This document was written by Professor Mererid Evans, Consultant Clinical Oncologist at Velindre University NHS Trust (VUNHST) with significant contributions from:
Physics: Tony Millin (Head of Radiotherapy Physics VUNHST), Philip Wheeler (Clinical Scientist, Dept. of Medical Physics VUNHST), Claire Power (Business Support Manager, Medical Physics).
Radiotherapy: Catherine Matthams (Radiotherapy Research and Development [R&D] Lead VUNHST), Bernadette McCarthy (Radiotherapy Services Manager VUNHST)
Clinical Oncologists: Tom Crosby (Clinical Lead for Transforming Cancer Services [TCS] Programme), James Powell (Clinical Lead for PBT VUNHST), Paul Shaw (Clinical Lead for Early Phase Drug-RT Trials VUNHST), Tom Rackley (Clinical Radiotherapy Lead VUNHST)
Management: Nicola Hughes (Senior Finance Business Partner, VUNHST)
Cardiff University: John Staffurth (Chair, Division of Cancer and Genetics, School of Medicine, Cardiff University and Honorary Clinical Oncologist VUNHST), Emiliano Spezi (Reader in School of Engineering, Cardiff University).
Version 1: 24 February 2020.
This document sets out a strategy for radiotherapy research at Velindre University NHS Trust (VUNHST), including Velindre Cancer Centre (VCC), the proposed Radiotherapy Satellite (RTS) and the new Velindre Cancer Centre (nVCC).
Velindre Cancer Centre currently delivers radiotherapy to approximately 4500 patients per year, with technical radiotherapy capabilities to deliver Intensity Modulated Radiotherapy [IMRT] (>80% of radical plans), Stereotactic Ablative Body Radiotherapy [SABR], Stereotactic Radiosurgery [SRS], Brachytherapy (High Dose Rate [HDR] and Low Dose Rate [LDR]) and Molecular Radiotherapy.
A Radiotherapy Satellite Centre (RTS) is planned in 2023 and a new Velindre Cancer Centre in 2024, to replace the existing site. This will be a world class facility with state of art radiotherapy technology and diagnostic capability [CT, MRI +/- PET-CT]. A dedicated research bunker, with the potential to accommodate a novel treatment machine, is planned as part of the new facility. This new capital infrastructure will enable Velindre radiotherapy research to flourish, building on existing strengths and capabilities, developing our talented workforce and harnessing the opportunities afforded by new technology to deliver a step change in our future research outputs.
It is vital that radiotherapy at VCC reflects patient needs, builds on the best clinical service and seamlessly integrates high quality research into daily clinical interventions. With that in mind, a Radiotherapy Development Program has been established with the aim of defining the radiotherapy service, focusing on service change for the future and aligning with the Transforming Cancer Services (TCS) Program which is overseeing the development of the RTS and nVCC. As part of the Radiotherapy Development Program there is a workstream for Research Development and Innovation (RD&I) which will work proactively in support of this research strategy. The strategy cuts across radiotherapy disciplines and has the Trust Board support.
Velindre University NHS Trust has an existing research partnership with Cardiff University, including a Memorandum of Understanding (MOU) and a shared commitment, supported at the highest level within both organizations, to develop an ever-closer strategic partnership between the NHS and academia around radiotherapy research. The Cardiff Radiotherapy Research Group, established in 2019, has given a new focus and shared vision for radiotherapy research in Cardiff and has agreed the key research themes and priorities set out in this document. These will also be incorporated into the VUNHST Research, Development and Innovation (RD&I) Strategy being developed in 2020.
1. Radiotherapy Clinical Trials:
Velindre has a strong track record of leading multi-centre, practice-defining radiotherapy clinical trials and implementing changes into routine NHS care. Velindre-based clinical oncologists currently lead 8 radiotherapy clinical trials (7 as Chief Investigators), which are run through the Centre for Trials Research [CTR] at Cardiff University and sponsored by VUNHST and/or Cardiff University. Our trials have changed national and international guidelines (e.g. MRC PR07/NCIC PR3 in prostate cancer [1]) and raised the quality of routine radiotherapy planning and delivery across the UK (e.g. the SCOPE trials in oesophageal cancer [2-3]). Our current portfolio of clinical studies includes the internationally adopted, Cancer Research UK (CRUK)-funded PATHOS phase III radiotherapy trial in patients with head and neck cancer [4] and trials in 5 other tumour sites: PLATO-ACT V and CORINTH [Anal cancer], SCOPE 2 [oesophageal cancer], the Neurocognitive Function Study [Brain cancer], the PEARL study [Head and Neck cancer], CONCORDE [Lung cancer], PRIME-RT [rectal cancer] and EAGLE [prostate cancer] .
