Most patients reported positively or neutrally of having served as controls in the trials within cohorts design

Objectives: To evaluate patients’ experience of having served as controls without a notification at the time of randomization in the context of the trial within cohorts (TwiCs) design. Methods: Patients were asked for their opinion on having served as controls in TwiCs, before and after having been provided the trial results. Patients had provided broad consent to randomization at cohort entry and had served as controls in one of two TwiCs (an exercise program after breast cancer treatment or radiotherapy dose-escalation for rectal cancer). Results: Two to 6 years after cohort entry, 15% (n = 16) of all patients remembered having provided broad consent to randomization. Before disclosure of trial results, 47% (n = 52) of patients thought positively, 45% (n = 50) neutrally, and 2% (n = 2) negatively of having served as controls in one of the two trials. Seventeen percent (n = 18) of patients were positive, 65% (n = 71) neutral, and 11% (n = 12) negative about not having been notified when serving as controls. The survey results were comparable after disclosure of trial results. Conclusions: These results support the use of the TwiCs design with the staged-informed consent procedure. Keeping patients engaged and aware of the consents provided might further improve patients’ experience of serving as controls in TwiCs

The National Dutch Breast Implant Registry: user-reported experiences and importance

Background: Robust (inter-)national breast implant registries are important. For some, registries are an administrative burden, for others they represent a solution for the discussions involving breast implants. The DBIR is one of the first national, opt-out, clinical registries of breast implants, providing information for clinical auditing and product recall. Four years after its introduction, it is time to address users’ comments in order to keep improving quality of registration, and patient safety. This study assesses users’ feedback focusing on importance of registration, logistics and user experience, and areas of improvement. Methods: In May 2018, a standardized online study–specific questionnaire was sent out to all members of the Netherlands Society of Plastic Surgery. Descriptive statistics were reported in absolute frequencies and/or percentages. Results: A total of 102 members responded to the questionnaire (response rate, 24.2%). Of all respondents, 97.1% were actively registering in DBIR. Respondents rated the importance of registration in DBIR as 8.1 out of 10 points. Ninety-one respondents suggested improvements for the DBIR. All comments were related to registration convenience and provision of automatically generated data. Conclusions: Respondents believe that registration is highly important and worth the administrative burden. However, we should collectively keep improving accuracy, usability and sustainability of breast

Oncology patients were found to understand and accept the Trials within Cohorts design

Background and Objective: The Trials within Cohorts design aims to reduce recruitment difficulties and disappointment bias in pragmatic trials. On cohort enrollment, broad informed consent for randomization is asked, after which cohort participants can be randomized to interventions or serve as controls without further notification. We evaluated patients' recollection, understanding, and acceptance of broad consent in a clinical oncology setting. Methods: We surveyed 610 patients with cancer participating in ongoing TwiCs; 482 patients (79%) responded, of which 312 patients shortly after cohort enrollment, 108 patients after randomization to an intervention (12-18 months after cohort enrollment), and a random sample of 62 cohort participants who had not been selected for interventions (1-6 months after cohort enrollment). Results: Shortly after providing cohort consent, 76% of patients (238/312) adequately remembered whether they had given broad consent for randomization. Of patients randomly offered interventions, 76% (82/108) remembered giving broad consent for randomization; 41% (44/108) understood they were randomly selected, 44% (48/108) were not interested in selection procedures, and 10% (11/108) did not understand selection was random. Among patients not selected for interventions, 42% (26/62) understood selection was random; 89% felt neutral regarding the scenario of "not being selected for an intervention while your data were being used in comparison with patients receiving interventions,"10% felt reassured (6/62) and 2% scared/insecure (2/62). Conclusion: Patients adequately remember giving broad consent for randomization shortly after cohort enrollment and after being offered an intervention, but recollection is lower in those never selected for interventions. Patients are acceptant of serving as control without further notifications. (c) 2020 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

The ethics of ‘Trials within Cohorts’ (TwiCs): 2nd international symposium - London, UK. 7-8 November 2016

