PLATO - Personalising anal cancer radiotherapy dose
ISRCTN | ISRCTN88455282 |
---|---|
DOI | https://doi.org/10.1186/ISRCTN88455282 |
IRAS number | 204585 |
Secondary identifying numbers | CPMS 31184, IRAS 204585 |
- Submission date
- 13/07/2016
- Registration date
- 03/08/2016
- Last edited
- 24/01/2025
- Recruitment status
- No longer recruiting
- Overall study status
- Ongoing
- Condition category
- Cancer
Plain English Summary
1. https://www.cancerresearchuk.org/about-cancer/find-a-clinical-trial/a-trial-looking-at-a-lower-dose-of-chemoradiotherapy-or-observation-for-early-stage-anal-cancer
2. https://www.cancerresearchuk.org/about-cancer/find-a-clinical-trial/a-trial-looking-at-higher-doses-of-chemoradiotherapy-for-people-with-locally-advanced-anal-cancer
3. http://www.cancerresearchuk.org/about-cancer/find-a-clinical-trial/a-trial-looking-at-a-lower-dose-of-chemoradiotherapy-for-people-with-anal-cancer-that-hasnt-spread
Contact information
Public
Clinical Trials Research Unit
Leeds Institute of Clinical Trials Research
University of Leeds
Leeds
LS2 9JT
United Kingdom
Phone | +44 0113 343 7903 |
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plato@leeds.ac.uk |
Study information
Study design | Both; Interventional; Design type: Treatment, Drug, Radiotherapy, Active Monitoring |
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Primary study design | Interventional |
Secondary study design | Randomised controlled trial |
Study setting(s) | Hospital |
Study type | Treatment |
Participant information sheet | Not available in web format, please use the contact details to request a patient information sheet |
Scientific title | PLATO - PersonaLising Anal cancer radioTherapy dOse - Incorporating Anal Cancer Trials (ACT) ACT3, ACT4 and ACT5 |
Study acronym | PLATO |
Study hypothesis | PLATO is an integrated protocol, comprising 3 separate trials (ACT3, ACT4 and ACT5) which aims to optimise radiotherapy dose (in combination with chemotherapy) for low-, intermediate- and high-risk anal cancer. ACT3: ACT3 is a non-randomised phase II trial for patients with early, small tumours who have undergone surgery (local excision). The aim of this study is to determine whether a treatment strategy of surgery alone, i.e. no further treatment, for patients with margins >1mm, and highly selective low-dose radiotherapy with chemotherapy for patients with close margins ≤1mm, results in acceptably low rates of cancer recurrence. ACT4: ACT4 is a randomised phase II trial for patients with intermediate-risk disease. The aim of this study is to compare standard-dose chemoradiotherapy (50.4Gy in 28 fractions) with reduced-dose chemoradiotherapy (41.4Gy in 23 fractions), to see if less radiotherapy is able to maintain the excellent success rates in treating the cancer, while reducing the side effects of treatment. ACT5: ACT5 is a randomised seamless pilot/phase II/phase III trial for patients with locally advanced anal cancer. The aim of this study is to compare standard-dose chemoradiotherapy (53.2Gy in 28 fractions) with two higher doses of chemoradiotherapy (58.8Gy and 61.6Gy, both in 28 fractions), to see if giving a higher dose of radiotherapy reduces the chance of the cancer coming back, whilst not causing too many extra side effects. |
Ethics approval(s) | Yorkshire & The Humber - Bradford Leeds Research Ethics Committee, 06/07/2016, ref: 16/YH/0157 |
Condition | Anal cancer |
Intervention | Current interventions as of 03/04/2023: ACT3 (recruitment end date: 31/10/2023): Observation arm No further treatment after local excision. Intervention arm Either a 3D conformal plan or a single phase inverse-planned IMRT treatment plan delivered with multiple fields, or arc techniques. Choice of delivery technique is at the discretion of the treating clinician. PTV_A = 41.4Gy in 23F (1.8Gy per F) in 4.5 weeks Chemotherapy: Mitomycin C 12mg/m2 iv Day 1 & Capecitabine 852mg/m2 oral bd 5 days/week (on days of radiotherapy) for 23 days ACT4 (recruitment end date: 01/12/2020): All patients will receive IMRT where different