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Holch P, Absolom KL, Henry AM, Walker K, Gibson A, Hudson E, Rogers Z, Holmes M, Peacock R, Pini S, Gilbert A, Davidson S, Routledge J, Murphy A, Franks K, Hulme C, Hewison J, Morris C, McParland L, Brown J, Velikova G. Online Symptom Monitoring During Pelvic Radiation Therapy: Randomized Pilot Trial of the eRAPID Intervention. Int J Radiat Oncol Biol Phys 2023; 115:664-676. [PMID: 36241128 DOI: 10.1016/j.ijrobp.2022.09.078] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 09/21/2022] [Accepted: 09/24/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Radiation therapy (RT) and chemoRT for pelvic cancers increase survival but are associated with serious treatment-related symptoms. Electronic-patient self-Reporting of Adverse-events: Patient Information and aDvice (eRAPID) is a secure online system for patients to self-report symptoms, generating immediate advice for hospital contact or self-management. This pilot study aimed to establish feasibility and acceptability of the system. METHODS AND MATERIALS In a prospective 2-center randomized parallel-group pilot study, patients undergoing radical pelvic RT for prostate cancer (prostateRT) or chemoRT for lower gastrointestinal and gynecological cancers were randomized to usual care (UC) or eRAPID (weekly online symptom reporting for 12, 18, and 24 weeks). Primary outcomes were recruitment/attrition, study completion, and patient adherence. Secondary outcomes were effect on hospital services and performance of patient outcome measures. Missing data, floor/ceiling effects, and mean change scores were examined for Functional Assessment of Cancer Therapy (FACT-G), European Organisation for Research and Treatment of Cancer, Quality of Life (EORTC QLQ C-30), self-efficacy, and EuroQol (EQ5D). RESULTS From 228 patients approached, 167 (73.2%) were consented and randomized (83, eRAPID; 84, UC; 87, prostateRT; 80, chemoRT); 150 of 167 completed 24 study weeks. Only 16 patients (9.6%) withdrew (10, eRAPID; 6, UC). In the eRAPID arm, completion rates were higher in patients treated with prostateRT compared with chemoRT (week 1, 93% vs 69%; week 2, 93% vs 68%; week 12, 69% vs 55%). Overall, over 50% of online reports triggered self-management advice for milder adverse events. Unscheduled hospital contact was low, with no difference between eRAPID and UC. Return rates for outcome measures were excellent in prostateRT (97%-91%; 6-24 weeks) but lower in chemoRT (95%-55%; 6-24 weeks). Missing data were low (1%-4.1%), ceiling effects were evident in EQ5D-5L, self-efficacy-scale, and FACT-Physical Wellbeing. At 6 weeks, the chemoRT-eRAPID group showed less deterioration in FACT-G, EORTC QLQ-C30, and EQ5D-Visual Analogue Scale than UC, after baseline adjustment. CONCLUSIONS eRAPID was successfully added to UC at 2 cancer centers in different patient populations. Acceptability and feasibility were confirmed with excellent adherence by prostate patients, but lower by those undergoing chemoRT for gynecological cancers.
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Affiliation(s)
- Patricia Holch
- Department of Psychology, School of Social Sciences, Leeds Beckett University, Leeds, United Kingdom; Leeds Institute of Medical Research at St James's and.
| | - Kate L Absolom
- Leeds Institute of Medical Research at St James's and; Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Ann M Henry
- Leeds Institute of Medical Research at St James's and; Leeds Teaching Hospitals NHS Trust, Leeds Cancer Centre, Leeds, United Kingdom
| | - Katrina Walker
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Andrea Gibson
- Leeds Institute of Medical Research at St James's and; Leeds Teaching Hospitals NHS Trust, Leeds Cancer Centre, Leeds, United Kingdom
| | - Eleanor Hudson
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Zoe Rogers
- Leeds Institute of Medical Research at St James's and
| | - Marie Holmes
- Leeds Institute of Medical Research at St James's and
| | | | - Simon Pini
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Alexandra Gilbert
- Leeds Institute of Medical Research at St James's and; Leeds Teaching Hospitals NHS Trust, Leeds Cancer Centre, Leeds, United Kingdom; Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Susan Davidson
- Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Anthony Murphy
- Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Kevin Franks
- Leeds Teaching Hospitals NHS Trust, Leeds Cancer Centre, Leeds, United Kingdom
| | | | - Jenny Hewison
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | | | | | - Julia Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Galina Velikova
- Leeds Institute of Medical Research at St James's and; Leeds Teaching Hospitals NHS Trust, Leeds Cancer Centre, Leeds, United Kingdom
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Love SB, Cafferty F, Snowdon C, Carty K, Savage J, Pallmann P, McParland L, Brown L, Masters L, Schiavone F, Hague D, Townsend S, Amos C, South A, Sturgeon K, Langley R, Maughan T, James N, Hall E, Kernaghan S, Bliss J, Turner N, Tutt A, Yap C, Firth C, Kong A, Mehanna H, Watts C, Hills R, Thomas I, Copland M, Bell S, Sebag-Montefiore D, Jones R, Parmar MKB, Sydes MR. Practical guidance for running late-phase platform protocols for clinical trials: lessons from experienced UK clinical trials units. Trials 2022; 23:757. [PMID: 36068599 PMCID: PMC9449272 DOI: 10.1186/s13063-022-06680-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 08/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Late-phase platform protocols (including basket, umbrella, multi-arm multi-stage (MAMS), and master protocols) are generally agreed to be more efficient than traditional two-arm clinical trial designs but are not extensively used. We have gathered the experience of running a number of successful platform protocols together to present some operational recommendations. METHODS Representatives of six UK clinical trials units with experience in running late-phase platform protocols attended a 1-day meeting structured to discuss various practical aspects of running these trials. We report and give guidance on operational aspects which are either harder to implement compared to a traditional late-phase trial or are specific to platform protocols. RESULTS We present a list of practical recommendations for trialists intending to design and conduct late-phase platform protocols. Our recommendations cover the entire life cycle of a platform trial: from protocol development, obtaining funding, and trial set-up, to a wide range of operational and regulatory aspects such as staffing, oversight, data handling, and data management, to the reporting of results, with a particular focus on communication with trial participants and stakeholders as well as public and patient involvement. DISCUSSION Platform protocols enable many questions to be answered efficiently to the benefit of patients. Our practical lessons from running platform trials will support trial teams in learning how to run these trials more effectively and efficiently.
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Affiliation(s)
- Sharon B. Love
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Fay Cafferty
- The Institute of Cancer Research, London, SW7 3RP UK
| | | | - Karen Carty
- Cancer Research UK Clinical Trials Unit, Level 0 The Beatson West of Scotland Cancer Centre, 1053 Great Western Road, Glasgow, G12 0YN UK
| | - Joshua Savage
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
| | - Philip Pallmann
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | | | - Louise Brown
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Lindsey Masters
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | | | - Dominic Hague
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Stephen Townsend
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Claire Amos
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Annabelle South
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Kate Sturgeon
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | - Ruth Langley
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
| | | | | | - Emma Hall
- The Institute of Cancer Research, London, SW7 3RP UK
| | | | - Judith Bliss
- The Institute of Cancer Research, London, SW7 3RP UK
| | - Nick Turner
- The Institute of Cancer Research, London, SW7 3RP UK
| | - Andrew Tutt
- The Institute of Cancer Research, London, SW3 6JB UK
| | - Christina Yap
- The Institute of Cancer Research, London, SW7 3RP UK
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - Charlotte Firth
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - Anthony Kong
- Comprehensive Cancer Centre, King’s College London, Guy’s Campus, New Hunt’s House, Room 2.36b, London, SE1 1UL UK
| | - Hisham Mehanna
- Institute for Head and Neck Studies and Education, University of Birmingham, Birmingham, B15 2TT UK
| | - Colin Watts
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT UK
| | - Robert Hills
- Doll Building, CTSU, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF UK
| | - Ian Thomas
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park Way, Cardiff, CF14 4YS UK
| | - Mhairi Copland
- Paul O’Gorman Research Centre, Gartnavel General Hospital, Glasgow, G12 0YN UK
| | - Sue Bell
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | | | - Robert Jones
- Beatson West of Scotland Cancer Centre, Glasgow, UK
| | | | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, 90 High Holborn, London, WC1V 6LJ UK
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Velikova G, Absolom K, Hewison J, Holch P, Warrington L, Avery K, Richards H, Blazeby J, Dawkins B, Hulme C, Carter R, Glidewell L, Henry A, Franks K, Hall G, Davidson S, Henry K, Morris C, Conner M, McParland L, Walker K, Hudson E, Brown J. Electronic self-reporting of adverse events for patients undergoing cancer treatment: the eRAPID research programme including two RCTs. Programme Grants Appl Res 2022. [DOI: 10.3310/fdde8516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Cancer is treated using multiple modalities (e.g. surgery, radiotherapy and systemic therapies) and is frequently associated with adverse events that affect treatment delivery and quality of life. Regular adverse event reporting could improve care and safety through timely detection and management. Information technology provides a feasible monitoring model, but applied research is needed. This research programme developed and evaluated an electronic system, called eRAPID, for cancer patients to remotely self-report adverse events.
