Striving for Evidence – With and Without a Randomised Controlled Trial

Tuesday 19th July 2022, 11:00-12:00 BST, with Professor Tom Treasure, Cardiothoracic Surgeon and Honorary Professor in the Clinical Operational Research Unit, University College London

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About this event

‘On the Shoulders of Giants’ is a series of educational online talks where experts will bring their perspectives to encourage and challenge wider thinking within the cancer research community.

Professor Tom Treasure is a Cardiothoracic Surgeon and Honorary Professor in the Clinical Operational Research Unit at University College London. Throughout his clinical career he has run funded randomised controlled clinical studies, randomised patients into multicentre trials led by others, and has been Chief Investigator on his own trials.

In this lecture, Prof. Treasure will discuss his experiences of striving to get the evidence to stop a cancer operation that does not help patients and introducing an operation that does. Prof. Treasure will discuss the perpetuation of a flawed belief, using lung metastasectomy in colorectal cancer as an example. He will also illustrate that that not everything is amenable to, or indeed needs, a randomised trial, using Marfan Syndrome as an example.

Example 1: Metastasectomy in colorectal cancer. Operating to remove lung metastases slipped into everyday practice about 40 years ago, particularly for colorectal cancer (CRC). Is it plausible that local removal of one or two metastases alters the progress of what is manifestly disseminated disease? In 1980 a sage Swedish surgeon, Torkel Åberg, had posed the question: “The Effect of Metastasectomy: Fact or Fiction?” His paper was ignored. Torkel Åberg and Prof. Treasure were consecutive Presidents of EACTS in the mid noughties, when Torkel drew his paper to Prof. Treasure’s attention. They decided that it needed a randomised controlled trial (RCT) because only 1 in 50 patients with CRC lung metastases has them removed and that 2% are selected on well-established factors for naturally long survival. In an RCT with well-balanced arms they found there was in fact no difference in survival.

Example 2: Marfan syndrome. Marfan Syndrome aortic root aneurysm killed members of affected families at a young age in successive generations. Since 1968 operative resection and replacement has saved many lives and extended survival. The large effect size and immediacy of a mechanistic benefit was accepted as evidence enough. But the price to be paid was a major ablative operation and life-long anticoagulation with associated risks of bleeding and thromboembolism. In 2000 Prof. Treasure was the guest speaker at a meeting of the Marfan Association when a professional engineer with the disease challenged him.  Taliesen Golesworthy argued that modern computer assisted design and manufacture might improve on our cut-and-sew methods. In 2004 he was the first to have his proposed operation. There have now been 630 operations internationally. We repeatedly explored the possibility of an RCT but two key decision-making factors — timing of surgery and the acceptance or avoidance of lifelong anticoagulation — are matters of cogent patient preference.

About the speaker

Professor Tom Treasure was a consultant Cardiothoracic Surgeon at The Middlesex and University College Hospitals in the 1980s, St George’s in the 1990s, Guy’s Hospital in the noughties and since 2007 has been an Honorary Professor in the Clinical Operational Research Unit, UCL, his present affiliation. He has a London University Master of Surgery and Doctor of Medicine for experimental research theses. Throughout his clinical career he has run funded randomised controlled clinical studies, and randomised patients into multicentre trials led by others. Later he was Chief Investigator on his own trials. Prof. Treasure was elected to the Counsel of the Royal College of Surgeons and was President of the European Association of Cardio-Thoracic Surgery.