SCOPE 2 - Still Answering the Unanswered Questions in Oesophageal Radiotherapy? SCOPE 2: a Randomised Phase II/III Trial to Study Radiotherapy Dose Escalation in Patients with Oesophageal Cancer Treated with Definitive Chemoradiation with an Embedded Phase II Trial for Patients with a Poor Early Response using Positron Emission Tomography/Computed Tomography

A qualitative study exploring participants' experiences of the SCOPE2 trial: chemoradiotherapy dose escalation in oesophageal cancer

INTRODUCTION

This qualitative study explored patients' experiences and perceptions of the SCOPE2 trial. The trial studied radiotherapy dose escalation in patients with inoperable oesophageal cancer treated with definitive chemo-radiation. SCOPE2 embedded a phase II trial for patients with a poor early response using positron emission tomography (PET) scans.

METHODS

This longitudinal interview study took place between 2017 and 2021. Patients eligible for chemoradiotherapy were recruited from five clinical sites in the UK. Participants were invited to participate in three semi-structured interviews across four different time points: baseline (before treatment) and at 2-3 months, 3-6 months or 6 months + after baseline. This paper focuses on recruitment to the trial, practical management, the impact of COVID-19 and reflections of being on the trial. Real-time reporting to the trial team was used to inform potential improvements to trial conduct and recruitment. The interviews were thematically analysed.

RESULTS

Ten participants were interviewed in 16 longitudinal interviews. There were five female and five male interview participants; three participants were accompanied by companions during their interviews. Recruitment to the trial and qualitative study was challenging. Motivations for joining the trial included altruism, potentially receiving better care and monitoring and the opportunity to improve their quality of life. Participants required adequate time to consider information and regular updates regarding trial and treatment process. Participants felt that their trial experience was minimally impacted by COVID-19, although some delays to treatment were reported.

CONCLUSION

Increased opportunities for patients to discuss and receive appropriate and timely information from trial staff and third sector partners could enhance patients' understanding of future trials, treatments and procedures. Slow recruitment to the trial and qualitative study was further impeded by the COVID-19 pandemic and future trials would benefit from a more fully integrated approach to qualitative recruitment.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT02741856 registered on 12 April 2016; ISRCTN: 9,712,546 registered on 26 October 2016.

Radiotherapy Quality Assurance in the SCOPE2 Trial: What Lessons can be Learned for the Next UK Trial in Oesophageal Cancer?

AIMS

The SCOPE2 trial evaluates radiotherapy (RT) dose escalation for oesophageal cancer. We report findings from the accompanying RT quality assurance (RTQA) programme and identify recommendations for PROTIEUS, the next UK trial in oesophageal RT.

MAETRIALS AND METHODS

SCOPE2's RTQA programme consisted of a pre-accrual and on-trial component. RTQA pre-accrual requirements included acceptable submission of 3D ± 4D benchmark contouring exercise(s) and a high-dose planning case. On-trial requirements for contouring and planning included prospective reviews (PRs) of each centre's first 3D ± 4D patient and all high-dose cases prior to formal safety review. Further PRs were at the RTQA team's discretion. Timely retrospective reviews (TRRs) were also undertaken for a random 10%. Submissions were assessed against pre-defined criteria and RT planning guidance document (RPGD). This study includes initial submissions only; subsequent resubmissions are not included in this analysis.

RESULTS

For contouring, 30/64 (47%) pre-accrual submissions were approved. 38/64 (59%) contained ≥1 target volume (TV) unacceptable variation from protocol (UV), most commonly in CTVB and ITV. Organ-at-risk (OAR) contour review was undertaken in 28/64 (44%); 6/28 (21%) contained ≥1 UV, most commonly in heart and spinal cord. 82/126 (65%) on-trial submissions were approved. 47/126 (37%) contained ≥1 TV UV, most commonly in CTVB, GTV and ITV. For OARs, 30/126 (24%) contained ≥1 UV, most commonly in heart and lungs. On-trial contour submissions were significantly more likely to be approved than pre-accrual (p = 0.016). For planning, 32/43 (79%) pre-accrual plans were approved, those unacceptable were due to PTV coverage/conformity. 118/120 (98%) on-trial plans were approved, the remaining unacceptable were due to PTV coverage/conformity. No UVs in OAR dose constraints were observed. All on-trial submissions were approved following resubmission where necessary.

CONCLUSION

Despite an RPGD, contouring atlas, and similar contouring protocols from preceding trials, the SCOPE2 RTQA programme demonstrates a high frequency of UVs. Our findings inform recommendations for future oesophageal RT trials.

Effect of end expiration breath hold on target volumes and organ at risk doses for oesophageal cancer radiotherapy

Background and Purpose

The end expiration breath hold (EEBH) technique has the potential to reduce tumour motion during radiotherapy treatment of lower oesophageal cancer, and therefore, motion artefacts, target volumes and dose to surrounding organs at risk (OAR). EEBH is an emerging technique and clinical data on its use in oesophageal cancer is scarce.

