Brain tumor research in the United Kingdom: current perspective and future challenges. A strategy document from the NCRI Brain Tumor CSG

Adult brain tumour research in 2024: Status, challenges and recommendations

In 2015, a groundswell of brain tumour patient, carer and charity activism compelled the UK Minister for Life Sciences to form a brain tumour research task and finish group. This resulted, in 2018, with the UK government pledging £20m of funding, to be paralleled with £25m from Cancer Research UK, specifically for neuro-oncology research over the subsequent 5 years. Herein, we review if and how the adult brain tumour research landscape in the United Kingdom has changed over that time and what challenges and bottlenecks remain. We have identified seven universal brain tumour research priorities and three cross-cutting themes, which span the research spectrum from bench to bedside and back again. We discuss the status, challenges and recommendations for each one, specific to the United Kingdom.

Utility of a prognostic assessment tool to predict survival following surgery for brain metastases

Background

Brain metastases account for more than 50% of all intracranial tumors and are associated with poor outcomes. Treatment decisions in this highly heterogenous cohort remain controversial due to the myriad of treatment options available, and there is no clearly defined standard of care. The prognosis in brain metastasis patients varies widely with tumor type, extracranial disease burden and patient performance status. Decision-making regarding treatment is, therefore, tailored to each patient and their disease.

Methods

This is a retrospective cohort study assessing survival outcomes following surgery for brain metastases over a 50-month period (April 1, 2014-June 30, 2018). We compared predicted survival using the diagnosis-specific Graded Prognostic Assessment (ds-GPA) with actual survival.

Results

A total of 186 patients were included in our cohort. Regression analysis demonstrated no significant correlation between actual and predicted outcome. The most common reason for exclusion was insufficient information being available to the neuro-oncology multidisciplinary team (MDT) meeting to allow GPA calculation.

Conclusions

In this study, we demonstrate that "predicted survival" using the ds-GPA does not correlate with "actual survival" in our operated patient cohort. We also identify a shortcoming in the amount of information available at MDT in order to implement the GPA appropriately. Patient selection for aggressive therapies is crucial, and this study emphasizes the need for treatment decisions to be individualized based on patient and cancer clinical characteristics.

Optimal care of people with brain cancer in the emergency department: A cross-sectional survey of outpatient perceptions

Objective

People diagnosed with brain cancer commonly present to the emergency department (ED). There is uncertainty about essential components and processes of optimal care from the perspective of consumers, and few guidelines exist to inform practice. This study examined the perceptions of outpatients and their support persons regarding what constitutes optimal care for people with brain cancer presenting to the ED.

Methods

A cross sectional descriptive survey study was undertaken. Participants included adults attending hospital outpatient clinics (n ​= ​181, 60% of eligible participants). Participants completed a survey assessing perceptions of optimal care for brain cancer patients presenting to emergency department and socio-demographic characteristics.

Results

The survey items endorsed as 'essential' by participants included that the emergency department team help patients: 'understand signs and symptoms to watch out for' (51%); 'understand the next steps in care and why' (48%); 'understand if their medical condition suggests it is likely they will die in hospital' (47%); 'ask patients if they have a substitute decision maker and want that person told they are in the emergency department' (44%); 'understand the purpose of tests and procedures' (41%).

Conclusions

Symptom management, effective communication and supported decision-making should be prioritised by ED teams. Further research to establish the views of those affected by brain cancer about essential care delivered in the ED setting, and to compare these views with the quality of care that is actually delivered, is warranted.

Nanocarriers Call the Last Shot in the Treatment of Brain Cancers

Our brain is protected by physio-biological barriers. The blood–brain barrier (BBB) main mechanism of protection relates to the abundance of tight junctions (TJs) and efflux pumps. Although BBB is crucial for healthy brain protection against toxins, it also leads to failure in a devastating disease like brain cancer. Recently, nanocarriers have been shown to pass through the BBB and improve patients’ survival rates, thus becoming promising treatment strategies. Among nanocarriers, inorganic nanocarriers, solid lipid nanoparticles, liposomes, polymers, micelles, and dendrimers have reached clinical trials after delivering promising results in preclinical investigations. The size of these nanocarriers is between 10 and 1000 nm and is modified by surface attachment of proteins, peptides, antibodies, or surfactants. Multiple research groups have reported transcellular entrance as the main mechanism allowing for these nanocarriers to cross BBB. Transport proteins and transcellular lipophilic pathways exist in BBB for small and lipophilic molecules. Nanocarriers cannot enter via the paracellular route, which is limited to water-soluble agents due to the TJs and their small pore size. There are currently several nanocarriers in clinical trials for the treatment of brain cancer. This article reviews challenges as well as fitting attributes of nanocarriers for brain tumor treatment in preclinical and clinical studies.

