Academic Clinical Oncology and Radiobiology Research Network (ACORRN): An NCRI Initiative to Address the Infrastructure and Capacity Deficit in Radiotherapy and Radiobiology Research in the UK

Abstract

Radiotherapy remains the most commonly used anti-cancer treatment, and currently 50% of cancer patients in the UK are treated with radiotherapy at some point in their management. Radiotherapy is second only to surgery in its curative potential. Over the past 10 years, rapid technological advances have allowed more accurate radiotherapy delivery. We are also moving closer to being able to optimise patient treatment based on a rapidly evolving understanding of the genetics and biology of individuals and their tumours, and how these relate to prediction of treatment outcomes. The expectation of these advances over the coming years is that more patients will now be cured of their cancer, with a reduction in treatment-related side-effects. The current position in the UK, however, contrasts with much of the progress seen in cancer biology, with a sharp decline in the number of clinical academics and radiation biologists over the past 10 years. This has resulted in the radiotherapy and radiobiology communities having insufficient infrastructure or individuals to respond to the Department of Health need to develop and capitalise on these advances. To address the infrastructure and capacity deficit, the National Cancer Research Institute (NCRI), in response to a proposal from the research community, has established a UK network (ACORRN), aiming to develop an integrated UK radiotherapy and radiobiology research strategy; deliver such a research strategy via networking within the UK; and develop mechanisms to support the necessary clinical research infrastructure. ACORRN was launched in February 2005, with a mission to (1) re-vitalise and support the remaining active radiotherapy and radiobiology research individuals and groups in the UK; (2) build capacity with training of increased numbers of, for example, clinical academics, scientists, research radiographers; (3) increase the number of internationally competitive grant applications (particularly interdisciplinary); (4) derive a consensus on state-of-the-art radiotherapy, and develop an increased number of radiotherapy and radiobiology National Cancer Research Network clinical trials. Funding has been made available by the NCRI from the Department of Health, Cancer Research UK and Medical Research Council (MRC) to set up a national office and to develop a strategy to reset the balance so that the UK can once again become competitive internationally in radiotherapy research and its translation into clinical practice. It is anticipated that ACORRN will apply through a co-ordinated approach for increased UK infrastructure funding. For the first time, the radiotherapy and radiobiology community has direct access to the Department of Health, Cancer Research UK and the MRC. There has never been a more appropriate time to co-ordinate our research efforts and build a future for radiation-based research within the UK. In 2002, the NCRI was asked to review the current state of radiotherapy and radiobiology research in the UK to identify the UK's strengths and weaknesses in these areas and to identify requirements for advancing these areas in the UK [1NCRI. Report of the radiotherapy and related radiobiology progress review group. London: NCRI, <http://www.ncri.org.uk/documents/publications/reportdocs/NCRI_Radiotherapy_Radiobiology_Report_August_2003.pdf>, Jan 2003 [last accessed 18 May 2005].Google Scholar]. This exercise derived a consensus of priority research questions for the UK. Examples of areas of research and development outlined in the 2003 NCRI Progress Review Group (PRG) report [1NCRI. Report of the radiotherapy and related radiobiology progress review group. London: NCRI, <http://www.ncri.org.uk/documents/publications/reportdocs/NCRI_Radiotherapy_Radiobiology_Report_August_2003.pdf>, Jan 2003 [last accessed 18 May 2005].Google Scholar] included (1) technical radiotherapy: intensity-modulated radiotherapy, image-guided radiotherapy, cone beam imaging, molecular imaging; (2) the biology base for advancing radiotherapy: multidisciplinary approach, individualisation of patient treatment, radiogenomics, tumour phenotyping, molecular imaging, chemoradiation; (3) quantification and analysis of late effects of radiotherapy on normal tissue. The report was followed by the NCRI Partners' response in July 2003, outlining their desire to respond positively to these priority research areas. In March 2004, the radiotherapy and radiobiology PRG held a follow-up meeting (‘Benefiting patients through high-quality radiotherapy/radiobiology research’), attended by representatives from the Department of Health, MRC, Cancer Research UK, other