Parent Perspectives on Information-seeking, Trustworthiness, and Decision-making in High-risk Neuroblastoma.

BACKGROUND: This study explores how parents of children with high-risk neuroblastoma incorporate information from multiple sources into treatment decision-making for their children as they evaluate the trustworthiness of the sources. METHODS: Following ethics board approval, parents of children with high-risk neuroblastoma were recruited through purposive sampling from a tertiary care pediatric oncology program in Vancouver, BC, Canada. Participants completed an in-depth, semistructured interview with a study member. The qualitative descriptive methodology was utilized to code interview transcripts and identify emergent themes. RESULTS: Nine parents of children with high-risk neuroblastoma during upfront therapy (n=4) or treatment of refractory disease (n=5) were included. Despite almost universal access of web-based information, parents acknowledged distrust in the reliability and consistency of these sources. Open communication between parents and physicians about sources of information outside the clinic and access to regulated, accurate information is highly valued. The impact on the quality of life and the costs, both financial and personal, of travel are key factors in decision-making. DISCUSSION: Health care providers shoulder an immense responsibility to augment and contextualize information available about high-risk neuroblastoma for parents to maximize benefit in decision-making. Health care providers should guide access to accurate, evidence-based resources that can be monitored and continuously updated.

Resilience, trust, and civic engagement in the post-CCSVI era.

BACKGROUND: Scientific and financial investments in chronic cerebrospinal venous insufficiency (CCSVI) research have been made to address both the hope for and scepticism over this interventional strategy for MS. Despite limited evidence in support of the CCSVI hypothesis, the funding of clinical research was responsive to a demand by the public rarely seen in the history of medicine. We characterize patient perspectives about the CCSVI research trajectory, with particular attention to its impact on other non-pharmaceutical areas of MS research with a focus on stem cell interventions. METHODS: Semi-structured interviews with 20 MS patients across Canada who did not have CCSVI interventions. Interviews were analysed for recurring themes and individual variations using the constant comparative approach. RESULTS: Participants had a critical view of the divestment of funds from longstanding research to support CCSVI trials. They retain a sense of optimism, however, about emerging evidence for stem cell interventions for MS, and highlight the need for greater caution and conscientious communication of advances in medicine and science. CONCLUSIONS: The unrealized hopes for CCSVI challenged but did not undermine the resilience of patient communities. The narrative that unfolded highlights the importance of drawing a socially-minded space for public participation in science.

"You don't want to lose that trust that you've built with this patient...": (dis)trust, medical tourism, and the Canadian family physician-patient relationship.

BACKGROUND: Recent trends document growth in medical tourism, the private pursuit of medical interventions abroad. Medical tourism introduces challenges to decision-making that impact and are impacted by the physician-patient trust relationship-a relationship on which the foundation of beneficent health care lies. The objective of the study is to examine the views of Canadian family physicians about the roles that trust plays in decision-making about medical tourism, and the impact of medical tourism on the therapeutic relationship. METHODS: We conducted six focus groups with 22 family physicians in the Canadian province of British Columbia. Data were analyzed thematically using deductive and inductive codes that captured key concepts across the narratives of participants. RESULTS: Family physicians indicated that they trust their patients to act as the lead decision-makers about medical tourism, but are conflicted when the information they are managing contradicts the best interests of the patients. They reported that patients distrust local health care systems when they experience insufficiencies in access to care and that this can prompt patients to consider going abroad for care. Trust fractures in the physician-patient relationship can arise from shame, fear and secrecy about medical tourism. CONCLUSIONS: Family physicians face diverse tensions about medical tourism as they must balance their roles in: (1) providing information about medical tourism within a context of information deficits; (2) supporting decision-making while distancing themselves from patients' decisions to engage in medical tourism; and (3) acting both as agents of the patient and of the domestic health care system. These tensions highlight the ongoing need for reliable third-party informational resources about medical tourism and the development of responsive policy.

"Is a cure in my sight?" Multi-stakeholder perspectives on phase I choroideremia gene transfer clinical trials.

PURPOSE: Ocular gene transfer clinical trials are raising patient hopes for the treatment of choroideremia--a blinding degenerative retinopathy. Phase I choroideremia gene transfer trials necessitate communicating about the risks of harm and potential benefits with patients while avoiding the sensationalism that has historically undermined this field of translational medicine. METHODS: We conducted interviews between June 2011 and June 2012 with 6 choroideremia patient advocates, 20 patients, and 15 clinicians about their hopes for benefits, perceived risks of harm, and hopes for the time frame of clinical implementation of choroideremia gene transfer. RESULTS: Despite the safety focus of phase I trials, participants hoped for direct visual benefits with evident discrepancies between stakeholder perspectives about the degree of visual benefit. Clinicians and patient advocates were concerned by limited patient attention to risks of harm. Interviews revealed confusion about the time frames for the clinical implementation of choroideremia gene transfer and patient urgency to access gene transfer within a limited therapeutic window. CONCLUSION: Differences in stakeholder perspectives about choroideremia gene transfer necessitate strategies that promote responsible communications about choroideremia gene transfer and aid in its translation. Strategies should counter historical sensationalism associated with gene transfer, promote informed consent, and honor patient hope while grounding communications in current clinical realities.

