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How informed is declared altruism in clinical trials? A qualitative interview study of patient decision-making about the QUEST trials (Quality of Life after Mastectomy and Breast Reconstruction)
Trials volume 17, Article number: 431 (2016)
Randomised controlled trials (RCTs) often fail to recruit sufficient participants, despite altruism being cited as their motivation. Previous investigations of factors influencing participation decisions have been methodologically limited. This study evaluated how women weigh up different motivations after initially expressing altruism, and explored their understanding of a trial and its alternatives. The trial was the ‘Quality of Life after Mastectomy and Breast Reconstruction’ (QUEST) trial.
Thirty-nine women participated in qualitative interviews 1 month post-surgery. Twenty-seven women (10 trial decliners and 17 acceptors) who spontaneously mentioned ‘altruism’ were selected for thematic analysis. Verbatim transcripts were coded independently by two researchers. Participants’ motivations to accept or decline randomisation were cross-referenced with their understanding of the QUEST trials and the process of randomisation.
The seven emerging themes were: (1) altruism expressed by acceptors and decliners; (2) overriding personal needs in decliners; (3) pure altruism in acceptors; (4) ‘hypothetical altruism’ amongst acceptors; (5) weak altruism amongst acceptors; (6) conditional altruism amongst acceptors; and (7) sense of duty to participate. Poor understanding of the trial rationale and its implications was also evident.
Altruism was a motivating factor for participation in the QUEST randomised controlled trials where the main outcomes comprised quality of life and allocated treatments comprised established surgical procedures. Women’s decisions were influenced by their understanding of the trial. Both acceptors and decliners of the trial expressed ‘altruism’, but most acceptors lacked an obvious treatment preference, hoped for personal benefits regarding a treatment allocation, or did not articulate complete understanding of the trial.
QUEST A, ISRCTN38846532; Date assigned 6 January 2010.
QUEST B, ISRCTN92581226; Date assigned 6 January 2010.
Randomised controlled designs for trials of different treatments (RCTs) are essential to minimise selection bias and ensure that treatments are based on the best possible evidence. However, many trials do not recruit the desired participant numbers required to meet study objectives, despite often citing altruism as their motivation for participating. The statistical power of the results then becomes compromised or the costs through extensions to the recruitment period are increased . In order to maximise the rates of trial participation whilst ensuring patients can make their decisions based on a clear understanding of what is involved, it is imperative to understand factors affecting motivation and patient decisions around participation and non-participation in trials.
Altruism, defined as ‘acting with an unselfish regard for others’ , has been identified as a potentially important factor in patient’s decision-making as to whether or not to consent to trials. Altruistic motivations in healthcare trials include patients’ desire to help others with the same condition and contribute to progressing medical knowledge . However, factors other than altruism may be motivating factors in patients’ decisions; although cancer trial participants within drug-intervention studies commonly reported that altruism contributed to their decision to enrol, they also expected to receive medical benefits [2–4].
Current studies evaluating the levels of trial participation are methodologically limited; involving either healthy participants responding to hypothetical scenarios in analogue studies; and by focusing exclusively on those patients consenting whilst ignoring those who declined . Previous surveys are difficult to interpret as respondents were rarely asked to make a choice between self-interest and altruism, typically reporting both motivations without exploring how these motivations were weighted .
Importantly, regulation of most new drugs and devices mean that they are available to patients only if they agree to participate in a clinical trial, making it difficult to disentangle their motivations toward science and themselves. Many agree to participate in the hope of receiving experimental treatment as well as contributing to medical knowledge. Different trial designs include control arms which could be a standard treatment or a placebo (even sham surgery in some cases), which compound the difficulty in interpreting results about motivation. [6, 7]. Recently, McCann et al.  conducted a qualitative study, embedded in a ‘patient-preference’ trial (in which patients could either select their preferred treatment or accept random allocation of those treatments). Results suggested that people rarely participate in trials out of purely altruistic reasons, and often require some perceived personal benefit from being randomised in a trial.
Our study investigates what is often regarded as a socially desirable, yet unexplored, response of altruism. To better understand how patients weigh altruism in their decision-making about participating in clinical trials we also examined any stated personal treatment preferences and understanding of fundamental aspects of RCTs, such as randomisation and clinical equipoise. The effects of altruistic motivations on decisions about participation might be moderated by misperceptions of randomisation, equipoise or by treatment preferences . For example, patients may be motivated to participate because they believe that the research will benefit others but decide against taking part because they have not understood the attributes of an RCT. On the other hand, a decision to participate in the trial might seem to be purely altruistic if the patient has a strong personal treatment preference and their decision to participate in the trial is made with a full understanding that, through randomisation, they may not receive the preferred treatment that they could have selected outside the trial.