funding bodies, a consumer representative and the radiotherapy and radiobiology community. At this meeting, it became clear that the UK academic radiotherapy and radiobiology community had been willing but unable to respond to the challenge, owing to a sub-critical mass of infrastructure and researchers. A consultation exercise was undertaken (Table 1), and it was agreed that proposals should be put forward to the NCRI for development of a UK Academic Clinical Oncology and Radiobiology Research Network (ACORRN) to create the necessary infrastructure and build capacity to deliver an integrated research strategy.Table 1Consultation exercise for development of ACORRNThe following groups were consulted in developing the case for ACORRN:•NCRI Director and Department of Health Deputy Director of Research and Development (September, 2003)•NCRI Progress Review Subcommittee (19 March, 2004)•Royal College of Radiologists 10-year strategy review meeting (29 April, 2004)•NCRI Radiotherapy Clinical Studies Group (17 June, 2004)•Individuals within the radiotherapy community (September, 2003 to June, 2004)•ACORRN consultation subcommittee (3 June, 2004)ACORRN, Academic Clinical Oncology and Radiobiology Research Network; NCRI, National Cancer Research Institute. Open table in a new tab ACORRN, Academic Clinical Oncology and Radiobiology Research Network; NCRI, National Cancer Research Institute. Within the above reports, it has been recognised that, over the past decade, UK radiotherapy and radiobiology research has declined, despite 50% of cancer patients being treated with radiotherapy, and there being a consensus on the important clinical and scientific questions and opportunities to address [1NCRI. Report of the radiotherapy and related radiobiology progress review group. London: NCRI, <http://www.ncri.org.uk/documents/publications/reportdocs/NCRI_Radiotherapy_Radiobiology_Report_August_2003.pdf>, Jan 2003 [last accessed 18 May 2005].Google Scholar]. Currently, because of the decline in critical mass, the radiotherapy and radiobiology community is not in a position to apply for any funding opportunities. A number of financial, organisational, institutional and cultural barriers to radiotherapy and radiobiology research have been identified (Table 2).Table 2Current barriers to radiotherapy and radiobiology research•Only 6% of the total National Cancer Research Institute funding is dedicated to radiotherapy and radiobiology research.•There is no specific Department of Health research and development funding for technical radiotherapy developments. There is therefore no mechanism to develop a strategy, or fund the very real developments needed in the UK to introduce the technical advances realised in the last 10 years (i.e. intensity-modulated radiotherapy and image-guided radiotherapy) safely and cost effectively.•Only two out of six of the translational radiotherapy and research units in the UK, active until the early 1980s remain. This situation reflects the change in emphasis in radiation research, but has been exacerbated by the fact that the UK lacks an integrated strategy for the future.•There is no credible career structure in place for academically inclined specialist registrars. There are few academic consultant posts for them to take up upon completion of the Certificate of Completion of Specialist Training, and few clinical senior lecturers will be awarded a Chair.•There is also a difficulty in creating and supporting academic posts at a consultant level, leading to a lack of research time for academic clinicians. This has led to an insufficient critical mass of academics, which in turn has led to a low profile with (1) insufficient trainees; (2) lack of career structure; and (3) the subject becoming unattractive.•The lack of critical mass has led to isolation of individual groups, which has resulted in insufficient grant applications of adequate quality to obtain significant research funding. This in turn has led to a lack of support from universities as sources of grant income are not materialising.•A lack of multidisciplinary collaborations has meant that the UK radiotherapy and radiobiology community has not been well placed to capitalise on advances in other areas of cancer research.•The lack of dedicated clinical research facilities.•The lack of access to soft monies for pump priming projects. Industry support is sparse, as this area is not mainstream to the pharmaceutical industry.•The lack of emphasis by the Department of Health and National Health Service Trusts on the need for, and value of, academics for training and development in a field that is changing rapidly due to technological advances.•An unattractive speciality for clinicians and graduates to enter owing to sub-critical mass, low-key profile with lack of buzz, and few opportunities for grant income.