Ocular gene transfer in the spotlight: implications of newspaper content for clinical communications.

BACKGROUND: Ocular gene transfer clinical trials are raising hopes for blindness treatments and attracting media attention. News media provide an accessible health information source for patients and the public, but are often criticized for overemphasizing benefits and underplaying risks of novel biomedical interventions. Overly optimistic portrayals of unproven interventions may influence public and patient expectations; the latter may cause patients to downplay risks and over-emphasize benefits, with implications for informed consent for clinical trials. We analyze the news media communications landscape about ocular gene transfer and make recommendations for improving communications between clinicians and potential trial participants in light of media coverage. METHODS: We analyzed leading newspaper articles about ocular gene transfer (1990-2012) from United States (n = 55), Canada (n = 26), and United Kingdom (n = 77) from Factiva and Canadian Newsstand databases using pre-defined coding categories. We evaluated the content of newspaper articles about ocular gene transfer for hereditary retinopathies, exploring representations of framing techniques, research design, risks/benefits, and translational timelines. RESULTS: The dominant frame in 61% of stories was a celebration of progress, followed by human-interest in 30% of stories. Missing from the positive frames were explanations of research design; articles conflated clinical research with treatment. Conflicts-of-interest and funding sources were similarly omitted. Attention was directed to the benefits of gene transfer, while risks were only reported in 43% of articles. A range of visual outcomes was described from slowing vision loss to cure, but the latter was the most frequently represented even though it is clinically infeasible. Despite the prominence of visual benefit portrayals, 87% of the articles failed to provide timelines for the commencement of clinical trials or for clinical implementation. CONCLUSIONS: Our analysis confirms that despite many initiatives to improve media communications about experimental biotechnologies, media coverage remains overly optimistic and omits important information. In light of these findings, our recommendations focus on the need for clinicians account for media coverage in their communications with patients, especially in the context of clinical trial enrolment. The development of evidence-based communication strategies will facilitate informed consent and promote the ethical translation of this biotechnology.

An internet-based health survey on the co-morbidities of choroideremia patients.

PURPOSE: To examine the prevalence of systemic and ocular disease among choroideremia patients and carriers. METHODS: A cross-sectional analysis was performed on responses from affected males with choroideremia, female carriers, and unaffected brothers to an Internet-based survey made available from September 2009 to November 2010. Affected males were classified into two groups, those with or without functional vision. Carrier females were classified into those with and without symptoms. Comparisons were made between these groups. RESULTS: There was a higher prevalence of dry eye in our respondents than the North American population. The prevalence of dry eye, cataract, hypertension, diabetes, psychological problems and hypercholesterolemia were higher in choroideremia males without functional vision compared to those with functional vision. Likewise, statin intake was more prevalent among the affected males without functional vision than those with functional vision. After age adjustment, any differences between the two subgroups of male patients (with and without functional vision) were not significant. CONCLUSION: Age plays an important role in determining the onset of severe visual impairment with loss of functional vision in male subjects affected by choroideremia. Although Internet surveys have limitations such as the use of self-reported diagnoses and the possibility that the responses may not be representative of the population as a whole, this study shows that such surveys can provide data quickly and easily, and for rare diseases such as choroideremia, with relatively large numbers of responses.

Participant perspectives on a phase I/II ocular gene therapy trial (NCT02077361).

Background: To learn from the experiences of potential clinical trial participants, participants in a Phase 1 ocular gene therapy trial, and their partners to improve communications and trial conduct. Materials and methods: Primary and secondary qualitative analysis of semi-structured interviews of potential participants (n = 20), clinical trial participants (n = 2) and their partners (n = 2) in a gene therapy clinical trial for choroideremia (NCT02077361). Analysis included: 1) thematic analysis of transcribed entrance and exit semi-structured interviews with trial participants and their partners; and 2) secondary qualitative analysis of interviews with potential trial participants, conducted prior to the initiation of the clinical trial. Results: Participants and partners who had received information during the consent process had a better understanding of the risks and benefits of participation in a Phase 1 gene therapy clinical trial than potential trial participants. However, participants and partners reported deficiencies in communication throughout the trial. Results highlight additional opportunities for trial staff to reinforce initial information about the trial, communicate logistical information and individual outcome data, and express appreciation for participation. Conclusions: Our study enabled clinical trial participants to describe their experiences in a clinical trial for a novel gene therapy. We provide practical recommendations to future clinical trial staff on communications and conduct participant perspectives. Communications strategies should address changing information needs over the course of the trial, express appreciation for participation and enable feedback from participants and their supporting family members, friends, or caregivers.

