Opportunities and barriers for the use of Australian cancer registries as platforms for randomized clinical trials

Integrating Cardio-Oncology Across the Research Pipeline, Policy, and Practice in Australia-An Australian Cardiovascular Alliance Perspective

Over 18 million people worldwide were diagnosed with cancer in 2020, including over 150,000 people in Australia. Although improved early detection and treatment have increased the survival rates, cardiotoxic treatment and inadequate management of cardiovascular risk factors have resulted in cardiovascular disease (CVD) being one of the leading causes of non-cancer-related death and disability among cancer survivors. International guidelines outline the standards of care for CVD risk surveillance and management. However, Australian cardio-oncology policies and clinical guidelines are limited. There is increasing growth of cardio-oncology research in Australia and support from leading Australian professional bodies and advocacy and research networks, including the Cardiac Society of Australia and New Zealand, the Clinical Oncology Society of Australia, the National Heart Foundation of Australia, and the Australian Cardiovascular Alliance (ACvA). Thus, opportunities to drive multidisciplinary cardio-oncology initiatives are growing, including grant funding, position statements, and novel research to inform new policies. The ACvA has a unique flagship structure that spans the translational research pipeline from drug discovery to implementation science. This article aims to highlight how multidisciplinary cardio-oncology innovations could intersect with the seven ACvA flagships, and to showcase Australian achievements in cardio-oncology thus far. We summarise eight key priority areas for future cardio-oncology research that emerged. These strategies will strengthen cardio-oncology research and care in Australia, and drive new guidelines, policies, and government initiatives to ensure equity in health outcomes for all cardio-oncology patients.

Cancer incidence and outcomes registries in an Australian context: a systematic review

BACKGROUND

Multiple cancer registries in Australia are used to track the incidence of cancer and the outcomes of their treatment. These registries can be broadly classed into a few types with an increasing number of registries comes a greater potential for collaboration and linkage. This article aims to critically review cancer registry types in Australia and evaluate the Australian Cancer registry landscape to identify these areas.

METHODS

A systematic review was performed through MEDLINE, EMBASE and Cochrane Library, updated to September 2022 using a predefined search strategy. Inclusion criteria were those that only analysed Australian and/or New Zealand based cancer registries, appraised the utility of cancer outcomes and/or incidence registries, and explored the utility of linked databases using cancer outcomes and/or incidence registries. The grey literature was searched for all operating cancer registries in Australia. Details of registry infrastructure was extracted for analysis and comparison.

RESULTS

Three thousand two hundred and sixteen articles identified from the three databases. Twelve met the inclusion criteria. Twenty-eight registries were identified using the grey literature. Strengths and weaknesses of Cancer Outcome Registries(COR) and Cancer Incidence Registries(CIR) were compared. Data linkage between registries or with other healthcare databases show great benefits in improving evidence for cancer research but are challenging to implement. Both registry types utilize differing modes of administration, influencing their accuracy and completeness.

CONCLUSION

Outcome registries provide detailed data but their weakness lies in incomplete data coverage. Incidence registries record a large dataset which contain inaccuracies. Improving coverage of quality outcome registries, and quality assurance of data in incidence registries is required to ensure collection of accurate, meaningful data. Areas for collaboration identified included establishment of defined definitions and outcomes, data linkage between registry types or with healthcare databases, and collaboration in logistical planning to improve clinical utility of cancer registries.

"Nothing to lose and the possibility of gaining": a qualitative study on the feasibility and acceptability of registry-based randomised controlled trials among cancer patients and clinicians

BACKGROUND

Randomised controlled trials (RCTs) are considered the "gold standard" for evaluating the effectiveness of interventions in clinical research. However, conventional RCTs are typically complex, expensive, and have narrow eligibility criteria, which limits generalisability. Registry-based randomised controlled trials (RRCTs) are an alternative approach that integrates the internal validity of an RCT with the external validity of a clinical registry by recruiting real-world patients and leveraging an existing registry platform for data collection. As RRCT is a novel research design, there has been limited research on the feasibility and acceptability of RRCTs from the patients' and trial team's perspectives. This study aims to explore patients', clinicians', and study coordinators' perspectives towards participation in and conduct of oncology RRCTs in Australia.

METHODS

Thirty-seven semi-structured interviews were conducted with 15 cancer patients, 15 clinicians, and 7 study coordinators. Interviews were audio-recorded and transcribed verbatim. The data were analysed using thematic analysis.

RESULTS

Three overarching themes were identified: (1) enablers and barriers to recruitment and enrolment of patients in RRCTs, (2) experiences of patients participating in RRCTs, and (3) recommendations for the implementation of future RRCTs. For patients, altruism and "trust in the clinician" were key reasons to participate in a RRCT. For clinicians and clinical trial coordinators, the RRCT study design was perceived as "simple and straightforward" but "less exciting" than RCTs. Competition from commercially sponsored RCTs poses challenges for investigator-led RRCTs recruitment, particularly if eligible patient numbers are low. There were limited impacts on patients' treatment experiences and clinicians' clinical workflow given that the RRCTs explored different standards of care. Recommendations to improve the enrolment of patients in RRCTs included generating greater buy-in from clinicians by increasing awareness of RRCTs via education initiatives and broader promotion of the "selling point" of RRCTs and providing monetary compensation to hospitals for enrolling patients.

CONCLUSIONS

Whilst patients, clinicians, and study coordinators were generally supportive of RRCTs, several barriers to effective RRCT implementation in oncology were identified. Developing strategies to increase acceptance of the methodology by clinicians will help enhance the uptake of RRCTs in Australia and internationally.

3D collagen microchamber arrays for combined chemotherapy effect evaluation on cancer cell numbers and migration

Breast cancer metastasis involves complex mechanisms, particularly when patients are undergoing chemotherapy. In tissues, tumor cells encounter cell-cell interactions, cell-microenvironment interactions, complex nutrient, and drug gradients. Currently, two-dimensional cell culture systems and animal models are challenging to observe and analyze cell responses to microenvironments with various physical and bio-chemical conditions, and microfluidic technology has been systematically developed to address this dilemma. In this study, we have constructed a combined chemotherapy evaluation chip (CCEC) based on microfluidic technology. The chip possesses 192 diamond-shaped microchambers containing MDA-MB-231-RFP cells, and each microchamber is composed of collagen to mimic breast cancer and its surrounding microenvironment. In addition, by adding medium containing different drugs to the medium channels of CCEC, composite drug (paclitaxel+gemcitabine+7rh and paclitaxel+fluorouracil+PP2) concentration gradients, and single drug (paclitaxel, gemcitabine, 7rh, fluorouracil, PP2) concentration gradients have been established in the five collagen regions, respectively, so that each localized microchamber in the regions has a unique drug microenvironment. In this way, we evaluated the composite and single chemotherapy efficacy on the same chip by statistically analyzing their effects on the numbers and migration of the cell. The quantitative results in CCECs reveal that the inhibition effects on the numbers and migration of MDA-MB-231-RFP cell under the composite drug gradients are more optimal than those of the single drugs. Besides, the cancer cell inhibition effect between the groups composed of two drugs has also been compared, that is the paclitaxel+gemcitabine, paclitaxel+fluorouracil, and paclitaxel+PP2 have better cell numbers and migration inhibition effects than paclitaxel+7rh. The results indicate that the bio-mimetic and high-throughput combined chemotherapy evaluation platform can serve as a more efficient and accurate tool for preclinical drug development and screening.