Hypofractionated radiotherapy versus conventionally fractionated radiotherapy for patients with intermediate-risk localised prostate cancer: 2-year patient-reported outcomes of the randomised, non-inferiority, phase 3 CHHiP trial

BACKGROUND: Patient-reported outcomes (PROs) might detect more toxic effects of radiotherapy than do clinician-reported outcomes. We did a quality of life (QoL) substudy to assess PROs up to 24 months after conventionally fractionated or hypofractionated radiotherapy in the Conventional or Hypofractionated High Dose Intensity Modulated Radiotherapy in Prostate Cancer (CHHiP) trial.

METHODS: The CHHiP trial is a randomised, non-inferiority phase 3 trial done in 71 centres, of which 57 UK hospitals took part in the QoL substudy. Men with localised prostate cancer who were undergoing radiotherapy were eligible for trial entry if they had histologically confirmed T1b-T3aN0M0 prostate cancer, an estimated risk of seminal vesicle involvement less than 30%, prostate-specific antigen concentration less than 30 ng/mL, and a WHO performance status of 0 or 1. Participants were randomly assigned (1:1:1) to receive a standard fractionation schedule of 74 Gy in 37 fractions or one of two hypofractionated schedules: 60 Gy in 20 fractions or 57 Gy in 19 fractions. Randomisation was done with computer-generated permuted block sizes of six and nine, stratified by centre and National Comprehensive Cancer Network (NCCN) risk group. Treatment allocation was not masked. UCLA Prostate Cancer Index (UCLA-PCI), including Short Form (SF)-36 and Functional Assessment of Cancer Therapy-Prostate (FACT-P), or Expanded Prostate Cancer Index Composite (EPIC) and SF-12 quality-of-life questionnaires were completed at baseline, pre-radiotherapy, 10 weeks post-radiotherapy, and 6, 12, 18, and 24 months post-radiotherapy. The CHHiP trial completed accrual on June 16, 2011, and the QoL substudy was closed to further recruitment on Nov 1, 2009. Analysis was on an intention-to-treat basis. The primary endpoint of the QoL substudy was overall bowel bother and comparisons between fractionation groups were done at 24 months post-radiotherapy. The CHHiP trial is registered with ISRCTN registry, number ISRCTN97182923.

FINDINGS: 2100 participants in the CHHiP trial consented to be included in the QoL substudy: 696 assigned to the 74 Gy schedule, 698 assigned to the 60 Gy schedule, and 706 assigned to the 57 Gy schedule. Of these individuals, 1659 (79%) provided data pre-radiotherapy and 1444 (69%) provided data at 24 months after radiotherapy. Median follow-up was 50·0 months (IQR 38·4-64·2) on April 9, 2014, which was the most recent follow-up measurement of all data collected before the QoL data were analysed in September, 2014. Comparison of 74 Gy in 37 fractions, 60 Gy in 20 fractions, and 57 Gy in 19 fractions groups at 2 years showed no overall bowel bother in 269 (66%), 266 (65%), and 282 (65%) men; very small bother in 92 (22%), 91 (22%), and 93 (21%) men; small bother in 26 (6%), 28 (7%), and 38 (9%) men; moderate bother in 19 (5%), 23 (6%), and 21 (5%) men, and severe bother in four (<1%), three (<1%) and three (<1%) men respectively (74 Gy vs 60 Gy, ptrend=0.64, 74 Gy vs 57 Gy, ptrend=0·59). We saw no differences between treatment groups in change of bowel bother score from baseline or pre-radiotherapy to 24 months.

INTERPRETATION: The incidence of patient-reported bowel symptoms was low and similar between patients in the 74 Gy control group and the hypofractionated groups up to 24 months after radiotherapy. If efficacy outcomes from CHHiP show non-inferiority for hypofractionated treatments, these findings will add to the growing evidence for moderately hypofractionated radiotherapy schedules becoming the standard treatment for localised prostate cancer.