The Centre for Trials Research [CTR] at Cardiff University is one of only 8 CRUK core funded UK Clinical Research Collaboration [CRC] registered clinical trials units in the UK, with a specific remit to develop and deliver cancer clinical trials, including radiotherapy-related clinical research. It has expertise in trial design and delivery which is available to local investigators, proactively working with VUNHST and/or Cardiff University as key sponsors of these trials nationally and internationally.
In collaboration with Cardiff’s Experimental Cancer Medicine Centre (ECMC), Velindre’s Early Phase Trials Unit (EPTU) has developed a track record of early phase drug:radiotherapy combination trial delivery (Paradigm 2, ORCA and CHARIOT). One arm of the CRUK-funded CONCORDE study, a UK-wide phase I platform study examining the efficacy of novel agents in combination with radiotherapy for the treatment of lung cancer, is led by a Velindre clinical oncologist.
Multidisciplinary input is key to enable effective clinical trial delivery and Radiotherapy Research Radiographers play a vital role within the clinical trial setting. They are responsible for assessing the feasibility of radiotherapy trials and ensuring that the correct techniques, technologies and resources are accessible. In addition to setting up clinical trials, Research Radiographers are involved in the screening and recruitment of eligible patients, providing complex trial information to patients, relatives and carers to ensure that they are in a position to provide informed consent. Once recruited to trial, Research Radiographers are responsible for following the patient through the trial timeline, completing toxicity reviews during treatment and into the follow-up stage. Our most recent success saw Velindre named as the top recruiter in 2019 for the UK-wide RAPPER [Radiogenomics of Radiation Toxicity] study.
As well as clinical trial leadership, Velindre provides radiotherapy quality assurance for national and international clinical trials, as one of 4 UK centres which form the National Radiotherapy Trials Quality Assurance (RTTQA) group. Velindre currently leads national RTTQA programmes for gastrointestional (oesophageal, rectal, anal) and head and neck cancers.
2. Automation, Computing and Data Analysis:
a. Automated Radiotherapy Plan Generation and Tumour Delineation:
Radiotherapy planning is a highly complex and time-consuming process. Researchers within the physics department at Velindre have developed EdgeVCC (Experience Driven plan Generation Engine by Velindre Cancer Centre), a pareto-guided automated radiotherapy planning solution, which generates high quality radiotherapy plans fully autonomously. Two key features of EdgeVcc are a unique calibration process, where trade-offs between competing clinical aims can be intuitively explored, and the possibility to calibrate the solution over a limited number of patients. EdgeVcc has been locally validated for prostate, prostate and pelvic nodes, and head and neck cancer, with Turing-type comparative studies demonstrating equivalence between automated plans and manual planning techniques [5, 6]. In a two centre external validation study for prostate patients, EdgeVcc was preferred over manual planning in 31/40 (77.5%) of study patients. With manual plan generation for standard patients requiring between 15-60 minutes of expert operator time, automation with EdgeVcc offers the potential for significant efficiency savings within the clinical environment and additionally opens up research opportunities with respect to automated planning of large datasets. EdgeVcc will be implemented into clinical service at VCC in 2020 and is being calibrated and evaluated in other tumour sites, as well as being incorporated into a fully automated radiotherapy planning process being tested in the Velindre-led PEARL clinical trial. Preliminary work is also underway to utilize automated planning to assess the dosimetric impact of inter observer-variability in target volume delineation and to investigate the feasibility of providing per-patient reference plans for on-trial QA purposes.
Velindre researchers have collaborated closely with colleagues in the Cancer Imaging and Data Analytics group (CIDA), led by Dr Emiliano Spezi at the Cardiff University School of Engineering (ENGIN) to develop a novel, machine learning tool called ATLAAS (Automatic Decision Tree Algorithm for Advanced Segmentation [7, 8]) which can select the optimal computer algorithm with which to automatically segment (or delineate) the biologically active tumour seen on 18F-fluorodeoxyglucose Positron Emission Tomography (PET) scanning, in order to guide radiotherapy planning. Originally developed in a Velindre study in head and neck cancer patients (POSITIVE: Optimization of PET scanning for Head and Neck radiotherapy treatment planning [9)], ATLAAS has subsequently been tested on other tumour types, including oesophageal cancer and is currently being implemented in the Velindre PEARL (PET-based Adaptive Radiotherapy) clinical trial in patients with head and neck cancer.