•The general unattractiveness of clinical academic careers due to pay differentials and other factors.•The perception that radiobiology research has not really delivered or moved with the times.•The developments in modern radiotherapy treatments over the past 10 years have been associated with one of the sharpest increases in advanced technology and computerisation in any field of medicine. However, there has not been a matched co-ordinated UK strategy to develop, assess and integrate such advances into service delivery. The ever-widening gap has meant that the UK radiotherapy service base is a less effective environment to respond to, and from which to develop a world class technical radiotherapy research strategy. Open table in a new tab Immediate remedial action is needed, and unless the UK can develop a long-term integrated strategy for radiotherapy and radiobiology research involving all stakeholders, it is likely that the critical mass of academics active in radiotherapy and radiobiology research will decline to the point where it will no longer be sustainable as an academic discipline. This will have a knock-on effect on our ability to deliver up-to-date and state-of-the-art clinical care as well engaging in opportunities for advancing this area. In rebuilding radiotherapy and radiobiology research, the UK community has a number of factors in its favour (Table 3).Table 3Factors in favour of rebuilding radiotherapy and radiobiology research•There remains a core group of enthusiastic and capable individuals within the radiotherapy and radiobiology field.•The UK Department of Health, Cancer Research UK and Medical Research Council offer excellent opportunities for networking.•There is a history of internationally competitive radiobiology, fractionation and translational research in the UK.•The size of the National Health Service community and patient population encourages networking. National Health Service datasets are a valuable resource.•The National Cancer Research Institute is committed to redeveloping this area, and is working with the radiotherapy and radiobiology community on this initiative.•The UK radiotherapy and radiobiology community has responded positively to the ACORRN proposal and has actively contributed to its development. Open table in a new tab Two main steps were proposed to reverse the decline in radiotherapy and radiobiology research: (1) network the whole power of the UK base in a strategic way, as the Academic Clinical Oncology and Radiobiology Research Network (ACORRN). In this manner, we could work together to become competitive again and build a strong base from which we can create an academic critical mass; and (2) via ACORRN, to strategically break both radiotherapy and radiobiology disciplines out of the boxes they are currently in and link more with appropriate cancer science. Establishing a sustainable radiotherapy and radiobiology community will require a coherent approach from stakeholders: the NCRI Partners, non-NCRI funding bodies, the Royal College, the radiotherapy and radiobiology community itself, and the wider research community. ACORRN has been established with 3 years' start-up funding (£351,000), with an aim to develop sufficient infrastructure and critical mass for successful grant applications and delivery of research, and increase the critical mass of scientists and trainees in this area. There are four main areas for development. Funding has been provided by NCRI to pump prime areas 1–3 for 3 years, and, over the next year, we hope to apply for funding for area 4. A national office has been set up for the co-ordination, strategic planning and management of networking and multidisciplinary working. The office is currently based in the Academic Department of Radiation Oncology at the Christie Hospital, Manchester. The National office is acting as an administrative resource for UK researchers to access for help with (1) administration of network grant applications; (2) contacts with other researchers in the field; (3) developing UK strategies in various site- or research-specific areas; and (4) establishing research topic-specific networks. The national office is also developing the ACORRN web site, which will be a fully interactive resource, providing a database of UK resources and people active in various fields, management of web-based radiotherapy and radiobiology research discussion groups, and a forum for collaboration of subgroups within multidisciplinary teams (e.g. research radiographers). These networks will be key to developing radiotherapy and radiobiology research in the UK. They will be designed to vitalise and link individuals and groups from different centres and/or disciplines with complementary research interests. The networks will provide opportunities for ‘brainstorming’ meetings to facilitate