"Could you give us an idea on what we are all doing here?" the Patient Voice in Cancer Research (PVCR) starting the journey of involvement in Ireland

"Could you give us an idea on what we are all doing here?" the Patient Voice in Cancer Research (PVCR) starting the journey of involvement in Ireland
Shé et al. Research Involvement and Engagement                 (2021) 7:63

 RESEARCH ARTICLE                                                                                                                                    Open Access

“Could you give us an idea on what we are
all doing here?” the Patient Voice in Cancer
Research (PVCR) starting the journey of
involvement in Ireland
Éidín Ní Shé1, Aoife Gordan2, Barbara Hughes3, Tom Hope4, Teresa McNally5, Ramon Whelan6, Mary Staunton7,
Margaret Grayson8, Liane Hazell9, Iseult Wilson10, Richard Stephens11, Elaine Quinn3 and Amanda McCann2,3*

  Background: Involving patients and their carers in research has become more common, as funders demand
  evidence of involvement. The ‘Patient Voice in Cancer Research’ (PVCR) is an initiative led by University College
  Dublin (UCD) in Ireland. It encourages and enables people affected by cancer, and their families to become
  involved in shaping and informing the future of cancer research across the island of Ireland. Its aim is to identify
  the questions and needs that matter most to (i) people living with a cancer diagnosis, and (ii) those most likely to
  improve the relevance of cancer research. The initiative commenced in April 2016.
  Methods: This paper presents a reflective case study of our journey thus far. We outline three key stages of the
  initiative and share what we have learnt. At the core of PVCR, is a focus on building long-term relationships.
  Results: We have developed over time an inclusive initiative that is built on trust and respect for everyone’s
  contributions. This work is grounded on collegiality, mixed with a good sense of humour and friendship.
  Conclusion: The development of PVCR has taken time and investment. The benefits and impact of undertaking
  this work have been immensely rewarding and now require significant focus as we enhance cancer research across
  the island of Ireland.
  Keywords: Patient and public involvement, Cancer research, Patients, Consumer engagement

Background                                                                              [2, 4]. There is evidence of changes within health charity
There is a diverse and growing literature capturing the                                 organisations of growing and enabling public and patient
various ways of undertaking public and patient involve-                                 involvement within their own structures [5, 6, 7]. Fund-
ment (PPI) in health and social care research [1, 2, 3, 4].                             ing schemes have also shifted, enabling involvement in
Our working definition of public and patient involve-                                   various activities such as peer reviewing applications,
ment, is that it is an inclusive enabling process where re-                             having members of the public as co-applicants and set-
search is carried out ‘with’ or by’ members of the public                               ting research priorities [4, 8]. In 2017, two national re-
                                                                                        search funders in Ireland; the Health Research Board
* Correspondence: amanda.mccann@ucd.ie                                                  (HRB) and the Irish Research Council (IRC), launched a
  UCD School of Medicine, University College Dublin, UCD, Belfield, Dublin 4,
Ireland                                                                                 joint call entitled ‘PPI Ignite’ to support higher education
  UCD Conway Institute of Biomolecular and Biomedical Research, University              institutions to embed PPI deeply into their organisa-
College Dublin, UCD Belfield, Dublin 4, Ireland                                         tional culture [4]. Recent international literature has
Full list of author information is available at the end of the article

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Shé et al. Research Involvement and Engagement   (2021) 7:63                                                   Page 2 of 15

focused on the improved integration of involvement             Description of the case study: the Patient Voice in Cancer
within research settings and infrastructures [9, 10]. Al-      research (PVCR)
though the influence of organisational contexts in sup-        The PVCR commenced in 2016. The three main phases
porting PPI is acknowledged as very important, it is           outlined in this case study cover 2016–2020 (Fig. 1).
rarely captured in the literature [11, 12]. The available
evidence suggests that the key enablers to move diverse        Study design
involvement from research and project specific context         The authors named in this paper contributed to sharing
to embedding it within an infrastructure include (i) hav-      their reflections in a format that suited them. The write-
ing a lead researcher who believes and champions PPI           up occurred during the Covid-19 pandemic, and we
and (ii) a culture of PPI that is supported and celebrated     wanted to be as flexible as possible. The data used was
as best practice [12].                                         captured in a number of ways:
   This paper presents a case study of the University Col-
lege Dublin (UCD) Conway Institute of Biomolecular               1. Reflections from the authors received via email,
and Biomedical Research’s commencement of their in-                 phone conversations facilitated by two authors who
volvement journey. The institute is a multidisciplinary             were not directly involved in the PVCR (ÉNS &
centre with over 400 research staff working in biomed-              AG).
ical research and innovation. There is a strong focus on         2. Feedback from Friendly Dragons (patient
translation of this knowledge through industrial, aca-              representatives and carers) n = 52 and researchers
demic and clinical partnerships [13]. “Patient voice” is a          n = 10 who attended and facilitated a Dragons Den
term that has become frequently used in health and so-              event in February 2020. Feedback was collected
cial care settings. It is often used to describe a compil-          from both the Friendly Dragons (patient
ation of many patients’ and carers’ expressed feelings,             representatives) (Appendix I) and researchers
concerns, and experiences during an illness [14, 15]. A             immediately following the event (via paper and
core focus within the Institute is on cancer research. Sig-         online forms). In addition, to preliminary feedback,
nificant work has been published on the merits and rea-             researchers were also required to complete a 6-
sons for undertaking PPI in cancer research [16–20].                month post-event update, with the aim of capturing
   The motivation to involve people in Ireland is no dif-           the impact of the PVCR/NCRI UK Dragons Den
ferent to international experiences. Each year in Ireland           session. The outcomes from this feedback is in
an average of 43,000 new cases of cancer are diagnosed              preparation as a subsequent publication.
[21]. The National Cancer Strategy 2017–2026 sets out            3. Initial review of the materials by two authors not
the vision for delivery of cancer services in Ireland [22].         directly involved in PVCR (ÉNS & AG) to scope
Central to the strategy is that services are in place to            out a case study approach using Fig. 1 as the guide.
better serve the needs of cancer patients, their families        4. Initial draft of a summary shared with all authors
and carers. The strategy sets out the need for future sup-          and iteratively refined for feedback with a focus on
port services to be enhanced through a better under-                lessons learnt.
standing of patient needs [22].
   In retrospect, the journey of the PVCR may seem quite         Merging of feedback and final paper sign off by all.
orderly and logical, but the reality was more of an evolu-
tion through discussion, especially in the first 2 years. It   Results
is best described by a conversation between a cancer pa-       Stage 1: getting started (2016–2018)
tient at the first steering committee meeting and Profes-      Since the inception of the UCD Conway Institute in
sor Amanda McCann. The lady asked, “Could you give             2000, one of the stated goals has been to ‘build bridges
us an idea on what we are all doing here?” to which            to the community at large’. UCD Conway established a
Amanda replied, “Quite honestly, I have no idea!”. This        public engagement programme to advance our objec-
paper sets out our collective experiences to date.             tives under this goal and give visibility of our research
                                                               programmes to the public. At the UCD Conway Insti-
Methods                                                        tute, we believe that our research is more relevant when
This is an exploratory reflective single case study of the     stakeholders are actively engaged in the process.
establishment of the Patient Voice in Cancer Research          Through engagement with patients and the public, our
(PVCR) initiative within the UCD Conway Institute over         research can reflect their valuable perspectives and is
4 years (2016–2020). Our focus is on sharing the PVCR          more likely to have a greater impact [14, 17]. In 2015,
journey and a case study approach allowed us to share          researchers and public engagement professionals began
our experience within our context “without control over        working with patient advocate groups on public engage-
actual behavioural events by the investigator” [23].           ment initiatives aligned with health awareness campaigns
Shé et al. Research Involvement and Engagement           (2021) 7:63                                                                     Page 3 of 15

