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Ursprung S, Mossop H, Gallagher FA, Sala E, Skells R, Sipple JAN, Mitchell TJ, Chhabra A, Fife K, Matakidou A, Young G, Walker A, Thomas MG, Ortuzar MC, Sullivan M, Protheroe A, Oades G, Venugopal B, Warren AY, Stone J, Eisen T, Wason J, Welsh SJ, Stewart GD. The WIRE study a phase II, multi-arm, multi-centre, non-randomised window-of-opportunity clinical trial platform using a Bayesian adaptive design for proof-of-mechanism of novel treatment strategies in operable renal cell cancer - a study protocol. BMC Cancer 2021; 21:1238. [PMID: 34794412 PMCID: PMC8600815 DOI: 10.1186/s12885-021-08965-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 11/04/2021] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Window-of-opportunity trials, evaluating the engagement of drugs with their biological target in the time period between diagnosis and standard-of-care treatment, can help prioritise promising new systemic treatments for later-phase clinical trials. Renal cell carcinoma (RCC), the 7th commonest solid cancer in the UK, exhibits targets for multiple new systemic anti-cancer agents including DNA damage response inhibitors, agents targeting vascular pathways and immune checkpoint inhibitors. Here we present the trial protocol for the WIndow-of-opportunity clinical trial platform for evaluation of novel treatment strategies in REnal cell cancer (WIRE). METHODS WIRE is a Phase II, multi-arm, multi-centre, non-randomised, proof-of-mechanism (single and combination investigational medicinal product [IMP]), platform trial using a Bayesian adaptive design. The Bayesian adaptive design leverages outcome information from initial participants during pre-specified interim analyses to determine and minimise the number of participants required to demonstrate efficacy or futility. Patients with biopsy-proven, surgically resectable, cT1b+, cN0-1, cM0-1 clear cell RCC and no contraindications to the IMPs are eligible to participate. Participants undergo diagnostic staging CT and renal mass biopsy followed by treatment in one of the treatment arms for at least 14 days. Initially, the trial includes five treatment arms with cediranib, cediranib + olaparib, olaparib, durvalumab and durvalumab + olaparib. Participants undergo a multiparametric MRI before and after treatment. Vascularised and de-vascularised tissue is collected at surgery. A ≥ 30% increase in CD8+ T-cells on immunohistochemistry between the screening and nephrectomy is the primary endpoint for durvalumab-containing arms. Meanwhile, a reduction in tumour vascular permeability measured by Ktrans on dynamic contrast-enhanced MRI by ≥30% is the primary endpoint for other arms. Secondary outcomes include adverse events and tumour size change. Exploratory outcomes include biomarkers of drug mechanism and treatment effects in blood, urine, tissue and imaging. DISCUSSION WIRE is the first trial using a window-of-opportunity design to demonstrate pharmacological activity of novel single and combination treatments in RCC in the pre-surgical space. It will provide rationale for prioritising promising treatments for later phase trials and support the development of new biomarkers of treatment effect with its extensive translational agenda. TRIAL REGISTRATION ClinicalTrials.gov: NCT03741426 / EudraCT: 2018-003056-21 .
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Affiliation(s)
| | - Helen Mossop
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ferdia A Gallagher
- CRUK Cambridge Centre, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Evis Sala
- CRUK Cambridge Centre, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Richard Skells
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- AstraZeneca, Cambridge, UK
| | - Jamal A N Sipple
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thomas J Mitchell
- CRUK Cambridge Centre, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Wellcome Sanger Institute, Hinxton, UK
| | - Anita Chhabra
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Fife
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Athena Matakidou
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gemma Young
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Amanda Walker
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Martin G Thomas
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Mark Sullivan
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, UK
| | - Andrew Protheroe
- Oxford University Hospitals National Health Service Foundation Trust, Oxford, UK
| | - Grenville Oades
- Department of Urology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Balaji Venugopal
- Institute of Cancer Sciences, University of Glasgow, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Anne Y Warren
- CRUK Cambridge Centre, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Tim Eisen
- CRUK Cambridge Centre, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James Wason
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Medical Research Council Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Sarah J Welsh
- CRUK Cambridge Centre, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Grant D Stewart
- CRUK Cambridge Centre, University of Cambridge, Cambridge, UK.
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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Osowiecka K, Nawrocki S, Kurowicki M, Rucinska M. The Waiting Time of Prostate Cancer Patients in Poland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16030342. [PMID: 30691113 PMCID: PMC6388381 DOI: 10.3390/ijerph16030342] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/14/2019] [Accepted: 01/23/2019] [Indexed: 12/24/2022]
Abstract
Background: Prostate cancer is the second most common reason of mortality due to cancer among men in Poland. The study aimed to determine the waiting time for diagnosis and treatment of prostate cancer. Methods: The study was carried out on patients treated for prostate cancer from May 2014 to February 2015 at five oncological centres in Poland. The median waiting time was measured from the time cancer was suspected to the histopathological diagnosis (SDI), from the cancer suspicion to the start of treatment (STI) and from the diagnosis to the start of treatment (DTI). Results: 123 males treated for prostate cancer were included for analysis. The median time for SDI, STI and DTI was 7.7, 18.7 and 8.7 weeks, respectively. Place of residence was the only factor which influenced STI (p = 0.003). For patients, who started treatment with radiation therapy DTI was longer than for other patients (p < 0.001). Conclusions: Median times of STI, SDI and DTI for prostate cancer patients in Poland are similar to the intervals described in other countries. Patients, who lived further from an oncology centre waited longer for treatment. The impact of waiting time in the case of prostate cancer on improving the prognosis is still unclear.
