1
|
O'Dwyer JL, Bryant LD, Hulme C, Kind P, Meads DM. Adapting the EQ-5D-3L for adults with mild to moderate learning disabilities. Health Qual Life Outcomes 2024; 22:37. [PMID: 38685039 PMCID: PMC11059748 DOI: 10.1186/s12955-024-02254-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 04/22/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Approximately 1.5 million adults in the UK have a learning disability. The difference between age at death for this group and the general population is 26 years for females and 22 years for males. The NHS Long Term Plan (January 2019) recognises learning disabilities as a clinical priority area. People with a learning disability are often excluded from research by design or lack of reasonable adjustments, and self-reported health status/health-related quality of life questionnaires such as the EQ-5D are often not appropriate for this population. Here, we systematically examine the EQ-5D-3L (its wording, content, and format) using qualitative methods to inform the adaption of the measure for use with adults with mild to moderate learning disabilities. METHODS Think-aloud interviews with carers/advocates of learning-disabled adults were undertaken to explore the difficulties with completing the EQ-5D-3L. Alternative wording, language, structure, and images were developed using focus groups, stakeholder reference groups, and an expert panel. Data analysis followed a framework method. RESULTS The dimensions and levels within the EQ-5D-3L were deemed appropriate for adults with mild to moderate learning disabilities. Consensus on wording, structure, and images was reached through an iterative process, and an adapted version of the EQ-5D-3L was finalised. CONCLUSION The EQ-5D-3L adapted for adults with mild to moderate intellectual/learning disabilities can facilitate measurement of self-reported health status. Research is underway to assess the potential use of the adaptation for economic evaluation.
Collapse
Affiliation(s)
- John L O'Dwyer
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL, UK.
| | - Louise D Bryant
- Division of Psychological & Social Medicine, Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Worsley Building, Leeds, LS2 9JT, UK
| | - Claire Hulme
- Department of Health & Community Sciences, University of Exeter Medical School, South Cloisters, St Luke's Campus, Exeter, EX1 2LU, UK
| | - Paul Kind
- Department of Applied Health Research, University College London, Gower Street, London, WC1E 6BT, UK
| | - David M Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL, UK
| |
Collapse
|
2
|
Kaur MN, Skolasky RL, Powell PA, Xie F, Huang IC, Kuspinar A, O'Dwyer JL, Cizik AM, Rowen D. Transforming challenges into opportunities: conducting health preference research during the COVID-19 pandemic and beyond. Qual Life Res 2021; 31:1191-1198. [PMID: 34661806 PMCID: PMC8521079 DOI: 10.1007/s11136-021-03012-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 11/30/2022]
Abstract
The disruptions to health research during the COVID-19 pandemic are being recognized globally, and there is a growing need for understanding the pandemic’s impact on the health and health preferences of patients, caregivers, and the general public. Ongoing and planned health preference research (HPR) has been affected due to problems associated with recruitment, data collection, and data interpretation. While there are no “one size fits all” solutions, this commentary summarizes the key challenges in HPR within the context of the pandemic and offers pragmatic solutions and directions for future research. We recommend recruitment of a diverse, typically under-represented population in HPR using online, quota-based crowdsourcing platforms, and community partnerships. We foresee emerging evidence on remote, and telephone-based HPR modes of administration, with further studies on the shifts in preferences related to health and healthcare services as a result of the pandemic. We believe that the recalibration of HPR, due to what one would hope is an impermanent change, will permanently change how we conduct HPR in the future.
Collapse
Affiliation(s)
- Manraj N Kaur
- Patient-Reported Outcomes, Value and Experience (PROVE) Center, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - Richard L Skolasky
- Departments of Orthopedic Surgery and Physical Medicine & Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Philip A Powell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, and Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - I-Chan Huang
- Department of Epidemiology and Cancer Control, and Comprehensive Cancer Center, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ayse Kuspinar
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - John L O'Dwyer
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Amy M Cizik
- Department of Orthopedics, University of Utah, Salt Lake City, UT, USA
| | - Donna Rowen
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| |
Collapse
|
3
|
House A, Bryant L, Russell AM, Wright-Hughes A, Graham L, Walwyn R, Wright JM, Hulme C, O'Dwyer JL, Latchford G, Meer S, Birtwistle JC, Stansfield A, Ajjan R, Farrin A. Managing with Learning Disability and Diabetes: OK-Diabetes - a case-finding study and feasibility randomised controlled trial. Health Technol Assess 2019; 22:1-328. [PMID: 29845932 DOI: 10.3310/hta22260] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Obesity and type 2 diabetes are common in adults with a learning disability. It is not known if the principles of self-management can be applied in this population. OBJECTIVES To develop and evaluate a case-finding method and undertake an observational study of adults with a learning disability and type 2 diabetes, to develop a standardised supported self-management (SSM) intervention and measure of adherence and to undertake a feasibility randomised controlled trial (RCT) of SSM versus treatment as usual (TAU). DESIGN Observational study and an individually randomised feasibility RCT. SETTING Three cities in West Yorkshire, UK. PARTICIPANTS In the observational study: adults aged > 18 years with a mild or moderate learning disability, who have type 2 diabetes that is not being treated with insulin and who are living in the community. Participants had mental capacity to consent to research and to the intervention. In the RCT participants had glycated haemoglobin (HbA1c) levels of > 6.5% (48 mmol/mol), a body mass index (BMI) of > 25 kg/m2 or self-reported physical activity below national guideline levels. INTERVENTIONS Standardised SSM. TAU supported by an easy-read booklet. MAIN OUTCOME MEASURES (1) The number of eligible participants identified and sources of referral; (2) current living and support arrangements; (3) current health state, including level of HbA1c, BMI and waist circumference, blood pressure and lipids; (4) mood, preferences for change; (5) recruitment and retention in RCT; (6) implementation and adherence to the intervention; (7) completeness