Consultant Clinical Oncologist Research Articles

Androgen Deprivation Therapy in Prostate Cancer: A Practical Approach to Complex Clinical Scenarios

Androgen deprivation therapy (ADT) has been a cornerstone in the treatment of advanced prostate cancer (PCa) for many years, and continues to form the basis of current therapeutic approaches. However, a recent dramatic upsurge in the number of treatment options available in this area creates a responsibility for healthcare professionals to carefully select optimal drugs and combinations of drugs, to ensure the best outcomes and greatest quality of life for all patients. This requires a thorough understanding of clinical trial data, and an ability to apply this knowledge to everyday clinical practice. This article summarises presentations delivered during a symposium held on 29ᵗʰ November 2023 at the Global Congress on Prostate Cancer (PROSCA) 2023 in Málaga, Spain, where three distinguished speakers described and explored practical approaches to the use of ADT in complex clinical scenarios. Nazareno Suardi, Associate Professor of Urology at the University of Brescia, Italy, described approaches to manage ADT prescription when a patient presents with cardiovascular (CV) risk factors. Matthias Saar, Director and Chairman of the Department of Urology and Uro-oncology at the University Hospital Aachen, Germany, explored whether intermittent ADT remains an alternative in the new era of hormonal therapy. Alison Birtle, Consultant Clinical Oncologist at the Rosemere Cancer Centre, Lancashire Teaching Hospitals NHS Trust, Preston, UK, investigated the importance of drug choice in triplet or doublet therapy in patients with metastatic hormone-sensitive PCa (mHSPC). The meeting was chaired by Antoni Vilaseca, Senior Specialist in the Urology Service at the Hospital Clinic, University of Barcelona, Spain, who introduced the symposium, and also co-ordinated a question and answer session to conclude the meeting.

Androgen Deprivation Therapy in Current Clinical Practice: Challenges and Future Perspective

Androgen deprivation therapy (ADT) has been used for many years for treating advanced prostate cancer (PCa) and remains the backbone of treatment. Luteinising hormone-releasing hormone (LHRH) receptor agonists are the most widely used ADT drugs. However, newer options, including gonadotropin releasing hormone (GnRH) receptor antagonists such as degarelix and relugolix, may be clinically more beneficial for some patients. GnRH antagonists reduce serum testosterone levels more rapidly than LHRH agonists, without an initial testosterone surge or subsequent microsurges. This article summarises a symposium delivered on 11th March 2023 at the 38th European Association of Urology (EAU) Annual Congress in Milan, Italy, where speakers from three different disciplines described challenges and future perspectives for ADT in current clinical practice. Kurt Miller, Urologist, Charité University Hospital, Berlin, Germany, described the evolution of ADT in the treatment of PCa, from early reports of the benefits of surgical castration to the recent development of oral treatment for chemical castration. Miller explained the acceleration in progress in ADT research over recent years, with the development of novel drugs, drug sequences, and combinations, which have transformed outcomes in PCa. Alberto Bossi, Radiation Oncologist, Amethyst Group, Institut Gustav Roussy (IGR), Paris, France, next described current challenges with ADT management, including outstanding questions about the personalisation of ADT. Finally, Patrick Davey, Consultant Cardiologist, Northampton General Hospital, UK, spoke about ways to maintain a healthy heart on hormone treatment, and noted that cardiovascular safety is a major challenge in the use of ADT. The meeting was chaired by Heather Payne, Consultant Clinical Oncologist, University College Hospital, London, UK, who introduced the speakers and co-ordinated a question-and-answer session at the end of the symposium.

“Learning From Every Patient” – Countdown for the Next Congress of the European SocieTy for Radiotherapy and Oncology (ESTRO)

Dr. Anna Kirby is the ESTRO President-Elect and a Consultant Clinical Oncologist working at the Royal Marsden and Institute of Cancer Research, UK. Dr. Kirby graduated from Cambridge University in 1995 with a first-class honors degree in Medicine and Psychology. She completed her oncology training at The Royal Marsden and Guy’s and St Thomas’ Hospitals followed by a research degree at the Institute of Cancer Research. She specializes in the treatment of patients with breast cancer and leads research into novel breast radiotherapy techniques. She is Chief Investigator of the UK HeartSpare and HeartSpare Plus studies, and breast Lead Investigator on the UK CORE trial evaluating the role of stereotactic radiotherapy in treating metastatic disease.

