Adolescent and young adult (AYA) patients aged 15 to 39 years are significantly underrepresented in cancer clinical trials. Underenrollment of AYAs limits the ability of researchers to determine the most effective treatments and improve survival and health-related quality of life in this population. Despite the recognition that disparities in AYA enrollment have existed for more than 2 decades, enrollment in this age group remains limited. But according to Michael Roth, MD, Director of the Childhood Cancer Survivorship Program and Co-Director of the Adolescent and Young Adult Oncology Program at MD Anderson Cancer Center, oncology navigators are well positioned to enhance this population’s access to clinical trials.
“The challenge is that cancer in AYAs is rare, and that’s a good thing; about 75,000 patients aged 15 to 39 are diagnosed with cancer in the US each year,” he said at the AONN+ 2019 Midyear Conference. “But because there are so few AYAs diagnosed with cancer, it’s very difficult to conduct clinical trials. This delays progress and delays our ability to understand what are the best options for these patients.”
Close collaboration between all stakeholders—medical oncology, pediatric oncology, research associates, navigators, and administrators—will be essential to increase AYA enrollment on these trials, he said.
Common Barriers to Enrollment
Although survival in many AYA cancers is improving, 5-year survival rates remain stagnant in malignancies such as acute lymphoblastic leukemia. Clinical trials provide the best setting in which to determine optimal treatment for these patients, but the problem is 2-fold: not only is there a lack of patient awareness of clinical trials, there is also a lack of provider awareness of eligible AYA patients. This is compounded by a lack of prioritization of these trials in general.
Additionally, AYAs are less likely to receive treatment at National Cancer Institute (NCI)-designated cancer centers, and community sites have limited access to research resources and clinical trials.
But collective efforts are being made to lessen disparities and increase AYA enrollment on trials. The Children’s Oncology Group Adolescent and Young Adult Responsible Investigator Network, launched in early 2018, is optimizing enrollment through a network of “AYA Champions.” Through collaboration with medical oncology and support from hospital leadership, these “Champions” utilize shared resources and approaches to enhance local enrollment. Another NCI Community Oncology Research Program is using a 2-step intervention plan to improve AYA enrollment onto trials at their own sites.
The Path Forward
According to Dr Roth, although navigators are still fairly new in the realm of AYA oncology, they can play a vital role in connecting trials to patients, patients to trials, hospitals to trials, and institutions to networks and resources.
“You are on the frontline of clinical trial enrollment. You know who your patients are, and you connect with them,” he said. “We’re lacking that connection for our AYAs in clinical trials.”
As it currently operates, the path to AYA trial enrollment is very linear. It starts with a diagnosis of cancer and is followed by a series of questions to determine a patient’s eligibility for enrollment on a trial (ie, Does a clinical trial exist? Is the clinical trial accessible? Was the clinical trial presented to the patient?) If the answer to any of these questions is “no,” the AYA is typically never enrolled.
But according to Dr Roth, the necessary framework to tackle these issues would provide alternative courses of action when these roadblocks arise. For example, if the clinical trial is not accessible, provide a referral to an AYA center. If the clinical trial was not presented, educate physicians on the importance of enrollment, and encourage crosstalk between pediatricians and medical oncology. He said this requires work at the local level, and developing AYA “Champion” Networks, involving stakeholders across the country and at every site, will be integral to making this happen.
“If we’re looking to develop strong interventions to tackle AYA enrollment strategies,” he added, “we need partners like you.”