FUNDING: Cancer Research UK, Department of Health, and the National Institute for Health Research Cancer Research Network.

Address inaccuracy in health registration data: determinants and impacts

Access to demographic data that are complete, accurate and up-to-date is fundamental to many aspects of public health, government and academic work and for accurate interpretation of other databases. Health registration data are the prime source of demographic information for health and social care systems; for example, as an indicator of need, as a source of denominators to convert number of events into rates, or in the case of the residential address information as the basis for generating the call-recall invitation letters that are used for most screening programs (e.g. breast, colo-rectal and AAA screening). However, list inflation (ghosts, duplicates or emigrants) and a degree of address inaccuracy are recognised caveats with the health registration data and a recent NILS-related study on breast screening suggests that improved address accuracy might be a fast and efficient means of increasing screening uptake rates in cities and amongst deprived populations. In NI these data are collated by the BSO who uniquely in the UK also have access to data relating to prescribing, dental registrations and use of A&E services. These can be used to supplement the standard demographic and address information by (i) indicating patients who are alive and resident in NI and (ii) providing an independent source of probably improved address information. This study will use the NI Unique Property Reference Number (UPRN), rather than the addresses per se which are difficult to work with, to compare the addresses registered in the BSO with those addresses in the enumerated 2011 census. Assuming that the census is a more accurate source of address information for individuals, a comparison of the health registration addresses with those recorded at the census, the aim of the proposed study will be to (i) characterise the amount and distributions of these differences, (ii) to see what proportion of those who do not attend for screening did not actually receive an invitation letter because the addresses were incorrect, (iii) to determine how much of the social gradient (and urban/rural differences) in screening uptake are due to address inaccuracies, (iv) a comparison of timing of address changes at the BSO will provide information on the delays in updating of addresses.

Design and optimization next generation passive all-optical networks

Este trabalho investiga novas metodologias para as redes óticas de acesso de próxima geração (NG-OAN). O trabalho está dividido em quatro tópicos de investigação: projeto da rede, modelos numéricos para efeitos não lineares da fibra ótica, impacto dos efeitos não lineares da fibra ótica e otimização da rede. A rede ótica de acesso investigada nesse trabalho está projetado para suprir os requisitos de densidade de utilizadores e cobertura, isto é, suportar muitos utilizadores ( 1000) com altas velocidades de conexão dedicada ( 1 Gb/s) ocupando uma faixa estreita do espectro ( 25 nm) e comprimentos de fibra ótica até 100 km. Os cenários são baseados em redes óticas passivas com multiplexagem por divisão no comprimento de onda de alta densidade (UDWDM-PON) utilizando transmissores/receptores coerentes nos terminais da rede. A rede é avaliada para vários ritmos de transmissão usando formatos de modulação avançados, requisitos de largura de banda por utilizador e partilha de banda com tecnologias tradicionais de redes óticas passivas (PON). Modelos numéricos baseados em funções de transferência das séries de Volterra (VSTF) são demonstrados tanto para a análise dos efeitos não lineares da fibra ótica quanto para avaliação do desempenho total da rede. São apresentadas as faixas de potência e distância de transmissão nas quais as séries de Volterra apresentam resultados semelhantes ao modelo referência Split-Step Fourier (SSF) (validado experimentalmente) para o desempenho total da rede. Além disso, um algoritmo, que evita componentes espectrais com intensidade nulo, é proposto para realizar cálculos rápidos das séries. O modelo VSTF é estendido para identificar unicamente os efeitos não lineares da fibra ótica mais relevantes no cenário investigado: Self-Phase Modulation (SPM), Cross-Phase Modulation (XPM) e Four-Wave Mixing (FWM). Simulações numéricas são apresentadas para identificar o impacto isolado de cada efeito não linear da fibra ótica, SPM, XPM e FWM, no desempenho da rede com detecção coerente UDWDM-PON, transportando canais com modulação digital em fase (M-ária PSK) ou modulação digital em amplitude (M-ária QAM). A análise numérica é estendida para diferentes comprimentos de fibra ótica mono modo (SSMF), potência por canal e ritmo de transmissão por canal. Por conseguinte, expressões analíticas são extrapoladas para determinar a evolução do SPM, XPM e FWM em função da potência e distância de transmissão em cenários NG-OAN. O desempenho da rede é otimizada através da minimização parcial da interferência FWM (via espaçamento desigual dos canais), que nesse caso, é o efeito não linear da fibra ótica mais relevante. Direções para melhorias adicionas no desempenho da rede são apresentados para cenários em que o XPM é relevante, isto é, redes transportando formatos de modulação QAM. A solução, nesse caso, é baseada na utilização de técnicas de processamento digital do sinal.