Objectives
The objectives were to address the following research questions: is it feasible to collect adverse event data from patients’ homes and in clinics during cancer treatment? Can eRAPID be implemented in different hospitals and treatment settings? Will oncology health-care professionals review eRAPID reports for decision-making? When added to usual care, will the eRAPID intervention (i.e. self-reporting with tailored advice) lead to clinical benefits (e.g. better adverse event control, improved patient safety and experiences)? Will eRAPID be cost-effective?
Design
Five mixed-methods work packages were conducted, incorporating co-design with patients and health-care professionals: work package 1 – development and implementation of the electronic platform across hospital centres; work package 2 – development of patient-reported adverse event items and advice (systematic and scoping reviews, patient interviews, Delphi exercise); work package 3 – mapping health-care professionals and care pathways; work package 4 – feasibility pilot studies to assess patient and clinician acceptability; and work package 5 – a single-centre randomised controlled trial of systemic treatment with a full health economic assessment.
Setting
The setting was three UK cancer centres (in Leeds, Manchester and Bristol).
Participants
The intervention was developed and evaluated with patients and clinicians. The systemic randomised controlled trial included 508 participants who were starting treatment for breast, colorectal or gynaecological cancer and 55 health-care professionals. The radiotherapy feasibility pilot recruited 167 patients undergoing treatment for pelvic cancers. The surgical feasibility pilot included 40 gastrointestinal cancer patients.
Intervention
eRAPID is an online system that allows patients to complete adverse event/symptom reports from home or hospital. The system provides immediate severity-graded advice based on clinical algorithms to guide self-management or hospital contact. Adverse event data are transferred to electronic patient records for review by clinical teams. Patients complete an online symptom report every week and whenever they experience symptoms.
Main outcome measures
In systemic treatment, the primary outcome was Functional Assessment of Cancer Therapy – General, Physical Well-Being score assessed at 6, 12 and 18 weeks (primary end point). Secondary outcomes included cost-effectiveness assessed through the comparison of health-care costs and quality-adjusted life-years. Patient self-efficacy was measured (using the Self-Efficacy for Managing Chronic Diseases 6-item Scale). The radiotherapy pilot studied feasibility (recruitment and attrition rates) and selection of outcome measures. The surgical pilot examined symptom report completeness, system actions, barriers to using eRAPID and technical performance.
Results
eRAPID was successfully developed and introduced across the treatments and centres. The systemic randomised controlled trial found no statistically significant effect of eRAPID on the primary end point at 18 weeks. There was a significant effect at 6 weeks (adjusted difference least square means 1.08, 95% confidence interval 0.12 to 2.05; p = 0.028) and 12 weeks (adjusted difference least square means 1.01, 95% confidence interval 0.05 to 1.98; p = 0.0395). No between-arm differences were found for admissions or calls/visits to acute oncology or chemotherapy delivery. Health economic analyses over 18 weeks indicated no statistically significant difference between the cost of the eRAPID information technology system and the cost of usual care (£12.28, 95% confidence interval –£1240.91 to £1167.69; p > 0.05). Mean differences were small, with eRAPID having a 55% probability of being cost-effective at the National Institute for Health and Care Excellence-recommended cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained. Patient self-efficacy was greater in the intervention arm (0.48, 95% confidence interval 0.13 to 0.83; p = 0.0073). Qualitative interviews indicated that many participants found eRAPID useful for support and guidance. Patient adherence to adverse-event symptom reporting was good (median compliance 72.2%). In the radiotherapy pilot, high levels of consent (73.2%) and low attrition rates (10%) were observed. Patient quality-of-life outcomes indicated a potential intervention benefit in chemoradiotherapy arms. In the surgical pilot, 40 out of 91 approached patients (44%) consented. Symptom report completion rates were high. Across the studies, clinician intervention engagement was varied. Both patient and staff feedback on the value of eRAPID was positive.
Limitations
The randomised controlled trial methodology led to small numbers of patients simultaneously using the intervention, thus reducing overall clinician exposure to and engagement with eRAPID. Furthermore, staff saw patients across both arms, introducing a contamination bias and potentially reducing the intervention effect. The health economic results were limited by numbers of missing data (e.g. for use of resources and EuroQol-5 Dimensions).
Conclusions
This research provides evidence that online symptom monitoring with inbuilt patient advice is acceptable to patients and clinical teams. Evidence of patient benefit was found, particularly during the early phases of treatment and in relation to self-efficacy. The findings will help improve the intervention and guide future trial designs.
Future work
Definitive trials in radiotherapy and surgical settings are suggested. Future research during systemic treatments could study self-report online interventions to replace elements of traditional follow-up care in the curative setting. Further research during modern targeted treatments (e.g. immunotherapy and small-molecule oral therapy) and in metastatic disease is recommended.
Trial registration
The systemic randomised controlled trial is registered as ISRCTN88520246. The radiotherapy trial is registered as ClinicalTrials.gov NCT02747264.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 1. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Galina Velikova
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kate Absolom
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Jenny Hewison
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Patricia Holch
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
- Psychology Group, School of Social Sciences, Leeds Beckett University, Leeds, UK
| | - Lorraine Warrington
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
| | - Kerry Avery
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hollie Richards
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Blazeby
- Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Bryony Dawkins
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Claire Hulme
- Health Economics Group, Institute of Health Research, University of Exeter, Exeter, UK
| | - Robert Carter
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
| | - Liz Glidewell
- Department of Health Sciences, University of York, York, UK
| | - Ann Henry
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kevin Franks
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Geoff Hall
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Karen Henry
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Mark Conner
- School of Psychology, University of Leeds, Leeds, UK
| | - Lucy McParland
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Katrina Walker
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Eleanor Hudson
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Julia Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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4
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Absolom K, Warrington L, Hudson E, Hewison J, Morris C, Holch P, Carter R, Gibson A, Holmes M, Clayton B, Rogers Z, McParland L, Conner M, Glidewell L, Woroncow B, Dawkins B, Dickinson S, Hulme C, Brown J, Velikova G. Phase III Randomized Controlled Trial of eRAPID: eHealth Intervention During Chemotherapy. J Clin Oncol 2021; 39:734-747. [DOI: 10.1200/jco.20.02015] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
PURPOSE Electronic patient self-Reporting of Adverse-events: Patient Information and aDvice (eRAPID) is an online eHealth system for patients to self-report symptoms during cancer treatment. It provides automated severity-dependent patient advice guiding self-management or medical contact and displays the reports in electronic patient records. This trial evaluated the impact of eRAPID on symptom control, healthcare use, patient self-efficacy, and quality of life (QOL) in a patient population treated predominantly with curative intent. METHODS Patients with colorectal, breast, or gynecological cancers commencing chemotherapy were randomly assigned to usual care (UC) or the addition of eRAPID (weekly online symptom reporting for 18 weeks). Primary outcome was symptom control (Functional Assessment of Cancer Therapy-General, Physical Well-Being subscale [FACT-PWB]) assessed at 6, 12, and 18 weeks. Secondary outcomes were processes of care (admissions or chemotherapy delivery), patient self-efficacy, and global quality of life (Functional Assessment of Cancer Therapy–General, EQ5D-VAS, and EORTC QLQ-C30 summary score). Multivariable mixed-effects repeated-measures models were used for analyses. Trial registration: ISRCTN88520246. RESULTS Participants were 508 consenting patients (73.6% of 690 eligible) and 55 health professionals. eRAPID compared to UC showed improved physical well-being at 6 ( P = .028) and 12 ( P = .039) weeks and no difference at 18 weeks (primary end point) ( P = .69). Fewer eRAPID patients (47%) had clinically meaningful physical well-being deterioration than UC (56%) at 12 weeks. Subgroup analysis found benefit in the nonmetastatic group at 6 weeks ( P = .0426), but not in metastatic disease. There were no differences for admissions or chemotherapy delivery. At 18 weeks, patients using eRAPID reported better self-efficacy ( P = .007) and better health on EQ5D-VAS ( P = .009). Average patient compliance with weekly symptom reporting was 64.7%. Patient adherence was associated with clinician's data use and improved FACT-PWB at 12 weeks. CONCLUSION Real-time monitoring with electronic patient-reported outcomes improved physical well-being (6 and 12 weeks) and self-efficacy (18 weeks) in a patient population predominantly treated with curative intent, without increasing hospital workload.
