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Kolovos A, Hassall MM, Siggs OM, Souzeau E, Craig JE. Polygenic Risk Scores Driving Clinical Change in Glaucoma. Annu Rev Genomics Hum Genet 2024; 25:287-308. [PMID: 38599222 DOI: 10.1146/annurev-genom-121222-105817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Glaucoma is a clinically heterogeneous disease and the world's leading cause of irreversible blindness. Therapeutic intervention can prevent blindness but relies on early diagnosis, and current clinical risk factors are limited in their ability to predict who will develop sight-threatening glaucoma. The high heritability of glaucoma makes it an ideal substrate for genetic risk prediction, with the bulk of risk being polygenic in nature. Here, we summarize the foundations of glaucoma genetic risk, the development of polygenic risk prediction instruments, and emerging opportunities for genetic risk stratification. Although challenges remain, genetic risk stratification will significantly improve glaucoma screening and management.
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Affiliation(s)
- Antonia Kolovos
- Department of Ophthalmology, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia; , , ,
| | - Mark M Hassall
- Department of Ophthalmology, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia; , , ,
| | - Owen M Siggs
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia;
- Department of Ophthalmology, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia; , , ,
| | - Emmanuelle Souzeau
- Department of Ophthalmology, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia; , , ,
| | - Jamie E Craig
- Department of Ophthalmology, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia; , , ,
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Dunlop KLA, Singh N, Robbins HA, Zahed H, Johansson M, Rankin NM, Cust AE. Implementation considerations for risk-tailored cancer screening in the population: A scoping review. Prev Med 2024; 181:107897. [PMID: 38378124 PMCID: PMC11106520 DOI: 10.1016/j.ypmed.2024.107897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/10/2024] [Accepted: 02/14/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Risk-tailored screening has emerged as a promising approach to optimise the balance of benefits and harms of existing population cancer screening programs. It tailors screening (e.g., eligibility, frequency, interval, test type) to individual risk rather than the current one-size-fits-all approach of most organised population screening programs. However, the implementation of risk-tailored cancer screening in the population is challenging as it requires a change of practice at multiple levels i.e., individual, provider, health system levels. This scoping review aims to synthesise current implementation considerations for risk-tailored cancer screening in the population, identifying barriers, facilitators, and associated implementation outcomes. METHODS Relevant studies were identified via database searches up to February 2023. Results were synthesised using Tierney et al. (2020) guidance for evidence synthesis of implementation outcomes and a multilevel framework. RESULTS Of 4138 titles identified, 74 studies met the inclusion criteria. Most studies in this review focused on the implementation outcomes of acceptability, feasibility, and appropriateness, reflecting the pre-implementation stage of most research to date. Only six studies included an implementation framework. The review identified consistent evidence that risk-tailored screening is largely acceptable across population groups, however reluctance to accept a reduction in screening frequency for low-risk informed by cultural norms, presents a major barrier. Limited studies were identified for cancer types other than breast cancer. CONCLUSIONS Implementation strategies will need to address alternate models of delivery, education of health professionals, communication with the public, screening options for people at low risk of cancer, and inequity in outcomes across cancer types.
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Affiliation(s)
- Kate L A Dunlop
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia; Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia.
| | - Nehal Singh
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Hilary A Robbins
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Hana Zahed
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Mattias Johansson
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Nicole M Rankin
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Victoria, Australia; Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Anne E Cust
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia; Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
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Laza C, Niño de Guzmán E, Gea M, Plazas M, Posso M, Rué M, Castells X, Román M. "For and against" factors influencing participation in personalized breast cancer screening programs: a qualitative systematic review until March 2022. Arch Public Health 2024; 82:23. [PMID: 38389068 PMCID: PMC10882761 DOI: 10.1186/s13690-024-01248-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/05/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Personalized breast cancer screening is a novel strategy that estimates individual risk based on age, breast density, family history of breast cancer, personal history of benign breast lesions, and polygenic risk. Its goal is to propose personalized early detection recommendations for women in the target population based on their individual risk. Our aim was to synthesize the factors that influence women's decision to participate in personalized breast cancer screening, from the perspective of women and health care professionals. METHODS Systematic review of qualitative evidence on factors influencing participation in personalized Breast Cancer Screening. We searched in Medline, Web of science, Scopus, EMBASE, CINAHL and PsycINFO for qualitative and mixed methods studies published up to March 2022. Two reviewers conducted study selection and extracted main findings. We applied the best-fit framework synthesis and adopted the Multilevel influences on the cancer care continuum model for analysis. After organizing initial codes into the seven levels of the selected model, we followed thematic analysis and developed descriptive and analytical themes. We assessed the methodological quality with the Critical Appraisal Skills Program tool. RESULTS We identified 18 studies published between 2017 and 2022, conducted in developed countries. Nine studies were focused on women (n = 478) and in four studies women had participated in a personalized screening program. Nine studies focused in health care professionals (n = 162) and were conducted in primary care and breast cancer screening program settings. Factors influencing women's decision to participate relate to the women themselves, the type of program (personalized breast cancer screening) and perspective of health care professionals. Factors that determined women participation included persistent beliefs and insufficient knowledge about breast cancer and personalized screening, variable psychological reactions, and negative attitudes towards breast cancer risk estimates. Other factors against participation were insufficient health care professionals knowledge on genetics related to breast cancer and personalized screening process. The factors that were favourable included the women's perceived benefits for themselves and the positive impact on health systems. CONCLUSION We identified the main factors influencing women's decisions to participate in personalized breast cancer screening. Factors related to women, were the most relevant negative factors. A future implementation requires improving health literacy for women and health care professionals, as well as raising awareness of the strategy in society.