Methods and Materials

A comparison of 20 lower oesophageal cancer patients was performed for radiotherapy treatment plans in both EEBH and free breathing (FB). EEBH and FB plans were evaluated and compared in terms of motion artefacts, target volumes and dose-volume metrics.

Results

EEBH was effective in reducing the observed motion artefacts seen in planning CTs compared to FB. EEBH also significantly reduced the average PTV size between EEBH and FB (ΔV = -48 ± 55 cm3; p < 0.001). OAR-PTV overlap volumes were also effectively reduced in EEBH compared to FB, including for lung-PTV overlaps (ΔV = -13 ± 13 cm3; p < 0.001) and for heart-PTV overlaps (ΔV = -8 ± 14 cm3; p = 0.02). Mean heart doses were lower on average by -1.2 ± 2.0 Gy with EEBH (p = 0.02), and mean lung doses by -1.0 ± 1.0 Gy (p < 0.001). Mean liver doses were on average reduced with EEBH by -0.6 ± 1.5 Gy, whereas spinal D2cm3 increased in EEBH compared to FB by 1.8 ± 6.3 Gy, but neither were statistically significant.

Conclusion

Use of EEBH for oesophageal cancer radiotherapy reduced motion artefacts and increased confidence in contouring volumes. Additionally, planning target volumes and doses to key OARs were reduced with EEBH compared to FB plans.

The experiences of patients with oesophageal cancer receiving chemoradiotherapy treatment: a qualitative study embedded in the SCOPE2 trial

OBJECTIVES

This qualitative study explored patients' experiences and perceptions of the SCOPE2 trial. SCOPE2 examined radiotherapy dose escalation in patients with inoperable oesophageal cancer treated with definitive chemoradiotherapy (dCRT).

SETTING

Recruitment at five clinical sites in England and Wales, UK.

PARTICIPANTS

SCOPE2 trial participants were invited to take part in interviews from across five clinical sites. Participants self-selected to take part in up to three interviews across four different time points: baseline (before treatment) and at 2-3 months, 3-6 months or 6 months+ after baseline. There were five female and five male interview participants.

INTERVENTIONS

Participants were randomised to standard dose dCRT prescribed carboplatin/paclitaxel or cisplatin/capecitabine, or an escalated dose dCRT prescribed carboplatin/paclitaxel or cisplatin/capecitabine.

METHODS

This qualitative study used semistructured longitudinal interviews to explore the impact of treatment on patient outlook and quality of life and the impact of the COVID-19 pandemic. Interview data were thematically analysed.

RESULTS

10 patients participated in 16 longitudinal interviews. Three participants were accompanied by companions. Participants experienced side-effects from radiotherapy and chemotherapy including nausea, throat pain, difficulties eating and regaining appetite, thrombosis and fatigue, although most of these symptoms gradually improved. Participants required more ongoing information and support regarding treatment side-effects and cancer status in order to improve their overall quality of life. Best practice examples involved key contacts providing practical advice and signposting support.

CONCLUSION

Participants of the SCOPE2 trial reported short and longer-term side-effects from chemoradiotherapy, but these usually lessened over time. Participants attempted to be positive about their survival prospects by readjusting their expectations, priorities and lifestyles. Providing patients with ongoing opportunities to discuss detailed and timely information regarding treatment side-effects, aftercare and cancer status could improve the overall health and well-being of patients during oesophageal cancer trials and pathways.

TRIAL REGISTRATION NUMBER

NCT02741856; ISRCTN: 97125464.

Advances in diagnosis and management of cancer of the esophagus

Esophageal cancer is the seventh most common malignancy worldwide, with over 470 000 new cases diagnosed each year. Two distinct histological subtypes predominate, and should be considered biologically separate disease entities.1 These subtypes are esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC). Outcomes remain poor regardless of subtype, with most patients presenting with late stage disease.2 Novel strategies to improve early detection of the respective precursor lesions, squamous dysplasia, and Barrett's esophagus offer the potential to improve outcomes. The introduction of a limited number of biologic agents, as well as immune checkpoint inhibitors, is resulting in improvements in the systemic treatment of locally advanced and metastatic esophageal cancer. These developments, coupled with improvements in minimally invasive surgical and endoscopic treatment approaches, as well as adaptive and precision radiotherapy technologies, offer the potential to improve outcomes still further. This review summarizes the latest advances in the diagnosis and management of esophageal cancer, and the developments in understanding of the biology of this disease.