b. Cancer Imaging and Data Analysis:
Cancer imaging and radiotherapy planning scans contain a wealth of features which can be extracted and interrogated to potentially reveal biomarkers of patient prognosis and tumour response to treatment. Working with CIDA, Velindre researchers have developed a portfolio of cancer imaging and non-invasive quantitative image biomarker (radiomic) analysis e.g. in oesophageal cancer [10-11] and established SPAARC: Spaarc Pipeline for Automated Analysis and Radiomics Computing Cardiff [12-13]). The group has established links with national (UKCAT) and international collaborators, including the European Computer Assisted Theragnostics project (EuroCAT) and CORAL (Community in Oncology for Rapid Learning) network of distributed learning, with close links to the MAASTRO clinic and an international award-winning collaboration in this space in 20,000+ lung cancer patients [14, 15]. CIDA is a founding member of the Image Biomarker Standardisation Initiative (IBSI) [16], developing international standardised radiomics algorithms and reporting guidelines and has been rated the top UK centre for performance. CIDA is also a core member of the IBSI2 2 (https://theibsi.github.io) which focuses on the standardization of the use of imaging filters.
3. Novel imaging and Image Guided Radiotherapy (IGRT):
Radiotherapy delivery depends on high-quality imaging to: a) precisely delineate the tumour prior to starting a course of radiotherapy (pre-treatment imaging); to b) re-define the tumor during a course of radiotherapy in order to potentially adapt the radiotherapy treatment according to tumour response and/or position (adaptive radiotherapy); c) to accurately verify tumour and patient position during radiotherapy (treatment verification); and d) to predict or assess tumour response to treatment and the effect of radiotherapy on surrounding normal tissues. Cross-sectional imaging (typically with CT and/or MRI scanning) can define the location, size and shape of a tumour, whilst functional imaging (typically with PET-CT and/or functional MRI scanning) can give complementary information about tumour biology (including metabolism/proliferation/hypoxia). Image Guided RadioTherapy (IGRT) can include all of these techniques.
Velindre radiotherapy researchers have established links with Wales’ Positron Emission Tomography Imaging Centre (PETIC) and Cardiff University’s Brain Research Imaging Centre (CUBRIC) which offer opportunities for novel imaging that can enhance the way we deliver radiotherapy and better understand its effects on tumours and normal tissues.
a. Links with Wales’ Positron Emission Tomography Imaging Centre (PETIC)
Links with PETIC (situated in the University Hospital of Wales, Cardiff) were initially forged during the POSITIVE study in head and neck cancer patients [17], which led to the development of ATLAAS, a novel, award winning [6] machine-learning tool for the delineation of PET images which eliminates inter-observer variability by selecting the best-fitting automatic segmentation method for every tumour. ATLAAS is currently being prospectively tested in the ongoing Velindre-led and sponsored PEARL (PET-based Adaptive Radiotherapy) study, set up to explore if serial functional imaging with 18FDG-PET-CT can detect early biological responses to radiotherapy which can be used to individually adapt and optimise radiotherapy plans in order to reduce side-effects for patients.
Thus far, Velindre research at PETIC has focused on using 18Fluorodeoxyglucose (FDG), a marker of tumour metabolism. The cyclotron at PETIC offers significant potential for future research using novel PET tracers (e.g. F-DOPA and Zr-89 are currently being generated for non-Velindre studies in patients with Gliobastoma Multiforme [GBM] and murine [mouse] immunotherapy studies respectively) which could be exploited in future studies.
b. Links with Cardiff University’s Brain Research Imaging Centre (CUBRIC)
CUBRIC (part of Cardiff University's Science and Innovation Campus on Maindy Rd, Cardiff) is a world class, and UK leading, research-dedicated imaging centre, which has unique multiparametric MRI imaging capabilities. It houses 4 advanced Siemens MRI scanners, including the UKs only 3T MRI Connectom scanner equipped with an ultra-strong whole-body gradient system (300mT/m) for detailed microstructural tissue characterisation, a 7T Magnetom and 2 x 3T Prisma MRIs and more than 20 MRI physicists and engineers. CUBRIC’s equipment and expertise, formerly largely devoted to basic neuroscience research, has branched out to include radiotherapy research, through collaboration with Velindre’s neuro-oncology and psychology teams: the ongoing Velindre-led and sponsored Neurocognitive Function Study [NFS] is studying changes in neurocognition and in MRI parameters in patients undergoing stereotactic radiosurgery (SRS) for brain metastases. Future research is planned in patients with primary glioma (brain cancer) and in patients with head and neck cancer.
