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Hansson E, Larsson C, Uusimäki A, Svensson K, Widmark Jensen E, Paganini A. A systematic review of randomised controlled trials in breast reconstruction. J Plast Surg Hand Surg 2024; 59:53-64. [PMID: 38751090 DOI: 10.2340/jphs.v59.40087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND For preference sensitive treatments, such as breast reconstructions, there are barriers to conducting randomised controlled trials (RCTs). The primary aims of this systematic review were to investigate what type of research questions are explored by RCTs in breast reconstruction, where have they been performed and where have they been published, and to thematise the research questions and thus create an overview of the state of the research field. METHODS Randomised controlled trials investigating any aspect of breast reconstructions were included. The PubMed database was searched with a pre-defined search string. Inclusion and data abstraction was performed in a pre-defined standardised fashion. For the purpose of this study, we defined key issues as comparison of categories of breast reconstruction and comparison of immediate and delayed breast reconstruction, when the thematisation was done. RESULTS A total of 419 abstracts were retrieved from the search. Of the 419, 310 were excluded as they were not RCTs concerning some aspect of breast reconstruction, which left us with 110 abstracts to be included in the study. The research questions of the included studies could more or less be divided into seven different themes inclusive of 2 key issues: Other issues - comparison of different categories of breast reconstruction, comparison of immediate and delayed breast reconstruction, surgical details within a category of breast reconstruction, surgical details valid for several categories of breast reconstruction, donor site management, anaesthetics, and non-surgical details. Only five studies compared key issues, and they all illustrate the challenges with RCTs in breast reconstruction. CONCLUSIONS A total of 110 publications based on RCTs in breast reconstruction have been published. Seven themes of research questions could be identified. Only five studies have explored the key issues. Better scientific evidence is needed for the key issues in breast reconstruction, for example by implementing a new study design in the field.
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Affiliation(s)
- Emma Hansson
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden.
| | - Camilla Larsson
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Alexandra Uusimäki
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Karolina Svensson
- The Breast Cancer Association Johanna, Gothenburg. Regional branch of the patient organisation the Swedish Breast Cancer Association
| | - Emmelie Widmark Jensen
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden
| | - Anna Paganini
- Department of Plastic surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Plastic and Reconstructive Surgery, Gothenburg, Sweden; Department of Diagnostics, Acute and Critical Care, Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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2
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Thomson S, Ainsworth G, Selvanathan S, Kelly R, Collier H, Mujica-Mota R, Talbot R, Brown ST, Croft J, Rousseau N, Higham R, Al-Tamimi Y, Buxton N, Carleton-Bland N, Gledhill M, Halstead V, Hutchinson P, Meacock J, Mukerji N, Pal D, Vargas-Palacios A, Prasad A, Wilby M, Stocken D. Posterior cervical foraminotomy versus anterior cervical discectomy for Cervical Brachialgia: the FORVAD RCT. Health Technol Assess 2023; 27:1-228. [PMID: 37929307 PMCID: PMC10641711 DOI: 10.3310/otoh7720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Posterior cervical foraminotomy and anterior cervical discectomy are routinely used operations to treat cervical brachialgia, although definitive evidence supporting superiority of either is lacking. Objective The primary objective was to investigate whether or not posterior cervical foraminotomy is superior to anterior cervical discectomy in improving clinical outcome. Design This was a Phase III, unblinded, prospective, United Kingdom multicentre, parallel-group, individually randomised controlled superiority trial comparing posterior cervical foraminotomy with anterior cervical discectomy. A rapid qualitative study was conducted during the close-down phase, involving remote semistructured interviews with trial participants and health-care professionals. Setting National Health Service trusts. Participants Patients with symptomatic unilateral cervical brachialgia for at least 6 weeks. Interventions Participants were randomised to receive posterior cervical foraminotomy or anterior cervical discectomy. Allocation was not blinded to participants, medical staff or trial staff. Health-care use from providing the initial surgical intervention to hospital discharge was measured and valued using national cost data. Main outcome measures The primary outcome measure was clinical outcome, as measured by patient-reported Neck Disability Index score 52 weeks post operation. Secondary outcome measures included complications, reoperations and restricted American Spinal Injury Association score over 6 weeks post operation, and patient-reported Eating Assessment Tool-10 items, Glasgow-Edinburgh Throat Scale, Voice Handicap Index-10 items, PainDETECT and Numerical Rating Scales for neck and upper-limb pain over 52 weeks post operation. Results The target recruitment was 252 participants. Owing to slow accrual, the trial closed after randomising 23 participants from 11 hospitals. The qualitative substudy found that there was support and enthusiasm for the posterior cervical FORaminotomy Versus Anterior cervical Discectomy in the treatment of cervical brachialgia trial and randomised clinical trials in this area. However, clinical equipoise appears to have been an issue for sites and individual surgeons. Randomisation on the day of surgery and processes for screening and approaching participants were also crucial factors in some centres. The median Neck Disability Index scores at baseline (pre surgery) and at 52 weeks was 44.0 (interquartile range 36.0-62.0 weeks) and 25.3 weeks (interquartile range 20.0-42.0 weeks), respectively, in the posterior cervical foraminotomy group (n = 14), and 35.6 weeks (interquartile range 34.0-44.0 weeks) and 45.0 weeks (interquartile range 20.0-57.0 weeks), respectively, in the anterior cervical discectomy group (n = 9). Scores appeared to reduce (i.e. improve) in the posterior cervical foraminotomy group, but not in the anterior cervical discectomy group. The median Eating Assessment Tool-10 items score for swallowing was higher (worse) after anterior cervical discectomy (13.5) than after posterior cervical foraminotomy (0) on day 1, but not at other time points, whereas the median Glasgow-Edinburgh Throat Scale score for globus was higher (worse) after anterior cervical discectomy (15, 7, 6, 6, 2, 2.5) than after posterior cervical foraminotomy (3, 0, 0, 0.5, 0, 0) at all postoperative time points. Five postoperative complications occurred within 6 weeks of surgery, all after anterior cervical discectomy. Neck pain was more severe on day 1 following posterior cervical foraminotomy (Numerical Rating Scale - Neck Pain score 8.5) than at the same time point after anterior cervical discectomy (Numerical Rating Scale - Neck Pain score 7.0). The median health-care costs of providing initial surgical intervention were £2610 for posterior cervical foraminotomy and £4411 for anterior cervical discectomy. Conclusions The data suggest that posterior cervical foraminotomy is associated with better outcomes, fewer complications and lower costs, but the trial recruited slowly and closed early. Consequently, the trial is underpowered and definitive conclusions cannot be drawn. Recruitment was impaired by lack of individual equipoise and by concern about randomising on the day of surgery. A large prospective multicentre trial comparing anterior cervical discectomy and posterior cervical foraminotomy in the treatment of cervical brachialgia is still required. Trial registration This trial is registered as ISRCTN10133661. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 21. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon Thomson
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gemma Ainsworth
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rachel Kelly
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Howard Collier
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rebecca Talbot
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sarah Tess Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Julie Croft
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Nikki Rousseau
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ruchi Higham
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Yahia Al-Tamimi
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Buxton
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Martin Gledhill
- Department of Speech and Language Therapy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Peter Hutchinson
- Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James Meacock
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nitin Mukerji
- Department of Neurosurgery, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Debasish Pal
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Anantharaju Prasad
- Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Martin Wilby
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Al-Sakkaf AM, Bonfill X, Ardiles-Ruesjas S, Bendersky-Kohan J, Sola I, Masia J. Risk-of-bias assessment of the randomized clinical trials and systematic reviews on surgical treatments for breast cancer-related lymphedema: A mapping review. J Plast Reconstr Aesthet Surg 2023; 84:134-146. [PMID: 37329747 DOI: 10.1016/j.bjps.2023.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 04/16/2023] [Accepted: 05/02/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Breast cancer treatment is the principal cause of lymphedema in the upper extremities. Breast cancer-related lymphedema (BCRL) treatments were previously based on conservative therapy; surgical treatments are alternative options that could be highly beneficial, especially for patients who are not responsive to conservative therapy. The main aim of this study was to describe and critically assess the risk of bias of randomized clinical trials (RCTs) and systematic reviews (SRs) on surgical treatment for BCRL. METHODS We conducted an evidence mapping review according to the methodology proposed by Global Evidence Mapping (GEM). An update was done for our previous systematic search in MEDLINE, EMBASE, CENTRAL (Cochrane), and Epistemonikos from the year 2000 onward. We assessed the risk of bias for the RCTs and SRs using the RoB-2 and ROBIS tools, respectively. RESULTS Two surgical RCTs and eight SRs were found among the 47 surgical studies that met the eligibility criteria. The overall risk-of-bias assessments of these studies were rated as some concerns (six outcomes) and high risk (three outcomes) for the measured outcomes among the RCTs and as a high risk of bias (five studies) and low risk (three studies) for the included SRs. CONCLUSIONS The overall evidence in the literature on surgical treatment for BCRL is low, as there are few published RCTs and SRs, and the risk-of-bias assessment for the majority was rated as high risk of bias or with some concerns. High-quality studies are needed to improve evidence-based decision-making by surgeons and patients.
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Affiliation(s)
- Ali M Al-Sakkaf
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Xavier Bonfill
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBERESP, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Josefina Bendersky-Kohan
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBERESP, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ivan Sola
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBERESP, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jaume Masia
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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Mohiuddin S, Hollingworth W, Glynn J, Jones T, Johnson L, Potter S. Secondary healthcare costs after mastectomy and immediate breast reconstruction for women with breast cancer in England: population-based cohort study. Br J Surg 2023; 110:1171-1179. [PMID: 37307518 PMCID: PMC10416683 DOI: 10.1093/bjs/znad149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/28/2023] [Accepted: 05/01/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Immediate breast reconstruction after mastectomy can improve the quality of life for women with breast cancer and rates are increasing. Long-term inpatient costs of care were estimated to understand the impact of different immediate breast reconstruction procedures on healthcare expenditure. METHODS Hospital Episode Statistics Admitted Patient Care data were used to identify women undergoing unilateral mastectomy and immediate breast reconstruction in English National Health Service hospitals (1 April 2009 to 31 March 2015) and any subsequent procedures performed to revise, replace, or complete the breast reconstruction. Costs were assigned to Hospital Episode Statistics Admitted Patient Care data using the Healthcare Resource Group 2020/21 National Costs Grouper. Generalized linear models were used to estimate mean cumulative costs for five immediate breast reconstruction procedures over 3 and 8 years, adjusting for covariates (age/ethnicity/deprivation). RESULTS A total of 16 890 women underwent mastectomy and immediate breast reconstruction: implant (5192; 30.7 per cent), expander (2826; 16.7 per cent), autologous latissimus dorsi flap (2372; 14.0 per cent), latissimus dorsi flap with expander/implant (3109; 18.4 per cent), and abdominal free-flap reconstruction (3391; 20.1 per cent). The mean (95 per cent c.i.) cumulative cost was lowest for latissimus dorsi flap with expander/implant reconstruction (€20 103 (€19 582 to €20 625)) over 3 years and highest for abdominal free-flap reconstruction (€27 560 (€27 037 to €28 083)). Over 8 years, expander (€29 140 (€27 659 to €30 621)) and latissimus dorsi flap with expander/implant (€29 312 (€27 622 to €31 003)) reconstructions were the least expensive, while abdominal free-flap reconstruction (€34 536 (€32 958 to €36 113)) remained the most expensive, despite having lower costs for revisions and secondary reconstructions. This was driven primarily by the cost of the index procedure (€5435 (expander reconstruction) to €15 106 (abdominal free-flap reconstruction)). CONCLUSION Hospital Episode Statistics Admitted Patient Care Healthcare Resource Group data provided a comprehensive longitudinal cost assessment of secondary care. Although abdominal free-flap reconstruction was the most expensive option, higher costs of the index procedure need to be balanced against ongoing long-term costs of revisions/secondary reconstructions, which are higher after implant-based procedures.
