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Editorial |
1 From the American College of Radiology Imaging Network (ACRIN) Headquarters, Philadelphia, Pa; Department of Radiology, University of Virginia Health System, PO Box 800170, Lee St, Charlottesville, VA 22908 (B.J.H.); and Department of Radiology, University of Pennsylvania, Philadelphia (M.D.S.). Received December 27, 2002; accepted January 2, 2003. Address correspondence to B.J.H. (e-mail: bjh8a@virginia.edu).
Index terms: American College of Radiology Imaging Network (ACRIN) • Editorials
The American College of Radiology Imaging Network (ACRIN) is a cooperative group that is funded by the National Cancer Institute and is dedicated to performance of trials of medical imaging technologies as they relate to cancer diagnosis and treatment. ACRIN was established in March 1999. During this nearly 4-year period, ACRIN investigators developed or are currently working to implement 17 multicenter clinical trials (Table). ACRIN start-up phase was focused on development of sufficient infrastructure to help manage the enormous complexity of conducting multidisciplinary multiinstitutional clinical trials and recruitment of outstanding researchers and institutions to lead and participate in the trials. ACRIN has been successful in this regard.
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A mixture of approaches have been used to determine the trials that will be pursued by ACRIN. To date, ACRIN trials have devolved from ideas that ACRIN originators determined would be important when they initially developed the concept of ACRIN, ideas proposed by the 12 ACRIN scientific committees, and unsolicited ideas proffered by either individuals or organizations. We believe that the diversity of sources from which the concepts for trials emerge is one of the real strengths of ACRIN. Good ideas are provided, as well as outstanding researchers who have been the principal investigators for ACRIN trials. Nonetheless, as ACRIN matures, the goal is to evolve from a "target of opportunity" approach to a more strategic paradigm to determine the clinical trials in which ACRIN resources will be invested. This evolution involves both a consideration of ACRIN objectives and an evaluation of the areas of imaging that have the greatest potential to improve health in the future.
After ACRIN leadership evaluated the initial response to their request for applications, which led to establishment of ACRIN, they developed a number of objectives. Among these objectives were the need to balance ACRIN activity between the assessment of new important emerging technologies and the testing of current practices that may be outmoded or inappropriate. Since the overriding goal of ACRIN is to improve the length and quality of the lives of patients with cancer, these objectives are still germane. As ACRIN leadership continues to pursue trials of both innovative new technologies and questionable practices, other ACRIN objectives will be facilitated. Other objectives include providing information that may help further development of imaging technology, hastening the recognition of the value of new imaging devices and methods, making new technology available to underserved populations, and improving the number and quality of radiology researchers by providing experiences in the development, implementation, and analysis of rigorous clinical research.
Looking into the future is more difficult, but it is evident that certain broad focuses of research are likely to be the most productive. Among these focuses are imaging-based screening and molecular imaging, as well as the use of imaging methods as early indicators of therapeutic outcome and of imaging guidance for interventional techniques. ACRIN leadership intends to ensure performance of trials in these broad areas in the future, and, as new major focuses of interest emerge, to remain flexible when they consider the addition of other areas of interest.
A great deal of attention is currently focused on screening. Debate concerning the efficacy of various forms of imaging screening pits the mortality-reducing potential of the sensitivity of such technologies as conventional CT and MR imaging against the health and economic impact of the associated high false-positive rates. Clinical trials are necessary to determine the extent to which screening actually reduces mortality and how much it costs. This is the goal of collaboration on the National Lung Screening Trial (ACRIN principal investigator, Denise Aberle, MD), which is funded by ACRIN and the National Cancer Institute Early Detection Branch. In this trial, the impact of low-dose CT screening for lung cancer on lung cancer–specific mortality will be evaluated.
Not only will ACRIN screening trials provide answers for specific screening-related questions, they will also provide data that can be used as inputs for modeling in the evaluation of new developments. In some instances, modeling and decision analyses may obviate reproduction of trials in the light of new information. For example, as molecular medicine is developed, the hope is that nonimaging screening techniques will evolve that will help stratify patients according to their risk of developing any number of important diseases. When these nonimaging techniques are developed, ACRIN investigators and others will be able to model the value of linking nonimaging screening methods to imaging screening methods as a means of improving the cost-effectiveness of cancer screening.
Recent innovations in molecular medicine are impelling the development of molecular imaging. In the long term, molecular imaging is the future of medical imaging. The prediction is that the transition from current gross anatomic and pathologic imaging to molecular imaging of physiology and metabolism may take 20 years or more, but the transition is inevitable (1). The leadership intends that ACRIN will be in the forefront of the validation of molecular imaging as clinical applications become available. Experimental imaging agents and techniques that address issues relevant to cancer, such as the interrogation of tumor vascularity and cell death, already exist. Although work in this field has focused largely on small animals, there are some molecular imaging techniques—particularly with PET and MR imaging—that are being applied to human disease.
ACRIN trials are underway to evaluate the role of imaging technologies as early markers of therapeutic efficacy. In one trial, the role of dynamic MR imaging in determining the success of neoadjuvant treatment for advanced breast cancer is evaluated (principal investigator, Nola Hylton, PhD). In another trial, the value of PET as a marker for successful treatment of non–small cell lung cancer is being investigated (principal investigator, Mitchell Mactay, MD). The advantages of using imaging in the evaluation of the effects of treatment are profound. Instead of having to wait for a change in clinical course or a change in tumor size to be depicted at anatomic imaging, physicians caring for patients may use new imaging techniques to assess changes in the composition or physiology of tumors. These techniques could allow speedier decisions about either continuing the therapeutic regimen or changing to an alternative course. If these techniques are successful, treatment-related morbidity could be reduced, health outcomes improved, and overall costs lowered.
Finally, new image-guided interventional techniques that will help reduce cancer-related symptoms or mortality continue to emerge. Methods of local control of cancer are already being studied in ACRIN trials. These trials include one to compare results with chemotherapy alone versus those with chemotherapy plus chemoembolization therapy to treat metastases of colorectal cancer to the liver (principal investigator, Michael Soulen, MD) and one to evaluate radio-frequency ablation of bone metastases to alleviate pain (principal investigator, Damien Dupuey, MD). Less invasive image-guided approaches are emerging, such as MR imaging–guided focused ultrasound ablation. ACRIN investigators hope to help assess the efficacy of these future technologies.
ACRIN membership is currently preparing a response to a request for application to renew funding by the National Cancer Institute. If the response is successful, funding will be renewed for ACRIN to continue clinical trials through December 2008. As the principal continuing structure in the performance of multicenter clinical trials in the specialty of radiology, ACRIN serves important roles by helping to determine the optimal use of imaging technologies for patients with cancer and by serving as a breeding ground for future imaging researchers. ACRIN leadership takes these responsibilities very seriously; they are dedicated to making the best use of ACRIN resources by choosing wisely among the trials that could be pursued. ACRIN leadership is addressing this objective by developing a more strategic approach to determine the portfolio of trials.
REFERENCES
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