"Why am I still suffering?": Experience of long-term fatigue and neurocognitive changes in oropharyngeal cancer survivors following (chemo)radiotherapy

Background

Late effects of cancer treatment, such as neurocognitive deficits and fatigue, can be debilitating. Other than head and neck-specific functional deficits such as impairments in swallowing and speech, little is known about survivorship after oropharyngeal cancer. This study examines the lived experience of fatigue and neurocognitive deficits in survivors of oropharyngeal squamous cell cancer and impact on their daily lives.

Methods

This work is part of the multicentre mixed method ROC-oN study (Radiotherapy for Oropharyngeal Cancer and impact on Neurocognition), evaluating fatigue and neurocognitive function in patients following radiotherapy +/- chemotherapy for oropharyngeal cancer and impact on quality of life. Semi-structured interviews were conducted in adults treated with radiotherapy (+/-chemotherapy) for oropharyngeal squamous cell carcinoma >/=24 months from completing treatment. Reflexive thematic analysis performed.

Results

21 interviews (11 men and 10 women; median age 58 years and median time post-treatment 5 years) were conducted and analysed, yielding six themes: (1) unexpected burden of fatigue, (2) noticing changes in neurocognitive function, (3) the new normal, (4) navigating changes, (5)insufficient awareness and (6)required support. Participants described fatigue that persisted beyond the acute post-treatment period and changes in neurocognitive abilities across several domains. Paid and unpaid work, emotions and mood were impacted. Participants described navigating the new normal by adopting self-management strategies and accepting external support. They reported lack of recognition of these late effects, being poorly informed and being unprepared. Follow-up services were thought to be inadequate.

Conclusions

Fatigue and neurocognitive impairment were frequently experienced by survivors of oropharyngeal cancer, at least two years after treatment. Patients felt ill-prepared for these late sequelae, highlighting opportunities for improvement of patient information and support services.

Hitting the Target: Developing High-quality Evidence for Proton Beam Therapy Through Randomised Controlled Trials

The National Health Service strategy for the delivery of proton beam therapy (PBT) in the UK provides a unique opportunity to deliver high-quality evidence for PBT through randomised controlled trials (RCTs). We present a summary of three UK PBT RCTs in progress, including consideration of their key design characteristics and outcome assessments, to inform and support future PBT trial development. The first three UK multicentre phase III PBT RCTs (TORPEdO, PARABLE and APPROACH), will compare PBT with photon radiotherapy for oropharyngeal squamous cell carcinoma, breast cancer and oligodendroglioma, respectively. All three studies were designed by multidisciplinary teams, which combined expertise from clinicians, clinical trialists and scientists with strong patient advocacy and guidance from national radiotherapy research networks and international collaborators. Consistent across all three studies is a focus on the reduction of long-term radiotherapy-related toxicities and an evaluation of patient-reported outcomes and health-related quality of life, which will address key uncertainties regarding the clinical benefits of PBT. Innovative translational components will provide insights into mechanisms of toxicity and help to frame the key future research questions regarding PBT. The UK radiotherapy research community is developing and delivering an internationally impactful PBT research portfolio. The combination of data from RCTs with prospectively collected data from a national PBT outcomes registry will provide an innovative, high-quality repository for PBT research and the platform to design and deliver future trials of PBT.

Randomized Phase 3 Trial of the Hypoxia Modifier Nimorazole Added to Radiation Therapy With Benefit Assessed in Hypoxic Head and Neck Cancers Determined Using a Gene Signature (NIMRAD)

PURPOSE

Tumor hypoxia is an adverse prognostic factor in head and neck squamous cell carcinoma (HNSCC). We assessed whether patients with hypoxic HNSCC benefited from the addition of nimorazole to definitive intensity modulated radiation therapy (IMRT).

METHODS AND MATERIALS

NIMRAD was a phase 3, multicenter, placebo-controlled, double-anonymized trial of patients with HNSCC unsuitable for concurrent platinum chemotherapy or cetuximab with definitive IMRT (NCT01950689). Patients were randomized 1:1 to receive IMRT (65 Gy in 30 fractions over 6 weeks) plus nimorazole (1.2 g/m2 daily, before IMRT) or placebo. The primary endpoint was freedom from locoregional progression (FFLRP) in patients with hypoxic tumors, defined as greater than or equal to the median tumor hypoxia score of the first 50 patients analyzed (≥0.079), using a validated 26-gene signature. The planned sample size was 340 patients, allowing for signature generation in 85% and an assumed hazard ratio (HR) of 0.50 for nimorazole effectiveness in the hypoxic group and requiring 66 locoregional failures to have 80% power in a 2-tail log-rank test at the 5% significance level.

RESULTS

Three hundred thirty-eight patients were randomized by 19 centers in the United Kingdom from May 2014 to May 2019, with a median follow-up of 3.1 years (95% CI, 2.9-3.4). Hypoxia scores were available for 286 (85%). The median patient age was 73 years (range, 44-88; IQR, 70-76). There were 36 (25.9%) locoregional failures in the hypoxic group, in which nimorazole + IMRT did not improve FFLRP (adjusted HR, 0.72; 95% CI, 0.36-1.44; P = .35) or overall survival (adjusted HR, 0.96; 95% CI, 0.53-1.72; P = .88) compared with placebo + IMRT. Similarly, nimorazole + IMRT did not improve FFLRP or overall survival in the whole population. In total (N = 338), 73% of patients allocated nimorazole adhered to the drug for ≥50% of IMRT fractions. Nimorazole + IMRT caused more acute nausea compared with placebo + IMRT (Common Terminology Criteria for Adverse Events version 4.0 G1+2: 56.6% vs 42.4%, G3: 10.1% vs 5.3%, respectively; P < .05).

CONCLUSIONS

Addition of the hypoxia modifier nimorazole to IMRT for locally advanced HNSCC in older and less fit patients did not improve locoregional control or survival.