Primary Brain Tumor Research Productivity in Southeast Asia and Its Association With Socioeconomic Determinants and Burden of Disease

Background

There is an unmet need to assess research productivity from southeast Asia (SEA) regarding primary central nervous system (CNS) tumors. The country’s economy, landscape of neurology practice, and disease burden are hypothesized to correlate with scientific output. This study aimed to objectively measure the impact of published studies on primary brain tumors in SEA and to assess for correlation with socioeconomic determinants and burden of disease.

Methods

We systematically searched electronic databases for relevant articles from SEA on primary CNS tumor until July 31, 2020. Bibliometric indices were reported and subjected to correlational analysis with population size, gross domestic product (GDP) per capita, percentage (%) GDP for research and development (R&D), total number of neurologists, disease incidence, deaths, and disability-adjusted life years.

Results

A total of 549 articles were included, consisting primarily of case reports (n=187, 34.06%) and discussed gliomas (n=195, 35.52%). Singapore published the most number of the articles (n=246, 44.8%). Statistical analysis showed a positive correlation between %GDP for R&D and total publication. Additionally, negative relationships were noted between burden of disease and total neurologist with most bibliometric indices. However, GDP per capita was not correlated with measures for research productivity.

Conclusion

The low impact of scientific output on primary CNS tumors in SEA does not address the growing epidemiology and burden of this disease. An increase in the GDP growth and financial and manpower investment to R&D may significantly improve research productivity in SEA.

Hospital teaching status associated with reduced inpatient mortality and perioperative complications in surgical neuro-oncology

PURPOSE

Studies have demonstrated that higher surgical volumes correlate with improved neurosurgical outcomes yet none exist evaluating the effects of hospital teaching status on the surgical neuro-oncology patient. We present the first analysis comparing brain tumor surgery perioperative outcomes at academic and non-teaching centers.

METHODS

Brain tumor surgeries in the Nationwide Inpatient Sample (NIS) from 1998 to 2014 were identified. A teaching hospital, defined by the NIS, must have ≥ 1 Accreditation Council of Graduate Medical Education (ACGME) approved residency programs, Council of Teaching Hospitals membership, or have a ratio ≥ 0.25 of full-time residents to hospital beds. Annual treatment trends were stratified by hospital teaching status, assessing yearly caseload with linear regression. Multivariable logistic regression determined predictors of inpatient mortality/complications. Hospitals were further divided into quartiles by case volume and teaching status was compared in each.

RESULTS

Teaching hospitals (THs) exhibited an average annual increase in brain tumor surgeries (+ 1057/year, p < 0.0001). In multivariable analysis, teaching status was associated with decreased risk of mortality (OR 0.82, p = 0.0003) and increased likelihood of discharge home (OR 1.21, p < 0.0001). In subgroup analysis, within the highest hospital quartile by caseload, higher mortality rates and lower routine discharges were again seen at non-teaching hospitals (NTHs) (p = 0.0002 and p = 0.0016, respectively).

CONCLUSION

THs are performing more brain tumor surgeries over time with lower rates of inpatient mortality and perioperative complications even after controlling for hospital case volume. These results suggest a shift in neuro-oncology practice patterns favoring THs to optimize patient outcomes especially at the highest volume centers.

Fostering open collaboration in drug development for paediatric brain tumours

Brain tumours have become the leading cause of child mortality from cancer. Indeed, aggressive brainstem tumours, such as diffuse intrinsic pontine glioma (DIPG), are nearly uniformly fatal. These tumours display a unique set of driver mutations that distinguish them from adult gliomas and define new opportunity for the development of precision medicines. The specific association of ACVR1 mutations with DIPG tumours suggests a direct link to neurodevelopment and highlights the encoded bone morphogenetic protein receptor kinase ALK2 as a promising drug target. Beneficial effects of ALK2 inhibition have now been observed in two different in vivo models of DIPG. Nonetheless, such tumours present a huge challenge for traditional economic models of drug development due to their small market size, high failure rate, tumour location and paediatric population. Moreover, a toolkit of different investigational drugs may be needed to fully address the heterogeneity of these tumours in clinical trials. One new business model is suggested by M4K Pharma, a recent virtual start up that aims to align diffuse academic and industry research into a collaborative open science drug discovery programme. Fostering scientific collaboration may offer hope in rare conditions of dire unmet clinical need and provide an alternative route to affordable medicines.