Team:UCL/Human Practices

Introduction Safety Survey Design Survey Results Integration

Integrated Human Practices

Introduction

Aims

  1. Evaluating public understanding of synthetic biology
  2. Understanding public acceptance of our project
  3. Assessing the factors that influence a stakeholder’s likelihood of accepting MESH
  4. Determining stakeholder preferences and concerns, and altering MESH design accordingly
  5. Developing product design criteria based on parameters identified for dosage, administration and frequency of treatment

Safety

In order to understand the views and opinions of the stakeholders of our technology, we got in touch with several breast cancer research charities, including Shine Cancer Support and Breast Cancer Now. We felt that it is imperative to voice the concerns of stakeholders of technology in order to better mould the design of our project around their preferences.

Although stakeholder preferences have been studied broadly for marketed products by pharmaceutical industries or around the time of submission to authorities and launch, these preference studies have rarely been used during the early drug development phases [1]. Hence, we strove to speak to breast cancer patients and incorporate their views into our project to develop a more stakeholder-driven treatment.

The first charity that we worked with was Shine Cancer Support. By speaking to some of their members, which were mainly cancer patients and survivors, we found that the side effects that the patient experiences as a part of their treatments greatly influence their perception of the treatment. Most people that we spoke to understood that the side effects were a part of their treatment and that the side effects were not universal, however the vast majority felt more ill from the side effects than from the cancer. Many patients had the fear that their chemotherapy treatment was being rejected or that their cancer was spreading, due to the sheer severity of the side-effects. A few quotes from breast cancer patients are shown below (due to ethical concerns, no names have been included):

“Bone pain, dizziness, stomach cramps and low platelets all made me concerned that my cancer was progressing.”

“The chemotherapy I had felt to make me more ill than I'd ever been. The sickness and mucositis meant I couldn't eat at all and I lost so much weight that I had absolutely no energy or reserves. I had blinding headaches and bone pain. It felt like my condition was getting worse not better. I think the worst side effect was the nausea, as I didn't feel I could look after myself nutritionally nor could I enjoy the comfort of food.”

“The treatment has produced so many side effects, especially in my joints and I know that bone pain can be a symptom of the recurrence of cancer - I'm not confident I would recognise recurrence, without assuming it was side effects for a long time.”

“The anti sickness medication I was on made me very sick through the first few cycles of treatment, which made me think I was rejecting the chemo and that it was not working and therefore my cancer would spread. I also had very bad peripheral neurotherapy from the ABVD (Adriamycin, Bleomycin, Vinblastine, Dacarbazine) chemo, again making me think I was rejecting the chemo.”

We also asked the patients their opinions on bacteria-derived treatments, and the responses were surprisingly positive, notwithstanding the current public image of GMOs and genetic engineering. Most patients answered that they would put their trust in medical research and would take anything prescribed to them by their doctors.

One patient said; “I have no idea how the drugs I received were produced. So long as they are safe and regulated I don’t mind.”

Another patient said that; “It would not concern me at all but I would expect to receive as much information as possible about long term impact of treatment.”

Only one patient considered the potential treatment ‘risky’, and many would prefer to have more information about the production/quality control of the treatment before they would trial it.

From these responses, we felt that by designing a targeted treatment, which would aim to reduce the side effects of conventional treatments, we would be satisfying many of the patient preferences through our product design. Additionally, we realised that making patients aware of the production processes involved in the development of our drug delivery platform was essential for cultivating patient trust.

Therefore, we implemented these findings, not only in our product design, but also in our next effort to connect with those affected by breast cancer. We contacted one of the largest breast cancer research charities in the UK, called Breast Cancer Now, with the aim of organising a focus group of breast cancer patients. We also approached the UCL Research Ethics Committee (UCL REC) in order to gain ethics approval for such an event, as breast cancer patients are a vulnerable group, therefore we decided to proceed in accordance with our university ethics and data-protection (GDPR - General Data Protection Regulation) regulations.