of data collection and values for candidate primary outcomes; and (8) qualitative data on participant experience of the research process and intervention. RESULTS In the observational study we identified 147 eligible consenting participants. The mean age was 54.4 years. In total, 130 out of 147 (88%) named a key supporter, with 113 supporters (77%) being involved in diabetes management. The mean HbA1c level was 54.5 mmol/mol [standard deviation (SD) 14.8 mmol/mol; 7.1%, SD 1.4%]. The BMI of 65% of participants was > 30 kg/m2 and of 21% was > 40 kg/m2. Many participants reported low mood, dissatisfaction with lifestyle and diabetes management and an interest in change. Non-response rates were high (45/147, 31%) for medical data requested from the primary care team. In the RCT, 82 participants were randomised. The mean baseline HbA1c level was 56 mmol/mol (SD 16.5 mmol/mol; 7.3%, SD 1.5%) and the mean BMI was 34 kg/m2 (SD 7.6 kg/m2). All SSM sessions were completed by 35 out of 41 participants. The adherence measure was obtained in 37 out of 41 participants. The follow-up HbA1c level and BMI was obtained for 75 out of 82 (91%) and 77 out of 82 (94%) participants, respectively. Most participants reported a positive experience of the intervention. A low response rate and difficulty understanding the EuroQol-5 Dimensions were challenges in obtaining data for an economic analysis. LIMITATIONS We recruited from only 60% of eligible general practices, and 90% of participants were on a general practice learning disability register, which meant that we did not recruit many participants from the wider population with milder learning disability. CONCLUSIONS A definitive RCT is feasible and would need to recruit 194 participants per arm. The main barrier is the resource-intensive nature of recruitment. Future research is needed into the effectiveness of obesity treatments in this population, particularly estimating the longer-term outcomes that are important for health benefit. Research is also needed into improving ways of assessing quality of life in adults with a learning disability. TRIAL REGISTRATION Current Controlled Trials ISRCTN41897033. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 26. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Allan House
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Louise Bryant
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Amy M Russell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Liz Graham
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Rebecca Walwyn
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Judy M Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Claire Hulme
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - John L O'Dwyer
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Gary Latchford
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Shaista Meer
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | | | - Ramzi Ajjan
- Division of Cardiovascular and Diabetes Research, University of Leeds, Leeds, UK
| | - Amanda Farrin
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| |
Collapse
|
4
|
Russell AM, O'Dwyer JL, Bryant LD, House AO, Birtwistle JC, Meer S, Wright-Hughes A, Walwyn REA, Graham E, Farrin AJ, Hulme CT. The feasibility of using the EQ-5D-3L with adults with mild to moderate learning disabilities within a randomized control trial: a qualitative evaluation. Pilot Feasibility Stud 2018; 4:164. [PMID: 30397508 PMCID: PMC6205783 DOI: 10.1186/s40814-018-0357-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/15/2018] [Indexed: 02/06/2023] Open
Abstract
Background In trials incorporating a health economic evaluation component, reliable validated measures for health-related quality of life (HRQOL) are essential. The EQ-5D is the preferred measure for cost-effectiveness analysis in UK trials. This paper presents a qualitative evaluation of the use of the EQ-5D-3L in a feasibility randomised control trial with participants who had a mild- to moderate learning disability and type 2 diabetes. Methods Researchers administered the EQ-5D-3L to 82 participants at baseline and 77 at follow-up. After each interview, researchers rated the ease of administering the EQ-5D-3L and made free-text entries on the administration experience. For a subset of 16 interviews, researchers audio-recorded more detailed journal entries. Ease of administration data were analysed using descriptive statistics. Free-text responses were subject to a basic content analysis. The EQ-5D-3L-related journal entries were transcribed, coded and analysed thematically. Results Over half of participants were perceived to experience difficulty answering some or all of the items in the EQ-5D-3L (60% at baseline; 54% at follow-up). Analysis of the free-text entries and audio journals identified four themes that question the use of the EQ-5D-3L in this population. The first theme is related to observations of participant intellectual ability and difficulties, for example, in understanding the wording of the measure. Theme 2 is related to the normalisation of adjustments for impairments, which rendered the measure less sensitive in this population. Theme 3 is related to researcher adaptation and non-standard administration. An overarching fourth theme was identified in that people with learning disabilities were viewed as ‘unreliable witnesses’ by both researchers and supporters. Conclusions It is recommended that the EQ-5D-3L should not be used in isolation to assess health-related quality of life outcomes in trials research in adults with a learning disability. Further research is required to develop and evaluate a version of the EQ-5D appropriate for this population in trials research. It is unrealistic to expect that adjustments to the wording alone will deliver an appropriate measure: supporter or researcher involvement will almost always be required. This requirement needs to be factored into the development and administration guidelines of any new version of the EQ-5D for adults with a learning disability. Trial registration Current Controlled Trials ISRCTN41897033 [registered 21 January 2013]. Electronic supplementary material The online version of this article (10.1186/s40814-018-0357-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- A M Russell
- 1Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - J L O'Dwyer
- 1Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - L D Bryant
- 1Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - A O House
- 1Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - J C Birtwistle
- 1Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - S Meer
- 1Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - A Wright-Hughes
- 1Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - R E A Walwyn
- 1Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - E Graham
- 1Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - A J Farrin
- 2Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - C T Hulme
