'ThinkCancer!' - Randomised feasibility trial of a novel practice-based early cancer diagnosis intervention.

BACKGROUND: UK cancer deaths remain high; primary care is key for earlier cancer diagnosis as half of avoidable delays occur here. Improvement is possible through lower referral thresholds, better guideline adherence, and better safety netting systems. Few interventions target whole practice teams. We developed a novel whole practice team intervention to address this. AIM: To test the feasibility and acceptability of a novel, complex behavioural intervention 'ThinkCancer!' for assessment in a subsequent Phase III trial. DESIGN & SETTING: Pragmatic, superiority pilot RCT with an embedded process evaluation and feasibility economic analysis in Welsh general practices. METHOD: Clinical outcome data were collected from practices (the unit of randomisation). Practice characteristics and cancer safety netting systems were assessed. Individual practice staff completed evaluation and feedback forms, and qualitative interviews. The intervention was adapted and refined. RESULTS: Trial recruitment and workshop deliveries took place between March 2020 to May 2021. Trial progression criteria for recruitment, intervention fidelity and routine data collection were met. Staff-level fidelity, retention and individual level data collection processes were reviewed and amended. Interviews highlighted positive participant views on all aspects of the intervention. All practices set out to liberalise referral thresholds appropriately, implement guidelines, and address safety netting plans in detail. CONCLUSION: 'ThinkCancer!' appears feasible and acceptable; the new iteration of the workshops was completed, and the Phase III trial has been funded to assess the effectiveness and cost effectiveness of this novel professional behaviour change intervention. Delivery at scale to multiple practices will likely improve fidelity and reach.

Public involvement and public engagement: An example of convergent evolution? Findings from a conceptual qualitative review of patient and public involvement, and public engagement, in health and scientific research.

Objective: Patient and public involvement (PPI) in health research is now well-established, whilst science, technology, engineering and mathematics (STEM) research has shifted from a focus on science communication alone to public engagement (PE) within its research processes. Despite frequently drawing on similar theoretical influences, and practical motivations, there is often a lack of dialogue between such settings meaning shared learning, practice and evidence from these two sectors are rarely pooled. Methods: In this article, we examine findings from a conceptual review of literature gathered between 1996 and 2019. Results: Analyzing 142 peer-reviewed articles, we ascertain shared definitions and concepts in patient and public involvement and public engagement, identifying key differences and similarities. Conclusion: The literature we review supports the notion that, in terms of origins, there are two distinct traditions, one based in science communication and one based in what we describe as public involvement in shared decision-making. Innovation: We find evidence that the two traditions are converging but our work also calls for the need for further conversations between these two settings, which are exploring intersecting issues but from parallel pathways.

Meta-analysis contrasting freshwater biodiversity in forests and oil palm plantations with and without riparian buffers.

The expansion of oil palm plantations has led to land-use change and deforestation in the tropics, which has affected biodiversity. Although the impacts of the crop on terrestrial biodiversity have been extensively reviewed, its effects on freshwater biodiversity remain relatively unexplored. We reviewed the research assessing the impacts of forest-to-oil palm conversion on freshwater biota and the mitigating effect of riparian buffers on these impacts. We searched for studies comparing taxa richness, species abundance, and community composition of macroinvertebrates, amphibians, and fish in streams in forests (primary and disturbed) and oil palm plantations with and without riparian buffers. Then, we conducted a meta-analysis to quantify the overall effect of the land-use change on the 3 taxonomic groups. Twenty-nine studies fulfilled the inclusion criteria. On average, plantations lacking buffers hosted 44% and 19% fewer stream taxa than primary and disturbed forests, respectively. Stream taxa on plantations with buffers were 24% lower than in primary forest and did not differ significantly from disturbed forest. In contrast, stream community composition differed between forests and plantations regardless of the presence of riparian buffers. These differences were attributed to agrochemical use and altered environmental conditions in the plantations, including temperature changes, worsened water conditions, microhabitat loss, and food and shelter depletion. On aggregate, abundance did not differ significantly among land uses because increases in generalist species offset the population decline of vulnerable forest specialists in the plantation. Our results reveal significant impacts of forest-to-oil palm conversion on freshwater biota, particularly taxa richness and composition (but not aggregate abundance). Although preserving riparian buffers in the plantations can mitigate the loss of various aquatic species, it cannot conserve primary forest communities. Therefore, safeguarding primary forests from the oil palm expansion is crucial, and further research is needed to address riparian buffers as a promising mitigation strategy in agricultural areas.