On 7-8 th November 2016, 60 people with an interest in the ‘ Trials within Cohorts ’ (TwiCs) approach for randomised controlled trial design met in London. The purpose of this 2 nd TwiCs international symposium was to share perspectives and experiences on ethical aspects of the TwiCs design, discuss how TwiCs relate to the current ethical frame- work, provide a forum in which to discuss and debate ethical issues and identify future directions for conceptual and empirical research. The symposium was supported by the Wellcome Trust and the NIHR CLAHRC Yorkshire and Humber and organised by members of the TwiCs network led by Clare Relton and attended by people from the UK, the Netherlands, Norway, Canada and USA. The two-day sympo- sium enabled an international group to meet and share experiences of the TwiCs design (also known as the ‘ cohort multiple RCT design ’ ), and to discuss plans for future research. Over the two days, invited plenary talks were interspersed by discussions, posters and mini pre- sentations from bioethicists, triallists and health research regulators. Key findings of the symposium were: (1) It is possible to make a compelling case to ethics committees that TwiCs designs are ap- propriate and ethical; (2) The importance of wider considerations around the ethics of inefficient trial designs; and (3) some questions about the ethical requirements for content and timing of informed consent for a study using the TwiCs design need to be decided on a case-by-case basis

Automatic coronary artery calcium scoring on radiotherapy planning CT Scans of breast cancer patients: Reproducibility and association with traditional cardiovascular risk factors

Objectives Coronary artery calcium (CAC) is a strong and independent predictor of cardiovascular disease (CVD) risk. This study assesses reproducibility of automatic CAC scoring on radiotherapy planning computed tomography (CT) scans of breast cancer patients, and examines its association with traditional cardiovascular risk factors. Methods This study included 561 breast cancer patients undergoing radiotherapy between 2013 and 2015. CAC was automatically scored with an algorithm using supervised pattern recognition, expressed as Agatston scores and categorized into five categories (0, 1-10, 11-100, 101-400, >400). Reproducibility between automatic and manual expert scoring was assessed in 79 patients with automatically determined CAC above zero and 84 randomly selected patients without automatically determined CAC. Interscan reproducibility of automatic scoring was assessed in 294 patients having received two scans (82% on the same day). Association between CAC and CVD risk factors was assessed in 36 patients with CAC scores >100, 72 randomly selected patients with scores 1-100, and 72 randomly selected patients without CAC. Reliability was assessed with linearly weighted kappa and agreement with proportional agreement. Results 134 out of 561 (24%) patients had a CAC score above zero. Reliability of CVD risk categorization between automatic and manual scoring was 0.80 (95% Confidence Interval (CI): 0.74-0.87), and slightly higher for scans with breath-hold. Agreement was 0.79 (95% CI: 0.72-0.85). Interscan reliability was 0.61 (95% CI: 0.50-0.72) with an agreement of 0.84 (95% CI: 0.80-0.89). Ten out of 36 (27.8%) patients with CAC scores above 100 did not have other cardiovascular risk factors. Conclusions Automatic CAC scoring on radiotherapy planning CT scans is a reliable method to assess CVD risk based on Agatston scores. One in four breast cancer patients planned for radiotherapy have elevated CAC score. One in three patients with high CAC scores don't have other CVD risk factors and wouldn't have been identified as high risk

Aquatic therapy for boys with Duchenne muscular dystrophy (DMD): an external pilot randomised controlled trial

