Assessment of the Implementation of Lung Cancer Consensus Statements From the Royal College of Radiologists in 2021; Progress and Barriers

BACKGROUND

Lung cancer outcomes in the UK are worse than those in many similar countries. The RCR developed a series of 43 consensus statements (CS) to facilitate improvements in care for patients treated with radiotherapy.

METHODS

We asked all 61 UK radiotherapy centres to self-assess the implementation of the CS and to describe their departmental key strengths and weaknesses in September 2021.

RESULTS

87% of centres returned their assessments. Whilst developmental activity was seen in most areas for most centres, 24 of the statements were felt to be difficult to implement within the next 2 years by at least one centre. The most frequently reported strengths were in the implementation of SABR (stereotactic body radiotherapy), concurrent chemoradiation for non-small cell lung cancer and technological aspects of treatment planning. The most frequently described departmental weaknesses were in pre-habilitation, timeliness of PET/CT scans and prophylaxis for Pneumocystis jiroveci Pneumonia (PJP). Barriers to implementation were often due to insufficient resource, a requirement for organisations to work together, and a perceived lack of evidence base. Strengths were often attributed to good team working, a local champion and being an early adopter.

CONCLUSIONS

This work confirms the commitment of lung cancer radiotherapy teams across the UK to improve outcomes for their patients. Most of the statements have been implemented at least partially. Themes have been identified to aid further progress, one of which is a requirement for significant investment.

Efficacy of dual-specific Bcr-Abl and Src-family kinase inhibitors in cells sensitive and resistant to imatinib mesylate

Monotherapy of chronic myeloid leukemia (CML) with imatinib mesylate has been cast into shadow by the evolution of clinical resistance during therapy. Resistance to imatinib can arise by multiple mechanisms including amplification or mutation of Bcr-Abl, and continuity of imatinib therapy is probably a poor option for either of these patient groups. Recently, however, a structurally distinct new class of drugs, the pyrido[2,3-d]pyrimidines, has been described, and these compounds are predicted to make different molecular contacts in the Abl kinase domain. These drugs potently target both the Bcr-Abl and Src-family kinase activities, both of which are thought to be relevant to survival of the leukemic cell. We asked whether these drugs could selectively induce cell death in murine cell line models of CML cells sensitive and resistant to imatinib by different mechanisms. We show that whereas the pyrido[2,3-d] pyrimidines are indeed highly potent in suppressing proliferation of Bcr-Abl-overexpressing imatinib-resistant cells, they are almost completely ineffective against cells expressing the T315I mutant. This implies that despite structural differences from imatinib, these drugs are unlikely to be useful in patients expressing this mutant Bcr-Abl protein, but may be effective in cases where selection of cells overexpressing the oncoprotein leads to refractoriness to imatinib.

Pattern recognition of 31P magnetic resonance spectroscopy tumour spectra obtained in vivo

Pattern recognition has been applied to the analysis of in vivo 31P NMR spectra. Using four different classes of tumour and three types of normal tissue, cluster analysis and artificial neural networks were successful in separating and classifying the majority of samples analysed. Although the phosphomonoester and P(i) regions appeared to be the most important spectral features, data representing the entire 31P spectrum were required for best separation of the tumour and tissue classes.

The effect of oestrogen ablation on the phospholipid metabolite content of primary and transplanted rat mammary tumours

The concentration of phospholipid metabolites was determined in chemical extracts from two types of rat mammary tumours and compared with proliferation data (S-phase fraction). One of the tumours was an oestrogen-sensitive transplanted tumour. In this tumour the concentration of phosphocholine (PC) and glycerophosphorylcholine (GPC) correlated strongly with the S-phase fraction but not with the number of cells actively synthesizing DNA. Oestrogen ablation resulted in tumour regression. Regressing tumours contained less PC and more GPC than those actively growing. The other tumour was induced in rats by intravenous administration of N-methyl N-nitrosourea. Phosphoethanolamine (PE), PC and GPC levels were not associated with the S-phase fraction in this tumour. Oestrogen ablation resulted in tumour regression. There was no significant difference between the regressing and growing tumours in PE, PC or GPC content.

Monitoring therapeutic response to tamoxifen in NMU-induced rat mammary tumours by 31P MRS

Tamoxifen injections were given once a week for 4 weeks to 19 rats bearing N-methyl-N-nitrosourea (NMU)-induced mammary carcinomas. NMR spectra were collected on days 2, 7, 14, 21 and 28. Only 42% of the tumours responded to the tamoxifen in that they regressed significantly; another 21% did not change in size and 37% grew significantly. In the ones that did subsequently regress there were significant changes in the NTP/Pi ratio as early as 2 days after treatment, before any detectable change in volume was recorded, and continuing up to 21 days. The significance of these findings and the possible mechanisms underlying the changes are discussed.