Metaanálisis contrastando la biodiversidad de agua dulce en los bosques y las plantaciones de palma de aceite con o sin bosques ribereños Resumen La expansión de las plantaciones de palma de aceite ha derivado en cambios en el uso de suelo y deforestación en los trópicos, afectando a la biodiversidad. Existe una revisión extensa del impacto de este cultivo sobre la biodiversidad terrestre, pero sus efectos sobre la biodiversidad de agua dulce todavía no están muy documentados. Revisamos las investigaciones que han evaluado el impacto de la conversión de bosque a plantación de palma de aceite sobre la biota de agua dulce y el efecto mitigante que tienen los bosques ribereños sobre este impacto. Buscamos estudios que compararan la riqueza de taxones, abundancia de especies y composición comunitaria de los macroinvertebrados, anfibios y peces en los riachuelos de los bosques (primarios y perturbados) y los sembradíos de palma de aceite con y sin bosques ribereños. Después realizamos un metaanálisis para cuantificar el efecto del cambio de uso de suelo en los tres grupos taxonómicos. Veintinueve estudios cumplieron con el criterio de inclusión. En promedio, las plantaciones carentes de bosques ribereños albergaron 44% y 19% menos taxones que los bosques primarios y perturbados. Los taxones en los sembradíos con bosques ribereños fueron 24% menos que en el bosque primario y no difirieron significativamente del bosque perturbado. Como contraste, la composición comunitaria del riachuelo difirió entre los bosques y los sembradíos sin importar la presencia de los bosques ribereños. Atribuimos estas diferencias al uso de agroquímicos y las condiciones ambientales alteradas en las plantaciones, incluidas los cambios térmicos, condiciones hidrológicas alteradas, pérdida de microhábitats y reducción de alimentos y refugios. En general, la abundancia no difirió significativamente entre los usos de suelo porque el incremento de especies generalistas en las plantaciones contrarresta la declinación poblacional de los especialistas de bosque vulnerables. Nuestros resultados revelan un impacto significativo de la conversión de bosque a plantación sobre la biota de agua dulce, particularmente la riqueza de taxones y la composición (pero no la abundancia agregada). Aunque mantener los bosques ribereños en las plantaciones puede mitigar la pérdida de varias especies acuáticas, no puede conservar las comunidades del bosque primario. Por lo tanto, es crucial salvaguardar los bosques primarios de la expansión del aceite de palma, además de que se necesitan más investigaciones para abordar los bosques ribereños como una estrategia prometedora de mitigación en las áreas agrícolas.

Is there a role for citizen science in death and dying research?

The COVID-19 pandemic has brought conversations about death and dying to the fore in a way not experienced for generations. This raises questions around perceptions of death and dying; the role of healthcare and the community in care; and the use of digital media for information and support. Public engagement can provoke a two-way conversation between researchers and the public and includes techniques that can engage the community not only with the topic but also in research. This perspective article considers the potential role of citizen science in death and dying research, including considerations around its potential benefits and constraints.

Earlier cancer diagnosis in primary care: a feasibility economic analysis of ThinkCancer!

BACKGROUND: UK cancer survival rates are much lower compared with other high-income countries. In primary care, there are opportunities for GPs and other healthcare professionals to act more quickly in response to presented symptoms that might represent cancer. ThinkCancer! is a complex behaviour change intervention aimed at primary care practice teams to improve the timely diagnosis of cancer. AIM: To explore the costs of delivering the ThinkCancer! intervention to expedite cancer diagnosis in primary care. DESIGN & SETTING: Feasibility economic analysis using a micro-costing approach, which was undertaken in 19 general practices in Wales, UK. METHOD: From an NHS perspective, micro-costing methodology was used to determine whether it was feasible to gather sufficient economic data to cost the ThinkCancer! INTERVENTION: Owing to the COVID-19 pandemic, ThinkCancer! was mainly delivered remotely online in a digital format. Budget impact analysis (BIA) and sensitivity analysis were conducted to explore the costs of face-to-face delivery of the ThinkCancer! intervention as intended pre-COVID-19. RESULTS: The total costs of delivering the ThinkCancer! intervention across 19 general practices in Wales was £25 030, with an average cost per practice of £1317 (standard deviation [SD]: 578.2). Findings from the BIA indicated a total cost of £34 630 for face-to-face delivery. CONCLUSION: Data collection methods were successful in gathering sufficient health economics data to cost the ThinkCancer! INTERVENTION: Results of this feasibility study will be used to inform a future definitive economic evaluation alongside a pragmatic randomised controlled trial (RCT).

A randomised controlled trial of a digital intervention (Renewed) to support symptom management, wellbeing and quality of life in cancer survivors.

