A Position Statement on the Utility of Interval Imaging in Standard of Care Brain Tumour Management: Defining the Evidence Gap and Opportunities for Future Research.

Thomas C Booth,Craig Buckley,Colin Watts,Florien Boele,Nick Morley,Michael D Jenkinson,Nicky Huskens,Marc Modat,Gerard Thompson,Matthew Williams,Catherine Mcbain,Caroline Murphy,Jorge Cardoso,Robin Grant,Aysha Luis,David Summers,Jack Kreindler,Mark Pennington,Samantha J Mills,Helen Bulbeck,Keyoumars Ashkan,J.r Powell ,Adam Waldman ,Sébastien Ourselin ,D Jenkinson ,Liane S Canas

doi:10.3389/fonc.2021.620070

Abstract

Objectiv eTo summarise current evidence for the utility of interval imaging in monitoring disease in adult brain tumours, and to develop a position for future evidence gathering while incorporating the application of data science and health economics.MethodsExperts in ‘interval imaging’ (imaging at pre-planned time-points to assess tumour status); data science; health economics, trial management of adult brain tumours, and patient representatives convened in London, UK. The current evidence on the use of interval imaging for monitoring brain tumours was reviewed. To improve the evidence that interval imaging has a role in disease management, we discussed specific themes of data science, health economics, statistical considerations, patient and carer perspectives, and multi-centre study design. Suggestions for future studies aimed at filling knowledge gaps were discussed.ResultsMeningioma and glioma were identified as priorities for interval imaging utility analysis. The “monitoring biomarkers” most commonly used in adult brain tumour patients were standard structural MRI features. Interval imaging was commonly scheduled to provide reported imaging prior to planned, regular clinic visits. There is limited evidence relating interval imaging in the absence of clinical deterioration to management change that alters morbidity, mortality, quality of life, or resource use. Progression-free survival is confounded as an outcome measure when using structural MRI in glioma. Uncertainty from imaging causes distress for some patients and their caregivers, while for others it provides an important indicator of disease activity. Any study design that changes imaging regimens should consider the potential for influencing current or planned therapeutic trials, ensure that opportunity costs are measured, and capture indirect benefits and added value.ConclusionEvidence for the value, and therefore utility, of regular interval imaging is currently lacking. Ongoing collaborative efforts will improve trial design and generate the evidence to optimise monitoring imaging biomarkers in standard of care brain tumour management.

Highlights

Over the last decade the treatment landscape for adult brain tumours has changed incrementally for some tumour types, such as metastases, where there have been improvements in systemic therapy and brain radiotherapy [1]
Edits and feedback were incorporated until all authors were in agreement with the content, and a position statement was produced around potential approaches to studying interval imaging in glioma and meningioma
Following explicit agreement that there was an evidence gap, and that the James Lind Alliance (JLA) priority (Box 1) should be addressed, an initial question was to determine which brain tumour types should be included in the position statement

Summary

Introduction

Over the last decade the treatment landscape for adult brain tumours has changed incrementally for some tumour types, such as metastases, where there have been improvements in systemic therapy and brain radiotherapy [1]. For other tumour types there has been little change. The management of glioblastoma remains largely based on maximum safe resection and radiotherapy with concomitant and adjuvant temozolomide chemotherapy [2]. Evidence from randomised controlled trials [level 1 [3]] underpins clinical treatments of adult brain tumours. There is little evidence (< level 3) to support the current imaging practices used to monitor disease progression or response to treatment [4, 5]. The clinical utility [the relevance and usefulness of an intervention in patient care using all sources of evidence [6]] of interval imaging (imaging at pre-planned time-points to assess tumour status, as compared with scanning for reasons of clinical deterioration) is largely unknown

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