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Affiliation(s)
- Kate Absolom
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Lorraine Warrington
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
| | - Eleanor Hudson
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Jenny Hewison
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Carolyn Morris
- Patient Representative, Independent Cancer Patients Voices, Brighton, United Kingdom
| | - Patricia Holch
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
- Psychology Group, School of Social Sciences, Faculty of Health and Social Sciences, Leeds Beckett University, Leeds, United Kingdom
| | - Robert Carter
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
| | - Andrea Gibson
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, United Kingdom
| | - Marie Holmes
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
| | - Beverly Clayton
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
| | - Zoe Rogers
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
| | - Lucy McParland
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Mark Conner
- School of Psychology, University of Leeds, Leeds, United Kingdom
| | - Liz Glidewell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Barbara Woroncow
- Patient Representative, Research Advisory Group to Patient-Centred Outcomes Research at Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
| | - Bryony Dawkins
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Sarah Dickinson
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
| | - Claire Hulme
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
- University of Exeter, St Luke's Campus, Exeter, United Kingdom
| | - Julia Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Galina Velikova
- Leeds Institute of Medical Research at St James's, University of Leeds, St James's University Hospital, Leeds, United Kingdom
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds, United Kingdom
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5
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Franks KN, McParland L, Webster J, Baldwin DR, Sebag-Montefiore D, Evison M, Booton R, Faivre-Finn C, Naidu B, Ferguson J, Peedell C, Callister MEJ, Kennedy M, Hewison J, Bestall J, Gregory WM, Hall P, Collinson F, Olivier C, Naylor R, Bell S, Allen P, Sloss A, Snee M. SABRTooth: a randomised controlled feasibility study of stereotactic ablative radiotherapy (SABR) with surgery in patients with peripheral stage I nonsmall cell lung cancer considered to be at higher risk of complications from surgical resection. Eur Respir J 2020; 56:2000118. [PMID: 32616595 DOI: 10.1183/13993003.00118-2020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 01/20/2020] [Accepted: 05/28/2020] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Stereotactic ablative radiotherapy (SABR) is a well-established treatment for medically inoperable peripheral stage I nonsmall cell lung cancer (NSCLC). Previous nonrandomised evidence supports SABR as an alternative to surgery, but high-quality randomised controlled trial (RCT) evidence is lacking. The SABRTooth study aimed to establish whether a UK phase III RCT was feasible. DESIGN AND METHODS SABRTooth was a UK multicentre randomised controlled feasibility study targeting patients with peripheral stage I NSCLC considered to be at higher risk of surgical complications. 54 patients were planned to be randomised 1:1 to SABR or surgery. The primary outcome was monthly average recruitment rates. RESULTS Between July 2015 and January 2017, 318 patients were considered for the study and 205 (64.5%) were deemed ineligible. Out of 106 (33.3%) assessed as eligible, 24 (22.6%) patients were randomised to SABR (n=14) or surgery (n=10). A key theme for nonparticipation was treatment preference, with 43 (41%) preferring nonsurgical treatment and 19 (18%) preferring surgery. The average monthly recruitment rate was 1.7 patients against a target of three. 15 patients underwent their allocated treatment: SABR n=12, surgery n=3. CONCLUSIONS We conclude that a phase III RCT randomising higher risk patients between SABR and surgery is not feasible in the National Health Service. Patients have pre-existing treatment preferences, which was a barrier to recruitment. A significant proportion of patients randomised to the surgical group declined and chose SABR. SABR remains an alternative to surgery and novel study approaches are needed to define which patients benefit from a nonsurgical approach.
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Affiliation(s)
- Kevin N Franks
- Leeds Cancer Centre, St James's University Hospital, Leeds, UK
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Joint first authors
| | - Lucy McParland
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Joint first authors
| | - Joanne Webster
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - David Sebag-Montefiore
- Leeds Cancer Centre, St James's University Hospital, Leeds, UK
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Matthew Evison
- Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Richard Booton
- Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, UK
| | - Corinne Faivre-Finn
- University of Manchester and The Christie NHS Foundation Trust, Manchester, UK
| | - Babu Naidu
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Clive Peedell
- The James Cook University Hospital, Middlesbrough, UK
| | | | - Martyn Kennedy
- Dept of Respiratory Medicine, Leeds Teaching Hospitals, Leeds, UK
| | - Jenny Hewison
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Janine Bestall
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Walter M Gregory
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Peter Hall
- Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Fiona Collinson
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Catherine Olivier
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Rachel Naylor
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sue Bell
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Peter Allen
- Patient and Public Involvement Representative, Leeds, UK
| | - Andrew Sloss
- Patient and Public Involvement Representative, Leeds, UK
| | - Michael Snee
- Leeds Cancer Centre, St James's University Hospital, Leeds, UK
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Gilbert A, Drinkwater K, McParland L, Adams R, Glynne-Jones R, Harrison M, Hawkins MA, Sebag-Montefiore D, Gilbert DC, Muirhead R. UK national cohort of anal cancer treated with intensity-modulated radiotherapy: One-year oncological and patient-reported outcomes. Eur J Cancer 2020; 128:7-16. [PMID: 32109852 DOI: 10.1016/j.ejca.2019.12.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 08/28/2019] [Revised: 12/13/2019] [Accepted: 12/26/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Concurrent chemoradiotherapy is the standard treatment for anal cancer. Following national UK implementation of intensity-modulated radiotherapy (IMRT), this prospective, national cohort evaluates the one-year oncological outcomes and patient-reported toxicity outcomes (PRO) after treatment. MATERIALS AND METHODS A national cohort of UK cancer centers implementing IMRT was carried out between February to July 2015. Cancer centers provided data on oncological outcomes, including survival, and disease and colostomy status at one-year. EORTC-QLQ core (C30) and colorectal (CR29) questionnaires were completed at baseline and one-year followup. The PRO scores at baseline and one year were compared. RESULTS 40 UK Cancer Centers returned data with a total of 187 patients included in the analysis. 92% received mitomycin with 5-fluorouracil or capecitabine. One-year overall survival was 94%; 84% were disease-free and 86% colostomy-free at one-year followup. At one year, PRO results found significant improvements in buttock pain, blood and mucus in stools, pain, constipation, appetite loss, and health anxiety compared to baseline. No significant deteriorations were reported in diarrhea, bowel frequency, and flatulence. Urinary symptom scores were low at one year. Moderate impotence symptoms at baseline remained at one year, and a moderate deterioration in dyspareunia reported. CONCLUSIONS With national anal cancer IMRT implementation, at this early pre-defined time point, one-year oncological outcomes were reassuring and resulted in good disease-related symptom control. one-year symptomatic complications following CRT for anal cancer using IMRT techniques appear to be relatively mild. These PRO results provide a basis to benchmark future studies.