Advancing Roles of Healthcare Professionals in Palliative Radiotherapy

New methods of working in relation to the management of patients requiring palliative radiotherapy are being embraced in hospital departments around the world. Team members are expanding on their previously assigned scope of practice to take on duties that had previously only been assigned to a consultant clinical oncologist. Career frameworks such as the four-tier model have been built upon to identify the skills held by other healthcare professionals and show how they may be best placed to take on additional roles within a patient pathway. Experiences of four departments in different countries report their local experiences in using both therapeutic radiographers and nursing staff to undertake advanced and consultant-level practice in relation to the management of both palliative radiotherapy patients and their research work streams. Involvement of other healthcare professionals within the clinical or research pathway for the management of palliative radiotherapy patients can be achieved. Their involvement can support clinicians and help to ensure the safe and efficient management of patients requiring palliative radiotherapy.

Digitising a consultant radiographer led palliative radiotherapy service

Keywords: Palliative Radiotherapy; Digitisation; Service Redesign; Audit. Introduction: The Clatterbridge Cancer Centre is a specialist tertiary centre covering the Cheshire and Merseyside region. A Palliative Radiotherapy Service was setup over 3 years ago as a once weekly clinic, led by a Consultant Clinical Oncologist (CCO). With the appointment of a Consultant Radiographer in Palliative Radiotherapy in place of a CCO, the service has expanded to provide greater access to patients requiring palliative radiotherapy. Method and Materials: In order to ensure equitable access to the service, a digitisation project was completed to streamline the referral and recording process. Historically, the services referral form would be received via several routes (fax / e-mail / hand-delivered / dictated). Dependent on the route of entry, this could introduce significant delay in patient management. With the development of a clear pathway for both internal and external referrals, they can now all be managed via a single integrated system which links directly to each patients record, allowing for ‘Live’ update of their notes. Results: Key data is now easily captured, including information such as time from referral to review, and treatment, allowing for on-going audit of the service. This will allow for further adaptations to be made in order to best meet future patient requirements. The digitisation of this clinical pathway not only has the ability to reduce time for referral vetting, but also to reduce the burden on the wider team who have previously been required to scan referral documents to the system, handle faxes from external referral sites, and continually review e-mail for information / feedback on the next steps of referrals. A survey of all service users is currently underway, with formal reporting expected in the coming month. Conclusion and Discussion: The Palliative Radiotherapy Service strengthens and works across traditional organisational boundaries within community, primary, secondary and tertiary care. The digitisation of this service has not only improved efficiency, promoted clearer data recording, and ensured a smoother referral process for professionals; it also aides to showcase the benefit of using specialist allied health professionals in areas where a clinical presence was previously a requirement. Numerical

Dr. Joseph Siu-Kie Au: beyond immunotherapy—discovering new possibilities

Dr. Au ( Figure 1 ) is a consultant clinical oncologist in Hong Kong Adventist Hospital. He has special interest in bioinformatics, translational research, clinical trials of new drugs and radiotherapy.

Addressing future challenges for cancer services: part I.