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Affiliation(s)
- Syed Mohiuddin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - William Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR ARC West, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Joel Glynn
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim Jones
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR ARC West, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Leigh Johnson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shelley Potter
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Breast Care Centre, Southmead Hospital, Bristol, UK
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5
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Florczynski MM, Chung KC. Choosing the Best Design in Surgical Research. Plast Reconstr Surg 2023; 151:1115-1122. [PMID: 37224338 DOI: 10.1097/prs.0000000000010173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Matthew M Florczynski
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
| | - Kevin C Chung
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
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Harvey KL, Sinai P, Mills N, White P, Holcombe C, Potter S. Short-term safety outcomes of mastectomy and immediate prepectoral implant-based breast reconstruction: Pre-BRA prospective multicentre cohort study. Br J Surg 2022; 109:530-538. [PMID: 35576373 PMCID: PMC10364707 DOI: 10.1093/bjs/znac077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/18/2022] [Accepted: 02/22/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Prepectoral breast reconstruction (PPBR) has recently been introduced to reduce postoperative pain and improve cosmetic outcomes in women having implant-based procedures. High-quality evidence to support the practice of PPBR, however, is lacking. Pre-BRA is an IDEAL stage 2a/2b study that aimed to establish the safety, effectiveness, and stability of PPBR before definitive evaluation in an RCT. The short-term safety endpoints at 3 months after surgery are reported here. METHODS Consecutive patients electing to undergo immediate PPBR at participating UK centres between July 2019 and December 2020 were invited to participate. Demographic, operative, oncology, and complication data were collected. The primary outcome was implant loss at 3 months. Other outcomes of interest included readmission, reoperation, and infection. RESULTS Some 347 women underwent 424 immediate implant-based reconstructions at 40 centres. Most were single-stage direct-to-implant (357, 84.2 per cent) biological mesh-assisted (341, 80.4 per cent) procedures. Conversion to subpectoral reconstruction was necessary in four patients (0.9 per cent) owing to poor skin-flap quality. Of the 343 women who underwent PPBR, 144 (42.0 per cent) experienced at least one postoperative complication. Implant loss occurred in 28 women (8.2 per cent), 67 (19.5 per cent) experienced an infection, 60 (17.5 per cent) were readmitted for a complication, and 55 (16.0 per cent) required reoperation within 3 months of reconstruction. CONCLUSION Complication rates following PPBR are high and implant loss is comparable to that associated with subpectoral mesh-assisted implant-based techniques. These findings support the need for a well-designed RCT comparing prepectoral and subpectoral reconstruction to establish best practice for implant-based breast reconstruction.
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Affiliation(s)
- Kate L Harvey
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Parisa Sinai
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Nicola Mills
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Paul White
- Applied Statistics Group, University of the West of England, Bristol, UK
| | | | - Shelley Potter
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, UK
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Roberts K, Mills N, Metcalfe C, Lane A, Clement C, Hollingworth W, Taylor J, Holcombe C, Skillman J, Fairhurst K, Whisker L, Cutress R, Thrush S, Fairbrother P, Potter S. Best-BRA (Is subpectoral or prepectoral implant placement best in immediate breast reconstruction?): a protocol for a pilot randomised controlled trial of subpectoral versus prepectoral immediate implant-based breast reconstruction in women following mastectomy. BMJ Open 2021; 11:e050886. [PMID: 34848516 PMCID: PMC8634330 DOI: 10.1136/bmjopen-2021-050886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure following mastectomy. IBBR techniques are evolving rapidly, with mesh-assisted subpectoral reconstruction becoming the standard of care and more recently, prepectoral techniques being introduced. These muscle-sparing techniques may reduce postoperative pain, avoid implant animation and improve cosmetic outcomes and have been widely adopted into practice. Although small observational studies have failed to demonstrate any differences in the clinical or patient-reported outcomes of prepectoral or subpectoral reconstruction, high-quality comparative evidence of clinical or cost-effectiveness is lacking. A well-designed, adequately powered randomised controlled trial (RCT) is needed to compare the techniques, but breast reconstruction RCTs are challenging. We, therefore, aim to undertake an external pilot RCT (Best-BRA) with an embedded QuinteT Recruitment Intervention (QRI) to determine the feasibility of undertaking a trial comparing prepectoral and subpectoral techniques. METHODS AND ANALYSIS Best-BRA is a pragmatic, two-arm, external pilot RCT with an embedded QRI and economic scoping for resource use. Women who require a mastectomy for either breast cancer or risk reduction, elect to have an IBBR and are considered suitable for both prepectoral and subpectoral reconstruction will be recruited and randomised 1:1 between the techniques.The QRI will be implemented in two phases: phase 1, in which sources of recruitment difficulties are rapidly investigated to inform the delivery in phase 2 of tailored interventions to optimise recruitment of patients.Primary outcomes will be (1) recruitment of patients, (2) adherence to trial allocation and (3) outcome completion rates. Outcomes will be reviewed at 12 months to determine the feasibility of a definitive trial. ETHICS AND DISSEMINATION The study has been approved by the National Health Service (NHS) Wales REC 6 (20/WA/0338). Findings will be presented at conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN10081873.
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Affiliation(s)
- Kirsty Roberts
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Nicola Mills
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Chris Metcalfe
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Athene Lane
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Clare Clement
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | | | - Jodi Taylor
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Chris Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Joanna Skillman
- Department of Plastic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Katherine Fairhurst
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Lisa Whisker
- Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ramsey Cutress
- Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Steven Thrush
- Breast Unit, Worcestershire Acute Hospitals NHS Trust, Worcester, Worcestershire, UK
| | | | - Shelley Potter
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Westbury on Trym, UK
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Davies L, Beard D, Cook JA, Price A, Osbeck I, Toye F. The challenge of equipoise in trials with a surgical and non-surgical comparison: a qualitative synthesis using meta-ethnography. Trials 2021; 22:678. [PMID: 34620194 PMCID: PMC8495989 DOI: 10.1186/s13063-021-05403-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/26/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Randomised controlled trials in surgery can be a challenge to design and conduct, especially when including a non-surgical comparison. As few as half of initiated surgical trials reach their recruitment target, and failure to recruit is cited as the most frequent reason for premature closure of surgical RCTs. The aim of this qualitative evidence synthesis was to identify and synthesise findings from qualitative studies exploring the challenges in the design and conduct of trials directly comparing surgical and non-surgical interventions. METHODS A qualitative evidence synthesis using meta-ethnography was conducted. Six electronic bibliographic databases (Medline, Central, Cinahl, Embase and PsycInfo) were searched up to the end of February 2018. Studies that explored patients' and health care professionals' experiences regarding participating in RCTs with a surgical and non-surgical comparison were included. The GRADE-CERQual framework was used to assess confidence in review findings. RESULTS In total, 3697 abstracts and 49 full texts were screened and 26 published studies reporting experiences of patients and healthcare professionals were included. The focus of the studies (24/26) was primarily related to the challenge of recruitment. Two studies explored reasons for non-compliance to treatment allocation following randomisation. Five themes related to the challenges to these types of trials were identified: (1) radical choice between treatments; (2) patients' discomfort with randomisation: I want the best treatment for me as an individual; (3) challenge of equipoise: patients' a priori preferences for treatment; (4) challenge of equipoise: clinicians' a priori preferences for treatment and (5) imbalanced presentation of interventions. CONCLUSION The marked dichotomy between the surgical and non-surgical interventions was highlighted in this review as making recruitment to these types of trials particularly challenging. This review identified factors that increase our understanding of why patients and clinicians may find equipoise more challenging in these types of trials compared to other trial comparisons. Trialists may wish to consider exploring the balance of potential factors influencing patient and clinician preferences towards treatments before they start recruitment, to enable issues specific to a particular trial to be identified and addressed. This may enable trial teams to make more efficient considered design choices and benefit the delivery of such trials.
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Affiliation(s)
- Loretta Davies
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK
| | | | - Francine Toye
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Jepson M, Lazaroo M, Pathak S, Blencowe N, Collingwood J, Clout M, Toogood G, Blazeby J. Making large-scale surgical trials possible: collaboration and the role of surgical trainees. Trials 2021; 22:567. [PMID: 34446065 PMCID: PMC8390009 DOI: 10.1186/s13063-021-05536-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/11/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Recruitment to surgical randomised controlled trials (RCTs) can be challenging. The Sunflower study is a large-scale multi-centre RCT that seeks to establish the clinical and cost effectiveness of pre-operative imaging versus expectant management in patients with symptomatic gallstones undergoing laparoscopic cholecystectomy at low or moderate risk of common bile duct stones. Trials such as Sunflower, with a large recruitment target, rely on teamworking. Recruitment can be optimised by embedding a QuinteT Recruitment Intervention (QRI). Additionally, engaging surgical trainees can contribute to successful recruitment, and the NIHR Associate Principal Investigator (API) scheme provides a framework to acknowledge their contributions. METHODS This was a mixed-methods study that formed a component part of an embedded QRI for the Sunflower RCT. The aim of this study was to understand factors that supported and hindered the participation of surgical trainees in a large-scale RCT and their participation in the API scheme. It comprised semi-structured telephone interviews with consultant surgeons and surgical trainees involved in screening and recruitment of patients, and descriptive analysis of screening and recruitment data. Interviews were analysed thematically to explore the perspectives of-and roles undertaken by-surgical trainees. RESULTS Interviews were undertaken with 34 clinicians (17 consultant surgeons, 17 surgical trainees) from 22 UK hospital trusts. Surgical trainees contributed to patient screening, approaches and randomisation, with a major contribution to the randomisation of patients from acute admissions. They were often encouraged to participate in the study by their centre principal investigator, and career development was a typical motivating factor for their participation in the study. The study was registered with the API scheme, and a majority of the trainees interviewed (n = 14) were participating in the scheme. CONCLUSION Surgical trainees can contribute substantial activity to a large-scale multi-centre RCT. Benefits of trainee engagement were identified for trainees themselves, for local sites and for the study as a whole. The API scheme provided a formal framework to acknowledge engagement. Ensuring that training and support for trainees are provided by the trial team is key to optimise success for all stakeholders.
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Affiliation(s)
- Marcus Jepson
- grid.5337.20000 0004 1936 7603QuinteT Research Group, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Michelle Lazaroo
- grid.5337.20000 0004 1936 7603Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Samir Pathak
- grid.5337.20000 0004 1936 7603Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Natalie Blencowe
- grid.5337.20000 0004 1936 7603Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
- grid.410421.20000 0004 0380 7336University Hospitals Bristol and Weston NHS Foundation Trust, Trust Headquarters, Marlborough St, Bristol, BS1 3NU UK
| | - Jane Collingwood
- grid.5337.20000 0004 1936 7603Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Madeleine Clout
- grid.5337.20000 0004 1936 7603Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Giles Toogood
- grid.443984.6Department of Hepatobiliary and Transplantation Surgery, St James’s University Hospital, Leeds, LS9 7TF UK
| | - Jane Blazeby
- grid.5337.20000 0004 1936 7603NIHR Biomedical Research Centre Bristol, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN UK
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10
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Johnson L, Holcombe C, O'Donoghue JM, Jeevan R, Browne J, Fairbrother P, MacKenzie M, Gulliver-Clarke C, White P, Mohiuddin S, Hollingworth W, Potter S. Protocol for a national cohort study to explore the long-term clinical and patient-reported outcomes and cost-effectiveness of implant-based and autologous breast reconstruction after mastectomy for breast cancer: the brighter study. BMJ Open 2021; 11:e054055. [PMID: 34408062 PMCID: PMC8375757 DOI: 10.1136/bmjopen-2021-054055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Breast reconstruction (BR) is offered to improve quality of life for women with breast cancer undergoing mastectomy. As most women will be long-term breast cancer survivors, high-quality information regarding the long-term outcomes of different BR procedures is essential to support informed decision-making. As different techniques vary considerably in cost, policymakers also require high-quality cost-effectiveness evidence to inform care. The Brighter study aims to explore the long-term clinical and patient-reported outcomes (PROs) of implant-based and autologous BR and use health economic modelling to compare the long-term cost-effectiveness of different reconstructive techniques. METHODS AND ANALYSIS Women undergoing mastectomy and/or BR following a diagnosis of breast cancer between 1 January 2008 and 31 March 2009 will be identified from hospital episode statistics (HES). Surviving women will be contacted and invited to complete validated PRO measures including the BREAST-Q, EQ-5D-5L and ICECAP-A, or opt out of having their data included in the HES analysis. Long-term clinical outcomes will be explored using HES data. The primary outcome will be rates of revisional surgery between implant-based and autologous procedures. Secondary outcomes will include rates of secondary reconstruction and reconstruction failure. The long-term PROs of implant-based and autologous reconstruction will be compared using BREAST-Q, EQ-5D-5L and ICECAP-A scores. Multivariable regression will be used to examine the relationship between long-term outcomes, patient comorbidities, sociodemographic and treatment factors. A Markov model will be developed using HES and PRO data and published literature to compare the relative long-term cost-effectiveness of implant-based and autologous BR. ETHICS AND DISSEMINATION The Brighter study has been approved by the South-West -Central Bristol Research Ethics Committee (20/SW/0020), and the Confidentiality Advisory Group (20/CAG/0021). Results will be published in peer-reviewed journals and presented at national meetings. We will work with the professional associations, charities and patient groups to disseminate the results.