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Affiliation(s)
- A Gilbert
- University of Leeds, Leeds Cancer Centre, St. James's University Hospital, Leeds, UK.
| | | | - L McParland
- Leeds Clinical Trials Research Unit, Worsley Building, University of Leeds, Leeds, UK
| | - R Adams
- Cardiff University - Centre for Trials Research and Velindre Cancer Centre, Cardiff, UK
| | - R Glynne-Jones
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Rickmansworth Road, Northwood, UK
| | - M Harrison
- Mount Vernon Centre for Cancer Treatment, Mount Vernon Hospital, Rickmansworth Road, Northwood, UK
| | - M A Hawkins
- CRUK MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - D Sebag-Montefiore
- University of Leeds, Leeds Cancer Centre, St. James's University Hospital, Leeds, UK
| | - D C Gilbert
- Sussex Cancer Centre, Royal Sussex County Hospital, Eastern Road, Brighton, UK
| | - R Muirhead
- Oxford University Hospitals NHS Trust, Department of Oncology, Churchill Hospital, Oxford, UK
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7
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Ofuya M, McParland L, Murray L, Brown S, Sebag-Montefiore D, Hall E. Systematic review of methodology used in clinical studies evaluating the benefits of proton beam therapy. Clin Transl Radiat Oncol 2019; 19:17-26. [PMID: 31372521 PMCID: PMC6660607 DOI: 10.1016/j.ctro.2019.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 05/22/2019] [Revised: 07/05/2019] [Accepted: 07/05/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Proton beam therapy (PBT) delivers high-energy radiation to target tumours while sparing surrounding normal tissues. The dosimetric advantages of PBT over traditional photon radiotherapy may be clear but the translation of this benefit into clinically meaningful reductions in toxicities and improved quality-of-life (QoL) needs to be determined. Randomised controlled trials (RCTs) are considered the gold standard for generating the highest-level evidence in medicine. The objectives of this systematic review were to provide an overview of published clinical studies evaluating the benefits of PBT, and to examine the methodology used in clinical trials with respect to study design and outcomes. METHODS PubMed, EMBASE and Cochrane databases were systematically searched for published clinical studies where PBT was a cancer treatment intervention. All randomised and non-randomised studies, prospective or retrospective, were eligible for inclusion. RESULTS In total, 219 studies were included. Prospective studies comprised 89/219 (41%), and of these, the number of randomised phase II and III trials were 5/89 (6%) and 3/89 (3%) respectively. Of all the phase II and III trials, 18/24 (75%) were conducted at a single PBT centre. Over one-third of authors recommended an increase in length of follow up. Research design and/or findings were poorly reported in 74/89 (83%) of prospective studies. Patient reported outcomes were assessed in only 19/89 (21%) of prospective studies. CONCLUSIONS Prospective randomised evidence for PBT is limited. The set-up of national PBT services in several countries provides an opportunity to guide the optimal design of prospective studies, including RCTs, to evaluate the benefits of PBT across various disease sites. Collaboration between PBT centres, both nationally and internationally, would increase potential for the generation of practice changing evidence. There is a need to facilitate and guide the collection and analysis of meaningful outcome data, including late toxicities and patient reported QoL.
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Affiliation(s)
- Mercy Ofuya
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, United Kingdom
| | - Lucy McParland
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Louise Murray
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Molecular Research, University of Leeds, Leeds, United Kingdom
| | - Sarah Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - David Sebag-Montefiore
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
- Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Emma Hall
- Clinical Trials and Statistics Unit at The Institute of Cancer Research, London, United Kingdom
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8
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Powell JR, Murray L, Burnet NG, Fernandez S, Lingard Z, McParland L, O'Hara DJ, Whitfield GA, Short SC. Patient Involvement in the Design of a Randomised Trial of Proton Beam Radiotherapy Versus Standard Radiotherapy for Good Prognosis Glioma. Clin Oncol (R Coll Radiol) 2019; 32:89-92. [PMID: 31607613 DOI: 10.1016/j.clon.2019.09.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/02/2019] [Accepted: 08/14/2019] [Indexed: 11/12/2022]
Affiliation(s)
- J R Powell
- Department of Oncology, Velindre University NHS Trust, Cardiff, UK.
| | - L Murray
- St James's Hospital and Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - N G Burnet
- Division of Cancer Sciences, Manchester Cancer Research Centre, University of Manchester, Manchester, UK; Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - S Fernandez
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Z Lingard
- Division of Cancer Sciences, Manchester Cancer Research Centre, University of Manchester, Manchester, UK
| | - L McParland
- Department of Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D J O'Hara
- Clinical and Health Psychology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - G A Whitfield
- Division of Cancer Sciences, Manchester Cancer Research Centre, University of Manchester, Manchester, UK; Department of Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - S C Short
- St James's Hospital and Leeds Institute of Medical Research, University of Leeds, Leeds, UK
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9
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Powell JR, Murray L, Burnet N, Fernandez S, McParland L, O’Hara D, Lingard Z, Whitfield G, Short SC. Patient engagement in the design of a randomised trial of proton beam radiotherapy versus photon radiotherapy for good prognosis glioma. Neuro Oncol 2019. [DOI: 10.1093/neuonc/noz167.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
UK Neuro-Oncologists and multidisciplinary colleagues are developing one of the first randomised clinical trials of proton beam radiotherapy(PBT) to compare quality of life(QOL), cognitive function and other late effects in adults with good prognosis glioma following either PBT or photon radiotherapy. The feasibility of running randomised studies with PBT is an important consideration, particularly in respect of participants’ views of a randomised design requiring treatment at national centres. We sought patient and carer engagement on our proposals to ensure we incorporate their views.
Methods
To explore these issues, we invited patients who had previously completed radiotherapy for oligodendroglioma and their carers to attend a focus group in Manchester in November 2018. Fifteen participants attended. We sought views on our trial proposal through small group discussions centred around 5 questions, led and facilitated by neuro-oncologists, a research radiographer, neuro-psychologist and statistician.
Results
Participants strongly endorsed the trial proposal and positively highlighted the opportunity to access PBT within a clinical trial and the group recognised and supported the need for randomisation and stated this should be 1:1. Patients disliked some traditional terminology such as ‘trial’ and ‘neurocognitive tests’ and preferred ‘research study’ and ‘neurocognitive assessments’. Patient and carers expressed the need for careful consideration of issues around travel and accommodation during PBT away from home. Interestingly, participants considered that standard QOL questionnaires fail to address some important areas reflecting daily wellbeing.
Conclusion
We acknowledge and will now incorporate these important patient and carer observations to strengthen our study and add validity to the key study endpoints.
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Affiliation(s)
| | - Louise Murray
- St James’s Hospital and Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
| | - Neil Burnet
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Lucy McParland
- Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
| | - Daniel O’Hara
- Clinical and Health Psychology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Zoe Lingard
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Gillian Whitfield
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Susan C Short
- St James’s Hospital and Leeds Institute of Medical Research, University of Leeds, Leeds, United Kingdom
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10
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Gilbert A, McParland L, Webster J, Bell S, Copeland J, Adams R, Harrison M, Muirhead R, Renehan A, Sebag-Montefiore D, Hawkins M. Pre-specified pilot analysis of a randomised pilot/phase II/III trial comparing standard dose vs dose-escalated concurrent chemoradiotherapy (CRT) in anal cancer (PLATO-ACT5). Ann Oncol 2019. [DOI: 10.1093/annonc/mdz246.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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11
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Renehan AG, Muirhead R, Berkman L, McParland L, Sebag-Montefiore D. Early stage anal margin cancer: towards evidence-based management. Colorectal Dis 2019; 21:387-391. [PMID: 30687991 DOI: 10.1111/codi.14571] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 01/12/2019] [Indexed: 02/08/2023]
Affiliation(s)
- A G Renehan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Cancer Research Centre, NIHR Manchester Biomedical Research Centre, Manchester, UK
| | - R Muirhead
- Oxford Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - L Berkman
- Patient and Public Involvement Trial Representative, London, UK
| | - L McParland
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - D Sebag-Montefiore
- Leeds Cancer Centre, St James University Hospital, University of Leeds, Leeds, UK
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12
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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.
