Mesothelioma PSP Protocol

Purpose

The purpose of this protocol is to set out the aims, objectives and commitments of the Mesothelioma Priority Setting Partnership (PSP) and the basic roles and responsibilities of the partners therein.

Steering Group

The Mesothelioma PSP will be led and managed by the following:
Patient/carer representatives:

• Ms Liz Darlison, registered nurse, Mesothelioma UK
• Mr John Flanagan, Asbestos Victims Support Groups Forum
• Mr Ian Jarrold, British Lung Foundation
• Mrs Chris Knighton, Mick Knighton Mesothelioma Research Fund
• Dr Andrew Lawson, patient representative
• Mr Graham Sherlock-Brown, patient representative

Clinical representatives:

• Dr Helen Clayson, Research Fellow, University of Strathclyde and Glasgow Caledonian University, Founder/Chair of Cumbria Asbestos-Related Disease Support (CARDS)
• Prof Dean Fennell, National Cancer Research Institute Lung Clinical Studies Group, Mesothelioma Sub-Group
• Dr Kate Hill, June Hancock Mesothelioma Research Fund
• Prof Loic Lang-Lazdunski, Professor of Thoracic Surgery, King’s College London and Consultant Thoracic Surgeon, Guy’s and St Thomas’ NHS Foundation Trust
• Dr Nick Maskell, Consultant and Reader in Respiratory Medicine, University of Bristol and North Bristol NHS Trust
• Dr Mick Peake, Consultant and Senior Lecturer in Respiratory Medicine, University Hospitals of Leicester, Chair of Board of Trustees, Mesothelioma UK
• Dr Sanjay Popat, Consultant Medical Oncologist, The Royal Marsden and Honorary Clinical Senior Lecturer, National Heart and Lung Institute, Imperial College London. Chair of the British

Thoracic Oncology Group

• Dr Robert Rintoul, Consultant Respiratory Physician, Lead Clinician for Thoracic Oncology, Papworth Hospital
• Dr Mark Slade, British Thoracic Society Lung Cancer and Mesothelioma Specialist Advisory Group
• Mr David Waller, Consultant and Honorary Senior Lecturer, Thoracic Surgery, Glenfield Hospital, Leicester

The Partnership and the priority setting process will be supported and guided by:

The James Lind Alliance (JLA)

• Katherine Cowan (PSP Chair, JLA Senior Adviser)
• Sarah Fryett (JLA)
• Sheela Upadhyaya (JLA Adviser)
• Caroline Whiting (JLA)

Additional support will be sought from the UK Database of Uncertainties about the Effects of Treatments UK DUETs – part of NHS Evidence), to ensure the data collected, once verified, is published in a repository which is publicly searchable. Please note the UK DUETs database was discontinued in 2015. All PSP uncertainties now appear on the JLA website.

Background to the Mesothelioma PSP

The JLA is a non-profit initiative which is overseen by the National Institute for Health and Care Research. Its aim is to provide an infrastructure and process to help patients, carers and clinicians work together to agree which are the most important treatment uncertainties affecting their particular interest, in order to influence the prioritisation of future research in that area. The JLA defines an uncertainty as a “known unknown” – in this case relating to the effects of treatment.

Mesothelioma is a type of cancer. It usually occurs in the pleura which is a thin lining surrounding the lungs. Less commonly, mesothelioma can affect a similar lining around the abdomen (the peritoneum) and very rarely around the heart (the pericardium) or the testes (tunica vaginalis). The vast majority of mesothelioma cases are caused by breathing in asbestos dust. The symptoms of mesothelioma only show up decades after being exposed to asbestos. The condition is slow to appear and then quick to progress. Mesothelioma is complicated. It is not easy to diagnose or treat.

Mesothelioma research has been identified in Parliament as a priority area for the Department of Health and Social Care to address. Following debate in the House of Lords, a proposal was agreed for the National Institute for Health and Care Research (NIHR) to fund a JLA Priority Setting Partnership to identify patient, carer and clinician priorities for mesothelioma research. This is part of a wider programme of work, to include a highlight notice issued by the NIHR for research on mesothelioma and related diseases. The highlight notice will be accompanied by a drawing of attention to the offer of support from the NIHR Research Design Service for advice in developing clinical and applied health research proposals.