BACKGROUND: Many cancer survivors following primary treatment have prolonged poor quality of life. AIM: To determine the effectiveness of a bespoke digital intervention to support cancer survivors. DESIGN: Pragmatic parallel open randomised trial. SETTING: UK general practices. METHODS: People having finished primary treatment (<= 10 years previously) for colo-rectal, breast or prostate cancers, with European-Organization-for-Research-and-Treatment-of-Cancer QLQ-C30 score <85, were randomised by online software to: 1)detailed 'generic' digital NHS support ('LiveWell';n=906), 2) a bespoke complex digital intervention ('Renewed';n=903) addressing symptom management, physical activity, diet, weight loss, distress, or 3) 'Renewed-with-support' (n=903): 'Renewed' with additional brief email and telephone support. RESULTS: Mixed linear regression provided estimates of the differences between each intervention group and generic advice: at 6 months (primary time point: n's respectively 806;749;705) all groups improved, with no significant between-group differences for EORTC QLQ-C30, but global health improved more in both intervention groups. By 12 months there were: small improvements in EORTC QLQ-C30 for Renewed-with-support (versus generic advice: 1.42, 95% CIs 0.33-2.51); both groups improved global health (12 months: renewed: 3.06, 1.39-4.74; renewed-with-support: 2.78, 1.08-4.48), dyspnoea, constipation, and enablement, and lower NHS costs (generic advice £265: in comparison respectively £141 (153-128) and £77 (90-65) lower); and for Renewed-with-support improvement in several other symptom subscales. No harms were identified. CONCLUSION: Cancer survivors quality of life improved with detailed generic online support. Robustly developed bespoke digital support provides limited additional short term benefit, but additional longer term improvement in global health enablement and symptom management, with substantially lower NHS costs.

The juxtaposition of the natural and the medical perspectives in noisy breathing at the end of life.

BACKGROUND: Noisy breathing is common at the end of life. Management of noisy breathing aims to reduce the noise via repositioning the person, suctioning the person's airways and using antimuscarinic drugs. Dying people are generally thought not to be distressed by noisy breathing at the end of life, but the noise may distress others. There is doubt on whether antimuscarinic drugs are any more effective than a placebo for noisy breathing. However, antimuscarinics are still commonly administered to people at the end of life. AIM: To illuminate reasons behind decision making and noisy breathing at the end of life. METHODS: Semi-structured interviews and 'self-recorded brief accounts' with healthcare professionals. FINDINGS: Noisy breathing at the end of life is viewed as both a natural and a medical phenomenon. However, while most participants in the interviews thought that antimuscarinics were uneffective, the prescription and administration of antimuscarinics were embedded within professional culture. CONCLUSION: Managing noisy breathing is a complex issue that incorporates natural and medical viewpoints and has a long-standing culture of practice. Research should aim to determine best practice and reduce a person's distress at the end of life.

A reappraisal of public engagement in Oxford during the pandemic: three case studies.

BACKGROUND: The COVID-19 pandemic has resulted in the majority of public engagement with research work moving online. This shift to online engagement is likely to affect inclusivity and diversity in such events and this requires further consideration as a result of the pandemic. Through comparing case-studies both pre-dating and during the pandemic, we are able to discern areas for ongoing improvement and learning in the public engagement sphere. MAIN BODY: The public engagement work of the Wellcome Centre for Ethics and Humanities has sought to include a broad discussion on its research from a range of demographics, attempting to be inclusive in the engagement work of the Centre. However such efforts have not always been successful and we reflect here on two different pre-pandemic 'in-person' case studies assessing public views on vaccination and medical data sharing. In contrast we compare these pre-pandemic activities to a fully online case study coordinated and completed during the pandemic. These three case studies are compared and assessed for evidence of their efficacy in a post-pandemic world. CONCLUSION: Research and public awareness benefit when multiple views are included in engagement events. Broader demographics enrich our ways of understanding societal responses to healthcare issues such as vaccination, data sharing and social responsibility. The move to online engagement as a result of the pandemic may open opportunities to widening engagement geographically, but it could also pose a threat to inclusivity with certain public groups on a more local level. Enabling access to online engagement is key, but considerations must be made regarding the new barriers created by a solely online world and the many groups of people inadvertently excluded from this work.