Neurocognitive function following (chemo)radiotherapy for nasopharyngeal cancer and other head and neck cancers: A systematic review

When radiotherapy is used in the treatment of head and neck cancers, the brain commonly receives incidental doses of radiotherapy with potential for neurocognitive changes and subsequent impact on quality of life. This has not been widely investigated to date. A systematic search of MEDLINE, EMBASE, Psycinfo Info and the Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases was conducted. Of 2077 records screened, 20 were eligible comprising 1308 patients. There were no randomised studies and 73.3% of included patients were from single center studies. IMRT was delivered in 72.6% of patients, and chemotherapy used in 61%. There was considerable heterogeneity in methods. Narrative synthesis was therefore carried out. Most studies demonstrated inferior neurocognitive outcomes when compared to control groups at 12 months and beyond radiotherapy. Commonly affected neurocognitive domains were memory and language which appeared related to radiation dose to hippocampus, temporal lobe, and cerebellum. Magnetic Resonance Imaging could be valuable in the detection of early microstructural and functional changes, which could be indicative of future neurocognitive changes. In studies investigating quality of life, the presence of neurocognitive impairment was associated with inferior quality of life outcomes. (Chemo)radiotherapy for head and neck cancer appears to be associated with a risk of long-term neurocognitive impairment. Few studies were identified, with substantial variation in methodology, thus limiting conclusions. High quality large prospective head and neck cancer studies using standardised, sensitive, and reliable neurocognitive tests are needed.

Lateral Tunnel Epitaxy of GaAs in Lithographically Defined Cavities on 220 nm Silicon-on-Insulator

Current heterogeneous Si photonics usually bond III-V wafers/dies on a silicon-on-insulator (SOI) substrate in a back-end process, whereas monolithic integration by direct epitaxy could benefit from a front-end process where III-V materials are grown prior to the fabrication of passive optical circuits. Here we demonstrate a front-end-of-line (FEOL) processing and epitaxy approach on Si photonics 220 nm (001) SOI wafers to enable positioning dislocation-free GaAs layers in lithographically defined cavities right on top of the buried oxide layer. Thanks to the defect confinement in lateral growth, threading dislocations generated from the III-V/Si interface are effectively trapped within ∼250 nm of the Si surface. This demonstrates the potential of in-plane co-integration of III-Vs with Si on mainstream 220 nm SOI platform without relying on thick, defective buffer layers. The challenges associated with planar defects and coalescence into larger membranes for the integration of on-chip optical devices are also discussed.

Large-scale meta-genome-wide association study reveals common genetic factors linked to radiation-induced acute toxicities across cancer types

BACKGROUND

This study was designed to identify common genetic susceptibility and shared genetic variants associated with acute radiation-induced toxicity across 4 cancer types (prostate, head and neck, breast, and lung).

METHODS

A genome-wide association study meta-analysis was performed using 19 cohorts totaling 12 042 patients. Acute standardized total average toxicity (STATacute) was modelled using a generalized linear regression model for additive effect of genetic variants, adjusted for demographic and clinical covariates (rSTATacute). Linkage disequilibrium score regression estimated shared single-nucleotide variation (SNV-formerly SNP)-based heritability of rSTATacute in all patients and for each cancer type.

RESULTS

Shared SNV-based heritability of STATacute among all cancer types was estimated at 10% (SE = 0.02) and was higher for prostate (17%, SE = 0.07), head and neck (27%, SE = 0.09), and breast (16%, SE = 0.09) cancers. We identified 130 suggestive associated SNVs with rSTATacute (5.0 × 10‒8 < P < 1.0 × 10‒5) across 25 genomic regions. rs142667902 showed the strongest association (effect allele A; effect size ‒0.17; P = 1.7 × 10‒7), which is located near DPPA4, encoding a protein involved in pluripotency in stem cells, which are essential for repair of radiation-induced tissue injury. Gene-set enrichment analysis identified 'RNA splicing via endonucleolytic cleavage and ligation' (P = 5.1 × 10‒6, P = .079 corrected) as the top gene set associated with rSTATacute among all patients. In silico gene expression analysis showed that the genes associated with rSTATacute were statistically significantly up-regulated in skin (not sun exposed P = .004 corrected; sun exposed P = .026 corrected).

CONCLUSIONS

There is shared SNV-based heritability for acute radiation-induced toxicity across and within individual cancer sites. Future meta-genome-wide association studies among large radiation therapy patient cohorts are worthwhile to identify the common causal variants for acute radiotoxicity across cancer types.

TORPEdO: A phase III trial of intensity-modulated proton beam therapy versus intensity-modulated radiotherapy for multi-toxicity reduction in oropharyngeal cancer

•There is a lack of prospective level I evidence for the use of PBT for most adult cancers including oropharyngeal squamous cell carcinoma (OPSCC).•TORPEdO is the UK's first PBT clinical trial and aims to determine the benefits of PBT for OPSCC.•Training and support has been provided before and during the trial to reduce variations of contouring and radiotherapy planning.•There is a strong translational component within TORPEdO. Imaging and physics data along with blood, tissue collection will inform future studies in refining patient selection for IMPT.

Near-IR & Mid-IR Silicon Photonics Modulators

As the silicon photonics field matures and a data-hungry future looms ahead, new technologies are required to keep up pace with the increase in capacity demand. In this paper, we review current developments in the near-IR and mid-IR group IV photonic modulators that show promising performance. We analyse recent trends in optical and electrical co-integration of modulators and drivers enabling modulation data rates of 112 GBaud in the near infrared. We then describe new developments in short wave infrared spectrum modulators such as employing more spectrally efficient PAM-4 coding schemes for modulations up to 40 GBaud. Finally, we review recent results at the mid infrared spectrum and application of the thermo-optic effect for modulation as well as the emergence of new platforms based on germanium to tackle the challenges of modulating light in the long wave infrared spectrum up to 10.7 μm with data rates of 225 MBaud.

Meta-GWAS identifies the heritability of acute radiation-induced toxicities in head and neck cancer

BACKGROUND AND PURPOSE

We aimed to the genetic components and susceptibility variants associated with acute radiation-induced toxicities (RITs) in patients with head and neck cancer (HNC).

MATERIALS AND METHODS

We performed the largest meta-GWAS of seven European cohorts (n = 4,042). Patients were scored weekly during radiotherapy for acute RITs including dysphagia, mucositis, and xerostomia. We analyzed the effect of variants on the average burden (measured as area under curve, AUC) per each RIT, and standardized total average acute toxicity (STATacute) score using a multivariate linear regression. We tested suggestive variants (p < 1.0x10-5) in discovery set (three cohorts; n = 2,640) in a replication set (four cohorts; n = 1,402). We meta-analysed all cohorts to calculate RITs specific SNP-based heritability, and effect of polygenic risk scores (PRSs), and genetic correlations among RITS.

