Patient Involvement in the Design of a Phase III Trial Comparing Intensity-modulated Proton Therapy and Intensity-modulated Radiotherapy for Oropharyngeal Cancer

Impact of patient information format on the experience of cancer patients treated with radiotherapy

Introduction

Radiotherapy (RT) stands as one of the main cancer treatments. The impact of RT and cancer treatment can have a physical and psychological impact on patients and their carers. To gain patient's trust, and ensure they feel valued, information should be provided before, during, and after RT. Patient and public involvement (PPI) has been lacking, and increased engagement with PPI groups could improve this. This rapid review aims to analyse the literature, and describe and report patient perception, experience, and satisfaction regarding the information received concerning their course of RT.

Methods

To allow the synthesis of results, a pragmatic decision was made to use a rapid review approach to analyse the literature, providing more timely information to inform future work. This rapid review utilised systematic review methods and was conducted according to a pre-defined protocol including clear inclusion criteria (PROSPERO registration: CRD42023415916).Electronic databases CINAHL, AMED, Pubmed/MEDLINE, EMBASE, and PsycINFO were searched using a comprehensive search for published studies from January 2012 to November 2023. Two independent reviewers applied the eligibility criteria. Evidence from literature was extracted and transcribed into qualitative data and Braun and Clarke's six-step thematic analysis (TA) was employed to determine themes by one reviewer and checked by a second [26]. Due to the heterogeneity of the included literature, the analysis of this review is presented primarily through narrative synthesis.

Results

Sixty eight articles met the inclusion criteria for this review. Emerging themes included; a desire for information based on patient characteristics, information format, patient preparedness, timing e.g. timing of information and changing priorities over time, health care professional (HCP) involvement, barriers to information, and motivators for better information delivery.

Conclusions

Several factors can influence a patient's desire for information, from whom and when they receive it, to what format they would prefer to receive it. There is benefit to be gained in employing PPI and patient advocacy to inform future studies that aim to further understand the themes that emerged from this review. Such studies can therefore inform HCPs in providing patient-specific information and support by utilising multiple teaching strategies available to them.

Elements of successful patient involvement in clinical cancer trials: a review of the literature

Patient involvement in clinical cancer research has gained much ground in the past few years and studies demonstrated positive outcomes of such involvement. Yet, they also indicated a lack of evidence around best methods and practices to achieve successful patient involvement. The aim of this literature review was to provide a synthesis of elements contributing to successful and meaningful ways of involving patients in oncology trials across different stages of research. This synthesis can offer practical support to researchers in their patient involvement journey. A PubMed literature search for original articles published between 2012 and early 2023 was carried out. In total, 3132 articles were identified, among which 152 were fully assessed for eligibility. Thirty-three articles met the predefined inclusion criteria and were subjected to a quality checklist. Patient involvement occurred most often in the development stage of cancer trials (85%) and was continuous and integrated throughout the entire lifecycle of research (67%). In total, 58 elements of successful patient involvement were identified, such as clearly defined roles and responsibilities of patient partners, input of multiple patients to ensure diversity, and regular touchpoints in the project. All these elements can be applied in future studies from the planning stage to the dissemination of study results. This review provides a set of practical recommendations that can be used by the cancer research community when planning to involve or already involving patients in their clinical trial activities.

Hitting the Target: Developing High-quality Evidence for Proton Beam Therapy Through Randomised Controlled Trials

The National Health Service strategy for the delivery of proton beam therapy (PBT) in the UK provides a unique opportunity to deliver high-quality evidence for PBT through randomised controlled trials (RCTs). We present a summary of three UK PBT RCTs in progress, including consideration of their key design characteristics and outcome assessments, to inform and support future PBT trial development. The first three UK multicentre phase III PBT RCTs (TORPEdO, PARABLE and APPROACH), will compare PBT with photon radiotherapy for oropharyngeal squamous cell carcinoma, breast cancer and oligodendroglioma, respectively. All three studies were designed by multidisciplinary teams, which combined expertise from clinicians, clinical trialists and scientists with strong patient advocacy and guidance from national radiotherapy research networks and international collaborators. Consistent across all three studies is a focus on the reduction of long-term radiotherapy-related toxicities and an evaluation of patient-reported outcomes and health-related quality of life, which will address key uncertainties regarding the clinical benefits of PBT. Innovative translational components will provide insights into mechanisms of toxicity and help to frame the key future research questions regarding PBT. The UK radiotherapy research community is developing and delivering an internationally impactful PBT research portfolio. The combination of data from RCTs with prospectively collected data from a national PBT outcomes registry will provide an innovative, high-quality repository for PBT research and the platform to design and deliver future trials of PBT.

