The study will be conducted as a pilot study to test efficacy, safety and feasibility of propranolol on preoperative anxiety in patients undergoing abdominal surgery for suspected pancreatic ductal adenocarcinoma (PDAC). Furthermore, the implementation of the trial including compliance of the participants in a hybrid type 1 setup will be examined.
A total of 30 participants will be included and randomized to receive either propranolol or placebo twice daily with 15 patients in each arm. Following this study, a power calculation will be done to reveal the actual number of needed participants in each arm for a potential follow-up randomized clinical trial on primary outcomes of interest. Thus, the results from this study can be used for future power calculations for clinical trials related to this topic.
Primary objectives: Efficacy
Evaluating the efficacy of preoperative propranolol on patient-experienced anxiety and on tumorigenic gene expression compared to placebo is the primary objective of this trial.
Primary objectives are further divided in to primary clinical objectives, primary translational objectives and exploratory endpoints.
Primary clinical objectives:
The primary clinical objectives are to evaluate preoperative patient-experienced anxiety in patients receiving the nonselective beta-2-adrenergic receptor inhibitor, propranolol, compared to placebo.
Further, heart rate variability (HRV) will be measured in order to evaluate changes in the autonomous nervous system in relation to surgery. HRV is calculated from the interval variation between consecutive R waves in an ECG time series and results suggest that it is associated with the intra- and postoperative complications. As HRV reflects sinoatrial node regulation, it is expected to be affected by the beta-adrenergic blockade caused by preoperative propranolol. Analyzing this relation will provide essential knowledge in understanding how HRV behaves perioperatively.
Lastly, follow up on the participants receiving propranolol compared to placebo will be done.
Primary clinical effect parameters:
The following primary effect parameters will be used to investigate the primary clinical objectives:
* Anxiety levels will primarily be measured by The Hamilton Anxiety Rating Scale (HAM-A) and secondarily by The Hospital Anxiety and Depression Scale (HADS). The European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QoL) for pancreatic cancer will be used to assess quality of life.
* HRV is calculated from continuous ECG gathered by a Holter monitor. The monitor is a small wearable apparatus with one lead, placed on the patient's sternum. It is applied on preoperative day 9 and will run continually until approximately postoperative day 7. The actual calculations are achieved post hoc using software specialized for HRV analysis.
* Follow up at 30- and 90-days after surgery including parameters such as survival and postoperative complications.
* Long-term follow up at as 1-year, 3- year and 5-year following surgery including survival and recurrence data.
Primary translational objectives:
The primary translational objectives are to examine the systemic (biochemical) and local changes (TME of resections) to propranolol treatment compared to placebo. Alterations in pro-metastatic and proinflammatory genes will specifically be analyzed.
Primary translational effect parameters:
* Blood sampling for the analysis of pro-metastatic and proinflammatory biomarkers.
* Expression of pro-metastatic and proinflammatory genes in formalin-fixed paraffin-embedded (FFPE) cancer tissue obtained after surgical resection.
Exploratory endpoints:
The potential influence of inter-participant genetic variations (pharmacogenetics) on measured levels of serum propranolol and response to surgical stress will be investigated as exploratory endpoints. The differences in drug metabolism (pharmacokinetics) among participants will also be of interest.
Secondary objectives: Safety
Secondarily, tolerance and safety of the intervention in this pilot study (e.g., adverse effects, number of patients that need dose reduction etc.) will be evaluated. Changes in heart rate (HR) and blood pressure (BP) during the intervention period will be examined to test safety and tolerability of preoperative propranolol.
Secondary effect parameters:
* Measuring the changes in resting HR and BP during the intervention period with handed out blood pressure monitors.
* Safety endpoints: light-headedness, lethargy, hypotension, bradycardia and other symptoms and side-effects that may be related to propranolol treatment.
Tertiary objectives: Feasibility
Additionally, the feasibility of this intervention using the APEASE framework, which assesses factors like affordability, practicability, effectiveness, acceptability, side-effects, and equity, thereby determining the willingness to adopt this strategy will be examined. This will help identify barriers and enablers to a future larger study. The details regarding the APEASE framework are described under assessments.
This trial will be conducted in accordance with the principles of Good Clinical Practice and reported according to the CONSORT and the complimentary StaRI standards for implementation studies.