RESULTS

From 393 suggestive SNPs identified in discovery set; 37 were nominally significant (preplication < 0.05) in replication set, but none reached genome-wide significance (pcombined < 5 × 10-8). In-silico functional analyses identified "3'-5'-exoribonuclease activity" (FDR = 1.6e-10) for dysphagia, "inositol phosphate-mediated signalling" for mucositis (FDR = 2.20e-09), and "drug catabolic process" for STATacute (FDR = 3.57e-12) as the most enriched pathways by the RIT specific suggestive genes. The SNP-based heritability (±standard error) was 29 ± 0.08 % for dysphagia, 9 ± 0.12 % (mucositis) and 27 ± 0.09 % (STATacute). Positive genetic correlation was rg = 0.65 (p = 0.048) between dysphagia and STATacute. PRSs explained limited variation of dysphagia (3 %), mucositis (2.5 %), and STATacute (0.4 %).

CONCLUSION

In HNC patients, acute RITs are modestly heritable, sharing 10 % genetic susceptibility, when PRS explains < 3 % of their variance. We identified numerus suggestive SNPs, which remain to be replicated in larger studies.

Pretreatment Lymphocyte Count Predicts Benefit From Concurrent Chemotherapy With Radiotherapy in Oropharyngeal Cancer

PURPOSE

There is a need to refine the selection of patients with oropharyngeal squamous cell carcinoma (OPSCC) for treatment de-escalation. We investigated whether pretreatment absolute lymphocyte count (ALC) predicted overall survival (OS) benefit from the addition of concurrent chemotherapy to radical radiotherapy.

PATIENTS AND METHODS

This was an observational study of consecutive OPSCCs treated by curative-intent radiotherapy, with or without concurrent chemotherapy (n = 791) with external, independent validation from a separate institution (n = 609). The primary end point was OS at 5 years. Locoregional control (LRC) was assessed using competing risk regression as a secondary end point. Previously determined prognostic factors were used in a multivariable Cox proportional hazards model to assess the prognostic importance of ALC and the interaction between ALC and cisplatin chemotherapy use.

RESULTS

Pretreatment ALC was prognostic for 5-year OS on multivariable analysis (hazard ratio [HR] 0.64; 95% CI, 0.42 to 0.98; P = .04). It also predicted benefit from the use of concurrent cisplatin chemotherapy, with a significant interaction between cisplatin chemotherapy and pretreatment ALC (likelihood ratio test, P = .04): higher ALC count reduced the 5-year OS benefit compared with radiotherapy alone (HR 2.53; 95% CI, 1.03 to 6.19; P = .043). This was likely driven by an effect on LRC up to 5 years (interaction subdistribution HR 2.29; 95% CI, 0.68 to 7.71; P = .094). An independent validation cohort replicated the OS (HR 2.53; 95% CI, 0.98 to 6.52; P = .055) and LRC findings (interaction subdistribution HR 3.43; 95% CI, 1.23 to 9.52; P = .018).

CONCLUSION

For OPSCC, the pretreatment ALC is prognostic for OS and also predicts benefit from the addition of cisplatin chemotherapy to radiotherapy. These findings require prospective evaluation, and could inform the selection of good prognosis patients for a de-escalation trial.

Similar long-term swallowing outcomes for accelerated, mildly-hypofractionated radiotherapy compared to conventional fractionation in oropharynx cancer: a multi-centre study

BACKGROUND AND PURPOSE

There is renewed interest in hypofractionated radiotherapy, but limited data and a lack of consensus to support use for head and neck cancer. In this multicentre analysis we compared outcomes for patients with oropharynx squamous cell carcinoma (OPSCC) treated with conventional and accelerated, mildly hypofractionated radiotherapy without chemotherapy.

MATERIALS AND METHODS

A multi-centre, observational study of consecutive OPSCCs treated between 2015 and 2018. Patients underwent curative-intent radiotherapy (oropharynx and bilateral neck) using conventionally fractionated (70 Gy in 35 fractions over 7 weeks, n = 97) or accelerated, mildly hypofractionated (65-66 Gy in 30 fractions over 6 weeks, n = 136) radiotherapy without chemotherapy. Locoregional control (LRC) and overall survival (OS) were compared. Patients alive and cancer-free at a minimum of 2 years post-radiotherapy (n = 151, 65%) were sent an MD Anderson Dysphagia Inventory (MDADI) questionnaire to assess swallow function.

RESULTS

LRC and OS were similar across schedules (p = 0.78 and 0.95 respectively, log-rank test). Enteral feeding rates during radiotherapy appeared higher in the 7-week group though this did not reach statistical significance (59% vs 48%, p = 0.08). Feeding rates were similar at 1 year post radiotherapy for both groups (10% vs 6%, p = 0.27). 107 patients returned MDADI questionnaires (71%); there were no differences between the 6- and 7-week groups for median global (60.0 vs 60.0, p = 0.99) and composite (65.8 vs 64.2, p = 0.44) MDADI scores.

CONCLUSION

Patients with OPSCC treated with radiotherapy alone have similar swallowing outcomes, LRC and OS following accelerated, mild hypofractionation and standard fractionation schedules, supporting its use as a standard-of-care option for patients unsuitable for concurrent chemotherapy.

Estimating the percentage of patients who might benefit from proton beam therapy instead of X-ray radiotherapy

OBJECTIVES

High-energy Proton Beam Therapy (PBT) commenced in England in 2018 and NHS England commissions PBT for 1.5% of patients receiving radical radiotherapy. We sought expert opinion on the level of provision.

METHODS

Invitations were sent to 41 colleagues working in PBT, most at one UK centre, to contribute by completing a spreadsheet. 39 responded: 23 (59%) completed the spreadsheet; 16 (41%) declined, arguing that clinical outcome data are lacking, but joined six additional site-specialist oncologists for two consensus meetings. The spreadsheet was pre-populated with incidence data from Cancer Research UK and radiotherapy use data from the National Cancer Registration and Analysis Service. 'Mechanisms of Benefit' of reduced growth impairment, reduced toxicity, dose escalation and reduced second cancer risk were examined.

RESULTS

The most reliable figure for percentage of radical radiotherapy patients likely to benefit from PBT was that agreed by 95% of the 23 respondents at 4.3%, slightly larger than current provision. The median was 15% (range 4-92%) and consensus median 13%. The biggest estimated potential benefit was from reducing toxicity, median benefit to 15% (range 4-92%), followed by dose escalation median 3% (range 0 to 47%); consensus values were 12 and 3%. Reduced growth impairment and reduced second cancer risk were calculated to benefit 0.5% and 0.1%.