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Affiliation(s)
- Leigh Johnson
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Chris Holcombe
- Linda McCartney Centre, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Joe M O'Donoghue
- Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Ranjeet Jeevan
- Manchester University NHS Foundation Trust, Manchester, UK
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
| | | | | | | | - Paul White
- Applied Statistics Group, University of the West of England, Bristol, UK
| | - Syed Mohiuddin
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | | | - Shelley Potter
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, UK
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11
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Amer MA, Herbison GP, Grainger SH, Khoo CH, Smith MD, McCall JL. A meta-epidemiological study of bias in randomized clinical trials of open and laparoscopic surgery. Br J Surg 2021; 108:477-483. [PMID: 33778858 DOI: 10.1093/bjs/znab035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/15/2020] [Accepted: 01/17/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Blinding, random sequence generation, and allocation concealment are established strategies to minimize bias in RCTs. Meta-epidemiological studies of drug trials have demonstrated exaggerated treatment effects in RCTs where such methods were not employed. As blinding is more difficult in surgical trials it is important to determine whether this applies to them. The study aimed to investigate this using systematic meta-epidemiological methods. METHOD The Cochrane Database of Systematic Reviews was searched for systematic reviews of RCTs that compared laparoscopic and open abdominal surgical procedures. Each review was then scrutinized to determine whether at least one of the included trials was blinded. Eligible reviews were updated and individual RCTs retrieved. Extracted data included the primary outcomes of interest (length of stay and complications), secondary outcomes and a risk of bias assessment. A multistep meta-regression analysis was then performed to obtain an overall difference in the reported outcome differences between trials that employed each bias-minimization strategy, and those that did not. RESULTS Some 316 RCTs were included, reporting on eight different procedures. Patient-blinded RCTs reported a smaller difference in length of stay between laparoscopic and open groups (difference of standardized mean differences -0·36 (95 per cent c.i. -0·73 to 0·00)) and complications (ratio of odds ratios 0·76 (95 per cent c.i. 0·61 to 0·93)). Blinding of postoperative carers and outcome assessors had similar effects. CONCLUSION Lack of blinding significantly altered the treatment effect estimates of RCTs comparing laparoscopic and open surgery. Blinding should be implemented in surgical RCTs where possible to avoid systematic bias.
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Affiliation(s)
- M A Amer
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - G P Herbison
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - S H Grainger
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - C H Khoo
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - M D Smith
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Department of General Surgery, Dunedin Hospital, Dunedin, New Zealand
| | - J L McCall
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Department of General Surgery, Dunedin Hospital, Dunedin, New Zealand.,Department of Surgery, School of Medicine, University of Auckland, Auckland, New Zealand.,New Zealand Liver Transplant Unit, Auckland, New Zealand
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12
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Dodwell D, Jauhari Y, Gathani T, Cromwell D, Gannon M, Clements K, Horgan K. Treatment variation in early breast cancer in the UK. BMJ 2020; 371:m4237. [PMID: 33262116 DOI: 10.1136/bmj.m4237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Yasmin Jauhari
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Toral Gathani
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford
- Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, UK
| | - Melissa Gannon
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, UK
| | | | - Kieran Horgan
- Department of Breast Surgery, St James's University Hospital, Leeds, UK
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13
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Clement C, Selman LE, Kehoe PG, Howden B, Lane JA, Horwood J. Challenges to and Facilitators of Recruitment to an Alzheimer's Disease Clinical Trial: A Qualitative Interview Study. J Alzheimers Dis 2020; 69:1067-1075. [PMID: 31156168 PMCID: PMC6598018 DOI: 10.3233/jad-190146] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Low participation in clinical trials is a major challenge to advancing clinical Alzheimer's disease (AD) research and care. Factors influencing recruitment to AD trials are not fully understood. OBJECTIVE To identify barriers to, and facilitators of, recruitment in a UK multi-center, secondary care AD trial (Reducing pathology in Alzheimer's Disease through Angiotensin TaRgeting (RADAR) trial) and implications for improving recruitment to AD trials. METHODS Semi-structured qualitative telephone interviews with a purposive sample of 17 trial site staff explored the RADAR trial recruitment pathway and views and experiences of recruitment. Interviews were analyzed thematically. RESULTS Diagnostic and care pathways hindered identifying patients with mild-moderate AD, with a lack of up-to-date patient records and data access problems affecting screening. Research is not routinely embedded in AD care but facilitated recruitment when it was. Clinicians' and patients' favorable view of the trial purpose facilitated recruitment, although the complexity of participant information sheets and requirement for study companion created challenges. CONCLUSION These findings have important implications for the design of future AD trials and for planning how to best interface with clinical commitments to ensure sufficient and timely recruitment. Challenges to AD trial recruitment can occur at care pathway, clinician, and patient and companion levels. Recruitment can be facilitated by: improving diagnostic processes and systems for recording and sharing patient information, embedding research into routine patient care, collaborating with a range of services to identify and approach eligible patients, training and engaging trial staff, and providing patients with clear and concise study information.
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Affiliation(s)
- Clare Clement
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lucy E Selman
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Patrick G Kehoe
- Dementia Research Group, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Beth Howden
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - J Athene Lane
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jeremy Horwood
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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14
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Davies G, Mills N, Holcombe C, Potter S. Perceived barriers to randomised controlled trials in breast reconstruction: obstacle to trial initiation or opportunity to resolve? A qualitative study. Trials 2020; 21:316. [PMID: 32252788 PMCID: PMC7132957 DOI: 10.1186/s13063-020-4227-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 03/03/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Implant-based breast reconstruction (IBBR) is the most commonly performed breast reconstruction technique worldwide but the technique is evolving rapidly. High-quality evidence is needed to support practice. Randomised controlled trials (RCTs) provide the best evidence but can be challenging to conduct. iBRA is a four-phased study which aimed to inform the feasibility, design and conduct of an RCT in IBBR. In phase 3, the randomisation acceptability study, an electronic survey and qualitative interviews were conducted to explore professionals' perceptions of future trials in IBBR. Findings from the interviews are presented here. METHODS Semi-structured qualitative interviews were undertaken with a purposive sample of 31 health professionals (HPs) who completed the survey to explore their attitudes to the feasibility of potential RCTs in more detail. All interviews were transcribed verbatim and data were analysed thematically using constant comparative techniques. Sampling, data collection and analysis were undertaken iteratively and concurrently until data saturation was achieved. RESULTS Almost all HPs acknowledged the need for better evidence to support the practice of IBBR and most identified RCTs as generating the highest-quality evidence. Despite highlighting potential challenges, most participants supported the need for an RCT in IBBR. A minority, however, were strongly opposed to a future trial. The opposition and challenges identified centred around three key themes; (i) limited understanding of pragmatic study design and the value of randomisation in minimising bias; (ii) clinician and patient equipoise and (iii) aspects of surgical culture and training that were not supportive of RCTs. CONCLUSION There is a need for well-designed, large-scale RCTs to support the current practice of IBBR but barriers to their acceptability are evident. The perceived barriers to RCTs in breast reconstruction identified in this study are not insurmountable and have previously been overcome in other similar surgical trials. This may represent an opportunity, not only to establish the evidence base for IBBR, but also to improve engagement in RCTs in breast surgery in general to ultimately improve outcomes for patients. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number ISRCTN37664281.
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Affiliation(s)
- Gareth Davies
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Nicola Mills
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Chris Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Prescot Street, Liverpool, L7 8XP UK
| | - Shelley Potter
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Southmead Road, Bristol, BS10 5NB UK
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15
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Nandra R, Brockie AF, Hussain F. A review of informed consent and how it has evolved to protect vulnerable participants in emergency care research. EFORT Open Rev 2020; 5:73-79. [PMID: 32175093 PMCID: PMC7047905 DOI: 10.1302/2058-5241.5.180051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A vulnerable participant in research lacks capacity to consent or may be exposed to coercion to participate. Capacity may be temporarily impaired due to loss of consciousness, hypoxia, pain and the consumption of alcohol or elicit substances.To advance emergency care, providing life-threatening measures in life-threatening circumstances, vulnerable patients are recruited into research studies. The urgent need for time-critical treatment conflicts with routine informed consent procedures.This article reviews ethical considerations and moral obligations to safeguard these participants and preserve their autonomy.A particular focus is given to research methodology to waive consent, and the role of ethics committees, research audits, research nurses and community engagement.Research on the acutely unwell patient who lacks capacity is possible with well-designed research trials that are led by investigators who are sufficiently trained, engage the community, gain ethical approval to waive consent and continuously audit practice. Cite this article: EFORT Open Rev 2020;5:73-79. DOI: 10.1302/2058-5241.5.180051.
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16
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Gardner HR, Treweek S, Gillies K. Using evidence when planning for trial recruitment: An international perspective from time-poor trialists. PLoS One 2019; 14:e0226081. [PMID: 31821373 PMCID: PMC6903711 DOI: 10.1371/journal.pone.0226081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 11/18/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Recruiting participants to trials is challenging. To date, research has focussed on improving recruitment once the trial is underway, rather than planning strategies to support it, e.g. developing trial information leaflets together with people like those to be recruited. We explored whether people involved with participant recruitment have explicit planning strategies; if so, how these are developed, and if not, what prevents effective planning. METHODS Design: Individual qualitative semi-structured interviews. Data were analysed using a Framework approach, and themes linked through comparison of data within and across stakeholder groups. Participants: 23 international trialists (UK, Canada, South Africa, Italy, the Netherlands); 11 self-identifying as 'Designers'; those who design recruitment methods, and 12 self-identifying as 'Recruiters'; those who recruit participants. Interviewees' had recruitment experience spanning diverse interventions and clinical areas. Setting: Primary, secondary and tertiary-care sites involved in trials, academic institutions, and contract research organisations supporting pharmaceutical companies. RESULTS To varying degrees, respondents had prospective strategies for recruitment. These were seldom based on rigorous evidence. When describing their recruitment planning experiences, interviewees identified a range of influences that they believe impacted success: The timing of recruitment strategy development relative to the trial start date, and who is responsible for recruitment planning.The methods used to develop trialists' recruitment strategy design and implementation skills, and when these skills are gained (i.e. before the trial or throughout).The perceived barriers and facilitators to successful recruitment planning; and how trialists modify practice when recruitment is poor. CONCLUSIONS Respondents from all countries considered limited time and disproportionate approvals processes as major challenges to recruitment planning. Poor planning is a mistake that trialists live with throughout the trial. The experiences of our participants suggest that effective recruitment requires strategies to increase the time for trial planning, as well as access to easily implementable evidence-based strategies.