- 1Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| |
Collapse
|
5
|
O'Dwyer JL, Russell AM, Bryant LD, Walwyn REA, Wright-Hughes AM, Graham EH, Wright JM, Meer S, Birtwistle J, Farrin AJ, House AO, Hulme CT. Developing and feasibility testing of data collection methods for an economic evaluation of a supported selfmanagement programme for adults with a learning disability and type 2 diabetes. Pilot Feasibility Stud 2018; 4:80. [PMID: 29713494 PMCID: PMC5911950 DOI: 10.1186/s40814-018-0266-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 03/25/2018] [Indexed: 11/10/2022] Open
Abstract
Background The challenges of conducting research with hard to reach vulnerable groups are particularly pertinent for people with learning disabilities. Data collection methods for previous cost and cost-effectiveness analyses of health and social care interventions targeting people with learning disabilities have relied on health care/health insurance records or data collection forms completed by the service provider rather than by people with learning disabilities themselves. This paper reports on the development and testing of data collection methods for an economic evaluation within a randomised controlled trial (RCT) for a supported self-management programme for people with mild/moderate learning disabilities and type 2 diabetes. Methods A case finding study was conducted to identify types of health and social care use and data collection methods employed in previous studies with this population. Based on this evidence, resource use questionnaires for completion by GP staff and interviewer-administered participant questionnaires (covering a wider cost perspective and health-related quality of life) were tested within a feasibility RCT. Interviewer-administered questionnaires included the EQ-5D-3L (the NICE recommended measure for use in economic evaluation). Participants were adults > 18 years with a mild or moderate learning disability and type 2 diabetes, with mental capacity to give consent to research participation. Results Data collection for questionnaires completed by GP staff requesting data for the last 12 months proved time intensive and difficult. Whilst 82.3% (121/147) of questionnaires were returned, up to 17% of service use items were recorded as unknown. Subsequently, a shorter recall period (4 months) led to a higher return rate but with a higher rate of missing data. Missing data for interviewer-administered participant questionnaires was > 8% but the interviewers reported difficulty with participant recall. Almost 60% (48/80) of participants had difficulty completing the EQ-5D-3L. Conclusions Further investigation as to how service use can be recorded is recommended. Concerns about the reliability of identifying service use data directly from participants with a learning disability due to challenges in completion, specifically around recall, remain. The degree of difficulty to complete EQ-5D-3L indicates concerns regarding the appropriateness of using this measure in its current form in research with this population. Trial registration Current Controlled Trials ISRCTN41897033 (registered 21 January 2013).
Collapse
Affiliation(s)
- John L O'Dwyer
- 1Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | - Amy M Russell
- 1Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | - Louise D Bryant
- 1Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | - Rebecca E A Walwyn
- 2Leeds Institute of Clinical Trials Research, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | - Alexandra M Wright-Hughes
- 2Leeds Institute of Clinical Trials Research, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | - Elizabeth H Graham
- 2Leeds Institute of Clinical Trials Research, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | - Judy M Wright
- 1Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | - Shaista Meer
- 1Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | - Jacqueline Birtwistle
- 1Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | - Amanda J Farrin
- 2Leeds Institute of Clinical Trials Research, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | - Allan O House
- 1Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | - Claire T Hulme
- 1Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| |
Collapse
|
6
|
Allsop MJ, Wright-Hughes A, Black K, Hartley S, Fletcher M, Ziegler LE, Bewick BM, Meads D, Hughes ND, Closs SJ, Hulme C, Taylor S, Flemming K, Hackett J, O'Dwyer JL, Brown JM, Bennett MI. Improving the management of pain from advanced cancer in the community: study protocol for a pragmatic multicentre randomised controlled trial. BMJ Open 2018; 8:e021965. [PMID: 29572400 PMCID: PMC5879575 DOI: 10.1136/bmjopen-2018-021965] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION For patients with advanced cancer, research shows that pain is frequent, burdensome and undertreated. Evidence-based approaches to support cancer pain management have been developed but have not been implemented within the context of the UK National Health Service. This protocol is for a pragmatic multicentre randomised controlled trial (RCT) to assess feasibility, acceptability, effectiveness and cost-effectiveness for a multicomponent intervention for pain management in patients with advanced cancer. METHODS AND ANALYSIS This trial will assess the feasibility of implementation and uptake of evidence-based interventions, developed and piloted as part of the Improving the Management of Pain from Advanced Cancer in the Community Programme grant, into routine clinical practice and determine whether there are potential differences with respect to patient-rated pain, patient pain knowledge and experience, healthcare use, quality of life and cost-effectiveness. 160 patients will receive either the intervention (usual care plus supported self-management) delivered within the oncology clinic and palliative care services by locally assigned community palliative care nurses, consisting of a self-management educational intervention and eHealth intervention for routine pain assessment and monitoring; or usual care. The primary outcomes are to assess implementation and uptake of the interventions, and differences in terms of pain severity. Secondary outcomes include pain interference, participant pain knowledge and experience, and cost-effectiveness. Outcome assessment will be blinded and patient-reported outcome measures collected via post at 6 and 12 weeks following randomisation. ETHICS AND DISSEMINATION This RCT has the potential to significantly influence National Health Service delivery to community-based patients with pain from advanced cancer. We aim to provide definitive evidence of whether two simple interventions delivered by community palliative care nurse in palliative care that support-self-management are clinically effective and cost-effective additions to standard community palliative care. TRIAL REGISTRATION NUMBER ISRCTN18281271; Pre-results.
