Access Denied: Inequities in Clinical Trial Enrollment for Pancreatic Cancer

Abstract

The influence of social determinants of health (SDH) on participation in clinical trials for pancreatic cancer is not well understood. In this study, we describe trends and identify disparities in pancreatic cancer clinical trial enrollment. This is a retrospective study of stage I–IV pancreatic cancer patients in the 2004–2016 National Cancer Database. Cohort was stratified into those enrolled in clinical trials during first course of treatment versus not enrolled. Bivariate analysis and logistic regression were used to understand the relationship between SDH and clinical trial participation. A total of 1127 patients (0.4%) enrolled in clinical trials versus 301,340 (99.6%) did not enroll. Enrollment increased over the study period (p < 0.001), but not for Black patients or patients on Medicaid. The majority enrolled had metastatic disease (65.8%). On multivariate analysis, in addition to year of diagnosis (p < 0.001), stage (p < 0.001), and Charlson score (p < 0.001), increasing age [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.96–0.97], non-white race (OR 0.54, CI 0.44–0.66), living in the South (OR 0.42, CI 0.35–0.51), and Medicaid, lack of insurance, or unknown insurance (0.41, CI 0.31–0.53) were predictors of lack of participation. Conversely, treatment at an academic center (OR 6.36, CI 5.4–7.4) and higher neighborhood education predicted enrollment (OR 2.0, CI 1.55–2.67 for < 7% with no high school degree versus > 21%). Age, race, insurance, and geography are barriers to clinical trial enrollment for pancreatic cancer patients. While overall enrollment increased, Black patients and patients on Medicaid remain underrepresented. After adjusting for cancer-specific factors, SDH are still associated with clinical trial enrollment, suggesting need for targeted interventions.