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Affiliation(s)
- Heidi R. Gardner
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, Scotland, United Kingdom
- * E-mail:
| | - Shaun Treweek
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, Scotland, United Kingdom
| | - Katie Gillies
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, Scotland, United Kingdom
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17
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Phelps EE, Tutton E, Griffin X, Baird J. Facilitating trial recruitment: A qualitative study of patient and staff experiences of an orthopaedic trauma trial. Trials 2019; 20:492. [PMID: 31399134 PMCID: PMC6688236 DOI: 10.1186/s13063-019-3597-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 07/18/2019] [Indexed: 11/10/2022] Open
Abstract
Background Qualitative research has been used to explore patients’ and healthcare professionals’ experiences of surgical randomised controlled trials (RCTs). From this research, reasons why patients accept or decline participation and barriers to engaging clinicians in trials have been identified. In a trauma setting, recruitment to surgical trials can be particularly difficult as patients may require urgent treatment and their ability to consider their options, ask questions and reach a decision may be hindered by the impact of their injury. Little research, however, has explored patients’ and healthcare professionals’ experiences of surgical RCTs in a trauma setting. This study aimed to understand patients’ and staff’s experiences of an orthopaedic trauma trial. Methods We carried out semi-structured interviews with 11 patients and 24 staff (10 surgeons and 14 research associates) participating in a UK multi-centre feasibility trial comparing intramedullary nails versus distal locking plates for fractures of the distal femur (TrAFFix). Interviews explored patients’ experience of TrAFFix and their reason for participating and staffs' experience of recruiting to TrAFFix and trauma trials more generally. Interviews were audio recorded and transcribed verbatim. Transcripts were analysed using thematic analysis. Results Three themes were identified. These were i) navigating research with patients after orthopaedic trauma, ii) knowing that it is the right decision and iii) making it work. These themes reflect: i) how research associates supported and guided patients through the consent process enabling them to participate, ii) the difficulty in engaging surgeons in a trial when individual equipoise and experience of the interventions are low despite the presence of community equipoise and iii) the way in which research teams worked together and encouraged the development of a research culture within the clinical teams in order to facilitate recruitment. Conclusions Our findings highlight the pivotal role of research associates (RAs) in facilitating trial recruitment. RAs supported patients to enable them to make a decision about participation and assisted in developing a research culture within the team by promoting studies and communicating research to clinical staff. Our findings also reinforce surgeons’ difficulty with equipoise and suggest that accepting community equipoise could facilitate recruitment.
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Affiliation(s)
- Emma Elizabeth Phelps
- NDORMS, Kadoorie Centre, level 3, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Elizabeth Tutton
- NDORMS, Kadoorie Centre, level 3, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK. .,Oxford University Hospitals NHS Foundation Trust, Oxford, UK. .,Warwick Research in Nursing, University of Warwick, Coventry, UK.
| | - Xavier Griffin
- NDORMS, Kadoorie Centre, level 3, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Janis Baird
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
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18
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Potter S, Conroy EJ, Cutress RI, Williamson PR, Whisker L, Thrush S, Skillman J, Barnes NLP, Mylvaganam S, Teasdale E, Jain A, Gardiner MD, Blazeby JM, Holcombe C. Short-term safety outcomes of mastectomy and immediate implant-based breast reconstruction with and without mesh (iBRA): a multicentre, prospective cohort study. Lancet Oncol 2019; 20:254-266. [PMID: 30639093 PMCID: PMC6358590 DOI: 10.1016/s1470-2045(18)30781-2] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/07/2018] [Accepted: 10/12/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Use of biological or synthetic mesh might improve outcomes of immediate implant-based breast reconstruction-breast reconstruction with implants or expanders at the time of mastectomy-but there is a lack of high-quality evidence to support the safety or effectiveness of the technique. We aimed to establish the short-term safety of immediate implant-based breast reconstruction performed with and without mesh, to inform the feasibility of undertaking a future randomised clinical trial comparing different breast reconstruction techniques. METHODS In this prospective, multicentre cohort study, we consecutively recruited women aged 16 years or older who had any type of immediate implant-based breast reconstruction for malignancy or risk reduction, with any technique, at 81 participating breast and plastic surgical units in the UK. Data about patient demographics and operative, oncological, and complication details were collected before and after surgery. Outcomes of interest were implant loss (defined as unplanned removal of the expander or implant), infection requiring treatment with antibiotics or surgery, unplanned return to theatre, and unplanned re-admission to hospital for complications of reconstructive surgery, up to 3 months after reconstruction and assessed by clinical review or patient self-report. Follow-up is complete. The study is registered with the ISRCTN Registry, number ISRCTN37664281. FINDINGS Between Feb 1, 2014, and June 30, 2016, 2108 patients had 2655 mastectomies with immediate implant-based breast reconstruction at 81 units across the UK. 1650 (78%) patients had planned single-stage reconstructions (including 12 patients who had a different technique per breast). 1376 (65%) patients had reconstruction with biological (1133 [54%]) or synthetic (243 [12%]) mesh, 181 (9%) had non-mesh submuscular or subfascial implants, 440 (21%) had dermal sling implants, 42 (2%) had pre-pectoral implants, and 79 (4%) had other or a combination of implants. 3-month outcome data were available for 2081 (99%) patients. Of these patients, 182 (9%, 95% CI 8-10) experienced implant loss, 372 (18%, 16-20) required re-admission to hospital, and 370 (18%, 16-20) required return to theatre for complications within 3 months of their initial surgery. 522 (25%, 95% CI 23-27) patients required treatment for an infection. The rates of all of these complications are higher than those in the National Quality Standards (<5% for re-operation, re-admission, and implant loss, and <10% for infection). INTERPRETATION Complications after immediate implant-based breast reconstruction are higher than recommended by national standards. A randomised clinical trial is needed to establish the optimal approach to immediate implant-based breast reconstruction. FUNDING National Institute for Health Research, Association of Breast Surgery, and British Association of Plastic, Reconstructive and Aesthetic Surgeons.
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Affiliation(s)
- Shelley Potter
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK; Bristol Breast Care Centre, North Bristol NHS Trust, Bristol, UK.
| | | | - Ramsey I Cutress
- Faculty of Medicine, Cancer Sciences Unit, University of Southampton, Somers Cancer Research Building, University Hospital Southampton, Southampton, UK
| | - Paula R Williamson
- North West Hub for Trials Methodology, University of Liverpool, Liverpool, UK
| | - Lisa Whisker
- Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Steven Thrush
- Breast Unit, Worcester Royal Hospital, Worcester, UK
| | - Joanna Skillman
- Department of Plastic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Nicola L P Barnes
- Nightingale Breast Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | | | | | - Abhilash Jain
- Department of Plastic Surgery, Imperial College London NHS Trust, London, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | - Matthew D Gardiner
- Department of Plastic Surgery, Imperial College London NHS Trust, London, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | - Jane M Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Chris Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Liverpool, UK
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19
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Rocco N, Catanuto G. More evidence for implant-based breast reconstruction. Lancet Oncol 2019; 20:174-175. [PMID: 30639094 DOI: 10.1016/s1470-2045(18)30831-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 10/31/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Nicola Rocco
- GRETA Group for Reconstructive and Therapeutic Advancements, Milan, Naples, Catania 30010, Italy.
| | - Giuseppe Catanuto
- GRETA Group for Reconstructive and Therapeutic Advancements, Milan, Naples, Catania 30010, Italy
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Byrne BE, Rooshenas L, Lambert H, Blazeby JM. Evidence into practice: protocol for a new mixed-methods approach to explore the relationship between trials evidence and clinical practice through systematic identification and analysis of articles citing randomised controlled trials. BMJ Open 2018; 8:e023215. [PMID: 30413510 PMCID: PMC6231588 DOI: 10.1136/bmjopen-2018-023215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Randomised controlled trials (RCTs) provide high-quality evidence to inform practice. However, much routine care is not based on available RCT evidence. Understanding this disconnect may improve trial design, reporting and implementation. Published literature commenting on RCTs may yield relevant insights. This protocol presents a new approach examining how researchers understand, contextualise and use evidence from RCTs, through analysis of letters, editorials and discussion pieces citing individual RCTs. Surgical case studies will illustrate its ability to identify wide-ranging factors influencing application of trials evidence. METHODS AND ANALYSIS In-depth study of published literature will explore written responses to RCTs. After purposefully selecting individual RCTs, we will systematically identify all citing articles covered in Web of Science and Scopus. Editorials, discussions and letters will be included. These are considered most likely to provide critiques and opinions about index RCTs. Original articles and reviews will be excluded. Clinical specialty, RCT design, outcomes and bibliographical data will be collected for RCTs and citing articles. Citing articles will be thematically analysed using the constant comparison technique to explore author understanding, contextualisation and relationship to clinical practice for the index trial. Coding will include generic issues relevant to all RCTs, such as sample size or blinding, and features specific to surgery, such as learning curve. Index trial quality will be examined using validated tools. Results will be combined to create a broad overview of the understanding and use of RCT evidence. ETHICS AND DISSEMINATION This study involves secondary use of existing articles and does not require ethical approval. Pilot work will establish its feasibility and inform progression to larger scale utilisation across a broad range of RCTs. Findings will be published in a peer-reviewed journal and presented at surgical and methodological conferences. Results will guide future work on trial design to optimise implementation of results.
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Affiliation(s)
- Benjamin E Byrne
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Helen Lambert
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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21
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Clement C, Edwards SL, Rapport F, Russell IT, Hutchings HA. Exploring qualitative methods reported in registered trials and their yields (EQUITY): systematic review. Trials 2018; 19:589. [PMID: 30373646 PMCID: PMC6206926 DOI: 10.1186/s13063-018-2983-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 10/13/2018] [Indexed: 12/19/2022] Open
Abstract
Background The value of qualitative methods within trials is widely recognised, but their full potential is not being realised. There are also issues with the visibility, recognition and reporting of qualitative methods in trials. To identify potential improvements in qualitative research within trials, we need to study trials that have included qualitative methods. We aimed to explore the frequency of reporting qualitative methods in registered trials, the types of trials using qualitative methods and where in the world these trials were conducted. Methods We included registries if they were searchable using keywords and held summaries of trials rather than listing reports or publications. We searched the included registries from the first available record in 1999 to the end of 2016 for the term ‘qualitative’. We included trials only if we could confirm that they used qualitative methods through documented use of qualitative data collection and analysis in the registry summary. We analysed registered trials reporting the use of qualitative methods by: year registered, the country responsible for overseeing governance of the trial and the type of trial intervention (categorised as surgical, medical device, behavioural, drug or other). Results We included three registries: ClinicalTrials.gov, the International Standard Randomised Controlled Trial Number Registry (ISRCTN) and the World Health Organisation International Clinical Trials Registry Platform (WHO ICTRP). A total of 615,311 trials appear in these three registries from 1999 until the end of 2016. Numbers differed across registries with the WHO ICTRP the largest (366,753 trials), ClinicalTrials.gov the second largest (233,277) and ISRCTN the smallest (15,301). Of these registered trials, we confirmed that 1492 (0.24%) reported using qualitative methods. The ISRCTN contributed the highest percentage of trials reported as using qualitative methods (3.4%); in contrast, ClinicalTrials.gov reported 0.3% and WHO ICTRP reported 0.03%. The number and percentage of trials reported to use qualitative methods increased over time from 0 (0.0%) in 1999 to 285 (0.38%) in 2016. Trials reported as using qualitative methods originated from 52 countries across the world. Most were in Western higher-income countries: 38% in the United Kingdom and 28% in the United States. Most registered trials reported as using qualitative methods evaluated behavioural (39%) or other interventions with many fewer trials evaluating drugs (5%), medical devices (5%) or surgical interventions (4%). Conclusion The reported use of qualitative methods in registered trials has increased over time and worldwide. They are reportedly more frequent in high-income countries and in trials of behavioural and other interventions. Trialists and other stakeholders need to recognise the benefits of using qualitative methods in surgical, device and drug trials, and trials conducted in poorer countries. Moreover, they should seriously consider using qualitative methods in these trials.
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Affiliation(s)
- Clare Clement
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, UK. .,Swansea University Medical School, Swansea University, Swansea, UK.
| | | | - Frances Rapport
- Australian Institute of Health Innovation, Centre for Healthcare Resilience and Implementation Science, Macquarie University, Sydney, Australia
| | - Ian T Russell
- Swansea University Medical School, Swansea University, Swansea, UK
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22
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Filleron T, Lusque A, Dalenc F, Ferron G, Roche H, Martinez A, Jouve E. Alternative methodological approach to randomized trial for surgical procedures routinely used. Contemp Clin Trials 2018; 68:109-115. [PMID: 29608972 DOI: 10.1016/j.cct.2018.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND In medical oncology, changes in practices are almost always based on randomized trials but medical history shows that it is different in surgical oncology. In the past, many surgical procedures were routinely performed without a rigorous evaluation of the risk-benefit. To highlight the complexity of developing randomized surgical trials, disquisitions on methodology presented in the medical literature. This is particularly true when we consider breast reconstruction after surgical treatment for breast cancer. It is illusory to perform and conduct a randomized clinical trial (RCT) when a surgical procedure is routinely used by most surgeons. METHODS As a case study, we present the scientific rationale and the design of the MAPAM01 trial which evaluates the security of the nipple sparing mastectomy. Other alternative approaches, such as propensity score and CUSUM, are presented. RESULTS In this situation, to design surgical trials using alternative methodological approaches present a particularly important challenge both for surgeons and methodologists. Alternative approach to randomized trials can be useful to evaluate surgical procedures routinely used. CONCLUSION Close collaboration between surgeons and methodologists is needed to propose appropriate and well-designed surgical trials.
