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Ge P, Han C, Reyila A, Liu D, Hong W, Liu J, Zhang J, Han X, Li X, Huang M, Fan S, Kaierdebieke A, Wu X, Huang X, Guo W, Liu S, Bian Y. Risk of antiangiogenic adverse events in metastatic colorectal cancer patients receiving aflibercept in combination with chemotherapy: A meta-analysis. Medicine (Baltimore) 2023; 102:e34793. [PMID: 37657052 PMCID: PMC10476758 DOI: 10.1097/md.0000000000034793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/26/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Aflibercept has been approved for the treatment of metastatic colorectal cancer for more than a decade, but its antiangiogenesis adverse effect profile during treatment remains unclear. This study is conducted to systematically review the risk of antiangiogenic adverse events in patients with metastatic colorectal cancer receiving aflibercept plus chemotherapy. METHODS We searched databases, including PubMed, Embase and the Cochrane Library up to September 9, 2021. Relevant randomized controlled trials (RCTs) and single-arm studies were included in the review. Statistical analyses were performed using R to calculate the summary incidence rate of antiangiogenic-related adverse events, odds ratios and 95% CIs. Heterogeneity among the included studies was assessed by subgroup analysis. Publication bias analysis and sensitivity analysis were performed to confirm the reliability of the results. RESULTS A total of 2889 patients from 10 studies met the inclusion criteria. The quality of the included studies was evaluated as qualified for further quantitative synthesis. In part of single-arm studies, the occurrence rates were 44.2% (95%CI, 39.7-48.7%) for hypertension, 31.3% (95% CI, 19.3-43.3%) for proteinuria, 27.3% (95%CI, 21.2-33.4%) for epistaxis, 22.5% (95%CI, 7.8-37.3%) for hemorrhage events, 8.0% (95%CI, 2.0-14 .0%) for venous thromboembolic event in all grades and 22.6% (95%CI, 19.1-26.2%) for grade III/IV hypertension, 7.4% (95%CI, 6.2-8.5%) for grade III/IV proteinuria. In part of RCT, compared to its counterpart, aflibercept containing arm was associated with the increased incidence rate in hypertension (OR:6.30, 95%CI: 3.49-11.36), proteinuria (OR:4.12, 95%CI: 1.25-13.61), epistaxis (OR:3.71, 95%CI: 2.84-4.85), III/IV hypertension (OR:7.20, 95%CI: 5.23-9.92), III/IV proteinuria (OR:5.13, 95%CI: 3.13-8.41). The funnel plot, Begg test and Egger test were carried out on the primary endpoints, III/IV hypertension rate and III/IV proteinuria rate, the result of which detected no obvious publication bias. No significant difference was observed in subgroup analysis in the primary endpoint between the subgroups stratified by treatment line (firstline or non-firstline), chemotherapy regime (FOLFIRI or others) and study design (RCTs or single-arm trials). CONCLUSION The available evidence suggests that using aflibercept is associated with an increased risk of antiangiogenic adverse events compared with controls. Further studies are needed to investigate this association. In the appropriate clinical scenario, the use of aflibercept in its approved indications remains justified. However, the results of this study should be interpreted with caution, as some of the evidence comes from single-arm clinical trials.