4. Immunology/Immunotherapy:
Cardiff University’s translational immunology laboratory (led by Professor Awen Gallimore), have expertise in measuring antigen-specific effector and regulatory T cell activity in preclinical models of cancer and completing the full circle of bedside-to-bench-to-bedside clinical, translational and discovery science, testing novel cancer vaccine strategies in the phase I/II TACTICC trial, carried out in collaboration with Velindre researchers [18,19]. In a developing collaboration between the immunology laboratory and Velindre clinical oncologists, a study has been set-up to generate pilot data to determine the effect of Stereotactic Ablative Radiotherapy (SABR) on immune responses in the peripheral blood of patients, which will be used to underpin future grant applications to expand this work further.
5. Living with and beyond cancer and patient focused research:
Cardiff has one of only 2 UK centres with Marie Curie core programme grant funding, and our local Marie Curie Research Centre (MCRC) has cross-cutting methodological expertise in both trial design and assessment of complex interventions, with a focus on patient and carer experience and patient/public involvement. There is a strong track record of collaboration between the MCRC and Velindre radiotherapy researchers, including the ROCS study of Radiotherapy in Addition to Oesophageal Cancer Stenting [20] and the development of a screening tool (ALERT-B) for late effects of pelvic radiotherapy treatment [21] and its management (EAGLE study) [22].
Therapeutic radiographers, based within the radiotherapy department at Velindre, play a vital role in the delivery of radiotherapy services and are ideally placed to develop and deliver patient focused research. Being the only health profession qualified to plan and deliver radiotherapy, they constitute over 50% of the radiotherapy workforce. This places the profession in an ideal position to transform the health and wellbeing of oncology patients through radiographer-led research. Recently Advanced and Consultant Practitioner roles have been established in Velindre which are of paramount importance in leading the way for patient focused research. The Allied Professions into Action Strategy emphasises that NHS leaders need to support therapeutic radiographers in research engagement, ensuring that research activity is recognised as one of the four pillars of Advanced Clinical Practice in Health and Care Practitioners. Recent patient focused Velindre radiographer-led research carried out in conjunction with the Cardiff School of Engineering for a PhD qualification was: ‘An investigation into the effects of radiotherapy on implanted cardiac devices’ and current research being undertaken by a Velindre Consultant Radiographer as part of a Professional Doctorate (DProf) is investigating: ‘The impact of taste changes during radiotherapy’.
Our vision is to deliver radiotherapy research that improves the survival and enhances the lives of patients treated with radiotherapy, by becoming one of the UK’s foremost radiotherapy research centres. The aims of our research will be to optimise and personalise radiotherapy treatment to improve patient outcomes, by enhancing cure rates and/or minimising toxicity.
We will generate innovative and impactful research, ultimately delivered by translationally-rich radiotherapy clinical trials. We will build on our existing strengths, develop and support our multi-disciplinary radiotherapy research workforce and strengthen collaborations with Cardiff University and other partners to deliver our research ambitions. In the future, we will harness the considerable opportunities afforded by the new technology and infrastructure in the new Velindre Cancer Centre to increase the impact of our research.
Our research activities will be consistent with the Velindre Radiotherapy Strategy 2016-2026 and its strategic aims, which include:
Our radiotherapy research aims will be delivered through 7 interconnected and complementary workstreams, which build on our current strengths:
1. Radiotherapy Clinical Trials:
Aim: To deliver translationally rich radiotherapy clinical trials, aiming to improve cure rates and/or minimise toxicity.
We will prioritise:
Participation in clinical trials will be embedded as ‘core business’, offering patients the opportunity to access the latest treatments and technologies, based on the best available evidence. We will build a portfolio of radiotherapy clinical trials which will strategically include a mix of early and late phase studies, interventional and observational studies and academic and industry-funded studies. Alongside this, new radiotherapy research, conceived, developed and led by Velindre researchers and supported by the Velindre Research, Development and Innovation (RD&I) department, will be a priority for the future. We will build on our successes in clinical trial leadership and acknowledge the work that remains to be done in terms of linking discovery research, through the translational pipeline, to the clinic.