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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
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13
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Teo MTW, McParland L, Appelt AL, Sebag-Montefiore D. Phase 2 Neoadjuvant Treatment Intensification Trials in Rectal Cancer: A Systematic Review. Int J Radiat Oncol Biol Phys 2017; 100:146-158. [PMID: 29254769 DOI: 10.1016/j.ijrobp.2017.09.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 08/23/2017] [Accepted: 09/21/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE Multiple phase 2 trials of neoadjuvant treatment intensification in locally advanced rectal cancer have reported promising efficacy signals, but these have not translated into improved cancer outcomes in phase 3 trials. Improvements in phase 2 trial design are needed to reduce these false-positive signals. This systematic review evaluated the design of phase 2 trials of neoadjuvant long-course radiation or chemoradiation therapy treatment intensification in locally advanced rectal cancer. METHODS AND MATERIALS The PubMed, EMBASE, MEDLINE, and Cochrane Library databases were searched for published phase 2 trials of neoadjuvant treatment intensification from 2004 to 2016. Trial clinical design and outcomes were assessed, with statistical design and compliance rated using a previously published system. Multivariable meta-regression analysis of pathologic complete response (pCR) was conducted. RESULTS We identified 92 eligible trials. Patients with American Joint Committee on Cancer stage II and III equivalent disease were eligible in 87 trials (94.6%). In 43 trials (46.7%), local staging on magnetic resonance imaging was mandated. Only 12 trials (13.0%) were randomized, with 8 having a standard-treatment control arm. Just 51 trials (55.4%) described their statistical design, with 21 trials (22.8%) failing to report their sample size derivation. Most trials (n=84, 91.3%) defined a primary endpoint, but 15 different primary endpoints were used. All trials reported pCR rates. Only 38 trials (41.3%) adequately reported trial statistical design and compliance. Meta-analysis revealed a pooled pCR rate of 17.5% (95% confidence interval, 15.7%-19.4%) across treatment arms of neoadjuvant long-course radiation or chemoradiation therapy treatment intensification and substantial heterogeneity among the reported effect sizes (I2 = 55.3%, P<.001). Multivariable meta-regression analysis suggested increased pCR rates with higher radiation therapy doses (adjusted P=.025). CONCLUSIONS Improvement in the design of future phase 2 rectal cancer trials is urgently required. A significant increase in randomized trials is essential to overcome selection bias and determine novel schedules suitable for phase 3 testing. This systematic review provides key recommendations to guide future treatment intensification trial design in rectal cancer.
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Affiliation(s)
- Mark T W Teo
- Radiotherapy Research Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK; Leeds Cancer Centre, St James University Hospital, Leeds, UK
| | - Lucy McParland
- Radiotherapy Research Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ane L Appelt
- Radiotherapy Research Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK; Leeds Cancer Centre, St James University Hospital, Leeds, UK
| | - David Sebag-Montefiore
- Radiotherapy Research Group, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK; Leeds Cancer Centre, St James University Hospital, Leeds, UK.
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14
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Zekri J, Marples M, Taylor D, Kandukurti K, McParland L, Brown JE. Complications of bone metastases from malignant melanoma. J Bone Oncol 2017; 8:13-17. [PMID: 28856087 PMCID: PMC5568878 DOI: 10.1016/j.jbo.2017.08.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 05/21/2017] [Revised: 08/08/2017] [Accepted: 08/10/2017] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Metastatic bone disease (MBD) carries significant morbidity for patients with cancer. MBD from malignant melanoma (MM) is understudied. We examined the characteristics, morbidity, management and outcome of MBD in patients with MM. METHODS Patients with metastatic MM managed at two referral cancer centres in England were identified. Those with bone metastases (BMs) were selected. Patient and disease characteristics including skeletal related events (SREs) were extracted from medical records. The Kaplan Meier method was used to calculate median survival. RESULTS Five hundred and eighteen patients with metastatic MM were managed between years 2000 and 2008. Eighty nine (17.2%) patients had BMs and are the subject of this study. Median age at diagnosis was 53 years and 55% were males. BMs were identified at the time of diagnosis of metastatic disease in 68.5% patients. Sixty-six (74.2%) had multiple bone lesions and 80.9% had axial skeleton involvement. One hundred and twenty nine skeletal related events occurred in 59 (66.3%) patients (50 radiotherapy, 28 hypercalcaemia, 20 bone fractures, 18 spinal cord compression and 13 orthopaedic surgery). The annual skeletal morbidity rate was 2.5. Median survival from diagnosis of BMs was 17.3 weeks and was 5.6 weeks from the first episode of hypercalcaemia. CONCLUSION MBD affects a clinically important proportion (17.2%) of patients with metastatic MM. It carries a substantial morbidity and mortality exceeding that caused by BMs from breast and prostate cancer. These patients should receive the currently licensed bone modifying agents and should be included in clinical trials addressing MBD.
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Affiliation(s)
- Jamal Zekri
- Weston Park Hospital, Sheffield S10 2SJ, England, UK
- Al-Faisal University, King Faisal Specialist Hospital & Research Centre, Jeddah, Saudi Arabia
| | - Maria Marples
- St James's Institute of Oncology, St James's University Hospital, Leeds LS9 7TF, UK
| | - Dominic Taylor
- St James's Institute of Oncology, St James's University Hospital, Leeds LS9 7TF, UK
| | | | - Lucy McParland
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds LS2 9PH, UK
| | - Janet E. Brown
- Academic Unit of Clinical Oncology, University of Sheffield, Weston Park Hospital, Sheffield S10 2SJ, England, UK
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15
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Kelly-Morland C, Zhong J, Goh V, Wah T, Ralph C, Thistlethwaite F, Patel P, Nathan P, Eisen T, Gregory W, McParland L, Cool H, Royle KL, Best E, Whincup L, Collinson F, Brown J. Prospective comparison of RECIST and alternative response assessment criteria in the evaluation of metastatic renal cell cancer patients from phase II of the multi-centre randomised STAR trial. Ann Oncol 2017. [DOI: 10.1093/annonc/mdx371.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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16
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Collett L, Howard DR, Munir T, McParland L, Oughton JB, Rawstron AC, Hockaday A, Dimbleby C, Phillips D, McMahon K, Hulme C, Allsup D, Bloor A, Hillmen P. Assessment of ibrutinib plus rituximab in front-line CLL (FLAIR trial): study protocol for a phase III randomised controlled trial. Trials 2017; 18:387. [PMID: 28830517 PMCID: PMC5568356 DOI: 10.1186/s13063-017-2138-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [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] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 08/04/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Treatment of chronic lymphocytic leukaemia (CLL) has seen a substantial improvement over the last few years. Combination immunochemotherapy, such as fludarabine, cyclophosphamide and rituximab (FCR), is now standard first-line therapy. However, the majority of patients relapse and require further therapy, and so new, effective, targeted therapies that improve remission rates, reduce relapses, and have fewer side effects, are required. The FLAIR trial will assess whether ibrutinib plus rituximab (IR) is superior to FCR in terms of progression-free survival (PFS). METHODS/DESIGN FLAIR is a phase III, multicentre, randomised, controlled, open, parallel-group trial in patients with previously untreated CLL. A total of 754 participants will be randomised on a 1:1 basis to receive standard therapy with FCR or IR. Participants randomised to FCR will receive a maximum of six 28-day treatment cycles. Participants randomised to IR will receive six 28-day cycles of rituximab, and ibrutinib taken daily for 6 years until minimal residual disease (MRD) negativity has been recorded for the same amount of time as it took to become MRD negative, or until disease progression. The primary endpoint is PFS according to the International Workshop on CLL (IWCLL) criteria. Secondary endpoints include: overall survival; proportion of participants with undetectable MRD; response to therapy by IWCLL criteria; safety and toxicity; health-related quality of life (QoL); and cost-effectiveness. DISCUSSION The trial aims to provide evidence for the future first-line treatment of CLL patients by assessing whether IR is superior to FCR in terms of PFS, and whether toxicity rates are favourable. TRIAL REGISTRATION ISRCTN01844152 . Registered on 8 August 2014, EudraCT number 2013-001944-76 . Registered on 26 April 2013.