 Fig. 1 The Patient Voice in Cancer Research (PVCR) Stages, Since 2016 there have been eight PVCR cancer events (Table 1)

(Movember, Breast Health Day, World Cancer Day,                                  A colleague of mine saw a PVCR event advertised
World Health Day, Cancer Week). This involved “pop-                              and sent me an email because she thought I would
up” information stands and tours of the Conway Insti-                            be interested. At that stage, I wasn’t long back to
tute laboratories, to give patients and the public the ‘be-                      work after my treatment for acute myeloid leukae-
hind-the-scenes’ view of research in action. The research                        mia, which I had been diagnosed with in 2012. I
teams spoke amongst other things, about using maths to                           wasn’t used to being in a group with others who
beat cancer; moving from biomarkers to post-                                     had similar experiences to me. I had come back to
mastectomy bras; dispelling myths around diet and sup-                           work as a “cancer survivor” and everyone was so
plements for cancer patients. There was a positive re-                           careful of me, which was lovely because I felt very
sponse to the ‘open house’ tours in particular.                                  safe and looked after. But it was wonderful to be in
Participants told us that they enjoyed going ‘behind-the-                        a space with people who had been through a lot of
scenes’ and hearing about ongoing research. Mary, a pa-                          the same experiences that I had been through. Some
tient representative, outlines how she initially got                             had come through them and some were still living
involved:                                                                        through them at the time. There was a great

Table 1 Summary of PVCR initiatives
Name                                                Format                                                                                 Date
Placing Survivorship at the Heart of the Research   Research laboratory tours & facilitated roundtable discussion (n = 100)                13–4-16
Creating the Roadmap                                Talks & designing a survey for patients to be involved in research (n = 65)            19–10-16
Is there a Clinical Trial for Me? Crowdsourcing     Talks & panel discussion (n = 85)                                                      12–4-17
Histopathological staining
Workshop 1: Fund my Research; Workshop 2;           Talks & interactive session on advanced diagnostics (n = 98)                           11–4-18
Know my DNA
Cancer laboratory tours - research in action        Research laboratory tours (n = 65)                                                     12–9-18
Have your Say - National Patient Experience         Facilitated workshop with the National Cancer Registry of Ireland (NCRI) (n = 53)      10–4-19
Streamlining participation in health research       Facilitated workshop with National Biobank Working Group (n = 49)                      9–10-19
Dragons’ Den - Involving Patients & Carers in       Facilitated roundtables hosted by research groups in partnership with the National     25–2-20
Research                                            Cancer Research Institute (NCRI) UK (n = 93)
Shé et al. Research Involvement and Engagement   (2021) 7:63                                                    Page 4 of 15

  warmth there and a great camaraderie. If you volun-          relating to patient information and supports as well as
  teer to go to something like that, you don’t go along        patient involvement in research and clinical trials. Our
  and sit in the corner, you go because you want to            table facilitators included representatives from research
  be involved and be useful.                                   funding agencies (Irish Cancer Society, Health Research
                                                               Board); patient advocacy groups and individuals (The
As an institute, we felt it was important to have greater      Irish Platform for Patient Organisations, Science and
insight into the issues that mattered most to patients         Industry (IPPOSI), Clinical Trials Ireland); allied health
and how the voice of cancer patients might be amplified        care professionals and researchers. Ramon, a patient rep-
within the cancer research journey to positively impact        resentative, reflects on his initial feelings and how this
on patient outcomes. The Patient Voice in Cancer Re-           has shifted:
search (PVCR) was born with an event taking place in
UCD on the 13th April 2016. The organising committee             I was a bit wary in the beginning. I didn’t want us to
comprised academic staff with active cancer research             just be token members, needed to fill the quorum.
programmes led by Professor Amanda McCann with re-               We are anything but! I even think the patients seem
search administrative support. We adapted an equitable           to be listened to that bit more. It’s good for us to be
and collegial approach to the organisation of this event         able to put a face to the researchers. It’s always said
both in terms of logistics and identifying and seeking ap-       that it’s good to put a face to the patient but it’s very
proval for small streams of funding from operational             important for us too, we have to know who’s there
unit budgets and research grant funding. Tom, a patient          fighting our corner. In the beginning, I remember sit-
representative, outlines his experience at the first event       ting around a table with researchers who were talk-
in 2016:                                                         ing in very technical terms – this code number and
                                                                 that code number. Other people around the table
  I got involved with the Irish Cancer Society in                were nodding and I hadn’t a clue. Now my confi-
  2013, when they asked me if I would be interested              dence has grown and I’m not afraid to interrupt
  in going on a training course to become a Peer to              them and not feel intimidated. I’ve found that by
  Peer supporter and to share my experience with                 speaking out, there are always others who are on the
  other prostate cancer patients. In 2016 the Irish              same page as myself. Also, I find now that the re-
  Cancer Society rang me up 1 day and told me                    searchers are much better and quicker at explaining
  about the Patient Voice in Cancer Research                     what they are trying to say in terms I can under-
  (PVCR) Committee who were just starting out in                 stand. So it really has developed into a two-way
  UCD and asked me would I be prepared to join                   dialogue.
  the committee as a patient representative. I went
  along to that first meeting in 2016. I was inter-               The report from that event (April 13th 2016) sum-
  ested and got involved in it from there. When                marised the key recommendations and provided us with
  you’re retired, you’re looking for something to get          a basis from which to develop the PVCR. The event it-
  involved in and be focused on. I found that first            self allowed us to meet patients who subsequently
  meeting to be very open and friendly. I already              expressed an interest in being involved in the PVCR ini-
  knew several people from other groups I had been             tiative. These individuals joined our organising commit-
  involved in. I was among friends. I felt the object-         tee, which at this point was evolving into a steering
  ive was very open and it was a way to contribute             committee chaired by Professor Amanda McCann; shar-
  to cancer programmes, advocacy and research.                 ing decision-making, defining the purpose of the group-
                                                               ing and organising two events per year that would try to
  We retained the ‘open house’ tour aspect and followed        address some of the recommendations arising from the
this with a facilitated roundtable discussion forum on         April 2016 report.
placing survivorship from cancer at the heart of the can-         After discussion, the steering committee devised the
cer research agenda. We define cancer survivorship’            format of the biannual workshop events such as the ex-
broadly to be inclusive of the many ongoing physical, so-      amples below:
cial and psychological needs of people who were living            Recommendation: Protocols should be developed to
with cancer and those who survived [24]. At the time,          seek consent from patients for the donation of tissue
we were unsure whether patients and their families             samples.
would be willing to travel to the university and openly           Workshop 2: ‘Creating the Roadmap’ – initial devel-
discuss their thoughts and concerns. We were again very        opment of survey to see if patients after a cancer diagno-
pleased by the positive response. More than 100 patients       sis would be interested in becoming involved in
and their families participated and discussed questions        research.
Shé et al. Research Involvement and Engagement   (2021) 7:63                                                     Page 5 of 15