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Affiliation(s)
- Pu Ge
- Institute of Chinese Medical Sciences, University of Macau, Macau, China
- State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Macau, China
- Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macau, China
| | - Chunyan Han
- School of Political Science and Public Administration, Shandong University, Qingdao, China
| | | | - Diyue Liu
- International School of Public Health and One Health, Hainan Medical University, Haikou, China
| | - Wenying Hong
- Faculty of Health Sciences, University of Macau, Macau, China
| | - Jiaxin Liu
- Xiangya School of Nursing, Central South University, Changsha, China
| | - Jinzi Zhang
- School of Humanities and Social Sciences, Harbin Medical University, Harbin, China
| | - Xiao Han
- The Fifth Affiliated Hospital of Sun Yat-sat University, Zhuhai, China
| | - Xialei Li
- School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Mengjie Huang
- School of Public Health, Shandong University, Jinan, China
| | - Siyuan Fan
- Department of Preventive Medicine, Yanjing Medical College, Capital Medical University, Beijing, China
| | | | - Xiaoyu Wu
- School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Xiaolu Huang
- Clinically Third Series, China Medical University, Shenyang, China
| | - Weirui Guo
- School of Clinical Medicine of Jining Medicine University, Jining, China
| | - Siyu Liu
- Stomatology College of Shandong University, Jinan, China
| | - Ying Bian
- Institute of Chinese Medical Sciences, University of Macau, Macau, China
- State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Macau, China
- Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macau, China
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Ge P, Wan N, Han X, Wang X, Zhang J, Long X, Wang X, Bian Y. Efficacy, safety, and cost-effectiveness analysis of aflibercept in metastatic colorectal cancer: A rapid health technology assessment. Front Pharmacol 2022; 13:914683. [PMID: 36110513 PMCID: PMC9469875 DOI: 10.3389/fphar.2022.914683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Metastatic colorectal cancer (mCRC) imposes a heavy tumor burden worldwide due to limited availability of therapeutic drugs. Aflibercept, a kind of recombinant protein of the anti-vascular endothelial growth factor (VEGF) family, has been approved in clinical application among mCRC patients since 2012. A comprehensive analysis of the efficacy, safety, and cost-effectiveness of aflibercept in mCRC treatment is necessary.Objective: To evaluate the efficacy, safety, and cost-effectiveness of aflibercept for the treatment of mCRC in order to provide a decision-making reference for the selection of targeted drugs for second-line treatment of mCRC in Hong Kong, Macao, and Taiwan regions of China and the selection of new drugs for medical institutions in these regions.Methods: A systematic retrieve on databases including PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, and Weipu, as well as relevant websites and databases of health technology assessment including the National Institute of Health and Clinical Optimization, Centre for Evaluation and Communication at the University of York, and the Canadian Agency for Medicines and Health Technology, was conducted. The literature was screened according to the inclusion and exclusion criteria, and data were extracted and analyzed by two authors, while the quality of the literature was assessed.Results: Finally, we included two HTA reports, 11 systematic reviews/meta-analyses, and two cost-effectiveness studies in the rapid health technology assessment. For mCRC patients receiving second-line treatment, aflibercept combined with FOLFIRI significantly increased progression-free survival (PFS) and overall survival (OS) and the objective response rate (ORR) also improved, compared with folinic acid + fluorouracil + irinotecan (FOLFIRI). In terms of safety, mCRC patients who received aflibercept combined with FOLFIRI therapy had a higher incidence of grade 3–4 adverse events than those who received FOLFIRI alone, including anti-VEGF–related adverse events (hypertension, hemorrhagic events, and proteinuria) and chemotherapy-related adverse events (diarrhea, weakness, stomatitis, hand-foot syndrome, neutropenia, and thrombocytopenia). In terms of cost-effectiveness, two economic studies conducted in the United Kingdom and Japan, respectively, found that compared with FOLFIRI, aflibercept combined with FOLFIRI had no cost-effectiveness advantage in mCRC patients receiving second-line treatment.Conclusion: Compared with FOLFIRI treatment, aflibercept combined with FOLFIRI for the second-line treatment of mCRC patients has better efficacy, worse safety, and is not cost-effective. More high-quality clinical studies are required for further exploration of aflibercept’s clinical value. Medical institutions in Hong Kong, Macao, and Taiwan regions of China should be cautious when using or introducing aflibercept plus FOLFIRI as a mCRC treatment.