dose fractionations are delivered to the elective nodal region (PTV_E) and to the areas of gross tumour (PTV_A). A single phase inverse-planned IMRT treatment plan should be produced and delivered with multiple fields or arc techniques. Standard-dose arm PTV_A: 50.4Gy in 28F in 5.5 weeks PTV_E: 40.0Gy in 28F in 5.5 weeks Chemotherapy: Mitomycin C 12mg/m2 iv Day 1 & Capecitabine 852mg/m2 oral bd 5 days/week (on days of radiotherapy) for 28 days Reduced-dose (experimental) arm PTV_A: 41.4Gy in 23F in 4.5 weeks PTV_E: 34.5Gy in 23F in 4.5 weeks Chemotherapy: Mitomycin C 12mg/m2 iv Day 1 & Capecitabine 852mg/m2 oral bd 5 days/week (on days of radiotherapy) for 23 days ACT5 (recruitment end date: 31/08/2023): All patients will receive IMRT where different dose fractionations are delivered to the elective nodal region (PTV_E) and to the areas of gross tumour (PTV_A and PTV_N). A single phase inverse-planned IMRT treatment plan should be produced and delivered with multiple fields or arc techniques. Standard-dose arm PTV_A: 53.2.Gy in 28F in 5.5 weeks PTV_N: 50.4Gy in 28F in 5.5 weeks (involved nodes ≤3cm) 53.2Gy in 28F in 5.5 weeks (involved nodes >3cm) PTV_E: 40.0Gy in 28F in 5.5 weeks Dose escalation arm 1 PTV_A: 53.2Gy in 28F in 5.5 weeks PTV_Boost: 58.8Gy in 28F in 5.5 weeks PTV_N: 53.2Gy in 28F in 5.5 weeks (involved nodes ≤3cm) 53.2Gy in 28F in 5.5 weeks (involved nodes >3cm) PTV_E: 40.0Gy in 28F in 5.5 weeks Dose escalation arm 2 PTV_A: 53.2Gy in 28F in 5.5 weeks PTV_Boost: 61.6Gy in 28F in 5.5 weeks PTV_N: 53.2Gy in 28F in 5.5 weeks (involved nodes ≤3cm) 53.2Gy in 28F in 5.5 weeks (involved nodes >3cm) PTV_E: 40.0Gy in 28F in 5.5 weeks Chemotherapy in all ACT5 arms (centre choice): Mitomycin C 12mg/m2 iv Day 1 & Capecitabine 852mg/m2 oral bd 5 days/week (on days of radiotherapy) for 28 days, or Mitomycin C 12mg/m2 iv Day 1 & 5-FU 1000mg/m2 per 24 hours by continuous iv infusion Days 1-4 and Days 29-32 Follow-up (ACT3, ACT4 and ACT5) All patients will be followed up at the following time points: 1. 6 weeks 2. 3-monthly (Years 1-2) 3. 6 monthly (Year 3), then 4. Annually Annually (Years 4+ until 3 years after the last participant has completed treatment or death)+ All timings are from the end of treatment, except the ACT3 observation arm, which is from the date of registration. Registration / Randomisation process Following confirmation of written informed consent and eligibility, participants will be registered (ACT3) or randomised (ACT4/5) into the trial by an authorised member of staff at the trial site. Registration/randomisation will be performed centrally using the CTRU automated 24-hour system which can be accessed via the web or telephone. ACT4: Patients will be randomised on a 1:2 basis (standard-dose:reduced-dose) to receive either standard-dose IMRT in combination with chemotherapy or reduced-dose IMRT in combination with chemotherapy. A computer-generated minimisation program that incorporates a random element will be used to ensure the treatment groups are well-balanced for the following participant characteristics: 1. T-stage (T1, T2) 2. N-stage (N0, NX) 3. Gender (M, F) 4. HIV status (positive, negative) 5. Randomising centre ACT5: For the pilot study and Phase II trial, patients will be randomised on a 1:1:1 basis to receive either standard-dose IMRT in combination with chemotherapy, or one of two increased-dose experimental arms of IMRT with SIB in combination with chemotherapy. In the Phase III trial, participants will be randomised on a 1:1:1 basis to receive either standard-dose IMRT in combination with chemotherapy, or an increased dose arm of IMRT with SIB in combination with chemotherapy. A computer-generated minimisation program that incorporates a random element will be used to ensure the treatment groups are well-balanced for the following participant characteristics: 1. T-stage (T2/3, T4) 2. N-stage (NX/0/1, N2/3) 3. Gender (M, F) 4. HIV status (positive, negative) 5. Chemotherapy regimen (5FU, Capecitabine) 6. Randomising centre Previous interventions: ACT3: Observation arm No further treatment after local excision. Intervention arm Either a 3D conformal plan or a single phase inverse-planned IMRT treatment plan delivered with multiple fields, or arc techniques. Choice of delivery technique is at the discretion of the treating clinician. PTV_A = 41.4Gy in 23F (1.8Gy per F) in 4.5 weeks Chemotherapy: Mitomycin C 12mg/m2 iv Day 1 & Capecitabine 852mg/m2 oral bd 5 days/week (on days of radiotherapy) for 23 days ACT4: All patients will receive IMRT where different dose fractionations are delivered to the elective nodal region (PTV_E) and to the areas of gross tumour (PTV_A). A single phase inverse-planned IMRT treatment plan should be produced and delivered with multiple fields or arc techniques. Standard-dose arm PTV_A: 50.4Gy in 28F in 5.5 weeks PTV_E: 40.0Gy in 28F in 5.5 weeks Chemotherapy: Mitomycin C 12mg/m2 iv Day 1 & Capecitabine 852mg/m2 oral bd 5 days/week (on days of radiotherapy) for 28 days Reduced-dose (experimental) arm PTV_A: 41.4Gy in 23F in 4.5 weeks PTV_E: 34.5Gy in 23F in 4.5 weeks Chemotherapy: Mitomycin C 12mg/m2 iv Day 1 & Capecitabine 852mg/m2 oral bd 5 days/week (on days of radiotherapy) for 23 days ACT5: All patients will receive IMRT where different dose fractionations are delivered to the elective nodal region (PTV_E) and to the areas of gross tumour (PTV_A and PTV_N). A single phase inverse-planned IMRT treatment plan should be produced and delivered with multiple fields or arc techniques. Standard-dose arm PTV_A: 53.2.Gy in 28F in 5.5 weeks PTV_N: 50.4Gy in 28F in 5.5 weeks (involved nodes ≤3cm) 53.2Gy in 28F in 5.5 weeks (involved nodes >3cm) PTV_E: 40.0Gy in 28F in 5.5 weeks Dose escalation arm 1 PTV_A: 53.2Gy in 28F in 5.5 weeks PTV_Boost: 58.8Gy in 28F in 5.5 weeks PTV_N: 53.2Gy in 28F in 5.5 weeks (involved nodes ≤3cm) 53.2Gy in 28F in 5.5 weeks (involved nodes >3cm) PTV_E: 40.0Gy in 28F in 5.5 weeks Dose escalation arm 2 PTV_A: 53.2Gy in 28F in 5.5 weeks PTV_Boost: 61.6Gy in 28F in 5.5 weeks PTV_N: 53.2Gy in 28F in 5.5 weeks (involved nodes ≤3cm) 53.2Gy in 28F in 5.5 weeks (involved nodes >3cm) PTV_E: 40.0Gy in 28F in 5.5 weeks Chemotherapy in all ACT5 arms (centre choice): Mitomycin C 12mg/m2 iv Day 1 & Capecitabine 852mg/m2 oral bd 5 days/week (on days of radiotherapy) for 28 days, or Mitomycin C 12mg/m2 iv Day 1 & 5-FU 1000mg/m2 per 24 hours by continuous iv infusion Days 1-4 and Days 29-32 Follow-up (ACT3, ACT4 and ACT5) All patients will be followed up at the following time points: 1. 6 weeks 2. 3-monthly (Years 1-2) 3. 6 monthly (Year 3), then 4. Annually (Years 4+ until 3 years post close of recruitment or death) All timings are from the end of treatment, except the ACT3 observation arm, which is from the date of registration. Registration / Randomisation process Following confirmation of written informed consent and eligibility, participants will be registered (ACT3) or randomised (ACT4/5) into the trial by an authorised member of staff at the trial site. Registration/randomisation will be performed centrally using the CTRU automated 24-hour system which can be accessed via the web or telephone. ACT4: Patients will be randomised on a 1:2 basis (standard-dose:reduced-dose) to receive either standard-dose IMRT in combination with chemotherapy or reduced-dose IMRT in combination with chemotherapy. A computer-generated minimisation program that incorporates a random element will be used to ensure the treatment groups are well-balanced for the following participant characteristics: 1. T-stage (T1, T2) 2. N-stage (N0, NX) 3. Gender (M, F) 4. HIV status (positive, negative) 5. Randomising centre ACT5: For the pilot study and Phase II trial, patients will be randomised on a 1:1:1 basis to receive either standard-dose IMRT in combination with chemotherapy, or one of two increased-dose experimental arms of IMRT with SIB in combination with chemotherapy. In the Phase III trial, participants will be randomised on a 1:1 basis to receive either standard-dose IMRT in combination with chemotherapy, or the most ‘acceptable’ increased dose arm of IMRT with SIB in combination with chemotherapy. A computer-generated minimisation program that incorporates a random element will be used to ensure the treatment groups are well-balanced for the following participant characteristics: 1. T-stage (T2/3, T4) 2. N-stage (NX/0/1, N2/3) 3. Gender (M, F) 4. HIV status (positive, negative) 5. Chemotherapy regimen (5FU, Capecitabine) 6. Randomising centre |
