The ESSO-EORTC Collaboration in Surgical Oncology Research 30/03/2017
Interview to Dr. Denis Lacombe, Director General of the European Organisation for Research and Treatment of Cancer (EORTC)
Two Complementary Needs
Over 80% of all cancers need some form of surgical treatment: surgery is in many cases the only modality of treatment with a concrete chance of success but, at the same time, inadequate cancer surgery can hinder a patient’s chances to be cured and survive. Over the years, surgical oncologists developed sophisticated techniques and improved their effectiveness, but the way surgical oncology operations are currently performed considerably varies across Europe. Quality improvement in this discipline goes hand in hand with improvement in research, and surgical techniques need to be tested and replicated in a standardized and verified way.
At present, however, most of the research efforts in oncology only focus on the improvement of cancer drugs. There are less research projects led by surgeons than the ones led by specialists in any other discipline, and their level of expertise in research is not comparable. Very few randomized controlled trials are published by surgeons and despite continuously adapted specific CONSORT criteria, most of the published RCTs are of poor quality. A fifth of surgical RCTs are abandoned and less than half are published. The reasons for this are multifactorial1. However, today’s landscape of clinical research can be an opportunity for surgical leadership.
The field of clinical research is in need of new leaders in the field of surgical academic research; this is what Dr. Denis Lacombe, the Director of the European Organisation for Research and Treatment of Cancer (EORTC), explained us during this exclusive interview.
A Win-Win Collaboration
Research in the field of surgical oncology is quite complex: it involves not just the expertise of the surgeon but also multifaceted data from the patient, the tumour, the quality of perioperative care, which needs to be processed and analysed by multidisciplinary teams, and needs to be sustainable from a financial point of view. In order to overcome these challenges, a collaborative approach is needed.
In the context of increasingly expensive and challenging clinical trials, EORTC started applying a new model of collaboration with other societies – each of them specialised in an oncology discipline – to be partners in developing specific platforms or quality assurance programmes. At the same moment, ESSO Clinical Research Director Prof. Serge Evrard, currently the coordinator of SURCARE, took the initiative to contact EORTC with the goal of conducting more prospective surgical research. Through these common interests and vision for better surgical care and research, SURCARE was born. The urgent need to increase the quantity and quality of surgical research was the driving force behind the partnership between EORTC and ESSO. Joining the two societies’ respective expertise avoided a duplication of efforts and created a “win-win” situation: EORTC has the capacity to perform prospective, international and multidisciplinary research while ESSO provides the expertise and network of surgical oncologists as well educational programs for young surgeons.
Moreover, ESSO and EORTC – already collaborating in “oncopolicy” initiatives such as Rare Cancers Europe – united their forces to have a stronger voice at the EU level. At present, European research policies and funding instruments focus too much on drugs and not at all on cancer surgery, even if better surgery could result in advantages also in terms of health economics. However, as Dr. Lacombe explains, “before we can make any progress, we need to demonstrate that we are credible” through solid performance indicators. The two projects which have been launched since the establishment of this partnership (EORTC 1409 CLIMB and EORTC 1527 DREAM) are therefore providing the evidence needed to advocate a better legislative and financial framework for surgical oncology research in Europe.
SURCARE: Laying the Foundations
Before the launch of this platform in 2013, surgical research had been branded as a “comic opera” because of the supposed inability of surgical oncologists to deliver successful clinical trials with excellent methodology. ESSO and EORTC therefore decided to create a sustainable surgical research quality assurance infrastructure to lead a new wave of surgical trials that are responding to society’s clinical unmet needs and founded on solid research methodology and quality assurance2.
SURCARE serves as a platform to develop prospective and multidisciplinary studies with focus on surgical questions. Under the umbrella of SURCARE, other surgical projects apart from CLIMB and DREAM, are being developed. This platform allows standardized review of surgical outcomes and operative procedures, credentialing of investigators, protocol development, data collection and publications. It also provides a platform to conduct an integrated central review by surgeons and pathologists via intraoperative photographs, imaging and clinical data. A global network of surgical researchers is being reached by SURCARE by developing a collaboration in Europe with Japan. Through the different initiatives of EORTC and ESSO, it is being recognized that research methodology must be part of the core curriculum of surgical training and that an accurate quality control and measurement of how operations are performed can have an impact on improving patients’ outcomes.