CONCLUSIONS

The most secure estimate of percentage benefit was 4.3% but insufficient clinical outcome data exist for confident estimates. The study supports the NHS approach of using the evidence base and developing it through randomised trials, non-randomised studies and outcomes tracking.

ADVANCES IN KNOWLEDGE

Less is known about the percentage of patients who may benefit from PBT than is generally acknowledged. Expert opinion varies widely. Insufficient clinical outcome data exist to provide robust estimates. Considerable further work is needed to address this, including international collaboration; much is already underway but will take time to provide mature data.

Ge Ion Implanted Photonic Devices and Annealing for Emerging Applications

Germanium (Ge) ion implantation into silicon waveguides will induce lattice defects in the silicon, which can eventually change the crystal silicon into amorphous silicon and increase the refractive index from 3.48 to 3.96. A subsequent annealing process, either by using an external laser or integrated thermal heaters can partially or completely remove those lattice defects and gradually change the amorphous silicon back into the crystalline form and, therefore, reduce the material’s refractive index. Utilising this change in optical properties, we successfully demonstrated various erasable photonic devices. Those devices can be used to implement a flexible and commercially viable wafer-scale testing method for a silicon photonics fabrication line, which is a key technology to reduce the cost and increase the yield in production. In addition, Ge ion implantation and annealing are also demonstrated to enable post-fabrication trimming of ring resonators and Mach–Zehnder interferometers and to implement nonvolatile programmable photonic circuits.

Comprehensive Quantitative Evaluation of Variability in MR-guided Delineation of Oropharyngeal Gross Tumor Volumes and High-risk Clinical Target Volumes: An R-IDEAL Stage 0 Prospective Study

PURPOSE

Tumor and target volume manual delineation remains a challenging task in head-and-neck cancer radiotherapy. The purpose of this study was to conduct a multi-institutional evaluation of manual delineations of gross tumor volume (GTV), high-risk clinical target volume (CTV), parotids, and submandibular glands on treatment simulation MR scans of oropharyngeal cancer (OPC) patients.

METHODS

Pre-treatment T1-weighted (T1w), T1-weighted with gadolinium contrast (T1w+C) and T2-weighted (T2w) MRI scans were retrospectively collected for 4 OPC patients under an IRB-approved protocol. The scans were provided to twenty-six radiation oncologists from seven international cancer centers who participated in this delineation study. In addition, patients' clinical history and physical examination findings, along with a medical photographic image and radiological results, were provided. The contours were compared using overlap/distance metrics using both STAPLE and pair-wise comparisons. Lastly, participants completed a brief questionnaire to assess participants' experience and CTV delineation institutional practices.

RESULTS

Large variability was measured between observers' delineations for GTVs and CTVs. The mean Dice Similarity Coefficient values across all physicians' delineations for GTVp, GTVn, CTVp, and CTVn were 0.77, 0.67, 0.77, and 0.69, respectively, for STAPLE comparison and 0.67, 0.60, 0.67, and 0.58, respectively, for pair-wise analysis. Normal tissue contours were defined more consistently when considering overlap/distance metrics. The median radiation oncology clinical experience was 7 years. The median experience delineating on MRI was 3.5 years. The GTV-to-CTV margin used was 10 mm for six of seven participant institutions. One institution used 8 mm and three participants (from three different institutions) used a margin of 5 mm.

CONCLUSION

The data from this study suggests that appropriate guidelines, contouring quality assurance sessions, and training are still needed for the adoption of MR-based treatment planning for head-and-neck cancers. Such efforts should play a critical role in reducing delineation variation and ensure standardization of target design across clinical practices.

Management of sinonasal cancers: Survey of UK practice and literature overview

INTRODUCTION

Sinonasal malignancy is a rare and heterogenous disease, with limited evidence to guide management. This report summarises the findings of a UK survey and expert workshop discussion which took place to inform design of a proposed UK trial to assess proton beam therapy versus intensity-modulated radiation therapy.

METHOD

A multidisciplinary working group constructed an online survey to assess current approaches within the UK to surgical and non-surgical practice. Head and neck clinical oncologists, ear nose and throat (ENT) and oral-maxillofacial (OMF) surgeons were invited to participate in the 42-question survey in September 2020. The Royal College of Radiologists Consensus model was adopted in establishing categories to indicate strength of response. An expert panel conducted a virtual workshop in November 2020 to discuss areas of disagreement.

RESULTS

A survey was sent to 140 UK-based clinicians with 63 responses (45% response rate) from 30 centres, representing a broad geographical spread. Participants comprised 35 clinical oncologists (56%) and 29 surgeons (44%; 20 ENT and 9 OMF surgeons). There were variations in preferred sequence and combination of treatment modalities for locally advanced maxillary squamous cell carcinoma and sinonasal undifferentiated carcinoma. There was discordant surgical management of the orbit, dura, and neck. There was lack of consensus for radiotherapy in post-operative dose fractionation, target volume delineation, use of multiple dose levels and treatment planning approach to organs-at-risk.

CONCLUSION

There was wide variation across UK centres in the management of sinonasal carcinomas. There is need to standardise UK practice and develop an evidence base for treatment.

Study into the spread of heat from thermo-optic silicon photonic elements

Phase modulators based upon the thermo-optic effect are used widely in silicon photonics for low speed applications such as switching and tuning. The dissipation of the heat produced to drive the device to the surrounding silicon is a concern as it can dictate how compact and tightly packed components can be without concerns over thermal crosstalk. In this paper we study through modelling and experiment, on various silicon on insulator photonic platforms, how close waveguides can be placed together without significant thermal crosstalk from adjacent devices.

PTCOG Head and Neck Subcommittee Consensus Guidelines on Particle Therapy for the Management of Head and Neck Tumors

Purpose

Radiation therapy is a standard modality in the treatment for cancers of the head and neck, but is associated with significant short- and long-term side effects. Proton therapy, with its unique physical characteristics, can deliver less dose to normal tissues, resulting in fewer side effects. Proton therapy is currently being used for the treatment of head and neck cancer, with increasing clinical evidence supporting its use. However, barriers to wider adoption include access, cost, and the need for higher-level evidence.

Methods

The clinical evidence for the use of proton therapy in the treatment of head and neck cancer are reviewed here, including indications, advantages, and challenges.

Results

The Particle Therapy Cooperative Group Head and Neck Subcommittee task group provides consensus guidelines for the use of proton therapy for head and neck cancer.