Intervention type | Other |
Primary outcome measure | Locoregional failure (failure at the primary site (local) and/or surrounding nodal sites (regional) i.e. any failure within the pelvis up to the level of the sacral promontory) at 3 years post close of recruitment. |
Secondary outcome measures | 1. Acute toxicities, assessed according to the current NCI-CTCAE or RTOG (for skin toxicity) criteria, during each week of treatment (with the exception of the ACT3 observation arm) 2. Late toxicities, measured by patient reported outcomes via EORTC QLQ-C30 and CR29 questionnaires at 6 weeks, 6, 12, 24 and 36 months post the end of treatment 3. Treatment compliance, measured on a weekly basis by assessment of total dose of radiotherapy received, duration of treatment, delays to treatment due to toxicity, and any chemotherapy dose modifications 4. Clinical response rate (cRR) (ACT4 and 5), assessed by MRI imaging in accordance with the Tumour Regression Grading System at 3 and 6 months post end of treatment 5. Disease-free survival (DFS), defined as time from randomisation to first documented evidence of pelvic failure. 6. Colostomy-free survival (CFS), measured at baseline, prior to the start of treatment and throughout follow-up and will look at patients who have a pre-treatment colostomy that is still present at 12 months post end of treatment, patients who have a colostomy fitted due to a treatment related toxicity or local disease failure 7. Progression-free survival (PFS), defined as time from randomisation to first documented evidence of disease progression or death from any cause 8. Overall survival (OS), defined as time from randomisation to date of death from any cause 9. Patient Reported Outcome Measures (PROMs), assessed by EORTC QLQ-C30 and CR29 questionnaires at baseline, end of treatment and 6 weeks, 6, 12, 24 and 36 months post the end of treatment Descriptive outcomes: 1. Pattern of pelvic failures i.e. site and position of failure 2. Proportion of participants undergoing salvage surgery (ACT4 and 5) |
Overall study start date | 01/06/2015 |
Overall study end date | 28/02/2027 |
Eligibility
Participant type(s) | Patient |
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Age group | Adult |
Lower age limit | 16 Years |
Sex | Both |
Target number of participants | Planned sample size = 711; UK sample size = 701. ACT3: 90 Over 3 Years; ACT4: 162 Over 2 Years and ACT5: 459 Over 5 Years |
Total final enrolment | 709 |
Participant inclusion criteria | Key inclusion criteria for all three trials include: 1. Provision of written informed consent 2. Histologically-proven, invasive primary squamous, basaloid, or cloacogenic carcinoma of the anus 3. Adequate bone marrow, hepatic and renal function 4. HIV negative or HIV positive and receiving effective antiretroviral therapy and CD4 count >200 5. Aged 16 years or over 6. Fit for all protocol defined treatments 7. Prepared to practice methods of contraception during treatment and until 6 months post end of treatment 8. Able to undergo all mandated staging and follow-up investigations, including MRI Trial-specific inclusion criteria: ACT3 T1 N0 or Nx anal margin tumour treated by local excision; ECOG performance status 0-2 ACT4 T1-2 up to 4cm N0 or Nx anal canal or anal margin tumour; ECOG performance status 0-1 ACT5 T2 N1-3 or T3-4 Nany anal canal or anal margin tumour; ECOG performance status 0-1 |
