Abstract P4-02-01: Analytical validation of an automated digital scoring protocol for Ki67: International multicenter collaboration study

Background/Goal: Ki67 expression has been a valuable prognostic marker in breast cancer, but has not seen broad adoption due to lack of standardization between institutions. Automation could represent a solution. Here we tested 3 automated digital image analysis (DIA) platforms including an open source platform to: (i) Investigate the reproducibility of Ki67 measurement across platforms with supervised classifiers performed by the same operator and by multiple operators. (ii) Compare accuracy of the 3 DIA platforms against outcome (prognostic potential). (iii) Assess inter-laboratory reproducibility of a calibrated DIA tool to evaluate Ki67 in breast cancer among 10 participating labs of the International Ki67 in Breast Cancer Working Group (IKWG).

Methods: The Mib-1 antibody (Dako) was used to detect Ki67 (dilution 1:100). HALO (H) (IndicaLabs), QuantCenter (QC) (3DHistech), QuPath (QP) (open-source software) digital image analysis (DIA) platforms were used to evaluate Ki67 expression. As a ground truth, we evaluated Ki67 LI with meticulous manual tissue segmentation using the Spectrum Webscope (SW) (Aperio). Calibration was performed using 30 ER+ breast cancer cases from phase 3 of the IKWG initiative where blocks were centrally cut and stained for Ki67. The inter-laboratory analysis was done with 10 participating laboratories divided into 2 groups where members within the same group were given the same set of images. The outcome cohort consisted of 149 breast cancer cases from the Yale Pathology archives in tissue microarray format. Intra-class correlation coefficient (ICC) was used to measure reproducibility with the pre-specified criterion for success being to exceed 0.80. Kaplan-Meier analysis supported with log-rank test was performed to assess prognostic potential.

Results: All 3 DIA platforms showed excellent inter-platform reproducibility (ICC: 0.933, CI: 0.879-0.966). Also, excellent reproducibility was found between all DIA platforms and the reference standard Ki67 values of SW (QP ICC: 0.970, CI: 0.936-0.986; H ICC: 0.968, CI: 0.933-0.985; QC ICC: 0.964, CI: 0.919-0.983). The intra-DIA reproducibility was also excellent for all platforms (QP ICC: 0.992, CI: 0.986-0.996; H ICC: 0.972, CI: 0.924-0.988; QC ICC: 0.978, CI: 0.932-0.991). Comparing each DIA against outcome, the hazard ratios were similar (QP=3.309, H=3.077, QC=3.731). The inter-operator reproducibility was particularly high (ICC: 0.962-0.995). As QP is open source software and also showed the lowest intra-DIA platform variability, we selected the QP platform to investigate inter-laboratory reproducibility among 10 IKWG labs. The different-section ICC across the 10 labs was 0.974 (CI: 0.954 - 0.986). The same-section ICC estimate was 0.984 (CI: 0.971-0.992) for group 1 and 0.978 (CI: 0.956-0.989) for group 2.

Conclusions: Our results showed outstanding reproducibility both within and between DIA platforms. We also found the platforms essentially indistinguishable with respect to prediction of breast cancer patient outcome. Automated Ki67 evaluation using a calibrated, open-source DIA platform (QuPath) met the pre-specified criterion of success in the multi-institutional setting. Assessment of clinical utility is planned.

Citation Format: Acs B, Leung SC, Pelekanou V, Bai Y, Martinez-Morilla S, Toki M, Chang MC, Gholap A, Jadhav A, Hugh JC, Bigras G, Laurinavicius A, Augulis R, Levenson R, Todd A, Piper T, Virk S, van der Vegt B, Hayes DF, Dowsett M, Nielsen TO, Rimm DL. Analytical validation of an automated digital scoring protocol for Ki67: International multicenter collaboration study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-02-01.

Breast cancer screening in women with cerebral palsy: Could care delivery be improved?

BACKGROUND

Women with disabilities (WWD) have reported lower mammography rates than the general population, however rates for women with cerebral palsy (CP) have not been specifically studied.

OBJECTIVE

To evaluate mammography rates in women with CP and to identify strengths and barriers with their screening experience.

METHODS

Women with CP 40 years or older (n = 118) participating in a prospective cross-sectional survey were queried regarding screening status, imaging modality, and accommodation needs and availability. Categorical variables were summarized and Chi-square testing used to assess factors contributing to screening compliance. The effect of functional factors on screening was evaluated using logistic regression.