Conclusion

This report can be used as a guide for clinical use, to understand clinical trials, and to inform future research efforts.

Nonvolatile programmable silicon photonics using an ultralow-loss Sb2Se3 phase change material

The next generation of silicon-based photonic processors and neural and quantum networks need to be adaptable, reconfigurable, and programmable. Phase change technology offers proven nonvolatile electronic programmability; however, the materials used to date have shown prohibitively high optical losses, which are incompatible with integrated photonic platforms. Here, we demonstrate the capability of the previously unexplored material Sb2Se3 for ultralow-loss programmable silicon photonics. The favorable combination of large refractive index contrast and ultralow losses seen in Sb2Se3 facilitates an unprecedented optical phase control exceeding 10π radians in a Mach-Zehnder interferometer. To demonstrate full control over the flow of light, we introduce nanophotonic digital patterning as a previously unexplored conceptual approach with a footprint orders of magnitude smaller than state-of-the-art interferometer meshes. Our approach enables a wealth of possibilities in high-density reconfiguration of optical functionalities on silicon chip.

High-speed silicon Michelson interferometer modulator and streamlined IMDD PAM-4 transmission of Mach-Zehnder modulators for the 2 μm wavelength band

We demonstrate high-speed silicon modulators optimized for operating at the wavelength of 2 μm. The Mach-Zehnder interferometer (MZI) carrier-depletion modulator with 2 mm phase shifter has a single-arm modulation efficiency (V_π ·L_π) of 2.89 V·cm at 4 V reverse bias. Using a push-pull configuration it operates at a data rate of 25 Gbit/s OOK with an extinction ratio of 6.25 dB. We also proposed a mathematically-analysed streamlined IMDD PAM-4 scheme and successfully demonstrated a 25 Gbit/s datarate PAM-4 with the same 2 mm modulator. A Michelson interferometer carrier-depletion modulator with 0.5 mm phase shift length has also been shown with modulation efficiency (V_π ·L_π) of 1.36 V·cm at 4 V reverse bias and data rate of 20 Gbit/s OOK. The Michelson interferometer modulator performs similarly to a Mach-Zehnder modulator with twice the phase shifter length.

Performance analysis of a silicon NOEMS device applied as an optical modulator based on a slot waveguide

In this paper, we analyse the performance of a silicon nano-opto-electro-mechanical system (NOEMS) applied as an optical modulator, based on a suspended slot waveguide driven by electrostatic forces. The analysis is carried out with the help of the finite element analysis (FEA) method involving the influences from Casimir force, optical force and electrostatic force. The performance of the modulator are analysed from aspects of actuating modes, actuating voltage, modulating frequency, effective index, phase change, and energy consumption using the FEA method. Simulation results show that a suspended slot modulator has the advantages of low actuation voltage, low power consumption, as well as large effective index and phase change compared with modulators based upon other approaches. The performance of such a modulator can fill the performance gap between the carrier-based approach and micro-opto-electro-mechanical system (MOEMS) approach for modulation.

Optimisation and scaling effect of dual-waveguide optical trapping in the SOI platform

Optical trapping has potential applications in biological manipulation, particle trapping, Raman spectroscopy, and quantum optomechanics. Among the various optical trapping schemes, on-chip dual-waveguide traps combine benefits of stable trapping and mass production. However, no systematic research has been conducted to optimise on-chip dual-waveguide traps so that the trapping capability is maximised. Here, a numerical simulation of an on-chip silicon on insulator (SOI) dual-waveguide optical trap based on Lumerical FDTD Solutions is carried out to optimise the on-chip dual-waveguide trap. It was found that the waveguide thickness is a crucial parameter when designing a dual-waveguide trap, and its optical trapping capability largely depends on the distance between the two waveguides. We show that the optimal waveguide thickness to achieve the maximum trapping capability generally increases with the gap distance, accompanied by a periodic feature due to the interference and the resonant effects within the gap. This optimal waveguide thickness and gap distance are analysed to have clear scaling effects over the input optical wavelength, which paves the way for the design and optimisation of dual-waveguide traps for various applications.

Practice recommendations for risk-adapted head and neck cancer radiotherapy during the COVID-19 pandemic: An ASTRO-ESTRO consensus statement

PURPOSE

Because of the unprecedented disruption of health care services caused by the COVID-19 pandemic, the American Society of Radiation Oncology (ASTRO) and the European Society for Radiotherapy and Oncology (ESTRO) identified an urgent need to issue practice recommendations for radiation oncologists treating head and neck cancer (HNC) in a time of limited resources and heightened risk for patients and staff.

METHODS AND MATERIALS

A panel of international experts from ASTRO, ESTRO, and select Asia-Pacific countries completed a modified rapid Delphi process. Topics and questions were presented to the group, and subsequent questions were developed from iterative feedback. Each survey was open online for 24 hours, and successive rounds started within 24 hours of the previous round. The chosen cutoffs for strong agreement (≥80%) and agreement (≥66%) were extrapolated from the RAND methodology. Two pandemic scenarios, early (risk mitigation) and late (severely reduced radiation therapy resources), were evaluated. The panel developed treatment recommendations for 5 HNC cases.

RESULTS

In total, 29 of 31 of those invited (94%) accepted, and after a replacement 30 of 30 completed all 3 surveys (100% response rate). There was agreement or strong agreement across a number of practice areas, including treatment prioritization, whether to delay initiation or interrupt radiation therapy for intercurrent SARS-CoV-2 infection, approaches to treatment (radiation dose-fractionation schedules and use of chemotherapy in each pandemic scenario), management of surgical cases in event of operating room closures, and recommended adjustments to outpatient clinic appointments and supportive care.

CONCLUSIONS

This urgent practice recommendation was issued in the knowledge of the very difficult circumstances in which our patients find themselves at present, navigating strained health care systems functioning with limited resources and at heightened risk to their health during the COVID-19 pandemic. The aim of this consensus statement is to ensure high-quality HNC treatments continue, to save lives and for symptomatic benefit.

Radiation Fractionation Schedules Published During the COVID-19 Pandemic: A Systematic Review of the Quality of Evidence and Recommendations for Future Development

PURPOSE

Numerous publications during the COVID-19 pandemic recommended the use of hypofractionated radiation therapy. This project assessed aggregate changes in the quality of the evidence supporting these schedules to establish a comprehensive evidence base for future reference and highlight aspects for future study.