  Recommendation: Ensure patients are aware of all              the table. This grouping comprised patients (n = 7), pa-
relevant clinical trials ongoing.                               tient advocates (n = 2), researchers (n = 6), allied health-
  Workshop 3: ‘Is there a Clinical Trial for Me’ ex-            care (n = 1) and professional staff (n = 2). A small
plained what clinical trials are, the different types of tri-   number of specified-purpose three-person subcommit-
als, how to find out about them and who do you ask.             tees were established to address areas of communication,
  Recommendation: Better information on cancer                  information governance and network development. Each
should be provided to the public.                               sub-committee has at least one patient involved as well
  Workshop 4: ‘Fund my Research and Know my DNA’                as a member of the management committee to provide
- demystifying how research is funded, explaining how           administrative support. The subcommittee lead provides
new technologies inform clinical decision making.               progress updates to the steering committee at their
  Workshop 5: Cancer laboratory tours coinciding with           quarterly meetings. Tom notes his experience of contrib-
the launch of a new UCD Centre in Translational On-             uting as a patient representative:
cology. This event gave participants an insight to re-
search in action – an opportunity to hear about ongoing           I get great satisfaction from contributing to some-
research directly from cancer researchers at their labora-        thing that I feel is adding to improvement in either
tory benches.                                                     the public perception of cancer treatment or science.
                                                                  In the Patient Voice meetings, you get that personal
Stage 2: establishing governance structures and funding           satisfaction. It’s nice going back and seeing the same
to enable research prioritisation                                 people and hearing how they are getting on in UCD
By 2019, there was growing interest in the PVCR initia-           or at home. It’s a two-way dialogue. I think you have
tive with participants returning to events and promoting          to enjoy it. You have to feel that your opinions are
workshop events through their respective networks.                helping. I wouldn’t say that I know everything, but
There was also growing awareness of public and patient            when I have an opinion, it goes into a pot. From that
involvement (PPI) among the research community, pri-              pot, policies appear and you feel you have contrib-
marily sparked by the efforts of the Health Research              uted. It works very well.
Board (Ireland) in particular [4, 6, 7, 8]. The steering
committee of patients (n = 11), patient advocates (n = 2),        With PPI becoming an emerging area in Ireland, there
researchers (n = 20), allied healthcare (n = 4) and profes-     was not an established framework within which aca-
sional staff (n = 5) now stood at 42 people, which was          demic institutions could easily involve patients in re-
becoming unwieldy in relation to decision-making. From          search [6, 8]. This led to us encountering a variety of
a UCD Conway Institute perspective, supporting the              stumbling blocks from on-campus parking restrictions
PVCR without a ring-fenced, dedicated budget was be-            and regulations (costs, wayfinding, difficulty parking in
coming increasingly more difficult. Initially we received       proximity to event location); determining and processing
seed funding from the Mater Misericordiae University            expenses incurred by patients for travel and caring re-
Hospital (MMUH) and were approached by the Irish                sponsibilities; and ethical and data sharing requirements.
Cancer Society (ICS) to discuss the possibility of submit-      A number of third-level institutions in Ireland received
ting a funding proposal. This would potentially place the       funding from the Health Research Board (PPI Ignite) to
PVCR initiative on a more formal footing in relation to         establish frameworks that would enable PPI. We were
governance and advance the establishment of a national          fortunate to be able to work with UCD colleagues
network of patients and researchers involved in the ini-        funded through HRB PPI Ignite to address these stum-
tiative for the first time across the island of Ireland.        bling blocks and create policies and procedures with
   In April 2019, the ICS announced the success of our          University College Dublin (UCD) to deal with them in
funding application, which enabled us to recruit a dedi-        future [6].
cated part-time resource for PVCR (Dr Barbara Hughes),            The UCD Conway Institute received funding from the
and begin planning for three events to establish a na-          Wellcome Trust to support capacity and development of
tional network. We established policies and procedures          public and patient involvement. We requested and were
around governance during this 12-month period. At the           granted some of this funding to help address our own
heart of PVCR governance is a commitment to a shared            skills and knowledge gap in the area of PPI by working
journey by patients and researchers with open discussion        with Derek Stewart and Bec Hanley (UK PPI experts).
and joint decision-making. This articulated purpose             They designed and delivered a 2-day ‘train the trainer’
helped us define the terms of reference for a new PVCR          workshop in August 2018 on introducing the concepts
steering group (Appendix II). We rationalised member-           of PPI to researchers. We subsequently developed and
ship to a smaller, more agile group of 18 representatives;      delivered half-day introductory PPI training for re-
each invited for the purpose of bringing diverse voices to      searchers at different career stages (PhD, postdoctoral);
Shé et al. Research Involvement and Engagement   (2021) 7:63                                                   Page 6 of 15