Targeted Photodynamic Therapy (PDT) of Lung Cancer with Biotinylated Silicon (IV) Phthalocyanine

BACKGROUND

Lung cancer is the leading cause of cancer-associated mortality in the world. Traditional cancer therapies prolong the life expectancy of patients but often suffer from adverse reactions. Photodynamic Therapy (PDT) has been recommended as a treatment option for lung cancer in several countries, due to its non-invasive procedures, high selectivity and weak side effects.

OBJECTIVE

We have designed and synthesized a biotin receptor-targeted silicon phthalocyanine (IV) (compound 1) which showed a good therapeutic effect on biotin receptor-positive tumors. Since the overexpression of Biotin Receptor (BR) is also present in human lung cancer cells (A549), we explored the therapeutic properties of compound 1 on A549 xenograft tumor models.

METHODS

The selectivity of compound 1 toward A549 cells was studied with a fluorescence microscope and IVIS Spectrum Imaging System. The cytotoxicity was measured using the MTT assay. In vivo anti-tumor activity was investigated on the nude mice bearing A549 xenografts.

RESULTS

In vitro assays proved that compound 1 could selectively accumulate in A549 cells via the BR-mediated internalization. In vivo imaging and distribution experiments showed that compound 1 could selectively accumulate in tumor tissues of tumor-bearing mice. After 16 days of the treatment, the volumes of tumor in the PDT group were obviously smaller than that in other groups.

CONCLUSION

This study demonstrates that compound 1 is a promising photosensitizer and has broad application prospects in clinical PDT of lung cancers.

Patient and Public Involvement Refines the Design of ProtOeus: A Proposed Phase II Trial of Proton Beam Therapy in Oesophageal Cancer

BACKGROUND

Neoadjuvant chemoradiotherapy for oesophageal cancer significantly improves overall survival but is associated with severe post-operative complications. Proton beam therapy may reduce these toxicities by sparing normal tissues compared with standard radiotherapy. ProtOeus is a proposed randomised phase II study of neoadjuvant chemoradiotherapy in oesophageal cancer that compares proton beam therapy to standard radiotherapy techniques. As proton beam therapy services are often centralised in academic centres in major cities, proton beam therapy trials raise distinct challenges including patient acceptance of travelling for proton beam therapy, coordination of treatments with local centres and ensuring equity of access for patients.

METHODS

Focus groups were held early in the trial development process to establish patients' views on the trial proposal. Topics discussed include perception of proton beam therapy, patient acceptability of the trial pathway and design, patient-facing materials, and common clinical scenarios. Focus groups were led by the investigators and facilitated by patient involvement teams from the institutions who are involved in this research. Responses for each topic were analysed, and fed back to the trial's development group.

RESULTS

Three focus groups were held in separate locations in the UK (Manchester, Cardiff, Wigan). Proton beam therapy was perceived as superior to standard radiotherapy making the trial attractive. Patients felt strongly that travel costs should be reimbursed to ensure equity of access to proton beam therapy. They were very supportive of a shorter treatment schedule and felt that toxicity reduction was the most important endpoint.

DISCUSSION AND CONCLUSIONS

Incorporating patient views early in the trial development process resulted in significant trial design refinements including travel/accommodation provisions, choice of primary endpoint, randomisation ratio and fractionation schedule. Focus groups are a reproducible and efficient method of incorporating the patient and public voice into research.