RESULTS

77 women (65.3%) had mammograms within the past two years; 56 (47.5%) were screening mammograms. Severity of fine motor deficits was associated with lack of screening (OR 0.559, p = 0.019). 85 (72.0%) experienced positive staff attitudes. Facilities most often met needs for ramps, elevators, and/or wide doorways (92.9%), exam explanations (84.4%), and accessible parking (82.5%). Needs least often met included accommodations for standing (59.3%) or for difficulties with arm/shoulder positioning (57.1%), and wheelchair-accessible mammogram machines (59.1%).

CONCLUSIONS

The screening compliance rate for women with CP is low, although the 2-year mammography rate is comparable to that reported for WWD and the general female U.S.

POPULATION

Women were usually offered respectful care. Adequate physical accommodations during the procedure were reported less often than overall facility environmental accommodations. These findings demonstrate the need for improved screening rates in women with CP, and highlight areas for improving their screening experience.

A systematic review and thematic synthesis of patients' experience of medicines adherence

BACKGROUND

Medicines non-adherence continues to be problematic in health care practice. After decades of research, few interventions have a robust evidence-based demonstrating their applicability to improve adherence. Phenomenology has a place within the health care research environment.

OBJECTIVE

To explore patients' lived experiences of medicines adherence reported in the phenomenonologic literature.

METHODS

A systematic literature search was conducted to identify peer-reviewed and published phenomenological investigations in adults that aimed to investigate patients' lived experiences of medicines adherence. Studies were appraised using the Critical Appraisal Skills Programme (CASP) Qualitative Research Tool. Thematic synthesis was conducted using a combination of manual coding and NVivo10 [QSR International, Melbourne] coding to aid data management.

RESULTS

Descriptive themes identified included i) dislike for medicines, ii) survival, iii) perceived need, including a) symptoms and side-effects and b) cost, and iv) routine. Analytic themes identified were i) identity and ii) interaction.

CONCLUSIONS

This work describes adherence as a social interaction between the identity of patients and medicines, mediated by interaction with family, friends, health care professionals, the media and the medicine, itself. Health care professionals and policy makers should seek to re-locate adherence as a social phenomenon, directing the development of interventions to exploit patient interaction with wider society, such that patients 'get to know' their medicines, and how they can be taken, throughout the life of the patient and the prescription.

A Team Approach to Enhance Scholarship Among Honors Students in Nursing

Honors programs within schools of nursing have the potential to enhance young nurses' interest in developing programs of research early in their careers and can thus contribute to the successful development of nursing knowledge. Such programs also provide opportunities to enhance knowledge and skill in leadership and teamwork at a critical time during the development of their professional nurse identity. This article presents the successful approach one organization took when revising its honors program to meet the current needs of students, society, and the profession.

Use and attitudes of obstetricians toward 3 high-risk interventions in MFMU Network hospitals

OBJECTIVE

We sought to evaluate the frequency of, and factors associated with, the use of 3 evidence-based interventions: antenatal corticosteroids for fetal lung maturity, progesterone for prevention of recurrent preterm birth, and magnesium sulfate for fetal neuroprotection.

STUDY DESIGN

A self-administered survey was conducted from January through May 2011 among obstetricians from 21 hospitals that included 30 questions regarding their knowledge, attitudes, and practice of the 3 evidence-based interventions and the 14-item short version of the Team Climate for Innovation survey. Frequency of use of each intervention was ascertained from an obstetrical cohort of women between January 2010 and February 2011.