METHODS AND MATERIALS

Based on a systematic review of published recommendations related to dose fractionation during the COVID-19 pandemic, 20 expert panelists assigned to 14 disease groups named and graded the highest quality of evidence schedule(s) used routinely for each condition and also graded all COVID-era recommended schedules. The American Society for Radiation Oncology quality of evidence criteria were used to rank the schedules. Process-related statistics and changes in distributions of quality ratings of the highest-rated versus recommended COVID-19 era schedules were described by disease groups and for specific clinical scenarios.

RESULTS

From January to May 2020 there were 54 relevant publications, including 233 recommended COVID-19-adapted dose fractionations. For site-specific curative and site-specific palliative schedules, there was a significant shift from established higher-quality evidence to lower-quality evidence and expert opinions for the recommended schedules (P = .022 and P < .001, respectively). For curative-intent schedules, the distribution of quality scores was essentially reversed (highest levels of evidence "pre-COVID" vs "in-COVID": high quality, 51.4% vs 4.8%; expert opinion, 5.6% vs 49.3%), although there was variation in the magnitude of shifts between disease sites and among specific indications.

CONCLUSIONS

A large number of publications recommended hypofractionated radiation therapy schedules across numerous major disease sites during the COVID-19 pandemic, which were supported by a lower quality of evidence than the highest-quality routinely used dose fractionation schedules. This work provides an evidence-based assessment of these potentially practice-changing recommendations and informs individualized decision-making and counseling of patients. These data could also be used to support radiation therapy practices in the event of second waves or surges of the pandemic in new regions of the world.

Integration of low loss vertical slot waveguides on SOI photonic platforms for high efficiency carrier accumulation modulators

Silicon accumulation type modulators offer prospects of high power efficiency, large bandwidth and high voltage phase linearity making them promising candidates for a number of advanced electro-optic applications. A significant challenge in the realisation of such a modulator is the fabrication of the passive waveguide structure which requires a thin dielectric layer to be positioned within the waveguide, i.e. slotted waveguides. Simultaneously, the fabricated slotted waveguide should be integrated with conventional rib waveguides with negligible optical transition losses. Here, successful integration of polysilicon and silicon slot waveguides enabling a low propagation loss 0.4-1.2 dB/mm together with an ultra-small optical mode conversion loss 0.04 dB between rib and slot waveguides is demonstrated. These fabricated slot waveguide with dielectric thermal SiO₂ layer thicknesses around 6 nm, 8 nm and 10 nm have been characterized under transmission electron microscopy allowing for strong carrier accumulation effects for MOS-capacitor electro-optic modulators.

Practice Recommendations for Risk-Adapted Head and Neck Cancer Radiation Therapy During the COVID-19 Pandemic: An ASTRO-ESTRO Consensus Statement

PURPOSE

Because of the unprecedented disruption of health care services caused by the COVID-19 pandemic, the American Society of Radiation Oncology (ASTRO) and the European Society for Radiotherapy and Oncology (ESTRO) identified an urgent need to issue practice recommendations for radiation oncologists treating head and neck cancer (HNC) in a time of limited resources and heightened risk for patients and staff.

METHODS AND MATERIALS

A panel of international experts from ASTRO, ESTRO, and select Asia-Pacific countries completed a modified rapid Delphi process. Topics and questions were presented to the group, and subsequent questions were developed from iterative feedback. Each survey was open online for 24 hours, and successive rounds started within 24 hours of the previous round. The chosen cutoffs for strong agreement (≥80%) and agreement (≥66%) were extrapolated from the RAND methodology. Two pandemic scenarios, early (risk mitigation) and late (severely reduced radiation therapy resources), were evaluated. The panel developed treatment recommendations for 5 HNC cases.

RESULTS

In total, 29 of 31 of those invited (94%) accepted, and after a replacement 30 of 30 completed all 3 surveys (100% response rate). There was agreement or strong agreement across a number of practice areas, including treatment prioritization, whether to delay initiation or interrupt radiation therapy for intercurrent SARS-CoV-2 infection, approaches to treatment (radiation dose-fractionation schedules and use of chemotherapy in each pandemic scenario), management of surgical cases in event of operating room closures, and recommended adjustments to outpatient clinic appointments and supportive care.

CONCLUSIONS

This urgent practice recommendation was issued in the knowledge of the very difficult circumstances in which our patients find themselves at present, navigating strained health care systems functioning with limited resources and at heightened risk to their health during the COVID-19 pandemic. The aim of this consensus statement is to ensure high-quality HNC treatments continue, to save lives and for symptomatic benefit.

Recommendations for head and neck surgical oncology practice in a setting of acute severe resource constraint during the COVID-19 pandemic: an international consensus

The speed and scale of the global COVID-19 pandemic has resulted in unprecedented pressures on health services worldwide, requiring new methods of service delivery during the health crisis. In the setting of severe resource constraint and high risk of infection to patients and clinicians, there is an urgent need to identify consensus statements on head and neck surgical oncology practice. We completed a modified Delphi consensus process of three rounds with 40 international experts in head and neck cancer surgical, radiation, and medical oncology, representing 35 international professional societies and national clinical trial groups. Endorsed by 39 societies and professional bodies, these consensus practice recommendations aim to decrease inconsistency of practice, reduce uncertainty in care, and provide reassurance for clinicians worldwide for head and neck surgical oncology in the context of the COVID-19 pandemic and in the setting of acute severe resource constraint and high risk of infection to patients and staff.

Silicon erasable waveguides and directional couplers by germanium ion implantation for configurable photonic circuits

A novel technique for realization of configurable/one-time programmable (OTP) silicon photonic circuits is presented. Once the proposed photonic circuit is programmed, its signal routing is retained without the need for additional power consumption. This technology can potentially enable a multi-purpose design of photonic chips for a range of different applications and performance requirements, as it can be programmed for each specific application after chip fabrication. Therefore, the production costs per chip can be reduced because of the increase in production volume, and rapid prototyping of new photonic circuits is enabled. Essential building blocks for the configurable circuits in the form of erasable directional couplers (DCs) were designed and fabricated, using ion implanted waveguides. We demonstrate permanent switching of optical signals between the drop port and through the port of the DCs using a localized post-fabrication laser annealing process. Proof-of-principle demonstrators in the form of generic 1×4 and 2×2 programmable switching circuits were fabricated and subsequently programmed.