The Quality of Life after Mastectomy and Breast Reconstruction (QUEST) trials (Cancer Research UK funded: C10318/A10077, reference Trial A ISRCTN: 38846532, Trial B 92581226) comprised two parallel feasibility phase III randomised multicentre trials to assess the impact of the type and timing of latissimus dorsi (LD) breast reconstruction on health-related quality of life (HRQL) when post-mastectomy radiotherapy is unlikely (Trial A) or highly probable (Trial B) . All women with either invasive breast cancer or ductal carcinoma in situ requiring mastectomy were eligible (Fig. 1) . Surgical treatment arms comprised a standard care arm versus a less practiced new intervention arm in both trials. The standard of care was implant-assisted LD breast reconstruction in Trial A, and staged-delayed (two-stage) extended autologous LD breast reconstruction in Trial B. Despite its pragmatic design, the LD breast reconstruction techniques were well established in the UK, and were potentially available to patients outside the trial.
The QUEST Perspectives Study (QPS) was an embedded study evaluating the perceptions of patients and healthcare professionals on randomisation (views on decision-making and subsequent experiences) to inform QUEST trial processes and enhance ongoing recruitment and patient acceptability. In the current analysis, we examined patients’ views about altruism, as a factor in their decision to participate (or not) in a clinical trial, in the context of: (1) their understanding of randomisation (the rationale and trial process); (2) their comprehension of clinical equipoise related to the impact of health-related quality of life (HRQL) on the types and timings of immediate LD breast reconstruction; and (3) their perceptions of and preferences towards the treatment options available to them both before and after randomisation.
Recruitment and procedure
QUEST and QPS were each approved by South West Exeter Health Research Authority (QUEST Trial A 10/H0206/41, QUEST Trial B 10/H0206/42) . Eligible patients approached to participate in QUEST were simultaneously invited (face to face) to participate in QPS. Informed consent was gained from all participants for both the QUEST trials and QPS. The women who consented to the QPS comprised both decliners and acceptors of QUEST. They were invited to participate in a semi-structured telephone interview 1 month after their breast reconstruction surgery with one of the researchers (NB or LM, both experienced qualitative researchers in behavioural medicine and independent from the research team conducting the QUEST trials). Interviews were audio-recorded with participants’ permission and transcribed verbatim. The interviews explored the women’s understanding of the QUEST trials, the process of randomisation and their perception of the surgical options. The interviews also explored patients’ decision-making processes in accepting or declining to enter QUEST and the factors they considered when making the decision including their eventual motivations influencing their decision.
One hundred and twenty-four patients were eligible to enter QPS, and 56 (45 %) consented, of whom 39 took part in qualitative interviews . Reasons for consenting to, but not completing, the interviews included the following: researchers were unable to contact the participant after multiple attempts and changes in participants’ personal circumstances making interviews inappropriate. The analysis presented here focuses on those interviews in which participants spontaneously raised ‘altruistic’ motivations to explore the meaning and types of genuine sentiment or socially desirable answers (n = 27). The demographic characteristics of this subset of the interviewees are summarised in Table 1.
Two authors (NB and LM) initially independently coded the transcripts using NVivo 10 software. Using the grounded theory approach, thematic analysis enabled codes to be conceptualised into common themes . Emerging themes were subsequently discussed with and guided by SE (an experienced bioethicist and qualitative researcher in research ethics and independent from the QUEST trial research team). The themes were further developed by NB and LM using the original interview transcripts. After independent coding, consensus agreement was reached through discussion where initial coding differed. Participants’ expressed motivations to accept or decline the trial were the key finding.
To explore the inter-relationships between these factors, the expressed altruism was cross-referenced with other expressed motivations, and with understanding of the trial, of randomisation, and of alternative treatment options (as judged independently and agreed by NB and LM), as well as with their actual decision. Patients’ overall understanding was assessed independently by drawing on different aspects of the transcripts (NB and LM) and noting consistency of responses with known consequences of their actual decisions for treatment allocation. (A participant stating a treatment preference with self-interested motivation, but accepting randomisation, may have misunderstood information about the trial). A full analysis of understanding will be reported elsewhere. Additional findings from QPS, other than the spectrum of altruistic motivations are presented elsewhere [9, 11].
The themes regarding expressed altruism are presented below with illustrative quotes from participants.