Jane Maher & Gina Radford speak to Gemma Westcott, Commissioning Editor Jane Maher has been Macmillan's Chief Medical Officer since 1999 and now shares the role as Joint Chief Medical Officer with general practitioner Rosie Loftus, reflecting the growing need for specialists and generalists to work more effectively together. She has been a National Health Service (NHS) Improvement Clinical Leader for over 10 years and is a Consultant Clinical Oncologist at Mount Vernon Cancer Centre where she has worked for more than 20 years, during which she helped develop nonsurgical oncology services in five district general hospitals. Jane chaired the Maher Committee for the Department of Health in 1995, led the UK National Audit of Late Effects Pelvic Radiotherapy for the Royal College Of Radiologists (RCR) in 2000 and, most recently, chaired the 'National Cancer Survivorship Initiative, consequences of treatment work stream'. She co-founded one of the first Cancer Support and Information services in the UK, winning the Nye Bevan award in 1992 and there are now more than 60 units based on this model. She is a member of the Older People and Cancer Clinical Advisory Group. She has written more than 100 published articles and is a UK representative for cancer survivorship in Europe and advises on Cancer survivorship programs in Denmark and Canada. Gina Radford is Deputy Chief Medical Officer for England, a post she took up in January 2015. Prior to that, she has held a number of roles in public health, at local and regional level. Most recently she was as Centre Director for Anglia and Essex for Public Health England, and as part of that role helped lead nationally on the public health response to Ebola. She was until very recently Chair of one of the NICE public health advisory committees. She has previously worked on a number of national projects, including leading the Department of Health's response to the Shipman Enquiry, undertaking a review of specialist public health for CMO Scotland, chairing a national short life working group looking at the issue of making difficult decisions in NHS Scotland, and undertaking the evaluation of the first pilot (regional bowel cancer detection pilot) for the Be Clear on Cancer National Awareness and Early Diagnosis campaign, on behalf of the Department of Health and Cancer Research UK. Outside work, Gina is a Licensed Lay Minister in the Church of England, and is training to be ordained. She enjoys riding, walking the somewhat aging dog, reading and is the village duck warden!

Addressing future challenges for cancer services: part II.

Jane Maher & Gina Radford speak to Gemma Westcott, Commissioning Editor Jane Maher has been Macmillan's Chief Medical Officer since 1999 and now shares the role as Joint Chief Medical Officer with general practitioner Rosie Loftus, reflecting the growing need for specialists and generalists to work more effectively together. She has been an National Health Service (NHS) improvement clinical leader for over 10 years and is a Consultant Clinical Oncologist at Mount Vernon Cancer Centre and Hillingdon Hospital where she has worked for more than 20 years, during which she helped develop nonsurgical oncology services in five district general hospitals. She is a senior Clinical Lecturer at University College London and Visiting Professor in Cancer and Supportive Care at the Centre for Complexity Management at the University of Hertfordshire. Jane chaired the Maher Committee for the Department of Health in 1995, led the UK National Audit of Late Effects Pelvic Radiotherapy for the Royal College of Radiologists (RCR) in 2000 and, most recently, chaired the National Cancer Survivorship Initiative Consequences of Treatment work stream. She co-founded one of the first Cancer Support and Information services in the UK, winning the Nye Bevan award in 1992 and there are now more than 60 units based on this model. She is a member of the Older People and Cancer Clinical Advisory Group. She has written more than 100 published articles and is a UK representative for cancer survivorship in Europe and advises on cancer survivorship programs in Denmark and Canada. Gina Radford is Deputy Chief Medical Officer for England, a post she took up in January 2015. Prior to that, she has held a number of roles in public health, at local and regional level. Most recently she was Centre Director for Anglia and Essex for Public Health England, and as a part of that role helped lead nationally on the public health response to Ebola. She was until very recently Chair of one of the NICE public health advisory committees. She has previously worked on a number of national projects, including leading the Department of Health's response to the Shipman Enquiry, undertaking a review of specialist public health for CMO Scotland, chairing a national short life working group looking at the issue of making difficult decisions in NHS Scotland, and undertaking the evaluation of the first pilot (regional bowel cancer detection pilot) for the Be Clear on Cancer National Awareness and Early Diagnosis campaign, on behalf of the Department of Health and Cancer Research UK. Outside work, Gina is a Licensed Lay Minister in the Church of England, and is training to be ordained. She enjoys riding, walking the somewhat aging dog, reading and is the village duck warden!

Patients with advanced lung cancer: is there scope to discontinue inappropriate medication?