original thinking and collaborative working, facilitating collaborative grant applications. The networks will also form the basis for interdisciplinary training and support. Leaders of such groups will identify themselves and act as drivers dedicated to the promotion of key research topics. Examples of work that has begun to establish such research-specific networks include (1) radiogenomics (Manchester, Cambridge, Gray Cancer Institute and the Pan London Radiogenomics group); (2) late effects (Mount Vernon, Norfolk and Norwich, Manchester); and (3) hypoxia (Mount Vernon, Oxford, Liverpool, Sheffield, Manchester). These groups have already had meetings, and have submitted two joint grant applications (both successful). Funding from the National office is available for the ongoing administrative support, travel and expansion and development of such networks. Many individuals have an important contribution to make to the radiotherapy and radiobiology field in the UK. However, they are often prevented from doing so because they are either too isolated or lack the time or infrastructure to be able to support a research programme. The aim is to identify key individuals who are currently working alone or who may benefit from protected academic time. Such individuals may be helped by strategies outlined in Table 4.Table 4How individuals can be helped by ACORRN•Key individuals around the country who are currently isolated, yet able, need to identify themselves and be helped to develop their ideas and infrastructure within the UK Network.•The individuals who wish to develop National Cancer Research Network or National Translational Cancer Research Network radiotherapy national protocols, and who would benefit from national networking, need to be identified and supported.•ACORRN will need to lobby Trusts and Universities to stress the importance of granting clinicians such academic sessions.•The UK network will provide links to other groups and networks with complementary research interests, enabling radiotherapy and radiobiology to harness the capacity of these individuals, once again increasing the critical mass of UK research.•ACORRN will provide synergy with links to research topic-specific networks for development of research ideas. Individuals will be given specialist support to facilitate the development of grants and research programmes. Open table in a new tab There is currently insufficient infrastructure in the UK to support a resurgence of radiotherapy and radiobiology research. Key facilities needed are networked laboratories and clinical facilities committed to radiation research. There are funding strategies via the research funding bodies for the former, such as the move of the Gray Cancer Institute to Oxford, but none exist for the latter. Agreement has been unanimous that the UK needs clinical research infrastructure outside or separately funded from the already hard-pressed service radiotherapy departments, and clinical research fellows to train and support the clinical research. We propose to develop National Clinical Radiotherapy Research Centres of Excellence (NCRRCEs) to develop the clinical research infrastructure and provide a training ground for the future generation of research active clinicians. The NCRRCEs will enable collaboration between many different disciplines (e.g. medical physics, clinical, radiobiology, radiography) to identify complementary research areas, provide added value and encourage different groups to work together. This will in turn encourage ‘out of the box’ thinking, and promote innovative ideas for research projects. Research training and exchange programmes will encourage a culture of multidisciplinary research and collaboration, which in turn will support and underpin the national research topic-specific networks and individuals within ACORRN. This will build capacity in research and increase the critical mass of academics in the field. It is proposed that NCRRCEs are regionally based to maximise the existing infrastructure and expertise. Strategic support is needed for the under-represented disciplines within the multidisciplinary teams, which will be needed to deliver a UK radiotherapy and radiobiology clinical research strategy. These include research radiographers and research physicists. Such activities cannot be bolted onto overstretched service departments. The recent Department of Health investment in new radiotherapy machines in the UK means that machine time is no longer such a limiting factor in research, but manpower is. These groups need to be developed in their own right within the networked multidisciplinary teams. This will also be vital for the effective and safe delivery of the emerging advanced radiotherapy techniques. The key to the success of ACORRN is empowering and supporting able UK individuals to lead on the UK ambitions as defined in the NCRI PRG 2003 report [1NCRI. Report of the radiotherapy and related radiobiology progress review group. London: NCRI, <http://www.ncri.org.uk/documents/publications/reportdocs/NCRI_Radiotherapy_Radiobiology_Report_August_2003.pdf>, Jan 2003 [last accessed 18 May 2005].Google Scholar]. Key potential barriers to the success of ACORRN are outlined in Table 5.Table 5Key barriers to the success of ACORRN•The current group of key individuals for this initiative is small. The responsibility rests on a few shoulders.