Canadian Optically Guided Approach for Oral Lesions Surgical Trial - COOLS
1.0. OBJECTIVES AND APPROACHES: 1.1. Objective 1 (Clinical evidence): To assess the effect
of FV-guided surgery on the recurrence-free survival of histologically confirmed disease
within the context of a randomized controlled trial (efficacy).
Hypothesis: FV-guided surgery will increase the recurrence-free survival. Approaches: This
Aim requires the establishment of a randomized controlled trial of 200 patients which will
compare outcome for patients in 2 arms: one with conventional surgery with margin delineated
under white light, and the other using FV guidance for margin delineation. Please see
attached Appendix 1 for a step-by-step protocol. This comprises a multidisciplinary team of
surgeons, pathologists, project coordinators, and FV Specialists. In addition to the
presurgery assessment, all participating patients will have 3-month follow-ups for the first
2 years and 6-month for the rest of the study period. Biopsy will occur when clinically
warranted or at 2-year post-surgery.
1.2. Objective 2 (Quality of Life evidence): To establish the cost per recurrence prevented
for this approach and assess quality of life issues.
Hypothesis: FV-guided surgery can be delivered in a cost effective manner and improve the
quality of life of patients.
Approaches: This aim requires the collection of economic and quality of life (QoL) data to
establish the cost per recurrence prevented for FV-guided surgery and to assess quality of
life impacts. To asses potential psychosocial consequences of FV-guided surgery we will
measure global QoL. We will use the validated EQ-5D and Functional Assessment of Cancer
Therapy Head and Neck Module (FACT-H&N) to determine the participant's QoL at each
assessment. The questionnaires will be applied at pre-surgery baseline, and at 6-week,
3-month, and 24-month post-surgery follow-ups.
1.3 Objective 3 (Scientific/Molecular evidence): To assess the presence of previously
validated molecular markers (microsatellite analysis, LOH) and histological change
(quantitative pathology) in surgical margins in a nested case-control study involving a
tumor bank created within this project.
Hypothesis: FV-guided surgery will spare normal tissue at the same time improving capture of
Approaches: This Aim requires the retrieval and cutting of the archive material for a nested
control study. The estimate number of cases reach outcome is 30 (5% of FV group (100) + 25%
of control group (100). Additionally, 60 matched controls will be selected (matched by
gender, age, smoking habit, and anatomical site). This Aim is critical to demonstrate a
shift in field, sparing normal tissue while catching high-risk occult tissue. Samples for
the nested molecular analysis will be performed in Rosin's Lab (for microsatellite analysis)
and Cancer Imaging at BC Cancer Agency (Dr. MacAulay for qualitative Pathology). The
protocols used to analyze these samples have been published.
2.0. STUDY TOOL - VELSCOPE® We have recently developed a simple hand-held field-of-view
device for direct visualization of tissue fluorescence in the oral cavity. This tool is
currently commercially available as VELScope® (LED Med Inc., White Rock, BC). We have
begun a longitudinal study to explore the effect of FV in defining the surgical margin on
outcome of oral cancer surgery27. Between 2004 and 2008, 60 patients with a ≤4 cm oral
cancer entered the study. Each case was treated with surgical excision alone and was
followed for at least 12 months. Thirty-eight patients had FV-guided surgery, with the
surgical margin placed at 10 mm beyond the perimeter of autofluorescence loss. The remaining
patients (control group) had the surgical margin placed at 10 mm beyond the tumor edge
defined by standard white-light examination. Among those, 7 of the 60 cases (12%) have
developed a recurrence of severe dysplasia, carcinoma in situ or squamous cell carcinoma at
the treated site, all in the control group (25% versus 0%, P = 0.002). These data suggest
the potential utility of autofluorescence changes within this clinical setting. There is a
need to design a larger scaled randomized controlled clinical trial to confirm the efficacy
of FV-guided surgery.
We are also using FV to monitor the potential re-emergence of regions of autofluorescence
loss at treated sites in the cases accrued to the longitudinal study and are currently
completing an interim assessment of these monitoring results. Autofluorescence loss
persists in some cases, increasing in size and intensity over time and giving rise to a
clinical lesion containing dysplasia or cancer.
3.0 Core members of the trial and project management We have a well-built core group with
long-term and strong working relationships, including surgeons (Drs. Anderson (Co-PI) and
Durham), Pathologists (Drs. Berean (Co-PI) and Zhang), and Oral Medicine (Drs. Poh (PI) and
Williams), and are in a world-leading position in using fluorescence visualization in
operating room and in follow-up. Dr. J. Lee, collaborator, from M.D. Anderson Cancer Centre
and has extensive experience in clinical trials with special expertise in randomized
controlled trial. He will be the trialist in this project, design a program for patient
randomization, oversee the trial protocol, and work with local statistician (Prof. Chen) for
day-to-day data management. Professor Jiahua Chen, Department of Statistics, the University
of British Columbia will serve as the biostatistician to the trial and will be responsible
for the data analysis and submission of interim analyses to the Data Safety Monitoring
4.0 Basic trial design The proposed study will be a double-blinded, randomized controlled
Phase III study to evaluate the effect of FV-guided surgery in patients diagnosed with
severe dysplasia, carcinoma in situ and invasive squamous cell carcinoma and undergoing
surgery treatment with an intent-to-cure. The trial will randomize 200 patients -100 in the
FV arm (using FV guided the surgery margin) and 100 in the control arm (using conventional
white light approach). The trial period is 5 years - 2 years to complete accrual and 3 more
years of follow-up.
Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Investigator), Primary Purpose: Treatment
Catherine Poh, DDS, PhD
University of British Columbia
Canada: Health Canada