the latter in conjunction with the UCD PPI Ignite coord-       compliant with data protection regulations. They are
inator. In addition to delivery for UCD-based re-              currently being reviewed by the Irish Data Protection
searchers, training was delivered to Irish Cancer Society      Commissioner.
funded PhD students and postdoctoral fellows on an
international training and career development fellowship       Stage 3: governance and shared decision-making
programme funded by Marie Sklodowska-Curie                     Toward the end of 2019, we began a discussion with the
COFUND Action (UCD TOPMed10). An important as-                 National Cancer Research Institute (UK) to co-host an
pect of these training workshops were contributions by         event based on the successful Dragons’ Den concept that
patients of their experience of involvement in the PVCR.       NCRI (UK) initiated and frequently use through their
We delivered communication workshops where patients            NCRI Consumer Forum [27]. At this point, there was a
and researchers would team up or ‘buddy up’ to develop         formal process in place for researchers or other organi-
plain English abstracts and engaging presentations de-         sations to submit a proposal outlining their idea for a
scribing research projects for patient and public audi-        patient event and how this might benefit attending pa-
ences. This format was used for PhD students preparing         tients, researchers and the wider patient network. The
for the 2019 UCD Conway Festival of Research and               PVCR steering committee were very strongly in favour
Innovation as well as the Professor Patrick G. Johnston        of the Dragons’ Den concept as it would bring the em-
Irish Association for Cancer Research (IACR) Award for         phasis of the workshop event back to the core premise
Excellence in Cancer Research Outreach (2019, 2020,            of facilitating discussion between patients and re-
2021).                                                         searchers about cancer research projects.
  The development of a brand and marketing collateral             The event date (25th February 2020) with a location
for the PVCR added to the sense of belonging and pride         in Galway, Ireland was chosen to immediately precede
that was inherent to the group’s success. Mary, a patient      the 56th Annual Conference of the Irish Association
representative who deals with graphic design companies         for Cancer Research (IACR), an All-Ireland, non-
in her professional life, secured services from a company      profit organisation for cancer researchers across all
on a pro-bono basis.                                           disciplines that aims to advance cancer research
                                                               across the island. Fifteen research groups from
  We eventually came up with a really vibrant iden-            around Ireland submitted proposals to participate in
  tity. We looked at hundreds of words that epitomised         the event. These researchers were keen to get input
  the group and whittled these down to about eight,            from those with a lived experience of cancer (our
  which form part of what the Patient Voice in Cancer          friendly Dragons) on specific questions or challenges
  Research is all about. They are the ones that are epi-       that they are faced with in cancer research projects.
  tomised in the identity. We are really happy with it         A sub-group of the PVCR steering committee short-
  now; it looks bright and inviting.                           listed ten projects for the event with an agreement to
                                                               proceed with the other five projects at a later point.
  In this stage of the initiative, there was an increased      Feedback was collected from both the Friendly
focus on collaborative approaches to setting and ad-           Dragons (patient representatives) and researchers im-
vancing research objectives. This led us to partner            mediately following the event (via paper and online
with organisations/networks such as the National               forms). In addition, to preliminary feedback, re-
Cancer Registry of Ireland (NCRI) and the National             searchers were also required to complete a 6-month
Biobanking Working Group (NBWG) to bring the                   post-event update, with the aim of capturing the im-
voices of patients to discussions and decision-making          pact of the PVCR/NCRI (UK) Dragons Den session.
processes relevant to cancer research. The PVCR                   Overall, the experience of both the Friendly Dragons
steering committee was keen to take full advantage of          and researchers was extremely positive and demon-
such opportunities as they arose. The facilitated work-        strated that facilitating Public and Patient Involvement
shop with the National Cancer Registry of Ireland              (PPI) in this format, led to productive and meaningful
allowed patients to input to the design of a proposed          discussion. Indeed, 96% of Friendly Dragons ‘agreed’ or
national patient experience survey for 9000 cancer pa-         ‘strongly agreed’ that their comments were listened to,
tients with a resulting report and National Cancer             and taken on board by the researchers; and felt that the
Registry of Ireland policy response paper [25, 26].            feedback provided would make a positive difference to
The facilitated workshop with the NBWG provided                the project.
patient feedback on the design of a standardised pa-
tient information leaflet and separate consent form to           “A great platform for patients to feel their voice mat-
streamline participation in health research biobanks.            ters. These inputs and experiences will hugely benefit
These documents must be clear and easy while also                other patients”.
Shé et al. Research Involvement and Engagement   (2021) 7:63                                                    Page 7 of 15

  “It felt very empowering to be part of the discussion        What have we learnt?
  and have a voice”.                                           Since the beginning of the PVCR initiative, feedback
                                                               from patients has been central to our learning. Taking
  Similarly, the research teams that took part in the ses-     time as a group to reflect after each event, and capture
sion regarded the Friendly Dragons feedback as ‘very’ or       our collective experiences is crucial. As we chronicled
‘extremely’ useful. This was further supported by the          our journey here, a few clear lessons should be noted.
range of associated benefits and impacts reported by the
researchers 6-months post-event.                               Adapting to digital engagement
  For the majority, the feedback directly informed spe-        The COVID-19 pandemic has brought changes to the
cific changes to their research project.                       way the PVCR operates. PVCR steering committee
                                                               meetings are now held virtually on the Zoom plat-
  “We have modified our patient involvement plan               form. We have found that connecting virtually has
  as a result of feedback from the Dragons…I have              allowed people to be involved from the comfort of
  found the discussion hugely beneficial to our                their homes, saving time, expense and the inconveni-
  research”.                                                   ence of travelling long distances. We have also held
                                                               four virtual Dragons Den events; each with a research
                                                               group, patients from the steering committee and
  “The Dragons Den was highly influential in my                those who have been involved in our events previ-
  work…the event led to an overhaul of my Interview            ously and the PVCR administrative team facilitating
  Topic guide”.                                                proceedings.