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MESH Headings
- Adenine/analogs & derivatives
- Adolescent
- Adult
- Aged
- Antineoplastic Agents, Immunological/administration & dosage
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/economics
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/economics
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cost-Benefit Analysis
- Disease Progression
- Disease-Free Survival
- Drug Costs
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/economics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Middle Aged
- Neoplasm, Residual
- Piperidines
- Protein Kinase Inhibitors/administration & dosage
- Protein Kinase Inhibitors/adverse effects
- Protein Kinase Inhibitors/economics
- Pyrazoles/administration & dosage
- Pyrazoles/adverse effects
- Pyrazoles/economics
- Pyrimidines/administration & dosage
- Pyrimidines/adverse effects
- Pyrimidines/economics
- Quality of Life
- Rituximab/administration & dosage
- Rituximab/adverse effects
- Rituximab/economics
- Surveys and Questionnaires
- Time Factors
- Treatment Outcome
- United Kingdom
- Young Adult
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Affiliation(s)
- Laura Collett
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Dena R. Howard
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Talha Munir
- St James’ Institute of Oncology, St James’ University Hospital, Leeds, UK
| | - Lucy McParland
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jamie B. Oughton
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Andy C. Rawstron
- Haematological Malignancy Diagnostic Service, St James’ Institute of Oncology, St James’ University Hospital, Leeds, UK
| | - Anna Hockaday
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Claire Dimbleby
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David Phillips
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Kathryn McMahon
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Claire Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - David Allsup
- Hull York Medical School, Department of Haematology, Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Cottingham, UK
| | - Adrian Bloor
- Department of Haematology, The Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Peter Hillmen
- St James’ Institute of Oncology, St James’ University Hospital, Leeds, UK
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Oughton JB, Collett L, Howard DR, Hockaday A, Munir T, McMahon K, McParland L, Dimbleby C, Phillips D, Rawstron AC, Hillmen P. GA101 (obinutuzumab) monocLonal Antibody as Consolidation Therapy In CLL (GALACTIC) trial: study protocol for a phase II/III randomised controlled trial. Trials 2017; 18:353. [PMID: 28747208 PMCID: PMC5530563 DOI: 10.1186/s13063-017-2107-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 07/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic lymphocytic leukaemia (CLL) is the most common adult leukaemia. Achieving minimal residual disease (MRD) negativity in CLL is an independent predictor of survival even with a variety of different treatment approaches and regardless of the line of therapy. METHODS/DESIGN GA101 (obinutuzumab) monocLonal Antibody as Consolidation Therapy In CLL (GALACTIC) is a seamless phase II/III, multi-centre, randomised, controlled, open, parallel-group trial for patients with CLL who have recently responded to chemotherapy. Participants will be randomised to receive either obinutuzumab (GA-101) consolidation or no treatment (as is standard). The phase II trial will assess safety and short-term efficacy in order to advise on continuation to a phase III trial. The primary objective for phase III is to assess the effect of consolidation therapy on progression-free survival (PFS). One hundred eighty-eight participants are planned to be recruited from forty research centres in the United Kingdom. DISCUSSION There is evidence that achieving MRD eradication with alemtuzumab consolidation is associated with improvements in survival and time to progression. This trial will assess whether obinutuzumab is safe in a consolidation setting and effective at eradicating MRD and improving PFS. TRIAL REGISTRATION ISRCTN, 64035629 . Registered on 12 January 2015. EudraCT, 2014-000880-42 . Registered on 12 November 2014.
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MESH Headings
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/therapeutic use
- Clinical Protocols
- Consolidation Chemotherapy/adverse effects
- Consolidation Chemotherapy/mortality
- Disease-Free Survival
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Research Design
- Time Factors
- Treatment Outcome
- United Kingdom
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Affiliation(s)
- Jamie B. Oughton
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Laura Collett
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Dena R. Howard
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Anna Hockaday
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Talha Munir
- St James’s Institute of Oncology, St James’s University Hospital, Leeds, UK
| | - Kathryn McMahon
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Lucy McParland
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Claire Dimbleby
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - David Phillips
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Andy C. Rawstron
- Haematological Malignancy Diagnostic Service, St James’s Institute of Oncology, St James’s University Hospital, Leeds, UK
| | - Peter Hillmen
- St James’s Institute of Oncology, St James’s University Hospital, Leeds, UK
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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.
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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
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Snee MP, McParland L, Collinson F, Lowe CM, Striha A, Baldwin DR, Naidu B, Sebag-Montefiore D, Gregory WM, Bestall J, Hewison J, Hinsley S, Franks KN. Erratum to: The SABRTooth feasibility trial protocol: a study to determine the feasibility and acceptability of conducting a phase III randomised controlled trial comparing stereotactic ablative radiotherapy (SABR) with surgery in patients with peripheral stage I non-small cell lung cancer (NSCLC) considered to be at higher risk of complications from surgical resection. Pilot Feasibility Stud 2016; 2:55. [PMID: 27976752 PMCID: PMC5154043 DOI: 10.1186/s40814-016-0095-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- M P Snee
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF UK
| | - L McParland
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, 71-75 Clarendon Road, Leeds, LS2 9PH UK
| | - F Collinson
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, 71-75 Clarendon Road, Leeds, LS2 9PH UK
| | - C M Lowe
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, 71-75 Clarendon Road, Leeds, LS2 9PH UK
| | - A Striha
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, 71-75 Clarendon Road, Leeds, LS2 9PH UK
| | - D R Baldwin
- Respiratory Medicine Unit, David Evans Research Centre, Nottingham University Hospitals and University of Nottingham, Hucknall Rd, Nottingham, NG5 1PB UK
| | - B Naidu
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, Edgbaston B15 2TT, UK
| | - D Sebag-Montefiore
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF UK ; Leeds Institute of Cancer and Pathology, Faculty of Medicine and Health, University of Leeds, Beckett Street, Leeds, LS9 7TF UK
| | - W M Gregory
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, 71-75 Clarendon Road, Leeds, LS2 9PH UK
| | - J Bestall
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, 101 Clarendon Rd, Leeds, LS2 9LJ UK
| | - J Hewison
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, 101 Clarendon Rd, Leeds, LS2 9LJ UK
| | - S Hinsley
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, 71-75 Clarendon Road, Leeds, LS2 9PH UK
| | - K N Franks
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF UK
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Sebag-Montefiore D, Adams R, Bell S, Berkman L, Gilbert D, Glynne-Jones R, Goh V, Gregory W, Harrison M, Kachnic L, Lee M, McParland L, Muirhead R, O'Neill B, Hutchins G, Rao S, Renehan A, Smith A, Velikova G, Hawkins M. The Development of an Umbrella Trial (PLATO) to Address Radiation Therapy Dose Questions in the Locoregional Management of Squamous Cell Carcinoma of the Anus. Int J Radiat Oncol Biol Phys 2016. [DOI: 10.1016/j.ijrobp.2016.06.1006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Snee MP, McParland L, Collinson F, Lowe CM, Striha A, Baldwin DR, Naidu B, Sebag-Montefiore D, Gregory WM, Bestall J, Hewison J, Hinsley S, Franks K. The SABRTooth feasibility trial protocol: a study to determine the feasibility and acceptability of conducting a phase III randomised controlled trial comparing stereotactic ablative radiotherapy (SABR) with surgery in patients with peripheral stage I non-small cell lung cancer (NSCLC) considered to be at higher risk of complications from surgical resection. Pilot Feasibility Stud 2016; 2:5. [PMID: 27965826 PMCID: PMC5153694 DOI: 10.1186/s40814-016-0046-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 01/18/2016] [Indexed: 12/25/2022] Open
Abstract