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Affiliation(s)
- Celmira Laza
- Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
- Biomedical Research Institute of Lleida Fundació Dr. Pifarré (IRBLleida), Lleida, Spain
| | - Ena Niño de Guzmán
- Cancer Prevention and Control Program, Institut Català d' Oncologia, Barcelona, Spain
| | - Montserrat Gea
- Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
- Biomedical Research Institute of Lleida Fundació Dr. Pifarré (IRBLleida), Lleida, Spain
| | - Merideidy Plazas
- Cochrane Associated Center- University Foundation of Health Sciences, Bogotá, Colombia
| | - Margarita Posso
- Department of Epidemiology and Evaluation, Hospital del Mar Research Institute, Barcelona, Spain
| | - Montserrat Rué
- Biomedical Research Institute of Lleida Fundació Dr. Pifarré (IRBLleida), Lleida, Spain
- Basic Medical Sciences, University of Lleida, Lleida, Spain
| | - Xavier Castells
- Department of Epidemiology and Evaluation, Hospital del Mar Research Institute, Barcelona, Spain
| | - Marta Román
- Department of Epidemiology and Evaluation, Hospital del Mar Research Institute, Barcelona, Spain.
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Tokutomi T, Yoshida A, Fukushima A, Nagami F, Minoura Y, Sasaki M. Stakeholder Perception of the Implementation of Genetic Risk Testing for Twelve Multifactorial Diseases. Genes (Basel) 2023; 15:49. [PMID: 38254940 PMCID: PMC10815213 DOI: 10.3390/genes15010049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024] Open
Abstract
Genome-wide association studies have been employed to develop numerous risk prediction models using polygenic risk scores (PRSs) for multifactorial diseases. However, healthcare providers lack confidence in their understanding of PRS risk stratification for multifactorial diseases, which underscores the need to assess the readiness of PRSs for clinical use. To address this issue, we surveyed the perceptions of healthcare providers as stakeholders in the clinical implementation of genetic-based risk prediction for multifactorial diseases. We conducted a web-based study on the need for risk prediction based on genetic information and the appropriate timing of testing for 12 multifactorial diseases. Responses were obtained from 506 stakeholders. Positive perceptions of genetic risk testing were found for adult-onset chronic diseases. As per participant opinion, testing for adult-onset diseases should be performed after the age of 20 years, whereas testing for psychiatric and allergic disorders that manifest during childhood should be performed from birth to 19 years of age. The stakeholders recognized the need for genetic risk testing for diseases that develop in adulthood, believing that the appropriate testing time is after maturity. This study contributes to the discussion on the clinical implementation of the PRS for genetic risk prediction of multifactorial diseases.
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Affiliation(s)
- Tomoharu Tokutomi
- Iwate Tohoku Medical Megabank Organization, Iwate Medical University, Shiwa 020-3694, Japan; (A.Y.)
- Department of Clinical Genetics, School of Medicine, Iwate Medical University, Iwate 020-8505, Japan
| | - Akiko Yoshida
- Iwate Tohoku Medical Megabank Organization, Iwate Medical University, Shiwa 020-3694, Japan; (A.Y.)
- Department of Clinical Genetics, School of Medicine, Iwate Medical University, Iwate 020-8505, Japan
| | - Akimune Fukushima
- Iwate Tohoku Medical Megabank Organization, Iwate Medical University, Shiwa 020-3694, Japan; (A.Y.)
- Department of Clinical Genetics, School of Medicine, Iwate Medical University, Iwate 020-8505, Japan
| | - Fuji Nagami
- Tohoku Medical Megabank Organization, Tohoku University, Sendai 980-0872, Japan
| | - Yuko Minoura
- Departments of Medical Genetics and Genomics, School of Medicine, Sapporo Medical University, Sapporo 060-8556, Japan
| | - Makoto Sasaki
- Iwate Tohoku Medical Megabank Organization, Iwate Medical University, Shiwa 020-3694, Japan; (A.Y.)