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Affiliation(s)
- T Filleron
- Biostatistics Unit, Institut Claudius Regaud, IUCT-O, Toulouse, France.
| | - A Lusque
- Biostatistics Unit, Institut Claudius Regaud, IUCT-O, Toulouse, France
| | - F Dalenc
- Oncology Department, Institut Claudius Regaud-IUCT-O, Toulouse, France
| | - G Ferron
- Surgical Department, Institut Claudius Regaud-IUCT-O, Toulouse, France
| | - H Roche
- Oncology Department, Institut Claudius Regaud-IUCT-O, Toulouse, France
| | - A Martinez
- Surgical Department, Institut Claudius Regaud-IUCT-O, Toulouse, France
| | - E Jouve
- Surgical Department, Institut Claudius Regaud-IUCT-O, Toulouse, France
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23
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Mills N, Gaunt D, Blazeby JM, Elliott D, Husbands S, Holding P, Rooshenas L, Jepson M, Young B, Bower P, Tudur Smith C, Gamble C, Donovan JL. Training health professionals to recruit into challenging randomized controlled trials improved confidence: the development of the QuinteT randomized controlled trial recruitment training intervention. J Clin Epidemiol 2018; 95:34-44. [PMID: 29191445 PMCID: PMC5844671 DOI: 10.1016/j.jclinepi.2017.11.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 10/31/2017] [Accepted: 11/21/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The objective of this study was to describe and evaluate a training intervention for recruiting patients to randomized controlled trials (RCTs), particularly for those anticipated to be difficult for recruitment. STUDY DESIGN AND SETTING One of three training workshops was offered to surgeons and one to research nurses. Self-confidence in recruitment was measured through questionnaires before and up to 3 months after training; perceived impact of training on practice was assessed after. Data were analyzed using two-sample t-tests and supplemented with findings from the content analysis of free-text comments. RESULTS Sixty-seven surgeons and 32 nurses attended. Self-confidence scores for all 10 questions increased after training [range of mean scores before 5.1-6.9 and after 6.9-8.2 (scale 0-10, all 95% confidence intervals are above 0 and all P-values <0.05)]. Awareness of hidden challenges of recruitment following training was high-surgeons' mean score 8.8 [standard deviation (SD), 1.2] and nurses' 8.4 (SD, 1.3) (scale 0-10); 50% (19/38) of surgeons and 40% (10/25) of nurses reported on a 4-point Likert scale that training had made "a lot" of difference to their RCT discussions. Analysis of free text revealed this was mostly in relation to how to convey equipoise, explain randomization, and manage treatment preferences. CONCLUSION Surgeons and research nurses reported increased self-confidence in discussing RCTs with patients, a raised awareness of hidden challenges and a positive impact on recruitment practice following QuinteT RCT Recruitment Training. Training will be made more available and evaluated in relation to recruitment rates and informed consent.
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Affiliation(s)
- Nicola Mills
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK.
| | - Daisy Gaunt
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Jane M Blazeby
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Daisy Elliott
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Samantha Husbands
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Peter Holding
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - Leila Rooshenas
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Marcus Jepson
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Bridget Young
- MRC North West Hub for Trials Methodology Research, Institute of Psychology Health and Society, University of Liverpool, Block B, Waterhouse Building, Brownlow Street, Liverpool L69 3GL, UK
| | - Peter Bower
- MRC North West Hub for Trials Methodology Research, Centre for Primary Care, University of Manchester, Williamson Building, Manchester M13 9PL, UK
| | - Catrin Tudur Smith
- MRC North West Hub for Trials Methodology Research, Institute of Translational Medicine, University of Liverpool, Block F Waterhouse Building, 1-5 Brownlow Street, Liverpool L69 3GL, UK
| | - Carrol Gamble
- MRC North West Hub for Trials Methodology Research, Institute of Translational Medicine, University of Liverpool, Block F Waterhouse Building, 1-5 Brownlow Street, Liverpool L69 3GL, UK
| | - Jenny L Donovan
- MRC ConDuCT-II Hub for Trials Methodology Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK; NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC), University Hospitals Bristol NHS Foundation Trust, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK
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24
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Laba JM, Senan S, Schellenberg D, Harrow S, Mulroy L, Senthi S, Swaminath A, Kopek N, Pantarotto JR, Pan L, Pearce A, Warner A, Louie AV, Palma DA. Identifying barriers to accrual in radiation oncology randomized trials. ACTA ACUST UNITED AC 2017; 24:e524-e530. [PMID: 29270062 DOI: 10.3747/co.24.3662] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Data about factors driving accrual to radiation oncology trials are limited. In oncology, 30%-40% of trials are considered unsuccessful, many because of poor accrual. The goal of the present study was to inform the design of future trials by evaluating the effects of institutional, clinician, and patient factors on accrual rates to a randomized radiation oncology trial. Methods Investigators participating in sabr-comet (NCT01446744), a randomized phase ii trial open in Canada, Europe, and Australia that is evaluating the role of stereotactic ablative radiotherapy (sabr) in oligometastatic disease, were invited to complete a survey about factors affecting accrual. Institutional ethics approval was obtained. The primary endpoint was the annual accrual rate per institution. Univariable and multivariable linear regression analyses were used to identify factors predictive of annual accrual rates. Results On univariable linear regression analysis, off-trial availability of sabr (p = 0.014) and equipoise of the referring physician (p = 0.014) were found to be predictive of annual accrual rates. The annual accrual rates were lower when centres offered sabr for oligometastases off-trial (median: 3.7 patients vs. 8.4 patients enrolled) and when referring physicians felt that, compared with having equipoise, sabr was beneficial (median: 4.8 patients vs. 8.4 patients enrolled). Multivariable analysis identified perceived level of equipoise of the referring physician to be predictive of the annual accrual rate (p = 0.023). Conclusions The level of equipoise of referring physicians might play a key role in accrual to radiation oncology randomized controlled trials. Efforts to communicate with and educate referring physicians might therefore be beneficial for improving trial accrual rates.
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Affiliation(s)
- J M Laba
- Department of Radiation Oncology, London Health Sciences Centre, London, ON
| | - S Senan
- Department of Radiation Oncology, VU University Medical Centre, Amsterdam, Netherlands
| | - D Schellenberg
- Department of Radiation Oncology, BC Cancer Agency, Surrey, BC
| | - S Harrow
- Department of Clinical Oncology, Beatson West of Scotland Cancer Centre, Glasgow, Scotland
| | - L Mulroy
- Department of Radiation Oncology, Dalhousie University, Halifax, NS
| | - S Senthi
- Alfred Health Radiation Oncology, The Alfred Hospital, Melbourne, Australia
| | - A Swaminath
- Department of Radiation Oncology, Juravinski Cancer Center, Hamilton, ON
| | - N Kopek
- Department of Oncology, McGill University, Montreal, QC
| | - J R Pantarotto
- Division of Radiation Oncology, University of Ottawa, Ottawa, ON
| | - L Pan
- Department of Radiation Oncology, Prince Edward Island Cancer Treatment Centre, Charlottetown, PE
| | - A Pearce
- Department of Radiation Oncology, Northeast Cancer Centre, Sudbury, ON
| | - A Warner
- Department of Radiation Oncology, London Health Sciences Centre, London, ON
| | - A V Louie
- Department of Radiation Oncology, London Health Sciences Centre, London, ON.,Department of Oncology, Western University, London, ON
| | - D A Palma
- Department of Radiation Oncology, London Health Sciences Centre, London, ON.,Department of Oncology, Western University, London, ON
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Tallouzi MO, Mathers JM, Moore DJ, Murray PI, Bucknall N, Blazeby JM, Calvert M, Denniston AK. COSUMO: study protocol for the development of a core outcome set for efficacy and effectiveness trials in posterior segment-involving uveitis. Trials 2017; 18:576. [PMID: 29191216 PMCID: PMC5709828 DOI: 10.1186/s13063-017-2294-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 10/27/2017] [Indexed: 12/17/2022] Open
Abstract
Background Uveitis, a group of disorders characterised by intraocular inflammation, causes 10–15% of total blindness in the developed world. The most sight-threatening uveitis affects the posterior segment of the eye (posterior-segment involving uveitis (PSIU)). Numerous different outcomes have been used in clinical trials evaluating alternative treatments for uveitis, limiting inter-trial comparison and aggregation of data. We aim to develop a core outcome set (COS) that would provide a standardised set of outcomes to be measured and reported in all effectiveness trials for PSIU. Methods A three-phase design will be used informed by recommendations from the Core Outcome Measures in Effectiveness Trials (COMET) initiative. Phase 1: a comprehensive list of outcomes will be identified through both a systematic review of effectiveness trials of PSIU and qualitative research with stakeholders. The qualitative study will comprise focus groups with patients and their carers in parallel with one-to-one telephone interviews with health professionals and policy-makers. In the focus groups, patients will be grouped according to whether or not their uveitis is complicated by the sight-threatening condition uveitic macular oedema (UMO) since it is hypothesised that the presence of UMO may significantly impact on patient experience of PSIU. Phase 2: Delphi methodology will be used to reduce the range of potential outcomes for the core set. Up to three Delphi rounds will be used through an online survey. Participants will be asked to rate the importance of each outcome on a 9-point Likert scale where 9 is most important. Phase 3: a consensus meeting will be held with key stakeholders to discuss the Delphi results and ratify the final outcomes to be included in the COS. Discussion The development of an agreed COS for PSIU would help ensure that outcomes which matter to key stakeholders are captured and reported in a consistent way. A COS for PSIU would allow greater comparison and aggregation of data across trials for the better evaluation of established and emerging therapies through evidence synthesis and meta-analysis to inform clinical guidelines and health policy. Trial registration COMET. http://comet-initiative.org/studies/details/640. August 2015.
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Affiliation(s)
- Mohammad O Tallouzi
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. .,Centre for Patient Reported Outcome Research, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Jonathan M Mathers
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - David J Moore
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Philip I Murray
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Nicholas Bucknall
- Patient Involvement Group in Uveitis (PInGU), Birmingham, B15 2TT, UK
| | - Jane M Blazeby
- Centre for Surgical Research, School of Social & Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK
| | - Melanie Calvert
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.,Centre for Patient Reported Outcome Research, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Alastair K Denniston
- Academic Unit of Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.,Centre for Patient Reported Outcome Research, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.,Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2WB, UK.,NIHR Biomedical Research Centre at Moorefield's Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, EC1V 2PD, UK
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Glasbey JC, Magill EL, Brock K, Bach SP. Recommendations for Randomised Trials in Surgical Oncology. Clin Oncol (R Coll Radiol) 2017; 29:799-810. [PMID: 29097072 DOI: 10.1016/j.clon.2017.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 09/20/2017] [Indexed: 01/06/2023]
Abstract
Trials of surgical procedures in the treatment of malignant disease face a unique set of challenges. This review aimed to describe recommendations for the design, delivery and reporting of randomised trials in surgical oncology. A literature search was carried out without date limits to identify articles related to trial methodology research in surgery and surgical oncology. A narrative review was framed around two open National Institute of Health Research portfolio trials in colon and rectal cancer: the STAR-TREC trial (ISRCTN14240288) and the ROCCS trial (ISRCTN46330337). Twelve specific challenges were highlighted: standardisation of technique; pilot and feasibility studies; balancing treatments; the recruitment pathway; outcome measures; patient and public representation; trainee-led networks; randomisation; novel techniques and training; learning curves; blinding; follow-up. Evidence-based recommendations were made for the future design and conduct of surgical oncology trials. Better understanding of the challenges facing trials in the surgical treatment of cancer will accelerate high-quality evaluation and rapid adoption of innovation for the benefit of patient care.