Aims and objectives of the Mesothelioma PSP

The aim of the Mesothelioma PSP is to identify the unanswered questions about mesothelioma treatment from patient, carer and clinical perspectives and then prioritise those that patients, carers and clinicians agree are the most important.

The objectives of the Mesothelioma PSP are to:

• work with patients, carers and clinicians to identify uncertainties about the effects of mesothelioma diagnosis, treatments and care
• to agree by consensus a prioritised list of those uncertainties, for research
• to promote the results of the PSP and process
• to work with NIHR to develop researchable questions from the top 10 priorities

The scope of the PSP will focus on interventional research, covering diagnosis, treatment and care. If questions relating to basic science and translational research are identified, these may be considered if relevant to the central theme of treatment uncertainties.

Partners

Organisations and individuals will be invited to take part in the PSP, which represent the following groups:

• people who have mesothelioma
• carers, relatives and friends of people who have or had mesothelioma
• health and social care professionals, including medical doctors, nurses and professionals allied to medicine with clinical experience of mesothelioma

Researchers with no current clinical practice may help advise on shaping questions but will not be part of the prioritisation process.

It is important that all organisations which can reach and advocate for these groups should be invited to become involved in the PSP. The JLA will take responsibility for ensuring the various stakeholder groups are able to contribute equally to the process. An expert in peritoneal mesothelioma may be co-opted onto the Steering Group to assist with the management of specific questions if required.

Organisations wishing to participate in the PSP will be asked to affiliate to the JLA in order to demonstrate their commitment to the aims and values of the JLA. Please note the affiliation procedure formerly available on the JLA website was discontinued in 2015.

Exclusion criteria

Some organisations may be judged by the JLA or the Steering Group to have conflicts of interest. These may be perceived to adversely affect those organisations’ views, causing unacceptable bias. As this is likely to affect the ultimate findings of the PSP, those organisations will not be invited to participate. It is possible, however, that interested parties may participate in a purely observational capacity when the Steering Group considers it may be helpful.

Methods

This section describes a schedule of proposed stages through which the PSP aims to fulfil its objectives. The process is iterative and dependent on the active participation and contribution of different groups. The methods adopted in any stage with be agreed through consultation with the partners, guided by the PSP’s aims and objectives. More details and examples can be found in the JLA Guidebook.

Identification and invitation of potential partners

Potential partner organisations will be identified through a process of peer knowledge and consultation, through the Steering Group members’ networks and through the JLA’s existing register of affiliates. Potential partners will be contacted and informed of the establishment and aims of the Mesothelioma PSP and invited to attend and participate in an initial stakeholder meeting to launch the PSP.

The JLA will draft the invitation, and the Steering Group will advise on its distribution.

Initial stakeholder meeting / awareness raising

The initial stakeholder meeting / awareness raising will have several key objectives:

• to welcome and introduce potential partners to the Mesothelioma PSP
• to present the proposed plan for the PSP
• to initiate discussion, answer questions and address concerns
• to secure the involvement of the partner organisations, particularly in respect to the promotion of the survey and the prioritisation exercises
• to establish principles upon which an open, inclusive and transparent mechanism can be based for contributing to, reporting and recording the work and progress of the PSP

The administrative process for convening this meeting will be led and managed by the JLA with input from the Steering Group.

Identifying treatment uncertainties

In consultation with the PSP Steering Group, the JLA will develop an online survey (with alternative formats available) to identify patients’ carers’ and clinicians’ unanswered questions about mesothelioma treatment. Steering Group members and partner organisations will be asked to promote the survey and ensure it reaches their members and respective constituent groups. A period of three months will be given to complete this exercise.

Existing sources of information about mesothelioma treatment uncertainties will be searched. These may include research recommendations in systematic reviews and clinical guidelines; protocols for systematic reviews being prepared and registers of ongoing research. The starting point for identifying sources of uncertainties and research recommendations is NHS Evidence.