Proton beam therapy: perspectives on the National Health Service England clinical service and research programme

The UK has an important role in the evaluation of proton beam therapy (PBT) and takes its place on the world stage with the opening of the first National Health Service (NHS) PBT centre in Manchester in 2018, and the second in London coming in 2020. Systematic evaluation of the role of PBT is a key objective. By September 2019, 108 patients had started treatment, 60 paediatric, 19 teenagers and young adults and 29 adults. Obtaining robust outcome data is vital, if we are to understand the strengths and weaknesses of current treatment approaches. This is important in demonstrating when PBT will provide an advantage and when it will not, and in quantifying the magnitude of benefit.The UK also has an important part to play in translational PBT research, and building a research capability has always been the vision. We are perfectly placed to perform translational pre-clinical biological and physical experiments in the dedicated research room in Manchester. The nature of DNA damage from proton irradiation is considerably different from X-rays and this needs to be more fully explored. A better understanding is needed of the relative biological effectiveness (RBE) of protons, especially at the end of the Bragg peak, and of the effects on tumour and normal tissue of PBT combined with conventional chemotherapy, targeted drugs and immunomodulatory agents. These experiments can be enhanced by deterministic mathematical models of the molecular and cellular processes of DNA damage response. The fashion of ultra-high dose rate FLASH irradiation also needs to be explored.

Nonconservative Coupling in a Passive Silicon Microring Resonator

The authors report on nonconservative coupling in a passive silicon microring between its clockwise and counterclockwise resonance modes. The coupling coefficient is adjustable using a thermo-optic phase shifter. The resulting resonance of the supermodes due to nonconservative coupling is predicted in theory and demonstrated in experiments. This Letter paves the way for fundamental studies of on-chip lasers and quantum photonics, and their potential applications.

Silicon photonics for high data rate applications -INVITED

The high speed conversion of signals between the optical and electrical domains is crucial for many key applications of silicon photonics. Electro-optic modulators integrated with electronic drive amplifiers are typically used to convert an electrical signal to the optical domain. Design of these individual elements is important to achieve high performance, however a true optimisation requires careful co-design of the photonic and electronic components considering the properties of each other. Here we present our recent results in this area together with a MOSCAP type modulator with the potential for high speed, high efficiency and highly linear modulation.

Enhanced efficiency thermo-optic phase-shifter by using multi-mode-interference device

We demonstrate a method for power reduction in thermo-optic based Mach-Zehnder interferometer (MZI) by using the multimode region of a 2x2 Multi-Mode-Interferometer (MMI) as the modulation region. The light is circulated through the same multimode region twice and therefore utilizes the already present change in temperature leading to additional phase change, and an increase in efficiency. Power saving of 29.6% compared to a conventional thermo-optic phase shifter using single mode waveguides has been experimentally demonstrated. The reported devices show minimal insertion loss penalty compared to generic devices and do not add any additional fabrication complexity. Such an approach could also be applied to higher speed devices, for example those employing free carrier effects.

High-efficiency apodized bidirectional grating coupler for perfectly vertical coupling

We propose and experimentally demonstrate an apodized bidirectional grating coupler for high-efficiency, perfectly vertical coupling. Through grating apodization, the coupling efficiency (CE) can be notably improved, and the parasitic reflections can be minimized. For ease of fabrication, subwavelength gratings are introduced, which are also beneficial for the coupling performance. Simulation shows a record CE of 72%. We found that the coupler is quite robust to the variation of incidence mode field diameter and fiber misalignment. A CE of -1.8  dB is experimentally measured with a 1-dB bandwidth of 37 nm.

HWCVD a-Si:H interlayer slope waveguide coupler for multilayer silicon photonics platform

We present interlayer slope waveguides, designed to guide light from one level to another in a multi-layer silicon photonics platform. The waveguide is fabricated from hydrogenated amorphous silicon (a-Si:H) film, deposited using hot-wire chemical vapor deposition (HWCVD) at a temperature of 230°C. The interlayer slope waveguide is comprises of a lower level input waveguide and an upper level output waveguide, connected by a waveguide on a slope, with vertical separation to isolate other crossing waveguides. Measured loss of 0.17 dB/slope was obtained for waveguide dimensions of 600 nm waveguide width (w) and 400 nm core thickness (h) at a wavelength of 1550 nm and for transverse electric (TE) mode polarization.

Ultra-sharp asymmetric Fano-like resonance spectrum on Si photonic platform

In this paper, we report the generation of an ultra-sharp asymmetric resonance spectrum through Fano-like interference. This generation is accomplished by weakly coupling a high-quality factor (Q factor) Fabry-Pérot (FP) cavity and a low-Q factor FP cavity through evanescent waves. The high-Q FP cavity is formed by Sagnac loop mirrors, whilst the low-Q one is built by partially transmitting Sagnac loop reflectors. The working principle has been analytically established and numerically modelled by using temporal coupled-mode-theory (CMT), and verified using a prototype device fabricated on the 340 nm silicon-on-insulator (SOI) platform, patterned by deep ultraviolet (DUV) lithography. Pronounced asymmetric resonances with slopes up to 0.77 dB/pm have been successfully measured, which, to the best of our knowledge, is higher than the results reported in state-of-the-art devices in on-chip integrated Si photonic studies. The established theoretical analysis method can provide excellent design guidelines for devices with Fano-like resonances. The design principle can be applied to ultra-sensitive sensing, ultra-high extinction ratio switching, and more applications.

Silicon-on-insulator free-carrier injection modulators for the mid-infrared

Experimental demonstrations of silicon-on-insulator waveguide-based free-carrier effect modulators operating at 3.8 μm are presented. PIN diodes are used to inject carriers into the waveguides, and are configured to (a) use free-carrier electroabsorption to create a variable optical attenuator with 34 dB modulation depth and (b) use free-carrier electrorefraction with the PIN diodes acting as phase shifters in a Mach-Zehnder interferometer, achieving a V_πL_π of 0.052  V·mm and a DC modulation depth of 22 dB. Modulation is demonstrated at data rates up to 125 Mbit/s.