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Lapointe J, Côté JM, Mbuya-Bienge C, Dorval M, Pashayan N, Chiquette J, Eloy L, Turgeon A, Lambert-Côté L, Brooks JD, Walker MJ, Blackmore KM, Joly Y, Knoppers BM, Chiarelli AM, Simard J, Nabi H. Canadian Healthcare Professionals' Views and Attitudes toward Risk-Stratified Breast Cancer Screening. J Pers Med 2023; 13:1027. [PMID: 37511640 PMCID: PMC10381377 DOI: 10.3390/jpm13071027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/02/2023] [Accepted: 06/19/2023] [Indexed: 07/30/2023] Open
Abstract
Given the controversy over the effectiveness of age-based breast cancer (BC) screening, offering risk-stratified screening to women may be a way to improve patient outcomes with detection of earlier-stage disease. While this approach seems promising, its integration requires the buy-in of many stakeholders. In this cross-sectional study, we surveyed Canadian healthcare professionals about their views and attitudes toward a risk-stratified BC screening approach. An anonymous online questionnaire was disseminated through Canadian healthcare professional associations between November 2020 and May 2021. Information collected included attitudes toward BC screening recommendations based on individual risk, comfort and perceived readiness related to the possible implementation of this approach. Close to 90% of the 593 respondents agreed with increased frequency and earlier initiation of BC screening for women at high risk. However, only 9% agreed with the idea of not offering BC screening to women at very low risk. Respondents indicated that primary care physicians and nurse practitioners should play a leading role in the risk-stratified BC screening approach. This survey identifies health services and policy enhancements that would be needed to support future implementation of a risk-stratified BC screening approach in healthcare systems in Canada and other countries.
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Affiliation(s)
- Julie Lapointe
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
| | - Jean-Martin Côté
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
| | - Cynthia Mbuya-Bienge
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, 1050, Av de la Médecine, Québec City, QC G1V 0A6, Canada
| | - Michel Dorval
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
- Faculty of Pharmacy, Université Laval, 1050, Av de la Médecine, Québec City, QC G1V 0A6, Canada
- CISSS de Chaudière-Appalaches Research Center, 143 Rue Wolfe, Lévis, QC G6V 3Z1, Canada
| | - Nora Pashayan
- Department of Applied Health Research, Institute of Epidemiology and Healthcare, University College London, Gower Street, London WC1E 6BT, UK
| | - Jocelyne Chiquette
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
- CHU de Québec-Université Laval, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
| | - Laurence Eloy
- Programme Québécois de Cancérologie, Ministère de la Santé et des Services Sociaux, 1075, Chemin Sainte-Foy, Québec City, QC G1S 2M1, Canada
| | - Annie Turgeon
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
| | - Laurence Lambert-Côté
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
| | - Jennifer D Brooks
- Dalla Lana School of Public Health, University of Toronto, 155, College Street, Toronto, ON M5T 3M7, Canada
| | - Meghan J Walker
- Dalla Lana School of Public Health, University of Toronto, 155, College Street, Toronto, ON M5T 3M7, Canada
- Cancer Care Ontario, Ontario Health, 525, University Avenue, Toronto, ON M5G 2L3, Canada
| | | | - Yann Joly
- Centre of Genomics and Policy, McGill University, 740, Ave Penfield, Montreal, QC H3A 0G1, Canada
- Human Genetics Department and Bioethics Unit, Faculty of Medicine, McGill University, 3647, Peel Street, Montreal, QC G1V 0A6, Canada
| | - Bartha Maria Knoppers
- Centre of Genomics and Policy, McGill University, 740, Ave Penfield, Montreal, QC H3A 0G1, Canada
| | - Anna Maria Chiarelli
- Dalla Lana School of Public Health, University of Toronto, 155, College Street, Toronto, ON M5T 3M7, Canada
- Cancer Care Ontario, Ontario Health, 525, University Avenue, Toronto, ON M5G 2L3, Canada
| | - Jacques Simard
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
- Department of Molecular Medicine, Faculty of Medicine, Université Laval, 1050, Avenue de la Médecine, Québec City, QC G1V 0A6, Canada
| | - Hermann Nabi
- Oncology Division, CHU de Québec-Université Laval Research Center, 1050, Chemin Sainte-Foy, Québec City, QC G1S 4L8, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, 1050, Av de la Médecine, Québec City, QC G1V 0A6, Canada
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Ayoub A, Lapointe J, Nabi H, Pashayan N. Risk-Stratified Breast Cancer Screening Incorporating a Polygenic Risk Score: A Survey of UK General Practitioners’ Knowledge and Attitudes. Genes (Basel) 2023; 14:genes14030732. [PMID: 36981003 PMCID: PMC10048009 DOI: 10.3390/genes14030732] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/10/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023] Open
Abstract