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Affiliation(s)
- Pu Ge
- Institute of Chinese Medical Sciences, University of Macau, Macau, China
- State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Macau, China
- Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macau, China
| | - Ning Wan
- General Hospital of Southern Theater Command, Guangzhou, Guangdong, China
- Guangdong Branch Center, National Clinical Research Center for Geriatric Diseases (Chinese PLA General Hospital), Guangzhou, Guangdong, China
| | - Xiao Han
- School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Xinpei Wang
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Jinzi Zhang
- College of Humanities and Social Sciences, Harbin Medical University, Harbin, China
| | - Xiaoyi Long
- The First Affiliated Hospital of Medical School of Zhejiang, Hangzhou, China
| | - Xiaonan Wang
- School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Ying Bian
- Institute of Chinese Medical Sciences, University of Macau, Macau, China
- State Key Laboratory of Quality Research in Chinese Medicine, University of Macau, Macau, China
- Department of Public Health and Medicinal Administration, Faculty of Health Sciences, University of Macau, Macau, China
- *Correspondence: Ying Bian,
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Zhao B, Zhao H, Zhao J. Incidence and Risk of Fatal Adverse Events in Cancer Patients Treated With Vascular Endothelial Growth Factor Receptor 2-Targeted Agents: A Meta-Analysis With Trial Sequential Analysis of Randomized Controlled Trials. Front Med (Lausanne) 2019; 6:176. [PMID: 31440509 PMCID: PMC6693387 DOI: 10.3389/fmed.2019.00176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/19/2019] [Indexed: 12/21/2022] Open
Abstract
Background/Aim: Agents targeting vascular endothelial growth factor (VEGF) pathway have dramatically improved the outlook of cancer treatment. Meanwhile, it is well-known that they are associated with increases in the risk of fatal adverse events (FAEs). Vascular endothelial growth factor receptor 2 (VEGFR2)-targeted drugs have been approved for the treatment of several malignancies. However, little is known regarding the FAEs induced by VEGFR2-targeted agents across different tumor types and treatment regimens. Methods: We searched PubMed and Embase database from January 1966 to April 2018 for randomized controlled trials (RCTs) to calculate the incidence and relative risks (RRs) of FAE. Results: Seventeen RCTs involving 6,982 subjects with solid tumors were included in this study. The overall incidence of FAEs associated with VEGFR2-targeted agents was 1.7% (95% CI: 0.9-2.4%). Compared with controls, the administration of VEGFR2-targeted agents did not increase the risk of FAEs (RR, 1.29; 95% CI: 0.90-1.86). No significant association was found between FAE and VEGFR2-targeted agents in subgroup analyses based on tumor type, treatment strategy, clinical phase, masking method, median treatment duration, and approval status. Additionally, FAEs occurred in the major organ systems dispersedly. Trial sequential analysis revealed that our results are solid and further studies are unlikely to change this. Conclusions: VEGFR2-targeted agents were not associated with an increased risk of FAEs.
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Affiliation(s)
- Bin Zhao
- The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Hong Zhao
- The Third Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiaxin Zhao
- The Fourth Affiliated Hospital of Harbin Medical University, Harbin, China.,Heilongjiang Academy of Medical Sciences, Harbin, China
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Ganjibakhsh M, Monshizadeh R, Nasimian A, Aminishakib P, Farzaneh P, Tavakoli Shiraji S, Gharajei A, Rahrotaban S, Baghaei F, Gohari NS. Anti-angiogenic efficacy of aflibercept and bevacizumab in primary oral squamous cell carcinoma cells. J Oral Pathol Med 2018; 47:575-582. [PMID: 29672933 DOI: 10.1111/jop.12717] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND In recent decades, anti-angiogenic treatment strategy has been well described in cancer treatment. The anti-angiogenic activity of both bevacizumab and aflibercept has been researched on 10 previously established primary oral squamous cell carcinoma (OSCC) cells of an Iranian population with different levels of purity, in an attempt to find the most effective anti-angiogenic-targeted drug. METHODS To investigate and compare the effect of bevacizumab and aflibercept on vascular endothelial growth factor (VEGF) secretion of 10 primary OSCC cells, cell proliferation and viability were assessed by ELISA and MTT assays. In addition, cell migration was studied using scratch assay. RESULTS The results showed that VEGF impressively expressed in all primary cancer cells. Although both drugs significantly reduced the secretion of VEGF, the effect of aflibercept was more prominent. Also, bevacizumab-treated cells migration was lower than the control group and the cells treated with aflibercept showed the lowest migration rate compared to bevacizumab and control groups. CONCLUSION The anti-angiogenic-targeted drugs, especially Af, might be effective in treatment of patients with OSCC in combination with conventional surgical treatments.