Polypharmacy-taking five or medications per day-is common in lung cancer patients. This patient group is prescribed medication to control acute symptoms associated with cancer and also to prevent or treat other long-term conditions. These medications increase the pill burden for the patient and also the probability of developing a drug-related toxicity. To assess the prevalence of inappropriate medication in patients taking erlotinib for the treatment of advanced non-small cell lung cancer. This was a multicentre study across three sites in the North of England. Medication histories for patients receiving erlotinib were retrospectively extracted from medical notes and assessed by the clinical team (a consultant pharmacist, nurse specialist and clinical oncologist) to determine if the medication was appropriate or inappropriate. The clinical team considered the following factors when deciding if the medication was appropriate or inappropriate: remaining life expectancy of the patient, time until benefit of the treatment, goals of care and treatment targets. Among the 20 patients assessed, 19 (95 %) according to the clinical team were taking medications that were inappropriate. The mean number of medications the patients were taking was 8 (range 1-16) and the most common class of medication used were drugs affecting the Central Nervous System. In addition, there were 11 patients (55 %) who were taking erlotinib in combination with a proton pump inhibitor (PPI)-a clinically significant drug interaction that impairs the absorption of erlotinib. Patients taking erlotinib for the treatment of advanced non-small cell lung cancer take many inappropriate medications for the treatment or prevention of long-term conditions. These patients should have their medications reviewed in the context of their original therapeutic goals.

Variation in Radiotherapy Target Volume Definition, Dose to Organs at Risk and Clinical Target Volumes using Anatomic (Computed Tomography) versus Combined Anatomic and Molecular Imaging (Positron Emission Tomography/Computed Tomography): Intensity-modulated Radiotherapy Delivered using a Tomotherapy Hi Art Machine: Final Results of the VortigERN Study

AimsContrast-enhanced computed tomography (CECT) is the current standard for delineating tumours of the head and neck for radiotherapy. Although metabolic imaging with positron emission tomography (PET) has been used in recent years, the studies were non-confirmatory in establishing its routine role in radiotherapy planning in the modern era. This study explored the difference in gross tumour volume and clinical target volume definitions for the primary and nodal volumes when FDG PET/CT was used as compared with CECT in oropharyngeal cancer cases. Materials and methodsTwenty patients with oropharyngeal cancers had a PET/CT scan in the treatment position after consent. Target volumes were defined on CECT scans by a consultant clinical oncologist who was blind to the PET scans. After obtaining inputs from a radiologist, another set of target volumes were outlined on the PET/CT data set. The gross and clinical target volumes as defined on the two data sets were then analysed. The hypothesis of more accurate target delineation, preventing geographical miss and comparative overlap volumes between CECT and PET/CT, was explored. The study also analysed the volumes of intersection and analysed whether there was any TNM stage migration when PET/CT was used as compared with CECT for planning. ResultsIn 17 of 20 patients, the TNM stage was not altered when adding FDG PET information to CT. PET information prevented geographical miss in two patients and identified distant metastases in one case. PET/CT gross tumour volumes were smaller than CECT volumes (mean ± standard deviation: 25.16 cm3 ± 35.8 versus 36.56 cm3 ± 44.14; P < 0.015) for the primary tumour. Interestingly, our study showed no significant differences in gross tumour volume for T1/T2 disease, although differences in gross tumour volumes for advanced disease (T3/T4) were significant. The nodal target volumes (mean ± standard deviation: CECT versus PET/CT 32.48 cm3 ± 36.63 versus 32.21 cm3 ± 37.09; P > 0.86) were not statistically different. Similarity and discordance coefficients were calculated and are reported. ConclusionPET/CT as compared with CECT could provide more clinically relevant information and prevent geographical miss when used for radiotherapy planning for advanced oropharyngeal tumours. Also, PET/CT provided a smaller better-defined target volume when compared with CECT. PET/CT-based volumes could therefore be used for treatment planning and targeted dose painting in oropharyngeal cancers.

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Corinne Faivre-Finn MD PhD is an internationally recognised Consultant Clinical Oncologist and an Honorary Senior Lecturer in Manchester with an interest in lung cancer. Dr. Faivre-Finn trained in Paris until 1998 and took a consultant post in the UK, at the Christie Hospital in 2001. Her interests lie in the development of multimodality treatments for stage III non small-cell lung cancer and limited disease small-cell lung cancer. She is also interested in the development of stereotactic radiotherapy for early stage NSCLC and early phase trials combining thoracic radiotherapy and mechanism based therapies. She is an active member of the EORTC radiotherapy and lung groups and became the Radiotherapy Chair of the EORTC Lung Group in 2008. She is also the chair of the multimodality working group of the European Thoracic Oncology Platform (ETOP). She is involved with the trial management groups of several UK clinical trials in lung cancer and is the Chief Investigator of several trials including the international CONVERT study looking at the optimisation of concurrent chemo-radiation in limited disease small-cell lung cancer.