Engineering the mode of morphogenetic signal presentation to promote branching from salivary gland spheroids in 3D hydrogels

Previously we developed a fibrin hydrogel (FH) decorated with laminin-111 peptides (L_1p-FH) and supports three-dimensional (3D) gland microstructures containing polarized acinar cells. Here we expand on these results and show that co-culture of rat parotid Par-C10 cells with mesenchymal stem cells produces migrating branches of gland cells into the L1_p-FH and we identify FGF-7 as the principal morphogenetic signal responsible for branching. On the other hand, another FGF family member and gland morphogen, FGF-10 increased proliferation but did not promote migration and therefore, limited the number and length of branched structures grown into the gel. By controlling the mode of growth factor presentation and delivery, we can control the length and cellularity of branches as well as formation of new nodes/clusters within the hydrogel. Such spatial delivery of two or more morphogens may facilitate engineering of anatomically complex tissues/mini organs such as salivary glands that can be used to address developmental questions or as platforms for drug discovery. STATEMENT OF SIGNIFICANCE: Hyposalivation leads to the development of a host of oral diseases. Current treatments only provide temporary relief. Tissue engineering may provide promising permanent solutions. Yet current models are limited to salivary spheroids with no branching networks. Branching structures are vital to an effective functioning gland as they increase the surface area/glandular volume ratio of the tissue, allowing a higher output from the small-sized gland. We describe a strategy that controls branch network formation in salivary glands that is a key in advancing the field of salivary gland tissue engineering.

Proton beam therapy: perspectives on the National Health Service England clinical service and research programme

The UK has an important role in the evaluation of proton beam therapy (PBT) and takes its place on the world stage with the opening of the first National Health Service (NHS) PBT centre in Manchester in 2018, and the second in London coming in 2020. Systematic evaluation of the role of PBT is a key objective. By September 2019, 108 patients had started treatment, 60 paediatric, 19 teenagers and young adults and 29 adults. Obtaining robust outcome data is vital, if we are to understand the strengths and weaknesses of current treatment approaches. This is important in demonstrating when PBT will provide an advantage and when it will not, and in quantifying the magnitude of benefit.The UK also has an important part to play in translational PBT research, and building a research capability has always been the vision. We are perfectly placed to perform translational pre-clinical biological and physical experiments in the dedicated research room in Manchester. The nature of DNA damage from proton irradiation is considerably different from X-rays and this needs to be more fully explored. A better understanding is needed of the relative biological effectiveness (RBE) of protons, especially at the end of the Bragg peak, and of the effects on tumour and normal tissue of PBT combined with conventional chemotherapy, targeted drugs and immunomodulatory agents. These experiments can be enhanced by deterministic mathematical models of the molecular and cellular processes of DNA damage response. The fashion of ultra-high dose rate FLASH irradiation also needs to be explored.

Codelivery of DOX and siRNA by folate-biotin-quaternized starch nanoparticles for promoting synergistic suppression of human lung cancer cells

In this paper, the self-assembled folate-biotin-quaternized starch nanoparticles (FBqS NPs) were used as carrier system of doxorubicin (DOX) and siRNAIGF1R for the codelivery of both into human lung adenocarcinoma cell lines (A549 cells) in vitro. The cytotoxicity, targeted ligand competition, cell proliferation inhibition, cellular uptake, endocytosis mechanism and target protein suppression of drug-loaded FBqS NPs were evaluated in detail. Compared with several other drug formulations under same condition, siRNAIGF1R/DOX/FBqS NPs exhibited the greatest cytotoxicity to A549 cells and the cytotoxicity was competitively inhibited by free folate in dose-dependent manner. The A549 cells treated by siRNAIGF1R/DOX/FBqS NPs showed the lowest cell proliferation capacity. The energy-dependent clathrin- and caveolae-mediated endocytosis might be the primary cellular uptake mechanism of drug-loaded FBqS NPs. The expression of IGF1R protein in A549 cells treated by siRNAIGF1R/FBqS NPs declined dramatically. So the FBqS NPs were expected as the co-carrier system of chemotherapeutants and siRNAs for future clinical application.

Systematic review of methodology used in clinical studies evaluating the benefits of proton beam therapy

BACKGROUND

Proton beam therapy (PBT) delivers high-energy radiation to target tumours while sparing surrounding normal tissues. The dosimetric advantages of PBT over traditional photon radiotherapy may be clear but the translation of this benefit into clinically meaningful reductions in toxicities and improved quality-of-life (QoL) needs to be determined. Randomised controlled trials (RCTs) are considered the gold standard for generating the highest-level evidence in medicine. The objectives of this systematic review were to provide an overview of published clinical studies evaluating the benefits of PBT, and to examine the methodology used in clinical trials with respect to study design and outcomes.