Low emission zones: the likely effects on the freight transport sector

London’s air quality has improved over recent decades, but is still the worst in the UK. Road transport emissions play an important part in this pollution. A low emission zone (LEZ) would help to accelerate the introduction of cleaner vehicles, and reduce the numbers of older, more polluting vehicles operating in London. The survey work carried out indicates that there is support among goods vehicle operators for an LEZ in London, depending on the precise scheme definition. Operators would generally try to comply with LEZ regulations, with most companies either using technical approaches to ensure that their London vehicle fleet complied with the required emission standard or by redeploying vehicles with the appropriate emission standard from other locations.

Logistics and the waste sector: a London case study

London has traditionally exported most of its waste to former mineral workings in surrounding counties for landfill. Many of these sites are being filled and opportunities for new sites are limited. Virtually all waste reprocessing and recycling facilities, with the exception of textile sorting and some facilities for glass and organic waste composting, are outside London. The Mayor of London's Vision for Waste in London is that by 2020, municipal waste should not compromise London’s future as a sustainable city. This will involve managing waste better, so that its impact on the local and global environment and on London communities, economy and health is minimised. The majority of waste and recyclable materials in London are currently collected and transported for recovery, disposal or reprocessing by road in large vehicles. Environmental costs include, adding to congestion, noise, energy usage, air pollution, and accidents. The Mayor is keen to increase recycling and reuse of waste materials in London, and to ensure that as more of London's waste is diverted away from landfill sites to recycling facilities. Several projects and initiatives have been established and these are reviewed in the paper.

Improving energy efficiency in the road freight transport sector: the application of a vehicle approach

Several approaches can be used to analyse performance, energy consumption and CO2 emissions in freight transport. In this paper we define and apply a vehicle-oriented, bottom up survey approach, the so called ‘vehicle approach’, in contrast to a ‘supply chain approach’. The main objective of the approach is to assess the impacts of various freight transport operations on efficiency and energy use. We apply the approach, comparing official statistics on freight transport and energy efficiency in Britain and France. Results on freight intensity, vehicle utilisation, fuel use, fuel efficiency and CO2 intensity are compared for the two countries. The results indicate comparable levels of operational and fuel efficiency in road freight transport operations in the two countries. Issues that can be addressed with the vehicle approach include: the impacts of technology innovations and logistics decisions implemented in freight companies, and the quantification of the effect of policy measures on fuel use at the national level.

Analysing energy use in supply chains: the case of fruits & vegetables and furniture

An increasing number of producers, retailers and third-party logistics providers are interested in carrying out energy assessments of their product supply chain. This is due to sensitivity about climate change and carbon emissions, but also to high energy prices. This paper presents an analytical approach developed to measure energy use in logistics activities in product supply chains. The approach (based on the Life Cycle Approach) quantifies energy use in transport and logistics activities at all stages of a product supply chain. The work has demonstrated that such an assessment approach based on the supply chain is useful in comparing the energy use implications of different strategies. This supply chain approach can be used to consider options such as sourcing and distribution centre locations, transport modes, road freight vehicle types and weights, vehicle load factors, empty running, transport distance and the balance between consumer shopping trips and delivery to the home.