Report to the NHS Central Research & Development Committee
Recommendations










PRIORITIES FOR R&D

The 25 priority areas identified by the Advisory Group are shown in Table 1. The Group recognised the difficulties of comparing priority areas from such a wide and disparate field as cancer research. It therefore felt that the priorities should be divided into two bands indicating those of very high priority separately from those of high priority. It should be emphasised that all of the areas identified are regarded as being important priorities for research in cancer focused on the NHS. Within the very high priority and high priority groups the individual cancer research priorities are listed in an order reflecting the natural history and clinical history of cancers from early disease through to palliative care.

Detailed descriptions and justifications for each of the 25 areas are given in
Annex 9.


ADDITIONAL RECOMMENDATIONS

The Advisory Group identified several additional areas which must be regarded as having great importance within the NHS and which differ in their nature from those represented by the 25 priority areas.
1. The first of these is the provision of a comprehensive infrastructure for clinical trials through the collaboration of all interested parties, including the NHS, and the need for a thorough examination, including overviews, of existing randomised trials for cancer management. The Advisory Group strongly recommend that the maintenance of a comprehensive clinical trials infrastructure should be a very high priority for the NHS.
2. Second, the Advisory Group recognise the importance of Cancer Registries not only as a valuable research tool but also for planning and monitoring cancer services. Their maintenance will be essential.
3. Third, the Advisory Group recommends that work on the economics of cancer be commissioned soon and preferably earlier than other work. The knowledge base on the costs of cancer to the NHS is considered to be inadequate. To know more here would be helpful when commissioning the priorities and would inform any future reviews of R&D needs in this field.

Health promotion was not separately identified as an R&D subject area. Nonetheless, it can be seen from the recommended priorities that this very important strategy for health gain has not been overlooked by the Advisory Group.

Taking into account the level of funding likely to be available for commissioning research, the Advisory Group recommends that clear lines of communication should be established between the Commissioning Group and other cancer research funding agencies who should be encouraged to take account of the agreed priorities in their forward planning. The Advisory Group recommends that a comprehensive infrastructure for clinical trials within the NHS should be maintained through the collaboration of all interested parties, including the NHS, in future large developments.


TABLE 1
RECOMMENDED R&D PRIORITIES IN CANCER


VERY HIGH PRIORITY
(The letters in brackets indicate the priority justifications in
Annex 9.)
(A) Ways of effecting, maintaining and evaluating behavioural changes leading to a reduction in smoking at all ages, particularly children.
   
(B) The organisation and evaluation of services, including medical, psychosocial, counselling and other services, to meet the needs of those found to be at high risk of cancer due to a genetic susceptibility.
   
(C) Factors influencing delayed presentation by patients (e.g. psychosocial) and variations in onward referrals by physicians to oncology specialists.
   
(D) Factors influencing the accrual of patients into cancer trials (including why clinicians are reluctant to enter patients into national multi-centre trials).
   
(E) Studies designed to explain variations in disease outcomes, particularly in relation to variations in patterns of practice.
   
(F) Comparison of care for common cancers (e.g. lung, breast, colorectal) in specialist and non-specialist treatment settings with respect to psychosocial and clinical outcomes; and the relative costs of managing each step of disease progression.
   
(G) The clinical utility of second-line chemotherapy in advanced common cancers, particularly its comparison to best supportive care.
   
(H) Effective ways of helping health professionals break bad news, elicit concerns and respond to patients and relatives for their best psychological adjustment.
   
(I) Optimal management strategies for unrelieved symptoms, including pain and non-pain, in cancer patients.
   
(J) The most appropriate and cost effective model of service delivery and level of provision of palliative care services, including the role of Nurse Practitioners in hospitals and the community, and for the care of patients dying in acute hospitals.

HIGH PRIORITY
   
(K) The early natural history of cancers that may particularly lend themselves to screening to reduce mortality (e.g. prostate, oral and skin cancers).
   
(L) Comparison of the value of MRI with current breast cancer screening methods in high risk women.
   
(M) Appropriate ways of screening for preventing and diagnosing colorectal cancer, including "once only" flexible sigmoidoscopy and molecular screening.
   
(N) The natural history of cervical neoplasia and the potential role of Human Papilloma Virus (HPV) sub-typing in screening.
   
(O) Application of new technologies, including imaging and molecular pathology (e.g. Polymerase Chain Reaction (PCR), Fluorescence In-Situ Hybridisation (FISH), cytogenetics) for improving tumour diagnosis and for the prediction of tumour behaviour and response to therapy.
   
(P) Imaging techniques for the definition of tumour spread, in the detection of metastases and in the evaluation of response to treatment.
   
(Q) The most cost effective way to provide information to meet the needs of cancer patients, their families, health care professionals and the public.
   
(R) The psychosocial consequences for patients who have increased participation in clinical decision making.
   
(S) Methods for managing the introduction of innovative therapies in a cost effective way.
   
(T) Optimal imaging methods for determining residual tumour mass and for the follow up of patients given primary treatment for common solid cancers.
   
(U) The roles of adjuvant, neo-adjuvant and combined modality treatments for primary common cancers.
   
(V) Cancer treatment of the elderly including clinical outcomes and cost effectiveness.
   
(W) The value of integrating quality of life data and data on costs in the measurements of outcome in prevention, treatment and care of cancer patients and their carers.
   
(X) Comparison of the cost effectiveness of different psychosocial interventions including complementary therapies and voluntary groups for patients and their families.
   
(Y) What prevents terminally ill patients from dying at home, if they so wish, and how can General Practitioners and their teams access information to help them care more effectively for their patients at home?

GUIDANCE FOR DEVELOPING RESEARCH PROPOSALS

When proposals are considered, the Commissioning Group will assess them on a range of criteria. Relevance to the NHS, scientific quality and the ability to complete the work adequately in the time set will be of paramount importance. Within the NHS R&D programme it is an important principle that funded work is relevant to the NHS. Factors such as the burden of disease and costs to patients, carers and the NHS will, therefore, be considered by the Commissioning Group. Research methods and the experience of researchers should be such that the R&D priorities can be adequately researched and appropriately directed towards the needs of the NHS; multi-disciplinary studies will be welcomed where these are relevant. Researchers should acquaint themselves with the recommendations for cancer R&D made by other CRDC Advisory Groups, such as the Standing Group on Health Technology, and any other relevant R&D priorities within the NHS R&D programme.


NHS CONSUMER GROUPS

Cancer places a major burden not only upon patients themselves but, also, upon their relatives, friends and carers. Cancer is a common disease and NHS consumers include people from many different backgrounds. Consideration of this wide community should not be forgotten - its needs and interests should be incorporated whenever possible into research protocols.



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