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Affiliation(s)
- Meysam Ganjibakhsh
- Human and Animal Cell Bank, Iranian Biological Resource Center (IBRC), ACECR, Tehran, Iran
| | - Roshanak Monshizadeh
- Department of Oral and Maxillofacial Pathology, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Nasimian
- Department of Clinical Biochemistry, School of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Pouyan Aminishakib
- Department of Oral and Maxillofacial Pathology, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran.,Dental Research Center, Dentistry Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Parvaneh Farzaneh
- Human and Animal Cell Bank, Iranian Biological Resource Center (IBRC), ACECR, Tehran, Iran
| | - Sahar Tavakoli Shiraji
- Hematology, Oncology and SCT Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ata Gharajei
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran.,Department of Head and Neck Surgical Oncology and Reconstructive Surgery, The Cancer Institute, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sedigheh Rahrotaban
- Department of Oral and Maxillofacial Pathology, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Fereshteh Baghaei
- Dental Research Center, Dentistry Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Neda Sadat Gohari
- Human and Animal Cell Bank, Iranian Biological Resource Center (IBRC), ACECR, Tehran, Iran
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Gonzaga-López A, Muñoz-Rodriguez J, Ruiz-Casado A. Necrotising fasciitis in a patient treated with FOLFIRI-aflibercept for colorectal cancer: a case report. Ann R Coll Surg Engl 2017; 99:e225-e226. [PMID: 28768426 PMCID: PMC5696931 DOI: 10.1308/rcsann.2017.0143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Anti-angiogenics have become an important part of the treatment of several types of tumours such as ovarian, breast, lung and colorectal cancer. Necrotising fasciitis has been reported with bevacizumab but no cases have been reported with aflibercept, ramucirumab or regorafenib in patients with colorectal cancer. Necrotising fasciitis is a rare complication affecting one in 5000 bevacizumab users. We report the case of a 64-year-old man with stage IV rectosigmoid cancer under treatment with folinic acid, fluorouracil and irinotecan (FOLFIRI) and aflibercept, who developed a Fournier’s gangrene.
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Affiliation(s)
| | | | - A Ruiz-Casado
- Medical oncologist at Puerta de Hierro Majadahonda University Hospital
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Shun Z, Lei G, Liu Q, Zheng W, Quan H, Hitier S. Concepts, Methods, and Practical Considerations of Meta-Analysis in Drug Development. Stat Biopharm Res 2016. [DOI: 10.1080/19466315.2016.1174148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Zhenming Shun
- Department of Biostatistics and Programming, Sanofi, Cambridge, MA, USA
| | - Gao Lei
- Department of Biostatistics and Programming, Sanofi, Cambridge, MA, USA
| | - Qianying Liu
- Department of Biostatistics and Programming, Sanofi, Cambridge, MA, USA
| | - Wei Zheng
- Department of Biostatistics and Programming, Sanofi, Cambridge, MA, USA
| | - Hui Quan
- Department of Biostatistics and Programming, Sanofi, Cambridge, MA, USA
| | - Simon Hitier
- Sanofi Research & Development, Chilly-Mazarin, France
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Echazarreta-Gallego E, Elía-Guedea M, Córdoba-Díaz de Laspra E. [Devastating surgical complications after aflibercept chemotherapy]. CIR CIR 2016; 85:260-263. [PMID: 27140945 DOI: 10.1016/j.circir.2016.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 10/29/2015] [Accepted: 02/10/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND The use of a new chemotherapy as adjuvant treatment of colorectal cancer is not free of complications. Monoclonal antibodies are associated with bleeding and intestinal perforations. OBJECTIVE To report the case of a patient who developed a serious complication after treatment with an antiangiogenic drug for colorectal neoplasm. CLINICAL CASE The case is presented of a 42-year-old male operated on due to subocclusive rectal cancer with metástasis at the time of diagnosis. Sixteen months after surgery during second-line adjuvant therapy, an intestinal perforation was observed with haemorrhage and intestinal leak to retroperitoneum and left lower extremity. Despite intensive medical and surgical treatment this complication had fatal consequences. CONCLUSIONS Future research should be directed at obtaining biomarkers for the specific use of antiangiogenic agents in order to decrease the rate of adverse factors.