Collapse
Affiliation(s)
- Matthew J Allsop
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Alexandra Wright-Hughes
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Kath Black
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
- Leeds Community Healthcare NHS Trust, Leeds, UK
| | - Suzanne Hartley
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Marie Fletcher
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Lucy E Ziegler
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Bridgette M Bewick
- Division of Psychological and Social Medicine, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - David Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - S José Closs
- School of Healthcare, Baines Wing, University of Leeds, Leeds, UK
| | - Claire Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Sally Taylor
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Kate Flemming
- Department of Health Sciences, University of York, Heslington, UK
| | - Julia Hackett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - John L O'Dwyer
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Julia M Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| |
Collapse
|
7
|
Howard DR, Munir T, McParland L, Rawstron AC, Chalmers A, Gregory WM, O'Dwyer JL, Smith A, Longo R, Varghese A, Smith A, Hillmen P. Clinical effectiveness and cost-effectiveness results from the randomised, Phase IIB trial in previously untreated patients with chronic lymphocytic leukaemia to compare fludarabine, cyclophosphamide and rituximab with fludarabine, cyclophosphamide, mitoxantrone and low-dose rituximab: the Attenuated dose Rituximab with ChemoTherapy In Chronic lymphocytic leukaemia (ARCTIC) trial. Health Technol Assess 2018. [PMID: 28628003 DOI: 10.3310/hta21280] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The conventional frontline therapy for fit patients with chronic lymphocytic leukaemia (CLL) is fludarabine, cyclophosphamide and rituximab (FCR). Rituximab (Mabthera®, Roche Products Ltd) targets the CD20 antigen, which is expressed at low levels in CLL. The standard dose of rituximab in CLL (375 mg/m2 in cycle 1 and 500 mg/m2 in cycles 2-6) was selected based on toxicity data only. Small doses of rituximab (as low as 20 mg) have biological activity in CLL, with an immediate reduction in circulating CLL cells and down-regulation of CD20. Phase II trials had suggested improved efficacy with the addition of mitoxantrone to FCR. The key assumption for the Attenuated dose Rituximab with ChemoTherapy In CLL (ARCTIC) trial was that the addition of mitoxantrone to fludarabine, cyclophosphamide and low-dose rituximab would be more effective than conventional FCR. OBJECTIVES To assess whether fludarabine, cyclophosphamide, mitoxantrone and low-dose rituximab (FCM-miniR) (100 mg of rituximab per cycle) was non-inferior to FCR in frontline CLL. Complete response (CR) rate was the primary end point, with the secondary end points being progression-free survival (PFS), overall survival (OS), overall response rate, eradication of minimal residual disease (MRD), safety and cost-effectiveness. DESIGN ARCTIC was a UK multicentre, randomised, controlled, open, Phase IIB non-inferiority trial in previously untreated CLL. A total of 206 patients with previously untreated CLL who required treatment, according to the International Workshop on Chronic Lymphocytic Leukaemia criteria, were to be randomised to FCR or FCM-miniR. There was an independent Data Monitoring and Ethics Committee (DMEC) with a pre-planned interim efficacy assessment on 103 participants. RESULTS The DMEC's interim analysis led to early trial closure. Although the response rates in both arms were higher than anticipated, FCM-miniR had a lower CR rate than FCR. This was partly attributable to the higher toxicity associated with mitoxantrone. A total of 100 participants completed FCR, 79 completed FCM-miniR and 21 commenced FCM-miniR but switched to FCR following DMEC recommendations. The CR rate for participants receiving FCR was 76%, compared with 55% for FCM-miniR (adjusted odds ratio 0.37; 95% confidence interval 0.19 to 0.73). Key secondary end points also showed that FCR was superior, with more participants achieving MRD negativity (57% for FCR vs. 46% for FCM-miniR). More participants experienced a serious adverse reaction with FCM-miniR compared with FCR (50% vs. 41%). At a median of 37.3 months' follow-up, the PFS and OS rates are good compared with previous studies, with no significant difference between the treatment arms. The economic analysis indicates that because FCM-miniR is less effective than FCR, FCM-miniR is not expected to be cost-effective over a lifetime horizon, producing a mean cost-saving of -£7723, a quality-adjusted life-year loss of -0.73 and a resulting incremental net monetary loss of -£6780. CONCLUSIONS FCM-miniR is less well tolerated, with poorer response rates, than FCR, partly owing to the additional toxicity associated with mitoxantrone. In view of this, FCM-miniR will not be taken forward into a larger definitive Phase III trial. The trial demonstrated that oral FCR yields extremely high response rates compared with historical series with intravenous chemotherapy. FUTURE WORK We shall compare the results of ARCTIC with those of the ADMIRE (Does the ADdition of Mitoxantrone Improve Response to FCR chemotherapy in patients with CLL?) trial, which compared FCR with FCM-R to assess the efficacy of low- versus standard-dose rituximab, allowing for the toxicity associated with mitoxantrone. TRIAL REGISTRATION Current Controlled Trials ISRCTN16544962. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 28. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Dena R Howard
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Talha Munir
- Department of Haematology, St James's University Hospital, Leeds, UK
| | - Lucy McParland
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Andy C Rawstron
- Haematological Malignancy Diagnostic Service, St James's University Hospital, Leeds, UK
| | - Anna Chalmers
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Walter M Gregory
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - John L O'Dwyer
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Alison Smith
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Roberta Longo
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Abraham Varghese