Altruism was initially expressed by both acceptors and decliners
Altruistic motivations were initially expressed both by women who accepted and declined the QUEST trials. They expressed a desire to help the investigators and to improve care for women with breast cancer in the future. In some cases, the altruistic decision to participate in the trial seemed to be taken with an understanding of trial processes and the desire to help others after receiving a life-changing diagnosis. Those who declined participation, however, also reported strong beliefs in the value and importance of research and of helping people (Table 2).
Not all the women expressing altruistic motivations were able to articulate full understanding of the rationale for and process of randomisation, and therefore their decision whether or not to take part could not be seen as fully informed (Table 2, participant 22).
The initial expression of altruism therefore did not seem to differentiate between decliners and acceptors. Some of those who declined to participate yet expressed altruistic intentions did not fully understand what randomisation involved. However, participants’ discourse often revealed other motivating factors beyond the initial desire ‘to help others’ by taking part in QUEST. These cause us to question whether those who declined would have reached a different decision had they had a better understanding of randomisation. The factors influencing the eventual decisions by decliners and acceptors are described in the following themes.
Personal needs took precedence in decliners
Other factors overrode the altruistic motivations initially expressed by those who declined. For most decliners, their own current needs took priority over any altruistic inclinations and, although they were interested in helping other people and accepted the importance of research (with many fully understanding both the rationale for and process of randomisation), they felt that, at this time, it was more important to focus on themselves and what was right for them (Table 3, participant 19).
While accepting the potential benefits of the trial to others, some women who declined to take part did so because they not only failed to see any personal advantage in participating, but also perceived randomisation to be detrimental to their individual needs (Table 3, participant 27).
Alternatively and despite there being clinical equipoise between the options offered in the QUEST trials, some decliners retained a belief that one option was better for them than the other and therefore held a treatment preference that eventually guided their decision. However, they did not fully understand the process of randomisation, which may have been too daunting, or they seemed to want to avoid one or other of the trial treatments (Table 3, participant 16).
Pure altruism (true selflessness) in an acceptor
Many acceptors also held treatment preferences going into the trial. Only in one case was an acceptor not allocated her expressed preference during randomisation. This lady accepted randomisation regardless, apparently demonstrating pure altruism. Her immediate preference was to have the surgery completed as quickly as possible in order to progress with her life. However, from her explanation it was clear that although she discussed a computer deciding the surgical option, she also referred to the doctors choosing the option and that they were likely to know which was better due to their experience, and therefore their decision would ultimately be better than her own decision. Therefore her understanding of randomisation was inaccurate (Table 4).
‘Hypothetical altruism’ (selfless behaviour stated but not put to the test) amongst acceptors
Of those acceptors with treatment preferences who were allocated to them during randomisation, most stated that they would have accepted the alternative had they been allocated to it, despite being able to withdraw after randomisation and select their preferred treatment, therefore demonstrating, hypothetically, a high commitment to the trial. We have therefore labelled this as ‘hypothetical altruism’.
Some participants who were allocated to their treatment preference, but claimed that they would have accepted the alternative fully comprehended the process of and rationale for randomisation (Table 5). However, one participant (participant 13) also expressed complete trust in her healthcare team and a certain belief in the ‘equivalence’ of the treatment options (as if there were evidence that the options were equally good rather than that there was currently no evidence of differences in HRQL), which could have indicated a misunderstanding about clinical equipoise and hence a therapeutic misconception associated with the trial.
Most ‘hypothetical altruists’ did not demonstrate a full understanding of randomisation and may not have fully appreciated the consequences of remaining in the trial and on a treatment they did not prefer (Table 6). Another acceptor (participant 12) thought that the trial coordinators decided on her allocation based on her clinical information. She was happy to accept either option despite a preference for no implant as she trusted the surgeon’s advice that she was suitable for both options.
Weak altruism amongst acceptors
Some acceptors did not have a treatment preference going into the trial and therefore demonstrated what could be described as a ‘weak’ form of altruism since there was an absence of personal benefit rather than an active intention to benefit others. Some of these participants had full understanding of randomisation and so their altruistic motivations were based on the knowledge that they could have been assigned to either treatment at random (Table 7).
Conditional altruism (selflessness dependent on perceived personal benefits) amongst acceptors
For some acceptors, their altruistic behaviour appeared to be contingent on perceived immediate personal benefits from taking part in the trial, recognised elsewhere and termed conditional altruism . Expanding on the weak altruism presented above, for some women, not having to choose was a direct benefit of participating in the trial. They reported that decision-making was extremely difficult either because they had no preference or because they were overwhelmed by their diagnosis and the quantity of information. The first participant demonstrated full understanding of randomisation, the second understood the rationale, but did not articulate an understanding of how it was conducted (Table 8).