Enablers will include funded research time for NHS staff (clinicians, physicists, radiographers and others who will become future Chief Investigators [CI’s] and Principle Investigators [PI’s]) and investment in a support team to advise on trial methodology, develop funding applications and facilitate study set-up. Sufficient resources are required in all radiotherapy and allied departments (radiotherapy, physics, clinical, pharmacy, nursing, AHPs) to support this activity. We will work closely with Cardiff’s Experimental Medicine Cancer Centre (ECMC) and Cardiff University’s Centre for Trials Research (CTR) to develop and deliver our trials and will link in with UK networks for radiotherapy trial development, including the National Cancer Research Institute’s Clinical and Translational Radiotherapy Research Working Group (NCRI CTRad) and CRUK’s RadNet centres and units.
2. Automation, Computing and Data Analysis
Aim: To deliver UK leading, translational research in radiotherapy automation and optimization, with the purpose of improving quality and/or efficiency of radiotherapy planning.
We will prioritise:
In order to expand our capabilities in automation, computing and data analysis, a successful application was made (in 2019) to the Wales Research Ethics Committee (REC) to establish an IT infrastructure within the NHS at Velindre called the Cardiff Computer Aided Theragnostics (CardiffCAT) database. CardiffCAT once resourced and fully established, will contain anonymised clinical imaging and dosimetry data for radiomic and distributed machined learning research and will enable large-scale, real-time databasing of multi-dimensional clinical data, building on established work in Velindre and Cardiff University. We will install our in-house software for PET segmentation (ATLAAS), pareto-optimised automated planning (EdgeVCC) and radiomic analysis (SPAARC), integrate them with commercial software and NHS systems and link with our national and international collaborators e.g. UK RTTQA group, MAASTRO clinic and CORAL network. CardiffCAT will enable a standardised and automated approach to imaging biomarker discovery and radiotherapy planning. Collation of data from radiotherapy planning systems will, for example, allow research studies correlating toxicity with doses to normal tissues/organs at risk. CardiffCAT could also be linked with Cardiff University-WCRC Infrastructure Accelerator Award grant to Sêr Cymru and plans to develop and implement Welsh Government’s genomics for precision medicine strategy.
The development of a database of radiotherapy treatment data including all images, radiotherapy plans and dose cubes will facilitate future research by providing large amounts of anonymized data that could be used for future investigations into automation, trend analysis of plan quality as new techniques are clinically introduced and correlation of treatment outcomes and doses delivered. The database will also be instrumental in supporting investigations of other themes described in this document enabling large scale analysis of postulated scenarios to be investigated.
RTTQA: Velindre will continue to provide leadership within the UK RadioTherapy Trials Quality Assurance (RTTQA) network, aiming to build an infrastructure and quality assurance process for future trials that utilise novel imaging, automation and adaptation to standardize and optimise radiotherapy planning and delivery. Data collected from pre-trial and on-trial radiotherapy plans will provide a rich source of data for analysis using our computing infrastructure.
3. Novel imaging and Technology
Aim: To deliver highly precise radiotherapy treatment in as few fractions as possible and/or adapt treatment during a course of radiotherapy to optimise outcomes. Novel imaging will also be used to better understand the effects of radiotherapy on tumours and normal tissues aiming to identify early imaging biomarkers of radiotherapy response and toxicity, which can be used in future studies designed to adapt and optimise treatment.
We will prioritise:
This work will build on existing collaborations with CUBRIC (developed through the Neurocognitive Function Study in brain) and PETIC (developed through the POSITIVE and PEARL studies in head and neck cancer), the considerable expertise our therapeutic radiographers have in Image Guided Radiotherapy (IGRT) and prior experience of running imaging-based adaptive radiotherapy clinical trials (e.g. PEARL) at Velindre. It will be enabled by funded research time for NHS staff (clinicians, physicists, radiographers) and possible investment in future Clinical Academic posts in imaging-based radiotherapy research).