It is widely recognised that research is improved when public groups are informed or consulted in this work. In university research settings, academics are actively encouraged to engage the public and seek their input and opinion. However, in order for this work to be of benefit to all involved, the public groups included should be diverse and represent a wide range of society.The Wellcome Centre for Ethics and Humanities is a Wellcome Trust funded research centre at the University of Oxford. The Centre aims to assess and interpret some of the major ethical questions of our time, essentially questioning what it means to be human in a world of rapid technological change. The public engagement work of the Centre strives to include public opinion on its research and raise awareness of the many ethical issues we face as a species.Before the onset of the pandemic in March 2020, the Centre held a range of 'in-person' events, where public groups and researchers were able to communicate in the same space. However, since the pandemic, this engagement work has moved fully online. Through evaluating these activities, we have been able to interpret which groups of people have participated. Through capturing this information, the Centre can monitor both the reach of its work and whether diverse groups of people have been included. We have found that there are a range of barriers and complications involved in solely online engagement and that future online work must address these issues, should it continue.

Empirical food webs of 12 tropical reservoirs in Singapore.

Background: Food webs summarise trophic interactions of the biotic components within an ecosystem, which can influence nutrient dynamics and energy flows, ultimately affecting ecosystem functions and services. Food webs represent the hypothesised trophic links between predators and prey and can be presented as empirical food webs, in which the relative strength/importance of the respective links are quantified. Some common methods used in food web research include gut content analysis (GCA) and stable isotope analysis (SIA). We combine both methods to construct empirical food web models as a basis for monitoring and studying ecosystem-level outcomes of natural (e.g. species turnover in fish assemblage) and intentional environmental change (e.g. biomanipulation). New information: We present 12 food webs from tropical reservoir communities in Singapore and summarise the topology of each with widely-used network indices (e.g. connectance, link density). Each reservoir was surveyed over 4-6 sampling occasions, during which, representative animal groups (i.e. fish species and taxonomic/functional groups of zooplankton and benthic macroinvertebrates) and all likely sources of primary production (i.e. macrophytes, periphyton, phytoplankton and riparian terrestrial plants) were collected. We analysed gut content in fishes and bulk isotope (d13C and d15N) profiles of all animals (i.e. fishes and invertebrates) and plants collected. Both sets of information were used to estimate the relative strength of trophic relationships using Bayesian mixing models. We document our protocol here, alongside a script in the R programming language for executing data management/analyses/visualisation procedures used in our study. These data can be used to glean insights into trends in inter- and intra-specific or guild interactions in analogous freshwater lake habitats.

Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales.

BACKGROUND: Compared to the rest of Europe, the UK has relatively poor cancer outcomes, with late diagnosis and a slow referral process being major contributors. General practitioners (GPs) are often faced with patients presenting with a multitude of non-specific symptoms that could be cancer. Safety netting can be used to manage diagnostic uncertainty by ensuring patients with vague symptoms are appropriately monitored, which is now even more crucial due to the ongoing COVID-19 pandemic and its major impact on cancer referrals. The ThinkCancer! workshop is an educational behaviour change intervention aimed at the whole general practice team, designed to improve primary care approaches to ensure timely diagnosis of cancer. The workshop will consist of teaching and awareness sessions, the appointment of a Safety Netting Champion and the development of a bespoke Safety Netting Plan and has been adapted so it can be delivered remotely. This study aims to assess the feasibility of the ThinkCancer! intervention for a future definitive randomised controlled trial. METHODS: The ThinkCancer! study is a randomised, multisite feasibility trial, with an embedded process evaluation and feasibility economic analysis. Twenty-three to 30 general practices will be recruited across Wales, randomised in a ratio of 2:1 of intervention versus control who will follow usual care. The workshop will be delivered by a GP educator and will be adapted iteratively throughout the trial period. Baseline practice characteristics will be collected via questionnaire. We will also collect primary care intervals (PCI), 2-week wait (2WW) referral rates, conversion rates and detection rates at baseline and 6 months post-randomisation. Participant feedback, researcher reflections and economic costings will be collected following each workshop. A process evaluation will assess implementation using an adapted Normalisation Measure Development (NoMAD) questionnaire and qualitative interviews. An economic feasibility analysis will inform a future economic evaluation. DISCUSSION: This study will allow us to test and further develop a novel evidenced-based complex intervention aimed at general practice teams to expedite the diagnosis of cancer in primary care. The results from this study will inform the future design of a full-scale definitive phase III trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT04823559 .

Land-use change erodes trophic redundancy in tropical forest streams: Evidence from amino acid stable isotope analysis.