Esophagogastric Cancer: The Current Role of Radiation Therapy

Radiation therapy is an effective treatment modality in the management of patients with esophageal cancer regardless of tumor location (proximal, middle, or distal esophagus) or histology (squamous cell vs adenocarcinoma). The addition of neoadjuvant CRT to surgery in patients who are surgical candidates has consistently shown a benefit in terms of locoregional recurrence, pathologic downstaging, and overall survival. For patients who are not surgical candidates, CRT has a role as definitive treatment.

Multi-disciplinary management of esophageal carcinoma: Current practices and future directions

Esophageal cancer in one of the most malignant and hard-to-treat cancers. Esophageal squamous carcinoma (ESCC) is most common in Asian countries, whereas adenocarcinoma at the esophago-gastric junction (EGJ AC) is more prevalent in the Western countries. Due to differences in both genetic background and response to chemotherapy and radiotherapy, both histologic subtypes need different paradigms of management. Since the landmark CROSS study has demonstrated the superior survival benefit of tri-modality including neoadjuvant chemoradiotherapy prior to esophagectomy, the tri-modality becomes the standard of care; however, it is suitable for a highly-selected patient. Tri-modality should be offered for every ESCC patient, if a patient is fit for surgery with adequate cardiopulmonary reserve, regardless of ages. Definitive chemoradiotherapy remains the best option for a patient who is not a surgical candidate or declines surgery. On the contrary, owing to doubtful benefits of radiotherapy with potentially more toxicities related to radiotherapy in EGJ AC, either neoadjuvant chemotherapy or peri-operative chemotherapy would be more preferable in an EGJ AC patient. In case of very locally advanced disease (cT4b), the proper management is more challenging. Even though, palliative care is the safe option, multi-modality therapy with curative intent like neoadjuvant chemotherapy with conversion surgery may be worthwhile; however, it should be suggested on case-by-case basis.

Treatment Outcomes and Risk Factors for Incomplete Treatment after Definitive Chemoradiotherapy for Non-Resectable or Metastatic Esophageal Cancer

Among patients with unresectable or metastatic esophageal cancer who receive definitive chemotherapy or chemoradiotherapy, the rates of treatment-related adverse events and incomplete treatment remain high. We conducted this study to investigate survival after definitive treatments and identify predicting factors for incomplete treatment. The data of patients who received definitive chemotherapy or chemoradiotherapy for esophageal cancer were retrospectively examined. The patients were assigned to Group 1: incomplete definitive treatment; Group 2: complete definitive treatment; or Group 3: complete definitive treatment with additional salvage surgery. The data of 273 patients (90, 166, and 17 in Groups 1, 2, and 3, respectively) were analyzed. In the survival analysis, the median overall survival of Groups 1, 2, and 3 were 2.6, 10.3, and 29.5 months, respectively. A significant difference in 3-year overall survival was observed among the groups (2.2%, 12.4%, and 48.5%, p < 0.001). In multivariable analysis, the independent risk factors for incomplete definitive treatment included poor performance score (hazard ratio (HR): 5.23, p = 0.001), bone metastasis (HR: 2.18, p = 0.024), airway invasion (HR: 2.90, p = 0.001), and liver cirrhosis (HR: 3.20, p = 0.026). Incomplete definitive treatment is associated with a far worse prognosis. Poor performance, bone metastasis, airway invasion, and liver cirrhosis are risk factors for incomplete treatment.

Low muscle mass measured at T12 is a prognostic biomarker in unresectable oesophageal cancers receiving chemoradiotherapy

BACKGROUND AND PURPOSE

Low muscle mass is an imaging biomarker of patient frailty that has been associated with increased toxicity and decreased survival in a number of cancers. Patients with unresectable oesophageal cancer receive chemoradiotherapy as standard of care. Muscle mass is not yet an established prognostic marker in this population. Muscle mass is usually assessed by segmenting skeletal muscle at the L3 vertebral level. But radiotherapy planning scans for oesophageal cancers do not always image this level, which has limited previous studies of body composition. Skeletal muscle is known to regulate immune function, but the association of muscle mass with lymphopenia in cancer patients has not been shown.

MATERIALS AND METHODS

We retrospectively analyse 135 oesophageal cancer patients who received chemoradiotherapy and investigate the prognostic value of skeletal muscle area assessed at T12. We also examine the association between muscle mass and radiation-induced lymphopenia.

RESULTS

We find that low muscle mass is associated with poorer overall survival (hazard ratio [95% confidence interval]: 0.72 [0.53-0.97]). However, this effect interacts with body mass index (BMI) such that the prognostic value of low muscle mass is removed by high BMI. In our study, patients with low muscle mass were more prone to radiation-induced lymphopenia (75% vs. 50% in patients with high muscle mass). A significant decrease in circulating lymphocytes was associated with poorer overall survival (hazard ratio [95% confidence interval]: 0.68 [0.47-0.99]).