Sources of uncertainties for research recommendations may include:

• Cochrane database
• NHS Evidence – UK DUETs
• NICE Guidance and NICE Research recommendations database
• BMJ clinical evidence
• Relevant College guidance
• NCRI review of mesothelioma research
• BTS mesothelioma statement

In consultation with the Steering Group, the JLA will commission an information specialist with appropriate skills and knowledge to carry out this piece of work, and to manage the process of refining the survey data, as described in the next section.

Refining questions and uncertainties

The Steering Group will need to have agreed who will be responsible for this stage – the JLA can advise on the skills required and the amount of time likely to be required for its execution. The JLA will appoint an information specialist to carry out the work, with agreement from the Steering Group. The JLA will participate in this process as an observer, to ensure accountability and transparency.

The consultation process will produce “raw” unanswered questions about diagnosis and the effects of treatments. These raw questions will be assembled and categorised and refined by the appointed information specialist into “collated indicative questions” which are clear, addressable by research and understandable to all. Similar or duplicate questions will be combined where appropriate.

The existing literature will be researched by the information specialist to see to what extent these refined questions have, or have not, been answered by previous research. The JLA definition of an uncertainty is that:

• no up-to-date, reliable systematic reviews of research evidence addressing the uncertainty about the effects of treatment exist
• up-to-date systematic reviews of research evidence show that uncertainty exists

The Steering Group will agree the scope of the literature and evidence against which each uncertainty will be checked. The limitations of this will be made clear in future reporting on the PSP.

Sometimes, uncertainties are expressed that can in fact be resolved with reference to existing research evidence - ie they are "unrecognised knowns" and not uncertainties. If a question about treatment effects can be answered with existing information but this is not known, it suggests that information is not being communicated effectively to those who need it. The Steering Group should keep an account of these and agree how these will be communicated to the wider population. Accordingly, the JLA recommends strongly that PSPs keep a record of these 'answerable questions' and deal with them separately from the 'true uncertainties' considered during the research priority setting process.

Uncertainties which are not adequately addressed by previous research will be collated and prepared for entry into a mesothelioma section within the UK Database of Uncertainties about the Effects of Treatments (UK DUETs) by the appointed information specialist. This will ensure that the uncertainties have been actually checked to be uncertainties. The data should be entered into UK DUETs on completion of the priority setting exercise, in order to ensure any updates or changes to the data have been incorporated beforehand.

Prioritisation – interim and final stages

The aim of the final stage of the priority setting process is to prioritise through consensus the identified uncertainties relating to the treatment or management of mesothelioma. This will be carried out by members of the Steering Group and the wider partnership that represents patients, carers and clinicians.

The interim stage, to proceed from a long list of uncertainties to a shorter list (eg up to 25), may be carried out over email, whereby organisations consult their membership and choose and rank their top 10 most important uncertainties. Or, it may involve individuals. The Steering Group will make a transparent decision about how to proceed once the process is under way.

The final stage, to reach 10 prioritised uncertainties, is likely to be conducted in a face-to-face meeting, using group discussions and plenary sessions.

The methods used for this prioritisation process will be determined by consultation with the Steering Group and with the advice of the JLA. The JLA will facilitate this process and ensure transparency, accountability and fairness. Participants will be expected to declare their interests in advance of this meeting.

Findings and research

The findings of the Mesothelioma PSP will be reported to the NIHR. Steering Group members will work with NIHR to develop the prioritised uncertainties into research questions.

Publicity

As well as alerting funders, partners and Steering Group members are encouraged to publish the findings of the Mesothelioma PSP using both internal and external communication mechanisms. The JLA may also capture and publicise the results, through descriptive reports of the process itself. This exercise will be distinct from the production of an academic paper, which members of the Steering Group are also encouraged to do. However, production of an academic paper should not take precedence over publicising of the final results.

This Protocol has been agreed by the Mesothelioma PSP Steering Group.