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Affiliation(s)
- J C Glasbey
- Academic Department of Surgery, University of Birmingham, Birmingham, UK; Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - E L Magill
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - K Brock
- Devices, Drugs, Diagnostics and Biomarkers (D3B), Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - S P Bach
- Academic Department of Surgery, University of Birmingham, Birmingham, UK; Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK; Devices, Drugs, Diagnostics and Biomarkers (D3B), Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK.
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27
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Understanding and Improving Recruitment to Randomised Controlled Trials: Qualitative Research Approaches. Eur Urol 2017; 72:789-798. [DOI: 10.1016/j.eururo.2017.04.036] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 04/28/2017] [Indexed: 11/22/2022]
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28
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Kolias AG, Hutchinson PJ, Santarius T. Chronic subdural haematoma: disseminating and implementing best practice. Acta Neurochir (Wien) 2017; 159:625-626. [PMID: 28127656 DOI: 10.1007/s00701-017-3094-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 01/19/2017] [Indexed: 10/20/2022]
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29
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Jones JE, Jones LL, Keeley TJH, Calvert MJ, Mathers J. A review of patient and carer participation and the use of qualitative research in the development of core outcome sets. PLoS One 2017; 12:e0172937. [PMID: 28301485 PMCID: PMC5354261 DOI: 10.1371/journal.pone.0172937] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 02/13/2017] [Indexed: 11/18/2022] Open
Abstract
Background To be meaningful, a core outcome set (COS) should be relevant to all stakeholders including patients and carers. This review aimed to explore the methods by which patients and carers have been included as participants in COS development exercises and, in particular, the use and reporting of qualitative methods. Methods In August 2015, a search of the Core Outcomes Measures in Effectiveness Trials (COMET) database was undertaken to identify papers involving patients and carers in COS development. Data were extracted to identify the data collection methods used in COS development, the number of health professionals, patients and carers participating in these, and the reported details of qualitative research undertaken. Results Fifty-nine papers reporting patient and carer participation were included in the review, ten of which reported using qualitative methods. Although patients and carers participated in outcome elicitation for inclusion in COS processes, health professionals tended to dominate the prioritisation exercises. Of the ten qualitative papers, only three were reported as a clear pre-designed part of a COS process. Qualitative data were collected using interviews, focus groups or a combination of these. None of the qualitative papers reported an underpinning methodological framework and details regarding data saturation, reflexivity and resource use associated with data collection were often poorly reported. Five papers reported difficulty in achieving a diverse sample of participants and two reported that a large and varied range of outcomes were often identified by participants making subsequent rating and ranking difficult. Conclusions Consideration of the best way to include patients and carers throughout the COS development process is needed. Additionally, further work is required to assess the potential role of qualitative methods in COS, to explore the knowledge produced by different qualitative data collection methods, and to evaluate the time and resources required to incorporate qualitative methods into COS development.
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Affiliation(s)
- Janet E. Jones
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Laura L. Jones
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | | | - Melanie J. Calvert
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Jonathan Mathers
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
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30
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Masters JPM, Nanchahal J, Costa ML. Negative pressure wound therapy and orthopaedic trauma: where are we now? Bone Joint J 2017; 98-B:1011-3. [PMID: 27482010 DOI: 10.1302/0301-620x.98b8.bjj-2016-0373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 05/10/2016] [Indexed: 11/05/2022]
Affiliation(s)
- J P M Masters
- The Kadoorie Centre, Orthopaedic Trauma, John Radcliffe Hospital Oxford OX3 9DU, UK
| | - J Nanchahal
- University of Oxford, Kennedy Institute of Rheumatology, Roosevelt Drive, Headington, Oxford, UK
| | - M L Costa
- The Kadoorie Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
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31
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Rooshenas L, Elliott D, Wade J, Jepson M, Paramasivan S, Strong S, Wilson C, Beard D, Blazeby JM, Birtle A, Halliday A, Rogers CA, Stein R, Donovan JL. Conveying Equipoise during Recruitment for Clinical Trials: Qualitative Synthesis of Clinicians' Practices across Six Randomised Controlled Trials. PLoS Med 2016; 13:e1002147. [PMID: 27755555 PMCID: PMC5068710 DOI: 10.1371/journal.pmed.1002147] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/07/2016] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) are essential for evidence-based medicine and increasingly rely on front-line clinicians to recruit eligible patients. Clinicians' difficulties with negotiating equipoise is assumed to undermine recruitment, although these issues have not yet been empirically investigated in the context of observable events. We aimed to investigate how clinicians conveyed equipoise during RCT recruitment appointments across six RCTs, with a view to (i) identifying practices that supported or hindered equipoise communication and (ii) exploring how clinicians' reported intentions compared with their actual practices. METHODS AND FINDINGS Six pragmatic UK-based RCTs were purposefully selected to include several clinical specialties (e.g., oncology, surgery) and types of treatment comparison. The RCTs were all based in secondary-care hospitals (n = 16) around the UK. Clinicians recruiting to the RCTs were interviewed (n = 23) to understand their individual sense of equipoise about the RCT treatments and their intentions for communicating equipoise to patients. Appointments in which these clinicians presented the RCT to trial-eligible patients were audio-recorded (n = 105). The appointments were analysed using thematic and content analysis approaches to identify practices that supported or challenged equipoise communication. A sample of appointments was independently coded by three researchers to optimise reliability in reported findings. Clinicians and patients provided full written consent to be interviewed and have appointments audio-recorded. Interviews revealed that clinicians' sense of equipoise varied: although all were uncertain about which trial treatment was optimal, they expressed different levels of uncertainty, ranging from complete ambivalence to clear beliefs that one treatment was superior. Irrespective of their personal views, all clinicians intended to set their personal biases aside to convey trial treatments neutrally to patients (in accordance with existing evidence). However, equipoise was omitted or compromised in 48/105 (46%) of the recorded appointments. Three commonly recurring practices compromised equipoise communication across the RCTs, irrespective of clinical context. First, equipoise was overridden by clinicians offering treatment recommendations when patients appeared unsure how to proceed or when they asked for the clinician's expert advice. Second, clinicians contradicted equipoise by presenting imbalanced descriptions of trial treatments that conflicted with scientific information stated in the RCT protocols. Third, equipoise was undermined by clinicians disclosing their personal opinions or predictions about trial outcomes, based on their intuition and experience. These broad practices were particularly demonstrated by clinicians who had indicated in interviews that they held less balanced views about trial treatments. A limitation of the study was that clinicians volunteering to take part in the research might have had a particular interest in improving their communication skills. However, the frequency of occurrence of equipoise issues across the RCTs suggests that the findings are likely to be reflective of clinical recruiters' practices more widely. CONCLUSIONS Communicating equipoise is a challenging process that is easily disrupted. Clinicians' personal views about trial treatments encroached on their ability to convey equipoise to patients. Clinicians should be encouraged to reflect on personal biases and be mindful of the common ways in which these can arise in their discussions with patients. Common pitfalls that recurred irrespective of RCT context indicate opportunities for specific training in communication skills that would be broadly applicable to a wide clinical audience.
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Affiliation(s)
- Leila Rooshenas
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Daisy Elliott
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Julia Wade
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Marcus Jepson
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Sangeetha Paramasivan
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Sean Strong
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Caroline Wilson
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jane M. Blazeby
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Alison Birtle
- Rosemere Cancer Centre, Royal Preston Hospital, Preston, United Kingdom
| | | | - Chris A. Rogers
- Clinical Trials and Evaluation Unit, Bristol Royal Infirmary, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Rob Stein
- University College London Hospitals, London, United Kingdom
| | - Jenny L. Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Trust, Bristol, United Kingdom
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Potter S, Brookes ST, Holcombe C, Ward JA, Blazeby JM. Exploring methods the for selection and integration of stakeholder views in the development of core outcome sets: a case study in reconstructive breast surgery. Trials 2016; 17:463. [PMID: 27664072 PMCID: PMC5034558 DOI: 10.1186/s13063-016-1591-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/31/2016] [Indexed: 01/13/2023] Open
Abstract
Background The development and use of core outcome sets (COSs) in trials may improve data synthesis and reduce outcome reporting bias. The selection of outcomes in COSs is informed by views of key stakeholders, yet little is known about the role and influence of different stakeholders’ views during COS development. We report an exploratory case study examining how stakeholder selection and incorporation of stakeholders’ views may influence the selection of outcomes for a COS in reconstructive breast surgery (RBS). We also make recommendations for future considerations. Methods Key stakeholder groups and subgroups were identified from the literature and expert opinion by the COS management group. They included health care professionals, subdivided by profession (breast and plastic surgeons, specialist nurses and psychologists) and patients, subdivided according to type of surgery received, timing of reconstruction, time since surgery and patient age. All participated in a survey in which they were asked to prioritise outcomes. Outcomes were prioritised using a 9-point scale from 1 (not important) to 9 (extremely important). The proportion of (1) all participants, ignoring stakeholder group (single heterogeneous panel analysis), (2) ‘professional’ and ‘patient’ groups separately (two heterogeneous panels), ignoring prespecified subgroups and (3) each participant subgroup separately (multiple homogeneous panel analysis) rating each item ‘extremely important’ was summarised and compared to explore how selection and integration of stakeholder views may influence outcome prioritisation. Results There were many overlaps between items rated as most important by all groups. Specific stakeholders, however, prioritised specific concerns and a broader range of outcomes were prioritised when the subgroups were considered separately. For example, two additional outcomes were prioritised when patient and professional groups were considered separately and eight additional outcomes were identified when the views of the individual subgroups were explored. In general, patient subgroups preferentially valued additional clinical outcomes, including unplanned surgery, whereas professional subgroups prioritised additional psychosocial issues including body image. Conclusion Stakeholder groups value different outcomes. Selection of groups, therefore, is important. Our recommendations for robust and transparent stakeholder selection and integration of stakeholder views may aid future COS developers in the design and conduct of their studies and improve the validity and value of future COS.
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Affiliation(s)
- Shelley Potter
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Clifton, Bristol, UK. .,Linda McCartney Breast Care Centre, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK.
| | - Sara T Brookes
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Clifton, Bristol, UK
| | - Christopher Holcombe
- Linda McCartney Breast Care Centre, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Joseph A Ward
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Clifton, Bristol, UK
| | - Jane M Blazeby
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Clifton, Bristol, UK.,Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin Street, Bristol, UK
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Potter S, Conroy EJ, Williamson PR, Thrush S, Whisker LJ, Skillman JM, Barnes NLP, Cutress RI, Teasdale EM, Mills N, Mylvaganam S, Branford OA, McEvoy K, Jain A, Gardiner MD, Blazeby JM, Holcombe C. The iBRA (implant breast reconstruction evaluation) study: protocol for a prospective multi-centre cohort study to inform the feasibility, design and conduct of a pragmatic randomised clinical trial comparing new techniques of implant-based breast reconstruction. Pilot Feasibility Stud 2016; 2:41. [PMID: 27965859 PMCID: PMC5154059 DOI: 10.1186/s40814-016-0085-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 06/10/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure in the UK. The introduction of techniques to augment the subpectoral pocket has revolutionised the procedure, but there is a lack of high-quality outcome data to describe the safety or effectiveness of these techniques. Randomised controlled trials (RCTs) are the best way of comparing treatments, but surgical RCTs are challenging. The iBRA (implant breast reconstruction evaluation) study aims to determine the feasibility, design and conduct of a pragmatic RCT to examine the effectiveness of approaches to IBBR. METHODS/DESIGN The iBRA study is a trainee-led research collaborative project with four phases:Phase 1 - a national practice questionnaire (NPQ) to survey current practicePhase 2 - a multi-centre prospective cohort study of patients undergoing IBBR to evaluate the clinical and patient-reported outcomesPhase 3- an IBBR-RCT acceptability survey and qualitative work to explore patients' and surgeons' views of proposed trial designs and candidate outcomes.Phase 4 - phases 1 to 3 will inform the design and conduct of the future RCT All centres offering IBBR will be encouraged to participate by the breast and plastic surgical professional associations (Association of Breast Surgery and British Association of Plastic Reconstructive and Aesthetic Surgeons). Data collected will inform the feasibility of undertaking an RCT by defining current practice and exploring issues surrounding recruitment, selection of comparator arms, choice of primary outcome, sample size, selection criteria, trial conduct, methods of data collection and feasibility of using the trainee collaborative model to recruit patients and collect data. DISCUSSION The preliminary work undertaken within the iBRA study will determine the feasibility, design and conduct of a definitive RCT in IBBR. It will work with the trainee collaborative to build capacity by creating an infrastructure of research-active breast and plastic surgeons which will facilitate future high-quality research that will ultimately improve outcomes for all women seeking reconstructive surgery. TRIAL REGISTRATION ISRCTN37664281.