Participant exclusion criteria | Key exclusion criteria for all three trials include: 1. Definite evidence of metastatic disease 2. Prior invasive malignancy unless disease-free for a minimum of 3 years (exluding basal cell carcinoma of the skin or other in situ carcinomas) 3. Prior systemic chemotherapy for anal cancer 4. Prior radiotherapy to the pelvis 5. Uncontrolled cardiorespiratory comorbidity 6. Pregnant or lactating 7. Immunocompromised (organ transplant) Trial-specific exclusion criteria: ACT3 Where a piecemeal local excision precludes assessment of tumour size and margin status |
Recruitment start date | 01/09/2016 |
Recruitment end date | 31/08/2023 |
Locations
Countries of recruitment
- England
- Ireland
- Northern Ireland
- Scotland
- United Kingdom
- Wales
Study participating centres
Leeds
LS9 7TF
United Kingdom
Old Road
Headington
Oxford
OX3 7LE
United Kingdom
Northwood
HA6 2RN
United Kingdom
Whitchurch
Cardiff
CF14 2TL
United Kingdom
Bristol
BS2 8ED
United Kingdom
Brighton
BN2 5BE
United Kingdom
London
SE1 9RT
United Kingdom
Guildford
GU2 7XX
United Kingdom
London
SW3 6JJ
United Kingdom
Sutton
SM2 5PT
United Kingdom
Hills Road
Cambridge
CB2 0QQ
United Kingdom
Glasgow
G12 0YN
United Kingdom
Crewe Road
Edinburgh
EH4 2XU
United Kingdom
Rhyl
LL18 5UJ
United Kingdom
Aberdeen
AB25 2ZN
United Kingdom
Cottingham
HU16 5JQ
United Kingdom
London
W6 8RF
United Kingdom
Cheltenham
GL53 7AN
United Kingdom
Nottingham
NG5 1PB
United Kingdom
Bebington
Wirral
CH63 4JY
United Kingdom
Colchester
CO4 5JL
United Kingdom
Maidstone
ME16 9QQ
United Kingdom
Northampton
NN1 5BD
United Kingdom
Edgbaston
Birmingham
B15 2GW
United Kingdom
Reading
RG1 5AN
United Kingdom
Exeter
EX2 5DW
United Kingdom
London
NW3 2QG
United Kingdom
Fulwood
Preston
PR2 9HT
United Kingdom
Sketty
Swansea
SA2 8QA
United Kingdom
Southampton
SO16 6YD
United Kingdom
London
EC1A 7BE
United Kingdom
Manchester
M20 4BX
United Kingdom
Middlesbrough
TS4 3BW
United Kingdom
London
NW1 2BU
United Kingdom
Sheffield
S10 2SJ
United Kingdom
Sponsor information
University/education
Medicine and Health Faculty Office
Worsley Building
Leeds
LS2 9JT
England
United Kingdom
https://ror.org/024mrxd33 |
Funders
Funder type
Charity
Private sector organisation / Other non-profit organizations
- Alternative name(s)
- CR_UK, Cancer Research UK - London, CRUK
- Location
- United Kingdom
Results and Publications
Intention to publish date | 28/02/2028 |
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Individual participant data (IPD) Intention to share | Yes |
IPD sharing plan summary | Available on request |
Publication and dissemination plan | To maintain the scientific integrity of the trial, data will not be released prior to the first publication of the analysis of the primary endpoint, either for trial publication or oral presentation purposes, without the permission of the DMEC and TSC. In addition, individual collaborators must not publish data concerning their participants which is directly relevant to the questions posed in the trial until the first publication of the analysis of the primary endpoint. An electronic copy of peer-reviewed, published papers arising from this research will be deposited in the Europe PubMed Central database. |
IPD sharing plan | The datasets generated during the current study will be available on request from the Clinical Trials Research Unit at the University of Leeds. De-identified individual participant data datasets generated during the current study will be available upon request from the Clinical Trials Research Unit, University of Leeds (contact CTRU-DataAccess@leeds.ac.uk in the first instance). Data will be made available at the end of the trial, i.e. usually when all primary and secondary endpoints have been met and all key analyses are complete. Data will remain available from then on for as long as CTRU retains the data. CTRU makes data available by a 'controlled access' approach. Data will only be released for legitimate secondary research purposes, where the Chief Investigator, Sponsor and CTRU agree that the proposed use has scientific value and will be carried out to a high standard (in terms of scientific rigour and information governance and security) and that there are resources available to satisfy the request. Data will only be