Studies have shown that food chain length is governed by interactions between species richness, ecosystem size and resource availability. While redundant trophic links may buffer impacts of species loss on food chain length, higher extinction risks associated with predators may result in bottom-heavy food webs with shorter food chains. The lack of consensus in earlier empirical studies relating species richness and food chain length reflects the need to account robustly for the factors described above. In response to this, we conducted an empirical study to elucidate impacts of land-use change on food chain length in tropical forest streams of Southeast Asia. Despite species losses associated with forest loss at our study areas, results from amino acid isotope analyses showed that food chain length was not linked to land use, ecosystem size or resource availability. Correspondingly, species losses did not have a significant effect on occurrence likelihoods of all trophic guilds except herbivores. Impacts of species losses were likely buffered by initial high levels of trophic redundancy, which declined with canopy cover. Declines in trophic redundancy were most drastic amongst invertivorous fishes. Declines in redundancy across trophic guilds were also more pronounced in wider and more resource-rich streams. While our study found limited evidence for immediate land-use impacts on stream food chains, the potential loss of trophic redundancy in the longer term implies increasing vulnerability of streams to future perturbations, as long as land conversion continues unabated.

Forest conversion to oil palm compresses food chain length in tropical streams.

In Southeast Asia, biodiversity-rich forests are being extensively logged and converted to oil palm monocultures. Although the impacts of these changes on biodiversity are largely well documented, we know addition to samples we collected in 201 little about how these large-scale impacts affect freshwater trophic ecology. We used stable isotope analyses (SIA) to determine the impacts of land-use changes on the relative contribution of allochthonous and autochthonous basal resources in 19 stream food webs. We also applied compound-specific SIA and bulk-SIA to determine the trophic position of fish apex predators and meso-predators (invertivores and omnivores). There was no difference in the contribution of autochthonous resources in either consumer group (70-82%) among streams with different land-use type. There was no change in trophic position for meso-predators, but trophic position decreased significantly for apex predators in oil palm plantation streams compared to forest streams. This change in maximum food chain length was due to turnover in identity of the apex predator among land-use types. Disruption of aquatic trophic ecology, through reduction in food chain length and shift in basal resources, may cause significant changes in biodiversity as well as ecosystem functions and services. Understanding this change can help develop more focused priorities for mediating the negative impacts of human activities on freshwater ecosystems.

Quantitative Evidence Synthesis Methods for the Assessment of the Effectiveness of Treatment Sequences for Clinical and Economic Decision Making: A Review and Taxonomy of Simplifying Assumptions.

Sequential use of alternative treatments for chronic conditions represents a complex intervention pathway; previous treatment and patient characteristics affect both the choice and effectiveness of subsequent treatments. This paper critically explores the methods for quantitative evidence synthesis of the effectiveness of sequential treatment options within a health technology assessment (HTA) or similar process. It covers methods for developing summary estimates of clinical effectiveness or the clinical inputs for the cost-effectiveness assessment and can encompass any disease condition. A comprehensive review of current approaches is presented, which considers meta-analytic methods for assessing the clinical effectiveness of treatment sequences and decision-analytic modelling approaches used to evaluate the effectiveness of treatment sequences. Estimating the effectiveness of a sequence of treatments is not straightforward or trivial and is severely hampered by the limitations of the evidence base. Randomised controlled trials (RCTs) of sequences were often absent or very limited. In the absence of sufficient RCTs of whole sequences, there is no single best way to evaluate treatment sequences; however, some approaches could be re-used or adapted, sharing ideas across different disease conditions. Each has advantages and disadvantages, and is influenced by the evidence available, extent of treatment sequences (number of treatment lines or permutations), and complexity of the decision problem. Due to the scarcity of data, modelling studies applied simplifying assumptions to data on discrete treatments. A taxonomy for all possible assumptions was developed, providing a unique resource to aid the critique of existing decision-analytic models.

Carer administration of as-needed subcutaneous medication for breakthrough symptoms in people dying at home: the CARiAD feasibility RCT.