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Affiliation(s)
- Shelley Potter
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Room 3.12 Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Elizabeth J. Conroy
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, L69 3GS UK
| | - Paula R. Williamson
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, L69 3GS UK
| | - Steven Thrush
- Breast Unit, Worcester Royal Hospital. Charles Hastings Way, Worcester, WR5 1DD UK
| | - Lisa J. Whisker
- Breast Institute, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, NG5 1PB UK
| | - Joanna M Skillman
- Department of Plastic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Nicola L. P. Barnes
- The Nightingale Centre Breast Unit, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT UK
| | - Ramsey I. Cutress
- Breast Unit, University Hospital Southampton, Tremona Road, Southampton, Hampshire SO16 6YD UK
- Faculty of Medicine, University of Southampton, University Road, Southampton, SO17 1BJ UK
| | - Elizabeth M. Teasdale
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Prescot Street, Liverpool, L7 8XP UK
| | - Nicola Mills
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Room 3.12 Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Senthurun Mylvaganam
- New Cross Hospital, Royal Wolverhampton Hospitals NHS Trust, Wednesfield Way, Wolverhampton, WV10 0QP UK
| | - Olivier A. Branford
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
| | | | - Abhilash Jain
- Imperial College London NHS Trust, London, SW7 2AZ UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7HE UK
| | - Matthew D. Gardiner
- Imperial College London NHS Trust, London, SW7 2AZ UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7HE UK
| | - Jane M. Blazeby
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Room 3.12 Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Christopher Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Prescot Street, Liverpool, L7 8XP UK
| | - on behalf of the Breast Reconstruction Research Collaborative
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Room 3.12 Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, Clinical Trials Research Centre, University of Liverpool, Liverpool, L69 3GS UK
- Breast Unit, Worcester Royal Hospital. Charles Hastings Way, Worcester, WR5 1DD UK
- Breast Institute, Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, NG5 1PB UK
- Department of Plastic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX UK
- The Nightingale Centre Breast Unit, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT UK
- Breast Unit, University Hospital Southampton, Tremona Road, Southampton, Hampshire SO16 6YD UK
- Faculty of Medicine, University of Southampton, University Road, Southampton, SO17 1BJ UK
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospital, Prescot Street, Liverpool, L7 8XP UK
- New Cross Hospital, Royal Wolverhampton Hospitals NHS Trust, Wednesfield Way, Wolverhampton, WV10 0QP UK
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, Fulham Road, London, SW3 6JJ UK
- City Hospital, Dudley Road, West Midlands, B18 7QH UK
- Imperial College London NHS Trust, London, SW7 2AZ UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7HE UK
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Rocco N, Rispoli C, Moja L, Amato B, Iannone L, Testa S, Spano A, Catanuto G, Accurso A, Nava MB. Different types of implants for reconstructive breast surgery. Cochrane Database Syst Rev 2016; 2016:CD010895. [PMID: 27182693 PMCID: PMC7433293 DOI: 10.1002/14651858.cd010895.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Breast cancer is the most common cancer in women worldwide, and is a leading cause of cancer death among women. Prophylactic or curative mastectomy is often followed by breast reconstruction for which there are several surgical approaches that use breast implants with which surgeons can restore the natural feel, size and shape of the breast. OBJECTIVES To assess the effects of different types of breast implants on capsular contracture, surgical short- and long-term complications, postoperative satisfaction level and quality of life in women who have undergone reconstructive breast surgery after mastectomy. SEARCH METHODS We searched the Cochrane Breast Cancer Group's Specialised Register on 20 July 2015, MEDLINE (1985 to 20 July 2015), EMBASE (1985 to 20 July 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 8, 2015). We also searched the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 16 July 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs that compared different types of breast implants for reconstructive surgery. We considered the following types of intervention: implant envelope surfaces - texturised versus smooth; implant filler material - silicone versus saline, PVP-Hydrogel versus saline; implant shape - anatomical versus round; implant volume - variable versus fixed; brands - different implant manufacturing companies and implant generation (fifth versus previous generations). DATA COLLECTION AND ANALYSIS Two review authors independently assessed methodological quality and extracted data. We used standard Cochrane methodological procedures. The quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. MAIN RESULTS Five RCTs with 202 participants met the inclusion criteria. The women participants were typically in their 50s, and the majority of them (about 82%) received reconstructive surgery following breast cancer, while the others had reconstructive surgery after prophylactic mastectomy. The studies were heterogenous in terms of implant comparisons, which prevented us from pooling the data.The studies were judged as being at an unclear risk of bias for most risk of bias items owing to poor quality of reporting in the trial publications. Three of the five RCTs were judged to be at high risk of attrition bias, and one at high risk of detection bias.Textured silicone versus smooth silicone implants: textured implants were associated with worse outcomes when compared to smooth implants (capsular contracture: risk ratio (RR) 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence; reintervention: RR 0.82, 95% CI 0.14 to 4.71; 1 study, 20 participants; very low quality evidence). No results in this comparison were statistically significant.Silicone versus saline implants: saline-filled implants performed better than silicone-filled implants for some outcomes; specifically, they produced less severe capsular contracture (RR 3.25, 95% CI 1.24 to 8.51; 1 study, 60 participants; very low quality evidence) and increased patient satisfaction (RR 0.60, 95% CI 0.41 to 0.88; 1 study, 58 participants; very low quality evidence). However reintervention was significantly more frequent in the saline-filled implant group than in the silicone-filled group (OR 0.08, 95% CI 0.01 to 0.43; 1 study, 60 participants; very low quality evidence).Poly(N-vinyl-2-pyrrolidone) hydrogel-filled (PVP-hydrogel) versus saline-filled implants: PVP-hydrogel-filled implants were associated with worse outcomes when compared to saline-filled implants (capsular contracture: RR 3.50, 95% CI 0.83 to 14.83; 1 study, 40 participants; very low quality evidence; short-term complications: RR 2.10, 95% CI 0.21 to 21.39; 1 study, 41 participants; very low quality evidence).Anatomical versus round implants: anatomical implants were associated with worse outcomes than round implants (capsular contracture: RR 2.00, 95% CI 0.20 to 20.15; 1 study, 36 participants; very low quality evidence; short-term complications: RR 2.00, 95% CI 0.42 to 9.58; 1 study, 36 participants; very low quality evidence; reintervention: RR 1.50, 95% CI 0.51 to 4.43; 1 study, 36 participants; very low quality evidence). No results in this comparison were statistically significant.Variable-volume versus fixed-volume implants: data about one-stage reconstruction using variable-volume implants were compared with data about fixed-volume implants positioned during the second surgical procedure of two-stage reconstructions. Fixed-volume implant reconstructions were possibly associated with a greater number of women reporting that their reconstruction corresponded with expected results (RR 0.25, 95% CI 0.10 to 0.62; 1 study, 40 participants; very low quality evidence) and fewer reinterventions (RR 7.00, 95% CI 1.82 to 26.89; 1 study, 40 participants; very low quality evidence) when compared to variable-volume implants. A higher patient satisfaction level (rated from 1 to 6, with 1 being very bad and 6 being very good) was found with the fixed-volume implants for overall aesthetic result (mean difference (MD) -1.10, 95% CI -1.59 to -0.61; 1 study, 40 participants; very low quality evidence).There were no studies that examined the effects of recent (fifth) generation silicone implants versus previous generations or different implant manufacturing companies. AUTHORS' CONCLUSIONS Despite the central role of breast reconstruction in women with breast cancer, the best implants to use in reconstructive surgery have been studied rarely in the context of RCTs. Furthermore the quality of these studies and the overall evidence they provide is largely unsatisfactory. Some of our results can be interpreted as early evidence of potentially large differences between different surgical approaches, which should be confirmed in new high-quality RCTs that include a larger number of women. These days - even after a few million women have had breasts reconstructed - surgeons cannot inform women about the risks and complications of different implant-based breast reconstructive options on the basis of results derived from RCTs.
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Affiliation(s)
- Nicola Rocco
- University of Naples "Federico II"Department of Clinical Medicine and SurgeryVia S. Pansini, 5NaplesItaly
| | | | - Lorenzo Moja
- University of MilanDepartment of Biomedical Sciences for HealthVia Pascal 36MilanItaly20133
- IRCCS Galeazzi Orthopaedic InstituteClinical Epidemiology UnitMilanItaly
| | - Bruno Amato
- University of Naples "Federico II"Department of Clinical Medicine and SurgeryVia S. Pansini, 5NaplesItaly
| | - Loredana Iannone
- Fatebenefratelli HospitalDepartment of General SurgeryVia Gabriele Jannelli 520NaplesItaly80131
| | - Serena Testa
- University of Naples "Federico II"Department of Anaesthesia and Intensive Care MedicineNaplesItaly
| | - Andrea Spano
- Fondazione IRCCS, Istituto Nazionale dei TumoriPlastic and Reconstructive Surgery UnitMilanItaly
| | - Giuseppe Catanuto
- Azienda Ospedaliera CannizzaroMultidisciplinary Breast UnitCataniaItaly
| | - Antonello Accurso
- University of Naples "Federico II"Department of General, Geriatric, Oncologic Surgery and Advanced TechnologiesNaplesItaly
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Thornley P, de Sa D, Evaniew N, Farrokhyar F, Bhandari M, Ghert M. An international survey to identify the intrinsic and extrinsic factors of research studies most likely to change orthopaedic practice. Bone Joint Res 2016; 5:130-6. [PMID: 27105650 PMCID: PMC4921052 DOI: 10.1302/2046-3758.54.2000578] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 03/09/2016] [Indexed: 11/10/2022] Open
Abstract
Objectives Evidence -based medicine (EBM) is designed to inform clinical decision-making within all medical specialties, including orthopaedic surgery. We recently published a pilot survey of the Canadian Orthopaedic Association (COA) membership and demonstrated that the adoption of EBM principles is variable among Canadian orthopaedic surgeons. The objective of this study was to conduct a broader international survey of orthopaedic surgeons to identify characteristics of research studies perceived as being most influential in informing clinical decision-making. Materials and Methods A 29-question electronic survey was distributed to the readership of an established orthopaedic journal with international readership. The survey aimed to analyse the influence of both extrinsic (journal quality, investigator profiles, etc.) and intrinsic characteristics (study design, sample size, etc.) of research studies in relation to their influence on practice patterns. Results A total of 353 surgeons completed the survey. Surgeons achieved consensus on the ‘importance’ of three key designs on their practices: randomised controlled trials (94%), meta-analyses (75%) and systematic reviews (66%). The vast majority of respondents support the use of current evidence over historical clinical training; however subjective factors such as journal reputation (72%) and investigator profile (68%) continue to influence clinical decision-making strongly. Conclusion Although intrinsic factors such as study design and sample size have some influence on clinical decision-making, surgeon respondents are equally influenced by extrinsic factors such as investigator reputation and perceived journal quality. Cite this article: Dr M. Ghert. An international survey to identify the intrinsic and extrinsic factors of research studies most likely to change orthopaedic practice. Bone Joint Res 2016;5:130–136. DOI: 10.1302/2046-3758.54.2000578.