- Department of Haematology, St James's University Hospital, Leeds, UK
| | - Alexandra Smith
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Peter Hillmen
- Section of Experimental Haematology, Leeds Institute of Cancer and Pathology (LICAP), University of Leeds, Leeds, UK
| |
Collapse
|
8
|
Harji D, Marshall H, Gordon K, Crow H, Hiley V, Burke D, Griffiths B, Moriarty C, Twiddy M, O'Dwyer JL, Verjee A, Brown J, Sagar P. Feasibility of a multicentre, randomised controlled trial of laparoscopic versus open colorectal surgery in the acute setting: the LaCeS feasibility trial protocol. BMJ Open 2018; 8:e018618. [PMID: 29472259 PMCID: PMC5879497 DOI: 10.1136/bmjopen-2017-018618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Acute colorectal surgery forms a significant proportion of emergency admissions within the National Health Service. There is limited evidence to suggest minimally invasive surgery may be associated with improved clinical outcomes in this cohort of patients. Consequently, there is a need to assess the clinical effectiveness and cost-effectiveness of laparoscopic surgery in the acute colorectal setting. However,emergency colorectal surgical trials have previously been difficult to conduct due to issues surrounding recruitment and equipoise. The LaCeS (randomised controlled trial of Laparoscopic versus open Colorectal Surgery in the acute setting) feasibility trial will determine the feasibility of conducting a definitive, phase III trial of laparoscopic versus open acute colorectal resection. METHODS AND ANALYSIS The LaCeS feasibility trial is a prospective, multicentre, single-blinded, parallel group, pragmatic randomised controlled feasibility trial. Patients will be randomised on a 1:1 basis to receive eitherlaparoscopic or open surgery. The trial aims to recruit at least 66 patients from five acute general surgical units across the UK. Patients over the age of 18 with a diagnosis of acute colorectal pathology requiring resection on clinical and radiological/endoscopic investigations, with a National Confidential Enquiry into Patient Outcome and Death classification of urgent will be considered eligible for participation. The primary outcome is recruitment. Secondary outcomes include assessing the safety profile of laparoscopic surgery using intraoperative and postoperative complication rates, conversion rates and patient-safety indicators as surrogate markers. Clinical and patient-reported outcomes will also be reported. The trial will contain an embedded qualitative study to assess clinician and patient acceptability of trial processes. ETHICS AND DISSEMINATION The LaCeS feasibility trial is approved by the Yorkshire and The Humber, Bradford Leeds Research Ethics Committee (REC reference: 15/ YH/0542). The results from the trial will be presented at national and international colorectal conferences and will be submitted for publication to peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN15681041; Pre-results.
Collapse
Affiliation(s)
- Deena Harji
- Newcastle Centre for Bowel Disease, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Helen Marshall
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Katie Gordon
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Hannah Crow
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Victoria Hiley
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Dermot Burke
- John Goligher Colorectal Department, St James' University Hospital, Leeds, UK
| | - Ben Griffiths
- Newcastle Centre for Bowel Disease, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Catherine Moriarty
- John Goligher Colorectal Department, St James' University Hospital, Leeds, UK
| | - Maureen Twiddy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - John L O'Dwyer
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Azmina Verjee
- Patient and Public Representative, Association of Coloprocotology of Great Britain and Ireland, London, UK
| | - Julia Brown
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Peter Sagar
- John Goligher Colorectal Department, St James' University Hospital, Leeds, UK
| |
Collapse
|
9
|
O'Dwyer JL, Meads DM, Hulme CT, Mcparland L, Brown S, Coates LC, Moverley AR, Emery P, Conaghan PG, Helliwell PS. Cost-Effectiveness of Tight Control of Inflammation in Early Psoriatic Arthritis: Economic Analysis of a Multicenter Randomized Controlled Trial. Arthritis Care Res (Hoboken) 2018; 70:462-468. [DOI: 10.1002/acr.23293] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 05/16/2017] [Indexed: 11/07/2022]
Affiliation(s)
- John L. O'Dwyer
- Leeds Institute of Health Sciences; University of Leeds; Leeds UK
| | - David M. Meads
- Leeds Institute of Health Sciences; University of Leeds; Leeds UK
| | - Claire T. Hulme
- Leeds Institute of Health Sciences; University of Leeds; Leeds UK
| | - Lucy Mcparland
- Leeds Institute of Clinical Trials Research; University of Leeds; Leeds UK
| | - Sarah Brown
- Leeds Institute of Clinical Trials Research; University of Leeds; Leeds UK
| | - Laura C. Coates
- Leeds Institute of Rheumatic and Musculoskeletal Medicine; Chapel Allerton Hospital; Leeds UK
| | - Anna R. Moverley
- Leeds Institute of Rheumatic and Musculoskeletal Medicine; Chapel Allerton Hospital; Leeds UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine; Chapel Allerton Hospital; Leeds UK
| | - Philip G. Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine; Chapel Allerton Hospital; Leeds UK
| | - Philip S. Helliwell
- Leeds Institute of Rheumatic and Musculoskeletal Medicine; Chapel Allerton Hospital; Leeds UK
| |
Collapse
|
10
|