BACKGROUND: Most people who are dying want to be cared for at home, but only half of them achieve this. The likelihood of a home death often depends on the availability of able and willing lay carers. When people who are dying are unable to take oral medication, injectable medication is used. When top-up medication is required, a health-care professional travels to the dying person's home, which may delay symptom relief. The administration of subcutaneous medication by lay carers, although not widespread UK practice, has proven to be key in achieving better symptom control for those dying at home in other countries. OBJECTIVES: To determine if carer administration of as-needed subcutaneous medication for common breakthrough symptoms in people dying at home is feasible and acceptable in the UK, and if it would be feasible to test this intervention in a future definitive randomised controlled trial. DESIGN: We conducted a two-arm, parallel-group, individually randomised, open pilot trial of the intervention versus usual care, with a 1 : 1 allocation ratio, using convergent mixed methods. SETTING: Home-based care without 24/7 paid care provision, in three UK sites. PARTICIPANTS: Participants were dyads of adult patients and carers: patients in the last weeks of their life who wished to die at home and lay carers who were willing to be trained to give subcutaneous medication. Strict risk assessment criteria needed to be met before approach, including known history of substance abuse or carer ability to be trained to competency. INTERVENTION: Intervention-group carers received training by local nurses using a manualised training package. MAIN OUTCOME MEASURES: Quantitative data were collected at baseline and 6-8 weeks post bereavement and via carer diaries. Interviews with carers and health-care professionals explored attitudes to, experiences of and preferences for giving subcutaneous medication and experience of trial processes. The main outcomes of interest were feasibility, acceptability, recruitment rates, attrition and selection of the most appropriate outcome measures. RESULTS: In total, 40 out of 101 eligible dyads were recruited (39.6%), which met the feasibility criterion of recruiting > 30% of eligible dyads. The expected recruitment target (≈50 dyads) was not reached, as fewer than expected participants were identified. Although the overall retention rate was 55% (22/40), this was substantially unbalanced [30% (6/20) usual care and 80% (16/20) intervention]. The feasibility criterion of > 40% retention was, therefore, considered not met. A total of 12 carers (intervention, n = 10; usual care, n = 2) and 20 health-care professionals were interviewed. The intervention was considered acceptable, feasible and safe in the small study population. The context of the feasibility study was not ideal, as district nurses were seriously overstretched and unfamiliar with research methods. A disparity in readiness to consider the intervention was demonstrated between carers and health-care professionals. Findings showed that there were methodological and ethics issues pertaining to researching last days of life care. CONCLUSION: The success of a future definitive trial is uncertain because of equivocal results in the progression criteria, particularly poor recruitment overall and a low retention rate in the usual-care group. Future work regarding the intervention should include understanding the context of UK areas where this has been adopted, ascertaining wider public views and exploring health-care professional views on burden and risk in the NHS context. There should be consideration of the need for national policy and of the most appropriate quantitative outcome measures to use. This will help to ascertain if there are unanswered questions to be studied in a trial. TRIAL REGISTRATION: Current Controlled Trials ISRCTN11211024. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 25. See the NIHR Journals Library website for further project information.

Most people in the UK would prefer to die at home, but only half of them achieve this. This usually depends on having able and willing lay carers (family or friends) to help look after them. Once swallowing is not possible, medicine is given continually under the skin (syringe driver). If common problems such as pain, vomiting or agitation break through, health-care professionals attend to give extra doses. The wait for a health-care professional to arrive can be distressing. In the UK, it is legal (but not routine) for lay carers to give needle-free subcutaneous injections themselves. We reworked an Australian carer education package for UK use. The best way to find out if this would work well is to do a randomised controlled trial. This is a test in which, at random, half of the people taking part receive 'usual care' and the other half receive the 'new care' or intervention. A pilot randomised controlled trial (a 'test' trial to see if a larger one is worth doing) was carried out to determine if lay carer injections were possible in the UK. We approached 90 dyads (a dying person and a key carer) and, of these, 40 were willing to take part and 22 completed the follow-up visit, so we could analyse their data. Of these 22 dyads, 16 were in the intervention group (lay carer injects) and six were in the control group (usual care). All carers were asked to keep a diary. Carers and health-care professionals were interviewed (qualitative study) and carer preferences were assessed. This new practice was safe, acceptable and welcomed. Carer confidence increased rapidly, symptom control was quicker and the interviews backed up these findings. Recruitment was low owing to overstretched health-care professionals. Only certain families were picked. Dyads in the usual-care group often wished they were in the intervention group. Carers found it difficult to complete some of the questionnaires that were used to measure the effect of the intervention. Therefore, uncertainty remains as to whether or not a full trial should proceed. Because the practice is already legal, some areas in the UK are already undertaking it. We plan to study what makes this practice possible or less possible to achieve.

The development of the Primary Care Clusters Multidimensional Assessment (PCCMA): A mixed-methods study.