Velindre radiotherapy researchers will strive to improve patient care by staying at the forefront of ground-breaking new technologies and techniques, in order to deliver the most effective treatments. The new VCC offers enormous opportunities to utilize new technologies optimize, personalize and adapt radiotherapy treatments in the future. For example, an MRI-LINAC would offer the potential to track changes identified on CUBRICs multi-parametric MRIs on real time LINAC-based MRI scanners during radiotherapy treatment. Furthermore, MRI-LINAC based technology, which can precisely define the location of a tumour on a daily basis, could enable extreme hypofractionation (high dose radiotherapy delivery in a small number of fractions) for tumour sites in which this would not otherwise be possible due to variations in day-to-day tumour positioning (e.g. prostate, rectum) – these schedules are likely to be tested in UK clinical trials within the next few years. FLASH radiotherapy using photons is also likely to enter into the clinical trial setting within the next few years. FLASH radiotherapy involves the ultra-fast delivery of radiation treatment at dose rates several orders of magnitude greater than those currently in routine clinical practice. Ultra-fast dose rates allow normal tissue tolerance levels to be exceeded, at least in animal models, with a greater probability of tumour control and little or no normal tissue damage. FLASH radiotherapy could therefore be more effective in killing hypoxic cancerous cells than standard dose rate radiotherapy with the added advantage of sparing normal tissue. Advanced linear accelerators that can deliver ultra-high dose rates are likely to be available within the next few years. The novel imaging and technology work stream will aim to be actively involved in discussions on which new technology(ies) should be included in the nVCC.
4. Immuno-oncology and radiotherapy
Aim: To increase our understanding of the immune effects of radiotherapy and use this knowledge to underpin the development of clinical trials combining immunotherapy with radiotherapy.
We will prioritise:
This work will build on existing strengths within the translational immunology group at Cardiff University, technical radiotherapy expertise (e.g. in SABR) at Velindre and Early phase Drug-RT expertise at Velindre EPTU and Cardiff’s ECMC. It will be enabled by investment in funding for laboratory-based researchers (e.g. PhD studentships) and NHS-based clinical researchers (including Clinical Research Fellowships, funded research time for Clinical Oncologists in the NHS, possible development of future Clinical Academic posts in immuno-oncology research).
5. Living with and Beyond Cancer (LWBC) and patient-focused research
Aim: To build a portfolio of patient focused research which is conceived and developed by radiographers and/or other members of the multidisciplinary team, is clinically meaningful, improves outcomes and enhances the lives of patients treated with radiotherapy.
We will prioritise:
These areas are National Cancer Research Institute (NCRI) priority research areas and likely to be included in the Cancer Research Strategy for Wales (CReSt) currently being developed. The generation and application of our research will be embedded into health and social care practice in order to improve services, promote health, wellbeing and safety of service users, and to optimise the effective use of resources.
Enablers will include funded research time for NHS staff (clinicians, physicists, radiographers and others who will become future Chief Investigators [CI’s] and Principle Investigators [PI’s]) and investment in a support team to advise on trial methodology, develop funding applications and facilitate study set-up. We will work closely with academic radiographers within the School of Healthcare Sciences at Cardiff University and researchers at the Cardiff Marie Curie Research Centre. Furthermore, we will work with the All Wales Genetics Laboratory (AWGL) on cell-free DNA (cfDNA) analysis (already incorporated into the PEARL study and into the translational programme of work associated with the PATHOS trial).
6. Proton Beam Therapy (PBT) research
Aim: To establish a PBT research programme in VCC that increases opportunities for patients in Wales to access PBT treatment.
We will prioritise:
VUNHST and the Rutherford Cancer Centre (RCC) currently provide a WHSSC commissioned clinical service for treating adult patients with proton beam radiotherapy (PBT) for NHS agreed clinical indications and VUNHST is currently working with the RCC to establish a PBT research governance infrastructure to facilitate research in the field of PBT.
The UK is currently developing a portfolio of PBT clinical trials through the NCRI CTRad-CRUK ART-NET infrastructure. The first of these trials is the TORPEdO trial in Oropharyngeal Carcinoma and is due to open imminently. Further trials in good prognosis glioma (APPROACH, co-CI is a Velindre consultant), oesophageal, breast and lung cancer will follow. UK patients enrolled in these trials are currently planned to receive PBT treatment in the NHS England centres in the Christie or UCLH. We will ultimately aim to treat Welsh patients with PBT in Wales.
Enablers will include establishment of a clinically led PBT research infrastructure that is embedded into the RD&I function of the trust R&D Office. This will ensure that the Trust has a lead role in delivering the PBT research portfolio, providing assurance that all research activity is conducted in accordance with the appropriate regulation and that research leads will be supported appropriately to deliver this work. Funded time will be required for a Velindre R&D PBT Research Consultant/Clinician to provide overall strategic leadership for PBT focused research activity at VCC, along with a PBT Clinical Research Fellow to support clinical trial development, a Medical Physicist to develop and ultimately implement automated plan comparison studies of PBT vs photon radiotherapy and resource within R&D to ensure that quality systems and processes are in place to ensure all PBT research activity involving Velindre is conducted safely, ethically, efficiently and in accordance with relevant regulations.