Background: Standard treatment of Duchenne muscular dystrophy (DMD) includes regular physiotherapy. There are no data to show whether adding aquatic therapy (AT) to land-based exercises helps maintain motor function. We assessed the feasibility of recruiting and collecting data from boys with DMD in a parallel-group pilot randomised trial (primary objective), also assessing how intervention and trial procedures work. Methods: Ambulant boys with DMD aged 7–16 years established on steroids, with North Star Ambulatory Assessment (NSAA) score ≥8, who were able to complete a 10-m walk test without aids or assistance, were randomly allocated (1:1) to 6 months of either optimised land-based exercises 4 to 6 days/week, defined by local community physiotherapists, or the same 4 days/week plus AT 2 days/week. Those unable to commit to a programme, with >20% variation between NSAA scores 4 weeks apart, or contraindications to AT were excluded. The main outcome measures included feasibility of recruiting 40 participants in 6 months from six UK centres, clinical outcomes including NSAA, independent assessment of treatment optimisation, participant/therapist views on acceptability of intervention and research protocols, value of information (VoI) analysis and cost-impact analysis. Results: Over 6 months, 348 boys were screened: most lived too far from centres or were enrolled in other trials; 12 (30% of the targets) were randomised to AT (n = 8) or control (n = 4). The mean change in NSAA at 6 months was −5.5 (SD 7.8) in the control arm and −2.8 (SD 4.1) in the AT arm. Harms included fatigue in two boys, pain in one. Physiotherapists and parents valued AT but believed it should be delivered in community settings. Randomisation was unattractive to families, who had already decided that AT was useful and who often preferred to enrol in drug studies. The AT prescription was considered to be optimised for three boys, with other boys given programmes that were too extensive and insufficiently focused. Recruitment was insufficient for VoI analysis. Conclusions: Neither a UK-based RCT of AT nor a twice weekly AT therapy delivered at tertiary centres is feasible. Our study will help in the optimisation of AT service provision and the design of future research. Trial registration: ISRCTN4100295

Protocol for the development of a CONSORT extension for RCTs using cohorts and routinely collected health data.

Background: Randomized controlled trials (RCTs) are often complex and expensive to perform. Less than one third achieve planned recruitment targets, follow-up can be labor-intensive, and many have limited real-world generalizability. Designs for RCTs conducted using cohorts and routinely collected health data, including registries, electronic health records, and administrative databases, have been proposed to address these challenges and are being rapidly adopted. These designs, however, are relatively recent innovations, and published RCT reports often do not describe important aspects of their methodology in a standardized way. Our objective is to extend the Consolidated Standards of Reporting Trials (CONSORT) statement with a consensus-driven reporting guideline for RCTs using cohorts and routinely collected health data. Methods: The development of this CONSORT extension will consist of five phases. Phase 1 (completed) consisted of the project launch, including fundraising, the establishment of a research team, and development of a conceptual framework. In phase 2, a systematic review will be performed to identify publications (1) that describe methods or reporting considerations for RCTs conducted using cohorts and routinely collected health data or (2) that are protocols or report results from such RCTs. An initial "long list" of possible modifications to CONSORT checklist items and possible new items for the reporting guideline will be generated based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statements. Additional possible modifications and new items will be identified based on the results of the systematic review. Phase 3 will consist of a three-round Delphi exercise with methods and content experts to evaluate the "long list" and generate a "short list" of key items. In phase 4, these items will serve as the basis for an in-person consensus meeting to finalize a core set of items to be included in the reporting guideline and checklist. Phase 5 will involve drafting the checklist and elaboration-explanation documents, and dissemination and implementation of the guideline. Discussion: Development of this CONSORT extension will contribute to more transparent reporting of RCTs conducted using cohorts and routinely collected health data

Efficacy of dose-escalated chemoradiation on complete tumour response in patients with locally advanced rectal cancer (RECTAL-BOOST); a phase 2 randomised controlled trial