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Affiliation(s)
- Estíbaliz Echazarreta-Gallego
- Sección de Coloproctología, Servicio de Cirugía General, Hospital Clínico Universitario de Zaragoza, Zaragoza, España.
| | - Manuela Elía-Guedea
- Sección de Coloproctología, Servicio de Cirugía General, Hospital Clínico Universitario de Zaragoza, Zaragoza, España
| | - Elena Córdoba-Díaz de Laspra
- Sección de Coloproctología, Servicio de Cirugía General, Hospital Clínico Universitario de Zaragoza, Zaragoza, España
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Treatment-related mortality with aflibercept in cancer patients. Eur J Clin Pharmacol 2014; 70:1269-70. [PMID: 25055958 PMCID: PMC4158179 DOI: 10.1007/s00228-014-1715-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 07/01/2014] [Indexed: 11/23/2022]
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Burke DL, Billingham LJ, Girling AJ, Riley RD. Meta-analysis of randomized phase II trials to inform subsequent phase III decisions. Trials 2014; 15:346. [PMID: 25187348 PMCID: PMC4162965 DOI: 10.1186/1745-6215-15-346] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 08/14/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND If multiple Phase II randomized trials exist then meta-analysis is favorable to increase statistical power and summarize the existing evidence about an intervention's effect in order to help inform Phase III decisions. We consider some statistical issues for meta-analysis of Phase II trials for this purpose, as motivated by a real example involving nine Phase II trials of bolus thrombolytic therapy in acute myocardial infarction with binary outcomes. METHODS We propose that a Bayesian random effects logistic regression model is most suitable as it models the binomial distribution of the data, helps avoid continuity corrections, accounts for between-trial heterogeneity, and incorporates parameter uncertainty when making inferences. The model also allows predictions that inform Phase III decisions, and we show how to derive: (i) the probability that the intervention will be truly beneficial in a new trial, and (ii) the probability that, in a new trial with a given sample size, the 95% credible interval for the odds ratio will be entirely in favor of the intervention. As Phase II trials are potentially optimistic due to bias in design and reporting, we also discuss how skeptical prior distributions can reduce this optimism to make more realistic predictions. RESULTS In the example, the model identifies heterogeneity in intervention effect missed by an I-squared of 0%. Prediction intervals accounting for this heterogeneity are shown to support subsequent Phase III trials. The probability of success in Phase III trials increases as the sample size increases, up to 0.82 for intracranial hemorrhage and 0.79 for reinfarction outcomes. CONCLUSIONS The choice of meta-analysis methods can influence the decision about whether a trial should proceed to Phase III and thus need to be clearly documented and investigated whenever a Phase II meta-analysis is performed.
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Affiliation(s)
- Danielle L Burke
- />Medical Research Council Midland Hub for Trials Methodology Research, School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT UK
| | - Lucinda J Billingham
- />Medical Research Council Midland Hub for Trials Methodology Research, School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT UK
- />Cancer Research UK Clinical Trials Unit, University of Birmingham, Edgbaston, Birmingham B15 2TT UK
| | - Alan J Girling
- />Medical Research Council Midland Hub for Trials Methodology Research, School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT UK
| | - Richard D Riley
- />School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT UK
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