7. New research opportunities
Aim: To develop new collaborations with discovery and translational scientists and to maximize opportunities afforded by new technology to extend our radiotherapy research portfolio and realize patient benefits.
This theme will allow us to be flexible and adaptable enough to embrace new research opportunities which may emerge over the next 5 years, associated with the following:
This workstream will link in with the other workstreams, RD&I Committee and research leads to identify and enable new opportunities for radiotherapy research at Velindre.
Management and Leadership is crucial in ensuring Velindre Cancer Centre is a thriving centre which pushes for continuous improvements. High quality clinical and translational research underpins all our activities and progress made to date. Thus it is vital that radiotherapy at VCC reflect patients need, builds on the best clinical service and seamlessly integrates high quality research into daily clinical interventions. Therefore research at VCC needs to be given the opportunity to grow. With that in mind, a Radiotherapy Development Program has been established with the aim of defining the radiotherapy service, focusing on service change for the future and aligning with the Transforming Cancer Services (TCS) Program. As part of the Radiotherapy Development Program there is a workstream for Research Development and Innovation (RD&I) which will work proactively in support of the radiotherapy research strategy, in conjunction with the Trust’s RD&I Committee. The strategy cuts across disciplines and has the Trust Board support.
The vision and aims will be delivered by using VCC’s high quality clinical platform to facilitate radiotherapy research through clinical trials, developing and recruiting staff and investing in leadership, making the best use of new technology, strengthening links with academic and commercial partners and generating and attracting future investment.
Building our multidisciplinary radiotherapy research workforce and investing in leadership
VCC will pursue its research and clinical activities and create an environment that is supportive to trainees, researchers and staff with an interest in research. Specifically VCC will:
• Recruit/develop clinical staff with the desire / capability to develop research programmes and support them to do this
• Find mechanisms to give research active radiotherapy research staff the scope to develop and deliver
• Designate or otherwise create posts that have research as a key part of their role description
• Invest in leadership to oversee delivery of the research strategy and the aims of each work stream, with administrative support
• Build a department and a clinical service where research is embedded in all aspects
Building our clinical research workforce, through recruitment, training and retention of research staff, will be essential to deliver the radiotherapy research aims and ambitions outlined in this document. Velindre has a highly talented workforce, which has the potential to generate impactful research when fully empowered and supported. We will develop a culture which supports and promotes RD&I at all levels across the broad radiotherapy workforce and put clear mechanisms in place to support staff with innovative ideas from conception to funding, delivery and publication of outputs.
Pathways for career development, for both clinical and academic research staff, will be established to grow our future research leaders. New ways of working will be developed, aiming to get the best out of our staff in order to make evidenced based changes to care which will benefit patients.
Research informed practice will be a core principle to the therapeutic radiography workforce. The National Institute for Health Research (NIHR) Clinical Research Network’s AHPs Strategy 2018-2020 recognises that realising the potential of AHP’s is core to delivering the NIHR’s mission to “to provide a health research system in which the NHS supports outstanding individuals, working in world class facilities, conducting leading edge research which is focused on the needs of patients and the public”. The Council of Allied Health Professions Research (CAHPR) ‘Shaping Better Practice Through Research: A Practitioner Framework’ describes the knowledge and skills required of AHPs and therapeutic radiographers working in research from basic competency to advanced and research leadership levels. This resource offers a practical framework which supports our aim of making research “core business” in practice, whilst also forging pathways and career progression for AHP’s and therapeutic radiographers to become leaders in the field of applied health research.
Building and supporting the radiotherapy research workforce will be the responsibility of the RT Development Program RD&I workstream, supported by the RD&I Committee and the Medical Director (or delegated research leads), under the oversight of the VUNHST Trust Board.
Embracing new technology
Moving to nVCC and the procurement of an Integrated Radiotherapy System (IRS) [potentially by 2021] could enable innovative workflow processes to be developed that streamline the patient pathway, increase efficiency and improve treatment quality. Whilst implementation will be overseen by the radiotherapy service, the RD&I workstream will support the implementation process to ensure that maximum patient benefit is obtained, robust quantification and analysis of the data is performed applying scientific principles to the process. Other opportunities for development are afforded by the introduction of automated systems for outlining and planning which improve efficiency, consistency and plan quality which could be utilized for research.