   Even when changes were not required, researchers still      Ensure an ongoing feedback loop and make changes
reported benefitting from validation of their assumptions      Feedback to all workshop attendees is crucial. It closes
or approach, which led to increased confidence and mo-         the circle and is a tangible acknowledgement of the
tivation for the project.                                      unique contributions that each attendee has made. Feed-
                                                               back enables all contributors to know how much their
  “After talking to the [Friendly Dragons] I realised the      unique input was valued, listened to and taken on board.
  true impact that this device can have. It was very             Participants were always very appreciative and enjoyed
  helpful for the motivation of our research team”.            the informative and social aspects of the workshops we
                                                               facilitated. However, quite rightly, it was noted by some
  For others, the feedback informed a redirection in           that while there was a great buzz around the workshops,
thinking, and an important reminder that what is               people left them feeling; “yes, that was interesting”, or
deemed a priority by a researcher or clinician, may            “that was well worth giving my time up for” but there
not always be a priority for the patient. Conse-               was no immediate action taken or follow through. We
quently, this stresses the importance of involving pa-         refined this and provided summary feedback for
tient representatives at all stages of the research            sessions.
process to ensure the outputs are both meaningful                Feedback was also instrumental in guiding us on the
and relevant.                                                  timing of our events. Initially, our workshops would have
                                                               started at 9 am. This made it difficult for attendees to
  “Previously we had spoken to surgeons and oncolo-            reach us without an overnight stay. Moreover, depend-
  gists, but the patients’ perspectives were very              ing on a person’s current health and medication regime,
  different”.                                                  starting later in the day is more feasible. We changed
                                                               the start times of events to commence after 10 am and
                                                               finish in the early afternoon to enable more patient rep-
  “I always thought I was thinking about the patient           resentatives to attend. Technological responses to deal
  perspective, but doing the Dragons Den I found out           with COVID-19 pandemic restrictions has advanced the
  what the patient perspective actually was”.                  option of digital engagement. This is something we will
                                                               continue with in the future and undertake more hybrid/
  The PVCR/NCRI Dragons Den event empowered both               blended events.
patient representatives and researchers and demon-
strated that anyone with a lived experience of cancer can      It takes time to build relationships and trust
contribute to research when given the appropriate plat-        We knew that there was a genuine need and enthusi-
form and support to do so.                                     asm from PPI partners and researchers to continue
Shé et al. Research Involvement and Engagement   (2021) 7:63                                                 Page 8 of 15

the dialogue that had commenced in our tours of the            uniquely identify how this research could be tailored to
cancer research laboratories in 2016 at UCD. We                improve outcomes. As time went on and due to the
wanted to continue that dialogue. This was a new               non-prescriptive nature of the agenda, we, as a group,
and uncharted environment for all of us, with many             developed a relationship with the concept of PVCR and
of us meeting for the very first time and therefore by         worked hard on our identity and structure; describing
default at the start of building up a relationship. Like       what defined us and how we would describe ourselves to
all relationships, it could only continue with trust and       others who were interested in our intent. This could
respect, on an equal footing for all; starting with get-       never have happened if at the very outset we already had
ting to know each other and having the sense that              a governance structure laid down. Our governance and
this was for the long haul and not just a one-off ef-          mission statement came together in 2019, 3 years later
fort. Honesty was crucial. There was some naivety at           when clarity and purpose had been chiselled and honed
the start of this initiative and that was openly ac-           into a vision equally shared by all in PVCR. A decision
knowledged. It made us want to support each other              had to be made to tailor our committee to be, as far as
and move the project forward and help in its develop-          possible, a truly composite committee that could reflect
ment and formation.                                            the voices of patients as broadly as possible. One could
  It should be noted that it took PVCR a considerable          say it was a co-designed governance which needed time
amount of time to work out what we were going to be            to get right.
able to accomplish. It is testament to our PPI partners
that their loyalty and commitment to PVCR gave so              Parking, accessibility and logistics
much support here. Experiences with cancer are so              University College Dublin (UCD), is a vast campus,
broad and unique. We began with an open call for inter-        and parking and accessibility are a huge challenge, es-
ested parties to join PVCR.                                    pecially when hosting large patient events. Due to
                                                               parking limitations, attendees who had in some cases
Support education and develop a shared language for            taken annual leave or planned a half day, gave up try-
understanding                                                  ing to find parking and left campus in frustration.
Listening is critical to facilitate shared language and un-    We worked with Estate Services in UCD, to allocate
derstanding. At the beginning, there was time allotted         some carpark spaces for our external attendees. We
for listening, sharing individual stories and building a       ensured that these spaces were very close to our
trustworthy relationship. When the PVCR committee              events to ensure accessibility. For our larger events,
first met, the cancer researchers at the table gave their      PVCR ambassadors/volunteers would line the path to
name, said who they were, and shared their cancer re-          where the event was taking place and sometimes stra-
search focus with the group. For our patients, they gave       tegically positioned signage and/or balloons, were
their name and the type of cancer they had. For a long         used to assist in this.
time, we did not know the occupations of our patients            Accessibility access was always detailed clearly ahead
and did not ask. On reflection, this was good as cancer        of our events. Initially, we had not appreciated how im-
may have determined that they might not be able to             portant having a quiet room was. An attendee at an early
work in their respective occupational fields again. They       event became unwell and needed a space to breathe,
were sharing with us the information that they would           compose themselves and talk with someone as needed.
like us to know and in the early stages this was with          There are emotions and circumstances that are unique
people that they had never met before, whether it be re-       to everyone that may be inadvertently triggered, that one
searchers or other patients. The shared language there-        can never prepare for in advance. A quiet room, a space
fore was a shared understanding that there was a mutual        to move away and a person to talk with were all made
interest, a sense of a new journey and a sense of really       available at subsequent events.
facilitating communication but listening carefully
throughout.                                                    Celebrating success
                                                               Feedback to our workshop attendees, with details on
Getting the governance right                                   how the workshop has contributed to a questionnaire, to
PVCR started with no structure or governance to speak          a policy document that will impact on cancer care, or to
of. This we found in hindsight was fortuitous as it en-        a cancer researcher’s grant application/public and pa-
abled our PPI partners could shape it from the start. We       tient involvement section, is a tangible way of celebrat-
had no idea what we were doing at the beginning with           ing success. Seeing patients who were with us from the
the crucial exception that we knew the absolute import-        very start of the PVCR journey become facilitators,
ance and immense impact of bringing researchers and            scribers, and co-applicants on grant applications is won-
patients together to discuss cancer research and to            derful and something to acknowledge and celebrate.
Shé et al. Research Involvement and Engagement   (2021) 7:63                                                    Page 9 of 15