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Affiliation(s)
- P Thornley
- McMaster University, 1280 Main Street West Hamilton, Ontario, L8S 4L8, Canada
| | - D de Sa
- McMaster University, 1280 Main Street West Hamilton, Ontario, L8S 4L8, Canada
| | - N Evaniew
- McMaster University, 1280 Main Street West Hamilton, Ontario, L8S 4L8, Canada
| | - F Farrokhyar
- McMaster University, 39 Charlton Avenue East Hamilton, Ontario, L8N 1Y3, Canada
| | - M Bhandari
- McMaster University, 293 Wellington Street North Hamilton, Ontario, L8L 8E7, Canada
| | - M Ghert
- McMaster University, 711 Concession Street Level B3 Surgical Offices Hamilton, Ontario, L6J 4J9, Canada
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Evrard S. Repenser la recherche clinique en chirurgie oncologique. De l’opéra-comique au contrôle qualité. Bull Cancer 2016; 103:87-95. [DOI: 10.1016/j.bulcan.2015.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 10/12/2015] [Indexed: 12/14/2022]
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Thomson PJ, McCaul JA, Ridout F, Hutchison IL. To treat...or not to treat? Clinicians' views on the management of oral potentially malignant disorders. Br J Oral Maxillofac Surg 2015; 53:1027-31. [PMID: 26471841 DOI: 10.1016/j.bjoms.2015.08.263] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 08/24/2015] [Indexed: 02/04/2023]
Abstract
Oral potentially malignant disorders (PMD) are recognisable mucosal conditions that have a variable and unpredictable risk of transformation to invasive squamous cell carcinoma (SCC). Modern management relies initially on clinical recognition of suspicious lesions and histopathological assessment and grading after incisional biopsy. However, it then varies from wide excision to observation and review, and depends not only on the severity of dysplasia but also on the clinician's preference as there is no high-level evidence to support best practice. We invited clinicians from oral and maxillofacial surgery, oral medicine, ear, nose, and throat (ENT), and plastic surgery, to complete an online questionnaire on current practice, which included 3 fictitious cases, to ascertain their views on the management of PMD and to find out whether they would be interested in becoming involved in a proposed future randomised controlled trial (RCT). Of the 251 who replied, 178 (71%) were oral and maxillofacial surgeons, and 99 (39%) expressed an interest in participating in a future RCT. Most respondents (n=164 or 99%) would always treat severely dysplastic lesions by excision or laser ablation, whereas only 8% (n=13) would always excise mild dysplasia. The greatest equipoise among those interested in taking part in a RCT was found in the case of moderate dysplasia for which 27% (n=27) favoured observation compared with surgical excision or laser ablation. This study shows that there is support for a multicentre, prospective RCT that compares observation with resection and laser ablation in patients with moderate dysplasia.
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Affiliation(s)
- P J Thomson
- Oral and Maxillofacial Surgery, School of Dental Sciences, Framlington Place, Newcastle upon Tyne NE2 4BW, UK.
| | - J A McCaul
- Maxillofacial Surgery, Bradford Teaching Hospitals NHS Foundation Trust
| | - F Ridout
- The Facial Surgery Research Foundation - Saving Faces
| | - I L Hutchison
- The Facial Surgery Research Foundation - Saving Faces
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Apramian T, Watling C, Lingard L, Cristancho S. Adaptation and innovation: a grounded theory study of procedural variation in the academic surgical workplace. J Eval Clin Pract 2015; 21:911-8. [PMID: 26096874 PMCID: PMC5578747 DOI: 10.1111/jep.12398] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2015] [Indexed: 12/27/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Surgical research struggles to describe the relationship between procedural variations in daily practice and traditional conceptualizations of evidence. The problem has resisted simple solutions, in part, because we lack a solid understanding of how surgeons conceptualize and interact around variation, adaptation, innovation, and evidence in daily practice. This grounded theory study aims to describe the social processes that influence how procedural variation is conceptualized in the surgical workplace. METHOD Using the constructivist grounded theory methodology, semi-structured interviews with surgeons (n = 19) from four North American academic centres were collected and analysed. Purposive sampling targeted surgeons with experiential knowledge of the role of variations in the workplace. Theoretical sampling was conducted until a theoretical framework representing key processes was conceptually saturated. RESULTS Surgical procedural variation was influenced by three key processes. Seeking improvement was shaped by having unsolved procedural problems, adapting in the moment, and pursuing personal opportunities. Orienting self and others to variations consisted of sharing stories of variations with others, taking stock of how a variation promoted personal interests, and placing trust in peers. Acting under cultural and material conditions was characterized by being wary, positioning personal image, showing the logic of a variation, and making use of academic resources to do so. Our findings include social processes that influence how adaptations are incubated in surgical practice and mature into innovations. CONCLUSIONS This study offers a language for conceptualizing the sociocultural influences on procedural variations in surgery. Interventions to change how surgeons interact with variations on a day-to-day basis should consider these social processes in their design.
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Affiliation(s)
- Tavis Apramian
- Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, Ontario, Canada
| | - Christopher Watling
- Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, Ontario, Canada
| | - Lorelei Lingard
- Department of Medicine and Director, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, Ontario, Canada
| | - Sayra Cristancho
- Department of Surgery and Scientist, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, Ontario, Canada
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Exploring information provision in reconstructive breast surgery: A qualitative study. Breast 2015; 24:732-8. [PMID: 26422125 DOI: 10.1016/j.breast.2015.09.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 02/12/2015] [Accepted: 09/07/2015] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Women considering reconstructive breast surgery (RBS) require adequate information to make informed treatment decisions. This study explored patients' and health professionals' (HPs) perceptions of the adequacy of information provided for decision-making in RBS. METHODS Semi-structured interviews with a purposive sample of patients who had undergone RBS and HPs providing specialist care explored participants' experiences of information provision prior to RBS. RESULTS Professionals reported providing standardised verbal, written and photographic information about the process and outcomes of surgery. Women, by contrast, reported varying levels of information provision. Some felt fully-informed but others perceived they had received insufficient information about available treatment options or possible outcomes of surgery to make an informed decision. CONCLUSIONS Women need adequate information to make informed decisions about RBS and current practice may not meet women's needs. Minimum agreed standards of information provision, especially about alternative types of reconstruction, are recommended to improve decision-making in RBS.
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Potter S, Holcombe C, Ward JA, Blazeby JM. Development of a core outcome set for research and audit studies in reconstructive breast surgery. Br J Surg 2015; 102:1360-71. [PMID: 26179938 PMCID: PMC5034747 DOI: 10.1002/bjs.9883] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 03/11/2015] [Accepted: 05/26/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Appropriate outcome selection is essential if research is to guide decision-making and inform policy. Systematic reviews of the clinical, cosmetic and patient-reported outcomes of reconstructive breast surgery, however, have demonstrated marked heterogeneity, and results from individual studies cannot be compared or combined. Use of a core outcome set may improve the situation. The BRAVO study developed a core outcome set for reconstructive breast surgery. METHODS A long list of outcomes identified from systematic reviews and stakeholder interviews was used to inform a questionnaire survey. Key stakeholders defined as individuals involved in decision-making for reconstructive breast surgery, including patients, breast and plastic surgeons, specialist nurses and psychologists, were sampled purposively and sent the questionnaire (round 1). This asked them to rate the importance of each outcome on a 9-point Likert scale from 1 (not important) to 9 (extremely important). The proportion of respondents rating each item as very important (score 7-9) was calculated. This was fed back to participants in a second questionnaire (round 2). Respondents were asked to reprioritize outcomes based on the feedback received. Items considered very important after round 2 were discussed at consensus meetings, where the core outcome set was agreed. RESULTS A total of 148 items were combined into 34 domains within six categories. Some 303 participants (51·4 per cent) (215 (49·5 per cent) of 434 patients; 88 (56·4 per cent) of 156 professionals) completed and returned the round 1 questionnaire, and 259 (85·5 per cent) reprioritized outcomes in round 2. Fifteen items were excluded based on questionnaire scores and 19 were carried forward to the consensus meetings, where a core outcome set containing 11 key outcomes was agreed. CONCLUSION The BRAVO study has used robust consensus methodology to develop a core outcome set for reconstructive breast surgery. Widespread adoption by the reconstructive community will improve the quality of outcome assessment in effectiveness studies. Future work will evaluate how these key outcomes should best be measured.
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Affiliation(s)
- S Potter
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - C Holcombe
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - J A Ward
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - J M Blazeby
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK.,University Hospitals Bristol Foundation NHS Trust, Bristol, UK
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Potter S, Browning D, Savović J, Holcombe C, Blazeby JM. Systematic review and critical appraisal of the impact of acellular dermal matrix use on the outcomes of implant-based breast reconstruction. Br J Surg 2015; 102:1010-25. [PMID: 26109277 DOI: 10.1002/bjs.9804] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 11/30/2014] [Accepted: 02/10/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Acellular dermal matrix (ADM) may improve outcomes in implant-based breast reconstruction (IBBR). The aim of this study was critically to appraise and evaluate the current evidence for ADM-assisted IBBR. METHODS Comprehensive electronic searches identified complete papers published in English between January 2000 and August 2013, reporting any outcome of ADM-assisted IBBR. All systematic reviews, randomized clinical trials (RCTs) and non-randomized studies (NRSs) with more than 20 ADM recipients were included. Studies were critically appraised using AMSTAR for systematic reviews, the Cochrane risk-of-bias tool for RCTs and its adaptation for NRSs. Characteristics and results of identified studies were summarized. RESULTS A total of 69 papers (8 systematic reviews, 1 RCT, 40 comparative studies and 20 case series) were identified, all of which were considered at high risk of bias, mostly due to patient selection and selective outcome reporting. The median ADM group sample size was 51.0 (i.q.r. 33.0-127.0). Most studies were single-centre (54), and they were often single-surgeon (16). ADM was most commonly used for immediate (40) two-stage IBBR (36) using human ADM (47), with few studies evaluating ADM-assisted single-stage procedures (10). All reported clinical outcomes (for example implant loss) and more than half of the papers (33) assessed process outcomes, but few evaluated cosmesis (16) or patient-reported outcomes (10). Heterogeneity between study design and, especially, outcome measurement precluded meaningful data synthesis. CONCLUSION Current evidence for the value of ADMs in IBBR is limited. Use in practice should therefore be considered experimental, and evaluation within registries or well designed and conducted studies, ideally RCTs, is recommended to prevent widespread adoption of a potentially inferior intervention.
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Affiliation(s)
- S Potter
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - D Browning
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK.,Department of Surgery, Royal United Hospital, Bath, UK
| | - J Savović
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - C Holcombe
- Breast Unit, Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - J M Blazeby
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK.,Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Winters ZE, Emson M, Griffin C, Mills J, Hopwood P, Bidad N, MacDonald L, Turton EPL, Horne R, Bliss JM. Learning from the QUEST multicentre feasibility randomization trials in breast reconstruction after mastectomy. Br J Surg 2015; 102:45-56. [PMID: 25451179 DOI: 10.1002/bjs.9690] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 05/08/2014] [Accepted: 09/30/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND Breast reconstruction aims to improve health-related quality of life after mastectomy. However, evidence guiding patients and surgeons in shared decision-making concerning the optimal type or timing of surgery is lacking. METHODS QUEST comprised two parallel feasibility phase III randomized multicentre trials to assess the impact of the type and timing of latissimus dorsi breast reconstruction on health-related quality of life when postmastectomy radiotherapy is unlikely (QUEST A) or highly probable (QUEST B). The primary endpoint for the feasibility phase was the proportion of women who accepted randomization, and it would be considered feasible if patient acceptability rates exceeded 25 per cent of women approached. A companion QUEST Perspectives Study (QPS) of patients (both accepting and declining trial participation) and healthcare professionals assessed trial acceptability. RESULTS The QUEST trials opened in 15 UK centres. After 18 months of recruitment, 17 patients were randomized to QUEST A and eight to QUEST B, with overall acceptance rates of 19 per cent (17 of 88) and 22 per cent (8 of 36) respectively. The QPS recruited 56 patients and 51 healthcare professionals. Patient preference was the predominant reason for declining trial entry, given by 47 (53 per cent) of the 88 patients approached for QUEST A and 22 (61 per cent) of the 36 approached for QUEST B. Both trials closed to recruitment in December 2012, acknowledging the challenges of achieving satisfactory patient accrual. CONCLUSION Despite extensive efforts to overcome recruitment barriers, it was not feasible to reach timely recruitment targets within a feasibility study. Patient preferences for breast reconstruction types and timings were common, rendering patients unwilling to enter the trial.
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Affiliation(s)
- Z E Winters
- Breast Reconstruction Patient Reported and Clinical Outcomes Research Group, School of Clinical Sciences, University of Bristol and North Bristol Trust, Bristol, UK
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