Upon speaking with UCL REC, we were made aware of various research ethics regulations, including a high-risk and a low-risk ethics and data-protection applications. We were advised against inviting a breast cancer patient focus group, as this would entail a multitude of ethical concerns, as well as privacy and data collection issues that we would need to consider. This is a lengthy and a time-consuming process, as it takes a month for the UCL REC review board to review the application. To avoid this issue, we considered inviting breast cancer survivors, as we believed their insight into various conventional therapies would be instrumental in our drug development.

We liaised with the research charity (Breast Cancer Now), once more, and asked for their opinion on inviting a focus group of breast cancer survivors, which would not require a high-risk ethics application. Surprisingly, our contact at the charity told us that many researchers tend to exclude breast cancer patients when organising focus group. They told us that breast cancer patients felt dissatisfied, angry and often helpless at not being able to share their experiences with researchers and research groups. They also felt that their experiences had not been considered in previous cancer drug development projects. They believe that this was primarily because their participation would require a high-risk ethics application process which, in their opinion, deters research groups from exploring the experiences of such a vulnerable group.

We carried these opinions to the advisors at UCL REC again. We felt that our research would benefit from a wider variety of opinions, especially if we were able to include breast cancer patients in our focus group. We questioned the possibility for any leniency in ethical restrictions at our university, so that we could conduct our research with feedback from vulnerable groups, such as breast cancer patients.

Here is their reply:

Thank you for your email. I believe that there is a misunderstanding on the behalf of the researchers and participants what the ethics approval is. The main purpose of the ethics evaluation is to make sure that everyone is safe and properly informed of the researcher and its risk. The issue is not with policies, often it is the attitude of the researchers themselves, who simply don’t want to do the required work or simply don’t plan for the realistic timelines. Ethics committee is not here to stop research, however, researchers do need to consider that ethics review does not happen overnight, and cannot expect immediate approvals within 24h. As an institution we cannot ignore the risks to the participants. It is up to the researchers to make sure that they design and do their research well. If that is the case, then ethics review process at UCL is quite straight forward. I wonder whether patient groups are actually thinking about NHS approval. This is something that is out of our hands and the application process is indeed quite complicated and not straight forward. If any research uses patients accessed via NHS services or on NHS premises, then they need HRA approval. There is nothing university can do about this. If you would like to conduct the focus groups or individual interviews, you will have to submit a high-risk ethics application.

Therefore, applying for a focus group ethics approval would be considered a high-risk ethics application, and would need to be reviewed by UCL’s Ethics Review Board and the Committee, which meets once a month. Considering the time constraints of our iGEM project, and in an attempt to incorporate the voice of stakeholders as early on in the development of our project as possible, we decided to launch a survey in collaboration with Breast Cancer Now, instead of organising a focus group.

Contrary to our expectations, launching a survey was not free from several complications, either. As it was imperative for us to incorporate patient preferences into our project design, we created a survey aimed at those affected by breast cancer. In order to ensure that privacy and personal data of such a vulnerable group was protected, we applied for a low-risk ethics and data protection application, and decided to use Opinio - a web-based survey tool which provides a framework for authoring and distributing surveys as well as a range of reporting facilities[1]. We did not use Survey Monkey as it collects IP addresses of respondents, and this would be in breach of GDPR regulations. Opinio does not collect any personal data of respondents and hence was an ideal choice of software. However, undergraduates are not allowed to have accounts on Opinio. Fortunately, our supervisor already had an account, and we were able to launch our survey with his help!

The ethics application can be viewed in the frame below, along with the required documentation, including a participant information sheet and consent form!

We applied for and received UCL Research Ethics approval in order to conduct our survey on 25 participants. We believed that 25 participants would provide us with enough data to derive statistically significant results.

Survey Design

We designed a survey that would allow us to gain an in depth understanding of prevailing public views about synthetic biology as well as allow us to gain feedback on our project design, so that we could develop a more stakeholder-driven breast cancer treatment.

Therefore, we carried out the Flesch-Kincaid readability analysis, which indicates how difficult a passage in English is to understand[2]. We did this to ensure that our survey would be understood clearly by our target audience. We also followed the guidelines offered by Cancer Research UK and iGEM to ensure that our survey was designed in an appropriate manner. Before being released to the breast cancer research charity, the survey was inspected by our supervisors and the ethics committee at UCL. Additionally, the survey was also inspected by Dr Martin Forster, who is involved in the management of patients with lung, head and neck cancers. He is interested in drug development and in using the increasing understanding of cancer biology to design studies that distinguish patient populations most likely to gain benefit from new drugs and new drug combinations. He is based at University College London Hospital. The survey was also tested out by our team members, and took 10 mins to complete.

