Introduction: Persistent inequities in access to cancer clinical trials (CCTs) continue to disadvantage rural patients, limiting exposure to novel therapies and contributing to poorer outcomes compared with metropolitan patients. Understanding why these gaps endure requires attention to the clinical encounter. This study explored the system- and physician-related factors that influence whether CCTs are discussed with patients in rural Victoria, Australia.
Methods: Straussian grounded theory combined with situational analysis were the exploratory methods chosen. Twenty-nine participants (21 medical and 8 non-medical) were recruited to participate in semi-structured interviews. Data collection and analysis were conducted concurrently in an iterative and cyclical process to identify emerging themes and enable theory development.
Results/Findings: CCT offer, review, and discussion were shaped by four interrelated domains: system fragmentation and uneven capacity, trial characteristics, physician capacity, and perceived patient capacity. Physicians appraised these factors through a value-based judgement of their fit with “good” cancer care. When these domains aligned—such that system supports were available, trial features were feasible, and both physician and patient capacity were sufficient—clinical trials achieved cognitive salience in consultations, increasing the likelihood of discussion. Where systems embedded trials within routine cancer care, trials were more readily legitimised as a treatment pathway. In the absence of such supports, cognitive salience depended largely on the individual capacity of physicians or patients to initiate and sustain trial engagement.
Conclusion: Study findings informed development of the Factors Affecting Clinical Trial Offer, REview and Discussion (FACTORED) model, which captures the dynamic interplay between system-, trial-, physician-, and patient-level influences. Alignment across these four domains determines whether CCTs become cognitively salient during physician-patient consultations in rural settings. By identifying the conditions under which CCTs are normalised as part of standard care, the FACTORED model provides a framework for understanding and addressing persistent inequities in trial access in rural settings.