During COVID-19, our zoom meetings deal with the               Moving the dial to ‘engaged research’
business in hand and then we always share a virtual tea,       The single biggest barrier or fear expressed by both pa-
coffee and social chat for up to an hour after the com-        tients and researchers in this PVCR journey is that the
mittee meeting; our token “Green Room”. In relation to         process of involving patients in research would be
payment for our partners, at a minimum, all out of             viewed as tokenistic. As patients and researchers work
pocket expenses should be covered for members of the           together in partnership during the research lifecycle, it is
public or patients to facilitate their involvement in re-      clear that involving those who stand to gain most from
search. There is no recommended set payment rate but           research outcomes is hugely beneficial. Patient represen-
depends on the project, funding available and the indi-        tatives describe the potential impact of this type of en-
vidual circumstances of the involvement. We use a guid-        gaged research:
ance document on public and patient involvement /
public engagement costings developed by the PPI Ignite           “I don’t think the patient should take over. It is im-
UCD team. The costings are benchmarked against those             portant to be involved in steering a project though.
used by the National Women’s Council of Ireland and              The researchers need to hear the patient experience
the Disability Federation of Ireland.                            to know which direction to go in. With the chemo-
                                                                 therapy I had, all my hair fell out which wasn’t a
Developing links across Conway, UCD and externally               big deal for me or for most guys I’ve talked to. But
There has been incredible support from the University,           hair loss is a huge deal for most women. So, if a re-
with the caveat that everyone is working voluntarily for         searcher is dealing with testicular cancer, focusing
PVCR. External funding from the Mater Foundation in              on a side effect other than hair loss would be more
the Mater Misericordiae University Hospital (MMUH)               beneficial. I think that’s where the patient voice
(2018–2019) and the Irish Cancer Society (ICS) (2019–            comes in. Even if you’re only getting a fraction of the
2020) allowed a significant possibility to bring PVCR out        population’s experience, it’s still very helpful.”
of Dublin and into the rest of the island of Ireland. This       (Ramon).
funding was instrumental. We developed links with
other areas of research in the UCD Conway Institute, to
share our learning, and established a patient voice learn-       “Prior to my involvement, I thought researchers were
ing network within the UCD Public and Patient Involve-           in a glass bubble, that they were very special and
ment Ignite programme.                                           that they did things that nobody questioned. Now, I
                                                                 have learned that they are out there, craving infor-
The ‘patient voice’ is important in the research process         mation from patients. They want to know “What ef-
The PVCR initiative grew from an instinctive belief by           fect does this have?”, “How does this affect you?”,
researchers and research support professionals that fa-          “What do you feel and think about this?” They need
cilitating dialogue with patients could positively impact        all of that to feed back into their work so that there
on the research process. Now, 5 years on, patients them-         is that subjective slant to their research. I never knew
selves are fully affirming the importance of having their        that was there.” (Mary).
voice heard as part of the research process. Patient rep-
resentatives, Mary and Tom give their perspective:
                                                                 “I have been involved in one or two projects with re-
  “For a long time during my illness, I didn’t even feel         searchers where we help them translate their grant
  that I had a voice because I was very ill and weak. I          application into layman terms. That was the thing I
  have heard researchers come along and talk about               felt I could help most with. I can’t help with the sci-
  what they are trying to achieve and you know, they             ence of it, but I can help them restate what their ob-
  really need patients to talk to them and share their           jective is in layman’s terms. I am an accountant by
  experiences and that has been a real eye opener.               trade. I know that accountants talk in accounting
  “(Mary).                                                       terms. The same is true in science and medicine. In
                                                                 a lot of cases, I felt I was able to help the researchers
                                                                 to get the right terminology. Sometimes you can
  “At 72, I know a lot more about life and diseases              throw too much information at somebody and it
  and how different events impact on your life than I            loses its relevance.” (Tom).
  did at 20. A lot of the researchers I have met are
  very intelligent and very young. They might not have         Conclusion
  the perspective or experience that a patient or sur-         At the core of PVCR is a focus on building long-term
  vivor does.” (Tom).                                          reciprocal relationships between patients and
Shé et al. Research Involvement and Engagement                 (2021) 7:63                                                                         Page 10 of 15

researchers. In this endeavour, it is crucial to improve                         Appendix I [Patient Representative Feedback] (Continued)
the reporting of public and patient involvement in re-
search [28] (Table 2 in Appendix III). We have devel-                            Table                                          No. feedback forms received
oped over time an inclusive initiative that is built on                          7                                              8
trust and respect for everyone’s contributions whether                           8                                              6
they be positive or negative. This work is grounded                              9                                              4
in collegiality, and a good sense of humour and                                  10                                             4
friendship undoubtedly helps. The ongoing develop-
ment of PVCR is time-consuming and does require
                                                                                   Question 3. 1. I was clear about what the DD
investment and flexibility. The benefits of undertaking
                                                                                 session was before the event.
this work cannot be ignored as we enhance cancer re-
search across Ireland.
                                                                                 Preference                                         No.                        %
                                                                                 Strongly agree                                     18                         34.1
Appendix I [Patient Representative Feedback]
PVCR/NCRI (UK) Dragons’ Den Summary Report.                                      Agree                                              24                         45.3
  PVCR/NCRI (UK) Dragons’ Den Tuesday, 25th                                      Neither agree/disagree                             5                          9.4
February 2020 Galway Bay Hotel.                                                  Disagree                                           4                          7.5
  Gender distribution of respondents.                                            Strongly disagree                                  2                          3.7
                                                                                 Note: In one case, the participant responded to all questions with ‘strongly
Male                  Female                 Not stated                  Total   disagree’ but all associated feedback was very positive. It has been recorded as
                                                                                 indicated by the participant in Q3.2, 3.3, 3.4 and Q5.1, 5.2
15                    23                     15                          53
28.3%                 43.4%                  28.3%                       100%
                                                                                      Question 3. 2. The venue for the DD was suitable.