RESULTS

A total of 329 obstetricians (74% response rate) who managed 16,946 deliveries within the obstetrical cohort participated in the survey. More than 90% of obstetricians reported that they incorporated each intervention into routine practice. Actual frequency of administration in women eligible for the treatments was 93% for corticosteroids, 39% for progesterone, and 71% for magnesium sulfate. Provider satisfaction with quality of treatment evidence was 97% for corticosteroids, 82% for progesterone, and 57% for magnesium sulfate. Obstetricians perceived that barriers to treatment were most frequent for progesterone (76%), 30% for magnesium sulfate, and 17% for corticosteroids. Progesterone use was more frequent among patients whose provider reported the quality of the evidence was above average to excellent compared with poor to average (42% vs 25%, respectively; P < .001), and they were satisfied with their knowledge of the intervention (41% vs 28%; P = .02), and was less common among patients whose provider reported barriers to hospital or pharmacy drug delivery (31% vs 42%; P = .01). Corticosteroid administration was more common among patients who delivered at hospitals with 24 hours a day-7 days a week maternal-fetal medicine specialist coverage (93% vs 84%; P = .046), CONCLUSION: Obstetricians in Maternal-Fetal Medicine Units Network hospitals frequently use these evidence-based interventions; however, progesterone use was found to be related to their assessment of evidence quality. Neither progesterone nor the other interventions were associated with overall climate of innovation within a hospital as measured by the Team Climate for Innovation. National Institutes of Health Consensus Conference Statements may also have an impact on use; there is such a statement for antenatal corticosteroids but not for progesterone for preterm prevention or magnesium sulfate for fetal neuroprotection.

Mixed methods feasibility study for a trial of blood pressure telemonitoring for people who have had stroke/transient ischaemic attack (TIA)

Background

Good blood pressure (BP) control reduces the risk of recurrence of stroke/transient ischaemic attack (TIA). Although there is strong evidence that BP telemonitoring helps achieve good control, none of the major trials have considered the effectiveness in stroke/TIA survivors. We therefore conducted a feasibility study for a trial of BP telemonitoring for stroke/TIA survivors with uncontrolled BP in primary care.

Method

Phase 1 was a pilot trial involving 55 patients stratified by stroke/TIA randomised 3:1 to BP telemonitoring for 6 months or usual care. Phase 2 was a qualitative evaluation and comprised semi-structured interviews with 16 trial participants who received telemonitoring and 3 focus groups with 23 members of stroke support groups and 7 carers.

Results

Overall, 125 patients (60 stroke patients, 65 TIA patients) were approached and 55 (44%) patients were randomised including 27 stroke patients and 28 TIA patients. Fifty-two participants (95%) attended the 6-month follow-up appointment, but one declined the second daytime ambulatory blood pressure monitoring (ABPM) measurement resulting in a 93% completion rate for ABPM − the proposed primary outcome measure for a full trial. Adherence to telemonitoring was good; of the 40 participants who were telemonitoring, 38 continued to provide readings throughout the 6 months. There was a mean reduction of 10.1 mmHg in systolic ABPM in the telemonitoring group compared with 3.8 mmHg in the control group, which suggested the potential for a substantial effect from telemonitoring. Our qualitative analysis found that many stroke patients were concerned about their BP and telemonitoring increased their engagement, was easy, convenient and reassuring.

Conclusions

A full-scale trial is feasible, likely to recruit well and have good rates of compliance and follow-up.

Trial Registration

ISRCTN61528726 15/12/2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0628-y) contains supplementary material, which is available to authorized users.

Telemonitoring for chronic obstructive pulmonary disease: a cost and cost-utility analysis of a randomised controlled trial

We compared the costs and cost-effectiveness of telemonitoring vs usual care for patients with chronic obstructive pulmonary disease (COPD). A total of 256 patients were randomised to either telemonitoring or usual care. In the telemonitoring arm, the touch-screen telemonitoring equipment transmitted data to clinical teams monitoring the patients. Total healthcare costs were estimated over a 12-month period from a National Health Service perspective and quality adjusted life year (QALYs) were estimated by the EQ-5D tool. Telemonitoring was not significantly more costly than usual care (mean difference per patient £2065.90 ( P < 0.18). The increased costs were predominantly due to telemonitoring service costs and non-significantly higher secondary care costs. Telemonitoring for COPD was not cost-effective at a base case of £137,277 per QALY with only 15% probability of being cost-effective at the usual threshold of £30,000 per QALY. Although there was some statistical and methodological uncertainty in the measures used, telemonitoring was not cost-effective in the sensitivity analyses performed. It seems unlikely that a telemonitoring service of the kind that was trialled would be cost-effective in providing care for people with COPD.

Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for exacerbation of chronic obstructive pulmonary disease: researcher blind, multicentre, randomised controlled trial

OBJECTIVE

To test the effectiveness of telemonitoring integrated into existing clinical services such that intervention and control groups have access to the same clinical care.

DESIGN

Researcher blind, multicentre, randomised controlled trial.