A strong primary care (PC) system is essential for an efficient and high-quality healthcare service. Many countries have adopted a model of PC that encourages different healthcare providers to work together, at scale, in multidisciplinary/multiagency teams (PC clusters). The aim of the present work was to develop a quantitative instrument for the systematic and comprehensive assessment of PC clusters. This was a non-experimental, mixed-methods study grouping four work packages (WP), and involving PC cluster leads and a wide range of key stakeholders from across Wales. Interviews with 22 PC cluster leads (34 %) investigated the clusters' functioning (WP1). A systematic review identified relevant PC assessment frameworks and instruments (WP2). An expert group reviewed the evidence and drafted the new assessment tool, further evaluated and amended in two stakeholder workshops (WP3). Thirty-eight cluster leads (62 %) completed the newly developed online assessment (WP4). The final instrument consisted of 53 indicators, across 11 systemic dimensions of PC and produced a comprehensive assessment of the functioning of PC clusters in Wales. This rigorous early development of an innovative instrument to evaluate PC at a scaled-up (cluster) level (particularly in the format of a 360-degree assessment) can inform healthcare policy decisions regarding the expansion and ongoing adjustment of the model in response to local needs and challenges.

A comparison of outcomes for patients with intermediate and high risk prostate cancer treated with low dose rate and high dose rate brachytherapy in combination with external beam radiotherapy.

INTRODUCTION: There is evidence to support use of external beam radiotherapy (EBRT) in combination with both low dose rate brachytherapy (LDR-EBRT) and high dose rate brachytherapy (HDR-EBRT) to treat intermediate and high risk prostate cancer. METHODS: Men with intermediate and high risk prostate cancer treated using LDR-EBRT (treated between 1996 and 2007) and HDR-EBRT (treated between 2007 and 2012) were identified from an institutional database. Multivariable analysis was performed to evaluate the relationship between patient, disease and treatment factors with biochemical progression free survival (bPFS). RESULTS: 116 men were treated with LDR-EBRT and 171 were treated with HDR-EBRT. At 5 years, bPFS was estimated to be 90.5% for the LDR-EBRT cohort and 77.6% for the HDR-EBRT cohort. On multivariable analysis, patients treated with HDR-EBRT were more than twice as likely to experience biochemical progression compared with LDR-EBRT (HR 2.33, 95% CI 1.12-4.07). Patients with Gleason ≥8 disease were more than five times more likely to experience biochemical progression compared with Gleason 6 disease (HR 5.47, 95% CI 1.26-23.64). Cumulative incidence of ≥grade 3 genitourinary and gastrointestinal toxicities for the LDR-EBRT and HDR-EBRT cohorts were 8% versus 4% and 5% versus 1% respectively, although these differences did not reach statistical significance. CONCLUSION: LDR-EBRT may provide more effective PSA control at 5 years compared with HDR-EBRT. Direct comparison of these treatments through randomised trials are recommended to investigate this hypothesis further.

Renewed: Protocol for a randomised controlled trial of a digital intervention to support quality of life in cancer survivors.

INTRODUCTION: Low quality of life is common in cancer survivors. Increasing physical activity, improving diet, supporting psychological well-being and weight loss can improve quality of life in several cancers and may limit relapse. The aim of the randomised controlled trial outlined in this protocol is to examine whether a digital intervention (Renewed), with or without human support, can improve quality of life in cancer survivors. Renewed provides support for increasing physical activity, managing difficult emotions, eating a healthier diet and weight management. METHODS AND ANALYSIS: A randomised controlled trial is being conducted comparing usual care, access to Renewed or access to Renewed with brief human support. Cancer survivors who have had colorectal, breast or prostate cancer will be identified and invited through general practice searches and mail-outs. Participants are asked to complete baseline measures immediately after screening and will then be randomised to a study group; this is all completed on the Renewed website. The primary outcome is quality of life measured by the European Organization for Research and Treatment of Cancer QLQ-c30. Secondary outcomes include anxiety and depression, fear of cancer recurrence, general well-being, enablement and items relating to costs for a health economics analysis. Process measures include perceptions of human support, intervention usage and satisfaction, and adherence to behavioural changes. Qualitative process evaluations will be conducted with patients and healthcare staff providing support. ETHICS AND DISSEMINATION: The trial has been approved by the NHS Research Ethics Committee (Reference 18/NW/0013). The results of this trial will be published in peer-reviewed journals and through conference presentations. TRIAL REGISTRATION NUMBER: ISRCTN96374224; Pre-results.

CARer-ADministration of as-needed subcutaneous medication for breakthrough symptoms in homebased dying patients (CARiAD): study protocol for a UK-based open randomised pilot trial.