Fisher BA, Everett CC, Rout J, O'Dwyer JL, Emery P, Pitzalis C, Ng WF, Carr A, Pease CT, Price EJ, Sutcliffe N, Makdissi J, Tappuni AR, Gendi NST, Hall FC, Ruddock SP, Fernandez C, Hulme CT, Davies KA, Edwards CJ, Lanyon PC, Moots RJ, Roussou E, Richards A, Sharples LD, Bombardieri M, Bowman SJ. Effect of rituximab on a salivary gland ultrasound score in primary Sjögren's syndrome: results of the TRACTISS randomised double-blind multicentre substudy. Ann Rheum Dis 2017; 77:412-416. [PMID: 29275334 PMCID: PMC5867400 DOI: 10.1136/annrheumdis-2017-212268] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 12/01/2017] [Accepted: 12/01/2017] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To compare the effects of rituximab versus placebo on salivary gland ultrasound (SGUS) in primary Sjögren's syndrome (PSS) in a multicentre, multiobserver phase III trial substudy. METHODS Subjects consenting to SGUS were randomised to rituximab or placebo given at weeks 0, 2, 24 and 26, and scanned at baseline and weeks 16 and 48. Sonographers completed a 0-11 total ultrasound score (TUS) comprising domains of echogenicity, homogeneity, glandular definition, glands involved and hypoechoic foci size. Baseline-adjusted TUS values were analysed over time, modelling change from baseline at each time point. For each TUS domain, we fitted a repeated-measures logistic regression model to model the odds of a response in the rituximab arm (≥1-point improvement) as a function of the baseline score, age category, disease duration and time point. RESULTS 52 patients (n=26 rituximab and n=26 placebo) from nine centres completed baseline and one or more follow-up visits. Estimated between-group differences (rituximab-placebo) in baseline-adjusted TUS were -1.2 (95% CI -2.1 to -0.3; P=0.0099) and -1.2 (95% CI -2.0 to -0.5; P=0.0023) at weeks 16 and 48. Glandular definition improved in the rituximab arm with an OR of 6.8 (95% CI 1.1 to 43.0; P=0.043) at week 16 and 10.3 (95% CI 1.0 to 105.9; P=0.050) at week 48. CONCLUSIONS We demonstrated statistically significant improvement in TUS after rituximab compared with placebo. This encourages further research into both B cell depletion therapies in PSS and SGUS as an imaging biomarker. TRIAL REGISTRATION NUMBER 65360827, 2010-021430-64; Results.
Collapse
Affiliation(s)
- Benjamin A Fisher
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, Birmingham, UK.,Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Rheumatology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Colin C Everett
- Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - John Rout
- Birmingham Dental Hospital, Birmingham, UK
| | - John L O'Dwyer
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Paul Emery
- Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - Costantino Pitzalis
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Wan-Fai Ng
- Institute of Cellular Medicine, University of Newcastle, Newcastle-upon-Tyne, UK
| | - Andrew Carr
- Newcastle Dental Hospital, Newcastle-upon-Tyne, UK
| | - Colin T Pease
- Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | | | | | - Jimmy Makdissi
- Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Anwar R Tappuni
- Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Frances C Hall
- Department of Clinical Medicine, University of Cambridge, Addenbrookes Hospital, Cambridge, UK
| | - Sharon P Ruddock
- Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Catherine Fernandez
- Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - Claire T Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Kevin A Davies
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Christopher John Edwards
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton, Southampton, UK
| | - Peter C Lanyon
- Nottingham University Hospitals NHS Trust, and Nottingham NHS Treatment Centre, Nottingham, UK
| | - Robert J Moots
- Department of Musculoskeletal Biology, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Euthalia Roussou
- Barking Havering and Redbridge University Hospitals NHS trust (BHRUT), King George Hospital, Goodmayes, UK
| | | | - Linda D Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Michele Bombardieri
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, London, UK
| | - Simon J Bowman
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, Birmingham, UK.,Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Rheumatology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
11
|
Bowman SJ, Everett CC, O'Dwyer JL, Emery P, Pitzalis C, Ng WF, Pease CT, Price EJ, Sutcliffe N, Gendi NST, Hall FC, Ruddock SP, Fernandez C, Reynolds C, Hulme CT, Davies KA, Edwards CJ, Lanyon PC, Moots RJ, Roussou E, Giles IP, Sharples LD, Bombardieri M. Randomized Controlled Trial of Rituximab and Cost-Effectiveness Analysis in Treating Fatigue and Oral Dryness in Primary Sjögren's Syndrome. Arthritis Rheumatol 2017; 69:1440-1450. [PMID: 28296257 DOI: 10.1002/art.40093] [Citation(s) in RCA: 157] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 03/07/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To investigate whether rituximab, an anti-B cell therapy, improves symptoms of fatigue and oral dryness in patients with primary Sjögren's syndrome (SS). METHODS We conducted a multicenter, randomized, double-blind, placebo-controlled, parallel-group trial that included health economic analysis. Anti-Ro-positive patients with primary SS, symptomatic fatigue, and oral dryness were recruited from 25 UK rheumatology clinics from August 2011 to January 2014. Patients were centrally randomized to receive either intravenous (IV) placebo (250 ml saline) or IV rituximab (1,000 mg in 250 ml saline) in 2 courses at weeks 0, 2, 24, and 26, with pre- and postinfusion medication including corticosteroids. The primary end point was the proportion of patients achieving a 30% reduction in either fatigue or oral dryness at 48 weeks, as measured by visual analog scale. Other outcome measures included salivary and lacrimal flow rates, quality of life, scores on the European League Against Rheumatism (EULAR) Sjögren's Syndrome Patient Reported Index and EULAR Sjögren's Syndrome Disease Activity Index, symptoms of ocular and overall dryness, pain, globally assessed disease activity, and cost-effectiveness. RESULTS All 133 patients who were randomized to receive placebo (n = 66) or rituximab (n = 67) were included in the primary analysis. Among patients with complete data, 21 of 56 placebo-treated patients and 24 of 61 rituximab-treated patients achieved the primary end point. After multiple imputation of missing outcomes, response rates in the placebo and rituximab groups were 36.8% and 39.8%, respectively (adjusted odds ratio 1.13 [95% confidence interval 0.50, 2.55]). There were no significant improvements in any outcome measure except for unstimulated salivary flow. The mean ± SD costs per patient for rituximab and placebo were £10,752 ± 264.75 and £2,672 ± 241.71, respectively. There were slightly more adverse events (AEs) reported in total for rituximab, but there was no difference in serious AEs (10 in each group). CONCLUSION The results of this study indicate that rituximab is neither clinically effective nor cost-effective in this patient population.