CONCLUSION

Our study shows that assessing muscle mass at T12 is feasible and provides prognostic information. Low muscle mass at T12 is associated with poorer overall survival and increased risk of radiation-induced lymphopenia. Muscle mass provides additional information over performance status and BMI. Low BMI patients are most affected by low muscle mass, highlighting the importance of close nutritional support in this population.

Efficacy of early PET-CT directed switch to carboplatin and paclitaxel based definitive chemoradiotherapy in patients with oesophageal cancer who have a poor early response to induction cisplatin and capecitabine in the UK: a multi-centre randomised controlled phase II trial

Background

The utility of early metabolic response assessment to guide selection of the systemic component of definitive chemoradiotherapy (dCRT) for oesophageal cancer is uncertain.

Methods

In this multi-centre, randomised, open-label, phase II substudy of the radiotherapy dose-escalation SCOPE2 trial we evaluated the role of ¹⁸F-Fluorodeoxyglucose positron emission tomography (PET) at day 14 of cycle 1 of three-weekly induction cis/cap (cisplatin (60 mg/m²)/capecitabine (625 mg/m² days 1-21)) in patients with oesophageal squamous cell carcinoma (OSCC) or adenocarcinoma (OAC). Non-responders, who had a less than 35% reduction in maximum standardised uptake value (SUV_max) from pre-treatment baseline, were randomly assigned to continue cis/cap or switch to car/pac (carboplatin AUC 5/paclitaxel 175 mg/m²) for a further induction cycle, then concurrently with radiotherapy over 25 fractions. Responders continued cis/cap for the duration of treatment. All patients (including responders) were randomised to standard (50Gy) or high (60Gy) dose radiation as part of the main study. Primary endpoint for the substudy was treatment failure-free survival (TFFS) at week 24. The trial was registered with International Standard Randomized Controlled Trial Number 97125464 and ClinicalTrials.govNCT02741856.

Findings

This substudy was closed on 1st August 2021 by the Independent Data Monitoring Committee on the grounds of futility and possible harm. To this point from 22nd November 2016, 103 patients from 16 UK centres had participated in the PET-CT substudy; 63 (61.2%; 52/83 OSCC, 11/20 OAC) of whom were non-responders. Of these, 31 were randomised to car/pac and 32 to remain on cis/cap. All patients were followed up until at least 24 weeks, at which point in OSCC both TFFS (25/27 (92.6%) vs 17/25 (68%); p = 0.028) and overall survival (42.5 vs. 20.4 months, adjusted HR 0.36; p = 0.018) favoured cis/cap over car/pac. There was a trend towards worse survival in OSCC + OAC cis/cap responders (33.6 months; 95%CI 23.1-nr) vs. non-responders (42.5 (95%CI 27.0-nr) months; HR = 1.43; 95%CI 0.67-3.08; p = 0.35).

Interpretation

In OSCC, early metabolic response assessment is not prognostic for TFFS or overall survival and should not be used to personalise systemic therapy in patients receiving dCRT.

Funding

Cancer Research UK.

PET-directed combined modality therapy for gastroesophageal junction cancer: Results of the multicentre prospective MEMORI trial of the German Cancer Consortium (DKTK)

BACKGROUND

Positron emission tomography (PET) may differentiate responding and non-responding tumours early in the treatment of locally advanced gastroesophageal junction adenocarcinomas. Early PET non-responders (P-NR) after induction CTX might benefit from changing to chemoradiation (CRT).

METHODS

Patients underwent baseline ¹⁸F-FDG PET followed by 1 cycle of CTX. PET was repeated at day 14-21 and responders (P-R), defined as ≥35% decrease in SUV_mean from baseline, continued with CTX. P-NR switched to CRT (CROSS). Patients underwent surgery 4-6 weeks post-CTX/CRT. The primary objective was an improvement in R0 resection rates in P-NR above a proportion of 70%.

RESULTS

In total, 160 patients with resectable gastroesophageal junction adenocarcinomas were prospectively investigated by PET scanning. Eighty-five patients (53%) were excluded. Seventy-five eligible patients were enrolled in the study. Based on PET criteria, 50 (67.6%)/24 (32.4%) were P-R and P-NR, respectively. Resection was performed on 46 responders, including one patient who withdrew the ICF, and 22 non-responders (per-protocol population). R0 resection rates were 95.6% (43/45) for P-R and 86.4% (19/22) for P-NR. No treatment related deaths occurred. With a median follow-up time of 24.5 months, estimated 18 months DFS was 75.4%/64.2% for P-R/P-NR, respectively. The estimated 18 months OS was 95.5% for P-R and 68.2% for P-NR.

CONCLUSION

The primary endpoint of the study to increase the R0 resection rate in metabolic NR was not met. PET response after induction CTX is prognostic for outcome with a prolonged OS and DFS in PET responders.

TRIAL REGISTRATION

NCT00002014-000860-16.