The future of trials in surgical oncology

Randomized controlled trials in lung cancer surgery: How are we doing?

Objective

Randomized control trials are considered the highest level of evidence, yet the scalability and practicality of implementing randomized control trials in the thoracic surgical oncology space are not well described. The aim of this study is to understand what types of randomized control trials have been conducted in thoracic surgical oncology and ascertain their success rate in completing them as originally planned.

Methods

The ClinicalTrials.gov database was queried in April 2023 to identify registered randomized control trials performed in patients with lung cancer who underwent surgery (by any technique) as part of their treatment.

Results

There were 68 eligible randomized control trials; 33 (48.5%) were intended to examine different perioperative patient management strategies (eg, analgesia, ventilation, drainage) or to examine different intraoperative technical aspects (eg, stapling, number of ports, port placement, ligation). The number of randomized control trials was relatively stable over time until a large increase in randomized control trials starting in 2016. Forty-four of the randomized control trials (64.7%) were open-label studies, 43 (63.2%) were conducted in a single facility, 66 (97.1%) had 2 arms, and the mean number of patients enrolled per randomized control trial was 236 (SD, 187). Of 21 completed randomized control trials (31%), the average time to complete accrual was 1605 days (4.4 years) and average time to complete primary/secondary outcomes and adverse events collection was 2125 days (5.82 years).

Conclusions

Given the immense investment of resources that randomized control trials require, these findings suggest the need to scrutinize future randomized control trial proposals to assess the likelihood of successful completion. Future study is needed to understand the various contributing factors to randomized control trial success or failure.

Selective Manipulation of the Mitochondria Oxidative Stress in Different Cells Using Intelligent Mesoporous Silica Nanoparticles to Activate On-Demand Immunotherapy for Cancer Treatment

Herein, the vitamin K2 (VK2)/maleimide (MA) coloaded mesoporous silica nanoparticles (MSNs), functional molecules including folic acid (FA)/triphenylphosphine (TPP)/tetrapotassium hexacyanoferrate trihydrate (THT), as well as CaCO3 are explored to fabricate a core-shell-corona nanoparticle (VMMFTTC) for on-demand anti-tumor immunotherapy. After application, the tumor-specific acidic environment first decomposed CaCO3 corona, which significantly levitates the pH value of tumor tissue to convert M2 type macrophage to the antitumor M1 type. The resulting VMMFTT would then internalize in both tumor cells and macrophages via FA-assisted endocytosis and free endocytosis, respectively. These distinct processes generate different amount of VMMFTT in above two cells followed by 1) TPP-induced accumulation in the mitochondria, 2) THT-mediated effective capture of various signal ions to cut off signal transmission and further inhibit glutathione (GSH) generation, 3) ions catalyzed reactive oxygen species (ROS) production through Fenton reaction, 4) sustained release of VK2 and MA to further enhance the ROS production and GSH depletion, which caused significant apoptosis of tumor cells and additional M2-to-M1 macrophage polarization via different processes of oxidative stress. Moreover, the primary tumor apoptosis further matures surrounding immature dendritic cells and activates T cells to continuously promote the antitumor immunotherapy.

Bioinspired Multiscale Mineralization: From Fundamentals to Potential Applications

The wondrous and imaginative designs of nature have always been an inexhaustible treasure trove for material scientists. Throughout the long evolutionary process, biominerals with hierarchical structures possess some specific advantages such as outstanding mechanical properties, biological functions, and sensing performances, the formation of which (biomineralization) is delicately regulated by organic component. Provoked by the subtle structures and profound principles of nature, bioinspired functional minerals can be designed with the participation of organic molecules. Because of the designable morphology and functions, multiscale mineralization has attracted more and more attention in the areas of medicine, chemistry, biology, and material science. This review provides a summary of current advancements in this extending topic. The mechanisms underlying mineralization is first concisely elucidated. Next, several types of minerals are categorized according to their structural characteristic, as well as the different potential applications of these materials. At last, a comprehensive overview of future developments for bioinspired multiscale mineralization is given. Concentrating on the mechanism of fabrication and broad application prospects of multiscale mineralization, the hope is to provide inspirations for the design of other functional materials.

Prevalence, trends, and characteristics of trials investigating local therapy in contemporary phase 3 clinical cancer research

BACKGROUND

Although most patients with cancer are treated with local therapy (LT), the proportion of late-phase clinical trials investigating local therapeutic interventions is unknown. The purpose of this study was to determine the proportion, characteristics, and trends of phase 3 cancer clinical trials assessing the therapeutic value of LT over time.