Experimental quantification of the free-carrier effect in silicon waveguides at extended wavelengths

We examine the electro-optic effect at wavelengths ranging from 1.31 to 2.02 μm for: (1) an Electronic Variable Optical Attenuator (EVOA); and (2) a Micro-Ring Resonator (MRR). For the EVOA, simulations were performed to ascertain the relationship between free-carrier concentration and optical attenuation, and are in agreement with our observation of an increase in attenuation with increasing wavelength. MRRs were fabricated for use around wavelengths of 2 μm to explore the sensitivity of operation to bus-to-ring coupling gap and p-n junction offset. Trends observed in the experiment are replicated by simulation, calibrated using the observations of the EVOA operation. The previously proposed efficiency increase of operation around 2 μm compared to more traditional wavelengths is demonstrated. Future development of devices for these wavelengths, supported by amplification using Thulium Doped Fiber Amplifier (TDFA) technology, is a promising route to aid in the alleviation of increasing demands on communication networks.

Silicon slot fin waveguide on bonded double-SOI for a low-power accumulation modulator fabricated by an anisotropic wet etching technique

We propose a new low VπL, fully-crystalline, accumulation modulator design based on a thin horizontal gate oxide slot fin waveguide, on bonded double Silicon-on-Insulator (SOI). A combination of anisotropic wet etching and the mirrored crystal alignment of the top and bottom SOI layers allows us for the first time to selectively pattern the bottom layer from above. Simulations presented herein show a VπL = 0.17Vcm. Fin-waveguides and passive Mach-Zehnder Interferometer (MZI) devices with fin-waveguide phase shifters have been fabricated, with the fin-waveguides having a transmission loss of 5.8dB/mm and a 13.5nm thick internal gate oxide slot.

Real-time monitoring and gradient feedback enable accurate trimming of ion-implanted silicon photonic devices

Fabrication errors pose significant challenges on silicon photonics, promoting post-fabrication trimming technologies to ensure device performance. Conventional approaches involve multiple trimming and characterization steps, impacting overall fabrication complexity. Here we demonstrate a highly accurate trimming method combining laser annealing of germanium implanted silicon waveguide and real-time monitoring of device performance. Direct feedback of the trimming process is facilitated by a differential spectroscopic technique based on photomodulation. The resonant wavelength trimming accuracy is better than 0.15 nm for ring resonators with 20-µm radius. We also realize operating point trimming of Mach-Zehnder interferometers with germanium implanted arms. A phase shift of 1.2π is achieved by annealing a 7-μm implanted segment.

Frequency comb generation in a silicon ring resonator modulator

We report on the generation of an optical comb of highly uniform in power frequency lines (variation less than 0.7 dB) using a silicon ring resonator modulator. A characterization involving the measurement of the complex transfer function of the ring is presented and five frequency tones with a 10-GHz spacing are produced using a dual-frequency electrical input at 10 and 20 GHz. A comb shape comparison is conducted for different modulator bias voltages, indicating optimum operation at a small forward-bias voltage. A time-domain measurement confirmed that the comb signal was highly coherent, forming 20.3-ps-long pulses.

Hybrid Photon-Plasmon Coupling and Ultrafast Control of Nanoantennas on a Silicon Photonic Chip

Hybrid integration of nanoplasmonic devices with silicon photonic circuits holds promise for a range of applications in on-chip sensing, field-enhanced and nonlinear spectroscopy, and integrated nanophotonic switches. Here, we demonstrate a new regime of photon-plasmon coupling by combining a silicon photonic resonator with plasmonic nanoantennas. Using principles from coherent perfect absorption, we make use of standing-wave light fields to maximize the photon-plasmon interaction strength. Precise placement of the broadband antennas with respect to the narrowband photonic racetrack modes results in controlled hybridization of only a subset of these modes. By combining antennas into groups of radiating dipoles with opposite phase, far-field scattering is effectively suppressed. We achieve ultrafast tuning of photon-plasmon hybridization including reconfigurable routing of the standing-wave input between two output ports. Hybrid photonic-plasmonic resonators provide conceptually new approaches for on-chip integrated nanophotonic devices.

Taxane, platinum and 5-FU prior to chemoradiotherapy benefits patients with stage IV neck node-positive head and neck cancer and a good performance status

PURPOSE

The benefit of adding docetaxel, cisplatin and 5-fluorouracil (TPF) induction chemotherapy to chemoradiotherapy (CRT) in head and neck squamous cell carcinoma (HNSCC) remains uncertain. We aimed to investigate whether ICT is well tolerated when given with prophylactic treatment against predicted adverse effects and which patients benefit most.

METHODS

A single-centre audit identified 132 HNSCC patients with stage IVa/b neck node-positive disease, prescribed TPF followed by CRT. TPF involved three cycles of docetaxel (75 mg/m² IV) and cisplatin (75 mg/m² IV) on day 1 plus 5-FU (750 mg/m² IV) on days 2-5. Planned CRT was 66 Gy in 30 fractions of intensity-modulated radiotherapy with concurrent cisplatin (100 mg/m² IV) at the beginning of week 1 and 4 (days 1 and 22). All patients received prophylactic antibiotics and granulocyte colony-stimulating factor.

RESULTS

Median follow-up was 39.5 months. 92.4% of patients completed three cycles of TPF; 95.5% of patients started chemoradiotherapy. Grade 3/4 adverse events were low (febrile neutropenia 3.0%), with no toxicity-related deaths. 3-year overall survival was 67.2%; disease-specific survival was 78.7%; locoregional control was 78.3%. Distant metastases rate was 9.8% (3.0% in those without locoregional recurrence). Good performance status (p = 0.002) and poor tumour differentiation (p = 0.018) were associated with improved overall survival on multivariate analysis.

CONCLUSION

With prophylactic antibiotics and granulocyte colony-stimulating factor TPF was well tolerated with good survival outcomes. TPF should remain a treatment option for stage IV neck node-positive patients with a good performance status. The use of tumour grade to aid patient selection for TPF warrants investigation.

Author Correction: Multipurpose silicon photonics signal processor core

Change History: A correction to this article has been published and is linked from the HTML version of this article.

49.6 Gb/s direct detection DMT transmission over 40 km single mode fibre using an electrically packaged silicon photonic modulator

We present the characterization of a silicon Mach-Zehnder modulator with electrical packaging and show that it exhibits a large third-order intermodulation spurious-free dynamic range (> 100 dB Hz^2/3). This characteristic renders the modulator particularly suitable for the generation of high spectral efficiency discrete multi-tone signals and we experimentally demonstrate a single-channel, direct detection transmission system operating at 49.6 Gb/s, exhibiting a baseband spectral efficiency of 5 b/s/Hz. Successful transmission is demonstrated over various lengths of single mode fibre up to 40 km, without the need of any amplification or dispersion compensation.