. urban settings trended toward increased likelihood of preferring physician- vs. patient-driven decision-making. Opportunities exist for providers to engage historically underrepresented patients for trial participation.