Collapse
Affiliation(s)
- Simon J Bowman
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | | | | | - Wan-Fai Ng
- University of Newcastle, Newcastle-upon-Tyne, UK
| | | | | | | | | | - Frances C Hall
- University of Cambridge, Addenbrookes Hospital, Cambridge, UK
| | | | | | | | | | | | - Christopher J Edwards
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton, Southampton, UK
| | - Peter C Lanyon
- University of Nottingham and Circle Nottingham, Nottingham NHS Treatment Centre, Nottingham, UK
| | | | - Euthalia Roussou
- King George Hospital, Barking Havering and Redbridge University Hospitals NHS Trust, Essex, UK
| | - Ian P Giles
- University College London Hospital, London, UK
| | | | | |
Collapse
|
12
|
Howard DR, Munir T, McParland L, Rawstron AC, Milligan D, Schuh A, Hockaday A, Allsup DJ, Marshall S, Duncombe AS, O'Dwyer JL, Smith AF, Longo R, Varghese A, Hillmen P. Results of the randomized phase IIB ARCTIC trial of low-dose rituximab in previously untreated CLL. Leukemia 2017; 31:2416-2425. [PMID: 28336937 DOI: 10.1038/leu.2017.96] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 01/27/2017] [Accepted: 03/08/2017] [Indexed: 01/20/2023]
Abstract
ARCTIC was a multicenter, randomized-controlled, open, phase IIB non-inferiority trial in previously untreated chronic lymphocytic leukemia (CLL). Conventional frontline therapy in fit patients is fludarabine, cyclophosphamide and rituximab (FCR). The trial hypothesized that including mitoxantrone with low-dose rituximab (FCM-miniR) would be non-inferior to FCR. A total of 200 patients were recruited to assess the primary end point of complete remission (CR) rates according to IWCLL criteria. Secondary end points were progression-free survival (PFS), overall survival (OS), overall response rate, minimal residual disease (MRD) negativity, safety and cost-effectiveness. The trial closed following a pre-planned interim analysis. At final analysis, CR rates were 76 FCR vs 55% FCM-miniR (adjusted odds ratio: 0.37; 95% confidence interval: 0.19-0.73). MRD-negativity rates were 54 FCR vs 44% FCM-miniR. More participants experienced serious adverse reactions with FCM-miniR (49%) compared to FCR (41%). There are no significant differences between the treatment groups for PFS and OS. FCM-miniR is not expected to be cost-effective over a lifetime horizon. In summary, FCM-miniR is less well tolerated than FCR with an inferior response and MRD-negativity rate and increased toxicity, and will not be taken forward into a confirmatory trial. The trial demonstrated that oral FCR yields high response rates compared to historical series with intravenous chemotherapy.
Collapse
Affiliation(s)
- D R Howard
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - T Munir
- Department of Haematology, St James's University Hospital, Leeds, UK
| | - L McParland
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - A C Rawstron
- Haematological Malignancy Diagnostic Service, St James's University Hospital, Leeds, UK
| | - D Milligan
- Centre for Haematology and Stem Cell Transplantation, Heartlands Hospital, Birmingham, UK
| | - A Schuh
- Department of Oncology, University of Oxford and Department of Haematology, Oxford University Hospital Trust, Oxford, UK
| | - A Hockaday
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - D J Allsup
- Department of Haematology, Hull and East Yorkshire NHS Trust, Hull, United Kingdom and Hull York Medical School, University of Hull, Hull, UK
| | - S Marshall
- Department of Haematology, City Hospitals Sunderland, Sunderland, UK
| | - A S Duncombe
- Department of Haematology, University Hospital Southampton, Southampton, UK
| | - J L O'Dwyer
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - A F Smith
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - R Longo
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - A Varghese
- Department of Haematology, St James's University Hospital, Leeds, UK
| | - P Hillmen
- Section of Experimental Haematology, Leeds Institute of Cancer and Pathology (LICAP), University of Leeds, Leeds, UK
| |
Collapse
|
13
|
Walwyn REA, Russell AM, Bryant LD, Farrin AJ, Wright-Hughes AM, Graham EH, Hulme C, O'Dwyer JL, Latchford GJ, Stansfield AJ, Nagi D, Ajjan RA, House AO. Supported self-management for adults with type 2 diabetes and a learning disability (OK-Diabetes): study protocol for a randomised controlled feasibility trial. Trials 2015; 16:342. [PMID: 26253237 PMCID: PMC4529698 DOI: 10.1186/s13063-015-0832-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Individuals with a learning disability (LD) are at higher risk of developing type 2 diabetes, but LD is not straightforward to define or identify, especially at the milder end of the spectrum, which makes case finding difficult. While supported self-management of health problems is now established, current material is largely educational and didactic with little that facilitates behavioural change. The interaction between the person with diabetes and others supporting their care is also largely unknown. For these reasons, there is considerable work needed to prepare for a definitive trial. The aim of this paper is to publish the abridged protocol of this preparatory work. METHODS/DESIGN Phase I is a prospective case-finding study (target n = 120 to 350) to identify and characterise potential participants, while developing a standardised supported self-management intervention. Phase II is a randomised feasibility trial (target n = 80) with blinded outcome assessment. Patients identified in Phase I will be interviewed and consented prior to being randomised to (1) standard treatment, or (2) supported self-management. Both arms will also be provided with an 'easy read' accessible information resource on managing type 2 diabetes. The intervention will be standardised but delivered flexibly depending on patient need, including components for the participant, a supporter, and shared activities. Outcomes will be (i) robust estimates of eligibility, consent and recruitment rates with refined recruitment procedures; (ii) characterisation of the eligible population; (iii) a standardised intervention with associated written materials, (iv) adherence and negative outcomes measures; (v) preliminary estimates of adherence, acceptability, follow-up and missing data rates, along with refined procedures; and (vi) description of standard treatment. DISCUSSION Our study will provide important information on the nature of type 2 diabetes in adults with LD living in the community, on the challenges of identifying those with milder LD, and on the possibilities of evaluating a standardised intervention to improve self-management in this population. TRIAL REGISTRATION Current Controlled Trials ISRCTN41897033 (registered 21 January 2013).