One acceptor regarded consenting to randomisation as a way of regaining personal control over her diagnosis (Table 9, participant 5). She demonstrated full understanding of randomisation and was in clinical equipoise as illustrated in the weak altruism theme above. Another perceived advantage for participants was that they felt they would gain more attention and be better listened to as part of the trial (Table 9). No such benefits were highlighted to participants during the recruitment process, yet participants could have perceived the additional contact time as being beneficial. In addition, the focus of the trial was quality of life outcomes after surgery, and therefore participants may have perceived that in participating there may be an increased emphasis on this. However, as illustrated by participants’ quotes in the themes previously discussed, these participants understood that the best surgical option for them was decided upon through their clinical information. Both expressed a preference for their surgery but would have been happy to accept the alternative due to their belief in the surgeon’s view that the other option was equally suitable for them clinically.
Sense of duty to take part
Some acceptors reported participating in the trial out of a sense of duty instead of expressing straightforward altruistic motivations in their reasons for wanting to take part (Table 10). They felt that by taking part they would be able to ‘pay back’ for all the treatment they had received and for the contributions that women before them had made to enable them to have the treatment they had. While most of these women had full understanding of randomisation as in the two quotes below, some did not and this misperception was that the most suitable treatment option would be selected based on their clinical information. Consequently, they did not perceive any personal sacrifice through participating in research. Two women who indicated this ‘sense of duty’ to participate had clear treatment preferences, but nevertheless consented to randomisation. One was allocated her preference and one was not and both indicated that they would have accepted the alternative as described in the previous sections.
This study explores the meaning of expressed altruism when patients are invited to participate in a surgical RCT where the primary outcome measure comprised HRQL and where the new surgical interventions were available outside the trial. This study illustrates how patients weighed up different motivations, after initially expressing altruism, to decide whether or not to accept the trial, and reports how informed those motivations were, given the patients’ understanding of the trial and the treatment options available, and any stated personal preferences.
Altruism was expressed initially by both acceptors and decliners of the QUEST trials. These initial motivations were often modified by understanding the trial and individual beliefs about the surgical options, and, in many cases, were overridden by personal interest according to treatment preference. Moreover, some acceptors who were in ‘clinical equipoise’ seemed simply not to mind being randomised. Altruism was still expressed by some who had accepted randomisation despite having a treatment preference. All but one of these patients were randomly allocated to their treatment preference and so did not have to ‘test’ their declared altruism afterwards by potentially withdrawing after randomisation.
Our findings somewhat corroborate results from a recent qualitative study suggesting that altruistic motivations amongst those who accept randomisation are often tempered by self-interested motivations in various ways even when they are in a state of clinical equipoise . However, it was unclear how informed these motivations were. Some patients perceived benefits of taking part in the QUEST trials, such as avoidance of making a difficult choice between surgical options, gaining an element of control by deciding to participate or perceived greater input from the healthcare team, and their altruistic motivations were conditional upon this. There is some, albeit weak evidence from comparative studies suggesting that patients may do better within trials on similar treatment to those outside of trials . This study further explores conditional altruistic motivations by cross-referencing the patient's declared motivations with their actual decisions and their understanding of the trial. Only one patient in our study consented against her declared treatment preference, but she did not fully understand the trial and it was unclear whether her decision to take part was an authentic choice to be altruistic (i.e. one that reflects the true preference of the individual).
Our finding that patients did not always fully understand the trial and its alternatives (both acceptors and decliners) concurs with previous work . There appeared to be misunderstanding of how the treatment option was decided if they entered the trial and, related to this, some participants did not hold views consistent with ‘clinical equipoise’. For decliners, misunderstanding randomisation and equipoise may not be the sole factors responsible for them choosing not to take part as they had strong preferences for a particular surgical option or they wished to make the decision by having control themselves. Findings from this study were regularly reported to the QUEST Trial Management group and the Trial Steering and Data Monitoring Committee whilst the trials were running, and helped inform ongoing recruitment strategies. A standardised trial information checklist was an early by-product of this study 3 months after trial commencement. The use of this checklist by the research nurse within trial consultations was standardised across all centres and was instrumental in attempting to balance expressed patient preferences .
We did not include all those respondents in QPS (namely those who did not express any altruism) in our present analysis because there would have been no way of weighing up different motivating factors in the unique way QUEST allowed. While an expression of self-interest alone does not necessarily exclude all altruistic motivation, we were primarily interested in those situations in which self-interest and altruism led to contradictory decisions to help gauge the strength of those motivations.