•No capacity for clinical research within National Health Service Trust service commitments.•Lack of funding and stability for research infrastructure.•Lack of buy-in from universities.•Lack of professional scientific administrative support. Open table in a new tab One of the remits of ACORRN will be to involve stakeholders (e.g. NCRI radiotherapy clinical study group, National Cancer Research Network, National Translational Cancer Research Network, Royal Colleges, Department of Health and other funding organisations). There is a need for ACORRN and its stakeholders to work with Trusts and universities to ensure radiotherapy and radiobiology priorities can be met (e.g. establishing the importance of research rather than service in NHS Trusts, leading to protected research time for consultants). There is also a need for universities to commit to academic clinical posts. The ACORRN communication strategy is outlined in Table 6.Table 6ACORRN communication strategy•The designated interactive, supported web site will provide information, act as a discussion forum and be a mechanism for networking.•Regular updates in Clinical Oncology, the official journal of the Royal College of Radiologists.•Regular oral updates at UK meetings.•Annual report to the National Cancer Research Institute and the Royal College of Radiologists' Faculty of Clinical Oncology. Open table in a new tab ACORRN has established a steering committee to develop the network strategy with the support of the central office, aiming for a consensus for the needs of the radiotherapy and radiobiology community and the funding bodies (see Table 7 for membership). The membership is derived from a range of UK expertise and geography. They are supported by an International External Advisory Committee and report to an NCRI oversight committee.Table 7ACORRN steering committeeMemberRepresentationLocationResearch interestsProfessor Ann BarrettUniversity of East AngliaLate effectsDr Neil BurnetCambridgeIntensity-modulated radiotherapy and radiogenomicsMs Julie DaviesSociety of Radiographers and Research Radiographer Working PartyChristie Hospital, ManchesterTechnical radiotherapyDr Ros EelesInstitute of Cancer ResearchClinical geneticsDr John GrahamGlasgowAdvanced radiotherapyProfessor Peter HoskinChair, NCRI Radiotherapy Clinical Studies GroupMount VernonClinical radiobiologyProfessor Tim IllidgeRoyal College of RadiologistsUniversity of ManchesterRadioimmunotherapyProfessor Gilles McKennaMedical Research Council Gray Cancer InstituteOxfordMolecular radiobiologyProfessor Malcolm MasonHealth Protection Agency Radiation Division and Committee on Medical Aspects of Radiation in the EnvironmentCardiffUrological cancers – clinical and laboratory-based research, evidence-based oncology and cancer immunotherapyProfessor Pat Price (Chair)University of ManchesterImage-guided radiotherapy and molecular imagingDr Trevor RobertsClinical Lead, NHS Modernisation Agency Radiotherapy SectionNewcastleService developments in radiotherapy and clinical research in management of urological cancersProfessor Michele SaundersMount Vernon/Gray Cancer InstituteClinical radiobiologyDr Catharine WestNCRI Radiotherapy Clinical Studies Group and Association for Radiation ResearchUniversity of ManchesterTranslational radiobiologyProfessor Eric WrightBritish Institute of RadiologyUniversity of DundeeRadiogenomicsNCRI, National Cancer Research Institute. Open table in a new tab NCRI, National Cancer Research Institute. There is an opportunity now to develop an integrated UK radiotherapy and radiobiology research strategy, with clearly defined deliverable end points that translate basic research into state-of-the-art cancer treatment. From the work done so far, we are confident that, with a relatively small initial networking investment, critical masses of radiotherapy and radiobiology individuals can be brought together, and academic radiotherapy and radiobiology can be rebuilt in the UK. With the NCRI supporting ACORRN, we now have a unique opportunity to stand up and be counted. Individually, we may not be able to compete internationally, but together we could be highly competitive! So please, get involved, get thinking, e-mail us with ideas, think big, we have a chance to really make a difference.