A copy of the survey can be accessed here

Survey Results

Our survey was completed by 25 participants all of which had been affected by breast cancer. The responses for acceptance of our proposed treatment were treated as numerical (rather than categorical) variables as previous studies that have evaluated attitudes towards synthetic biology have set the precedent that genetic engineering attitudes, using a Likert scale, can be treated as continuous variables[3].

To confirm the validity of our study, we conducted a comparison of our results on attitudes towards genetic engineering with previous findings. Previous studies have suggested that the public tends to be more accepting for synthetic biology for medical research purposes than for genetic engineering of crops and cattle[4][5]. This result was consistent in our survey, as approval for genetically engineering of human cells to treat human diseases (mean = 4.12) was significantly higher than the mean for approval of genetically modified food (mean = 2.69; P-value=0.0049). The mean for the engineering of non-human cells to treat human diseases was even higher, with a mean of 4.25 and a P-value=0.0011.

We hypothesized that the level of trust in synthetic biology and genetic engineering was dependent on people’s understanding of the science. However, this was found to be statistically insignificant, after conducting a paired-t test, where the P-value was found to be 0.1074. Although, 59% of all respondents understood synthetic biology and genetic engineering, only 42% of the respondents trusted the technology completely for medical purposes.

Nonetheless, the overall public opinion on synthetic biology was positive, with the vast majority (67%) agreeing that synthetic biology can have a positive impact on their lives. This result was comparable with people’s understanding of synthetic biology (56%). Additionally, though we hypothesised most patients would be reluctant to use bacteria-derived treatments, such as ours, we did not find a statistically significant result to prove this hypothesis. In fact, 100% of the patients agreed that they would be willing to use our proposed treatment, as long as it was FDA approved.

People who have a greater trust in conventional drug development procedures and clinicians (mean=4.33), were also more likely to approve of MESH (mean=4.47) with a P-value<0.0001.

From the analysis of the survey results, we can conclude that education about synthetic biology and genetic engineering can have a considerable positive impact on people’s acceptance of the technology in the realm of medicine and targeted therapeutics. We can also conclude that the overall concerns tend to be related to the potential side effects, efficacy, cost, FDA-approval and duration of treatment.

Overall, the public’s approval of MESH was found to be 5.00, which was above the median approval score of 3.00.

Integration
  1. Through our discussions with breast cancer patients and our survey, we found that patients generally preferred a treatment that wasn’t produced in bacteria, so we considered developing our technology in a cell-free system and modelled this to assess feasibility.
  2. We also expressed encapsulins using a cell free protein synthesis (CFPS) system, shown in the gel below (indicated by the red arrows in Figure X). Note we expressed the T.maritima encapsulin constructs from EPFL 2018's team, which were only possible to be purified using heat purification. Time constraints prevented us from expressing our encapsulin constructs in CFPS, however we predict that due to succesful expression of the EPFL constructs, and considerable examples of expression of encapsulins in cell free systems, that expressing our constructs using CFPS systems should not pose a considerable challenge.
    3. Figure 5: SDS PAGE of CFPS and heat purification of T. maritima encapsulins constructs (indicated by the red arrows). M: molecular marker, 1: CFPS of T. maritima encapsulin; 2: Heat purification of T. maritima encapsulin; 3: CFPS of T. maritima encapsulin with 6-His insert; 4: Heat purification of T. maritima encapsulin with 6-His insert. 5: CFPS of M. xanthus encapsulin; 6: Heat purification of M. xanthus encapsulin.
  3. Previous research by Mironova et al. has suggested to test DARPin binding at 4 °C and atmosperic oxygen conditions[6]. Following advice from oncologist Dr Yin Wu we simulated the tumour microenvironment during our experiments as variance in conditions could affect binding as we would transfer the drug from in virto experiments to further trials. Specifically, the conditions were modified to body temperature (37 °C) and 2% oxygen saturation (hypoxic conditions that are usualy found near the tumour site). While during the validation studies we discovered that this change did not significantly affect the results, we now know that the binding of the drug delivery system will not be hampered during the transition from in virto to in vivo tests.
  4. As we were encouraged by pharmaceutical industry specialists, including Dr Christopher van der Walle, to devise a dosage for our proposed treatment. Following comparison with existing targeted therapies aimed at HER2+ breast cancer, namely Herceptin® [7], we predict the following dosages and schedules. This therapy would be administered intravenous infusions, as opposed to via subcutaneous infusions because this would be more comfortable for the patients, as advised by Dr Yin Wu. We do not recommend mixing our proposed treatment with any other targeted, or chemotherapeutic treatment, due to risk of unknown and unpredictable side effects at this time.