CLIMB: Learning from Each Other
This first collaborative project of EORTC and ESSO is CLIMB, a prospective study on surgery for complex and unresectable colorectal (CRC) liver metastases. Considering that up to 50% of all CRC patients develop metastasis after initial surgery, this pilot project aimed to prospectively identify the variability of the treatment of CRC liver metastases across different countries and institutions in Europe in terms of defining the limits of resectability and treatment options for patients.
After almost two years since its inception, CLIMB proved to be quite successful. The initial aim was to demonstrate how clinical data obtained through the SURCARE platform could improve research in this field, but Dr. Lacombe explained that the project also benefitted from the contribution of many new young surgeons who participated as investigators. This was a positive sign that the surgical community is engaged and committed to “grow” in clinical research.
Indeed, one of the challenges encountered in this project was that only a few surgeons previously received a specific research training. Another obstacle for surgeons to take part in CLIMB was the lack of personnel to support the research activity in their own institution. However, as Lacombe puts it, “you need to build and fly the plane at the same time”: this pilot project allowed the two societies to learn from each other “by doing” and resulted in a very fruitful collaboration.
DREAM: A Landmark Collaboration between Europe and Japan
The second joint project is more within the scope of personalised medicine: the DREAM Study indeed addresses the need to explain, and solve, the issue of “disappearing liver metastases” in the colorectal cancer.. By correlating clinical, imaging and pathologic response data, DREAM aims to analyse the accuracy of diffusion-weighted MRI to predict complete response among patients with borderline resectable or initially unresectable CRC liver metastasis. The study also permits to perform the necessary follow up on the lesions, ensuring thereby that the radiologic response fully corresponds with the pathologic response.
Dr. Lacombe proudly explained that DREAM acquired so much visibility to attract the attention of the Japan Clinical Oncology Group (JCOG), and it represents now the first intergroup collaboration between 3 leaders in the field of surgical oncology and research: ESSO, EORTC and JCOG. Today, it involves 16 European sites, 12 Japanese sites and 2 sites from the United States.
Integration of Clinical Research Methodology in Surgical Training
These experiences show the importance of strategic networking both within and outside Europe, to raise awareness about the importance of quality assurance in surgical oncology, and to pave the way for a global educational exchange of a new generation of surgeons committed to cancer research.
To address the existing lack of research-focused education, both ESSO and EORTC believe that education on clinical research methodology must be integrated in surgical training. In this regard, participation in courses such as the MCCR Workshop on Methods in Clinical Cancer Research and in the EORTC Fellowship Programme represents a brilliant opportunity for surgical oncologists to deepen their research expertise.
Dr. Lacombe explained that a former surgical research fellow, Dr. Carmela Caballero, is now the co-coordinator of SURCARE and all surgical related programs at EORTC and is closely following all ESSO-EORTC initiatives. EORTC would like to see more surgical research fellows and investigators in the future, and Dr. Lacombe confirmed the possibility that the collaboration between the two societies will soon include the organisation of more “hands on” training courses on surgical oncology research.
Finally, the choice of colorectal liver metastases as the research focus for both DREAM and CLIMB is due to the fact that colorectal cancer is the second most common cause of all cancer deaths in Europe, and about one fourth of all patients have metastasis at the time of diagnosis. It also represented the main area of expertise of the ESSO and EORTC partners involved when the collaboration was launched, but Dr. Lacombe assured that this fact does not limit the scope of the joint programme. On the contrary, future clinical trials involving surgery could be either transversal – across multiple disease areas – or focus on other types of tumour.
SURCARE, through the collaboration of EORTC, ESSO and its new partner, JCOG, is responding to an urgent societal need to find a cost effective way to combat cancer. In the current landscape of oncological advances, it may well be a golden opportunity for the surgical community to take the lead and be at the forefront of cancer treatment and research.
- ESSO Website – CLIMB
- EORTC Website – CLIMB
- ESSO Website – DREAM
- EORTC Press Release – A new global partnership to improve surgical care: EORTC 1527 DREAM opens
- MCCR Workshop on Methods in Clinical Cancer Research website
(1) Evrard S, McKelvie-Sebileau P, van d, V, Nordlinger B, Poston G. What can we learn from oncology surgical trials? Nat Rev Clin Oncol 2015.
(2) Evrard S, Audisio R, Poston G, Caballero C, Kataoka K, Fontein D et al. From a Comic Opera to Surcare an Open Letter to Whom Clinical Research in Surgery Is a Concern: Announcing the Launch of SURCARE. Ann Surg 2016; 264(6):911-912.