A polygenic risk score (PRS) quantifies the aggregated effects of common genetic variants in an individual. A ‘personalised breast cancer risk assessment’ combines PRS with other genetic and nongenetic risk factors to offer risk-stratified screening and interventions. Large-scale studies are evaluating the clinical utility and feasibility of implementing risk-stratified screening; however, General Practitioners’ (GPs) views remain largely unknown. This study aimed to explore GPs’: (i) knowledge of risk-stratified screening; (ii) attitudes towards risk-stratified screening; and (iii) preferences for continuing professional development. A cross-sectional online survey of UK GPs was conducted between July–August 2022. The survey was distributed by the Royal College of General Practitioners and via other mailing lists and social media. In total, 109 GPs completed the survey; 49% were not familiar with the concept of PRS. Regarding risk-stratified screening pathways, 75% agreed with earlier and more frequent screening for women at high risk, 43% neither agreed nor disagreed with later and less screening for women at lower-than-average risk, and 55% disagreed with completely removing screening for women at much lower risk. In total, 81% felt positive about the potential impact of risk-stratified screening towards patients and 62% felt positive about the potential impact on their practice. GPs selected training of healthcare professionals as the priority for future risk-stratified screening implementation, preferring online formats for learning. The results suggest limited knowledge of PRS and risk-stratified screening amongst GPs. Training—preferably using online learning formats—was identified as the top priority for future implementation. GPs felt positive about the potential impact of risk-stratified screening; however, there was hesitance and disagreement towards a low-risk screening pathway.
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Affiliation(s)
- Aya Ayoub
- National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK
- Correspondence:
| | - Julie Lapointe
- Oncology Division, CHU de Québec-Université Laval Research Center, Québec City, QC G1R 3S3, Canada
| | - Hermann Nabi
- Oncology Division, CHU de Québec-Université Laval Research Center, Québec City, QC G1R 3S3, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, QC G1V 0A6, Canada
| | - Nora Pashayan
- Department of Applied Health Research, University College London (UCL), London WC1E 7HB, UK
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McWilliams L, Evans DG, Payne K, Harrison F, Howell A, Howell SJ, French DP. Implementing Risk-Stratified Breast Screening in England: An Agenda Setting Meeting. Cancers (Basel) 2022; 14:cancers14194636. [PMID: 36230559 PMCID: PMC9563640 DOI: 10.3390/cancers14194636] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
It is now possible to accurately assess breast cancer risk at routine NHS Breast Screening Programme (NHSBSP) appointments, provide risk feedback and offer risk management strategies to women at higher risk. These strategies include National Institute for Health and Care Excellence (NICE) approved additional breast screening and risk-reducing medication. However, the NHSBSP invites nearly all women three-yearly, regardless of risk. In March 2022, a one-day agenda setting meeting took place in Manchester to discuss the feasibility and desirability of implementation of risk-stratified screening in the NHSBSP. Fifty-eight individuals participated (38 face-to-face, 20 virtual) with relevant expertise from academic, clinical and/or policy-making perspectives. Key findings were presented from the PROCAS2 NIHR programme grant regarding feasibility of risk-stratified screening in the NHSBSP. Participants discussed key uncertainties in seven groups, followed by a plenary session. Discussions were audio-recorded and thematically analysed to produce descriptive themes. Five themes were developed: (i) risk and health economic modelling; (ii) health inequalities and communication with women; (iii); extending screening intervals for low-risk women; (iv) integration with existing NHSBSP; and (v) potential new service models. Most attendees expected some form of risk-stratified breast screening to be implemented in England and collectively identified key issues to be resolved to facilitate this.
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Affiliation(s)
- Lorna McWilliams
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Correspondence:
| | - D. Gareth Evans
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Genomic Medicine, Division of Evolution and Genomic Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary’s Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Nightingale & Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 55 Wilmslow Road, Manchester M20 4GJ, UK
| | - Katherine Payne
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Manchester Centre for Health Economics, School of Health Sciences, Faculty of Biology Medicine and Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | | | - Anthony Howell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Nightingale & Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 55 Wilmslow Road, Manchester M20 4GJ, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - Sacha J. Howell
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Nightingale & Prevent Breast Cancer Research Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 55 Wilmslow Road, Manchester M20 4GJ, UK
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | - David P. French
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester M13 9WU, UK
- Manchester Breast Centre, Manchester Cancer Research Centre, University of Manchester, 55 Wilmslow Road, Manchester M20 4GJ, UK
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