     Question 1. How did you hear about the DD?                                  Preference                                         No.                        %
                                                                                 Strongly agree                                     35                         67.3
How                                                       How many times?        Agree                                              14                         27
Word of mouth                                             10                     Neither agree/disagree                             1                          1.9
No response                                               8                      Disagree                                           1                          1.9
Online/social media                                       7                      Strongly disagree                                  1                          1.9
Advocate/support group                                    6                      No answer                                          1                          0
PVCR                                                      5
TV/Nationwide                                             4                       Question 3. 3. The number of friendly dragons at
IACR                                                      3                      my table was suitable.
NUIG                                                      3
                                                                                 Preference                                         No.                        %
Email                                                     3
                                                                                 Strongly agree                                     32                         61.5
Healthcare professionals                                  2
                                                                                 Agree                                              17                         32.7
HRB                                                       2
                                                                                 Neither agree/disagree                             0                          0
‘Science on Screen’                                       1
                                                                                 Disagree                                           1                          1.9
Note: In some cases, participants reported more than one method of hearing
about the event and all have been recorded separately                            Strongly disagree                                  2                          3.8
                                                                                 No answer                                          1                          0
     Question 2. Indicate your Dragons Den table.
                                                                                      Question 3. 4. The session length was suitable.
Table                                        No. feedback forms received
1                                            7                                   Preference                                         No.                        %
2                                            5                                   Strongly agree                                     19                         36.5
3                                            6                                   Agree                                              22                         42.3
4                                            4                                   Neither agree/disagree                             3                          5.7
5                                            3                                   Disagree                                           7                          13.5
6                                            6                                   Strongly disagree                                  1                          1.9
Shé et al. Research Involvement and Engagement            (2021) 7:63                                                                              Page 11 of 15

Appendix I [Patient Representative Feedback] (Continued)                         Appendix I [Patient Representative Feedback] (Continued)
Preference                                   No.                        %        Preference                                        No.                       %
No answer                                    1                          0        No answer                                         5                         0

 Question 3. 5. I knew who to contact if I had                                     Question 5. 2. The feedback your group
questions about the DD.                                                          provided will make a positive difference to the
Preference                                   No.                        %
Strongly agree                               30                         56.7     Preference                                        No.                       %
Agree                                        20                         37.7     Strongly agree                                    32                        63
Neither agree/disagree                       2                          3.7      Agree                                             17                        33
Disagree                                     1                          1.8      Neither agree/disagree                            1                         2
Strongly disagree                            0                          0        Disagree                                          0                         0
No answer                                    0                          0        Strongly disagree                                 1                         2
                                                                                 No answer                                         2                         0

  Q4. Additional comments/suggestions- synopsis of
recurring themes.                                                                     Question 6. Did DD meet your expectations?

Perhaps too many at table                                                        Yes                    No                    No answer                     %
Communication pre-event was great. A very wide range of voices. Real             17                      0                          6                       100
commitment to patient voice                                                      Note: Only 17 participants answered this question directly
More advertising where you host meetings coming up to event eg.
local papers, hospitals, cafes
                                                                                  Question 7. Did you feel there was enough
Would like to get more information on the other tables                           opportunity for questions and discussions?
May be an idea not to have tables but chairs around flip chart as
difficult to hear with number of groups in room. Without the table, we
                                                                                 Yes             No             No answer                % yes            % No
would be nearer to the researcher
                                                                                 27               21                  5                       56            44
More time would have been useful. It takes some time to get into the
subject and warm up
Would love follow up from research team                                            Question 8. Suggestions to improve DD – synopsis
Its good to meet other people living with cancer. Set up and venue               of key suggestions.
I love Amanda’s little bit of wit                                                Have a really simple overview of the project questions as not
Thank you for organising this wonderful event. Amazingly beneficial to           everyone pre reads info
all of us out here!                                                              More information in advance
Exceptional organisation and facilitation. There was a great tone set for        More time
the whole night
                                                                                 Specific protected time at start of session to give an overview of
Keep up the good work. During my journey I said ‘I don’t want                    research to dragons
sympathy, I want positivity’
                                                                                 Give more time for discussion
Such a lovely atmosphere in the room and the whole set up was
excellent - makes it easy and comfortable to talk about cancer                   More time and no tables, just chairs around a flipchart to hear
                                                                                 Perhaps a meet and greet with the researcher where they can
  Question 5. 1. Your comments were listened to and                              present their study/research in a more formal way before the discussion
                                                                                 (separation of the two parts slightly)
taken on board.
                                                                                 To be able to give input to the other topics - maybe a questionnaire
                                                                                 emailed. Ask which topics people would like input on and email them a
Preference                                   No.                            %    questionnaire
Strongly agree                               31                             65
                                                                                 Not sure how this could happen due to layout and different tables all
Agree                                        15                             31   talking at once but if one could hear better what is being said during
Neither agree/disagree                       1                              2
Disagree                                     0                              0
Strongly disagree                            1                              2
Shé et al. Research Involvement and Engagement             (2021) 7:63                                                    Page 12 of 15