METHODS

This was a cross-sectional analysis of interventional randomized controlled trials in oncology published from 2002 through 2020 and registered on ClinicalTrials.gov. Trends and characteristics of LT trials were compared to all other trials.

RESULTS

Of 1877 trials screened, 794 trials enrolling 584,347 patients met inclusion criteria. A total of 27 trials (3%) included a primary randomization assessing LT compared with 767 trials (97%) investigating systemic therapy or supportive care. Annual increase in the number of LT trials (slope [m] = 0.28; 95% confidence interval [CI], 0.15-0.39; p < .001) was outpaced by the increase of trials testing systemic therapy or supportive care (m = 7.57; 95% CI, 6.03-9.11; p < .001). LT trials were more often sponsored by cooperative groups (22 of 27 [81%] vs. 211 of 767 [28%]; p < .001) and less often sponsored by industry (5 of 27 [19%] vs. 609 of 767 [79%]; p < .001). LT trials were more likely to use overall survival as primary end point compared to other trials (13 of 27 [48%] vs. 199 of 767 [26%]; p = .01).

CONCLUSIONS

In contemporary late-phase oncology research, LT trials are increasingly under-represented, under-funded, and evaluate more challenging end points compared to other modalities. These findings strongly argue for greater resource allocation and funding mechanisms for LT clinical trials.

PLAIN LANGUAGE SUMMARY

Most people who have cancer receive treatments directed at the site of their cancer, such as surgery or radiation. We do not know, however, how many trials test surgery or radiation compared to drug treatments (that go all over the body). We reviewed trials testing the most researched strategies (phase 3) completed between 2002 and 2020. Only 27 trials tested local treatments like surgery or radiation compared to 767 trials testing other treatments. Our study has important implications for funding research and understanding cancer research priorities.

Lost in the shadow of giants: The neglected treatment modalities in oncologic trials

Phase 3 clinical trial trends demonstrate a widening gap between the rates of systemic and local therapy trials, with the former increasing whereas the latter stagnates. This editorial provides an overview of the key points found by Sherry and colleagues in their analysis of >700 trials and allows for actionable interventions in the design of future trials to optimize clinical outcomes and dissemination into practice.

Randomized controlled trials and alternative study designs in surgical oncology

Surgery is central to the cure of most solid cancers and an integral part of modern multimodal cancer management for early and advanced stage cancers. Decisions made by surgeons and multidisciplinary team members are based on best available knowledge for the defined clinical situation at hand. While surgery is both an art and a science, good decision-making requires data that are robust, valid, representative and, applicable to most if not all patients with a specific cancer. Such data largely comes from clinical observations and registries, and more preferably from trials conducted with the specific purpose of arriving at new answers. As part of the ESSO core curriculum development an increased focus has been put on the need to enhance research literacy among surgical candidates. As an expansion of the curriculum catalogue list and to enhance the educational value, we here present a set of principles and emerging concepts which applies to surgical oncologist for reading, understanding, planning and contributing to future surgeon-led cancer trials.

Analysis of Female Participant Representation in Registered Oncology Clinical Trials in the United States from 2008 to 2020

BACKGROUND

Female underrepresentation in oncology clinical trials can result in outcome disparities. We evaluated female participant representation in US oncology trials by intervention type, cancer site, and funding.

MATERIALS AND METHODS

Data were extracted from the publicly available Aggregate Analysis of ClinicalTrials.gov database. Initially, 270,172 studies were identified. Following the exclusion of trials using Medical Subject Heading terms, manual review, those with incomplete status, non-US location, sex-specific organ cancers, or lacking participant sex data, 1650 trials consisting of 240,776 participants remained. The primary outcome was participation to prevalence ratio (PPR): percent females among trial participants divided by percent females in the disease population per US Surveillance, Epidemiology, and End Results Program data. PPRs of 0.8-1.2 reflect proportional female representation.

RESULTS

Females represented 46.9% of participants (95% CI, 45.4-48.4); mean PPR for all trials was 0.912. Females were underrepresented in surgical (PPR 0.74) and other invasive (PPR 0.69) oncology trials. Among cancer sites, females were underrepresented in bladder (odds ratio [OR] 0.48, 95% CI 0.26-0.91, P = .02), head/neck (OR 0.44, 95% CI 0.29-0.68, P < .01), stomach (OR 0.40, 95% CI 0.23-0.70, P < .01), and esophageal (OR 0.40 95% CI 0.22-0.74, P < .01) trials. Hematologic (OR 1.78, 95% CI 1.09-1.82, P < .01) and pancreatic (OR 2.18, 95% CI 1.46-3.26, P < .01) trials had higher odds of proportional female representation. Industry-funded trials had greater odds of proportional female representation (OR 1.41, 95% CI 1.09-1.82, P = .01) than US government and academic-funded trials.