Perspectives About Time Frames in Stem Cell Research for Multiple Sclerosis: "Time Is Brain".

BACKGROUND: Stem cell research has been a focus of inquiry in the field of neurology for nearly 3 decades and has led to much hope for people with multiple sclerosis (MS). Previous studies, however, demonstrate that information about the pace of developments in the stem cell arena is less accessible than are representations of potential benefits. METHODS: To explore the understanding and perspectives of adult patients with MS and MS clinicians about the time frames associated with stem cell research, we conducted semistructured interviews with 20 patients with MS across Canada and 15 clinicians who specialize in MS. Patients who participated did not have any previous stem cell interventions. Interviews were analyzed for recurring themes and individual variations using the constant comparative approach. RESULTS: We found that patients with MS have a limited understanding about the time that it takes for stem cell research to reach the clinic. In parallel, they express a desire to know more than they do about the translational process. Clinicians offer strategies to address patients' questions about the pace of stem cell research and to promote informed hope about experimental interventions. CONCLUSIONS: These results underscore opportunities to promote transparency in clinical discourse about the pace of stem cell research for MS and other progressive neurologic diseases.

Reflections on translation: Views of participants in a multisite Canadian CCSVI clinical trial.

BACKGROUND: We sought to characterize the perspectives of participants in Canada's phase I/II chronic cerebrospinal venous insufficiency (CCSVI) clinical trial prior to and after the disclosure of trial results. METHODS: This was a researcher-administered survey of individuals who participated in Canada's CCSVI trial (Clincialtrials.gov, NCT01864941) about their (1) motivations for participating, (2) understanding of the trial process, and (3) perspectives on the social value of the trial. RESULTS: A total of 63 participants completed the survey. Participants were motivated to participate by altruism (mean score = 4.56 out of 5) and a desire to access the intervention in Canada (mean score = 3.63 out of 5). Many participants expected medical benefits, such as partial disease reversal (mean score = 3.32 out of 5). Participants felt strongly that the crossover trial design promoted fairness (mean score = 4.65 out of 5). Participants' familiarity with the CCSVI controversy increased significantly after the results were revealed (p = 0.0001). Despite negative trial results, participants still felt that the trial was an appropriate use of tax dollars (mean score = 4.68 out of 5). Many (38%) upheld the belief that further CCSVI research is necessary (responses of 4 out of 5 or higher). CONCLUSIONS: There is a strong movement in science today to ensure that research agendas reflect the perspectives of multiple stakeholders, including research participants. While previous work suggests that negative findings adversely affect trust in science, the perspectives of participants in this study demonstrate that good trial design and resilience can prevail over expected tensions.

A blueprint for the next generation of ELSI research, training, and outreach in regenerative medicine.

Regenerative medicine has attracted the interest of scientists, physicians, and patient communities, and as well as policy-makers and the broader public given related ethical, legal, and social implications. Here we examine past initiatives in the ethical, legal and social implications arena in regenerative medicine, and offer our views on actionable priorities for the future in six key areas: capacity building, policy, engagement with industry, resaerch ethics, communication, and community building.

Social Responsibility in Stem Cell Research - Is the News All Bad?

Transparent public discourse about translational stem cell research promotes informed hope about scientific progress and the sustainable development of biotechnologies. Using an a priori coding scheme, we surveyed articles from leading news media about stem cell interventions for neurodegenerative diseases (1991-2014) from United States (n = 83), Canada (n = 29), and United Kingdom (n = 65). While, this analysis of translational contexts in the news demonstrates a lingering tendency to celebrate the benefits of research with little context of its caveats even for chronic neurologic diseases, in a departure from many previous studies, the data also reveal conscientious reporting about stem cell tourism and timeframe estimates for the development of relevant therapeutics.

Communicating the promise for ocular gene therapies: challenges and recommendations.

PURPOSE: To identify challenges and pose solutions for communications about ocular gene therapy between patients and clinicians as clinical research progresses. DESIGN: Literature review with recommendations. METHODS: Literature review of science communication best practices to inform recommendations for patient-clinician discussions about ocular gene therapy. RESULTS: Clinicians need to employ communications about ocular gene therapy that are both attentive to patient priorities and concerns and responsive to other sources of information, including overly positive news media and the Internet. Coverage often conflates research with therapy-clinical trials are experimental and are not risk free. If proven safe and efficacious, gene therapy may present a treatment but not a cure for patients who have already experienced vision loss. Clinicians can assist patients by providing realistic estimates for lengthy clinical development timelines and positioning current research within models of clinical translation. This enables patients to weigh future therapeutic options when making current disease management decisions. CONCLUSIONS: Ocular gene therapy clinical trials are raising hopes for treating a myriad of hereditary retinopathies, but most such therapies are many years in the future. Clinicians should be prepared to counter overly positive messaging, found in news media and on the Internet, with optimism tempered by evidence to support the ethical translation of gene therapy and other novel biotherapeutics.