BACKGROUND: While the majority of seriously ill people wish to die at home, only half achieve this. The likelihood of someone dying at home often depends on the availability of able and willing lay carers to support them. Dying people are usually unable to take oral medication. When top-up symptom relief medication is required, a clinician travels to the home to administer injectable medication, with attendant delays. The administration of subcutaneous injections by lay carers, though not widespread practice in the UK, has proven key in achieving home deaths in other countries. Our aim is to determine if carer-administration of as-needed subcutaneous medication for four frequent breakthrough symptoms (pain, nausea, restlessness and noisy breathing) in home-based dying patients is feasible and acceptable in the UK. METHODS: This paper describes a randomised pilot trial across three UK sites, with an embedded qualitative study. Dyads of adult patients/carers are eligible, where patients are in the last weeks of life and wish to die at home, and lay carers who are willing to be trained to give subcutaneous medication. Dyads who do not meet strict risk assessment criteria (including known history of substance abuse or carer ability to be trained to competency) will not be approached. Carers in the intervention arm will receive a manualised training package delivered by their local nursing team. Dyads in the control arm will receive usual care. The main outcomes of interest are feasibility, acceptability, recruitment rates, attrition and selection of the most appropriate outcome measures. Interviews with carers and healthcare professionals will explore attitudes to, experiences of and preferences for giving subcutaneous medication and experience of trial processes. The study has obtained full ethical approval. DISCUSSION: This study will rehearse the procedures and logistics which will be undertaken in a future definitive randomised controlled trial and will inform the design of such a study. Findings will illuminate methodological and ethical issues pertaining to researching last days of life care. The study is funded by the National Institute for Health Research (Health Technology Assessment [HTA] project 15/10/37). TRIAL REGISTRATION: ISRCTN, ISRCTN 11211024 . Registered on 27 September 2016.

Trial of personalised care after treatment-Prostate cancer: A randomised feasibility trial of a nurse-led psycho-educational intervention.

OBJECTIVE: The present parallel randomised control trial evaluated the feasibility of a nurse-led psycho-educational intervention aimed at improving the self-management of prostate cancer survivors. METHODS: We identified 305 eligible patients from a district general hospital, diagnosed 9-48 months previously, who completed radical treatment, or were monitored clinically (ineligible for treatment). Ninety-five patients were recruited by blinded selection and randomised to Intervention (N = 48) and Control (N = 47) groups. Participant allocation was revealed to patients and researchers after recruitment was completed. For 36 weeks, participants received augmented usual care (Control) or augmented usual care and additional nurse support (Intervention) provided in two community hospitals and a university clinic, or by telephone. RESULTS: Data from 91 participants (Intervention, N = 45; Control, N = 46) were analysed. All feasibility metrics met predefined targets: recruitment rate (31.15%; 95% CI: 25.95%-36.35%), attrition rate (9.47%; 95% CI: 3.58%-15.36%) and outcome measures completion rates (77%-92%). Forty-five patients received the intervention, with no adverse events. The Extended Prostate Cancer Index Composite can inform the minimum sample size for a future effectiveness trial. The net intervention cost was £317 per patient. CONCLUSIONS: The results supported the feasibility and acceptability of the intervention, suggesting that it should be evaluated in a fully powered trial to assess its effectiveness and cost-effectiveness.

Development of an intervention to expedite cancer diagnosis through primary care: a protocol.

BACKGROUND: GPs can play an important role in achieving earlier cancer diagnosis to improve patient outcomes, for example through prompt use of the urgent suspected cancer referral pathway. Barriers to early diagnosis include individual practitioner variation in knowledge, attitudes, beliefs, professional expectations, and norms. AIM: This programme of work (Wales Interventions and Cancer Knowledge about Early Diagnosis [WICKED]) will develop a behaviour change intervention to expedite diagnosis through primary care and contribute to improved cancer outcomes. DESIGN & SETTING: Non-experimental mixed-method study with GPs and primary care practice teams from Wales. METHOD: Four work packages will inform the development of the behaviour change intervention. Work package 1 will identify relevant evidence-based interventions (systematic review of reviews) and will determine why interventions do or do not work, for whom, and in what circumstances (realist review). Work package 2 will assess cancer knowledge, attitudes, and behaviour of GPs, as well as primary care teams' perspectives on cancer referral and investigation (GP survey, discrete choice experiment [DCE], interviews, and focus groups). Work package 3 will synthesise findings from earlier work packages using the behaviour change wheel as an overarching theoretical framework to guide intervention development. Work package 4 will test the feasibility and acceptability of the intervention, and determine methods for measuring costs and effects of subsequent behaviour change in a randomised feasibility trial. RESULTS: The findings will inform the design of a future effectiveness trial, with concurrent economic evaluation, aimed at earlier diagnosis. CONCLUSION: This comprehensive, evidence-based programme will develop a complex GP behaviour change intervention to expedite the diagnosis of symptomatic cancer, and may be applicable to countries with similar healthcare systems.