METHODS

PubMed, EMBASE and Cochrane databases were systematically searched for published clinical studies where PBT was a cancer treatment intervention. All randomised and non-randomised studies, prospective or retrospective, were eligible for inclusion.

RESULTS

In total, 219 studies were included. Prospective studies comprised 89/219 (41%), and of these, the number of randomised phase II and III trials were 5/89 (6%) and 3/89 (3%) respectively. Of all the phase II and III trials, 18/24 (75%) were conducted at a single PBT centre. Over one-third of authors recommended an increase in length of follow up. Research design and/or findings were poorly reported in 74/89 (83%) of prospective studies. Patient reported outcomes were assessed in only 19/89 (21%) of prospective studies.

CONCLUSIONS

Prospective randomised evidence for PBT is limited. The set-up of national PBT services in several countries provides an opportunity to guide the optimal design of prospective studies, including RCTs, to evaluate the benefits of PBT across various disease sites. Collaboration between PBT centres, both nationally and internationally, would increase potential for the generation of practice changing evidence. There is a need to facilitate and guide the collection and analysis of meaningful outcome data, including late toxicities and patient reported QoL.

An introduction to proton beam therapy

Radiotherapy is a highly effective anti-cancer treatment commonly used alongside systemic therapies and surgery to achieve long-term cancer-free survival. Conventional radiotherapy uses photon beams to deliver a high dose of radiation to the tumour volume to eradicate cancer cells. This has to be offset against the irradiation of surrounding normal tissues, as increasing this dose causes more treatment-related toxicity. In August 2018, the NHS's first high energy proton beam therapy centre opened at The Christie NHS Foundation Trust in Manchester. A second NHS centre is scheduled to open in 2020 at the University College London Hospitals NHS Trust. Proton beam therapy may offer dosimetric advantages compared to conventional radiotherapy as a result of its characteristic dose deposition - proton beams deliver a comparatively higher proportion of their dose to the target volume relative to normal tissues, without significant exit doses when compared to conventional photon therapy. Therefore proton beam therapy may be indicated for certain tumours situated next to critical organs or in the paediatric population where quality of life and the reduction of secondary effects from radiation are particularly significant. The indications for proton beam therapy and patient outcomes after treatment will be carefully monitored and evaluated in order to provide a robust evidence base for its use.

Innovating public engagement and patient involvement through strategic collaboration and practice

BACKGROUND

Patient and public involvement and engagement is an important and expected component of health-related research activity in the UK. Specifically within the health research sphere, public engagement (usually defined as raising awareness of research) and patient involvement (usually defined as actively involving people in research) have traditionally been seen as separate but have much to gain from working together towards a common goal of better health outcomes for all.

METHODS

This paper describes a unique approach taken by the Public Programmes Team: a small interdisciplinary team of public engagement specialists, with backgrounds in science, community development, public engagement and involvement, policy, ethics, communications, industry, museums and creative practice, embedded within translational research infrastructure and delivery in Manchester in the North West of England. We propose a new model of professional practice - a 'cycle' of engagement and involvement - innovating across the complementary fields of public engagement and patient involvement, and working inclusively and in partnership with people in health research. Further, our approach capitalises on strategic collaboration offering economies of scale and a joined up way of working. Our ambition is to boldly experiment, learn and reflect, responsibly and based on evidence and partnerships, using methods of engagement that address issues of social justice.

RESULTS

Here, we report on preliminary case studies exemplifying the impact of our approach, and data relating to achievements and learning between April 2017 and March 2018. Informed by our findings, we propose that our approach has the potential to be replicated elsewhere.

CONCLUSIONS

Our practice and the beginning of its evaluation lead us to believe that our way of working and model of professional practice - the 'cycle' of engagement and involvement - is effective in: addressing our vision of making health research relevant and inclusive for everyone; and embedding and joining up public involvement in a busy and fertile translational health research ecosystem.