The equipment procurement programme for nVCC (commencing q1 2020) will consider the radiotherapy research vision and aims outlined in this document in full. A research bunker, housing an additional machine dedicated for research purposes, could vastly enhance our profile, capacity and capability to deliver our radiotherapy research ambitions, with far greater impact and reach than would otherwise be possible. Presently, because the vendor is unknown, the treatment modality of the additional research machine cannot be specified. However, the aims and objectives described above could be applied and developed further in the following scenarios:
Other partnerships with the IRS provider are possible, including in the areas of imaging, computing, automation and/or novel work flows. Detailed proposals for the research that will be undertaken will be developed once the vendor is known, which will be firmly based on the priorities described for each workstream in this document and wholly consistent with our overarching vision and aims for radiotherapy research at VUNHST.
Strengthening links with academic and commercial partners
Cardiff University:
The Cardiff CRUK RadNet bid in 2019 represented a new level of strategic partnership between Cardiff University and Velindre in the field of radiotherapy research. Although not successful, the bid generated collaborations and partnerships, now overseen by the Cardiff Radiotherapy Research Group (CRRG). Through this group, academic researchers from 3 Schools in Cardiff University (Medicine, Engineering, Psychology) and NHS clinical researchers from Velindre are committed to working together in an ever-closer partnership. The group provides a focus to develop new research ideas, supports applications for response mode funding, initially project grants, ultimately leading to programmatic funding. In future, the group will require dedicated research time for Velindre staff (clinicians, physicists, radiographers, nurses, AHPs) as well as administrative and infrastructural support. The key oversight committee for this groups’ activities is the existing joint CU - Velindre Strategic Partnership Board which meets every 6 months and includes the Chief Executive and Executive Medical Director of Velindre University NHS Trust, Pro Vice Chancellor, Registrar and Cancer Theme Lead of the College of Biomedical Life Sciences Director of the Cancer Group of the CTR. Ongoing discussions on building the clinical and academic radiotherapy workforce and alignment of the groups’ activities with overarching institutional strategies will occur at these board meetings. It is anticipated that the CRRG could, in future, be hosted by the Wales Cancer Research Centre (WCRC), becoming a Multidisciplinary Research Group (MDRG) for Radiotherapy Research, and will aim to develop Wales-wide radiotherapy research collaborations.
Commercial Partners:
VUNHST and the Rutherford Cancer Centre (RCC) currently provide a WHSSC commissioned clinical service for treating adult patients with proton beam radiotherapy (PBT) for NHS agreed clinical indications and VUNHST will continue to work with the RCC to establish a PBT research governance infrastructure to increases opportunities for patients in Wales to access research involving PBT, as described above.
Links to other commercial partners (radiotherapy vendors and/or pharmaceutical companies) will be developed, where there is potential that such collaborations could offer new opportunities for Welsh patients to access research involving the latest technologies and/or treatments.
Generating and attracting new investment
The appointment of a new Velindre Charity Director and development of a new Charitable Funds Strategy offer significant opportunities to raise charitable funds dedicated to radiotherapy research at Velindre, which will be overseen by the Advancing Radiotherapy Fund and Charitable Funds Committee.
The Cardiff Radiotherapy Research Group (and ultimately the Radiotherapy Research MDRG) will bid for future academic response mode funding/trial grants and programmatic funding. In addition, the Radiotherapy Development Program workstream for RD&I will encourage NHS staff involved in radiotherapy research to apply for protected time for research. For clinicians, this includes applications for Clinical Research Fellowships and Health and Care Research Wales [HCRW] Clinical Research Time Awards. An example of funding with respect to radiographer research is the College of Radiographers Industry Partnership Scheme (CoRIPS) Research Grant with the purpose of supporting at least one grant to professionals who have minimal experience of undertaking research and development projects. As part of the College of Radiographers’ commitment to the implementation of the SCoR's new research strategy, the organisation is funding small grants for projects related to any aspect of the science and practice of radiography. Bids of up to £10,000 will be considered while bids for funding in excess of these amounts will also be considered particularly if matched funding or other institutional contributions are available. Other funding opportunities will be scoped by the group to build the multidisciplinary team capacity for radiotherapy research at Velindre.
This radiotherapy research strategy will significantly enhance the Trust’s reputation and commitment to radiotherapy research. We will build on existing strengths, establish new leadership to support and develop the research workforce, harness opportunities afforded by the new technology within nVCC, and build ever-closer links with our academic partners in order to deliver patient focused, scientifically robust radiotherapy research, which will improve the outcomes and enhance the lives of patients treated with radiotherapy at Velindre and across Wales.