CONCLUSIONS

Stakeholders should look to hematologic, pancreatic, and industry-funded cancer trials as exemplars of female participant representation and consider female representation when interpreting trial results.

Analysis of Registered Clinical Trials in Surgical Oncology, 2008-2020

This quality improvement study characterizes surgical oncology trials, analyzes growth, identifies associations with early discontinuation or results reporting, and evaluates proportions of trials involving each neoplasm site.

Prognosis of C4 dislocation with spinal cord injury following psychological intervention

OBJECTIVE

To investigate the effect of psychological intervention on the prognosis of patients with C4 dislocation and spinal cord injury.

METHODS

We investigated target patients admitted between 2010 and 2018. Patients' mental state, quality of life and neurological function at different time points were evaluated to examine the relationship between psychological intervention and recovery and prognosis of acute and critical spinal cord injury.

RESULTS

All patients showed improvements in clinical symptoms, neurological function and quality of life. Psychological intervention significantly improved Zung Self-Rating Anxiety Scale score, Zung Self-Rating Depression Scale score and SF-36 Mental Component Summary score within 3 months. Japanese Orthopaedic Association neurological function score and SF-36 Physical Component Summary score were significantly improved after 1-year follow-up. Psychological intervention did not improve 2-year survival.

CONCLUSION

Timely and professional psychological intervention can eliminate the psychological disorders of C4 dislocation patients with spinal cord injury. This has a positive effect on their quality of life and prognosis.

Novel nanomaterial-organism hybrids with biomedical potential

Instinctive hierarchically biomineralized structures of various organisms, such as eggs, algae, and magnetotactic bacteria, afford extra protection and distinct performance, which endow fragile organisms with a tenacious ability to adapt and survive. However, spontaneous formation of hybrid materials is difficult for most organisms in nature. Rapid development of chemistry and materials science successfully obtained the combinations of organisms with nanomaterials by biomimetic mineralization thus demonstrating the reproduction of the structures and functions and generation of novel functions that organisms do not possess. The rational design of biomaterial-organism hybridization can control biological recognition, interactions, and metabolism of the organisms. Thus, nanomaterial-organism hybrids represent a next generation of organism engineering with great potential biomedical applications. This review summarizes recent advances in material-directed organism engineering and is mainly focused on biomimetic mineralization technologies and their outstanding biomedical applications. Three representative types of biomimetic mineralization are systematically introduced, including external mineralization, internal mineralization, and genetic engineering mineralization. The methods involving hybridization of nanomaterials and organisms based on biomimetic mineralization strategies are described. These strategies resulted in applications of various nanomaterial-organism hybrids with multiplex functions in cell engineering, cancer treatment, and vaccine improvement. Unlike classical biological approaches, this material-based bioregulation is universal, effective, and inexpensive. In particular, instead of traditional medical solutions, the integration of nanomaterials and organisms may exploit novel strategies to solve current biomedical problems. This article is categorized under: Implantable Materials and Surgical Technologies > Nanomaterials and Implants Therapeutic Approaches and Drug Discovery > Nanomedicine for Oncologic Disease Therapeutic Approaches and Drug Discovery > Nanomedicine for Infectious Disease.

Improvement of organisms by biomimetic mineralization: A material incorporation strategy for biological modification

Biomineralization, a bio-organism controlled mineral formation process, plays an important role in linking biological organisms and mineral materials in nature. Inspired by biomineralization, biomimetic mineralization is used as a bridge tool to integrate biological organisms and functional materials together, which can be beneficial for the development of diversified functional organism-material hybrids. In this review, recent progresses on the techniques of biomimetic mineralization for organism-material combinations are summarized and discussed. Based upon these techniques, the preparations and applications of virus-, prokaryotes-, and eukaryotes-material hybrids have been presented and they demonstrate the great potentials in the fields of vaccine improvement, cell protection, energy production, environmental and biomedical treatments, etc. We suggest that more researches about functional organism and material combination with more biocompatible techniques should be developed to improve the design and applications of specific organism-material hybrids. These rationally designed organism-material hybrids will shed light on the production of "live materials" with more advanced functions in future. STATEMENT OF SIGNIFICANCE: This review summaries the recent attempts on improving biological organisms by their integrations with functional materials, which can be achieved by biomimetic mineralization as the combination tool. The integrated materials, as the artificial shells or organelles, confer diversified functions on the enclosed organisms. The successful constructions of various virus-, prokaryotes-, and eukaryotes-material hybrids have demonstrated the great potentials of the material incorporation strategy in vaccine development, cancer treatment, biological photosynthesis and environment protection etc. The suggested challenges and perspectives indicate more inspirations for the future development of organism-material hybrids.