Background Stage I non-small cell lung cancer (NSCLC) is potentially curable, and surgery is considered to be the standard of care for patients with good performance status and minimal co-morbidity. However, a significant proportion of patients with stage I NSCLC have a poorer performance status and significant medical co-morbidity that make them at higher risk of morbidity and mortality from surgery. Stereotactic ablative radiotherapy (SABR), which uses modern radiotherapeutic techniques to deliver large doses of radiation, has shown superiority over conventional radiotherapy in terms of local control and toxicity and is a standard of care for patients with stage I NSCLC who are at too high risk for surgery. However, it is not known whether surgery or SABR is the most effective in patients with stage I NSCLC who are suitable for surgery but are less fit and at higher risk surgical complications. Previous randomised studies have failed to recruit in this setting, and therefore, a feasibility study is required to see whether a full randomised control trial would be possible. Methods/design SABRTooth is a UK-based, multi-centre, open-label, two-group individually (1:1) randomised controlled feasibility study in patients with peripheral stage I NSCLC considered to be at higher risk from surgical resection. The study will assess the feasibility of conducting a definitive large-scale phase III trial. The primary objective is to assess recruitment rates to provide evidence that, when scaled up, recruitment to a large phase III trial would be possible; the target recruitment being 54 patients in total, over a 21-month period. There are multiple secondary and exploratory objectives designed to explore the optimum recruitment and data collection strategies to help optimise the design of a future phase III trial. Discussion To know whether SABR is a better, equivalent or inferior alternative to surgery for higher risk patients is a key question in lung cancer. Other studies comparing SABR to surgery have closed early due to poor recruitment, and therefore, the SABRTooth feasibility study has been designed around the UK National Health Service (NHS) cancer pathway incorporating many design features in order to maximise recruitment for a future definitive phase III trial. Trial registration controlled-trials.com ISRCTN13029788
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Affiliation(s)
- M P Snee
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF UK
| | - L McParland
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, 71-75 Clarendon Road, Leeds, LS2 9PH UK
| | - F Collinson
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, 71-75 Clarendon Road, Leeds, LS2 9PH UK
| | - C M Lowe
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, 71-75 Clarendon Road, Leeds, LS2 9PH UK
| | - A Striha
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, 71-75 Clarendon Road, Leeds, LS2 9PH UK
| | - D R Baldwin
- Respiratory Medicine Unit, David Evans Research Centre, Nottingham University Hospitals and University of Nottingham, Hucknall Rd, Nottingham, NG5 1PB UK
| | - B Naidu
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, Edgbaston B15 2TT UK
| | - D Sebag-Montefiore
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF UK.,Leeds Institute of Cancer and Pathology, Faculty of Medicine and Health, University of Leeds, Beckett Street, Leeds, LS9 7TF UK
| | - W M Gregory
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, 71-75 Clarendon Road, Leeds, LS2 9PH UK
| | - J Bestall
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, 101 Clarendon Rd, Leeds, LS2 9LJ UK
| | - J Hewison
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, 101 Clarendon Rd, Leeds, LS2 9LJ UK
| | - S Hinsley
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, 71-75 Clarendon Road, Leeds, LS2 9PH UK
| | - K Franks
- Department of Clinical Oncology, Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF UK
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Coates LC, Moverley AR, McParland L, Brown S, Navarro-Coy N, O’Dwyer JL, Meads DM, Emery P, Conaghan PG, Helliwell PS. Effect of tight control of inflammation in early psoriatic arthritis (TICOPA): a UK multicentre, open-label, randomised controlled trial. Lancet 2015; 386:2489-98. [PMID: 26433318 PMCID: PMC4920221 DOI: 10.1016/s0140-6736(15)00347-5] [Citation(s) in RCA: 316] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Early intervention and tight control of inflammation optimise outcomes in rheumatoid arthritis but these approaches have not yet been studied in psoriatic arthritis. We aimed to assess the effect of tight control on early psoriatic arthritis using a treat-to-target approach. METHODS For this open-label multicentre randomised controlled trial, adult patients (aged ≥18 years) with early psoriatic arthritis (<24 months symptom duration), who had not previously received treatment with any disease-modifying anti-rheumatic drugs, were enrolled from eight secondary care rheumatology centres in the UK. Enrolled patients were randomly assigned in a 1:1 ratio to receive either tight control (with review every 4 weeks and with escalation of treatment if minimal disease activity criteria not met) or standard care (standard therapy according to the treating clinician, with review every 12 weeks) for 48 weeks. Randomisation was done by minimisation incorporating a random element, to ensure treatment groups were balanced for randomising centre and pattern of arthritis (oligoarticular vs polyarticular). The randomisation procedure was done through a central 24-h automated telephone system based at the Leeds Institute of Clinical Trials Research (Leeds, UK). This was an open-label study in which patients and clinicians were aware of treatment group assignment. Clinical outcomes were recorded by a masked assessor every 12 weeks. The primary outcome was the proportion of patients achieving an American College of Rheumatology (ACR) 20% (ACR20) response at 48 weeks, analysed by intention to treat with multiple imputation for missing ACR components. Cost-effectiveness was also assessed. This trial is registered with ClinicalTrials.gov, number NCT01106079, and the ISCRCTN registry, number ISCRCTN30147736. FINDINGS Between May 28, 2008, and March 21, 2012, 206 eligible patients were enrolled and randomly assigned to receive tight control (n=101) or standard care (n=105). In the intention-to-treat patient population, the odds of achieving an ACR20 response at 48 weeks were higher in the tight control group than in the standard care group (odds ratio 1·91, 95% CI 1·03-3·55; p=0·0392). Serious adverse events were reported by 20 (10%) patients (25 events in 14 [14%] patients in the tight control group and eight events in six [6%] patients in the standard care group) during the course of the study. No unexpected serious adverse events or deaths occurred. INTERPRETATION Tight control of psoriatic arthritis disease activity through a treat-to-target approach significantly improves joint outcomes for newly diagnosed patients, with no unexpected serious adverse events reported. FUNDING Arthritis Research UK and Pfizer.
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Affiliation(s)
- Laura C Coates
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, LS7 4SA, UK
- Leeds NIHR Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Anna R Moverley
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, LS7 4SA, UK
- Leeds NIHR Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Lucy McParland
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Sarah Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Nuria Navarro-Coy
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, LS7 4SA, UK
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - John L O’Dwyer
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9LJ, UK
| | - David M Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9LJ, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, LS7 4SA, UK
- Leeds NIHR Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, LS7 4SA, UK
- Leeds NIHR Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Philip S Helliwell
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, LS7 4SA, UK
- Leeds NIHR Musculoskeletal Biomedical Research Unit, Leeds, UK
- Corresponding author Philip Helliwell, NIHR Leeds Musculoskeletal Biomedical Research Unit, LIRMM, Chapel Allerton Hospital, Chapel Town Road, Leeds, LS7 4SA, Ph: 0113 392 3064; Fax: 0113 392 4991;
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Teo M, McParland L, Sebag-Montefiore D. EP-1211: A systematic review of novel neoadjuvant treatment intensification of locally advanced rectal cancer. Radiother Oncol 2015. [DOI: 10.1016/s0167-8140(15)41203-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Coates LC, Navarro-Coy N, Brown SR, Brown S, McParland L, Collier H, Skinner E, Law J, Moverley A, Pavitt S, Hulme C, Emery P, Conaghan PG, Helliwell PS. The TICOPA protocol (TIght COntrol of Psoriatic Arthritis): a randomised controlled trial to compare intensive management versus standard care in early psoriatic arthritis. BMC Musculoskelet Disord 2013; 14:101. [PMID: 23517506 PMCID: PMC3610193 DOI: 10.1186/1471-2474-14-101] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 02/28/2013] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Psoriatic arthritis (PsA) is estimated to occur in 10-15% of people with psoriasis and accounts for 13% of people attending early arthritis clinics. With an increasing awareness of the poor outcomes associated with PsA and the availability of new effective, but costly, treatments, there is an urgent need to research the optimal treatment for patients with PsA. The aim of the TICOPA study is to establish whether, in treatment naive early PsA patients, "tight control" intensive management with protocol driven therapies and pre-defined objective targets for treatment can improve clinical outcome compared to standard care alone. METHODS/DESIGN TICOPA is a UK multicentre, open-label, randomised controlled, parallel group trial of 206 patients with early PsA. Patients will be randomised on a 1:1 basis to receive either standard care (12 weekly review) or intensive management (4 weekly review) for a period of 48 weeks. Patients assigned to the intensive management group will follow a strict treatment protocol whereby dose continuation/escalation is determined through the objective assessment of the minimal disease activity (MDA) criteria. Patients assigned to the standard care group will have treatment prescribed as felt appropriate by the treating clinician, with no set protocol. The primary objective of the trial is to compare intensive management with standard care in terms of the proportion of patients achieving an ACR 20 response at 48 weeks post-randomisation, in order to determine whether intensive management has superior clinical efficacy. Key secondary outcomes include ACR 50 and 70, PASI 75 and X-ray Van der Heijde score at 48 weeks post-randomisation along with cost-effectiveness at 12, 24 and 28 weeks. DISCUSSION The TICOPA trial will provide direct evidence as to whether the use of early and intensive treatment in PsA in routine clinical care leads to an improvement in patients' disease activity and a reduction in radiological joint damage. TRIAL REGISTRATION ISRCTN30147736, NCT01106079.