  Question 9. Selection of best quotes summing up                               (i) Improve communication between both parties
the experience (subjective!)                                                     ensuring that cancer research is seen as a joint
                                                                                 venture to overcome the disease and improve
Fantastic opportunity to positively influence researchers’ ideas and             quality of life and overall survivorship during and
thinking                                                                         post treatment.
Good atmosphere promising positive change                                      (ii) To improve the understanding of cancer
So nice to have my voice heard                                                   research in a concise and clear message to the
If my contribution can help one person, I am happy.                              wider community.
An insightful, eye opening and thought-provoking evening                     Inform policy-makers and healthcare professionals
A great platform for patients to feel their voice matters. These inputs       of research needs that will benefit cancer patients.
and experiences will hugely benefit other sufferers                          Provide greater clarity to patients on the capture,
Very relaxed and informal. I enjoyed meeting other people                     collection, management and use of data in cancer
Empowering and creative opportunity for patient involvement                   research.
Excellent opportunity to interact with like-minded people
                                                                             2.2 The PVCR steering committee may form such and
Regardless of your association with cancer, everyone has something to
offer                                                                     as many sub-committees as it deems necessary to per-
                                                                          form its functions, and may delegate any of its functions
Excellent day - empowering patients, clinicians and researchers
                                                                          to a sub-committee. This list is not exhaustive but ini-
A step forward in democratising patient care
                                                                          tially includes: communications, information govern-
It was a brilliant event. It felt very empowering to be part of the       ance, community network and training sub-committees
discussion and have a voice
                                                                             3. Composition
Progressive, informative and providing patients with a chance to
participate in the future of cancer research                                 At a minimum, the PVCR Steering Committee will
An invaluable discussion with open minded people from a diverse
background. Excellent fun!                                                   ▪ 6 patients (balance with respect to gender, age,
                                                                          socio-economic background and cancer type)
                                                                             ▪ 1 patient advocate group representative
Appendix II                                                                  ▪ 1 representative from each registered charity
                                                                             ▪ 1 social science allied health professional (nursing,
                                                                          clinician, psycho-oncologist)
                                                                             ▪ 2 research active academics
                                                                             ▪ 2 early career researchers (up to seven years out of
                                                                          their PhD, as per ERC guidelines)
                                                                             4. Membership
Patient Voice in Cancer Research (PVCR) Steering                             4.1 The Steering Committee will consist of a minimum
Committee.                                                                of 15 and a maximum of 25 core members, with a
  Terms of Reference.                                                     quorum of 13.
  1. Mission                                                                 4.2 Membership will be for 2 years in order to allow
  The Patient Voice in Cancer Research (PVCR) Steer-                      adjustments as required.
ing Committee is responsible for an initiative to actively                   4. 3 Members are free to withdraw from the Steering
engage cancer patients, cancer researchers and other in-                  Committee at any time by contacting the Chair.
terested parties (patient advocates, families, carers,                       4. 4 The Chair will be appointed by the Steering Com-
healthcare professionals, policy-makers and those with                    mittee for a 3-year period, after which time a new Chair
an interest in cancer research) in discussions and                        or a second term of office will be discussed.
decision-making processes, which positively impact on                        4. 5 People with specific expertise or specialised know-
cancer research and outcomes for patients.                                ledge can be invited to PVCR meetings on request
  2. Functions                                                            through or by the Chair.
  2. The PVCR steering committee, will                                       4. 6 New members can be nominated by Steering
                                                                          Committee members, and must complete an application
   Build connections between patients and cancer                         form        which      is     available     by      emailing
      researchers.                                                        patientvoicecancer@ucd.ie
   Facilitate a two-way dialogue between patients and                       5. Meetings
      cancer researchers.                                                    5.1 Steering Committee meetings will be held 3–4
   Provide education and training for patients and                       times a year, usually in advance of PVCR events to facili-
      cancer researchers to:                                              tate planning.
Shé et al. Research Involvement and Engagement   (2021) 7:63                                                 Page 13 of 15

  5.2 The Steering Committee will be provided with a             This is an exploratory reflective single case study of
meeting agenda and supporting papers in good time be-          the establishment of the Patient Voice in Cancer Re-
fore the meeting. To avoid unnecessary burden, the             search (PVCR) initiative within the UCD Conway In-
paperwork will be concise.                                     stitute over four years (2016–2020). Our focus is on
  5.3 Detailed minutes and actions arising will be circu-      sharing the PVCR journey and a case study approach
lated to the Steering Committee following meeting.             allowed us to share our experience within our context
  5.4 Steering Committee members who are patients              “without control over actual behavioural events by the
will be reimbursed for travel and reasonable expenses          investigator”.
to attend PVCR meetings in accordance with the
guidance from UCD Bursar’s Office and the PPI Ig-               3. Study Results (Outcomes:- Report the results of
nite team. As a public sector body, expenses claimed               PPI in the study, including the positive and
are subject to public scrutiny by the Comptroller &                negative outcomes):-
Auditor General and through Freedom of Information
requests. It is important that all expense claims sub-           Positive.
mitted should be exemplary in terms of compliance                - UCD Conway has established a PPI programme and
with procedures, accurate, easy to review and clearly          given visibility of our research programmes to the public
justifiable. The relevant forms are available by email-        that is branded and trusted.
ing patientvoicecancer@ucd.ie                                    - Biannual workshop events (n = 8) themed according
  5. 5It is anticipated that PVCR members representing         to patient interest have been successfully hosted pre-
external agencies will claim reimbursement for travel ex-      Covid-19. During the COVID-19 pandemic, the DD
penses from their employer.                                    events have successfully moved to the virtual
  6. Reporting                                                 environment.
  The Steering Committee will report to funders, as per          -Specifically in relation to the PVCR Dragons Den
the terms and conditions of any grant received.                (DD) events, these have involved circa 150 “experts”
  7. Partners                                                  and to date 15 cancer researchers, in focused dis-
  7.1 University College Dublin (UCD) provides sup-            cussions on what researchers need expert advice on
port to the PVCR in its initial stages.7.2 Fudge Cre-          and insight on. Feedback (3 month and 6 month)
ative provides support in terms of branding and                from researchers who have requested and hosted
identity.7.3 The Irish Cancer Society approved a grant         these DD events, have been most positive of the im-
of €30,000 for one year of operation (May 2019–May             pact these unique discussions have had, on the way
2020), to be reviewed on completion.7.4 The Mater              they have re-thought certain aspects of their original
Foundation has provided a grant of €20,000 for PVCR            research plan, and howthey have incorporated new
events 2018–2020.                                              ideas from the experts. Importantly, in some cases,
                                                               these unique contacts have become team members
Appendix III                                                   in co-designing cancer research projects moving for-
GRIPP2 SHORT FORM.                                             ward. The specific outcomes of the feedback col-
   Staniszewska, S., Brett, J., Simera, I. et al. GRIPP2       lected is currently in preparation for a subsequent
reporting checklists: tools to improve reporting of pa-        publication.
tient and public involvement in research. Res Involv             -Our Governance and Terms of Reference were co-de-
Engagem 3, 13 (2017). https://doi.org/10.1186/s40900-          signed with our “Experts by Experience”.
017-0062-2                                                       -Through PVCR we have established training for in-
                                                               vestigators in PPI, and routinely deliver communication
  1. Aim (Report the aim of PPI in the study):-                workshops where patients and researchers team up to
                                                               deliver plain English Abstracts.
  To encourage and enable people affected by cancer              -PVCR has worked with organisations for example
and their families to become involved in shaping and           the National Cancer Registry of Ireland (NCRI), the
informing the future of cancer research across the island      National Biobanking Working Group (NBWG), and
of Ireland. Its aim is to identify the questions and needs     the National Cancer Research Institute (NCRI) UK,
that matter most to (i) people living with a cancer diag-      to bring the voices of patients to discussions and
nosis, and (ii) those most likely to improve the relevance     decision-making processes relevant to cancer
of cancer research.                                            research.
                                                                 -Feedback to attendees for all events is crucial and in-
  2. Methods (Provide a clear description of the               deed critical.
     methods used for PPI in the study):-                        Negative.
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