The challenges of surgical trials are well described by Cook et al. (2015) with recommended trial designs including a feasibility phase and embedding qualitative research to inform trial processes . As the first multicentre trials in this setting, the QUEST feasibility trials showed overall patient acceptability rates of 19 % (17 out of 88) in Trial A and 22 % (8 out of 36) in Trial B, respectively over 18 months of recruitment .
The findings from this study should be considered in light of its limitations. The interviews were conducted after surgery, and at least a month after the women had made the decision whether or not to accept randomisation. In addition to potential difficulties with accurate recall, it is possible that initial preferences and perceptions were modified as a result of the outcome of randomisation (for acceptors) and post-surgery experiences. Furthermore, the QUEST trials were surgical RCTs, comparing the impact on HRQL of different types and timing of LD breast reconstruction. In addition, the treatments offered in the trial, while available outside the trial, may not always have been offered to patients making the trial a ‘quasi-preference’ trial. The findings from the current study may not be generalizable to other RCTs attempting to recruit from different patient populations, or to evaluate the efficacy of a novel drug treatment against either an active or placebo control, and under different conditions.
Nevertheless, the knowledge gained from this study provides valuable insight that can inform and refine attempts to recruit participants to future RCTs. In particular, information given to patients at the time of consent should clarify the potential benefits of trial participation. The dedicated trial consultation should be led by non-biased healthcare professionals using standardised informed consent where iteration of pros and cons may change/balance patient preferences and perceptions. Evaluation of the patient’s understanding of information as this pertains to randomisation should be routinely assessed to ensure that any expressed altruism is based on truly informed consent. In addition, more research is needed in this area to explore the limits to conditional altruism once patient understanding of trials has been improved in practice. For example, it is not yet clear how perceiving beneficiaries of the trial influences feelings of altruism. Currently, patients are often simply told - vaguely - that the trials to which they are invited to participate in, are designed to benefit patients in the future. This futuristic expectation risks undermining the fundamental precepts of good informed consent, where the patients’ understanding of the rationale and benefits of trial participation are key goals in current trial recruitment. Recommended testing of patient’s understanding of informed consent should be an integral part of feasibility and pilot phase studies within RCTs.
This study makes a valuable and unique contribution to the understanding of the factors influencing patients’ decision whether or not to enter a surgical RCT where the treatment options may be preference-sensitive, despite being technically established and poorly evidenced in terms of patient-reported HRQL. By employing qualitative methods and thereby avoiding some of the limitations of previous research in this area, we have highlighted how different motivations, including altruism, were evaluated by the participants in the context of their understanding of the trial and randomisation. Although both acceptors and decliners of the QUEST trials initially expressed altruistic motivations, these were often revised or outweighed by other factors related to the participants’ own interests and perceptions.
Health-related quality of life
QUEST Perspectives Study
Quality of Life after Mastectomy and Breast Reconstruction
Randomised controlled trial
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The authors sincerely thank the patients who participated in QPS and QUEST; the breast care and research nurses at the recruiting centres; and members of the QUEST Trial Steering and Data Monitoring Committee. The authors also extend their gratitude to the Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU) who conducted the QUEST trials, and who were instrumental in the setting up of the QPS trial.
This research was funded by the BUPA Foundation as part of the QUEST studies (A and B). The QUEST trials were supported by a Cancer Research UK feasibility studies grant (CRUK/08/027), and core funding to the Institute of Cancer Research Clinical Trials and Statistics Unit from Cancer Research UK (C1491/A9895). Professor Rob Horne is supported by a National Institute for Health Research (NIHR) Senior Investigator Award. Dr Sarah Edwards is funded by the NIHR with support from the Centre for the Advancement of Sustainable Medical Innovation. The sponsors had no role in the study design, collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the manuscript for publication.
NB conducted interviews and thematic analysis, and drafted the manuscript. LM conducted interviews and thematic analysis, and drafted the manuscript. ZW contributed to the conception and design of the study, and drafted the manuscript. SE guided and refined the thematic analysis, and drafted the manuscript. ME contributed to the conception and design of the study, and the revision of the manuscript. CG contributed to the conception and design of the study, and the revision of the manuscript. JB contributed to the conception and design of the study, and the revision of the manuscript. RH contributed to the conception and design of the study, guided the thematic analysis, and revised the manuscript. All authors have read and approved the final manuscript.
The authors declare that they have no competing interests.
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Bidad, N., MacDonald, L., Winters, Z.E. et al. How informed is declared altruism in clinical trials? A qualitative interview study of patient decision-making about the QUEST trials (Quality of Life after Mastectomy and Breast Reconstruction). Trials 17, 431 (2016). https://doi.org/10.1186/s13063-016-1550-7
- Breast cancer
- Informed consent