    Dosage: Typically, Herceptin® is used in combination with other chemotherapeutic drugs, as we do not recommend starting another treatment in conjunction with MESH, we would suggest an dose of 9mg/kg as an intravenous infusion over 90 minutes, then at 4.5mg/ml as an intravenous fusion over 30 minutes weekly for 42 weeks. Please note that these are very rough estimates calculated theoretically, with comparison to other targeted therapies used for HER2+ breast cancer, including Herceptin® and Xeloda® [7][8]. Additionally, we predict a lower duration of treatment, as opposed to conventional targeted therapies, as we believe that our drug delivery platform is highly efficient in its design. See our experimental data for further evidence.

    Preparation for administration:

    Reconstitution:

    1. Prepare a dose solution of 32mg/ml, by reconstituting each 640mg vial of MESH with 20mL of bacteriostatic water for injection, containing 1.1% benzyl alcohol as a preservative. In patients with known hypersensitivity to benzyl alcohol, reconstitute with 20mL of sterile water for injection without preservative to yield a single-use solution.

      Dilution:

    1. Determine the dose (mg) of MESH (see above). Calculate the volume of the 21mg/ml reconstituted MESH solution needed, withdraw this amount from the vial and add to an infusion bad containing 250mL of 0.9% NaCl injection[9]. Invert bag to mix contents gently.
  5. As we observed that greater knowledge/awareness of synthetic biology contributes significantly to its acceptance in society, we organised a creative and interactive exhibition titled ‘Synthetic Biology and the Senses’ at New Scientist Live, which is a popular science festival, with over 40,000 attendees, from the 10th-13th October, in order to improve the public’s engagement with synthetic biology. Surprisingly, we were approached by at least 10 people who had been affected by breast cancer in some way. Their reviews of MESH, as a targeted drug delivery therapy, were very supportive and encouraging.

References

  1. Review of web-based survey tools [Internet]. Information Services Division. 2019 [cited 19 October 2019]. Available from: https://www.ucl.ac.uk/isd/services/learning-teaching/e-learning-services-for-staff/e-learning-core-tools/opinio/review-web
  2. ReadablePro. A readability tool, with extra power [Internet]. Readable. 2019 [cited 19 October 2019]. Available from: https://readable.com/
  3. Likert Scale Questions: Definitions, Examples + How To Use Them | Typeform [Internet]. Free Beautiful Online Survey & Form Builder | Typeform. 2019 [cited 19 October 2019]. Available from: https://www.typeform.com/surveys/likert-scale-questionnaires/
  4. UK public cautiously optimistic about genetic technologies | Royal Society [Internet]. Royalsociety.org. 2019 [cited 19 October 2019]. Available from: https://royalsociety.org/news/2018/03/genetic-technologies/
  5. Jasanoff S, Hurlbut J. A global observatory for gene editing. Nature. 2018;555(7697):435-437.
  6. Mironova, K.E., Chernykh, O.N., Ryabova, A.V. et al. Biochemistry Moscow (2014) 79: 1391. https://doi.org/10.1134/S0006297914120141
  7. [Internet]. Accessdata.fda.gov. 2019 [cited 19 October 2019]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/103792s5250lbl.pdf
  8. [Internet]. Accessdata.fda.gov. 2019 [cited 19 October 2019]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/020896s037lbl.pdf
  9. [Internet]. Accessdata.fda.gov. 2019 [cited 19 October 2019]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/103792s5250lbl.pdf