'25 at 25': Optimising treatments for people with cancer
06 Mar 2024
The cancer trials that hit the headlines tend to be about improving how long people with cancer live or delaying the disease from getting worse. This is obviously very important, particularly for types of cancer which have a poor prognosis. What can sometimes get overlooked is the need to optimise treatments, to make them easier for patients and less costly in terms of time and resources to the health system while still having the same effect on the cancer.
Cancer treatments can sometimes be tough for patients. Treatments may have unpleasant side-effects in the short or longer-term. Or they may be difficult in other ways, for example requiring frequent visits to hospital, which can be inconvenient (particularly for those who have work or caring responsibilities) and costly (especially for people who live a long way from the hospital, or in areas with poor public transport).
Some of our trials focus on addressing these challenges, seeing if cancer treatment can be made easier for patients, without becoming less effective. While the results may not be so headline-grabbing, they can make a real difference to the experience of cancer treatment for people going through it. Here we look at four examples of trials that aimed to optimise treatments.
TE19: reducing side-effects from treatment of stage I testes cancer
Each year almost 2,000 new cases of testes cancer are diagnosed in England. Most of these cases are in young men. A large proportion of diagnoses are made when the cancer is at an early stage, meaning it has not spread outside the testicle (stage I).
Men who are diagnosed with stage I testes cancer generally do well with treatment, with 97% surviving for at least five years. Before the TE19 trial men were usually treated with surgery followed by a course of radiotherapy. While this had good outcomes, radiotherapy caused side-effects in some men, and also increased the risk of men developing secondary cancers later in life. The TE19 trial was designed to see if chemotherapy would control the disease as well as radiotherapy, with fewer side-effects.
The TE19 trial involved 1,447 men with stage I testes cancer. After surgery these men were randomised to receive either a single dose of carboplatin or a course of radiotherapy. The aim of the trial was to see if carboplatin was as good as radiotherapy in terms of the rate of relapse. It also looked at deaths, incidence of secondary cancers, and side-effects.
The study found that carboplatin was as good as radiotherapy at preventing relapses. Carboplatin caused fewer and milder side-effects than radiotherapy. It also seemed to reduce (or at least delay) secondary cancers. Another advantage of carboplatin is that it only requires one hospital visit, whereas radiotherapy meant men had to come to hospital five days a week for two weeks.
TE19 changed clinical guidelines for the treatment of stage I testicular cancer, leading to men being offered this as an alternative to radiotherapy after surgery.
QUARTZ: Lung cancer patients whose tumour has spread to the brain could be spared radiotherapy
More than 48,000 people are diagnosed with lung cancer in the UK every year. An estimated 85 per cent of cases are non-small cell lung cancer. Up to 30 per cent of patients with non-small cell lung cancer have the disease spread to the brain.
When this trial was ongoing, typically, patients were given steroids and supportive care, including medications such as painkillers to manage their symptoms. They were also offered whole brain radiotherapy, a treatment that means attending hospital daily for one to two weeks. Before this trial, doctors had little evidence to prove whether giving these patients whole brain radiotherapy improved symptoms or benefitted them.
Whole brain radiotherapy can cause side effects and involves daily visits to the hospital. The QUARTZ trial looked at whether patients could avoid whole brain radiotherapy without reducing either how long they were likely to live or the quality of their life.
The trial studied 538 patients from the UK and Australia. Half of the patients had whole brain radiotherapy and the other half did not. All the patients received steroids and supportive care.
The trial found no clear difference in survival and quality of life between the patients who did and didn't receive whole brain radiotherapy. This evidence has helped patients and doctors to make informed decisions based on understanding the level of benefit whole brain radiotherapy offers.
PATCH: Testing an alternative way to receive hormone therapy for prostate cancer
More than 50,000 people are diagnosed with prostate cancer in the UK every year. Prostate cancer needs the male hormone testosterone to grow. In men with cancer that has spread from the prostate to other parts of the body (advanced prostate cancer), hormone therapy is used to lower the level of testosterone, which helps to control the growth of the cancer. Unfortunately, standard hormone treatment with injections or implants can cause a range of long-term side effects. They may cause bones to thin which might lead to them becoming fragile (osteoporosis) and more likely to break. They might also increase the chance of developing diabetes or heart disease.
An alternative way of giving hormone therapy is through the use of patches, called transdermal (meaning through the skin) oestradiol. These patches allow oestradiol (a type of hormone) to pass through the skin. Giving hormone therapy this way might control the cancer just as well as standard hormone therapy, without causing some of these side effects.
Around 2,400 people with prostate cancer are taking part in the PATCH trial, which is comparing standard hormone therapy with transdermal oestradiol patches. The PATCH trial has already shown transdermal oestradiol can suppress testosterone as effectively as standard hormone therapy, while having a number of other potential benefits:
- Men treated with transdermal oestradiol showed increased bone strength in comparison with those on standard hormone therapy.
- Men treated with transdermal oestradiol reported better quality-of-life in the first 6 months of treatment than those on hormone injections.
- Cholesterol and glucose levels increased in men on hormone injections but decreased in those on transdermal oestradiol.
The PATCH trial is testing whether transdermal oestradiol patches are as effective as standard hormone treatment at controlling prostate cancer. We expect to release results from some groups of men treated in PATCH this year, and on other groups within the next 1-2 years.
REFINE: optimising the use of immune checkpoint inhibitors in renal cancer and melanoma
Immune checkpoint inhibitors are a relatively new type of treatment for cancer, which work by stimulating the body’s own immune system to fight against cancer cells. They can be very effective for some patients.
Immune checkpoint inhibitors are given to patients through an injection into a vein every 3-6 weeks in a hospital or clinic. Blood tests are needed before each injection. This means that patients spend a lot of time (and possibly money) on hospital visits.
Clinical trials have proven the effectiveness of immune checkpoint inhibitors in the treatment of different cancers. However, the best way to give these drugs is not fully understood. It is likely that immune checkpoint inhibitors work for longer than originally thought. This means it should be possible to give the drugs less often and still have the same effect on the cancer. The REFINE trial is testing whether giving patients with advanced cancer longer gaps between immunotherapy treatments results in fewer side effects and improved quality of life, whilst continuing to be an effective treatment.
This approach also has potential benefits for the health system. Immune checkpoint inhibitors are very costly. If we can get the same effectiveness from less frequent doses, it could potentially result in large savings for the NHS.
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