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Affiliation(s)
- Karolina Osowiecka
- Department of Public Health, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-082 Olsztyn, Al. Warszawska 30, Poland.
- Department of Public Health, Medical University of Warsaw, 02-097 Warszawa, Ul. Nielubowicza 5, Poland.
- Radiotherapy Center Nu-Med, 82-300 Elblag, Ul. Królewiecka 146, Poland.
| | - Sergiusz Nawrocki
- Radiotherapy Center Nu-Med, 82-300 Elblag, Ul. Królewiecka 146, Poland.
- Department of Oncology and Radiotherapy, Medical University of Silesia in Katowice, 40-515 Katowice, Ul. Ceglana 35, Poland.
| | - Marcin Kurowicki
- Radiotherapy Center Nu-Med, 82-300 Elblag, Ul. Królewiecka 146, Poland.
| | - Monika Rucinska
- Department of Oncology, Collegium Medicum, School of Medicine, University of Warmia and Mazury in Olsztyn, 10-228 Olsztyn, Al. Wojska Polskiego 37, Poland.
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Impact of the length of time between diagnosis and surgical removal of urologic neoplasms on survival. World J Urol 2013; 32:475-9. [PMID: 23455886 DOI: 10.1007/s00345-013-1045-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 02/18/2013] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Our aim was to assess the effect of surgical wait time on the survival of patients with urological neoplasms, including prostate, bladder, penile, and testicular cancers and upper tract tumours (UTUC). MATERIALS AND METHODS Current, relevant studies were identified from the literature. Keywords used for article retrieval were as follows: delay; surgery; prostate cancer; urothelial carcinoma; renal cell carcinoma; testicular cancer; bladder; renal pelvis; ureter; and survival. RESULTS Regarding the length of surgical wait time, it does not matter in cases of incidental T1a renal cell carcinomas. In other cases of renal cell carcinomas, surgery should be considered within <1 month; it is of crucial importance in bladder cancer and should be <1 month for a TURBT in cases of non-muscle-invasive bladder cancer and <1 month for a radical cystectomy in cases of muscle-invasive bladder cancer; it is important in invasive UTUC and should be <1 month for a radical nephroureterectomy; it is not crucial in cases of low-risk prostate cancer. In any other case, radical prostatectomy should be considered within <2 months; it is important in testicular cancer and should be fewer than 10 days for an orchiectomy. CONCLUSION Prolonged surgical wait times have an impact on the overall quality of life and anxiety of the patient. Extending the wait time beyond a given threshold can also have a negative impact on the patient's clinical outcomes, but this threshold differs between urological neoplasms.
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Kim KH, You D, Jeong IG, Song C, Hong JH, Ahn H, Kim CS. The impact of delaying radical nephrectomy for stage II or higher renal cell carcinoma. J Cancer Res Clin Oncol 2012; 138:1561-7. [PMID: 22547152 DOI: 10.1007/s00432-012-1230-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 04/10/2012] [Indexed: 12/19/2022]
Abstract
PURPOSE To evaluate the impact of surgical waiting time (SWT) on outcomes of patients who underwent radical nephrectomy for stage II or higher renal cell carcinoma (RCC). METHODS Of the 1,732 patients who underwent surgery for RCC between 1989 and 2007, medical records of 319 with clinical stage II or higher RCC without distant metastases were retrospectively reviewed. Ten patients with SWT greater than 3 months were excluded from analysis, and we compared pathological upstaging and survival rates between patients with SWT <1 month (234/319, 73.3 %) and 1-3 months (75/319, 23.5 %). RESULTS Clinicopathological characteristics between two groups were not different except the presence of symptom. The pathological upstaging was higher in patients with SWT of 1-3 months but statistically not significant. SWT of 1-3 months was not an independent predictor of pathological upstaging, recurrence-free survival (RFS; p = 0.896), or cancer-specific survival (CSS; p = 0.737). On subgroup analysis by TNM stage (cT2NxcM0 and cT3-4NxcM0), SWT of 1-3 months was not an independent predictor of pathological upstaging and was not associated with RFS or CSS. SWT, treated as a continuous variable, was also not an independent predictor of outcome in any subgroup. Similar results were found in symptomatic patients. CONCLUSIONS The outcomes of patients with prolonged SWT did not differ from those of most patients who underwent nephrectomy within 1 month. In patients with stage II or higher RCC who underwent nephrectomy within 3 months after diagnosis, prolonged SWT was not an independent predictor of pathological upstaging, RFS, or CSS.