Collapse
Affiliation(s)
| | - Amy M Russell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Louise D Bryant
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Amanda J Farrin
- Clinical Trials Research Unit, University of Leeds, Leeds, UK.
| | | | | | - Claire Hulme
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - John L O'Dwyer
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Gary J Latchford
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | | | - Dinesh Nagi
- Mid Yorkshire Hospitals NHS Trust, Wakefield, UK.
| | - Ramzi A Ajjan
- Division of Cardiovascular and Diabetes Research, University of Leeds, Leeds, UK.
| | - Allan O House
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| |
Collapse
|
14
|
O'Dwyer PJ, LaCreta FP, Daugherty JP, Hogan M, Rosenblum NG, O'Dwyer JL, Comis RL. Phase I pharmacokinetic study of intraperitoneal etoposide. Cancer Res 1991; 51:2041-6. [PMID: 2009523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The synergistic interaction of etoposide with cisplatin in certain tumors prompted an evaluation of its potential role in the i.p. treatment of ovarian cancer and other intraabdominal malignancies. We conducted a Phase I evaluation of etoposide as a single agent to determine the maximum tolerated dose i.p., to describe dose-limiting and other toxic effects, and to examine the pharmacokinetics of etoposide in this setting. Etoposide was diluted in 2 liters of normal saline, and instilled i.p. over 10 to 25 min following maximal drainage of ascites. The dwelling time was 4 h, followed by peritoneal drainage. Twenty-two patients received 56 courses at doses which ranged from 100 to 800 mg/m2. The median age was 49, the median performance status was 1, and 18 patients had received prior chemotherapy, with or without radiation. The principal acute toxicity was abdominal pain in 10 patients; this was usually accompanied by signs of peritoneal irritation and was always responsive to nonsteroidal antiinflammatory medications. The major toxicity was dose-related neutropenia; Grade 3 or 4 toxicity affected five of six patients at 800 mg/m2. Thrombocytopenia, nausea and vomiting, and alopecia were also observed. The recommended dose for further study is 700 mg/m2. The pharmacokinetics of etoposide in plasma and peritoneal fluid was measured in 19 patients. Peritoneal levels over the 4-h dwelling time declined monoexponentially with a harmonic mean half-life of 3.5 h (range, 1.9 to 7.8). Plasma levels rose to a peak at 2.9 +/- 1.7 (SD) h and then declined exponentially with a harmonic mean terminal half-life of 7.7 h (range, 4.2 to 15.6). The plasma area under the concentration-time curve increased linearly with respect to dose. The relative pharmacological advantage (ratio of peritoneal to plasma area under concentration-time curve) for i.p. administration was measured as 2.8 and was independent of dose. Based on the high plasma protein binding of etoposide (94%) and the minimal protein binding in the fluid instilled i.p., the ratio of the areas under the concentration-time curves of free drug is estimated to be 4%. These results illustrate that tumor confined to the peritoneal cavity would be exposed to substantially higher free (diffusible) drug concentrations following i.p. than following i.v. administration and support the further evaluation of etoposide by this route.
Collapse
Affiliation(s)
- P J O'Dwyer
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania 19111
| | | | | | | | | | | | | |
Collapse
|
15
|
Abstract
Based on the previous demonstration of a high peritoneal-to-plasma ratio of drug exposure for intraperitoneal (IP) etoposide, the authors performed a clinical/pharmacokinetic trial of etoposide (600 mg/m2) in combination with cisplatin (100 mg/m2). The drugs were administered concurrently IP, and allowed to dwell for 4 hours, after which the peritoneum was drained. Six patients received 13 cycles of treatment. Grade 4 neutropenia occurred in three patients; toxicity was otherwise moderate. Plasma etoposide concentrations reached a peak at 4.2 +/- 2.5 hours and declined exponentially with a terminal half-life of 9.5 +/- 3.6 hours. Peritoneal etoposide concentrations declined monoexponentially with a half-life of 3.7 +/- 2.6 hour. The calculated peritoneal-to-plasma ratio of unbound etoposide was 35. The plasma and peritoneal half-lives of ultrafilterable cisplatin were 21.7 +/- 14.1 hours and 1.8 +/- 0.7 hours, respectively. The peritoneal/plasma area under curve AUC ratio was 18.3. These pharmacokinetic indices for both drugs are consistent with those obtained with the use of each drug as a single agent. Thus, the concomitant use of one does not alter the pharmacokinetic activity of the other. The high AUC ratios support the further clinical development of these drugs in combination in the intraperitoneal setting.
Collapse
Affiliation(s)
- P J O'Dwyer
- Department of Medicine, Fox Chase Cancer Center, Philadelphia, PA 19111
| | | | | | | | | | | |
Collapse
|