Purpose Pathological complete tumour response following chemoradiation in patients with locally advanced rectal cancer (LARC) is associated with favourable prognosis and allows organ-sparing treatment strategies. We aimed to investigate the effect of an external radiation boost to the tumour prior to chemoradiation on pathological or sustained clinical complete tumour response in LARC. Methods and materials This multicentre, non-blinded, phase 2, randomised controlled trial followed the trials within cohorts-design, which is a pragmatic trial design allowing cohort participants to be randomized for an experimental intervention. Patients in the intervention group are offered the intervention (and can accept or refuse this), whereas patients in the control group are not notified about the randomisation. Participants of a colorectal cancer cohort referred for chemoradiation of LARC to either of two radiotherapy centres were eligible. Patients were randomised to no boost or an external radiation boost (5 x 3 Gy) without concurrent chemotherapy directly followed by standard pelvic chemoradiation (25 x 2 Gy with concurrent capecitabine). The primary outcome was pathological complete response (pCR, i.e. ypT0N0) in patients with planned surgery at 12 weeks or, as surrogate for pCR, a 2-year sustained clinical complete response for patients treated with an organ preservation strategy. Analyses were intention to treat. The study was registered with ClinicalTrials.gov, number NCTXXXXXX. Results Between Sept 2014 and July 2018, 128 patients were randomised. Fifty-one of the 64 (79.7%) patients in the intervention group accepted and received a boost. Compared with the control group, fewer patients in the intervention group had a cT4-stage and a low rectal tumour (31.3% versus 17.2% and 56.3% versus 45.3% respectively), and more patients had a cN2-stage (59.4% versus 70.3% respectively). Rate of pathological or sustained clinical complete tumour response was similar between the groups: 23 of 64 (35.9%, 95%CI 24.3-48.9) in the intervention group versus 24 of 64 (37.5%, 95%CI 25.7-50.5) in the control group (OR=0.94 95%CI 0.46-1.92). Near-complete or complete tumour regression was more common in the intervention group: 34 of 49 (69.4%) versus 24 of 53 (45.3%) in the control group (OR=2.74, 95%CI 1.21-6.18). Grade >3 acute toxicity was comparable: 6 of 64 (9.4%) in the intervention group versus 5 of 64 (7.8%) in the control group (OR=1.22 95%CI 0.35-4.22). Conclusion Dose escalation with an external radiotherapy boost to the tumour prior to neoadjuvant chemoradiation did not increase the pathological or sustained clinical complete tumour response rate in LARC

Innovations in patient-centered breast cancer research

Although breast cancer prognosis has improved in the past decades, treatment still severely impacts patients’ quality of life (QoL), emotional and sexual functioning. Many experimental interventions rapidly arise aiming to improve breast cancer care. Randomized controlled trials (RCTs) are required to identify which of these interventions are (most) effective, with the least side effects and best QoL. To evaluate side effects and QoL, patient-reported outcomes (PROs) are needed. RCTs are the gold standard to show effectiveness of treatments, but are often beset by recruitment issues, disappointment bias and limited generalizability. PROs are gaining popularity, but the questionnaires used to collect PROs are often long. Therefore, novel ways to conduct efficient randomized studies are needed, and novel ways to efficiently collect PROs are needed as well. The focus of this thesis was to explore and evaluate potential solutions for these challenges. The main focus of part 1 of this thesis (Chapter 2 – 5) was implementation and evaluation of the novel cmRCT design in a clinical breast cancer setting. In Chapter 2 ethical pros and cons of cmRCT were evaluated with reference to ethical guidelines (e.g. Declaration of Helsinki). A staged-informed consent procedure was proposed to avoid the identified ethical challenges. Chapter 3 described the implementation of the UMBRELLA cohort – the first cmRCT cohort in a clinical breast cancer setting. Chapter 4 presented survey results evaluating patients’ understanding of the cmRCT design. This study was conducted among participants of the three ongoing cmRCT cohorts with embedded trials in our hospital in the field of breast cancer, bone metastases and colorectal cancer. Chapter 5 showed results from an observational study conducted within UMBRELLA with routine care data and PROs. This study aimed to assess prevalence, and determinants of breast edema in patients treated with breast-conserving therapy, and its effect on QoL. In part 2 (Chapter 6 – 8), the aim was to evaluate novel methods to improve PRO utilization. Chapter 6 explored potential advantages of using a supportive breast cancer app in clinical practice, including its potential to collect PROs. In Chapter 7, results were presented from the first RCT (i.e. BRIOS trial) where the PRO-instrument ‘BREAST-Q’ was used as the primary outcome. The BRIOS trial was a pragmatic RCT comparing cosmetic satisfaction and HR-QoL after a novel one-stage implant-based breast reconstruction technique using an acellular dermal matrix (ADM), and the standard of care two-stage procedure (i.e. tissue expanders followed by definitive breast implant). Chapter 8 described the development and evaluation of the short and individualized version of the BREAST-Q by applying computerized adaptive testing (CAT). Chapter 9 provided an overall summary, and Chapter 10 concluded with a general discussion and future perspectives on patient-centered breast cancer research. This thesis concluded by stating that the cohort multiple randomized controlled trial (cmRCT) design is a logistically and ethically feasibly study design. Also, PROs may be used as primary endpoints in RCTs, health apps are promising to collect PROs, and computerized adaptive testing successfully shortened the BREAST-Q with acceptable loss of measurement precision