released in line with participants' consent, all applicable laws relating to data protection and confidentiality, and any contractual obligations to which the CTRU is subject. No individual participant data will be released before an appropriate agreement is in place setting out the conditions of release. The agreement will govern data retention, usually stipulating that data recipients must delete their copy of the released data at the end of the planned project. The CTRU encourages a collaborative approach to data sharing and believes it is best practice for researchers who generate datasets to be involved in subsequent uses of those datasets. Recipients of trial data for secondary research will also receive data dictionaries, copies of key trial documents and any other information required to understand and reuse the released datasets. The conditions of release for aggregate data may differ from those applying to individual participant data. Requests for aggregate data should also be sent to the above email address to discuss and agree on suitable requirements for release. |
Study outputs
Output type | Details | Date created | Date added | Peer reviewed? | Patient-facing? |
---|---|---|---|---|---|
Other publications | investigation of prognostic factors | 20/05/2021 | 25/05/2021 | Yes | No |
Abstract results | 01/10/2019 | 14/11/2022 | No | No | |
Poster results | 14/11/2022 | No | No | ||
Plain English results | ACT4 early results summary version 1.0 |
05/06/2023 | 05/06/2023 | No | Yes |
Plain English results | ACT5 early results summary version 1.0 |
23/06/2023 | 26/06/2023 | No | Yes |
HRA research summary | 28/06/2023 | No | No | ||
Plain English results | ACT4 | 24/08/2023 | No | Yes | |
Protocol file | version 8.0 | 07/02/2024 | 10/10/2024 | No | No |
Protocol file | version 9.0 | 04/12/2024 | 24/01/2025 | No | No |
Additional files
- ISRCTN88455282 Early results lay summary_v1.0_230605.pdf
- ACT4 early results summary
- ISRCTN88455282_ACT5_PlainEnglishResults_V1.0_23June23.pdf
- ACT5 early results summary
- ISRCTN88455282_PROTOCOL_V8.0_07Feb24.pdf
- ISRCTN88455282 PLATO Protocol v9.0_04Dec24.pdf
Editorial Notes
24/01/2025: Uploaded protocol v9.0 (not peer-reviewed) as an additional file.
10/10/2024: Protocol uploaded. Saint Luke’s Centre for Radiation Oncology at Beaumont Hospital was removed from the study participating centres.
11/09/2023: IPD sharing statement added.
31/08/2023: The recruitment end date was changed from 31/10/2023 to 31/08/2023. Total final enrolment added.
24/08/2023: Plain English results of ACT4 added.
26/06/2023: A plain English summary of early results was added.
05/06/2023: A plain English summary of early results was added.
04/04/2023: Internal review.
03/04/2023: The following changes have been made:
1. The following trial participating centres were removed: Belfast City Hospital, Hammersmith Hospital, Ipswich Hospital, Kent and Canterbury Hospital, Leicester Royal Infirmary, New Cross Hospital, North Devon District Hospital, Northern Centre for Cancer Care, Royal Shrewsbury Hospital, The Cumberland Infirmary and Worcestershire Royal Hospital.
2. IRAS number added.
3. The interventions have been changed.
4. The target number of participants has been changed from "Planned Sample Size: 929; UK Sample Size: 814" to "Planned sample size = 711; UK sample size = 701. ACT3: 90 Over 3 Years; ACT4: 162 Over 2 Years and ACT5: 459 Over 5 Years".
27/03/2023: The recruitment end date has been changed from 31/08/2021 to 31/10/2023.
14/11/2022: Abstract and poster added.
20/09/2021: Internal review.
25/05/2021: Publication reference added.
04/05/2020: The public contact has been updated.
28/03/2019: The condition has been changed from "Specialty: Cancer, Primary sub-specialty: Colorectal; UKCRC code/ Disease: Cancer/ Malignant neoplasms of digestive organs" to "Anal cancer" following a request from the NIHR.
04/12/2017: internal review.
22/09/2017: Internal review.
13/03/2017: Cancer Help UK lay summary link added to plain English summary field.
06/02/2017: Internal review.