Inhibiting Cell Viability and Motility by Layer-by-Layer Assembly and Biomineralization

Herein, we proposed a drug-free strategy named cell surface shellization to inhibit the motility of SKOV-3 and HeLa cells. We alternately deposited two- or three-layer cationic polyelectrolyte (PE) and anionic PE films on the surface of SKOV-3 and HeLa cells. Then, a mineral shell (calcium carbonate, CaCO₃) was formed on the surface of polymer shells via electrostatic force and biomineralization. The CCK-8 assay results and live/dead staining showed that the surface shells strongly aggravated the cytotoxicity. The monolayer scratch wound migration assay results and immunofluorescence staining results showed that the shells, especially the mineral shells, could efficiently inhibit the migration of SKOV-3 and HeLa cells without any anticancer drugs. The immunofluorescence results of the three small G proteins of the cells showed that the immunofluorescence intensity in SKOV-3 did not change. Preliminary results from our laboratory showed an increase in MMP-9 secreted by cancer cells after coating with films or mineral shells. It suggests that mechanisms that inhibit cell migration are related to the MMP signaling pathway. All the results indicated that shellization (films or nanomineral shells) but not limited to calcification can be used as one of the tools to change the function of cells.

A Ferritin-Albumin-Cu Nanoparticle that Efficaciously Delivers Copper(II) Ions to a Tumor and Improves the Therapeutic Efficacy of Disulfiram

The application of disulfiram can be traced back to the 1920s, from when it was utilized to facilitate alcohol abstinence by producing allergic reactions toward alcohol. In previous research, combination of disulfiram and copper ions has demonstrated significant anti-tumor activity. However, both disulfiram and copper ions lack the ability of specific targeting to tumor tissues and may lead to a high risk of side effects, especially for copper ion, which is a kind of toxic heavy metal. Herein, a ferritin-albumin-Cu nanoparticle (FHC NP) was introduced. The nanoparticle was synthesized by first covalently cross-linking ferritin and albumin and then encapsulating the copper ions in the ferritin nanocage. The nanoparticle showed good accumulation in a tumor and when combined with disulfiram exhibited good in vitro selectivity toward cancer cells and better in vivo anti-tumor activity. Herein, the nanoparticle invented here represented a good strategy to efficaciously deliver copper ions into tumors and thus improve the therapeutic efficacy of disulfiram in tumor therapy.

European Society of Surgical Oncology's strategy for clinical research: Paving the way for a culture of research in cancer surgery

As part of its mission to promote the best surgical care for cancer patients, the European Society of Surgical Oncology (ESSO) has been developing multiple programmes for clinical research along with its educational portfolio. This position paper describes the different research activities of the Society over the past decade and an action plan for the upcoming five years to lead innovative and high quality surgical oncology research. ESSO proposes to consider pragmatic research methodologies as a complement to randomised clinical trials (RCT), advocates for increased funding and operational support in conducting research and aims to enable young surgeons to be active in research and establish partnerships for translational research activities.

Multidisciplinary quality assurance and control in oncological trials: Perspectives from European Organisation for Research and Treatment of Cancer (EORTC)

Quality assurance (QA) programmes are one of the mainstays of clinical research and constitute the pillars on which European Organisation for Research Treatment of Cancer (EORTC) delivers multidisciplinary therapeutic progress. Changing practice treatments require solid evidence-based data, which can only be achieved if integral QA is part of the infrastructure sustaining research projects. Cancer treatment is a multimodality approach, which is often applied either in sequence and/or in combination. Each modality plays a key role in cancer control. The modalities by which QA is applied varies substantially within and across the disciplines. In addition, translational and diagnostic disciplines take an increasing role in the era of precision medicine. Building on the structuring effect of clinical research with fully integrated multidisciplinary QA programmes associated with the solutions addressing the chain of custody for biological material and data integrity as well as compliance ensure at the same time validity of clinical research output but also have a training effect on health care providers, who are more likely to apply such principles as routine. The principles of QA are therefore critical to be embedded in multidisciplinary infrastructure to guarantee therapeutic progress. These principles also provide the basis for the functioning of multidisciplinary tumour board. However, technical, operational and economic challenges which go with the implementation of such programmes require optimal know-how and the coordination of the multiple expertise and such efforts are best achieved through centralised infrastructure.