Lillian Mary Matheson

David Matheson writes: At the time of her death, Lillian had just taken early retirement from her post as consultant clinical oncologist at the Western General Hospital in Edinburgh and...

Work-based learning, role extension and skills mix within dose planning: Target volume definition for carcinoma of the prostate by non-clinicians

We developed this programme in 2002 to facilitate role extension for dosimetrists and physicists already involved in dose planning, who were prepared to extend their role and offer technical leadership in this field. The dosimetrist group in the Northern Centre for Cancer Treatment are mostly trained therapy radiographers, and were already routinely outlining critical organs, generating complex treatment plans and carrying out associated quality-control procedures. An obvious progression was to evaluate disease sites where, within a framework of written protocols, the consultant clinical oncologist could delegate the task of outlining clinical (CTV) and planning target (PTV) volumes.

Evaluating the efficacy of scalp cooling using the Penguin cold cap system to reduce alopecia in patients undergoing chemotherapy for breast cancer

H. J. PeckMA,RGN/ RSCNCurrent Appointment: Research Sister (breast cancer clinical trials) H.Mitchell BSc Hons, MA, RGNDipN (Lond), Current Appointment: Nurse Practitioner DrA.L.StewartMBChB, MD, FRCR,Current Appointment: Consultant Clinical Oncologist,The Christie Hospital NHS Trust,Wilmslow Road, Withington,Manchester M20 4BX,UK Correspondence and oiprint requests to: H.J. Peck19 Eskdale Avenue,Chesham, Bucks HP5 3AX,UK E-mail: Helen.Peck@V|rgin.Net

An Audit of Indications and Techniques for Supraclavicular Fossa Irradiation in Early Breast Cancer in the United Kingdom

This article describes an audit of the indications and techniques used by clinical oncologists in the United Kingdom (UK) in the delivery of adjuvant radiotherapy to the supraclavicular fossa (SCF) in patients with early breast cancer. A postal questionnaire was sent to one consultant clinical oncologist in each UK radiotherapy centre in November 1999. These were the same individuals listed in the Maher Committee Report as providing breast cancer services. Forty-one out of 51 completed forms were returned. The results show significant variation in the indications for SCF irradiation and for the definition of the radiotherapy target volume. We discuss the possible basis for the variations found in the audit. There was broad agreement on technique, in particular on the need for matching the tangential and SCF fields and maintaining patient position between fields, factors that are likely to minimize serious morbidity, including brachial plexus injury.

Referring Patients Abroad for Proton Therapy

A working party of the Royal College of Radiologists has produced a report, published in this edition, about proton therapy for base of skull chordoma and other uncommon malignancies. There is a proton facility in the UK, at Clatterbridge, which is suitable for treatment of superficial tumours, such as ocular melanoma. Patients with deep-seated tumours for whom the treatment of choice is protons would therefore need to be referred to a facility abroad. This editorial briefly sets out the procedure for making such a referral for proton therapy, but it is generically applicable to treatment abroad for any condition. The procedure differs according to whether the patient is referred to a hospital inside or outside the European Economic Area (EEA). Countries to which UK patients have been referred for proton therapy are France, which is within the EEA and the USA, outside the EEA. As with any treatment, the first step is for the consultant clinical oncologist, in consultation with other doctors involved and the patient, to reach a decision that proton therapy is appropriate. This will require full explanation to the patient of the added complication of having to go abroad for treatment. In these special circumstances agreement from the patient’s health authority (HA) will be required for the proposed treatment, since the treatment will be expensive and the HA will fund it. It would be prudent to consult the HA at an early stage, perhaps before the doctor and patient have reached a decision to have proton therapy. The consultant clinical oncologist will need to consult his or her counterparts at one or more proton facilities abroad, in order to decide to which centre the patient should be referred. The clinical oncologist then needs to present an evidence-based case to the HA that the patient should be referred to a specific proton facility abroad. The HA will expect the case to be made by a clinical oncologist because the treatment is radiotherapy, rather than by the patient’s neurosurgeon, who does not prescribe radiotherapy. Similarly, the clinical oncologist at the proton facility