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Affiliation(s)
- Laura C Coates
- Division of Rheumatic and Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, Leeds LS7 4SA, UK.
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Collinson FJ, Gregory WM, McCabe C, Howard H, Lowe C, Potrata D, Tubeuf S, Hanlon P, McParland L, Wah T, Selby PJ, Hewison J, Brown J, Brown J. The STAR trial protocol: a randomised multi-stage phase II/III study of Sunitinib comparing temporary cessation with allowing continuation, at the time of maximal radiological response, in the first-line treatment of locally advanced/metastatic renal cancer. BMC Cancer 2012; 12:598. [PMID: 23241439 PMCID: PMC3583710 DOI: 10.1186/1471-2407-12-598] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [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] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 11/22/2012] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Over recent years a number of novel therapies have shown promise in advanced renal cell carcinoma (RCC). Internationally the standard of care of first-line therapy is sunitinib™, after a clear survival benefit was demonstrated over interferon-α. Convention dictates that sunitinib is continued until evidence of disease progression, assuming tolerability, although there is no evidence that this approach is superior to intermittent periods of treatment. The purpose of the STAR trial is to compare the standard treatment strategy (conventional continuation strategy, CCS) with a novel drug free interval strategy (DFIS) which includes planned treatment breaks. METHODS/DESIGN The STAR trial is an NIHR HTA-funded UK pragmatic randomised phase II/III clinical trial in the first-line treatment of advanced RCC. Participants will be randomised (1:1) to either a sunitinib CCS or a DFIS. The overall aim of the trial is to determine whether a DFIS is non-inferior, in terms of 2-year overall survival (OS) and quality adjusted life years (QALY) (averaged over treatment and follow up), compared to a CCS. The QALY primary endpoint was selected to assess whether any detriment in terms of OS could be balanced with improvements in quality of life (QoL). This is a complex trial with a number of design challenges, and to address these issues a feasibility stage is incorporated into the trial design. Predetermined recruitment (stage A) and efficacy (stage B) intermediary endpoints must be met to allow continuation to the overall phase III trial (stage C). An integral qualitative patient preference and understanding study will occur alongside the feasibility stage to investigate patients' feelings regarding participation or non-participation in the trial. DISCUSSION The optimal duration of continuing sunitinib in advanced RCC is unknown. Novel targeted therapies do not always have the same constraints to treatment duration as standard chemotherapeutic agents and currently there are no randomised data comparing different treatment durations. Incorporating planned treatment breaks has the potential to improve QoL and cost effectiveness, hopefully without significant detriment on OS, as has been demonstrated in other cancer types with other treatments. TRIAL REGISTRATION Controlled-trials.com ISRCTN 06473203.
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Affiliation(s)
- Fiona J Collinson
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Walter M Gregory
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Chris McCabe
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Helen Howard
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Catherine Lowe
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - DrBarbara Potrata
- Charles Thackrah Building, Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9JT, UK
| | - Sandy Tubeuf
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Pat Hanlon
- Patient Representative National Cancer Research Institute (NCRI) Renal Cancer Clinical Studies Group, Leeds, UK
| | - Lucy McParland
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - T Wah
- Department of Radiology St James’s University Hospital, Leeds, LS9 7TF, UK
| | - Peter J Selby
- Cancer Research Building, St James’s University Hospital, Leeds, LS9 7TF, UK
| | - Jenny Hewison
- Charles Thackrah Building, Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9TF, UK
| | - Julia Brown
- Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Janet Brown
- Cancer Research UK Experimental Centres at Leeds and Sheffield, Leeds, LS2 9TF, UK
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Woodward E, Jagdev S, McParland L, Clark K, Gregory W, Newsham A, Rogerson S, Hayward K, Selby P, Brown J. Skeletal complications and survival in renal cancer patients with bone metastases. Bone 2011; 48:160-6. [PMID: 20854942 DOI: 10.1016/j.bone.2010.09.008] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 09/02/2010] [Accepted: 09/08/2010] [Indexed: 10/19/2022]
Abstract
Skeletal metastases occur in around one third of patients with advanced or metastatic renal cell carcinoma (RCC). Skeletal involvement is commonly an aggressive, lytic process which causes substantial morbidity through skeletal complications and occurrence of skeletal related events (SREs). However, compared with bone metastases in breast and prostate cancer, there is a paucity of data relating to the demographics of bone metastases in RCC and their sequelae in terms of SREs and survival. The study population included all patients (N=803) with advanced or metastatic RCC treated in a tertiary centre serving a regional population of 2.6 million between 1998 and 2007. Demographic and survival data and information relating to metastatic disease were extracted from electronic records. Thirty-two percent (N=254) of the study population presented with (N=131) or later developed (N=123) bone metastases and 83% of these (N=210) also developed metastases elsewhere. The mean number of SREs experienced by the bone metastatic patients over the course of their disease was 2.4 and only 37 patients experienced no SRE. A high proportion of patients (80%) received radiotherapy for bone pain and there was a surprising and strikingly high incidence of spinal cord/nerve root compression, which was experienced by 28% patients. Although bisphosphonate use increased following the availability of zoledronic acid in 2004, approximately 50% patients with bone metastases did not receive bisphosphonate treatment. The skeletal morbidity rate (number of SREs per patient years at risk) was 1.0 and 1.4 for patients who received or did not receive bisphosphonates, respectively. The median survival following diagnosis of RCC was similar in patients who developed bone metastases (20.4 months) and those who did not (20.9 months). Median survival from diagnosis of metastases was 13.3 months for those who never developed bone metastases, 10.6 months for those who presented with them, 19.6 months for those who developed them later and 22.6 months for patients who had bone only metastases. This is the largest study to date focusing specifically on skeletal complications in RCC. A striking finding was the high incidence of spinal cord/nerve root compression and more research into this area is needed. Clearer, internationally accepted guidelines are recommended for the management of this patient group.
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Affiliation(s)
- Emma Woodward
- Section of Oncology and Clinical Research, Leeds Institute of Molecular Medicine, University of Leeds, Leeds, UK
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27
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Steele C, Steel D, Bone H, McParland L, Green L, Fraser S. Managing 'suspicious glaucomatous discs' identified during digital-photography-based diabetic retinopathy screening. Ophthalmic Physiol Opt 2006; 26:19-25. [PMID: 16390478 DOI: 10.1111/j.1475-1313.2005.00361.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE An audit to demonstrate the outcome of patients identified with suspicious glaucomatous discs within a digital-photography-based diabetic retinopathy screening programme. METHODS Primary care based digital photographic screening was performed utilising mydriasis and two-field digital photography for all patients with diabetes. Patients identified with discs suspicious of glaucomatous optic neuropathy (GON) were initially referred to an accredited community-based optometrist for further assessment. Some patients were then referred to secondary care where appropriate. RESULTS From 1st April 2002 to 31st March 2003 a total of 3868 patients were screened for diabetic retinopathy. This audit revealed that 55 subjects were identified by retinal screeners as having discs suspicious of glaucoma. A total of 29 were already under glaucoma clinic review. A total of 23/26 remaining were referred for an assessment by an accredited optometrist. Of these 13 were normal, 6 were referred to secondary care and 4 failed to attend. The three remaining were referred directly to secondary care. CONCLUSIONS All nine referrals to secondary care were deemed appropriate by a glaucoma specialist. This suggests that the system described does not lead to over-referral of suspicious discs - although the issue of how many glaucomatous discs are missed during screening (false negatives) will only be answered in the longer term.
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