Innovations in patient-centered breast cancer research

Although breast cancer prognosis has improved in the past decades, treatment still severely impacts patients’ quality of life (QoL), emotional and sexual functioning. Many experimental interventions rapidly arise aiming to improve breast cancer care. Randomized controlled trials (RCTs) are required to identify which of these interventions are (most) effective, with the least side effects and best QoL. To evaluate side effects and QoL, patient-reported outcomes (PROs) are needed. RCTs are the gold standard to show effectiveness of treatments, but are often beset by recruitment issues, disappointment bias and limited generalizability. PROs are gaining popularity, but the questionnaires used to collect PROs are often long. Therefore, novel ways to conduct efficient randomized studies are needed, and novel ways to efficiently collect PROs are needed as well. The focus of this thesis was to explore and evaluate potential solutions for these challenges. The main focus of part 1 of this thesis (Chapter 2 – 5) was implementation and evaluation of the novel cmRCT design in a clinical breast cancer setting. In Chapter 2 ethical pros and cons of cmRCT were evaluated with reference to ethical guidelines (e.g. Declaration of Helsinki). A staged-informed consent procedure was proposed to avoid the identified ethical challenges. Chapter 3 described the implementation of the UMBRELLA cohort – the first cmRCT cohort in a clinical breast cancer setting. Chapter 4 presented survey results evaluating patients’ understanding of the cmRCT design. This study was conducted among participants of the three ongoing cmRCT cohorts with embedded trials in our hospital in the field of breast cancer, bone metastases and colorectal cancer. Chapter 5 showed results from an observational study conducted within UMBRELLA with routine care data and PROs. This study aimed to assess prevalence, and determinants of breast edema in patients treated with breast-conserving therapy, and its effect on QoL. In part 2 (Chapter 6 – 8), the aim was to evaluate novel methods to improve PRO utilization. Chapter 6 explored potential advantages of using a supportive breast cancer app in clinical practice, including its potential to collect PROs. In Chapter 7, results were presented from the first RCT (i.e. BRIOS trial) where the PRO-instrument ‘BREAST-Q’ was used as the primary outcome. The BRIOS trial was a pragmatic RCT comparing cosmetic satisfaction and HR-QoL after a novel one-stage implant-based breast reconstruction technique using an acellular dermal matrix (ADM), and the standard of care two-stage procedure (i.e. tissue expanders followed by definitive breast implant). Chapter 8 described the development and evaluation of the short and individualized version of the BREAST-Q by applying computerized adaptive testing (CAT). Chapter 9 provided an overall summary, and Chapter 10 concluded with a general discussion and future perspectives on patient-centered breast cancer research. This thesis concluded by stating that the cohort multiple randomized controlled trial (cmRCT) design is a logistically and ethically feasibly study design. Also, PROs may be used as primary endpoints in RCTs, health apps are promising to collect PROs, and computerized adaptive testing successfully shortened the BREAST-Q with acceptable loss of measurement precision