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Affiliation(s)
- Kwang Hyun Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap 2-dong, Songpa-gu, Seoul, 138-736, Korea
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Stevens C, Bondy SJ, Loblaw DA. Wait times in prostate cancer diagnosis and radiation treatment. Can Urol Assoc J 2010; 4:243-8. [PMID: 20694099 PMCID: PMC2910767 DOI: 10.5489/cuaj.09122] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Wait times for cancer diagnosis and treatment are a significant concern for Canadians. Men with prostate cancer experience longer waiting times for diagnosis and treatment than those observed for other cancers. Longer waits are associated with both patient and family psychosocial distress and may be associated with worse prognosis. METHODS Men referred for treatment of prostate cancer at a single Canadian cancer centre were interviewed. The intervals from suspicion to definitive therapy were calculated, factors associated with delays along this pathway were identified, and common causes of delay identified by patients were described. RESULTS A total of 41 consecutive patients participated. The median interval from suspicion to the first fraction of radiotherapy for all patients was 247 days (interquartile range [IQR] 168-367 d). The median diagnostic interval was 53 days (IQR 28-166 d). The median treatment interval was 127 days (IQR 100-180 d). Patients under 70 years old and patients with INTERPRETATION In this study, 12% and 0% of patients met Canadian Strategy for Cancer Control and Canadian Association of Radiation Oncologists wait time recommendations, respectively. A large component of wait time is patient driven. Alternate strategies should be developed and measured to shorten the intervals between the suspicion and treatment of prostate cancer.
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Affiliation(s)
- Christiaan Stevens
- Fellow, Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, ON
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Waiting time from initial urological consultation to nephrectomy for renal cell carcinoma--does it affect survival? J Urol 2008; 179:2152-7. [PMID: 18423724 DOI: 10.1016/j.juro.2008.01.111] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2007] [Indexed: 11/23/2022]
Abstract
PURPOSE We report survival and recurrence outcomes in all patients undergoing radical or partial nephrectomy for renal cell carcinoma, as related to surgical waiting time. MATERIALS AND METHODS We retrospectively reviewed the records of 722 patients who underwent surgical resection for renal cell carcinoma. Patients were subdivided by waiting time from the initial urology visit until surgery. Surgical waiting time was evaluated as a continuous variable and by monthly subgroups. Univariate and multivariate analyses were performed to evaluate factors associated with overall, disease specific and recurrence-free survival. RESULTS Mean time from the first visit to surgery was 1.2 months with 64.1% and 94.3% of patients undergoing surgery within 30 days and within 3 months, respectively. Overall and disease specific survival was not affected by surgical waiting time regardless of how time was analyzed. On univariate analysis 5-year recurrence-free survival was poorer in patients undergoing surgery within 1 month vs more than 1 month (75.7% vs 88.4%, p = 0.02). On multivariate analysis T stage (p <0.0001), grade (p = 0.009), lymph node involvement (p = 0.0001) and histology (p = 0.006) were independent predictors of recurrence-free survival, while surgical waiting time was not (p = 0.18). Surgical waiting time less than 1 month was associated with higher stage and higher grade tumors (p <0.0001 and 0.0006, respectively). CONCLUSIONS Surgical waiting time from initial urological consultation to operative intervention does not adversely affect the outcome of renal cell carcinoma within the time frames analyzed in this study, in which 94% of cases occurred within 3 months. Individual urologist judgment remains a critical factor in the appropriate and timely care of the patient with a suspicious renal mass.
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Abstract
OBJECTIVE The 2-week wait (TWW) fast-track referral system for patients suspected of having colorectal cancer (CRC) has fallen well short of its expectations of streamlining prioritization of colorectal referrals. Our study reviews most of the audits/studies that have been published on the system as its inception. Our aim was to identify where the shortcomings are and also to review the various alternatives that have recently been put forward. METHOD All articles on the TWW system published in mainstream peer reviewed journals were reviewed, as were all the abstracts on the system presented at the Association of Coloproctology and the British Society of Gastroenterology meetings. Implementation, compliance with guidelines, cancer detection rate, impact on waiting times and the overall effectiveness of the system are evaluated. RESULTS While the implementation of the system has been generally robust in most centres, the compliance with guidelines has been poor. This coupled with the inherently poor specificity of the system has resulted in a poor (and decreasing) cancer detection rate and a steadily growing volume of the hospital referrals. The system has been shown to have an adverse impact on the waiting times for routine colorectal referrals - a group that contributes significantly to the total number of CRC detected. The various alternatives to the TWW system that have been proposed recently, including our own, are discussed. CONCLUSION The shortcomings of the TWW system in its original form have now been demonstrated beyond doubt. What is needed is a fresh approach to find a cost effective and viable alternative in a climate of increased expectations and finite resources.
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Affiliation(s)
- S Rai
- Specialist Registrar in General Surgery, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Leicester, UK.
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