SETTING

UK primary care (Lothian, Scotland).

PARTICIPANTS

Adults with at least one admission for chronic obstructive pulmonary disease (COPD) in the year before randomisation. We excluded people who had other significant lung disease, who were unable to provide informed consent or complete the study, or who had other significant social or clinical problems.

INTERVENTIONS

Participants were recruited between 21 May 2009 and 28 March 2011, and centrally randomised to receive telemonitoring or conventional self monitoring. Using a touch screen, telemonitoring participants recorded a daily questionnaire about symptoms and treatment use, and monitored oxygen saturation using linked instruments. Algorithms, based on the symptom score, generated alerts if readings were omitted or breached thresholds. Both groups received similar care from existing clinical services.

MAIN OUTCOME MEASURES

The primary outcome was time to hospital admission due to COPD exacerbation up to one year after randomisation. Other outcomes included number and duration of admissions, and validated questionnaire assessments of health related quality of life (using St George's respiratory questionnaire (SGRQ)), anxiety or depression (or both), self efficacy, knowledge, and adherence to treatment. Analysis was intention to treat.

RESULTS

Of 256 patients completing the study, 128 patients were randomised to telemonitoring and 128 to usual care; baseline characteristics of each group were similar. The number of days to admission did not differ significantly between groups (adjusted hazard ratio 0.98, 95% confidence interval 0.66 to 1.44). Over one year, the mean number of COPD admissions was similar in both groups (telemonitoring 1.2 admissions per person (standard deviation 1.9) v control 1.1 (1.6); P=0.59). Mean duration of COPD admissions over one year was also similar between groups (9.5 days per person (standard deviation 19.1) v 8.8 days (15.9); P=0.88). The intervention had no significant effect on SGRQ scores between groups (68.2 (standard deviation 16.3) v 67.3 (17.3); adjusted mean difference 1.39 (95% confidence interval -1.57 to 4.35)), or on other questionnaire outcomes. Conclusions In participants with a history of admission for exacerbations of COPD, telemonitoring was not effective in postponing admissions and did not improve quality of life. The positive effect of telemonitoring seen in previous trials could be due to enhancement of the underpinning clinical service rather than the telemonitoring communication.

TRIAL REGISTRATION

ISRCTN96634935.

FUNDING

The trial was funded by an NHS applied research programme grant from the Chief Scientist Office of the Scottish government (ARPG/07/03). The funder had no role in study design and the collection, analysis, and interpretation of data and the writing of the article and the decision to submit it for publication. NHS Lothian supported the telemonitoring service and the clinical services.

Performance of two Aspergillus IgG EIA assays compared with the precipitin test in chronic and allergic aspergillosis

Detection of Aspergillus IgG antibodies is important in the diagnosis of chronic pulmonary aspergillosis and allergic bronchopulmonary aspergillosis. Immunoprecipitation techniques to detect these antibodies appear to lack sensitivity and accurate quantitation compared with enzyme immunoassays (EIA). This study assessed the performance of two commercial EIAs compared with counterimmunoelectrophoresis (CIE). This was a prospective cohort study of 175 adult patients with chronic or allergic pulmonary aspergillosis. Aspergillus IgG antibodies were detected using CIE, Phadia ImmunoCap Aspergillus IgG and Bio-Rad Platelia Aspergillus IgG. Inter-assay reproducibility was determined for each method and 25 patients had two serum samples analysed within a 6-month interval. When compared with CIE, both ImmunoCap and Platelia Aspergillus IgG had good sensitivity (97 and 93%, respectively) for detection of Aspergillus IgG antibodies. The level of agreement between the two EIAs for positive results was good, but the concentration of antibodies was not correlated between the tests or with CIE titre. ImmunoCap IgG inter-assay coefficient of variation was 5%, whereas Platelia IgG was 33%. Median ImmunoCap IgG values for CPA and allergic aspergillosis were 95 and 32 mg/L, respectively, whereas Platelia IgG values were >80 and 6 AU/mL. The direction of CIE titre change over 6 months was mirrored by ImmunoCap IgG levels in 92% of patients, and by Platelia IgG in 72% of patients. Both ImmunoCap and Platelia Aspergillus IgG EIAs are sensitive measures of Aspergillus IgG antibodies compared with CIE. However, ImmunoCap appears to have better reproducibility and may be more suitable for monitoring patient disease.